Stephen Smith is the CEO and Founder of NOCD, a digital community and telehealth platform that delivers OCD prevention and management therapy to people who have traditionally been stigmatized, misunderstood and misdiagnosed. NOCD is on a mission to create a world where anyone can access effective OCD therapy, no matter where they live or how much money they make.
PH: What was the inspiration behind founding NOCD?
SS: NOCD was founded off of my personal experience. I have OCD, a very misunderstood condition that affects about one in 40 people. I would say the term is recognized by pretty much everyone in society, right? People always use the term “OCD,” but very rarely do people actually know what it means. It’s a condition that’s similar to PTSD, where PTSD is intrusive thoughts about the past – for example, a war veteran who has flashbacks about their time in Iraq or Afghanistan, whereas OCD is intrusive thoughts about the future. They are typically what we call ego-dystonic thoughts, because they violate the person’s core values and character, and they often manifest in very taboo formats. So people can have religious, sexual, violent, relationship-based, or existential OCD, and they may have no idea what it actually means or why they’re having the fears and the recurring thoughts.
You know, back in the day I was doing really well. I was doing well in school. I played football at a very small school down in Texas and OCD onset after my sophomore year, which pretty much crippled me. I was misdiagnosed five times and developed comorbidities. I eventually had to leave school, I stopped playing football, and that’s what caused me to really hit rock bottom. So from there, I tried to search for help online, because I didn’t know what else to do and I was embarrassed. I was searching my symptoms and I stumbled upon a group of other people going through the same thing and they defined their symptoms as OCD.
First of all, I had really no idea that what I was going through had a name, and second, that it was common and third, that there was seemingly help available. When I started searching for help, I realized it’s a very manageable chronic condition; you can’t really cure it, but you can manage it. It’s managed through a therapy called exposure and response prevention (ERP), a type of cognitive behavioral therapy. So I tried to go find this treatment. There was one clinician in my area and she was cash only, charging $350 out of pocket per session with a seven-month waitlist. The only chance to really get better was to see that clinician and it was beyond challenging to do it.
Thanks to the help of a family member, I eventually got off the waitlist, saw the clinician and I ended up being diagnosed with this condition. The clinician said, “look, we’re going to go through this therapy. It’s very effective, but it’s going to take work.” We started doing the therapy and it was very challenging because between sessions she wasn’t available, but nonetheless, I got through the treatment and ended up regaining my life. I went back to school, finished up my degree and played football.
At the very end of my college experience, I was looking back and thinking, “how could so many people out there globally be suffering with this condition but yet there’s treatment that’s very effective for it?”
PH: What makes OCD different from other chronic or mental health conditions?
SS: It’s not a clinical issue; it’s an operational issue. We’re not doing a good enough job identifying people who have this condition and managing them because of a variety of things. There’s not enough awareness about what OCD really is. There’s not a centralized care network that people can access. There’s no support between sessions. And so unlike other chronic conditions where you might have great identification tools and great networks available, OCD had none of it. So I thought, what if we solve that? What if we made it easier to identify people, what if we connected them to clinicians that specialize in OCD, what if we gave them support between sessions and, and what if we did that all using technology? That became the catalyst for NOCD. Today, we’re one of the fastest growing companies in behavioral health, thanks to the hard work of our team and the support we’ve received from our investors, and the community. And so we’re very grateful for all of that.
PH: What’s the grand vision for NOCD?
SS: We’re looking to end global suffering caused by OCD.
PH: Mental Health has become such a hot topic, particularly during COVID. What’s the difference that you’re seeing in the conversation at the tail end of 2021 vs 2019?
SS: Well I think there has been a change in what we call “consumer behavior.” People are more likely to trust virtual solutions, knowing that the world’s gone virtual. Initially, there was some skepticism about whether going virtual can actually work – not just from payers, or from providers, but also from the people seeking help. And then by everything going virtual, it pretty much proved that you can actually do meaningful work and get meaningful treatments.
That’s one thing that we have been leading within the OCD community and I think our model that we’ve developed as a result of our scale, is applicable to treating serious behavior health issues. Through our work, we have developed this overarching model that is not only virtual first, but it’s also community driven.
PH: There are a number of companies out there that say they do mental health at large. Why is it so important to have a company like NOCD that focuses on a very specific mental illness or a condition?
SS: I would say when thinking about NOCD, we’re not necessarily condition-specific, we’re community-specific. If you think about the people with OCD, they define themselves by having OCD, a specific condition, because that’s often what’s “most wrong.” So if I have OCD, I may also have anxiety, depression, stress, or a substance use disorder. I may also have a variety of other conditions, but what’s driving the unhealthiness is the core problem and in many cases, it’s OCD. So if you hear someone in the community say, “well, I have OCD and that’s pretty much why my life is crippled right now,” what happens is that you basically have a root problem that doesn’t get addressed and as a result, it creates many other issues.
Just from just growing this community of OCD patients, we’ve learned that having a community-driven model that speaks to “what’s wrong,” ultimately helps you identify populations that have this condition as the the core or primary diagnosis. And then it allows us to also address the whole person by addressing the root cause. This community-specific and community-driven approach enables us to bring in personalized services to really address the root cause and keep people healthy long-term.
PH: Let’s unpack some of those services. Tell us more about how a person might use NOCD. What is their experience like?
SS: I’ll give you a specific type of example. Postpartum OCD affects 7.8% of new mothers. This is a very different subtype and very misunderstood. What often happens is a mother with a newborn child may fear, “what if I harm my child?” This is called a violent intrusive thought and it’s a hallmark symptom of OCD. It violates the mother’s core values in her character and it causes her tremendous amounts of distress. So she spends all day long trying to make that thought go away. At a certain point, she’ll have so much anxiety that she will ultimately not be able to function like she normally would and that will cause her to be depressed. She’ll ultimately go to her PCP and say, “look, I am completely disabled. I feel depressed. I feel anxious all the time,” but she won’t actually describe what she’s going through because she’s embarrassed. If she tells her PCP that she has intrusive thoughts, will they take her child away? And so in that case, she’ll be prescribed medication, she’ll get referred to anxiety treatment, and that treatment might not only be ineffective, but it might actually be harmful.
What we do at NOCD is we first create content to meet that consumer or that new mother online in a way that is really safe. The new mother may search her fears to try to make them go away and then she’ll stumble upon our content that educates her on what’s really happening. That content might be from key opinion leaders in the form of a blog article. It might even be from a community member – someone in our peer feeds who are describing what they’re going through.
From that experience she’ll realize she’s not alone and what she’s going through is normal and it’s actually very manageable through evidence-based therapy. So then she’ll book a 15-minute call with our team and do her first NOCD therapy session with one of our licensed therapists with specialty training in OCD and ERP, the gold standard therapy for OCD. And at that point, if she has it, she’ll be diagnosed and if she is not diagnosed with OCD, she’ll be referred out. If she is diagnosed, she’ll get treated, do live face-to-face sessions with her provider virtually. In between sessions, she’ll get support from different peer communities and different self-help tools, and so she’ll never be alone. She can even message her therapist asynchronously if she’d like.
Eventually, she’d make clinical strides and see reductions in not only the OCD severity, but also anxiety, depression, and stress. From there, she’s just maintaining her results. At that point, because we’ve gained trust with that member, we want to connect her back into the healthcare system in a way that is also very personalized. So we might even refer her to a group of different digital health companies focused on serving its exact same population or we may refer in network to a PCP that might be helpful. There’s many different things that we can do to ensure that she stays healthy and when she stays healthy, it not only affects her, but also affects her child and it makes their family’s life better as a whole. It’s not just one specific condition. It’s also longitudinally focused on just making someone’s life much better after we’ve gained their trust.
PH: What has changed on the supply side, in this case, the therapists in this new landscape?
SS: I’ve also seen changes in the industry where you have this fixed market supply of therapists, let’s call it 600,000 licensed therapists in the U.S., but you have millions of people. How do you scale and where does that fixed therapist supply go? So I think you’re starting to see therapists getting stretched in many different directions. I think you’ll see therapists that are serving more acute populations, groups that have a little bit more severe nature. That’s what NOCD is focused on, really providing community-driven therapy for the OCD population and building up that network that can really scale overall for severe behavioral health issues. So I think you’re seeing that change happen too.
PH: You mentioned within your personal story, that there were a couple of different points where access was difficult. One was that waitlist, so clearly NOCD solves that. But the other component is that it’s $350 a session, and that’s not something that is available to every individual. Can you talk about how a person may pay for this? Is it reimbursed or do they always have to come out of pocket?
SS: I faced three big barriers to getting effective care– (1) I was in San Antonio, Texas and there was one clinician in my area so if I didn’t see her, the next clinician available was in Houston, which would have been a six-hour round trip visit. (2) The cost was $350. (3) There’s a long waitlist. And (4) lack of support between sessions. And these challenges were all after I finally understood what I was going through, so really the biggest barrier was just figuring things out.
We unpacked the problem where we said, okay let’s first give people support between sessions who actually know what they’re going through. That was our step one. Then once we realized that was effective we said, let’s go rebuild this network and let’s make sure the network can offer people care no matter where they live in their state, no matter how much money they make, and in a very quick and easy way.
But to your point, we have virtual services so no matter where you live in your state, you can access a licensed therapist that specializes in ERP. We have 105 million lives under coverage right now in the U.S. We have partnered with national payers, managed behavioral health organizations, and different regional payers across the country. And we have brought ERP specialty care in-network. We have a unique model to do that, allowing us to serve members using their insurance. For example, they can find us and realize that their own insurer whether it be Kaiser Permanente or Cigna, etc. covers this and they can actually see a licensed therapist specializing in ERP and I don’t have to pay $350 a session.
For wait times, we’re growing our network and we’re doing it in specific regions of the country. That’s one of our big focuses right now – let’s keep growing our network so we can keep our average wait time within seven days. So we’ve taken it from seven months industry average to seven days. Now we’re trying to get even better. We want to get it within three days.
PH: You guys have been growing a lot – 105 million lives under coverage is incredible! What are some of the other ways in which NOCD has grown in 2021?
SS: We raised a $33 million Series B. We partnered with F-Prime Capital who led the round, and Kaiser Permanente Ventures and Eight Roads. Also our current investors all participated, so we were excited about that.
Our network has grown considerably. We’re getting close to having thousands of therapists in our network. We’ve done hundreds of thousands of therapy sessions in 2021 alone. Our goal is not only providing great outcomes and serving people, which we’ve done with thousands and thousands of patients, but also redefining OCD. Everyone recognizes the term OCD, but very rarely do people know what it actually means. It’s about creating more awareness so that when people hear the term, they won’t think of it as a joke.
We’ve partnered with Maria Bamford, a celebrity comedian and she has helped us create content. We’ve done some OCD awareness campaigns in partnership with certain companies and so all these efforts give us hope for what this condition can really be known as in the future.
PH: With all that momentum, what are you most proud of?
SS: I’m really proud of how our team has rallied together and you have persevered. It’s not easy, as I’m sure you see from working with talent all across the country, to work virtually every day and trying to solve problems and communicate in this new world. There are challenges with that. There are also challenges within the population from a behavioral health standpoint. There is demand across the board. How do you keep up with demand and how do you ensure that you are solving problems with quality? How do you keep focused when you have so many different things getting added to your plate? How do you focus on the right priorities? So I’m proud of our team and how our team has responded and how our team has grown. You see people who came in as entry-level team members, right out of college who are now leading and that development is inspirational. I think that’s stuff that has allowed us to grow here in a sustainable way.
PH: How has your thinking evolved about how to attract and more importantly, retain the right people who can help you attain your big vision?
SS: When thinking about NOCD, there are short-term, mid-term and long-term values. In the short-term, you’re not just going to come to a mission-centered company, you’re going to come to a life-altering company. We’re actually completely transforming people’s lives. We’re bringing people who come to us in a crippled state and usually in two or three months, they leave completely transformed. They can do everything that they once weren’t able to do and I think that that’s really amazing in this moment. There’s nothing that drives encouragement to come to work like helping people through that and just seeing the results. That has helped us scale our network. It’s also helped us retain people that work at the company.
In the mid-term, we really are a company that’s focused on giving each of our team members upside in the long term nature of the company. We do have competitive programs to help people obtain value as the company scales.
We also really think about the long-term nature of life. When you retire and look back, you’re going to want to say that you’ve actually made a huge difference in solving a massive problem and we’ve ultimately given people the chance to do just that. They’re coming here and they are actually solving a crisis that has never been solved before.
PH: What’s been the best advice that you’ve received relating to being CEO?
SS: I’ve received a lot of advice. The best advice that I think that is also most applicable, especially in early stages, is to focus on sales early on, because if you don’t have sales, it’s really tough to grow. There are many more problems that will emerge if you don’t have sales. This really experienced CEO pulled me aside at a conference and he said, “usually operations can catch up to sales. Sales is the place where you could make the most impact in your business to help it sustain and reach its long term goals.” That message was reinforced by our Executive Chairman Glen Tullman, who has been absolutely tremendous to NOCD both as an investor and advisor. The way to grow is to just keep focusing on getting a great product people don’t just like, but that they love. Then you also need to focus on selling and marketing that product.
Focus is really key because there are so many things that you have to do during the day– you’ll have to manage people, talk to customers, and strategize. But what is the most important? At the end of the day you have to grow, you have to have revenue coming in the door to cover costs. Otherwise it makes it really challenging to function. So that’s where the CEO should focus on making sure there’s capital coming in the door through growth channels for the business.