Psychiatry & Psychotherapy Podcast - Psychotherapy for Obsessive-Compulsive Disorder

Episode Date: September 28, 2021

On this podcast episode, we interview Dr. Fred Penzel who received both his MA and PhD in School and Clinical Psychology from Hofstra University in 1985. In 1989, he founded Western Suffolk Psychological Services in Huntington, New York, where he is the executive director and a practicing psychologist. Since 1982, he has been involved in the treatment of numerous disorders including OCD, body dysmorphic disorder, body-focused repetitive behaviors such as hair-pulling disorder (Trichotillomania) and excoriation disorder (compulsive skin-picking), panic and agoraphobia, phobias, and post-traumatic stress disorder. He specializes in the treatment of these disorders within his practice. He is a founding and active member of both the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the TLC Foundation for BFRB's Science Advisory Boards. He is also a member of advisory board of the United Kingdom's Anxiety UK organization. In addition, he is an adjunct faculty member and community supervisor for the doctoral psychology program at Long Island University (C.W. Post campus). He is the author of Obsessive Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2017) and The Hair Pulling Problem: A Complete Guide to Trichotillomania (2003). He has no conflicts of interest to report. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog.

Hello and welcome to the psychiatry and psychotherapy podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is email to you in seconds.

All right. Today we are joined with Dr. Fred Penzel. He wrote a book called Obsessive Compulsive Disorders, a complete guide to getting well and staying well. I reached out to him after we found, we were doing our OCD episode, and we used his book pretty extensively because it was a great book. So I reached out to him, and he was more than happy to come out here and teach us some stuff. He has been treating OCD since he was, let's see, an intern in 1980. He was a founding member of the International Obsessive Compulsive Disorder Foundation and the TLC Foundations for BFRB's Science Advisory Board.

He's still active in both foundations. He has a book also on Trichitellomania and a pretty extensive CV. So it's really great to have you. Give some wisdom to our audience here. Great. So you are speaking largely to mental health professionals or future mental health professionals and wanted to kind of just jump in and ask what led you into your interest in treating obsessive-compulsive spectrum disorders?

That's always a very interesting question to me. The main reason was when I was still a graduate student, one of my professors in an abnormal psych course, we were talking about OCD, and he said that, We shouldn't bother wasting our time treating people with OCD because they didn't get better, essentially, and it was just too frustrating and, you know, not to bother, essentially. And that kind of bothered me because I sort of had heard a few things about the possibility that OCD could be treated successfully. So I'm more sort of a natural skeptic, so I didn't believe him.

So I went out and checked for myself a little further, and I found out that there were actually two-plains in the United States, where they seem to be getting good results in treating OCD. And one of them actually happened to be practically in my backyard. And I applied for an internship there, and I got it. And then I started treating OCD. My idea was, well, if it's as difficult to treat as they say, if I learn how to treat this, I can do almost anything, basically, because I was like a challenge. So I figured I'd take on the hardest one I could find.

So anyway, I found out that people with OCD could. be treated successfully, and I liked it so much that I have stayed with it for going on 40 years now. Wow. Has the treatment in your mind changed very much in the last 40 years? It has been augmented by the fact that we now have a lot of medications that are effective in treating therapy. But the therapy itself, essentially with a few tweaks here and there, is essentially the same because it works.

The principles are sound, and we haven't found anything that works better, essentially. Okay. Coming on with us, Dr. Fletcher, going into psychiatry. She's joining us. She did the handout for OCD that you read. And, yeah, so what are some of the misconceptions of OCD? And how does the public wrongly view OCD? Well, I think the public has a very stereotypical view of OCD.

You know, it's the thing that people with OCD actually hate to hear where people say, oh, you know, my closet is arranged in color and size order with all my clothes lined up equally. And I'm so OCD. And people with OCD hate to hear that because that's not OCD. That's the idea, it's like the idea of somebody who's sort of over-organized and very perfectionistic about everything. High consciousness, high order. Yeah. So that's, I would say, the biggest misconception. The other misconception, of course, is that the one that still has persisted from my student days,

which is that it couldn't very well be treated, that people with OCD were too difficult to treat. In fact, I talk about, it's also about people who wash their hands is another misconception. In fact, I had a new patient recently who came to me and said that they had come from a psychiatrist who told them that they couldn't have OCD because they didn't wash their hands. So this is kind of the things you typically hear still after all these years. Okay. Yeah, what would you say is the difference between a traumatic event leading to repetitive thoughts and obsessions in OCD? Well, you're talking about the difference between PTSD and OCD. OCD and PTSD are really nothing alike.

OCD is likely to have at least partly genetic origins, whereas PTSD, of course, is the result of traumatic experience. So, and OCD has thoughts that could be literally about anything, not even relating to any real experiences or knowledge in a person's life, basically, whereas PTSD relates directly to an event or a series of events, let's say. But OCD may have nothing to do with any real events at all. It can be triggered sometimes by stress or something traumatic, but it's not the cause, basically.

It's just the trigger. Okay. Yeah, and Dr. Fletcher, you can jump in and ask questions and stuff, and I'm sure she'll have questions as well. You talk about this spectrum, which I think some listeners will have not heard the obsessive-compulsive spectrum disorders. On one end, you have more like OCD, body dysmorphic disorder, anorexia. On the other end, you have more like self-injurious behavior. tell me how this way of thinking has been helpful for you. Well, I'm not sure what you mean by self-injurious behavior.

If you're talking about things like tricketillomania and stuff like that, that's actually a misconception about body-focused repetitive behaviors. They are not in the same classification as people who cut or burn themselves or do things of that nature. It's quite different, actually. Those things are more connected with things like dissociative disorders, whereas, you know, trichotillomania and excoriation disorder, which is, you know, skin picking are actually more attempts on the part of a person to manage levels of stimulation within their nervous

system, basically. So they're really very different disorders. So I would be careful because, in fact, people with BFRBs or that's what we refer to as the, you know, picking and pulling type disorders don't like being lumped together with people who do self-injuring because it's not a deliberate act, basically. In fact, they really wish they could stop and would do anything to stop, but can't. So I have a question regarding, I guess,

for example, like with excoriation disorder. So I know that, like, with excoriation disorder, it's technically not, like, self-harm, like, in a sense that it's not deliberate. But, like, since the results still, I mean, if you're picking at your skin, it's technically going to harm your skin. So can you, like, make sure that, like,

we kind of understand how those two things are different? Well, I think they're different in that, as I say, one is an attempt to regulate levels of stimulation within the nervous system. People do these things when they're either in an overstimulated state like stressed or anxious or in an understimulated state where they're sedentary, for instance, or that sort of thing. So people are trying to either get stimulation or relief stimulation in like self-harm basically, self-endjurious behavior. people are trying to generally distract themselves from feelings of anxiety or to just feel something when they're in that numb, dissociated state, basically. So they really are nothing alike. In fact, people with BFRBs really hate the fact that these things happen to them, that

they do this to themselves, and they would give anything to stop, basically, and even actively resist it, but just can't. It's a very compelling urge, basically, when they, you know, when they, you know, when they, you get overcome by their own nervous systems basically. It's an external attempt to manage your an internal experience, basically. So I guess in that respect, both have some similarities, but they manifested very differently. Okay. So specifically, I was looking at figure 1.1 from your book. I had never kind of seen this compulsive, impulsive sort of spectrum. So would you, and you have self-injurious behavior on the right side of this thing near the impulsive spectrum.

So is this, do you consider this to be part of the obsessive compulsive spectrum to have more of like the self-harm like borderline type things or is that something separate? To be very straightforward, I've actually changed some of my thinking since I wrote some of those things that would probably revise them at this point. I think the spectrum is probably somewhat smaller than that I would probably not include self-injurious behaviors. At the time, I originally wrote the book, this was kind of prevalent thinking, and I, you know, I could see no reason to disagree with it at the time, but I've learned a lot over the years. When I first wrote this book, it was 21 years ago when I wrote the first edition, basically.

So I've learned a lot since then. I'm always learning, and that's why I like my job, basically. Okay, that's helpful. So you have this quote. Let's see. if we have to sum up the majority of obsessions, two words would be sufficient. They would be pathological doubt. How does pathological doubt play a central role in OCD?

Very, that's a good question, and it's very central to understanding OCD entirely, because in the 19th century, actually, OCD was referred to as the doubting disease, because that's all they could make of it, basically. And that's what it really is. It's like the person gets these, you know, extreme thoughts of either harm coming to them or they're going to harm other people either deliberately or let them come to harm through negligence. And the first thing that occurs to a person is, you know, the thoughts are intrusive. Obviously, they're not what we would call egosynonic, basically.

The person sees these, unlike people with say thought disorders, they see these thoughts as not their own or not coming from them. But yet the logical part of their mind says, well, why would I be thinking these things if I didn't want to do them? How do I know I'm not going to do these things or how do I know these things are not going to happen? So it's a constant, because the thoughts are sort of a constant bombardment, the doubts are also sort of a constant accompaniment to that. And all the attempts at doing compulsions are attempts to get certainty and to eliminate risk, basically, which is what people are trying to do in OCD. They're trying to eliminate these things from their lives, which of course is impossible and cannot be done. but it doesn't stop them from trying to do it because that's human nature. So that brings up a question for me.

I know in your book you talk about like, you know, the perfectionism versus like avoiding harm. And can you kind of point us out to like how doubt plays a role and like, let's say, like, feeling that feeling of discomfort versus things aren't right versus like there's an actual danger that I need to avoid? Well, there's actually, we've discovered now that there are a number of different types of OCD. actually. One, of course, is just your standard OCD, which we've been talking about. Then there's what we call disgust-based OCD, which is not anxiety-based OCD, which is what we've been talking about. Discussed-based OCD is actually emanates and includes a different region of the brain where disgust registers, as they've discovered. And people, they're not afraid of harm,

per se, but they say, when I touch something or I get it on me or I come in contact with something I feel revolted or I feel disgusted or I just want to get it off me or get away from it in some way. So there's that there's that type of OCD. And then there's also something we've come to realize it's called Touretic OCD, which is interesting because a fairly high percentage of people with OCD have tick disorders or Tourette's and vice versa, actually. There's a lot of, it may be some genetic linkage between OCD and tick disorders. And what we find in Touretic OCD is that people do ticks, of course, as you do when you have a tick disorder, but then they become incorporated into the OCD, and the ticks have to be performed in special or repetitive

ways in order to reduce risk or harm or doubt. So it's like an interesting blend of the two. A lot of practitioners don't understand this, and they totally miss it. They don't get it at all, but there are at least three sort of like subgroups under OCD itself. Interesting. The discussed one is contamination. I'm sure that's gone up somewhat with COVID. It's one kind of contamination. Actually, there's a fear of germs and disease, chemicals, toxic substances. But then the discussed one person says, I don't really, I'm not really afraid of anything happening to me. I just don't like this feeling. I don't like the way it feels. I just want to get rid of it. That's all. But there's no harm or fear of harm

connected to it really. So how does that feeling of disgust, like, compared to, like, people who really just, I don't know, you're like, you know how there's, like, germophobes or just people who, like, are very particular about things, like, they don't want to touch things in public, like, in certain spaces because they probably think it's gross or, like, things that people do, like, really disrupt in the wrong way. So at what point does it become, like, okay, this is OCD with disgust versus, like, well, that's just disgusting.

Well, you know, people ask me that question a lot. Like, how can you tell when it's a disreferral, like, order versus just, you know, ordinary squeamishness and stuff. And the answer, I guess the best answer that I've been able to come up with is that when it begins to affect your ability to function. Okay. That's fair enough. That's the best that I can put it, because there's no other real, you know, scale or dividing line or anything. But that's, you know, when people ask me, that's what I tell them, when it affects your ability to function. Would you put religious sort of obsessions in the disgust category or the regular?

OCD category? No, they would be under the regular OCD category because generally there are fears of going to hell, being damned, doing, you know, being irreligious or sinful, violating religious law. And that's not the same as discussed more about physical, that area of the brain that keeps us from eating spoiled food or staying away from things that smell bad or things like that. It's a very sort of primitive level of the brain, basically, that even lower, you know,

forms of animals have that protects them basically. Okay, one study you cite says 13% of people with trichitelemania have OCD. Talk to me about some of the basics of tricketelemania, how there's some doubt over control, how it kind of relates to OCD in your mind. They're probably distant cousins if you had to relate them. There are no obsessive thoughts, basically, and behaviors aren't done to get rid of doubt uncertainty. They are to either get stimulation or to relieve stimulation. That's about it, plain and simple, basically. And part of the therapy for them actually is helping people find substitute forms

of stimulation that are not destructive or ways of reducing stimulation when they're overstimulated. So it's like learning how to manage your nervous system in non-destructive ways, essentially. That's what we're trying to do. Is it different for kids? I've seen there's been some kids that have this trichotillomania that are really young, like six years old. Is it the same pathology as maybe an adult? Or how do you sort of think about these? Generally, we would consider it the same. There's a form of tricketylomania that you sometimes see in toddlers called, we call it baby trick, basically. But that's more akin to things like thumb sucking. It's usually lasts for a number of months and then it sort of fades. But when

it's plain old regular tricketilomania or any other BFRB, it doesn't go away. It continues. And it just goes on without let up, basically. And then that's how you know the fact that it doesn't go away with, as the child gets older. That's interesting. So like at that age, you compared it to like thumb sucking and things like that. So do you just start to consider it like, okay, this is an actual disorder if it persists beyond the age with which? Yeah, just like you wouldn't consider a thumb-sucking a disorder, basically, unless, you know, let's say a kid's seven years old and is still doing that, you know, and damaging their teeth or something like that. Yeah. Okay, so what should patients look for in a therapist for treating OCD? Well, I think primarily expertise, having proper training, having treated quite a number of patients, and also just having a clear understanding.

of what the disorder is and, you know, having had some kind of supervised practice. I think it's unethical to treat things that you have not been trained to treat, basically would pretend to have knowledge that you don't actually have. And unfortunately, there's quite a few people out there who think they know what you're doing. They don't even know what they don't know, unfortunately. And they use ineffective methods or very limited methods, things that couldn't possibly work, but they waste a lot of time and money on the part of their patients. What are some unscientific or unsubstantiated treatments for OCD?

For OCD itself? Oh, gosh. Well, one is EMDR, which has been used a lot for PTSD. And studies show that it is effective for that, but a lot of claims have been made for it to be able to treat OCD that aren't accurate. There was this four-step approach, you know, by Dr. Jeffrey Schwartz years ago. that was basically response prevention without exposure, which didn't work because studies showed. And the correct treatment for OCD is exposure and response prevention. And studies showed that you needed that either one alone, either half, was not as effective as both together, basically. So I've seen people treated with relaxation, psychoanalysis.

I have one fellow who was in psychoanalysis for 30 years, as a matter of fact, with nothing to show for it, essentially. also trying to think just plain old talk therapy, cognitive therapy, et cetera, alone. And of course, again, these things have not, there's no data to support them that they work. I believe in evidence-based therapy. And there's plenty of evidence for exposure and response prevention, little or not. Oh, hypnosis is another one. I've also run into that also. But there's no evidence that these things are affected. Nobody can produce any clinical evidence. Have you had any patients who've experienced any, like, marginal benefit from any of those things?

Well, anecdotally. Yeah, yes and no. I mean, a lot of therapists spend the sessions like reassuring people that nothing bad is going to happen. And the person's okay for a little while, but, of course, the doubts are constant and they're recurring. So the effects don't last. And then the person's back next week seeking more reassurance. So it becomes the therapist becomes kind of like a drug dealer almost, you know, doling out reassure. that makes the person feel better for a little while, then the person has to keep coming back.

So it forms like a very unhealthy dependency, basically, on the therapist. So that's one thing you typically see. Yeah, and for my audience, you know, I talk a lot about, like, common factors between therapists and the importance of, you know, therapeutic alliance, empathy. I would say those are vital to keeping patient with OCD in therapy. But it's really the behavioral therapy that's going to make. the change. So it's kind of like, you need that therapeutic alliance to get them into therapy, but the behavioral therapy, and would you agree?

Yeah, what really gets people into the therapy is when they, for instance, when they talk to a therapist and they see that the therapist really knows what they're talking about and really gets them and gets their symptoms and understands OCD. And you can make that very clear in the first 10 minutes of a first session with someone that you understand exactly what's happening to them. And And people are very gratified to find that because they have not been able to find that before. I have people who've been to as many as four or five other therapies without any success or anything to show for it. Yeah. And part of therapeutic alliance is the patient feeling that their provider has expertise and feeling like there's good goals.

Go ahead. Yeah. With regards to the therapeutic alliance, I know that they say that sometimes that matters more than the techniques that you're using. and a lot of the effect of therapy can be like attributed to the relationship that the therapist and the patient has. But with regards to OCD, since like it kind of requires like a specific kind of therapy, how would you say that saying relates to OCD treatment? Well, you can be, you know, the nicest, most affable, most understanding therapist that there is. But if you don't have the methods and you don't have the technique or the understanding,

that's not going to last very long. And it's not going to go very far. I think people, you know, come to us because they want a desired result, basically. They don't want to just have a relationship. They want to get better. They want to resume their lives, basically. They want to get back to where they were or have the lives that they have not yet been able to establish. And this is what we are obligated to give them.

And I tell them that I take their desire to do this very seriously. And that this is exactly what I intend to make happen with their cooperation. And I tell them, you know, I can do this, but I just need you to. do your part and if we work together, we're going to get this. It's, you know, and I tell people, look, it's not easy. I tell them this from the very beginning. It's not fun. It's not entertaining. It's therapy, you know, just like physical therapy can be painful, but it's going to get you functioning again in a physical way. And this is kind of the same thing. It's not meant to be enjoyable, but I tell them you will enjoy the results, but it takes hard work to get better. And, you know,

no matter what anybody else tells you, this is what I have to offer. And this is what, what you can expect. But if you're prepared to do the hard work and you're prepared to work on this every day, you will get your results because this is what I see repeatedly over the years. Yes, I would say your ability to enlist the client in that work is a sign that you're building a good alliance with them. You give a quote from Seneca, one of the main Stoic philosophers, and you say, there is nothing which persevering, effort and unceasing and diligent care cannot overcome. How does this relate to behavioral therapy? Well, it's, I tell them, I say, we're literally retraining your brain and any retraining process involves practice and it involves

regular practice and steady practice. And it requires you to practice this as a discipline, basically, in order to get better because, you know, OCDs are very stubborn disorder. So your efforts have to be equally stubborn if you want to overcome it, basically. It's like anything else, If you want to accomplish anything that's difficult or challenging, it's going to entail hard work. So this is what it takes. And if you're here to do that, you will get your results. But I tell them, I say, you don't have to be the strongest or the smartest or anythingest. You have to be the most persistent, I say, if you're going to get better.

That's what you have to be and refuse to quit no matter what, even in the face of days or weeks where things aren't going so well, you don't feel like you're getting anywhere. I mean, I've had people who I remember one patient who worked on one particular assignment for three months steadily every day until he got it right. And he finally did. And the guy recovered, it was like a big breakthrough for him. But if he hadn't hung in there for three months working every day, he wouldn't have gotten there. How do you help patients, like, tolerate that? Well, number one, you prepare them.

I think if people know what to expect and they see it coming, they're not caught off guard or surprised by it. I tell them this is exactly what it's going to be. And I think, you know, if you're prepared for something, you can handle it and cope with it a lot better than if it catches you by surprise, basically, you know, when you're not prepared for it, essentially. So I do that, but I assure them that it will all pay off in the end and that they can, that no one gets well perfectly. It doesn't go in a straight line that it's, you know, again, it takes hard work. They may setbacks. Like I tell them, I say, they're a potholes. on the road to recovery. And you're going to hit a few. So get expected. Don't beat yourself up.

Don't, uh, uh, you know, say, oh, I quit. It's too hard. It's not too hard. It's just hard. That's all. Okay. So let's let's make this really practical. So let's say you had an anesthesiologist who came in. I'm making, I'm making this up. This, this is a imaginary person. And every night before they leave work, they feel like they have to go check the vent settings. and then they do they let's say they have 20 patients so they go check all the vent settings and then they have to go back and recheck the vent settings and they do this for about an hour so every every night for an hour they are rechecking the vent settings with incredible doubt so what behavioral therapy would you start with with this person like what would that look like

well i i tell patients that our goal is to kind of hit the problem from many different directions at once We try to surround it, basically. Like, we don't just do one single technique, and that's it. I employ a whole group of techniques and try to get this thing for many different channels. So now, again, this is, I'm just speaking theoretically. Obviously, we start at low levels and gradually work our way up to the more challenging things. For instance, some people might be able to cut down their checking gradually, like week by week. Other people tell me, they say, I won't be able to do that.

I just have to go cold turkey. You have to tell me I can't do it at all, or I won't be able to resist it. So there's that. But beyond that, what we try to do is we get the person to either way to reduce the checking to what we would call a normal level. I would ask a patient, look, I'm not well versed in your field, but what is considered to be proper practice? What do other anesthesiologists do? And our goal is going to be due. I say, if you want to be average, you have to do what average people do.

So if you want to be like the average anesthesiologist, you have to do what the average anesthesiologists. you have to do what the average anesthesiologist does. And even if you can't do that right away, we're going to work up to that point, basically. So we would one way or another cut down the level of checking. Secondly, I would have the person agree with all their thoughts that bad things are going to happen, that it's going to be their fault,

and that nothing can save them from that. I would also have them resist. Wait, slow down. So what is that one? It's their fault, if what? If anything bad happens as a result of they're not checking. So you would agree, you would agree with their obsession? They would have to agree with the thoughts, yeah, and stay with them, let the thoughts be there,

stay there true, and not try to avoid or escape them in any way. Okay, so you're not, you're not countering it with cognitive distortions, you're not, you're just kind of like, okay, and what is the value of doing that? Well, the overall goal is the only way to overcome a fear, now we're talking about anxiety in general, The only way to overcome fear is to face it. You can't escape from fear. Fear is an internal experience. We're wired to feel these things.

Like you can't run away from hunger or fatigue. You can't run away from fear either. Your evolution has equipped you to feel fear. And sometimes that's adaptive. Sometimes, as in the case of OCD, it isn't very adaptive. So our goal is to build up the person's ability to tolerate these particular forms of anxiety so that when it happens, the person can say, okay, I can get this thought, but I don't have to do anything about it.

I can just let it be there and go about my business and do what I know is normal and accepted. So in a way, they kind of just become, like, bored with a thought? Ah, you hit the nail right on the head. That's the exact word I use. I say the goal is to become bored with these things. I say that you can't be bored and scared at the same time. That's what I tell my patient. So that's what we try to do, literally.

So we agree with the thoughts. We let them be there. We say they're true. We tell them to resist all forms of reassurance. either from themselves or from others. We tell them to, I have them write series of graduated sentences every day 25 times, starting with, you know, I might harm somebody to, I've definitely harmed somebody, and I don't care if I harm somebody and so forth.

So we have them write, and eventually they move up to writing whatever their worst thought is 25 times every day. So we do it in that channel also. And they write it and they say it out loud as they write it also. So another thing we have them do is have them read stories of people who've done the very thing that they're afraid of doing or is going to happen to them. So I have them read either watch videos or read stories online about these things every day. They have to do this. They have to agree that they are like that person or that's going to happen to them.

Wow. In addition, I have them write two-page compositions that are graduated, starting at low-level fearful things and work up. to the most fearful thing, and they record them on their phone and they listen to them six times per day spread out over the day. So these are typical kind of assignments that we give in these cases. And how much anxiety would you say they typically experience while watching these videos or reading or writing? Well, we try to gauge it so that they feel at least a moderate level. Low level isn't going to do anything. Too high a level is going to scare the person away, and I don't want them to drop out of therapy, which is a mistake that novice therapists make very often

is they in their zeal to get people better, they overload them and the person freaks out and says, I can't do this. It's too hard. And they just drop out of therapy. So we don't want that either. But we want to give them enough so that they, by the end of the week, they can say, yeah, when I first started doing this assignment, it made me anxious now. I don't care about it.

I could listen to it all day or read these things all day and I don't care. Okay. So like graduated stories. So initially for this guy with a ventilator. it would be like a story of like what would be a low level and story versus a high level story. A low level story might be somebody who, you know, made some mistakes and, you know,

found out in time to do something about it. But then high level would be somebody who killed patients, maybe several patients, and who lost their license and even got jailed, for instance. So you're going to have them tell them eventually, tell them, tell himself stories that he's going to listen to every day about how he forgot to do someone's vent settings and he got he killed the person and then went to jail and that's going to eventually distinguish the fear well it will extinguish the fear ultimately because the person will get

bored with hearing that when you know it's like a psychologist friend of what he says he says it's like this is like watching a horror movie a thousand times okay wow that's good ultimately you You just don't react to it anymore. You just, you become numb to it. You don't feel it. It's just like, okay, fine, whatever. So what about, like, let's say they have the fear of COVID, of getting COVID. And so they don't want to, like, leave home.

They don't want to rejoin society. They don't want to go out to dinner. They don't want to see any friends. Let's say they're vaccinated or they're previously infected. So they're, you know, have natural. immunity, what would you say to this person? Well, again, I would say let's stick with the science. Let's follow whatever CDC guidelines say to do.

And if the CDC guidelines say you don't have to wash your groceries, then you don't have to wash your groceries. Or if it says, you know, if you're masked up and you can go to the supermarket, you can go to the supermarket, or you can take your mail in and open it up without washing it first or something. Okay, so that would be like, that would be your identification of the average, like the average level of like, yeah,

following recommended guidelines, yeah. Okay. And then what would be the, well, what if, what if this person then, like, still has the fear that they're going to get infected? Would you have them play out stories that they do get infected? We would always do all these other things as well. This is pretty standard with all my patients. Yeah, they would listen recordings, they would write sentences,

they would read articles and watch videos about people getting COVID and dying. They would agree with all their thoughts about it. I mean, you know, go through the whole. There are some things that I call permanent assignments. And permanent assignments include agreeing with the thoughts, letting them be there, not reassuring yourself and not doing compulsions, of course, is what we're working with zero, zero compulsions. The problem, as I tell people, it's not the anxiety.

The anxiety is not the problem. The compulsions are the problem. Because when you get rid of the compulsions, then you're facing things and there's going to be no more anxiety ultimately. But if you think the anxiety is the problem, you're just going to do more compulsions. Okay. Do you think this, like does this method, like let's say you didn't have someone who had OCD, but they just had a lot of fear about things, fear about life.

Would you do the same sort of techniques or would you do it differently? Something very similar, yeah, because again, as I said, all anxiety, and I don't care what the disorder is, is basically treated the same way. you have to face what you fear to overcome it says there is no escape there's no escape from what we fear whatever it happens to be whether it's ocd or phobia or or anything else it all involves that if you if you look at anyone that ever overcame a fear of anything they only did it ultimately by facing it they couldn't run away from it i mean they tried but they didn't really escape the fear really it's still there okay like let's say you had like a therapist who had a fear that they're an

imposter, that they're not good enough, they have a lot of self-doubt. Would you treat that in a similar way? Or would you have them agree with that, that they're an imposter and that they? I would probably, yeah, I would do exposure for that, although I would not rule out using cognitive therapy also to get them to challenge their beliefs, you know, in other words, to say, well, where's the evidence that these things are true? Prove, you know, can you prove this? Is it logical, can you, you know, provide, where's the evidence? Where's your data, basically? And, and, of course, you know, people aren't going to be able to come up with any. So, you know, it depends. A good therapist, a good therapist has to be adaptable and flexible. Some people might respond

better to a more behavioral approach, but other people might respond better to a more cognitive approach. And some people might do well with a blend of both. So you have to be prepared. You can't be so doctrinaire that you can only do, you're like a one-note, uh, a composer basically. Okay. Okay, so the cognitive approach is actually looking at the thoughts, putting the thoughts on trial, which is very different than your kind of line of,

except the thought is true, right? Because with OCD, there's no, you can't argue with OCD. OCD is not, OCD doesn't care about the facts. OCD is just going to keep saying what OCD says over and over again. It's just going to keep broadcasting the same stuff. So you can't talk to OCD. You can't reason with it. So we don't even try because it's,

It's useless exercise. Okay. So, yeah, what are some of the main cognitive therapy that you use for people with OCD? Generally, I don't use cognitive therapy for OCD. Okay. I might use it for other issues in their lives if they're having relationship problems, if they're having job issues, if they're having, you know, problems in dealing with the damage that OCD has caused to their lives, I would use cognitive therapy, like the idea that I'm,

because I've had OCD or because I've been dysfunctional, I'm less than other people, or I'm defective or, you know, et cetera. I would use cognitive therapy for something like that, but I wouldn't use it for the OCD itself, but OCD won't respond to cognitive therapy. Okay, so that's good. That's a good distinguishing thing. So you wouldn't have them accept that that is true and then get them to tolerate that, sort of like self-concept, self-belief.

I might also use cognitive therapy to get it. people to do behavioral therapy also to get them to challenge, you know, whatever it is that's holding them back from facing their fears. I would do that. But I wouldn't use it for the OCD itself. Okay. In your book, you talk about the nine steps of behavioral therapy. Are there any other steps that you haven't talked about yet that would be worth maybe? I'm just trying to think. Not particularly. I mean, OCD is, you know, it's interesting. how homogenous OCD actually is between people. I get emails from literally all over the world. I mean, from small islands in the Indian Ocean to Asia, to Africa, to Central Europe, to South

America. And the emails are all the same, basically, and the things that people are doubtful about are incredibly identical, you know, and it seems to be what it is regardless of cultural, racial, national differences. It's, it's, OCD is no respecter of. those things. It's like universal, basically. It seems to have penetrated the human genome somehow, and it's, it's like, everywhere. And it's basically pretty much the same everywhere you go. That's what's so interesting about it, basically. So treatment is pretty much, I think as I've kind of outlined it, I hope I've given a fairly complete idea of what I would do for these things. So, you know, the one thing I haven't really mentioned so far, but I think is very important, is maintenance and relapse prevention.

I always like to say that the person most likely to relapse is somebody who thought that they were cured. And they're not because OCD is a, it's chronic, basically. It's not an acute problem that just goes away in your well. But if you do some maintenance later on, like if you get a thought, you agree with it, if you sense a compulsion, kind of brewing, you immediately put a stop to that right away. But people who, you know, who learn their lessons and who expect that things are going to come up and are prepared to deal with them when they happen, they're going to do a lot better. And I should also say that medication can also be a very important help in doing therapy as well, because it can lower the level

and the intensity of the thoughts enough to allow people to approach these things better and be more successful at therapy. There's some people who couldn't even approach therapy without medication. Their fears and their thoughts are so severe. So medication can be a very helpful adjunct. And I work very closely with quite a number of psychiatrists. And I definitely find that what they do is extremely helpful to what I do and what I do is extremely helpful to what they do. So we make each other more successful. So what do you do in an instance in which you have a patient and, like, for some reason they can't take medication? I'm trying to think of what that might be if they're seeing you. Perhaps a woman who's pregnant might be a good example.

Okay, yeah. In which case, well, we just have to proceed without it. If we can't do it, we can't do it. Obviously, we can't do anything that would harm the person. So, you know, we just have to work with what we have and then start from where we are. That's all. Might not be ideal, but then, you know, you don't always get a choice. How do you gauge when to refer to medications?

You know, like, is it severity level when they come in? Are there patients that from day one, you're like, well, let's, you know, do you usually try to do the behavioral therapy, and then if it's not succeeding, then consider medications? Do you refer day one to medications, or how does that work for you? Actually, you've mentioned several possibilities that I would consider. One, of course, is if a person who comes in is so agitated and so anxious and, you know, pretty much jumping out of their skin with anxiety, and I've had people who couldn't even use the words to describe what was bothering them because they were so anxious, just they couldn't even say the words,

basically those kind of people who are that anxious are going to need medication. I can see right from the beginning that they're not going to be successful without it. Other people will come in and say, you know, I'd like to try without it. I say, okay, give it a shot. But if it looks like you're not succeeding, we'll revisit this idea again. So people will give them a chance at it, will work for several weeks. And if I sense that they're struggling and they're really not able to do the therapy, even at the lowest level successfully, then I'll say, look, you know, I think we have to reconsider

medication because I don't think we're going to make the kind of progress we need to make without it. And I say, you know, it doesn't mean you're weak. It doesn't mean you're a failure. It doesn't mean you can't do it on your own. Or, you know, that's not even the issue. I say, you know, it can help you to do the therapy. And then you're going to be more successful that way. And people tend to trust me.

I mean, I've got a lot of experience at this. I've probably treated well over 2,000 people with this already. So I have a pretty good sense of who's going to need it by now and who isn't. So you can tell. Some people actually will come in, they'll either already be on medication or they'll say, I got to have medication. I can't do it without medication. So, you know, no problem.

The medication's fine. It can't hurt you. I do tell them that it's trial and error because there's no one medication for everybody. They always say, what's the best medication? And I say, it's the one that works best for you. Basically, that's the answer. But medication is extremely helpful. But it becomes pretty clear, if not immediately, then within a short time, who's going to need it.

Yeah. Here's one other case I will mention. Sometimes people will get recovered without medication, and they'll say, you know, I'm not doing compulsions anymore. I'm not anxious anymore, but you know what? I still have this stuff going through my head all day long. It's always like banging on my head. I want it to stop. So I say, okay, well, let's bring in some medication here and see if it lowers the level of the thoughts.

and often it does. And so that's another case where you would use medication. Do you ever get them to a place where they're doing really well through the therapy? And then you're like, you know what? We can lower the medications and see what happens. And then kind of re-challenged them and redo the behavioral therapy at that lower dose? Or how does that work? I'm a big proponent of the idea, as they say, if it ain't broken, don't fix it, basically.

So if someone's doing well. They're managing their symptoms. They're functioning well. Everything's going good. My belief is, you know, let's, at least for the present, let's leave it as it is. I know, like in severe depression, usually when someone's doing well, they like to see the person do really well for about maybe 18 to 24 months before they even consider lowering medication. That's kind of a standard approach. So I would say if at a later date you want to try lowering it gradually over months and months, do that.

But that way, if you find that your symptoms are starting to creep back in, you can always raise the dosage back up, no harm done. Sometimes when people go off a medication, we don't understand this phenomenon very well. But when they go on in a second time, it doesn't work. And we don't know why that is. It's kind of strange. I haven't had it happen to a lot of people, but I've seen it in a few cases. So I tell people, do it very, very slowly and see what happens. There's no, you can't get into trouble by doing things gradually, just by rushing it and overdoing things.

That's where you get into difficulty. Yeah, for the patients with OCD that I've treated, I'll make a change and then wait two months at least. Like, so a small decrease, if they really want to get off their meds, small decrease and then see where they're at in two months. That kind of gives me. I'll see the main reason, the main reason why people come back to me in a state of where they've lapsed into symptoms again, is because they stop their medication. The effects don't happen right away either. It can take several months before the symptoms start to creep back in after they've discontinued.

So they get like this false sense of security right away. But ultimately, it will come back, I would say, in most cases, because the medication is just a control. It's not a cure. So I have a question on that point. If they can feel it coming back, and I know you talked about earlier about, like, maintenance, what are there things that they can do before they have to go back to medication? Like let's say you're very aware of this is coming back. Like, what do I do?

Oh, absolutely. Well, one thing I tell people is that the purpose of therapy is to give you tools to use that the goal is to become your own therapist, basically. To not, in fact, I like to tell them, I say, you know, your job is to put me out of a job, essentially. You have to take over your own self-management because that is the goal, ultimately. I will not have succeeded if I don't achieve that. don't want people dependent upon me for the rest of their lives. So that's not desirable either. I want them to get out there and function on their own. But generally, so they have the tools. I tell them to save their old homework, refer back to them. Sometimes they have written lists of

homework. The time they say refer back to that if you need some ideas about what to do and give yourself homework yourself. And if you find that, you know, something new and different is popped up where you're not quite sure what to do. You can always contact me. And maybe a few booster sessions, we'll get things going again. Okay, that makes sense. And I know you said you don't use as much cognitive therapy in the treatment of OCD, but I remember in your book you mentioned something called the Downward Arrow that I thought sounded really interesting.

Do you ever find that patients, like, use that in their maintenance, or what do you have to say about that? I don't use that so much as a treatment tool. I use it as a diagnostic tool, basically. So I'll say to someone, well, you know, so you do this particular thing, what do you think is going to happen? And then, you know, they tell me to say, well, and then what's going to happen? And so we try to keep spinning it out until we get to the very conclusion, to the end point. So we know what it is.

We're working toward an exposure. Okay. The goal, people sometimes ask me, say, well, how do you know when you're recovered? And my answer is I say, when we run out of homework, basically, when there's nothing left that we can assign you that will trigger your anxiety any further, that, that, you know, whatever we give you to do, you can handle it, no problem. that's what recovery looks like i tell them i say now you're free to have the same problems as everybody else what what are some of the most challenging aspects of working with this population or working with oCD okay wow that's a good question i would say um well sometimes i will get patients who have uh uh religious obsessions and who are very very and it come from religious backgrounds

who are very convinced that if they do anything to oppose their OCD, that they're going to be blasphemous and going to be damned and go to hell or God's going to punish them or something like that. So those folks can take a lot of convincing that it's really about OCD, that it's not really about religion, basically, even though the OCD may tell them that it is. So that's one type of person who's very challenging. Another challenge comes up in people who's OCD. is the only disorder I tell people that actually attacks its own therapy. So the OCD will actually go after the therapy and start giving them doubt saying, well, how do you know you have OCD? Maybe you can't get better. OCD can't, or therapy can help you. You don't know how to do it right.

You'll never get better. That can be an obstacle sometimes. So then you have to do exposure for that basically for the fact that they're not going to get well on top of the rest of the therapy. Yeah. Also children who have, not just children, but adults, anybody who has little insight, basically, and who really highly believes the thoughts is going to be harder to treat because their degree of belief is so much greater and that's going to take a lot more work to just convince them to even do the therapy at all because they really buy into the thoughts. So they're, you know, I tell my, the interns that I supervise sometimes that I do supervision with doctoral interns from Long Island University, and I tell them that,

you know, that being a psychologist involves the art of salesmanship, basically, you're trying to sell people on the idea of doing things that, you know, scare the heck out of them and that they really don't want to do. So that's a pretty tough sell, I would say. That would be the therapeutic alliance right there, I would say. And I think your competence and your confidence from doing this probably allows you to do it very well. you know, it's hard not to believe your mere neurons that you're going to be successful. I don't know. But I don't know on there.

My self-doubt's creeping in here. I know. Really? Agree with him, yeah. So you have this one statement, use a quote from Seneca. Most powerful is he who has himself in his own power. and kind of talking about self-help, taking the first step. So I imagine someone's going to listen to this, inevitably, who has OCD.

Let's say they couldn't, they can't do therapy for whatever reason. What are some self-help things that they can do on their own? And are there any therapy resources for people who may not be able to afford it or from other countries that listen to this? Well, there's several possibilities. One is, that's what other reason I wrote my book was so that people could use it for self-help who didn't have access. And when I wrote this book, there was considerably less professional help available than

there is now, although we still have a long way to go. There's also a lot of good information online, but you have to be careful because some of it is not so good. Like the International OCD Foundation is an excellent source of information and some of the major universities, you know, like Harvard, the Harvard Medical School. the Mayo Clinic, you know, places like that are, again, good sources of information. There are university clinics where people can get treatment from students who are working under the supervision of experienced psychologists, such as the university that I'm affiliated with.

So there's lots of possibilities. I think, you know, you can. And there's quite a few books out now also, besides my own, not just my book. And there's also videos, some very good videos. There's a good video series called the OCD stories where people and practitioners both are on there. I've made a couple of videos on there myself. But there's also a lot of people with OCD talking about their recovery. A lot of books have been published also by people who overcame OCD themselves and have shared their experiences. So there's a lot.

When I first started treating OCD, I think there was one book that was written by a psychoanalyst that was completely useless. And there was no internet. There was nothing. So basically you were just out there alone. if you had OCD. But now the picture is quite different. There's lots of information, and there's lots of helpful resources out there that didn't used to be.

So that would be what I would suggest. Very good. Very good. Chantelle, any other further questions that are on your mind that you want to? Yeah, there is one. Do you think that mindfulness meditation is something that can help, like relieve some patient symptoms, like something that they can do on their own?

Not for OCD. It would be good for other things, I think. I mean, it certainly can't hurt, but I don't think it's going to directly address the problem of OCD. Again, I have seen many things come and go over the years, but exposure and response prevention has always been there and it's always worked. And again, nobody's come up with anything better. If they did, believe me, I would switch to doing that if someone came up with a better. I just want to do. do what is most effective. That's all. Okay, that makes sense. Have you had patients who have overcome doubt, self-doubt, and then gone on to do, like, I feel like sometimes people's giftedness is like almost restrained until they're able to battle through that self-doubt, that fear?

Have you seen them go on to do accomplishments and things that you get excited about? Oh, yes, definitely. A number of my patients have actually gone on and become psychologists. Some have become social workers. Some have become psychiatrists and even other medical specialties and all they all felt they wanted to give something back. So I've had people become university professors and all kinds of other things too. I mean, you know, not that those are the only, the only respectful professions, but I would, I would, I've seen people, you know, but to me, that that's great. But to just see people resume ordinary life and just go back to. taking care of their homes and gardening or joining a local club or just being able to enjoy life again and just have quiet moments. I think that that's fine. I think that's wonderful. I'm just as happy to see that. They don't have to do those things to impress me. Good. Yeah, that's wonderful. I think both sides, you know, enjoying just the here and now present beauty of nature. And also it sounds like you've

had a number of clients that have gone on to help other people. So you have that kind of multiplier effect. which is really meaningful. Anything else you'd like us to know about you, about resources that we could tap into? The book will link in our show notes and on our website. We'll write a summary of this on our website, which maybe I'll have you co-author or just kind of look over and make sure you agree with

if that's okay with you. And then is there anything else that you want to kind of put out there? you have a practice. Are you in New York? That's correct, right? And you have other people that work there that you've trained in this method as well? Yes, I do. I do. Two of the psychologists who work there are former interns of mine who decided to specialize in OCD and who wanted to continue working with me, basically. My wife also was a psychologist and also treats OCD and we have identical practices as well. In fact, my wife, started out in investment banking. Oh, wow. Once she got a good look at what I was doing and got very interested in it, she went back to school, got her doctoral degree and went into practice.

Oh, wow. Really cool. I guess I must have had a good influence on her. That's great. Yeah, so we'll put all the links to all of your different ways and getting a hold of you. And, yeah, is there any other final thoughts you'd like to share? Oh, one thing that's another resource I should mention is on my clinic's website, just about every article I've ever written about OCD is actually posted on the website for people to read, download whatever they want to do with it. It's all for free. I put it out there just, you know, to help people. One of them are newsletter articles that I wrote for the International OCD Foundation. And I continue to write for them also. I just have another article is coming out this fall on.

perfectionism in the school children without CD. But so many kids are going back to school, I thought it would be kind of timely. Yeah. But, you know, overall, I believe that the vast majority of people have it within themselves to recover. They just have to get the right kind of help and learn how to mobilize themselves. And, you know, I think it, you know, it's not a dead end. It's not hopeless. I think there's hope for anybody who's willing to work hard and face their fears.

That's great. Well, it's been a pleasure, Dr. Penzel, having you on and your expertise, and I'm sure my audience has appreciated it. And, yeah, maybe part two on Trichotillomania. Sure. If you desire, we'll be an email. Absolutely. I can even recommend some people from the TLC Foundation if you want to get one of them on as a sufferer to speak about the disorder itself as well. You don't have to just hear what I have to say.

You can actually hear it from the mouth of someone who has suffered with this as well. Maybe we could get both of them on, both you and that person on. If you find that person, let me know. And that would be a fun episode. Or if you have someone in mind for OCD and you want to, someone who's recovered and gone through it and done well, that would also be an interesting episode, I think, to have someone kind of tell their story. Look, although I got to say most people, for the most part, don't want to really, there's only a few really who really want to talk about. their OCD publicly. Yeah.

Because they're worried about, you know, being stigmatized or just giving away personal information. But the, the, the, trick-and-telmany people, though, tend to be a bit more militant. And really not afraid to get out there and talk about it. So I would not have any problem getting someone to talk about that. Well, I'm sure someone will reach out to me or maybe 100 people will reach out to me who have OCD, who have recovered and listened to this. They'll be like, I'll be odd.

I get these emails quite a bit. Sure, no problem. No problem. All right. Well, thank you so much again, and we'll leave it there. Okay, thank you for having me. I always enjoy being questioned. It makes me stop and think about how I know what I know, basically.

Excellent. Thank you.