248: Understanding Real Event OCD: When the Past Fuels Obsession

All right, welcome back to the podcast. I am joined today with Kevin Foss. He is an OCD expert. He is a clinician in practice. And today we are going to be talking about something called real event OCD. This is when the past becomes a source of obsession. Some people I imagine with OCD really just have a lot of this, and maybe they don't have a lot of the normal hand washing, contamination fears. But let's start it off. Kevin, tell us a little bit about real event OCD. Let's just launch into it. Awesome. Well, thanks so much for having me on. All right. So yeah, you gave a really good like snapshot of what that is. So real event OCD is a subtype of obsessive compulsive disorder, and we call it real event. There aren't different diagnoses. It's not like a whole separate thing from, as you mentioned, contamination. It's just another way that it manifests, and it's kind of a colloquial way for us to get a quick shorthand to what the types of obsessions are, the general themes that someone is struggling with. So with real event, as you said, it's going to be focused on something that actually did, in fact, happen, whereas we contrast that with a lot of the other subtypes. They're related to things that could happen, that might happen, that if I do this or if I don't do that, then I'm going to experience some calamity or something I don't want. Whereas with real event, the obsession is about something that did happen, and then a lot of the rumination is going to be about what effect that's going to have on the future, whether or not those values are or like what value was broken, how do I atone for it, what sort of punishment should I accept or get, and or the compulsion has to do with trying to eliminate a sense of guilt and a sense of shame related to it. Okay, so you have real event, then you have these obsessions, which are unwanted thoughts, distressing thoughts. Sometimes it's like what really happened, but then sometimes they're questioning, I've had a couple of patients who question if what happened, if more happened, like if they're forgetting some details that may be like just getting real, like if they're having thoughts like, oh, did I hurt that child when I interacted with my cousin? Maybe they didn't really hurt the child at all, they didn't touch the child, but they're fearing these thoughts, these obsessions. Is that what we're talking about or is it, how would you kind of add to that? Yeah, and there's going to be some, a lot of this ultimately, as we're talking about these subtypes, right, at the end of the day, it's all OCD, right? So it's all an obsessive thought, a what if question, right? What if, if then type of proposition, which leads into a sense of anxiety, discomfort, fear, numbness, terror, whatever you want to call it, an unwanted feeling state followed by a compulsion to try to undo that feeling or to try to make sure that whatever you're afraid of, whatever that feared story is, never comes to fruition. So there are going to be some disagreements and some nuances to what fits under this title of real event. And, you know, some people will kind of put it into that category of imagining what else could have happened, but regardless of all that, yes. So to answer your more direct question, that fear of one of the compulsions that someone might do would be to, you know, go back in time in their memory and to try to figure out if they are, if something else happened, right, they might recognize, alright, I did hang out with my cousin or whoever, you know, whoever it might be. There could be an imagined story of, well, did I do this, right? I think what, what you're kind of alluding to also is there can be a false memory OCD, which is often attached to a real event OCD. Real event again is going to be, alright, I know that I hung out with my, with my cousin and we, you know, I hung out with my cousin that day, right? False memory OCD can kind of come in and suggest, well, you know, maybe, maybe you're not remembering everything correctly. Maybe you did something else. Maybe something else happened that, you know, would violate your, your, would violate some sort of value that you have, right? You did something wrong. So in that, a lot of compulsions are going to be, you know, playing that story over and over and over again to try to figure out, was there something else that happened? If I did this, you know, they might've done this, they made this facial expression. I wonder what that means, right? Playing all these out to try to get to a point of confirmation that nothing happened or get to this place of, you know, confirmation that something did happen so that they can take action on it, right? Some of the stuff that I, you know, that I would categorize, you know, as, as really clearly under a real event would be things like, you know, a memory about, you know, maybe cheating on a test in high school. Okay. They have that, that memory, like, I did cheat on that test. I know I did, right? I know it's, I know it's wrong, I made that choice. But then the rumination might be about, well, if I cheated on that test, and then if I, you know, if I didn't get that actual grade, gosh, maybe I wouldn't have gotten into the college that I got into. And gosh, if I didn't get into that college, maybe I wouldn't have gotten that career that I now have. So, you know, the long-term impacts of that, you know, can just go and go and go. So that compulsion might be, well, you know, I got, I have to go back and, you know, see if I can find that same test. Like, if I could prove to myself that I did know all the information on that test without cheating, well, I can feel better that, you know, getting into that college was justified. Or maybe I can go back to find my teacher and just confess to them and say, hey, I cheated on that test, for them to say, you know, that's okay, you're absolved of this guilt and you can move on with your life. So I hope that answers your question, or perhaps it makes it a little bit more muddled. Yeah. And I think it's like, what is normal guilt regret, you know, versus what is real event OCD? Because I think there are people who do things that are wrong and they come to my practice and they grow, you know, a new set of values or they understand like, oh, I did that thing and that didn't feel good. And then it's like, okay, I have a value here that I didn't even know existed maybe. And then that leads to more thriving in the future. So that's different than necessarily what we're talking about here. And I think it's important to kind of differentiate the two. Right, right. I wonder for what you're kind of talking about. Yeah, I can see some of these folks as well, where they, you know, they see that they might be, you know, hung up on something or feel guilty about making a mistake in the past. The difference is going to be with OCD is that there is this, it's persistent in the sense of guilt, it kind of doesn't let them off the hook a lot of times, right? There can be a sense of, you know, generally speaking, you know, when we see that we've made a mistake, we acknowledge it, we take ownership of it, we try to take some measures to apologize or make atonement for whatever those mistakes are, try to learn from it and then commit to not doing that or doing something different in the future, right? You know, someone with real event OCD, they're going to go through that process, right? But once they get to the end, their brain says, well, you know, but what if it's worse than you actually imagined, right? So then they go back to the beginning of it and then ruminate about it again and so on, right? Or it's, they've done the process, but that feeling just persists. So now the battle is, well, what do I have to do to get rid of this feeling and get to a sense of confidence and certainty again? Certainty. Yeah. OCD, one of the things I took away from the Penzell work, you know, episodes, Penzell, if you haven't listened to those on OCD, he's a leader in the field. I think you respect him quite a bit too, right? And so he talked about how OCD is the doubting disease. So the doubting does not stop. And I've seen these patients, they'll spend four to six hours a day. They'll spend every waking moment going back. Absolutely. And that's a huge difference. Like if you have a patient or if you yourself are listening to this and you're spending four to six hours in regret, going back in time with a component of doubt, with a component of uncertainty, seeking for certainty, you may have real event OCD. Now how many of your patients with it have other types of OCD as well, or do you see people with just isolated real event? Both, both. So we kind of expect, and OCD is kind of tricky in this way, is that, you know, it finds its way into a lot of other areas of life and the real event kind of element of this, remember as we talked about, you know, real event is not its own diagnosis, right? It's just OCD. And OCD, as you mentioned from your Penzell episode, it's the doubting disease, right? So there's going to be this, this kind of sense of doubt, the sense of lack of, of trust in oneself, lack of abilities to be able to have that sense of confidence and assurance with, with oneself in these various areas. So you can kind of see a sense of real event OCD showing up in other quote subtypes as well, right? So you know, you, so to that end, yeah, oftentimes there's going to be other subtypes, but it doesn't mean that, you know, if someone has five subtypes or they just are experiencing real event as an isolated obsession that, you know, that person is more broken or sicker or whatever verbiage they might want to use on themselves. What it means is that they have OCD and they are in this pattern of questioning doubt reassurance. And what that reassurance does is it goes back and reinforces the idea that I can't trust myself, I did something wrong and bad. And the way to alleviate that bad feeling is by going through this ruminative or reassurance or avoidance or ritual cycle. Yeah. And so reassurance, I think that's an important thing to mention or emphasize. They could ask for reassurance from other people too. So you may not be the one with real event OCD, you may have a loved one who continually seeks reassurance. And is giving reassurance the best way to help them? Generally speaking, no. It's kind of a, reassurance is kind of a four letter word around OCD land, as it were. That's a very counterintuitive thing. And I think this is why, like, I usually, I'm more psychodynamically oriented, I'm more transference focused, I'm more like logotherapy, existential type stuff. But for OCD, it's like, I refer these to my OCD experts. Because if I, you know, and I've tried working with some of these people, and it's like, if I'm just using empathy, trying to find the deeper meanings of things, it just, they still are obsessing four to six hours a day. Exactly. And, you know, it's, it's, it is, it's counterintuitive, because we as emotional, caring, loving people, you know, we see someone who's in pain, who's obviously struggling with something, we want to do anything that we can to make them feel better, right? And it feels like the right thing to do is to say, you know, like, nothing happened, you're fine, right? You're going to be okay, like, we, like, we can just get over this, like, you're, you're a great guy, you're awesome, you're like, whatever the verbiage is, right? And, you know, as you said, like, somebody with real event or, you know, another subtype of OCD, they may be spending four or five plus hours a day ruminating about something. And so sometimes they'll come to therapy. And if someone isn't really attuned to some of these eccentricities, and the uniqueness of cognitive behavioral therapy and exposure and response prevention, they're ultimately now just going to have another hour of ruminating and trying to go deeper and deeper and deeper, which is what they've been doing on their free time already. Really what we're trying to get at here is this disconnection from that pattern. And so breaking the cycle of compulsion, to then get to a place where we can learn to sit with the feeling of discomfort, of uncertainty, and not to get rid of it, but instead, to get to, in a sense, get used to the fact that it's there. And you know, in this, in the process of doing that, what we often find is the subjective discomfort of that does start to come down, but ultimately, through the process of increasing our willingness to simply have discomfort and uncertainty about things that sometimes we're never going to be able to actually get the answer of anyways. Yeah. Okay, so let's rewind a little bit. Let's rewind. Okay. So I think, I think we just got to be, give some examples. Maybe you can give some examples. I think a lot of these things have to do around taboos. So in my experience, it could be months before my patient even tells me what's really going on in terms of the events they're going back to, the things that they're concerned about. How often do you see that? How often do they tell you right off the bat versus they hold it in? What kind of things are we talking about? Yeah, that's a good question. And I also want to back up a little bit too, and I do want to answer this question. When we're talking about the reassurances that we do, it is important for us, and as a therapist, when someone comes in, I'm not jumping to, you know, hardcore exposure day one. There is, there are some things that we can do, and I think we'll get to this part about how you can support your loved one without giving inappropriate and unhealthy reassurances. Because you can give encouragements and assurances that aren't speaking to the feared narrative, right? So, I think that's an important acknowledgment. We're not just saying, don't say anything or don't support that person at all. I think there is a way to be encouraging and supportive without feeding into that compulsive cycle. But I, now that I sidetracked myself... Okay, let me go with your sidetrack. I love it. Okay. So, like, okay, so what is assurance versus what is reassuring? Yeah. Which is part of the compulsion. Yes, yeah. So when you're, you know, in relationship with someone, right, outside of therapy, right? You'll see, you'll see your, you know, your family member, your friend, and they're coming up to you and trying to seek, quote, reassurance, what we'd be calling it, right? And that reassurance can take many, many different forms. But a lot of times it's speaking to that feeling of, you know, goodness or badness, or is the relationship okay, or did I do something wrong and bad, right? So their question might be about, you know, hey, did I, did I say something yesterday that offended you, right? Well, they're going to come up and say, like, they might not come out and directly say, like, hey, did I say something bad yesterday? But what they might do is, you know, they'll, they'll say, like, you know, they'll just come up and say, like, hey, how are you doing today? And then really spending a lot of time gauging whether or not that person is, like, upset with them or angry at them and, or, or say, like, hey, you know, or, like, hey, are we good or something like that? Just a simple way to try to get them to say, yes, we're okay. And they extract from that, that, that they're, that they're fine, their relationship's fine, they didn't do anything bad, right? When we're talking about, when we're talking about assurances, or we're talking about the, catching this, catching those subtle compulsions, we're trying to pull back on anything that's going to, anything that's going to address that what if, that feared narrative in an inappropriate way, right? And we're not trying to take away that feeling or justify or glorify, in a sense, that, that doubtful thought. So what that might look like is, instead of talking to the feared story, that narrative, maybe we want to speak more to the feeling itself, right? So we can acknowledge and we can acknowledge that, hey, that person's in pain, right? So you know, the, the line that I often give to family members and friends in this situation is, if they, you know, family members coming up and, and doing something to try to seek reassurance, we kind of catch you, like, let's say, you know, you were coming up to me and said, hey, we, you know, you're trying to get some type of reassurance, I'd say, you know what, look, it looks, it sounds like you're trying to get a little bit of reassurance right now. I love you and I support you, but I'm not going to answer that question. Or you can, and it's, it's hard because we could easily say something that would take that away. You can also say like, hey, it sounds like you're, you know, it sounds like you're really anxious, but it also sounds like you're trying to get some reassurance, it sounds like you're trying to get compulsion, right? You can say that's really hard, it sounds like that's really scary, it sounds like that's really uncomfortable, right? But we're not saying anything about the content of the narrative, the content of the obsession. Yeah. So that'd be a kind of a broad difference between assurance and support and the reassurance that would be feeding into the obsession. And different therapists are going to call it different things, but generally reassurance is kind of the, you know, general title that we would give them. Okay. And then so we're going into, I think, I think just to give people an understanding of what are some of the common real event OCD types of obsessions. Yeah, yeah. So not as a exhaustive list, because I know that, you know, we're going to go through and kind of name some things, but they'll be like, you know, someone out there is going to say, well, he didn't mention mine, it's not what I have, maybe I don't, it's, again, it's going back into this is all OCD. But you know. So you could see how someone would be obsessive about not being on your list, right? Absolutely. Yeah. And if you are, and you're listening to this, you should probably reach out to Kevin Foss to give you some reassurance that you are indeed on his list. And I'm, I will provide all the reassurance that you want. You can't see me shake my head. And he'll start to help you. Okay, let's, let's, let's go. Okay. So, you know, some of the, you know, some things that, you know, people can experience, you know, it might be like, you know, they, they looked at, or they maybe have talked to somebody who, you know, who's not their partner. And then they might go into their head about like, did I, like, did I flirt with that person, right? Was I on the road towards cheating on that person, right? Or cheating on my partner, right? Or I did, or therefore, I think I did cheat on my partner. I did. Yeah. Because of that, because of that, that, that was infidelity, right? So now they're going, they might go through an atonement process with their partner and just apologize. And, you know, you can see how this would go, right? If they're convinced, right, OCD is saying, well, you cheated on your partner. And they go up to their partner and they say, hey, honey, I, you know, looked at that person at the supermarket. I'm, I'm so sorry. I, I, I, I really hurt you. And they, the partner might say, I'm really hurt. Well, they might say I'm really hurt, but they might also go, you looked at a person. Oh, okay. Like, that's, that's fine. You looked at it. Like, did you, you know, did you have sex with that person? Did you kiss that person? Did you, you know, grab them inappropriately? No, I didn't do any of that stuff. So you, you just looked at them, but remember the guilt and the individual is overwhelming. The guilt is, yeah, it would be absolutely overwhelming. Absolutely. So even when the partner, again, reassurance, it's fine. I'm fine. We're good. No problem. You would think that would clarify some things, but that doesn't. some things, but that doesn't speak to this feeling because now the individual might go in and say, well, maybe I didn't, maybe I didn't explain it clearly enough, right? Maybe I, maybe, maybe I did do something more, right? Let me, let me now go back into my memory and see if I, you know, see if I, you know, did something more than just say hi or just look at this, you know, maybe I should go to the supermarket and get their security camera footage just so I can verify that I didn't do anything, right? So you can see where the snowball is, where the reassurance doesn't happen, or the reassurance, excuse me, the reassurance doesn't ultimately help from the partner. We now need to help this person sit with that discomfort. I mean, we can keep going with this or go through other examples. I think we should just stay with this one. So I'll be, how about I be the patient and you be the, the OCD expert. Okay. Okay. Yeah, so I, um, maybe not, maybe not. This would be bad. Like, what if my wife listens to this and then what if she hears it, only a clip of it, right? And that could be like really bad. Are you worried that she's going to take that line out of context and where you're going to have said, I cheated on my wife or I cheated on you and she's going to hear that? What if she did? Right? I don't know if anyone's sent her that. Okay. Okay. I'm not in person right now. I'm coming out of like the role play. All right. Oh boy. I'll tell you the, the conversations and the things that I have Googled and the stuff that I have said as an OCD therapist, uh, and then the stuff that I share with my wife is, it's, it is wild. So the, you know, it's, I kind of say with, with OCD, you know, anxiety will latch itself onto anything that we can imagine, but we as humans can imagine quite a bit, right? I'm, I'm lucky that my, my wife is also a therapist. She's a psychologist. So, you know, she, she gets the process. So okay. With this type of person, cause I've seen this type of thing before. Um, I also think they could go back to confessing, you know, so if they're Catholic, I'm not Catholic, but if they were, they could go to their priest, um, multiple times, you know, to try to confess the same thing. I think historically, when I, when I read about scrupulosity, the, the tales are like the Catholic priest will eventually say, you're not allowed to confess anything twice, you know, because they're getting barraged by constant confessing. Um, Sorry to cut you off. That's, that's a really good example of how these, you know, the, these subtypes names start to fall apart because in that, you know, it can certainly be seen as real event, but it can certainly be seen as religious scrupulosity, right? And the, the answer is yes, it's both, right? Somebody may have, may have committed a sin, right? What would be a sin in the, in the Catholic church. So rightly so, they'd be going to their, going to their confessor, confessing, and then doing whatever the priest says, right? But OCD won't let them off the hook just because they did it that one time, right? So they're going to want to go in. Interestingly enough, religious scrupulosity is one of the first places where OCD was seen because priests would see somebody coming in and confessing the same thing or confessing things that they might have done, but they didn't actually do. Yeah, and, and, and like, I could see them, they've, they've told me that, you know, citing verses like, if you look upon a woman with lust, you commit adultery. So it's like, it's like I committed adultery and it's like, they, but the weight of it is, is that intense guilt to the level as if they did, you know, have the affair. Right. Yeah. Exactly. But again, we're, we're, we're noticing the difference between, you know, the feelings and the reality, right? The feelings in this don't match up to what actually happened or would be typically justified by the, the infraction, right? Whatever the thing is that was done, right? That anxiety felt so much more intensely and it felt so much more real. Now the, the person with OCD, I kind of say like they, you know, they, they have these, they're of two minds, right? They have their logical, reasonable, rational side, and they have their, you know, anxious side, right? The, the, they have the experience both. There's a, there's the insensitive OCD joke, it was like this, what's the difference between someone with OCD and someone who's crazy? The person with OCD knows they're crazy. Again, I know it thrown around that word, but it's some, these are the words that we use about ourselves sometimes, right? There's insight into, into the reality of the situation. I know because I've treated very, very complex cases of OCD with schizophrenia, right? And sometimes you're, I'm scratching my head. Am I treating the OCD right now? Or am I treating the schizophrenia? And in treatment-resistant schizophrenia, it's even more complicated because then they're on clozapine, and is the clozapine causing the OCD? Yeah. And then, or if, is it, if the clozapine's too high, they're more obsessive, if the clozapine's too low, they're more psychotic. And so it's kind of like you're, you're, you're kind of in this very difficult balancing act. Right, right. Yeah. Yeah. And I'm obsessing about that four to six hours a day now, I'm sure. I mean, luckily I'm not obsessing four to six hours a day, but it does tie my brain in knots. Yeah. Yeah, it absolutely can. And it's, it's, you know, getting back to, you know, real event, it can be, it's, it's hard because, you know, somebody is, you know, raking themselves over the coals to try to ultimately do the right thing, right? And it, it illustrates that they, you know, they're, they are good, they're good people. And they, you know, with real event oftentimes, or sometimes I'll say, you know, they might, they made a mistake, they did something they didn't like, they didn't, they did something they didn't want to do, or their values changed and they reflect, they reflect on a time when they did something that, you know, was with it, perhaps within their values then, but is now not, and they, they want to make it right. But in order to, in order to do that, they, they just become overwhelmed with the sense that they are this terrible person, and they're just overwhelmed by the sense of guilt and the shame related to whatever that thing is. So that compulsive cycle, it being so hard to get through and so hard to fight against, it just feels like it's persisting. Yeah. Okay. So other examples, just kind of making this more alive to like, give examples, I think helps, helps people kind of root this in. Totally. All right. So, I mean, you know, another example could be like, you know, somebody may, may have made like an offhanded joke years ago, or, you know, put up a tweet, you know, years ago that, you know, maybe the culture has changed and now that joke is inappropriate. Right. And now they're, not only have they deleted it, but they also fear that someone took a screenshot before they deleted it. Yeah. Or maybe just, yeah, maybe somebody just remembered it. Right. And there's no way you can go back and do that. You can go back and find historical, you know, snapshots in time of what the internet looks like. So maybe it exists there. That's very scary. And so maybe that tweet is going to resurface. Their boss is going to find it. Their spouse is going to find it. It's going to be released on the news, right? Hey, you know, you know, Dr. Puder said this thing a couple of years ago, boy, how terrible is he? Right? So it can be this fear of... And then everything falls apart. And then everything falls apart. Everything falls apart. I'm going to lose everything. Yep. Yep. Probably. I've had that. Yeah. Not with the tweet, but, you know, it's like, I've had that feeling, I think. How do I, how do we differentiate someone like myself who has had that feeling, right, of concern to someone who maybe ruminates about it endlessly and needs like exposure response prevention to really overcome it? Right. Right. Yeah. How do you differentiate that? I think it depends on the severity and, you know, as we say in the DSM, right, it causes marked distress. It's getting to that point where it's causing significant impacts on your emotional well-being. It's impacting your relationships. It's impacting your ability to function in your day-to-day requirements and, you know, just your life. Right. And it significantly is, it's significantly different than, you know, the kind of typical guilt that we all experience, you know, having lived life, we are all going to do and say things that we maybe later regret, or, you know, sometimes immediately regret, but, you know, we are going to do and say things and make mistakes, right, but while the rest of us in a typical way, we'd feel that, we might feel that sense of guilt, that heaviness, and we do our best to apologize or to try to make it right, you know, we can kind of get on with our day without it being, you know, wildly impactful on our day-to-day, whereas for someone where else it, you know, graduates into this sense of, you know, diagnostically OCD, right, now, you know, fits within that category, you know, this person is now ruminating about this, you know, for an extended period of time, it's causing them extreme or significant emotional distress. They may be avoiding people, places, other responsibilities that they have or to, in service of this feeling, in service of this thought, in the sense of guilt, right? Okay, but then how, because I'm thinking of like PTSD, like a trauma, like a trauma-like experience could result in rumination, going back to it, nightmares, flashbacks, how is that different than this or, yeah, how do you differentiate, like when you're talking to someone, when do you lean more towards like, okay, you had a traumatic experience versus, oh, this kind of seems more like real event OCD? Yeah, no, that's a really good question and there's going to be a lot of, there's a lot of overlap between those and, you know, we kind of, you know, I think one of the biggest questions we're going to ask is like, where's the anxiety and like, what's the anxiety story? What's the compulsive response to it, right? Now, also, I think it's fair to say that OCD treatment and PTSD treatment is kind of going to be a little similar. There's going to be exposure and response prevention involved with both, right? There's going to be an acknowledgement of, you know, for PTSD, acknowledgement of the trauma, kind of processing through what, you know, the significance of that for that person and then also progressively being able to have that thought, have that feeling or experience that, you know, elements of that event and try to work towards kind of tolerating that feeling or being in that if they're willing, if they're interested in wanting to have those things back in their life, right? I think, you know, I'm thinking about someone who's like, you know, a veteran who struggles with fireworks, right? So, you know, they might be practicing exposure and response prevention to loud and sudden sounds. That does mimic a lot of what we might be doing with OCD. So you know, I'd say there's going to be a lot of overlap between those two. Okay. That's good. Yeah. I think of trauma as like, often in the midst of a traumatic scenario, there was an element of dissociation or like this profound near-death experience, whereas a real event OCD, it could be just things that almost like a moral injury, no, not moral, but see, moral injury is, I would put it in a separate category as well. I don't know if you've thought about like moral injury, I had an episode on that with a vet talking about like, when people go through things that really push them past what they want to do morally, like sometimes then they kind of have this different type of trauma that occurs to them, like a moral injury trauma. Yeah. Do you think in categories of moral injury as well, and differentiate that from real event OCD? When I think real event OCD, I'm thinking doubting, and I'm thinking going back to the event to try to make sense of it in kind of a more compulsive way, and all the compulsions that follow. And the person is more of an OCD type of person, like they're more, they may have had other obsessions throughout and compulsions throughout their life as well. Yeah. Yeah, exactly. Yeah. They're oftentimes going to have other elements as we talked about. I think you pointed out something really important to this, is that there's going to be more of an emphasis on the impact of that event on other areas of their life, and it's going to kind of be, it can kind of go into this extreme sort of bizarre story, right? Like what's going to be the impact of this one event, right? Going back to like, you know, did I cheat on that test, right? They recognize that they did cheat on that test, but it's now what is the long-term impact of that, and how do they stop that thing from happening, or how do they ultimately just feel better from it, even if it's a temporary better, right? Temporary relief. So that might be one of those diagnostic differences. And so for the examples that you've given, like going to the supermarket to check the video footage, for something like that, does the person, because I could also see that kind of a little bit psychotic, right? Like does the person, if it was psychotic, the person would be doing it in a sense of there would be no insight that what they're doing is anything like a compulsion. Right, right, right. And that's kind of that, you know, the fixity of beliefs, right? How certain are they in their thought, where it then kind of graduates into a delusion, versus do they have that kind of mixed insight, where they have that, you remember that logical part of their brain and their fear-irrational part of their brain, right? How much, like which side is getting the microphone in their life, right? And is there, you know, if there is too much, or there's a significant lack of insight, that's going to be a slightly different approach, right? It's going to be, if someone does have a little bit of insight and can kind of experiment with and play with that idea that, you know, maybe the thought that they have is overblown, is irrational, you know, doesn't make sense, and yet that anxiety is still speaking really loudly that it is vital and important and true, you know, then that's where you can kind of put a wedge in between those two and try to pull the microphone away from that illogical side of their brain and have that rational side speak, even if it's a quiet little voice, but that can help to break down the, you know, the importance of that story, the rationale of that story, so that perhaps they can practice exposure and response prevention and it gives them permission to then say, maybe the story isn't correct. So if it's incorrect, if it's inaccurate, well, maybe I don't need to do anything about it, maybe I don't need to go look into it or keep apologizing for it. All right, so let's talk a little bit about exposure response prevention. What are some of the go-to things that you usually start someone with? Yeah, yeah, so exposure and response prevention is going to be part of the gold standard of treatment. It's going to be the main thing that OCD therapists are going to want to do. What we're doing with that is we're progressively getting closer and closer to whatever the fear is while resisting anything that would undo, neutralize, or help to avoid that feeling, that bad feeling, right? So, you know, when we're working with someone, we're going to first start by building a hierarchy of all the things that that trigger their anxiety, right? Situations, places, people, ideas, activities that, you know, tap into that sense of anxiety. And then we're going to rank that from easiest to hardest. And generally speaking, we'd start with the easiest stuff and start, you know, start exposing them to that and then working their way up. A really basic idea of exposure and response prevention, you know, I think about like, like maybe a fear of spiders, right? It's like if someone has a fear of spiders, we'd, we wouldn't start by getting a tarantula and putting it on their face, right? You would never do that to me, by the way. Challenge accepted. If, but so we'd start, like we might just start with writing the word spider, right? We might just write, we might start with just writing the letter S if that is going to be kind of activating. And then again, it's exposure and the other part response prevention. The response in this is the compulsion. It's the avoidance. It's the neutralizing behavior. So, you know, we'd write S and then we, we wouldn't get rid of it, look away from it. We wouldn't try to think about something peaceful and safe. We wouldn't think about squishing a spider. We'd sit with the thought and the feeling, right? Do you ever think about having a reality TV show and doing this? They did. They did. It was, it was called Obsessed. It's called Obsessed. Oh man, I just don't watch any TV anymore. Yeah. But interestingly, my, my old supervisor was, yeah, it was one of the therapists and they, they did exactly this. So they helped someone in the show, you know, walked them through their process of, you know, through exposure and response prevention. It's, it's. So let's talk about plane flights, fear of plane flights. Let's do that. So what's the, let's say they, they've tried VR, they've tried, specifically the turbulence is what gets them. Okay. And the fear of death and going to hell. Sure. Okay. Makes sense. So what would you start? All right. So with, so for anybody out there who's interested, who has a fear of flying, there's a program called SOAR, S-A, wait, S-O-A-R. That is, it's a great program specifically designed for fear of flights. But for someone who, you know, may not have access to that, again, we're, we're going to, if we're just in the response, exposure and response prevention phase of treatment, you know, we're going to look at, we're going to make that hierarchy of like, what is it about flights that trigger their anxiety, right? Different elements of it, right? So it might be, you know, they, they were going to put down on that list, all right, the turbulence, right? They're going to put down, they're going to put down the thought of dying and, and going to hell, right? Which is his own whole can of worms, right? They're going to put down all the sounds that they might hear, right? So they're going to put down this whole list and then we're going to put it in order. And then we're going to start with the easiest stuff and then start, start exposing. So like some step in that would, would likely be, you know, just watching videos of, of flights. It really, this would be a relatively easy exposure, right? So we're going to pull up videos on YouTube of airplanes taken off and landing. Totally fine. But in that it's going to be likely triggering some, you know, emotional anxiety response. And then we're going to turn our attention towards that, make space for it, notice where it is in one's body and resisting the urge to try to look away from it, to neutralize the feeling. And what we find, what we've learned is that, that the subjective discomfort of that will slowly start to come down. Now, do you do like a, with behavioral therapy, my understanding is it's kind of like before you do the experience, it's like, okay, this is what I think is going to happen. Maybe you write that down and then you do the experience and this is what actually happened. And then the discrepancy between them. Do you ever do that sort of thing where you get them to look at the discrepancy before, before the behavior? before the behavior, after the behavior? Yeah, there's an approach called the inhibitory learning model, and it includes that as well, where you anticipate what an exposure you're gonna be in. You think about what you're likely to feel, what you're gonna want to do, and you also identify what compulsions you're gonna be avoiding doing. And then you do the exposure, right? And in that model, you're gonna look at, you're gonna kind of look at two things. One is gonna be, you know, what was the actual outcome of that exposure? And then through that, as you kind of mentioned, it's, you know, how does that differ from what the feared expectation was? What was surprising about it? What stuck out? What was different? And then you build on, you know, what can you do differently next time? How can you kind of amp that up or take one step further? The other avenue of that is looking at how, like, were you able to handle the anxiety, just the discomfort in that process, right? Not did the anxiety come down, but were you able to sit with that discomfort for longer than you imagined it? Sometimes it's, you know, I can't be in a room with a spider for, you know, more than a minute. So we go, let's try a minute and 10 seconds. And what that does is at the end of it, they go, I didn't, like, I thought I was gonna run out of that room at a minute, but I was in there for a minute and 10. That's amazing, right? Nothing bad happened. It didn't kill you. It didn't bite your eyeballs out, whatever the fear is. Great, but next time, well, let's try a minute and 20. Right? So you're extending that out. What's that? Let's not do that. Really? Okay. No, I'm joking. I'm joking. No, let's talk about the real event OCD though, because I think it's like, like, so we have the idea of the basic, like, we're progressively going through more and more distressing, higher levels of anxiety things. So with real event, like, what is the list? Is it things that actually happened that we're writing in the list? And you're writing, like, a hierarchy of the most distressing and least distressing, or? Yeah, yeah, that's a great question. So, you know, let's go with, I mean, let's go with the cheating example. Sorry, the cheating on the test example, right? If you want, we can go with the cheating on the supermarket example too. But let's say, like, let's say it's the school, right? So it might be, you know, you could think about somebody might be, you know, anxious or be triggered by things that remind them of that time. It can be things that, you know, locations, it could be the high school, it could be the name of the teacher. It could be the test that, the kind of test that they were taking, right? It could be, you know, almost anything with that. And then, you know, if it's, let's say it's just the idea of their high school is kind of activating, because it kind of brings up, you know, this whole story. So we might start by looking at pictures of it online, right? We might move to, you know, drawing pictures of it. We might move to, I like to do what I call environmental exposures, which is make it so that it's impossible to get away from whatever your fear is. So we're gonna print out pictures of their high school and put it all over their room. It's gonna be the home screen on their phone or the background of their computer. So they're gonna constantly see it. Okay, so if it was this fear of this girl that you met in the supermarket, who was very attractive, you would recommend printing out pictures of her and putting her all around the house? Possibly, yeah. That may be one of the things, if it's seeing this person or it may be seeing someone like this person, right? You might do that, right? Now, that does get into, you know, an ethical question, which we can also talk about with that. But yeah, it might be the supermarket. It might be, we're gonna go to the supermarket every day, right? Being in that supermarket's gonna bring up all that sense of anxiety and guilt and all that stuff. Great, so we're gonna allow that feeling to be there. Say, you know, this is my alarm system going off and it's too sensitive in this place. So I'm gonna lock up. How do you differentiate like being a stalker, you know? Yeah. And printing out pictures of this girl that you got off the video thing and going back to the place where you met her to try to interact with her potentially again as a behavioral experiment. I mean, it's- To being like, you know, not a stalker. Yeah, yeah, I'm not here to advise stalking. So no one get any ideas, y'all. But, you know, that is where, you know, some of the ethical questions come in when it comes to exposures, right? Are we doing things that are, you know, violating someone's rights, violating somebody's autonomy? Are we taking advantage of somebody? Or is the exposure that we're doing hurting somebody anyway? And, you know, we're not gonna, I'm not here for that, right? There are wild stories out there that you might hear horror stories of exposure and response prevention. But, you know, if it's the idea of a certain person- Yeah, and I'm just being, I'm being playful, but I think I'm just- I hear you, and these are conversations that are never ending in the OCD community of how far do you go in exposures? I mean, two great examples of this. So I know you're being playful, but, you know, for anybody out there who's hearing this, who goes, man, I read, you know, I looked on Reddit and people were describing their exposures, and that's crazy, I'm never gonna do that. Like examples are, you know, eating Skittles off toilet seats. Okay, that's not too weird. That's not too weird for you. This is what Dr. Puder is doing in his free time. No, not doing that. Okay, so that's something that somebody might read and go, like, that's, I'm not doing that, right? But the question is, is it necessary, right? Is it required to get success and treatment and freedom from OCD? Is that required? Now, another example for religious scrupulosity, I love talking about religious scrupulosity, is that, you know, I've heard examples of people, therapists advising clients tear pages out of their Bibles, right, of their fear of blaspheming or offending God. Now, as, I don't think, or no, I don't think, I confidently would never advise somebody do that in any faith for any, you know, for any reason. I think that, I think that would be a disrespectful move, and I think it's, I don't think it's necessary for exposures, right? Or, you know, taking that Bible page and, you know, wiping your butt with it, right? You know, related stories like that. So there are things that, like, is it a good exposure? It's a great exposure, but I'll never suggest it, right? Well, it's, I think it's culturally insensitive to someone's values, and I think that's where it's, it takes some nuance, right? Like, if someone was having scrupulosity for us, but out of a spiritual background that I don't have, I'm not gonna try to violate their spirituality. I think you can work around it, right? If that's what you're saying. Yes, absolutely, and, you know, let's go with, you know, maybe somebody, you know, sinned or blasphemed or said something, you know, let's go back to that, like, tweet, right? They made an inappropriate, you know, joke about, you know, their religion when they weren't actively religious, and now they're more religious, so now that that tweet is, you know, a terror in their life, right? Well, you know, we do have to acknowledge that it was said, right? That we don't, but ultimately there's, we need to first start with cutting down on any of those compulsions that somebody might do to continuously apologize or continuously atone for whatever that thing is that they made a mistake for, right, but as an exposure, I'm not gonna then say, all right, as an exposure, all we're doing is active blasphemy, right? We're gonna live at the risk of blasphemy, which is what you and I do on a regular basis anyways, and everybody else does, so we're living life as an exposure, but the response prevention is resisting, scrutinizing oneself, like playing through their whole day. Did I blaspheme? Was this blasphemy? Did this qualify as that, right? So we're resisting those compulsions. So, okay, blasphemy, like give me an appropriate exposure. Let's say the patient says, you know, Kevin Foss, I fear that I may have blasphemed God, and therefore, I've done some unforgivable sin, and therefore, I'm going to hell. Okay, so depending on the place in therapy, like one thing we may do is a script or a cognitive exposure, so what that is, or it's imaginal exposure, excuse me. What that would be is we're gonna write out a story of somebody's worst fear actually happening and actually coming to fruition, and this is something that we use a lot in Real Event OCD to kind of play out this story, right? So we'd be writing a story about somebody blaspheming, you know, somebody blaspheming in one way or another, and then writing out what the consequences and the impact would be. So maybe it is, you know, they said or did something, and then they made God upset, and then they lived their life, and maybe they have, you know, subtly bad luck throughout their entire life, or, you know, up to their lightning bolted immediately, but maybe they die, and they go to hell, and, you know, God specifically says, hey, remember that thing that you did when you were 20? Yeah, it's because of this, right? So we play out that story, and we write that story out, and then we reread and reread and reread that story until the subjective anxiety of that starts to come down. Now, notice in this, we're not saying, you know, God provides forgiveness and recognizes that I make mistakes, and I repent for it, and everything's fine, and I avoid hell, right? That's not what you write out. You don't write that up. Correct, we are not writing that out in this exposure. We're writing out the worst-case scenario because it's gonna be activating, right? But we're also acknowledging it's a story, right? It's playing with that thought that's in your mind and activating that sense of anxiety. We're showing your brain, then, that you can have this thought. It's a thought about blaspheme. It's not writing a story riddled with blasphemy. It's saying, well, maybe I did, and then that is gonna likely trigger someone's anxiety. We sit with that feeling. We notice where it is in our body. We make space for it, and over time, our body starts to tolerate that story and kind of becomes bored with it. Yeah, okay, but what is the difference between that and someone just on their own going back through the story and seeking for certainty? Ah, right there. We're not seeking certainty in this story. We're not trying to get comfort. We're not trying to get confidence that we need to do anything about this. We're just simply saying, here's this story. Here is this stimulus that's going in my head that activates my sense of anxiety, right? Let's put it in a different way. What's your favorite food? Dark chocolate. In what form? 85% dark chocolate, single source, single origin. Bar? Bar, yeah. Okay. Oh, like with coffee would be the best, like a good Americano. Okay, so let's say you have, so I want you to just have that chocolate for every day, for every meal for a month. The first couple of days are gonna be awesome. By day 30, you're like, I just want anything other than my favorite thing. Right? Okay. We habituate, we tolerate, we habituate to the excitement of that. It's that in reverse, right? It's we're having this story, we're playing it out over and over and over again to the point where eventually our brain starts to become bored with it. And we can get used to almost anything, pretty much anything. You know what I think about, is I think about the men, and it's usually men that have this job that go down into like sewer systems in those suits. Yeah. You know, where like literally they can't see because they're surrounded by shit. And it's like, how do they do that? Because that is like, have you seen videos of guys that do that? And it's just like, what? Oh yeah, yeah. How is this guy even doing? He's going down there, he's got his wrench, he's gonna open up this thing, unclog this thing or something like that. Yeah. Oh my gosh. I mean, that's a fantastic example that we can get used to anything. Now, I bet he doesn't say, you know what I love doing? I love crawling down in the sewer and just being covered head to toe in poop. It's my favorite thing that I do. I love it. No, he would say, I love the paycheck that I get at the end of the day so I can go home and take care of my family with my paycheck. That's what he would say. He probably does, right? He probably would say, and by the way, what we're talking about here is actually there's a whole other avenue called the mastery model, which kind of describes this, is what we call kind of just gross OCD, where it's not like a feared story, just something just feels gross, right? That's a whole other conversation. But it's kind of this idea that like, we don't love it, but we do it. I mean, as a parent, you know, how many times did you get poop on your hands from your ridiculous pooping child? A lot. Countless. Countless, and at no point did you say, this is great, right? But we, and if before that, if someone said like, hey, by the way, you're gonna have a little human and they're gonna poop all over you, how do you feel about that? We'd probably go, I'm against it, not for it, right? But we get used to it, not because, but through the process of just showing up and doing what you value, you want to care after your child. You do your value. And in the process, you got used to the thing that's bad. I'm in LA, we have traffic all the time. I don't love it, but it's part of life. You get used to it, right? You're in Florida, how's the humidity? You know what I did to overcome this? I built a sauna. No, you didn't. And I use the sauna every morning. And so when I get in, when I get to my lunch break, I actually go outside at noon in Florida all year round now and I sit outside with my lunch and I eat in the heat and I love it. I totally changed my mindset, but it's that, I'll tell you what, the first 10 times I did the sauna was not fun, but my body is like adapted. Yeah, that's exactly it, right? So it's so interesting to find that we can get used to so much stuff. In the case of OCD, somebody's terrified of X, Y, or Z and they can get to that point where they kind of like the idea of something. That's gonna be terrifying to a lot of people. And the vast majority of folks who go through treatment, they don't end up loving the thing that they're deathly afraid of initially, but they get to a point where they go, it's just a thing. It's just a thought, a real event. The idea is we're trying to make space for and learn that we can sit with the uncomfortable emotions, the uncomfortable, that sense of uncertainty. And instead of engaging with that feared story or the shame, they can disconnect from that and re-engage with life as best they can in enacting their current and most important values in life. I know it's such a therapy thing to say, but it's kind of saying, I made this mistake, it's in my past, it sucks, I don't love it. And I'm gonna do my best right now to do something different, to be the person I would like to be and make space for the reality that we're gonna make mistakes again because we're human. And that's what we do. Okay, so here's a question for you. At what point do you say, okay, now I'm going to recommend this person get on medication? Like you're working with someone, how often, like what are the markers that you have that this person is going to need medication for a time? Or what are the, like if we're working together with a client, at what point do you say to me, like, hey, I think we can go down on the medication? Yeah, it's a good question, it's a good question. Well, so as I'm not a psychiatrist, I'm not gonna pretend, I refer out for that. Now, meaning I don't wanna say you need medication because I don't wanna make that call and say, hey, Kevin, that ridiculous person said I need medication. All right, so getting back to that. My markers for that are often gonna be, if we're in treatment and we're doing the process and we're working up the hierarchy or we're trying to make some headway and we just kind of hit this wall or it's, they have this overwhelming sense of unwillingness to continue pushing in the process and I've exhausted every tool and idea that I can think of, I might say, maybe you wanna consider medication for this because for some people, that can be the missing puzzle piece in treatment. Now, medication is, there are gonna be people who are on medication and still struggling in treatment, there are people who are not on medication and they're thriving and doing great, right? So I don't think it's a magic pill necessarily, but I also think it's one of the tools in our toolbox. So when someone gets to that point where it feels like we're just beating our head against the wall and not making a whole lot of progress, I might encourage them to go chat with their psychiatrist about medication. And then, so your other question is when they come down. So if they're on medication and we're doing treatment and they're doing really, really well, we're kind of getting to the tail end of their hierarchy, we might talk about pulling down on medication, right? So they can make a choice, right? It's up to them. If they wanna stay on medication because they say, gosh, my life is just more functional and better on medication. Yeah. Great. Live your dream. But if they say, my ultimate goal is to get off this medication, then under the guidance of their psychiatrist, they're gonna pull it down a little bit and we're gonna keep doing treatment. We're gonna keep doing exposures because that anxiety might now be a little bit higher, right? So we wanna continue reinforcing what they've been doing as they've been on medication and showing themselves, yes, I can have, I can still do this thing, though it might feel a little bit uncomfortable, I can still do it. And then it comes down, we still do exposures to the point where, the goal would be to be off medication, showing themselves that they can still engage their life, resist their compulsions, tolerate uncertainty without medication. That would be kind of the arc of that. Great. Okay, we're gonna wrap it up cause I'm gonna get to dinner here with my kids. Any kind of final thoughts, any things that you didn't say that you'd wanna say? Oh boy. I know we could have covered a lot more. We could probably keep going for another three hours. We probably could. I mean, I know we didn't talk a lot about kind of the process of shame and guilt. And we see a lot of that, shame being that bad feeling when we've done something bad, shame being that bad feeling when we are something bad. Guilt, I've done something bad, shame, I am bad. Is that how you see it? Yeah, it's like this core sense of self. For that, just very briefly, is I try to encourage folks to shift their shame language to guilt language, right? So their shame language is I'm ruined, I'm screwed, I'm bad, right? Instead, we wanna talk about guilt as, all right, I acknowledge that I didn't do something that's within my value system, I made a mistake, and I'm gonna own it, I'm gonna make atonement for it if possible, if reasonable. And then instead of beating myself up and continuing in this cycle of disengagement and shame and isolation, instead I'm gonna go pursue life and pursue life and try to make a different choice in a similar situation in the future. So I'd encourage folks out there, if they're experiencing real event OCD, boy, go chat with an OCD therapist, talk about what's been going on. And there's recovery to be found in this process and getting your head out of the past and starting to live your life in the present. Yeah, and I think my final word would be, if you have a patient that's not getting better, that's ruminating four to six hours a day, and you feel stuck, and you could be trying things that have worked for most of your clients, but unless you get some specialized training, exposure response prevention, send them to a specialist. You know, I think these are the clients that, if you decide not to treat these clients, that's fine. But learn how to refer, find someone in your area. I have a couple. I have Kevin, Foss is one of them. L.A. area? L.A. Orange County, yeah. L.A. Orange County, California. Where else do you have a license? Montana, and I can meet with folks online in Florida. Okay, and do you do any like coaching as well? Like if someone from another country was like a clinician and they wanted to learn more about this? Absolutely, yeah, I'm happy to do that. I also have a podcast where the focus of it is a question and answer based. It's question and answer based, so folks message me questions about OCD and anxiety disorders, and I yammer on about it for about a half an hour or so. Awesome, I would love to come on sometime. Absolutely, let's do it. Let's do it. All right, thank you so much. Have a great day and we'll leave it there for now. Thanks so much for having me on. ♪♪ ♪♪