Nate Gruner: Functional Analytic Psychotherapy (FAP) for OCD (#379)

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 379 and in this one I got back on Nate Gruner. Nate is a staff behavioral therapist at McLean OCD Institute. I chat with Nate about functional analytics psychotherapy or FAP for short. The history of FAP, what is FAP? The five rules of FAP, why FAP may be helpful for people with OCD, content-versed process, the principles of awareness, courage and love. Nate shares some client examples where he has used FAP with OCD and much more. And then I talk about a training idea in FAP with Dr. Gareth Coleman. In fact, it's Gareth Coleman, so I just wanted to clarify that Dr. Gareth Coleman. But I really enjoyed this conversation with Nate. I find FAP particularly interesting. Hopefully you guys get something out of it too. 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 OCD, their therapy plans, if they currently take your insurance or to download their free app, head to go.treatmyocd.com/cocdstories. Or the link will be in the episode description. Thank you to all of our patrons for supporting our work. This podcast episode is available as a video recording on our Patreon. To sign up to our Patreon and to check out the other benefits you receive as a patron, please see the link in the show notes. So thank you to Nate for his time. I appreciate it. And of course, thank you to you guys for listening. It means a lot. And without further ado, here is Nate. Welcome back to the show, Nate. Thanks for having me, Stu. It's good to have you on. I personally enjoyed the last episode. So I'm happy to be discussing functional analytics like a therapy in more detail again. So first question is just how you've been, what you've been up to, Penny News? Yeah. I think we did that interview in 2021. I think that's when it was. So maybe about two years ago. And I would say after the interview, some people reached out from clinics in Boston and other places just asking more about FAP. And I can tell you more about that, but it's been interesting to sort of see how the interest has grown in it. We started a group, kind of a FAP learning group between the Houston OCD program and the Boston OCD program. And now we're trying to roll that out more at the Boston OCD program. I can tell you more about that, but just been having a lot more conversations with clinicians about it. So it's been cool to see the interest. Yeah, that's really good. I'm glad people have reached out and I'm glad it's progressing. It's not, you know, I wouldn't, wouldn't have known that because it's not something you see, you know, earlier I was scanning the internet for FAP CPD, you know, continuous professional development as part of my therapy training. And I just couldn't find any. There's one by Gareth Coleman, which I've already done. That was done in the UK. So yeah, it's, you don't really see it. It's good to hear that it is going on. It's, that's, I think we talked about this last time. It's kind of bizarre that the one of the only behavioral approaches to the interpersonal relationship and therapy is practically unknown in the US. Yeah, it's really, well, to be fair, it's really unknown here as well, because it was that training I mentioned Gareth. He's American, I think. And he was doing it with a UK company, but yeah, it's just, it's a shame. So, for those that haven't heard the first episode, or have no idea what functional analytics like a therapy is, how would you describe it to them? Yeah. So let's see, the history of it is actually kind of interesting. And I may be getting some of the details wrong, but basically what I know is, may the SI and Bob Colenberg, husband and wife, Bob just actually passed away recently. They were the developers of this, back in the 80s. The first book was written in 1991. And I think what basically happened is, Mavis was doing therapy sessions, and they were video recording them. And Bob was noticing that Mavis was doing brilliant interpersonal work in the sessions. You sort of hear stories like this, sometimes with psychodynamic therapists that like, something's going on in the therapy, but it's really cool. You can't quite describe it. So he's watching it, and he's noticing that she's getting really good outcomes when the relationship is really good. And he's a behavior analyst. So he's someone who's trying to figure out what is she actually doing behaviorally in these sessions? And what he starts noticing is that when clients are doing things that are improvements in how they relate to her and how they relate to other people in their life, she's naturally reinforcing those improvements. And he starts giving those labels. So he calls improvements in therapy, CRB-2s, clinically relevant behaviors that are moving towards connection, both to yourself and other people. And CRB-1s are behaviors that you're doing in session that are causing disconnection with the therapist or with yourself. And they start developing this behavioral framework for how really, really good relationships happen in therapy. And fat grows out of that. I'll let you respond, but I can go into the details of what fat looks like, but that's kind of the history, I think, of how this develops. Yeah. So I guess what came to my mind as an example of and fat by no means is a therapy I keep in my mind, but it's one I'm very weak on and but I have a lot of interest in getting stronger in. But how I view it with the CRB-1 and CRB-2, CRB-1 might be I work with teens, you know, it's not uncommon that a phone might be out and they get a text message, you know, and they keep looking down at the phone, which is obviously impacting our connection and our relationship. And then if they one session starts to, you know, they come in and they tell me their phones on airplane mode or whatever it is. And then throughout the session, I might say, I feel closer to you, you know, it's been a better session. Is that kind of reinforcing that change of behavior? Yeah. Yeah, that's exactly right. And so CRB-1s can literally be anything. So they could be having your phone out in session. They could be being overly positive in a session when you're actually feeling pain. So they could be expressing yourself in a way that isn't authentic. It could be talking too much. It could be talking too little. It could be not tracking the impact that you're having on the therapist. And then CRB-2s, like I said, are if someone was struggling with being genuine or authentic, anything that's a move in the direction of authenticity, then can get reinforced by the therapist, by like you said, the therapist, singing how they're feeling in reaction to that. And so what that leads to, I'll sort of go through the five rules of FAF. It's sort of been kind of updated over the years. I won't get into the modern forms of this, but the sort of general five rules are you're watching for clinically relevant behavior that happens in the session. And a key thing I want to point out there is clinically relevant behavior means behavior that the therapist thinks causes problems in the therapy relationship and in their life outside the therapy relationship. And then this is what's really interesting and unique about FAF. You're responding to behaviors that are occurring in the session. You're not talking about behaviors that are occurring out of the session. Meaning that's not the focus of the therapy. The focus is the therapy is how it's showing up in the moment with the therapist. Which by the way, is very new for a lot of therapists to actually talk about what's occurring between you and the person in front of you, because most therapists actually talk about what occurs outside in their life. That's what a lot of therapy is. So anyways, you're watching for clinically relevant behavior, CRB1s and CRB2s. Then the therapist is trying to evoke clinically relevant behavior. So if the client struggles with genuineness, the therapist might say something like, you know, I feel like you're being really real with me right now. And it's really nice to see this. In fact, I was really looking forward to seeing you today. And for someone who's not good with emotional closeness, that could trigger a CRB1, which might be like changing the subject or becoming over. positive or saying thank you like in sort of the fake way. And then what the therapist is then doing is differential reinforcement. And I know I use that term the last time we talked but essentially what that means is watching for when clinically relevant behavior comes up and when the ones come up either ignoring them or pointing them out and then giving the client a chance to do a CRB-2. So if you get a thank you kind of response and then you're like oh it seemed like you know that might have been a hard thing to hear when I just said that I was looking forward to seeing you and then you sort of give them a chance to say like what was it that you've actually felt when I just said that. And if they say something that feels a little bit more genuine then you reinforce it we'll talk about reinforcement in a second but essentially differential reinforcement is ignoring or pointing out the ones and then reinforcing the tubes. Then the next step the rule 4 is noticing your impact. So noticing to see if what you just did actually reinforce the CRB-2. So you have to check to see if you're now getting more genuine behavior in the session or the phones actually being put away in future sessions because remember this is a behavioral treatment so you're checking to see if you're getting more of the behavior you want. And one thing I just want to point out about that is clinicians often don't check to see if they're being reinforcing or not. They just think well if I'm nice or positive that means that it's going well and if they're being nice and positive that means it's going well. It could be you've just created dependency in a relationship or some kind of fake connection instead of a real one. So you're watching for whether you're getting more of the behavior you want. And then step 5 is whatever they've done well in the session, the CRB-2s that are starting to come out in the session that becomes their homework. Go try these behaviors with people in your life who are likely to reinforce them and people in your life who really matter to you. So your friends, your family, your partner, those are the five rules of fact. Yeah. Thank you. That that's really useful. And I probably asked you this last time but why do you think it's useful for OCD? So I'm going to say this more generally not just for OCD and then we can zoom back to OCD. So I don't know if you heard this but there was a research study that just came out this longitudinal study out of Harvard basically assessing what is it that makes humans happy over the course of their lifetime. I don't know if you heard about this. It was a sort of big big news in the US. Can you guess what the number one factor was that they found? Family? Close. It was the quality of your relationships with people. Now you know that comes out and so I think to myself wait a second. If one of the strongest predictors of human well-being is social connection and you sort of hear that coming out of research. Let's see if it gets replicated but that sounds right to me because I think about my own life and I think a lot of people think about their own lives and they think well when I'm doing well socially my mental health is pretty good. That's not universally true but I think it's often true. So what is fat have to do with psychological problems? My sense is that when people aren't doing well psychologically usually something isn't going well interpersonal and so what does this have to do with OCD? You said this last time we talked and I've become more and more in line with this idea. I don't know if you remember you said this but OCD could be thought of. This isn't universally true but I think it often can be true as a symptom of distress in someone's life meaning a way of expressing distress, a way of coping with distress. In some ways you can think of OCD as like a symptom of something else not the problem in and of itself and I just want to be clear that isn't always true but if it's true a fair amount of the time then the problem clinicians make is they overly focused on the OCD and they lose track of the function it's playing in the person's life. So just to give you an example like that's more medical in nature during COVID I started running more because the gym's closed and I started noticing I was getting pain and tightness in my left leg. So I went to go see a physical therapist here in the US and she was really smart and she was sort of assessing the pain and tightness in my left leg and she said I want to see you walk I want to see you stand I want to see you sit I want to see you jump and she starts watching me do all these things and she says you broke your leg when you were 14 you're right leg right and I said yeah and she said did you ever do physical therapy for it and I said no after I recovered and she said your right leg is weaker than your left leg so you favor your left leg for everything and now it's tight and it's in pain and the way she figured that out was through watching me do all these behaviors and then I said all right so can we fix my left leg and she said we actually need to work on your right leg because your right leg is weak does that make sense yeah it does and so if you bring this back to therapy in OCD I think a lot of times patients come in and they say you know I'm really struggling with this fear that I'm gay or this fear that I'm possessed by the devil or you know these sensations in my body or whatever the symptoms are and what I'm always trying to do is zoom out and try to understand what role is this playing in the context of the person's life and I want to be clear sometimes it just is the thing that they're talking about and nothing else and you can just do ERP and act and sort of evidence-based treatments for that but I've just noticed and we do see fairly complex patients at the OCD clinic at McLean where I work where a lot of times people are coming in and these symptoms are occurring in a very complicated context that really needs to be understood in order to help them that's a really good point and yeah and I guess what you're saying and why I said on that podcast initially might be seen as controversial by some OCDs or CBT therapists but how I do with at least my older clients teens not necessarily children I do say caveat exactly what you're saying could just be OCD that's there's nothing deeper than that not to take away from the pain of it the pain is exactly the same but it's where if I was exploring some other stuff you know like the history and childhood and attachment and to see if there's anything there and sometimes there's nothing and that's okay we just crack on with ERP and act and sometimes there is something and we crack on the ERP and act but also address those more relational things yes and so I think this was interesting when I started giving more talks about fat after I had the interview with you a lot of the really good questions I got was wait a second isn't this psychodynamic because you're saying that the distress the person is expressing with OCD rituals is about something else that sounds like a psychodynamic interpretation does that make sense and what I was what I was saying in response was it's actually not psychodynamic because what you're doing is you're it's very similar to the physical therapist she's going I wonder if his left leg hurts and is tight because his right leg is weak and then what you do that's sort of the functional analysis she's zooming out and going is this thing causing this thing then what you have to do is test to see if it's right so if she strengthens my right leg and then the pain and tightness starts going down in the left leg then she was right that is just sort of basic hypothesis case conceptualization testing and then seeing if it worked so I I think that what I want to make sure people understand is this isn't like oh I just have this hunch that your OCD is about this thing that's what I'm gonna go with and screw you if you think it's something else it's really more let's test out this hunch that I have see how it goes and if it works then by definition I was right meaning like we but if you start doing intense focus on the ERP for this specific problem and you're not making progress It could be you're missing what the real conceptualization is. Yeah, yeah. And if you stick with your physical therapist, if, if, sorry, which one was the knee that was hurting? The left leg was in pain. Yeah. The left leg. Knee, knee, our left leg. Sorry. Yeah, left leg is in pain. If they just gone down the route of a K-let's work on the left leg, it may have resolved some of it. But if that initial problem with the right leg wasn't resolved, it's going to flare up again in the future, which could explain relapses. You know, exactly. Exactly. Exactly. So, so another way to say that in fact, terms is if the client isn't good at knowing what they're feeling, knowing how to express it in a way that creates connection, being able to take that on the road with other people in their life outside of therapy, their specific OCD problem either won't resolve or it will just turn into something else. If these more interpersonal emotional factors aren't addressed in the context of therapy, again, not universally true. No. But, but if you're not targeting those things and those are what are driving the distress, then you're missing what's important. Yeah, it's an important question and we know from all the randomized control trials and metronalises of ERP, it doesn't help everyone. So, we've got a question, well, why is that? Because why would it help some people and not others that doesn't make sense? And maybe is what we're saying here is the more relational aspects need to be worked on. And then ERP will work. Yeah, and it's, I'll go into case examples in a bit, but it's, you're, we're basically saying there, this is how I would say it, you're getting the case conceptualization wrong. This isn't always true, but I think some of the treatment failures that we see before they come to the OCDI is that the case conceptualization was the client described to these OCD symptoms. They showed them to the therapist. The therapist responded to the symptoms and then they didn't improve. And when I first started treating OCDI, what I was told was those clients aren't getting a high enough dose of ERP. So that's why they need to come to us. But I think what our clinic has started to see is, sometimes it's that, but often it's the case conceptualization was wrong, that they just weren't seeing the interpersonal emotional factors that were at play. Really good point. So I, I won't give too much context around this for an anonymity, but I spoke to someone that worked with you at some point in time. And they had been through several rounds of ERP with several different people, all highly skilled and good at what they do. But the thing that made this person really commit to ERP and not to commit, for ERP to start to be effective and work was you said something to them that really in a good way shook them. And they didn't say this, but in my head I was like, that sounds like he was doing fat. He was trying to and it and it they bought in and they started to make progress of ERP. But there was, and I can't really give too much away, but yeah, you made something click through something that wasn't behavioral. It was well, not in the sense of ERP. Yeah. Yeah. Let me linger on that point. And, and then again, we can get the case examples because that'll flesh it out more. But I think I talked about last time we met the difference between process and content in therapy. So just defining that content is what the client actually says to you. So I'm afraid I'm going to be possessed by the devil. I'm afraid that I'm gay. I have sensations in my body that I can't stop obsessing about. Therapists love content. Meaning, and I admit this for myself. This is what I used to always do. They say the thing. And then we're like, I have a hammer for that. Meaning I know what the treatment is for that. And then we go start doing it ERP after like all the things that we were trained in. But process is how they're saying it. What you feel when they're saying it. So let me give you a sense of what that looks like. How invested is the client in their mental illness? This is a very interesting complicated kind of taboo subject. Although I think it's really important to talk about, which is as mental illness has become destigmatized, that's been super helpful, especially here in the US for people to like speak more openly about their issues and go seek treatment. But one of the problems you can see is some clients can get overly identified with their symptoms. And so when they're talking about their OCD, in some ways you can watch as they're talking about it, they feel kind of proud of it. Or it feels like it's a big part of who they are. Or it's like as they're talking about it, it sounds almost like this is just what I do. And I think some clinicians miss that. They miss that the way the client is talking about it is so much more interesting and important to me than the content of what they're saying. And so much of what fat is, is watching how people talk about their problems. I'll go into case examples in a minute, but just does that make sense? It does, yeah. Yeah, yeah, you're right. He just reminds me of something Michael too, he said, you know, the research effort act. He said something similar to that of the context of what they're saying and the way they're saying it. And he will respond back to them not to what they've said, but the hidden meaning behind what they've said. I love that. In fact, I think when Mike too excels that, and this is something I definitely learned as I was getting trained in act is you can't do diffusion for a client by just saying, oh, thoughts are just thoughts. Don't you get it? You have to do it in a way that really lands for them. And like kind of, how do I say this? The words that you're using, if you're just literal about it and you're like, remember thoughts are just thoughts. You're missing that there's a way to talk about diffusion that will actually connect for the client. That's why you'll hear Mike too, and other people say, make sure you really get like what they're into and they're like, if they're into sports, for example, like give sports metaphors and analogies for how to describe diffusion. The act people really, I think, get it that like content doesn't matter as much as process. And then the fat people are like all about process. It's not that the content never matters, but I'm just so much more interested in how the client relates to their problem. Yeah, yeah, really good point. So that I got one more question, then we'll get into the case material examples. So, fat and fat therapists are all about ACL awareness, courage and love. And I just, I guess just talk about that and why that's relevant. Yeah, so that is what I was saying before is kind of this updated modern version of fat, and actually I think there's a little bit of controversy in the field because there's like the old school fat people and the new school fat people, and that's probably true with any kind of therapy, but those five rules that I laid out before is kind of the old modern, sorry, the old version of fat. Awareness, courage and love as I understand it is awareness is about you becoming the client becoming very aware of themselves and their impact on others. Courage is being able to do behaviors like CRB-2s that are courageous and vulnerable and open that are in service of being your best self in the therapy relationship and then outside. And love is the therapist's natural reinforcement of the client's effort to be courageous. And it works in both directions, the client and the therapist both are practicing these things, but I think they kind of simplified it down to ACL awareness courage love. By the way, I think those terms, even though I like them, can freak people out to have what does love have to do with therapy. They mean therapeutic love, which means reinforcing connection. Oh, and one thing I said this I think the last time we met, but reinforcement in fat, the loving reinforcement that they're talking about in fat, is what they call natural reinforcement. And that means that you're responding naturally to what the person said. So it means you're noticing how you feel and then sharing it with the client. Arbitrary reinforcement is when a client does two and then you give them a candy bar, which obviously won't work unless they're motivated by candy. But also it's not genuine and that you felt something in response. share that with them instead of clap your hands or give them a candy bar. So you're naturally reinforcing client behaviors. - Yeah, so I guess arbitrary reinforcement is like when I'll set up a reward system where the kids I work with, free RP and their parents give them rewards. - Yep, and so just to be clear about that, if you're working with much lower functioning people who actually don't have the ability to speak, you need to reinforce with those kinds of things because they're not as motivated by social connection or don't have the sophisticated social skills to be able to express things to the client. Whereas when you're working with these very complex OCD cases that we see at the OCD clinic, you really do want to provide natural reinforcement that is about genuine connection. And this gets back to that Harvard study. I wouldn't be surprised if one of the most reinforcing things humans experience is social connection. That's why fat, I think, is a powerful treatment. - Yeah, really good point. Yeah, one of the last things I'll say and we will get to the case examples is it, the therapeutic relationship is from what I gather the most researched aspect of therapy ever. And what was the study? But they found in all studies, at least 30%, or 35% of the effectiveness was the relationship, which fat is using that, so it kind of makes sense why it would be helpful. - Yeah, and this is where I think the CBT world, and I mean CBT writ large, including AFD RP, all of that, is where it ran into trouble is, I think, they sort of said, well, okay, so the therapeutic relationship's important, so we need to be supportive and positive and kind and caring. But that's about it. And I think what fat is saying is, wait a second, if 50% or more of what works in therapy is the relationship, why don't we develop a much more sophisticated behavioral approach to the therapeutic relationship? And not just that, this is a behavioral idea here. Reinforcement that happens very close to the time that a behavior occurs is much more powerful than reinforcement that happens way later. And so I think what the fat people figured out was, let's reinforce behaviors that are occurring in the session. Does that make sense? Like, oh great, you did it out in the world, but oh, you're doing it here with me right now. And it's kind of brilliant when you think about it, because I mean, all of the behaviors that the client struggles with really will show up in the therapy relationship, if the therapist is similar enough to what they experience out in the world. So the fat people basically are saying, why don't we just work on the things that are occurring in the moment and reinforce them in the moment? And I think what's tricky about that for therapists is there are actually very few times in your life where you have conversations with people about what's occurring between you and the person in the moment. It happens in romantic relationships sometimes or like deep friendships sometimes, or like moments in life where something really big is happening, like a wedding or a funeral, but it just isn't often the case that you say how you feel about someone else in front of them in the moment. - Not when you're sober, that's so sure. (laughing) Yeah, yeah, that's a really valid point, absolutely. Yeah, yeah, a really good point. So let's jump into case example. So I'll let you kind of start and then we'll go from there. - Yeah, so I have a couple that I thought of. I'll start with one. So this is someone who has fairly classic, I don't know if anything's classic anymore, but concerns about sensations in their body. And these came on a couple of years ago and the obsession is what if these sensations don't go away and I can't stop thinking about them. I can't sort of be myself anymore with people and I'll just always be thinking about these for the rest of my life. It's similar to what someone might describe if they had chronic pain, but we know with OCD that people can get these obsessions about sounds in the room or swallowing or blinking. I forget the term, do people call these sematicor obsessions? - Yeah, yeah. - Yeah, so this person, their life is sort of being destroyed by this. Here's what's really interesting about them. Extremely smart, socially skilled, successful in their career, kind, thoughtful, suffering internally in a way that almost no one knows, constantly thinking about these sensations and the pain. And even has a pretty major suicide attempt to a couple of years ago. So I start working with them and with all of my background in ERP and acts, I'm thinking, well, I can help them trigger the sensations and then practice psychological flexibility responses, act responses like diffusing from it, practicing acceptance, shifting to a valued behavior. And I'm thinking, that's the way I typically would go with this kind of case, but they've seen pretty good therapists over the years and nothing's really worked. And I'm talking to them and getting a sense of whether this will work. And I start noticing some of these interpersonal things we've been talking about. So one of them is, although this person is kind of just great in all aspects of their life, they're overly positive with me. There's sort of this, hi, how are you doing? You were so helpful today, kind of like passing me in the hall in kind of an anxious way, kind of trying to avoid me a bit. I would characterize this as like not really great with vulnerability. So sort of slow them down and session and say, how are you really feeling right now after I get that kind of positive response? And then the tears come. And it's, I don't know how much longer I can live like this. It's so hard to be myself with you right now when I'm so focused on this. And I so value connection in my life and I can't do it anymore because I'm thinking about this. And I respond with that felt so genuine, what you just said. Just that you're so badly wanna connect with me right now and it's so hard to do it. The tears start coming more. And we're sort of getting into those kinds of interactions and at the end of the session, they say to me, I feel better. Now I don't mean the obsessions are gone and I don't mean the sensations are gone, but I ask, well, why? They say, I just feel like you understand me. You really get what I'm experiencing and you care. Now, people listening to this might be like, okay, so what? Like, yeah, you wanna do that with clients. But then here's what the treatment plan becomes. The exposure work is this person needs to have conversations with staff where, at my clinic, where they're practicing having a real conversation where they're both the client and the staff member are genuinely connecting with each other about whatever they wanna talk about. And here's the interesting part. I want the client to be able to talk about the sensations and the obsessions when that creates connection and not talk about it when it creates disconnection. So what I mean is the way they talk about it is gonna matter here. For example, if I say, what I want you to do is just vent about how miserable this is and how the big, sob, fest, and get really, really depressed and then do it again, that's clearly not gonna work. And if I say, I want you to pretend the sensations aren't there and be extremely positive fake it till you make it, that's clearly not gonna work. Those are both CRB ones. So the CRB two is, how do I relate someone these obsessions and these sensations in a way that makes me feel close to them and close to myself where I feel that sense of understanding and connection. It's like this sweet spot between suppression and indulgence. Basically, if you said to act people, what is he doing here? They would say that's just valued behavior. But I think we're acts, I'm not criticizing it, but where it can fall short here is with that kind of valued behavior, it's very nuanced how to do it. And it needs to be carefully reinforced by the therapist and you're sort of shaping more and more authentic connection with yourself and expression of that to someone else in a way that makes you feel close. Let me just give a quick sense of what this means. Like, you know, when you lose someone who's really close to you and you're going through grief and mourning, it doesn't work to like go see a therapist and they say, all right, here's the protocol for like how you grieve. You share three things about the person you lost in every conversation and no more. I mean, if I said to you, like, how do you grieve the loss of someone and how do you move forward in your life with that pain? What would you say? Me as the client or me as the therapist. Just a person who's lost someone close to you, like how do you move forward in her? My go to is you just keep you have to keep going. But it's not, but it's not just keep going put your head down and never talk about it and think about it. And it's also not tell everyone you interact with how much pain you're in. It's something in between. And I actually think really smart people don't know how to do this. Meaning they don't know how to connect with what they're feeling and express it to other people in a way that moves them forward in life. And why don't they know how to do it? The act people have a lot to say about this. They develop rules in their head. Like this client says to me, I thought what I should do was when I noticed the sensations to almost pretend they're not there and just fake it till I make it. It kind of makes sense, right? But what is that actually going to do? It's going to disconnect them from what they're actually experiencing and make them feel totally alone when they're interacting with other people. And then if I say to them, so I do want you to share this more, they're like, well, how much? And again, from a fat perspective, I'm saying the amount that makes you and I feel connected. That's what we're going to work on in here. And then we're going to go do it in other relationships. Now, one other sort of really kind of nuance, the piece to this is I'm doing a lot of this work with the client and they say to me, so will this help me get better? And this is my reaction to that. If you're using me and our relationship as a means to an end, meaning I'm only willing to work on this vulnerability with you, if it means I won't have this problem anymore, they're actually not going to get better. And I guess I'll ask you to do. Do you know why that is? I don't know. I feel like it's there. I just can't quite put a pin in it. Yeah. So I started noticing this a couple of years ago when I was doing more act and I think then when I started doing more fat, I realized this is really relevant. If you see therapy as a means to an end, you can get better if your problem is something pretty straightforward, like panic disorder, where you're just saying to the therapist, like, what do I need to do? And then they're doing all these interceptive exposures and getting you out into the world to face situations that scare you. You just need a smart, competent therapist to tell you what to do. But if your problem is more interpersonal or more, I'm going to say an inability to relax and connect and enjoy yourself in the presence of something you're obsessing about, you can't use the therapist as a means to an end because then you're missing the thing you actually have to do, which is see your life as happening right now. Do you get what I mean? Like it's not happening in a year when you're better. It's happening in the moment you're connecting with the therapist. And it's not like, oh, hey, this was really cool, but do you think this is going to help me? It's, this was your life. Like, you just felt this sensation in your body. It freaked you out. You expressed it to me in a way that made you feel more comfortable and safe and close. And we got connected. And that felt good. And you want more of that in your life. Not, um, you know, oh, Nate, like, can you just be the person who fixes me? So I think clients don't actually know this when they go into therapy is that the relationship actually should feel pretty real. Like, this is a real part of your life. This isn't a like, just a thing you're doing on the way it's getting better. That's a really good point. And what counts my mind is like, thinking about going to the GP or maybe even the physiotherapist, you know, and not to discredit those professions, but when I use those services, you go in, you're there to fix a problem you leave. Whereas therapy is different, you are forming a deep connection relationship. Yeah. And, and I just think that clients who see their therapist as a means to an end, this is from a fat perspective, what you would hypothesize, they see other people as a means to an end. Um, meaning they, um, let's assume it this way, when they're using me to get better, they're out to dinner with their friends and they're thinking, how do I, like do the things that I need to do right now that the therapist says to help me feel better right now? And they're missing the connection part. You get what I'm saying? Yeah. Yeah. That reminds me, and you said it earlier and you also mentioned it's like a dinner at therapy. It reminds me of a transference, right? That, yeah, we're taught and this is just another word for that, right? Yeah. You know what's interesting is when I tell clinicians, things like what I just described to you that case, some of them hear it and they have no idea what I'm talking about. They're like, how would you even know that they were having an interpersonal problem? How would you even know that they're not being genuine? How would you even know they're using you as a means to an end? And then I have other clinicians who hear that case example and they, they say things like this to me. I know exactly what you're talking about. And they say, wait, what's this therapy that you're talking about? And I say fat, it's like a behavioral framework for how to do these kinds of things. And they say, I've been doing this for years, I just never had like words for what I was doing. So that's what's cool about FAP is like, it's almost giving a name and labels like CRB1s and 2s to things that therapists kind of are tuned into already. But now you have like a much more kind of clear way of conceptualizing what's going on with the client and then intervening on it. I agree. I think that's why I'm drawn to fat because I feel sometimes if I get lucky in a session, I do this naturally. And it feels like something moved and it was really powerful. But then I can't replicate it. And I think fat gives you that framework to consistently replicate it. Yeah. I love what you just said. And like another point about this is this is probably more of a early career therapist mistake. But when a client comes in and they're expressing a lot of distress about an OCE problem or an anxiety problem, most clinicians think what you're supposed to do is respond to the distress, meaning that is what therapists do. They care about people who are in pain. But from a fat perspective, you shouldn't respond to distress that is being expressed in a way that's disconnecting. Or that's creating passivity or that is reinforcing a client's over identification with a mental health problem. And so I think therapists often are like, wait, what? You don't always respond to their distress. And again, from a fat perspective, you respond based on whether it's a CRB one or two. And the clients don't tell you what's a one and what's a two. They just do the behavior and you have to sort out for yourself. Does this thing feel like it's connecting this person to their best self and to me? Or does this feel like they're getting stuck in the way that they're expressing their pain? Back to the case I was presenting, I've had clients before who love talking about about their pain. This client actually doesn't. They're more in the other direction of, they're afraid to talk about it. Because they're afraid if they start focusing on it, they won't be able to connect with other people. - Yeah, yeah, good point. Yeah, fascinating. But do you wanna go into the second case? - Yeah, let me, I'll give you one that's a little bit more, this is something that maybe a lot of OCD clinicians are more familiar with. So the client who comes in, we see this a lot at the OCD clinic where they really are overly identified with their symptoms and what I mean is, it's given them a lot of social connection in their life to have OCD. For obvious reasons, you can be part of the IOC DF. You can listen to this podcast, you can connect with people around it, which is all great that you're developing all these really positive relationships through having OCD. - Yeah. - The problem is it starts to go into a CRB1 area when it becomes who you are in a way where you sort of lost touch with other parts of yourself that might connect you to your best self, your best life, other people. And so we'll have this problem where people will come in and they'll say, "I'm so glad to be at the OCD. I finally, you know, where I wanted to be my whole life, you guys are the best." And they even write there if they say something like that really concerns me because there's this feeling already like, your life was on hold until you finally got to be with us. And then you can just see it in the way they talk that they're saying, "I have this symptom and I have this one and I have this one and I used to have that one, but it got replaced by this one and now I do that, but I don't do that anymore." And you can just see there's this whole complicated story they have about their OCD and who they are. So they often want to do ERP and they wanna do a lot of it. And they wanna talk about their OCD as much as they can. And it's so hard for me because what I have to do is jump in and say, "Wait a second, I wanna get to know who you are outside of this." And oftentimes they don't know who they are outside of it. So you're dealing with a blank canvas and that scares them because they don't know what to say. And you often then have to send them out in the world to go have experiences that then will give them things to say and experience and talk about. And so for example, I have worked with people where they'll say, "Okay, I'm afraid of demonic possessions. Just take that for example." And they wanna do exposures around that. They wanna listen to music with those themes or watch movies with those themes or play video games with those themes. And I watch them do those exposures and they don't look that distressed. They look kind of almost like they're in their element in some way. And I don't mean that they aren't distressed but they sort of know what they're doing. This is what they came to do. And so then I'll start saying things to them like, "You know, I have noticed that in your interactions with other people here, you seem like you're kind of dominating conversations or you're often kind of left on the outside of when people make plans to go out." And I sort of get this sense that your self-esteem isn't really great. Is that right? And then the tears start coming and we're starting to expose something like, this person has never felt great about themselves. And they've sort of used OCD as a way to like make sense of why they're struggling so much in their life and express that distress and distract from it in some way. And so then we started a FAP group here at the OCD clinic where the patients are in the group and we're working on CRB1s and 2s in the group. And I'll have that client go in and start talking about his insecurities in the group with the 15 people in the room. And the tears just start flowing and I'm looking at that and I think, wait a second. Why are the tears happening here, but not when they're listening to the demon music? And I start realizing, this is part of the functional analysis. I'm like, they're really in a lot of pain around whether people like them. And being open and vulnerable about that is both really scary and really connecting. So when this person shared about the, do people like me feeling insecure, I had the group members really reinforce it. Wow, we feel so connected to you right now. This is the first time we've ever seen you cry. What is really going on? I didn't know that you felt so insecure. So that kind of a case, I just can't tell you how many times we'll get the referral and the clinician will say, they have like 15 different symptoms. This is super complex. You guys are going to have your hands full. Like definitely needs a higher dose of ERP. And then I send them back after three months and I say, please don't do any ERP. Just do this in a personal work. And that's, I think I said this too last time. That's when a lot of clinicians are like, what? What that? I don't know what that is. And that's one of the reasons I'm talking you about this is, if clinicians don't have this in their arsenal, they're just going to do ERP for those cases. And it's just taking clients too literally to be treating them that way. Yeah, really good example. So obviously you, as you, as you, all you do to you do ERP as well, right? All of it. Yeah. And again, I just want to say my evolution here is, all I really did was ERP when I first started at the OCDI. Then I started learning about ACT and as the field was moving in that direction, I was as well just because I think psychological flexibility, which you've talked about on other podcasts really captures, I think a lot of what people are struggling with at the core of OCD. But then as I kept going in my career, I started noticing cases like the two I just described where I was like, there's something else going on here. I don't know quite what it is. I don't know how to treat it just with the ERP and ACT. And this is where a lot of clinicians here and I think in other places will go, oh, it's probably a personality disorder. They need DBT. You know, I really worry about that kind of an approach, just not DBT, I think DBT is great, but just this like, oh, something weird is going on and a personally, there's a hammer for that. Because you're sort of missing that, some of these interpersonal behaviors you can work on with them. Not always, sometimes they need a full course of DBT or just to be referred to a more interpersonal approach, but I think if OCD clinicians could see themselves more as, look, if we're behavior therapists or cognitive behavior therapists or whatever you wanna call ourselves, we need to be able to interact with all different kinds of behavior. And interpersonal behavior is behavior. It's not something magical. - That's a good point, viewing it as a behavior, nothing else. Yeah, so with this guy, I think you were just talking about that case where you said after three months, please don't do any ERP with him, just doing interpersonal stuff. Had you been doing ERP before then, or is it? Yeah, okay. - Oh, yeah, so, but this is actually a good example. So, for all the clinicians listening to this and thinking, oh, so if I get a case like this, I should just tell them, I'm not gonna do ERP with you, I'm just gonna do fat. What I often do, especially if their ego is kind of fragile around this, meaning their whole identity is wrapped up and having OCD. I'll just very carefully start saying, let's do some ERP, listen to some demon music and whatever, even though I don't think that's where the action is, I'm just gonna give them some of that just to kind of have it. And also for me to assess what's really going on there, but I'm really focusing in on the interpersonal work with them and I'm trying to get the counselors that are clinic to focus in on the interpersonal work. And what usually happens over time is the client starts dying in because they just feel something's changing in the way they're relating to me and they just start talking less about the OCD. I mean, when you start crying in front of 15 people about how insecure you feel, it's hard to forget the power of that moment, you know what I mean? Like to just then wanna go back to talking about OCD. So I think like from a fat perspective, if you're differentially reinforcing CRB2s, you're then gonna get the person moving in the direction of wanting to talk more about interpersonal things. Yeah, really a really good point. So, last is there anything else you wish you could have said on this topic today? I just think it's hard to talk about FAP. In fact, I think you and I were talking right before the show. I would rather just show people videos of this than talk about it because I think clinicians hear this and they're like, I have a sense of what he's saying, but I really need to see it to know. I think what we're going to have to do as a field, just more in general, is show people what we're doing in videos. I think that's how clinicians learn. So, if people are going to learn more interpersonal approaches to OCD, we're going to have to show it in a video what we really mean when we say a CRB2 and how it gets reinforced. So, I'm trying to talk about it with you, but it's not easy to capture it. No, I agree. You're right. That's just not FAP. It's all therapies right. Need video case material. If it's role play, I mean, it's still good. It's not as good, but it's safer, obviously, for the clients. It's a real shame. We've kind of moved away a bit. Yeah, I think that in medical treatments, if you were learning how to perform surgery, or say, you were learning to do physical therapy on someone's leg, you really do want to watch exactly what the clinician does. You don't just want to read a book about it, but I think in psychological treatments, there's so many privacy issues around it that it's hard for clinicians to show what they're really doing. Yeah, I agree. Yeah, well, if someone has a clever idea, let us know. Cool, but I thank you so much. I really enjoyed this one and talking more about it. Yeah, I was great to talk to you. 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 over one time tips/denation, please go to the OCD stories.com/support. All tips, no matter how large or small, are greatly appreciated. Please subscribe and rate the show wherever you listen to the podcast. And thank you to no CD for supporting our work. If you want to find out more about no CD, head to go.treatmyocd.com/theocdstories. I'll click the link in the episode description. And quick disclaimer guys, this podcast is not therapy. It's not a replacement for therapy. Please seek treatment from a trained professional. And until we speak, take care. 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