1 00:00:07,649 --> 00:00:11,969 Alex Stavros: Welcome Dr. RAMAN to our podcast Roadmap to Joy. 2 00:00:12,569 --> 00:00:15,929 Thank you. I appreciate it. Alex, Dr. Brad Raman is Embark 3 00:00:15,929 --> 00:00:19,349 senior clinical advisor and as a member of our Clinical Advisory 4 00:00:19,349 --> 00:00:22,469 Council, he participates in clinical quality activities and 5 00:00:22,469 --> 00:00:25,979 makes recommendations to Embark on care, treatment and services. 6 00:00:26,249 --> 00:00:29,729 His extensive experience in mental health positions. Help 7 00:00:29,729 --> 00:00:33,059 them advise us on clinical curriculum practice guidelines, 8 00:00:33,299 --> 00:00:36,599 and specialty clinical programs such as obsessive compulsive 9 00:00:36,599 --> 00:00:40,499 disorders, Autism Spectrum Disorder, substance use disorder 10 00:00:40,499 --> 00:00:44,309 and eating disorders. Dr. Ramin really has an impressive resume. 11 00:00:44,519 --> 00:00:48,419 He has been specializing in OCD and OCD related disorders for 12 00:00:48,419 --> 00:00:52,649 over 35 years and is considered one of the foremost OCD experts 13 00:00:52,649 --> 00:00:56,429 and clinicians across the world. In fact, Dr. Freeman is widely 14 00:00:56,429 --> 00:00:59,129 regarded in the healthcare community for helping more 15 00:00:59,129 --> 00:01:03,629 people recover from OCD than any other clinician in America. One 16 00:01:03,629 --> 00:01:06,899 of the many areas we Embark have found alignment with Dr. Freeman 17 00:01:06,959 --> 00:01:11,069 is his significant contributions to measurement based care, and 18 00:01:11,069 --> 00:01:15,089 standardizations of care. He's a prolific researcher and serves 19 00:01:15,089 --> 00:01:18,089 as a member of the scientific advisory board of the 20 00:01:18,089 --> 00:01:21,569 International obsessive compulsive disorder Foundation, 21 00:01:22,019 --> 00:01:25,229 acting as expert consultant to the organization on research 22 00:01:25,229 --> 00:01:28,649 matters. And in fact, his research has been published in 23 00:01:28,649 --> 00:01:32,879 nearly 100 articles and professional journals, which is 24 00:01:32,879 --> 00:01:34,589 particularly impressive given. 25 00:01:34,000 --> 00:01:39,370 He is someone who is in the practice setting, not the 26 00:01:39,370 --> 00:01:42,790 research or academic setting. Suffice to say Embark is 27 00:01:42,790 --> 00:01:46,090 fortunate to have Dr. RAMAN as a clinical leader and partner. 28 00:01:46,630 --> 00:01:47,650 Welcome Dr. Raman. 29 00:01:48,130 --> 00:01:51,250 Brad Riemann: Thank you very much. I appreciate that Alex, 30 00:01:51,250 --> 00:01:54,910 and I'm, I'm so excited to partner with with Embark I mean, 31 00:01:54,910 --> 00:01:58,390 it's such a mission driven organization. And certainly, 32 00:01:58,600 --> 00:02:01,270 that's a real credit to you and your leadership team. So thank 33 00:02:01,270 --> 00:02:04,480 you. Thank you. Thank you, Dr. Raman. Well, you know, there's 34 00:02:04,480 --> 00:02:07,870 so much we could talk about, but what I would love to do is to 35 00:02:07,870 --> 00:02:13,210 focus this conversation on teens and young adults with OCD, and 36 00:02:13,210 --> 00:02:16,270 their family and parents that are looking for ways to support 37 00:02:16,270 --> 00:02:20,170 them. It's really a unique disorder, and very debilitating 38 00:02:20,320 --> 00:02:24,010 condition. There's also so many misunderstandings, as I'm sure 39 00:02:24,010 --> 00:02:27,850 you're gonna share with us, and it's very commonly misdiagnosed. 40 00:02:27,000 --> 00:02:30,960 Alex Stavros: And often parents will do things though well 41 00:02:30,960 --> 00:02:35,010 intended, that can enable the disorder as well. So it's great 42 00:02:35,010 --> 00:02:37,650 to be able to spend time with you to hopefully provide some 43 00:02:37,650 --> 00:02:40,200 content for parents to help their children who may be 44 00:02:40,200 --> 00:02:43,020 struggling with this issue. So maybe first off to lay the 45 00:02:43,020 --> 00:02:47,670 groundwork. How would you define OCD? At a more high level? 46 00:02:48,150 --> 00:02:52,830 Brad Riemann: Yeah. So OCD is characterized by obsessions and 47 00:02:52,830 --> 00:02:57,030 compulsions Alex and and obsessions are these unwanted 48 00:02:57,150 --> 00:03:01,200 thoughts, images or urges that generate high levels of anxiety. 49 00:03:01,200 --> 00:03:05,040 So some common examples might be the fear of becoming dirty or 50 00:03:05,040 --> 00:03:08,670 contaminated. By coming in contact with things in your 51 00:03:08,850 --> 00:03:11,790 normal daily environment or doubting whether you did 52 00:03:11,790 --> 00:03:14,910 something or did something correctly. Did I turn off the 53 00:03:14,910 --> 00:03:17,970 stove? do that math problem, right, Did I lock the door. 54 00:03:18,960 --> 00:03:22,110 compulsions, on the other hand, are some sort of repetitive act 55 00:03:22,140 --> 00:03:25,590 and, and typically, it is some sort of behavioral act that we 56 00:03:25,590 --> 00:03:29,100 can observe something that someone feels compelled to do to 57 00:03:29,100 --> 00:03:33,150 try to neutralize that unwanted obsessional fodder to get rid of 58 00:03:33,150 --> 00:03:36,840 the anxiety that it causes. So this might be something like in 59 00:03:36,840 --> 00:03:41,310 response to say, the fear of dirty becoming dirty and 60 00:03:41,310 --> 00:03:44,400 contaminated washing and cleaning over and over again. 61 00:03:44,850 --> 00:03:48,600 But compulsions can also be another thought. I mean, it can 62 00:03:48,600 --> 00:03:51,420 be something that we can't observe something that someone 63 00:03:51,420 --> 00:03:55,050 does silently in their own mind, again, in an attempt to prevent 64 00:03:55,050 --> 00:03:58,890 something bad from happening, or to get rid of that anxiety that 65 00:03:58,890 --> 00:04:01,200 is caused by that social thought. So it's important to 66 00:04:01,200 --> 00:04:04,140 think about it as really a two part problem obsessions and 67 00:04:04,140 --> 00:04:04,920 compulsions. 68 00:04:06,480 --> 00:04:08,820 Alex Stavros: That makes a lot of sense and providing a clarity 69 00:04:08,820 --> 00:04:14,640 on OCD isn't necessarily always something that's outward, and 70 00:04:14,640 --> 00:04:20,640 something that can be visible to others around you. And also, 71 00:04:20,670 --> 00:04:25,260 what I found interesting is a lot of examples you gave. I've 72 00:04:25,260 --> 00:04:28,950 dealt with myself and probably most people have dealt with 73 00:04:28,950 --> 00:04:33,480 themselves. The question is, you know, what are some of those 74 00:04:33,480 --> 00:04:37,620 common misconceptions with OCD and misdiagnosis where some 75 00:04:37,620 --> 00:04:42,330 people think they may have it or may think they don't have it is 76 00:04:42,990 --> 00:04:47,310 just because I have certain thoughts about something that 77 00:04:47,310 --> 00:04:51,930 may be stressing me out, doesn't necessarily mean that I have 78 00:04:52,230 --> 00:04:57,030 diagnoseable OCD. What have you seen in your work that are some 79 00:04:57,030 --> 00:04:59,970 of the most common misconceptions and what leads to 80 00:05:00,510 --> 00:05:03,570 misdiagnosis and how should people be thinking about it in 81 00:05:03,570 --> 00:05:08,580 terms of when are the those behaviors? Maybe something that 82 00:05:08,640 --> 00:05:13,770 more represents OCD than just typical thoughts and behaviors 83 00:05:13,770 --> 00:05:15,720 that people may have? 84 00:05:16,320 --> 00:05:18,720 Brad Riemann: Yeah, great questions. And, you know, there 85 00:05:18,720 --> 00:05:22,110 are some that really believe that OCD is a great, great 86 00:05:22,140 --> 00:05:26,100 exaggeration of the norm. You know, to your point, Alex, 87 00:05:26,730 --> 00:05:31,440 everyone has probably washed their hands from time to time 88 00:05:31,440 --> 00:05:35,640 when they just felt dirty. Everyone has gone back and and 89 00:05:35,640 --> 00:05:38,580 checked the door lock even though they were quite certain 90 00:05:38,580 --> 00:05:41,970 that they had closed that door and locked it. So some people 91 00:05:41,970 --> 00:05:44,850 again feel it's it's just a tremendous, but I do emphasize 92 00:05:44,850 --> 00:05:48,780 the word tremendous exaggeration of the norm. Point simply being 93 00:05:48,780 --> 00:05:52,230 as we go back to our 2.2 part definition obsessions and 94 00:05:52,230 --> 00:05:56,250 compulsions. The obsessional part Alec seems to be universal. 95 00:05:56,280 --> 00:06:01,770 I mean, everyone gets unwanted thoughts from time to time. And 96 00:06:01,770 --> 00:06:04,500 it just seems that again, this exaggeration of the norm where 97 00:06:04,500 --> 00:06:10,560 someone with OCD has so many of those thoughts, and does so many 98 00:06:10,740 --> 00:06:13,410 repetitive compulsions, whether it's checking, washing, 99 00:06:13,410 --> 00:06:16,080 counting, cleaning, whatever it might be, that it creates 100 00:06:16,110 --> 00:06:19,650 interference or disorder in their life. And then that's when 101 00:06:19,650 --> 00:06:22,140 someone like me says, Well, you have obsessive compulsive 102 00:06:22,140 --> 00:06:26,250 disorder. But again, to your point, everyone's you know, 103 00:06:26,250 --> 00:06:28,560 this, a lot of these symptoms kind of ring bells and say, you 104 00:06:28,560 --> 00:06:31,650 have done that from time to time. But you know, when your 105 00:06:31,650 --> 00:06:35,550 child or young adult starts to do, you know, starts to have 106 00:06:37,320 --> 00:06:40,680 these issues so much that it creates this interference in 107 00:06:40,680 --> 00:06:43,860 their life, you know, that's when it really is time to be 108 00:06:43,860 --> 00:06:46,710 thinking about getting an assessment and perhaps, 109 00:06:46,920 --> 00:06:50,820 treatment, but it is commonly misdiagnosed as you as you said, 110 00:06:50,820 --> 00:06:55,740 and the real error, I guess here is that just because someone 111 00:06:55,770 --> 00:07:00,090 does or thinks something over and over and over again, does 112 00:07:00,090 --> 00:07:03,720 not make it obsessive compulsive disorder. And, you know, like 113 00:07:03,720 --> 00:07:06,840 the media in lay people, you know, really kind of 114 00:07:06,840 --> 00:07:11,070 misunderstand that. And a perfect example, Alex is, you 115 00:07:11,070 --> 00:07:14,100 know, kind of excessive video game playing. You know, I've 116 00:07:14,100 --> 00:07:17,700 gotten phone calls from parents saying, oh, you know, Dr. 117 00:07:17,700 --> 00:07:20,070 Freeman, you're an expert in OCD. My son has OCD. I'm so 118 00:07:20,070 --> 00:07:22,980 sorry to hear that. What sort of symptoms he has, he cannot stop 119 00:07:22,980 --> 00:07:26,340 playing video games. And I'll say, Well, you know, I never say 120 00:07:26,340 --> 00:07:29,790 never, but chances are, that's actually not OCD. And they'll 121 00:07:29,790 --> 00:07:32,550 say, Well, I don't understand. He's thinking about them all the 122 00:07:32,550 --> 00:07:34,860 time. He can't stop playing them. It's the he can't go to 123 00:07:34,860 --> 00:07:37,650 school, it's interfering with the social life of the 124 00:07:37,650 --> 00:07:40,200 differences. Again, if we go back to the definition of an 125 00:07:40,200 --> 00:07:44,340 obsession, it's an unwanted thought, right? Whereas if you 126 00:07:44,340 --> 00:07:47,250 ask Johnny, do you like thinking about playing video games? He 127 00:07:47,250 --> 00:07:51,270 says, yep. And do you like playing video games? Yep. It's a 128 00:07:51,270 --> 00:07:54,300 problem. And it can be a serious problem. But in a way, it's 129 00:07:54,300 --> 00:07:57,540 almost kind of the opposite. And so the, again, the take home 130 00:07:57,540 --> 00:08:00,870 message is just because you think or do something over and 131 00:08:00,870 --> 00:08:03,750 over again, does that make it OCD? Great 132 00:08:03,749 --> 00:08:06,389 Alex Stavros: take home message and about on the flip side, in 133 00:08:06,389 --> 00:08:11,219 terms of kind of undiagnosed, OCD. So some people may think 134 00:08:11,219 --> 00:08:13,109 they have it, but it's not really there. How about those 135 00:08:13,109 --> 00:08:17,399 that are struggling and kind of day to day and may not be aware 136 00:08:17,399 --> 00:08:20,759 of how much it's getting in the way of their daily functioning 137 00:08:20,789 --> 00:08:24,089 work and relationships? And others may not be aware of it 138 00:08:24,089 --> 00:08:28,109 too, or perhaps are? How should we think about OCD? That's 139 00:08:28,559 --> 00:08:30,569 undiagnosed? Yeah. 140 00:08:30,600 --> 00:08:33,150 Brad Riemann: Great, great question again. You know, first 141 00:08:33,150 --> 00:08:35,940 and foremost, we got to keep in mind that people with OCD for 142 00:08:35,940 --> 00:08:39,600 the most part do have some level of insight into their symptoms. 143 00:08:39,600 --> 00:08:44,040 And as a result, they fear embarrassment. You know, they 144 00:08:44,040 --> 00:08:48,000 really are quite good at hiding their symptoms, even from their 145 00:08:48,000 --> 00:08:51,750 parents or their teachers or their spouse. You know, we've 146 00:08:51,750 --> 00:08:55,230 gone into the classroom and spoken to teachers, of course, 147 00:08:55,230 --> 00:08:59,250 after obtaining proper consent, and teach us a passion, we had 148 00:08:59,250 --> 00:09:01,980 no idea, you know, that Johnny had these problems, because, 149 00:09:01,980 --> 00:09:05,790 again, Johnny, he might be washing his hands like mad at 150 00:09:05,790 --> 00:09:09,570 home, but you know, he is not going to display the symptoms in 151 00:09:09,570 --> 00:09:12,780 front of his friends. And so he's kind of sweating bullets 152 00:09:12,780 --> 00:09:17,430 all day long at school. Because again, just this fear of 153 00:09:17,760 --> 00:09:22,200 embarrassment. So you have this tendency for people with OCD to 154 00:09:22,200 --> 00:09:25,890 not discuss this stuff, they tend to hide it, they tend to 155 00:09:25,890 --> 00:09:30,120 keep it to themselves. Most people who come into an OCD 156 00:09:30,120 --> 00:09:32,910 treatment program, for example, will say I've never met anyone 157 00:09:32,910 --> 00:09:35,730 else who had this problem. I've never been able to talk with 158 00:09:35,730 --> 00:09:37,290 someone else who has this problem. So there's this 159 00:09:37,440 --> 00:09:43,020 tremendous relief and kind of normalization, if you will, when 160 00:09:43,020 --> 00:09:48,030 patients do come in but so this is a problem that is common. 161 00:09:48,810 --> 00:09:52,830 It's also commonly misdiagnosed. And then there are many, many 162 00:09:52,830 --> 00:09:56,190 people who are suffering in silence because of again, this 163 00:09:56,190 --> 00:10:00,450 fear of embarrassment and not wanting to discuss This with 164 00:10:00,450 --> 00:10:04,650 friends, family, whatever, even to the point of not wanting to 165 00:10:04,650 --> 00:10:06,720 discuss it with their mental health care providers, so they 166 00:10:06,720 --> 00:10:10,890 might have engaged in mental health care. I've gotten calls, 167 00:10:10,890 --> 00:10:13,110 you know, Hey, doctor even Yeah, this is Dr. Smith, I have this 168 00:10:13,110 --> 00:10:16,710 patient who has OCD. I've been seeing them for three years. 169 00:10:16,710 --> 00:10:19,800 They just told me last night they have OCD. Well, what were 170 00:10:19,800 --> 00:10:22,260 you treating them for depression? So they were even 171 00:10:22,260 --> 00:10:25,530 afraid to admit this type of issue, even to their mental 172 00:10:25,530 --> 00:10:26,340 health care provider? 173 00:10:27,450 --> 00:10:31,830 Alex Stavros: And what kind of advice would you give? Or what 174 00:10:31,830 --> 00:10:36,540 would you suggest for those friends or family members? That, 175 00:10:36,960 --> 00:10:40,380 that think that somebody may be struggling with OCD, but they're 176 00:10:40,380 --> 00:10:44,520 not sure. Particularly it's, it's difficult, somewhat because 177 00:10:44,520 --> 00:10:48,540 of not only a stigma, but also fairly common in our society for 178 00:10:48,540 --> 00:10:52,320 somebody to say, Oh, I'm, I'm being a little OCD right now or 179 00:10:52,320 --> 00:10:56,940 stop being so OCD and we throw it around flippantly is, how can 180 00:10:56,940 --> 00:10:59,550 we have a more serious conversation with somebody and 181 00:10:59,550 --> 00:11:04,650 get over that stigma? To figure out if we should be trying to 182 00:11:04,650 --> 00:11:10,110 find more help for that family member for that child? Yeah, 183 00:11:10,440 --> 00:11:12,870 Brad Riemann: yeah. And to your point, I mean, it has become a 184 00:11:12,870 --> 00:11:17,400 little bit of a, you know, just a coined phrase that people kind 185 00:11:17,400 --> 00:11:20,880 of do throw out there. And, and it really, you know, 186 00:11:20,880 --> 00:11:25,290 unfortunately, woefully underestimates the pain and 187 00:11:25,290 --> 00:11:29,460 suffering that people with OCD go through. You know, at the top 188 00:11:29,460 --> 00:11:33,030 of this podcast, you had mentioned the, how disabling it 189 00:11:33,030 --> 00:11:38,460 can be, and the World Health Organization, or WHO has rated 190 00:11:38,460 --> 00:11:42,270 as it the 10th leading cause of disability in the world, Alex, 191 00:11:42,270 --> 00:11:45,240 and they're not just talking about behavioral health 192 00:11:45,240 --> 00:11:48,180 problems, they're actually talking about medical problems, 193 00:11:48,180 --> 00:11:52,410 such as anemia, and falls, all these things. OCD is in 10th, 194 00:11:52,410 --> 00:11:56,190 leading cause of disability so it's, it's very disabling, very 195 00:11:56,190 --> 00:12:00,540 impairing causes a lot of pain and suffering. And, you know, 196 00:12:00,570 --> 00:12:05,880 when, when a loved one starts to feel that maybe something's off, 197 00:12:06,120 --> 00:12:09,600 maybe they start to pick up on some of these symptoms, again, 198 00:12:09,600 --> 00:12:11,970 keeping in mind it's a two part problem obsessions and 199 00:12:11,970 --> 00:12:14,880 compulsions. If you start picking that up, you know, I 200 00:12:14,880 --> 00:12:18,810 think the best thing to do is to approach your loved one, have a 201 00:12:18,810 --> 00:12:21,510 conversation with them, you know, ask them if they're having 202 00:12:21,540 --> 00:12:26,940 issues. Hopefully, they would feel comfortable in confiding in 203 00:12:26,940 --> 00:12:30,480 their parent, or sibling or whatever it might be. The other 204 00:12:30,480 --> 00:12:32,460 thing that I would suggest, and you had mentioned the 205 00:12:32,460 --> 00:12:37,200 international OCD Foundation, their website is a tremendous 206 00:12:37,200 --> 00:12:41,100 wealth of psychoeducation material, I mean, that they they 207 00:12:41,100 --> 00:12:45,360 go into great length of what it is what it's not what to do, you 208 00:12:45,360 --> 00:12:49,560 know how to talk with a loved one? And, you know, certainly 209 00:12:49,560 --> 00:12:53,010 that's another thing that someone could do just even 210 00:12:53,010 --> 00:12:55,560 inform themselves a little bit, you know, hey, I don't know, is 211 00:12:55,560 --> 00:12:58,260 this OCD? Isn't it? Is it normal, you know, going there 212 00:12:58,260 --> 00:13:02,070 and reading up a little bit on some of the resources they have, 213 00:13:02,760 --> 00:13:05,790 can be very, very helpful. And then when talking with a family 214 00:13:05,790 --> 00:13:09,990 or friend, you know, perhaps even suggesting that they go on 215 00:13:09,990 --> 00:13:13,080 the internet, and there are other organizations as well. 216 00:13:13,080 --> 00:13:15,390 But, you know, the iocdf is really kind of that 217 00:13:15,390 --> 00:13:18,210 clearinghouse for information for patients and their families. 218 00:13:18,480 --> 00:13:18,810 Great. 219 00:13:18,870 --> 00:13:21,090 Alex Stavros: Appreciate that. We'll put a link to that those 220 00:13:21,090 --> 00:13:27,660 resources in the show notes. Can I ask you to maybe do a little 221 00:13:27,660 --> 00:13:32,100 bit of role playing? Sure. And you can assume either I'm your 222 00:13:32,100 --> 00:13:39,210 child or a friend. And you you observed pretty serious OCD 223 00:13:39,240 --> 00:13:43,350 behaviors, and you're not sure if I am. If I have been 224 00:13:43,350 --> 00:13:46,980 diagnosed, and maybe I am seeing somebody, but you feel like, I 225 00:13:46,980 --> 00:13:51,060 need to hear something from us, for us to be able to start to 226 00:13:51,060 --> 00:13:54,630 have a more serious conversation. Would you mind 227 00:13:54,630 --> 00:13:59,970 doing that as we think about parents, and, or a loved one or 228 00:13:59,970 --> 00:14:03,150 an older sibling? is they want to bring it up? They're not sure 229 00:14:03,150 --> 00:14:06,870 exactly what words? How do I bring it up? And how do I start 230 00:14:06,870 --> 00:14:10,800 that conversation? How would you do that? Maybe do that with me 231 00:14:10,800 --> 00:14:11,880 right now? Sure. 232 00:14:11,880 --> 00:14:14,910 Brad Riemann: Sure. Sure. Sure. Yeah, you know, and just to 233 00:14:14,910 --> 00:14:17,910 preface it, I mean, you know, there's really no right or wrong 234 00:14:17,910 --> 00:14:22,350 way of going about doing this, for the most part, I mean, you 235 00:14:22,350 --> 00:14:26,970 know, and if someone goes about this in a compassionate and 236 00:14:27,030 --> 00:14:30,780 empathetic way, you know, I think nothing but good things 237 00:14:30,780 --> 00:14:33,810 are gonna happen. No, maybe not immediately, but at some point, 238 00:14:34,200 --> 00:14:36,750 you know, that conversation is going to register with someone 239 00:14:36,750 --> 00:14:39,090 and they're going to realize that, you know, hey, you're, 240 00:14:39,120 --> 00:14:42,120 you're a trusted person who cares about me, but yeah, you 241 00:14:42,120 --> 00:14:45,330 know, I think that my suggestions more specifically, 242 00:14:45,360 --> 00:14:48,090 you know, you know, I would approach you Alex and just say, 243 00:14:48,090 --> 00:14:51,090 hey, look, you know, I was noticing that you were kind of 244 00:14:51,090 --> 00:14:55,710 getting stuck over there. And having trouble you know, with 245 00:14:55,710 --> 00:14:59,640 that door lock or, or I notice you you know, you were avoiding 246 00:14:59,640 --> 00:15:03,090 touch Everything's at the dinner table and then had to go and 247 00:15:03,090 --> 00:15:06,540 wash a couple of times during the meals. And, you know, and I 248 00:15:06,540 --> 00:15:10,290 don't know what's going on Alex, you know, I'm just doing this 249 00:15:10,290 --> 00:15:15,120 because I care about you. And it just seems like you were really 250 00:15:15,120 --> 00:15:18,270 struggling. So it's something up, you know, I mean, is there 251 00:15:18,270 --> 00:15:22,470 something going on? You know, I'm a person you can trust, I'm 252 00:15:22,470 --> 00:15:26,730 a person you can confide in, you know, I, assuming I'm a 253 00:15:26,730 --> 00:15:31,620 layperson, you know, I don't really know, you know, but I am 254 00:15:31,620 --> 00:15:34,410 aware of this condition known as obsessive compulsive disorder, 255 00:15:34,410 --> 00:15:37,770 and just a little bit I know of it, it seems like, maybe some of 256 00:15:37,770 --> 00:15:40,620 these things are relevant for you. But again, you know, please 257 00:15:40,620 --> 00:15:44,460 feel free to talk with me, whatever you say, I'll keep to 258 00:15:44,460 --> 00:15:47,820 myself, I won't share with your parents or, you know, unless you 259 00:15:47,910 --> 00:15:51,240 give me permission to do so. But, you know, I'm here for you. 260 00:15:52,230 --> 00:15:57,330 I can listen, I can try to help you in any way, shape, or form. 261 00:15:57,600 --> 00:16:00,060 I'm not trying to exaggerate what was going on. But it did 262 00:16:00,060 --> 00:16:02,190 seem like you were really struggling. And it just gave me 263 00:16:02,190 --> 00:16:05,010 a sense that this is kind of a something, you know, your 264 00:16:05,010 --> 00:16:07,590 parents had told me that you were kind of struggling with a 265 00:16:07,590 --> 00:16:11,910 few things. And, and you know, if nothing else, you maybe you 266 00:16:11,910 --> 00:16:14,430 could talk to some friends, your school counselor, but I'm always 267 00:16:14,430 --> 00:16:17,220 here for you, and we'll help you in any way that I can. 268 00:16:18,090 --> 00:16:20,400 Alex Stavros: Right, great, nice work, you know, I think it's 269 00:16:20,700 --> 00:16:24,690 part of it is, you know, like you mentioned is we can get in 270 00:16:24,690 --> 00:16:27,930 our own way, when we feel like we're trying to accomplish 271 00:16:27,930 --> 00:16:31,410 something like I'm trying to get you to do something or, versus 272 00:16:31,740 --> 00:16:38,250 just saying, I'm here to talk, I see you, I accept you, that 273 00:16:38,250 --> 00:16:42,660 allows that person to feel more comfortable. And it may be that 274 00:16:42,660 --> 00:16:46,050 they don't want to talk to you about it. But that experience of 275 00:16:46,050 --> 00:16:48,510 acceptance will allow them to talk to the person they did want 276 00:16:48,510 --> 00:16:51,570 to wasn't able to tell them those words, but they feel like 277 00:16:51,600 --> 00:16:54,240 I really want to tell this person. And because you helped 278 00:16:54,240 --> 00:16:57,030 me feel accepted in the situation. Now I feel 279 00:16:57,030 --> 00:16:59,760 comfortable telling them. And so I think it's a great way to 280 00:17:00,120 --> 00:17:04,710 engage with a friend or even even a child in that way as is. 281 00:17:05,430 --> 00:17:08,430 It's maybe maybe it's one of many conversations, maybe it's 282 00:17:08,430 --> 00:17:11,100 one and nothing comes up for a couple of weeks. And then they 283 00:17:11,100 --> 00:17:14,790 say, Hey, Dad, you were you brought that up? And you saw me 284 00:17:14,790 --> 00:17:17,910 during this break that I was doing this thing? Can we talk a 285 00:17:17,910 --> 00:17:20,400 little bit more about that? And exactly, 286 00:17:20,760 --> 00:17:22,380 Brad Riemann: yeah, and you don't need to be a trained 287 00:17:22,380 --> 00:17:26,370 mental health care provider to you know, to reach out and to 288 00:17:26,370 --> 00:17:31,020 show somebody compassion and empathy, right. And, you know, 289 00:17:31,020 --> 00:17:34,830 to your point to it may not have that immediate impact. They 290 00:17:34,830 --> 00:17:40,500 might get defensive, they might, you know, it might stress them 291 00:17:40,500 --> 00:17:43,620 out. But they're going to remember that you cared about, 292 00:17:43,680 --> 00:17:48,090 right. And in, like you said, a week later, two weeks later, a 293 00:17:48,090 --> 00:17:50,820 month later, you know, they they may let their guard down and 294 00:17:50,820 --> 00:17:51,750 have a conversation with you. 295 00:17:51,780 --> 00:17:53,730 Alex Stavros: So tell me a little bit about the 296 00:17:53,730 --> 00:17:57,690 environment, and maybe parenting, how much does the 297 00:17:57,690 --> 00:18:01,440 environment in parenting play, first of all, into the 298 00:18:01,440 --> 00:18:06,360 development of OCD in the first place? or to what extent are we 299 00:18:06,360 --> 00:18:10,590 born with it? And to what extent does that environment or 300 00:18:10,620 --> 00:18:14,370 parenting, make it better or make it worse? 301 00:18:14,999 --> 00:18:17,489 Brad Riemann: Yeah. Yeah. I mean, so Alex, I mean, we're all 302 00:18:17,489 --> 00:18:21,119 products of our past, right. And so, you know, parents have a 303 00:18:21,119 --> 00:18:25,499 tremendous impact on who we are and who we're not, and so forth. 304 00:18:25,979 --> 00:18:31,109 But OCD. First and foremost, we don't know what causes OCD, 305 00:18:31,139 --> 00:18:35,399 we're just really learning more and more about it each year. The 306 00:18:35,399 --> 00:18:38,969 evidence that comes out of research every year is pointing 307 00:18:38,969 --> 00:18:44,159 more and more to a neurobiological abnormality that 308 00:18:44,249 --> 00:18:49,799 appears to be at least in part genetically influenced. So when 309 00:18:49,799 --> 00:18:51,899 you're talking about parents, and you're talking about 310 00:18:51,899 --> 00:18:55,619 genetics, you know, obviously what that means is that at least 311 00:18:55,619 --> 00:18:59,969 in part, you know, this was passed on OCD tends to run in 312 00:18:59,969 --> 00:19:04,589 families, right? It does not appear, though, to be really 313 00:19:04,589 --> 00:19:08,159 kind of parenting in and of itself. And so for example, when 314 00:19:08,159 --> 00:19:12,179 you look at adoption studies, and so say you have someone who 315 00:19:12,179 --> 00:19:16,979 is adopted, who there's positive biological family history of 316 00:19:16,979 --> 00:19:22,169 OCD, and they're adopted into a family that is OCD, free, they 317 00:19:22,169 --> 00:19:25,739 are more likely to have OCD because of that biological 318 00:19:25,739 --> 00:19:31,079 influence. Vice versa is also true if your biological parents 319 00:19:31,679 --> 00:19:36,089 were OCD free and you're adopted into a family that is positive 320 00:19:36,089 --> 00:19:40,319 for OCD. You're not going to develop OCD, you can't really 321 00:19:40,319 --> 00:19:45,929 make someone OCD, so it does seem to be neuro biologically 322 00:19:46,079 --> 00:19:49,469 abnormality that's influenced at least in part genetically. But 323 00:19:49,469 --> 00:19:53,849 again, we are all products of our our past and influenced in 324 00:19:53,849 --> 00:19:58,289 the environments that we are brought up in but you know, the 325 00:19:58,319 --> 00:20:02,219 the biggest thing that seems to be involved with the parents. 326 00:20:02,219 --> 00:20:04,979 And you had mentioned this in some of your opening remarks is 327 00:20:04,979 --> 00:20:10,289 this concept of what we call family accommodation. And it you 328 00:20:10,289 --> 00:20:13,739 are absolutely right, it is always very, very well intended 329 00:20:13,769 --> 00:20:18,719 to begin with. None of us like to see our children or our loved 330 00:20:18,719 --> 00:20:26,099 ones in distress. OCD causes lots of distress. And so parents 331 00:20:26,699 --> 00:20:30,299 try to kind of run to the rescue of their children. So they start 332 00:20:30,329 --> 00:20:34,349 opening doors for their kids so that they don't have to touch a 333 00:20:34,349 --> 00:20:37,919 door handle that appears to be contaminated. They start trying 334 00:20:37,919 --> 00:20:43,679 to help them in other ways. And initially, it does allow Johnny 335 00:20:43,679 --> 00:20:47,759 to kind of sidestep their OCD and get on with whatever it is 336 00:20:47,759 --> 00:20:50,249 that they're trying to do get to their little league game on time 337 00:20:50,249 --> 00:20:53,939 type of thing. But what it ultimately does, those kind of 338 00:20:53,939 --> 00:20:58,139 fanned the flame of OCD, and it actually literally makes the 339 00:20:58,139 --> 00:21:02,309 severity of the OCD worse, and reduces the response to 340 00:21:02,309 --> 00:21:08,729 treatment, unless addressed. And so that is one way that 341 00:21:08,729 --> 00:21:12,959 unfortunately, families can kind of make the situation more 342 00:21:12,959 --> 00:21:15,929 difficult. But again, it's it's natural. I'm not saying I 343 00:21:15,929 --> 00:21:19,559 wouldn't do it myself, right, or you. We care about our kids. We 344 00:21:19,559 --> 00:21:21,899 love our kids. We don't want to see him in distress. But it has 345 00:21:21,899 --> 00:21:25,379 this kind of paradoxical effect, it has this kind of opposite 346 00:21:25,409 --> 00:21:29,219 negative impact on the OCD in the long run. So it has to be 347 00:21:29,219 --> 00:21:30,149 addressed in treatment. 348 00:21:30,780 --> 00:21:34,230 Alex Stavros: Yeah, that I think that's a great point of just, 349 00:21:34,260 --> 00:21:38,490 you know, well intended. And it's even when you have a child, 350 00:21:38,490 --> 00:21:43,230 for example, that struggles in in social situations, you you 351 00:21:43,230 --> 00:21:46,770 almost want to go and talk to them or pull them aside because 352 00:21:47,040 --> 00:21:51,720 you don't like to see them feel uncomfortable. Yeah. And so what 353 00:21:51,720 --> 00:21:57,150 would you say, if, as a family member, as a parent, if, in that 354 00:21:57,150 --> 00:21:59,760 case where we got to get to the baseball game, or we got to get 355 00:21:59,760 --> 00:22:03,060 to school on time, we're going to be late again, instead of 356 00:22:03,090 --> 00:22:05,670 accommodating, which they do instead? 357 00:22:06,150 --> 00:22:08,790 Brad Riemann: Yeah, great question. And, and it's not an 358 00:22:08,790 --> 00:22:11,760 easily answered one. I'll just say that right from the get go. 359 00:22:11,760 --> 00:22:17,130 But, you know, in the context of treatment, right. And so we've 360 00:22:17,130 --> 00:22:20,430 been talking about, you know, OCD being a two part problem 361 00:22:20,430 --> 00:22:24,120 obsessions, and compulsions. And in the treatment of choice, so 362 00:22:24,120 --> 00:22:27,510 the gold standard of treatment is something called exposure and 363 00:22:27,510 --> 00:22:31,140 response prevention. So it's a two part problem with a two part 364 00:22:31,140 --> 00:22:35,610 solution. So the exposure is geared toward the obsessions, 365 00:22:35,610 --> 00:22:38,850 the response prevention, as some people refer to it as ritual 366 00:22:38,850 --> 00:22:42,360 prevention, is targeting the compulsion. So again, two part 367 00:22:42,360 --> 00:22:46,830 prompt two part solution, if a if a family is engaged in that 368 00:22:46,830 --> 00:22:50,970 type of treatment, then their clinician, their provider, will 369 00:22:50,970 --> 00:22:56,220 be instructing them in kind of a series of steps to address and 370 00:22:56,220 --> 00:23:01,530 reduce accommodation. It's tricky, Alex, if you try to do 371 00:23:01,530 --> 00:23:04,830 this without being in that context of treatment, and let me 372 00:23:04,860 --> 00:23:10,320 tell you why, you know if that child is because is going to 373 00:23:10,320 --> 00:23:16,320 become quite dependent on that accommodation. And if parents 374 00:23:16,320 --> 00:23:18,900 were to just say, okay, look, you know, I listen to this 375 00:23:18,900 --> 00:23:22,470 podcast, it's Reman guy said accommodations bad starting to 376 00:23:22,470 --> 00:23:27,000 come out, we're just not doing it anymore, right? That's not 377 00:23:27,000 --> 00:23:29,490 gonna go so well. I mean, it could cause World War Three in 378 00:23:29,490 --> 00:23:33,960 the house, it could cause a tremendous rush of distress for 379 00:23:33,960 --> 00:23:37,110 that young one, because, again, they've become dependent on it. 380 00:23:37,410 --> 00:23:40,650 So it's something that, you know, I think families need to 381 00:23:40,650 --> 00:23:44,640 note has to be addressed, I would encourage them to reach 382 00:23:44,670 --> 00:23:48,540 out to a provider to try to get some assistance on kind of the 383 00:23:48,540 --> 00:23:53,670 step wise approach to reducing and ultimately eliminating that, 384 00:23:53,970 --> 00:23:56,460 but just pulling the rug out from under on probably is not 385 00:23:56,460 --> 00:23:57,150 gonna go so well. 386 00:23:57,540 --> 00:24:01,590 Alex Stavros: Yeah, great advice. How earlier you had 387 00:24:01,590 --> 00:24:06,090 mentioned about that colleague of yours that had been treating 388 00:24:06,090 --> 00:24:11,460 that client for three years and found out that they had OCD, how 389 00:24:11,460 --> 00:24:15,690 common are co occurring disorders, like depression with 390 00:24:15,690 --> 00:24:21,210 those OCD? And how should a parent think about treating 391 00:24:21,210 --> 00:24:26,970 these co occurring issues? is, should one be more important 392 00:24:26,970 --> 00:24:29,850 than the other should both be handled the same time? Should I 393 00:24:29,850 --> 00:24:34,980 be going to find an OCD expert, or should I find it depression? 394 00:24:35,580 --> 00:24:39,840 Expert? Sometimes they're the same. A lot of times, they're 395 00:24:39,840 --> 00:24:43,200 not or maybe there's other anxiety issues, or there could 396 00:24:43,200 --> 00:24:47,790 be substance use issues or eating disorder. Eating issues 397 00:24:47,790 --> 00:24:53,250 is how often do you find co occurring disorders and how 398 00:24:53,250 --> 00:24:58,320 should parents think about seeking help for their child? 399 00:24:58,740 --> 00:24:59,250 Yeah, 400 00:24:59,280 --> 00:25:02,430 Brad Riemann: great, great quote. And so comorbidity is the 401 00:25:02,430 --> 00:25:05,640 rule when it comes to OCD. But keep in mind, you know, 402 00:25:05,880 --> 00:25:09,270 behavioral health issues, do kind of cluster. So I mean, it's 403 00:25:09,270 --> 00:25:14,340 it's not just an OCD issue, it's pretty common for someone who 404 00:25:14,340 --> 00:25:16,890 has, you know, issues in one area of their life to 405 00:25:16,890 --> 00:25:19,650 potentially have it in another but pertaining to OCD, 406 00:25:19,650 --> 00:25:23,670 comorbidity is the rule meaning. Most studies find that children 407 00:25:23,670 --> 00:25:29,700 with OCD have about 60% of kids with OCD will have at least one 408 00:25:29,700 --> 00:25:35,070 additional diagnosis, the really common comorbidities in kids, 409 00:25:35,460 --> 00:25:40,770 ADHD, tic disorders, depression, as you mentioned, other anxiety 410 00:25:40,770 --> 00:25:46,140 disorders. So it is pretty common. And, you know, some of 411 00:25:46,140 --> 00:25:48,990 these things like the depression, Alec seems to be 412 00:25:49,290 --> 00:25:53,550 kind of secondary to OCD. In other words, as you learn more 413 00:25:53,550 --> 00:25:57,870 about OCD, it's not really a question as to why is somebody 414 00:25:57,870 --> 00:26:02,340 sad and feeling hopeless and helpless, it's a bad thing to 415 00:26:02,340 --> 00:26:05,040 have, right. And so I think quite naturally, it starts to 416 00:26:05,040 --> 00:26:08,730 pull people's mood down. So depression, for example, is 417 00:26:08,820 --> 00:26:11,760 commonly secondary to the OCD. And what I mean by that is, if 418 00:26:11,760 --> 00:26:17,250 you get into good treatment, if you are in treatment for OCD is 419 00:26:17,250 --> 00:26:20,940 really kind of you want high quality exposure and response 420 00:26:20,940 --> 00:26:24,450 prevention, but you also need the right dose of it. And I'll 421 00:26:24,450 --> 00:26:27,450 get back to that in a moment. But if you're getting high 422 00:26:27,450 --> 00:26:31,200 quality treatment for their OCD, and their OCD symptoms go down, 423 00:26:31,560 --> 00:26:35,370 the depression tends to go along with it more often than not, I 424 00:26:35,370 --> 00:26:38,430 mean, they're depressed because they're anxious, right. And so 425 00:26:38,460 --> 00:26:41,100 the good news is there as you you know, you can kind of get a 426 00:26:41,100 --> 00:26:43,110 little too for one, but some of these other things that you 427 00:26:43,110 --> 00:26:47,010 brought up are freestanding problems. And at times, there 428 00:26:47,010 --> 00:26:50,670 may be some treatment overlap, a clinician treating your OCD 429 00:26:50,880 --> 00:26:53,580 could maybe just pivot the treatment plan slightly to be 430 00:26:53,580 --> 00:26:56,430 able to address some of these other conditions. And then some 431 00:26:56,430 --> 00:27:00,270 of them may need some expertise that your OCD provider might not 432 00:27:00,270 --> 00:27:06,120 have. And so then there there may need to be, you know, a 433 00:27:06,120 --> 00:27:12,060 referral elsewhere. And the the order of that treatment also 434 00:27:12,090 --> 00:27:15,360 depends, I mean, again, if it's a primary OCD, that really means 435 00:27:15,360 --> 00:27:18,120 that it is the number one problem causing interference in 436 00:27:18,120 --> 00:27:23,190 your child's life, then that should be the priority. And 437 00:27:23,190 --> 00:27:29,130 these other things can, can can wait. Now, it also depends get 438 00:27:29,130 --> 00:27:32,310 back to the dose from for a moment, and we talk about dose 439 00:27:32,310 --> 00:27:35,040 of treatment all the time when we think about medication, you 440 00:27:35,040 --> 00:27:37,770 know, 20 milligrams of this versus 40 milligrams of this 441 00:27:38,220 --> 00:27:41,340 dose rarely comes up Alex when we're talking about psychosocial 442 00:27:41,340 --> 00:27:45,600 treatments, but there is truly a dosage effect for many 443 00:27:45,900 --> 00:27:49,410 behavioral health and addiction problems with OCD for sure. And 444 00:27:49,410 --> 00:27:54,120 what I mean by that is, you know, the, the more complex, the 445 00:27:54,120 --> 00:27:59,160 more complicated the OCD, and that is within OCD, also with 446 00:27:59,370 --> 00:28:02,100 comorbidity, right, I mean, you know, do they have other things 447 00:28:02,100 --> 00:28:06,480 going on, which we said is already the rule. It's how much 448 00:28:06,480 --> 00:28:09,570 good ERP how much high quality treatment do you need to get 449 00:28:09,570 --> 00:28:13,230 better, and there is this dosage effect. And many people because 450 00:28:13,230 --> 00:28:15,690 of that level of disability, remember, it's a 10th leading 451 00:28:15,690 --> 00:28:19,620 cause of disability, the world may need more than high quality 452 00:28:19,620 --> 00:28:22,950 one or two hours a week. So they may need intensive outpatient, 453 00:28:22,950 --> 00:28:25,860 which might be two, three hours a day, three to five times a 454 00:28:25,860 --> 00:28:28,350 week, they may need a day treatment program, they may need 455 00:28:28,350 --> 00:28:32,700 residential care, and that 24 hour support. Now, thankfully, 456 00:28:33,150 --> 00:28:36,150 you know, that is a small minority of these patients. But 457 00:28:36,150 --> 00:28:39,390 it is enough that obviously there are specialty OCD 458 00:28:39,390 --> 00:28:43,500 residential programs that in that case, they have they have 459 00:28:43,500 --> 00:28:46,710 enough time with this youngster to not only address the severe 460 00:28:46,710 --> 00:28:49,980 OCD, but these other comorbid problems as well. Yeah. 461 00:28:51,299 --> 00:28:56,969 Alex Stavros: So we had a you mentioned ERP, we have a as you 462 00:28:56,969 --> 00:29:01,769 know, Southern California outpatient clinic that offer OCD 463 00:29:01,769 --> 00:29:08,909 programs for teenagers in an IOP using ERP, which as you 464 00:29:08,909 --> 00:29:14,519 mentioned is the gold standard. And we also offer a virtual IOP 465 00:29:14,849 --> 00:29:22,889 OCD program also using ERP as as the gold standard. We once had a 466 00:29:22,889 --> 00:29:26,429 child who lived nearby one of our brick and mortar outpatient 467 00:29:26,429 --> 00:29:32,099 clinics and had enrolled in the OCD program, but can never get 468 00:29:32,099 --> 00:29:37,409 there. They just weren't able to leave the house. And so there's 469 00:29:37,409 --> 00:29:39,869 part of it in terms of there was this initial step and it didn't 470 00:29:39,869 --> 00:29:43,649 mean that that first step we couldn't even accomplish. So 471 00:29:43,649 --> 00:29:49,469 fortunately, we were able to enroll in the virtual program as 472 00:29:49,469 --> 00:29:54,089 a first step with the main goal of helping this young boy teen 473 00:29:54,089 --> 00:29:57,839 boy be able to leave the home first of all, to be able to 474 00:29:57,839 --> 00:30:01,529 transition to be to his near his Tom and accessible to be there 475 00:30:02,189 --> 00:30:06,419 in person and continue that treatment. You know, we we know 476 00:30:06,419 --> 00:30:10,979 that you recently co authored an article on the benefits of 477 00:30:10,979 --> 00:30:14,879 telehealth for pediatric OCD, I would love if you could share a 478 00:30:14,879 --> 00:30:17,609 little bit what you found in that study? 479 00:30:18,059 --> 00:30:20,399 Brad Riemann: Yeah, yeah, no, that's, that's, it's 480 00:30:20,399 --> 00:30:22,979 interesting. And you brought up a perfect example. I mean, 481 00:30:22,979 --> 00:30:26,669 sometimes, you know, whether it's a child or an adult, I 482 00:30:26,669 --> 00:30:29,039 mean, they're debilitated enough by this condition and their 483 00:30:29,039 --> 00:30:33,809 anxiety, that they're really not able to access care outside of 484 00:30:33,809 --> 00:30:37,709 their home. You know, COVID, obviously changed everything. 485 00:30:37,799 --> 00:30:41,459 And all of the programs that I had been associated with over 486 00:30:41,459 --> 00:30:45,239 the years, were always in person treatment. But we had to pivot 487 00:30:45,869 --> 00:30:49,439 very, very quickly, right. And within seven days, we 488 00:30:49,439 --> 00:30:54,149 transitioned, you know, literally over 1000, patients 489 00:30:54,149 --> 00:30:58,979 that were receiving intensive treatment in IOP, AND PHP, to 490 00:30:58,979 --> 00:31:03,659 telehealth because of the, you know, the pandemic, obviously. 491 00:31:04,049 --> 00:31:06,209 And we began to collect data immediately, because we wanted 492 00:31:06,209 --> 00:31:10,799 to make sure that this treatment was still effective. This study 493 00:31:10,799 --> 00:31:14,789 that you mentioned, that we published, really supports that. 494 00:31:14,789 --> 00:31:19,919 So to make a long story short. Now, again, this is primary OCD. 495 00:31:21,179 --> 00:31:25,409 In kids, and they're receiving three hours a day of treatment, 496 00:31:26,399 --> 00:31:30,419 a day or six hours a day of treatment in the day treatment, 497 00:31:30,419 --> 00:31:34,289 or partial hospital programs, the outcomes were basically 498 00:31:34,289 --> 00:31:39,479 identical. This treatment, when done in a high quality 499 00:31:39,509 --> 00:31:45,389 structured kind of protocolized or manualized, fashion, produced 500 00:31:45,419 --> 00:31:49,919 equal outcomes in these in these patients. The only difference is 501 00:31:49,919 --> 00:31:54,299 we needed two days longer for the telehealth IOP to get the 502 00:31:54,299 --> 00:31:56,849 same benefit, which was kind of an interesting little thing. 503 00:31:57,209 --> 00:31:59,729 It's not insignificant. I mean, especially if you're a payer, I 504 00:31:59,729 --> 00:32:03,089 mean, two extra days that there's a cost to that. But the 505 00:32:03,089 --> 00:32:08,099 bottom line is, is these kids got better equally telehealth or 506 00:32:08,609 --> 00:32:12,569 in person. Now, what I think will be fascinating, Alex, any 507 00:32:12,569 --> 00:32:16,709 kind of follow ups to those things? Is we also however, were 508 00:32:16,709 --> 00:32:21,149 aware that there were probably, you know, some young individuals 509 00:32:21,149 --> 00:32:24,119 who did not do as well, telehealth I mean, at the 510 00:32:24,119 --> 00:32:27,119 individual level, not at the group level with hundreds and 511 00:32:27,119 --> 00:32:29,339 hundreds and hundreds of patients. And there were 512 00:32:29,339 --> 00:32:33,119 probably people who didn't respond to telehealth, who would 513 00:32:33,119 --> 00:32:36,269 have responded to in person. And I think the the interesting 514 00:32:36,269 --> 00:32:40,229 thing would be to kind of find out what predictors, you know, 515 00:32:40,259 --> 00:32:43,799 would we be able to what kind of data could we collect from an 516 00:32:43,799 --> 00:32:47,759 individual who is considering treatment, and say, you know, 517 00:32:47,759 --> 00:32:49,979 what, Alex, based on your responses to this, you have a 518 00:32:49,979 --> 00:32:53,729 choice, you could do telehealth or in person, or based on your 519 00:32:53,729 --> 00:32:58,019 responses here, you know, you really need to do in person. And 520 00:32:58,019 --> 00:33:02,129 that ability to predict would be incredibly powerful. You brought 521 00:33:02,129 --> 00:33:06,599 up a perfect example of someone who could get geographic access 522 00:33:06,599 --> 00:33:10,769 to this clinic, but was too anxious. And the goal in 523 00:33:10,769 --> 00:33:13,439 treatment was to lower that to get him to come up with some, as 524 00:33:13,439 --> 00:33:15,929 you know, no matter how many clinics you have, say, 525 00:33:15,929 --> 00:33:18,959 California that you brought up, it's an enormous state. And you 526 00:33:18,959 --> 00:33:22,649 could still be four or five, six hours away from your nearest 527 00:33:22,709 --> 00:33:26,519 specialty clinic. And as a result, being able to plug in 528 00:33:26,519 --> 00:33:29,099 telehealth would be a huge advantage. 529 00:33:29,669 --> 00:33:32,939 Alex Stavros: Yeah, yeah. It's really a great, great study and 530 00:33:32,999 --> 00:33:36,869 great conclusion, given the issues of accessibility and 531 00:33:37,319 --> 00:33:42,869 realizing that the vast majority of teens who are struggling with 532 00:33:42,869 --> 00:33:48,779 OCD, vast majority do not have geographic access to high 533 00:33:48,779 --> 00:33:53,579 quality. That's right. IOP for specialized in OCD, or PHP using 534 00:33:53,579 --> 00:33:56,579 the gold standard of ERP, it's the vast majority don't have 535 00:33:56,579 --> 00:34:00,869 that. So knowing that there are these telehealth options, that 536 00:34:00,869 --> 00:34:04,079 when done right, can provide similar outcomes. 537 00:34:04,649 --> 00:34:07,559 Brad Riemann: Yeah, yeah. And to your point, I mean, even though 538 00:34:07,559 --> 00:34:12,029 it's such a common problem, and it's such a treatable problem, 539 00:34:12,059 --> 00:34:15,119 the vast majority of sufferers do not have that geographic 540 00:34:15,119 --> 00:34:18,869 access. In obviously, you were mentioning the programs that 541 00:34:18,869 --> 00:34:22,169 Embark is opening up that's welcomed, right, I mean, in 542 00:34:22,169 --> 00:34:27,689 other words, the the demand exceeds the ability to provide 543 00:34:27,689 --> 00:34:31,439 and these new programs are going to open up access to a lot of 544 00:34:31,439 --> 00:34:32,729 young people who need care. 545 00:34:33,899 --> 00:34:37,949 Alex Stavros: You mentioned how treatable disorder is can you 546 00:34:37,949 --> 00:34:41,699 share a little bit more that can provide some hope for if there's 547 00:34:41,699 --> 00:34:44,429 a teenager young adult watching this podcast or for a parent? 548 00:34:44,459 --> 00:34:46,799 What are some of those statistics or some of your 549 00:34:46,799 --> 00:34:50,969 experience around when when treatment is done? Well 550 00:34:50,999 --> 00:34:56,069 standardized and with protocols and, and using ERP with 551 00:34:56,099 --> 00:34:59,969 experienced clinicians? How treatable is it? Yeah, 552 00:35:01,140 --> 00:35:03,090 Brad Riemann: In my opinion, Aleks, honestly, it's the most 553 00:35:03,090 --> 00:35:07,230 treatable psychiatric problem we have, when treated properly and 554 00:35:07,230 --> 00:35:10,650 properly being again defined as the right kind of treatment 555 00:35:10,650 --> 00:35:13,020 delivered in a high quality care, and then the right 556 00:35:13,020 --> 00:35:16,050 quantity that we're talking about that dosage effect, right. 557 00:35:16,440 --> 00:35:19,530 And so plugging somebody into the appropriate level of care, 558 00:35:19,950 --> 00:35:23,580 the majority of people with OCD can benefit from high quality 559 00:35:23,580 --> 00:35:27,270 ERP just one or two hours a week. But then there's a subset 560 00:35:27,270 --> 00:35:29,940 of patients who just have to have more than that, I mean, 561 00:35:29,940 --> 00:35:34,200 it's just the dose isn't high enough. And so then this is 562 00:35:34,200 --> 00:35:37,920 where the IOP has come into play. In some cases, even those 563 00:35:38,280 --> 00:35:41,910 partial hospital programs or PHPs, provide six hours and then 564 00:35:41,910 --> 00:35:45,960 of course, residential for thankfully, the minority of 565 00:35:45,960 --> 00:35:49,260 patients. But again, it is a fairly large number because of 566 00:35:49,260 --> 00:35:53,100 how common the problem is, but it's very, very treatable. Just 567 00:35:53,130 --> 00:35:57,450 some examples. You know, the the overall kind of success rates 568 00:35:57,450 --> 00:36:02,730 that one will read about in the field 80 to 85% of people who 569 00:36:02,730 --> 00:36:05,310 will engage in this treatment, respond to care and get 570 00:36:05,310 --> 00:36:10,380 significantly clinically meaningfully better. In my 571 00:36:10,380 --> 00:36:16,710 world, you know, 90% of our IOP patients responded, 81% of our 572 00:36:16,710 --> 00:36:20,010 residential patients responded. And that's interesting, because 573 00:36:20,340 --> 00:36:24,600 these residential patients were considered treatment refractory, 574 00:36:24,630 --> 00:36:28,200 you know, they were considered patients who were were not able 575 00:36:28,200 --> 00:36:31,170 to get better from treatment. And it's all about the dose 576 00:36:31,170 --> 00:36:36,180 piece, right, they just didn't have enough dose of it. And once 577 00:36:36,180 --> 00:36:39,330 given that proper dosage, they got better. The reality of 578 00:36:39,330 --> 00:36:43,440 though is this, you get out of it, what you put in it, and this 579 00:36:43,440 --> 00:36:48,060 is not a treatment, Alex that one can benefit from, passively. 580 00:36:48,240 --> 00:36:52,290 This is not something that one can absorb, but it is one that 581 00:36:52,290 --> 00:36:56,280 you have to be an active participant in. And as a result, 582 00:36:56,310 --> 00:37:00,480 you know, when you hear things like 85%, or 90%, or whatever it 583 00:37:00,480 --> 00:37:06,330 might be, you know, there are patients who do put in effort 584 00:37:06,330 --> 00:37:09,540 who don't respond, nothing's perfect. But the vast majority 585 00:37:09,540 --> 00:37:13,350 of patients who don't respond are unfortunately, either 586 00:37:13,350 --> 00:37:17,400 unwilling or unable to really do the work that they need to do it 587 00:37:17,400 --> 00:37:22,230 is against something where, you know, it is an active engagement 588 00:37:22,230 --> 00:37:25,650 in this treatment. But if people do that, they get better. 589 00:37:26,220 --> 00:37:29,190 Alex Stavros: You mentioned about the doses and and levels 590 00:37:29,190 --> 00:37:33,960 of care. Something that's so important to be able to provide 591 00:37:33,960 --> 00:37:38,070 that as simply having a continuum of care were starting 592 00:37:38,070 --> 00:37:41,310 at that lower level of care. And maybe that one or two hours a 593 00:37:41,310 --> 00:37:45,600 week is able to address the issue. But if it's not, we want 594 00:37:45,600 --> 00:37:48,210 to move to that three hours a day, three times a week. And if 595 00:37:48,210 --> 00:37:50,790 that doesn't work three hours a day, five times a week, then 596 00:37:50,790 --> 00:37:54,540 five, six hours a day, and RTC being able to step up. And 597 00:37:54,930 --> 00:37:58,290 that's good, just good health care, good health care system 598 00:37:58,290 --> 00:38:01,440 where we intervene at the lowest level of care, possible, least 599 00:38:01,440 --> 00:38:04,260 invasive, try to get that to work. But if it doesn't, we can 600 00:38:04,260 --> 00:38:07,050 quickly step up so we can nip nip it in the bud and then step 601 00:38:07,050 --> 00:38:10,860 them back down, it's less expensive, less invasive, that 602 00:38:10,860 --> 00:38:14,610 continuum of care is really important for delivering good 603 00:38:14,610 --> 00:38:15,150 outcomes. 604 00:38:15,420 --> 00:38:18,090 Brad Riemann: And as you point out, both up and down. In other 605 00:38:18,090 --> 00:38:22,350 words, you know, if somebody is in a residential program, you 606 00:38:22,350 --> 00:38:25,170 know, as you know, Alex, the goal is not to get them symptom 607 00:38:25,170 --> 00:38:29,400 free. It the goal is to get them to the point where they're, you 608 00:38:29,400 --> 00:38:32,490 know, responding to care that they don't need 24 hour support 609 00:38:32,490 --> 00:38:36,300 anymore. And then if they go right back into outpatient, if 610 00:38:36,300 --> 00:38:39,690 they go from that to one hours a week, that's kind of a big thud, 611 00:38:39,930 --> 00:38:45,570 if you will, and, and and to your point in, in medicine, in 612 00:38:45,570 --> 00:38:47,910 a, you know, general medical surgical world, you know, 613 00:38:47,910 --> 00:38:51,510 there's these step downs. And that's exactly what we have to 614 00:38:51,510 --> 00:38:55,290 build in our world. And, and so it's, it's being able to ratchet 615 00:38:55,290 --> 00:38:59,160 it up if they need more dose, but then it's that stepping down 616 00:38:59,190 --> 00:39:03,960 as well. And in the key here, to your point, Alex, is that even 617 00:39:03,960 --> 00:39:09,510 if someone has tried what they believe is truly high quality 618 00:39:09,510 --> 00:39:13,350 ERP, you don't want to throw the ERP baby out with the bathwater, 619 00:39:13,350 --> 00:39:15,570 so to speak. You don't want to sit back and say, Well, we tried 620 00:39:15,570 --> 00:39:19,530 that and it didn't work. It could be again, that the dose of 621 00:39:19,530 --> 00:39:22,620 the treatment you're receiving did not match the severity and 622 00:39:22,620 --> 00:39:24,870 the complexity of what you needed. 623 00:39:25,440 --> 00:39:27,840 Alex Stavros: Yeah, yeah. And I love that you brought up the 624 00:39:28,380 --> 00:39:32,430 kind of general health care as you don't see people going to 625 00:39:32,430 --> 00:39:36,540 get knee surgery and then being sent home without a brace or any 626 00:39:36,540 --> 00:39:40,410 physical therapy wouldn't go very well and they have follow 627 00:39:40,410 --> 00:39:43,170 ups with their doctor but often that happens in our mental 628 00:39:43,170 --> 00:39:45,240 health care system for you. There's they'll end up in a 629 00:39:45,240 --> 00:39:48,840 hospital or even a residential treatment center and then 630 00:39:48,840 --> 00:39:53,070 afterwards discharged, and haven't seen improvements and go 631 00:39:53,070 --> 00:39:56,520 straight home. It's as if you had knee surgery, and you go 632 00:39:56,520 --> 00:39:59,100 straight home with no physical therapy. That doesn't mean the 633 00:39:59,100 --> 00:40:01,920 knee surgery. What wasn't effective, as long as you didn't 634 00:40:01,920 --> 00:40:05,880 do the proper continuing, continuing care needed, 635 00:40:06,210 --> 00:40:10,710 developing more of that. If I'm a parent, and I'm looking for a 636 00:40:10,710 --> 00:40:13,320 therapist, because it may be the one to two hours, or maybe you 637 00:40:13,320 --> 00:40:15,630 have been doing the one or two hours, but it's not working. And 638 00:40:15,630 --> 00:40:18,690 so I want a higher dose. So I'm looking for an IOP, or the PHP, 639 00:40:18,990 --> 00:40:21,360 partial hospitalization program, therapeutic day treatment 640 00:40:21,360 --> 00:40:25,320 program, or even RTS C. Now I'm a parent, what should I be 641 00:40:25,320 --> 00:40:28,680 looking for? What should I be Googling, what type of 642 00:40:28,680 --> 00:40:32,130 treatments exist? What type of programs are there out there? 643 00:40:32,520 --> 00:40:36,090 And how can you guide me a little bit into making sure that 644 00:40:36,090 --> 00:40:39,840 it is high quality and that I know that we likely are going to 645 00:40:39,840 --> 00:40:42,720 get the right dosage, the right interventions and treatments 646 00:40:43,170 --> 00:40:44,250 that are the most effective? 647 00:40:45,120 --> 00:40:47,160 Brad Riemann: Yeah, those are great questions. I mean, in 648 00:40:47,160 --> 00:40:51,060 again, in the OCD realm, you know, the thing that you are 649 00:40:51,060 --> 00:40:54,390 looking for is exposure and Response Prevention, or again, 650 00:40:54,390 --> 00:40:56,610 sometimes referred to as exposure and ritual prevention. 651 00:40:56,610 --> 00:41:00,450 It's the same treatment, ERP, nonetheless, that is the key 652 00:41:00,450 --> 00:41:04,110 ingredient you're looking for. You don't want to just find 653 00:41:04,110 --> 00:41:09,450 someone who says they treat OCD. You don't want to find someone 654 00:41:09,450 --> 00:41:12,510 who says they use evidence based treatment, evidence based 655 00:41:12,510 --> 00:41:17,580 treatment, Alex's. That is this idea that research has found 656 00:41:17,580 --> 00:41:22,770 this treatment to work for this condition. But when we think 657 00:41:22,770 --> 00:41:25,110 about evidence based treatment, we also have to make sure Yeah, 658 00:41:25,110 --> 00:41:30,150 but that clinician can apply that evidence based treatment to 659 00:41:30,150 --> 00:41:34,890 patients just as well as that study did, right. So you know, I 660 00:41:34,890 --> 00:41:38,280 can, I can say I do these things. But that doesn't mean I 661 00:41:38,280 --> 00:41:43,320 really know what to do. And so you got to do your homework, 662 00:41:43,320 --> 00:41:46,560 most people spend more time picking out the person who's 663 00:41:46,560 --> 00:41:48,900 going to tile their bathroom than they do their mental health 664 00:41:48,900 --> 00:41:51,300 care provider, unfortunately, you know, right, Alex, and so 665 00:41:51,510 --> 00:41:53,670 you got to do your homework, you have to do your due diligence, 666 00:41:53,670 --> 00:41:56,670 and you want to make sure that they do this. You want to ask 667 00:41:56,670 --> 00:42:00,150 them, how many patients with OCD have you treated? How many have 668 00:42:00,150 --> 00:42:04,260 you treated successfully? You know, if they're starting to use 669 00:42:04,260 --> 00:42:09,360 some of the jargon, ERP, obviously, or exposure work or 670 00:42:09,360 --> 00:42:12,660 exposure hierarchies, and that's just the big master list of all 671 00:42:12,660 --> 00:42:16,260 of the exposures that that this young person with OCD is going 672 00:42:16,260 --> 00:42:20,460 to have to do that starting to ring some bells. But you know, 673 00:42:20,820 --> 00:42:24,120 ask questions, I mean, be informed. This is important. 674 00:42:24,150 --> 00:42:28,410 And, sadly, there are not that many people who specialize in 675 00:42:28,410 --> 00:42:31,860 this, we did mention the international OCD foundation 676 00:42:31,860 --> 00:42:36,330 before they do have a tab, find a therapist, I'm assuming 677 00:42:36,420 --> 00:42:40,530 parents could reach out to Embark in Embark would also 678 00:42:40,530 --> 00:42:43,020 steer people in the right direction. I mean, obviously, 679 00:42:43,020 --> 00:42:45,720 you might have a program that could help them in the vicinity 680 00:42:45,720 --> 00:42:49,770 that they live, or you could direct them elsewhere. But it 681 00:42:49,770 --> 00:42:55,110 takes a very specific kind of intervention to be effective. 682 00:42:55,140 --> 00:42:58,260 And in the end the dose to your point. 683 00:42:59,280 --> 00:43:02,190 Alex Stavros: Speaking of dose, can you discuss a little bit the 684 00:43:02,190 --> 00:43:07,320 role of medication and treat OCD? What? What are the 685 00:43:07,320 --> 00:43:10,260 considerations? And What should parents know about medication? 686 00:43:10,260 --> 00:43:11,910 OCD? Yeah, 687 00:43:11,940 --> 00:43:14,100 Brad Riemann: so So there are medicines that have been found 688 00:43:14,100 --> 00:43:19,200 to be helpful Alex and treating OCD. These medicines all come 689 00:43:19,200 --> 00:43:24,090 from a subset of antidepressants that affect a brain chemical 690 00:43:24,090 --> 00:43:29,130 called serotonin. The good news we mentioned before that, you 691 00:43:29,130 --> 00:43:32,100 know, like, for example, depression is a common comorbid 692 00:43:32,100 --> 00:43:36,090 condition. So if you have a youngster with OCD, who is also 693 00:43:36,090 --> 00:43:39,000 depressed, these medicines kind of give you a little bit of a 694 00:43:39,030 --> 00:43:42,270 double whammy or a two for one, you know, you're kind of helping 695 00:43:42,390 --> 00:43:47,070 nudge that depression along as well as the OCD. These medicines 696 00:43:47,550 --> 00:43:53,310 provide somewhere between 25 and 30% symptom reduction in the 697 00:43:53,310 --> 00:43:57,210 average patient. Some people get much more production than that 698 00:43:57,300 --> 00:44:00,210 some people unfortunately, get none. But on average, you can 699 00:44:00,240 --> 00:44:04,260 expect about a 25 to 30% symptom reduction, which could be the 700 00:44:04,260 --> 00:44:07,230 difference between being able to go to school or not, or being 701 00:44:07,230 --> 00:44:09,600 able to go to work or not, or being able to engage in social 702 00:44:09,600 --> 00:44:13,320 relationships or not. The medicines are rarely enough in 703 00:44:13,320 --> 00:44:17,430 and of themselves. In ERP is really again, considered the 704 00:44:17,430 --> 00:44:21,240 gold standard. So there was an expert consensus study done many 705 00:44:21,240 --> 00:44:25,110 years ago that I participated in and the consensus of the expert 706 00:44:25,110 --> 00:44:30,150 OCD community was that everyone with OCD should get exposure and 707 00:44:30,150 --> 00:44:33,390 response prevention, some should get exposure and Response 708 00:44:33,390 --> 00:44:35,610 Prevention Plus medication. Great. 709 00:44:35,700 --> 00:44:37,770 Alex Stavros: Thank you. As you'd mentioned earlier, it's 710 00:44:38,310 --> 00:44:42,150 the 10th leading cause of disability and there are 711 00:44:42,570 --> 00:44:46,620 millions of people in United States who are affected by OCD. 712 00:44:47,400 --> 00:44:51,570 So a lot more common than people know. In fact, my guess is some 713 00:44:51,570 --> 00:44:55,020 people may be surprised to know that Cameron DS and Leonardo Di 714 00:44:56,070 --> 00:45:03,000 Caprio and Justin Timberlake are all living with The OCD. And I 715 00:45:03,000 --> 00:45:08,130 share that just to open up a question around awareness and 716 00:45:08,130 --> 00:45:12,270 stigma. What would you recommend? And what advice would 717 00:45:12,270 --> 00:45:15,210 you give? What steps can individuals take to raise 718 00:45:15,210 --> 00:45:19,590 awareness about OCD and reduce that stigma? and advocate for 719 00:45:19,590 --> 00:45:22,530 better understanding and support? Yeah, 720 00:45:22,560 --> 00:45:24,060 Brad Riemann: no one, as you pointed out, I mean, there's 721 00:45:24,060 --> 00:45:27,720 been many famous people over, over the centuries, and 722 00:45:27,720 --> 00:45:32,010 certainly even currently, that have that an and I do think, 723 00:45:32,040 --> 00:45:35,160 Alex, that that does help, especially young people, I mean, 724 00:45:35,370 --> 00:45:39,240 you know, if you look up to athletes, or movie stars, or 725 00:45:39,270 --> 00:45:43,260 musicians and, and, you know, it just, it does normalize things. 726 00:45:43,260 --> 00:45:47,160 And I think, you know, to fight stigma, that is what you have to 727 00:45:47,160 --> 00:45:52,980 have is normalization. You're not crazy, you're not weird. You 728 00:45:52,980 --> 00:45:56,400 have a medical condition. Right? And, and we unfortunately, 729 00:45:56,400 --> 00:46:01,230 separate out mind from body. This is a medical condition, as 730 00:46:01,230 --> 00:46:03,960 I said, every year we get more and more evidence that it is 731 00:46:03,960 --> 00:46:10,500 truly a neurobiological issue, a medical issue. And, you know, I 732 00:46:10,500 --> 00:46:13,830 think that that's the key, I mean, it just realize that there 733 00:46:13,830 --> 00:46:17,550 are many people out there with this condition, some famous, 734 00:46:17,550 --> 00:46:21,540 most not but many people with this condition. And then I think 735 00:46:21,540 --> 00:46:25,200 just that the hope of treatment, I mean, you know, I think, you 736 00:46:25,200 --> 00:46:28,590 know, knowing that there is effective care out there, and 737 00:46:28,590 --> 00:46:33,120 that there is hope. And there is help, also, you know, 738 00:46:33,120 --> 00:46:36,180 dramatically reduces all that fear and stigma as well. 739 00:46:38,040 --> 00:46:41,460 Alex Stavros: Love the overarching message of of hope 740 00:46:41,550 --> 00:46:45,900 that particularly that evidence that this is one of the most 741 00:46:45,900 --> 00:46:51,000 treatable of behavioral health conditions. What else would you 742 00:46:51,000 --> 00:46:54,870 leave parents and others and the family or community or friends 743 00:46:55,350 --> 00:46:59,160 who have a loved one? who's struggling with OCD? Any, any 744 00:46:59,370 --> 00:47:02,220 parting thoughts, or comments you'd want to share with them? 745 00:47:02,850 --> 00:47:08,700 Brad Riemann: Yeah. You know, it is common. It is very 746 00:47:08,700 --> 00:47:13,650 debilitating, unfortunately. And it rarely goes away on its own 747 00:47:13,650 --> 00:47:16,950 Alex again, I never say never, but it really doesn't, it's 748 00:47:16,950 --> 00:47:21,210 going to take intervention medication, ERP or a combination 749 00:47:21,210 --> 00:47:26,070 of the two. And if anything, it tends to continue to kind of 750 00:47:26,070 --> 00:47:30,240 exacerbate over time, right. So in youth, it tends to kind of 751 00:47:30,240 --> 00:47:35,820 continue to escalate, then somewhere in you know, young 752 00:47:35,820 --> 00:47:40,020 adulthood, late 20s, maybe around 30. For most, it tends to 753 00:47:40,020 --> 00:47:43,530 plateau off, but it's plateauing off at a pretty debilitating 754 00:47:43,530 --> 00:47:48,240 level, right. And so, you know, it is common, it's debilitating, 755 00:47:48,270 --> 00:47:52,710 it's not going to go away on its own. And there are resources to 756 00:47:52,710 --> 00:47:56,640 help. And you're just going to have to, again, kind of roll up 757 00:47:56,640 --> 00:48:00,990 your sleeves and find the right provider. The good news is, as 758 00:48:01,020 --> 00:48:04,080 you know, there are more and more trained providers every 759 00:48:04,080 --> 00:48:07,500 year. There are more and more intensive programs every year, 760 00:48:07,500 --> 00:48:11,490 still not nearly enough. And then to your point, if you don't 761 00:48:11,490 --> 00:48:14,760 have geographic access, you might be able to plug into a 762 00:48:14,760 --> 00:48:18,990 good telehealth program. And the good news is insurance tends to 763 00:48:18,990 --> 00:48:23,460 support these programs. You know, they insurance understands 764 00:48:23,820 --> 00:48:26,370 OCD, and understands how debilitating it is and and 765 00:48:26,370 --> 00:48:30,300 understands it's not just a whim or a phase that Johnny's going 766 00:48:30,300 --> 00:48:33,510 through. And if anything, it's going to get worse. And so they 767 00:48:33,510 --> 00:48:36,870 do support treatments and including intensive treatments. 768 00:48:37,620 --> 00:48:37,950 Great. 769 00:48:37,950 --> 00:48:39,930 Alex Stavros: Well, thank you, Dr. Raman. So much for your 770 00:48:39,930 --> 00:48:43,110 time. We're really grateful for your clinical leadership and 771 00:48:43,320 --> 00:48:47,460 clinical expertise. And we love that we're partnered together 772 00:48:47,460 --> 00:48:51,420 and working together now as your partner Embark team on on 773 00:48:51,420 --> 00:48:55,230 developing more comprehensive and even higher quality and more 774 00:48:55,230 --> 00:48:58,290 accessible treatment interventions and programs. And 775 00:48:58,290 --> 00:49:00,390 thank you again for your time today. We appreciate Thank you. 776 00:49:00,480 --> 00:49:03,930 Thank you all for listening to today's podcast. It was great to 777 00:49:03,930 --> 00:49:08,730 have Dr. Freeman on to talk about OCD. We appreciate you 778 00:49:08,730 --> 00:49:13,830 following liking and sharing this episode. You can go to 779 00:49:13,830 --> 00:49:18,210 where you can find our podcasts or our YouTube channel to follow 780 00:49:18,720 --> 00:49:20,610 and we look forward to seeing you on the next one.