On this week’s episode of Purely OCD our hosts, Lauren Rosen, LMFT, and Kelley Franke, LMFT, are joined by special guest, Dr. Patrick McGrath.
Dr. Patrick is the Chief Clinical Officer of NOCD and has a wealth of knowledge and experience when it comes to managing OCD.
We hope you enjoy this episode.
Lauren: Hello everyone, and welcome to this week’s episode of Purely OCD. You may notice that there is a third square in our Brady Bunch situation. For those of you who are not familiar with our fabulous special guests, this is Dr. Patrick McGrath and Patrick is the Chief Clinical Officer for NOCD.
…he has a wealth of knowledge. We’re thrilled to have him on today. And he’s also just an awesome human. So there you go.
The critical parts of treatment
Lauren: What do you think are the most critical parts of treatment for OCD?
Dr. Patrick: First thing that comes to mind is practice. Right? You don’t do ERP once and change just like you don’t go to your first piano lesson and become a virtuoso. Maybe there’s a rare bird that can do that. But the vast majority of people have to practice these things. OCD took a long time to get you where you were. Why wouldn’t it also take a while to get you where you want to be?
Kelley: Patience. Without it, a lot of clients can get frustrated because they want to see results faster.
Dr. Patrick: …and that leads to watching the shoulds. They will definitely get in the way of therapy. And if you are ‘shoulding’ all over the place, you’re really going to have a lot of trouble in the work that you’re doing. Because you don’t want to ‘should’ on therapy, it’s going to really interfere with the work that you’re doing.
Watch those all-or-nothing kinds of words that you tell yourself. Self-talk is very important to me. How are you talking to yourself? How are you motivating yourself? Right? Are you motivating yourself in a way that would be motivating to others? Or are you putting yourself down as a way to try and motivate yourself to be better? If it wouldn’t be motivating to anyone else, why would it be motivating to you?
So my favorite topic is specialness. Why do you believe the rules of the world apply to you differently than they do to everyone else? And can I help you break the notion that that’s the case for you? Because I don’t find it to be true. You believe it. But I don’t find it to actually be true. I don’t see that the rules apply to you differently than they do to other people.
Your OCD will try to convince you of the fact that it is it’s fine for everyone else to do all of these things. But if you do them, you have a different set of rules that you must apply in order for you to be successful that others just don’t have to do. If anybody else were to have this thought or image or urge it would be okay. But when you have it, you must now do these special things in order to neutralize it. Because it has a different meaning when it happens in your brain compared to in someone else’s brain.Dr. Patrick McGrath
I can’t treat ‘I can’t do it’
Lauren: …you kind of segwayed into motivation and I think that that’s a really interesting topic. Because oftentimes, when people start to ‘should’ on themselves, it’s almost a way of externalizing the part of them that wants change. It’s like a lack of ownership to say, “I knew I should do this.”
Dr. Patrick: I want and I should do feel very different. When I say that I want or I don’t want to do something, that is very personal. But when I say I shouldn’t do it, or I can’t do it, it’s very externalizing.
I always talk about can’t versus won’t. One of my favorite examples was when I had someone in my office who said, “I can’t get on an elevator”, and I said, “Well, let’s go down to the elevator want to test something.” As I was going into the elevator with him I was pointing things out. Now we’re going to walk through the doorway here. Okay, so we walked through, and now we’re going to walk down the hall, and now we’re going to walk to the elevator.
And when we got to the elevator, I pressed the button, and I said, “I’d like you to try to get on the elevator because I wanted to watch you bounce off the invisible force field that appears in front of the elevator.” I said, “Well, you can walk through a doorway. So you’ve proved that already. You’ve walked in and out of my office and the building here and you’ve walked. So the two things required to get onto an elevator involve walking and walking through doorways, you’ve proven the ability to do both. Therefore, the only reason in my mind why you can’t get on an elevator must be that an invisible force field appears in front of it, and it blocks you so I’d like to see you bounce off.”
He joked and told me that he hated me but then told me that he didn’t want to go into the elevator and it was because he was afraid of it.
Now that is something we can treat. But I don’t know how to treat “I can’t do it.”
How to motivate yourself to do the difficult things
Dr. Patrick: …how do you get someone to do something that’s really hard and look forward to it and enjoy it? When I use motivational interviewing in a therapy session, one of the things I say to people all the time is you can spend the rest of your life sitting next to your tombstone wondering when you’re going to be six feet under it. Or you could live your life and on the day of your death look at your tombstone and think – WOW, what a party that was.
Either way, you’re going to be six feet under it at some point, how you going to approach it is what’s most important, right? I can’t stop the inevitable that’s going to happen at some point. But do you want to live the rest of your life worrying about when it’s going to happen? Or do you want to enjoy your life and do what you want to do? Rather than whatever intrusive thought or image or urge that might be popping into your head is telling you what to do?
Treating co-occurring substance use
Lauren: …supporting people’s motivation to do things that part of them definitively does not want to do comes up a lot in addiction treatment. Do you use a lot of motivational interviewing?
Dr. Patrick: Yes. And the other piece on the back end of it as well is really showing the similarities between why people use substances and why people do compulsions. And both of them are to eliminate uncomfortable experiences, right? So I could use a substance because it neutralizes thoughts and images and urges in my head very quickly. I could also use a substance because if I don’t, I go into withdrawal. And that’s very uncomfortable. And I could do a compulsion because if I don’t, I have to sit with something very uncomfortable as well. So both of them involve the mitigation of something that’s uncomfortable. They maybe use different mechanisms for getting there. But they do get you there.
What questions might you use when there is resistance in an OCD client?
If you’re choosing not to do ERP, are you okay with today being the best you’ll ever feel for the rest of your life? Because OCD gets a little bit more difficult every day as you do more compulsions, and it gets more and more ingrained. So are you fine with today being the best you’ll ever feel for the rest of your life? I like to say to people, you can wait for a miracle to happen or you can make the miracle happen. Which will you choose to do?Dr. Patrick McGrath
Lauren: I really like weighing the decisional balance with clients. Asking them what they imagine happening if they do the compulsions versus what would be the outcome of not. And which do you like the answer to?
Acceptance in OCD
Dr. Patrick: …we have to accept the fact that the goal of therapy is not to make any thought or image or urge go away. It’s to allow it to be there and not care that it’s there. But how many of our patients have said to us, but I don’t know if I can live with having this thought, or this image, or this urge in my head? I don’t ever want to experience it again. And I have to be honest with people and say that I don’t know how to do that.I haven’t figured that out yet. I haven’t figured out how to make a thought never appear ever again.
Kelley: You have to be willing to have all of them.
Dr. Patrick: I’ve absorbed every single intrusive thought image or urge of anyone I’ve ever treated now. And so I can’t do anything in my life without having intrusive thoughts with me no matter what I do.
Lauren: And you still live a very full and meaningful and rich life.
Dr. Patrick: I like to think so. But I also know that if I’m ever with the two of you at a conference on a staircase. I’ll think about throwing you down the stairs. It’s true.
…We are not here to get people to be without something. That’s not our goal. As therapists, we are here to help people accept the fact that they are human, and have weird things pop into their heads. And that, just because that happens, doesn’t mean that anything must be done about it.
What can hinder treatment?
Dr. Patrick: …there’s the attempt to be in control. How many of our patients are afraid to not feel in control of something? And yet, they also don’t recognize one thing which is, there is something else in control. And that’s the OCD. And if they have combined substance use, it’s the substances and the OCD that is actually in control. So in the goal to find control, I’ve given up control to something else that has convinced me that I could gain control if I just do what it tells me to do.
It’s totally messed up.
OCD cares only about itself. It does not care about your friends, your family, your job, your loved ones, your home, or anything. I describe OCD, in fact, as the koala bear of disorders because koalas eat one thing and that is eucalyptus leaves and that’s all they survive on. OCD’s one thing is compulsions, and therefore OCD has to do whatever it can to get you to do compulsions in order to survive. Because if you don’t do compulsions, you don’t feed OCD. And if you don’t feed OCD, it starves and fades into the background. So it has one singular goal. How can I get you to do a compulsion?
Have you worked through worse-case scenarios with your clients?
Dr. Patrick: …many of you know that my wife passed away five months ago. That was the worst-case scenario. What if, when she was diagnosed with cancer, I refused to accept that she had cancer? What if I refused to accept that she will die from cancer? She was stage four metastatic, she was going to die. And there were not going to be any treatments that we did that were going to stop this. So imagine if we applied not accepting worst-case scenarios to other areas of our life.
So I accepted from day one, the worst-case scenario and we lived with that for five years until she died. Now along the way, we did everything that we could to try to make her as comfortable as possible and still have some fun. Even a week before she had a seizure that led to her death, we even went to the movies. It was a large ordeal to get her there. But I got her to a movie theater. We made attempts to still do things, even though we were living in a worst-case scenario.
Kelley: That’s a beautiful way of explaining it actually. This is the worst-case scenario, but how do I want to show up? And how do I want to be?
Dr. Patrick: …What if OCD was the worst-case scenario? Not what OCD tells you the worst-case scenario could be? What if it’s just that OCD itself is the worst-case scenario? And therefore our job isn’t to really work as much on what OCD tells you. It’s just to help get rid of OCD in and of itself? Because to me, having OCD might actually be the worst-case scenario.
OCD therapists have one goal
Dr. Patrick: I just like to say to people, the biggest thing that will work against you will be the thing that you’re trying to get rid of… Therapists have one goal in working with you and that is to help you not be ruled by obsessive-compulsive disorder anymore. Let them do their job, trust in what they tell you and give it a chance. Because here’s why I don’t think OCD is scary – because it’s amazingly predictable. And we know exactly what it’s going to do. But it becomes scary because even though it’s predictable, it throws one more thing at you and says, but what if this is the time, right? But if you know that that’s also predictable and that it’s going to do that, then maybe you recognize that OCD does have a pattern. I’m stuck in the pattern. And the one goal is to get out of the pattern. And if I get out of the pattern, maybe I can get better.