#362 ‒ Understanding anxiety: defining, assessing, and treating health anxiety, OCD, and the spectrum of anxiety disorders | Josh Spitalnick, Ph.D., A.B.P.P.

24:30Now what about the individual who goes out to seek medical attention for something, but the pattern is so illogical. So they just keep having unexplained symptoms and they create a story that says this is cancer or this is heart disease or this is whatever. And they follow through with the medical checkup as they should. And And the medical checkup keeps coming back crystal clear. You're fine, you're fine, you're fine, you're fine, you're fine. And the goal post keeps moving. So it's, I think I've got this, I think I've got that, I think I've got this, I think I've got that, everything they get checked up was fine.

25:06Is that health anxiety? That's possibly health anxiety. And first of all, health anxiety is not a disorder. It's a class of disorders. It's a buzzword online. It's something you can google. But the disorders within them, there's breakdown in really two, sometimes three disorders. one's called illness anxiety disorder, which used to be called hypokondriasis, and one's called somatic symptom disorder, which used to be called somatiform disorder, and then there's a third one that's a bit curious, which is conversion disorders, or functional neurological disorders. But what you're saying is, is in this case, someone has some set of symptoms, and whether the symptoms stay or change, they're going to doctor after doctor, they've had all the appropriate medical workups, and every doctor said negative result, negative result, negative result.

25:50I have to be careful how I talk about this. I've done other podcasts where I've said a story like this and I'm about to share and I've triggered some people and I'm not trying to upset people or trigger people, but in your situation, I feel very comfortable probably saying it sounds a lot like a healthy anxiety kind of disorder. You're having physical ailments. You're going to doctors if you're at what's going on. We would most commonly diagnose that as somatic symptom disorder. If your medical charts are clear, if the doctors have consistently said, ma 'am, sir, I'm sorry but there's nothing there.

26:19The problem is, is you and I both have anecdotal stories of someone getting a breast exam, going for their annual, going for a pap smear. They've had all the medical clearance, and all of a sudden a month later they find a pea -sized shape under their armpit. Oh my goodness, they have breast cancer. So I have a personal story. It won't spend too much time on it, where my wife, I was almost a widow about a decade ago, which is not funny to me. She was having some radiating discomfort and pain going up her right abdomen and backside, and she's thin and healthy, and we have no history of medical issues.

26:46We went to a primary care doctor, we trusted dearly, and he's checked her out and said, you might have a tiny umbilical hernia. You're young, you're healthy, you're thin, don't worry about it. And we said, okay, we'll see what happens. And a week later, she's still complaining. We then go to her OB and OB did a full exam and found absolutely nothing. We then went to a surgeon who the OB recommended just to make sure. I don't remember honestly what the surgeon did. I know we had, I think, an ultrasound and a CT, I believe. And surgeon said, I would not do an umbilical surgical right now. You're fine, you're young, let's wait on it.

27:14Nothing's going on. Those are three doctors who basically gave her a clean bill of health with some superficial observation and then some very basic non -invasive procedures. And then a week later she said, Josh, it's not going away and something's not right and it's rating up my back. And they checked for gallstones, they checked for kidney stones and all the sort of standard stuff, blood work, your analysis, all of it. Someone said, why don't you go to a GI specialist and see what's going on. And she went there and she had a mass on her liver that was compromised over 50%. That required immediate surgery.

27:44If that had ruptured blood out, she would have possibly died. The liver is one of the, of the only organ that regenerates itself. So we got very lucky. Had a significant resection liver surgery. She's doing well today. But if we waited on that and took three nose as, okay, I guess she is, takes some ibuprofen, stretch, maybe it's gas, figured out, I don't want to know the answer to that end of that story. So the problem is that sometimes we have to trust our own bodies. And sometimes we can't trust the doctor. In your situation, I think if you're chasing symptoms, you've been to multiple doctors with multiple workups and everyone's saying it's nothing that we can diagnose.

28:19For most of us, we're describing that you have some physical anomalies going on that maybe don't require medical intervention. So now in the health things out of your spectrum, we're now starting to describe symptoms in three categories. Symptoms that are medical, symptoms that are physical, and symptoms that are psychological. So in all the health things out of your spectrums, we break those symptoms into three categories. If they're medical and require medical intervention and you worry about them, no kidding. So you and I would as well. And whether we call that an adjustment reaction peter or something else, if you have a medical condition that requires medical intervention, you worry about it, most of us do.

28:53And I don't require a therapist or medication for that unless that's something that you want. If you're having physical symptoms that are not deemed medical, either because the lab reports are not back yet or because the doctor hasn't talked to you yet or because the lab results are negative. At some point we have to admit maybe there's nothing medical here unless we're like waiting for lab results but the worry associated with that we would typically describe as somatic symptom disorder. You don't know what you have yet. You may have nothing and you're worrying about it and not leaving the house and doctor shopping and going online and checking your labs and wearing a pulse oxometer and all the things you're doing to constantly monitor physical symptoms, body scanning, checking, pretty common ones.

29:34At some point your quality of life is going down. Could something medical come from that? Absolutely, but currently we have no data to support that you have a medical condition and you're still worried about it. We have an issue and then the other categories when it's all psychological long time ago, it was about AIDS that we don't see that that much anymore But so much afraid they're going to get AIDS. They're afraid they're going to have a stroke a brain tumor No symptoms disappointed. They're just worried about getting an illness or disease Back in the day people would call that person a hypochondriacal The disorder was called hypochondriasis and today we call that illness anxiety disorder people can have all three.

30:07They can have medical issues, A, they can have physical issues that are not medical and worry about them, and they can also worry about getting other diseases, which we would call illness anxiety disorder. But the most common presentation that I see in my practice and that people reach out to me for is when someone has a combination of physical things and they're convinced it's something. And usually by the time they're reaching out to me, they've been to multiple doctors. When someone reaches out to an anxiety specialist with physical things, the first thing I would say and you would say is, go get to work up.

30:34So I'm never going to get in the way of medical care, not first, second, and third opinions. I think it's a smart thing to do. But at some point, when is enough enough if every doctor who is of quality and competence has ruled out what everything is going on, any of them, people go to great lengths. I've had patients get spinal taps off the record for cash to determine if they have a leaking CSF because they think they're having a stroke or having early on set Alzheimer's. That's one of the things I guess I would say that makes that playbook challenging is in this day and age, you have more and more, I don't know, for lack of a better word, just quacks out there that are going to come up with every reason under the sun for your symptoms.

31:11So you will find somebody who will come up with an explanation for your symptom. It'll be the mold in your house. It'll be the slight elevation of cadmium in your blood or in a little cat litter. Go down the list, absolutely. Yeah, now we've opened a Pandora's box, which is this individual who's feeling a little fatigued, can't figure out why something's wrong with them. They're fatigued. Maybe it's fill in the blank. I don't know what it is. First doctor they see does traditional work up and says all your hormones look great. Everything that I can see, but you're going to find that person within the first three, depending on which door you open, who's going to come up with an explanation.

31:54And they're typically going to have a solution for you that's pretty off the beaten path. If you go to a car mechanic and say your car is squeaking in the engine, they're going to have a wonderful solution for your engine even if it's not required. If you go to a psychiatrist and say, I think I need meds, guess what they're going to give you? Medication. And if you don't have doctors, they're going to find some problem and recommend some intervention, whether it's homeopathic, whether it's diagnostics, whether it's a prescription, something. They'll give you something because they want you to feel better.

32:22Yeah, I think part of it is the when you're a hammer everything is a nail syndrome and that would be the most charitable Explanation for what I think is going on which is truly there are just a lot of real charlatans out there that are Just not practicing any form of reasonable medicine not even evidence informed evidence -based I get as its limitations and I will fully acknowledge the limitations of evidence -based medicine But there is at least a threshold of evidence informed medicine But when you start saying that the answer to your slightly elevated cesium level, which by the way, no lab has ever documented what the upper limit of that should be anyway.

32:59But let's just assume that my arbitrary level is too high and you're slightly above it. So that's clearly the explanation of everything that's going wrong with you. And I'm going to hand you some supplement that, by the way, I happen to also sell. Happened to sell. I just happened to sell. How lucky are you? Yeah, look, it's your lucky day. It's right here too much. It's in the office. You found the guy that knows how to cure elevated cesium levels. That's the challenge I suppose I have. That's the challenge I have. We're in the same boat. You're asking me as a non -medical person to make sure that someone is getting advocated for, spoken for and referred to by providers, they're going to go to find anyone.

33:35It's above my pay grade to know whether that doctor knows what they're doing, whether recommending medications or off -label things that are, how am I going to argue against that? So, most things I specialize like myself who work in the space of a lot of health and medical and I have a career where we haven't talked about where I've done lots of medical training, medical work in my career. I'm informed, I'm knowledgeable. I also have medical people in my family. I can ask the right things, but I'm trusting the medical people around me. So I'm on faculty at a university in Atlanta. My mom had jumped faculty there.

34:03I got colleagues there. I got medical people around me. I surround myself with people that I think are sharp, psychiatrist, physicians, oncologists, just in case, and still my patients are gonna go to other doctors because they're just looking for the answer. To me, that's sort of within that health things I spectrum. If every doctor you've gone to that I trust has given you the best medicine possible or the best assessment possible, and you're getting no answer and you go to the next person, you don't need the DSM to go, maybe this is more than just a medical issue. I'm still gonna advocate for the medical needs.

34:33I'm still gonna support them and join them. And I'm still gonna help them see that your physical symptoms are real. Physical symptoms are real that doesn't mean they're indicative of or prognosticate a medical condition. half the battle I'm doing is education around that topic. Yeah, I think that's worth stating that again. If a person says, I'm experiencing this pain, that's real. 100%. You're just saying, don't assume necessarily that that means that there is an underlying medical reason for that. Or even something that you would find on the total best -case scenario diagnostic. more often than not, there's not a great medical diagnosis or category that fits into the things that someone like I, I mean, I see.

35:18I mean, I don't specialize that much in FND or that functional neurological space of pseudocesures or tingling arms or body parts that can go numb. That's a whole another space of conversion disorders. But I'm talking about people that have chronic headaches, aches, tummy issues, leg cramps, bones that feel sore. And they've had every workup you could imagine that would be considered for someone who has bones that are sore. And there's about three or four conditions most of us are gonna jump to and you say your bones are sore. And when that's all been ruled out and they're trying to convince you about my thigh, like I can feel the bone, I can feel the marrow, feels like it's tearing itself up and we were talking about pain conditions.

35:57We're talking about neuropathic conditions. At some point, the intervention, which is them doctor shopping becomes worse than the pain itself. At some point, someone will prescribe you something, and hopefully we're not dealing with opiates at that point, but someone will prescribe you something, think that they have the magical cure to fix your distress, your pain, and that scares me. And my job is to sit with them and say, the pain is real, the sensation is real, the symptom is real, but it may not really be indicative of the thing that you think it could be. And by the way, going on WebMD or Google or because a social media influencer said, if you have this, this is probably what it is does not diagnose you.

36:34And so there's really this wonderful space of social media wearable devices, which I'm a big believer of, and the access that we all have to our medical records scares that hell out of me because we are now patients being our own advocates and showing up to doctors saying, this is what I found out online. I think I have this or this is what this person said. And I think I have this. I'm looking at my watch here. My heart rate's been up all week. doesn't that mean something? Yeah, it means your heart rates up. Period. Doesn't that mean anything else except your heart rate is up. Most people would assume that means you're at risk for a heart attack or a stroke or it means if you stare at your watch long enough, you don't have hair on your head like I do.

37:12But if we talk about Lice, guess what's gonna happen a few seconds. We're both gonna be doing this, because that's what happens. And if I mention your left pinky toe, Peter, have you thought about your left pinky toe this entire time we've been together? Because you are now, how's the toe next to it doing? And by the way, now how's the right pinky toe going? Now we get to think about that. So if you think about that long enough, you're going to feel your left pinky toe. It's going to be tactile and sticky and maybe sensory. It was there the whole time. Your brain didn't have to think about it.

37:38How's your breathing right now? We don't think about breathing. And I treat people who get fixated on swallowing breathing. There's got to be something in here. I have thyroid cancer. I have a soft joe cancer because I feel something in there. You probably do feel something in there. And by the way, if you do this all day long and you create some bruising, you're going to feel a whole bunch more stuff in there. You know that better than I do. But to convince someone that there may not be something in there because they've been scoped, and tested, and blood checked. And there's no signs of anything that's anatomical or physical in their throat, but they can feel it.

38:06It's not my job to say it's fake. It's my job to say you're struggling with something. And what are we going to do about that? Is the message there, do you go one step further and say, you're creating this? Or are you saying, no, I don't need to go that far. I just need to get them to understand that there's another explanation for this. There's no need to do that. If I take that stance, I'm now the next person who's the naysayer, on the next one who's invalidating them, and almost no therapist that I know would ever basically weaponize that or blame them for that kind of thing. What I can say is you may not have created it.

38:40You probably didn't create it. Leg pain's not being created. But if you sit there and focus on your left pinky toe, or if you talk about life's long enough, it's going to create head sensations of itch. That's how it works. When you focus on something long enough, you pay attention to it. And if you pay attention to it, you're more aware of it. You're from more aware of it and your brain actually works. It'll feel it. Phantom limb syndrome research has demonstrated that. People putting a dummy arm and a fake arm and a mirror and whacking an arm, we can feel that in our nerve endings because our brain's processing information.

39:10So do we have a dead arm that's not connected to that's actually causing pain? No. Do we have a pain reception or an information process and thing going on? Probably. That's fascinating research. The point is is I don't have to tell them it's your fault or that you're creating it. But I can tell them that the thing you're doing is keeping it active, it's keeping it prominent in your focus. And as long as you focus on that, you're not focusing on anything else. And if you're not focusing anything else, we have a whole other disease. Disease one, there's something wrong with your thigh. Maybe not medical.

39:43Disease two, you're fixated on it. You won't leave the house, your demanding opiates, your complaining to people, your husband doesn't want to hear anymore, your doctors have cut you off. And I've worked with patients, I'm in Atlanta, that have been blacklisted from two of the three major hospital medical systems because I've done so much doctor shopping and so much fighting with their doctors that it's a stress on the system. But they have the wearables and the social media and the online and access to their patient portal that proves that something's wrong. And just as an example, what types of things would they actually be doctor shopping for?

40:14What's a symptom that's a real world example? The ones I usually see the most are memory loss or memory slip ups, which some people actually put into the functional neurological disorder spectrum. A lot of chest pain that has had every EKG and medical workup you can imagine, sensations like ants crawling or physical pain or a pathocaine, for which it has no explanation. Let's just take each of those in as much as you know details. I mean, what would be triggering events? I'll tell you where I want to kind of go with this, which is I want to understand the genetic factors that would predispose a person to this versus the environmental factors that would predispose an individual to this.

40:51I've had a number of folks on this podcast where we've talked at length about the heritability of various psychiatric illnesses. Using Concordin and Discordin Twin Studies, we can get a pretty good sense of how these things work. And we know that with how things are, the heritability is about 30 to 40 % it's on the lower side. So it's low to where we see with... It gets a frenion on the autism. in our very hot. On the 70s to 80s sometimes. Yeah, okay. So we're on the low side, but it's there. There's a genetic loading that's there. Yep. But when you say 30 % heritability, I hear environmental triggered.

41:21Yeah, so do I. Okay. I hear in the diathesis stress model, you have the diathesis there, it's low, but it just takes that right context to make it come alive. And for some populations, for some people we work with, trauma can induce this. Trauma can cause all sorts of physical manifestations of discomfort and distress and pain, whether that's a physical or sexual trauma or an emotional trauma or loss. Plus, there's enough research and large scale studies to demonstrate even with seizures, PNES, psychogenic, non -epileptic seizures. That emotional and physical traumas can demonstrate then bodily reactions that are not explained, which we used to call conversion disorder.

41:53So trauma is a notable thing. Family history of it where parents are complaining and describing similar symptoms. So I see that quite a bit. I see that both with OCD. OCD has a heritability rate of about 50 % and 40 % to 50%. Health things eyes a little bit lower. I mean both populations and what about general anxiety? So general anxiety I go by disorder unfortunately, okay So if I go by disorder I can tell you but in general anxiety I assume it's probably still in that 30 to 40 % range just in general I don't know if any other disorder outside of OCD that has a higher heritability rate of There's nine anxiety disorders.

42:25I usually refer to that one usually has the highest genus of the 40 to 50 That's a 45 % so I assume across the board if we merge them all together We're gonna be in that 30 to 40 % range at best It's very atypical for me to meet a child or teen with OCD and to not have a first degree relative who has it. Doesn't mean the first degree relative assault treatment or agrees with it. But when I was a child, it's like, oh, yeah, my mom does the exact same thing. And do you think that it is a learned behavior in that sense? Well, we have to not deny that there's a genetic component to it, but when you are in a household where someone is doing things in a very hyper -vigilant way constantly or always washing down on the counters or always doing things on repeat, like tapping the door or asking to say something over and over and over again, at some point social learning kicks in.

43:13And they won't necessarily be the same. So in other words, if mom washes her hands 100 times a day, Johnny could easily manifest what clothing folding or ruminating on some other. Yeah, you're describing a lot of the subcontent areas of OCD. I don't know if there's any research study out there that has demonstrated that parents sub classification of OCD mimics child, but at a macro, OCD falls down to the next generation. It's pretty well documented. If I've seen a hundred people last year with OCD, and I haven't seen them any in the last year, I'd be shocked if more than 15 didn't have a first degree relative to that OCD.

43:49It'd be very atypical that they see that they live with. That they live with or have lived with. Yeah. So it would just be very uncommon, which makes it difficult to parse out how much it's very difficult to know nature versus nurture. It's very difficult. Health anxiety for me is almost identical. So I view health anxiety as a subcategory of OCD. I think probably 20 years ago, people viewed the HIV focus much more as an OCD condition. Today we call it illness anxiety disorder, but most of the colleagues I work with, people I've done research with, people that I talk about stuff with, view health anxiety as a subcategory academically, it's its own special category in the DSM.

44:24But I see the exact same things that you're asking about, which is that it is very rare for me to see someone as health anxiety for which a first degree relative doesn't also have health anxiety. And health anxiety, OCD for most populations usually starts around age 7, 8, 9, pre -pubescent. Health anxiety usually starts around the teenage years. A few kids I've seen can have health anxiety epidemiological research would support that health anxiety typically starts in teenage years and young adulthood. I see kids with a metaphobia if you're a throw up, kids that complain of tummy aches because are afraid to go to school.

44:54I think they're most focused on situational symptoms in response to situations. Then what you and I would think about more existential dread about health anxiety. So it'd be a little bit unconventional for a kid to be thinking about morbidity and mortality and things like that because kids are not developed to worry about that in general, though it can be the case. But it'd be very unconventional for me to see someone who has health anxiety where they wouldn't say, yeah, my mom also worried about that. A metophobia is no different. Fear of throw up. Very common in family dynamics. So first thing when I see someone who has a fear of throat or a metaphobia is which one of your family members also has that fear It's like the first question you ask.

45:27Oh that one great now that I know biologic behavioral both So you've referenced HIV and AIDS twice is that really the first big Landmark introduction of widespread health anxiety or is it just the most recent one prior to our curates? Probably the loudest you can go back few wanted to research on us go back in Greece and ancient time people focus on the stuff and it brain mapping and I joke before we started talking, I used the word trefinition, all sorts of crazy psychobrain surgeries to help people alleviate stuff. But the HIV epidemic probably became the most prominent thing in the last 30 to 40 years that got people's awareness of what if I get that terrible disease because we don't know enough about it.

46:04The treatments weren't available at the time. The life expectancy was short and that scared everyone. But you could look at trends in the last 10 years and when I get together with all my colleagues and we nerd out about this stuff, you can see trends during Black Lives Matter movement a few years ago and the hashtag me to movement when you see people coming in fearful of like what if I say a racial slur? What if I get accused of sexually assaulting someone in the past and you see those sociocriven moments where you see spikes of people coming concerned about that COVID lit that on fire literally and they're still lingering effects of that that we can discuss but I don't know if I've seen an HIV concern in the last five to ten years.

46:43I mean just don't hear it but I know a lot of work in HIV and STD prevention. I've worked in HIV clinics. I did an NIH research fellowship on HIV and STD. I'm a weird psychologist, but I've done lots of medically based research and clinical work. So I've been in the HIV space actually for about 20 years. As an OCD anxiety specialist, I'm sure I've colleagues that could speak to this. I haven't heard of someone complain about HIV concerned about getting it in my career, probably in the last 10, 15 years. But you name your regular condition stroke, heart attack, Alzheimer's, Parkinson's, every kind of cancer.

47:12I mean, cancer is the most notorious. It's allowed us, it's the scariest, and it's what everyone talks about. Is that signal getting louder? Yes. Okay, so let's now go over the three things you alluded to earlier. Social media, wearables, and access to medical records. Is there anything else that you think is contributing to that? Let's assume genetic drift is not increasing the genetic predisposition to that, so that the increase that you see in the incidence is environmental or triggered. Anything else driving it besides those three, you think? Those are research based with me citing those things.

47:42I'm going to speak more on a personal anecdotal level. I have a general sense in the last five years since the pandemic. And since we've seen a shift in culture around medical access and insurance and people getting proper care and political things in turmoil, I think most mental health providers and at the research would show this peer that we've seen a significant increase in mental health awareness, a significant increase in people coming to therapy for the first time, a significant increase in people staying in therapy longer and longer. And we've seen a significant spike in general anxiety since 2020, almost a two -fold spike in most research studies.

48:26So all of that combined with a general sense of not being able to afford health care or frustration with your health care providers, I just feel like we're hitting this unfortunate it perfect, terrible storm of people being more vigilant about their medical and mental health needs in good ways, trying to be advocates and trying to seek services. But also I think we are at least in the United States. There's just a general sense of increased anxiety and stress on all of us. And as you know, stress and anxiety turned somatic, turns biologic. But I think those three big areas of social media wearables and access to healthcare are big players, but COVID got all of us to think about this stuff.

49:07And I was joking with some of your team before I came in here, but I even on the flight over here. Someone was coughing in the robot. I mean, I thought crap. When am I going to come home with? 2019? Never would have thought that honestly. 2018? I mean, I have kids. I have a kid going to college in a 14 year old. When they're kids, they had snots and boogers and gross and diarrhea and you pumped up of meds and sent them to preschool. You just didn't care. Today, when you're kids sick, you're thinking, how many days of work am I going to miss? So, I'm wearing the last years and I don't battle health anxiety, I don't get too caught up on that.

49:35I think about it more than I want to because of the work I do. But somewhere in the last few years we've all become more in tune to our upper respiratory stuff and people are wearing masks before they never did in other countries in China and Japan. We saw people wearing masks before the pandemic. We see this all over the United States now. I'm out of the restaurant just a few minutes before I came over here and three people wearing masks. Do they have it? Are they trying to prevent me from getting it? Are they afraid of them getting it? I don't know. But five years ago, I didn't say any restaurant person wearing a mask.

50:01By the way, would there be any pathology there? Explain. Well, if you see a person wearing a mask and let's just say you make the assumption that they're not sick. So they're not doing it in that section. No, no, no, I'm making that assumption. If you see people walking through airports with masks, and again, I'm not trying to ask this question through any lens other than pure inquiry. And I realized these are very loaded questions. But what I'm really trying to understand is if a person's walking through an airport wearing a mask and you knew that they were not sick, So they're doing it for fear of getting sick.

50:30Is there any reason to say that person's not psychologically functioning on all cylinders at the moment? It depends on their situation. Sorry, let me further assume that they are in cancer. No, yeah, look exactly true. Okay, no, no, no, I'm going to throw all that out. So you're not immune compromised. Yes. You're a 40 year old, perfectly healthy person who's not undergoing chemo. You don't live with someone who's undergoing chemo. Man, you get involved in categories. Yeah, yeah, yeah. No, I'm just trying to get a. You're a person who pre -COVID would have never thought of wearing a mask, but you haven't escaped the COVID mindset.

51:02You could argue it's not causing anybody harm. It's their face. They're covering up. I mean, aside from the fact that the barista at Starbucks can't take their order, like no one's actually paying a price. Is there any maladaptive behavior there? Possibly. Sounds like a real therapist here. A real psychologist possibly. I think if that mask is being used as a cover to avoid social interactions, as a way to get out of other events to make sure you're not working in a certain part of the restaurant possibly when you really don't need to do so. If you're just wearing the mask because you're just a little bit extra cautious, don't want to get sick.

51:33Again, if we don't care about it and you stay employed, let's say it's an employee or you're walking through the airport, I don't think there's anything pathological about that. I think that's indifferent to someone you're taking one of those vitamin C packets before they get in a plane. People do that all the time. Costco and other companies sell boxes and boxes at stuff. Do I think this stuff works? Not really, but people are pounding that vitamin C powder stuff to make sure when they go on their flight or they travel, they don't get sick. Is that any different? I don't know if it's any different.

51:57I think we all take our own approaches for homeopathics and I put the mask in that category of people who are taking over the counter kind of things or supplements to boost their immunity or to prevent themselves from catching something that would compromise their immunity. I think good for them and I don't think anything about it. What about driving with a mask on? That the only way for my mind. If you're not an Uber driver or a... Right, right now I'm gonna come here. The other day, someone driving on the freeway. They're the only person in their car. I assume it was their car, but there was nobody else in it.

52:26And they're driving with a mask. If it wasn't a rental car, and if it's a rental car, you might go, gosh, like I could see what if they thought, again, I think that's pathological to me. And I think we can probably say both are, but if you're in a rental car, and you and I both know how the transmission of respiratory issues go, and you're in a rental car that's whether they've been cleaned or not, someone smoked in it, someone coughed in it, But at the time you get in it, we're beyond that potential range of infection from COVID or other respiratory ailments wearing a mask isn't going to do a darn thing medically.

52:52I'm not a medical provider I get to be careful. I say that on this on here But I know enough about the science that that's not how you're going to get some kind of disease That baffles me is that pathological it looks funny. It doesn't make sense to me Maybe it's they're going to be going to the next place and they forgot to take it off Maybe they are immunocompromised. I don't know what their situation is but if to your point if someone doesn't have an illness and they're not trying to spread it. And we don't believe they have any state of immunocompromised status. And they're wearing a mask.

53:18It seems off. And so should the majority of people who are not wearing masks look at that person with empathy as opposed to disdain, which is probably how most people look at that individual? I think anyone who's in situational, like that, would should look at someone with empathy, with compassion and think that that's not my situation. And I hope that whatever they're going through is okay. But again, we start talking about like what you can see and what you can see going back several discussions ago about mental versus behavioral. I've never been in a podcast and so on said, hey, what do you think about people taking emergency or vitamin C or whatever, whatever those powders are?

53:50No one's ever asked me that. Is that different than wearing a mask? Not to me, but we can see the mask. It is a little different and I think that's the point. If you take the vitamin C pack, you're putting it in your water, you're drinking it, for all intents and purposes, you're taking a bunch of electrolytes. The person who takes that next step to put a mask on presumably in an environment where nobody else is wearing it. Oh yeah, I'm sorry. I'll tell you what in the airport know the situation is a restaurant. In a car situation, that feels pathological to me. Sure. No, even in the airport, my point is they're doing it in an environment where nobody else is wearing a mask.

54:23That, Timmy, is a higher threshold. They're more concerned. Absolutely. They're focused on it more than the rest of us. And my one of my arguments with them maybe the rest of us should be focused on it as well. And I just don't feel like I have to do that. How would you talk to that person? So let's assume that I'm making this up. This is completely untrue. Let's say my wife can't stop wearing a mask everywhere we go. This is not true, just for all her friends listening, I'm not eroding out my wife who never wears a mask. But let's just assume my poor wife can't stop wearing the mask. And I'm getting kind of annoyed.

54:53I'm like, honey, this is getting a little ridiculous. Every time we go out for dinner, you're wearing a mask. Frankly, I'm embarrassed. And she's like, Peter, I just don't want to get sick. I don't want the downtime. She comes up with whatever seemingly rational argument she has. And I said, I get it, honey, but when I'm sitting across from you, it didn't or I like to see your face. Sure. She's like, I appreciate that you like my face, but I just can't afford to get sick. I like my health. Yeah. Yeah. And so let's say we present to you for therapy. Tell me how you're going to engage. First of all, I see this all the time.

55:24It's just metaphorically it's not the mask. It's the romantic partner that I see quite a bit in my work because I run national romantic partner support groups, free support groups for people around the world, mean at college and California, and yesterday from my hotel I ran one of those. We see this all the time. It's just not different topics. And feel free to come up with a better example. This is just a dumb one I came up with. No, the example is is I have a romantic partner and his or her partner come in saying, my partner is never going to events or my partner is constantly scrubbing down the counter or my partner makes sure that we have to have our shoes off for a walk in and my partner makes me say I love you 17 different ways before we go to bed because the version I said wasn't good enough.

55:56It's the same point, which is what the person with, I'm used to phrase lived experience, which is a pretty colloquial common phrase for a mental person to say that someone has some things. I guess I'm already making the case that they might have a condition, but I see quite often when the person lived experience is doing excessive behaviors as causing impairment and disruption to the people around them. So we'll use your mask example. You said, Josh, she can't, that word means a lot to me. Can't take it off. She won't. I can't even see her face at dinner. And that first meaning I'm trying to figure out not Peter what's wrong with that when I can't you get over because I know why you can't get over it.

56:31I'm trying to understand from my perspective what is it doing for her life? What is she solving? And I'm trying to hear her story to figure out do I have any end roads in here to figure out how rational this is really getting, how functional it really is. And so in the interventions for how things out of your OCD are starting to talk about cognitive behavioral interventions, I'm using motivational interviewing techniques and and so credit questioning with a lot of compassion and kindness to try and hear her story, hear her concerns, because you're just the husband, you're sick and tired of it.

56:57You've lived with it. I'm coming in with a short fuse at this point. But my job is to help her figure out as there any wiggle room in wearing this. And I probably may not do that in the first meeting, but I'm gonna start assessing other areas of her life that she's not doing that are probably more protective. And every person who does my work knows the research is undeniable, not getting on a plane is the funniest thing in the world. Because if you drive a car, you're not paying it all to statistics because driving in a car within five miles of the radius of your house is the most likely place you're going to get into.

57:24Maybe not a fatal car accident, but a car accident. Airplanes, by all the stuff in the last six months to two years, is still by far statistically the safest form of transportation by the millions in millions of people that fly. But it feels terrifying when we start seeing planes colliding and things happening and changes with the FAA and stuff. But no one looks at that and goes, I'm going to change my situation. I'm just not going to get an airplane, but they drive. So I'm trying to find those moments with your out what is the value for her? Does she see that it's impacting her husband and her friendships?

57:52Does she see that it's limiting opportunities in her life? I'm trying to find what's the cost and is there any way for that cost to outweigh the benefit of what she is not being immunocompromised for? I'm also trying to find out what other curious behaviors she doing that look like the mask as well. Is she washing her hands a little bit extra? Does she keep hand sanitizer on her? Does she refuse to shake hands? Does she make sure she brings her own straw? So how often do you see that? where a person shows up and there's sort of one chief complaint, but then upon further probing, there's a series of concentric circles they're building out from it.

58:27It's the whole point of the success of therapy, because the answer is all the time. It's very, very, very rare. Where I see a single anomalous symptom behavior action being the only thing that is worthy of attention or treatment. You can go as far as to play this out in substance abuse and eating disorders. There might be the primary substance or eating behavior so much engaging in, trust me, there are other character logical and other tendencies that so much engaging in that may not look as dysfunctional or impairing, but they're there, they're under the surface, and a lot of them are probably happening.

58:59So I'm assuming that she's spending time at the restaurant also scanning who's coughing, also seeing when the waiter brought the credit card machine, if that still exists, the fold out of their butt back pocket. How disgusting is that, Peter, that the waitress to stick that in their butt, back pocket or in their pants, and they pull it out and ask us to pay for it. That's foul. Does that make you stop from paying? No. Most of us don't care about that, but that's pretty messed up. Do you really think that a person didn't go to the bathroom and do you think they watched her hands every single time?

59:30Of course not. But if you don't see it, you don't think it. So I'm starting to assess in her this out of sight, out of mind concept. What are the things is your wife paying attention to that she's aware of? What are the things, and this gets a little fun. and should she be paying attention to that she probably doesn't want to, and that she's thinking, great, thanks there, best of her make me worry about the other stuff out there. And my point is to say, maybe the mask is a bit of an overreach, maybe it can be sometimes modified. And so if someone is completely vigilant about doing said behavior, in this case, the mask, and she can't take it off with you, with her bow at a restaurant in the corner, I think we have something to work on there.

1:00:07If she's like, well, okay, I can do at least one on with Peter. Okay, we've broken some ground. We have some wiggle room there, but often someone has no wiggle room and they're not willing to give up whatever that thing is and That's where we start talking about doing various interventions and interventions for this recommendation of addressing cognitive flaws Understanding the behaviors mental and behavioral that he or she is doing that are way more pervasive than just the mask Starting to ask them to make minor Modifications those behaviors which we typically call ritual prevention and then if I get lucky enough We actually get into a place called exposure therapy and we haven't talked all about that but a real anxiety therapist going back to the very first thing I said to you, you're not going to come to my clinic and be seen by an anxiety specialist no matter what their degree credential years of service are and not get some version of exposure therapy.

1:00:55An all exposure therapy is as an intervention that helps someone approximate their fear facing it head on in a safe ethical compassionate way without putting them in any ethical, legal or medical risk. Some people might think it puts them at risk, and some people might think they can't handle it. But exposure therapy, which goes back to the 60s, is the leading intervention for things like PTSD, phobias, social anxiety, OCD, and health anxiety. But to get someone to get there means you have to get them across this process of readiness for change. This model of pre -contemplation to contemplation to ready to take action.

1:01:30If your wife is like, I am never going to take off this mask, she is so pre -contemplation. I've got to figure out then what concessions or changes can she make. Maybe her impeter go to a cafe restaurant outside that's completely aerated, not inside, and she tries to take off the mask even for five minutes. And if she can do that, Peter, we're breaking ground. We're now putting some wiggle room between a dogmatic, anxiolytic, no way wiggle room action. And now as long as it's outside air, and when the waiter comes over, she puts it back on her face, okay, I'm okay with that. But now you get to see your beautiful face.

1:02:02You guys can get outside and then you're gonna start picking cafes outside more than inside restaurants to slowly start building some resistance or strength bravery for her to try it in different locations and if she doesn't and get sick the next day You're gonna fire me and hate me But if she doesn't then maybe we're starting to break ground and find other things that she can modify or change Slowly that meets her pace and that makes you happy. That's all good anxiety therapists is gonna do So is the idea that you use cognitive behavioral therapy to bridge the gap until they're ready for exposure therapy?

1:02:31Sometimes, sometimes if so and so pre -contemplation or so wedded in their rituals, and we see people who are literally scrubbing walls with lysolum bleach, where the walls are down to the studs. That's more for things like contamination based OCD. People are doing behaviors that require almost hospital -level care. Some of them are not ready for exposure -based therapy. In that case, I'd like to recommend so on if they're not on medication, probably going to be seriously considered medication. But exposure therapy is the first line treatment for almost everything to do with OCD and health anxiety.

1:02:59once you get them ready for the exposure. You can say that once you get them ready, but I'm never walking into a client with those of your health things I am not thinking I'm not gonna do exposure therapy. They're gonna be getting it some version or another. I'm an exposure therapist. Okay, so I don't know if this is a realistic enough example. So if it's not, just say Peter, that's not how these people present. So let's say I said, Josh, I travel a lot for work, but I gotta tell you with all this news around air traffic controllers losing sight of airplanes, I don't know if I can fly anymore.

1:03:27This is now actually posed a real risk to my career. My career depends on me being able to get on a plane every week to go and meet my clients or whatever it is I do. This is a rural snail, by the way. There are people that are having increases in aerophobia or fear of flying way more than we had in the last few years. Sure. Because of stuff that's going on. This is real stuff. So, yeah. So the environmental trigger is there has been a rash of airplane crashes coupled with objective data that say air traffic controllers are overworked worked and the system is failing and something bad is going to happen.

1:04:00And unfortunately, my job necessitates that I'm on the road all the time. And I can't take buses. It's too far. I can't take trains. Basically, I'm going to lose my job if I'm not willing to get on a plane every Monday and come back every Thursday. I just don't know how to do it. And I've got two weeks of PTO. I'm going to do a little bit of medical leave, but I'm running out of options. How the hell are you going to get me on a plane? First of all, that person is trying to figure out values. They're trying to figure out what's more important. The belief that I'm going to die in a plane crash versus my job and my livelihood and they're in the trenches and that.

1:04:34So I want to join them there before we do anything. I'm going to do an assessment. We're going to have that first meeting or two. I'm trying to figure out what... Tell me a bit about the assessment. You mentioned this earlier. Yep. Yep. So almost any therapist is going to do an initial intake evaluation which is gathering a lot of information that they have filled out in advance. Going through that and then interviewing them for usually between 60 to 90 minutes to really better understand their story what they're coming to treatment for, what their history of treatment is. In situations like this, have they had other moments of fear of flying, fear of driving, other significant avoidant behaviors.

1:05:04Ultimately, the goal of an intake evaluation of first meeting is trying to figure out diagnostically what's going on. And so once you know what that diagnosis is, treatment commences from there. So by the end of a first meeting, a first intake, they have filled out generic survey forms, some forms that we would describe as evidence -based assessments that have been demonstrated in research to be the best for specificity and sensitivity of forgetting to symptoms of a diagnosis. And in each sub -disorder depression, social anxiety, OST, everyone sort of has their tried and true that are research grade that we all sort of know or standard in the field.

1:05:35And so, I'm going to fill those out, fill out some general packets about their life and medical history. And I'm going to meet with them to try and help understand their story, to try and build rapport, to try and connect with them, because ultimately I want to have them run through that brick wall with me at some point in therapy for this person. It'll eventually be getting back into flying. Is that five sessions or 50 sessions? I don't know right away. And it's based on a lot of factors. But in the first meeting or two, I'm gathering a lot of raw data to put together a story, which we would call a case formulation, that explains their diagnosis or diagnoses and tell them what the treatment options are.

1:06:08And in a case like this, more likely Peter, so does probably come in saying, do you prescribe benzos? And I don't prescribe. And honestly, if they have to get in a flight right away and they don't want to miss up travel and PTO, I'm not a fan of medication in general, though I know it helps people and it definitely saves lives. I'm definitely not a fan of medication that has a high addiction potential, but sadly when it comes to things like panic attacks or not being able to get in an airplane, here she's probably not going to drive 24 hours or 12 hours across the country, then unfortunately what people usually do is they drink heavily or take benzos to get at least through the flight.

1:06:40And what happens on the other side, they're now inebriated. So they got through the flight by whitenuckling it and getting under the influence, but now they they can barely get off the plane, that's not a great solution, but it does end up being what people often do with fear of flying, because that's the only way they can get through that flight, to get through TSA and to get in the plane, is gonna be some sort of pharmacological, whether it's alcohol or pills or a combination. But that's not my goal. What about alternative medications? So what about SSRIs or SNRIs, which again have this sort of bad rap as being anti -depressants, although there probably a much broader category than that.

1:07:11Do medications like that have a role in at least being part of the tip of the spear to create some increase in psychological resilience. In a story like this to be blunt, probably not. If the story is that this person has never really seen a therapist before, has never really struggled with things like anxiety or depression, have never taken a medication, and this is an end of one kind of situation where they're like, yeah, I'm terrified of flying and it's ruining my life. An SSRI is going to take, or an SNRI is going to take several weeks to take action. I'm trying to be careful not to speak out of turn as a PhD.

1:07:44I don't usually speak too much about medication, but I'm speaking the way almost anyone would, who knows about it knows. SSRIs don't treat the tip of the peak of anxiety. So soon as having a panic attack, SSRIs have been on them for six months, doesn't help with the panic attack. It can help long -term reduce chronic anxiety, which itself can reduce panic attacks, but if you're in the throes of a panic episode, which is what often fear a flyer's experience, and SSRI in that moment acutely does not solve that issue. Does it help you as a therapist by increasing the sort of emotional resilience that then makes them more open to therapy?

1:08:20If this is just about fear -flying in this unique situation, probably not again. But if someone has a multitude of symptoms and problem areas, and this has been going on for a while, so this gentleman's missed a few meetings because he doesn't love public speaking, he has to sit around a table and present stuff, and he doesn't go into parties because he just doesn't do well unless he drinks at parties. And he's kind of a little bit more of a recluse recently social in the last few years, maybe because of medical issues or health issues, or he's just in a flunk of life. Oh, there's also this flying issue.

1:08:47I think an SSRI in this situation might be a good thing, Dileist, help calm some of the things that we're talking about. We're talking about basically an increase in serotonin of aloebodean in the brain. An SSRI could be helpful here. But it's really just a medication for us to actually get to the real tools I want to teach him, Because if this is much more of a longstanding issue, an SSRI might help him, but I want to teach him skills where he can basically have his own tools, his own skills, where long term he's both off the SSRI and doesn't need a therapist anymore. But in this flying situation, honestly, if I was involving a medical person, I'd probably recommend nothing more than a benzo, which I'm not here supporting or in love with, but that's more likely to get someone in that immediate moment through TSA on the flight into the other side.

1:09:29You're saying we're going to give you a benzo because you have to get on a plane on Monday, and it's Thursday. And you're going to lose your job. I need a bandaid. And it's going to be a very, very, very tiny dose of Xanax such that it just gets you on the plane and not freaking out, but that's it. Now, let's talk about what you're ongoing CBT exposure therapy is to get him, let's say, six months from now to be feeling like his old self. Yeah, so fear flying is an interesting one because it is so in a unique way a hard one to Ultimately do the real exposures with because you don't have a flight simulator Well, I used to so I worked for six years in a virtual reality company that actually pioneered virtual reality interventions for Fear flying for public speaker super interesting.

1:10:14Yeah, yeah, and the 2000s after graduate school And I was on faculty at a university in Atlanta for a few years I'm still I junk there. I left a research and clinical career working in a hospital to to then work for our startup and work in a private practice who actually had fear flying simulators that had virtual -routing goggles, platform that would vibrate, an olfactory system, you could click buttons and make the smell of diesel fuel and like a stinky ham sandwich next to you and perfume a full sensory experience to have that suffocating, horrible fear flying experience. But again, there's a few clinics around the country, there's not many that still use these kind of things, it's kind of a clunky system.

1:10:48So most of us who treat fear flying don't have access to simulators and those kind of things. I mean, prior to 9 -11, many people would actually to take short flights with their clients and patients because you could afford it and do like a, and I'll anti -acflite us Savannah back in an afternoon and it wasn't very costly. Today, it's almost impossible. Shy of me going to the airport, maybe getting up to TSA, having the person buy a plane ticket that's refundable to go through TSA to sit by the terminal to then leave the airport and then get their money back. That's probably the closest real world exposure, but what we're doing is we're addressing all of the cognitive distortions or the faulty thinking, faulty logic associated with the fears of flying.

1:11:23I have a 30 tip hand that I often give people about understanding what flights are like. That air pockets and the flights are not real things, the people feel things, and that the wings can go in each direction when we see wings sort of wobbling. They can go almost seven feet in each direction. So 14 feet worth of movements when you see the wing doing this, it's not breaking off. And that there's always mechanisms in place when the pilots are flying to keep things safe. That flight's going one direction or just certain altitude and flight's going the other direction or different altitudes. They don't have head on collisions in air.

1:11:51basic facts to teach people stuff that sometimes helps people. How much is their fear based on facts that your sheet is addressing? Sometimes in this fictional situation, am I afraid of a mid -air collision? Am I afraid of the landing because the air traffic controller loses us? Am I afraid of something as vague as turbulence because I don't understand what turbulence is? It's almost none of those. Honestly, the most common aspect of fear flying is having a full on panic attack on the flight inside of a metal tube. That you can't get out of. That you can't get out of. Ironically, though, people have a fear of dying and a fear of crashing and a fear of mirror collisions, what they're really afraid of is having that feeling of losing their mind on the plane and that they're stuck on it.

1:12:38And so, yes, there are some real elements of teaching people the basics. They're correct in that assessment, by the way. Yes, yes. But then the treatment gets focused much more on panic disorder. So when we're treating fear of flying, you're almost inevitably treating panic disorder, which again, by the way, highly responsive to exposure therapy. In fact, the leading intervention for panic disorder, unless you go back to my scenario, you have to give someone a benzo, which I don't prescribe. And there's acute moments just to get through a singular moment. And usually if a psychiatrist would prescribe that, they wouldn't have take their first dose on the flight.

1:13:07You'd usually try that as you pointed out, Xanax, a low dose of Xanax a few days before, just to see how your body responds. That would be a pretty standard medical care practice thing. But when we're treating these kind of conditions like panic disorder, something called interoceptive exposure, or treating someone to their interoceptives or bodily sensations is of all the things out there, the undeniable grand champion of interventions. It is super effective. It is highly compassionate. It is not hard to learn as a therapist and it teaches someone that they are not having to respond to these bodily sensations that they think are going to lead to a full -on panic attack.

1:13:43So it would be very rare for me to be treating a fear of flying, a fear of being in a car, a fear of being in sort of situations, but also not treating some version of a fear of panic reaction. Where you feel like you're going to lose your mind, you're going to hyperventilate, you're going to pass out. That pretty much goes along with whether you diagnose both conditions, panic disorder and fear of flying. The DSM would say you wouldn't, but in this situation, I'm treating both situations. I'm sorry, misunderstood. What is the exposure therapy before that specifically? Let's step back. Exposure therapy, again, is one of usually four techniques.

1:14:15One of them is called in vivo exposure, and that is Latin for in life. Meaning, you're actually doing real things with real objects. If I had a fear of podcasting on public speaking, coming in here would be a great in vivo exposure. There's something called a marginal exposure. A marginal exposure is actually writing a narrative down or a story, which sometimes we do with trauma, sometimes we do with a marginal situations that have never happened. So there's two different kinds of a marginal exposure. But you're essentially coming up with a story that you're going to write down a record and listen to.

1:14:42So this is just the first part of exposure therapy as I'm describing. There's a second part that's even more important to me. The third kind of exposure is interoceptive exposure, and that's commonly used for people who have health anxiety, physical symptoms, or panic disorder. And in this case, we're actually inducing real, low -grade physical symptoms like ibulariness, rapid breathing, sweating, tummy aches, arm soreness. by you and I see her and do a two minute plank, my arms are gonna be wobbly. So I'm inducing things that people experience in the real world that immediately make them freak out.

1:15:16I think they're having a panic attack. I think they're having a stroke. You're saying if somebody is worried about eye blurring as you're gonna put eye drops in their eye? I'm not gonna put eye drops in their eyes. We're probably gonna look at an iPad that has these cool visuals that's gonna make their eyes. There's all these optical illusions I like to use. What about the tummy aches? How do you induce that? You have someone spin in a chair. You have someone sort of do some cardiovascular exercise in your office like sitting up and down, sitting up and down very quickly. You have someone spin on a baseball bat, creating nauseousness and queesiness is not hard to induce.

1:15:43We're not having someone eat something or ingest something because that's going, I think one step further than you need to. But you can create any sort of physical symptom from leg soreness to a headache kind of symptom, to a tummy ache, to tight shoulders, to cotton mouth. People who have a fear of swallowing, fear of like something getting clogged in their throat, you can recreate almost any physical, not medical, physical symptom, safely. If you're already going to treadmill and work out, we're going to create 95 % of the symptoms that people experience with a panic attack. If you go to a really high level of a treadmill or an elliptical, I'm going to create all those symptoms, but I'm not going to bring exercise equipment into my office.

1:16:18So I am helping people bring real world physical symptoms to light in a my safe laboratory in a safe place. I'm going to get to the second part of the point of exposure in a second, just so they can experience a thing that they're terrified to experience, but they already experienced it out there. nothing we do in exposure therapy have they not already experienced. The fourth kind is just called media augmented or virtual rad exposure therapy. And it has people who are using either 3D goggles, virtual radigogles, videos, audio clips to use AV audio visual tools that are kind of mimicking the in vivo and imaginal and interoceptive experience.

1:16:54And that can be something as elaborate as real world simulators, virtual radigogles, or even like watching flight land on YouTube 20 times a road to see what happens when the flight comes down. All those things, we treat people who have audio intact out things like misophonia, which is a high sensitivity sounds, or people who are afraid of hearing something. So anything that brings that tool into the place using audio video, that's part one of exposure therapy, which is you and a patient have come up with an elaborate hierarchy ladder, a list of easy medium and hard scenarios in their mind that they think that they could some point do.

1:17:29Most people think they can never do the hard ones and they almost always do successfully. And you're coming up with this hierarchy based on what you asked about that first meeting, that first session, that second session. I'm collecting a lot of raw data to figure out what are the things in their life that are triggering them that I can recreate to help them face their fears head on and come up with new learning. And so Peter back in the 60s and 70s, we thought that habituation or just getting used to it, was the cremdella crem of exposure therapy. We found out that that wasn't really solving it.

1:18:01And then we started shifting more towards cognitive models, not just habituation and being in a distressed moment, but actually now coming up with new meaning about it, which is called inhibitory learning, that was really started at a seminal article in 1986 by Michael Kozak and Ed Nifoa. Ed Nifoa was one of the pioneers of exposure therapy, both in PTSD and OCD, has done an amazing work out of UPEN, her Marty Franklin, a bunch of people at UPEN were the pioneers of exposure therapy, and 86, they pioneered an article that taught us that how habituation or just getting use to symptoms, it helps, but it's not really getting people moving further.

1:18:36And so when you start having these corrective experiences, when you start unlearning what you thought was going to happen, which anxiety is all about anticipating something and being colossally wrong. Thank God, we need to get people to experience being wrong in a situation that mimics what they actually experience. So exposure therapy has shifted from just a behavioral physiological model to a cognitive model. And that cognitive model is helping people process that information after the exposure. So you just did some weird stuff for 20 to 45 minutes, whether you're huffing and puffing, practicing giving a speech to a screen, putting yucky things in your hands if you have germocity, if you're afraid of bugs and spiders, maybe going to a local pet shop and looking at spiders behind a glass tank or putting spiders that are in like resin, fake spiders that are dead, like on your arms, all sorts of things that start, whatever it is that you can create that sense of fight -flighter freeze, that sense of fear, that sense of dread.

1:19:28So you're amygdala, start to produce in the chemicals that you experience in your own life and in my private safe place. Sometimes we go out in the community, we go to restaurants and shops and do odd weird things. And so we're doing that to have people experience that stuff, but also not engage in rituals and compulsions. So exposure therapy is a combination of doing things that bring on a sense of safe, predictable, but uncomfortable, emotional, physical feelings while also not doing the mental and behavioral things that bring it back down. And if you can stay in that state for 30 to 45 minutes and do that multiple times a week, Peter, you start learning real distress tolerance, real resiliency skills.

1:20:08you start disproving that the thing that I thought I had to do either to avoid it all together or to undo this sense of dread or feeling if I don't undo that and I sit with it Maybe just maybe when it happens in the real world. I don't have to pop a pill. I don't have to run home I don't have to wash my hands. I don't have to wear the mask and so we're combining inducing a sense of a rousal psychophysiological rousal cognitive interpretations that are usually faulty, not doing things to bring it down and stay with that, doing a few different interactive things through 30 to 45 minute experiences.

1:20:43And then afterwards, processing those lessons learned, making meaning out of these weird situations, finding out that you're stronger than you thought you were, finding out that no one died, finding out that in that moment, you didn't do that horrible thing you were wondering if you were going to do. Again, we're treating things like people afraid of being pedophiles, people are afraid of getting horrible diseases. People afraid of killing themselves or killing other people. People afraid of contaminating things and ruining someone down the road. Some things are imminent and some things that you won't know for fears from now.

1:21:11And so we're really tapping into this intolerance of uncertainty. This belief that I can't deal with the fact that something terrible is going to happen. So I've created this fabricated world around me wearing the mask to make sure it doesn't happen. You gave an interesting example there. You said people have a fear of being a pedophile. Yes. Okay. This is very controversial. Yeah. I was about to say, is this a person? So let's just pause it. That this is a person who's never acted out any such absolutely. Okay. But do they fantasize about pitofilia? Not fantasized, but they have thoughts and feelings about it.

1:21:43Just like you and I have thoughts and feelings about driving off the bridge. Thoughts and feelings of robbing a bank. Every time you see an armored truck, I'm thinking, that'd be fun to take those four million dollars. But what do I do? Move on with my day. So So everyone has intrusive thoughts. 99 .9 % of us have thoughts about sex, drugs, rock and roll, horrible things, and for most of us, wait those things are bad. Sorry, nevermind. It turns on the band. 93 to 94 % of the population, so there's about 4 to 6 % population in battles, OCD, they just tephalon right off of us. I thought about like punching so many to restaurant.

1:22:14I have the thought, stabbing them in the eye, and moving on. Road rage, I've thought of telling that person and doing something back then, and I just move on. But for the person who has OCD, that thought doesn't go away so easily. And then they start thinking about it. And then they start wondering about it. And again, if I start making you think about your left pinky toe, you're going to feel your left pinky toe. If you have these unwanted intrusive thoughts about a kid or her body parts or doing horrible things, guess what's going to get lit up if we did a brain scan on you? The parts of the brain that regulate sex and arousal and gets what happens when that part of the brain gets lit up.

1:22:48Things down there start getting lit up because your brain's working. So, I'll be very clear because I have a few people out in social media, colleagues and dear friends of mine, who have been attacked on social media. These are not influencers though, they might be influencers. These are evidence -based, science -backed, amazing clinicians who use their advocacy and knowledge for good to help people to destigmatize some really wonderful people out there. And they've been attacked by some creepy people out there saying, you're endorsing pedophilia, absolutely not. When we talk about OCD and these kind of conditions, we talk about people who have ego -sintonic versus ego -distonic experiences.

1:23:23Ego -syntonic is, I want to be here on this podcast. I want to be a little bit nervous coming in here because it matters to me. It matters whether you like me. It matters if I sound good. That means this is aligned with my values. I want to put information out there. I want to be a voice of reason and I want to educate your community about all these sort of anxiety conditions. That's aligned with my values. That means it's ego -syntonic both to be nervous but also to want to do well here. I'm okay with that. Ego -distonic means you're having thoughts and feelings that are not aligned with your values.

1:23:51And so in OCD, it's epidemic that the things you're afraid of do not align with your values. Whether it's about hurting someone accidentally because you didn't wash your hands from chicken or stabbing someone or killing someone or molesting someone or getting punished by God, there's all sorts of topics that people get really fixated on accidentally and they get terrified by that and they spend time thinking about it because they're trying to get rid of it or doing something about it, like not going to the park. Does that mean that an ego -distonic person rarely, if ever, will act on the impulse because it is creating so much internal tension?

1:24:26Not only will they not act on the impulse, they don't even want to talk about it, they don't want to think about it. I don't want to be gross or offensive here, but I don't care about saying the word pedophilia doesn't face me at all because I don't think about it. It doesn't bother me. To someone who has what's acronymed as P -O -C -D, pedophilia O -C -D, they don't even want to hear the word. They don't even want to see it on a checklist. How does that differ from a pedophile? A pedophile is completely at peace with the fact that they think about it. Whether they're a piece or not, whether they ever eventually actually hurt a child, they think about it.

1:24:56They're turned on by it. They want to pursue it. We're going to start talking about the difference between ideation, which is just a clinical word for thought, versus want, intent, and action. And so someone who is a pedophile or someone who wants to hurt someone else or who wants to rob a bank thinks about it, plots it. Whether they're lucky enough to do it or not, robbing a bank, maybe they do, maybe they don't, but they have full intent on it. And maybe they don't have the guts to rob a bank, but they want to. So that's someone who's aligned with that value. People who have OCD are not aligned with anything associated with hurting other people, wanting to bother other people.

1:25:28In fact, it's a common knowledge and sort of my work. Those are usually the gentlest and kindest of souls. They're tortured by the notion of having the most impure thoughts, thoughts of harm. your goal is to help those people understand they're not bad people and you want to reinforce. You are not going to be acting out on this impulse. Actually, I won't do that. You won't do that. No, because that's their putic reassurance giving. Probably from the very beginning, back to the first meeting, I'll probably say, I know who you are. I know what's going on here. Welcome home. We have groups. We have podcasts.

1:26:00We have meetings. You're in a safe place. And I know this is not alone with your values. And I'll probably say of them, this might be the last time in our relationship, if I see you for 15 to 20 sessions. This might be the last time I ever say to you, I know you're not a pedophile or I know you don't want to hurt a kid and they look at me like, wait, what? Because in therapy and in life, reassurance seeking is one of the most insidious, classic symptoms in OCD. We see it in health anxiety as well. But reassurance seeking is asking for clarity and for permission and for confession and wanting to get that back.

1:26:29And if the therapist does that, this is for me one of the best litmus tests When I say, go find that anxiety specialist. When I find an anxiety specialist, rabbit ears, anxiety specialist, does reassurance, he says, you're going to be fine. I'm sure you don't have cancer. I've never said this one. I'm sure you don't have cancer. I don't know if you have cancer. I have no idea. I'm sure you're not going to have a stroke. You're never going to get Alzheimer's. I'm sure you're not a pedophile. When I hear that from a therapist, they weren't trained by me or someone like me, and you're barking up the wrong tree because now you are weaponizing that certainty principle, which is all the anxiety stuff for her once.

1:27:04I can't promise you're not gonna die in a plane crash, Peter. And I can't promise if your wife takes off her mask, she's not gonna get sick at the restaurant. What I can promise is, is if she takes it off, her husband gets to enjoy her more. I can promise if she takes it off, she may be able to do other things that feel risky and scary, but actually add to her life. That if she takes it off, maybe she'll have more opportunities, but I can guarantee if she keeps it on, she's losing her husband, her friendships. She's like, I don't care, I just don't wanna get sick. Okay, well now you're choosing your own values here.

1:27:29And is that exactly where you need to get people? Absolutely. That is the risk calculation. There is no risk -free asset here. The only thing I can promise someone in this world is that they're not going to live at some point, which sounds morbid and terrible. I'm actually wearing a bracelet that one of my patients gave me that says, you're not dead yet. The only thing I know in this world is that at some point we're both not gonna be here. Between now and that data point, what do you want to do to have the biggest and best life? But if I sit here and promise them that they're going to be okay, and that's going to be, I can guarantee you, it's 14 sessions.

1:28:04I guarantee you that ProZec's going to work for you. I'm selling them a false sense of hope. I hope it works. I'm assuming you're not going to molest someone, but that's not my job here. My job is to help you understand what are your values, which I already know what their values are. What are you doing aligned with them? Trying to not think about stuff and trying to be the best person possible. I already knew that. What things are you missing out on because you're so scared that your values could get compromised. I can't go to birthday parties, or I can't see my aunt and uncle because of the niece and nephew or, okay, so how do we start approaching the situations?

1:28:34If you believe that you don't want to hurt anyone and you want to approach them, what things are going on the inside and your body and your mind that are preventing you from going there, how do we start that process? Before we're doing exposure therapy, we're trying to figure out how do we start chipping away some of those rituals, some of those avoidant tendencies that you're doing? So walk me through that example. Again, this is such a fascinating one that never even crossed my mind as a condition, but it also strikes me as if you can fix something like that, you can almost fix anything. So you said something a second ago about within 14 or whatever, 15 sessions, I'm never going to once, but this first time reassure them.

1:29:07Okay. The implication of that to me is, you think this person's going to be fine in six months, potentially? Most likely, pre -pandemic, I was seeing people pretty consistently 10 to 15 sessions. And most research studies for most of the conditions that I treat and that we've discussed today, deviation from the manual a little bit. We like to talk about how to customize an intervention for the person but it's very evidence -based. 10 to 15 sessions, 13 to 16 sessions is pretty standard. Post -pandemic, people want to talk about everything and it's my job to figure out how do we get to the core of what we're working on.

1:29:36I'm seeing people for way more than 15 sessions traditionally now. Don't love that. Whenever I was going to be doing that. But most of my colleagues around the country would agree that we have now elongated the length of therapy not because we want to. Because people have more stuff they want on one pack, more things they want to discuss. us. When that person leaves your care, whether it's 15 or 20 sessions later, do they have just as many thoughts about children as they did when they came in? So in general, I find that people have many less of those accidental, internal, unwanted symptoms in general.

1:30:08I'm going to say something that might be upsetting to the people listening or the people that I've supported. I don't care. I don't care how many thoughts they do we don't have because you and I are not defined by our thoughts. We're not defined by our physiology. We're not defined by our hunger cravings or what we think until you say them or act on them. We are judged by our outward objective or when we avoid actions and inactions. And that's why when people were not taking anti -racist actions, I understand what people were judged for that because that's still inaction. If you chose not to vote, you voted for whoever won.

1:30:43So all of those principles apply to me and I tell this to my clients. I don't care what you think and feel. I care what you do next. And when you're coming to me, because what you're doing next is shrinking your life. And I know who you are and I know what you want, but you're not pursuing that because you're so afraid that that bad thing might happen. And so in any situation, fear of flying, fear of contamination, fear that you might hurt someone, fear that you might have a disease. I know you don't want to die. But all the things you're doing to prevent cancer are costing you financially. You can't see doctors.

1:31:18Your family doesn't want to talk to you. You think you're trying to prevent dying. You're dying right now. I call health anxiety to the cancer of psychiatry, which is what it is to me. It's eating you from the inside. It's its own pathology. It's killing you and spreading everything around you. And you think you're trying to prevent this horrible disease down the road. You spent your career trying to help people elongate now and down the road. I'm trying to help people not eat away what's happening right in front of them. And so their value system is mission critical. So now in our discussion, we're shifting from cognitive behavioral therapy, which was really, I think, the biggest change in the field of psychiatry to help people find evidence -based, randomized controlled trial interventions at a research grade that really help people to the next wave, which is still under cognitive behavioral therapy.

1:32:01And we talk about exposure. Now we're talking about ACT, acceptance and commitment therapy, which CBT, historically did not talk about these kind of things like values. What do you really want in this world? Who are you on the inside? And so, act as an extension of doing CBT, and I guess CBT is the umbrella exposure therapies underneath that, and I put act underneath CBT, act pioneered by Stephen Hayes and other wonderful researchers and therapists really developed this six construct called the Hexophlex. This six construct paradigm that identifies your ability to accept things that are happening inside of you, thoughts and feelings, without it defining who you are.

1:32:44Your ability to be present in moments, even if you're having like toothache, if you had like a medical pain right now going on, the your ability to be present in the moment, to be able to use yourself as a self -concept, that I'm not defined by my thoughts and feelings. I just have thoughts and feelings, and so we teach people when they have the thought, Like, God, what if I kill someone? Or like, what if I'm gay? There's something called sexual orientation OCD, which we haven't talked about. Or like, what if I get cancer? You can shift that to, I'm having the thought. What if I have cancer? I'm having the thought.

1:33:14What if I kill someone? You've now created some space between you and your thoughts. That's a powerful skill. And there's a bunch of techniques out there called cognitive diffusion that help people separate themselves from their content of their thought. And now we're looking at a thought as a process rather than an object, Peter, very powerful stuff. Within that act, Hexaflex is values. And values are mission critical, because for the work that I do with anxiety, for the work that you do in your work, you and I actually kind of have the same goal. We have the goal of people today, living their healthiest and richest lives, and elongating that as much as possible, so when we get to the end, the end doesn't happen as rapidly and as destructively as it sometimes does.

1:33:57We're doing the same thing here, But when psychiatry and anxiety come together, values fall apart. People's values become focused on intolerance of uncertainty. I use the word yucky a lot with three -year -olds and 50 -year -olds, making yucky go away. Not feeling. Not thinking. Your value shift to a negative reinforcement process of doing things or not doing things to remove some bad outcome. In your position, in mind as well, as doing things that increase good outcomes. And so I'm trying to shift people and I have this sheet I use in my office all the time from the right side of the paper Doing or not doing to remove some bad thing that's going to happen which is called negative reinforcement to doing or not doing whatever You want that has the not a guarantee but the possibility of Increasing your lifespan increasing your marriage increasing your sex life increasing your health increasing your cardio vascular Functioning increasing your ability to go to the doctor and hear the results and if you have questions ask them appropriately And if you don't believe them, go to one more doctor.

1:34:58And after that, move on with your life if you can. Because at some point, all of the fact finding that you're doing, it's like the worst puzzle ever. I gave you a thousand piece black puzzle with no corners. And I took one piece away and I snuck it in my pocket. And I just haven't told you that yet. And you're trying to solve this puzzle and you're never going to solve it. And your value is solving the puzzle at all costs. I'm not leaving the house. I'm not going anywhere. I'm going to quit my job. I'm not even going to eat until I solve this puzzle. That's not solvable. So your value shifted from doing a puzzle to only solving the puzzle.

1:35:33And the problem is in my work, most of my patients can't solve the puzzle. They have to drop the rope and pick a different game. And that's the game of life. Values, people, love, health. Therapy is about getting people to see that shift, that cognitive shift, that paradigm shift from removing discomfort, removing ambiguity, removing uncertainty, to doing things that make your life bigger and better. There's no guarantee for that, but that's a much more exciting life to support someone in than just making symptoms go away. So I don't care if they stop having thoughts. That's ideal. We often see that with medication and talk therapy.

1:36:06I don't care if they feel less or more. I care that when those insidious and uncomfortable symptoms show up, they choose a healthy action that gives them life. They do that. I'm done seeing them. And I don't care what the topic is. I don't care what the disorder is. If they have the skill of stepping back from their internal symptomatology and choosing a healthy action that increases their world, they're their own therapist. We have talked about this directly and indirectly a couple of times, which is it's been referenced through being present, directly through mindfulness. We've talked repeatedly about the space between stimulus and response.

1:36:42Is mindfulness meditation as a formal practice a part of this therapy with anxiety? Absolutely. I don't typically teach breath work or meditation per se, but anyone who has the capacity to cognitively or physiologically be present with themselves and with the world around them and stay in control, it's a winning intervention. So meditation has a place in this, mindfulness has a place in this, relaxation training has a place in this. If taking a cold plunge or going into a sauna is going to get you to a place of recognition of what your needs and values are in this world that has a place for it, I find exercise even though I'm a therapist who does cognitive hero therapy, I'm a pickleball fanatic.

1:37:21I can't get enough of it. I find exercise to be the best form of meditation and mindfulness. You can't play or do the sports, not talking much like weightlifting or walking on a treadmill. High level sports, which I'm an amateur. I'm just playing pickleball with people at a local community center, but I like to play pretty intensely. You can't do that and not be both mindful of what's happening around you. And in this state of almost euphoria, which I view meditation to be, And that's why paddle sports are always viewed as some of the best sports for longevity of life for cognitive functioning for hand eye coordination for staying present and obviously for cardiovascular functioning if you don't break a hip or break a leg Which some people do I think any of those interventions or activities that increase your sense of awareness Your sense of how your body operates and that encourage you to do things that are healthy and increase Healthy actions all those have a place as does extra curricular activities prayer knitting clay, drawing, painting, all of those.

1:38:17None of those suck away your life. None of those keep you away from loved ones unless they become an obsession or an addiction in a bad way. What are some signs or things that you see in therapy that give you concern that a person is not going to recover? And maybe we start with that question, which is, what is the success rate, success defined as a person who after some finite number of sessions gets to the point where actions and behaviors are remediated, independent of thoughts. I want to make a statement on that question and I promise you I'll answer it because there's a lot of controversy in the field of psychotherapy research.

1:38:55And even in my world of O -seeing anxiety researchers about what research is and what real outcomes are, the medical field does not debate this. I wish the psychotherapy field of research didn't debate this either. It's not just about when you're doing better after therapy, which I don't think is that hard to achieve. It's doing better after months of no therapy. I know my patients are doing better when I don't hear back from them when they truly become their own therapist. The best research to me is psychotherapy and the best RCTs, randomized control trials, show when there's six months, 12 months, eight months of follow -up that is demonstrating continued symptom remittance or subdiagnostic.

1:39:33So my answer to your question is when someone, this is funny because we're talking about health anxiety when someone is therapist shopping usually called doctor shopping would be therapist shopping when they've been a five to seven therapist in a short amount of time that scares me. Because what the tells me is they're looking for a certain answer or certain kind of therapist and no therapist is matching their needs and that's something fun and romantic partner when someone has been through multiple partners in a short amount of time. They're the consistency in that that concerns me. When someone is a yeah but in therapy, that really scares me.

1:40:03Because again, that means that they know all the answers. They're struggling with what we call cognitive flexibility. And in acceptance and commitment therapy and in CBT, cognitive flexibility is mission critical. Unfortunately, I'm going to be teaching you this goes back to the FOA and COZAC 1986 article about corrective information that may be your wrong. And when someone is characterologically unwung to be wrong, you're not going to do well in therapy. It's just a fact. And you figure that out how soon. Within the first two or three sessions, I think most therapists have a general sense. I would say in the first two or three dates, someone knows whether there's an attraction here.

1:40:36I think in the first three sessions, most therapists know whether or not there's some wiggle room in here. To be fair, I'm going to 25 team practice. We have therapists in three states, Georgia, mostly. We see people in 40 states. We're out in a mega practice. In the state of where my career is at, I'm very privileged to say this, I'm very appreciative that can say is, I see the sickest of sickest. That's what turns me on intellectually. That's what gets me going. I could treat a dog phobia, we treat that. I could treat someone who's having weird eating issues. I can treat panic attacks. I did that years ago.

1:41:08So I'm seeing people who are very ill, who have been to hospitals, who have failed medication trials, who have tried TMS and ketamine. I'm seeing very ill people, And I'm not perfect that I'm not getting 100 % results here, but I'm seeing people who think that they have no chance to get better But they want to and they're desperate for information and they're desperate for someone who can see them and they're seeing what's going on And so my success rates probably not better than the other people I saw that were easier to treat But I'm seeing people who shouldn't be getting better and they still get better But it's because they want it They're willing and they're trying everything they can even if they're stubborn Even if they're hopeless even if they're not doing well So for me, I don't know if I use word character logical, but there are these sort of intrinsic cognitive states that people are in where they just can't see anything but what's in front of them.

1:41:53And if I can't push them beyond that, I'm gonna be the next therapist that they fire and I'm aware of that. When people are open and want to new ideas to weird interventions, if someone's never had exposure therapy, I see plenty of people who have been a multiple therapist, who've never even had exposure therapy. And to me, that's like you treating someone for how know what medical condition and not giving them cholesterol medication. And I think that's the no brainer. I see people who have a condition that the only intervention they should get is some version at least of cognitive behavioral therapy And they haven't had that they're seeing a support of therapist an analyst or they're doing soft therapy I'm like I close my mind So when I see someone who is not willing to hear my ideas when I see someone who when I share with them videos or clips They're not willing to watch them.

1:42:35I'm watching that resistance plant and I'm like how do I connect with them? Another major factor and this has been proven in psychotherapy research across psychotherapies is the in -between session experience. What? What sessions are weekly, typically or typically weekly? I see most people weekly. When I'm seeing someone that needs a high level of care sometimes I'm seeing two or three times a week. We have an intensive outpatient program where I don't manage a run -see patients that have a staff that does that, but typically weekly. And there are in -session interventions, things I'm doing with the person, funny moments we have, light bulb moments and techniques we practice.

1:43:08And then I don't like to use the word homework, but then there's homework. The research is undeniable in a homework driven, structured kind of therapy like cognitive hero therapy, dialectical behavioral therapy, acceptance and commitment therapy, mindfulness based CBT, all the interventions that utilize skills between sessions. This is no difference in working out with the trainer. If you go with the trainer and then don't work out for the rest of the week, guess what happens in week two? You've gained nothing. If you practice through golf instructor in week one, you did no practicing in the course between the next appointment, your stroke's not going to be any better.

1:43:41Encyclotherapy research is no different. If you're not doing the assignments between sessions, you're not learning and messing up. I love when people mess up their assignments. I don't care if they do them right. I just care if they try them. Because if they mess up, guess what I get to do? Correct information. So this is all about learning and messing up, learning and messing up, and learning from that, and building from that. So that's another critical ingredient. When I see someone, when they are asking like, what do you guys do between sessions? nothing. Would they ask you, would they assign you?

1:44:08I really didn't do it or I didn't like what they gave me. I'm like, oh, okay, am I going to give them the right assignment or are they just going to block me as well? So I thought that under again more cognitive inflexibility or they think they know the right way but interventions between sessions is where we gain mastery of skills and then they come back and I refine them and we practice them and then they practice them and then I come back and that in between stuff is actually pretty important. When someone doesn't do work between sessions, if there's work to be done, I'm having groundhog day.

1:44:34I'm having the session of like, well, let's talk about what we talked about last time and what got in the way and did I not assign a right? Did you not understand it? And we're having a little bit of playback, which can be defeating in therapy when you're thinking you know what's best for them. And sometimes we're wrong. And then you can try something else, but if they're not trying it, I can't learn from their mistakes. Does anxiety, whether it be health anxiety or any of the subsets that we've talked about today, does it tend to traffic with other comorbidities, either health comorbidities directly or more more importantly psychiatric comorbidities.

1:45:05I said earlier, one of the most common symptoms in anxiety, which are the most common is avoidance. So it's not shocking that we see low grade, we're not substance abuse specialty clinic, but we see people dabbling in alcohol and marijuana use in opiates and stimulants to feel better. So you'll see pretty common co -occurrence of substance related usage, maybe not full on abuse and the causality there, Josh, you think is, I am using the substance to Medicaid the anxiety, or is it the other way around? Both. It's probably bidirectional, but there's definitely an element of I'm self -medicating because I don't want to deal with my stuff.

1:45:42That's not shocking to most of us. And so, especially if we're doing exposure therapy, having someone who is muting their anxiety response, who's muting their sympathetic, parasympathetic activation, if I can't tap into that to have their amygdala and limbic region light up if I was doing brain imaging, to then have them feel that, to then teach some corrections. if I can't tap into that because they're numbed out, I can't make those changes. So that's one subarea. I want to dig into that a bit more. How do you manage that then? So when you get under the hood of somebody who's coming to see you and you realize, actually, they're kind of high every day.

1:46:14Not with you, let's just assume that they come in and they're not. But they're basically using marijuana every single day. They're using alcohol or whatever it is. How do you manage that? Do you say, listen, I can't really help you until we get you off this, because I need to experience you in your native state. How do you guys sometimes? Sometimes it's a black and white if you're at this level of usage Even if it's not impairing their lives completely. I may not be the right therapist for you But I come from a harm reduction model I've worked in abstinence only models and I'm a believer that if we can reduce this and get into a moderate state Whatever it is you're using as a starting point.

1:46:46This is the concept of working out the hierarchy of exposure therapy I can't ask them just to quit. That's not even a concept to me So we're taking baby steps if someone's willing to make a concession or two What if they say, but, Dr. Listen, I have to use this is actually helping me. No one's probably going to actually say that on alcohol because I think they down. They'll say it on benzos. Yes, they'll say it on benzos and they'll say it on marijuana. They're saying you don't understand. This is an angiolitic. This is actually reducing my anxiety. We shouldn't be cutting this back. I've seen patients who use weed chronically but are functioning the most areas of their life in general.

1:47:17Occupationally, their partner smokes with them or their partner doesn't care. But they're coming with anxiety issues. It can create a real dilemma. I need pockets of time where they're not just always feeling not gonna say good. NUM. I want them to feel distressed in small doses. I want them to have these hiccups where they can feel and have differentiation. Ultimately, the short answer is, if someone is wedded to using a substance and it's just gonna get in the way of my work, I will probably refer them to someone who's more likely to work with them. I don't know who that person is sometimes because most therapists don't want to work with someone who is chronically using a substance that's causing impairment and they're not willing and they give it up.

1:47:51And if they're not willing to go for treatment for that, then we have a different issue. I think more often what I'm finding is I'm like, okay, so the first three sessions I'm gonna discuss this, I'm gonna bring it up. I'm gonna ask if there's any way for us to change it and to see again, if there's any wiggle room, there's any flexibility in there to make changes in anywhere of your life. Can we just give it up on Tuesdays? Can you just make sure you don't smell like weed when you walk into my office and Georgia, it's not legal, but people still smoke it like I wrote out. But if you're smoking and driving, that's DUI, that's DWI, that concerns me.

1:48:17So in general, I'm in a harm reduction model. I'm like, how can we do things that bring less harm to your life and open up your life more? If someone is wedded to anything in their life that I find to be destructive and I think it's going to get away with our therapy, I'm not the right therapist for them. Having said that, there's again, an interesting sub -area of research in the exposure literature for which exposure therapists who get really literal and very dogmatic won't do exposures for people who are under the influence. They won't do exposures on the day where someone's taken a benzo. And so in a lot of exposure research.

1:48:49Again, if you think about PTSD populations, Peter or polypharmacy is honestly usually the baseline where people are taking sometimes SSRI, one or two benzoes, one long acting, one short acting, maybe a stimulant, maybe even a low dose anti -psychotic, you're doing a research study if someone is taking a benzo on the day of exposure, you can't tap into the things we're trying to tap into into that bulb of the amygdala, that bulb of emotional centeredness to have that lit up so we can and have some corrective experiences. So you'll see in research studies whether people noted people were not allowed to take benzos on the day of exposures.

1:49:21And so that becomes a challenge. When I'm doing anxiety work and someone's doing something, I don't view it as a legal ethical issue, but it's muting my ability to tap into real presence, talk about presence. I mean, that'd be the right therapist. That's really the message, right? It's not a judgment. It's simply an efficacy question. It's just that I can't actually help you. Effective you. You want from me and what I'm able to offer you is attenuated by the fact that we're not going to remember this conversation in the same way. That's not good for us. The question about comorbidity, ADHD, or I'll say attention issues is pervasive.

1:49:54And we see lots of kids in our clinic, but I can't even tell you the chicken and egg of do you have ADHD or anxiety or both or neither, half the time. And even the best diagnosticians can't tell you because if you have pervasive intrusive thoughts, Peter, how the heck are you not constantly interrupted in your prefrontal cortex? How, if you're thinking about raping and killing or health or disease or dying or morbid topics, how can you possibly be attending to all the things in the room? And so, people who have anxiety have these attentional biases and disruptions. OCD and health anxiety related conditions, we don't know all the mechanisms, but there's a breakdown between executive function operation and the emotional or limbic region.

1:50:32Like, there's a breakdown there. There's a disruption there. And so, attention is pervasive in the OCD community. we're seeing higher rates of co -occurrence of autism, endocity is pretty common. And then when you get into the molecularity of obesity, we see a lot of people that have these interesting areas like ticks, body -focused repetitive behaviors, something called tricketylamania, which is hair pulling of different parts of your body or dermatillomania, which is skin -picking. And so we see co -carnages of ticks, tricketylamania and dermatillomania are called body -focused repetitive behaviors, so they're called BFRBs.

1:51:02So ticks, BFRBs, medical issues, a lot of co -carns of chronic like medical, it's like IBS, Russell's leg syndrome with people that have chronic anxiety, ADHD, autism. I mean, it's really a little bit of everything. So in an anxiety center, like I said, we all, the center, fugive at all, all treat the primary nine anxiety disorders. And then all of us dabble in some new autism, some new ADHD, some are doing more mood disorders, some are doing a lot of regular relationship and emotional dysregulation stuff. You have to know the science and molecularity of anxiety to understand that. and if you're not the right person to treat that, we'll make a referral out or referral within our team.

1:51:38What do you think is the biggest myth about health anxiety? There's someone's making it up. That someone's looking for attention, that they're secondary gain. It is disheartening and sad to see a medical professional or loved one tell the person that they're just drug seeking or seeking attention. I know that's the case on an occasion, but nobody wants to have, I'll say OCD as well, nobody wants to have OCD or health anxiety. It is not functional. It is not fun. It is not enjoyable. It is not adaptive. And once someone says, oh, my OCD helps me like be better at work. That's not OCD. You're talking about something else there.

1:52:11Whether we're talking about perfectionism or OCP, the obsessive -compulsive personality disorder or something else, there is not an ounce of functionality with OCD in anyone who I've worked with, anyone who I care for. All my social media friends are out there that are an Instagram and TikTok who are amazing humans, destigmatizing these conditions. no one believes that OCD has any adaptive healthy aspects to it. Health anxiety for me is terrible because you and I are in different professions, but we're trying to help people live their best quality of lives, live their fullest lives. And it breaks my heart when I see someone who has health anxiety who is convinced.

1:52:44And I'm not talking like they're wondering. They're convinced that there's something wrong. Despite my loving, compassionate guidance, five to seven doctors who have told them, they're crazy, which is what they end up hearing, or go to the ER, or go see a shrink. that's the message they get. They are 100 % centonic convinced that there's something wrong with them. And it's absolutely heartbreaking to see that. And until you can get them to shift that needle and be a little more flexible, they're stuck. And they're losing their quality of life. And the thing they're trying to preserve is the exact same thing they're killing.

1:53:14So I think that sense of I'm making it up. I'm fabricating it. I'm looking for attention. Or I'm just looking for drugs. It's just not the case. And I know again, anecdotally, I'm sure it's out there. We all know that. But these people don't want to be this way. They don't want to be seeing doctors. They don't want needle So they don't want all the exams they go through but they won't do it I've written about this and I put out a book a year and a half ago at that's in our book I have a health anxiety online platform that people come to for support groups and information and cool challenges and weird stuff That's all out there and we get this unfortunate story of the time.

1:53:46I'd rather just have cancer. I'd rather have my army imitated I think I have an osteosarcoma here. I'd rather just have that nerve clipped I'd rather be paralyzed so I don't feel my leg pain anymore. And you're thinking, did you just say that? You'd rather have finality of impairment or disease that every physician has told you you don't have rather than a different approach that I'm trying to offer you. And whether that's some medication, talk therapy or something else, you'd rather be impaired or a quadriplegic or have the diagnosis of cancer that you don't have just to you stop worrying about it.

1:54:20I'm like, wow, that's another level of willingness is to get answers. And that's how insidious and how disgusting and how horrible these sticky tricky conditions are, which I'm mostly referring to OCD and Helping Zadi, they have these thoughts and belief systems that are so entrenched and so believable and it's the biggest ruse in the world. And if I can get them to hear that, if I can get them to realize that maybe if we can drop the rope and come back and try it a different way, maybe just maybe trying to figure out whether you have cancer or not is not the most important thing you do today.

1:54:48Do you have a sense of what the prevalence is today of people that are as ill as you just described? At your research in the last 10 -15 years is pretty consistent. About 4 -8 % of population has some version of health anxiety in their life. Of people with chronic illnesses, a third, over 30 % of people who have chronic illnesses, Crohn's, Cancer, Diabetes, Sickle Cell, etc. Over a third have some version of health anxiety. Most studies I've read and have gone through and when I report this and share this about 20 to 30 % of us have consistently some subclinical health anxiety notable preoccupations.

1:55:27As we get older, it obviously increases because we have more health and medical issues. And there is an interesting Swedish, I think Swedish study that came out a year or two ago in the in a 2024 big study post pandemic that Health anxiety has skyrocketed in the last four years, just because of whatever the pandemic has done to the world and people's hyper focus on stuff. So the level of people that I see, I think in the OCD and Health anxiety community, if we're saying that six to eight percent of the population as OCD or Health anxiety, probably over a third of them are at that severity level where you start wondering about insight, you start wondering about their ability to reality test.

1:56:07and that's why medication, in this case, Peter I think is usually pretty fundamentally critical. It is pretty rare for me to see someone with severe OCD or health anxiety who does not benefit from or who would not benefit from an SSRI or an SNRIF, some kind. And often you'll see psychiatrists add a low dose of an atypical anti -psychotic for a lot of mood instability. Thorazine or Cypraxacerequil. Oh, sircoy. Yeah, Thorazine's a little bit older, but a billify, which is sort of in that mixed class, just to help with the mood issues. So at least a third of the patients that come to our clinic and we see the wide range of everything and the patients that my colleagues see I'd say at least a third or that such severe level and there's not enough providers out there and is the medication temporary to get them through the therapy.

1:56:50It's necessary to get them through the therapy. It's sometimes for certain people. How many of them can get off the medication? I don't have an answer to that. I'd rough estimate probably at least a third half. But for a lot of people, they're afraid to come off the medications if they're to stable point and I'm a believer in if you're on the medication doing well And you want to stay on it great for you some people trying to come off and it creates a spike in symptoms and we merely get back on That's why most people will taper down and not just go off medication My bigger concern is when someone is unfortunately not because they're trying to be whether or fortunately treatment resistant Which has a much more pejorative term than I want to be but there are treatment non -responders as I should say They're not responding to the normal pharmacology and that's why we see people today I have very little knowledge of the science and mechanics.

1:57:30I can't speak much about it, but I see people now getting deep brain stimulation, ketamine and other kind of pretty new age medication interventions or device interventions. I know in the last few years there's been research looking at things like MDMA and other sort of hallucinogens, sometimes with a better in populations that are trying to figure out what other medications out there, what other poorly controlled medications out there can help people. That excites me. It scares me because people go, oh, I can take low dose silocybin and get better. you're not taking regularly the low -dose silo -sive and you're experimenting with mushrooms.

1:58:00That's not the same thing. You're trying ecstasy, that's not controlled MDMA. So all these new age technologies and medications are important because unfortunately, there's gonna be a population out there that doesn't respond to CBT. Still, even with the best studies, these kind of interventions are like 60 to 65 % effective. There's other interventions out there, like other meta -cognitive therapies and an intervention called inference -based CBT. So like other cognitive -based interventions that people have been developing and refining and improving. But that's still in that CBT range. 60 % is not enough.

1:58:29And so, you know, I'm excited to see next wave genetic research and testing and medication research to figure out, what are the ways can we find a way to fix where the brain is falling apart and where genetics kick in? You mentioned TMS briefly. Where do you see the promise there? I don't right now. I mean, I think it's still in experimental phases. You know, there's people that have short -term memory losses. My experience is that people have an initial improvement early on and then it fades. That's been my anecdotal experience of maybe knowing 15 to 20 patients in Atlanta, and Atlanta has a few TMS centers and ketamine infusion centers.

1:59:00I'm seeing actually more psychiatrists right now. Actually, psychiatrists in private practice, not even at like the universities I belong to and I go to are now offering ketamine infusions in private practice, which to me is brand new kind of thinking. They're trying everything they can to offer patient stuff. So I don't know enough about the research and the science behind TMS and ketamine to speak to it at a large scale and then whether people should try it, but these are options that researchers and psychiatrists are looking into because we know that, again, CBT is 60 % effective. SSRIs on a good day are 40 % to 60 % effective.

1:59:30For most studies, the combination of an SSRI or SNRI and CBT is usually the best outcome, but they're still not treating everyone and not everyone can access them. And I love what I do. I'm a pretty awesome therapist. I'm proud of what I do. I've trained a lot. I disseminated it. I try and make it as available and accessible and affordable to the people that come to our clinic. I'm in a Facebook group of about 5 ,000 specialists listen to a very closed private Facebook group. This is all we discuss. This kind of stuff, 24 -7. It's an amazing Facebook group. It's been around for about eight or nine years.

2:00:01Four practitioners only. Only for practitioners. There's tons of Facebook groups and social media platforms out there and other kind of things out there. And I'm on 20 other Facebook groups. But I'm in this one special one out there that two my colleagues launched, I think 2017, 2018, that has right now almost 5 ,000 OCD body folks should be headed for BFRB, like specially, especially specialists of junior trainees too, as senior and seasoned as they get, which I'm getting to that stage in my career. And we all have these discussions. We all debate like, what are the medication options? What are the alternative interventions?

2:00:33What do you think about this thing that someone podcasted about? And we're all trying to figure out, how do we get another 5 % to 10 % efficacy with these populations who are just not getting better? Hospitals in the last few years have changed about 10 years ago. That felt like there were more hospital centers willing to take on residential patients. And right now, there's only about five that I know in the country that I would view as the best OCD centers. There's tons that pop up every day in things that IOP and KHB centers that sort of show up. And I'm always supportive of them, but not they're not doing evidence -based practices.

2:01:02There's not enough of what I do out there, Peter, to meet the needs. And so hopefully other biologies and genetic testing and other interventions sort of increase this. But at the end of the day, the kind of work that I do and that my staff does for cognitive, the behaviorally based exposure based work for health anxiety and obesity. Sometimes with and without medication seems to be the most effective, the most available and the most that gives people their life back afterwards. That excites me. I love that. How much are you guys seeing long COVID that may or may not be long COVID? I mean, it's not something I know anything about.

2:01:36So I want to be mindful of not actually demonstrating just how ignorant I am. But I'm not sure what long COVID is. I'm sure that there is undoubtedly a subset of people who had COVID, who are having an ongoing issue as a result of it. My intuition is there are also a lot of people who think they have that. And in reality, they either don't have anything medically wrong with them, or maybe they have something else medically wrong with them. So you're probably far closer to that, but what are you seeing? I'm going to join you in the ignorance and humility of I don't know enough about it to say anything major, but I think prior to COVID, people describe identical symptoms that they're describing now, and now attributing it to long COVID.

2:02:14And so if you look at that, I've been practicing for almost 25 years. You can look at it and go, well, if it wasn't long COVID then because that word didn't exist, that phrase didn't exist. How could it be so high today? I don't know the answer to your question, but I see people coming up with a set of head fog, fuzziness, and attentive stuff, low grade depression, not feeling great, having a hard time articulating. I had COVID a few times, I'm wondering if it's that and I'm joining them thinking I'm wondering if it's that too, but I have no idea. That doesn't serve my needs. How do I help you be adaptive?

2:02:41How do I help you function? So I don't have a good sense of that, but I think it's an easy thing to latch onto. And people have gotten on disability for this. People have sought out medication treatments for this. When in the past, they just assumed that they had ADD or headaches or they had some head stuff going on. But is there a benefit in that situation of saying, everything you just said, which is, actually, I don't know what it is, but I want to help you. I want to help you adapt to it. Can you take the next step and say, let's assume, for example, that whatever you're feeling, which is real.

2:03:11we're going to acknowledge that it's real. Let's assume it's not attributable to a biologic symptom. And then we go down the same pathway. Is that a helpful framing? It will remove the best second part. Let's assume it is or is not a byproduct of biologic. You don't have a solution for it if it is biologic. I have solutions for it whether it isn't what you want to do next. So I really do stay in that gray space of, I don't know if you have cancer. Even in the book, I have a case report that a kind person allowed me to share where I treated her for health anxiety of GI track, a soft joe issues, Peter.

2:03:43It was very successful and went great and she was starving herself and losing weight and losing her life to a new medical conditions. Any year and change later, Shrewite's being says, by the way, I have thyroid cancer. Now, did we miss that? And the answer is no because she was being followed by a thyroid specialist and was on scinthoroid and other stuff. But it's tricky because I don't take away from the work that we did. No, it keeps you up. Yeah. I don't know what I don't know. What I do know is your life is not as good as it could be. Can we try some stuff? I don't know whether you're gonna get cancer or not 33 % of us.

2:04:11I hate to say this to people gonna watch us 33 % of us are gonna get cancer. I have patients that don't know that we're born with cancer cells or does that piss them off when I tell them that by the way, I don't know if it's gonna express itself or not but we all have cancer cells. Don't tell me that so I don't know which people I'm gonna see that are eventually gonna have that thing that they were terrified of. I don't know the people I'm seeing right now that have something that's been unassessed and undiagnosed. What I know is there are things that I can teach someone of mind and body. You're not doing anything much different.

2:04:37You're that can give you better life today, that can elongate your life today, that can have you more present in your life today. And if you die tomorrow or six years from now, will you regret the things that we did to improve your life? I'm serious like there's bracelet, you're not dead yet, you're not dead yet. So what do you want to do about it now? Because the other stuff you're concerned about, go to a doctor or not, go to an immunologist or not, go to your ENT or not, that's your space, here's what I can offer you. I'm a believer of mind over matter, and you are what you think, and you are what you do.

2:05:06And there are so many things that we don't tap into in our physical and mental capabilities. I love that part of my work as a CBT specialist. That's why I got board certified, I can get board certified in like 17 domains. I got board certified in this CBT space is called behavioral and cognitive because there's so much that we can teach people about diet nutrition and exercise. These are things that are bigger for you than are for me about healthy lifestyle habits, about not getting fixated on thoughts like greed and regret and guilt that really eat at people alive. have their poisons to us and they manifest thematically.

2:05:37Those things come out of us. So when someone comes to me and says, I think I have this condition, whether it's seizure disorder, cancer, or long COVID, I get to play, I don't know anything about that. What I do know is here at set of skills I can teach you, if you wanna join me in that process, I can make your life a little bit better or a lot better. What do you wanna do? Now you have agency, now you get to choose. And you might have that thing, go do that thing, go follow up with that doctor. But ultimately, at the end of the day, people are gonna make decisions for themselves, are you going to be about removing discomfort, ambiguity, and uncertainty, negative reinforcement, and or it's not just or doing things that give them a chance to improve their quality of life, relationships, romance, financial status, whatever it is.

2:06:18And so I like to help people do that build rather than just remove bad. But people come to someone like you and me and say, can you help me get rid of my symptoms? I'm like, I can. But can we also like add to your life? And that's what positive reinforcement is. That's what living the fullest life is possible until you and I no longer have that time. Finally, I want to get a sense of where you think the balance lies between the abundance of information we have today about health and whatever we want to call it, the triggering of more health anxiety. So at the outset of this podcast, we talked about, hey, look, I'm sure indirectly, well, directly, but inadvertently I'm contributing people like me contribute to health anxiety.

2:06:57But of course, we contribute to a lot of good things as well. We can be too a lot of good. I think we're a far net positive. So what steps could someone like me take to Without diminishing the good reduce the bad. I appreciate you asking me that because the work that you're doing is having people go to Unbelievable lengths with biomarkers and physical things for now and in the future and my career and the things I focused on about letting go of the future and focusing on the now so there's a little bit of attention there There's the attention there, and I appreciate you acknowledging that I think one of the nicest and kindest things that you can do is make sure that people are not absolutely dogmatic looking for a singular answer or a singular diagnosis or a singular cure.

2:07:40I know you don't, but I would get concerned if someone was going to Great Lakes because they believe that there's only one fuel, one vitamin, one diagnosis, one biomarker that answers everything. And people who think that way, you and I both know are set up for failure because nothing is 100%. That's point one. And the work that you do is to not purport the belief that if we just solve that one genetic anomaly, or if you just build more muscle mass, you're set. Because people hear that, and your word is God, they're going to do that. And they're not going to be able to fulfill that. I also think teaching flexibility, cognitive flexibility is critical.

2:08:12So you're asking people to take on a lot of new ideas. You're asking people to try new things, explore new things, and that cognitive flexibility includes, hey, let's try something different than the thing you wanted to try. Exposure therapists are funny cats. We do weird stuff. I mean, if you came to my office, Peter, we got stumps like dead stumps fake dead stumps and fake blood and fake semen and needles and animal skulls and band aids and Weird outfits. We wear all sorts of like we are disrupting a lot and disruptions a good idea Especially when someone's not expecting it and they get better for it So I think in your space if you can continue to do what you're doing But add elements of surprise and disruption where it's not linear and it's not a silver bullet and you thought it was this and then you public say, well, we thought, we're changing our course.

2:08:56That level of disruption and flexibility just promotes that. We're all trying to achieve this final linear option, but we're never gonna get to linearity. There's gonna be so many paths that we're all unique on and keeping people curious and flexible and not believing that if I take this shake and do this thing and find this bar of marker, I'm gonna live the best life possible because even you know that's not true. But people want that. People want the one solution. You know, we have these wonderful medications right now that are helping people lose weight. That's fantastic, but that's one of a thousand other options out there.

2:09:23It's the quickest and maybe the easiest for certain people with and without side effects, but those are not the only options. And so I think when we start looking at these sort of medical and biologics that are so effective and so efficient and so quick, I think the medical industry sells that a little bit too much. And that's why people don't want to come see someone like me because they don't want to do therapy. They don't want to do this for 15 to 20 sessions. They don't have to learn stuff. Just give me the pill or the laser and I'll be great. I always get worried about when physicians or medical people are selling wonderful, lovely ideas that make your life better, but they're so, this is like Jurassic Park.

2:09:58You're jumping science and when you're at the single thing and you've jumped science and learning and knowledge and have you not learned from your past mistakes. And so that curiosity and that flexibility, I think, should be built into anything that you're doing, anything that I'm doing. And with my patients, I'm trying to be curious. I'm not right about everything. I'm probably wrong about half the things I'm telling them. But I'm going to keep trying and keep learning. And we're going to have this relationship that is collaborative. And it's going to be, we call it collaborative impuarsism. And we're going to learn together.

2:10:23And hopefully we're, as you said, not positive, more right than we are wrong. But inevitably a small percentage of the people that follow what you and other people put out there about living your best healthiest life, which is fantastic, are going to take it one degree too far and believe that that is all they can do. And unfortunately, that's a percentage of any population out there that's going to get trapped into looking for the single solution or the single medicine or the single biomarker, and they're going to go to great lengths to solve that and in my work, that ruins people's lives. So it doesn't discredit all the amazing things you do.

2:10:53It's just staying flexible and curious and not believing that anyone thing solves anything, is all I would ask of you. You mentioned that your practice takes care of patients in 40 states. So I assume that means telemedicine is a big part of what you guys do. Yeah. Prior to the pandemic, a lot of states for psychologists came together and developed a jurisdiction approval called SciPact PSY -PACT. This started before the pandemic, which was very innovative, and then in the pandemic it sort of just exploded. Were therapists, if they got approved by this, with going through a few checkboxes, probably paid a few fees, which I paid and filled out your credentials and history and proved you have no bad stuff, become a SciPact eligible provider.

2:11:31And that means I can see people in the 40 states that have agreed interstate, jurisprudence or allowance that has expanded our ability to do telehealth. Prior to the pandemic, I already did telehealth in the state of Georgia. There's plenty of rural pockets. More people that just want to land a traffic sucks. People don't like driving a land to us. So I was doing telehealth anyways. SciPak has allowed providers who have doctorate level degrees to be approved to see people in those many states. What are the 10 that don't? You can guess two of them that want to hold on to their money in regulations.

2:11:58Who do you think those two are? I would guess California, New York. Yep. Those two, that's all right. Well stop. I don't care about, but those two are probably never going to agree because of all the reasons that are just so wrong. Unfortunately, and I only ask because I know that people listening to this are going to want to have an opportunity to probably reach out and work with you. So sadly, people who live in California, New York, you are not able to work with. Unless you're licensed in that state, you cannot do telemedicine with people in that state. Sadly, there's no good reason for that.

2:12:24The other eight states I couldn't tell you what they are, but it's probably just because they haven't addressed it or approved it yet. And currently, there's an equivalent thing called compact for the master's level providers up there. They're get a California license. I can, but I'm not going to. I see. The cost and the time to get a California license. By the way, I have a ton of California colleagues that are fantastic and do great work, same thing in New York. So ironically, despite those two states that I can't have an abundance of people who qualify. They've got plenty of people who are doing great stuff there.

2:12:52Got it. At a master's level, there's another thing called compact that might come around to the next year or two. I increased access and increased availability to these kind of vulnerable interventions. But yeah, so we've been doing telemedicine and I think in the last year or two of as we've been monitoring it, we're probably doing more than 50 % sessions on video, post because to 60%. I don't love it. I do it. I love it when I'm doing it with people who need it because they can't get to someone like me any other way. I don't love it doing with people who just don't want to drive across town or just want to find the easy way out.

2:13:22I get that. But it has increased the ability for someone like me and colleagues in my space who are doing what I hope is described as best practices and being very ethical, being very compassionate and helping people get their lives back as soon as possible. It's increased our availability and accessibility, which I think is absolutely fantastic and should be the way. Well, Josh, appreciate you coming out here. This has been a really interesting discussion. Honestly, this is more complex than I had imagined, but I think that's often the case whenever I do an interview on a podcast. I always come out learning much more than I thought I would learn even.

2:13:53So thanks for sharing your expertise and thanks for what you're doing. I appreciate it. Thank you. Thank you for listening to this week's episode at the drive. Head over to peteratia -md .com forward slash show notes if you want to dig deeper into this episode. You can also find me on YouTube, Instagram, and Twitter all with the handle peteratia -md. You can also leave us a review on Apple podcasts or whatever podcast player you use. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, is including the giving of medical advice.

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