Ep155 "Why Can’t Some People Stop Thinking Certain Thoughts?" with Jon Hershfield

Why do brains generate strange thoughts sometimes? And why do some brains refuse to let go of those thoughts? Today we'll talk about Obsessive Compulsive Disorder (OCD) with expert Jon Hershfield, getting a view from the inside and the outside. Why do some people lock the door but go back repeatedly to check it, and still have a feeling of uncertainty that it’s locked? Why do some people wash their hands over and over and never feel that they reach a point when it’s “done”. How, for some people, are intrusive thoughts like junkmail that the brain just cant help opening? We’ll see how obsessive thoughts can get caught in loops, and how those loops might therapeutically be broken.

Episode Transcript

Speaker 1 (00:00):
Why do brains generate weird thoughts sometimes, and why do
some brains refuse to let go of those thoughts but
ruminate on them. Today we're going to talk about obsessive
compulsive disorder OCD. Why do some people lock the door
but go back to check it over and over and
still have a feeling of uncertainty about whether it is locked.

(00:23):
Why do some people wash their hands over and over
and never feel that they reach a point when it's done.
What happens when doubt becomes a full time occupation. How
for some people are intrusive thoughts like junk mail that
the brain just can't help opening. Today we talk with

(00:43):
OCD expert John Hirshfield, where we'll get a view from
the inside and the outside. We'll see how obsessive thoughts
can get caught in loops and how those loops might
get broken. This is the fourth episode for Mental Health
Awareness Month, and you want to listen if you have OCD,
and even if you don't, because it's prevalent enough in

(01:05):
our society that you almost certainly have people in your
life who suffer from.

Speaker 2 (01:09):
These internal loops. Welcome to Inner Cosmos with me.

Speaker 1 (01:16):
David Eagleman I'm a neuroscientist at Stanford, and in these
episodes we sail deeply into our three pound universe to
understand why and how our lives look the way they do.

(01:42):
Let's start with Sigmund Freud's proposed concept of a death drive.
So he imagines you're standing at the edge of a
cliff and this intrusive thought that you keep having of
stepping off the cliff into the void. Now, that's part
of why it's scary to stand near the cli cliff's edge,
because you have zero desire to die, but you don't

(02:04):
totally trust your own brain because it keeps putting up
this thought about stepping off of it. So in nineteen
twenty Freud called this the death drive or sanatos. He
suggested that we have a drive for life, and there's
also this opposing force that pulls organisms towards stillness and dissolution. Now,

(02:24):
his explanation of that strange feeling of standing on the
cliff's edge it was quite controversial even in his time,
and I think nowadays we can take a different view
on this. As you hear me say often on this podcast,
the main job of the brain.

Speaker 2 (02:40):
Is to simulate possible futures.

Speaker 1 (02:43):
So, when you're standing on the cliff's edge, your brain
unconsciously thinks, what if I simulate moving around here? What
if I simulate stepping to the left? Okay, cool? What
if I go to the right, cool? Backwards?

Speaker 2 (02:57):
Cool? What if I were to step forward? Whoa oh.

Speaker 1 (03:01):
The salience of that simulation then bursts above the surface
of consciousness, and now you find yourself thinking about the
act of stepping forward.

Speaker 2 (03:10):
It's not because you're wishing for death.

Speaker 1 (03:12):
It's because the outcome of that particular simulation of stepping
forward shoots it to the top of your conscious awareness.
Now that's an example of what we call an intrusive thought.
You're standing on the cliff's edge, and now you can't
stop thinking about stepping forward. Now, sometimes you have intrusive
thoughts that are even stranger. Every brain on Earth generates

(03:36):
strange thoughts. Sometimes you're in an important meeting and you
imagine saying the worst possible thing, or you're holding a
baby and an image flashes into consciousness of you dropping
the baby. These are all equivalents to standing on the
cliff side. The brain spits up these random, awful thoughts

(03:56):
all the time, and it's just because it's general futures,
and the really salient ones will sometimes intrude, even though
you are not the kind of person who would jump
to your death off a cliff, or shout out a
cussword in a meeting, or drop the baby. Often a
thought comes up precisely because it's the worst possible choice

(04:19):
for you. Now, for most people, these thoughts come into
our consciousness and then evaporate quickly because you're not actually
going to do those things. The brain kicks these up
and then they get.

Speaker 2 (04:30):
Put out with the trash.

Speaker 1 (04:31):
But for some people, the thought sticks and the mind
suddenly treats it as meaningful because it's a dangerous thought
or it's morally urgent, and they think, what kind of
person would think that? Why did that thought appear? Could
I actually do it? And now the brain starts looking

(04:53):
for certainty and reassurance, and paradoxically, the harder the brain
searches for certainty, the less certain that it feels. This
is the first step of obsessive compulsive disorder or OCD.
From the outside, you might have a sense that OCD
is something like someone excessively washing their hands or being

(05:15):
super neat and organized but it involves this much deeper
issue about threat detection and uncertainty and the inability to
let a thought simply pass through consciousness. A thought gets
flagged with enormous emotional salience, and then the brain begins
constructing rituals around it, things like checking on something over

(05:38):
and over, or avoiding or seeking reassurance, or mentally reviewing,
or excessively googling about some possible illness that you're worried about,
or repeating actions over and over. All of this is
in an attempt to get certainty. But the certainty never
fully comes. As we'll see, the behaviors become a loop

(06:01):
and the brain gets trapped inside its own architecture of
reinforcement learning. Now, people with OCD generally know intellectually that
the loop doesn't really make sense. They know that the
probability of whatever they're worrying about is tiny. They know
that the ritual shouldn't matter, and they know that any

(06:23):
reassurance they get from the ritual isn't going to last.
But the emotional urgency overpowers the intellectual machinery. So that's
what we're going to learn about today. And our guest
has spent years helping people to try to untangle these loops.
John Hirschfield is a therapist specializing in obsessive compulsive disorder.

(06:45):
He's the director of the Center for OCD and Anxiety
at Shepherd Pratt and he's the author of several books
on the topic. And one of the things I appreciate
most about John's work is that he approaches OCD with
scientific clarity and compassion because he's been on both sides
of this.

Speaker 2 (07:04):
Here's John Hirschfield.

Speaker 1 (07:10):
So, John, let's start with what is an intrusive thought?

Speaker 3 (07:14):
So we have these objects, these mental objects that arise
in our consciousness, and they usually come in the form
of words, but sometimes they come in the form of images,
and we called a thought. And an intrusive thought is
one that is perceived as a rising in consciousness against
our will. We don't want it there. We immediately tag
it as problematic, it shouldn't be there, some sense of

(07:36):
it invading our space.

Speaker 2 (07:37):
What's then, example of a normal intrusive thought.

Speaker 3 (07:39):
You know, maybe I'm my way down here to the studio.
The car went over a stick or something, or a bump.
But how do I know as a bump? You know,
maybe I killed somebody and They're lying bleeding on the
side of the street, and I'm this like terrible human
being because I was like, well, I got to get
to this podcast. I can't be bothered with that, So
I might start feeling like I really need to like
investigate this and make sure that that's like something I

(08:02):
don't have to deal with. So another way to think
about it is it's sort of like the junk mail
of the brain, but it's very very good junk mail.
So when we have an email account, you expect to
get junk mail in your inbox is not surprising, but
some of it can be convincing enough that you accidentally
click on it and you know, like, oh, no, what
have I done. I've met a lot of intrusive thoughts
are like that. They're typically what we call ego dystonic,

(08:22):
meaning they don't line up with your sense of identity
or what you would expect your brain to provide you.
So they're sort of tagged with this like well what
is that doing there kind of feeling, and then that
generates a lot of distress that then starts the OCD cycle.

Speaker 1 (08:35):
Okay, so this is what I was going to ask you,
What is the difference between normal intrusive thoughts, which presumably
everyone has once well, and obsessive compulsive disorder.

Speaker 3 (08:45):
Right, So normal intrusive thoughts are not actually different from
intrusive thoughts in OCD, so much as the way people
with OCD tend to respond to them is they misappraise
them as urgent and there's this sense of moral urgency.
I have to fix it. It doesn't belong there in taminant.
You know, people think about their hands being contaminated, but
imagine your mind being contaminated by a dirty thought or

(09:06):
an immoral or violent thought or sexual thought. You're not
you think you're not supposed to have. So what happens
in folks with OCD is something is going wrong in
the part of the brain that is detecting error and
detecting whether or not error has been resolved, and it
puts all this pressure on the individuals say, I gotta
do something about this. I have to get certain that
this thought either you know, wasn't true or isn't true,

(09:27):
or isn't going to become true. And it's usually about
things that really matter to you. So like nobody wants
to be sick, or nobody wants their children to be unsafe.
So if you have a thought about either of those
things happening, it's normal to be like, huh, what's that.
Most people can be like, yeah, that's just my brain
being silly. Someone with OCD doesn't feel like they have
the moral authority to make that decision, so then they

(09:49):
start to engage in behaviors to try to get that certainty.
Andy call those behaviors compulsions, and.

Speaker 1 (09:53):
So give us some specific examples of the thoughts and
the behaviors that you see in your practice.

Speaker 3 (10:01):
Yeah, so common to OCD. The most common themes that
we see are contamination, concern with harm or injury or
bad luck, so called unacceptable or taboo thoughts, moral, religious,
sexual violence, those types of things, existential obsessions, and sort
of just write obsessions, you know, feeling like something isn't
lined up or organized the way that it's supposed to be.

(10:23):
And then common compulsions would be things like excessive washing, grooming, sanitizing, avoiding, reassurance, seeking, checking, repeating,
and then all sorts of mental rituals like trying to
figure it out, ruminating, whatever you can do in your
mind to sort of lock it down and say like, okay,
this is done. This is complete. I can walk away

(10:44):
from this now.

Speaker 1 (10:46):
And why is there such a mismatch? If somebody is
looking at that person, they think that's anterrational thought that
the person is having, But to them there's the moral urgency.
How does that mismatch happen?

Speaker 3 (10:58):
I'm not sure we really know. I mean, you look
at somebody, if you know somebody with OCD, you can
feel for them. But there's probably also a part of
you that's like, all right enough already, you know, like
why don't they just let it go? Because you're thinking
I would be able to let it go. But if
you felt the way that they felt, you wouldn't. You
would do whatever it took to try to get back
to that place of zero, of certainty, of balance.

Speaker 2 (11:19):
And is it about fear or uncertainty or other things?

Speaker 3 (11:24):
I think the predominant way of thinking about it is
that it is it's mostly about uncertainty or disgust. But
we used to always think of it as anxiety, and
then we stopped calling an anxiety disorder because people are
reporting all kinds of distress beyond anxiety, you know, abject terror,
And again, disgust is a very common one or sometimes
just a feeling of offness, like I know that I'm

(11:45):
not going to be the same person until I fix
this thing, until I go back and check one more time,
or get one more answer to this question that's already
been answered ten times. And so there's this like intense
internal turmoil. And what makes it kind of even more painful,
what increases the suffering for people is that from the
outside it looks like this is a person who has

(12:07):
no insight at all, Like can't they just see this
is not a big deal. But on the inside, the
inside is usually pretty high. Most people with OCD know
what they're doing and how they're thinking is not I
don't want to call it irrational, but it's not reasonable.
Part of what makes a compulsion of compulsion that it's
unrealistically tied to the problem as trying to solve it's
too much, it's too excessive, or it's too kind of

(12:29):
indirect in the way that it's going about it. And
so having insight to Okay, something's going wrong with my
brain but also feeling like you can't do anything about
it is a bit scarier than just sort of being
guided on a leash by your brain and be like, well,
we'll see what happens.

Speaker 2 (12:45):
So I want to set the table here. How common
is OCD in our population?

Speaker 3 (12:49):
Our best understanding so far as it affects about two
to three percent of the adult population and about one
percent of kids.

Speaker 1 (12:55):
So we all know somebody with OCD or more than
one person. Yeah, yeah, yeah, And so what age does
it typically start?

Speaker 3 (13:03):
So for childhood on set, which is very common. I mean,
most adults that you'll meet with OCD will tell you
they've had OCD since they were a kid, or at
least since they're an adolescent. For males, it's typically age
six to eight. And also that that's more likely to
coincide with tick disorders than you would see in females.

Speaker 1 (13:21):
Which I think disorders meaning like Tourette's and their movements.

Speaker 3 (13:26):
Yeah, for females it shows up closer to puberty, usually
age ten to twelve. But many people that don't. You know,
they might just start as being kind of perfectionist or
have some anxiety and then it kind of bubbles over
into OCD later in life in response to a stressor
sometimes in response to a trauma as a kind of
offshoot of PTSD. There's there's so much we know about

(13:46):
OCD because it's so common and it's been so well researched,
and there's so much we don't know about OCD.

Speaker 1 (13:51):
SOCD on a spectrum or is it Do you think
of it as a binary?

Speaker 3 (13:56):
That's also open for debate because the question is whether
or not you can cure thing. So it's an exaggeration
of a natural state of being. Like you said before,
we all have intrusive thoughts and sometimes we respond to
them and they're like, Okay, I'm being silly, and then
we stop. Sometimes they spire a lot of control, so
people without OCD might even have episodes of OCD. When

(14:16):
we measure these things, we usually measure them in terms
of mild, moderate, severe, or extreme. And then the question
is when someone goes through treatment and they're no longer extreme,
they're no longer severe, they're no longer moderate, and they're
just sort of mild and they're living unburdened by this condition,
then do they have it or do they not have it?
If you tested them and say, well, you know their

(14:37):
number of like how often they're thinking these things, or
how much they feel like I thy dow compulsions, or
how distressed they are, it's subclinical, so it's you know,
they don't need to go on meds, they don't need
to see a therapist. But then there's something about knowing
you have OCD that also protects you from having OCD symptoms.
Because you might be minding your own business, you get
an intrusive thought knocks you off your feet and like, oh,

(14:58):
I know what this is. This is my OCD. Okay,
I know what to do.

Speaker 1 (15:03):
Oh great, Okay, we're going to come back to that point.
But the first thing I want to ask you is
you are a therapist. You specialize as in OCD. But
that's not accidental. You found that you had OCD. Tell
us about that.

Speaker 3 (15:16):
Yeah, I guess I'm lucky in some regards. In many
regards that I alwaysknew ADOCD. It wasn't a huge secret.
And sometime around adolescence when I started complaining about it
that you know, various forms of IF X, y Z,
then something bad will happen. And this was on my
mind all the time, and I was made so unhappy
by it. And at the time, and this was the nineties,

(15:39):
it's like, oh, you have OCD. Well, here are the
medications for OCD, and you know there were things that
were helpful and things that weren't helpful, but nothing really
fundamentally changed the way I understood myself. So I kind
of adopted this sort of self stigma of I am
a crazy person with a crazy person problem. I have OCD.
It's genetic. There's nothing I could do about it. It
runs in the family. And it wasn't in some my

(16:00):
late twenties when I had an OCD episode that was
so bad that I started thinking, I cannot live this way.
I cannot picture the next several decades of my life
being characterized by waking up every morning and this being
the first thought in my head and this being the
first feeling that I have in my chest, my stomach.
I gotta do something about this. So I went into treatment.

(16:23):
And then it was hardcore cognitive avial therapy and exposure
and response prevention, the gold standard of OCD treatment. And wow,
it was hard. A lot of tears were involved, and
a lot of like a lot of homework, a lot
of you know, working with a therapist basically looking at
me like, listen, you gotta do something about this. This
is really bad. You've really bad OCD. In the process

(16:45):
of going through this hard work. I reached out to
the internet, and so you got to picture this. It's
like two thousand and five or so, and so reaching
out to the internet. There was no chat Gypt, you know,
there's nothing like that. It was actually Yahoo discussion board
of all things. Right, So I'm writing an email out
to the ether on some like OCD support group, and

(17:05):
you know, the moderator is an OCD expert and it's
got a couple thousand people in it, all with OCD.
And I'm reading all these stories and they're all different
from mine, but they're exactly the same, if you know
what I mean. Like it's different content, it's different, you know, demographics,
but it's like, yep, I think that way too. And
I was mostly just writing to blow off steam and
complain like this therapy is hard. My therapist thinks I

(17:28):
should be able to just tolerate this uncertainty.

Speaker 2 (17:30):
What does she know?

Speaker 3 (17:31):
Like, why shouldn't somebody have to tolerate this? It's terrible pain.
And people started writing to me and telling me their stories,
and I started giving them feedback based on what I
was learning in therapy, and then they started giving me
feedback like, oh, I hadn't thought of it that way
that's actually really helpful. I'm going to try to apply that.
So I became this, like, you know, a keyboard warrior
of fake therapists.

Speaker 2 (17:52):
Like.

Speaker 3 (17:54):
Like in front of my computer. I'm not ashamed of.
I mean for hours a day. I mean it was
kind of compulsive. I was like, I got to check
the discussion board, see how things are going. But I
built this alter ego of online therapist as a way
of processing what I was going through in therapy. And
then it sorted to occur to me not so bad
at this and actually like people seem to be like

(18:15):
resonating with it and it's helping me. And so now
fast forward several you know, you know, well over a
decade later, realizing that part of what has kept me
in the shape that I'm in mentally is that I'm
constantly teaching the thing that is that has been, you know,
haunting me. So I'm not haunted by it as much
anymore because I'm I'm constantly giving people information. I'm training

(18:40):
people to do the very things that also remind me
of like I need to remember I need to keep
doing these things.

Speaker 2 (18:45):
Oh wonderful.

Speaker 1 (18:46):
I want to hit one tangential point and then come
back to what you actually do in therapy. But the
tangential point is, I've been interested in across cultures O
c D. People have obsessions about different things, and you
mentioned on the Yahoo board people had all kinds of
different content to their obsessions, and yet it was you know,

(19:07):
you recognize the same thing. So what do you see
across cultures?

Speaker 3 (19:11):
All the research shows that the prevalence stays the same.
So different cultures have different relationships with seeking help, and
so you might see certain kind of more neurotic conditions
more prevalent in certain cultures, but that's not actually true.
It's just that they're more likely to ask for help
and more likely to talk about it people like me.

(19:31):
Other cultures might view some of these mental health challenges
in spiritual terms, religious terms or something like that, or
they might like.

Speaker 2 (19:39):
What like I'm going to go to hell? Oh right,
Oh sure.

Speaker 3 (19:42):
I've had people email me like, you know, not just
like that they have religious obsessions, but to try to
convince me that the intrusive thoughts are actually the voice
of a demon and that you should listen to it
because of your mortal soul, is you know, et cetera, et cetera.
So I think there's different ways of understanding how this works.
If you do the research and you just look at
you know, asking people the right question, you find that
two to three percent of the adult population across the

(20:04):
board have OCD. Now, the content might differ from person
to person, and also from culture to culture, and also
from period of time to period of time, so people
are more sensitive to kind of what's going on around them.
We think about what our ultimate fears are. It's usually
something like being alone and being rejected from the tribe.

(20:24):
So think about the things that happened in culture that
make us feel that way. In the nineties, in the
eighties and the nineties, there were a lot more people
with OCD around fear of contracting HIV than there are now.
People didn't know what it was. It was in the
news all the time, and can I get it from
a door knobs? You know, those types of OCD thoughts
were much more prevalent than they are now. And then
we went through the phase the me too, for example,

(20:46):
And then I was seeing in my practice there's a
lot more people coming to me saying, you know, I
woke up two in the morning and I had this
thought that when I kissed my girlfriend in college, you know,
maybe she didn't consent, and like, I don't remember, I
can remember her name. I went to look her up
on Facebook, and he did try to see if there
was any instead ruined for life and just going, you know,
down the rabbit hole, so taking like, you know, things
that are real and that are serious, but then having

(21:07):
the OCD sort of commandeer them and saying, you know,
this is your life now. You have to figure this
out now.

Speaker 1 (21:12):
And I assume in twenty twenty with COVID you must
have seen a flavor of that.

Speaker 3 (21:16):
COVID was interesting to watch from a therapist perspective because
first it was it was the first sort of major
trauma that I had to go through with everybody else, right,
So it wasn't like, oh, I'm sorry, this is happening
to you. It's like I'm also in the guest room
of my house, like trying to keep my practice together online,
you know, and worrying about the future and my kids

(21:36):
and the rest of it. But I found some of
my patients at the beginning anyway of the COVID epidemic
got better because they were like, Okay, this is bigger
than me, Like I'm if they didn't or if they
didn't have contamination ocity, they were you know, they were
obsessing with some other thing and then they're like, oh,
the world is ending, all right. Well then I guess
it doesn't really matter so much if I if I
figure out this one thought from seventeen years ago, or

(21:58):
what if I step on a crack or what cares?
And they got a little bit better, you know, briefly.
And if you if you talk to people with those city,
they'll they'll often report feeling calm in the states of crisis.
You know, calm is during turbulence on an airplane, because
they're just like, okay, now, uncertainty, it's not my problem.

Speaker 1 (22:17):
Wow, Because the other thing is breaking them out of
this loop, this ruminative loop that they're stuck in.

Speaker 3 (22:24):
It's breaking them out of the loop. And I think
it's also reframing the loop as like so personal and
not broader, like you know, like we're going to war
or something like that.

Speaker 2 (22:34):
Uh.

Speaker 3 (22:34):
That that said, I also saw a lot of patients
get demonstrably worse during COVID because you know, did I
wash my hand, not just did I wash my hands enough?
And am I going to get COVID but a lot
of moral obsessions. Did I accidentally move my mask a
little bit to the right when I went to scratch
an itch? And does that mean that I then expose
somebody else to something and I'm going to get them

(22:55):
sick and they're going to die of COVID. It's gonna
be my fault. And might now a murderer because I
wasn't vigilant enough to pay attention to when I touched
my mask. Would be an example of the kind of
thing I would hear.

Speaker 2 (23:04):
I was going to ask you about this.

Speaker 1 (23:05):
So with obsessive compulsive disorder, there are some people that
are pure oh, the obsessive part, So it's not you know,
we often think about OCD as washing hands obsessively or
checking a lock and thinking, hey, did I did I
actually lock the door and going back and checking and
so on, But one can be all the way on
the side of oh without the compulsions.

Speaker 2 (23:27):
Is that right?

Speaker 3 (23:28):
So it's sort of commonly understood that there are these
folks who, if you were, you know, filming them, you
wouldn't be able to tell they have OCD because they're
not doing the thing with the locks over and over
and they're not going up and down the stairs, and
then I not washing their hands all the time, but
they're doing something right. So actually it turns out that
the people we thought fell into this category. And it's
a little bit tricky because the Diagnostic and Statistical Manual

(23:50):
does say, you know, you have these different kinds of OCD,
and there's the O with the C, and then there's
the sea without the O, and they most people who
do what I do, I actually don't subscribe to that thing.
If you have an obsession. Essentially, what you're saying is
you have an unwanted intrusive thought, and you're responding to
it in a way that maintains it as an unwanted
intrusive thought. Like I said before about junk mail, we

(24:12):
usually ignore our junk mail. We know not to click
on it, open it, and certainly not to reply to it.
And so these unwhet intrusive thoughts, if they're persisting, it's
probably because you're responding to it in some behavioral way.
And so where things got a little bit confusing for
some folks was that people were responding with these sort
of mental behaviors. They might be let's say your fear.

(24:34):
Your obsessive fear was being sick. And every time you
had a thought about being sick, you might repeat the
word healthy, healthy, healthy, you know, three times, and you
got to do it three times, and you got to
do it in your head, and you got to make
sure you said it the right way and with the
right intention. Or let's say you had a triggering thought
about your your faith and you had to say a
specific prayer or something like that over and over in
your head. So these are behaviors. These are attempts to

(24:56):
wash your mind of a contaminant, but they're unseen. So
the obsessions are obsessional and the compulsions are obsessional. So
they're pure in that sense and that they're not escaping
the head. But they're not pure in the sense of,
you know, I've yet to meet in my career somebody
who just has these on one intrusive thoughts, and that's
just because they're unlucky in that way, got it.

Speaker 1 (25:15):
So it means that you can't always see behaviorally from
the outside. Do you suppose that religious figures and icons
and leaders sometimes have OCD and they develop a flock
of people who follow them because they think, wow, this
guy's really.

Speaker 3 (25:31):
I think people who rise to positions of having a
lot to say about something tend to be obsessive, right,
and they tend to keep going back to it, and
they tend to be rule followers in certain ways, and
they tend to be perservative, right. So I think that sure,
you could look at a lot of famous historical people

(25:52):
or religious figures and say, you know, maybe they're just
responding to intrusive thoughts and they kind of came up
with a spiritual explanation for and then that's how they
got their followers. I think you could say a lot
about the same thing about autism.

Speaker 2 (26:05):
I think you could say, why wait, double click on that?

Speaker 3 (26:07):
Well, when you when you think about what it would
mean to from a neurodiversent perspective, to really feel like
your functioning is going to be at its best when
you have an exact script for how to live.

Speaker 2 (26:21):
Ah.

Speaker 3 (26:21):
Yes, and we have the script and it's called our
Holy Book, and all the words are in the book,
and if you're not doing what it says in the book,
then you might be doing something wrong. There's a there's
a fairmount of crossover. It's a much higher incidence of
O city and the autistic population than a non autistic population,
but they're not the same thing. Think about some of
our world leaders and you think, well, why do they
keep getting in trouble for things, you know, like affairs

(26:44):
and things like that. I like to think if I
was a world leader, I'd be very very careful to
behave very very well well. Part of the reason I'm
not a world leader is I'm not impulsive enough, and
I don't take the kind of risks that a impulsive
narcissist would take that would get them to the top.

Speaker 2 (26:57):
Oh fascinating.

Speaker 1 (26:59):
So I want to make sure I understand this issue
about why the compulsions seem to temporarily relieve the anxiety
going on where somebody feels like, Okay, I've just saved
the situation because I've done this thing. Does this end
up making a reinforcement loop.

Speaker 3 (27:16):
Yeah. We call it the OC cycle or the obsessive
compulsive cycle. So the model is you have these unwanted
intrusive thoughts, which are normal events. You know you have
however many thoughts. You would know what the exact number
of thoughts are that you have in a given day,
and you know they're not all going to be gems,
and some of them are going to be disturbing. And
maybe they're disturbing because they're just objectively disturbing, you know,

(27:37):
they're violent or perverse or something like that. Or maybe
they're disturbing because they're just so not you. Why would
you think that thought? You know, you've never been in
a fight. Why are you having a violent thought? You
love your faith? Why are you having a blasphemous thought?
So you notice this thought's a bit off, it's ego dystonic.
It's disturbing to you, So you start to feel distressed.
I don't like it. It makes me uncomfortable. So in a

(27:58):
completely rational way, you just but I need to get
away from this discomfort. The discomfort is there. You know,
your body is trying to tell you, like you know,
something is not the way it's supposed to be, and
it's trying to motivate you to do something about it.
So that's why you start to get tense muscles and
your brain starts to rev up a little bit. I mean,
it's it's all there to help you. It's just it's
a false alarm. You know, your brain can't always get

(28:18):
it right. So now you're in this situation where your
brain and your body are telling you your trouble. Get
out of trouble. You know, okay, how do I get
out of trouble? So you start engaging in compulsions, right, So,
if it's a contamination thing, you're busting out the hand
sanitizer again, You're washing your hands even though you just
wash them, but you know you might have bumped into something,
so now you're gonna go wash them again. Or you're
doing the mental ritual over and over again, and then
it works, you know, it works just a little bit,

(28:41):
just enough to make you feel like I am now
certain that the content of this intrusive thought is false.
It's not gonna hurt me of the people I care about,
and it feels so good to get that relief, and
that triggers this thing in the brain called negative reinforcement.
So as complicated as brains are, they kind of only
have two settings. It's keep doing this or don't keep

(29:01):
doing this, right, And a lot of what a person's
personality comes down to is like how often do they
do this? And how often are they inhibited from doing this?
And so we repeat things that are reinforced positive reinforcement.
I want you to do something, you do it, you know,
I pay you, and the next time I asked you
to do it, you're like, oh, that sounds a great idea.
We called a job right punishments and other kind of

(29:21):
reinforcement and negative reinforcement is essentially you're already in a
distressed or unpleasant state and then something you do makes
that distress go away, and your brain goes, that was great,
do it again. Then what happens is the intrusive thought,
the initial invader, comes back because it's a normal event.
You're going to have these thoughts sometimes, and it comes back,

(29:42):
but now it's tagged with additional information. We know this
thought's important because last time you had it, you had
to do something about it. We know what you have
to do about it because last time you couldn't tolerate
how it felt, and you did that thing and it
felt better. And we know there's no way you could
just say like, Okay, this is my OCD and let
it go, because last time you had a chance, you
didn't take it, so you kind of ended up bullying
yourself into repeating these behaviors desperately trying to get that relief.

(30:03):
So it shares some territory with addiction, but it's different
from addiction and that it doesn't really have the positive
reinforcement side of it. You don't get the high. You
just get the relief and the relief, you know. Like
I said before, it's you know, could be discussed, could
be anxiety. Oftentimes it's guilt. It's the sense of like,
if I decide that this is O city and let
it go, if I'm willing to risk my soul, my children,

(30:25):
whatever it is that my ocd's going on about, I
must be a terrible narcissist or a bad person, Like
it's so guilty, right, But if I know I've done
everything in my power to keep this bad thing from happening, Okay,
then at least they know I'm like baseline. Okay, So
now you buld yourself into doing it again. Now there's
more negative reinforcement, and around and around we go. Because
the thoughts are going to do what they're going to do.

(30:47):
They're not consulting with you whether or not to show up.
The question isn't whether or not they show up, it's
how they show up and how easily you can see
them as just like noise or signal.

Speaker 1 (31:06):
Why do rituals expand over time. Why doesn't the brain say, okay,
we're safe now.

Speaker 3 (31:10):
So again, there's probably a great cerebral neurological explanation for it,
But essentially what's happening is the good enough mechanism in
the brain is not fully doing its job. Right, So
think about what it's like to lock a door, walk away,
know that you locked it, have an image in your
head of having locked it, but not have the feeling

(31:32):
of task completion. Something's missing, something hasn't been done. It
can't be that I didn't really lock the door. But
could it be that I didn't lock the door? And
is that why I'm now having all these intrusive images
of people breaking into my house and murdering my family. Okay,
maybe I should go back and lock the door again,
just in case, right, and now you're unlocking it and
you're locking in you know, just so I remember this time.

(31:54):
Let me unlock it and lock it in a very
specific number exchange while saying out loud it is it
is locked. It is locked. And actually, let me also
take a picture of it and take that with me
so I can refer to it later. All these things
are inhibiting you from being able to accept the uncertainty,
which is expanding the uncertainty. It's basically you're training yourself
to think of yourself as incompetent at not just of

(32:17):
locking a door, but of tolerating the unknown. So the
natural trajectory of most OCD is to get worse. It's
not a phase doesn't go away on its own. We
used you know, people say this to kids, like you know,
they're just going to get grow out of it, you know,
grow out of it. You have to actually change it
because it's it has its own internal learning mechanisms. So
you're learning how to be more obsessive compulsive. The more

(32:38):
compulsive you are. And what do.

Speaker 1 (32:41):
People with OCD, So the fact that it's two or
three percent of the population, what kind of jobs do
people typically go into?

Speaker 3 (32:49):
That's an interesting question. A lot of us are therapists.

Speaker 2 (32:54):
For each other.

Speaker 3 (32:55):
I mean, it's true if you go to a conference
like the International OCD Foundation conference like to every year,
there's a sizeable percentage of people there with lived experience.
You know, I'm speaking in a non scientific way though
what I say, You know, people with OCD tend to
be very compassionate, very sensitive, very thoughtful, you know, much
to their chagrin. I mean, they would try to sometimes

(33:17):
rather be less thoughtful. But there's an upside and a
downside to it. I never like to say there's an
upside to having a psychiatric condition. It's causing me to suffer.
But the way I think about people with OCD, and
myself included, is that they have a like a broader,
brighter spotlight on the available thought content at any given time.
And so what that looks like on the positive side

(33:39):
is a person with OCD might notice a very subtle
detail about a painting or a scene in a movie,
or or the way their romantic partner smiles or something
like that, and they'll catch it and they'll be like,
I see that, and that's awesome. And they might even
speak to it, and I'm like, Oh, this person's creative,
this person's so romantic, this person's so thoughtful. And so

(34:00):
people with OCD tend to have a great sense of
humor and tend to be very attentive to each other's
needs when they're not in the hole, you know, trying
to get out out of the hole. Now, that's that's
the upside, right, But if you think of it as
a spotlight if you think of it as a sort
of wide spectrum on all the available things a person
could be thinking about. The downside is thoughts that most

(34:21):
people throw away see as drunk male you kind of
perceive as muffled or underground or not worth attention. For
the person with OCD have a bright light shining on them, right.
So it's so it's I'm having this thought of like
what's what what if this terrible thing happens? And it
feels as significant as having a thought like what day

(34:41):
is it? Or like you know, what am I going
to have for lunch? Like I thought that belongs there
that you know, And but it's this like terrible, terrible content.
If you ask someone to think something terrible, you know
what's worse? Fire or electrocution, you know, for for death,
most people will think about it like I don't know,
I guess this or that, right, But a person with
city'll be like fire like immediately because I've run this experiment.

(35:05):
It's in front of people every just like raising their hand,
you know.

Speaker 2 (35:08):
You mean, because they've thought through it before.

Speaker 3 (35:10):
Because it's just obvious to them. It's just it's it's
not something that needs to be thought about it. It's so available.
So when you think about the kinds of things people
obsessed about. I'll give you an example. When my kids
are little. You know, we get them ready to get
on the school bus, and there's all this process involved.
Do they have the right clothes? And then you know,

(35:32):
is their lunch packed? And you put in all this
effort to make sure that they're safe and ready to
go off to school. And then you you're take them
to the end of the driveway and you like hold
their hand and you're like, I'm like the best parent,
I'm like taking such good care of them, right, and
then and then you put them on a giant vehicle
with no seat belts, driven by a person you don't know,
You have no idea if they're sober, if they're like whatever,

(35:55):
and you're like, see, I got to go to work.
There's a point at which you say and enough, this
is the most I can do. Right. But a person
with OCD is much more likely to be aware of
how awful that story I just told really is and
what level of risk is involved, and they might have
to pull themselves away to go to work because they

(36:16):
know that the consequences of like driving behind the school
bus and spying through the window are also problematic.

Speaker 2 (36:21):
So let me just understand.

Speaker 1 (36:23):
The thing about saying fire is the worst way to
die is so if you ask me that question, I've
never really thought about I don't have OCD. I've never
thought about being on fire or being extrocuted, So I
would have to sort of walk through it. But is
the point that someone has already gone down that path
and thought about But.

Speaker 3 (36:38):
I think the point is that it's more readily available
to them. It's part of what makes people with OCD
tend towards creativity and the sense of humor is they
can think the exact wrong thing at the exact wrong moment.
And so where the misfire is happening is a confusion
between the brightness or a loudness or availability of the
thought and its importance.

Speaker 2 (36:57):
I see.

Speaker 3 (36:58):
So if I say, if I whisper to you that
there's a bomb in the building, or if I yell
at you that there's a bomb in the building, it
actually doesn't matter. What matters is if there's a bomb
in the building, right, But if you're having this internal process,
the tendency is to go with the loudest thought at
any given time.

Speaker 1 (37:13):
Ah Okay, Now what I'd really like to get into
then is your therapeutic approach.

Speaker 2 (37:18):
So tell us about that. What do you do? Someone
with OCD comes in and sits in front of you,
what do you do?

Speaker 3 (37:23):
So the very first thing you do is you get
to know them. I mean, I think sometimes when people
get into specialty areas, they're like, all right, we're going
to just like surgically remove the problem that I specialize in.
So you have to do all the same things you
do as a regular therapist, which is establish rapport, established
that you're invested in reducing this person suffering. And then
there are reasons that they should trust you or learn

(37:45):
to trust you to do that. So by the time
someone's come in for OCD therapy, they're already halfway up
some fear hierarchy because they're telling you things that they
think are going to make them sound crazy. And that's
a very vulnerable thing to do to with a stranger. Right,
So you go through the initial part of the therapeutic process.
Then you go into psycho education. Look, based on what

(38:06):
you've told me, based on you know, these scales that
we've used and things like that, I'm fairly confident you
have this thing called obsessive compulsive disorder and that's why
you're having trouble letting go of this thought and then
letting go of these behaviors. And here's how we're going
to treat it. And you run them through that oc
cycle that I described before. And what I like to
do after kind of running them through it in a
lot of detail is ask them how do you treat OCD?

(38:28):
And I'll be like, I'm new here, Just tell me
how to do this, because if you explain it well
enough that the problem of the intensity of the thoughts
is that they're being fed with the negative reinforcement, and
that the negative reinforcement is coming from this fake, limited
temporary relief system called the compulsions, then then the solution
becomes kind of obvious, Like I need to identify all

(38:51):
of my compulsions because I might not be aware of
all of them, right. I might be aware of the
ones where I'm like tapping in prime numbers, but not
aware of the five hours I spent in the middle
of the night on on you know, googling how to
tell if I have this disease? Right, Okay, so that's
compulsion too, So identifying what's compulsive, what's feeding that negative reinforcement,

(39:12):
and then learning to resist it. And the point of
resisting it is both to learn that you can tolerate
the discomfort and the uncertainty and then it'll go down
on its own, like like most fears over time, but
also to just unpair it. Right, So there's this this
pairing of thought terror. Right, Okay, what if I get unpaired?
What if I'm gonna have this is this is a
concept called inhibitory learning. What if I could repeatedly put

(39:35):
myself in situations where I want to do compulsions. So
now that's called exposure. Okay, now I want to do
the compulsion, but I'm not going to do the compulsion.
So now I know I can feel dirty or I
can feel triggered, and I can survive not doing the compulsion,
and either that's going to get easier because I'll be
less distressed, or it'll still be distressing, but I'll be

(39:55):
able to tolerate that distress or know that like I
don't have to take it seriously because nothing terrible happened.

Speaker 2 (40:01):
And so you're breaking the loop.

Speaker 3 (40:02):
It's breaking the loop exactly. So it's ERP exposure and
response prevention. And one way to think about the inhibittory
learning side of things is how a lot of people
relate to scary movies. I'm a huge horror movie enthusiast myself,
and one of the reasons people like it is they
they go to the movie theater and they're like, I'm
gonna get ysregulated. This is my plan. I'm gonna spend money,

(40:23):
and I hope something happens up there that makes me
feel bad, because that's exciting. It's exciting to feel that
way and know that you're safe at the same time.
It's the same reason people go on roller coasters, and
what happens is, you know, the monster jumps out and
you're like ah, and if you do an analysis of
what's going on in the brain of the body, it's
like it's not good. You know you're in danger. But
then what happens Then you're like oh, You turn to

(40:44):
your friend and like that was crazy. You get some popcorn,
and you're right back into the movie. At no point
do you think I got to get out of this
movie theater? Right I'm in danger. So you've learned that
it's okay to be triggered because you're pairing the trigger
with something that's not threatening. And the best way to
do that is to practice it. Go see a lot
of these movie and don't just see in the theater,
you know, rent them at home too, Like, make sure
you generalize and do it in different settings, different contexts.

(41:05):
So it's the same thing with other forms of OCD.
Maybe you have contamination OCD and all the excessive washing
and avoiding that comes with that. Yes, we want you
to build a hierarchy gradually, you know, don't jump in
the deep end of learning to touch that doorknob or
that toilet handle or whatever the triggering thing is. Then
resist washing and sit with that feeling of like am

(41:26):
I dirty? Am I spreading something? And don't just sit
there with your hands on. Make sure you don't touch anything,
you know, spread the wealth, you don't get it on
your face, you know, shake hands with people, do whatever
it is your ocd's telling you're not allowed to do.
And then let's see what happens over time. And the
results are really impressive for most people.

Speaker 1 (41:43):
Wow, because they're building up new reinforcement loops on this stuff.
They're getting feedback telling them that their prediction was not accurate.

Speaker 3 (41:52):
Yes, wow, but without the certainty, right, they're not proving
that they can't get sick. If they're proving anything is
that they don't need to know if they're going to
get sick.

Speaker 2 (42:01):
Can you just double click on that.

Speaker 1 (42:03):
I want to understand this difference between addressing the uncertainty
part of it.

Speaker 3 (42:07):
Right, So if I tell you if I touch this
and don't wash my hands, I'm going to die, and
then I touch this and I don't wash my hands
and I don't die, it doesn't prove that touching that
and not washing my hands guarantees I want die might
die tomorrow. Right. What I'm trying to overcome when I'm
trying to overcome OCD is this false message in my
brain that says I'm not allowed to move forward with
my life unless i'm certain ah. And so what we're

(42:30):
ultimately training people how to do, regardless of the content,
is change the process by which people relate to that
sense of I don't know and I need to know.
So one of the ways I explain this to my
patients is we have knowing skills and we have not
knowing skills. And part of problem with OCD is a

(42:50):
deficit in the not knowing part. Right, to fly a plane,
you have to know what all the buttons and knobs
and stuff do and how to fly the plane. But
if you can't tolerate not knowing if a goose is
going to get in the engine and then you're gonna
have to do an emergency landing or something like that,
you're going to be too anxious and distracted to efficiently
and competently fly that plane. You have to also be

(43:12):
good at not knowing.

Speaker 2 (43:13):
Excellent right, And that reminds me.

Speaker 1 (43:14):
There's a quotation that I think is yours thoughts are
just thoughts, are not threats?

Speaker 2 (43:20):
What is that distinction there?

Speaker 3 (43:22):
So it goes back to what I was saying before
about this idea that something is happening where a person
is having a thought, they're perceiving the thought is very
loud and very obvious, and they're misappraising it as a
particularly important or super relevant to what's going on in
their life and not just the junk mail that it is.
So they're saying like, this thought is a threat, and
I have to remove the threat to keep myself or

(43:44):
my family or my loved ones with somebody safe. But
I think when I'm thinking about just like this, the
expression of thoughts or thoughts not threats. I mean it
even more globally than that, right, I mean to say
that a thought cannot be a threat unless you make
it a threat, unless you relate to it like it's
a threat. I can't hold a thought in my hand
no matter how many thoughts I throw at you, David,

(44:06):
none of them are going to bruce you. And I
would go on to say feelings are feelings, not facts,
which is a whole other mess. But still we have
these internal things and these stories about these internal things,
and well, this means, you know, I'm anxious.

Speaker 2 (44:18):
This means something.

Speaker 3 (44:19):
Bad's gonna happen, right, I feel guilty. It means I
did the wrong thing. And then he said, well, like,
are your feelings reliable? No, They're terribly unreliable. Like okay,
so there's a mismatch here. What I'm touching on there
is the see of CBT. So exposure and response prevention
is the behavioral part of CBT. I think all good
exposure therapists do some see in their CBTs.

Speaker 2 (44:42):
And cognitive exactly.

Speaker 3 (44:44):
Yeah, okay, so the cognitive part being like, you know,
all things being the same. There are better or worse
ways to think about your experience, and in some ways
of thinking about your experience. Again, I'm not saying they
are good and bad thoughts. I'm saying there are effective
and ineffective ways of thinking about your thoughts. And the
most ineffective ways of thinking about your thoughts are the
ones that convince you that compulsions are not a choice,

(45:05):
that compulsions are an inevitability. How did you get to
I have to do this thing? Well, I had this
thought and then I was like, oh, and if I
don't wash my hands, you know, it's something terrible is
going to happen. Or if I don't reassure myself you're
not going to be a terrible human being. Okay, well
that's called catastrophizing. You can't predict the future, Like, I
get it, that's a scary idea. But if you're going
to go along with that, you're just training your mind

(45:28):
to just run off with you, you know, And you
need to get a little bit of control over how
you think about things, not what you think about, but
how you think about them, which then opens us up
to this whole other thing called mindfulness, which I'm a
big fan.

Speaker 1 (45:41):
Of great tell us about that and how you think
about mindfulness in your practice.

Speaker 3 (45:46):
So you asked me before about saying thoughts or thoughts
not threats. That's really at the heart of mindfulness. It's
basically saying, you can be an observer of your experience
in the present moment, and you can do it without judgment.
You can even do it without thinking, and I need
to change this immediately. So it's learning how to show up.

(46:06):
The experience of someone with OCD is very often one
of being having your mind calm endeared by almost like
an external force. I was doing fine and then this
thing triggered me, and now I just I'm not in
control of my life. All I do is think about
this thing all day. Every day. I can't sleep, It's
in my dreams, and I'm constantly trying to make it
go away. So it's it's really like having your mind stolen,

(46:28):
and mindfulness is stepping back from all that and saying like, okay,
so you're observing what's happening. You're observing the thoughts floating by.
There's a thought, there's a thought you're observing, there's some emotions,
maybe there's some aversion to that thoughts some resistance. Okay,
that's another thing that's floating by this thing called resistance.
So a lot of you know, sometimes people hear mindfulness,
they go, oh goodness, you know he's here with the

(46:50):
mindfulness again, you know, the mindfulness, this mindfulness that I mean,
it does get overused a little bit, but essentially learning
how to say, hey, look at that before everything that happens.
Oh hey, look at that ahead a thought. Oh now
you're in relation to a thought as opposed to the
thought happens, and you're immediately scrambling to get rid of it.

Speaker 2 (47:06):
Right, you don't have to be the thought, and you're
watching it exactly.

Speaker 3 (47:10):
So it's it's understanding yourself as an observer of what's
going on in your mind, which gives you some agency
of Okay, all right, this is how this feels. What
are we going to do about it?

Speaker 1 (47:19):
Yeah, And this is what allows you to separate feeling
from fact, because you look at the feeling, Oh, I'm
feeling anxious, feeling angry, I'm feeling guilty, and you get
to just observe that as opposed to it is true
that that feeling has meaning.

Speaker 3 (47:34):
Yeah, one hundred percent. And when people get caught up
in some of these you know, cognitive distortions, you know,
all or nothing thinking, magnifying, discounting, positive, all that stuff.
What's really happening there is they're not maintaining an awareness
that thinking is happening. They're just they're in the stream.
They're not on the bank watching the leaves go by
on the stream. And so the goal is to really
help people say like, oh, wait a second, I'm thinking,

(47:57):
there's a way that I'm thinking. This way of thinking
doesn't serve me in this moment, you know, And this
actually sounds a little bit like my OCD. I'm gonna
make a choice not to do this compulsion, and I'm
gonna give myself some credit for doing the hard work
of my exposure there.

Speaker 2 (48:10):
Yeah.

Speaker 1 (48:11):
You know, this has been one of the most fascinating
things to me about neuroscience. There was a French writer
in the eighteen hundreds, I'm totally blanking on his name
who said a brain bears thoughts the way that an
apple tree bears apples. It's just, you know, this is
what it does. You're gonna get thoughts popping up all
the time. Yeah, and you just have to live with that. Yeah, Yeah.

Speaker 3 (48:32):
The imagery that's just popped in my head is someone
like biting an apple is full of maggots and they're like,
oh no, what happened?

Speaker 2 (48:38):
Right?

Speaker 3 (48:38):
That's I think how many people with OCD feel is
that they are there's a part of their brain that's
out to get them, that's victimizing them. And so one
of the things that's super helpful in the OCD treatment
is self compassion, just like a part of mindfulness. It's
basically just acknowledging like this is hard. A lot of

(48:59):
people think of self comp you give yourself a hug,
be nice to yourself. That's a part of it, but
it's not the most important part of it.

Speaker 2 (49:05):
The most the struggle, it's telling the truth.

Speaker 3 (49:09):
It's telling the truth is saying I need help. This
is hard. I'm a human being who's vulnerable. I can't
do this on my own right now. And then when
you can apply that to other things like oh, I'm
having an intrusive thought, I don't like the way that
it makes me feel. I'm going to stand up to it,
you know, you know, I'm doing the best I can
with what I got. Right, All of that is super helpful,

(49:29):
and it really kind of lends itself to what I
think is the most logical conclusion, which is, if you
have a thought that is tearing you down, like a bully,
learn how to stand up to it in a way
that's effective, right, And the different ways of responding to
a bully. Right, So, if you're fighting fire with fire,
try to fight OCD logic with better logic. It doesn't

(49:51):
really work, actually, but it doesn't work with bullies either, right.
A bully wants to rile you up. So if you're
willing to go into that fistfight them, they've already kind
of won. But there are different ways you could respond
to bullies to make them say huh yeah, I don't
want a piece of this.

Speaker 2 (50:05):
I'm walking away. Like what how would you respond?

Speaker 3 (50:08):
Well, think about exposure therapy, what about agreeing with it?

Speaker 2 (50:11):
Hmmm?

Speaker 3 (50:12):
I saying oh yeah, that's great. I hope that bus
goes right off a cliff. Right. You don't have to
mean it, you just say, you know. The bully's like
do this, or I'm going to make something bad happen. Great.
I love it when baden, bad things happen. It's my
favorite thing. And the bully's like, okay, you're weird. I'm
gonna go pick up and pick on somebody else. Oh
much more effective than always playing defense.

Speaker 1 (50:31):
Oh fascinating. Okay, So a couple of closing questions. So
you know I asked you before about culturally what's going
on with OCD, how it differs across cultures, but it
also differs across time. So what are you seeing now
right now in twenty twenty six with patients with OCD.

Speaker 3 (50:47):
I'm observing a spike in existential obsessions. This is something
that kind of always existed, So existential obsessions being the
sort of unwe intrusive thoughts about what's real? Am I
a simulation? And what if I'm the only consciousness? What
happens after I die? And like, how am I going
to tolerate not having answers these questions? It's too overwhelming.

(51:08):
And I think we're going through a cultural moment now
where you know everybody's talking about AI is coming for
all of your jobs and all of your human experiences
can be replaced by robots. Politics is an absolute disaster
no matter you know who you are, what you're bent is.
No one's like, yeah, everything's going great politically. No, it
isn't And I think, you know, it's just sort of

(51:31):
everybody's anxiety is I think a little bit raised. And
when that happens, everybody with OCD has it raised times ten.
And so I'm just hearing a lot more of obsessions
about like what is real, like what matters? And you
know what if none of this matters? And you know
what if in the future AI does this and does
that and all of my love for my family is

(51:56):
just like a bunch of numbers and doesn't matter. And
you know, people can you know, I don't think it's
so strange to go down a philosophical rabbit hole and
then think, hmm, I wish I hadn't done that. I
kind of want out, you know. I don't think that's
a strange thing. It's just that when it happens to
someone with OCD and they have that predisposition, they can't
just get out. They can't to be like, well that's that,
I'm going to go watch TV. Now there's the dodd

(52:18):
says like, no, we need more, we need to figure
it out. There's unfinished business. And you match that with
other symptoms like anxiety and depression.

Speaker 1 (52:25):
Does it help somebody with OCD to just physically move
out of the situation they're in and go do something
some task.

Speaker 2 (52:33):
Does that help?

Speaker 3 (52:34):
Yeah, I think so. I think you can use distraction compulsively. Right,
if you're running from your thoughts, you're sending the signal
to your brain that your thoughts are dangerous. But if
you're saying, yeah, I just think it's not gonna deal
this right now, I'm gonna go do something else instead,
then you're sending this signal to your brain that even
though that thought's really terrible and you don't really know
what's going to happen, you're much more interested in your

(52:55):
video game right now than anything else. And I think
that can also be a kind of exposure. It's another
thing I tell my patients a lot, which is your
brain doesn't know you have OCD. It doesn't have an
opinion about any of this. It thinks everything you're doing
is great. It's just like totally rational and totally reasonable.
So if you avoid something, your brain's gonna be like, good,
that was probably bad. If you wash your hands, your

(53:15):
brain's gonna be yeah, they're probably dirty. Right, So when
you do exposure therapy over time, it's gonna say, oh,
I guess there's new rules, right, like, Oh, this person
can have this thought and then they can override it
and do this other behavior. So I guess that thought
probably is junk mail. I'm gonna start tagging as junk mail.
It starts to reverse engineer the OCD cycle. The challenge
is the reason why exposure therapy is so hard. Sometimes

(53:37):
a brain should be quick to learn danger and slower
to learn safety, and really slow to learn safety after
you've established danger. Yeah, so if you've convinced yourself that
it's dangerous to have a certain thought or to touch something,
or to do something the wrong number or something like
that because of your OCD, and then you're like, I'm
not gonna live this way anymore. I'm standing up to
my OCD. I can to do exposure therapy. A healthy

(54:00):
brand is going to say, what are you doing? Don't
don't do that. That's incredibly dangerous, And so you're going
to get these really intense emotions. And then what's beautiful
about ERP is when you get through that, when you're
a witness to the other side of it, you realize,
I'm stronger than I thought I was, I'm more capable
than I thought I was Feelings can't destroy me. Thoughts
are thoughts, not threats. You get all that prize at

(54:22):
the end of it as long as you're willing to
go through that scary part. And I think, well often
forget that the scary part is actually normal and healthy.
You want a brain that's a little bit slow to
change its mind once something's been established as dangerous, but
you can change it, and you you know you're going
to want to change it if you have OCD.

Speaker 1 (54:42):
And so for listeners who have OCD, and I also
want to ask you about listeners who know or love
somebody with OCD, what would you recommend they do?

Speaker 3 (54:52):
I think you know, first things first, any part of
you that's saying this is because you're weak, or you're
crazy or something is like terribly wrong with you. I
know we're using the word disorder, but we have to
use words to label things. Try to step back from
that and try to open up to the idea that, look,
this is a common treatable psychiatric condition. Everybody's got issues.

(55:15):
This is your issue. This has nothing to do with
the content. If the content is you're a bad person,
this has nothing to do with you being a bad person.
The content has to do with contamination or lock checking whatever,
It's not about that. That's just how it's manifesting behaviorally.
What this has to do with is you've got OCD.
It's created this deficit in your ability to tolerate certain

(55:35):
types of uncertainty and doubt, and your strategies, your instinctive
strategies are just a little misguided because nobody's perfect, and
you can train that out of yourself with the right therapies.
So ask for help right. Asking for help is never
a weakness position. It's always a strength position. And you're
always saying like, hey, I'm smart enough to know I

(55:56):
deserve better than this. So I'm going to go find
some nerve out there who thinks about this stuff all
the time. It doesn't and and and you know it
isn't isn't sort of predisposed to help me for no reason.
I can actually employ them to to care about this
part of my life. Yeah, and then and then you'll
see the results. So start with self compassion and then

(56:18):
then go for help. And there's lots of great resources
out there now that we didn't have before. Uh And
and since we're talking about the OCD, the first one
I would go to is iocd f dot org. That's
the International OCD Foundation, and that's just full of information
everything you could possibly want to know about OCD, including uh,
where to find help?

Speaker 1 (56:35):
Great And I'm gonna link that to the show notes.
And what about people who have a loved one in
their life with OCD? What would you recommend they do
besides have them listen to this podcast?

Speaker 3 (56:45):
Yeah, and buy my book. So I wrote a book
called When a Family Member Has OCD, and it covers
all of those issues. It's really an amazing and powerful
thing to love somebody with OCD.

Speaker 2 (56:57):
Uh.

Speaker 3 (56:57):
Ask my wife, you know, she had to learn when
I was going through that process, how to make sense
of my behavior because it affected her, and she had
to learn how to respond or more often, how not
to respond to some of the things that I was
doing to mine her for reassurance, to rope her into
my OCD process. So I would like bring up a

(57:21):
subject of the content of my obsession and just I'd
be talking about it for you know, no reason, you know,
you ever think about this, you know, I would, you know,
kind of like or or I would ask her a
question that I've asked her a thousand times, or I
would come to and say, I know you're not supposed
to answer this question, but let me just ask it
one more time, and she'd have to make a decision about, like,
you know, essentially the equivalent of am I going to

(57:41):
give him the soap to wash his hands or I'm
gonna tell him no, this is your OCD And those
are hard decisions for family members to make. So what
happens in family systems, romantic relationships, or parents and kids
is people get roped into accommodating the rituals. You don't
like to see your loved one's suffer. You see, that's
your loved one suffering, and there are things that you
can do that are part of the OCD cycle to
make their suffering or at least their short term pain

(58:04):
go away immediately. Oh, let me just check that for you, right,
let me just answer that question for a moment time.
So part of the treatment process is if you have
a family member who's roped into the OCD, they also
need to be trained and educated that the compassionate thing
to do is not always just do whatever makes them
feel better. The compassionate thing to do is sometimes say, like,
I know you can't see that this is your OCD

(58:25):
right now. But I'm telling you, this is your CD
right now. I'm not going to answer that question. And
then you collaborate with each other. I'm like, okay, what's
the best way to team up against the OCD? And
those situations, I mean, when you see them take shape,
it's just so beautiful when you see a whole family
decide like, this isn't about my kid misbehaving, and this
isn't about my irritation with you know, having all these

(58:46):
OCD problems in my house. This is actually about us
as a family getting together and declaring war on the OCD.
It's not about my kid. It's about the OCD. And
then you see everybody get better.

Speaker 2 (59:05):
That's John Hirschfield.

Speaker 1 (59:07):
By the way, I found the quotation I couldn't quite
recall during our interview. It's by the French writer Antoine
Fabre de Olive, and in eighteen twenty four he wrote quote,
man is a plant which bears thoughts, just as a
rose tree bears roses and an apple tree bears apples.

(59:27):
So in other words, your blossoming thoughts every moment of
your life, and if you pay attention, you can detect
some really wild thoughts buried in there, some thoughts that
might be violent, or sexual or blasphemous. Our minds are
noisier than we generally appreciate. As John and I discussed,
the problem in OCD, isn't the original thought because thoughts

(59:51):
emerge from billions of neurons interacting under the surface of awareness,
and this generates junk mail constantly. The problem is taking
the thought too seriously. For a person suffering from OCD,
the thought becomes visceral and urgent and existential, as in,

(01:00:11):
if I had this thought, what does that say about me?
Can I trust my own mind? So the brain starts
interrogating itself, and this is one reason OCD is so exhausting.
People think, did I lock the door? What if I
secretly want this terrible thing? Did I contaminate somebody? Am

(01:00:31):
I absolutely certain about this? And the problem is that
the feeling of certainty becomes like a mirage in the distance,
and as you try to move toward it, it's always
receding away from you. So a person with OCD looks
for relief. I'm just gonna check this one more time.
I'm just going to ask one more question I'm just
gonna review the memory one more time, and just for

(01:00:54):
a moment, they get relief, and then the doubt returns,
and so the loops strengthens. The ritual has to keep going.
So the bottom line is that for a person with OCD,
mental health depends less on eliminating uncertainty than on changing
your relationship to it. And this is one of the
reasons exposure therapy seems to work. It teaches coexistence with uncertainty.

(01:01:20):
You gradually learn that you can survive the feeling of
uncertainty without resolving it completely. You learn that thoughts are
events of the brain and they don't always have to
be taken so seriously. Thoughts can be observed with a
little bit of a distance, allowing them to pass through
your awareness like a cloud moving across the sky.

Speaker 2 (01:01:44):
If you know anyone.

Speaker 1 (01:01:45):
Who needs to hear this week's podcast, please pass it
forward to them. Go to eagleman dot com slash podcast
for more information and defined further reading. Join the weekly
discussions on my substant and check out and subscribe to
Inner Cosmos on YouTube for videos of each episode and
to leave comments. Until next time. I'm David Eagleman and

(01:02:08):
this is inner cosmos,