An Interview with Steven Phillipson, Ph.D. on the Nature and Treatment of Obsessive Compulsive Disorder (OCD)
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Dr. Steven Phillipson regarding the treatment of Obsessive Compulsive Disorder, or OCD. Dr. Phillipson is a clinical psychologist, and takes a fairly behavioral, rather than cognitive-behavioral approach to his work. His specialization in treating OCD had its genesis in experiences he had while completing his psychology training. Notably, he and a mentor started the first support group for OCD patients in New York City in 1987.
OCD is an anxiety disorder characterized by obsessions, which are involuntary thoughts associated with heightened levels of anxiety, and compulsions that are ritualized behaviors, which are performed in order to address and calm the anxiety associated with the obsessions.
Dr. Phillipson stresses that OCD is an anxiety disorder, not a thought disorder (e.g., a psychotic disorder such as Schizophrenia). People with OCD are generally aware that their obsessions are irrational, however, they are seemingly helpless to override their anxiety responses to these thoughts with any rational argument. Instead, they behave in ways that neutralize the anxiety associated with their obsessions, which has the effect of strengthening the legitimacy and power of the obsessions to compel further compulsive acting out.
Dr. Phillipson has a special interest in promoting awareness of lesser-known varieties of obsessive-compulsive disorder. Broadly, OCD expresses itself in two ways: Through observable rituals or compulsions, and compulsions that are not observable. The former group is the more famous of the two, and includes the popularly known OCD themes that are familiar to most people. The most well known observable ritual group are the people who have fears of contamination, and wash themselves repeatedly or avoid the use of public bathrooms. Another group includes checkers (e.g., those people who check to see if a door is locked, a window closed, or a stove off and may repeat their checking multiple times in a row).
People with non-observable compulsions display more subtle ritual behavior and do not appear to be visibly obsessional. These people, who Dr. Phillipson calls "Pure Obsessional" or "Pure O", may experience extreme distress in response to thoughts of harming others, or themselves, sexual perversion, or offense to God. Many people who are not obsessional will experience such thoughts from time to time, and associated with these thoughts a momentary pang of emotion, but the thought and the emotion pass quickly and are not dwelled upon. For people who have "Pure O", however, these obsessions occur repeatedly and are accompanied by great distress and accompanying subtle rituals which are designed to reduce the distress. An example of people with "Pure O" are people who present with "hyper scrupulosity" or an obsessive fear that their behavior is unlawful either in a civil or religious context. Such people may pray excessively, for example. In addition to the anxiety that always defines obsessions, hyper scrupulous people are also likely to experience guilt over what "bad people" they are.
As an aside, the concept of Pure-O is interesting to me (Dr. Dombeck) in part because of an interaction that occurred in the Mental Help Net Support Community not long ago when a participant started asking whether he was a pedophile. Since this is a very distressing thought for everyone, moderators gave this participant a short leash and community members attacked him. However, it eventually became clear that the person was probably more obsessional in the Pure O fashion than an actual pedophile. The fact remains that it is not easy to tell the difference between a pedophile and a person with a pedophile-threat obsession on the surface of it. People have repeatedly suggested on the Mental Help Net website (some of whom are possibly also "Pure O") that "Pure O people never actually do the things they are afraid of doing". I find this assertion of absolute confidence (e.g., that a behavior cannot occur when a Pure O obsession exists) among participants to have a defensive quality. However, Dr. Phillipson's suggestion during the interview that Pure O diagnosed patients frequently desire to distance themselves from media portrayals of OCD as "dangerous people who act out on their obsessions", provides insight into why this would be the case.
There is some disagreement within the professional community of therapists as to the best way to treat OCD with psychotherapy. The two general approaches that are currently being explored are exposure therapy with response prevention (ERP), a behavioral approach to which Dr. Phillipson subscribes, and a cognitive behavioral approach with a greater emphasis on the obsessional thoughts. It might help to think of these as non-verbal and verbal approaches to therapy. The cognitive therapy approach emphasizes helping patients to build up their rational response skills so that when OCD confronts them with irrational obsessive thoughts, they can reduce their anxiety by disputing the basis for the anxiety. Cognitive therapy, developed for the treatment of depression, is still debated in the professional community regarding its efficacy for the treatment of anxiety.
The behaviorally based exposure therapy approach bypasses argumentation and works to undermine the association between the obsessive thoughts and the irrational anxious response to those thoughts. Exposure therapy does this by exploiting a learning phenomenon known as habituation. The behavioral (and cognitive behavioral) theory of anxiety suggests that the feeling of anxiety remains paired or associated with obsessional thoughts because rituals provide no opportunity for the person to live through the anxiety and learn at the non-verbal feeling level that the experience of anxiety is: 1) not harmful in itself, or 2) merited and appropriate to the situation. No learning can occur because the experience of anxiety is not tolerated, but is instead escaped through the process of acting out compulsive behaviors that are designed to contain or otherwise neutralize the feeling of anxiety. The act of escaping the anxiety ends up maintaining and even strengthening its grip.
Exposure therapy for OCD helps people to bypass their escape into compulsive ritual behaviors by providing them with a structured intervention that helps them to gradually learn (over a period of several months) that their anxiety is not relevant. The first step in Dr. Phillipson's treatment (which is a modification of an earlier protocol designed by Dr. Edna Foa) involves the creation of a threatening thought hierarchy. In collaboration with their therapist, OCD patients generate a variety of individualized obsessive thoughts that occur to them and then rank those thoughts in terms of how threatening and anxiety provoking they are. The completed hierarchy is a format used to guide a process known as "graded flooding". By way of example, Dr. Phillipson describes how a person obsessed with the idea of contamination by bodily fluids might do therapy. In this example, the lowest level of threat on the hierarchy is the idea that a public light switch might be contaminated. The therapist then instructs the patient to swab a tissue over a threatening light switch to contaminate the tissue, and then take the tissue home and swab various items in their house to contaminate them as well. This action will likely generate a mild feeling of threat that is pervasive, because the contamination has been spread through the home. Being unable to escape from the low-level contamination, the patient instead habituates to it and over time, the anxiety associated with that low level of threat more or less goes away. When that occurs, the therapist and client ratchet up the baseline level of anxiety that the person experiences in relation to the contamination threat by moving up to the next threatening item on the hierarchy, in which the process of global contamination is repeated. Over several weeks of raising the floor, ideas that were formerly threatening cease to provoke the powerful anxiety response they used to.
Though this graduated protocol seems simple enough, Dr. Phillipson cautions people against trying to treat themselves in a self-help mode. He notes that there are numerous tricks to getting the therapy process to function correctly that individuals with OCD are unlikely to understand.
During the interview, Dr. Phillipson states that some research suggests that the cognitive component of therapy does not add anything beyond exposures. He argues that the emotional parts of the brain (e.g., the amygdala and associated limbic system) are able to trump the rational parts of the brain (e.g., the frontal brain), and points out that OCD patients are already aware that their obsessions are irrational. In Dr. Phillipson's view, the actual thought content of OCD is only loosely associated to the anxiety associated with those thoughts, except for the somewhat arbitrary pairing process that somehow locks a person into an obsessional cycle on a particular theme. As evidence of this, Dr. Phillipson stated that an estimated 80-90 percent of the non-clinical population has experienced a disturbing thought such as jumping off a cliff, harming a loved one, or having inappropriate religious thoughts. The thoughts are not driving the anxiety but instead only arbitrarily paired with the anxiety, therefore it is unhelpful to focus on the thoughts as a means of unraveling the OCD symptoms. Noting this assertion, Dr. Van Nuys asks (at 26 minutes), if this is the case, then why are obsessional themes always so predictably about contamination, checking, or harm to others and not about other things? According to Dr. Phillipson, our mind misfires a signal of desperation and then selects a topic to justify the experience of terror. He also gives an anecdote that helps make his point: he worked with a patient who cycled through various different obsessions, and who at various points of his cycle would be either unaffected by particular thoughts or made terribly anxious and compulsive by them, at different points in time. His belief is that these periods of non-distress in relationship to the presence of certain thoughts, are evidence that thoughts are not the primary contributor to the anxiety. Though the origin of how thoughts become obsessions may be unknown at this time, the point is that there is nothing special about the obsessive thoughts themselves; it is more about the spontaneous attachment of intense anxiety to some thought that is important to focus on clinically.
Links Relevant To This Podcast:
Dr. Phillipson's website http://www.OCDonline.com contains articles and information about the nature and treatment of OCD, and in particular, the lesser known forms of OCD such as "Pure O".
Dr. Phillipson recommends the therapist referral list available at ocfoundation.org website, but cautions that the credentials of therapists on this list are not authenticated by that website. Patients should not hesitate to interview the therapists to try to distinguish between someone who dabbles in OCD treatment and someone who specializes in it.
About Steven Phillipson, Ph.D.
Dr. Steven Phillipson is the clinical director and founder of the Center for Cognitive Behavioral Psychotherapy located in New York City. He has functioned as a site supervisor at several APA approved clinical Psy.D. and Ph.D. programs for the past few decades. In his capacity as site supervisor for pre and post-doctoral fellowships, Dr. Phillipson serves as adjunct faculty at Columbia University, Rutgers University, Fordham University, Yeshiva University, and many other local doctoral programs.
Dr. Phillipson received his B.S. in psychology at Lynchburg College. He has a Masters degree from Towson University in clinical psychology and from Hofstra University in school and clinical psychology. In 1989, Dr Phillipson received his Ph.D. from Hofstra University in school and clinical psychology. At that time, only one of two APA approved programs in the country. Dr. Phillipson has completed internships at both John's Hopkins University Hospital and the Institute for Behavior Therapy in New York City and received a distinguished alumni award from Lynchburg College in October of 1991.
As an advocate for the use of innovative behavioral techniques, he has been an invited speaker at the Obsessive Compulsive Disorder Foundation's national conference for years and has published numerous articles for the world-renowned OCD Newsletter. Dr. Phillipson is the creator and author of OCDonline.com, a website 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 outpatient basis to patients within the New York City metropolitan area, and around the world through the use of video-conferencing.
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 in the New York City area.
I've followed this guy for a long time - Blake - Jan 3rd 2014
I often find when talking about my case of OCD, citing Dr Philipson's "I think it moved" article, as explanation of how the disorder affected me. Nowhere else had I seen any reference to sexual identity and perversion obsessions, and I scoured the psychology textbooks for months, wondering why I thought I was gay, but knew I wasn't. I don't think people understand the dynamics of that, really. It didn't start with being gay, it all started one day I was walking to class with my girlfriend, and she seemed to walk awkwardly, and I felt unattracted to her. That sent me into a unbelievably traumatic spiral of obsession into why I had that feeling, and eventual presumptions that I didn't like women at all, and that I must indeed be homosexual. I wish I could express what that feels like, having your whole identity of yourself and all of those dreams of having a family and kids and the white picket fence removed, and replaced with some kind of belief that you're actually into the same sex, or worse, you're into animals or small children.
I received CBT, and large doses of Prozac, which worked. I remember a defining moment in therapy, that unlocked me from the obsession (although I'm not sure a therapist would agree with my approach), when my therapist said to me, "Blake, being homosexual means you desire to have sex with the same sex". I realized that her question contained something that I hadn't been posing myself...I had always asked myself, while testing, would I do x or y with that person. Instead of asking myself, do I WANT to. I asked myself, do I want to do these things? And the answer was no, and I never really had thought about it that way. Instead of recognizing that I didn't desire these things, I was caught up in this sort of, "force inside myself that I have no control over". From that day on, I was relieved from that obsession (for the most part).
I've still battled with it off and on a bit (that particular obsession), and I still don't know today whether I'm for sure straight or not. It's sort of like a mildly scary ghost that crops up when I see the likes of a Freddie Mercury clone. But I know I like the same sex, so I'm sticking with that.
Anyway, thought I'd share my story. I always wanted to contact Dr Philipson about his article. To me it is very fascinating...maybe because I experienced exactly what he described, but also because it is less known, and I wish I could tell the other 17 year olds out there with it (I'm 35 now btw), the flaws in their logic, and that they'll get through it and still be able to have a family.