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Anxiety Disorders

Wise Counsel Interview Transcript: An Interview with Steven Phillipson, Ph.D. on the Nature and Treatment of Obsessive Compulsive Disorder (OCD)

David Van Nuys, Ph.D.
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David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

On today's show we'll be talking about obsessive-compulsive disorder with Dr. Steven Phillipson, who's the clinical director and founder of the Center for Cognitive Behavioral Psychotherapy. Dr. Phillipson serves as adjunct faculty at Columbia University, Rutgers University, Fordham University, Yeshiva University and many other doctoral programs. In addition to his pervasive caseload of OCD patients, Dr. Phillipson provides treatment for all forms of anxiety disorders including panic attacks, agoraphobia, social anxiety, PTSD, and generalized anxiety disorder. He also possesses an expertise in the treatment of personality disorders such as obsessive-compulsive personality, borderline and narcissistic. In 1987 Dr. Phillipson started the first behavior therapy group for persons with obsessive-compulsive disorder. Dr. Phillipson is the creator and author of, a website that is exclusively devoted to the conceptualization of the lesser known forms of obsessive-compulsive disorder and their treatment. He and his staff provide individual and group psychotherapy on an out-patient basis to patients within the New York City metropolitan area and around the world through the use of video conferencing.

Now, here's the interview.

Dr. Steven Phillipson, welcome to Wise Counsel

Steven Phillipson: Thank you.

David: Let's start out with your background; you're an expert in OCD or obsessive-compulsive disorder. How did you get started in psychology in the first place?

Steven Phillipson: I didn't start in psychology; it was actually a choice to follow in my father's footsteps. He was a psychologist in the '50s, and unfortunately he died when I was very young and I chose psychology for no other reason than to pay reverence to him. But once I got involved in the profession, I found that I had a thorough enjoyment of it and felt a great deal of satisfaction.

David: Well, that's a really great reason for getting into it. Tell us a little bit about your schooling.

Steven Phillipson: I got my bachelor's degree at Lynchburg College and they're a very behaviorally and experimentally based institution in Southwest Virginia. Then while I was getting a master's degree in clinical psychology, I had a very fortunate opportunity to do a full year internship at Johns Hopkins University Hospital. And that internship really taught me how to conceive of psychology from a very data-based viewpoint. They really drove home the rigors of a scientific approach using empirically based evidence to come to hypotheses and developing perspective. Then I was lucky enough to enter Hofstra University in 1984 and start my doctoral studies; and while there, I did another full year internship at the Institute for Behavioral Therapy, where I started my career working with adult patients and really started my expertise there with OCD.

David: Yes, I wanted to ask you how you came to specialize in OCD. Was it as a result of that experience?

Steven Phillipson: It was. Most of my patients ask me that question and, funnily enough, it was purely by coincidence that I got involved with OCD. While I was doing my internship, a mentor of mine was a renowned specialist in Manhattan, Dr. Gordon Ball, and he and I teamed up in 1987 and started the first behavioral therapy OCD support group probably in the country. And while in that group, I really became very fascinated by the nature of the thinking process of persons with this condition.

David: Well, let's make sure we're all on the same page by having you tell us what OCD is. In other words, what are the symptoms/experiences that characterize this disorder?

Steven Phillipson: OCD is an anxiety disorder in which the mind sends a very powerful signal of distress, emergency, associated usually with some thought that pairs with the profound experience of terror. And what happens is that a person who is otherwise extraordinarily reasonable in their thinking and very rational in their thinking experiences a tremendous distress over a threat which they themselves already are aware of as being irrational. But the mind pairs such an emotionally discordant experience that the person is compelled to act in contradiction to the reasoning mind and they behave in a way that seeks to neutralize or nullify the irrational thought that is paired with the discordant experience.

David: Now you say it's not a thought disorder, even though the problem seems to be in part persistent, unwanted thoughts. So clarify that for us, if you would.

Steven Phillipson: That's correct and I think, tragically in the field, that a number of people in the CBT - the cognitive behavioral community - are chasing the thought aspect of it, and I think that that is a tragic mistake within the field. There's really a division between the behaviorally oriented specialists like a Stephen Hayes, and some of the cognitively-based specialists who are located predominantly in Boston, including Gail Steketee.

So the way I conceptualize OCD is that a person has a thought that is paired with this powerful emotion; and the funny thing is, they report very readily that prior to the onset of the anxiety, that they had had similar thoughts that did not produce a distress or did not produce an effort on their part to seek safety. I think that what's interesting is, research shows that about 85-90% of the non-clinical population also reports having similar thoughts, such as harming a new-born child, jumping off of cliffs, jumping in front of trains, having thoughts in church to be disrespectful to God; and that we have these thoughts, and we might have a pang of distress that lasts about two or three seconds and then the event is over. With OCD these thoughts are paired with a profound amount of distress. I look at it like the difference between a nuclear device and a firecracker. And with OCD when these thoughts occur with the very powerful kind of meltdown of the emotional brain, a person is very much motivated - and often acts in a way - to neutralize the thought or neutralize the distress by looking at the thought as being an irrelevant factor, which indeed it is not at all.

David: Okay, I was intrigued to encounter a new term on your website, one I might not have thought to connect to OCD. I'm referring to "hyperscrupulocity". Tell us a little bit about that.

Steven Phillipson: Scrupulocity is one of the many subsets of OCD in which a person feels a profound distress at the idea that they're behaving in a way which is in contradiction to either law or religious law. And so a person will find that they will behave in rituals to ensure that they're behaving in accordance with predominantly a kind of religious or God-given law. So it occurs often in praying, and the term scrupulocity actually comes from 16th century monks, who had observed that some of the brethren were engaged in excessive need to perform their duties beyond what was ordinarily expected of them. So it's actually a derivative of a Catholic definition from the 1600s.

David: That's fascinating. Well, you indicate that that's one variant, so take us through the varieties of OCD, if you will, because I gather it can manifest in several different ways.

Steven Phillipson: That is absolutely correct. Actually the reason for my website was because so much of the media was paying attention to such a very narrow band perspective of OCD. So to start with, the entities of OCD which are most known, obviously, is the variable of cleaning out of distress that a person might receive germs or diseases through objects which might be in contact with the public. People will engage in extensive cleaning rituals after they've come in contact with things that might have lingering AIDS on it, or herpes, any distressing disease that is often a threat to life. So these people are very limited in their ability to use public facilities because of the idea that they might contact these contagions and then suffer the disease from them.

So that's the most common and well-known form, and then second to that are the other, what are referred to as the observable ritualizers, which means that you can see that the person is engaging in an overt behavior in order to reduce or escape the distress. And the second most common form is the people who engage in "checking". So they will often check stoves, check windows, check faucets, to make sure that the associated threats, such as fire or break-ins or floods, do not occur.

The interesting thing is, once again, that these people know or are aware that after they shut a light off that the electricity has shut off, but in their mind they experience the idea - or they're actually feeling - that after shutting off the light, there may be some still lingering threat. So they will engage in these behaviors repeatedly in order to kind of ensure what they believe to be a cognitive locking out of the threat, when in fact, it's actually they'll keep engaging the ritual until the emotion is reduced, and then they feel safe in order to leave that moment of checking.

David: You know, you mentioned the media, and that made me think of "Monk". Have you ever seen that series on television?

Steven Phillipson: Unfortunately, yes. I'm not a fan, although I've heard some snippets that seem somewhat amusing. The people who have OCD often experience a profound amount of distress and it's kind of like handicapping; and unfortunately the media has found these behaviors amusing and in shows like "As Good As It Gets", which was, I think, a complete misrepresentation of OCD, "Monk" or "Matchstick Men" or even "The Enemy Within", they portray people with OCD as being dangerous or a lot more divergently disturbed than is actually the case. So I'm not really a fan, nor do I find it amusing.

David: Okay, well that's a good perspective to learn about. Now, you say all of us tend to have some OCD-like tendencies. What are some examples of this?

Steven Phillipson: As I mentioned, you know, I find that people often report thoughts of harming innocent children, or harming animals, having associations in church or temple to yell out something inappropriate, thoughts of jumping off of cliffs or, as Woody Allen joked about, he talked about having thoughts of driving into oncoming traffic. And I think these are common associations that, when a person doesn't have OCD, they tend not to be paired with the profound emotional distress, so they kind of come and go and we tend to dismiss them pretty readily.

David: I know that in going through graduate school, I feel like I became more compulsive, that is, just kind of more organized and more detail oriented than I was before it. And it sort of has come into everyday language; people call themselves, they say they're being obsessive or they say they're compulsive.

Steven Phillipson: Actually what you're referring to sounds a little bit more like an article that I've written about on my website, which is more perfectionistic. There is a large difference between a person who strives to be perfect and reduce the possibility of mistakes versus a person who is kind of running from these associated threats. So in the article I speak about perfectionism as being a tendency that is driven by a concept, the concept being to kind of ratchet up control variables or to give in to kind of rules to reduce the idea that life is getting out of control. Whereas with OCD there is more of an immediate distress or anxiety factor, whereas compulsiveness is really driven by worry and OCD is driven by anxiety.

If I can, I'd actually like to go back to your question about the different forms of OCD because that was really my main area of interest in writing the website in the first place, and that is to talk about persons not only who have scrupulocity, which is driven by both the anxiety of needing to do God's will or to behave in extreme compliance with the law, but also that facet of OCD is driven by guilt, the idea that if I violate these rules, then I'm not only going to be anxious, but I will also be guilty of being a bad person. So with this form of OCD, there's a great deal of what I refer to as a "character indictment spike" or threatening association, in which case the person is really kind of trying to disprove an indictment against their nature as a human being.

And the other large subset is what I refer to as the "purely obsessional" type of OCD, which has actually stirred up a little bit of controversy because I'm fully aware as a scientist that the term is a misnomer. There really is not such a thing as a purely obsessional form of OCD, but for the patients who have the non-observable ritualizing subtype, they kind of like that little phrase because it distinguishes them from the majority of persons with OCD that the media has given attention to.

And these people have thoughts that fall under about three or four subsets which is the idea of violence, either to other people or themselves; the idea of inappropriate sexual thoughts, so a person might think that they're going to or might actually have molested a child at some point in their time, or they might be capable of molesting children and they become highly distressed because they have these thoughts of engaging in these inappropriate sexual behaviors and they then ritualize to ensure that they won't give in to these thoughts.

Now, once again, keep in mind that people who have these thoughts are as likely to be guilty of these behaviors as you and I, and I know very much that any patient who comes to see me for a type of sexually inappropriate association I'd be just as happy to let stay with my own children for a week in baby-sitting them as anyone else. They're completely discordant with having any increased likelihood of acting on these thoughts.

And the third subset from religion or sex is the idea - so it's violence, sex, and then the other one is religion, that idea that a person might have engaged in some thought which is a violation of God's will. So those are really the majority of the subtypes of what I call the Pure-O that I've given the greatest amount of attention to.

David: Great, and these people recognize somehow that the thought is irrational? Even though they're compelled to keep mulling over or engaging in these rituals, at the same time they do have a sense that it's irrational, is that right?

Steven Phillipson: That is correct, and that's been the part of OCD that's been most fascinating to me, is that these very logically based people, very intelligent people, are on one hand aware that the associations that they have are irrational, and yet they behave in a way as if they truly believe these thoughts to be legitimate; and their behavior is more in correspondence to reducing the experience of distress than it is the rational reasoning of it.

And, you know, with any of the anxiety disorders like, let's say, panic attack where a person will go to a hospital thinking they're having a heart attack, be told by an emergency room physician, "You're in great shape, your heart's perfect, you're just having a panic attack." The next time they have one, the anxiety becomes overwhelming and so their ability to use reason to convince themselves, oh, this is just anxiety, is displaced by the mind's creativity that says, "Yeah, but the doctor might have missed something. This feels a little bit different. You really can't be absolutely sure, so go back and get another stress test," or something.

David: Yeah, this is reminding me of when I was first starting out as a clinician, I saw a young man who had concerns that he had run over somebody with his bicycle. And somehow pointing out that, well, jeez, if you ran over somebody with a bicycle, you'd really know it; there wouldn't be any doubt, there wouldn't be any question. You'd probably fall off your bike. But that didn't seem to hold great sway, as I recall.

Steven Phillipson: I was laughing because most of the people I work with who have that thought have it more with a car, in which there may be some greater likelihood that we could run over a child or an old lady and not be aware of it, even though highly unlikely. But I'm amused by the idea of the bicycle, which really demonstrates the nature of the disorder not being a person's faulty reasoning, but that person, I'm sure, thought there was some possibility that they might have nicked somebody or that they might have caused someone's harm by a near miss.

And so this person also has what is referred to as responsibility OC which is the type of OCD where a person feels that they might be guilty of some crime and guilty of someone else being at harm because of their own negligent actions. So his distress once again involves both the anxiety that he might have hurt someone, but also again there's the element of the guilt. How can he walk away from an accident like this? How can he have injured somebody and not have stopped or not go back and return to the scene to clearly come to a conclusion that he's innocent of that accident?

My first exposure to OCD coincidentally was a young, attractive woman who came to Hofstra University in my third year, and she also talked exactly about this, that she would drive to work - or try to drive to work - and on the way there she would have some thought that maybe she hit a neighbor. And then she would circle around her neighborhood because of the anxiety, looking for bodies or injured people. And when she would get to work, she would call local emergency room hospitals, she would call police stations, she'd call ambulance services, to make sure that nobody was dispatched to that part of her town. And despite all the reassurances, the thought did not disappear, it persisted; and each time she drove to work there was some other possibility of an accident. And she knew, also, that her behavior was completely irrational, but once again it was so driven by the experience that she was really helpless to do anything about it.

David: And I can imagine how disruptive it would have been on her life because all of those activities are so time consuming. On your website, which I'll mention is, I was struck by your statement that OCD is still minimally understood by the vast majority of mental health professionals. What is it that they don't get?

Steven Phillipson: I think that it's so enticing to listen to a person with OCD talk in terms of being so flagrantly irrational, and I think that that hooks many clinicians to try to help a person sort of see the truth or see the reason in it. Just as you said that you tried to help this person by convincing them that they would have surely been aware of a bicycle if they had hit somebody, so it's very tempting to think that we can educate a sufferer about the irrational nature of their thoughts and help them in that way.

And, in fact, I think that the majority of clinicians, whether they be of the cognitive mindset, which asks patients questions like, "What's the evidence?" which is a very common type of intervention for a cognitive-behavioral psychologist. Which I think is great for people with depression, but when you're dealing with anxiety I think it completely misses the mark, because with OCD the driving force is a misfiring signal, probably in the amygdala, which is sending out an emergency distress signal independent of their being any justification for it.

So I think that there may be some imbalances in the neurophysiology which are producing these misfirings. And it's my belief that when a person engages in ritualizing to try to neutralize that distress, that you're sending back a signal to the brain on a very conditioned level that the emergency signal was legitimate; and their behavior then justifies the brain's need to protect itself and it becomes more and more sensitized to finding other ways in which threats might kind of exist in a person's world.

David: So you're saying that carrying out the ritual or having the thoughts, if I understand, is somehow reinforcing this response to panic that's originating in the amygdala. Do I understand that correctly?

Steven Phillipson: The first part was correct, when you said carrying out the ritual. Having the thoughts is completely independent of a person's control, and this is sort of a tough part, I think, for clinicians and patients themselves, being able to look at the brain as a machine that's capable of marvelous things - it regulates your body temperature, it regulates appetites, sleep cycles, heart rate - but it can also create thoughts independent of our voluntary will.

If I'm walking across a room and I stub my toe, it wouldn't be unusual for my brain to say, "Steve, you're a clumsy idiot." Now that thought is a reflex. Steve does not believe that stubbing his toe is evidence for him being a clumsy idiot. I think that humans occasionally engage in clumsy behavior and so I've behaved in a very human way. That's what Steve chooses to believe.

But my brain has these associations, you know, they're sort of programmed responses developed way, way early on; and just like with OCD, when there's distress, the brain looks for associations that might vindicate or justify this distress. So it automatically creates these associations. The person who has them, interestingly enough, there's no variable to the nature of the thought and a quality within the person. If I had thought about stabbing pregnant ladies, that wouldn't indicate any kind of underlying anger or that wouldn't indicate any variables about who I am; it's just how the mind links up this distress with an associated thought.

David: I'm puzzling over this just a little bit here because I'm thinking that it's not just some kind of random conditioning that's happening here, that there's arousal in the brain and then some event that's happening or some thought that's happening becomes associated with it; because there seems to be such regularity in the kinds of thoughts, that the thoughts are about running over people or about cleanliness and so on. So it seems to me it's challenging to figure out why are there these certain patterns associated with the syndrome.

Steven Phillipson: It is, I think once again, very tempting; and I definitely think most clinicians would share that temptation. When I present to psychologists I get a similar reaction because it just seems so clinically rich that these people are having thoughts of either violence or cleaning, but really there's also thoughts of what's called sexual orientation anxiety. So people will have thoughts that maybe I'm gay, people will have thoughts maybe the person I'm dating I don't love enough.

And what's interesting is that it's not uncommon that people will actually have their OCD thoughts morph. So I had a patient who had three distinct different types of OCD and only one would show up at a time, it would last about a month or two. So one of his thoughts was to kill his children, one of his thoughts was that when he would masturbate his semen would end up all over the world, and that was unacceptable. And one of his thoughts was that he was going to blurt out racially inappropriate comments to his co-workers.

So when he had one theme, the other two themes he would joke about; he would have absolutely no distress. He didn't care about them whatsoever; he looked at them in the exact same light as anyone else would. But when his mind would then shift to that theme, he would sort of pray that he would go back to the other themes because they seemed to be a lot more easy to manage, and the one that his mind was locked on was the one that created all this distress and created a sense of absolute concern.

So cases like that tend to suggest that the thoughts are sort of arbitrarily selected by the mind, and once that bond creates - you know we know from neurophysiology of something referred to as the strength of the association, which basically says that, when we reinforce an association, when we behave in a way that legitimizes it, that our brain then makes the link between those two things a lot quicker and a lot stronger. And I think that that kind of understanding of neurophysiology really helps understand why people who are incredibly rational, incredibly level headed are giving in to thoughts that they know themselves as being completely illegitimate, when you look at it from that kind of a neurological perspective.

David: Okay, well, let's switch our attention a bit to treatment. I gather your approach to treatment is cognitive-behavioral therapy or CBT, and inasmuch as you've already noted that CBT is probably the most widely practiced form of therapy these days, what's different about your approach? I gather that you have a unique spin in terms of treating this disorder.

Steven Phillipson: Well, believe it or not, one of your other speakers, the renowned Dr. Edna Foa, is kind of the basis of my developing the type of treatment that I did; only what I did is I took her fundamental principles .And you know she is really the country's leader for the longest period of time in really treating OCD, and she really got her notoriety working with the more observable ritualizers, so in her in-patient placement in Philadelphia she and I would probably operate identically. We would be very aggressive in doing what are called exposure exercises. And what she does in three weeks usually takes me about two to eight months in working on an out-patient basis with a patient, but she does it in a very intensive kind of 8-hour day controlled environment.

So what we do for the observable ritualizers would be developing a hierarchy. So let's say a person were afraid of contracting AIDS through blood or other bodily secretions, so what I would do is I would have a person probably start just taking a paper towel and swabbing it on, let's say, a public light switch. And let's say on the scale from 0 to10 that the contents of disease on that light switch might represent a 2 for a beginning patient. What I then have the patient do is take that paper towel after they've swabbed it on the public light switch and then bring it home and basically stroke it on all items in their home that they have daily and regular contact with. And I get pretty creative in this regard, so that means things like each of their phones, their glasses, they would put it all over their dishware, they'd put it on the refrigerator door handle, they'd put it on their bath towels, they'd put it on their toothbrush, they'd put in their pillow case.

So basically what we're doing is referred to as a "graded flooding". And what that means is, although we're starting small, we're taking that item of distress or threat and we're spreading it to every part of their world. So after they would take the paper towel and spread it around their home, they would then carry it with them at all times in a pocket; and for any time that they would wash their hands, if they encounter a distressing item that is above a 2 - so let's say a person shakes hands with someone and they notice that person has blood on their cuticles. That would probably be an 8 on the subscale, and so naturally they would engage in some washing behavior to reduce that level 8 distress back to a 0. But because they now have that paper towel in their pocket which has a level 2 on it, they would take out the paper towel and immediately wipe it on their hands. So at this point the bottom of their hierarchy is always going to be a 2 and every facet of their life will be a 2.

And so with this form of ERP and graded flooding, you just gradually have people climb the hierarchy from, let's say, public light switches to public door handles to maybe the outside of a public bathroom, to the inside door handle of a public bathroom, to faucets in a public bathroom. And we work all the way up to actually, like, rubbing the paper towel on a public toilet seat or occasionally even dipping a corner of the paper towel into a clean toilet in a public toilet. And when I talk to people about the ERP hierarchy, I often don't talk to them about the higher ends of it right from the beginning, because they always say the same thing, they always say, "Oh, I'll never do that." And usually about four to eight months later that's exactly what they're doing, and experiencing not nearly as much distress as they might imagine, because as you climb the hierarchy, it's kind of like a stack of dominoes, where you knock off the bottom items and the top items on the hierarchy really collapse down. So by the time you get to a 10, the experience is not much more than you would experience if you touched a 2 or a 3.

David: Interesting. Now you have people actually doing things and I think some therapists have had people do things in imagination. Has there been research or do you have experience that can talk about the comparison between actually doing the feared activity versus imagining the feared activity?

Steven Phillipson: I think the use of imaginal exposure is really more for probably kind of inconvenient phobias, let's say, like fear of flying. So I will, with certain phobias that are inconvenient to be reproduced, use imaginary exposure. But usually even then it's recommended that the person engage in the in vivo or in real life exposure, so I'm not exactly up to date on the comparisons because, really, the modern psychologists in working with ERP will always try to produce as much in vivo exposure as possible.

And that sort of takes me to where I've taken Dr. Foa's work and really transposed it to what I refer to as the Purely Obsessional type of OCD. So let's say I'm working with someone who has fears of being inappropriate in a religious way, so they might write down on an index card the statement "God makes mistakes." And that might be a very low item on their hierarchy and I'll have a person write it down because I believe that having a tangible exposure to carry around with a person produces a greater habituation response. And so I will have a person read the index card about 10 times a day, maybe on a once an hour bases, and they'll read it to themselves and basically say, "Yeah, God might make mistakes." And then kind of put up to the heavens the idea that now God might be upset with me.

And it's interesting because a lot of people who use more traditional cognitive therapy, they believe the goal of the treatment is to produce a greater sense of logic and reason for the person to see that oh, you know what, God wouldn't be upset with you. But for some things you really can't get an answer as to saying God makes mistakes whether he'd be upset with that. So what we would do is we would build up on the hierarchy. We might say things like, God is stupid, God is a jerk, and then you can use your imagination; we can really kind of take it very high and produce a greater degree of tolerance and resilience to the idea that God might be sending me to Hell any day now and I might be in big trouble with God. But because a person engages in these exposures over and over again, they really develop a nice habituated response, meaning that the amount of emotional distress goes down tremendously as a person engages in the exposures on a repeated basis each day.

David: I noticed on your site that you mention humor. What's the role of humor in your approach to treating OCD?

Steven Phillipson: It's interesting because certain experiences in the brain can be sort of mutually exclusive. I remember reading research early on in my training when I was working on becoming a sex therapist, that the use of anxiety and laughter are mutually exclusive entities. So the idea of having a patient produce a humorous response to the anxiety that their brain produces, creates almost what is identical to the ideas of reciprocal inhibition, meaning that you can't really be anxious and find it funny at the same time. So by choosing humor, it kind of overrides the anxiety function and shows the brain that these threats and these challenges are no longer going to have a substantive part in a person's life.

So basically I think the real potency of the treatment that I do - and I tell this to the patients all the time - that the goal of therapy is the idea of irrelevance, and when you engage in exposure exercises you show your brain that these associated threatening thoughts are now irrelevant to you. By engaging in these exposures, by recreating the fearful thoughts that the brain is producing automatically, you sort of preempt the brain's need to warn you.

And I tell patients a great deal that the brain is really not trying to be self-destructive, which is a very common, sad way of looking at OCD and many disorders. But with OCD or any anxiety disorder in general, the brain is merely sending a protective emergency warning signal. The problem is that there was nothing to be warned about in the first place, but you can't really tell the brain that because this part of the brain that sends out these distress signals has no capacity for verbal functioning. So there's no way to say to the brain, "This is not a problem." That's why you can't use a cognitive, rational response in trying to tame this part of the brain. And in effect by using kind of a rational approach to treating OCD, you actually reinforce the brain's desperation to feel better and to prove that these thoughts aren't legitimate. And that's just called ritualizing.

So by engaging in exposure exercises, you show the brain that you're not going to act in a way that is substantiating of the brain's fear. You show the brain that these ideas and experiences are not going to be met with avoidance and escape, but are going to be met with a very aggressive exposure paradigm that says, "I'm so not concerned about this, that I'm doing it on purpose over and over again." And fortunately research shows in my clinical experience of 25 years that this is an amazingly powerful approach. And the liberation that it provides people is tremendously gratifying.

David: Is there any way a person with OCD can treat themselves?

Steven Phillipson: That's kind of funny that you ask that because I've written, whether you can tell, a pretty comprehensive website on treating the lesser known forms of OCD. And about half of the people who email me will say things like, "Dr. Phillipson, thank you so much for this website, it's been tremendously helpful. I've been engaging in now a new strategy for approaching OCD and I'm feeling much better. I just have a few little questions in terms of enhancing my effectiveness." And my response to them is almost absolutely universal, which is, "Hey, thanks for the feedback, but please do not use this website as a substitute for treatment."

There are many nuances to treating OCD, particularly in the end stages of it, that really require, in my belief, an expert. People will engage in these therapeutic procedures and think that they're supposed to feel better, when in fact the therapeutic exposure exercises are designed to produce the potential for anxiety. And so if people engage in exposure exercise and feel anxious, they will think, "Oh my goodness, something is wrong", when actually the goal of the therapy which is irrelevance, if you experience anxiety then there's nothing wrong at all. You're just being willing to have your brain react with some distress.

Now another thing that can be complicated is almost the opposite effect. When people engage in very aggressive exposure exercises, oftentimes the brain will not respond with anxiety whatsoever; and then a person will think, "Oh my goodness, I must not be doing it correctly because here I've said this really bad thing about God and I didn't get anxious at all. So, what's the problem?" And the situation in that case is that the person was so willing to feel anxious, that they basically short-circuited their brain's need to protect them. And that's a very common effect when people engage in this treatment in a very aggressive way, where they, right from the start, realize that being willing to expose themselves to anxiety is their pathway to recovery. They'll be so aggressive with it that they'll experience very little to no anxiety, and then they'll think that they're not engaging the treatment correctly. When, if you assess it in a kind of very expertise way, you can really see the difference between whether a person is really secretly ritualizing or whether they're just so tenacious and so aggressive that their brain isn't delivering the anxiety response. So I'm very much opposed to people, whether they're using books or websites, to engaging in just independent treatment. I think that bibliotherapy can be an excellent adjunct to working with an expert, but I don't recommend that people use it as a substitute.

David: Okay, well, if one of our listeners suffers from OCD, how can they find a qualified therapist in their area?

Steven Phillipson: Fortunately there is an organization called the OCD Foundation and that is now in Massachusetts. They have a website and they provide a list of persons who have identified themselves as qualified experts. Unfortunately it's not a jurored list, so a person has to go into the process with a willingness to kind of shop and really interview the therapist. I think that there's a clear difference between a therapist who says, yes, OCD is one of the things I work with, and a therapist who says, OCD is about 80% of my caseload. And I think if a person gets some of the excellent literature that's out there, including my website or some of the really excellent books written by perhaps Jonathan Grayson; Gail Steketee has written an excellent book; even Edna Foa has written an excellent book. For more of the observable ritualizing types of people, a person can really get the background education on what their understanding of OCD is and what they understand the treatment is. And then really interview a person in terms of their use of what's called ERP, which stands for Exposure and Response Prevention. And that means that the therapist works with a patient through a very graded, gradual process of having the patient expose themselves gradually in a hierarchy to increasing levels of items that are distressing, and working with the patients and providing them with coping strategies along with the exposure exercises. And the response prevention means to do the exposure and then not engage in the ritual. So it's not enough, let's say, to go into a public bathroom to touch a public toilet seat and then come into my office and eat pretzels with your fingers; it also means that you have to really avoid washing or telling yourself things like, "Well, Steve did it, then it must not be dangerous." Because I tend to be a risk taker and half the things that I do my wife never finds out about.

David: Well, we'll close on that note. Dr. Steven Phillipson, you've been very generous with your time and information. Thanks so much for being our guest today on Wise Counsel.

Steven Phillipson: Thank you for having me.

David: I hope you found this interview with Dr. Steven Phillipson as informative as I did. If you're interested to learn more, you'll find a video presentation that he did which is both on YouTube and his website at, and you'll also find an abundance of resource information about OCD causes and treatment on that site. You've been listening to Wise Counsel, a podcast interview series sponsored by If you found today's show interesting, we encourage you to visit, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the home page. If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.