Treating OCD
May 29, 2020
In this episode we are joined by Dr. Chad Brandt, a licensed clinical psychologist who specializes in severe to extreme cases of OCD. Dr. Brandt will be answering our questions about OCD and explaining how he creates treatment plans that help his patients return to their lives. Following Dr. Brand we are joined by Nick Jaworski, the CEO of Circle Social Inc., an addiction treatment and behavioral-health agency. Nick will be be giving us insight into how his company helps patients get connected to the treatment centers best equipped to meet their healthcare needs.
Welcome to Recovery Radio by Landmark Recovery with your host, Zach Crouch. In this program we’ll discuss the root causes and treatments of alcohol and substance addiction, speak with experts in related fields, and help navigate the road to recovery.
Now, here’s the host of Recovery Radio, Zach Crouch.
Zach: Hi. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and don’t forget to subscribe to get the most up-to-date information from leading experts.
We have guest Dr. Chad Brandt joining us on the show today. Dr. Brandt received his PhD in Clinical Psychology from the University of Houston and completed his pre-doctoral fellowship at the Baylor college of Medicine. Dr. Brandt is a licensed clinical psychologist in the state of Texas and he specializes in severe to extreme cases of OCD.
Dr. Brandt is a certified provider of the Bergen 4-Day Treatment, also known as B4DT and uses his training in the B4DT as well as Acceptance and Commitment Therapy as well as Cognitive Behavioral Therapy to develop and implement personalized and intensive OCD treatments to help people move on from OCD and return to their lives.
Dr. Brandt, it is a pleasure to have you on the show today.
Dr. Brandt: It’s a pleasure to be here. Thank you so much for having me.
Zach: You specialize in severe to extreme cases of OCD. I’m curious to know when is an extreme case of OCD and how does that impact someone’s life on a daily basis, so to speak?
Dr. Brandt: Absolutely. I can start by talking about maybe like a mild case of OCD and compare that to how it can get extreme. OCD is when somebody has obsessions or repeated unwanted, usually anxiety-producing thought. That’s the O of OCD, obsessions and C stands for compulsion which is the thing we do to get rid of the thoughts and D, disorder means it gets in the way of your daily life.
Kind of a mild or moderate OCD that people might be familiar with it might be a concern with contamination. I might have recurrent obsessions about having germs on my hands and maybe spraying them to other people and hurting other people. Somebody with mild OCD might have those once-an-hour for a couple minutes let’s say when they would do a compulsion.
They might wash their hands longer or more often than most people. They might avoid touching other people or might call and check in on family members to make sure they’re not sick, something like that. They’d have recurrent unwanted thoughts, the hand washing to get rid of the thought, maybe some other things and it would just get in the way of being able to focus on what’s important. OCD can just expand and kind of grow intimately.
The McLean OCD Institute of Houston is where I’m working now. We have one of the few residential OCD programs in the country. I’ve had patients who would spend eight, ten, twelve hours a day in the shower.
Zach: You mean non-stop they would be in the shower? Non-stop?
Dr. Brandt: Yes, non-stop, absolutely.
Zach: Wow.
Dr. Brandt: Yes, yes. You could imagine that would completely derail your life. I’ve had patients who have trouble doing things like walking because they’re afraid they might step with the wrong foot and get say, punished by God or harm a family member.
I’ve had patients who are very…to have obsessions about harming family members or loved ones so they might stay away from knives. They might stay away from sharp objects. They might completely withdraw from their family just to avoid hurting them which is just heartbreaking. When the OCD comes in…
Zach: Sure.
Dr. Brandt: Yes, it just takes what’s important to them. I have young family members who are just completely isolated from their family, long shower rituals, praying rituals, avoidance just really of all forms.
Zach: Right, right. I’ve got to ask a question and just as you brought all that up I was thinking about how your population’s responding right now due to the pandemic that’s going on. How has that affected the patients that you see?
Dr. Brandt: Yes, that is a good question. You know it’s interesting. There are some of my patients, a smaller percentage than you would get, ten or 20 percent maybe who are really, really worried or something about the coronavirus that they would spend hours and hours and hours washing, checking the news, checking their temperature, a handful of patients who really fall into the rabbit hole of checking their health or their family members’ health.
That’s a portion of my patients that I have, but it’s interesting that the vast majority of them actually aren’t as worried about coronavirus. What they’re doing is, the vast majority of the country right now is going the social distancing and the work-from-home and so they’re sitting at home with really nothing to do other than just kind of sit around and think. I’ve got some patients who are really falling into other kind of OCD rabbit holes, you might say and spending all of this extra time worrying about family members or washing their hands or other reasons or praying or doing things.
Even if they’re not concerned about the coronavirus, the downtime is really affecting a lot of people.
Zach: I can imagine. Are you having success with these…let me ask the question. Are you seeing people currently in person or is it mostly tele-health?
Dr. Brandt: I’m seeing people exclusively in tele-health right now. I’ve got a HIPAA compliant service to talk to people. I’m in my father-in-law’s office. My wife is in her office at home. A lot of states have actually relaxed the Leisinger laws to help people, help therapists get to the patients that we need. We had to close down our residential program when the virus hit, but I got temporary licenses in a few other states so I can still be checking in with my residents who all had to go home.
Zach: Are they responding pretty well given the restraints that you and they are under right now given this tele-health sort of scenario?
Dr. Brandt: You know tele-health was something I think we all had to get used to at first. I’m a people person. I just love to be in a room with somebody talking with them in person. It’s a little different doing it on tele-health, but you get a lot of access that you don’t get otherwise. I’m in that person’s home with them. If they need to do kind of exposure therapy, the facing your fear therapy with their OCD and it’s around their toilet, it’s great. We actually have their toilet right there.
I don’t have to ride to their home or practice on some other toilet. There are actually a lot of really unique benefits that we’re finding, too.
Zach: I’m curious to know as well. You bring up household objects being centers of fear would be my vernacular I guess for some of your patients that you see. Are there times when you actually do make home visits to people?
Dr. Brandt: Yes. I have a history of making home visits. Sometimes it’s just important to be in their home where their triggers are and sometimes I have a lot of patients who really can’t or haven’t left their home in days, weeks, months, sometimes years. I’m used to home visits and then to be able to do it, be in tele-health actually that part was easy. That part was fun. I get to be in their environment with them.
Zach: Absolutely. In our industry, in the substance use industry, there’s been a huge uptake especially in the past several years about recovery coaches and people following after they leave treatment. Do you find that that’s the case with your population as well, if that’s an effective form of course of treatment?
Dr. Brandt: Yes, that’s a really good question. It’s interesting because I’ve had patients who fall in both ends of the spectrum. I’ll tell my patients usually when I first meet them, “My job is to help you get better. Go back to your life, really don’t need me anymore.” I have some patients who really get a handle on their OCD, do the treatment. They really are able to do it themselves and I don’t have to speak with them. That’s fantastic. I love it when that happens.
I’ve got a number of patients who do like to touch base with me, still meet once a week, once a month, once a quarter just to kind of clean up around the edges. OCD, substance use these things can be sneaky and they can kind of leak in when we’re not paying attention. There are a number of people that I do check in with just intermittently. That can be again, over tele-health, over the phone. I’ve done in person in my office, home visits. You got to go where it’s important for them.
Zach: Do you see OCD as something that can, to sort of word it out it can be cured or is treating OCD similar to addiction in that you’re never really cured from the substance use disorder but you can like a chronic illness you can manage it?
Dr. Brandt: That’s a good question. I think that the field still grapples with that sometimes. The way I think about OCD, in order to be cured, in order to cure something there has to be something wrong or something kind of broken. I really don’t think people with OCD are broken. I don’t think there’s anything wrong with them. I see OCD for a lot of people as kind of a trick.
Once we’ve identified the trick that the OCD would use to get you kind of get stuck washing or whatever it is and gotten you out of the trick enough time, you can stay out of it on your own. What I’ll tell people sometimes is I really want them to move on from their OCD. I really want them to identify what it is and how to move on from it which is different than care.
That means every now and again we need to touch base. Maybe it means you figured out and you have it on your own. That’s just different for each person.
Zach: Yes. It’s an interesting thing you’d say, ‘learn the trick’. I remember in my grad school training. We had this theory of some kind. They’re going through the parental things that happen with potty training. There’s this one child. I think they brought up an example of the kid who would never learn potty train. They used to learn pooping as almost like as you said, trick. The name of the poop that will poop will be called the ‘sneaky poo’.
Sneaky poo will find a way to just kind of creep up on you and sneaky poo will show up or whatever, but the parents use that sort of terminology to help this person, this little kid potty train or whatever. Is that at all similar to what you’re talking about like with sort of maybe externalizing the OCD and making it something that you’re really trying to battle?
Dr. Brandt: I think that’s really common. I really like that term. I’ve got a two-and-a-half year old and four-and-a-half year old and my wife is also pregnant. I’m going to start using that. Thank you for that one.
Zach: Sure.
Dr. Brandt: We’ll try to personify OCD in a lot of ways in therapy that we do at our clinic. I really think it helps people say, “Oh, this isn’t me. This isn’t me kind of saying, we are making mistakes or whatever. I’m just kind of getting tricked by,” sometimes I call OCD like a cult, like a cult leader who’s kind of tricking you into thinking you can have the perfect answer to salvation if you just pray one more time and people get stuck praying for hours and hours.
Their OCD might be kind of Mr. Clean who’s kind of saying, “Oh yes. No. Toilets can be one hundred…I can guarantee you with a hundred percent certainty the toilet can be clean. Just clean over here just for ten more seconds and you’ll all be fine.” Of course, it’s never fine. How would we know? There’s a lot of talking about kind of brain tricks there, personifications that help people separate from it a little bit.
Zach: It makes sense. In your opinion, why can OCD lead I guess to substance use disorder? Is that common?
Dr. Brandt: It is really common. About 30 percent of people, 25, 30 percent of people with OCD will have a substance use disorder at some point in their lifetime and 70 percent of people who have both, the OCD comes first. People with OCD have more substance use and the OCD tends to come before the substance use.
If we think about what OCD is, it’s this unwanted thought that comes up. “Maybe I’m dirty,” let’s say. There’s an emotional reaction that comes with it. “Maybe I’m dirty and now I’m scared. I can get somebody else dirty. I could be gross forever,” or something like that.
The compulsion, the C of OCD is all aimed at making the fear go away. It’s like an emotional control strategy. There are things other than compulsions that we can use to control our emotion and substances are absolutely one of those things.
Zach: Absolutely.
Dr. Brandt: Yes. It just makes so much sense if somebody with OCD who might be stuck washing their hands right now would say at one point, “Golly, I’m so sick of this. My wife is yelling at me. I’m wasting the kids. If I just like have a beer,” at the onset of this thought and usually I relax enough to keep going.
You do that once. You do that twice. You do that three times and before we know it that’s come into your new kind of coping mechanism which certainly isn’t the healthy way we want to deal with thoughts at 10:00 in the morning or really anytime.
Zach: Absolutely.
Dr. Brandt: I think there’s a lot of a relapse.
Zach: If you take a look at some of…I mean if you’re looking at major mental illness like schizophrenia typically you can see the onset of that in the late teen, early 20’s that people have it. What about OCD? Are there signs or symptoms that you look for? When does this stuff usually develop full-blown, so to speak for people?
Dr. Brandt: Yes, yes. It’s a good question. People with OCD, you can develop OCD really at almost any point in life. I’ve had patients who can remember symptoms as young as two, three or four. I’ve had patients who developed it much later in life. I have patients who developed it gradually or some who developed it real suddenly like with a birth of a child or a traumatic event or something.
I’ve got patients who have OCD who have no family members with OCD and some who have a lot of family members with OCD. There’s not really a kind of consistent theme to when people get it. I think our brain’s job is just to ask a bunch of questions about the world. Is this safe? Is this clean? Am I happy? Is this okay for me right now?
At some point, people would just start answering those questions, start kind of getting tricked into answering those questions in a non-helpful way. For some people, that will start as young as five and some people it would be 30. I’ve had patients, I see kids as young as about five in my practice. I have kids who do a lot of ritualistic behaviors — hand washing in a certain way, counting things a certain number of times, asking their parents, “Am I going to be okay” over and over and over and over.
Zach: Sure.
Dr. Brandt: It will come. It’s interesting in that way. It all just kind of comes whenever it comes.
Zach: I’m curious to know how with your experience and maybe even with the literature, research says about how trauma plays into all this, too.
Dr. Brandt: The trauma link is I think the literature is still trying to figure that out. The way I’ll think about trauma, I don’t think that trauma would cause OCD. I think traumas happen and then fear comes up and then we have a tendency to look around more, to ask more questions, to be a little bit more fearful. When we’re experiencing more fear, more anxiety we look to things for comfort.
Zach: Yes.
Dr. Brandt: For some people with PTSD that might be straight up avoidance, going out of the house or eating or whatever it is based on the trauma. For some people it might be substances and for some people it might be this kind of magical OCD-thinking of “If I lock and unlock my door three times every time I go in and out of the house, we won’t get robbed again,” or something like that. I think it’s just another one of the ways that trauma will kind of sneak out or our emotions will come out to fix it. Yes.
Zach: I want to touch base on your residential center. You mentioned you’re one of a couple it sounds like at the McLean OCD Institute in Houston. It’s a residential treatment center for people with OCD. How long are people typically there for?
Dr. Brandt: Our average length of stay is six to eight weeks.
Zach: Okay.
Dr. Brandt: Our minimum is two and people have been there for a month for the very, very severe symptoms. In terms of a treatment day, it’s pretty active. The treatment for OCD we call exposure and response prevention so if you have a contamination or hand washing OCD, exposure would be to touch dirty stuff and the response prevention would be not to wash your hands and kind of go about your day.
Our treatment day goes about 9:00 to 4:00 normally. That includes a little bit of group therapy. That includes a good amount of one-on-one work and that includes some time on the patient’s own to kind of do some exposure to handle those feelings themselves. They get some guidance individually, some guidance as a group, some time on their own to kind of figure out, make mistakes, try it again, things like that.
They all just do that really in the residential treatment center seven days a week and the treatment goes seven days. If you’re not fighting the OCD, the OCD is normally fighting back and taking more ground. It’s pretty active. It’s pretty tiring, but usually it’s very meaningful, too.
Zach: You mentioned part of your courses of action in your treatment center is to touch dirty stuff. Can you give some examples of what that looks like?
Dr. Brandt: Oh, I could give you examples for hours. I like to pair my exposures with something kind of fun or meaningful. We could stick our heads in toilets and just sit there. I’ll do that with a patient if they needed to. I don’t like it and I find it boring.
Zach: You find it boring.
Dr. Brandt: Yes. It isn’t fun to sit and hold the toilet and look at the toilet and talk about the toilet. For younger kids and young adults, sometimes we play some board games. We can play a game on a toilet. We can touch the pieces or put the pieces in the toilet water and we’ll play so we’re able to be dirty, to be gross, to have some fun or we try to anyway and kind of show OCD it doesn’t get to boss me around. I don’t have to recoil from my life because I’m dirty.
We’ll do a lot of…we’ve got dumpsters. It’s the city of Houston. There’s bayou water everywhere, toilet, dirt everywhere, gross gas stations, all of those things. We’ve got all kinds of kind of harm rituals that we would do, too. A patient might tell me, “Oh no. I’m really afraid that I would grab a knife and I would stab somebody. I have intrusive thoughts that last for hours of me just going on this murdering rampage.”
I’ve actually got a death drawer of butcher knives in my office. I’ll just normally tell the patient, “It sounds like there’s only one way to figure this out. Here, just hold this knife.” I’m just going to turn around and close my eyes. We’re just going to kind of see what happens. Let’s test it out instead of arguing with the OCD for hours here because it loves an argument. Let’s just see if he murders me or not.
My wife is going to hear this and she’s going to get angry at me, but it’s usually quite meaningful to patients. I haven’t been stabbed yet.
Zach: I’m curious to know. When someone you’re doing that exercise with, they have a knife in their hand and you’re not facing them, is there some sort of emotional reaction that takes place a lot of the time with these folks or what happens during an exercise like that?
Dr. Brandt: It is usually very, very, very emotional. The OCD is a problem with emotion regulation. Somebody with this type of OCD would see a knife or hold the knife or have a thought about a knife and have this big strong emotional reaction they’re trying to run away from for fear of hurting somebody. My job is to teach them that they can have a strong emotional reaction and continue on with their day.
I’m usually trying to elicit a strong emotional reaction. I might even, for some patients I might put headphones in and just say, “I can’t hear you. You can really do whatever right now.” I might just talk about a family and how terrible it would be if everybody died. I’m usually probing to get at something the OCD wouldn’t want them to feel and again the goal is just to let them feel it for a little while and say, “Oh, that’s okay. I can feel that. I’m okay to feel this and keep on moving with my day.”
Zach: Interesting. I mentioned the question that I had about trauma. When you sort of dig down and you look at people’s histories and their family of origin, is there a genetic piece to this at all? Do you find that it goes back generations? Maybe it was undiagnosed. Is there a cause of any kind that you look towards? I think you mentioned some things earlier, but just curious to know what your findings have been over the time as a professional.
Dr. Brandt: Yes. It’s interesting because there is a link. If a parent has OCD, the children are more likely to have it. The question would be why is that a link. Is that a link because there’s some kind of chemical problem or a brain structure difference or something or is it just kids are really perceptive? If I see that my dad every time he has this unwanted thought, he rushes off and washes his hands, do I tend to model that behavior as a kid?
In my experience just professionally, I would tend to say that OCD doesn’t have some a group cause that we’re missing. I think it’s just our brains have questions. It’s a pretty normal part of the process to being human. We have emotions that we don’t like sometimes. It’s all part of the normal process to being human.
Sometimes people handle those and move on. Sometimes people drink and do whatever drugs. Sometimes people have depression and lay in bed. Sometimes people develop OCD and complicated rituals normally into controlling those emotions.
Zach: You mentioned earlier about praying enough and maybe you’ll get salvation of some kind. You have people for sure who come in with that. Do you find at all there’s any correlation with certain people who are raised in particularly conservative religious backgrounds and OCD?
Dr. Brandt: It’s interesting especially with the kids I work with. There are some kids who are very, very concerned with upsetting God and they come from an atheist household. The parents are so confused on how it happened. Sometimes it’s just the opposite; a very religious household and the kid don’t care about kind of God reaction at all. It will be something else.
I think it’s important when you work with somebody with any kind of we call it scrupulosity or just obsessions about being good or bad or your relationship with God; that we attack the OCD, but we don’t attack a person’s beliefs.
Zach: That’s well put.
Dr. Brandt: Yes. It’s normally pretty easy to prise apart. Somebody’s usually very able to say to me, “Yes, yes. God wants me to pray. Yes, I should pray once a day at the end of the day. No, God would never want me to pray eight times a row until it sounds right. God doesn’t really work that way.” Then we can push in and say, “Let’s take the risk. Let’s only pray once and see if God smites you,” because the chances of it pretty much won’t happen.
If it does happen then we need to rethink this whole religion thing anyway if that’s how it works. Normally they’re really willing to jump in with me and test some of that out.
Zach: I imagine a big part of what you’re doing particularly this population is building rapport and building trust early on.
Dr. Brandt: Yes, yes. People come in with all types of intrusive thoughts and the intrusive thoughts are almost always related to harm, related to sex, related to religion or being good or bad person. These are really sensitive topics for people.
I’ve got people who don’t tell their spouses about their intrusive thoughts or their family or anything like that so to be a person that is trustworthy, but they know they can come and tell me, “Oh sometimes I really think about stabbing my wife. I really don’t want to, but I’m terrified of it. I obviously don’t feel I can tell her that.”
To have me be non-judgmental and say, “Oh yes. No. Okay. Great,” from that perspective it makes a lot of sense. Here are the things we can do to help you get your life back that we can involve your wife in or not. It’s up to you. I think it’s really helpful for people and very important.
Zach: One of the models that we use within our facility at Landmark Recovery is the Seeking Safety curriculum. That’s an integrated trauma/substance use disorder model to address both trauma that’s underlying or there present as well as substance use disorder. It’s a present-oriented model in that Seeking Safety would not find it necessarily necessary, so to speak to go deep down into the trauma and then start to process a lot of that stuff. When it comes up it’s there and it’s important to deal with what’s going on in the present.
Do you find in treating OCD that it’s important to stay in the present or do you find also it’s quite useful to go back into the past and start process some of those memories, thoughts, feelings, emotions, etc.?
Dr. Brandt: With OCD, I will focus almost exclusively on the present. We have to kind of identify this trick. We got to break the system up. We got to get you back to your life. Once we’ve kind of pulled the power away from OCD or pull the OCD kind of out of you then for some people there are some things, some childhood histories, their traumas or whatever that we have to go into, but if you try to combine the two it usually gets kind of confusing for patients and kind of overwhelming.
I will normally say perfectly in the present let’s work on the OCD and then we’ll see what’s left over. Usually an OCD treatment in terms of noticing and letting yourself have your emotions without having to regulate them, people will learn something, an OCD treatment they can apply to their trauma or depression or something like that. Normally that is the most effective way to work with people.
Zach: You guys are from Houston. I’m sure you all get people coming from different parts of the country. As you and I talked before the podcast began, I really know here in Louisville, Kentucky it’s a city of roughly a million people, there’s probably a therapist that work with this population, but there’s really Dr. Street Russell at the Louisville OCD Clinic I think that as far as I can intensive out-patient program goes I think he’s the only game in town.
Do you guys find that challenging to find after-care partners for people that are out of state?
Dr. Brandt: Sometimes, sometimes. It’s a big I think weakness in kind of the American healthcare system is if I have a patient go home to anywhere in North Dakota, for instance I don’t know of resources there for them. I think if you have OCD and you are looking for treatment, the most important thing is to find an OCD-specific therapist, somebody who really knows how to work with these thoughts and feelings and have experience with it. That is a problem.
My hope is that tele-health, tele-care we will really grow from this and we’ll find a way to get people who live in rural parts of the country or just even the bigger cities about resources, find a way to get them connected in to somebody who really specializes.
Zach: For sure. Big piece of my job as a person that is both part clinical and part educating is to do presentations with both lay people and professionals about addiction and sort of removing the stigma around it. I’m sure that in your area of expertise that’s something that you do. How would you go about educating just I guess lay people on OCD and in helping people get more access to treatment?
Dr. Brandt: Yes, that’s a good question. I think my number one education piece when I talk about OCD is that people with OCD are normal. If you’ve ever had the thought did I leave the stove on, did I leave the garage door open, did I lock the front door, what if I just hit somebody with my car, I just had this kind of weird sexual thought that I don’t understand right now, those are all thoughts that most of us probably had at some point in our life.
The only difference is most of us are able to say, “That’s kind of weird. Okay.” They brush it off and they move on. People with OCD say, “Wait, oh no. Maybe this is important. I need to think about it.” They just build kind of a system around that. OCD isn’t bad. OCD isn’t twelve. It isn’t bad to have it, but it’s not broken. It’s not particularly dangerous in terms of your thoughts not being dangerous.
It’s just kind of normal people who just kind of get tricked into doing silly things. I think when we can break it down that way and say all of us have these little OCD tendencies. We turn around and check the door again. For some people is just spins out of control.
I think it normalizes it and I think it makes it look scary, but I think for family members or friends or even providers who really don’t know OCD, I’ve had patients who come in and tell me quite frequently, “What if I kill myself? What if I’m suicidal? I had a thought the other day that I jumped off a bridge and I don’t want to die. What happens if it happens?” I wouldn’t call that person suicidal.
They’re telling me, “I don’t want to die right now, but what if,” versus somebody who comes in and says, “I really want to die. I’ve been depressed for years and I see no way out” and just to see okay, this is OCD and we need to treat it accordingly versus kind of panicking or sending someone to a facility they wouldn’t need to be to. It’s just important to know that these are kind of normal thoughts. We can move on from them and here’s how we deal with it.
Zach: I mentioned local resource Dr. Street Russell here in Louisville. He’s a fantastic clinical therapist and works really well. It’s interesting, too because we’ve talked a little bit at length about OCD and treating it. He is, believe it or not he’s actually he’s back as a stand-up comedian.
Dr. Brandt: Oh really?
Zach: I imagine as we’re treating this population and me helping addicts get into recovery, too I think humor can also go a long way with lightening things up because it is a serious thing, but I think that the work that we do with both our populations it can be pretty daunting and to have that sort of light-heartedness at times can certainly be helpful.
Dr. Brandt: Oh, absolutely, absolutely. I think fear sends a very strong message to the brain. If I’m scared and I act on that fear, my brain really learns quickly in that scenario. I think fun sends a really strong message into the brain, too. Fun sends the message of “Hey, this is cool. This is fine. We’re kind of okay right now.”
I love this like I said, get my hands in toilets and then play board games. I love to make fun of a lot of things that try really, really hard to murder somebody by walking through a doorway in a way that OCD would like. I think the fun will normally break it up for people absolutely.
Zach: Tell us a little bit more about how people would be able to find information about the Mclean…is it McLane or McLean OCD Institute?
Dr. Brandt: You know what? It’s fine. I say McLane, but I’m from the South so take that for what it’s worth.
Zach: Okay.
Dr. Brandt: Right now? We were formerly the Houston OCD Program for about the last ten years. We were just kind of partnered in with Mclean really actually about two weeks ago. Right now our website is still houstonocdprogram.org. Anybody can find us there. I’m sure if you type that in at any point in the future we’ll redirect you to whatever the new link is.
I have a website, too drchadbrandt.com. You can reach out to me there in the website or read more about OCD, ideas of whether or not you have it, how to find treatment and good treatment near you. Anybody can also e-mail me. I’ll give you my current e-mail which I guess will be forwarded when we change over, but it’s cbrandt, C-B-R-A-N-D-T @houstonocd.org.
Please, just anybody who’s looking and has any questions or thoughts about OCD no matter what state you live in or anything, I would be more than happy to answer some questions or direct you to what might be helpful for you.
Zach: Really appreciate that, Dr. Brandt.
Dr. Brandt: Absolutely.
Zach: I really appreciate you coming on the show today. Thank you.
Dr. Brandt: Absolutely. I appreciate being here.
Zach: Listen, if you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn more about substance abuse programs that are both saving lives and empowering families.
Until next week, I’m Zach Crouch with Landmark Recovery Radio.
Zach: Hi. I’m Zach Crouch and you’re listening to Landmark Recovery Radio, your source for addiction and recovery news and knowledge. You can find us online wherever you get your podcasts and please don’t forget to subscribe to get the most up-to-date information from leading experts.
We have guest Nick Jaworski joining us on the show today. Nick is the CEO of Circle Social Incorporated. They are an addiction treatment and behavioral health agency and also the host of Recovery Executive podcast. Nick also speaks internationally on the data and research behind effective addiction treatment and also [Inaudible][36:51] both treatment centers and especially those seeking treatment.
Nick, as I mentioned at the beginning of the episode before we got on this is a topic that’s so near and dear to me because I think that there’s so much misinformation about it. I’m happy to have you on.
Nick: Yes, Zach. I really appreciate you guys inviting me. I’m definitely excited to be here. You guys are kind of close to us. We’re based here in Indianapolis and you guys just opened up a treatment center North near Carmel and you have a new facility coming online and actually an old kind of hospital orthopedic building that…another treatment center that we really looking at working with, was originally occupying, but weren’t set up so financial securely and now you guys are there which is great.
Zach: Awesome, awesome. Tell me about Circle Social. It’s specifically an addiction and behavioral health marketing agency. What did you see in the market that sort of inspired you to start the company?
Nick: Yes. We have a pretty interesting journey. I think like a lot of entrepreneurs I started this company out of my house. I don’t know. Was five years ago or something like that now? We’d originally just started the office digital marketing, kind of social media marketing firm working in a variety of business sectors, but we were quite good at what we did.
We took a different approach. We took what I consider a performance marketing-based approach. A lot of marketing is very fluffy. It’s about colors and branding and feel-good stories, not that that stuff doesn’t have a place in marketing, but at the end of the day if you’re not driving actions with the people that you’re reaching as a matter of fact whether that’s sales or donations or just trying to find volunteers, you need to be able to actually create some kind of measureable impact.
Zach: Yes.
Nick: We did that and as we’re kind of building the company it became very unwieldy. We were in construction. We were in education. We were in addiction treatment. Each sector is very different. Running marketing for a car dealer is worlds apart from running marketing and community outreach for addiction treatment.
Zach: Right.
Nick: As we kind of realized that it was impacting our ability to grow, I said, “Who do we really care about? What do we want to do? Who do we want to be?” We had two things [Inaudible][39:18] One, addiction treatment was very meaningful for us. You’re not selling t-shirts. You’re helping people find and seek care that they need.
Zach: You’re saving lives.
Nick: Yes, exactly. That was big. That was meaningful for us. I have my own addiction treatment story. I went through treatment when I was 18 after a couple of DUIs. I had some experience personally with the industry and then also we were quite good at it. We were getting results for clients and we were doing it in a way that other agencies in the space were not.
We decided to kind of move in that direction. As we kind of came into it, I have an operational background. I used to run school systems across the world — China, Turkey, the US. We saw issues that the clients where they were struggling to capitalize on what was running in sort of the marketing campaign. We found out that it wasn’t the marketing campaigns. It was actually them.
Their call team was not good. Their reputation in the area wasn’t good, their workflows, their leadership communication, all these operational components that really lead to successful growth in an organization. We added on a consulting wing to the marketing wing and became very hands on with clients. Because we did that we built up a reputation very quickly because no one else was doing it and we got results.
We end up becoming one of the largest agencies in the country serving some of the top providers across the country. We’ve worked with HSBC, Behavioral Health Investing Division. We’ve worked with KKR which is one of the largest private equity firms in the country kind of helping around behavioral health analysis and marks analysis. We did work with so many providers.
We also worked with their data. We’re very data-driven. We have over a hundred million dollars’ worth of marketing data just purely in addiction treatment and over a billion worth of operating data. We [Inaudible][41:14] data. We do nationwide trend analysis. All of this together has just really allowed us to become well-respected in the space. To something you just mentioned I’m just very personally committed to quality addiction treatment and quality behavioral health.
Zach: Yes, absolutely.
Nick: It’s something that just hasn’t been benchmarked and hasn’t been standard for a long time. It’s something that bothered me. It bothered me when I do treatment myself and it bothered me as I started looking at the field more broadly. That’s something that we wanted to change.
Zach: I appreciate all that. I want to come back to something you brought up in your comments especially the piece around your organization taking on more of a hands-on approach because what I’ve seen in the ten years certainly in the addiction space but 20 years in the mental health field is that you will have people come along and this is not to say they have bad ideas or they have really good ideas as a matter of fact, but consultants, marketers, whatever, consultants come by.
They basically teach an organization what to do, but then there’s really not a lot of follow-up that goes on with that. You got all these people organization-wide pumped up about this new initiative. You’ve got people bought in and then six months, a year down the road and that’s not to consider even people who are turning over in that organization. You’ve got a complete, what you started with it doesn’t look anything like when it began or it was pitched as.
I’m curious to know just from you. How is that hands-on approach help the organizations that you work with sustain growth and also a consistency?
Nick: Yes, that’s a really good question. It’s a problem within what I kind of consider the solution shock business model. You come in. You provide solutions to problems or you provide solutions to co-strategy that organizations are having, but then do they follow through with that yes or no. There are a couple different ways that we approach. We definitely learned this over time. One is really providing a lot of concrete step-by-step approaches.
When we go in, let’s say we’re just looking at the marketing component. We’ll say, “Here are the channels that you have. Here’s the marketing budget you should be allocating per channel. Here’s what you should be doing with those channels. Here’s the staff that you need to execute on those channels. Here’s the accountability metrics to make sure that things are working and what you need to look for in terms of trend line, growth, momentum, traction, that kind of thing.” We’re providing a really concrete framework for them that’s very specific with timelines and budgets and all that kind of thing.
The other component is [Inaudible][44:08] That’s something that we continue to add on [Inaudible][44:13] information and help them out, but if they weren’t prepared to move forward at that time or they didn’t have internal resources for it so then we actually created those internal resources ourselves so we will go in.
We’ll install business development on boarding processes and systems. We’ll train their teams. We’ll go in and build their entire marketing department if they want to build an internal marketing department. We continue to provide consultative advice and feedback as we move on to process.
Another thing we do is we just run everything. If they don’t have the internal resources and they want ongoing support, obviously we have the whole marketing wing. We’ll just execute on that for them and then we continue to provide the kind of strategic consultative services throughout the relationship that allows us to help them partner and move the entire organization forward.
Most programs have a vendor relationship. They hire someone from a space and they say, “We need four blogs. Can you write them?” The people say yes. Where’s the strategy in that? How is that aligned with your clinical program and model? How does that messaging flow through so that you make sure your communicating appropriately and the patients are finding you and then getting what you say that you’re providing? You’d be surprised often that it doesn’t…
Zach: I want to stop you there because I have another question to that because I think that brings up a really good point. Why in our space is the alignment of what you mentioned about the clinical program and the organization, goals, etc. so important with the marketing message that’s put out there?
Nick: Yes, that’s a great question. The way that I always phrase this to clients because they don’t often see this, sometimes you have a leadership that’s not connected to the clinical as much where they don’t understand. They’re more business-minded. They have a hard time understanding why clinical has to be front and center of everything you do.
Zach: Absolutely.
Nick: Good business, I don’t care if you’re an addiction treatment organization or something else, good business is delivering a quality product and a quality service.
Zach: Right.
Nick: If you don’t deliver that your business will eventually fail. You might survive. You might limp along. You might get lucky or maybe you can hop from place to place. Shut down the business and pop up another one, but you’ll never be long-term successful.
The reason for that is because what your service, your product is is what drives long-term value and sustainability. From the marketing perspective we have to make sure and providers have to make sure that their marketing what they say that they do and their marketing, what is in their RIs, clinical excellence and clinical differentiation.
A real simple example is let’s say that I’m selling chocolate. If I market to you and I say, “I’ve got the best, the sweetest chocolate in the entire world. You’ll absolutely love it,” and then you go and buy that chocolate and it’s bitter and it tastes like crap you will never buy that chocolate again. You will tell your friends not to buy that chocolate and you might potentially leave a bad online review about that chocolate warning people not to buy it.
The same exact thing is going to happen within addiction treatment or any other business model.
Zach: I would say especially in addictions treatment because you’re dealing with as we mentioned before you’re dealing with people’s lives, but also you’re dealing with I would say the stakeholders that are part of that patient’s treatment — the family, the people that are sacrificing, the people that maybe are even funding some of this treatment and it’s real dollars. It’s real emotional stuff.
Nick: Yes. You have to…and that’s the other piece that we relay to clients all the time. You are. You’re dealing with people’s lives here. If you are not communicating the messaging appropriately about what you’re good at then you’re bringing the wrong people into your program that’s negative from a clinical aspect as well as the business aspect.
It’s really, really a serious matter. I think there’s not enough alignment between the marketing and the clinical teams and really as we’re talking about here everything should flow from the clinical.
Zach: Sure it is.
Nick: Clinical is everything and the marketing is just an amplification of the clinical program.
Zach: Very well said, absolutely. Let’s dive into some of this other topic. I know that a big focus for you at Circle Social and yourself personally for that matter is research behind effective addiction treatment and more specifically the data around efficacy and multifactor causality. For our listeners, can you explain what those mean — efficacy and multifactor causality and why they’re so important?
Nick: Yes. This is a pretty complex issue and some people struggle with and not just the average person, but even when I speak in national and international conferences among addiction treatment professionals. This is something that they really struggle with.
To kind of give a little bit of background, as I mentioned I spent some time abroad about a decade abroad. I tend to think a little bit differently than most people just because I’ve had different experiences and perspectives. I tend to be more of a non-linear thinker. I think more from a systems approach which is where this multifactor causality comes in.
When most people are looking at addiction and even mental health in the US, it tends to be a very large overreliance on what’s really considered the traditional biomedical model in the sense that there’s either some kind of genetic issue or there’s some kind of chemical imbalance in the brain that is driving these behaviors. Your biology is always a part of who you are and what you do, but it’s a much, much smaller part than most people really realize.
The problem that I’m always advocating against is when you look at the data and just when you talk to people you find out their experiences in their lives there are cultural factors that come into play. There are socioeconomic factors that come into play. They really have a big impact on whether or not someone ends up struggling with addiction or a mental health issue.
Zach: A hundred percent.
Nick: If we don’t address those in treatment especially that person is not going to be successful. They’re not going to be successful on the path to recovery. That’s probably my biggest problem is we have to recognize all these factors to make sure people find what they need.
Zach: Especially, too in an industry that’s driven a lot by the dictates of insurance which they are and the constraints that we’re under I think as an industry with resources, people who perform get quality work one thing that I’m really appreciative of what we do at Landmark is that we spend a good two to three hours on the front end just for the initial interview to really get a thick description of who this person is in front of us.
I’d like to see that happening at all treatment centers even if they have more time to do it. In a three-hour time span or so, you can get a pretty good idea of who this person is. That friend piece as with a lot of things, if you don’t do that then you’re going to miss a lot moving forward. Drawing in other clinical people that have maybe made the referral to the facility or family especially, those are super important things to really be mindful of because they are part of that person’s system, that person’s life.
Nick: Yes. You know what I always say to your point is you can’t help a person get out of addiction unless you understood how they got into addiction.
Zach: Right, absolutely.
Nick: It’s different for everybody. Everyone comes in differently. It’s different life experiences that drive it. It’s different biology that drives it. There’s all this different factors that are coming in and you have to understand how all those pieces interplay. The thing I think I like to do, make very clear to people whether it’s the regular person out there or professionals is that individuals and families have the potential to change.
There’s this big misconception in the US is that if there is some kind of genetic component that people can’t change or they can’t improve for the better which is absolutely a wrong understanding of how genetics work. I always give the example of let’s imagine that you have a predisposition to lung cancer.
Just because you have a ten percent higher chance of getting lung cancer than your neighbor across the street, does that mean that you’re going to get lung cancer? No. Does that mean that if you smoke a cigarette once you’re going to get lung cancer? No. Does it mean that you can’t take actions to prevent or reduce the chance of yourself getting lung cancer? No.
We always have the power and the potential to change outcomes around health regardless of whether there is a genetic component to that or not.
Zach: Right. I’m curious, too as I mentioned in that question about data. Who do you look to, Nick? Are there sources that you trust that you pull the data from or is this all something that happens within sort of your own house, within Circle Social? You guys created it. You manage it. You kind of figured out what works best. How do you go about data now? Who and what is to trust in terms of reliable data?
Nick: Yes, it’s a really good question. I rely a lot in kind of our internal analyses and our ability to parse data and look at from more of a systematic approach. What I found in addiction treatment but in a lot of areas in life, in addiction treatment in particular, people tend to approach things with preconceived world views. What they’ll do is they’ll design, research or mold the data to fit their world view rather than using the data to drive what should be the appropriate analysis. It’s been a pretty common issue.
Who do I use for data? I love the work of Stanton Peele. If you are familiar with him, he’s an interesting guy. He can be challenging to talk to, but his research is fantastic especially a lot of his earlier work.
Zach: What was his name again?
Nick: Stanton Peele, P-E-E-L-E, it’s the last name.
Zach: Okay.
Nick: He’s created just some fantastic very well-researched information for decades now. I really like Mark Lewis and the work he does. He’s one of the leading neurobiologists on addiction. He’s done a lot of fantastic work and then Carl Hart would probably be another one of my standouts. Carl Hart has a lot of excellent research into addiction and kind of understanding that multifactor causality.
Zach: Got it. Data, having all these additional data how does that help the patients seeking treatment?
Nick: That’s a really good question because as Dr. Lewis so often say there’s often this gap between what you can find out from a neurobiological process and does it actually translate into clinical care and does it help in any approach in any ways to perform. My talent has always been that there are opportunities to help people understand it and part of it is kind of what we’re talking about here.
A really interesting data point that people are often shocked by is what’s the percentage of people that become addicted to prescription opioids when they take them? The national data is two percent. Two percent of people that take a prescription opioid will end up struggling with addiction.
Zach: Interesting.
Nick: If they take their prescription opioid for more than three months so it’s more long-term then that number jumps up to eight percent, but it’s still a very, very small percentage of the overall number that people take it.
In the US it’s a misconception and has been for a long time that drugs somehow drive addiction, they hijack is the term that’s been misused so much the brain’s muscle limbic reward system and this idea that it’s somehow connected to someone’s genetic predisposition.
I’ve even had professionals tell me, “I understand what you’re saying. I’m lucky I don’t have that genetic predisposition so I can’t become addicted,” which is one of the stupidest comments I’ve ever heard. It’s like saying you can’t get lung cancer from smoking if you don’t have a genetic predisposition for lung cancer. The bio-mental impact of smoking is what’s going to drive the lung cancer, not the fact that they do or don’t have a genetic predisposition.
Addiction works and mental health work in the same ways there. That kind of knowledge helps people understand that it’s not about just having them stop using. It’s not about abstinence. While these drivers [Inaudible][57:38] psychosocial to understand that.
You look at adverse childhood consequences, adverse childhood experiences. If you’ve got three or more ACEs, you’re five to seven times more likely to become an IV heroin user. If you’re unemployed, you’re significantly much more likely to be struggling with addiction. The research is really clear on that that the addiction happens after the unemployment.
For example, if people get a job then the addiction tends to subside. Sometimes we’ll get these comments that people say, “Maybe it’s because they’re addicted that they’re becoming unemployed.” That’s not the case. The research has been pretty clear that unemployment comes first and then addiction comes after because people lose purpose. They lose meaning. They lose hope.
Zach: Connection, they also lose connection.
Nick: Exactly. They lose their connection to community. We understand those data points. It helps you understand that. From a clinical perspective what we’re doing is we’re helping people find meaning and purpose.
We’re giving them skill sets from a cognitive behavioral standpoint about how to cope, how to plan, how to do goals, how to self-talk in positive ways, but it allows us to kind of have this clinical intervention that gives people the right tools that they need to be successful in recovery.
Zach: Let’s talk a little bit about the clinical intervention piece because I was a counselor. I still am. I was a practicing counselor in an intensive outpatient program for about three years. I was working with both the families, adolescents, and also the adult population. I know for me I was just tasked with so much because it was me and another part-time counselor running really two groups a day.
I’m curious to hear from you. What’s an easy way or an effective way for clinicians to stay informed, effective, and also I would say innovative with all this data that’s out there? How do they sort of sort through what’s important, what’s not for them?
Nick: Yes, that is an excellent question. It’s challenging because just as you said you’re really busy every day. Working as a therapist, it’s very emotionally taxing. It’s very psychologically draining. When you come home from work you don’t necessarily want to pick up a book…
Zach: You’re done.
Nick: Right, exactly.
Zach: You’re spent.
Nick: Fortunately on my end that stuff I enjoy. I just enjoy getting into data and research. For me it’s kind of relaxing and I’m happy to kind of lose myself in that, but that’s definitely not most people.
Zach: Sure.
Nick: My advice is conferences. Get out there. Talk to people. Go on live conferences. Join online conferences. The physical ones are too expensive or just don’t make sense from a travel standpoint, but also reach out and talk to people outside of your network. There’s such huge value in seeing what other people are doing in your industry but also looking across industries and saying, “What are people doing in psych-behavioral? What are people doing in healthcare? How do they approach addiction?”
It’s getting different perspectives about it. I have found it to be immensely valuable. The biggest issue I see when I talk to professionals in the field that have a hard time looking at things differently or just don’t or completely unfamiliar with the research and the data is because they’re not putting themselves out there. They’re not talking to other people. They got what they got at university and they’ve literally never gone beyond it 20 years later.
Zach: Got it. I’m curious as we’re on a podcast today. You host the Recovery Executive podcast. Can you tell our listeners a little bit more about that and what you all cover on the show?
Nick: Sure. I don’t know how interested people will be at your end, but we work with…a gap that I saw within addiction treatment…what we’re always trying to do is we’re trying to provide value. We’re trying to build infrastructure. We’re trying to reshape the field for the better. A big gap that we noticed was you have a lot of people that come into addiction treatment without a lot of business knowledge.
Some of those are clinicians. They’re people with pretty good hearts. They really care about providing good clinical care, but they don’t know anything about a business which is not surprising. It’s not something that they learn when they got their PhD in Psychology.
Zach: Exactly.
Nick: What we said is how can we help them do this? We started just basically just interviewing professionals in the space, people that were really good operators, really good business owners, people from every branch that we thought would be useful, whether it’s billing, revenue, psycho management, marketing, insurance reimbursement, operations, leadership, communications, cultural change, business development.
We just started networking with people that we determined to be really, really good and we have a very good sense of who’s good and who’s not just because of the work that we do and the data that we have. We bring good people to the table. What people often told me is that the Recovery Executive podcast is basically a college business course on how to run a treatment program.
Zach: I think an individual private therapist stopped there who are struggling especially with billing and just how to run a business. This could be something that really could be useful because I hear that a lot.
Nick: Yes, I appreciate that. The feedbacks we get and it’s probably one of the things that I enjoy the most about what we do people just constantly reach out and say, “Thank you.” Sometimes they’re clients. Sometimes they’re not.
Sometime they’re planning to be clients, but they say, “We’ve been following you forever. We follow your podcast. We follow your blog content. We follow your LinkedIn content. We just learned so much to your contributions to the field and we think we do a better job now than we did before just because of the content that you guys put out.”
For me that’s just really, really meaningful and it just lets me keep going because some days it’s hard with all the work you got to put in, but it all makes it worthwhile.
Zach: Sure. That’s fantastic, man. Listen, Nick I really appreciate you coming on to the show today. This has been a very I think worthwhile topic to discuss not only for our professional listeners but also for the people, the families, potential patients who are listening as well because I think they’ll get a lot out of this.
Nick: I appreciate you having me on, Zach. It was good.
Zach: Listen. If you know someone struggling with an addiction and are searching for answers, visit us at landmarkrecovery.com to learn more about substance abuse programs that are both saving lives and also empowering families.
Until next week, I’m Zach Crouch with Landmark Recovery Radio.
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