Podcast: Treating OCD with Exposure and Response Prevention (ERP) Therapy with NOCD's Dr. Patrick McGrath

Inside Mental Health Podcast Guest and Host Bio

Dr. Patrick B. McGrath serves as the Chief Clinical Officer for NOCD, an app-based platform for the treatment of OCD, leading their teletherapy services across the world. He opened Intensive Outpatient, Partial Hospital, and Residential Treatment Programs for Anxiety Disorders, School Refusal, and OCD. He is also a member of the Scientific Advisory Board of the International OCD Foundation. He is a Fellow of the Association for Behavioral and Cognitive Therapies. He authored “Don’t Try Harder, Try Different,” and “The OCD Answer Book.” He was featured on Discovery Health Channel’s, “Panic” and on three episodes of TLC’s “Hoarding; Buried Alive.”

Our host, Gabe Howard, is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without.

To book Gabe for your next event or learn more about him, please visit gabehoward.com.

Episode Transcript

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Welcome to the show, everyone. I’m your host, Gabe Howard, and calling in today we have Dr. Patrick McGrath. Dr. McGrath serves as the chief clinical officer for NOCD, an app based platform for the treatment of OCD. He is also a member of the Scientific Advisory Board of the international OCD Foundation. He’s the author of “Don’t Try Harder, Try Different” and “The OCD Answer Book.” Dr. McGrath, welcome to the podcast.

Patrick B. McGrath, PhD: Well, thanks for having me, Gabe. I appreciate being here.

Gabe Howard: Oh, and we appreciate you being here as well. Now, today’s episode is sponsored by NOCD, which is an online therapy platform offering exposure and response prevention or ERP therapy, which of course, we’ll be discussing later in the episode. To learn more about treating OCD and NOCD’s services, just visit treatmyOCD.com. Let’s jump in. Dr. McGrath, what exactly is OCD?

Patrick B. McGrath, PhD: OCD is a really serious mental health condition that affects millions of people and isn’t just about washing or cleaning things or a little personality quirk. It can be about was that a pothole? Or did I just run someone over? When I was walking past that family, did I move my arm toward them because I wanted to steal their child and molest them? That prayer I just said, I think I might have made a mistake during it. I’ll probably go to hell if I don’t correct it. I better correct it over and over until it’s just right. There are so many taboo types of things that OCD will go into. OCD loves to attack the things that you love. Iqf you really, really are into something or love something, the OCD will grab onto it and give you doubt and uncertainty about it and lead you to wonder all sorts of things about it that are just totally antithesis to the way that you actually feel about it. But it’s so powerful because it triggers that fight, flight, or freeze response in our brain that we start to wonder, well, what if it’s true? And what if it’s real? And so maybe, maybe I should just do that compulsion anyway, just in case.

Gabe Howard: All the time, I hear people say, oh, I’m a little OCD or even say something like, oh, I wish I had a little OCD because then I could really clean this place up or get organized or whatever. I got to say, I never hear anyone express the desire to be a little bit diabetic, for example. But I do want to ask you, is there any truth to the idea that quote, a little bit of OCD unquote can actually be helpful?

Patrick B. McGrath, PhD: So. If if OCD was really helpful, my job would be to give it to people. I’d go up to you and say, hey, it looks like you’re having a rough day. Have you thought about OCD? Well, I’d lose my license if I did that right. OCD is never something that we would suggest as a way for life to get better. And boy did this annoy me during COVID. I was watching a newscast one time and there were a bunch of newscasters. They were out in the backyard of one of the newscasters and they were, you know, appropriately distanced from each other and everything. One of them said to the others, well, wouldn’t it be great if we all had a little bit of OCD right about now to help get through COVID? And I almost threw a brick through the TV because I thought why is it that OCD is the only mental health disorder that we suggest would be helpful to people in order to make their lives better? You know, imagine going to a weight loss group and saying, have you all considered some anorexia? That again, I would lose my license if I said anything like that whatsoever. Why is it okay to suggest some OCD is helpful? I don’t understand that.

Gabe Howard: Dr. McGrath, I did a lot of research for this episode, and if I understand correctly, a barrier to getting treatment for OCD is that the ruminations are often very disturbing. The thoughts can surround violence, sexual assault, and even murder. And in fact, an example that I heard is that if someone is having obsessive thoughts surrounding molesting a child, the barrier to care is twofold. One, sharing that information often doesn’t lead to help, but to negative consequences job loss, friend loss, or law enforcement action,

Patrick B. McGrath, PhD: Correct.

Gabe Howard: And two, the person suffering from those thoughts, are also terrified and don’t necessarily have the ability to ask for help. Now, I want to be very clear for our listeners, these thoughts are 100% part of the disease process of OCD and not something that the person would ever act on. So it seems to me that the thought is being responded to in much the same way as the actual action.

Patrick B. McGrath, PhD: Yeah, we call that thought action fusion. The idea that a thought is as bad as an action, and that having a thought will make you do something. So. So I want you to do something. I want you to wish for the ceiling to collapse on you and do nothing to try to prevent it and see if you can make it happen.

Gabe Howard: Okay. I’m thinking obviously that’s not going to happen.

Patrick B. McGrath, PhD: But. But if a thought makes things happen, then why wouldn’t the thought cause the ceiling to collapse?

Gabe Howard: Gotcha. Gotcha.

Patrick B. McGrath, PhD: So I could think about while I’m driving running people over. In fact, I don’t know if you ever saw the movie Toxic Avenger. It was one of those B horror films that I watched when I was a kid in high school, and my buddies, and we loved it. And there was a scene in there where he runs people over who used to make fun of him before he became the Toxic Avenger, and he calls out points every time he runs people over. To this day, when there’s people crossing the street, I assign a point value to them. I can’t help it. But guess what? I’ve never gone and run anybody over, even though I assign point values to them. So I mean,

Gabe Howard: Well, I don’t think that that’s unfair, right? How many people have said, oh my God, I’m going to kill my kids? Oh my God, I’m

Patrick B. McGrath, PhD: Yeah.

Gabe Howard: Going to shoot my boss. Oh my God, I’m going to strangle my father-in-law, mother-in-law. We actually threaten murder quite a bit for for a society that really does have a very low volume of actual murders.

Patrick B. McGrath, PhD: Oh, we, we overuse terms all the time and yes, we hear the word molest, right? And we think awful, horrible. Oh my gosh, how could that happen? But here’s the difference. People with OCD have what we call egodystonic thoughts. They’re disgusted by them. They hate them. They don’t want them to be there. And they what if these things all the time. It’s all about what if I were to do this? What if this were to happen? What if I did it and I don’t know that I did it? Or something of that nature. And for people who have never suffered with this, that can be very hard for them to comprehend that anybody would even go down this route. But I’ll tell you, it happens all the time. We treat people for this all the time. And, there are people like who have have never touched their child after they’re born for months because they’re afraid. What if they were to do something that would be untoward to their child? Right? And when you have OCD, you live in a world of the worst case scenario, what if scenarios,w your brain can throw at you and you start to wonder what if that might become true? And wouldn’t it be best for me just to do something to make sure that it doesn’t? Because on the off chance that it does, and I knew that it could, and I didn’t do something to try to stop it, what a horrible, awful person I am. So wouldn’t it be best for me just to make sure at all costs, no matter what, that I try to prevent that thing from happening?

Gabe Howard: Wow. So you have a parent who is afraid to touch her newborn because she is afraid she might hurt the baby. That’s incredibly sad, but you know, it does also show the lengths people with OCD are willing to go through to protect their loved ones. What happened in this case? I feel like there’s a lot missing from this story. Was that mom able to get help?

Patrick B. McGrath, PhD: Yeah. And I can talk about this story because we did publish it. So I have more free rein to talk about this than I would most cases that I’ve worked with due to confidentiality. But even before her having the child, she was worried that things could be done that could harm her child while the child was in utero. So she comes to this experience out of an ultimate fear that anything bad could ever happen to her child. That is what’s driving this. And she wants to protect that child as much as she possibly can. And so when you have OCD and you go to the worst case scenarios, now the child is born, well, guess what OCD wants to do? Let’s run through all the scenarios of all the worst things that anybody could ever do to a child after they’re born. Throw them down the stairs, murder them, molest them, drown them, you know, all these kinds of things. And so now she’s got OCD and it’s screaming at her constantly. What if you were to do this? What if you were to do this? What if you do this? So she calls her mom and has her mom come and move in with her and her mother and her husband for the first six months of her child’s life. Take care of the child, and she watches from six feet back because she wants to make sure that there’s plenty of room between her and the child, so she can’t accidentally do something that would be harmful or molesting wise to the kid. And finally, the family said, listen, you need some help because this is your child and you’re going to have to be a part of this child’s life. So I used to run an intensive outpatient program at a hospital where people would come in for 3 to 6 hours a day for intensive treatment.

Patrick B. McGrath, PhD: And first she came in alone and we started to work on her doing some what we call exposure and response prevention therapy. That’s really the treatment that you use for OCD. And it’s really two parts. We’re purposely exposing you to the intrusive thoughts, images or urges. And we’re having you not to do any compulsions because it turns out you don’t have to actually do compulsions. They sure they feel good in your brain when you do them, and they relieve you of the anxiety and the distress and the guilt and the shame and whatever other uncomfortable feelings you may have, but they don’t actually keep you safe or prevent bad things from happening. And so once we worked on some things, then we had her bring the baby in with her husband or her mother, and they brought in the child and we started to do things like we put them in a room and we had them practice changing diapers together and changing the child together. And we brought in a little tub and giving the child a bath together. And then there was one day where we left her alone in the room with her child to change the child’s diaper on her own. And about two minutes later, the door opened and she had the child in her arms. And it was literally the very first time she’d ever picked up and held her child.

Gabe Howard: That’s amazing. Just amazing. It’s heartbreaking.

Patrick B. McGrath, PhD: Yeah.

Gabe Howard: But at least she was able to get some help. Now, you said that in this case you used exposure and response prevention therapy. Can you explain what that is?

Patrick B. McGrath, PhD: So ERP, Exposure and Response Prevention can work very, very fast. Because fundamentally, once you learn that you don’t have to trust everything that pops into your head, then you can start living the life you want to live and not the life that OCD wants you to live. But think about this when we have a thought pop into our head, we’re kind of trained to think, well, it must be true. Why would I have thought it if it didn’t have some merit or some truth to it? Right. And OCD can take advantage of that and say, well, if you’re going to think everything’s true, I’m going to pump a lot of stuff into you that I’m going to get you to believe is true. Because OCD is driven by one thing. It wants you to do a compulsion. Why? Because OCD eats compulsions for breakfast, lunch, and dinner. So if you want to keep OCD around, do more compulsions. If you want to go away, do less. Which is amazingly counterintuitive to anyone who has OCD, who believes the only reason everything in my life is going okay is because of the compulsions I’m doing, and if I were to stop doing them, there would be mayhem and bedlam and all sorts of other awful and horrible things happening.

Sponsor: There are few words more misunderstood and misused than OCD. Imagine having unwanted thoughts stuck in your head all day, no matter how hard you try to make them go away, and then having to pretend that everything is okay despite having to feel crippled inside. That’s OCD. One in 40 people suffer from it globally, but there’s hope. If you have OCD and need help, you can get better with specialized treatment. NOCD offers effective, affordable and convenient treatment for OCD and is covered by many major insurance plans. Go to NOCD.com to learn more. That’s NOCD.com.

​​Gabe Howard: And we are back with the Chief Clinical officer for NOCD, Dr. Patrick McGrath. As you’re explaining it. The best example that I can think of in my head is the cycle of addiction, right? People have withdrawal symptoms and they know that they can remove the withdrawal symptoms by by utilizing the drug or substance that they’re addicted to, which will work in the very, very short term. But of course, it feeds that cycle of addiction because then they will withdraw again, which creates the urges, etc. Is that a reasonable analogy for the process of OCD?

Patrick B. McGrath, PhD: Yeah, I’m really glad you brought that up too, because there are so many people with OCD who use substances as a way to try to mitigate the the just horrible feelings they have because of the obsessions, and that’s led people to die. But the speeches that I give to people with OCD actually apply, like you said, amazingly well to the people with addiction as well too. And I often use an example similar to what you said when I’m talking about ERP. I’ll say to therapists who are kind of on the fence about, I don’t know, ERP sounds uncomfortable and isn’t our job in therapy to make people comfortable? And I’ll say, well, maybe sometimes it is, but not when it’s OCD, because if you’re making people comfortable with OCD, you’re probably doing a compulsion. So I’ll say to therapists, imagine you have a niece or nephew in a detox unit, and you go to visit them and they beg you to go down the street to the liquor store just to get a couple of bottles of vodka and sneak it in for them so they can stop going through withdrawal. Would you do it? And every one of them say no. And so I come back to them with, so you’re okay with your niece or nephew suffering physically now in order to be better later, but you’re not okay with them being emotionally uncomfortable now in order to be better later? Because that’s all I’m doing with ERP is I’m taking that from the physical aspect of addiction to the emotional aspect of obsessive compulsive disorder.

Gabe Howard: So let’s talk about exactly how ERP works. Right. So I’ve made an appointment with you. I’ve walked in, I sit down across from you and you say, go.

Patrick B. McGrath, PhD: First say hello.

Gabe Howard: I knew you were going to say that, and I’m glad that you introduced yourself. I do appreciate that. It is a flaw in the question.

Patrick B. McGrath, PhD: And then I’m going to spend some time getting to know you. Because here’s the thing. If you’re going to reveal to me your obsessions, which are some of maybe what you think are the deepest, darkest, darkest secrets of your life, you’re going to have to trust me. And so we’re going to spend some time just building some rapport, and then I’m going to do a diagnostic with you to make sure that you understand all of the clinical things going on with you. And then we’re going to work together on building a hierarchy. I am not here to throw you in the deep end of the pool to tell you to sink or swim. I’m going to have you start with low level stuff, and we’re going to work our way up to the higher level things that are going on in your life, so that you learn that you can handle those things slowly and gradually. I want you to keep coming back to therapy, you know, with a name like Patrick McGrath. I’m a bit Irish, and my favorite Irish phrase is only an Irishman can tell you to go to hell and make you look forward to the journey. And I joke that that’s kind of how I see ERP as well . It’s going to feel like I’m going to ask you to do awful and horrible things, but you know what? I’m going to get you excited to do those things, and you’re going to want to come back week after week. Because when you start to do this, you start to get your life back. You start to do things you want to do and not things OCD wants you to do. Will it be tough? Yes. Will it be uncomfortable? Yes. Will you not want to do it? Sometimes, absolutely. But you know what? You stick through it. And in the end, again, you’re living the life you want to live and not OCD’s life.

Gabe Howard: So you mentioned that you’re going to ask people to do things that make them uncomfortable and that they’re not going to want to do. And you even use the phrase that you were going to have them look forward to going through hell. What are some

Patrick B. McGrath, PhD: Yeah.

Gabe Howard: Examples of that?

Patrick B. McGrath, PhD: Well, when going back to that case, we talked about when I met with that woman and her child and we talked about her child, I said, my goal is that you’re going to be holding your child and you’re going to not only hold your child, but you’ll be able to have some skin to skin time with your child that we think is important and, if appropriate, still breastfeed your child or those types of things. And that sounded horrifying to her, even though those were also the very things that she was hoping for and that she wanted because she saw all of her friends who were having children were doing these things and establishing these relationships with their children. And yet she was having that relationship interfered with by OCD. So that’s what I said to her, and it frightened the heck out of her to even think about doing those things. But it was also exactly what she wanted to do.

Gabe Howard: So just to clarify, when you say that people are going to go through hell, it invokes to the outsider. Oh my God, you’re going to have to do something that is horrific. But when you were explaining it, I was like, none of that sounds bad, but that’s

Patrick B. McGrath, PhD: No.

Gabe Howard: Really the point, right? For someone living with OCD? The the ordinary is extraordinarily terrible, and that’s what drives this illness.

Patrick B. McGrath, PhD: Yeah, yeah. You know, what the hell is the hell is in their own mind? That’s the hell. So you know what I’m going to have you do? I’m not literally putting you through hell. I’m not going to have you do anything just for fun. I’m not going to create new things for you. But you think the thoughts that you’re having are the worst things in the entire world. They are equivalent to a hellish experience. Do you even have those? So that’s exactly where we got to go. We have to go to those things, and we have to teach you that. It’s because those things pop in your head doesn’t mean that you have to pay any attention to them whatsoever. They have absolutely no merit whatsoever at all.

Gabe Howard: When talking about the case study of the mom who had the reoccurring thoughts of of hurting, harming, molesting her child, I still I’m still stuck on this. How can you not tell somebody? Because that’s got to be awful to live with. Now, now, I understand the explanation is incredibly plausible, right? You’re a new mom, so you’re already under all the pressure to be perfect, and then you’ve got this horrific thing that makes everybody squirm, right? It’s just it’s an uncomfortable thing to discuss. But but that’s sort of my point. It’s living in her and she’s just just compulsively, obsessively thinking about this over and over and over again. That’s it. It sounds absolutely horrifying. How

Patrick B. McGrath, PhD: Yeah.

Gabe Howard: Did how did she how did she finally get help?

Patrick B. McGrath, PhD: Really it was the influence of other people saying, like her mom saying, I can’t stay here forever and raise your child. So we’re going find some help for you. But the other thing you had said, think about when people have kids, how many people go up to them and say, oh my gosh, isn’t it so wonderful? Aren’t you just so happy? And they’re so cute and everything? I don’t say that to to newborn family members. I go up to them and I say, how are you feeling? How’s it been? How are you? Any, anything I can help you with? Any issues or concerns or something like that? I make no assumption that anything is great or wonderful anymore, because I know that just because there is something that is often considered by most to be a wonderful experience, it is also a stressor and loves a stressor. And therefore I look at things and I judge them by the amount of stress they bring to people’s lives.

Gabe Howard: Just to make sure that our listeners can close the loop on this particular case study. How is she doing now?

Patrick B. McGrath, PhD: Well, that was a long time ago, but I did see her at support groups for a couple of years after, and every time I did, she had her kid with her in the stroller and running around the group and everything. And and it was just her. There was no one else coming to the group with her. She was still bringing her kid there. So, I mean, that kid is probably a teenager now, but the last I saw, everything was great.

Gabe Howard: That is wonderful and it makes me happy to hear. Before we go, Dr. McGrath, I want to offer our listeners some hope. According to the NOCD website, the average time of first symptoms to diagnosis is an incredibly long 17 years. However, once somebody receives that correct diagnosis, what is the average amount of time that it takes somebody to start showing improvement?

Patrick B. McGrath, PhD: We published the largest study on OCD at NOCD, and we found that people were receiving significant reductions in OCD symptoms in 12 to 14 therapy hours. So it can happen very quickly once people go through the treatment and do the therapy. You can see very significant change very, very fast if you put yourself into those situations and again, allow yourself to not give in to compulsions.

Gabe Howard: I know that NOCD has been on the front lines of OCD research for a while, and sincerely, I can’t thank them enough for that. And I have to think from a patient perspective, being able to see relief in such a short amount of time has to be, well, a relief. Now, speaking of NOCD and their information and services, where can folks find them online?

Patrick B. McGrath, PhD: You can go to NOCD.com or treatmyOCD.com. Either of those will take you to our website.

Gabe Howard: Dr. McGrath, thank you so much for being here. And thank you to NOCD for sponsoring this episode. NOCD offers live video sessions with a licensed therapist specializing in ERP therapy, the gold standard treatment for OCD. You can get started with a completely free 15 minute phone call, and NOCD is covered by many insurance plans. Check them out right now at NOCD.com or treatmyOCD.com. That’s NOCD.com or treatmyOCD.com. We also want to give a big thank you to all of you, the listeners. We appreciate you being here. My name is Gabe Howard and I’m an award winning public speaker and I could be available for your next event. I also wrote the book “Mental Illness Is an Asshole and Other Observations,” which is available on Amazon. However, if you go to my website, you can get a signed copy with free show swag. You can also learn more about me there. Just head over to gabehoward.com. Wherever you downloaded this episode, please follow or subscribe to the show. It is absolutely free and you don’t want to miss a thing. And listen up! Can you do me a favor? Recommend the show, share it on social media, share it in an email. Share it in a text message. Tell your mom. Tell your dad. Tell your support group. Just tell everyone because sharing the show is how we grow. I will see everybody next Thursday on Inside Mental Health.

Announcer: You’ve been listening to Inside Mental Health: A Psych Central Podcast from Healthline Media. Have a topic or guest suggestion? E-mail us at show@psychcentral.com. Previous episodes can be found at psychcentral.com/show or on your favorite podcast player. Thank you for listening.

Sponsor: There are few words more misunderstood and misused than OCD. Imagine having unwanted thoughts stuck in your head all day, no matter how hard you try to make them go away, and then having to pretend that everything is okay despite having to feel crippled inside. That’s OCD. One in 40 people suffer from it globally, but there’s hope. If you have OCD and need help, you can get better with specialized treatment. NOCD offers effective, affordable and convenient treatment for OCD and is covered by many major insurance plans. Go to NOCD.com to learn more. That’s NOCD.com.