Mclean Hospital

Podcast: Being Me With OCD With Nathaniel Van Kirk

November 12, 2019

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Trevor is joined by Nathaniel Van Kirk, PhD, coordinator of clinical assessment at McLean’s OCD Institute. He talks about his personal journey with obsessive compulsive disorder and how he has used his own experience and recovery path to become one of the top clinicians/advocates in the United States.

Dr. Van Kirk also talks about why he volunteered for the Deconstructing Stigma campaign and why he thinks it’s valuable for clinicians to be open about their own mental health challenges.

Episode Highlights

  • Nathaniel recalls his first experience with OCD (02:00)
  • Nathaniel discusses how OCD can create a disconnect with reality (36:53)
  • Nathaniel describes “the sandwich” and how it’s an effective form of exposure therapy (47:13)

Relevant Content

Episode Transcript

Trevor: It seems like you’ve really found, not the answers, but it really seems like you’ve found the balance. The balance that we’re all trying to get. And I’m sure ... Well, now I know from the pre-interview that it took a lot of work.

Nathaniel: Yes.

Trevor: Yeah.

Nathaniel: It took a lot of work, a lot of time and it’s also one of those that ebbs and flows over time. Like if you kind of let your guard down, there’s always times that I’ll notice would creep up or like I kind of noticed the anxiety would rise a little bit and have to kind of really get back to work in a sense and make sure that I’m actually kind of doing what it is that I suggest others do. Go to my clinical practice but actually being honest with whether or not I’m doing those things for myself. And so it’s always an ongoing experience. I think one of the interesting things about it is I thought this when I was going through it initially during high school and as I started to move past kind of my OCD in college—

Trevor: You started noticing it in high school or did you notice it earlier.

Nathaniel: I noticed little pieces of it earlier but I would say about the end of middle school, the very beginning of high school was when I had a pretty sudden spike in OCD and kind of the first time that I knew something was wrong.

Trevor: Probably related to puberty, that’s when I really knew something was off about me, was puberty and then things just got ... It gets awkward for everybody but things just got really out of whack.

Nathaniel: Yeah. It was interesting when I think back about that experience. I actually developed my ... My OCD really took hold, before I didn’t know much about it. I wasn’t a very anxious kid in a lot of times, spent a lot of times outdoors, those types of things. But then I went to a tennis camp, coincidentally it was at the University of Virginia, and over those two weeks that I was at tennis camp, for some reason, my OCD just took off. I had never really known what it was or what was going on—

Trevor: You never found the trigger.

Nathaniel: No. It was just one of those things that I think the right amount of stress, being in a new place, all those things combines, my anxiety skyrockets, I started to have these kind of fears and thoughts that I didn’t understand. It was interesting because during that time, I remember getting picked up by my parents and like most parents do, they seem to know when something was off, and they asked me on the car ride, “Are you okay? What’s wrong? Something seems different.” And being a teenager and do what we all do as a teenager, I was like, “I’m fine, stop asking questions.”

Trevor: Yeah, right. Right.

Nathaniel: Very quickly realized everything was not fine, I just had no clue how to really explain what was happening or why. And so I do what most teenagers try to do, hide it till you figure it out. Little did I know that that was actually probably the worst thing I could have done. And from that point forward, my OCD kind of skyrocketed. But even when I look back on it today, one of the things that kind of resonates with me is that even as I have moved past struggling with my OCD on a day-to-day basis or I live most of my day-to-day without really even thinking about it, that doesn’t mean there aren’t other struggles that come up. And when you’re in the midst of it, that struggle feels like the only one.

Now as I look back across my life with a little bit of more hindsight, and each year I get a little bit more, I start to realize that it’s kind of each of those struggles that really set me up to be able to deal with some of the other life challenges that are literally going to be thrown at you no matter what. So ultimately, we’re all just kind of figuring out as we go hoping that we look like we have it all together, especially when anyone else is watching.

Trevor: Right, yeah. So you said you eventually figured it out, is that true or did you eventually figure out that you needed to do something about it? That there was a doctor that needed to be seen or you needed to come clean to your parents and be like, “Something’s wrong and I don’t know what.”

Nathaniel: I would say I didn’t figure it out and I still haven’t figured it out because we’re still trying to understand OCD. Part of it is that it’s all based on uncertainty so there’s no way to truly figure it out, you just learn to function and sit with that uncertainty, and in some times, embrace it. When I got back from camp, there was definitely a point where I really didn’t have a choice in hiding it anymore. I primarily struggled initially with a lot of using PURELL and hand washing and kind of fears of contamination and there was a point where I had actually flooded the bathroom because I was getting up around 3:00 or 4:00 in the morning to try to wash my hands for multiple hours because I just couldn’t stop but I knew I had to get it done before anyone else in the house woke up. The idea—

Trevor: How old were you?

Nathaniel: At that point, I think I was about 14. 13 or 14. And I would get up early, I’d start washing. Unfortunately, I hadn’t really gotten the efficiency of hand washing down that I would later develop. I thought using just regular concentrated kind of hand soap made the most sense because that’s what was there. And I’ll never forget the morning where I didn’t really watch the time and I was so stuck in the rituals that my mom kind of kicked the door open because I had tried to barricade it shut a little bit and there I was just standing in front of the sink where I had made a pyramid of bubbles as the sink was overflowing kind of cascading down to the floor. And I’d scooped out the little top of it and just moved it off to the side so I could keep going. And my mom was, “What’s going on? Are you okay?” And the only thing I could think to say is, “I’m fine.” And then just kicked the door shut. Luckily, I was very lucky that my mom at the time was actually in a psychology class and they had just talked about OCD so something about that rang true.

Trevor: Would you wash your hands till they bled?

Nathaniel: Mm-hmm. Yeah, over the years if I used to kind of close my fist to write—

Trevor: They would crack.

Nathaniel: They would crack and bleed. I learned later I left blood on a lot of tests that I would hand in when I tried to take them but there wasn’t a whole lot of way to hide it at that point.

Trevor: Shot in the dark question, I don’t know why, it just ... Did you ever develop an eating disorder? No. So there was nothing with food.

Nathaniel: There was always contamination around like my hands are contaminating the food or getting sick from eating it but not in terms of ... Usually it was what was ever in my hand or the environment around me and—

Trevor: Would you ever starve yourself because you didn’t want to touch the ... I mean, you had utensils but you put your hands on those utensils.

Nathaniel: Yes. Very carefully. Sometimes wrapped—

Trevor: You’d be very careful about it—

Nathaniel: Wrapped in plastic or using gloves or otherwise.

Trevor: Could food touch each other on the plate?

Nathaniel: Yeah, that was okay.

Trevor: Yeah.

Nathaniel: Sometimes it was easier if it was all together because I only had to deal with eating once. Burritos and Tacos were always a great thing.

Trevor: Yeah. Yeah. What if somebody touched your food? Was it just you touching your food or anybody?

Nathaniel: That varied over time—

Trevor: If somebody handed a piece of pizza, “Oh, could you put a slice on my ...”

Nathaniel: That varied over time and by person. Most times it was okay. There were certain people that, especially those that were around me a lot, that I feel like I had contaminated or if they had touched something that I thought was contaminated or some of my stuff, then I would sort of think twice about it. Sometimes I would eat around that part and kind of try to subtly toss it away. But it really depended on the person, so OCD kind of has this aspect to it that one of the things that I always think of is, which was kind of a strength, that whenever I work with someone with OCD too, we always talk about what are the inherent strengths that even allow OCD to exist? Because those strengths have to be there first. And one that’s always—

Trevor: Do they really? Yeah.

Nathaniel: Yeah, OCD tends to leverage the things that you care about and use what you’re good at against you.

Trevor: Okay.

Nathaniel: I remember working with many people and for myself at the time, something that I would always feel like I’m keeping track of everything that hadn’t been touched and I always had a list running of like 100 things in my head that were contaminated around the house. Somehow, I knew what they were. I was also looking back now well aware that when I got anxious, my ability to kind of organize that really went away and so everything became contaminated. But you do tend to be very kind of hypervigilant tracking where things that are contaminated touch, things that you touch, things that others touch. And so, the world kind of closes in on you pretty rapidly. And so there’s a lot of time where I wasn’t necessarily leaving the house as much. I would try to get to school but I pretty much always missed the bus and would chase it for a little bit and be like, “Might as well go back, keep washing.”

Trevor: And if you learned that your stomach had enzymes, that the body was designed to handle a certain amount of bacteria or contamination, you dismissed that immediately? Dismissed it as in that’s false or dismissed as I’m just not going to take that into account.

Nathaniel: Probably the best way I can kind of describe it ... So, for my particular OCD, one of my fears, and I had, over the years, mine morphed a lot and changed pretty rapidly. But what it initially started out with was kind of two main contamination fears. One was getting anything that was a life-threatening illness, and specifically around blood-borne diseases and STDs. So, the idea that I would touch something that someone might have touched and I might get any blood-borne virus or pathogen that was incurable at that time. And—

Trevor: I’m sorry, I got to ask, did you just not date?

Nathaniel: Coincidentally, it took a little while to date, yes. In hindsight, when I look back, part of it was time. I was spending hours a day ritualizing, it wasn’t really something that I had time for initially. And the other part was that there were a lot of concerns around sex-transmitted diseases. The other thing that I had that really initially started was that I was actually afraid by touching somebody, just by touching something that they had touched, by handing them a pen or if they touched, for example my locker, that somehow I would magically get them pregnant and that I’d be responsible for ruining their life, knowing full well that is not fully possible. I knew full well that these kind of obsessions and fears weren’t realistic, they didn’t abide by the laws of physics but in the moment that didn’t really matter because I felt like your own brain was kind of turning against you.

Trevor: Right. You specifically said ruin their life, was that the ultimate fear or was ruining their life a byproduct of if I touch them, they’re going to get pregnant? I don’t know if I’m wording that right. Is that where everything was rooted in? Is that somehow, I’m going to ruin this person’s life, this person’s life, this person, by touching them or them touching me or something like that?

Nathaniel: I’d say not necessarily in terms of the core feature, it was definitely a part of it. I think the thing with OCD is that it takes so many different forms and parts that it can vary just based on the day, what I was thinking about that day, what I was stressed out about that day. That core fear kind of would pop around a little bit and it would kind of take this core fear of kind of either magically getting an illness or a blood-borne disease and then having accidentally touching someone else, especially since my hands were always bleeding and then I passed it along to them and might be responsible for them dying. Or all of those fears kind of swirled together, sometimes they overlapped.

Trevor: Did you obsessively take HIV tests?

Nathaniel: No. I didn’t really take many medical tests or things like that. I mostly focused on hand washing, checking ... There were times like I noticed when I’d go to the doctor and they’d do blood tests, right before the results came in, definitely my anxiety would go sky high. OCD doesn’t have to play by the rule of physics, it pretty much takes your creativity and just runs wild with it. And it always asks like what is that .001% chance that could happen? And where a lot of times with anxiety, if you’re like, “Oh, so 95% chance this won’t happen. I feel better.” With OCD, usually that’ll say, “There’s a 99% that won’t happen, so you’re telling me there’s a shot.”

Trevor: Right, right. It’s the Jim Carrey Dumb and Dumber thing. It’s like, “So you’re telling me I have a chance.”

Nathaniel: Exactly.

Trevor: Yeah.

Nathaniel: And that chance was never anything good. It was always the worst possible scenario that you could ever imagine.

Trevor: Okay. But hold on, that sounds like it was rooted in catastrophizing.

Nathaniel: Correct. That is one of the main kind of cognitive styles and what we call cognitive distortions that maintain OCD. The thing about the catastrophizing—

Trevor: Did you have low self-esteem?

Nathaniel: Definitely.

Trevor: Yeah.

Nathaniel: It definitely takes a toll on both your aspect of your identity, your self-esteem, who you are. You never feel like you’re really able to cope with anything.

Trevor: Were you picked on, bullied?

Nathaniel: Actually, not really. I mean, there were times I wasn’t—

Trevor: You dropped a pen in high school and you get mocked for it so for somebody who has to wash their hands all the time, I mean, anything that seems outside of the norm of how high school kids view each other, that you’ve got to be ...

Nathaniel: At times there was some. I wouldn’t say it was excessive by any means, only a few stand out. I remember my backpack ending up in a trashcan once, which was a fascinating piece because trashcans were highly contaminated—

Trevor: And did people know that you had OCD?

Nathaniel: No. No one really knew what that was. But at the same time, I also had a few really, really good friends, who over the years, they really would even just sit downstairs. I remember one of my best friends just used to sit downstairs, I would wash my hands for hours, sat down and ate ice cream for the entire time. Walked down, act like nothing happened, said, “You’re ready? Let’s go.” And over the years, it was those kind of friendships that really helped me push past those fears, face them head-on and started to develop a little bit of confidence kind of in myself, in my ability to tolerate the uncertainty, the anxiety. And if the .01% chance thing happen, I’ll deal with it and I’ll figure it out.

Trevor: Silly question, but I don’t know, I don’t think it’s silly, could you ... And I mean this as a serious question, could you watch the trash compactor scene in Star Wars or would that trip you out?

Nathaniel: No, that was actually okay. I love Star Wars so that was actually okay with me. If I could lose myself in a movie or cartoons—

Trevor: I mean, we talked ... You’re a gamer so I mean, gaming gets such a bad rap but I got to tell you it is the one ... Even more than cinema, and I love cinema, nothing takes me away more than gaming. Gaming is how I can literally ... My brain can just let go off everything.

Nathaniel: It’s a wonderful escape.

Trevor: It really is. And then the second I’m done, I’m back to all the craziness in my brain. But it’s the one way I can give my brain a vacation, is gaming. It’s just been great. Were you always a gamer?

Nathaniel: I was. I had a group of friends that we all played video games a lot together. It was one of those escapes. I would say my OCD tended to dive into it a little bit because the controller is a good contaminator and I didn’t want anyone to know so I would pretend to design them by putting electrical tape around them or a coat or I spray paint them essentially. Really what I was doing was trying to cover up and you create a barrier between me and the contamination or I learned to play with just my two fingers. So, I had to get a little bit creative for something that was important—

Trevor: But I remember blinging out your controller was kind of like a cool thing to do so you were able to kind of hide it that way.

Nathaniel: That’s what I was hoping.

Trevor: Yeah.

Nathaniel: Having found some of those controllers recently, I wasn’t as artistic as I thought I was, but it was a good shot.

Trevor: So, at what age were you when you finally went to your parents and was like, “I got to ...” And hold on, do you have siblings?

Nathaniel: No I don’t.

Trevor: So you’re an only child.

Nathaniel: Yeah.

Trevor: How old were you when you went to your parents?

Nathaniel: I would say from the moment that my mom caught me washing my hands and creating my bubble masterpiece, as it were, she actually kind of brought me to therapy right away, which was very lucky. It was a very long road. OCD at the time wasn’t very well known.

Trevor: Sure. How old were you?

Nathaniel: I was 14 at that time, give or take a couple of months.

Trevor: That’s good to get in at 14.

Nathaniel: It was. I unfortunately got a lot of not great treatment to start or people that didn’t really know what OCD was.

Trevor: What area, you don’t have to say the city, what area did you grow up in?

Nathaniel: I grew up in Virginia and I was actually outside of DC and it was one of those that at the time, I didn’t even know places like McLean or any of the other hospitals that had OCD programs. I came to find out many years later when I went to grad school there was actually an intensive OCD program and there was a lot of treatment for OCD that was really, really good. But there were many people that I worked with that maybe weren’t as familiar with it. Everyone had good intentions but OCD was still somewhat new in the field in terms of knowing that there was a treatment that worked. And so, over the following years, my OCD tended to intensify pretty significantly. I think I may still hold one of the records for the most missed days of school, mostly because I was stuck washing my hands or showering or ... You name it. And so—

Trevor: Did you ever get held back or threatened to be held back?

Nathaniel: Yes.

Trevor: Yeah.

Nathaniel: I luckily had a guidance counselor and a principal at our school who was incredibly understanding and supportive and really went out of the way to help.

Trevor: And I’m sure you weren’t like goofing off or when you were there, you did your work.

Nathaniel: I tried.

Trevor: Yeah. You tried, exactly.

Nathaniel: I would get stuck in the bathroom a good bit. I would go, feel anxious, I’d end up going to the bathroom in between and then spend a lot of time walking in and out while washing my hands, while keeping count because I had a counting ritual with it, trying to pretend like I wasn’t in here the whole time. That gets pretty complicated when there’s only like three bathrooms in the high school and you’re walking in and out of each of them in a rotation trying to make it back to class. But they were really supportive. And over the years, I did actually find a treatment provider in the area who really ...

The way that I kind of remember it, is coming in and learning about my OCD a little bit. And they were very honest with me saying like, “Your OCD is quite severe.” And what really stood out to me, and it’s funny, now as a clinician, this provider and I have done panels and talks together and our recollection of this experience is incredibly different. But the thing that just stood out to me from that interaction was I just walked away with it with the idea that they were willing to give me a chance, to take a chance on me. They weren’t guaranteeing that this was or wasn’t going to work but they were offering to figure it out with me, no matter how long it took.

Trevor: What was the discrepancy?

Nathaniel: I’m not sure they used those exact words but that’s the meaning that I took from it. When we did the talk, he was explaining what OCD treatment was, I was so anxious I didn’t quite hear all the details—

Trevor: Sure. Yeah, well, that makes sense.

Nathaniel: ... but I took away from it that there was an option and he was willing to give it a shot with me and—

Trevor: Okay.

Nathaniel: And really that chance was all I needed. It took many years after that but through the work together, as I went off to college, I was able to do treatment, did really well in treatment, tapered off as I was in college and then eventually didn’t see the need to go anymore.

Trevor: Did you go to a local college so you could stay home or did you go away?

Nathaniel: I went to Virginia Tech. So I went away, not super far, it was like four hours.

Trevor: Still. Four hours.

Nathaniel: It was great. It was the one school that accepted me.

Trevor: Yeah.

Nathaniel: And I wrote my essay about having OCD and why I pretty much failed out of my first two and a half years and then had a weird school schedule after and they took a chance on me. I actually ended up staying there because they also took a chance on me again as a graduate student. And so I finished my PhD there as well and stayed at Virginia Tech for just about 10 years.

Trevor: Have they asked you to come back and talk or anything?

Nathaniel: We actually go down every once in a while to go see our old professors and we talk together at conferences. So, it’s been a great opportunity, great relationship and I’m really thankful for the help that I received and the support that they taught me how to kind of use my experiences a little bit differently. There’s a piece in the field sometimes where you’re kind of encouraged not to disclose or it’s seen as a bad thing. And what always stood out to me is that there was that moment where they were honest with me that there is some stigma in the field, whether it should or shouldn’t be there, it’s there. And if you want to change it, you’ll have to face it head on, understand it and figure out what you’re going to do about it. And so they taught me how to take my experience as not let them kind of influence my clinical judgment but to be an asset and how to tell my story kind of in my way over the years, which I was incredibly grateful for.

Trevor: Did your parents, one of your parents, both of your parents, were they supportive entirely or were they disappointed?

Nathaniel: In terms of ...

Trevor: In terms of you having a mental illness.

Nathaniel: I’d say they were supportive. They were scared.

Trevor: Sure.

Nathaniel: Which makes total sense, it’s—

Trevor: I mean, I know some parents are just disappointed like, “Oh, my kid’s a screw up, a failure.”

Nathaniel: No. I always felt that they were supportive. They always encouraged me to continue to go after whatever goal I wanted to. They’re full supporters. I wanted to go into grad school and initially I’d wanted to be an MBA and I’m like, “I’m going to go to business school. That’s just the direction.” After OCD, that all changed pretty drastically and they were—

Trevor: You wanted to go to business school.

Nathaniel: I did.

Trevor: Yeah.

Nathaniel: That was my eight year old me. For some reason, the eight year old me had decided, “You know what? I have my life planned. I’m going to go get an MBA.” That was probably a precursor of liking to plan a little too much and then I changed all of it, and happy I did.

Trevor: Yeah. Oh my God, you’re so positive and it’s sincere too. It’s amazing because that sounds really rough, all of it sounds really rough. Suicidal ideations, suicide attempts?

Nathaniel: No attempts. Definitely ideation, kind of thoughts of death over the years a lot. The idea—

Trevor: Thoughts or obsessions with death.

Nathaniel: A little of both.

Trevor: Yeah.

Nathaniel: A lot of it in the midst of it was it would just be easier if I weren’t here.

Trevor: But with OCD, sorry folks to get all dark, but with OCD I imagine because of contaminants and stuff, you probably only had very specific ideas of how you could kill yourself, probably cutting your wrist or something would not be something that you’d want. That would not be something a person suffering from OCD would do.

Nathaniel: No. I’d say that very much all of those possibilities are within the realm with OCD—

Trevor: Really?

Nathaniel: Very much so. Partially because OCD doesn’t really exist in a vacuum. It’s one of those things that kind of can really move depression along a lot. It can make it really overwhelming just to face any day. And so things like suicidal ideation, thoughts of death, are common when someone’s struggling with OCD. There are also things that we know that we can help with, that there are great treatments, there are strategies that we can use. And at times, I definitely struggled with it. I struggled with some versions of ... I’d always get angry at myself for not being able to do what I thought I should be able to do or to block the rituals. I remember multiple times punching the walls, all sorts of things.

Trevor: Punching the ... But ...

Nathaniel: And one of them, the wall punched back because I knocked the shelf out and it hit me in the face and I had to go to the ER. So that was a learning experience but ... And there are times, I remember actually one moment that was somewhat of maybe a turning point just because it kind of scared myself and my family. Was I had been stuck so long in the bathroom that I started slamming my head into the wall because I just wanted the thoughts to go away and couldn’t stop. And—

Trevor: Did you cut your head open?

Nathaniel: I honestly don’t remember. I do remember being held back. Luckily, my parents were home and were able to hold me back to keep me safe because I was kind of slamming my head against the wall, in the corners. I just wanted the thoughts to go away and I had kind of just become so overwhelmed. And then as I calm down and kind of went back to treatment, learned some strategies for it. Over the years, I was able to recognize what was happening as I was just feeling overwhelmed.

Trevor: Right. So, I want to back up to something real quick. In my notes here, it says that when you were at tennis camp, that there was a specific incident that happened regarding a tennis racket and some hand sanitizer. Could you go into that?

Nathaniel: Yes. My very early rituals. The first thing that I kind of had developed was this idea of using hand sanitizer because PURELL started strong with its marketing campaign. 99% bacteria elimination and when I was anxious and feeling contaminated, that seemed like a great, great idea. Unfortunately a few drops of PURELL like you were supposed to use, quickly after just a couple of hours, and especially after a few days, was no longer enough. And I remember—

Trevor: And you were at camp, how were you getting all this PURELL?

Nathaniel: I was sneaking out of the tennis camp dorms that we were in at night and trying to find 7-Elevens to be able to buy PURELL—

Trevor: How old were you?

Nathaniel: I was about 14 at that ... This was the onset.

Trevor: Oh my God, I’m so sorry.

Nathaniel: And I’d just kind of sneak out and/or during lunch breaks and I was like, “Okay, I got to find some PURELL.” I started using it then it just wasn’t enough. But I did get that momentary relief.

Trevor: If you couldn’t get PURELL, could you go to sleep?

Nathaniel: After a very long time of being very, very anxious ...

Trevor: Yeah.

Nathaniel: In that moment, I got this momentary relief from using it, which was in hindsight, the start of kind of the ritual cycle. And I would use it more and more, and each time I’d cover more and more of my body. And so, by the time we got towards the end of tennis camp, I was putting PURELL on my hands, my arms, my face and then my belongings started to feel contaminated so I started rubbing PURELL over all my belongings. So I coated my tennis racket in PURELL and my shoes, including the soles of my shoes in PURELL, which as you can probably imagine, we’re trying to play a tennis match and everything you own is coated in a very thick layer of PURELL, things get a little slippery. So I spent most of that match sliding back and forth over the tennis court.

And at one point I remember going to swing my racket to hit a serve and just lost control of it, just slid right out of my hand because of all the PURELL and just flew off the court. And that was kind of ... At that point, I definitely knew something was wrong but I still didn’t know what was happening. But that was the start of the way in which my rituals intensified so quickly and started to interfere with day to day. And of course, I didn’t win many matches for the rest of camp. But an interesting story to look back on.

Trevor: There is this work of art, I’m going to say that because I’m not going to tell you what medium it is because I don’t want you to find it because I have a feeling if you looked at it, I don’t know what it would trigger. But it ultimately, without saying it, had to do with OCD but it rooted it in trauma. Were you, and if you don’t want to answer, it’s fine, were you abused?

Nathaniel: No. So there is some research around OCD and trauma, and especially for adult-onset. But when we talk about trauma as a precursor to OCD, it can be a traumatic event, it could be a stressful life experience. For me, I was stressed at that time. I wouldn’t say I had a trauma at that time. I was incredibly stressed during that time, my parents were in the middle of a divorce. As many kids are, there was ... And one of the kind of hallmarks of OCD is this hyper-responsibility and I had started to take this hyper-responsibility even though no one had really asked me to do it but to me I felt responsible for anything and everything that happened that went wrong.

And so at the time, I was very stressed, there was a lot of environmental stressors and it was kind of all these things happened just at the same time and made the right combination to where my brain kind of slid into this OCD cycle where I was trying anything to get rid of the uncertainty that I was facing day to day. And it kind of lashed on to things like contamination, fear of causing harm to others. I, over the years, developed a fear of running over people while I was driving. Every time I hit a pothole, I thought I had hit someone without seeing them so I’d turn around, go back and do it again. And then I’d see, “Oh, no one was there.”

Trevor: Did you have pets growing up?

Nathaniel: I did.

Trevor: Yeah.

Nathaniel: Yeah.

Trevor: That must have been tough.

Nathaniel: They don’t give you a lot of room to keep things clean, which turned out was a great thing for me.

Trevor: Well, it’s a little bit of exposure therapy.

Nathaniel: 100%.

Trevor: Yeah.

Nathaniel: And so it turned out to be a great thing.

Trevor: A dog.

Nathaniel: I did. Dogs and some cats—

Trevor: Oh okay. Because if it was just a cat, a cat would be like, “Screw you, whatever. I’m going to do my own thing.” But if it’s a dog, they’re in your face.

Nathaniel: Over the years, we had many pets. We actually lived kind of a little bit out in the country and had guinea pigs, hamsters ...

Trevor: Oh my gosh.

Nathaniel: Then over the years, I ended up moving to Oklahoma partway during high school and we lived on a farm with cattle, peacocks, all sorts of stuff. And I’d say about that part, as I started working more and more in the farm, I had exposure that I really couldn’t do anything about. The point where I really realized that treatment was going pretty well was when I was working on a farm mucking a pig pen when it had flooded.

Trevor: Oh Jesus.

Nathaniel: And went inside, ate an Eggo Waffle and was holding Eggos while mucking and then I thought about it at some point I’m like, “There’s no way I would have done this a couple of years ago.” And so for me it was a way ... Farm life was kind of a way that I integrated exposure into everything I was doing and that was probably one of the things that also was incredibly helpful.

Trevor: Silly question, I’ve heard you’ve mentioned waffles three times, are you a waffle guy because I—

Nathaniel: I love waffles—

Trevor: Yeah, me too. I mean, like it’s kind of hard core. Like it’s kind of a problem. Like I love them and I have gluten and dairy allergy too so I have to get those kind of crappy gluten-free dairy—

Nathaniel: The cardboard waffles.

Trevor: Yeah. And—

Nathaniel: They’ve gotten better over the years.

Trevor: They’ve gotten better over the year, they really have. But I’ve actually had to cut back because I used to make them way too often.

Nathaniel: It’s now a weekend thing. My wife and I try to make brunch on the weekends and so pancakes and waffles have kind of been relegated to the weekends.

Trevor: I’m jumping ahead here but you said, what, you’re married, which completely goes against my theory founded in nothing that specifically for me I don’t date and I don’t date anymore, I don’t ask people out on dates, I’ve just assumed I’m doing this thing solo because who’s going to want to deal with this? But you found somebody that has been ... I’m assuming. I mean, you’re married, you said that you’ve been together for 10 years, that’s been supportive. I assume they’ve seen the real ugly sides of this.

Nathaniel: They’ve seen parts of it. We actually met in graduate school and we’re both in grad school together and by that point, most of my OCD had kind of been really pushed behind me. I wasn’t really struggling day to day with my OCD anymore. There were moments where it would flare up and definitely they’ve seen those sides. They’ve also seen the sides where just to get anxious or overwhelmed and in many ways that’s also part of kind of day to day life even without OCD or without any mental health struggles, and anxiety is kind of a part of day to day life. And they’ve been incredibly supportive and it’s been a really nice—

Trevor: How soon were you able to tell her?

Nathaniel: That I had OCD.

Trevor: Yeah.

Nathaniel: Well, since we went to grad school together and we trained clinically together, she knew very, very soon.

Trevor: Yeah, she did.

Nathaniel: Partially as I was going through training and this was ... I had started at that point trying to do advocacy as well and so was sharing my story with undergraduate classes. And so well before we started dating, she kind of knew.

Trevor: Sure.

Nathaniel: And so OCD is really based on this idea of a difficulty tolerating and uncertainty. And in any relationship, there’s a lot of uncertainty. And now when I look back on hindsight, sure, I probably have a harder time making decisions and there were kind of challenges at times around figuring out where the relationship’s going.

Trevor: Let’s expand on that into territory that some listeners might groan at, but if you’re talking about the unknown, I mean, were existential crisis’s like a part of your ... Yeah?

Nathaniel: I’d say at times. There’s a version of OCD that’s called existential OCD.

Trevor: Really? I do not know this—

Nathaniel: And it’s very much that uncertainty around is this real or not? Am I doing the right thing or not? Am I being enough of me or not? And so it can take so many forms. As I mentioned before, OCD it’s only hindered by the creativity of your imagination. And definitely there were times where it wasn’t one of my primary ones so it wasn’t something that I struggled with as much as some of the others, and especially like the harm things. But it was one of those that at times it would creep in and it would be like, “Am I making the right decisions in my life? Is this truly what like it’s supposed to be like?” And then I was able to recognize them as obsessions, maybe, maybe not. I guess we’re going to find out. Only way to find out is keep going.

Trevor: What about moments of like extreme social uncertainty? Say for example like 9/11, what was that like for you?

Nathaniel: I would say that in many ways, being outside of DC, having many friends who were in the ... Parents were working in the Pentagon or otherwise, I think my memory of it is experiencing it like my classmates did. In those moments where the worst come true, OCD does tend to take a step back because you realize that there’s something here that you have to deal with and—

Trevor: Something that’s bigger than you.

Nathaniel: Yeah.

Trevor: Yeah.

Nathaniel: And something that needs immediate attention. And OCD, in the moment, it only survives kind of as long as you have time to think about it. And so it did take a step back at that point, I would say. I wasn’t really focused on my OCD at that point, didn’t really directly relate to my OCD at that point. I was kind of focused on what was happening in that moment kind of with my classmates, with my family, with my loved ones.

Trevor: So it doesn’t stop you from reacting in a situation where you may need to react.

Nathaniel: No. In many ways, it’ll kind of disappear but it’ll come back later and want you to review that over and over again like, “Did you make the right call? Are you sure you didn’t make a mistake? Did you miss something? Are you sure you’re remember this correctly?” It used to be called the kind of doubting disease because you start to doubt everything, your memory, your senses, yourself. And so usually it’ll kind of come back around, to circle back around to it.

Trevor: Have you ever been in a car accident?

Nathaniel: Oh yes.

Trevor: That you were the operator.

Nathaniel: Definitely.

Trevor: Yeah. And what’s that like?

Nathaniel: I’d say my OCD actually didn’t latch onto it all that much because it was an actual car accident and I had some things to deal with in that moment.

Trevor: But you’re saying afterwards, was there a lot of post processing?

Nathaniel: Not for the actual accidents. Usually it’s the ones that I actually had more trouble with the potholes. Like hitting potholes or sticks in the road thinking that they were people or kids or something like that, that I had accidentally missed them and hit them.

Trevor: So it sounds like potholes, sticks in the road, it sounds that these things are instead of it being an end point or an end game like a car accident or 9/11 where it’s something that you’re watching from a distance but still close to, it sounds like it’s the things, whatever happens, there are catalysts that trigger something that lets your imagination then take it the rest of the way.

Nathaniel: Yes.

Trevor: If you hit a pothole, there’s enough mystery there to let you fill in the blanks that say, “Well, I didn’t see me hit the pothole so it could have been a person. I didn’t see myself hit the stick even though I know the sound of driving over a stick but I didn’t see it.” How much is seeing a part of it?

Nathaniel: I’d say you can still see it and still doubt it. So you may see the stick, hit it and say, “Are you sure that’s a stick? What if it only looked like a stick? What if it was a leg?”

Trevor: Right.

Nathaniel: And then from there, your anxiety kind of runs with it. Like, well, what if? Essentially, it’s all around the questions of what if. There are times in life where there really isn’t no what if, like you’re very certain on what you saw, OCD doesn’t always ... And it can vary person to person. For me, it didn’t really latch on to those moments but it did latch on to the potential worst case scenario or was I truly paying close enough attention or full attention? Do you know that you were watching every part of the road or do you think that you were watching every part of the road? What if you just zoned out for a minute? What if it was that second that you zoned out that something terrible happens and you don’t remember?”

Trevor: Did you freak out when you realized ... I mean, I assume you’ve realized that your OCD disconnects you from reality or gives you a reality that’s not true according to the ... Personally speaking, this is something that I’ve only now realized in my early 40s, is that my BPD that I’ve been living in a false reality, this is something I could have dealt with much easier in my 20s. It sucks dealing with it now. It sounds like you reached that realization already.

Nathaniel: I think by the nature of OCD, within that first couple of weeks of my symptoms developing, I kind of was very clear that I couldn’t ... I felt like I couldn’t trust my own mind, my own senses, my own version of reality, my memory. That’s kind of what OCD banks on, is the ability to doubt everything that you think, see and hear, everything that you kind of think is true. And so a good portion of OCD is about questioning that reality and feeling like ... In some ways for me, it was feeling like my mind had turned against me and I could no longer trust it. It was almost splintered. Like I had the OCD, the obsessions of feared thoughts kind of screaming in my head that were never ending. And over time, I actually started to realize and then I knew. There was kind of like that part of me that knew what was kind of going on, that knew that these fears weren’t realistic, that this wasn’t what had happened. And even some of many of these things weren’t possible and that my rituals weren’t really helpful but it was just drowned out by the intensity of the anxiety.

And over time, it became easier and easier to say, “All right, that’s my OCD, that’s an obsession. Well, maybe my obsession’s right. Maybe something terrible happened. Oh well, I guess I’ll find out eventually but until then, I’ve got a couple hours of destiny that I need to go play because I’m behind.”

Trevor: That’s awesome. So, I just realized I’m being really selfish. I could talk to you about this for hours so we need to start talking about how not only do you suffer from OCD, but you work here at McLean and you treat people with OCD in the OCDI Department.

Nathaniel: Yeah.

Trevor: How did you go from wanting to get an MBA at the age of eight to ... I mean, I understand how you got there but how did you get there?

Nathaniel: For me, it actually came partway through the process of treatment where I’d gone to a number of providers and at one point, I was labeled as what they considered like treatment refractory or that I was kind of—

Trevor: Well, what the hell does that mean?

Nathaniel: Essentially, it means that I’m not responding to treatment as expected. I also later learned that the treatment at that time that I was getting was not the gold standard treatment, which is Exposure and Response Prevention. But at that moment, there was that kind of realization that no one really thought that I could get better or that I could hold a full job and that I would be kind of dependent on my parents for the rest of my life. That this was something that I’d never be able to move past.

Trevor: Yeah, I didn’t know until recently that up until recently people treated BPD as something that just wasn’t treatable.

Nathaniel: Yeah.

Trevor: And a lot of doctors esteemed in their field, wrote off BPD as, “Oh, good luck with that.”

Nathaniel: Definitely, there were many myths about what could and couldn’t be treated that we now know were completely false. We do have great treatments for many things that we struggle with. And it was about that point that I guess I was a slightly stubborn teenager too at that point and evidently told one of my treatment providers, “Well, you know what? I can do this better than you and I’m going to go into the field.” That was probably me being anxious and frustrated. I decided to stick to that goal. Luckily, I love what I do and it was about that turning point that I kind of wanted to actually focus as a clinician and a researcher on what it is about OCD and how can we enhance treatment? What’s going on in the times when kind of treatment we know and has a research backing it, maybe doesn’t work fully? What are ways that we can augment it, tweak it to make it fit for that person to enhance outcomes in the long run?

And so that’s kind of what drove me to continue to work on my treatment and kind of motivated me to do that, the hard work and things that I really didn’t want to do or I was terrified to do so that I could go to graduate school. And I was lucky enough to be accepted into graduate school though one school that accepted me was Virginia Tech, they took a chance on me and from that point forward, that’s really where my focus has been. Has been on both clinical outcomes, treatment of severe and complex case presentations in OCD and working here at the OCDI, understanding treatment outcome and how do we enhance treatment outcome? And how do we help those who have struggled to get the results that they want, chase the life that they want to live?

Trevor: It’s really amazing that you suffer and treat at the same time. And that probably, without crossing that line, there has to be that very definitive line between therapist and patient. I’m sure it makes connection between you and the patient and/or patients a little easier.

Nathaniel: I think it can. And—

Trevor: Do you tell them?

Nathaniel: Some. I’d say one of the things I’ve learned over the years ...

Trevor: Has a patient ever figure it out?

Nathaniel: Oh yes.

Trevor: Oh yeah.

Nathaniel: Without a doubt, also with the Deconstructing Stigma campaign, it’s quickly become, if you google my name, that has now replaced my fourth grade picture with the bowl cut, which is a wonderful thing that got replaced. But it says Nathaniel and OCD. So, it’s been one of those things that over the years, as I’ve used it in therapy and one of the things that I’ve really thought a lot about and tried to see supervision on is the idea of how to use kind of self-disclosure as a skill. In many ways, we disclose things about ourselves without even really realizing it all the time. And as clinicians, we learn how to ... Kind of what to talk about, when to talk about it, how to kind of disclose things like I’ve also ... I know what it’s like to lose someone. We talk about that and don’t think of it much as self-disclosure, but it’s a strategy to help connect with someone and help someone kind of feel heard and understood.

Trevor: Yeah. I understand it’s a strategy, however, you got to be really, really careful with that because—

Nathaniel: That’s exactly it.

Trevor: ... if someone who’s really suffering sees it as a strategy, you can lose them pretty fast.

Nathaniel: Correct. And that’s why I think there’s been this kind of holdover.

Trevor: Any therapist that is strategized, to me I’ve been like, “Screw you.”

Nathaniel: Yeah. It has to come across as authentic.

Trevor: No, it doesn’t have to come across as authentic, it has to be authentic. It can’t come across as ... That is ... Okay, I’m speaking for myself, that to me is unacceptable, if it comes across ... It has to be authentic. And it took me a long time to realize that there are people in this field that actually care but there are people who care.

Nathaniel: Exactly. And so, with self-disclosure, there is this piece of like you never self-disclose. And part of that is that holdover of not knowing how to do it or when to do it and the concern that it can be damaging.

Trevor: Sure.

Nathaniel: And I think in many ways when we think about self-disclosure, and the way that I think about it is that for me I have my line in the sand. Like people know I have OCD. If someone asks me about it, I’m never going to lie about it because that’s worse in my opinion. I always struggled with the idea that somehow if you’re in this field you’re not supposed to ever struggle with anxiety or mental illness because you’re a therapist, but as a therapist, we’re also human. And people figure it out, as you mentioned. And if you tell them, “No, I’ve never struggled,” and you’re well aware that they did, you’re not going to trust them. And so, but I also kind of also believe that its each person’s decision to whether or not they want to self-disclose, and if they feel comfortable and whether or not they should.

There’s no right or wrong answer about it but it does have to be thought through because it can be harmful, it can be ill-timed, it can come across as not genuine. It can also be incredibly helpful for some and not helpful for others. It’s about being thoughtful about it so that you’re actually putting your client first in trying to help them with what would be best for them. And I’ve heard times where I’ve really had in depth discussions with someone about my experience with OCD because they said they’ve never met anyone who’s gone through OCD and come out the other side, so they didn’t think it was possible. And I’ll let them ask me questions about it. There are other times where they don’t care and I’m not going to push it on them because it’s about what’s most important for them.

Trevor: Right.

Nathaniel: And so when I think about kind of stigma in the field, one of the things that I hope for moving forward is that it’s okay to struggle and if you want to be a clinician or a treatment provider, a researcher and that’s your goal, run for it and do whatever it takes to get there. Know it’s going to take a lot of really hard work, a lot of kind of critical evaluation of yourself. I’ve looked at things about myself that I’m not sure I really ever wanted to look at but were necessary for me to do my job and the idea that as you move through that process, there’s nothing special about what I did. I know a ton of clinicians I learn from every day who have their own experiences and are some of the best clinicians and researchers I’ve ever had the pleasure of working with. And I hope that for those that are going through treatment, if that’s what their goal, I don’t want the field to send them the message that that’s not okay. As long as you’re willing to put in the work, go for whatever goal you want.

Trevor: I got to ask, you got to tell me about the sandwich.

Nathaniel: About the sandwich?

Trevor: Yeah. The presentation you do with sandwich or have done with the sandwich.

Nathaniel: Around putting the sandwich on the floor or wiping on the bottom of my shoe and eating it?

Trevor: Yeah. I was seeing a film last night and I was talking about you in a de-identified way. I was talking to my friend and she was like, “What do you got to do tomorrow?” I’m like, “I’ve got two interviews to do and one of them is really interesting and OCD and this thing with the sandwich.” And we’re trying to cross ... We’re in Harvard Square and we’re trying to cross over where ... You know where the big legendary new shop and it’s closing after being open, it’s heartbreaking. We’re on that side where Starbucks was and we’re crossing the street and going over to the Brattle Theater to see a movie on Brattle Street. And that intersection, that’s the busiest intersection of Harvard Square and I was explaining to her the sandwich thing as we were crossing that and she just stopped. And I’m like, “You’re going to get hit by a car. You got to ... Come on, let’s keep going.” She’s like, “No way.” She’s like, “I don’t even have OCD and no way.” And I’m like, “That’s the power of this dude, is that he can do that.”

Nathaniel: And I will say, I cannot take full credit for those examples because I’ve seen many people do those variations That actually, the one that happened here with the sandwich was because I had another idea and then I forgot the prop that I was going to use for it and so I had to improvise what was there, which happened just to be a platter of sandwiches. And we were talking about the idea that Exposure Response Prevention is about feeling ... Learning you are capable of tolerating the stress of living at the other side. A lot of times people say, “I just want to get back to normal.” Which I’ve always struggled with because normal is just really like a statistical average.

And normal, if you’re just going for that top end, when you get anxious for OCD a lot of times, your rituals will creep back up to where they were before. But if you learn that, “Hey, I can take all of the contamination and the disgust, all the things. And I might get sick and I can deal with that also.” Then even when you get stressed, it’s still easy to go about your day to day. You can tolerate the anxiety that comes with it or the uncertainty. And so, to kind of exemplify that idea, I said, “What would you say if I took the sandwich and wiped it on my shoe? What kind of thoughts would probably come up?”—

Trevor: Did you drop it on the floor, step on it, pick it up and eat it? How did you do it? First of all, your bare hands so A, number one, bare hand on the sandwich, lifting it up, and then what’s next?

Nathaniel: I’m pretty sure, if it’s what I’m thinking of, I took my shoe off and just wiped it down the bottom of my shoe and then took a bite of it—

Trevor: And your shoe, hold on, let’s go through all the possibilities. And not to torture you, I’m just talking about people who don’t have OCD, I swear, this is going through their heads. There’s dirt, there’s possibly fecal matter, there’s bacteria, blah, blah, blah, we’re also in Massachusetts so the ground out here is contaminated with whatever chemicals that governments have been flushing into the water for decades. So not only the contaminants on your hand, but the contaminants on the bottom of your shoe and then you’re going to put that in your mouth.

Nathaniel: Yes.

Trevor: And you did that all in one move?

Nathaniel: Just all at once and then asked people, “What would be your initial thought if you had just done that?” Because that’s really what OCD is about. All those thoughts and once someone prompts you to do something like that, all of a sudden, you just notice, what if that ... As you described, what if there’s dirt, fecal matter, what if there’s chemicals? What if there’s things that we don’t know about yet? And that’s really what OCD is like. It’s the millions of what ifs that flood every moment. And in the same way that if I’m going to ask my clients to do the same thing, to challenge and fight their OCD and overcome it, I have to be willing to take those risks too.

Trevor: Did you throw up?

Nathaniel: Not that time.

Trevor: Wait, you’ve done it and you threw up?

Nathaniel: I didn’t throw up but I did get very sick once.

Trevor: You actually got sick.

Nathaniel: I did. I made an agreement with someone that they wanted to try a brand new exposure, they were really scared to do it and they asked, “Well, would you lick your shoe?” And I said, “If you’ll do your exposure, I’ll lick my shoe.” I’d happened to just come out of ... At that time, I was working in a hospital setting and just come off of a hospital floor into this meeting. And I 100% admit, I had all sorts of thoughts of what if, what am I doing, this is probably a terrible, terrible idea. But we made an agreement and they did their exposure, I licked my shoe. I did spend the next three days feeling incredibly ill.

Trevor: So you got probably what the equivalent of food poisoning.

Nathaniel: Yeah. It actually wasn’t quite that bad but it was close, more like the flu.

Trevor: Wow.

Nathaniel: But it was worth it.

Trevor: That story is epic.

Nathaniel: Because it was a good turning point for the exposure. So it was worth it.

Trevor: Oh my gosh, were you able to ever watch Jackass?

Nathaniel: Yeah.

Trevor: Were you able to enjoy it?

Nathaniel: I was. When it wasn’t happening to me necessarily and I was watching it on TV, I could lose myself in those.

Trevor: Really? Like Steve-O swimming in a river of fecal matter and then getting ... Like none of that ... That didn’t bother you, you could find the humor in that.

Nathaniel: I could find the humor in it.

Trevor: Yeah.

Nathaniel: By the time it was on, I’d also learned to find some of the humor in some of my own stuff that I was doing and I think that had helped a good bit. Sometimes you just got to find the humor in life even amongst all the really disgusting things that happen and the weird unexpected things that happen. Sometimes there can be a little bit of humor in there as well, even when you’re struggling.

Trevor: Did you have any OCD triggers during this interview?

Nathaniel: No.

Trevor: No. Good.

Nathaniel: A little bit of recollection. It was nice to kind of, in a way, think about what that experience is like.

Trevor: Wait, actually that’s a great question. Can recalling thoughts or past experiences kick off or trigger an episode?

Nathaniel: I’d say they could. Part of what we do with exposure is actually learning to confront those thoughts purposefully all the time and so that they don’t kind of catch you off guard in that same way. And so, I’d say that now many of these kind of recalling those events don’t trigger the anxiety or the obsessions as they would when I was in the middle of it. When I was in the middle of it, definitely. If I had anything related to one of those obsessions or thoughts or a memory of something that happened before, it would kick off all sorts of what ifs and anxiety. Now, not so much, partially because that’s what I love about also being a clinician with OCD, is that it does keep me honest and keeps me working on what I’m doing. And it reminds me we all face our fears, it’s about how you face them and what you do next.

Trevor: Right. I remember there was a period, and I am not at all equating this to OCD, I did not have OCD but there was something that I remember for a period of my childhood really taking too far and that was I heard the phrase or the rhyme step on a crack and break your mother’s back. And there was a point of my childhood where I obsessively avoided cracks.

Nathaniel: Yes. I think what you’re getting at is one of the things that I think is an important point about OCD is that OCD behaviors—

Trevor: I mean, I really thought I was going to bring my mother’s back.

Nathaniel: Yeah. And there’s a normative piece of development through childhood where things like lining things up or believing those nursery rhymes almost all kids go through it.

Trevor: Sure.

Nathaniel: OCD by nature actually starts out with a behavior that makes a decent amount of functional sense. If you think about checking a paper over and over again to make sure it’s right before you turn in your midterm or your final, it makes sense. The thing with OCD is that it takes these fears and behaviors and takes them to such an extreme where any behavior becomes kind of very rigid. It becomes something that’s no longer adaptive and gets in the way and it can take any form. I think one of the biggest kind of misconceptions about OCD is that it is just hand washing or ordering things but really OCD takes so many different forms, the main dimensions that we talk about a lot of times are the contamination hand washing. There’s also the fear of harm, fear of causing harm to self or others and some of the checking behaviors and rituals that come with that. But then there’s also this aspect of intrusive unwanted violent and sexual thoughts and they’re usually these thoughts that we feel like are inappropriate for us to have. They might be thoughts of causing harm to a loved one, they might be thoughts of if I’m not careful enough and I step on that crack, my mother’s back will actually break or she might die and I’d be responsible for it. One of the things that I really think is the most important—

Trevor: To this day, I can’t throw away Christmas cards for at least a year because if they die in that year ... If I throw that card away and they die, I feel like there isn’t a connection, that I would have posthumously disrespected them.

Nathaniel: Right.

Trevor: To this day, I hold on to them for about a year.

Nathaniel: Yeah. It’s that idea of trying to plan for that future and not make a mistake. What’s interesting and—

Trevor: That’s exactly what it is. Holy shit. Wow, okay.

Nathaniel: Yeah. I think that experience that you’re describing, it’s the experience that when you start to understand the core of what OCD is, that many of us will have is, “Oh, I can resonate with that. I may not understand how extreme or how debilitating it becomes but I understand the concept.”

Trevor: Right.

Nathaniel: And one thing that we tend to forget is that all of us as humans have intrusive unwanted violent sexual thoughts. There are studies dating back to 1978 that showed that in those moments, 80, 90% of people in that sample who did not have OCD reported intrusive violent, sexual, unwanted and distressing thoughts. The other 10 to 20% probably just didn’t realize it. Because when you don’t have OCD or when you’re not struggling with anxiety, a lot of times you can just go through the day and say, “Well, that was a weird thought.” And you let it go. But very quickly it becomes with OCD, “Why did I have that thought? What does that mean about me? What does that mean about who I am or what I could be capable of?” And so, you start to try to do anything possible to make sure that that doesn’t come true, but in reality, we all have those type of thoughts. If you ever question that, just drive through downtown Boston during rush hour, you’ll have plenty of intrusive thoughts. And it’s that idea that we just kind of notice them and then move past.

And that’s part of what we’re trying to do with OCD too, is help people realize all the different ways that plays out. It’s not just about a fear of getting sick. In the course of ... When my symptoms got really bad, I had all sorts of ... I kind of ran the gambit on them. I had intrusive violent, sexual thoughts, what we call like scrupulosity, a concern over sending people to hell or being responsible for blaspheming God. And I wasn’t really ... I’m not particularly religious at this point but those thoughts, it was anything that my kind of mind could take responsibility for. I tried—

Trevor: When I had an anxiety disorder, it was all rooted in harming obsessions. I was obsessed over ... My mind was obsessed with harming but I had no inclination to do it so I was pre-judging myself, “Well, if I have these thoughts, then ...”

Nathaniel: What does that mean?

Trevor: Right. Should I just go to the police and turn myself in?

Nathaniel: Yeah.

Trevor: Yeah. And this was the scariest part, when I finally went to a doctor, he literally got up, went to a book, opened, he’s like, “Oh, it’s harming obsessions. You’re fine.” And I just sat there like, “What?”

Nathaniel: There probably could have been a little better way to maybe—

Trevor: Yeah, yeah. He was just like, “You’re fine, really.” And maybe that was his tact to bring me down from the ledge—

Nathaniel: But it just doesn’t feel fine.

Trevor: Yeah. It doesn’t. But he’s like, “Really, you’re fine.” And maybe that took out the fear but it added confusion and at least it was something different.

Nathaniel: One of the things that I hear the most is, “Well, normal people just don’t have these thoughts.” I always ask people, “Think about the game Cards Against Humanity, they made millions off that. A lot of thoughts sound very similar to thoughts that you’re having because we all have those thoughts but it’s about what you do with it. And anxiety and OCD makes it mean something about you when it’s really just a random passing thought.

Trevor: Right. I mean, think of the work of Goya or even Bret Easton Ellis’s American Psycho, somebody had that thought and challenged us with those thoughts. And if you’re afraid of having those thoughts, I think that’s the point of the artist. You’re afraid of having these thoughts so I’ll have them and I’ll put them down on paper for you and you go and deal with them.

Nathaniel: It challenges you to deal with things that you’re really uncomfortable dealing with in day to day. When you struggle with anxiety and OCD as you described, they’re the thoughts that you end up struggling with day in and day out, almost 24 hours a day. And it can be terrifying.

Trevor: Sure.

Nathaniel: Part of the process of treatment is also learning that it’s okay to have those thoughts. Just having a thought doesn’t mean ... You still get to choose what you’re going to do.

Trevor: Right, absolutely. No, that was one of the first things I learned is no matter how bad it is, they’re just thoughts.

Nathaniel: Yeah.

Trevor: And it took me a while to get around that.

Nathaniel: It’s a hard concept to—

Trevor: It really is. It’s not an action but to me I believed a thought was an action.

Nathaniel: Thought action fusion is one of the hallmarks of OCD.

Trevor: Yeah.

Nathaniel: It’s that ... And anxiety across the board honestly is that having a thought is the same thing as doing it pretty much.

Trevor: That’s where I began with my therapy road, that’s where I started. And then every layer that’s been peeled back reveals something else until we’ve gotten pretty close to the core at this point. Yeah, that’s some intense stuff.

Nathaniel: Yeah. And I think it really ... The important part for those suffering with OCD, if you’ve never really heard about it, from media in general, the only thing you’re going to think about is, “Oh, it’s just people putting things in order.” And I think there’s been a lot of misinformation around what OCD is but also that it’s just this quirky thing that you do. Oh, I like to organize but that is not it at all about liking, it’s this urge, this I have to or I feel like the world’s coming down. It’s not pleasurable but it’s torture day in and day out and it’s never ending.

Trevor: Right. Lauren is going to make me cut this out, I’m going to fight her on it tooth and nail but Lauren you’re an admitted hoarder.

Lauren: Yes, I am.

Trevor: Is the core of that, like what he talked about, is that to prepare for a future that’s unknown. I need to keep this because I have no idea when I might need it.

Lauren: For me, it’s partly that but I always joked that I was a hoarder and then didn’t realize I was actually one until I went to Ecuador with Jeff Szymanski and he was talking to me on a bus and I was fascinated by everything that he was saying. For me, I find sentimental value in almost everything. I keep my receipts for months—

Trevor: I mean, when I said the thing about the—

Lauren: ... before I can throw them away.

Trevor: When I said the thing about the Christmas cards, you nodded your head big time—

Lauren: I keep every card.

Trevor: Yeah.

Lauren: I only threw cards away literally from like ... I kept them probably from age eight until I moved two years ago. That was when I threw things away. I don’t know sort of why. I grew up in a very poor family and I don’t know if that’s a piece of it but one is every ... “Oh, this was given to me when I was in third grade by my best friend and we don’t talk anymore so I’d love to keep this note that says, ‘Do you like to play basketball?’” But the other piece of it is yes, I do feel that I will need everything. So, for example—

Trevor: For the future.

Lauren: I don’t need to have 21 notebooks but if I come across a notebook, like a free notebook that I got at a conference, why would you ever get rid of a notebook? You will always need a notebook. I love to tell this story because—

Trevor: Well, hold on, let’s break that down. Why would you ever get rid of a notebook? You always need a notebook. That sounds like something we’re ... The thing about the unknown and preparing for the unknown.

Nathaniel: So, a hoarding disorder is actually a variant of OCD. It’s under that ... It used to be part of OCD but realizing there are some kind of subtle differences, like the sentimentality. The idea that if I get rid of this, what if I forget about this and I have no way to remember it? What if I lose part of this memory or part of something that was important to me? And then on the flip side is the what if I need this someday? What if there’s another way that this could be used or utilized and then I don’t have it? what if I’m unprepared or why would I get rid of it if I already have it? Wouldn’t that be wasteful?

Trevor: Right.

Lauren: And that’s a huge issue for me too so I used to be really good at couponing, so that coupled with hoarding things, which is terrible—

Trevor: She’s still good at couponing because she taught me—

Lauren: Thank you. I appreciate that—

Trevor: And my coupon game is awesome now and it’s all because of Lauren.

Lauren: Well, I don’t eat cereal, rarely. I can’t remember the last time I had a bowl of cereal but I used to be able to get free boxes of cereal with all my coupons and I thought it was great. And remember one day, I lived with my mom at the time and I was younger but I don’t think she really ate cereal either. We had six boxes of cereal, Special K. I think it was all the same. I went, “Mom, we need to get more cereal. We do not have enough cereal, we’re going to run out of this cereal.” And I left and I went and got more cereal. Guess what, we never ate any of the cereal. It all expired and I threw it away.

But my favorite story is I’m a big fan of the foaming hand soaps from Bath & Body Works. However, I find them really expensive so I will only buy them when I can get them for under $2 combining coupons, it’s fantastic. And I was here at work, there was a big sale, it was the last day of the sale, I couldn’t get there before the mall closed so I called my brother, I go, “Jamie, I need a favor please.” “Anything you want, what do you need?” I said, “You got to go to the galleria today and I need 20 bottles of hand soap.” And he says, “No, you don’t.” And I go, “Let me finish. You got to use these coupons but you can only do 10 at a time so you’ve got to do different purchases, use this coupon then I’m going to give you this coupon.”

He refused and he had to convince me that I would be okay with just 10 and he said, “Well, I’ll do one purchase, I’m not playing your dumb coupon game. I will go get the 10.” And I said, “But I was going to give you two as a thank you so then I’ll only have eight and I’ve only got eight left at home so that’s just not enough and they go on sale all the time.” And he said, “How long till they go on sale again?” And I said, “Probably not till November.” I think this was in September and he goes, “Yeah, you’re fine.” But it’s very much this feeling of I’m not actually fine. I need to have these things. But I’ll tell you, we never run out, we always have it when we need it.

Trevor: When I hear this, I hear that, and not just material items but without these things or without this process or without this end goal, it sounds like self-definition is always up in the air. Like this will complete me or the vision of me I have in my head.

Nathaniel: I think it can be in a completion piece and it can also be this is how, like from the OCD side too, this is how I prevent myself from becoming the thing I’m afraid I might be.

Trevor: Oh yeah.

Nathaniel: And so it’s a way to protect yourself from that possibility and the uncertainty that that could be true and so it can kind of go from either side. But ultimately, a lot of these things they do attack your identity or the idea of who you are as a person and kind of strip it down. And OCD, it tends to attack things that are most important to you and then turn them against you. The things that you value like friendship, family, it takes those things and kind of turns them against you thinking, “I’m going to be responsible for something terrible happening to them or to me because I wasn’t careful enough, because I wasn’t prepared enough.”

Trevor: Right. When I was doing the partial program here and I first witnessed true OCD, I’ve told this story on the podcast plenty of times, I’m not going to go into it, but it was horrific. And I immediately made a decision that ... And it was common rhetoric at the time and I still hear it now, is people saying, “Oh my gosh, I’m so OCD about this.” And I made a choice right there, I’m like, “I am never going to say that again.” And I’m not patting myself on the back. I haven’t and I won’t, because it’s beyond insulting to somebody that suffers from true OCD. Do you find people avoid that kind of rhetoric around you or do they amplify it?

Nathaniel: I’d say it’s fluctuated over time. I think at times when—

Trevor: Do you feel like people, they just take their little peccadilloes and amplify them to seem like they could connect with you?

Nathaniel: I think so at times, more in just general small talk conversation. I’d say those close to me, not so much. I think those that have been close to OCD or struggle with it, they tend not to. But I do think it’s something, as you mentioned, like we see all over the place. It’s all over social media, people talk about it all the time as if it’s such a trivial thing. It’s something that you can be proud of or kind of ... That you can turn on and off and use when it’s helpful when in reality it isn’t. I actually much prefer when people come up and ask me questions and I’ve had people come up and be interested in OCD. Someone’s going to ask me like, “Is this OCD or what do you think this is?” I’m actually okay with those questions because it comes across as they’re interested to learn. And to me, I think that’s important, to really learn what is and isn’t OCD. Because for each person that’s curious or says like, “I’m fascinated by this,” I think that’s a great thing because that means that they’re interested in learning more and it’s an opportunity to kind of break down some of the stigma and misinformation around OCD.

A lot of times when people ask something like, “Should I get treatment for this? Or do you think this is something I should get addressed?” Generally, the way that I approach it, because sometimes it’s, “I’m doing okay, I’m functioning. Like I’m living my daily life. Do I need to deal with this?” The question I’ll usually ask is, “Is it causing a lot of distress? Is it getting in the way of doing the things that you want to do? And if so, why not?” A lot of the skills that we learn when it comes to treating anxiety disorders or depression, there are day to day skills that can be helpful for everybody.

There are things that would be great if people would teach as we go through school and part of a school curriculum. Learning to face your fears and tolerate discomfort, uncertainty, I think is an important part. And if it’s causing you distress, why not? Why not reach towards that kind of better life that you want? If it’s not getting in the way and it’s not causing distress, then keep living your life. And if that changes, we’re here to help and there are options. One of the questions I feel like I get a lot is, “Well, why do you keep doing it if it causes so much pain?” When I was going through OCD and I think I hear this a lot of times from individuals who are struggling with OCD.

Trevor: I’m sure you’d have a better answer than me because mine would be F you.

Nathaniel: There are many times that is the first thing that would come to mind.

Trevor: Yeah.

Nathaniel: But one of the things that when I think back on it now, that’s important to know is that the difficulties that there are those moments where the rituals, they work for just a split second. Not in terms of they get rid of the fear but they reduce that anxiety so much—

Trevor: I know exactly what you’re talking about. I know exactly what you’re talking about. Yes.

Nathaniel: And I think that gets missed sometimes and so it’s very easy, both as a clinician and as a friend or loved one, to say, “Well, just stop.” And the thought I always have is when someone says, “Well, have you tried just stopping?” Like, “Oh yeah. No shit, I never tried that before.”

Trevor: Yeah, right.

Nathaniel: Because sometimes what’s missed is that this really is the anxiety so intense and there is a little bit of like a reward component. Like once you get it just right and every time you get it right, it gets harder the next time to get it. But that feeling of relief is so intense that at least you get 15 seconds of relief versus of 24 hours of torture. And so that does motivate. It makes it hard to do treatment. Treatment is very, very difficult but it’s incredibly effective.

Trevor: This might be unfair but I lump that right in with stigma. To me, that’s just as ignorant. That’s stigmatizing.

Nathaniel: I agree, I think it is a part of the stigma process, that misinformation—

Trevor: Oh, you’re just unable to ... You can’t just turn it off, that to me is stigma. That is just ... You don’t know, shut up.

Nathaniel: 100%.

Trevor: Yeah.

Nathaniel: If it was that easy, I would have stopped a long time ago.

Trevor: Yeah.

Nathaniel: And I think that’s important for everyone to keep in mind and for those going through it to remember it is hard because I think it can be easy to get really down on yourself when you’re going through treatment of why is this not going faster? Or what am I doing wrong? Is my OCD different? No, just recovery is different for each person, there’s no right or wrong around it. As long as you continue to work for what’s important to you, that’s what’s more important.

Trevor: Right. So tonight we talked about how I’m going to go wait in line in the pouring rain for an hour to go see the new Breaking Bad movie in a movie theater, which I could just stay at home and watch on Netflix. And you’re going to go home and you and your wife are going to separate to your own different consoles and you’re both going to play the Destiny 2 expansion pack or just you.

Nathaniel: We’ll probably alternate.

Trevor: You’ll alternate.

Nathaniel: One console in the living room so we’ll—

Trevor: Do you guys swap controllers?

Nathaniel: At times.

Trevor: You pass the controller?

Nathaniel: Well, we’ll switch back and forth.

Trevor: Let me tell you what happened, my ex, who used to play video games, we used to do that with Red Dead Redemption 1 and I had to go to the bathroom when I handed her the controller and I said, “Here, I’m going to run to the bathroom. Take over for a little bit.” Because that was a game she didn’t get into but she enjoyed watching and she was like, “Okay, fine.” I was gone for three minutes, I came back, my horse was dead, my health was completely wiped out. She said some mountain cat came out of nowhere and killed the horse and attacked, it’s just brutal. So good for you that you can share the controller because after that situation, I’ve never been able to hand off the controller again. Like I hit the save and I’m like, “I’m out.” If I have to shut down just to go to the bathroom for three minutes, that’s fine. So good for you that you are in a relationship where you could pass that controller and trust them with your character and your stats and your weapons and all your goods and stuff like that.

Actually, hold on, I actually want to ask that, could you ... Is there ... And people who game will get this, do you sometimes have an OCD reaction with handing off a controller? Like I’ve built this character, I’ve built these stats. Like trusting somebody else with it.

Nathaniel: No, not really. Partially, because that’s just not how my OCD manifested. And those type of things, I’d say it’s kind of just an easy hand off, just not something that my kind of anxiety or OCD had ever really latched on to.

Trevor: Right. Okay. That was not what I was hoping for but that’s okay. Is there anything you want to add before we wrap up?

Nathaniel: No. I just think in general that I hope ... Over the years, I think so much has been learned about OCD and I’m really appreciative of the Deconstructing Stigma and McLean and of you of having me on the podcast because I think the more that we can kind of share an understanding of what OCD is, and that there’s treatment that works, it’s very, very effective even though it’s incredibly difficult, but that there’s hope out there. And that just because you have OCD doesn’t mean that you can’t be a therapist that specializes in OCD or a researcher or a CEO or whatever you want to be. As long as you really end up putting the work and chase it, go chase it.

Trevor: And speaking of chasing, to bookend things, I’ll be chasing your positivity and your outlook on life, you’re one of my goals. My goals ... Really. I mean this sincerely. I need to approach my mental illness the way you approach yours because it’s so inspiring that as you could tell, it could be infuriating. You carry yourself in a way Nathaniel that is just amazing and—

Nathaniel: Thank you very much.

Trevor: ... I’m telling the audience this isn’t hero worship. I know a lot of things that I’ve been saying lately sounds like hero worship. You got to meet Nathaniel, there’s just a way he carries himself that is proof to something that I didn’t believe was possible and that there’s a way out. I still don’t believe that there’s a way out but I have proof of it sitting in front of me and hopefully, that will eventually change my mind. Because I won’t be able to find a way out until I believe it.

Nathaniel: Thank you very much. I’m glad. And the idea of continuing to chase it. There is always a way out. It can be hard to see at times.

Trevor: Absolutely.

Nathaniel: But there’s definitely a way out. And continuing to chase it, that’s how you get there.

Trevor: Yeah.

Nathaniel: So one step at a time.

Trevor: Thank you so much.

Well, what did you think of that? That one runs along and there’s a good reason for it. We could have gone on all day and I’m going to out her, Lauren said that specifically. We wrapped it up and she said, “This was one of my favorites.” And we could have gone on forever. I loved that one, we could have talked to him for ... And we could have. Nathaniel is very open, very accessible and he has something very rare about him. He’s disarming and soothing. And even though he made the point that appearances aren’t always what they seem and he still has his everyday struggles, he doesn’t have that look about him that says, “Oh, he’s just barely ... He’s smiling, he’s all good but he’s barely keeping it together.” No. He’s ... Like I said, I’ll sometimes see him and he looks like everything’s 100 with him. And I know it’s not, I know it’s not. But for somebody like me who lets my feelings get in the way, I get jealous. But then you talk to him and you can’t help but feel just a sense of ease by his approach and then right away you’re rooting for him.

Anyways, two weeks I think will be close to Thanksgiving so I’ll see you all/you’ll hear from me in two weeks. Okay, two weeks. Thank you for listening to Mindful Things, the official podcast of McLean Hospital. Please subscribe to us and rate us on iTunes or whatever you listen to podcasts. If you have any suggestions for special topics or future guests, email us at mindfulthings@mclean.org. And don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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