An Interview with Dr. Jordan Gregory
Mary and Dave Thornsen, owners of GR TherapyGroup, are proud of the amazing therapists they work with at GRTG and love to learn from them. This interview series is a way to share some of those conversations. The transcripts are edited for brevity and readability.
Transcript
Mary: Thanks for taking the time to meet with us today.
Jordan: Thanks. Yeah, of course.
Mary: We’re going to talk about Obsessive Compulsive Disorder today. This is an area of specialty in your practice. And I just love how you opened up the discussion on OCD among other clinicians and have invited clinicians to share and discuss this topic. Could you give us a short description of OCD?
Jordan: Yeah, of course. So, OCD, it really is in the name. With the disorder, you have to have the obsessions and/or the compulsions for it to qualify as OCD. Obsessions are characterized by these intrusive and unwanted thoughts that cause distress of some kind. And compulsions are things people do to mitigate the distress those intrusions cause. They’re typically formed in a pretty rigid way. Everybody’s got intrusive thoughts at some point or another, but it’s something that ends up taking up an hour or more of your day. And starts to impact quality of life. That’s what makes it a disorder.
Dave: So, do people tend to identify OCD as their issue to work on when they first come in, or is it something you notice while you’re working with them?
Jordan: I think both. So, I think with increased awareness of mental health, more and more people are kind of coming in with some idea of what they’ve got going on before they walk in the door. I see both people who come in knowing they need to work on OCD, either because they’ve been diagnosed before or because they’ve done their own research before they came in.
I think with OCD, in particular, the kinds of thoughts and intrusions people are having are so distressing and sometimes very taboo that people are not really encouraged to come in and seek help for it until they’re able to do their own research and kind of identify, oh, I’ve got a label for this now. I can tell someone else what’s going on. And on the flip side, like I do get people who come in who have been diagnosed with anxiety before, and I’m starting to see that it actually might look more like OCD kind of based on the things that we talk about or get into as the therapy progresses.
Dave: Okay, I see. What are some of the less obvious or less characteristic ways that OCD might show up?
Jordan: I think sometimes OCD might disguise itself as like maybe as a phobia of some kind or as really kind of rigid moral beliefs or religiosity. And I think those, areas, it might be not as obvious what’s going on for somebody until further questions are asked. And I’m happy to expand on that more.
Mary: What questions might you ask when you suspect someone might be having this disorder? What are the questions you might ask to screen for it? And is there a particular screening tool you like to use?
Jordan: Yeah, well, I’ll just go ahead and start with the screening tool that I like to use. I utilize the Y-BOCS-II, the Yale-Brown Obsessive-Compulsive Scale-Second Edition. I really like that one because it goes through a big list of different kinds of obsessions and compulsions people might have. A lot of times when people go through that list, they realize things they experienced when they were younger were actually kind of the beginnings of this disorder. So you get a much wider picture of what people have experienced throughout their life in terms of obsessive and compulsive behavior.
It also has a separate section where it goes through the criteria for the disorder and creates a score in terms of severity. I like that as well because I think people will sometimes present and say, yeah, I’m doing okay. And maybe they are, but when you do a screening like that, it really gives you a little bit more of a concrete comparison of exactly how much they’re being impacted by what they’re going through.
Mary: I really like that because when you said, you know, it kind of helps them look back on their whole life. That can be a very intense therapeutic moment when people realize, oh, wow, this has been with me for a long time.
Jordan: Yeah. Sometimes people just don’t come in until it reaches a certain threshold where they’re so impacted, they need help, or they’re experiencing intrusive thoughts that are so distressing they’re finally asking for help.
As far as what kinds of questions I ask to screen for it, I wouldn’t say I screen everybody for OCD. It’s more so like if I get a sense that they’re engaging in repetitive behavior… so that’s a question I might ask… like if somebody is talking about like one particular distressing thought, or rumination, let’s say it’s health anxiety. It might be really easy to just write it off as, oh, this is just typical health anxiety. But something that can help to differentiate is asking the question, are there compulsions around the fears they have about their health anxiety? For example, are they like checking their whole body, head to toe, multiple times a day? Are the thoughts they have, like, do they know that the compulsions don’t really make sense.
Some of the intrusions might be really upsetting, like, oh, if I look at that person, I’m going to get cancer. And that is a little bit less grounded in reality and might point more to OCD. So in comparison with generalized anxiety or health anxiety, a lot of times the fears people have are very much grounded in reality, but maybe just excessive.
OCD tends to have a much wider range in terms of how rooted in reality the fears are and can end up being. Things like, oh, if I don’t touch the table 10 times this way, my mom will get cancer or, you know, I won’t make it across the street… things that are very disconnected or extremely excessive in terms of checking in order to keep them safe or healthy.
Mary: Yes, and I would assume that there’s a wide range in how grounded in reality a person might recognize it as, right? Like they might recognize that this is, you know, objectively this just doesn’t make sense, but I have to do it anyway, versus on the other extreme, maybe not recognize at all… that it doesn’t make sense. Is that correct?
Jordan: Yeah, there is a really wide range of insight. I would say for the most part, people that are in an outpatient setting do recognize like, oh, I know this is a bit silly, but I’m afraid that if I don’t do it, this thing will happen. And so it’s kind of like not worth the risk for them to stop the compulsions up until a certain point where it’s, you know, no longer containable or it’s disrupting their life. And that’s usually when people come to treatment.
Dave: So that’s very interesting. I think we just generally tend to think of OCD as having those sort of behavior patterns, like I have to do this so many times or that sort of thing. But that is not always the case? Can somebody have OCD without having those sort of behaviors?
Jordan: There is like a type of OCD that’s called Pure-O, which is referencing pure obsessions, but it’s really not just obsessions. It just means they don’t have physical manifestations of their compulsions. So if they’re having intrusive thoughts about, let’s say it’s something, you know, like, I’m not safe right now, then like a mental compulsion that they might do is say a prayer five times to feel safe. And so even though nobody can see them do that or hear them do that, they’re still doing something mentally to kind of neutralize the distress of the intrusive thought.
And the difference is, like a healthy connection with religion, like there’s some flexibility with that. Like people recognize that you can say a prayer like once and that might be sufficient or it’s more about their connection with God. But with OCD, it’s very rigid. It has to be done in the super ritualistic way or it doesn’t count. There’s this pull to have to repeat it or do it perfectly or just in the right order to kind of neutralize that intrusive thought or decrease the distress. And it’s repetitive. So usually you can’t just do it once. With OCD, people, it’s every time they have the intrusive thought. And this can go on for hours.
Dave: So what are some of the different subtypes of OCD?
Jordan: Yeah, I think I kind of touched on a few up to this point. There’s a really wide range. OCD is just about as creative as you are. So, it can kind of latch on to just about anything, although it does tend to kind of like attack people’s values. OCD is very ego dystonic. It’s things that you don’t want to happen or things that you would really fear might happen. And so it can be everything from this more classic symmetry and ordering OCD where, you’ve got to have things in a certain way or contamination OCD where you’re afraid of contact with germs to postpartum OCD where people have really intrusive fears about their newborn and all the way to things like relationship OCD and kind of obsessing about the state of a romantic relationship or friendship. And it goes on, yeah.
Dave: This is fascinating. You just listed so many ways people tend to struggle in daily life.
Mary: How are OCD and hoarding disorder related and how are they different? Can you talk about that a little bit?
Jordan: That’s a great question. You know, hoarding disorder isn’t actually something that I’ve worked with directly in treatment, but I do know that it is characterized as an obsessive compulsive related disorder in the DSM-5-TR. Hoarding disorder is like really specifically about being connected to, from my understanding, with objects and having a very hard time parting from them. And so the people tend to have really strong emotional attachments to their items. They hold like memories, emotions, and things like that. And because of that, it’s very difficult for people to get rid of these items. So it can be things like newspapers, toilet paper holders, trinkets, photographs. It can be a really wide range of items.
Mary: Can you also tell me a little bit like about how generalized anxiety disorder is different from OCD?
Jordan: Well, Generalized Anxiety Disorder specifically tends to be a lot more variable in terms of what people are concerned about. Worries can really shift very rapidly from thing to thing. Whereas in OCD, it tends to be at any given time for a long period of time, there’s a very specific obsession or concern.
Also with Generalized Anxiety Disorder, worries tend to be more rooted in reality and there aren’t these rituals that are necessary to neutralize a distressing thought. One reason why it’s important to differentiate is that with generalized anxiety disorder, you tend to be able, once people are in a regulated place, combating the thought can be really helpful, challenging the evidence and the validity of what they’re going through can help them kind of rationalize their experience and make forward progress.
With OCD, the danger with doing a lot of rationalizing and challenging about the specific obsessions is that can kind of become one of the compulsions people do. So, I have to… you know, it can turn into: “If I have this thought, I have to think of all the reasons why this thought isn’t true in order to be okay or to make this distress go away.” And that’s kind of at the root of what I’ll get into later about treating OCD with ERP. Yeah, I think there might be more differences between the two. That’s all I can think about at the moment.
Dave: So if worry takes the form of sort of rigid or at least repetitive patterns, it is possible it might be really more of an OCD situation?
Jordan: Yeah, I would say that’s a good tip off. Like if there isn’t the ability to be flexible with the thought or to tolerate any sense of uncertainty. Yeah. Because anxiety doesn’t like uncertainty either, but OCD takes it to another level.
Dave: Tries to control it.
Mary: Is there a certain kind of treatment you like to use when you’re working with OCD?
Jordan: Yeah. So, I utilize a combination of Exposure and Response Prevention or ERP and Acceptance and Commitment Therapy or ACT. I’ll start with ERP. In the literature it’s referred to as the gold standard for the treatment of OCD. The reason for that is they have a lot of research on it and they know it can help most people in a relatively short time span. It doesn’t mean that there aren’t other things that can be helpful. It’s just what it’s been referenced to as in recent literature. So ERP, at the heart of it, is essentially exposing yourself, with a therapist, to your fears in a hierarchical way. So if your OCD is really centered around, let’s say, I don’t know.
Dave: Thunderstorms.
Jordan: Thunderstorms. That’s a good idea. Yeah. You might start to create like a hierarchy of feared situations. So we might start, maybe something really low level for you might be reading about getting caught in a thunderstorm. At a higher level, it might be listening to sounds of thunderstorms. Above that, it might be something like taking a walk in the middle of a thunderstorm when, you know, you’re at relatively low risk of being hit by lightning. You know, because your therapist is never going to ask you to do something that’s unreasonable or unsafe. The hierarchy would probably have more items in it, but just for simplicity, we’ll keep it there.
When you go through these exposures with your therapist, something that they’re going to ask you to do is to refrain from engaging in any compulsions. So, let’s say with that fear of thunderstorms, you all are reading like an article together about a bad storm that happened. And so, if you’ve got compulsions related to making sure you don’t get hit by lightning or that you’re safe, you’re going to postpone doing those for about as long as you can. I recommend to people if they can start with 30 minutes, that’s great, but two hours is even better. And what a lot of times people find is that it can be very difficult to wait, but by the end of that time, you feel like you can tolerate the distress. So, either the distress goes down or it feels like something you can hold for just a little bit longer. And so the point of doing that is really to break the connection between the obsessive, intrusive thoughts and the compulsive cycle. Because what happens with OCD is that those really just strengthen each other over time. And so when you kind of like create some distance between these two, it helps to weaken that connection. And that’s really at the heart of the treatment. Yeah.
Dave: That’s really good. I’m feeling a little self-conscious about yelling out my idea there, because would that be more of a phobia than something that would be OCD?
Jordan: It really depends because with a phobia, phobias tend to be extremely context specific. So if you know there’s going to be a thunderstorm and you’ve got these fears and you’re probably doing things that are like pretty reasonable to make sure you’re not going to get, let’s say, struck by lightning, like checking the weather radar, staying inside, stuff like that. But with OCD, It’s something that will typically be an ongoing concern even when there’s no real sense of threat or danger. Like it could be a totally, perfectly cloudless day and you might hyper fixate on that one cloud way off in the distance. Like, can I be sure it’s not darker? Everybody says it’s white, but I think it looks a little dark. And then do things in a repetitive way to make sure you’re safe. So it might be checking the weather radar like every 10 seconds. So like, does that make sense kind of like the difference between how you might characterize the two? However, I will say you can treat phobias in a really similar way to obsessive and compulsive behavior. And so ultimately you can do exposure for both. So it’s okay if you’re not quite sure whether it falls under one category or another.
Dave: OK. Thanks.
Jordan: Another part of how I like to treat OCD is integrate components of Acceptance and Commitment Therapy. And so that includes things like really disconnecting between thoughts and reality. So really trying to hammer home that your thoughts are not you and you can think things and that doesn’t necessarily make them true. So, we might demonstrate that by asking the client to sit and think, “I am walking” while they’re sitting or walk across the room and think, “I am sitting” while they’re walking. I invite people to get very playful with their intrusive thoughts. So, you’re having these intrusive thoughts, like turning them into a silly song or singing them to the tune of Happy Birthday. So trying to rewire and kind of create different connections with these kind of feared intrusions. And it can be silly and fun. And so I like that part too.
Dave: I can imagine that might surprise a client. Like: “Really? This is how we’re doing this?” And I’m just curious, what do people find? What do you find people are most surprised by when they start treatment for OCD? Whether it’s ERP or the ACT.
Jordan: What I’ve noticed is that people have a lot of fear around talking about their intrusions. Because one: they fear that it will make it more real, but really talking about it helps. And two: people have a lot of nervousness about starting ERP. And I get it. I mean, you’re literally confronting feared outcomes. But what they’re surprised by is that especially after they get started, it wasn’t as bad as they thought it would be. And it can really help.
Dave: Yeah, that’s really good. So I’m curious, are there any intrusive thoughts that are too taboo to say out loud?
Jordan: No. Good question. I think that you’ll find if you’ve got a therapist who likes to work with OCD specifically, they’ve, if you thought it, they’ve probably heard it at some point and you’re not alone. There are all kinds of subtypes out there and there probably is a name to what you’re going through. And I think people are specifically most nervous to bring up ones related to harming themselves or another person. And I think that I’ll just go ahead and name that because let’s just get it out of the way. Why not, you know?
Mary: I can see how there could be a lot of embarrassment or even shame connected to OCD, people’s compulsions and repetitive thoughts. But, can you talk a little bit about why discussing intrusive thoughts or compulsive behaviors, in a safe therapeutic setting, is helpful? Maybe they’ve never even just said it to anybody else out loud. Just saying it, just having the space to trust somebody to share that with, why that could be helpful?
Jordan: I think it’s really the first step in just taking away some of the power the thought or the intrusive experience has on you. Being able to say it out loud and still being okay.
Mary: Great answer. So Jordan, what do you love about treating OCD?
Jordan: Yeah, I love that, one: I feel like the treatment makes a lot of sense to me. Not everything is really straightforward and things are complicated at times, but I think that the way I work with people, it just conceptually fits with how I understand the disorder and the treatment. And two: like flowing from that, I really love to see how people can gain freedom from the anxiety and the fear that they come in with. And I love being able to help people with that.
Mary: I love that. That’s wonderful. So Jordan, you are all telehealth now. Can OCD be treated via telehealth, and why might that be even an advantage?
Jordan: Yes, absolutely. There’s a lot of research studies to support that it can. I think that in some ways, it can be an advantage if there are things that you want to quickly share with each other over telehealth that’s easy to do. If there are really context-specific compulsive behaviors, it might even be helpful to be in the setting with a person when they’re going through that. It can also be more convenient. Sometimes it’s hard to get to an office, but maybe it’s easier to find a quiet space where you can tune in on your laptop or on your phone.
Dave: Thank you, Jordan. That was super informative and helpful. I feel like I learned a lot and I love just picturing people coming to you and finding out that they don’t need to struggle and that there’s relief available. And clearly they’re in good hands when they get to work with you. So if someone is struggling with OCD and would like to work with you, what should they do?
Jordan: Call our office or reach out through our webpage.
Mary: Yes, thank you Jordan. You’re very knowledgeable.