Today’s Q&A might read a little different to you, a little more casual—that’s because Dr. Steven Phillipson and I had a long phone call, and I didn’t follow my prepared questions to a tee. The conversation flowed as it needed to, and I learned just how dedicated he is to helping people with obsessive-compulsive disorder, and how little he cares about what others think of him as long as he’s doing right by people who are suffering. Based in New York, Dr. Phillipson treats patients in person as well as via teletherapy, and his clinic uses a sliding fee scale.
Feel free to jump into the Q&A now or familiarize yourself with Dr. Phillipson by reading his article “Choice” first. Yes, it’s 47 pages, but you can listen to an audio version as well.
How long have you treated OCD? Why did you choose to focus your practice on OCD?
It’s been about 30 years now that I’ve been an OCD specialist. I fell into it quite by accident. I was doing an internship at a location where one of the senior staff was a very known expert in the area of OCD. He was a behavioral psychologist and I had done an internship at Johns Hopkins in behavioral psychology, and I really liked the way he looked at the condition, at the way he treated the condition. It was what we call empirically based treatment, very, very scientifically based, and I asked him if he would consider sending me patients that couldn’t afford his fee, perhaps supervising me on those cases so I could learn what was going on, what to do, and he agreed to that.
After about six months one of my patients asked me if I knew of any support groups in the city, and I thought, “Oh, surely, there has to be one,” and in doing a lot of research discovered that there was not an OCD support group, so I spoke to this mentor and we agreed we would start the first behavior therapy and support group for OCD in the city, perhaps even the country. During that time we combined about eight to ten patients and started the group. I took copious notes about what was going on and started to develop a fascination with the condition: It didn’t make sense to me that our own brain would produce such a self-destructive pattern, so I went back to my learning about neurophysiology and basically constructed a treatment model for the Pure O population based on what was already being offered to the observable ritualizing OCD types like handwashing and light checking. I applied the principles that already existed very successfully in the treatment of OCD toward the Pure O population and wrote about it. I got a very resounding positive response across the country because my article appeared in the International OCD Foundation (IOCDF) newsletter, and that’s basically where my career started as being a well-known entity in the world of OCD.
What year was that?
My article came out about 1989, 1990 , and then in 1991 they started doing video broadcasts of specialists with OCD and that video broadcast is actually on my website based on my writing an article title back then, “Thinking the Unthinkable.” That video is on OCDOnline.com. And I haven’t changed a bit, by the way, I look exactly the same as that 1991 video.
You mentioned Pure O. Is it true that you coined that term?
It is true, that was me. That term was coined in my article “Thinking the Unthinkable,” so I’ve got a time stamp on that.
Why did you use that term? What does it mean?
Back then many patients were still exposed to a tremendous amount of ignorance, both in the media and amongst people who were calling themselves therapists qualified to treat OCD, despite how little knowledge there was and how much misinformation there was. Persons were misidentifying the diagnosis because there weren’t observable rituals. In a way it’s a misnomer but in a way it reflects that both the intrusive thoughts—or what I refer to as a spike—and the undoing response, the ritual, were both obsessional in nature, meaning that they were conducted both as a thought, so the brain produced an intrusive thought (that’s the obsessional spike), and then the person would engage in an obsessional ritual to “undo” the intrusive thought. So that’s why I called it Pure O, because the initiating intrusive thought and the undoing response were both obsessional in nature. All persons with OCD engage in the ritualization to escape the intrusive thought, so in that regard that is the compulsion, but back in the early ’90s people were looking at compulsions as only observable phenomena rather than obsessive phenomena, so that’s why I coined that term. I think that it has been from the client population a very welcomed term because people who have been so misunderstood, or those who suffer from that form of OCD, really appreciate a differential term that delineates them from the more widely known aspects of OCD.
“I’m an outspoken, controversial person. I don’t mind being a controversial spokesperson.”
If you’ve gotten any pushback or someone arguing with you has it normally been a therapist, a practitioner?
Well, believe it or not, the greatest pushback has been from the IOCDF in recent years. They don’t like the term because they believe that it misleads and confuses the population, and I disagree. I see it as a nickname for a certain subtype of OCD. There has been that ongoing differential, and persons like Chrissie Hodges or Aaron Harvey who are big advocates of the concept of intrusive thoughts and the obsessional nature of undoing those thoughts definitely understand it as being a positive addition to the clinical vocabulary in understanding OCD.
Right. Just my personal take on it is that it was helpful for me. It was kind of labeling what was going on, and then with that label I knew where to look for more resources and more support. I still have a hard time differentiating what’s considered a mental compulsion and what’s considered an obsession, so just knowing “You still have OCD even if you can’t always identify it as obviously a compulsion” helps.
Right, the compulsion is generally speaking, but not always, the gatekeeper’s effort to undo, escape, neutralize the intrusive thought, so in that regard it’s generally the conscious, voluntary effort to reduce the anxiety or reduce the perceived problem as it were.
Can you give an example of how someone might confuse an intrusive thought, an obsession, with a mental compulsion? Mine were probably praying, but for the most part I didn’t have a lot of obvious compulsions—I learned later that staying in my house and avoiding the grocery store was a compulsion, but it took a long time to get to that point where I realized that.
Sure. So you’re saying that in your case you’d use prayer as a means of undoing the sinful intrusive thought.
Generally speaking, I think occasionally people confuse whether the thought is coming from their machine brain, meaning it happens spontaneously and without our voluntary choice, versus whether or not they are voluntarily engaging in an intrusive thought or trying to undo the intrusive thought. That occasionally is confused, but generally where there’s a question I encourage people to write it off as the spontaneity of the brain rather than it being volitional.
I’ve heard some therapists say their patient will come in and say, “I have HOCD, or I have ROCD, can you treat that?” and the therapist will be like, “I don’t know what you’re talking about, I’ve never heard of that, I just treat OCD.” So should therapists be following their patients’ lead more and looking into more of what the community is talking about, and still getting out the message that OCD is OCD and we’re going to treat it with the same research-based therapies, but to get more of a grasp of what we talk about in our support groups and in our community?
If you are a specialist in understanding and treatment of OCD, whether you know the letters or not, you certainly would be familiar with what the letters stand for. I think a true specialist also would want to understand that if someone has HOCD it really is important to look into the potential that this person also qualifies for a condition I refer to as perfectionism—although it’s still referred to as obsessive-compulsive personality disorder—which means a higher degree of attachment to trying to find the answers. One of the other things I’ve done in my work is really examine how certain subtypes of OCD correspond very significantly with certain personality styles, and I think a true expert would want to be aware that a female patient with body dysmorphic disorder is likely to also have features of borderline personality disorder and a man would have features of narcissistic personality disorder. This is a level of expertise that I think unfortunately very few clinicians across the country are up to speed with, so in that regard, the differentiation of the subsets of OCD are clinically very relevant.
One of the reasons I waited so long to get professional help was that I was afraid I’d be reported to the authorities if I shared my sexual intrusive thoughts with anyone. Do you hear this yourself? What would you tell someone with this same fear?
It’s understandable that they’re very afraid that they might disclose information to a clinician and if that clinician is not an expert, they may be misdiagnosed, or the clinician may develop an unreasonable or unnecessary concern about the patient’s safety or safety to others. I would interview any clinician before I opened up about any of the specific content of an intrusive thought to see what level of expertise they have and to say, “If I disclose the content of my intrusive thoughts and they involve topics that might seem dangerous or paranoid, are you aware that we’re talking about an anxiety disorder and not an actual threat?”
I didn’t know I had OCD, so I wouldn’t have known to ask a therapist that question, because I thought I might be a threat, so how do you go about that? Maybe that’s an unanswerable question…
Well, I think the answer lies in what you probably did, which was go online and unfortunately have to use your own judgment to find resources that determined what was going on in your world. Thank goodness that exists, and for you to be able to develop your own database, knowledge base, to be able to have an intelligent interview with a potential clinician who was claiming to be a specialist with OCD.
In some ways I’m glad I waited so long because when I finally went in it was the right person. He recommended The Imp of the Mind. I didn’t have to say much to him for him to know, which was great, because I was really afraid “I’m not going to be able to tell this person my awful thoughts—”
Hey, don’t judge your brain’s creative thoughts.
Yeah, super creative. I really am a strong advocate that we not judge our brains’ creativity. My brain has had a great deal of creativity in many different departments in life. I don’t have OCD, so I can’t fully comprehend the pairing of what is exactly my brain’s creativity as it would be for yourself, because when my brain shares these creative thoughts it doesn’t pair it with a tsunami of emotional distress, and that’s really the only difference between your brain and mine, is that there’s probably a malfunction in your amygdala that pairs an “I’m about to die” signal with these creative thoughts. But most humans report having these associations of one kind or another—without OCD they don’t have that paired distress signal, so it’s literally a three-second “Oh, thanks for sharing, brain” and it’s over event.
I get the other kind, the three years and it might be over event.
Right, but with the proper remediation you could definitely show your brain that you’re not going to be fragile about its creativity. I’ve seen people really put their OCD into a dormant state like a volcano that hasn’t erupted in years. I think there’s wonderful hope in aggressive treatment of OCD.
So if you’re saying that some people can put their OCD into a dormant state, do you think that means that it will explode like a volcano and that a dormant state is bad?
Not at all. I think a dormant state is wonderful. Many of my patients, after a successful treatment, have had their OCD go into a dormant state for years. Some contact me to say that their brain is kind of recharging on its signals and energy on some topics, and no big deal—usually it’s a four-session booster process of putting the monster back in the cage, and we’re the helpful best friends I sometimes like to say, and putting the cap on it again. All of our brains are capable of malfunctioning in this way—I’ve had about 27 panic attacks, not that I’m counting, in my life, and they’re very powerful and very overwhelming, but they’re very survivable. My relationship with my panic attacks is to say to my brain, “Come and get me, I’m here, I’m ready, and I’m not going to go to the hospital even though it feels like I’m about to die of a heart attack.” Anxiety is a very manageable entity.
Sometimes people will say to me that they’re afraid of going back to square one, but do you think that once someone has had therapy, and even medication, they never really will be at square one again, even if the volcano does erupt, so to speak?
Yes, absolutely. I don’t agree that people do go back to square one. I tell my patients when they have a bit of a setback that you’ve already blazed the recovery trail, you’ve already kind of gone through the process of recovery and therefore the likelihood of you doing it again is very great. I think that with behavior therapy; I wouldn’t necessarily say that with medication because medication doesn’t teach skills—it offers the potential for relief without developing a skill set to manage one’s brain’s creativity and diversity.
And could you tell them that there’s anything about their brain that’s actually changed with therapy and that it would take longer—I mean, I’m totally throwing this out there—but what would be the scientific answer for that, to be like, “Look, you actually reconfigured some parts of your brain and it will take more time than that to undo it all”?
Exactly, that’s very well put. The wonderful term is neuroplasticity, and, yeah, you do reconfigure the brain, you reconfigure the neural pathways and the speed with which they connect and you demonstrate the irrelevance of the alarm system, so yes, one cannot relapse in a single day. I tell my patients when they’re kind of signing the goodbye contract, “Look, if your brain is challenging you in a way you’re not managing well for two weeks, definitely give me a call and don’t let it go beyond that” because you can kind of reconstitute those more anxious neuropathways by giving in for a longer stretch of time.
So don’t call after one day, but two weeks is a reasonable amount of time.
A common question I get from individuals with OCD is whether ERP can help with sexual, violent, and religious intrusive thoughts. How does ERP work in these cases?
All of behavior therapy for OCD is predicated on exposure therapy, so you can basically do exposure therapy for any aspect of OCD: if you have a thought about God, you could write it down, as I have patients do on an index card, and carry that index card around with the statements of your own brain in terms of what the nature of the intrusive thought is and expose yourself to that topic ten times a day without engaging in an undoing response.
I’m a fan of what’s called repeated exposure. I always tell my staff—the center I work at and am a director at is a training facility—to think of exposures as something that could be done ten times a day. Exposures are based on the premise of facilitating what’s called habituation. It’s a scientific concept of how our brain stops reacting to stimuli that are redundant and voluntary, so that’s the beauty of behavior therapy, that it really takes advantage of neurophysiology, which is what’s responsible for the condition, so that’s why the treatment is so potent. I have done what are referred to as in vivo exposure exercises where I walked on the street with patients and we might walk close to an oncoming pedestrian and create the idea that maybe that pedestrian just injected you with an AIDS needle, or maybe that pedestrian looked at you and realized that you are gay.
What’s funny is a very well-known specialist named Jonathan Grayson used to do weekend camping trips with a gang of patients and they would go dumpster diving, and there were no showers permitted for the entire weekend, so that’s a form of flooding, which I certainly am a fan of, but I’ve never gone on a weekend camping expedition with contamination patients. But I certainly salute him for doing so.
What’s a misconception about OCD you’d like to clear up for the general public or even for people with OCD?
The biggest misconception, basically, I think from bad media sources like As Good As It Gets or The Aviator, is that OCD is often mistaken for perfectionism, you know people who are, say, lining their shoes up in a nice straight line, they’ll be like, “Oh, I’m so OCD about the way I put away my shoes.” OCD is not about perfectionism—that’s an entirely different diagnosis. OCD is about very threatening intrusive thoughts that are paired with a tsunami of distress and emotions and I think that the public is turning the term OCD into an adjective rather than a diagnosis and most of my patients who have OCD, when they hear that from the lay population, are pretty offended. They recognize right away that the person is not OCD, they’re just being a little bit quirky, and I think a lot of my patients feel very alienated and misunderstood when they hear people use that phrase “I’m so OCD about X” in a way that so clearly is a misdiagnosis.
That actually reminds me of another question I have. I grew up in a town that definitely did not have an OCD therapist. That sounds smart, obviously, to say, “Don’t go to just anyone, don’t rely on just reading about it,” but what does a person do when they’re in a rural community or maybe a different country where they’re just desperate for help, they don’t have someone within driving distance or they don’t have insurance. What do they do?
My very long answer—as I’ve been giving you very long answers—to that question, is that when I first wrote that article on thinking the unthinkable and it was distributed across the country by the IOCDF, I got a lot of phone calls in 1992 through the ’90s asking to work with people over the phone (because Skype hadn’t been invented yet). In fact, I used to say to patients, “Fly to New York, I want to meet you first, I want to see if we can develop a good working rapport, and then I’ll work with you over the phone.” So that started in 1992, I worked with patients over the phone, and for about ten years I noticed something very peculiar, because I’m a scientist and I keep track of a lot of things. I noticed the patients I worked with over the phone—guess what, Alison, got better quicker, got better the same, or got better slower than patients I worked with face to face. What would be your guess?
Well, I mean, my guess would be—ugh, now you’re making me—I’m gonna say they got better faster because that seems like the opposite…
That’s correct. Fifteen percent of my patients improved faster and had better outcomes than patients I worked with face to face. I thought about that, and it’s not because being in the same room with me and seeing my ugly face is a distraction: I guessed that patients who called me from across the country had had in local treatment failure done extensive research, and when they reached out to me they were very ready and willing to do very aggressive therapy, and that is obviously the ingredient for success, to be willing to engage in no-nonsense, brass knuckles exposure therapy. That’s where my national, and what’s now become my international, career launched, working with people such as yourself who live in a rural community where there aren’t experts but they wanted to work with an expert. The center provides, at this point, video therapy with VSee or Skype or Facetime. We work with people all around the world at this point, exactly to the reason you mentioned, that many patients who reach out to us don’t have access within a hundred miles of qualified experts.
What about a workbook that actually guides you through a hierarchy—obviously they’re not going to be held as accountable as they would with a therapist—but would you consider that a good first step, or a last resort, or a complement to therapy?
No, I never recommend people substitute bibliotherapy for face-to-face therapy. I think bibliotherapy is great as a learning instrument to say, okay, when I meet an expert these are the things they’re going to recommend that I do, but, no, I would never substitute reading, as I said before, in any way, for working with a qualified expert, because OCD is a complicated condition. My latest article is on how resentment is a form of ritualizing, and in this article I say I worked with many patients who are very treatment compliant and yet in the final stages of treatment are still not crossing the line into recovery because they’re expecting their brain to stop sending these cognitive signals. That expectation produces resentment and frustration and anger, and all those emotions are a form of ritualizing that perpetuates the condition. If you’re not working with an expert you’re not going to be aware of those nuances of treatment and recovery, and, you know, you won’t read about that in a book.
If you could share just one piece of advice with someone who has OCD, what would it be—to read your 45-page paper?
Forty-seven pages! Sure, I would start there, but I would also say never think therapy can be done through reading or through working with someone who has taken a weekend course in the understanding and treatment of OCD. OCD is a complex condition that ultimately benefits from working with an expert, someone who really knows the ins and outs of the condition, because working with someone who doesn’t understand OCD can be more detrimental than beneficial. My Choice article is a wonderful manual on how to be successful in therapy, but in no way is it a substitution for therapy. It just basically says to patients who read it, “These are the characteristics of people who get better in the treatment of OCD and this is why they derive improvement and this is a level of understanding of the condition that I want you to look for in any clinician who calls themselves an expert.”