Dr Michael Greenberg - Rumination is a compulsion (#252)

[Music] Hey guys and welcome to episode 252 of the ochthistories.com podcast. Now in this episode I interview Dr. Michael Greenberg. Michael is a licensed clinical psychologist. And then this episode I go on to specifically talk about rumination. And then we talk about his own OCD journey. The line between obsession and compulsion. What is rumination? Why rumination is a compulsion? Ideas around stopping rumination. The idea of a core fear in OCD. The importance of understanding the core fear. How understanding the idea that OCD is a strategy to keep you safe allows you to start to let it go. Our rumination may be the core of OCD. The idea of letting go of rumination when scared. How to stop ruminating about ruminating. The issues that may be getting in the way of stopping rumination. Why it matters how we talk about OCD. Words I hope and much, much more. Really interesting episode. I enjoyed chatting with Michael. And a quick shout out for our podcast partners, no CD. No CD therapy matches you with a licensed therapist trained to treat OCD. Offers a personalized treatment plan delivered through Face to Face at Video Sessions. Between therapy sessions you can use their therapeutic tools in the app 24/7. Message your therapist and learn what helps other people in the OCD. Community. To find out more head to go.treatmyocd.com/cold/cold stories, I'll click the link in the episode description. So there you have it. Thank you so much to Michael for his time. And as always to you guys for listening, I deeply appreciate it. And without further ado, here is Michael. On the podcast today is Dr. Michael Greenberg. Michael is a licensed clinical psychologist specialising in CBT for anxiety. So anxiety disorder is an obsessive compulsive disorder. Welcome to the show Michael. Thanks for having me. Yeah, it's good to have you here. And as you may have heard, I like to get when I get therapists on psychologists, I like to hear their story. So what got them into being a therapist or psychologist and then specifically working with OCD. I'll give you one guess why I work with OCD. You have it. So I don't know if I say that I have it because I'm overcovered enough that it's not like an issue in my life anymore, but I did suffer from it for many, many, for many, many years. And throughout that I was what we'd call a pure O sufferer. And nobody had an answer for me. And I was somebody who had I read every book on the topic. I did trainings. I trained as a psychologist and did two and a half years of training in OCD. And I could rattle off a list of every strategy that was supposed to work for me that didn't work. So I got her through necessity. Yeah, well, thank you for being honest. And so yeah, I guess actually let's just just on pick that a bit further if you're okay. And so yeah, so you said pure I was more of your experience. And you got here by necessity. When did you start to kind of figure out what was going on for you and what was going to work for you? I think that I had some like classic OCD symptoms around like contamination or like carcinogens and things like that. But nothing that really made me think of CD because stereotypically we think of somebody washing their hands. And it was only when I was in college at some point that I rolled a question that that brought me to like reading about rumination and things like that. So I remember so I was it was like 20 years before I even realized what the issue was. And then the excitement and relief of finding a diagnosis quickly did not give way to an answer because there was nothing that I could find at the time that told me what to do about rumination. The best the best the best people out there could tell me that it was rumination, but nobody really had an answer to what to do about that. Yeah. Okay. Sorry, the welcome question. I'm very. That's very interesting. The start of the question. Did you want to continue or should I kind of ask the question? Your question was how I how I. Yeah, how you kind of figured it out, I guess. Obviously that makes it sound simple. I'm sure it was a long process, but what started clicking for you? So the answer is definitely that it was a very developmental process. For some reason, the first step was realize that what people don't realize if they don't have OCD is that it's just a mess of emotion and anxiety and thought in your head. And you don't really it doesn't it doesn't come in the sort of our theory to one-eated way. And so being able to label the parts of that thought process and take it apart is something that once you know how to label it, it's extremely obvious. You know, I do which way is up. So something as simple as identifying, I mean, sort of the key. The key realization where you draw the line between the obsession and the compulsion. Sounds like a simple matter, but it is not a simple matter. And delineating demarcating the parts of this thought process are everything toward how you treat it. And there's a process of realizing that rumination was a thing realizing that I was room it realizing that I was room and hating but not being sure what to do about it. Thinking that if I found the right exposure that should zap a compulsion, which is not the case that exposure does not treat a compulsion. And then sort of realizing that the whole thing is a compulsion. That's the big realization. The big realization is that obsessions kind of don't exist. And obsession is just a thought that occurs to every human. The thing that characterizes OCD is that the person is often running trying to figure out what to do about that thought. So really the whole thing is compulsion. And I'm not truly saying that. There is a thought that occurs to you and it occurs to you more if you're a C.D. But in terms of labeling this thought process, the whole thing is compulsion and that means you have to stop doing the whole thing. Does that make sense? Yeah, I think I'm getting it because yeah, like you said, there's that study that came out a few years ago where so my 94% said they had interesting thoughts. And I've said this kind of joke before in the podcast, but I think the other 6% are liars. If you see the lady next to the train track, and you think of pushing her in front of the train, that is not an OCD thought. That is a normal fucked up human thought. What happens to somebody with OCD is that after they have that thought, they're off to the races trying to figure out what to do about it, trying to figure out. And the reason that so anyway, so labeling parts of the thought process. And then the big realization was that. Rumination is not just all of this is rumination, but all this is an analytical thinking and it's all controllable. And if it's controllable, you can stop it. And if you stop it, the whole problem goes away. That sort of that was the trajectory. Did that answer the question? It did absolutely. Yeah, thank you. Yeah, I like the view that it's the compulsions that make the disorder. But yeah, so, but people's yes, but people say the compulsions make the disorder in the sense that the compulsions are driving the disorder. Right, that's the sort of the cycle of the OCD cycle of this common idea, which I reject, because I think the compulsions don't drive the disorder. The compulsions are themselves the disorder. It's not that if you eliminate the compulsions, then the whole thing falls apart. It's that if you eliminate the compulsions, you are eliminating the OCD period. Yeah, that makes sense. It does, but that's a very good point because yeah, someone may get get rid of them doing so speech marks of the compulsions or stop doing them. But then still worry and maybe freak out that they're having these thoughts, but these thoughts, which you're saying, it's just perfectly normal human thoughts. So, yeah, I was just. I think we're saying the same thing, but just to clarify, we're saying, if a person the thought of occurring to you, that is not the interesting part. That is just everybody. But everything beyond the thought of occurring to you, everything beyond the split second, it might not even notice is something you are doing. So, when you said a person might worry about it, I would say worrying is rumination. So, if a person is worrying about having those thoughts, that is still compulsion and that still needs to go. Yeah, absolutely. Yeah, I agree. That's a great way to look at it. And yeah, I like this. This is a new. Well, I'm sure it's been said in different ways before, but I like how you're saying it on this show. So, thank you. So, you know, that does actually lead me in to actually, I've got a lot of questions around rumination, but because I've kind of put it in order. I'm going to put a pin in that, but I definitely want to unpack everything you just said. And I pull these questions from your articles. And one of them was around kind of just the people listening. What is the core a core fear in OCD or the core fear? And why is it important to identify it? So, the first of all, the concept of a core fear is not my idea. And I, after I got my license, I did a year of training with Ellie, a Dean, who is one of the co authors of the, at no foe a manual. Okay. She's amazing. One of the best in the world. And. the idea of a core fear is hers. So when I asked her, so her and she used to say that there were like just a handful of core fears being bad, ruining death and suffering. And I agree with you. Basically, once you know, the core fear is the underlying fear that explains the rest of what you're seeing. So it's this extremely parsimonious explanation for all of this like chaos that you see in OCD. So if you don't understand what the core fear is, then you're doing just superficial whack-a-mole concrete. Oh, you're doing a compulsion this way. So let's do it the wrong way. Oh, you think that thought. So let's, you know, do something that triggers you. So understanding the core fear helps you to make sense, to have a sense of coherency and organization and see the whole bigger picture of what's going on. So just off the, so okay, but you're not asking what to do with it. You're asking what is it? So I think that the core fear is always emotional. So the core fear, OCD is always about a fear of making a mistake. You can't take back an irreversible mistake that leads you to feeling a certain way forever and inescapable emotional suffering. And then what that emotional suffering is depends on the person, whether it's feeling ashamed forever, you know, being cancelled and being a social prior forever, whether it's feeling being alone, being alone forever, whether it's feeling helpless, but it can be very personal. Like one that comes to mind is like it can be the way I felt when I was a kid and we were poor and we were in the store and that woman was looking at me and I felt disgusting and I felt alone and I felt so angry. That feeling for that person might be the worst way they'd ever felt. And once you can find that sort of that core, all of a sudden this entire disorder makes sense and all of a sudden this entire disorder can be seen as simply a strategy of protecting that person against ever feeling that way. But again, it's always about irreversibility. It's about making an irreversible mistake that leads you to feeling that way forever. And what's notable about thinking about a core fear in terms of emotional suffering is that it leads us straight back from cognitive behavioral therapies straight into the world of the psychoanalytic. Because once we're talking about emotional avoidance or emotional affect phobia, all of a sudden we're talking in analytic terms. Where the symptom is something that's protecting you, defending you from feeling a certain way? Yeah. So yeah. Yeah, no, it's fascinating. And then you kind of alluded to it the start of that. So obviously it may not be a simple answer, but simply put how would you kind of work with that? Or if you do or if you just keep it as like a formulation in your own mind. You mean the psychoanalytic piece of a core fear? The core fear. Sorry. So the core fear, if you don't understand what the core fear is, you don't understand the case. Like if you don't know what this is about, then you're just kind of like again playing whack-a-mole. So basically what you want is a clean case conceptualization where you can line up here in my forms of avoidance, here in my form of compulsion, and I understand how each of them relates in turn to the core fear. And by helping a person to see these symptoms as actual strategies that they're using to protect themselves, you restore a sense of agency. A sense that no, this isn't something that I can't stop doing. This is something I'm scared to stop doing because I'm doing it on purpose to protect myself. And if I would define a compulsion by the subjective lack of agency that a person has about it, if I'm doing something, even something extreme, but I want to be doing it, that's not a compulsion. It might deserve treatment, but it's not a compulsion. A compulsion is when I feel like I can't stop doing this thing even though I want to. I feel like I don't have agency. And by helping a person to see that what they're doing is actually a strategy that they're scared to let go of, that they can let go of, you restore the sense of agency that then facilitates letting go of that compulsion, making a cost benefit analysis, recognizing you have the ability to let go of it is a step towards making the decision to let go of it and eliminating the symptom, the compulsion, the importance, etc. That makes sense here. So basically seeing it as seeing it in one of the core fear helps you to see it as a strategy, which restores a sense of agency, which allows you to make the decision to let it go. Is that? Yeah, yeah, it does, absolutely. And we're finding people's core fears. I can imagine it can probably be quite complex and ingrained and deep down. Do you really need to nail, like you gave a very clear memory of someone in the supermarket or grocery store and being perceived as poor and the trauma they felt as a result of that? Do you need to understand that in every case and every person or? I don't think you necessarily need to know what the like trauma, I also don't think that it's really one one like moment. I just think that sometimes there are memories of one or several sort of capture that that very personal feeling. But typically, especially for thinking psychologically, typically this is something that's repeated itself over and over again. So you do need to know, I think you do need to know what the core fear is, but I don't think it's so essential to know where it came from. I think the more you understand where it came from, the greater the sense of coherency, the greater the sense of of this makes sense. This isn't sort of just this out of control chaos. So I think it's better to understand it, but I think you always need to know what the core fear is or you are just going to like, thoughts around to make a mess of the case because you're not really you don't really know what you're doing exposure wise if you don't understand what the core fear is. But in terms of where it came from, I think that's relatively less important. Okay, cool. Yeah, thanks for the distinction. Okay, well, let's kind of loop back to where we started with rumination and rumination being a compulsion. I guess before we get into that, why if you could just clarify again specifically what rumination is and why it's a compulsion because I think a lot of people, at least historically, how I viewed it, it was always something that I was kind of, it was like a thought process in my mind. And it seems obvious now it's a compulsion at the time it didn't. So people will present with with pure, you know, as it's called and say, I can't stop having the thought that I'm a pedophile over and over and over again. So the person will tell you that they're having thought over and over again, but upon further investigation, that is not what's going on mentally. What's going on mentally is that they're constantly trying to figure out if they're a pedophile. It's not that the thought is occurring to you. If the thought were just occurring to you, you couldn't do anything about that. That's where pink elephants and thoughts are pressing come in. You can't stop a thought from occurring to you, but you can control analytical thinking. The fact that you're sitting there, thinking, and that what's happening is, let's say for example, I see a knife, I see a baby, the thought occurs to me, I could kill the baby with the knife. Then I get scared and I launch into, oh my god, could I do it? And then I'm actively imagining killing the baby with the knife to see what my reaction is. And then regardless of what my reaction is, then I'm doing it again or in a different way or with a different baby or with a different knife to try to figure out if I would do this. And before you know it, I'm thinking about killing a baby over and over and over again, right? Or maybe I'm spending the whole day every day thinking about this, but it's not that the thought is just occurring to me over and over again. It's that I'm on a rampant pursuit of the answer to this question. Yeah. Even, and sort of it's just an extra piece to that, even if I'm not literally sitting there analyzing, I'm at least directing attention towards this issue. And directing attention, like analytical thinking, is controllable. It's all a bit of behavior if you will. It's something I'm doing towards solving this problem that is actively keeping it in my mind all the time. So the analogy I like to use is that if you say to someone, you're doing this on purpose, right? You're not trying to stop. That's very invalidating. So I usually like to say it's like you're it's like you're holding on to a basketball as hard as you possibly can and also trying to drop it as hard as you possibly can. It is true that you are trying to drop the ball, but it is also true that you're holding on to it as tightly as you can and that you can't do both of those things at the same time. So people are pure or saying that they're trying to stop thinking about this, but they're also desperately trying to answer this question. And those two things are obviously mutually exclusive. It does. Yeah, that's so true. I'm smiling. That's the great analogy. And how is that received when you kind of give that basket? It's usually very well. Usually people are like, that's exactly what's happening. I haven't really had anybody ever say, oh, that's so invalidating. Because they're like, yeah, that is what I mean, I can tell you from personal experience. That's what I was doing. And I wanted something, something exogenous, like an exposure to come in and zap, zap my rumination and make me stop. But I hadn't made a decision to stop. Once I made the decision to stop, I made the clear decision to stop no matter what the risk was, all of a sudden, it's gone. You can't do both at the same time. And of course, people are conflicted because they're terrified. Like any other compulsion, they're terrified to stop doing this thing that is a strategy for keeping them safe. So it's understandable that they're not stopping. They're terrified. But let's establish that they are doing it on purpose. Again, on purpose is a, isn't it? If you want to say, I get it. They have control over the thing that they are doing. Even if they don't experience themselves. as having control. Yeah, absolutely. Yeah, so that was going to be one of my questions. I can imagine when you when you talk about the basketball analogy and then you, I can imagine some people say that's absolutely correct. I want to drop the ball, but I'm just so afraid of letting go. How would you work with them then to kind of get them to that place where they're willing to? As you said, might this decision type the risk? So I think that that's sort of the the crux of the therapy. So the fastest I've ever, if people have to work through recognizing why they're doing it, doing a cost benefit analysis, establishing if it's doing anything for them, it's usually pretty obvious upon investigation that this compulsion is not accomplishing anything, right? It's not like, I usually think of it like this. If if we were doing cost benefit analysis, even if there were some benefits of this compulsion, the cost far outweighs it, but that's never the case. It's always the case that there's no benefits of this, right? Like like ruminating about whether you're gay all day, it's just not a good way to figure out if you're gay, right? It's not that if a person says, well, what I need to figure out a friend gay, the answer isn't, oh, well, that's true, but the OCD is still making you sick and so you have to weigh those things. No, what I'm saying is there is no benefit. You cannot figure out if you're gay by sitting there and ruminating about it all day. If that worked, you would already know, right? Oh, it's sort of like a it's it's helping them to see what they're doing, why they're doing it, establishing that it's not working. Yeah. And then making decisions to let it go, but that process can be that process can take a bit if to really get under the justification, what it's doing, how it's protecting them. Sometimes that's very nuanced. That's where I think, you know, that's where help can sometimes be important. But for the record, people who are ready to just drop it, I see the problem ready to let it go. People get better extremely quickly. The fastest pure O case I've ever treated was three sessions. You're doing this, here's how you stop and then they stopped. It's more typical to have to work through this piece of like why are you doing it? Are you willing to let it go? What's the justification? Right? And that park is sort of stretch out. But at the end of the day, it's just about making the decision to let it go. Yeah. Yeah. That kind of valued commitment. As you said, see, this isn't serving me. It's making no positive difference to my life. Not working. Yeah. Working. Yeah. Yeah. No, thank you. Well, let's stay on rumination for a bit longer. I can't have a room for the rest of my life. There's not only your hair, right? I'm trying to find one that you've kind of answered this. Okay. So maybe this one. How do you get unstuck when ruminating about how to stop ruminating? People talk about this, like, it's a complicated question, like, it's like that. This is not a complicated question. Rumination is analytical thinking. If you're sitting there trying to figure out how to stop ruminating, the same way that you would stop ruminating about anything else, you need to stop ruminating about that. Does that mean that's the same thing? If you're directing attention toward it, or you're sitting there figuring out, okay, what do I do? How would I ever? Then you need to stop. That's it. It's the whole story. Yeah. Absolutely. It's not it's not by complicated. No, thank you. I like that. And yeah, just with rumination generally, it being a compulsion. How do you go about, because you said free sessions there, and I'm sure it's not, as you say, in many cases, not that simple. But I'm saying it can. No, no, absolutely. Yeah. But for some people, many weeks, many months, who knows, many years, how. I don't know about many years. I think then we have a problem. Okay. How do you work? We've like, cutting out that compulsion. So, like, I. It's distinguished between problems in methodology and problems in justification. So there's a difference between the two questions. I sort of have two questions from the Y-box that I use in this regard. One question is, how consistently do you make the decision to stop ruminating? Do you make the clear decision? Not, I'm conflicted, I'm waffling. How often do you make the clear decision to stop? That's one question. And then a separate question is, how often are you successful? If we have somebody who is not making the clear decision to stop, then what we need to focus on is justification. Why are you doing this? Are you to sign to let this go, etc.? Right? But if we have somebody who's saying, "No, I really am definitely committed to stopping, but I just can't do it." Then what we need to look at is issues in methodology. You're doing something right. If this is hard, not rumating is easy. It's not doing anything. There's no replay, it's not mindfulness, it's not thinking about something else, it's not pushing it away. It is literally doing nothing. It's getting off the treadmill. So if somebody can't do that, there's something wrong in their approach. If it's hard. And so sorting through those issues are then a separate issue, a separate problem from justification. However, there's just a handful of issues that people have. It's not like infinite. It's like five. It's the same things over and over again that are getting people stuck. For example, it is, I'm holding it at bay. I'm trying to keep the waters at bay. No, stop. You don't need to do that. Rumination is not something that happens to you. It's something you do. Just don't do it. It won't assert itself. You don't have to lean up against the lock door. That's one. People will often try to distract themselves, which nobody asked them to do. You don't need to distract yourself to stop analyzing. Another one is mindfulness. No, nobody's asking you to do mindfulness because we need to not ruminate all the time. And you cannot do mindfulness all the time. It's also unnecessary. So there are just a handful of things that people are doing or arguing with the thought. There are just a handful of problems that people have in terms of methodology. And you just have to figure out what they're doing, zap them, and then they're good. To that make sense. But that can be done. That part's easy. That can be done in a matter of minutes. The justification side is that. So you have to sort of keep tabs of both of these things and assess what the problem is. Does this person know how to ruminate? How to not ruminate? And they're just not doing it? Or is there some issue with their approach? And they need to clean that up. It does. Yeah. As you have to speak in, I've got the voice of some of my listeners in my head. And I can imagine them thinking, this all sounds brilliant. But how do I just stop ruminating? So I think it's those two things. It depends on what we're asking. Is it how do I stop? How do I make the decision to stop? Or how do I stop? Like, what does it mean to stop? Yeah, that one. What does it mean to stop? Yeah. Do you know how to stop ruminating? Because if not, I would love to teach you. Yeah, please do. I think I figured out, but I don't, I couldn't put into words. So basically, I would say to someone, here's this question that's haunting you. This issue, am I pedophile? Am I God forbid straight? Am I gonna murder my grandma? Whatever it is, right? Here's this issue that's bothering you that I'm usually paying attention to in trying to solve. But I want you to do is we're aware of that issue. Yes, we know that's a question. But I want you to do is don't try to solve that now. I'm not asking you to keep it in mind. I'm not asking you to push it away. It's there. It exists. It exists like corona exists. You know, it's corona, right? Right? Don't want you to like think about what we're going to do about it. Okay. And then I asked the person to do that. Okay. And then they either say, yeah, I say, was that easy? And either they say, yeah, that was easy. Good. That's what it means to not ruminate. If they say, well, I don't know, it was a little hard. Then my question, what were you doing? I was asking you to do nothing. So what were you doing? And then we solve whatever that is. So, for example, were you keeping an eye on it? Were you directing your attention toward it? Okay. So we're not going to do that. Were you trying to think of what you should think about instead? Okay. We're not going to do that. What you just peel back those few pieces. And then it's like, okay, to not ruminate is to do nothing. I get it. It's easy. Now the question is, am I willing to do that all the time? And that's where we move into the question of justification and letting it go. But does that make sense? So how do not ruminate is to stop trying to solve this problem in one line? Yeah. I got that. I'm a very visual person. So I saw you using your hands and it wasn't like, I'm asking you to put this over here. Or it was just kind of, we see it, we acknowledge it. Now don't. But acknowledging in a very passive sense, I think the word acknowledging or accepting makes people think that they have to do something to that like an active acceptance. That is not what acceptance is. Acceptance is it's COVID. Like it just it you don't need to accept that it's COVID. It just is COVID. That question exists. Yeah. That's it. You don't need to hold it. Just noticing it. That's it. But not in an act of it is in your aware. I'm aware. You're periphery. Yeah. But again, not in the sense that you're doing anything. In the sense that you're not doing anything. You're not holding it in your mind. You're not pushing it away. It just is. The question exists and your job is to not do anything about it. Okay. That clarifying. It does. Yeah. Absolutely. Yeah. Important distinction. Yeah. Because I can imagine that's the first time someone hears that trying to get the head around the idea of, well, am I putting it on kind of a shelf or am I, you know, but just, you know, they're looking to what am I supposed to do in the end? answer is you're not supposed to do anything. You're supposed to do nothing. The answer to a compulsion is not to do the compulsion. It's not to do an exposure or to, you know, repeat an affirmation. The answer is to not do it. So the same is through for remination. Yeah, that's probably yeah, a good way of putting it. Whatever a physical compulsion is, the idea of the RP or the RP is to stop doing the compulsion. No, the RP is everything. Yeah, there's no exposure for remination. There's RP for remination. Yeah, nice. Thank you. Yeah, I like it. Okay, let me dig out my next question. So okay, let's go on to, I made a note that something you said on your website, one of your blog posts, I can't remember which now, you said it matters how we talk about OCD. What is this about and why is it important? I'm so glad that of all the topics you picked this one. So going back to what we said earlier about agency, when people talk about, yeah, this really comes in two forms. This comes in the form of talking about the OCD as if this it's this exogenous outside force, you know, that's exerting. It's it's control on me. Right, that's one problem when we talk about OCD as if it has a life of its own. And then the other problem is what I would call behavioral or neurological reductionism. Oh, it's just a chemical imbalance, which is a theory that has been debunked, or it's my operative cutting nucleus, or it's my serotonin levels, or it's whatever it is. All of these things undermine the sense that you have agency. All these things undermine the fact that you have choices that you are making that are producing this problem. So when we talk about, if the definition of a compulsion is that I have a subjective lack of agency. And the answer is to restore my sense of agency so that it can make a decision to not do the compulsion and the avoidance, anything that takes away from a person's sense of agency, that they are the one doing this, that they are doing it on purpose to protect themselves and that they need to stop is a problem. So when we talk about like, oh, like the OCD said to me, or like your OCD said, no, you were conflicted, right? Or the thought occurred to me. Or, you know, I wanted to, I don't know, what's a good example? Just, yeah, basically anything, anything that undermines a person's sense of agency is a huge problem in how we talk about OCD. I never use the term, the OCD, and even with children, where people like the externalized, oh, it's the OCD monster, I don't like that. I never do that. My idea is you are doing some, what are you doing and what is the consequence of what you are doing? That means if I'm doing it, I can stop. Even for a tiny kid, you are scared, so you are making a decision to do this. And I want to be clear, this isn't victim blaming. I understand it's terrifying. I live this. It's terrifying. But that doesn't change the fact that because you are terrified, you are making a choice to do something. And therefore, you can make an alternative choice. So I think that's in a nutshell the answer to the question. Yeah, no, thank you. And thank you for the distinction because, yeah, I'm sure some people could have interpreted that as potential victim blaming, although I don't think you at all put it across like that. You put your adjustifications through. But yeah, I am all four personal agencies. As soon as you rob someone of that, you quote unquote, paralyze them, you know. And I think that's the OCT is. OCT is I don't have a choice that can stop from doing this. That's what it feels like. Yeah, we want the person to realize that you can stop you're just scared. Absolutely. Yeah, I mean, that's a good point. I OCT itself, that I mean, I've heard it many times. I've found myself, I don't have a choice here. I'm not in control. It's more powerful than me. And as I'm speaking, I'm saying it's an external thing. When that's just, yeah, not the case. Okay, now thank you. Thank you. I love that. Okay, so you did talk about Forts Suppression earlier. And is it the pink elephant? Yeah, just if you could explain that a bit more and why it doesn't work. So I would argue that Forts Suppression is one of the most harmful concepts or one of the most harmful forces in the world of OCT. So Forts Suppression for those who don't know, and I'm sure they don't exist, I'm sure everybody knows. Forts Suppression is the idea that if you try not to think of something, you'll think about it more, right? That only applies to a thought occurring to you. That only applies to being aware of something. Because obviously, if I'm standing around thinking, don't think about something, then I'm thinking about something. The crucial distinction is that Forts Suppression does not apply to analytical thinking. If you try to stop doing a math problem, you don't do it more. If you try to stop planning your vacation, you don't do it more. If you try to stop, that's about example. Yeah. And therefore, understanding that if you think of rumination or pure O as thoughts occurring to you, then the conclusion you would come to is that you have to let those thoughts be there because otherwise it's thought suppression and you'll think about it more. But when you realize that rumination is compulsion, is analytical thinking, it's something you were trying to figure out. All of a sudden, Forts Suppression has nothing to do with anything. It is irrelevant. And telling somebody to just let the thoughts be there, which is why I hate act and rage by act. I want somebody to just let the thoughts be there is the most harmful thing. You could possibly say to someone who is ruminating. That's Iatrogenic. You are making them sick by telling them to just let the thoughts be there because they can sit there just letting the rumination go. I noticed the thought that I am just letting the thought be there that I am afraid that I am trans, not that I am not trans, whatever. I am noticing this piece of evidence, but I am noticing that memory, but I am noticing that time I like that dress, but I am noticing whatever it is. That's rumination, and you are just letting the thoughts be there. That's a kin to mindfully washing your hands. Thought suppression does not apply to rumination because rumination is analytical thinking. Or put another way it is controllable thinking. Yeah. It applies to the random human natural intrusive thoughts that everyone gets, but not rumination because that's a compulsion. Correct. It applies to the thought of occurring to you. You are going to try to stop it from occurring to you. You are in trouble. Everything that follows that, which is everything after the initial micro millisecond, everything after that is not subject to thoughts suppression. Thank you. Yeah. I thank you for your views on act. It's good to get some alternative perspectives. I am sure I will make a lot of enemies that work. That's so good. I am not sure how you are going to ask this question, but advice for living with uncertainty. I think that focusing on living with uncertainty is actually missing the mark in OCD. When people say people in OCD can't live with uncertainty, I think it's totally not the case. People with plenty of uncertainty. In every area of their life, other than their core fear, when it comes to this one area where they are terrified and making a mistake, they can't take back that leads to their worst fear forever, they are not willing to take any risks in that department. That is not about the fact that they can't live with uncertainty. It's not like we need to know what's for dinner. Right. So I don't think that people at OCD have some like essential problem with uncertainty. I don't think we need to think in terms of living with uncertainty. I think we need to think in terms of making a decision to let go of this thing that I'm doing to protect myself, which I guess at the end of the day is taking a risk and is living with uncertainty. But I think that it's suddenly, I think that that issue suddenly misses the mark of what's going on in OCD. Yeah. No, thank you. That question has divided people before. Okay. So how has your view of treatment changed over the last sort of few years if it has? Oh boy. Okay. Here we go. So I was, I was, I would call it classically trends in ERP, at Mount Sinai with excellent supervisors who were, it was a great program. And that model was the habituation model, right, which is we need to expose you to the thing that makes you nervous or expose you to the anxiety and how you gradually habituate to it. That is something that makes perfect sense on paper, but I don't think actually makes sense in real life. So I would explain it to people as you know if you're afraid of a dog and then you avoid the dog, you'd never stop being afraid of the dog, but if you play with the dog, then you'll habituate to the dog, right? Yeah. Well, I'm talking so fast. I'm sorry. So good. Yeah. Okay. So I don't think that's what's happening when you're playing with the dog. The reason I expose your works is because you're like finding out that the dog doesn't bite you. You're finding out that you don't pass out. You're finding out that it's fun. You're like having a whole new experience that disabuses you. You're previously held, you know, beliefs about dogs. So the way Emily Adian puts it is earthworms habituate, humans learn. So the whole idea of habituation has gone out the window for me. And then I'll come back to that in a second. The other piece is with the rumination. So I don't just think that rumination. is an issue in pure O. I think that rumination is an issue in OCD and anxiety in general. I think it is the cornerstone of the entire disorder and I think it has to be the starting point and the crux of treatment. And when you put these things together, you come to a very interesting conclusion, which is that not only do I not think that anxiety is important during exposures, I actually think that if you're anxious during an exposure, it means you're ruminating. And so I actually want an exposure to be done with no anxiety. And so classically, classical ERP, let's say we had somebody with a metaphobia who was afraid of eating sushi. Okay. So classical ERP might look like we're going to eat the sushi, we're going to think about vomiting, we want you to be anxious, stay with the fact that you might vomit, anxious, anxious on purpose, stay at whatever. What I want to do is, okay, we're going to eat the sushi. I want you to not ruminate about what we're going to do. So we're not ruminating. Okay. Pop it in. Don't ruminate. Don't monitor your stomach. Don't think about vomiting. Okay. Carry on with your day. We're going to move on. Don't ruminate about what we just did. The goal is to actually have no anxiety during the exposure. So this is really turning ERP on its head. So we don't, in my practice, we don't start with exposure. We start with response prevention. We start with making sure that you know how to stop ruminating and doing that on a regular basis. And only then do we do exposure in the context of not ruminating. And it works. So it's, it's incredible how much faster and better it works. Because a person learns that if they can modulate their rumination, then they're not anxious. So put another way, you can think of OCD as sort of two fears. There's the core fear that we talked about. But then there's the fear of the anxiety itself, the fear that, at any time, something can trigger you and you will fall into this abyss of compulsive rumination and anxiety. And teaching people that they can actually control their anxiety by controlling their rumination addresses that fear. They're not living in fear of being triggered and falling into compulsion. Because if they stop ruminating, they can actually rein that in. It does. Yeah. And so, so the way that my practice has changed is actually diametrical. Not only am I not a moving for anxiety, I'm aiming for no anxiety during exposures. Yeah, that's really interesting. And yeah, I can see how with the sushi example, and I could have done with this example earlier today because I'll see you in some shellfish. And some of it didn't quite look right. And I thought, I want to eat it. But if I eat it and it gives me an upset stomach, I've got a chat with Michael and it's not going to be fun for me. So I put it, I pushed it aside and didn't risk it. So maybe that was a smart choice, I don't know. But I can see how yet with that, trying to get to a place where there's no anxiety and exposure of say eating sushi, I am then learning, for example, the sushi isn't bad, it's fine and it's whatever. You're just learning that you can make the choice to eat it. And that it doesn't make you anxious. Yeah. Right. If you eat it, if you do it and you're anxious afterwards, then yeah, you'll learn that you can eat it, but you learn that if you eat it, you'll be really anxious afterwards. You do it without ruminating, you learn that it's not a big deal. Yeah. Yeah. And yeah. So habituation is very much the traditional classic model. But then I was seeing, "Hibitory Learning" came along. How does this differ from inhibitory learning theory? This is in the same direction as inhibitory learning, but I think it's a little, I think it's like, stuff. It's further. Right. It's further. It's moving away. It's saying habituation anxiety is not just not important. It's harmful. It's a problem. And it's because there's a compulsion going on. Yeah. Okay. Cool. Now, thank you for the distinction. Cool. I'm glad I asked you that question. Okay. So I'll ask this one. Where's the hope for those of ACD? I think that one of the most problematic issues in the OCD community is the myth that OCD is a chronic condition that you will never get better from. And there are four, first of all, don't hope for all better. This is like a lifetime problem. And also, I think that's used as an excuse by clinicians to knock at people all the way better. So you do something that works ish or gets them a little better or gets them below Y-Box 12, which is still pretty sick. Right. And then you say, "Well, OCD is just a chronic condition and you just have to manage it and do your exposures and blah, blah, blah." So I don't believe that. I think that that is just that the treatment has not been completely effective. I think that's largely because people don't know what the core fear is and rumination has not been addressed. Right. I think that's really the crux of it is compulsive rumination is a big problem. And I do think that OCD is fully treatable. I don't use the word cure because at the end of the day, if you go back to compulsion and avoidance, you'll still be sick. But I think that you can get so much better from OCD that it's really not a part of your life anymore and that you don't think about it. It doesn't bother you. It's not even there most of the time. Maybe occasionally have a moment, but you know exactly what to do. So my words of hope for the OCD community are, let's get rid of this idea that OCD is a chronic condition and let's not settle for anything less than 100% better. Thank you. Yeah, thank you, Vizierna. Okay. So slight change now is if you could pick up the phone and call your 20 year old self, what would you tell him? Rumination is a compulsion. Nice. Love it. And then you've got a billboard. What do you want written on that billboard? Thanks, that's a rumination. Good to have to one can have that on, but I want a new answer. Okay. No exposure is never a replacement for response prevention. There is no exposure that you can do that will stop you from doing a compulsion. You need to stop yourself from doing a compulsion. So my billboard says exposure is never a replacement for response prevention. Yeah, I love that. Yeah, absolutely. Yeah, I always say exposure is like the sexy part of the treatment, but it's not really the thing that helps. It's the kind of, it's the starting block, but it's not. If you're coming from a habituation perspective, it makes sense that exposure is the most important thing because that's what causes the situation where you're habituating to them. But if you don't believe in habituation, then yeah, exposure is not the only purpose of exposure in my book is either just to eliminate an avoidance, right? Obviously, or to practice response prevention. In other words, its value is only in the response prevention and has no value in and of itself. We do an exposure so that you can practice response prevention even when you're anxious, even when you're triggered, I should say. Yeah. So exposure, I think it needs to be really deemphasized. We do exposure. My practice does ERP. We do exposure, but the purpose, the conceptualization of what you're doing and why you're doing it has to be radically different. Yeah, yeah, littlely big RP. Big RP. Yeah. Yes. Nice. Cool. This has been really eye opening for me, and I'm sure my listeners. Is there anything else you wish you could have said today? I just want to apologize for realizing and retrospect how fast I was talking. You're trying to cram in so good. It makes me think of my, my, my apartment speech. You're efficient. I don't think anybody heard a word. Yeah. Anyway, so people can just, you know how you, people listen to podcasts. I'm like, I'm going to slow it down. Yeah. I'm looking to the point. Yeah. Excellent. Thank you so much for coming on. I really appreciate your answers. I'm talking about your own OCD. Thank you so much. This is really fun. Thanks a lot to Michael for his time. Thanks a lot for your time for listening. And don't forget today's episode is sponsored by no CD. If I don't more write no CD and to check out their ferrary plans, head to go.treatmyocd.com/thedestories. And a quick disclaimer, this podcast is not therapy. It is not a replacement for therapy. Please seek treatment for a trained professional. And until we speak, take care.