Nate Gruner and Meaghan Cleary: Functional Analytic Psychotherapy for OCD (#475)

You're listening to the OCD Stories podcast hosted by me Stuart Ralph. The OCD Stories is a podcast dedicated to raising awareness and understanding around obsessive-compulsive symptoms. I do this for interviewing inspired therapists, psychologists and people who have experienced OCD. Welcome to the OCD Stories. And welcome to episode 475 of the podcast. And this one I got back on Nate Gruner and Megan Cleary. Nate is a staff behavioral therapist at the obsessive-compulsive disorder institute at McLean Hospital. Megan is a licensed mental health counselor and a registered dance movement therapist. She is also a behavioral therapist and group facilitator at the obsessive-compulsive disorder institute at McLean Hospital along with Nate. So in this one we discuss what is functional analytics like a therapy or FAP for short, the rules of FAP using the therapeutic relationship to create change, what FAP looks like in a session, case examples, the therapist training on FAP that we are running through the center I co-run, integrating FAP with exposure and sponsored prevention therapy and acceptance of commitment therapy, why I'm interested in FAP and much more. And thank you to OCD for supporting the podcast. OCD offers effective and convenient therapy available in the US and outside the US. To find out more about no CD, their therapy plans, if they currently state your insurance or to download their free app, head to go.treatmyocd.com/cocdstories or the link will be in the episode description. So thank you to Nate and Megan for their time. It was awesome speaking with them. Interpersonal therapies and FAP is something that's peaked my interest for a while so it was great to go into this in more detail and of course thank you to you guys for listening as always it means a lot and without further ado here is Nate and Megan. Welcome to the podcast Nate and Megan. There. Thanks for having me back on. No worries. Thanks for letting Megan join us. Yeah, absolutely. I say there's always there's always gaps when there's more than two guests because then like no one knows who to speak. So you know, so Nate as you said you've been on the podcast before but it'd be good to get just you know, an elevator pitch on who you are and Megan just to introduce yourself as well. So I'm at the OCD Institute at McLean Hospital and I'm a behavior therapist there. I've been on your podcast twice before talking about functional analytics, like a therapy and I invited Megan to join us today because we are eventually going to be doing a training on FAP or your clinic which we'll talk about later in that episode and I think Megan is one of the best therapists I know and she really gets fat so she's here joining us today as well. Thank you. That's like quite the introduction. Thank you. So I am on Megan. This is my first time on the podcast though I I have really sort of enjoyed them listening to them for quite some time and I have I'm currently at the OCD Institute. I've been here since about as a behavioral therapist 2021 prior to that I worked in sort of hospitals focused around eating disorder care and sort of I am I like to say sort of a bit of like a regular therapist as much as I am also a dance and a movement therapist so for me really thinking about how someone experiences their body, how they feel in their body and also what they're communicating through that and how their nervous system is just handling the world around them is sort of very much a passion of mine. So and that's I think why I've always been so drawn to FAP is that a lot of behavior is happening in a given interaction with someone that I'm working with but bringing that into awareness and being able to work on that is something I've always been so curious about and that's very much how neat and I actually got connected around this. Okay amazing amazing so McLean is there like a cohort of therapists who have taken to FAP and are using it or is it like mandated down through McLean how did FAP become a thing at McLean? Well I'll tell you the short story and then Megan can add to it. So I got interested in FAP probably I think I said this on a previous podcast probably around 2015 and I got supervised in it and then really started doing it more with patients and then when I went on your podcast in 2021 I started realizing that we should probably more formally be rolling it out at the OCD Institute and it wasn't clear yet to the staff that like this was something that we were going to be doing with our patients. We really were on board with ERP and ACT and the evidence-based therapies for OCD but we really didn't know that interpersonal work was something that we would do at the OCDI and so Megan and I started I think it was in 2022 a FAP kind of consultation team with the BT's the behavior therapists at Arclinic and what I've found interesting is I think they're very interested in FAP the staff here the counselors who Megan supervises the entry level counselors and the senior therapists here but when it comes to us actually living and breathing FAP in our interactions with each other I think it's been very scary for us so Megan and I have tried to do like this consultation group where we give each other feedback on how we're experiencing each other which is we'll get into that in this podcast and I think our staff have been pretty nervous about that it's been very vulnerable for them to share with each other things that are happening interpersonally in the moment. I definitely see a lot of our staff really seeing the utility in it is that you know we introduced a FAP group amongst our patients sort of weekly and it has had such a wonderful response from the patients around it being something they look forward to something that feels really integral to their treatment and so I do think that we see a staff how important it is and how given that we are a residential setting we do see so much of these people right and not only just our individual sessions but groups sort of personal interaction just on the unit and I think there's a lot of merit in sort of bringing attention to those almost like target behaviors that could be worked on in treatment but I think very much so we're still like in the very early stages of like how we really fully incorporate that into our program. Yeah yeah absolutely and I think you know FAP is it's not new I don't know when it was created but it's not like yesterday you know it's but it's been around long enough that you you could argue it probably should be bigger than it is and partly I think that is there's just no trainings you know when I look to do more I did I did supervision with Nate actually he supervise me for a little bit on FAP and OCD and but then when I looked at other trainings I could find one through a website it was like a two hour training I couldn't find any other trainings or diplomas or courses definitely not on OCD. I guess I don't know what my question is here maybe it's just why why is it they just terrible at marketing themselves or is it is it rubbish like what why I'm just putting my you know I have I have a quick thought on this and I want to hear what Megan has to say I do have a feeling they haven't marketed themselves as well as the act in ERP community but I actually think it's pretty hard to sell FAP to clinicians who have been used to using treatment protocols so this is especially true in evidence-based therapy that they then I was so guilty of this early in my career I could basically do therapy with patients where I said a bunch of smart things that I knew of about ERP and act that were all on target but they had nothing to do with my relationship with the patient they were mostly focused on like the thing the patient needed to do internally or like out in their life that would make their life better but not between me and the patient and I think a lot of clinicians are scared to talk about what's happening in the room between them and their clients and the interesting thing about Megan is I think Megan's always been drawn to that approach to be honest with you I've always been drawn to it as well because I just really like genuine relationships in my life but I was sort of trained not to do that with my patients to really talk about what's happening between us and I think a lot of clinicians are scared of that yeah I totally agree Nate I think that there's a this sort of like division I was exposed to it more from like a psychodynamic approach and I think there is sort of it feels almost like this you know bad thing to bring in to behavioral work of like oh that's something you know that is counter-transference and that's something separate and you manage it in supervision but it's not something to sort of bring into the work so I think there is this hesitancy like how and almost in a very like rigid like concrete way ourselves and like how do I do this like please show me the steps of how I might sort of implement this kind of work and I have to to say even sometimes my pet peeve is like what and someone says, how do I do FAP? It's like they're looking to some sort of manual. And I think that's a big part of why it hasn't caught on as much as sort of ERP or ACT or CVT right classically. And it is challenging, I think, even when Nate and I sort of talk about it with other clinicians that we have, really to articulate it in a way that doesn't feel sort of even going away too far past boundaries between patient and therapist. I think there's a lot of years that people have around misusing it. So in some ways, we've avoided it almost all together. Yeah. Yeah, I mean, that's a really, really good answer. I think, yeah, when you've been so focused on symptom reduction or externalizing things rather than, yeah, we always remind of Erwin Yolom and his gift, the gift of therapy book. He says in that, the here and there relationship is the most powerful thing we have, which is what FAP's using, right? Is what's happening in the here and now between therapist and client or patient and FAP has kind of found us somewhat systematic way or structure to use that here and now relationship. So as you said, Megan, with the psychodynamic stuff, they've been thinking this way for years. And then CVT went completely the other direction. And now maybe FAP is that bridge between the two. So what is FAP? What is functionalistic psychotherapy? How would we describe it to the people listening? Do you want to start, Megan? Do you want me to go for it? OK. Well, I was going to say-- so I'm going to answer the question-- but what I was going to say is, I actually think in all of the evidence-based treatments-- and by the way, when I say that FAP is an evidence-based treatment, I think a lot of people would argue that it's not because it actually doesn't have enough randomized controlled trials backing it to say that it is. So this is still kind of emerging as an evidence-based treatment. But in all the evidence-based treatments, the only two that I know that target deep interpersonal connection are emotionally focused couples therapy. So anyone listening to this who's a couples therapist knows that that's one of the gold standard treatments for couples. And that therapy is all about expressing vulnerability and sort of hidden emotions and getting that reinforced with your partner. FAP is the only individual therapy that I know of that targets deep emotional connection and authentic self-expression as its primary target. And there are five rules of FAP that orient the therapy. So the first rule is watching for the things that the client does in your relationship with them that create connection or disconnection with you, the therapist, and assuming that those things that are showing up are showing up out in the world in their other relationships. So really seeing your relationship as a microprosm for how they're showing up out in the world. So you're watching for those what we call clinically relevant behaviors to occur. And then the rule too is you're trying to evoke them in session. So a classic example is a client who's afraid of emotional closeness with other people. Megan might say to a client when they walk in, I was really looking forward to seeing you today. If she knows that that person struggles with letting in closeness, and then if that client was able to say something, like even if they were nervous, but said like I was really looking forward to seeing you too, Megan would then do rule three, which is to reinforce that person's effort to show more closeness with Megan. And rule three uses what we call natural reinforcement, which means Megan would respond how she actually feels, not some contrived way. But if she actually sees this person showing more authentic interest in being close with Megan, Megan might say something like, I really liked it when you paused and looked at me and told me that you were also looking for this seeing me today. The thing about rule three is that you have to make sure that when you reinforce someone, that it actually is reinforcing them. So rule four is checking to make sure that that happened, which means your intention of reinforcing them doesn't matter. What matters is that you actually were reinforcing. I think Megan is one of the most reinforcing people I know when it comes to vulnerability. So I'll let her speak about this. So rule four is checking your impact to make sure you actually reinforce the behavior you want. And then rule five is talking with the client about how they're going to take that thing that they started doing better with you in session, out into their life and practice it with people who are likely to reinforce it out in the world. Those are the five rules of that. Yeah, that's a good description. And especially that last bit, is it considered a behavioral therapy as well? It's basically combining skinter, meaning kind of classic behavioral principles with all of this yalom, humanistic kind of authentic interpersonal therapy. And I really think it's the behavior therapy effort to try to get the interpersonal relationship into the therapy. Yeah, because I've seen it. Sorry, go on, go Megan. That's kind of a say, right? I'm incredibly happy to hear you reference yalom, because that's very much actually how I was almost introduced to FAF is via that idea. And I do, I think it's behavior's attempt to really start to track these really relevant behaviors that are occurring that might be related to their OCD or outside of their OCD and actually give it a framework. Yeah, yeah, I agree. I think that's where like Cole Rogers, he had some good ideas, some really good ideas. But I just find it times the humanistic approach, it just lacked that behavioral element that just pushed that change that extra bit. And I think that's maybe my prediction why it fell short a lot of the time is there was just nothing creating the change. Obviously some conversations did, but there was no, no, then extra element. All structure. So I think sometimes humanistic therapists couldn't figure out what they were doing or why they were doing it, or it was just on these core conditions. Just to add to that, I think Megan and I have talked about this and I know that Bob Colenberg and Mavisai who developed FAF talked about this that, I think I said this on your last podcast that the way FAF started was, Bob Colenberg was this hardcore behaviorist who was supervising Mavisai and he was watching her do therapy and he was realizing she's getting these amazing outcomes and having these amazing relationships with her patients. I want to try to understand in behavioral principles what she's doing. And I actually think when I met Megan and we started talking about therapy in OC, I saw Megan just having amazing relationships with her clients and getting really good outcomes, but she was doing it with all this authenticity and kind of reinforcing. I think who the patient really is and I think it was helpful for Megan to hear me say things like you're doing rule one, you're doing rule two, that's a CRB one, that's a CRB two, to give actual behavioral terms to what she was doing. - Like speaking, it was like learning how to speak a new language and be that much more effective than I think any ERP. And in some ways, right? I think we talk about even at or claim here, it's that ERP is being the person that you want to be in the face of anything that is difficult for you. And like how much vulnerability is entailed within that and also gives a person, I think a reference point, right? Where if we're able to sort of articulate the behavior, track it, shape it, like move it in a direction that those start to serve them, it's very clarifying, I think both for me as a therapist, but also for the individual that I'm working with. But we actually are creating change just in a kind of different way that I find that clients really respond well to. - Yeah, yeah, good responses guys. And I think maybe the kind of voice I have in my head of people listening of, oh, it sounds like the therapists are kind of not manipulating, that's probably not the right word. Well, there's something I think that of like, oh, they're just praising me around this, 'cause they know it's an error I struggle in and do do do do do. But from what I gather with FAP is, it's gotta be genuine. Like you've gotta believe what you're saying. You can't just say, I feel really close to you if you don't feel close to them. Is that fair to say? - Yeah, I would say this, and I'm curious what Megan thinks. I think what good ERP and good act and good FAPR, I see them all as related, is they are trying to watch for who is the person you're talking to at their core. I know this is gonna sound a little hokey at first, so we'll put some behavioral downs on it. But like, who is this person who is the right person? at their core, underneath their OCD and all of the things they're struggling with. And how do I pull that best version out of them by authentically tuning into that? And I think that's how Megan and I try to relate to our clients. We sort of try to see past like all of the CRB ones, the clinically relevant behaviors that they're doing that kind of push them away from connection and pull out who they really are. And I think that's what ERP does at its core, is helps people stand in face of fear in a way that feels really true to who they are. And I think too, there's something to be said about that it isn't all sort of sunshine and rainbows or disingenuous in praise. What I always can felt drawn to about FAP is that it is about that this is a real relationship. And in some ways, my job as the therapist is I'm really working very hard to know myself so well that my reaction, my response to the person in front of me and their behavior is a good gauge of, you know, is this behavior that the person is engaging in creating connection and closeness or just even like a healthy adaptive relationship or is it creating this distance, connection, disruption in the relationship. And I think even just to your earlier point, I think that's actually a very hard thing to do as therapists is to know yourself well enough to trust that you're an objective gauge of behavior as best as we can be, right? There's obviously, you know, deliver me a perfect mark. But I think that sometimes why, you know, many therapists I find are hesitant to that is like being able to use yourself as the tool in the therapy and not feeling very overwhelming. But I think, you know, when I approach the work, it is very much my aim is to think of it as like a very genuine relationship. So if there are behaviors that are challenging or difficult, I'm finding a way to speak these sort of names, speak to these to the person in front of me in a way that's not shaming or sort of hurtful, but really thinking about how it's impacting us right in the here and now. Yeah. Yeah. I like that. Yeah. Good responses. So why fat for ACD? So why in the sense of, you know, I have these obsessions, these compulsions, these strong emotions that go along with it. ACD is ruling my life. How is working on how I am with others in the real world going to change my symptoms? Always in or about the symptoms. Yeah. I think that there isn't enough research on this that you guys tell me at all. But I said this last time on your podcast, dude, that like we know that close relationships are incredibly important to human well-being. There's studies showing that loneliness is worse for your health than smoking cigarettes or obesity. Like we really know that interpersonal connection is extremely important for people. I think the thing that I'm interested in and I'm Megan and I talk about this a lot is are a lot of mental health problems, kind of symptoms of expressions of interpersonal disconnection, meaning not actually feeling close to who you are and how to express that to other people in a way that makes you feel connected. And by the way, I'll bet there's a lot of people listening to this who are like, man, that sounds like a reach. I don't know. Like I really think this is worth us talking about is like it's not in any of the OCD treatment manuals. There's no chapter on authentic self expression. Like you go look, there isn't one. But Megan and I I think can say this pretty confidently. When we get patients expressing themselves authentically with us, they do better with their OCD and we'll give case examples in a little bit. But I think there's a strong link between interpersonal disconnection and mental health problems and fat targets interpersonal connection. Yeah. I'm thinking in sort of like in a very concrete way. I know of a Nate and I will see folks at McLean here and for many a period of time for this individual, it's been focused on symptom reduction. I do the ERP. I sort of nail down my symptoms and that sort of what quote unquote will make me better. And sometimes I think of that is like having it's like strongest utility and almost like phase two where okay, like I've got my OCD into a place where I can really sort of manage and turn outwards towards my life. And someone, either because of how pervasive their OCD has been other factors, they don't almost have the skill set on board to foster genuine connection and closeness in their life. And they're sort of left in this sort of like intersection where I can turn back towards my OCD and just keep doing ERP and make sure my symptoms are down. But I'm also sort of lacking like this very important domain or component in my life. But I actually don't know how to relate to others. I don't know how to sort of step into the person I want to be. And I think of that so much as as we start to lower sort of OCD symptoms. And through ERP, through act, all the things that we usually do, FAP does have this a beautiful way of folding in like a next step for the person that they're equally sort of fostering and building up interpersonal skills. Yeah, yeah, I like that. And I think, you know, and I think sometimes it will directly overlap with OCD symptoms anyway, you know, some several clients of mine come to mind where, because I work with children and young people and they, they've confessing is a bit compulsion or ask for reassurance. You know, they're in the therapy room with me confessing to me continuously like there's no room for actual human connection. And then I know they're going away to their parents and they haven't had a decent conversation with their parents in like two years. So, you know, one client comes to mind where we did, I wasn't using FAP, but we directly targeted that of in the session, we're going to have a normal conversation. Every time you get distracted, we're going to bring it back. And then I was reinforcing, you know, that I feel is really good talking to you in this way. I feel like I'm getting to know you, and I meant it. And then slowly this client started to have genuine conversations with their parents again, and they found that closeness and that connection and that made a world of difference in their lives. So, I mean, that, for me, is just an example where the two directly overlap as well, symptoms and interpersonal stuff. So, just looking at my questions, I guess I wanted to ask around like a typical FAP session. Are you just bringing in FAP alongside maybe the ERP Act work you're doing? Are you dedicating sessions to the FAP targets? What does it kind of look like? Is this where we should do case example, Megan, or do you want to respond to what you just thought? I can probably answer the question best through a case example. I think someone comes to mind where this individual came to me and our residential treatments to target sort of intrusive thoughts, fears of catastrophic things happening to his home. And so a lot of checking behaviors, a lot of sort of compulsive almost like monitoring of his home, monitoring of whether looking through his home for potential pitfalls of where essentially at the core of it, he felt like his life would fall apart. And his home was this thing that he could control. And in exploring sort of an understanding, his poor fear really was that I would be sort of incapable of handling a disaster. And my life would fall apart. My wife would leave me. I just would be left in ruins and I would not be able to handle that. Initially, in first meeting, we do very much just sit a very traditional standard ERP approach. Videos of home improvement shows gone wrong, whether events occurring, he sort of deleted a lot of the applications on his phone that helped him sort of monitor whether events work his home. But within sort of like the first two weeks of knowing this individual, what stood out to me as like quite interesting was that yes, the ERP was like generating anxiety, he was sitting with distress, he was doing the things that he really needed to do. But almost in this like overlap of fear was this like feeling of like low self-worth, I don't feel capable in my life. And a lot of his relationships, not just with me, that it started to sort of present itself, but very much with his wife, his mom, particularly female individuals in his life, was this inability to self-suitive sort of overly reliant on seeking out another person to manage his emotional experience, but also simultaneously pushing those individuals away to sort of feel confident or feel secure within himself. And that was very apparent in our relationship. And it sort of took a few sessions to realize like what was happening, right? Like this grist for the male idea, like what is happening here now is, you know, very much this person coming into therapy saying you need to fix me, you need to do the work for me and tell me what to do and how to live my life. And then feeling very much sort of rebuffed or upset at me when that like I either didn't go the way that he wanted it to. or very much creating distance through conflict, through creating conflict in our therapeutic relationship. And I think that sort of was this like moment, like light bulb moment of like this is where I'd like to use FAP. I think this has a ton of utility and starting to very much like rule number one, like watch for these behaviors and have frequently they're occurring. So for me, that's a huge job of even some of the initial sessions, kind of tracking these behaviors into myself, naming them and seeing what sort of response I'm getting when I do invoke them and gave me like how he is receiving then what I'm reinforcing, whether it be sort of trying to promote more self-efficacy, expressing feeling quite distanced or misunderstood in moments when conflict was created. And eventually sort of probably around session six or seven I would say, they're sort of sharing this with him that I'm noticing these behaviors are occurring in real time and getting a better sense of then like how the history of these sort of like presenting CRBE ones and did this show up with his wife or did this show up with his mom and it was very apparent that it was pretty pervasive across his relationships in his life and then discussing like how we might work on that and sort of dedicating our sessions to FAP while still all the while when he's working with our European coaches doing these sort of exposures to kind of maintain that piece of it. - Yeah, that's interesting. How did he progress with FAP when you switched more to that? - I have to say, I mean like objectively right is, it's difficult to do my own horn I think he did quite well. You know, it was very much sort of almost this like light house of act, right? Of this is something that he always interpreted as sort of just something wrong with him and sort of his again in capabilities. I think very much both as like a person but also as a man and it gave us this ability to, I think a, bring him more as an active participant in the therapeutic relationship rather than sort of sitting back saying, "You tell me what to do." He was able to really engage more fully, I think in our sessions. He, at the end of treatments, that like you're the first person being a therapist but like you are the first person that I've actually felt my most genuine with and I've felt that actually this was a real relationship where historically I have sort of used therapists to get what I need but I've never, it's never translated to improvement in my life. And this is the first time I'm sort of seeing it as, and like this is an extension of my struggles in my life and I get what I need to do differently back in my life now and I can sort of understand what you feel. - Yeah, that's interesting that there are, where he said he's kind of used therapists before and I've definitely felt that way with clients where they've just come in that like fix me and there's a distance and it just feels like the work is not gonna work, nothing's gonna work here. And I don't know, I wonder if that's just a byproduct or side effect of the more evidence-based therapies like CBT over the years, dominating that we've lost this idea of she therapies about a relationship and maybe that's why I don't know if it's a trend, it's just, yeah. - Well, I think that what I noticed about what Megan said is that I can't see her or me at this point in my career doing therapy with someone where we don't talk about those things that she started noticing were happening in the relationship. But I think that a lot of evidence-based therapists, including in those few world, they don't talk about them. Some of them don't even feel it, but I think a lot of them feel it, they just don't know what to do with it. And so they just kind of set it aside and focus on what the patient came to work on. But Megan and I are trying to say, like we actually bring up the things that we're feeling in the relationship, which is often the first time they've heard it from a therapist because a lot of therapists don't help them. - These things. - Yeah, and probably also maybe in the first time they've heard it in a calm way, 'cause maybe in their own lives, they're getting attacked by their loved ones, and why you like this, why you always do it at a person's, you can't do that as a therapist. You have to be more caring and consider it in your responses. - I mean, I think that's, yeah, it's truthful. I think there's sort of, there's a therapist actually here at the OCD Institute that always comes to mind when she often will say, like I respect you too much to not telling you what's going on. And it just, I think like rings so true to me all of the time. I mean, she's a remarkable therapist, but I think that sort of, for me, I must at this center point of fact, is that if I can really become and compassionate and objective and engage someone in a conversation to help them improve their relationships outside of here, and use our time together as a means of practicing that, and not just intellectualizing it and talking about it as an idea or something abstract, but really learning through experience, I think it has so much more power than to actually translate in the way that a patient might want. - Yeah, yeah, absolutely. Yeah, good point. And, and, and, night, is there any of us who case studies you wanna add to the mix? - Yeah, I'll give one that is a recent. It's a good example because it's a patient who was referred to me by someone who used to work at the OCD Institute. She works at another clinic in Boston, and she's an amazing therapist, but I remember when she referred this patient here, she said something like, and I think Megan can relate to this, she said, "Oh, I hope this person gets neat when they come to the OCDI," which I think means, I hope that she gets a therapist who talks more about what's happening in their relationship. And so, she comes in and she looks like a classic OCD patient that she does a ton of reassurance, seeking, checking, repeating behaviors, gets a very emotionally dysregulated when she's struggling with all of that. And her mom, you, I'm sure everyone listening can relate to this. Her mom is incredibly engaged, would be symptoms, so reinforces a lot of them, accommodates a lot of them. And the thinking, I think, from this therapist was, she needs a higher dose of ERP for sure. Maybe some relational work, she didn't say that. But I was trying to do the higher dose of ERP with this patient, so we were giving her a ton of coaching for showering, changing all of the activities of daily living she has to go through without doing, checking, repeating, reassuring, seeking. And she wasn't getting any better, and I could see why. There was a huge dependency on the staff as she was going through that. And you could just feel it, almost like this people pleasing quality of like really nice woman, but wanting to connect with me and the other staff around how well she moves doing in the ERPs. And I felt totally disconnected from that. And in fact, I felt like this is not who she really is. This kind of success with ERP is not something I'm relating around. So this is what's great about working at a clinic like ours. I got all of the staff to commit along with me to stop working on her OCD and to stop talking about her OCD and to just work on getting to know her and then just reinforcing all of the things she was telling us that were really true about her. And she's so much better now that like, I just saw her yesterday, I'm seeing her privately now. You almost can't recognize her when she comes into the office. She's just talking about her dating life, her friend life, the department she just moved into. And I remember in one of our last sessions at the OCDI, she cried for pretty much the entire session about how it was so hard for her to say goodbye to the staff here because it was like the first time in her life that she felt the staff and the people here really saw who she was as a person that she really had struggled all of her life with insecurities and self-doubt and people pleasing and didn't really trust that she could show up authentically with people and that they would really understand her. And I could see that like something profound had changed inside of her, relationally with all of the staff. And I'm throwing this out to the audience here to say like, she got better without ERP. Meaning it was actually ERP was making her worse. If you're gonna call ERP like blocking, repeating and checking and reassurance behaviors while she's doing activities of daily living, that was making her worse. Authentic self-expression and putting herself out in her life and kind of an active, all-in-based way while learning how to be who she was. really is, that's what got her better. And I'll say one last thing on this, when she was leaving my office yesterday, I let her into a bathroom and she had asked me to let her in and we were saying goodbye. And then she looked at me and said something like, goodbye again with kind of that reassurance, look in her eye like, are we good? That kind of look. And I, I'm saying that to the audience just to say like, that's kind of who she is. There's like a self doubt in her about like, are we good? And I think the staff, you're really learned how to connect with that part of her in a way that wasn't reinforcing her dependency, but was pulling out her confidence. - Yeah, that's really interesting. It just, it makes me think of a particular client I'm working with. Yeah. Yeah, that's really interesting. Okay, so yeah, you've gone down the route there of, well, actually, yeah, it was ERP at that point for that case had nothing to do with it. And of course, you're not saying, Bap is the answer for everyone. You're just saying in certain situations, it might be a option. - That's why Bap matters so much for a patient like her is, oh, and I left this part out. So she, she, she's seeing me privately and now she's seeing the old outpatient therapist privately as well. I'm kind of bridging the transition back because she did such good fat work here. And I said to the outpatient clinician, who's interested in Bap, are you sold now on Bap? Like are you gonna do this with her? And she was like, I'm all in. Like this is a changed woman coming back to me. And so why does this matter? Because this comes down to CRB1s and 2s. So if you said this patient taking a 10 minute shower which she did with me early on coaching her, without rituals and then telling me how proud she was of taking a 10 minute shower, if you said that's a CRB2, meaning an improvement in her life, I think it's wrong. I think it's a CRB1, meaning I think she's trying to connect with me around success in an ERP, but she's not connecting with me around authentic expression of her insecurities that she struggles with in her life. And we can talk more about that. But I think a lot of clinicians think that progress in ERP is always a 2. And Megan and I are trying to say, it depends on the function of it. Sometimes it really is. And you should be doing ERP. And sometimes it's pulling them away from authentically expressing what their core struggle really is. - Yeah, very much so it all comes down to the function of the behavior. Like sometimes it is very much like a bid for connection. And this is perhaps the only behavior that this person knows how to create closeness or connection in their life. And we're looking at the function of that and actually going like that's actually a one, right? That's creating distance between myself, the other staff members, her peers, right? And we're being able to see them in the context of their own environment. And I do think that sort of gives us an extra sort of option that there are lots of folks who come in here and very much so like, oh, it's we're just doing ERP, right? Like we are, that's sort of our sole sort of intervention. But sometimes when these individuals who have come in of like ERP maybe hasn't been successful and we can't quite pinpoint like maybe why that is or you know intellectually this person really understands and gets what ERP is, but there's just something that isn't generalizing for them in terms of well-being. I think that really does give us this extra opportunity to kind of look at sort of the interpersonal behaviors more closely and target those in a very, I think effective and more organized way. - Yeah, yeah. Absolutely. And I think what you're saying there about maybe, if I heard you right, the OECD is their way of communicating at how they together, yeah, their interpersonal needs met. I guess everything is symptoms generally. They're a symptom of something. Be that a serotonin imbalance, a something gone wrong in the brain or trauma or maybe in what you're saying in some interpersonal issue that they've never been able to express something or connect in a deep way or yeah. - Megan, do you wanna say anything about how you determine what's the one and a two? 'Cause this is something we talk about a lot. I think this is something clinicians are probably listening and they're like, yeah, how would you have known? Being a 10-minute shower was not a good thing. - It's very much for me, I think sort of this, sort of like deep dive when I first sat down with someone, I am really, yes, like trying to take an inventory of like their OCD symptoms, like where sort of OCD is creating challenge in their life. But I also pretty quickly am tuned into, you know, what are their relationships? Like, like perhaps if someone's had a lot of ERP treatment, it's like, you know, a very compassionate way getting curious, like, huh, like what hasn't worked then? Like really what has sort of, they're kept us stuck, maintain the OCD and really start in like from the initial intake to really understand this person in the context of their environment, like how, how they are not only showing up with me, but peers in the middle of the year, you know, peers in their life. I'm also someone who's like very tuned into nonverbal behavior, obviously like I am someone, I must would consider myself a body-based clinician in a lot of ways. So I am sometimes looking at affect, you know, either excess of or lack of thinking about, you know, when they're talking about really difficult or painful things, you know, how are they communicating that? Both in the content of what they're saying, but also how they're saying that, how they are looking to me, are looking to peers, right, in the milieu, to almost gauge their own impact. And so like I can see them almost tracking, you know, how am I being received, right, by others around me. And so a lot of that is I'm thinking about, perhaps like behavior that other clinicians might just set to the side. Like that for me is that I'm very much a tune to that from the moment like someone walks into my office of how is this person connecting with me, peers, and understanding just historically how this is worked for them. Like the important thing, it is, can be challenging to track and really articulate how you might define the behavior and why you're sort of labeling that behavior as a one or a two and why. - I agree, I think-- - And this is just so, oh, I was just gonna say, this is so like important what Megan's talking about because like I see Megan as a clinician where she can say things that she's picking up on. And I do this too where it's kind of hard for me to articulate exactly why I'm feeling the way I'm feeling about it. Like what let's give an example, like is crying a one or two. It depends on how it's functioning in the relationship but also how you're experiencing it. And I think Megan is someone who like, she's kind of wired this way where like she can just pick up on this stuff, whereas I think a lot of clinicians when they got trained to be therapist, they like read a lot of books on how to like say the right thing but they didn't learn a lot about like how to deeply tune in to and see what your patient is really communicating to you. And even as I'm saying this, I'm like, God, there's so many CBT, ACT people, ERP people, listening to this who are like, what is he talking about? Like how do you read into like deeply into someone's, but I gotta tell you, Megan I think has been told this by patients. When I'm doing good, that patient say to me, I feel like you're seeing through me. You're like seeing through all of the things I'm saying to like what I'm really feeling. - Sort of I like to think about in I know in physics and I do not have a math or physics brain whatsoever but the cost of concept of attunement, right? It's sort of aligning your frequency to another frequency. And in some ways that's not just sort of an intellectual process that is something like we say like a bottom-up process, right, that they're I'm attuning to how someone is feeling in the moment and trying to track that. And it is behavior, right? Like I think it's challenging sometimes because we have these very amorphous experiences that we're trying to put language to in some ways that it is a very intuitive process. And so we have words in fact like authentic or like close, deep meaningful connections, right? And vulnerability and it can be difficult to place a language to what is being experienced in the room but I think fat has like always done for me. Like why does it feel it felt so validating, right? That's sort of someone who came from a very different orientation who wants to do really again, good evidence-based behavioral work so then have sort of a map for how to do that. But much like any of us would do with good OCD work, right? Is someone crying while they're talking about very inclusive thoughts? Like does that function as a potential ritual, right? And alleviating the distress. like we're looking at the function of that behavior. And with fat, we're just looking at the function of that behavior as it pertains to the relationship. Yeah. Yeah. Yeah. Yeah. Yeah. It's just, yeah, it's getting me thinking a lot. It's just why I'm lost for words. I just, I guess as you guys talk, it just brings to mind, you know, if it's stuff in my clients, but not just that, because I think I'm more alert. It's like stuff in my own personal life. So yeah, all that stuff comes into my mind. But I guess the hardest thing I've found with fat is I've got my head around like the core principles and in a very rinked ink way, I use it sometimes the clients. But I've struggled with, yeah, how do I really formulate in my mind the CRB ones and when am I reinforcing and, yeah. Yeah. So, so you know, when we do the training, obviously, I'm sure you guys will cover that and I have passed the I'm really excited for the training. Well, so that that right there, Steve is like when, when Megan and I are preparing to do this training, we decided that we wanted to try to videotape our sessions to show ourselves doing this because people are probably listening to this podcast and they're like, how would you actually know what a one or two is and then how do you actually reinforce it? I think that they're really wanting to see that and Megan and I can show that easier in a video than we can just describing it. But it's I'm going to say it this way it's a vibes based therapy. It's like when Megan was saying tuning, it's like a you're sensing this nonverbal stuff that's happening, which by the way, I think that's over 50% maybe more of what people actually need to focus on in therapy is these kind of nonverbal things that are either on or they're off in the relationship. Well, put in Megan's concert, it's a dance, right? Is that back and forth? Very much. They mentioned, you know, emotionally focused work like Sue Johnson really often will talk about that within couples, right? If they're entering into this dance with one another and she'll speak about sort of like speaking to someone's in big deal, right? That there is affect occurs like in our bodies. I sort of will make even this joke with many of my patients here like none of us are floating brains that it's, you know, we can't sort of intellectual eyes our way through this and that, you know, both in ERP, right? It's important to connect to the affect, but also in a relationship how integral that is. And no, that does really ask that of us both as the therapist, right? Having our own ones and two's, you know, as much as, you know, the person we're sitting down with has their ones and two's. And how are we trying to actually like enter into that dance together and of course correct is when we need to. True and even if we even if we say that fat has no impact on ACD, of course, that's not what we're saying, but even if we were very conservative about it and said, you know, it's not going to change symptoms. Well, if it changes in it improves interpersonal relationships, it doesn't matter if you've got your OCD right down, if your relationships are a dire, you're going to be miserable. So even from that lens as a bare minimum, it will make a world of difference to people's lives. Cool. Yeah, so is there anything else you guys wanted to share today on this? I mean, we're doing a four hour training on this so we could talk about it for hours, but I don't know, I guess maybe maybe one question I have for you to do if you're up for it is like, why are you so interested in that you've had me on the podcast three times you've asked us to do a training on it like what what draws you to this kind of work. Yeah, I've not thought about it in detail. I mean, the first answer that comes to my mind is, you know, I did eight years. I mean, about four years of that was probably three, four years was four nightly, but yeah, eight years of humanistic slash psychodynamic therapy with the same therapist. Annabelle. And I ended March last year and she didn't use FAP as far as I knew and this wasn't for OCD. I got my OCD somewhat under control by this point. It was more working on other stuff in my past and how it was showing up for me now in my everyday relationships and just the safe security ship I had with her. It challenged me at times when I was shutting down because that was a big thing for me is not expressing emotionally and it's something I still work on. And at times she, I think she did do a semblance of FAP without being structured with it, but the key thing, you know, I remember once I always struggled to show our fact and unless it was say anger, that was, I wasn't angry, but it was easy for me to get annoyed about stuff. In terms of sadness, emotion, that sort of thing, I would shut down. I remember one time she just kind of looked to me as I was talking about something I guess I know was was troubling, but for me, I was so disconnected from it and I looked up like I just see she wasn't crying, but her eyes are glazed in like a teary way. And for me, that expression of I felt love and she was showing me my emotions and that really helped me, I remember it to this day, it was probably the most meaningful thing she did and she didn't say a word, but it helped me calibrate in such an important way and she could have hid that emotion as some therapist would, but she didn't she she put it out there and that was so meaningful for me. So just the relationship I have with her and if I have issues again in life, I'll go back to her for a bit, no doubt. She always be someone who's incredibly meaningful in my life, I respect and understand the boundaries between me and her and in therapy, but that's probably why that, you know, she really changed a lot for me just by being a great person and being a loving presence and challenging me when I needed to be challenged. So yeah, I see the power of it, I guess is what I'm saying and that's why FAP I love ERP act, I'm learning about ICPT and other stuff, but for me, the relationship's just not there and that that is a big issue for me personally and that's why I like FAP. And I just want to say something to reinforce what you just said, Stu and curious what Megan thinks, I think that you are interested in this because the way I experience you is you're like a sensitive guy in like a really good way like the way you run this podcast is like so tuned into what your guests need and like to make them feel safe and comfortable. I told Megan before she came on, I was like, Stu is such a nice guy, he's going to make you feel so comfortable and I just sense that about you that you like you are sensitive and that maybe partly what draws you to more relational work. Yeah, no, thank you, yeah, I appreciate that. I think I was very sensitive, I am, but always as a kid and maybe the environment I was in didn't allow for that. Yeah, I appreciate that. I was saying to Nate, Stu, like this is very, these things are very much not my cup of tea, I think it took a lot of coaxing to have me join, but I do, I think even in that response right is like really just sort of like warm my heart because I can see you then right like transitioning into your own work with the clients that you work with and being sort of having an access to that reference point of like this is how I want to be showing up and sort of embodying compassion with the folks that I work with. In a way where I understand it for myself, I have those boundaries, I really can, you know, put some reins on it and understand how I want to, you know, bring something really special to the work, which I think has always been something that, you know, has felt so deeply meaningful to me is that I do think of am a terrible liar and I do think of myself as I'm showing up as myself as a therapist and having a little bit of an ability to do that. I think for me prevents burnout, like it allows me to very much so be myself treat these relationships as sort of like these very joyful and meaningful like paths crossing right that if I get to show up really as a person myself as a therapist with the person I'm sitting down with. It's a real privilege, frankly, but then to be able to genuinely connect with somebody and use it in the work that has such utility, it's very special. Yeah, I agree with that. I think the days I leave my office and I've not been out of connect with people with who way too structured about things, I just, I feel tired, I feel exhausted, I even like I'm not looking forward to tomorrow. And the days that I really connected with people and had deep, meaningful connections like I leave the office really excited, happy content, excited about tomorrow. So yeah. So thank you so much guys. I mean, I love talking about fat, anything relational, so as evidence based therapies. So yeah, just I really appreciate you guys coming on. I'm excited about the training. So any therapist listening that want to do that and a link will be in the show notes and stuff. Yeah, thanks again, I appreciate it. Thank you for listening to this week's podcast. And thank you to our patrons who helped make this episode possible. And if you would like to find out more about Patreon and the rewards and benefits, then there will be a link in the episode description. If you enjoy the OCD Stories podcast and would like to support us, please subscribe and rate the show wherever you listen to the podcast. And thank you to NoCD for supporting our work. If you want to find out more about NoCD, head to go.treatmyocd.com/theocdstories. I'll click the link in the episode description. And quick to exclaim, guys, this podcast is not therapy. It's not a replacement for therapy. Please seek treatment from a trained professional. Until we speak, take care. (upbeat music) [BLANK_AUDIO]