perfectionism and - Obsessive-Compulsive Foundation
perfectionism and - Obsessive-Compulsive Foundation
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Table of Contents<br />
DISCLAIMER: Please be aware that some of the content included in this h<strong>and</strong>out booklet contains<br />
material appropriate for a mature audience. It is up to the discretion of parents <strong>and</strong> guardians to allow<br />
children to view this material.<br />
Friday<br />
Imagine That! A Scripting Exposure Workshop.................................. 1<br />
Themes <strong>and</strong> Variations: Theoretical <strong>and</strong> Clinical Implications of Non-<br />
Anxiety Based OCD......................................................................... 3<br />
The Social Experiment....................................................................19<br />
Exposure <strong>and</strong> Response Prevention for OCD:<br />
A Roleplay Demonstration............................................................. 22<br />
OCD 101........................................................................................ 28<br />
ERP Exposed: A H<strong>and</strong>s on Experience............................................. 39<br />
Strategic Model of Cognitive Treatment for OCD............................. 47<br />
Partner Accommodation of OCD Symptoms................................... 56<br />
Ask an Attorney! What Are My Rights on the Job.......................... 65<br />
Don’t Try Harder, Try Different........................................................84<br />
My Child/Brother/Sister Has OCD But I’m Suffering Too!................. 89<br />
Saturday<br />
“I’m Afraid I’m Really Gonna Do It” - Responding to Fear of Loss of<br />
Impulse Control.............................................................................91<br />
Help! I Can’t Get to Sleep..............................................................102<br />
Manipulating Language to Improve Patient Connections <strong>and</strong> Treatment<br />
Compliance in the Pediatric OCD Population.................................107<br />
The BDD Challenge.......................................................................113<br />
Therapy, Insurance, <strong>and</strong> School - Oh My! Solutions for Families<br />
Overwhelmed by OCD.................................................................124<br />
Conceptualizing <strong>and</strong> Treating Hoarding Disorder............................ 133<br />
Perfecting Perfectionism................................................................151<br />
Addressing Relapse in CBT for OCD............................................... 163<br />
Comorbidity of OCD <strong>and</strong> Eating Disorders...................................... 172<br />
OCD Taboos: Strategic Responses to Sexual <strong>and</strong> Violent Intrusions...... 192<br />
Sunday<br />
We’re All in This Together: The Power of Group Therapy for OCD....200<br />
For Support Persons Only: Help for the Helpers!........................... 206<br />
People <strong>and</strong> Places - Emotional Contamination in OCD................... 213<br />
Challenging Kids, Challenged Adults: When OCD Has Dual Diagnoses... 221<br />
How Can the Whole Family Fight OCD With Their Kindergartener.....241<br />
Scrupulosity: When OCD Invades Our Religious <strong>and</strong> Moral Life .... 246<br />
Assessment <strong>and</strong> Treatment of Postpartum OCD........................... 249<br />
Cognitive-Behavioral Strategies in the Treatment of Hypochondriasis <strong>and</strong><br />
Health-Related OCD...................................................................... 251<br />
Challenges in Treating Comorbid OCD <strong>and</strong> ADHD......................... 266<br />
So You Expect Them to Leave Home...........................................279<br />
Support Groups<br />
Scrupulosity Support Group......................................................... 298<br />
Some speakers have also made these h<strong>and</strong>outs<br />
available electronically on our website here:<br />
www.OCD2013.org/H<strong>and</strong>outs<br />
FRIDAY
IMAGINE THAT!: A SCRIPTING WORK-<br />
SHOP<br />
Jon Hershfield, MFT <strong>and</strong> Jonathan Grayson, Ph.D.<br />
International OCD <strong>Foundation</strong> Conference July 19 th , 2013<br />
Scripting (a.k.a. imaginal exposure) is a form of Exposure with<br />
Response Prevention (ERP) that allows you to make contact with<br />
your fear <strong>and</strong> confront your discomfort with uncertainty using the<br />
written word. Thoughts present themselves in the mind as words<br />
or strings of words, so our ability to read what the OCD is broadcasting<br />
can be used to construct exposure assignments when direct<br />
contact with feared consequences may be unrealistic or inaccessible.<br />
Below you will find a few different approaches to scripting. No one<br />
approach is automatically better than another. Which style or combination<br />
of styles you use will be something you <strong>and</strong> your therapist<br />
will collaborate on, but the general rule is TAKE THE FIGHT TO<br />
THE OCD.<br />
How you employ each imaginal script in your treatment can also<br />
vary. You may write a script from scratch every day, read one script<br />
many times throughout the day, or record your script in an audio<br />
format to listen to on a loop. Which of these styles you use is also<br />
something to collaborate with your therapist on as you balance<br />
what you are likely to be consistent with against what level of discomfort<br />
you are willing to tolerate.<br />
Before beginning any ERP work, it is helpful to start by identifying<br />
the “facts” of your OCD:<br />
· What are your obsessions, e.g. what are you afraid of<br />
· What are your compulsions, how do you try to “fix” things<br />
or try to be sure you are safe<br />
· What is likely to happen if you stop doing compulsions in<br />
the short-term<br />
· What about the long-term<br />
***<br />
Imagine That! A Scripting Exposure Workshop<br />
The acceptance/motivation script – The objective here is to establish<br />
a launching point for treating your OCD with ERP.<br />
· What have you lost to OCD Be explicit, not just “I’ve lost<br />
time,” but write about a painful occasion in which you lost<br />
time, or a time you were humiliated by your OCD, or a job or<br />
relationship you lost.<br />
· How have you hurt your family Arguing, making them late,<br />
forcing them to ritualize, nagging them for reassurance<br />
Again write about specific times not generalizations.<br />
· What values do you have that you permit OCD to interfere<br />
with For example, being a good parent or role model<br />
(making your children late or forcing them to ritualize is not<br />
being a good parent or role model).<br />
The uncertainty script – The objective here is to confront your<br />
fear of living with uncertainty about your obsession so you can<br />
stop doing compulsions.<br />
· What obsession are you accepting could be true<br />
· What thing are you going to stop avoiding, though it may<br />
make your fear come true<br />
· What unwanted consequences could this bring about (be<br />
detailed)<br />
· What kind of person would this make you if you allowed<br />
this feared consequence to take place<br />
· How will you probably deal with those consequences<br />
· What would your life look like if you never took this risk<br />
<strong>and</strong> just continued to obey the OCD<br />
· How well do your rituals work – are there flaws in the rituals,<br />
so that your fears could still happen<br />
· Are your feared consequences more likely or less likely than<br />
other disasters you wish to avoid, e.g. car accidents<br />
o Why don’t you expend effort avoiding those<br />
· Why is it worth it to you to risk the uncertainty<br />
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The short-form flooding script – Unlike uncertainty scripts, the<br />
objective here is simply to make brief, but meaningful contact with<br />
the discomfort you feel in the presence of your obsessions<br />
· What fear do you imagine coming true<br />
· What would be the direct consequence of that fear coming<br />
true<br />
· How would these consequences affect the people you care<br />
about<br />
· How would your try to recover from these consequences<br />
<strong>and</strong> what would it look like if you failed<br />
The exposure flooding script – The objective here is to make<br />
prolonged contact with the discomfort you feel in the presence of<br />
your obsessions for the purpose of being able to resist compulsions<br />
in that presence.<br />
· What OCD fear are you permitting to come true (pretend)<br />
· Now that you’ve permitted this, what terrible thing could<br />
happen next<br />
· What are the details of the event (include sounds, smells,<br />
tastes, etc.)<br />
· How would you feel after doing this terrible thing<br />
· How would others be affected by this thing<br />
· What would your lifestyle be following the acceptance of<br />
your fear as a reality<br />
· Would you be punished for your behavior, <strong>and</strong> if so, how<br />
· How might your inability to tolerate this punishment ruin<br />
your life<br />
o How would you try to cope with this <strong>and</strong> what if the<br />
coping failed<br />
o What might the end of your life look like <strong>and</strong> what<br />
legacy could you leave behind<br />
Remember, whether you are using scripting to motivate towards<br />
doing other ERP, whether you are using it to solidify your acceptance<br />
of uncertainty, or whether you are using it to make contact<br />
with your fear <strong>and</strong> increase your distress tolerance, you have a<br />
major advantage against your OCD. You have your imagination,<br />
<strong>and</strong> though the OCD may at times comm<strong>and</strong>eer this gift <strong>and</strong> use it<br />
against you, honing it as an exposure tool gives you immense power<br />
over the OCD.<br />
FRIDAY<br />
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Themes <strong>and</strong> Variations - Theoretical <strong>and</strong> Clinical Implications of Non-Anxiety Based OCD - PT 1<br />
6/14/13<br />
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Themes <strong>and</strong> Variations - Theoretical <strong>and</strong> Clinical Implications of Non-Anxiety Based OCD - PT 2<br />
6/14/13 <br />
Disgust-‐Based OCD <br />
Part 2 <br />
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FRIDAY<br />
(Olatunji & Sawchuk, 2005) <br />
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FRIDAY<br />
(Morales & Fitzsimons, 2007)<br />
A Study Illustrating The Law Of Similarity<br />
Tsao & McKay, 2004<br />
4 <br />
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• Subjects (N = 20) with marked contamination concerns<br />
were treated with 30 min. of repeated in vivo exposure<br />
(cleaning a ‘dirty’ bed pan), during which time their fear<br />
<strong>and</strong> disgust levels were repeatedly measured.<br />
• Results indicated that repeated exposure led to a<br />
significant decline in fear but not disgust. The observed<br />
decline in fear remained significant after accounting for<br />
changes in disgust <strong>and</strong> vice versa.<br />
• There was also evidence that lower fear decline during<br />
repeated exposure was associated with higher disgust<br />
ratings after the exposure was completed.<br />
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FRIDAY<br />
End <br />
Part 2 <br />
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10
The Social Experiment<br />
6/14/13 <br />
The Social Experiment <br />
Take 2 <br />
IOCDF Conference 2013 -‐ Atlanta, Georgia <br />
Jason Spielman, Psy.D, Lindsay Stewart, Ph.D, <br />
Michelle Otelsberg, MFT, Ethan Smith <br />
• Plan for today... <br />
• Introductions <br />
Welcome! <br />
• Summary of the Research <br />
• Exposures <br />
• Discussion <br />
ABC’s of OCD <br />
• Diagnostic criteria for <strong>Obsessive</strong>-<strong>Compulsive</strong> Disorder <br />
• A. Either obsessions or compulsions: <br />
• Obsessions as deDined by (1), (2), (3) & (4): <br />
• 1. Recurrent & persistent thoughts, impulses, or images that are experienced, at <br />
some time during the disturbance, as intrusive & inappropriate & that cause <br />
marked anxiety or distress. <br />
• 2. Thoughts, impulses, or images are not simply excessive worries about real-‐life <br />
problems <br />
• 3. The person attempts to ignore or suppress such thoughts, impulses, or images, <br />
or to neutralize them w/ some other thought or action <br />
• 4. The person recognizes that the obsessional thoughts, impulses, or images are a <br />
product of his own mind <br />
• Compulsions as deDined by (1) & (2): <br />
• 1. Repetitive behaviors or mental acts the person feels driven to perform in <br />
response to an obsession, or according to rules that must be applied rigidly <br />
2. The behaviors or mental acts are aimed at preventing or reducing distress or <br />
preventing some dreaded event or situation; however, these behaviors or mental <br />
acts either are not connected in a realistic way w/ what they are designed to <br />
neutralize or prevent or are clearly excessive <br />
• B. At some point during, the person recognizes the obsessions or compulsions are <br />
excessive or unreasonable. Note: This does not apply to children. <br />
• C. Obsessions or compulsions cause marked distress, are time consuming (take >1 hr <br />
a day), or signiDicantly interfere w/ the person's normal routine, occupational (or <br />
academic) functioning, or usual social activities or relationships. <br />
ABC’s of OCD <br />
• What are some common <br />
obsessions <br />
• How about common compulsions <br />
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OCD & Social Functioning <br />
• By deDinition, OCD can cause impairment in important <br />
areas of functioning, with social functioning often being <br />
affected. <br />
• What are some ways OCD affects you socially <br />
• Not being able to focus during conversation with <br />
friends because your counting in your head... <br />
• Not being able to join friends or family for meals due <br />
to fears of contamination... <br />
• Not being able to play sports because of fears of <br />
contact with sweaty or germy people... <br />
• The list goes on.... <br />
Social Anxiety Disorder <br />
• OCD is often “co-‐morbid” with other problems. This means it <br />
tends to co-‐occur with other things, like depression, tic disorders, <br />
or panic. <br />
• Torresan & colleagues (2013) <br />
• Studied 858 men & woman OCD patients; assessed for lifetime <br />
prevalence of other Axis I Disorders using the YBOCS & SCID <br />
• 90% had a secondary diagnosis <br />
• 72% had a Mood Disorder <br />
• 20% had Panic Disorder <strong>and</strong>/or Agoraphobia <br />
• 34% had Generalized Anxiety Disorder <br />
• 36% had Social Anxiety Disorder <br />
• Brown & colleagues (2001) <br />
• Studied 1127 patients presenting for treatment of anxiety disorders; <br />
used ADIS-‐IV <br />
• 79% of the patients with OCD had at least one additional diagnosis at <br />
the time of the evaluation <br />
• OCD (along with Social Anxiety <strong>and</strong> PTSD) was associated with <br />
signiDicant risk of Depression. <br />
FRIDAY<br />
What is Social Anxiety <br />
Disorder (or Social Phobia) <br />
• Diagnostic Criteria for Social Anxiety Disorder <br />
• A. A marked & persistent fear of > 1 social or performance situations in <br />
which the person is exposed to unfamiliar people or to possible scrutiny <br />
by others. The individual fears that he will act in a way (or show anxiety <br />
symptoms) that will be humiliating or embarrassing. <br />
• B. Exposure to the feared social situation almost invariably provokes <br />
anxiety, which may be situationally bound <br />
• C. The person recognizes that the fear is excessive or unreasonable. Note: <br />
In children, this feature may be absent. <br />
• D. The feared social or performance situations are avoided or else are <br />
endured w/ intense anxiety or distress. <br />
• E. The avoidance, anxious anticipation, or distress in the feared social or <br />
performance situation(s) interferes signiDicantly w/ the person's normal <br />
routine, occupational (academic) functioning, or social activities or <br />
relationships, or there is marked distress about having the phobia. <br />
• F. In individuals under age 18 years, the duration is at least 6 months. <br />
How Do We Treat OCD <br />
• ERP <br />
• Anxiety Curve <br />
• SUDS <br />
• ACT / Radical Faith (Ethan) <br />
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How Do We Treat Social <br />
Anxiety Disorder <br />
• Good news! It’s pretty much the same <br />
thing... <br />
• Cognitive Behavioral Therapy <br />
consisting of: <br />
• Psychoeducation <br />
• Cognitive Restructuring <br />
• In-‐vivo exposure <br />
What Exactly Are We Doing <br />
Here Today <br />
• In vivo ERP for OCD <strong>and</strong> Social Anxiety <br />
• Form into four small groups <br />
Wrap Up <br />
• What did we learn <br />
• How can we use this in our lives <br />
• QuesVons <br />
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ERP for OCD - a Roleplay Demonstration<br />
6/14/13 <br />
Exposure <strong>and</strong> Response <br />
Preven5on (ERP) for OCD <br />
Jonathan S. Abramowitz, PhD <br />
University of North Carolina at Chapel Hill <br />
Conceptual View of OCD <br />
• Obsessional s5muli evoke fear, anxiety, distress <br />
• Compulsions produce an immediate reduc5on in <br />
obsessional anxiety <br />
• Compulsions <strong>and</strong> avoidance are reinforced by the <br />
immediate reduc5on of anxiety they engender <br />
• The performance of avoidance <strong>and</strong> compulsions prevents: <br />
– Learning that obsessional anxiety is temporary <br />
– Learning that obsessions, anxiety, <strong>and</strong> uncertainty are tolerable <br />
– Learning that feared consequences are unlikely <br />
FRIDAY<br />
Empirical Basis for the <br />
Conceptual Model <strong>and</strong> for ERP <br />
ERP for OCD Includes: <br />
Anxiety<br />
(Intensity Rating)<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Urge to ritualize<br />
Anxiety/discomfort<br />
//<br />
BE AE AC AE .5h 1h 1.5h 2h 2.5h 3h<br />
BE - Before exposure to anxiety-evoking stimulus<br />
AE - After exposure<br />
AC - After compulsion<br />
Rachman, de Silva, & Roper, 1976<br />
• Procedures that evoke obsessional anxiety <br />
– Exposure to obsessional cues (floors, driving) <br />
• Procedures that eliminate the con5ngency <br />
between performing compulsions <strong>and</strong> anxiety <br />
reduc5on <br />
– Response preven5on (refrain from washing or <br />
checking rituals) <br />
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Exposure therapy is: <br />
A set of techniques designed to help <br />
pa5ents confront situa5ons that elicit <br />
excessive or inappropriate fear <strong>and</strong> <br />
anxiety. <br />
The Treatment of Fear <br />
• Exposure to fear-elici5ng<br />
s5muli or <br />
situa5ons <br />
• Resis5ng ritualis5c <br />
behaviors <br />
• Anxiety increases <br />
ini5ally, followed by <br />
habitua5on <br />
Fear level<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Time<br />
Exposure <br />
• OCD symptoms are reduced when the person comes to <br />
believe his/her fears are unfounded <strong>and</strong> acts accordingly <br />
• Simply talking about probabili5es of danger is not as <br />
convincing as direct evidence from experience <br />
– Pa5ents need to directly confront their fears to truly master <br />
them <br />
• Exposure is a behavioral interven5on, but it changes <br />
beliefs about external cues, obsessional thoughts, <strong>and</strong> <br />
the experience of anxiety <strong>and</strong> doubt <br />
What Happens During Exposure <br />
• We don’t “unlearn” a fear, we acquire new learning <br />
that competes with previous learning <br />
• The current context determines our percep5on of <br />
danger or safety <br />
• The central task in ERP is to create context-independent<br />
learned safety <br />
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Basics of Exposure <br />
• ERP is a set of “experiments” that test the accuracy of <br />
anxious predic5ons, such as: <br />
– Obsessions are signs of disastrous consequences <br />
– I can’t tolerate anxiety/uncertainty <br />
• Pa5ents prac5ce confron5ng their fears in a planned <br />
<strong>and</strong> systema5c manner (oaen using a hierarchy) <br />
• Exposures are prac5ced without the use of compulsive <br />
rituals (i.e., response preven5on) <br />
Types of Exposure used for OCD <br />
• In vivo exposure -‐ confron5ng feared s5muli <br />
in the environment <br />
• Imaginal exposure -‐ confron5ng feared <br />
mental s5muli such as thoughts, images, <br />
impulses, worries, <strong>and</strong> memories <br />
FRIDAY<br />
Response Preven5on <br />
Response Preven5on (cont’d) <br />
• Ra5onale: weaken the pabern of using rituals to control <br />
anxiety <br />
– Learn that rituals are unnecessary <br />
• Goal is to refrain from all ritualizing <strong>and</strong> avoidance <br />
– May have to start with par5al RP <br />
• Washers: 1 daily 10-‐minute shower otherwise no contact <br />
with water <br />
• “Effortless” rituals: do them incorrectly <br />
• Coun5ng: count to the wrong number <br />
• If a ritual is performed: re-‐expose <br />
• Self-‐monitoring of rituals <br />
– Situa5on or thought that evoked the ritual <br />
– Anxiety level <br />
– Time spent ritualizing <br />
• Viola5on of RP means we have to work harder on <br />
that par5cular area <br />
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Detailed Inves5ga5on of <br />
OCD Symptoms <br />
• “Func5onal (behavioral) analysis” <br />
ERP Treatment Program <br />
• Guided by the conceptual framework <br />
• Gather specific informa5on about the antecedents, behaviors, <br />
<strong>and</strong> consequences <br />
– External fear cues <br />
– Intrusive obsessional thoughts <strong>and</strong> beliefs <br />
– Feared consequences associated with cues <strong>and</strong> obsessions <br />
– Avoidance <strong>and</strong> rituals <br />
– Consequences of avoidance <strong>and</strong> rituals <br />
• Leads directly to the treatment plan <br />
Segng Up the Treatment Plan <br />
Sample Exposure Hierarchy <br />
• Generate list of situa5ons <strong>and</strong> thoughts for exposure <br />
– Realis5cally safe <br />
– Evoke obsessional distress <strong>and</strong> urges to ritualize <br />
• Pa5ent rates subjec5ve units of discomfort (SUDS) for <br />
each situa5on or thought <br />
• Collabora5ve effort in genera5ng exposure hierarchy <br />
– Start with s5muli of moderate difficulty <br />
– Highest items must be included <br />
• Generate a list of rituals to target <br />
• Public surfaces (doors, bubons) (48 SUDS) <br />
• Floors (60) <br />
• Garbage cans/dumpsters (60/65) <br />
• “Buggy” room (75) <br />
• Clothes from “buggy” dresser (80) <br />
• Bugs (90) <br />
• Home bathroom <br />
• Public bathroom <br />
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Early Treatment Sessions <br />
• Begin with only moderately distressing <br />
s5muli <strong>and</strong> intrusions <br />
• Coaching <strong>and</strong> encouragement in abstaining <br />
from rituals <br />
• Trouble-‐shoo5ng <strong>and</strong> planning future <br />
exposure exercises together <br />
Moving Up the Hierarchy <br />
• Build on past successes from earlier sessions <br />
• Encourage pa5ent to choose from among <br />
equivalent s5muli for exposures <br />
• Note changes in impairment & decreased <br />
symptoms to highlight improvement <br />
FRIDAY<br />
Confron5ng the Greatest Fears <br />
Stylis5c Considera5ons <br />
• Encouragement <strong>and</strong> praise for efforts <br />
• Modeling <br />
• Discussion of acceptable vs. unacceptable risk <br />
• Repeated <strong>and</strong> prolonged exposure <br />
• Emphasis on learning to tolerate fear <strong>and</strong> <br />
uncertainty <br />
• Confront fears in mul5ple contexts <br />
• Therapist as coach <strong>and</strong> cheerleader <br />
• Therapist <strong>and</strong> pa5ent vs. OCD <br />
– not therapist vs. pa5ent + OCD <br />
• Focus on “choosing to be anxious” <strong>and</strong> “increasing risk <br />
tolerance” <br />
• Discourage reassurance-‐seeking or analyzing <br />
• Use of humor <br />
• Providing treatment outside of the office <br />
• It’s OK if anxiety doesn’t subside – fear tolera5on <br />
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Why Imaginal Exposure <br />
• Helps pa5ents access experiences that <br />
cannot be confronted with situa5onal <br />
exposure <br />
• Helps weaken mistaken beliefs about <br />
intrusive thoughts <br />
• Helps with tolerance for uncertainty <br />
• Helps the pa5ent confront <strong>and</strong> accept (rather <br />
than abempt to fight) obsessional thoughts <br />
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OCD 101<br />
6/14/13!<br />
OCD 101<br />
FOR CONSUMERS AND FAMILIES<br />
Bruce Mansbridge, PhD<br />
Director, Austin Center for the Treatment of <strong>Obsessive</strong>-<strong>Compulsive</strong> Disorder<br />
Assistant Clinical Professor of Psychology, University of Texas at Austin<br />
20th Annual Conference of the <br />
International OCD <strong>Foundation</strong><br />
Atlanta<br />
July 19, 2013<br />
<strong>Obsessive</strong>-compulsive<br />
disorder (OCD) is a<br />
neurobiological disorder<br />
characterized by the presence<br />
of obsessions, compulsions, or<br />
(usually) both.!<br />
FRIDAY<br />
Obsessions$<br />
• Obsessions are involuntary, unpleasant, unwanted<br />
thoughts, images, or feelings you can’t (seem to)<br />
get rid of. If they do go away, they keep coming<br />
back.!<br />
• They make you anxious, worried, fearful,<br />
unhappy.!<br />
• You may know they’re ridiculous or irrational,<br />
but instead of bringing comfort, that realization<br />
may make you feel that you’re losing your mind.!<br />
Common obsessions $<br />
(“What if . . . ”) $<br />
• Contamination: Dirt, germs, pesticides, mold,<br />
solvents, trash, toxic waste, sticky residue,<br />
animals, roadkill, bodily waste or fluids, getting<br />
AIDS or cancer, dirty people, “cooties”#<br />
• A$ression/responsibility: Hurting self or others<br />
accidentally or on purpose (“hit & run OCD”),<br />
leaving door unlocked or stove on, being<br />
responsible for something bad happening#<br />
(continued)#<br />
-28-<br />
1!
6/14/13!<br />
Common obsessions, continued$<br />
• Disorder, asymmetry, <strong>perfectionism</strong>, “just right”#<br />
• Fear of losing or not having something: Throwing<br />
away something valuable by mistake#<br />
• Scrupulosity: Religious (blasphemy) <strong>and</strong> secular<br />
(that they have done or might do something<br />
wrong, like stealing or telling a falsehood)#<br />
• Superstitions: Unlucky numbers, colors, etc.#<br />
• Pathological doubting: That the alarm clock is<br />
set correctly, that they have OCD#<br />
Compulsions$<br />
• Compulsions are voluntary behaviors performed to<br />
reduce or control the anxiety brought on by<br />
obsessions.#<br />
• Mental compulsions <strong>and</strong> avoidance (“preëmptive<br />
compulsions”) are common. #<br />
• The relief brought on by performing compulsions,<br />
including mental compulsions, is transient at best.!<br />
• Avoidance is terrific at reducing anxiety but is a<br />
terrible long-term strategy.#<br />
Common compulsions $<br />
• Washing, cleaning; avoiding dirt, germs, etc.#<br />
• Checking: Locks, stoves, irons, babies, health<br />
(e.g., AIDS test), under the car, ad infinitum!<br />
• Other protective actions: Putting knives away!<br />
• Seeking reassurance, “researching”: Asking<br />
people (doesn’t have to be in the form of a<br />
question), getting on internet to research<br />
symptoms, dangers !<br />
(continued)#<br />
Common compulsions, continued $<br />
• Ordering, arranging, correcting#<br />
• Hoarding, compulsive acquiring: Things, trash,<br />
animals!<br />
• Counting, making decisions by counting#<br />
• Confessing, te'ing#<br />
• Mental reassurance/researching: Mentally<br />
reviewing events (“Did I hurt her feelings”)#<br />
-29-<br />
2!
6/14/13!<br />
Who gets OCD $<br />
• 2 - 3 % of population, all cultures.!<br />
• Genetic component: Odds roughly double<br />
if one parent has OCD.!<br />
• Equal male/female ratio.!<br />
• Usually begins in childhood or adolescence,<br />
but can appear in infants <strong>and</strong> older adults.#<br />
What causes OCD!<br />
• Genetic factors!<br />
• Rarely, traumatic events, accidents!<br />
• Sometimes, PANS (Pediatric Acute-onset<br />
Neuropsychiatric Syndrome), née PANDAS<br />
(Pediatric Auto-immune Neuropsychiatric<br />
Disorders Associated with Streptococcus)!<br />
• Hormonal influences!<br />
• NOT parental behavior (e.g., strict toilet<br />
training) or intrapsychic conflicts!<br />
FRIDAY<br />
OCD is a neurological $<br />
glitch, like:!<br />
• Stuttering!<br />
• Déjà vu!<br />
• Phantom limb pain!<br />
In OCD, there is an overactive<br />
brain circuit that involves $<br />
three parts of the brain:!<br />
• Frontal cortex: “executive”!<br />
• Striatum: “executive secretary”!<br />
• Thalamus: “mail room”!<br />
-30-<br />
3!
6/14/13!<br />
1#<br />
This circuit is called the<br />
frontostriatothalamic loop:!<br />
• fronto- (frontal cortex)!<br />
• striato- (striatum)!<br />
• thalamic (thalamus)!<br />
The frontal cortex’s $<br />
job is to figure out $<br />
what’s happening, $<br />
given all the available<br />
information.!<br />
What’s happening =<br />
Experience =$<br />
Consciousness =$<br />
Reality =$<br />
Perception!<br />
-31-<br />
4!
6/14/13!<br />
Sensation <strong>and</strong> Perception!<br />
Sensation takes place at the level of the sense<br />
organ (e.g., taste bud, fingertip, retina) <strong>and</strong> the<br />
subsequent transmission of signals to the brain;<br />
relatively mechanical.!<br />
Perception is “figuring out what’s happening”;<br />
it takes place after the signals reach the brain,<br />
essentially in the frontal cortex. Extremely<br />
complex, but is usually experienced as totally<br />
simple <strong>and</strong> obvious.!<br />
Sachs, Oliver: To See <strong>and</strong> Not See. The )<br />
New Yorker, May 10, 1993, 59-73.$<br />
At First Sight, 1999, PG-13. With Val $<br />
Kilmer, Mira Sorvino, et al.!<br />
FRIDAY<br />
-32-<br />
5!
6/14/13!<br />
-33-<br />
6!
6/14/13!<br />
FRIDAY<br />
-34-<br />
7!
6/14/13!<br />
People with OCD experience $<br />
“emotional hallucinations”!<br />
• Like phantom limb pain, but<br />
emotional, not physical!<br />
• Two components:!<br />
1. There’s something very wrong.#<br />
2. You’ve got to do something about it.#<br />
There’s something !<br />
terribly wrong!!<br />
Have you done anything !<br />
about it yet!<br />
NO<br />
YES!<br />
Whew!!<br />
Cognition!<br />
(thinking)!<br />
Mood!<br />
(feeling)!<br />
Behavior!<br />
(acting)!<br />
-35-<br />
8!
6/14/13!<br />
How is OCD Treated!<br />
1. Cognitive-behavior therapy (CBT)!<br />
2. Medication!<br />
3. Psychosurgery!<br />
3. Psychosurgery !<br />
• Anterior cingulotomy!<br />
• Capsulotomy!<br />
• Limbic leukotomy!<br />
Less invasive, less destructive techniques:!<br />
FRIDAY<br />
See the Expert Consensus Guidelines for the Treatment of OCD,<br />
Journal of Clinical Psychiatry, vol 58, supplement 4, 1997; also<br />
available online at http://www.psychguides.com/ocgl.html.#<br />
• Deep brain stimulation (DBS)!<br />
• Vagus nerve stimulation!<br />
• Transcranial magnetic stimulation!<br />
First-line:!<br />
Second-line:!<br />
2. Medication!<br />
TRADE NAME GENERIC NAME TYPE!<br />
Anafranil!<br />
Prozac!<br />
Paxil!<br />
Zoloft!<br />
Luvox!<br />
Celexa!<br />
Lexapro!<br />
Effexor!<br />
Cymbalta!<br />
Nardil!<br />
Parnate!<br />
Viibryd!<br />
clomipramine!<br />
fluoxetine!<br />
paroxetine!<br />
sertraline!<br />
fluvoxamine!<br />
citalopram!<br />
escitalopram!<br />
venlafaxine!<br />
duloxetine!<br />
phenelzine!<br />
tranylcypromine!<br />
vilazodone!<br />
SNRI!<br />
SSRI!<br />
SSRI!<br />
SSRI!<br />
SSRI!<br />
SSRI!<br />
SSRI!<br />
SNRI!<br />
SNRI!<br />
MAOI!<br />
MAOI!<br />
SSRI+!<br />
Glutaminergic drugs that can augment SRIs: !<br />
Namenda (memantine), Rilutek (riluzole), <strong>and</strong> NAC (n-acetylcysteine)!<br />
1b. Cognitive Therapy!<br />
• Attempts to correct erroneous beliefs, irrational<br />
thinking, inaccurate reasoning, <strong>and</strong> harmful<br />
attitudes through Socratic questioning <strong>and</strong> other<br />
techniques.!<br />
• Is good for <strong>perfectionism</strong>, exaggerated estimates<br />
of risk.!<br />
• Can help pave the way for behavioral exposures.!<br />
• Is less helpful when people believe their fears are<br />
very rational (overvalued ideas) or very irrational.!<br />
-36-<br />
9!
6/14/13!<br />
1a. Behavior Therapy!<br />
• Exposure to situations that bring on obsessions<br />
(e.g., h<strong>and</strong>ling “dirty” things) can help reduce<br />
anxiety, obsessions, <strong>and</strong> compulsions by itself.!<br />
• Ritual (or response) prevention (e.g., not washing<br />
or not avoiding “dirty” things) can help reduce<br />
anxiety, obsessions, <strong>and</strong> compulsions by itself.!<br />
• Exposure <strong>and</strong> ritual prevention (ERP), almost<br />
always used together, are the most effective<br />
treatment for both obsessions <strong>and</strong> compulsions.!<br />
Key Elements of Successful $<br />
Behavior Therapy!<br />
• Have the right attitude!<br />
• Target the right thought (don’t shower<br />
quicker)!<br />
• Start in an area where progress will bring relief,<br />
a payoff, or improvement in quality of life (to<br />
self or significant other)!<br />
• Start easy, then go for harder (don’t start half<br />
way up the ladder)!<br />
• Keep up motivation!<br />
Three Steps for H<strong>and</strong>ling$<br />
<strong>Obsessive</strong> Thoughts!<br />
1. Is it OCD!<br />
2. Like phantom limb pain, it feels tota'y real;<br />
but it’s bogus, <strong>and</strong> you don’t have to act on it.!<br />
3. “You may be right,” “Oh well, so what” “I’m<br />
willing to take that risk.”!<br />
Finding a Good Therapist!<br />
(from AustinOCD.com)!<br />
1. Get some names#<br />
Insurance company lists of providers, IOCDF,<br />
local support groups, ABCT, ADAA, state &<br />
local professional groups (e.g., psychologists,<br />
psychiatrists), university training clinics, etc.!<br />
2. Check them out#<br />
Ask about “experience,” type of approach<br />
(CBT, BT, CT), “I’ve heard of, um, exposure<br />
<strong>and</strong>, um . . . something about prevention . . . ”!<br />
-37-<br />
10!
6/14/13!<br />
“Arguably the best!<br />
book on OCD!<br />
ever written”!<br />
– Bruce Mansbridge, PhD#<br />
Contact info:#<br />
austinocd.com!<br />
512 327-9494!<br />
mansbridge@austinocd.com!<br />
FRIDAY<br />
Personalized, signed !<br />
copies available at!<br />
AustinOCD’s!<br />
booth.!<br />
-38-<br />
11!
ERP Exposed<br />
OCD Cycle<br />
Obsessions<br />
Relief<br />
Anxiety<br />
Compulsions<br />
Physical:<br />
Mental:<br />
Avoidance:<br />
-39-
ERP exposed:<br />
A h<strong>and</strong>s-on experience<br />
OBSESSIONS<br />
OCD Definition:<br />
• Recurrent, persistent thoughts, images or<br />
impulses that are experienced as disturbing,<br />
intrusive <strong>and</strong> inappropriate, causing marked<br />
distress or anxiety.<br />
• Not just excessive worries or ruminations.<br />
FRIDAY<br />
UCLA OCD Program<br />
OCD Definition:<br />
OBSESSIONS CONT’D<br />
• A person tries to ignore, suppress or neutralize<br />
the thoughts.<br />
• Degree of insight varies.<br />
OCD Definition:<br />
COMPULSIONS<br />
• Repetitive or ritualized behaviors that a person<br />
feels driven to perform as a result of the<br />
obsession.<br />
• The behaviors are aimed at reducing distress or<br />
preventing something bad happening.<br />
• May be observable, physical acts, or<br />
unobservable mental acts, or conscious efforts<br />
to avoid objects or situations.<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
-40-
OCD Definition:<br />
OCD Cycle<br />
COMPULSIONS<br />
• Anything that is consciously, volitionally done<br />
to alleviate the anxiety caused by the obsession.<br />
Obsession<br />
Relief<br />
Anxiety<br />
Compulsion<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
Aggressive Obsessions<br />
Contamination Obsessions<br />
• Fear of harming self or others<br />
• Concern/ disgust with bodily waste<br />
• Violent/ horrific images<br />
• Fear of being responsible for something terrible<br />
happening<br />
• Concern with environmental contaminants<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
-41-
Contamination Obsessions<br />
Sexual Obsessions<br />
• Concern will get ill because of contaminant<br />
• Concern will make others ill<br />
• Horrific/ offensive sexual thoughts<br />
• Fear of molesting children or others<br />
FRIDAY<br />
• Fear of being gay<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
Religious Obsessions<br />
Symmetry <strong>and</strong> Exactness<br />
Obsessions<br />
• Concern with sacrilege or blasphemy<br />
• Excessive concern with right <strong>and</strong> wrong <strong>and</strong> morality<br />
• Need for things to be exactly right<br />
• Need to do things until it ‘feels’ right<br />
(May be associated with magical thinking)<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
-42-
Somatic Obsessions<br />
Miscellaneous Obsessions<br />
• Concern with illness or disease<br />
• Excessive concern with bodily functioning<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
Compulsions<br />
Compulsions<br />
• Physical<br />
• Checking<br />
• Washing<br />
• Doing things until it feels just right<br />
• Arranging things until it feels right<br />
• Asking for reassurance<br />
• Superstitious behaviors<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
-43-
Exposure & Response<br />
Prevention<br />
Exposure <strong>and</strong> Response Prevention is the gradual<br />
exposure of a person to the objects or situations<br />
that cause anxiety . The person then resists<br />
carrying out the rituals they would typically do.<br />
Anxiety decreases.<br />
Exposure &<br />
…Response Prevention<br />
• No Compulsions<br />
• No behaviors to reduce anxiety<br />
• Stay with the anxiety<br />
FRIDAY<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
Exposure <strong>and</strong> Response<br />
Prevention<br />
How to optimize your ERP<br />
10 – <br />
9 –<br />
8 –<br />
7- <br />
6 –<br />
5 –<br />
I am going to die<br />
I could die<br />
Maybe I won’t die - this time<br />
This feels horrible<br />
This feels bad<br />
I don’t like this feeling<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
-44-
Exposure <strong>and</strong> Response<br />
Prevention - rules<br />
1. Focus is better than distraction<br />
Distraction<br />
Focus<br />
Exposure <strong>and</strong> Response<br />
Prevention - rules<br />
10 <br />
10 <br />
A<br />
n<br />
x<br />
i<br />
e<br />
t<br />
y<br />
0 <br />
Time <br />
A<br />
n<br />
x<br />
i<br />
e<br />
t<br />
y<br />
0 <br />
Time <br />
UCLA OCD Program<br />
UCLA OCD Program<br />
Exposure <strong>and</strong> Response<br />
Prevention - rules<br />
Exposure <strong>and</strong> Response<br />
Prevention - rules<br />
4. Complete cessation of compulsions is better<br />
than graduated –<br />
but not always achievable<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
-45-
Exposure <strong>and</strong> Response<br />
Prevention - rules <br />
good enough.<br />
Exposure <strong>and</strong> Response<br />
Prevention - rules<br />
6.Vary exposures to the same obsession<br />
Driving<br />
Side streets<br />
Freeways<br />
Night time<br />
Rain<br />
Variation will lead<br />
to generalization <br />
FRIDAY<br />
With passengers<br />
Without passengers<br />
UCLA OCD Program<br />
UCLA OCD Program<br />
Ending Treatment<br />
UCLA OCD Intensive<br />
Treatment Program<br />
http://www.semel.ucla.edu/adc/ocd_treatment<br />
Phone: 310 794 7305<br />
Email: Kmaidment@mednet.ucla.edu<br />
UCLA OCD Program<br />
-46-
Strategic Model of Cognitive Treatment for OCD<br />
Reid Wilson, Ph.D.<br />
Anxiety Disorders Treatment Center<br />
421 Bennett Orchard Trail<br />
Chapel Hill, NC 27516<br />
[919] 942-0700<br />
rrw@med.unc.edu<br />
www.anxieties.com<br />
1<br />
2<br />
Segment 1<br />
Look for any signs that they can dissociate<br />
from the content. Work that.<br />
• “In my mind…”<br />
– “What does that tell you”<br />
• “Naïve question: so why don’t you just not<br />
wash, since you know it’s in your mind”<br />
Flesh out & get rapport with their struggle<br />
Be curious & respectful<br />
• “Tell me how it’s hard to resist”<br />
Any attempts to change Any tricks Any<br />
control in some arenas<br />
3<br />
4<br />
-47-
Segment 2<br />
Personify & externalize OCD. When they are<br />
all better, they will have separated from the<br />
disorder. Why don’t we start treatment from<br />
that position<br />
• “What’s your OCD tell you is going to<br />
happen”<br />
• She immediately follows suit: “The main thing<br />
OCD tells me is…”<br />
5<br />
If they have made any gains, use them to<br />
challenge their OCD logic<br />
Move away from a continuum & toward a<br />
black or white, either/or scenario<br />
Continue with naïve curiosity<br />
• “If you believe it is about contamination, then<br />
why would relaxation help”<br />
6<br />
FRIDAY<br />
It’s “great news” if they have used any<br />
therapeutic strategy to dissociate from the<br />
content. This means we don’t have to add<br />
anything from outside of them. We simply<br />
have to embellish a resource within them.<br />
Embellish, reinforce actions that manifest<br />
belief that content is irrelevant.<br />
• Here she uses relaxation<br />
You have a perspective<br />
The problem is that the closer you get to the<br />
threat, the further away that perspective drifts<br />
[And that will be our goal: to find a way to<br />
maintain that perspective while facing threat.<br />
The work is moment-by-moment.]<br />
7<br />
8<br />
-48-
Segment 3<br />
Every step of the way, check in if they have<br />
alliance with you about the principles<br />
• “Am I saying this correctly for you Do you<br />
want to fix something I am saying”<br />
Step-by-step, we are dismantling their OCD<br />
protocol & building the therapeutic protocol<br />
9<br />
Build a logical system that explains how OCD<br />
wins<br />
― OCD takes a natural part of all of us & uses<br />
it against us<br />
― And then, it looks for what each of us is<br />
personally vulnerable to<br />
Seek agreement with that principle<br />
[Again] Personify OCD as our challenger who<br />
is pretty damn smart!<br />
10<br />
Segment 4<br />
[Again] You must dissociate from the content.<br />
That is OCD’s territory. You can’t win within<br />
that territory.<br />
• “You & I want to figure out how to step out of<br />
the territory of contamination”<br />
• “We want to get into the territory that makes<br />
you vulnerable to the disorder” [intolerance<br />
of uncertainty]<br />
We want to go one level up in abstraction.<br />
“I wash my h<strong>and</strong>s to get rid of contamination”<br />
becomes<br />
“I do a repetitive behavior to get rid of my<br />
doubt about something that seems risky or<br />
dangerous.”<br />
11<br />
12<br />
-49-
Segment 5<br />
I reflectively listen to what I want to emphasize.<br />
I control the conversation & dominate our<br />
direction.<br />
• “So you’re saying, ‘What I do is too timeconsuming<br />
& mind-consuming.’ What would<br />
you rather be doing”<br />
Build a competing agenda. Reflective<br />
listening:<br />
• “So you’re saying, ‘I value some things<br />
greatly, & I am not living into them like I<br />
would like to’”<br />
13<br />
Segment 6<br />
Plant seeds about doing a behavioral<br />
experiment<br />
1. “You have to be motivated, because they call<br />
this ‘work’… what you & I are about to do.”<br />
2. “We’re going to go do that in a few<br />
minutes…”<br />
Inquire: how you think a person gets better<br />
Embellish anything they say that has validity.<br />
14<br />
FRIDAY<br />
Segment 7<br />
DISSOCIATION & ABSORPTION<br />
We are not removing the obsessive voice. We<br />
are bringing up a parallel voice.<br />
You need to dissociate from the obsessive<br />
voice & absorb yourself in the messages of<br />
the therapeutic voice.<br />
Generate a simple protocol.<br />
— You absolutely know how to tolerate<br />
uncertainty<br />
— You simply cannot tolerate uncertainty<br />
about this topic<br />
— That’s our job: to strengthen your skill of<br />
tolerating uncertainty<br />
[Verify that they underst<strong>and</strong>]<br />
15<br />
16<br />
-50-
You also have to tolerate anxiety<br />
• “You have been in a treatment where you<br />
provoke the distress & then calm yourself<br />
down. For a little bit, we’re going to throw<br />
that out.”<br />
17<br />
[Again] We are going to externalize &<br />
personify OCD<br />
Instead of trying to calm down, ask for more<br />
anxiety<br />
Therapeutic stance: “I am in a relationship<br />
with OCD. That’s not going to change. I’m<br />
going to stay in a relationship with OCD. But<br />
I’m going to redefine the nature of the<br />
relationship.”<br />
18<br />
Quiz them:<br />
For OCD to win, what do you need to do<br />
• “Do what it says”<br />
And for you to win<br />
• “Ignore it”<br />
Let’s go one step further than to ignore it<br />
• “Do the opposite”<br />
Yes. But only in the early stages of the<br />
work. When you are all done, you will do<br />
just that: ignore it.<br />
19<br />
Normalize obsessions: everybody has them<br />
You don’t need to get rid of them<br />
20<br />
-51-
Our work is to get you willing to not know.<br />
This is the generic experience of uncertainty,<br />
not a content-specific one. The only reason<br />
we go get content is to generate a generic<br />
experience of uncertainty & distress.<br />
• “The opposite of knowing that my h<strong>and</strong>s are<br />
clean is…”<br />
—“Know that they’re dirty”<br />
• Let’s change that to, “not know whether they<br />
are clean.” [uncertainty]<br />
21<br />
Segment 8<br />
This is not just exposure<br />
It’s an attitude change<br />
• “I am not asking you to feel contaminated.<br />
I’m asking you to want to feel contaminated,<br />
& then feel contaminated. I am asking you to<br />
actually go get it, on purpose.”<br />
22<br />
FRIDAY<br />
EXTERNALIZE – DISSOCIATE<br />
“Why am I asking you to change your attitude<br />
about getting contaminated What happens to<br />
OCD when you start saying, ‘I’m looking for<br />
opportunities to feel a sense of<br />
contamination’”<br />
• “It’s not feeding it” [meaning “then my stance<br />
would not feed the OCD”]<br />
23<br />
“When you do that, you will now feel<br />
anxious. What’s going to happen to OCD if<br />
you then say, ‘This is exactly what I want<br />
right now; I don’t like this, but I want it’”<br />
• “Maybe it makes the OCD uncomfortable”<br />
“Like turning the tables on OCD How would<br />
you like that, theoretically, to turn the tables<br />
on OCD”<br />
• “That would be awesome!”<br />
24<br />
-52-
Segment 9<br />
Segment 10<br />
Habituation requires<br />
— Frequency<br />
— Intensity<br />
— duration<br />
We are not doing that. We are just using that<br />
as a logic, to rationalize our strategy.<br />
25<br />
Ownership<br />
— Put your game face on<br />
Dissociation & Absorption<br />
— Focus on your outcome picture<br />
— I want my family back, etc. So, I don’t<br />
like it, but I want it!<br />
Take the hit<br />
26<br />
Segment 11<br />
DISSOCIATION & OWNERSHIP<br />
• Challenging the difference between what<br />
OCD is asking her to be afraid of & what<br />
she’s actually afraid of. She is just plain<br />
scared. Perfect.<br />
• Therefore, we can [but don’t have to] go to<br />
the highest item on OCD’s list. And why not<br />
It’s a meaningless hierarchy.<br />
• She picks the dirtiest spot on the floor to<br />
touch. Ownership in the protocol!<br />
27<br />
Segment 12<br />
Ownership by linking with outcome picture<br />
• She can’t get behind “I want this”<br />
• But totally gets behind “I want the outcome”<br />
[Again] The work is always moment-bymoment<br />
[Again] “It is totally underst<strong>and</strong>able that you<br />
want to resist, but…”<br />
28<br />
-53-
Segment 13<br />
You bring the frequency<br />
Make OCD bring the intensity & duration<br />
Give all the work to OCD<br />
• “What we are doing is changing your<br />
mindset. It doesn’t matter whether your<br />
uncertainty is strong or your anxiety is strong.<br />
It matters that you ask for OCD to make it<br />
strong.”<br />
Hebb’s Law: neurons that fire together, wire<br />
together<br />
Self-messages that motivate or comm<strong>and</strong><br />
Short & sweet<br />
• “I’m doing this for my family”<br />
FRIDAY<br />
29<br />
30<br />
Segment 14<br />
Play the game<br />
Score points<br />
Operate as though the more points you score,<br />
the stronger you get<br />
The tally counter<br />
NOT COVERING THESE NEXT 3 SLIDES<br />
Some General Principles of<br />
Strategic Treatment of OCD<br />
Reid Wilson, Ph.D.<br />
www.anxieties.com<br />
31<br />
32<br />
-54-
Get rapport (<strong>and</strong> get it again)<br />
Get placebo<br />
Collaborative curiosity<br />
Persuade them to adopt paradoxical frame of<br />
reference<br />
Collaborative paradoxical strategies<br />
Frame-up the action<br />
Behavioral experiments<br />
33<br />
Pull them away, step-by-step, from their frame of<br />
reference (FofR)<br />
• dismantle their logical system<br />
• box it all up into one entity<br />
― “It’s irrelevant”<br />
― “It’s white noise”<br />
― “That’s the disorder talking”<br />
Get them to disconnect, to detach, to put distance<br />
between them & old FofR<br />
34<br />
It’s NOT that. It’s THIS!<br />
“Keep coming this way; keep coming this way”<br />
Continually check that they are still with you<br />
― “What do you think”<br />
― “Does that make sense to you”<br />
Build a compelling new logical system<br />
― Don’t just explain it; install it!<br />
― Install it NOW, at the beginning of treatment<br />
― Install it deeply enough that it holds over time<br />
But do all this with finesse<br />
35<br />
-55-
Partner Accommodation of OCD Symptoms<br />
6/14/13<br />
Partner Accommoda@on <br />
of OCD Symptoms <br />
Why it’s a problem <br />
<strong>and</strong> what you can do about it <br />
Outline <br />
• What is accommoda@on <br />
• Accommoda@on & OCD <br />
• What to do about accommoda@on <br />
FRIDAY<br />
Jonathan S. Abramowitz <br />
Ryan J. Jacoby <br />
University of North Carolina at <br />
Chapel Hill <br />
What is Accommoda@on <br />
• Par@cipa@ng in rituals <br />
• Assis@ng with avoidance <br />
• Providing reassurance <br />
• Doing tasks for the person with OCD <br />
• Cleaning up aJer rituals (e.g., spilled water) <br />
Example #1: “Ashley” <br />
• 28 yr old woman <br />
• Married, with no children <br />
• Obsessions about needing to know <strong>and</strong> remember things <br />
(e.g., what spent money on) <br />
• <strong>Compulsive</strong> checking (e.g., web history) <strong>and</strong> asking for <br />
reassurance <br />
• Avoidance (e.g., using cash) <br />
• Rela@onship distress (e.g., partner would lose pa@ence) <br />
• Partner accommoda@on <br />
– Helping with checking, avoidance, <strong>and</strong> providing <br />
reassurance <br />
• Partner on board with treatment <strong>and</strong> stopped <br />
accommoda@on <br />
• Successful outcome <br />
-56-<br />
1
6/14/13<br />
Example #2: “Dave” <br />
• 34 yr old married man <br />
• Lives with wife, no children <br />
• Obsessions: contamina@on from dead animals (rabies) <br />
• Compulsions: washing, cleaning, reassurance-‐seeking <br />
• Avoidance behavior <br />
• Partner accommoda@on <br />
– Answering ques@ons <strong>and</strong> helping with washing/cleaning <br />
• Partner not able to resist Dave’s reassurance-‐seeking <br />
requests <br />
• Couple distress <br />
• Unsuccessful treatment outcome <br />
OCD on an Individual Level <br />
• Situa@ons, thoughts, body sensa@ons that trigger <br />
obsessions <strong>and</strong> fear <br />
• <strong>Compulsive</strong> rituals <strong>and</strong> avoidance <br />
– Behaviors/mental acts to lower anxiety <br />
– Func@on as immediate escape <strong>and</strong> avoidance <br />
– Prevents natural ex@nc@on of irra@onal fear in the <br />
longer-‐term <br />
OCD on an Interpersonal Level <br />
• Person organizes the environment to <br />
– Minimize obsessions <strong>and</strong> anxiety <br />
– Maximize perceived safety <br />
• Significant others oJen become part of avoidance <br />
<strong>and</strong> compulsive rituals <br />
– Minimizes conflict <strong>and</strong> anxiety <br />
– Provides support <br />
Accommoda@on to OCD: <br />
“Symptom-‐System Fit” <br />
Symptom Avoidance Ritual / Safety <br />
Behavior <br />
Contamina@on <br />
Sources of <br />
contamina@on <br />
Reassurance, <br />
cleaning/washing <br />
(e.g., showering <br />
before sex) <br />
Responsibility Assume liability Checking, <br />
reassurance <br />
Symmetry Order-‐related tasks Arranging <br />
Unacceptable <br />
Thoughts <br />
Obsessional triggers <br />
(e.g., photos of <br />
gr<strong>and</strong>children) <br />
Reassurance <br />
-57-<br />
2
6/14/13<br />
OCD as a “Third Wheel” in the <br />
Rela@onship <br />
• Avoidance <strong>and</strong> safety behaviors begin to dictate the <br />
couple’s life together <br />
• Partner expresses love, care, <strong>and</strong> concern through <br />
accommoda@on <br />
• Frequent conflicts couple distress worsening of <br />
OCD symptoms <br />
What leads to Accommoda@on <br />
• Loved ones can be very persuasive when they are <br />
scared <br />
• Accommoda@on develops as a way of showing care <br />
<strong>and</strong> concern for a suffering partner <br />
• Life has to keep moving-‐-‐ accommoda@on helps <br />
things stay on track <br />
• Accommoda@on helps avoid/reduce conflict <br />
FRIDAY<br />
What can Couples do about <br />
Accommoda@on <br />
1. Iden@fy accommoda@on <strong>and</strong> its effects <br />
2. Consider the pros <strong>and</strong> cons of <br />
accommoda@ng <br />
3. Learn how to communicate effec@vely about <br />
OCD <br />
4. Make decisions about stopping <br />
accommoda@on <br />
5. Reward each other for following the plan <br />
Iden@fy Accommoda@on <strong>and</strong> its <br />
Effects <br />
• Recognize accommoda@on behaviors <br />
• How is OCD accommodated in the family <br />
• How much @me is spent <br />
• How much does it get in the way of family life <br />
– What can we not do because of OCD <br />
– What’s the family atmosphere with OCD in it <br />
– What extra responsibili@es do people have to take on <br />
because of OCD <br />
-58-<br />
3
6/14/13<br />
Talking about Accommoda@on <br />
Consider the Pros <strong>and</strong> Cons of <br />
Accommoda@ng <br />
• You <strong>and</strong> your partner might discuss these <br />
ques@ons <br />
– How does OCD affect your rela@onship <br />
– What pagerns have developed because of OCD <br />
– How would life together be different without OCD <br />
– Who (besides the sufferer) is affected (in any way) by OCD <br />
– What have you tried to do as a couple to cope with OCD, <br />
<strong>and</strong> how well has that worked <br />
Pros <br />
• Protects partner from <br />
anxiety <br />
• Keeps partner happy <br />
• It’s easier on everyone <br />
• Not such a big a deal <br />
• Shows I love my partner <br />
Cons <br />
• Burdensome <br />
• Disrupts rela@onship/ <br />
family life <br />
• Gets worse over @me <br />
• Maintains the cycle of <br />
OCD over @me <br />
The pros are short-term; the cons are longer-term<br />
Communica@ng in Rela@onships <br />
• Two types of conversa@ons <br />
– Sharing thoughts <strong>and</strong> feelings <br />
– Problem-‐solving <br />
• Conversa@ons when one partner has OCD <br />
– OCD sufferer tries to share thoughts <strong>and</strong> feelings <br />
– Non-‐OCD partner tries to problem-‐solve using logic <br />
Sharing Thoughts <strong>and</strong> Feelings: <br />
The Speaker’s Role <br />
• Talk about thoughts <strong>and</strong> opinions, not <br />
absolute truths <br />
• Include emo@ons or feelings <br />
• Discuss how you feel about your partner <br />
• Share both posi@ve <strong>and</strong> nega@ve feelings <br />
• Be specific <br />
• Use tact <strong>and</strong> good @ming <br />
• Give your partner a chance to respond <br />
-59-<br />
4
6/14/13<br />
Sharing Thoughts <strong>and</strong> Feelings: <br />
The Listener’s Role <br />
• While your partner is speaking <br />
– Show acceptance (acceptance is not agreement) <br />
– Try to put yourself if your partner’s place <br />
• When your partner finishes speaking <br />
– Summarize his or her most important feelings, desires, <br />
conflicts, <strong>and</strong> thoughts <br />
• Do NOT <br />
– Change the meaning of your partner’s statements <br />
– Judge what your partner says <br />
– Try to solve a problem <br />
Making Decisions about <br />
Accommoda@on <br />
• Discuss accommoda@on together <br />
– State problems in terms of behaviors, not people <br />
– Choose one area at a @me <br />
– Make sure both partners agree this is an area they are <br />
ready to try to address or change <br />
FRIDAY<br />
Making Decisions about <br />
Accommoda@on <br />
• Discuss why accommoda@on is an important <br />
problem <br />
– Share your underst<strong>and</strong>ing of the problem <br />
– Explain what you’d like to be taken into account when you <br />
make a decision <br />
• Don’t give any solu@ons yet <br />
Making Decisions about <br />
Accommoda@on <br />
• Discuss possible solu@ons <br />
– Focus on the solu@on, not who is right or wrong, or what <br />
the truth is <br />
– Think about how to do things differently in the future <br />
– Brainstorm if it’s hard to find solu@ons <br />
-60-<br />
5
6/14/13<br />
Making Decisions about <br />
Accommoda@on <br />
• Decide on a solu@on <br />
– Must be agreeable to both partners <br />
– If no solu@ons is perfect, compromise <br />
– State the final decision in terms of specific behaviors (who <br />
will do what, when) <br />
– Do NOT make decisions that you will not do, or that make <br />
one partner angry or resenjul <br />
Making Decisions about <br />
Accommoda@on <br />
• Have a trial period <br />
– Give it @me <br />
• You might have to try out the new solu@on several <br />
@mes before it really works <br />
– Review how the solu@on is working <br />
Rewards for Non-‐OCD Behavior <br />
• Make rewards part of the new solu@on <br />
• Make the rewards <strong>and</strong> rules for earning them very <br />
clear <br />
• Be consistent! <br />
• Consider material, behavioral, <strong>and</strong> emo@onal <br />
rewards <br />
– Examples: giJs, reduc@on in chores, extra closeness, <br />
support, verbal praise <br />
Troubleshoo@ng <br />
• High anxiety <br />
• Refusal to cooperate <br />
• Remember, you’re not a therapist—seek professional <br />
help if needed <br />
Aside – rewards work be
6/14/13<br />
Comments for Family Members to use <br />
when the Person with OCD is Anxious <br />
• “I know this is hard, but you’re doing a great job” <br />
• “Think of how good you’ll feel in a ligle while” <br />
• “Remember that anxiety will go away if you give it a <br />
chance. It’s not going to hurt you.” <br />
• “If I do this ritual for you, it will only make your OCD <br />
worse” <br />
• “It sounds like you are asking for reassurance, but it’s <br />
not helpful for me to try to answer that ques@on” <br />
More Comments <br />
• “I can’t give you that guarantee– I don’t know for <br />
sure” <br />
• “How can I help you without doing rituals for you” <br />
• “If I did that for you it would only be making your <br />
problem worse. How else can I help you” <br />
• “I know it is difficult. Let’s talk about the problems <br />
you’re having gepng through this” <br />
FRIDAY<br />
Comments for when the Person with <br />
OCD is Successful <br />
• “I’m proud of you– I knew you could do it!” <br />
• “Great job– I know this is not easy for you.” <br />
• “I really love how hard you’re working on this.” <br />
• “I’m so happy that you chose to go with the anxiety <br />
this @me.” <br />
Comments to Avoid <br />
• “Everything is going to be fine, don’t worry” <br />
• “I’ve done this before, your fears are irra@onal” <br />
• “Believe me, it’s not that dangerous” <br />
• “You’d beger not ritualize or I’ll…” <br />
-62-<br />
7
6/14/13<br />
Dealing with Arguments <br />
• Ra@onal debates over risk <strong>and</strong> uncertainty <br />
– Don’t engage in debates or arguments <br />
• This is essen@ally doing a ritual <br />
– Summarize the discussion <br />
– The partner could be correct, but rather than taking it for <br />
granted, put it to the test <br />
– Recognize that his or her decision is difficult <strong>and</strong> that fear <br />
plays a large role <br />
Defusing Arguments over OCD <br />
• “Remember that we agreed on this decision. I <br />
hope you’ll hold up your end of the bargain.” <br />
• “You’re right. Something bad could happen, <strong>and</strong> I <br />
can’t convince you that it won’t. But if we never <br />
took any risks, we’d never have a normal life <br />
together. This is about helping you live with <br />
normal risks.” <br />
• “It looks like you’re having a lot of trouble right <br />
now. I underst<strong>and</strong> that it’s very hard for you.” <br />
• Share thoughts <strong>and</strong> feelings (as described earlier) <br />
Helpful vs. Hurjul Partner Behaviors <br />
• Characteris@cs of a helpful partner <br />
– Considerate, sensi@ve, op@mis@c <br />
– Warm <strong>and</strong> thoughjul, nonjudgmental <br />
– Willing to challenge or confront OCD in a construc=ve way <br />
• Characteris@cs of an unhelpful partner <br />
– Pessimis@c, sarcas@c <br />
– Highly cri@cal, antagonis@c <br />
– Smothering, overbearing, overly involved <br />
What if my Partner Doesn’t want to <br />
Change <br />
• Share thoughts <strong>and</strong> feelings together <br />
• Seek assistance from an OCD expert individually <br />
• Consider couples therapy <br />
– For OCD <br />
– General rela@onship distress <br />
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8
6/14/13<br />
Role of the Partner in <br />
Couples Therapy for OCD <br />
• Learn about the vicious cycle of OCD <strong>and</strong> how <br />
treatment works <br />
• Be present at the treatment sessions, but gradually <br />
withdraw from involvement in treatment <br />
• Posi@ve reinforcement of healthy (non-‐OCD) <br />
behavior <br />
• Gentle but firm reminders not to avoid or use safety <br />
behaviors <br />
• Emo@onal support during exposure <strong>and</strong> response <br />
preven@on <br />
FRIDAY<br />
-64-<br />
9
Ask an Attorney - What Are My Rights on the Job<br />
Marilynn Mika Spencer!<br />
The Spencer Law Firm"<br />
San Diego, CA 92108<br />
Ask an Attorney! !<br />
Questions <strong>and</strong> Answers !<br />
about Employment Law!<br />
for People with OCD <strong>and</strong>!<br />
other Mental Health Disabilities!<br />
Go ahead . . . Ask me anything! Really!<br />
`<br />
“Congress finds that . . . Disability is a<br />
natural part of the human experience<br />
<strong>and</strong> in no way diminishes the right of<br />
individuals to live independently;<br />
make choices; contribute to society;<br />
pursue meaningful careers; <strong>and</strong> enjoy<br />
full inclusion <strong>and</strong> integration in the<br />
economic, political, social, cultural,<br />
<strong>and</strong> educational mainstream of<br />
American society . . . .”<br />
Rehabilitation Act 1973 amendment<br />
IOCDF 2013 Ask an Attorney<br />
Marilynn Mika Spencer<br />
2<br />
Key laws"<br />
• Rehabilitation Act!<br />
29 U.S.C. sections 794 et seq. "<br />
• ADA!<br />
Americans with Disabilities Act of 1990!<br />
42 U.S.C. sections 12101 et seq. "<br />
• ADA Amendments Act of 2008<br />
P.L. 110-325"<br />
• FMLA!<br />
Family <strong>and</strong> Medical Leave Act!<br />
29 U.S.C. section 2101 et seq. "<br />
IOCDF 2013 Ask an Attorney<br />
Marilynn Mika Spencer<br />
3<br />
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Marilynn Mika Spencer<br />
4<br />
-65-
The ADA<br />
protects people with<br />
disabilities<br />
from discrimination<br />
What is “disability”<br />
“Disability” has different definitions in SSDI,<br />
workers’ compensation, disability insurance,<br />
state disability statutes <strong>and</strong> the ADA.<br />
No single definition applies to everything!<br />
IOCDF 2013 Ask an Attorney<br />
Marilynn Mika Spencer<br />
6<br />
FRIDAY<br />
What is a disability under the ADA<br />
A physical or mental impairment that<br />
substantially limits one or more major life<br />
activities<br />
Mitigating measures<br />
Things that can reduce the<br />
effects of an impairment<br />
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Marilynn Mika Spencer<br />
7<br />
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Marilynn Mika Spencer<br />
8<br />
-66-
What is a major<br />
life activity<br />
Basic activities the average person can perform with little or<br />
no difficulty, such as seeing, hearing, walking, speaking,<br />
breathing, thinking, learning <strong>and</strong> sleeping.<br />
Who is protected<br />
A qualified individual with a disability who<br />
can perform the essential functions<br />
(duties) of a position with or without a<br />
reasonable accommodation<br />
IOCDF 2013 Ask an Attorney<br />
Marilynn Mika Spencer<br />
9<br />
IOCDF 2013 Ask an Attorney<br />
Marilynn Mika Spencer<br />
1 0<br />
Who is a Qualified<br />
Applicant or Employee<br />
with a Disability<br />
Two parts of the ADA<br />
One who has the necessary<br />
knowledge, skill, <strong>and</strong> experience<br />
required for the position <strong>and</strong> can<br />
perform the essential functions of<br />
the position with or without<br />
reasonable accommodation.<br />
No. 1: Prohibits discrimination against<br />
people with disabilities<br />
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1 2<br />
-67-
Discrimination: treating an applicant or<br />
employee with a disability differently <strong>and</strong><br />
adversely from people without disabilities<br />
with respect to:<br />
• hiring<br />
• firing<br />
• promotion<br />
• training<br />
• shift assignments<br />
• evaluations<br />
• etc. etc. etc.<br />
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1 3<br />
Discrimination is prohibited against:<br />
1. People with disabilities; <strong>and</strong><br />
2. People with record of disability;<br />
<strong>and</strong><br />
3. People regarded as having a<br />
disability.<br />
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1 4<br />
FRIDAY<br />
The disability must be<br />
known to the employer<br />
in order to receive<br />
protection under the ADA<br />
Two parts of the ADA<br />
No. 2 Employers must provide<br />
reasonable accommodation to qualified<br />
applicants <strong>and</strong> employees with<br />
disabilities.<br />
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1 5<br />
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1 6<br />
-68-
What is<br />
Reasonable<br />
Accommodation<br />
Modifications or adjustments to a job or<br />
work environment that allow a qualified<br />
applicant or employee with a disability to<br />
participate in the application process or to<br />
perform essential job functions without<br />
causing undue hardship on the<br />
employer.<br />
Is the accommodation<br />
reasonable<br />
For the employee:<br />
allows the individual to<br />
perform essential functions<br />
without threat to self or others<br />
For the employer:<br />
does not cause undue hardship<br />
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1 8<br />
An Interactive Process is required<br />
between employer <strong>and</strong> employee!<br />
Employer is allowed<br />
only enough medical<br />
information to support<br />
the need for<br />
accommodation<br />
Employer must keep<br />
medical information<br />
confidential (“need to<br />
know” only)<br />
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2 0<br />
-69-
Medical inquiries: What can an employer know<br />
about your medical condition And when<br />
Before a job offer is made<br />
very limited info<br />
After job offer made but before employment starts<br />
almost unlimited info<br />
After work begins<br />
only for business necessity<br />
Disclosure!<br />
But when<br />
During an authorized medical<br />
exam<br />
When accommodation<br />
needed<br />
To address absences, errors,<br />
or gossip<br />
FRIDAY<br />
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2 1<br />
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Marilynn Mika Spencer<br />
2 2<br />
bad thing<br />
happens<br />
The complaint process<br />
180<br />
days<br />
365<br />
days<br />
file claim<br />
mediate mediate<br />
settle<br />
Components of an ADA medical lette:r<br />
diagnosis + MLA affected + accommodation suggested + duration<br />
–––––––––––––––––––––––––––––––––––––––––––<br />
I am treating Oscar <strong>Obsessive</strong> for a<br />
neuro-physiological disorder<br />
physiological condition<br />
mental health condition.<br />
This condition is substantially limitS Oscar <strong>Obsessive</strong>’s ability to<br />
concentrate<br />
think<br />
perform manual tasks.<br />
litigate<br />
90 days<br />
right-to-sue<br />
letter<br />
investigation<br />
cause<br />
conciliate<br />
determination<br />
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Marilynn Mika Spencer<br />
2 3<br />
Accordingly, Mr. <strong>Obsessive</strong> needs a reasonable accommodation of<br />
a quiet work environment<br />
white noise<br />
a “do not disturb” option on her telephone.<br />
Mr. <strong>Obsessive</strong>’s condition is<br />
permanent<br />
expected to last for more than one year.<br />
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2 4<br />
-70-
Family <strong>and</strong><br />
M edical<br />
L<br />
A<br />
eave<br />
ct<br />
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2 5<br />
weeks of unpaid leave<br />
due to serious health condition<br />
of self, immediate family member or birth/adoption of child<br />
if<br />
employer has 50+ employees with 75 mile radius<br />
<strong>and</strong><br />
employee has worked at least 12 months for same employer<br />
at any time<br />
<strong>and</strong><br />
employee has worked at least 1,250 hours for same<br />
employer in immediately preceding year<br />
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2 6<br />
FMLA:<br />
2 years<br />
Components of an FMLA medical letter<br />
NO diagnosis + leave requirement + frequency or length<br />
–––––––––––––––––––––––––––––––––––––––––––––––<br />
I am treating Carla <strong>Compulsive</strong> for a<br />
serious medical condition.<br />
Due to this condition, Ms. <strong>Compulsive</strong> requires<br />
regular medical treatments<br />
a leave of absence.<br />
The frequency of the medical treatments is<br />
twice per week for one hour<br />
The length of the leave of absence<br />
is three weeks.<br />
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Protect yourself! Write it down!<br />
1. Date <strong>and</strong> time<br />
2. Who said or did something<br />
3. Who else was present<br />
4. What happened What was said <br />
Who said it<br />
5. What you did or said in response<br />
6. How it made you feel<br />
7. How did the situation end<br />
EXAMPLE<br />
July 17, 2010 about 2:30 p.m. Livia asked me “Can you cover<br />
Gary’s last hour on the shift He has to go <br />
somewhere.” I had therapy appointment that afternoon so<br />
I told Livia “I am sorry. I am busy already <strong>and</strong> cannot do<br />
it.” Livia said “You are always busy doing stupid stuff<br />
instead of my work.” I asked “What do you mean” She<br />
laughed <strong>and</strong> said “You’re a joke.” That hurt my feelings. I<br />
was embarrassed because Carlos <strong>and</strong> Soo-yen could hear<br />
what Livia said. I went back to my work station for the<br />
rest of the day <strong>and</strong> went home at end of shift. Livia didn’t<br />
talk to me for several days after that.<br />
FRIDAY<br />
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Marilynn Mika Spencer<br />
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Rely on yourself<br />
Others: May not remember<br />
<br />
<br />
<br />
<br />
May remember differently<br />
May not be available<br />
May not be credible<br />
May have their own agenda<br />
IOCDF 2013 Ask an Attorney<br />
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3 1<br />
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THE SPENCER LAW FIRM<br />
2727 Camino del Rio South • Suite 140 • San Diego, CA 92108<br />
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The Americans with Disabilities Act (ADA)<br />
as Amended by the ADA Amendments Act of 2008 (ADAAA):<br />
Disability Discrimination in Employment<br />
The Americans with Disabilities Act of 1990 1 (ADA) is broad legislation designed to<br />
integrate people with disabilities into the mainstream of all aspects of society. The<br />
ADA is divided into five sections, called ”titles.“ Title I covers employment. Titles<br />
II, III, IV <strong>and</strong> V cover public services, public accommodations, telecommunications,<br />
<strong>and</strong> miscellaneous provisions.<br />
The ADA's protection applies to people with disabilities. The ADA explicitly includes<br />
people with mental disabilities, including individuals with psychiatric impairments.<br />
Title I of the ADA prohibits private employers with at least 15 employees, religious<br />
entities with at least 15 employees, state <strong>and</strong> local governments, employment<br />
agencies <strong>and</strong> labor unions from discriminating against qualified individuals with<br />
disabilities in job application procedures, hiring, firing, advancement, compensation,<br />
job training, <strong>and</strong> other terms, conditions, <strong>and</strong> privileges of employment. Federal<br />
sector employees are covered by the Rehabilitation Act 2 , which has been amended to<br />
parallel the ADA.<br />
To discriminate on the basis of disability means to treat a person with a disability<br />
differently <strong>and</strong> adversely from other people who do not have a disability. A qualified<br />
employee or applicant with a disability is an individual who, with or without reasonable<br />
accommodation, can perform the essential functions of the job in question.<br />
Congress passed the Americans with Disabilities Amendments Act of 2008<br />
(ADAAA) 3 specifically to overturn a series of Supreme Court decisions that made it<br />
difficult to prove an impairment is a “disability.” The ADAAA made significant<br />
changes to the definition of “disability” so that the ADA’s protection should now<br />
apply to a much larger number of people.<br />
Under the ADA, a person with a disability is protected by the law if one<br />
1. Has a physical or mental impairment that substantially limits one or more<br />
major life activities; or<br />
2. Has a record of such an impairment; or<br />
1<br />
2<br />
3<br />
42 U.S.C. sections 12101 et seq. (ADA).<br />
29 U.S.C. sections 794 et seq.<br />
Pub. L. 110-325.<br />
ADA as Amended<br />
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3. Is regarded as having such an impairment.<br />
The ADAAA did not define “substantially limits” but it did specifically reject the<br />
Supreme Court’s rigid <strong>and</strong> limited definition. A better underst<strong>and</strong>ing of<br />
“substantially limits” will emerge over time.<br />
The ADAAA greatly broadened the definition of “major life activities” to include<br />
“major bodily functions.” As of January 01, 2009, these definitions apply:<br />
Major life activities include, but are not limited to, use of the five senses, caring for<br />
oneself, interaction with others, performing manual tasks, seeing, hearing, eating,<br />
sleeping, walking, st<strong>and</strong>ing, lifting, bending, speaking, breathing, learning, reading,<br />
concentrating, thinking, communicating, <strong>and</strong> working.<br />
FRIDAY<br />
Major Bodily Functions include, but are not limited to, functions of the immune<br />
system, normal cell growth, digestive, bowel, bladder, neurological, brain,<br />
respiratory, circulatory, endocrine, <strong>and</strong> reproductive functions.<br />
The ADAAA redefines <strong>and</strong> exp<strong>and</strong>s coverage under the “regarded as” prong of the<br />
definition of “disability.” To satisfy the “regarded as” st<strong>and</strong>ard an individual need<br />
only show that he or she was subjected to an action prohibited under the statute<br />
(e.g., termination; failure to hire) because of an actual or perceived impairment. It is<br />
no longer necessary that the impairment be perceived by the employer to limit or<br />
“substantially limit” a major life activity.<br />
Before the ADAAA, “mitigation measures” that increase the functioning of a person<br />
with an impairment were considered in determining whether a person met the<br />
definition of “person with a disability.” In other words, the determination of<br />
whether a person was substantially limited was made after the person received the<br />
benefit of the mitigating measure. For example, if a person with diabetes controlled<br />
his or her diabetes with Insulin, that person may not have been considered as having<br />
an impairment, because the Insulin removed the limitations which were present<br />
before the medication.<br />
Now, after the ADAAA, the determination must be made regardless of the<br />
mitigating measures; that is, before those measures are used or applied.<br />
Additional protections of the ADA<br />
Under the ADA it is unlawful to retaliate against an individual for opposing<br />
disability discrimination in employment, or for filing a discrimination charge,<br />
testifying, or participating in any way in an investigation, proceeding, or litigation<br />
under the ADA.<br />
The ADA also protects other individuals in certain circumstances, including family<br />
members who are associated with a person with a disability.<br />
ADA as Amended<br />
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Importantly, the ADA requires covered employers to make reasonable accommodation<br />
to the known physical or mental limitations of qualified individuals with<br />
disabilities, unless it results in undue hardship. Undue hardship is defined as<br />
something requiring significant difficulty or expense with respect to the employer's<br />
size, financial resources, <strong>and</strong> the nature of its operations.<br />
Reasonable accommodation may include making existing facilities readily accessible;<br />
job restructuring; modifying work schedules; reassignment to a vacant position;<br />
acquiring or modifying equipment or devices; adjusting or modifying examinations,<br />
training materials, or policies; providing qualified readers or interpreters; <strong>and</strong> more.<br />
The ADA also requires covered employers to provide qualified individuals with<br />
disabilities with equal access to all employment-related opportunities. This includes<br />
medical insurance, social activities, vending machines, rest rooms, <strong>and</strong> more.<br />
In addition, the ADA limits the disability-related questions an employer can ask a<br />
job applicant before a job offer is made. Employers may not ask about the existence,<br />
nature, or severity of a disability, but can ask applicants about their ability to<br />
perform specific job functions. A job offer may be conditioned on the results of a<br />
medical examination, but only if the examination is required for all entering<br />
employees in similar jobs. Medical examinations of current employees must be job<br />
related <strong>and</strong> consistent with the employer's business needs.<br />
Although an employer may not discriminate on the basis of disability, if an<br />
applicant or employee poses a direct threat to the health or safety of him or herself,<br />
or of others, an employer may treat that individual differently due to the direct threat.<br />
An employer’s direct threat defense requires proof there is significant risk of<br />
substantial harm which cannot be reduced or eliminated by reasonable<br />
accommodation. An employer’s stereotyped assumption that people with<br />
disabilities are more prone to harm is not an excuse for discrimination.<br />
To pursue a case under the ADA, a person must file a claim with the U. S. Equal<br />
Employment Opportunity Commission (EEOC) within 180 days of the date of<br />
discrimination or failure to accommodate, or within 300 days if in a state with a fair<br />
employment practices agency. A person cannot file a lawsuit until the EEOC has<br />
had the opportunity to investigate <strong>and</strong> resolve the claim, <strong>and</strong> issues a right-to-sue<br />
letter.<br />
Claims of disability discrimination in employment may be filed at any EEOC field<br />
office. For the appropriate EEOC field office, call the EEOC at (800) 669-4000 (voice)<br />
or (800) 669-6820 (TTY).<br />
Many states have laws that are similar to the ADA or are more favorable to people<br />
with disabilities. Some state laws provide more generous remedies, a longer time to<br />
file the claim, easier procedures, <strong>and</strong> more.<br />
ADA as Amended<br />
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THE SPENCER LAW FIRM<br />
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(619) 233-1313 telephone • (619) 296-1313 facsimile • spencerlaw@spencerlawoffice.com<br />
Reasonable Accommodation for<br />
People with <strong>Obsessive</strong> <strong>Compulsive</strong> Disorder or Hoarding Disorder<br />
The Americans with Disabilities Act (ADA) requires covered employers to make reasonable<br />
accommodation to the known physical or mental limitations of qualified individuals with<br />
disabilities, unless it results in undue hardship. Undue hardship is defined as something<br />
requiring significant difficulty or expense with respect to the employer's size, financial<br />
resources, <strong>and</strong> the nature of its operations.<br />
FRIDAY<br />
Reasonable accommodation may include making existing facilities readily accessible; job<br />
restructuring; modifying work schedules; reassignment to a vacant position; acquiring or<br />
modifying equipment or devices; adjusting or modifying examinations, training materials,<br />
or policies; providing qualified readers or interpreters; <strong>and</strong> more.<br />
Accommodations must be determined on an individual, case-by-case basis. There is no<br />
cookie-cutter approach to finding an appropriate accommodation.<br />
The Job Accommodation Network (JAN) is a free service designed to increase<br />
employment of workers with disabilities by providing individualized work<br />
accommodations solutions <strong>and</strong> suggestions, providing technical assistance regarding the<br />
ADA <strong>and</strong> other disability-related laws, <strong>and</strong> educating callers about self-employment<br />
options. JAN is provided by the Office of Disability Employment Policy of the U.S.<br />
Department of Labor. JAN represents the most comprehensive resource for job<br />
accommodations available. www.jan.wvu.edu<br />
(800) 526-7234 telephone – (877) 781-9403 TTY<br />
JAN suggests the following inquiries to help assess what accommodations are appropriate:<br />
1. What limitations is the employee with a mental impairment experiencing<br />
2. How do these limitations affect the employee <strong>and</strong> the employee’s job performance<br />
3. What specific job tasks are problematic as a result of these limitations<br />
4. What accommodations are available to reduce or eliminate these problems Are all<br />
possible resources being used to determine possible accommodations<br />
5. Has the employee with a mental impairment been consulted regarding possible<br />
accommodations<br />
6. Once accommodations are in place, would it be useful to meet with the employee<br />
with a to evaluate the effectiveness of the accommodations <strong>and</strong> to determine whether<br />
additional accommodations are needed<br />
7. Do supervisory personnel <strong>and</strong> employees need training regarding mental<br />
impairments<br />
Reasonable Accommodation<br />
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Some possible reasonable accommodations for persons with anxiety disorders, including obsessive<br />
compulsive disorder (OCD) <strong>and</strong> hoarding disorder, include:<br />
Allow a self-paced workload, flexible work hours, make-up time, part-time, or job sharing<br />
Allow additional time to learn new responsibilities, training, or end-of-day clean up<br />
Allow frequent or longer breaks, with backup coverage<br />
Allow telephone calls or time off during work hours to consult with doctors <strong>and</strong> others for needed<br />
support, counseling or therapy<br />
Allow the employee control of his/her workspace<br />
Allow the employee to take a break to use stress management techniques to cope with frustration<br />
Allow the employee to tape record meetings <strong>and</strong>/or provide typed minutes<br />
Allow the presence of a support animal<br />
Allow working from home all or part of the time, <strong>and</strong> provide necessary equipment<br />
Ask for <strong>and</strong> implement employee input<br />
Develop a procedure to objectively evaluate the effectiveness of the accommodation<br />
Develop strategies to h<strong>and</strong>le problems before they arise<br />
Develop written work agreements that include the agreed upon accommodations, clear expectations of<br />
responsibilities <strong>and</strong> the consequences of not meeting performance st<strong>and</strong>ards<br />
Divide large assignments into smaller tasks <strong>and</strong> goals<br />
Do not require all employees to attend work related social functions<br />
Educate all employees on their right to accommodations<br />
Encourage employees to move non-work conversations out of work areas<br />
Ensure employees are welcome to communicate openly with managers <strong>and</strong> supervisors without reprisal<br />
Establish written long term <strong>and</strong> short term goals<br />
Increase natural lighting or provide full spectrum lighting<br />
Make daily To Do lists <strong>and</strong> check items off as they are completed<br />
Move the employee to a private office or an area with less distractions<br />
Plan for uninterrupted work time<br />
Provide written flow-charts<br />
Provide job coaches<br />
Provide labels to help employee with filing or putting items away<br />
Provide positive praise <strong>and</strong> reinforcement<br />
Provide sensitivity training to coworkers <strong>and</strong> supervisors<br />
Provide storage space the employee can control<br />
Provide regular meetings with supervisors to discuss productions levels, where to put items, etc.<br />
Provide written job instructions <strong>and</strong> checklists<br />
Providing gradual updates on forthcoming changes<br />
Recognize that a change in environment or supervisors may be difficult, so allow contact with the prior<br />
supervisor to assist in an effective transition<br />
Reduce distractions in the work area: provide white noise/environmental sound machines; allow<br />
employee to play soothing music with a headset; use sound absorption panels, cubicle walls <strong>and</strong> doors<br />
Refer the employee to counseling <strong>and</strong> employee assistance programs<br />
Remind employee of important meetings <strong>and</strong> deadlines, <strong>and</strong> provide a calendar<br />
Restructure the job to include only essential functions<br />
Use electronic organizers, watches, <strong>and</strong> timers with prompts<br />
Reasonable Accommodation<br />
Marilynn Mika Spencer<br />
Page 21<br />
Employment Law Protection for People with Hoarding Disorders<br />
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Sample requests for accommodation<br />
July 17, 2012<br />
Sonia Supervisor (or Human Resources, or Personnel)<br />
Evil Empire, Inc.<br />
0987 Sixth Street<br />
Fifth City, CA 98765<br />
Wilma Worker<br />
1234 Fifth Avenue<br />
Sixth City, CA 54321<br />
(555) 555-5555<br />
wilmaworker@whatever.com<br />
FRIDAY<br />
DELIVERED BY U.S. MAIL (or inter-office mail, or h<strong>and</strong> delivery, or e-mail)<br />
Dear Ms. Supervisor:<br />
I request reasonable accommodation for my disability of hoarding disorder. I believe an appropriate<br />
accommodation would be providing me with a file cabinet with labels specifying what should be filed in each<br />
drawer, plus private time to talk to you about documents that don’t fit into any of the categories. Please<br />
contact me to begin the interactive process. Thank you.<br />
Sincerely,<br />
Wilma Worker<br />
July 17, 2010<br />
Sonia Supervisor (or Human Resources, or Personnel)<br />
Evil Empire, Inc.<br />
0987 Sixth Street<br />
Fifth City, CA 98765<br />
Wilma Worker<br />
1234 Fifth Avenue<br />
Sixth City, CA 54321<br />
(555) 555-5555<br />
wilmaworker@whatever.com<br />
DELIVERED BY U.S. MAIL (or inter-office mail, or h<strong>and</strong> delivery, or e-mail)<br />
Dear Ms. Supervisor:<br />
This confirms my previous request (or requests) for request reasonable accommodation for my disability of<br />
obsessive compulsive disorder (OCD). I made my previous requests on these dates: _________<br />
_________ _________ _________ . I believe an appropriate accommodation would be providing me<br />
with a white noise machine. Please contact me to begin (or continue) the interactive process. Thank you.<br />
Sincerely,<br />
Wilma Worke<br />
Sample Request for Accommodation<br />
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THE SPENCER LAW FIRM<br />
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Family <strong>and</strong> Medical Leave<br />
Summary of Key Provisions<br />
The federal Family <strong>and</strong> Medical Leave Act, 29 U.S.C. section 2101 et seq. (FMLA)<br />
provides job security to an employee who is absent from work due to the<br />
employee’s own serious health condition; or to care for a spouse, parent or child<br />
with a serious health condition; or due to the birth or adoption of a child.<br />
Eligibility The law applies to private sector employers with 50 or more employees<br />
(for at least 20 workweeks in the current or preceding calendar year), <strong>and</strong> to state,<br />
local <strong>and</strong> federal agencies <strong>and</strong> local education agencies (schools) regardless of the<br />
number of employees.<br />
To be eligible for family <strong>and</strong> medical leave, an employee must work for a covered<br />
employer <strong>and</strong>:<br />
• have worked for that same employer for at least 12 months, even if not<br />
consecutively; <strong>and</strong><br />
• have worked 1,250 or more hours in the 12 months prior to the start of the<br />
family <strong>and</strong> medical leave; <strong>and</strong><br />
• work at a location with 50 or more employees employed by the employee’s<br />
employer within a 75 mile radius.<br />
Leave permitted An eligible employee may take up to 12 workweeks of unpaid leave<br />
in a 12-month period:<br />
• if the employee is unable to work due to a serious health condition;<br />
• if the employee is caring for an immediate family member (spouse, child, or<br />
parent) with a serious health condition; <strong>and</strong>/or<br />
• due to the birth of <strong>and</strong> care for a newborn child, or newly placed adopted or<br />
foster child.<br />
The 12 weeks of leave do not have to be taken at the same time. For example, leave<br />
may be taken for a few days in January, one week in early February, one day in late<br />
February, etc. Leave may also be taken by the hour, for example, to attend medical<br />
appointments or to work a reduced schedule (for example, six hours per day instead<br />
of eight hours per day). The only limitation is that the total amount of leave cannot<br />
exceed 12 weeks in one 12-month period. Accrued paid leave, such as vacation or<br />
sick leave, may be used for all or part of the leave.<br />
FMLA Key Provisions<br />
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A serious health condition as defined by the family <strong>and</strong> medical leave laws means an<br />
illness, injury, impairment, or physical or mental condition that involves:<br />
• incapacity or treatment connected with inpatient care; or<br />
• incapacity requiring more than three calendar days absence from work,<br />
school, or regular daily activities <strong>and</strong> involving continuing treatment by (or<br />
under the supervision of) a health care provider; or<br />
• incapacity due to pregnancy, or for prenatal care; or<br />
• incapacity or treatment due to a chronic serious health condition (asthma,<br />
diabetes, epilepsy, etc.); or<br />
• permanent or long-term incapacity due to a condition for which treatment<br />
may not be effective (Alzheimer's, stroke, terminal diseases, etc.); or<br />
• absences to receive multiple treatments by, or on referral from, a health care<br />
provider for a condition that likely would result in incapacity of more than<br />
three consecutive days if left untreated (chemotherapy, physical therapy,<br />
dialysis, etc.), including absences due to recovery from such treatment.<br />
FRIDAY<br />
Notice An eligible employee who wishes to use family <strong>and</strong> medical leave must give<br />
reasonable notice to the employer:<br />
• 30 days in advance of the need if the need is foreseeable; or<br />
• as soon as practicable if the need is not foreseeable; generally, this means<br />
providing verbal or written notice within one or two business days of<br />
learning of the need.<br />
The notice must contain enough information for the employer to underst<strong>and</strong> the<br />
employee needs family <strong>and</strong> medical leave, but does not have to specifically identify<br />
the FMLA. The notice must specify the anticipated duration of the leave. The notice<br />
does not have to specify a medical diagnosis. The notice can be provided by the<br />
employee, the employee’s spouse or medical provider, by another adult family<br />
member or by the employee’s spokesperson or attorney. The notice may be given<br />
verbally (by phone or in person) or in writing (by letter, fax, or e-mail).<br />
An employer must notify the employee in advance <strong>and</strong> in writing that a leave of<br />
absence will be considered family <strong>and</strong> medical leave. Some courts have held that<br />
an employer may not include in the 12 week limit any leave time which precedes<br />
the written notice.<br />
Benefits while on leave A covered employer must maintain group health insurance<br />
coverage, including family coverage, under the same terms as for active employees.<br />
Benefits such as seniority or paid leave need not accrue during unpaid family <strong>and</strong><br />
medical leave, provided these benefits do not accrue for employees on other types of<br />
unpaid leave. An employer is not obligated to maintain other benefits, such as life<br />
FMLA Key Provisions<br />
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insurance, sick leave, education benefits or pension accrual. Upon return to work,<br />
all discontinued benefits must be reinstated immediately, with no disqualification<br />
period.<br />
Returning to work In most cases, upon return from family <strong>and</strong> medical leave, an<br />
employee must be restored to his or her original job, or to an equivalent job. An<br />
“equivalent job” is one that is virtually identical to the original job in terms of pay,<br />
benefits, <strong>and</strong> other employment terms <strong>and</strong> conditions.<br />
Employer obligations It is unlawful for any employer to interfere with, restrain, or<br />
deny the exercise of any right provided by the family <strong>and</strong> medical leave laws, or to<br />
discharge, discriminate or retaliate against any individual for opposing any practice,<br />
or due to involvement in any proceeding related to the family <strong>and</strong> medical leave<br />
laws. Employers cannot use the taking of family <strong>and</strong> medical leave as a negative<br />
factor in employment actions, such as hiring, promotions, or disciplinary actions,<br />
<strong>and</strong> family <strong>and</strong> medical leave cannot be counted under "no fault" attendance<br />
policies.<br />
An employer must maintain as confidential all medical information related to family<br />
<strong>and</strong> medical leaves. These records must be kept in files which are separate from<br />
ordinary personnel files. The only exceptions are that confidential medical records<br />
may be disclosed to supervisors <strong>and</strong> managers regarding necessary work<br />
restrictions or accommodation; to first <strong>and</strong> aid safety personnel when emergency<br />
medical treatment may be required; or government officials investigating the<br />
employer.<br />
Enforcing family <strong>and</strong> medial leave rights To pursue a claim for denial of family <strong>and</strong><br />
medical leave, reprisal for taking family <strong>and</strong> medical leave, privacy violations, or<br />
any other claim related to family <strong>and</strong> medical leave rights, the employee must<br />
initiate the process. To file a claim under the FMLA, an employee may file a charge<br />
with the Department of Labor, Wage <strong>and</strong> Hour Division, or may go directly to court<br />
within two years of the violation of the statute.<br />
Remedies An employee whose rights have been violated under the family <strong>and</strong><br />
medical leave laws may be entitled to reinstatement, promotion, injunctive relief,<br />
lost wages <strong>and</strong> benefits, direct costs, interest, attorney's fees <strong>and</strong> cost, compensatory<br />
<strong>and</strong> punitive damages, or double damages for aggravated cases.<br />
FMLA Key Provisions<br />
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THE SPENCER LAW FIRM<br />
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(619) 233-1313 telephone • (619) 296-1313 facsimile • spencerlaw@spencerlawoffice.com<br />
Disability Employment Law Resources<br />
U.S. Equal Opportunity Employment Commission<br />
Enforces the Americans with Disabilities Act, Title I (employment), <strong>and</strong> other laws<br />
1801 L Street, N.W.<br />
Washington, D.C. 20507<br />
(202) 663-4900 telephone<br />
(800) 669-6820 TTY<br />
www.eeoc.gov<br />
to find a local office: http://www.eeoc.gov/offices.html<br />
FRIDAY<br />
United States Department of Labor (DOL)<br />
Enforces the Family <strong>and</strong> Medical Leave Act, as well as other laws<br />
U.S. Department of Labor<br />
200 Constitution Ave., NW<br />
Washington, DC 20210<br />
(866) 487-2365 telephone<br />
(877) 889-5627 TTY<br />
http://www.dol.gov/dol/topic/benefits-leave/fmla.htm<br />
Job Accommodation Network<br />
The Job Accommodation Network (JAN) is a free consulting service that provides information<br />
about job accommodations, the Americans with Disabilities Act (ADA), <strong>and</strong> the employment of<br />
people with disabilities. JAN offers individualized worksite accommodations solutions, technical<br />
assistance regarding the ADA <strong>and</strong> other disability-related legislation, <strong>and</strong> education about selfemployment.<br />
JAN is provided by the Office of Disability Employment Policy of the U.S.<br />
Department of Labor. JAN represents the most comprehensive resource for job accommodations<br />
available.<br />
West Virginia University<br />
PO Box 6080<br />
Morgantown, WV 26506-6080<br />
(800) 526-7234 telephone<br />
(877) 781-9403 TTY<br />
www.jan.wvu.edu<br />
The American Bar Association Commission on Mental & Physical Disability Law<br />
The American Bar Association's Commission on the Mentally Disabled was established in 1973 to<br />
respond to the advocacy needs of persons with mental disabilities. After the passage of the<br />
Americans with Disabilities Act of 1990, the ABA broadened the Commission’s mission to serve all<br />
persons with disabilities <strong>and</strong> changed its name to the Commission on Mental <strong>and</strong> Physical<br />
Disability Law (CMPDL). The Commission's mission is "to promote the ABA's commitment to<br />
justice <strong>and</strong> the rule of law for persons with mental, physical, <strong>and</strong> sensory disabilities <strong>and</strong> to<br />
promote their full <strong>and</strong> equal participation in the legal profession." The directory For assistance,<br />
please email cmpdl@abanet.org or call .<br />
The ABA Disability Lawyer Directory lists lawyers who provide legal representation to<br />
persons with disability-related claims or disputes.<br />
(202) 662-1570<br />
http://www.abanet.org/disability/disabilitydirectory/home.shtml<br />
Resources<br />
Marilynn Mika Spencer<br />
Ask an Attorney!<br />
IOCDF 2013 Annual Conference<br />
-82-
Protection <strong>and</strong> Advocacy<br />
The Protection <strong>and</strong> Advocacy (P&A) System <strong>and</strong> Client Assistance Program (CAP) comprise the<br />
nationwide network of congressionally m<strong>and</strong>ated, legally-based disability rights agencies. P&A<br />
agencies have authority to provide legal representation <strong>and</strong> advocacy services to all people with<br />
disabilities (based on a system of priorities for services). These agencies devote considerable<br />
resources to ensuring full access to inclusive educational programs, financial entitlements,<br />
healthcare, accessible housing <strong>and</strong> productive employment opportunities. CAP agencies (many of<br />
which are housed within P&A offices) provide information <strong>and</strong> assistance to individuals seeking<br />
or receiving vocational rehabilitation (VR) services under the Rehabilitation Act, including<br />
assistance in pursuing administrative, legal <strong>and</strong> other appropriate remedies.<br />
900 Second Street, NE, Suite 211<br />
Washington, DC 20002<br />
(202) 408-9514 telephone<br />
(202) 408-9521 TTY<br />
http://www.ndrn.org/aboutus/PA_CAP.htm<br />
Judge David L. Bazelon Center for Mental Health Law<br />
National, non-profit organization that engages in legal advocacy for people with mental<br />
disabilities.<br />
1101 15th St. NW<br />
Suite 1212<br />
Washington, DC 20005<br />
(202)467-5730 telephone<br />
(202)467-4232 TTY<br />
HN1660@h<strong>and</strong>snet.org<br />
http://www.bazelon.org<br />
Office of Disability Employment Policy<br />
The Office of Disability Employment Policy (ODEP) is an agency within the U. S.<br />
Department of Labor. ODEP provides assistance to increase employment<br />
opportunities for adults <strong>and</strong> youth with disabilities.<br />
200 Constitution Avenue, NW, Room S-1303<br />
Washington, DC 20210<br />
(202) 693-7880 telephone<br />
(202) 693-7881 TTY<br />
infoODEP@dol.gov<br />
www.dol.gov/odep<br />
National Employment Lawyers Association<br />
National bar association for employment attorneys. NELA has a “find a lawyer” search option.<br />
44 Montgomery Street, Suite 2080<br />
San Francisco, CA 94104<br />
http://www.nela.org<br />
http://www.nela.org/NELA/index.cfmevent=showPage&pg=findalawyer<br />
Workplace Fairness<br />
National organization promoting workers’ rights. Workplace Fairness has a detailed website<br />
covering employment law in all 50 states, as well as an attorney search tool.<br />
920 U Street NW<br />
!Washington D.C. 20001<br />
(202) 683-6114 telephone<br />
http://www.workplacefairness.org/<br />
http://www.workplacefairness.org/find-attorney<br />
Resources<br />
Marilynn Mika Spencer<br />
Ask an Attorney!<br />
IOCDF 2013 Annual Conference<br />
-83-
Don’t Try Harder, Try Different<br />
Don’t Try Harder, Try Different<br />
Patrick B. McGrath, Ph.D.<br />
Director, Alexian Brothers Center for Anxiety<br />
<strong>and</strong> <strong>Obsessive</strong> <strong>Compulsive</strong> Disorders<br />
Alexian Brothers Behavioral Health Hospital<br />
Hoffman Estates, IL<br />
President, OCD Midwest<br />
President, Anxiety Centers of Illinois<br />
Four Basic Fears<br />
Threats to the integrity of:<br />
*Physical Status<br />
*Mental Status<br />
*Social Status<br />
*Spiritual Status<br />
FRIDAY<br />
Common Distortions<br />
• Severity<br />
– It will be the worst thing in the world <strong>and</strong> I will<br />
die.<br />
• Probability<br />
– It will definitely happen, no question.<br />
• Efficacy<br />
– I will not be able to h<strong>and</strong>le it.<br />
Don’t Try Harder, Try Different:<br />
• Should<br />
– When was the last time you used the word<br />
should to describe something that went well<br />
– Should is always negative.<br />
– Should is an opinion.<br />
– What if we made shoulds come true<br />
– Should just leads to arguments.<br />
-84-<br />
1
Can’t - vs. -Won’t<br />
• If you say that you can’t do something, then that<br />
is exactly what is going to happen.<br />
• If you can’t do it, then no therapist or medication<br />
will ever be able to help you with it.<br />
• Can’t implies that you lack the ability to do<br />
something.<br />
• OCD not about something you can’t do, it is<br />
about something that you won’t do.<br />
Practice makes _________<br />
• Practice does not make perfect.<br />
• There is no such thing as perfect.<br />
• Perfect is just an opinion – just like should.<br />
• Example – Name the perfect appetizer.<br />
• Practice makes ROUTINE.<br />
• Routines can be modified – some work for<br />
you <strong>and</strong> some do not. The goal of therapy<br />
is to modify the ones that are not working<br />
for you.<br />
Control is an Illusion<br />
• Control is often attempted through worry.<br />
• Worry serves two functions –<br />
– If I worry about something hard enough, I can<br />
prevent it from happening.<br />
– If I worry about everything bad that might<br />
happen, then I can be prepared for everything<br />
bad that might happen, so then I won’t need<br />
to worry about it anymore.<br />
Specialness<br />
• The rules of the world apply to me<br />
differently than they do to the other 7<br />
billion people that live on the planet.<br />
• Try these exercises:<br />
– Today, treat yourself as if you were your very<br />
best friend or most cherished loved one.<br />
– Tomorrow, treat everyone like you would<br />
normally treat yourself (or maybe just think it<br />
in your head instead).<br />
-85-<br />
2
Neutrality<br />
• From an anxiety perspective, nothing is<br />
actually scary or horrible or wonderful or<br />
great.<br />
• Everything that anyone is anxious about is<br />
actually neutral.<br />
• Elevator example.<br />
Perception<br />
• Everything that people are anxious about<br />
is subject to their perception or opinion.<br />
FRIDAY<br />
Reverse the Talk<br />
• An anxiety disorder is Perceiving Neutral<br />
events in a Special way, thinking that you<br />
have to Control them to make them<br />
Perfect, because you Can’t h<strong>and</strong>le it any<br />
other way, <strong>and</strong> that is just how your life<br />
Should be.<br />
• OR -<br />
• OCD is two words…. What if<br />
What maintains Stress<br />
• Safety Seeking Behaviors<br />
– Avoidance<br />
– Reassurance seeking<br />
– Distraction<br />
-86-<br />
3
Rewards<br />
Fear Stimulus<br />
CBT Model of Stress:<br />
Phobia Example<br />
Great America<br />
Misinterpretation of threat<br />
Anxiety<br />
Avoidant Coping<br />
Absence of Corrective<br />
Experience<br />
If I get on a roller coaster, it will crash<br />
<strong>and</strong> I will die.<br />
Anxiety<br />
Refuses to ride the coasters, even<br />
though friends are riding them <strong>and</strong><br />
there are no problems with them.<br />
Does not learn that thinking there will<br />
be a problem does not mean that<br />
there actually will be a problem.<br />
Correction of a Potential<br />
Stressor<br />
Fear Stimulus<br />
Misappraisal of<br />
Threat<br />
Anxiety<br />
Adaptive<br />
Coping<br />
Corrective<br />
Experience<br />
Adjustment of<br />
Threat<br />
Appraisal<br />
Next<br />
Presentation of<br />
Fear Stimulus<br />
Accurate<br />
Threat<br />
Appraisal<br />
Adaptive<br />
Emotional<br />
Response<br />
Adaptive<br />
Behavior<br />
Exposure <strong>and</strong> Response<br />
Prevention<br />
• Make a list of feared stimuli/situations.<br />
• Arrange stimuli in hierarchical fashion.<br />
• Develop <strong>and</strong> implement plan of systematic<br />
exposure to stimuli/situations, using the<br />
hierarchy.<br />
• Goal is to get a person to confront their fears<br />
<strong>and</strong> learn that they can h<strong>and</strong>le the situation.<br />
• The exposure is assisted by the therapist <strong>and</strong> is<br />
never forced on the patient.<br />
-87-<br />
4
Books by Dr. McGrath<br />
Contact<br />
• Patrick B. McGrath, Ph.D.<br />
• Director, Alexian Brothers Center for<br />
Anxiety <strong>and</strong> <strong>Obsessive</strong> <strong>Compulsive</strong><br />
Disorders<br />
• Alexian Brothers Behavioral Health<br />
Hospital<br />
• 847-755-8531<br />
• patrick.mcgrath@abbhh.net<br />
FRIDAY<br />
-88-<br />
5
My Child-Brother-Sister Has OCD But I’m Suffering Too!<br />
6/14/13 <br />
Common distorted thinking about OCD <br />
My Child/Brother/Sister Has<br />
OCD But I’m Suffering Too!<br />
Rodney J. Benson, Ph.D. <br />
Gwenne Gorman <br />
Chris
6/14/13 <br />
Common distorted thinking about OCD <br />
• Labeling: instead of focusing on a single <br />
instance or behavior, you adribute a global, <br />
nega
I’m Afraid I’m Really Gonna Do It<br />
I’m Afraid I’m Really Gonna Do It!<br />
Responding to the fear of<br />
loss of impulse control<br />
Fear of loss of impulse control<br />
Case Presentations<br />
Defining characteristics for this OCD subgroup<br />
Review of ERP through Storytelling<br />
Application of treatment to case presentations<br />
Concluding statements/questions<br />
Fear of loss of impulse control<br />
Adam is an 11 year old boy who is<br />
afraid that he will blurt out a curse word<br />
in church during the preacher’s sermon.<br />
-91-<br />
1
Fred is a 31 year old married cable guy<br />
who finds that whenever he is installing<br />
satellite dishes on houses he becomes<br />
gripped with the fear that maybe he will<br />
impulsively throw himself off the roof.<br />
SATURDAY<br />
Kelly is a 25 year old first time mom, who<br />
is terrified that she might accidentally drop<br />
her newborn baby.<br />
-92-<br />
2
Roger is a 52 year old widowed dentist<br />
who lives with his college-aged daughter.<br />
He is terrified that he might poison her by<br />
accidentally adding household cleaning<br />
chemicals to her food when he is cooking<br />
for her.<br />
Lauren is a 14 year old high school<br />
freshman who is afraid that she might grab<br />
at the breast area of another girl when she<br />
is near her.<br />
-93-<br />
3
Fear of loss of impulse control<br />
Defining characteristics for<br />
fear of loss of impulse control:<br />
A: Obsessions<br />
B: Experience<br />
C: Compulsions<br />
Fear of loss of impulse control:<br />
A: obsessions<br />
SATURDAY<br />
-94-<br />
4
Fear of loss of impulse control:<br />
B: experience<br />
Fear of loss of impulse control:<br />
C: compulsions<br />
Fear of loss of impulse control: other concepts<br />
Differentiate from OCD with intrusive<br />
blasphemous, sexual, or violent thoughts:<br />
Am I gay<br />
Am I a pedophile<br />
I have intrusive thoughts of killing someone that<br />
disturb me<br />
I find myself thinking bad thoughts about God<br />
In fear of loss of impulse control, the focus is on<br />
the specific fear that I will act out on my<br />
thoughts<br />
-95-<br />
5
Fear of loss of impulse control<br />
Exposure <strong>and</strong> Response Prevention<br />
(ERP or ExRP)<br />
SATURDAY<br />
-96-<br />
6
Fear of loss of impulse control<br />
ERP for fear of loss of impulse control<br />
Exposure of your body to the environment<br />
Exposure of your mind to your thoughts<br />
Elimination of accommodations of others<br />
Create a hierarchy (swimming pool)<br />
Schedule practice time (duration, frequency,<br />
intensity)<br />
Record practice times <strong>and</strong> Subjective Units of<br />
Discomfort (SUDs) levels<br />
Use serendipitous exposure as opportunities to make<br />
further progress<br />
Slowly cut back on accommodations of others<br />
Make adjustments <strong>and</strong> change foci as needed<br />
No one protocol is best<br />
-97-<br />
7
SATURDAY<br />
-98-<br />
8
S<strong>and</strong>ra<br />
Practices walking with delayed checking <strong>and</strong> with longer periods<br />
of time where she only peripherally scans the ground as she<br />
walks<br />
Practices walking more quickly, <strong>and</strong> is timed<br />
Imagines that she walked by pebbles, then sharp stones, tabs from<br />
cans, glass<br />
Actually places pebbles <strong>and</strong> small stones on walkway <strong>and</strong> leaves<br />
them there<br />
Writes, reads, imagines stories of how people hurt themselves<br />
due to her “negligence”<br />
-99-<br />
9
Roger<br />
Writes stories of how he inadvertently puts more <strong>and</strong> more toxic<br />
items into daughter’s food<br />
Lauren<br />
Special case: as a minor, Lauren’s parents should be consulted<br />
about the rationale <strong>and</strong> purpose of the therapy<br />
Has daughter repeatedly pull further <strong>and</strong> further back from doing<br />
cooking, <strong>and</strong> from how closely she watches him cook, ultimately<br />
leaving him alone for longer <strong>and</strong> longer periods of time<br />
Garage closet is unlocked, chemicals are slowly brought into the<br />
house, then placed on the kitchen floor, then kitchen counter<br />
where Roger is cooking<br />
Ultimate exposure is for Roger to pick up <strong>and</strong> put down chemical<br />
bottles in between prepping dinner, while alone, <strong>and</strong> while<br />
imagining the stories he has written<br />
Fear of loss of impulse control<br />
Writes stories of how she loses impulse control with different<br />
females in different situations <strong>and</strong> grabs at their breasts<br />
Spends longer <strong>and</strong> longer periods of time increasingly physically<br />
closer to different females, working her way up to the ones that<br />
are most anxiety producing, such as those her own age<br />
Lauren imagines that she loses impulse control <strong>and</strong> grabs at the<br />
females while close to them<br />
SATURDAY<br />
-100-<br />
10
-101-<br />
11
Help! I Can’t Get to Sleep<br />
6/14/13 <br />
Help! I Can’t Go to<br />
Sleep!<br />
Goals of this Presentation<br />
Define the Problem of Sleep <strong>and</strong> OCD<br />
Describe the Interventions<br />
Mary Kathleen Norris, LPC<br />
DFW Center for OCD <strong>and</strong> Anxiety<br />
2700 Tibbets Drive Suite 500<br />
Bedford, TX 76022<br />
Tel: 817-237-9889<br />
Fax: 817-545-8417<br />
www.dfwocd.com<br />
Defining the Problem-<br />
When Sleep Meets OCD<br />
1<br />
Troubleshooting Potential Speed-Bumps<br />
Defining the Problem-<br />
Night Rituals<br />
2<br />
SATURDAY<br />
Difficulties with Night Rituals<br />
All about “Just So”<br />
Counting, Checking, <strong>and</strong> Others<br />
Difficulties with Racing Thoughts <strong>and</strong><br />
Worry<br />
Concept of “The Ticket”<br />
Blackmail or Poker Bluff<br />
When Just About Asleep<br />
Difficulties with Separation Anxiety<br />
3<br />
4<br />
-102-<br />
1
6/14/13 <br />
Defining the Problem-<br />
Racing Thoughts<br />
Impact of Fatigue<br />
Loss of Stamina<br />
Mood Elevator<br />
More Awareness of Thoughts<br />
Tendency to Crater<br />
Defining the Problem-<br />
Separation Anxiety<br />
Reassurance for Intrusive Thoughts<br />
Need for Emotional Symmetry<br />
(provided by others)<br />
Desire for a “Guard”<br />
Somatic Complaints<br />
5<br />
6<br />
Overall Interventions<br />
Concept of Sleep Hygiene<br />
What are Good Rituals<br />
Overall Setting for Sleep<br />
Quiet, cool, dark, no TV<br />
Overall Interventions<br />
Snack<br />
Shower or Bath<br />
Deep Breathing<br />
Relaxation<br />
7<br />
8<br />
-103-<br />
2
6/14/13 <br />
Relaxation in Depth<br />
Relaxation in Depth<br />
Reading<br />
Linear Exercises for Adults<br />
Relaxation Sounds<br />
Linear Exercises for Children<br />
Relaxation Scripts<br />
Progressive<br />
Autogenic<br />
*Remember to go<br />
Slowly, step-by-step<br />
Ideas for children<br />
Include as many senses as possible<br />
Night Ritual Interventions<br />
9<br />
Racing Thoughts Interventions<br />
10<br />
SATURDAY<br />
ERP Component<br />
Let Thoughts Race<br />
Use of 3x5 cards, r<strong>and</strong>om<br />
OHIO- only h<strong>and</strong>le it once<br />
Concept of “velcro”<br />
Decide on Which One to Ride<br />
Suggested exercises<br />
11<br />
12<br />
-104-<br />
3
6/14/13 <br />
Time for ERP<br />
Separation Anxiety<br />
Interventions<br />
Concept of a “Bedtime Champ”<br />
Gradual Desensitization<br />
“guards”<br />
“visitors”<br />
Manipulation<br />
Separation Anxiety<br />
Interventions<br />
Manipulation vs. Anxiety<br />
Anxiety<br />
vs.<br />
Manipulation<br />
Anxiety<br />
*They may look the same<br />
13<br />
14<br />
Separation Anxiety<br />
Interventions<br />
Use of Contingences<br />
Creative Use of Rewards<br />
Underst<strong>and</strong>ing the Use of<br />
Consequences<br />
Summary<br />
Sleep can be quite a challenge for OCD<br />
sufferers. Sleep is essential for<br />
maintaining the overall stamina needed<br />
to keep OCD symptoms in check. Armed<br />
with the concepts of good sleep hygiene<br />
<strong>and</strong> strategies for relaxation, sleep can<br />
be a positive experience to enhance<br />
one’s strength in defeating OCD.<br />
15<br />
16<br />
-105-<br />
4
6/14/13 <br />
Bibliography<br />
Johnson, Lynn, PhD The Healing Power of Sleep 2010<br />
Head Acres Press<br />
Ferber, Richard, MD Solve Your Child’s Sleep Problems<br />
2006 Simon <strong>and</strong> Schuster<br />
Brokering, Herbert F. Hello Night! Healing Thoughts for<br />
Sleepless Nights 1999 Augsburg Fortress<br />
Garth, Maureen Moonbeam-A Book of Meditations for<br />
Children 1992 Harper Collins<br />
Garth, Maureen Starbright- Meditations for Children<br />
1991 Harper Collins<br />
17<br />
SATURDAY<br />
-106-<br />
5
Manipulating Language to Improve Patient Connections <strong>and</strong> Treatment Compliance in the Pediatric OCD Population 6/24/13<br />
MANIPULATING LANGUAGE<br />
TO IMPROVE PATIENT CONNECTIONS<br />
& TREATMENT COMPLIANCE IN THE<br />
PEDIATRIC OCD POPULATION<br />
Sarah A. Haider, Psy.D.<br />
Jenny C. Yip. Psy.D., ABPP<br />
Effective versus Ineffective Language:<br />
Cognitive Theories<br />
Research indicates that the language we<br />
use can shift our thought patterns<br />
Renewed Freedom Center for Rapid Anxiety Relief<br />
Los Angeles<br />
www.RenewedFreedomCenter.com<br />
CAROL DWECK: FIXED MINDSET<br />
VS. GROWTH MINDSET<br />
Fixed Mindset<br />
o Child assumes that you<br />
either have talent or<br />
you do not (e.g., “I am<br />
smart.” or “I am not<br />
creative.”).<br />
o Problem: Every failure<br />
becomes evidence that<br />
child is “stupid” <strong>and</strong><br />
that nothing can be<br />
done to change that<br />
sentiment.<br />
Growth Mindset<br />
o Child assumes that<br />
intelligence, talent, etc.<br />
is not an either/or<br />
situation.<br />
o These characteristics<br />
are built by hard work<br />
LINK BETWEEN “FIXED MINDSET” AND<br />
ANXIETY & OCD:<br />
ATTRIBUTION THEORY<br />
An attribution is the explanation we give<br />
ourselves for why something happened.<br />
Our attributions shape our beliefs <strong>and</strong> our<br />
behaviors.<br />
Thus, if we change a patient’s attribution, we<br />
can change his or her belief set <strong>and</strong><br />
behaviors.<br />
-107-<br />
1
6/24/13<br />
ATTRIBUTION THEORY<br />
INNATE VERSUS ACQUIRED SKILLS<br />
ATTRIBUTION THEORY<br />
INNATE VERSUS ACQUIRED SKILLS<br />
Innate<br />
(Mimics thought patterns<br />
for Anxiety <strong>and</strong> OCD)<br />
o Inherent<br />
o Black <strong>and</strong> White: It is this<br />
way- <strong>and</strong> I am powerless to<br />
change it.<br />
Acquired<br />
o These are teachable.<br />
o Spectrum: It is this<br />
way now- <strong>and</strong> I need<br />
to do something to<br />
change it.<br />
Research<br />
Littering<br />
Attribution Training vs.<br />
Persuasion Training vs.<br />
Reinforcement Training<br />
o Fixed Mindset<br />
o Growth Mindset<br />
IDENTIFY EXPLANATIONS FOR THE EVENT<br />
Therapists CAN influence a patient's attributions<br />
about an event!<br />
Promote the concept that skills are acquired.<br />
Praise for effort <strong>and</strong> persistence: Praise the<br />
behavior, NOT the feeling.<br />
Concept of shaping.<br />
“Even though you were afraid <strong>and</strong> washed, you<br />
h<strong>and</strong>led the situation without washing<br />
immediately. You were able to delay <strong>and</strong> tolerate<br />
the discomfort for a while.”<br />
SHIFT LANGUAGE TO PROMOTE HEALTHY COGNITIONS<br />
Praise DOs, to promote a<br />
Growth Mindset<br />
Praise effort,<br />
persistence, hard<br />
work, determination,<br />
overcoming<br />
challenges, or<br />
thinking differently as<br />
a way to problem solve.<br />
Praise DON’Ts, which<br />
promote a Fixed Mindset<br />
Praising children in a<br />
way that indicates<br />
inherent talent.<br />
Statements that don’t<br />
tell children how to<br />
apply a technique next<br />
time.<br />
Blanket statements may<br />
seem insincere.<br />
SATURDAY<br />
-108-<br />
2
6/24/13<br />
SHIFT LANGUAGE<br />
TO PROMOTE HEALTHY COGNITIONS<br />
Continually send messages to patient that<br />
challenges are necessary to learn <strong>and</strong> adapt<br />
better in life.<br />
You can have each child choose to do<br />
something differently or try a new approach<br />
to a problem area or struggle.<br />
Reframe defeating OCD as a life skill. When<br />
new compulsions arise, help patients see this as<br />
a challenge, NOT a relapse or failure in<br />
treatment.<br />
SHIFT LANGUAGE<br />
TO PROMOTE HEALTHY COGNITIONS<br />
Shift “Good job!” to “Good effort!”<br />
Shift “You are brave!” to “You work hard!”<br />
Shift “You are a (kind, good, nice, smart) kid” to<br />
“Your hard work really shows in your<br />
improvements.”<br />
Shift “You need to try better.” to “What can you do<br />
differently”<br />
Continually push for improvement, in order to grow<br />
the mind.<br />
Shift “Perfect!” to “What can you take on as your<br />
next challenge”<br />
RE-FRAMING FAILURE<br />
VIGNETTE: SUCCESS IN THERAPY<br />
Reframe failure as a challenge that you can<br />
work together to overcome.<br />
Overcoming challenges are a necessary part to<br />
help the brain grow <strong>and</strong> adapt to defeat<br />
anxiety.<br />
Respond to success in ways that allow patients<br />
to underst<strong>and</strong> how they influenced outcome.<br />
Identify what was done well (hard work,<br />
problem-solving in the moment, being flexible<br />
with plans, etc.).<br />
Determine how those tools can be applied to<br />
hypothetical situations in future.<br />
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6/24/13<br />
VIGNETTE: RESISTANCE TO COMPLETING<br />
THERAPY HOMEWORK<br />
Alfred B<strong>and</strong>ura’s self-efficacy theory:<br />
Help patients identify something they have<br />
accomplished.<br />
Help patients identify what skills were necessary<br />
to accomplish the task.<br />
EMPHASIZE THAT BRAIN IS MALLEABLE<br />
Therapist praise <strong>and</strong> SELF-PRAISE can<br />
impact how one thinks, acts, <strong>and</strong> feels.<br />
Use of metaphors can foster the patient’s<br />
underst<strong>and</strong>ing of how s/he can impact<br />
change.<br />
Point out how those skills can be used for current<br />
goal/task.<br />
UTILIZATION OF METAPHORS<br />
Sledding Metaphor<br />
Horse <strong>and</strong> Plow Metaphor<br />
Brain as a muscle metaphor<br />
METAPHORS THAT EXPLAIN SETBACKS IN<br />
TREATMENT<br />
Envision setbacks that a hero or role model<br />
may have encountered a setback.<br />
Take previous metaphors <strong>and</strong> account for<br />
unexpected circumstances.<br />
SATURDAY<br />
Neurons that fire together wire together!<br />
Exercise Metaphor<br />
Exercise Metaphor: Sports injury allows you to<br />
build other muscles which could be an<br />
advantage in the end.<br />
-110-<br />
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6/24/13<br />
LABEL ANXIETY AND OCD<br />
Again… Elaborate metaphor. Name<br />
anxiety, draw it, create narratives of<br />
life without “worry monster”.<br />
Externalizes problem.<br />
Aligns therapist, patient, <strong>and</strong> family<br />
as a team.<br />
PROBLEM-SOLVING<br />
Demonstrate curiosity by asking<br />
questions.<br />
This will show patients that you are<br />
interested in hearing their perspective.<br />
Allows you to gain valuable information,<br />
which provides material for motivation.<br />
PROBLEM-SOLVING<br />
SOCRATIC QUESTIONING<br />
Effective tool that builds on language in<br />
session.<br />
Ask questions in ways that promote change.<br />
Fosters collaborative environment.<br />
By answering questions, patient takes ownership<br />
of responses.<br />
Although you guide the process, patient is less<br />
likely to feel s/he is being “told” what to do.<br />
Must roll with resistance.<br />
PROBLEM-SOLVING<br />
SOCRATIC QUESTIONING<br />
Strive to look at reason why patient is engaged in<br />
unhealthy behavior.<br />
Interest in process of reaching goals, not merely the<br />
goal alone.<br />
Allows recognition of challenges that may occur.<br />
Allows patient to commit to overcoming challenges.<br />
Play Devil’s Advocate.<br />
Challenges patient to look at situations from different<br />
perspectives.<br />
Continue to ask questions until patient makes a<br />
statement that supports your objective.<br />
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6/24/13<br />
SINCERITY<br />
Develop genuine mutual points of interest.<br />
Create joint responsibility for the problem by<br />
using appropriate language.<br />
“What can we do differently”<br />
Puts patient in control by asking him/her the<br />
question.<br />
Responsibility for accomplishing tasks goes to<br />
patient.<br />
“You worked hard.”<br />
“You beat this.”<br />
SATURDAY<br />
-112-<br />
6
The BDD Challenge<br />
6/14/13<br />
The BDD Challenge<br />
Key Concepts<br />
Our body parts aren’t meant for this<br />
Scott M. Granet, LCSW<br />
The OCD-BDD Clinic of Northern California<br />
The IOCDF 20 th Annual Conference<br />
Atlanta, GA<br />
July 20, 2013<br />
Feeling good has to be more important<br />
than looking good<br />
We have these thoughts because of having<br />
BDD; not because we should or need to<br />
look better<br />
We’re more sensitive to minor changes in<br />
appearance than someone who doesn’t<br />
have BDD<br />
***We actually DO look different everyday<br />
Key Concepts Cont.<br />
Our negative thoughts <strong>and</strong> irrational<br />
beliefs are the main culprits<br />
We don’t treat others differently based on<br />
how they look on any particular day, so<br />
why should we do it to ourselves<br />
Yes, appearance is important in our<br />
culture, but is it supposed to be THIS<br />
important<br />
Does it really make sense to hold onto<br />
behaviors <strong>and</strong> beliefs which ultimately fail<br />
us<br />
It works<br />
Importance of CBT<br />
It takes: COURAGE<br />
PERSISTENCE<br />
RESILIENCE<br />
PATIENCE<br />
It’s VERY HARD work<br />
-113-<br />
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6/14/13<br />
Enough Talking! Let’s Get<br />
to the BDD Challenge!<br />
BDD PREVALENCE<br />
This isn’t meant to be just TALK about BDD<br />
<strong>and</strong> treatment<br />
<br />
<br />
Estimates: 3-5 million in U.S. alone<br />
Men <strong>and</strong> women equal<br />
Who’s first Me<br />
Getting well is about taking chances<br />
<br />
Age of onset: teens<br />
Inpatient settings: 13%<br />
BDD PREVALENCE CONT.<br />
Source: K. Phillips <strong>and</strong> R. Dufresne, Am J Cln Dermatol 2000 Jul-Aug<br />
WHERE ARE THEY<br />
SATURDAY<br />
In dermatologic settings: 11.9%-15.8%<br />
--1 in 8 patients seeking dermatologic<br />
treatment*<br />
--1 in 7 patients seeking cosmetic surgery*<br />
<br />
<br />
1 in 8 to 9 outpatients with social phobia<br />
(11%-13%)<br />
6-14% of patients receiving treatment for anxiety<br />
or depressive disorders**<br />
Shame<br />
Seeking medical appointments <strong>and</strong><br />
procedures<br />
Frequently misdiagnosed<br />
*Source: Katharine Phillips, Current Psychiatry, Jan. 2002<br />
**Source: Feusner, Winograd, Saxena, Current Psychiatry, October 2005<br />
-114-<br />
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6/14/13<br />
WHICH BODY PARTS<br />
ASSOCIATED BEHAVIORS<br />
Any may be focus of attention<br />
Most common: hair, skin, nose<br />
Body type: “Muscle Dysmorphia”<br />
Others: lips, teeth, skin tone, cheekbones,<br />
lines on face, breasts, penis, height,<br />
weight<br />
<br />
<br />
<br />
<br />
Mirror checking or avoidance (on rare<br />
occasions, mirror checking may serve to<br />
temporarily relieve anxiety, which only further<br />
complicates the problem)<br />
Checking with other reflective surfaces<br />
Camouflaging<br />
Excessive medical appointments/procedures<br />
ASSOCIATED BEHAVIORS CONT.<br />
THE TRAGEDY OF BDD<br />
Comparing body part<br />
Excessive grooming<br />
Touching body part<br />
Skin picking<br />
Social isolation/becoming housebound<br />
Troubled relationships, divorce<br />
School/work problems<br />
Poor self-esteem<br />
Reassurance seeking<br />
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6/14/13<br />
THE TRAGEDY OF BDD CONT.<br />
A MODEL OF INSIGHT<br />
Unnecessary medical appointments <strong>and</strong><br />
procedures<br />
Bodily damage<br />
Alcohol <strong>and</strong> drug use<br />
Psychiatric hospitalizations<br />
Depression/Suicide<br />
BDD TREATMENT<br />
GOOD POOR ABSENT<br />
3% had excellent insight<br />
9% good insight<br />
28% fair insight<br />
18% poor insight<br />
41% absent insight<br />
52% had been delusional at some point for<br />
several weeks<br />
Source: The Broken Mirror, Phillips, 1996<br />
MEDICATIONS – SRI’s Tried First<br />
SATURDAY<br />
Research studies indicate 70%<br />
improvement with SRI’s. Research also<br />
suggests significant improvement with<br />
CBT*<br />
As in OCD, best treatment is considered to<br />
be combination of CBT <strong>and</strong> medication.<br />
Clomipramine (Anafranil) 150-250mg<br />
Fluvoxamine (Luvox) 100-300mg<br />
Sertraline (Zoloft) 50-200mg<br />
Fluoxetine (Prozac) 20-80mg<br />
Paroxetine (Paxil) 20-50mg<br />
Citalopram (Celexa) 20-60mg<br />
Escitalopram (Lexapro) 10-20mg<br />
*Source: Phillips, 1996<br />
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6/14/13<br />
WHAT DOESN’T APPEAR<br />
TO WORK<br />
WHAT DOESN’T APPEAR<br />
TO WORK CONT.<br />
Anti-psychotics when used without an SRI<br />
Tricyclic antidepressants (except Anafranil)<br />
ECT (can be effective for depression<br />
component)<br />
Neurosurgery (limited case examples; results<br />
mixed)<br />
*Source: Phillips, The Broken Mirror, Revised Edition, 2005<br />
Plastic surgery <strong>and</strong> dermatologic treatments<br />
Most likely outcome is either no or limited<br />
relief, or another body part becoming focus<br />
of concern<br />
Psychodynamic psychotherapy (or does it)<br />
Everyone with BDD has a story<br />
Diet, excessive exercise, natural remedies,<br />
hypnosis<br />
BDD AND COSMETIC TREATMENTS<br />
BDD AND COSMETIC TREATMENTS CONT.<br />
<br />
<br />
<br />
Most commonly sought: rhinoplasties <strong>and</strong><br />
breast augmentation. Other procedures<br />
include microdermabrasions <strong>and</strong> collagen<br />
injections<br />
Two studies reported 71% to 76% of people<br />
with BDD sought cosmetic treatment <strong>and</strong><br />
64% to 66% received it*<br />
7.3% of people reported overall improvement<br />
with BDD** (lower percentage in another<br />
smaller study)<br />
<br />
<br />
<br />
Several incidents of patients threatening their<br />
doctors <strong>and</strong> at least 4 reported cases of surgeons<br />
murdered by a BDD patient*<br />
29% have threatened cosmetic surgeons with legal<br />
action**<br />
Self surgery/bodily harm, i.e., home dental work,<br />
picking off moles, damaging a part of the body to get<br />
surgery for it<br />
*Crer<strong>and</strong>, et al., Plast Reconstr Surg., 2008<br />
**Sarwer, Aesthet Surg J., 2002<br />
*Crer<strong>and</strong>, et al., Psychosomatics, 2005 <strong>and</strong> Phillips, et al., Psychosomatics, 2001<br />
**Phillips, et al., Psychsomatics, 2001<br />
-117-<br />
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6/14/13<br />
BDD AND COSMETIC TREATMENTS CONT.<br />
HOW TO ADDRESS MEDIA INFLUENCE<br />
Why doesn’t surgery work Can’t fix a<br />
psychiatric problem by altering a body part<br />
People often overlook that a procedure on<br />
one part of the face will then alter how other<br />
features look in relation to that<br />
Acknowledge that our society places a<br />
premium on physical appearance<br />
Billboards, Movies, TV, Magazines, etc…<br />
We’re all exposed to the same, yet relatively<br />
few people have BDD<br />
Is patient willing to acknowledge that his/her<br />
concerns are beyond what is normal<br />
“Anything would be better than I have now”<br />
TREATMENT CONT.<br />
BDD patients may be more sensitive to<br />
aesthetics <strong>and</strong> beauty than those without it*<br />
*Source: Buhlmann <strong>and</strong> Wilhelm, Psychiatric Annals, 2004<br />
COGNITIVE THERAPY<br />
SATURDAY<br />
Cognitive therapy: to challenge<br />
distorted beliefs<br />
Behavior therapy: challenges beliefs<br />
by confronting maladaptive coping<br />
strategies <strong>and</strong> behaviors<br />
“Exaggerated” exposure therapy<br />
To disprove beliefs that appearance means as<br />
much as person thinks it does<br />
To learn that life can be meaningful without<br />
altering or disguising body part(s)<br />
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6/14/13<br />
COGNITIVE THERAPY CONT.<br />
IDENTIFYING CORE BELIEFS<br />
Ask: “Does anyone else really care as much<br />
as you think they do”<br />
Need to confront belief that happiness/<br />
success/life satisfaction is linked to<br />
appearance<br />
Important Goal: Ultimately, feeling good has<br />
to be more important than looking good<br />
“I have to look perfect” (for some)<br />
“Life has meaning if I look good”<br />
“I’m unlovable <strong>and</strong> worthless if I don’t<br />
look better”<br />
IDENTIFYING CORE BELIEFS CONT.<br />
COMMON COGNITIVE DISTORTIONS<br />
“If I feel I don’t look good, then it must be<br />
true”<br />
“If I don’t look good people will treat me<br />
poorly”<br />
“No one will ever want to marry me unless I<br />
look better”<br />
<br />
<br />
<br />
<br />
All or Nothing Thinking “No one will ever<br />
want to be with me if I look like this”<br />
Mind Reading “The person I passed earlier<br />
was thinking my nose looks disgusting!”<br />
Thinking with your Feelings “Since I feel ugly<br />
that’s how I must look”<br />
Discounting the Positive “Does it really matter<br />
that people think I’m a caring person if I look<br />
so bad”<br />
-119-<br />
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6/14/13<br />
COMMON COGNITIVE DISTORTIONS CONT.<br />
BEHAVIOR THERAPY<br />
Catastrophizing “My skin looks so horrible<br />
that I’ll never get passed the first interview”<br />
Mirror checking needs to be addressed:<br />
“6pm rule,” “arms-length” policy<br />
Unfair Comparisons “Why can’t I have skin<br />
like the models in magazines”<br />
Personalization “The person in the store<br />
earlier turned away from me because he was<br />
so disgusted by how I look”<br />
BEHAVIOR THERAPY CONT.<br />
Hair: Instead of avoiding fallen hairs,<br />
look for them; wear hair in ways you<br />
believe to be less attractive<br />
Muscle Dysmorphia: Resist working out 1<br />
day; Omit part of the exercise routine<br />
ERP HIERARCHY #1<br />
BDD ISSUE: HAIR<br />
SATURDAY<br />
Acne: Go out either with less make-up or<br />
none at all<br />
Weight: Wear tighter clothes which you<br />
feel may not conceal your size<br />
Teeth: Speak to others without putting<br />
h<strong>and</strong> in front of mouth<br />
Upon waking, resist mirror checking for 15<br />
minutes<br />
<br />
<br />
<br />
<br />
Shower without first checking hair in<br />
mirror<br />
Use smaller amounts of shampoo<br />
Exit shower without checking scalp in<br />
mirror<br />
Comb/brush hair while still wet<br />
-120-<br />
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6/14/13<br />
ERP HIERARCHY #1<br />
BDD ISSUE: HAIR CONT.<br />
ERP HIERARCHY #2<br />
BDD ISSUE: USE OF MAKE-UP<br />
<br />
<br />
<br />
Look at comb/brush with hair in it<br />
Look at floor of bathtub after showering<br />
In shower, look at h<strong>and</strong>s after shampooing<br />
<br />
<br />
While at home, take make-up off for a<br />
period of 1 hour prior to bed<br />
While at home, take make-up off after<br />
work, <strong>and</strong> leave off until next morning.<br />
<br />
<br />
After towel drying hair, look for hair on<br />
towel<br />
Take hair from comb/brush <strong>and</strong> place in<br />
sink, look at it, <strong>and</strong> leave it there for several<br />
hours<br />
<br />
<br />
<br />
Pick up mail without wearing any makeup<br />
At night, drive around neighborhood<br />
without any make-up<br />
Same as above, but in daylight hours<br />
ERP HIERARCHY #2<br />
BDD ISSUE: USE OF MAKE-UP<br />
Do not wear make-up at home in the<br />
presence of family members<br />
Go out to the mall without make-up<br />
Go to dinner with family without make-up<br />
Go to dinner with friends without make-up<br />
RELAPSE PREVENTION<br />
CBT exercises need to continue after<br />
formal therapy ends<br />
Continue with medication for agreed upon<br />
time<br />
Anticipate likely stressors<br />
Practice healthy stress management<br />
Periodic “booster” sessions<br />
-121-<br />
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6/14/13<br />
GROUP THERAPY<br />
GROUP THERAPY CONT.<br />
Support from others with similar<br />
problems<br />
Helps to combat shame <strong>and</strong> isolation<br />
Provides encouragement to do behavior<br />
therapy<br />
Opportunities for modeling<br />
Group ERP exercises<br />
Limit telling of “horror stories”<br />
FAMILIES: THEY SUFFER TOO<br />
Educate yourself about BDD<br />
Limit discussions about the body part(s)<br />
More affordable than individual treatment<br />
Can be effective within managed care<br />
restrictions<br />
Can be difficult to manage many people<br />
with diverse problems, <strong>and</strong> different<br />
levels of functioning<br />
Requires clients who are motivated to do<br />
homework assignments<br />
Providing group structure important<br />
SUPPORTS<br />
The International OCD <strong>Foundation</strong><br />
www.ocfoundation.org<br />
SATURDAY<br />
Avoid giving reassurance: if it worked it<br />
wouldn’t be asked for so much<br />
Avoid enabling, i.e., buying unnecessary<br />
cosmetic products, paying for plastic surgery<br />
Don’t forget to take care of yourself; therapy<br />
The <strong>Obsessive</strong>-<strong>Compulsive</strong> <strong>Foundation</strong> of the<br />
San Francisco Bay Area<br />
www.ocfoundation.org/affiliates/bay-area/<br />
BDDAlliance.org<br />
-122-<br />
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6/14/13<br />
IN CLOSING<br />
EDUCATION<br />
TREATMENT<br />
SUPPORT<br />
HOPE<br />
Contact Information<br />
The OCD-BDD Clinic of Northern California<br />
501 Seaport Court, Suite 106<br />
Redwood City, CA 94063<br />
650-599-3325<br />
www.ocd-bddclinic.com<br />
sgranet@ocd-bddclinic.com<br />
The Palo Alto Medical <strong>Foundation</strong><br />
Department of Psychiatry <strong>and</strong> Behavioral Health<br />
795 El Camino Real<br />
Palo Alto, CA 94301<br />
650-853-2875<br />
granets@pamf.org<br />
-123-<br />
11
Therapy, Insurance, <strong>and</strong> School - Oh My! Solutions for Families Overwhelmed by OCD<br />
6/14/13<br />
THERAPY, INSURANCE, AND<br />
SCHOOL – OH MY! SOLUTIONS<br />
FOR FAMILIES OVERWHELMED<br />
BY OCD<br />
Jenny C. Yip, Psy.D., ABPP<br />
Sarah A. Haider, Psy.D.<br />
VICIOUS OCD CYCLE<br />
OBSESSIONS<br />
(FEARS)<br />
negative thoughts, images, impulses<br />
RELIEF ANXIETY<br />
distress subsides distress, fear,<br />
temporarily shame, disgust<br />
Renewed Freedom Center for Rapid Anxiety Relief<br />
Los Angeles<br />
www.RenewedFreedomCenter.com<br />
At least 1 in 200 kids <strong>and</strong> teens have OCD, which is<br />
double the number of kids with diabetes.<br />
OCD is under-recognized <strong>and</strong> many individuals wait<br />
years before being diagnosed.<br />
OCD is a real illness that affects the brain <strong>and</strong> tends to<br />
run in families. It is NOT a result of something that the<br />
child, parent, or others did wrong.<br />
Shame <strong>and</strong> embarrassment from OCD interferes with a<br />
student’s social interactions.<br />
Intrusive obsessions <strong>and</strong> repetitive compulsions<br />
negatively impact academic functioning.<br />
Many professionals, artists, actors, <strong>and</strong> athletes have<br />
OCD. A child’s future success does not have to be limited<br />
by OCD!<br />
COMPULSIONS<br />
(SAFETY BEHAVIORS)<br />
repetitive thoughts, images, actions<br />
EFFECTS OF OCD<br />
ON FAMILY FUNCTIONING<br />
OCD typically involves other family members,<br />
impact the quality of family life, <strong>and</strong> cause impaired<br />
functioning in the family system.<br />
In an attempt to reduce the child’s anxiety <strong>and</strong> fear,<br />
family members tend to become servants to the<br />
child’s avoidance behaviors, reassurance seeking,<br />
<strong>and</strong> compulsive rituals.<br />
Family members often assume tasks that belong to<br />
the child’s responsibility (i.e., avoidance behaviors).<br />
Families frequently modify leisure-time activities to<br />
accommodate the child in an effort to reduce the<br />
sufferer’s distress.<br />
Sufferers tend to react in distress or anger if family<br />
members do not accommodate the compulsions.<br />
SATURDAY<br />
<br />
-124-<br />
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6/14/13<br />
FAMILY ACCOMMODATION &<br />
MAINTENANCE OF OCD<br />
Family members generally accommodate in order to avoid<br />
conflict <strong>and</strong> maintain peace.<br />
Accommodations only serve to reinforce the fear <strong>and</strong> the<br />
maintenance of the vicious anxiety cycle.<br />
Family members may be uncertain whether the repetitive<br />
rituals <strong>and</strong> persistent reassurance seekings are part of the<br />
symptommology or only dem<strong>and</strong>s for attention <strong>and</strong> control.<br />
It is important for family members to learn how to be<br />
supportive without giving into or enabling the OCD.<br />
The family structure <strong>and</strong> support system significantly impact<br />
the prognosis <strong>and</strong> outcome of OCD treatment.<br />
BEHAVIOR THERAPY GUIDELINES<br />
You cannot control your thoughts.<br />
You cannot control your feelings.<br />
You can control your behaviors.<br />
As you change your behaviors, your<br />
thoughts <strong>and</strong> feelings will also change.<br />
TREATMENTS THAT WORK<br />
Evidence-based treatments for OCD <strong>and</strong> other anxiety<br />
disorders are short-term <strong>and</strong> very effective.<br />
Psychoeducation – Reduces misattribution of psychophysiological<br />
symptoms.<br />
Cognitive-Behavioral Treatment (CBT): Learning to deal<br />
with fears by modifying the ways we think <strong>and</strong> behave.<br />
Cognitive Restructuring – Maintains changes in belief<br />
system.<br />
Rational Emotive Behavior Therapy (REBT) – Corrects<br />
faulty belief system <strong>and</strong> over-appraisal of danger.<br />
Acceptance & Commitment Therapy (ACT) –<br />
Addresses acceptance of uncertainty <strong>and</strong> letting go of<br />
control.<br />
Mindfulness Training – Increases awareness of<br />
physiological sensations to enhance emotional<br />
processing during exposures.<br />
TREATMENTS THAT WORK (CONT)<br />
Behavior Therapy: Behaving in ways to confront fears<br />
<strong>and</strong> reduce unnecessary fight-or-flight triggers.<br />
Prolonged Exposures – Confronts feared situations to<br />
change belief system of danger <strong>and</strong> ability to endure<br />
fight-or-flight discomforts.<br />
Response Prevention – Resists compulsive or safety<br />
behaviors <strong>and</strong> avoidances that only reinforce the<br />
anxiety cycle.<br />
Family Therapy: Reduces conflict, decreases unhealthy<br />
accommodations, <strong>and</strong> focuses on effective solutions.<br />
Parent Training: Provides support, improves<br />
communication skills, <strong>and</strong> educates methods to decrease<br />
anxiety.<br />
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6/14/13<br />
QUALIFICATIONS<br />
Treatment Orientation<br />
Behavior Therapy – ERP<br />
Cognitive Therapy<br />
Family Systems Therapy<br />
× Insight-Oriented Therapy – i.e., “Talk Therapy”<br />
Specialized Training<br />
Type of training – short-term vs. long-term<br />
Number of years’ experience with ERP<br />
Training from expert clinician<br />
Known specialist – locally or nationally<br />
Previous Successful Cases<br />
Number of successful treatments.<br />
Length of treatment.<br />
WHO NOT TO GO TO<br />
Professional Organizers w/o Hoarding specialist.<br />
Pure CBT<br />
ERP<br />
Concrete & Tangible<br />
STYLE OF TREATMENT<br />
Measures symptoms, improvements, etc.<br />
Looks for triggers & consequences<br />
Goal-oriented<br />
Always assigns HW<br />
Integrative Therapy<br />
More flexible<br />
Doesn’t adhere to measurements<br />
Assigns HW on occasion<br />
Integrates insight processing<br />
Useful for certain personality traits<br />
UNDERSTANDING INSURANCE BENEFITS<br />
The Basics: HMO vs PPO<br />
SATURDAY<br />
Life Coaches.<br />
Practitioners only reading books to learn to help<br />
you.<br />
Strictly insight oriented “talk” therapists.<br />
Practitioners with no training in ERP.<br />
Practitioners with no previous successful cases or<br />
expert consultations.<br />
Anyone you’ve seen for more than 6 sessions w/o<br />
experiencing relief.<br />
Advantages/Disadvantages<br />
Out of Network/In Network Provider<br />
Member Eligibility<br />
At THEIR rate!<br />
Single Case Authorization<br />
Disclosure of Allowable Reimbursement /Payment<br />
Determination Request<br />
Certification Process<br />
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HMO<br />
HMO = Health Maintenance Organization<br />
If you have an HMO, then the doctors <strong>and</strong><br />
hospitals are part of the same tight network.<br />
Choosing your primary care physician will serve<br />
as the “gatekeeper’ to your HMO.<br />
Advantages:<br />
Medical Records<br />
Set Rates<br />
Level of Care<br />
Level of Benefits<br />
Disadvantages:<br />
Limited Geographical Availability<br />
Having to Choose a Primary Care Provider<br />
PPO<br />
PPO = Preferred Provider Organization<br />
If you have a PPO, then you have the option to<br />
choose any provider within or outside of the<br />
network.<br />
Advantages<br />
Choice<br />
Availability<br />
Disadvantages<br />
Variation of out of pocket cost<br />
Transferring medical records.<br />
IN NETWORK PROVIDERS<br />
Each provider PPO or HMO in your network has<br />
agreed to accept your plan’s contracted rate as<br />
payment in full.<br />
The contracted rate includes both your insurer’s<br />
share of the cost + your share.<br />
OUT OF NETWORK PROVIDERS<br />
HMO – Generally don’t provide Out-of-Network benefits.<br />
PPO<br />
• Higher deductible<br />
• Co-pay<br />
• Higher percentage of allowed amount<br />
• Difference between allowed amount <strong>and</strong> providers actual<br />
rate.<br />
Reasonable/Allowed Amount: Determined by insurance.<br />
$25<br />
$75<br />
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SINGLE CASE AUTHORIZATION (SCA)<br />
KNOW YOUR RIGHTS<br />
Allows members with no out-of-network benefits to see a<br />
non-contracted professional.<br />
Certain conditions must exist for a SCA to be made:<br />
• An area that is geographically remote from any innetwork<br />
provider.<br />
• A clinical specialty is not available with-in-network.<br />
Clinical Review: A licensed care manager contacts the<br />
out-of-network clinician to discuss diagnosis, evidencebased<br />
treatment goals, symptoms, <strong>and</strong> rationale for the<br />
necessity of an out-of-network professional.<br />
If SCA approved, out-of-network provider will receive an<br />
approval letter detailing the certification (e.g., number<br />
of visits, start/end dates).<br />
HOW TO FIGHT FOR YOUR RIGHTS<br />
1) Call your insurance <strong>and</strong> ask for names of OCD/anxiety<br />
specialists in your area.<br />
2) Find out where these practitioners are<br />
located. Usually, you cannot be required to see<br />
someone outside a certain radius.<br />
3) Call the list of practitioners <strong>and</strong> grill them on:<br />
How many cases they've successfully treated<br />
What treatment methods they use<br />
Typical length of treatment<br />
What kind of specialized training they have to treat<br />
this<br />
Are they known specialists locally, nationally<br />
4) Inform your insurance that none of their practitioners<br />
are skilled to provide ERP, <strong>and</strong> you have found an outof-network<br />
clinician who is considered competent.<br />
Disclosure of Allowable Reimbursement / Payment<br />
Determination Request: Insurance form filled out by clinician<br />
to determine reimbursement rate before starting treatment.<br />
Secret insurance companies don't want you to know:<br />
Insurance companies must provide adequate treatment by<br />
properly trained practitioners for both HMO <strong>and</strong> PPO.<br />
Fact: Most “specialists” do not contract with insurance plans.<br />
Goal: Get insurance companies to admit that they have no<br />
providers who can treat OCD/anxiety.<br />
After many back-<strong>and</strong>-forth battles, insurance may agree to<br />
contact your chosen out-of-network practitioner to negotiate<br />
an "ad hoc," out-of-network, or SCA.<br />
HOW TO FIGHT FOR YOUR RIGHTS (CONT.)<br />
5) If the insurance denies your request, be assertive <strong>and</strong><br />
remind them that they’re required to provide adequate<br />
care under the terms of your contract. Convince them<br />
that you are going out-of-network not by choice, but<br />
because there are no sufficient alternative.<br />
6) Talk to a supervisor <strong>and</strong> assertively inform them that<br />
you’ve done your HW, <strong>and</strong> the practitioners they have:<br />
a) Really isn't qualified.<br />
b) Isn't taking new patients.<br />
c) Didn't even know what Exposure & Response<br />
Prevention was, etc.<br />
7) Document EVERYTHING!<br />
SATURDAY<br />
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RECOGNIZE THE SIGNS OF OCD<br />
Excessive concerns about safety or potential harm/threat.<br />
Constant worries about family, friends, school, activities.<br />
Repetitive, senseless behaviors that must be obeyed.<br />
Excessive time getting ready in the morning <strong>and</strong>/or for bed.<br />
Extreme clinginess or worries about being away from home<br />
or loved ones.<br />
Panic/Tantrums toward changes in rituals.<br />
Does not participate in usual activities because something<br />
bad might happen.<br />
Trouble sleeping/nightmares.<br />
SIGNS OF OCD (CONT.)<br />
Repeating phrases, words, songs, prayers, numbers.<br />
Perfectionism, fears of making mistakes.<br />
Excessive time spent in bathrooms.<br />
Raw, dry, chapped h<strong>and</strong>s.<br />
Constantly seeking approval/reassurance.<br />
Specific “do <strong>and</strong> don’t” rules that must be rigidly<br />
followed.<br />
School refusal.<br />
Excessive time spent on HW.<br />
Constant negotiation, pleading to avoid feared situation/<br />
object.<br />
SIGNS OF OCD (CONT.)<br />
Oppositional/Defiant behaviors when rigid rules are<br />
broken or dem<strong>and</strong>s are not met.<br />
Avoids social contact, fears of embarrassment.<br />
Overly cautious in new situations.<br />
Excessive anticipatory worries.<br />
Physical Complaints (Headache, Stomachaches, Fatigue,<br />
Muscle Tension).<br />
Difficulty concentrating/easily distracted.<br />
Overly dependent on family members for daily routines.<br />
Changes in mood, easily upset, irritable.<br />
TYPES OF ENABLING & ACCOMMODATIONS<br />
Reassuring senseless fears.<br />
Waiting while child performs rituals.<br />
Doing rituals for child or participating in it.<br />
Providing supplies for rituals.<br />
Doing things for child s/he can do.<br />
Allowing child to avoid situations.<br />
Not talking about things that provoke anxiety.<br />
Putting up with unusual dem<strong>and</strong>s.<br />
Showing fear.<br />
Giving up self-care time.<br />
Not setting limits/consequences.<br />
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TOOLS TO PROVIDE SUPPORT W/O ENABLING<br />
Avoid giving reassurance.<br />
Stay out of child's rituals.<br />
Make sure child contributes around the home.<br />
Let child do things on his/her own.<br />
TOOLS TO PROVIDE SUPPORT (CONT.)<br />
Set appropriate limits <strong>and</strong> consequences.<br />
Provide structure <strong>and</strong> boundaries for acceptable<br />
behaviors.<br />
Be clear <strong>and</strong> specific of your expectations.<br />
Resist bargaining, arguing, pleading.<br />
Allow child to experience some anxiety.<br />
Practice facing feared things every day.<br />
Take time for self-care.<br />
Resist avoiding your own fears in situations.<br />
Laugh at your own mistakes.<br />
Find things your child is good at.<br />
COLLABORATING WITH SCHOOLS<br />
Outreach <strong>and</strong> In-Services<br />
• Increase awareness of behavioral manifestations of<br />
various childhood disorders.<br />
• Ensure proper interventions.<br />
Communication with teachers <strong>and</strong> school personnel is key!<br />
• Schedule regular check-ins with school personnel.<br />
• Use notebooks <strong>and</strong> engage in regular, brief conversations<br />
with teachers to facilitate communication.<br />
Ask teachers to document behavioral changes in student,<br />
both positive <strong>and</strong> negative.<br />
Be open & honest rather than secretive &<br />
manipulative (triangulation).<br />
Avoid punishing for OCD, anxious behaviors.<br />
Encourage rather than force exposures.<br />
With Siblings:<br />
Set Safety Limits: No Name calling or Teasing<br />
Validate Feelings: Frustration, Sadness<br />
COLLABORATING WITH SCHOOLS<br />
Help teachers establish rapport with student.<br />
Calm, supportive teacher can improve outcome of<br />
treatment.<br />
If student is in harsh/critical environment, stress levels<br />
<strong>and</strong> anxiety naturally increases -> anxious behaviors will<br />
also increase.<br />
Always speak clearly, calmly, in kindly manner.<br />
Student with anxiety may have difficult time making<br />
decisions for fear of not making perfect decision.<br />
If student is having difficult time making choices,<br />
encourage him/her to do so within set time frame (e.g., 5<br />
seconds).<br />
Continue to encourage him/her to practice making quick<br />
decisions.<br />
SATURDAY<br />
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COLLABORATING WITH SCHOOLS<br />
Make sure teachers note student’s progress based on his/<br />
her own behavior <strong>and</strong> achievements, without comparisons<br />
to other classmates.<br />
If student engages in anxiety/compulsive behaviors in the<br />
classroom:<br />
Help him/her postpone behavior with distraction if<br />
possible.<br />
Remind student that his/her urge to engage in behavior<br />
is “OCD Monster” playing a trick on him/her <strong>and</strong> not<br />
necessarily an actual need.<br />
Encourage student to step outside or take break to think<br />
through situation & reframe as OCD Monster’s needs<br />
rather than student’s own needs.<br />
COLLABORATING WITH SCHOOLS<br />
If student is engaged in anxiety-types of behavior in the<br />
classroom <strong>and</strong> doesn’t respond to any methods, do not put<br />
pressure on him/her to stop.<br />
Students with anxiety seek reassurances to satisfy their<br />
need to know.<br />
Can indicate need for perfection or to get things “just<br />
right”.<br />
Learn to identify when student is asking for<br />
reassurances.<br />
Respond with ambivalent answers.<br />
POTENTIAL ACCOMMODATIONS<br />
Students with severe test anxiety:<br />
Breaks during testing.<br />
Testing in nondistracting quiet location.<br />
Take tests orally.<br />
Extra time.<br />
Write directly into test booklets rather than transferring<br />
answers.<br />
Students with <strong>perfectionism</strong> or fears of getting things wrong:<br />
Having directions/instructions available on paper,<br />
whiteboard, or elsewhere lessens anxiety about getting<br />
information incorrectly due to distraction, misunderst<strong>and</strong>ing,<br />
or <strong>perfectionism</strong>.<br />
Ask direct questions rather than open-ended ones.<br />
Provide time estimates for each assignment, so student can<br />
attempt to stay within 10% of the estimated time.<br />
Allow perfectionistic students to make-up work they’ve<br />
missed following legitimate absences.<br />
POTENTIAL ACCOMMODATIONS<br />
Students with reading compulsions or anxiety:<br />
Encourage student to read only once through.<br />
Break down reading assignments into shorter<br />
increments/sections.<br />
Reading material tape recorded, books on tape.<br />
Students with writing compulsions or anxiety:<br />
Tape record lessons.<br />
Photocopy teachers notes or notes from another student.<br />
Provide outline of lesson notes.<br />
Having someone else scribe while student dictates<br />
answers.<br />
Assignments <strong>and</strong> tests may be typed or submitted on<br />
tape.<br />
No deduction for sloppy h<strong>and</strong>-writing, misspelled words.<br />
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POTENTIAL ACCOMMODATIONS<br />
Classroom/School Environment - Because change <strong>and</strong><br />
uncertainty can be unsettling, anxious students perform best<br />
in a calm, supportive, <strong>and</strong> structured classroom.<br />
Seat students with anxiety away from rambunctious<br />
classmates to decrease distractions.<br />
Allow students to sit in an area where necessary breaks<br />
can be taken without being easily noticeable.<br />
Minimize competition between students in the classroom.<br />
Create ties for socially anxious students by forming small<br />
groups of shared activities (e.g., art projects, lunch bunch).<br />
Limit allowing students to choose groupings themselves<br />
with counting-off technique.<br />
Pair classroom buddies.<br />
Assign a point person for student to check in with to dispel<br />
worries, take deep breaths, <strong>and</strong> return to class.<br />
SPECIALIZED SCHOOL SERVICES<br />
For severe or persistent anxiety, request<br />
psychological evaluation or psychoeducational testing<br />
from school.<br />
Consult with the appropriate school staff to<br />
determine if the student is eligible for:<br />
IEP for IDEA (Individuals with Disabilities<br />
Education Improvement Act) special education<br />
services.<br />
Section 504 Plan (individuals with a h<strong>and</strong>icap).<br />
SATURDAY<br />
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Conceptualizing <strong>and</strong> Treating Hoarding Disorder<br />
6/24/13 <br />
Conceptualizing <strong>and</strong> Trea8ng <br />
Hoarding Disorder <br />
Workshop for Clinicians <br />
Road map for HD <br />
• Phenomenology <br />
R<strong>and</strong>y Frost, PhD <br />
Gail Steketee, PhD, MSW <br />
July, 2013 IOCDF <br />
• Diagnosis & Assessment <br />
• Conceptual Model <br />
• Mo8va8on <br />
• Behavioral <strong>and</strong> Cogni8ve Treatment Methods <br />
Manifesta8ons of Hoarding <br />
Other Features of Hoarding <br />
Acquisi'on <br />
Saving <br />
Disorganiza'on <br />
• Indecisiveness <br />
• Perfec8onism <br />
• Procras8na8on <br />
• Central Coherence <br />
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DSM-‐5 criteria for HD <br />
DSM-‐5 criteria for HD <br />
• A. Persistent difficulty discarding or par8ng with possessions, <br />
regardless of their actual value. <br />
• B. This difficulty discarding is due to a perceived need to save <br />
the items <strong>and</strong> distress associated with discarding them. <br />
• C. The symptoms result in accumula8on of possessions that <br />
congest <strong>and</strong> cluVer ac8ve living areas <strong>and</strong> substan8ally <br />
compromise their intended use. <br />
– If living areas are uncluVered, it is only because of the <br />
interven8ons of third par8es (e.g., family members, <br />
cleaners, authori8es). <br />
• D. The hoarding causes clinically significant distress <br />
or impairment in social, occupa8onal, or other <br />
important areas of func8oning <br />
– (including maintaining a safe environment for self <strong>and</strong> <br />
others) <br />
• E. The hoarding is not aVributable to another <br />
medical condi8on <br />
– (e.g., brain injury, cerebrovascular disease, Prader-‐Willi <br />
Syndrome). <br />
www.dsm5.org <br />
DSM-‐5 criteria for HD <br />
www.dsm5.org <br />
DSM-‐5 criteria for HD <br />
SATURDAY<br />
• F. The hoarding is not beVer accounted for by <br />
the symptoms of another DSM-‐5 disorder <br />
– (e.g., hoarding due to obsessions in <strong>Obsessive</strong>-‐<strong>Compulsive</strong> <br />
Disorder, decreased energy in Major Depressive Disorder, <br />
delusions in Schizophrenia or another Psycho8c Disorder, <br />
cogni8ve deficits in Demen8a, restricted interests in <br />
Au8sm Spectrum Disorder). <br />
• Specify if: “With Excessive Acquisi5on: If symptoms are <br />
accompanied by excessive collec5ng or buying or <br />
stealing of items that are not needed or for which there <br />
is no available space.” <br />
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DSM-‐5 criteria for HD <br />
Specify if: <br />
• Good or fair insight: Recognizes that hoarding-related<br />
beliefs <strong>and</strong> behaviors (pertaining to <br />
difficulty discarding items, cluVer, or excessive <br />
acquisi8on) are problema8c. <br />
• Poor insight: Mostly convinced that hoarding-related<br />
beliefs <strong>and</strong> behaviors are not problema8c <br />
despite evidence to the contrary. <br />
• Absent insight (Delusional beliefs about <br />
hoarding): Completely convinced that hoarding-related<br />
beliefs <strong>and</strong> behaviors are not problema8c <br />
despite evidence to the contrary. <br />
Prevalence of Hoarding <br />
• Samuels et al. (2008) = 5% in US (adjusted) <br />
• Iervolini et al. (2010) = 2.3% (UK) <br />
• Mueller et al. (2009) = 4.6% (Germany) <br />
• Timpano et al. (2011) = 5.8% (Germany) <br />
OCD prevalence = 1-‐2.5% <br />
COMORBID DISORDERS IN HD <br />
30 <br />
Age of Onset in Hoarding <br />
60% <br />
DX <br />
25 <br />
26.6 <br />
24.1 <br />
50% <br />
40% <br />
30% <br />
20% <br />
10% <br />
0% <br />
MDD GAD SAD ADHD OCD PTSD <br />
DX <br />
% Repor'ng Onset <br />
20 <br />
15 <br />
10 <br />
5 <br />
0 <br />
13.8 <br />
10.8 <br />
8.1 <br />
3.7 <br />
4.8 4.4 <br />
2.5 <br />
0.7 <br />
0.1 0.1 0.1 <br />
5 10 15 20 25 30 35 40 45 50 55 60 65+ <br />
Tolin et al. (2010) <br />
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% of Respondents with Moderate to Severe <br />
Hoarding <br />
Hoarding in Children <br />
100%!<br />
90%!<br />
80%!<br />
70%!<br />
60%!<br />
50%!<br />
• Overlapping with ADHD <br />
• Reac8ons to touching/moving objects <br />
• LiVle insight <br />
40%!<br />
30%!<br />
20%!<br />
10%!<br />
0%!<br />
0-5 yrs! 6-10 11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70<br />
yrs! yrs! yrs! yrs! yrs! yrs! yrs! yrs! yrs! yrs! yrs! yrs! yrs!<br />
Tolin DF, et al. Depress Anxiety. 2010. <br />
Hoarding in Elders <br />
• Abnormal personifica8on <br />
• Essen8alism <br />
Hazards of Hoarding <br />
SATURDAY<br />
• 15 – 30% of elderly people in private <strong>and</strong> public <br />
housing had hoarding problems <br />
• Medical problems <br />
– Medica8on <strong>and</strong> dietary mismanagement can worsen <br />
medical condi8ons <br />
– Risk of falling <br />
• Impairment in ac8vi8es of daily living <br />
– Loss of important items, tracking finances <br />
• Housing problems <br />
– Premature reloca8on to senior housing or evic8on <br />
– Risk of losing independent living status <br />
• Social isola8on <br />
• Poor Sanita8on <br />
• Mobility Hazard <br />
• Blocked Exits <br />
• Community Cost <br />
• Homelessness <br />
• Fire Hazard <br />
Ayers et al., 2012; Diefenbach et al., 2012; Kim et al., 2001; Marx & Cohen-‐<br />
Mansfield, 2003; Whimield et al., 2011 <br />
Frost et al. (2000) <br />
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Family Burden <br />
• Growing up in a hoarding home associated <br />
with… <br />
– Increased embarrassment <br />
– Decreased invi8ng friends over <br />
– Increased strain in rela8onship with parents <br />
– Less happy childhood <br />
• Rejec8on <br />
• Isola8on <br />
Child & Adult Protec8ve Services <br />
Assessing Risk <br />
Safety <br />
Fire hazard, exits blocked, stairways clear, room for <br />
emergency personnel & equipment, cluVer outside <br />
Condi8on of Home <br />
Squalor -‐ Home Environment Index <br />
RoVen food, insects, animal waste <br />
Cleaning <strong>and</strong> hygiene behavior <br />
Structural damage <br />
Ac8vi8es of Daily Living-‐Hoarding <br />
Impact on ac8vi8es of daily living <br />
Tolin et al. Behav Res Ther. 2008;46:334-‐344. <br />
Frost & Hristova, J Clin Psychol 2011;67:456-‐466 <br />
Rasmussen et al., submiVed <br />
ADL-Hoarding (ADL-H)<br />
Hoarding Interview <br />
Ac'vi'es affected by Can do <br />
hoarding problem easily <br />
liDle <br />
difficulty <br />
moderate great Unable <br />
difficulty difficulty to do <br />
1. Prepare food 1 2 3 4 5 <br />
2. Use refrigerator 1 2 3 4 5 <br />
3. Use stove 1 2 3 4 5 <br />
4. Use kitchen sink 1 2 3 4 5 <br />
5. Eat at table 1 2 3 4 5 <br />
6. Move around home 1 2 3 4 5 <br />
7. Exit home quickly 1 2 3 4 5 <br />
8. Use toilet 1 2 3 4 5 <br />
• Home <strong>and</strong> cluVer <br />
• Objects <strong>and</strong> reac8ons <br />
• Where to start <br />
• Organiza8onal system <br />
• Acquiring <br />
• Reasons for saving <br />
• Family & friends <br />
• Health & safety <br />
• Problems from hoarding <br />
• Comorbidity (MDD, OCD, <br />
ADHD, etc.) <br />
• Family history of hoarding <br />
• Onset & course <br />
• Interven8on efforts <br />
15. Find important things <br />
(bills, tax forms, etc.) <br />
1 2 3 4 5 <br />
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Hoarding Ra8ng Scale (HRS) <br />
Saving Inventory-‐Revised: <br />
0 1 2 3 4 5 6 7 8 <br />
Not at all Mild Moderate Severe Extremely <br />
Difficult <br />
Difficult <br />
1. Because of the cluDer or number of possessions, how difficult is it for you <br />
to use the rooms in your home <br />
2. To what extent do you have difficulty discarding (or recycling, selling, giving <br />
away) ordinary things that other people would get rid of <br />
3. Do you currently have a problem with collec'ng free things or buying more <br />
things than you need or can use or can afford <br />
4. To what extent do you experience emo'onal distress because of cluVer, <br />
difficulty discarding or problems with buying or acquiring things <br />
5. To what extent do you experience impairment in your life (daily rou8ne, <br />
job / school, social ac8vi8es, family ac8vi8es, financial difficul8es) because <br />
of cluVer, difficulty discarding, or problems with buying or acquiring <br />
things <br />
Tolin, D.F., Frost, R.O., & Steketee, G. (2010). Psychiatry Research, 30, 147-‐152. <br />
Why do people hoard <br />
• 23 items; excellent reliability <strong>and</strong> validity <br />
• Clinical cutoff scores <br />
– Excessive Acquisi8on -‐ 9 <br />
– Difficulty Discarding -‐ 14 <br />
– CluVer -‐ 17 <br />
– Total Score -‐ 41 <br />
Core beliefs & <br />
vulnerabilities <br />
Information<br />
processing <br />
SATURDAY<br />
Attachments &<br />
Valuation of objects <br />
The Cogni8ve Behavioral Model <br />
Nega8ve <br />
Reinforcement <br />
Emotions <br />
Neg. Pos. <br />
Posi8ve <br />
Reinforcement <br />
Saving & <br />
Acquiring <br />
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Biological vulnerability <br />
• Gene8cs <br />
– Family history of hoarding <br />
– Linkage studies <br />
– Twin study <br />
• Neural mechanisms <br />
– FMRI studies <br />
– PET studies <br />
– Brain damage studies <br />
• Evolu8onary biology <br />
– Hoarding by animals <br />
– Nes8ng behavior <br />
Psychological Vulnerabili8es <br />
• Core Beliefs <br />
– Low self-‐worth <br />
– Helplessness <br />
• Depressed Mood <br />
• Mental Health <strong>and</strong> Health Co-‐morbidity <br />
• Early history of loss or trauma8c events <br />
Informa8on Processing Deficits <br />
Emo8onal AVachments <strong>and</strong> Beliefs <br />
• AVen8on <br />
• Percep8on <br />
• Categoriza8on <br />
• Associa8on <br />
• Memory <br />
• Complex Thinking <br />
Decision-‐making Difficul8es <br />
• Beauty/aesthe8cs <br />
• Memory <br />
• U8lity/opportunity <br />
• Sen8mental <br />
• Comfort <br />
• Uniqueness <br />
• Iden8ty/poten8al <br />
iden8ty <br />
• Control <br />
• Mistakes <br />
• Responsibility/ waste <br />
• Completeness <br />
• Safety <br />
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8<br />
Learning Processes <br />
Avoidance condi8oning <br />
• Posi8ve reinforcement (posi8ve emo8ons) <br />
• Nega8ve reinforcement (nega8ve emo8ons) <br />
• No opportunity to test beliefs & appraisals <br />
(avoidance) <br />
• No opportunity to develop alterna8ve beliefs <br />
(avoidance) <br />
Developing the Client’s <br />
Conceptualiza8on <br />
• Start with client’s explana8on <br />
• Add features based on interview <strong>and</strong> <br />
experimenta8on <br />
• Connect features to saving/acquiring <strong>and</strong> core <br />
beliefs / vulnerabili8es <br />
• Do func8onal analyses of individual features <br />
• Distress <br />
• Decisions <br />
• AVending to cluVer <br />
• Feelings of loss <br />
• Feelings of vulnerability <br />
• Worries about memory <br />
• Invi8ng people into the <br />
home <br />
• Making mistakes <br />
• Losing opportuni8es <br />
• Losing informa8on <br />
• Depression <br />
• Purng things out of <br />
sight <br />
Client L: 72 year old gr<strong>and</strong>mother <br />
• Lives alone, no visitors for years <br />
• Severe hoarding <br />
– CIR = 8 <br />
– Bruised hips <br />
• Lifelong problem <br />
• Moderate acquisi8on <br />
• Moderate to high squalor <br />
SATURDAY<br />
-140-
6/24/13 <br />
• Depression <br />
• Self-‐Worth <br />
• Perfec8onism <br />
• Helplessness <br />
• Health <br />
• Physical Constraints <br />
Vulnerabili8es <br />
Client L’s Beginning Explana8on <br />
• Time <br />
• Energy <br />
• Mo8va8on <br />
• Condi8on of the item <br />
Informa8on Processing Deficits <br />
• ADHD symptoms <br />
• Memory <br />
• Categoriza8on <br />
• Percep8on <br />
• Associa8on <br />
• Complexity of thoughts <br />
• Decision-‐making <br />
Beliefs & Meanings: based on <br />
interview & experimenta8on <br />
• Responsibility <br />
• Control <br />
• U8lity <br />
• Memory <br />
• Concern over mistakes <br />
• Belief about God <br />
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6/24/13 <br />
• Pleasure from re-reading<br />
<br />
• Excitement <br />
• Relief from mortality <br />
worries <br />
Feelings <br />
• Guilt <br />
• Grief <br />
• Sadness <br />
• Anger -‐ at others <br />
exer8ng control <br />
Func8onal Analysis of <strong>Compulsive</strong> Shopping <br />
Episode <br />
Depression, <strong>perfectionism</strong>,<br />
self worth, health <br />
Nega8ve <br />
Reinforcement <br />
Responsibility, Control,<br />
Utility, Memory, Mortality <br />
Pleasure, excitement,<br />
relief <br />
guilt, grief, anger <br />
Saving & <br />
Acquiring <br />
ADHD, memory,<br />
Categorization, decision<br />
making <br />
Posi8ve <br />
Reinforcement <br />
SATURDAY<br />
40 year old professional <br />
woman <br />
Husb<strong>and</strong> & 12 year old son <br />
$27,000 credit card debt <br />
Clothes buying compulsion <br />
Serious hoarding problem <br />
<strong>Compulsive</strong> <br />
Buying <br />
Episode <br />
-142-<br />
10
6/24/13 <br />
Mo8va8on <strong>and</strong> Ambivalence: <br />
Why don’t people change <br />
Insight Problems <br />
• Anosognosia (nosos + gnosis) <br />
Costs of change <br />
• CluVer Blindness <br />
Benefits of change <br />
• Overvalued Idea8on <br />
• Defensiveness (therapeu8c reactance) <br />
Frost et al. (2010) <br />
Mo8va8on <br />
• What makes people mo8vated to change <br />
– Importance <br />
– Confidence <br />
• Mo8va8onal Interviewing <br />
– A client-‐centered, direc8ve method for <br />
enhancing intrinsic mo8va8on to change by <br />
exploring <strong>and</strong> resolving ambivalence <br />
Establish Personal Values <strong>and</strong> Goals <br />
• Values <br />
– What you care most about -‐ <br />
• Personal goals <br />
• What do you most want to do in the remainder of your <br />
life <br />
• Short term goals <br />
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11
6/24/13 <br />
Example: Sharon’s Goals <br />
Specialized Treatment for Hoarding <br />
• To enjoy my instruments again <br />
• To create breathing space, order, <strong>and</strong> beauty in my <br />
bedroom (esp. in front of the closet) <br />
• To have a living room that a friend or family could <br />
enter <br />
• To have a safe kitchen with working surfaces <br />
• To take a bath <br />
• To remove bagged items <br />
Treatment Format <br />
• Assessment <strong>and</strong> case formula8on <br />
• Mo8va8onal enhancement <br />
• Skills training <br />
– Organizing <br />
– Problem solving <br />
• Changing emo8onal aVachments to things <br />
• Evalua8ng thoughts/beliefs <br />
• Restric8ng acquiring <br />
• Preven8ng relapse <br />
Steketee & Frost, 2007 <br />
Treatment Rules <br />
SATURDAY<br />
• Individual or group <br />
• Sessions <strong>and</strong> prac8ce in office <strong>and</strong> at home <br />
• Prac8ce in acquiring loca8ons <br />
• Family consulta8on <br />
• Use of a coach <br />
• Cleanouts <br />
• Never touch without permission <br />
• Client decides rules for acquiring, keeping <strong>and</strong> <br />
discarding <br />
• Client makes all decisions <br />
• Proceed systema8cally by room or type of <br />
spaces <strong>and</strong>/or objects <br />
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12
6/24/13<br />
Skills Training: Objec8ves <br />
• Manage aVen8on/distrac8on <br />
• Teach clients problem-‐solving skills <br />
• Improve decision-‐making skills <br />
• Develop categoriza8on skills <br />
• Develop Personal Organizing Plan <br />
• Learn to maintain the system <br />
Distress Tolerance is Important <br />
• Clients must learn to tolerate… <br />
– Distress <br />
– Fa8gue <br />
– Depression <br />
• Without avoiding discarding <br />
Trea8ng Excessive Acquisi8on <br />
Effect on Mean Urges <strong>and</strong> Discomfort for 8 People with Acquiring<br />
Problems on Non-shopping Trip at OC <strong>Foundation</strong> Workshop<br />
• Bringing context to the decision <br />
– Ques8ons <br />
– Rules <br />
• Tolera8ng the urge <br />
– Drive-‐by non-‐shopping <br />
– Walk-‐through non-‐shopping <br />
– Browsing <strong>and</strong> picking non-‐shopping <br />
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13
6/24/13<br />
Changing AVachments to <br />
Possessions <br />
• Ques8ons about possessions <br />
Challenging Beliefs <br />
• Iden8fy problema8c beliefs during sor8ng <strong>and</strong> <br />
acquiring prac8ce <br />
• Discarding Exercises <br />
• Challenging Beliefs <br />
Downward Arrow Technique <br />
• Socra8c ques8oning to examine beliefs <strong>and</strong> <br />
consider alterna8ves <br />
• Design <strong>and</strong> conduct <br />
experiments to test beliefs <br />
Downward Arrow 2 <br />
SATURDAY<br />
• What would happen if you threw that out <br />
– “I’ll never find it again.” <br />
• Why would that be so bad <br />
– “I would lose an opportunity.” <br />
• What would be so bad about that <br />
– “I’d be stupid for not taking advantage of an <br />
opportunity.” <br />
• What’s the worst part about that <br />
– “Just that, I’d be a stupid person.” <br />
• It sounds like you are worried that if you threw this <br />
out, that would mean you were a stupid person. Let’s <br />
take a look at that idea. <br />
– “I guess I never thought about it. I do worry about doing <br />
something stupid.” <br />
• Sounds like you also worry that you might be a stupid <br />
person. Does that seem right <br />
– “Yeah, I guess so. All through school….” <br />
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14
6/24/13 <br />
Behavioral Experiment: Consider <br />
Discarding <br />
• Rate ini8al distress <br />
• Predict dura8on of distress <br />
• Do the experiment (not acquire, discard) <br />
• List thoughts <br />
• Evaluate thoughts <br />
• Re-‐rate distress <br />
• Discuss outcome of experiment <br />
Behavioral Test of <br />
Hoarding Predic8ons <br />
(top of lost board game box) <br />
• Predic8on 1: “If I throw this away, it will feel <br />
like death.” <br />
• Predic8on 2: “If I throw it away, I will feel this <br />
way (like death) forever.” <br />
Outcome of Predic8ons <br />
Conclusions <strong>and</strong> New <br />
Hypotheses <br />
• One minute ayer discarding <br />
– SUDS ra8ng at 100, but “It does not feel like <br />
death.” <br />
• 24-‐hours ayer discarding <br />
– SUDS ra8ng at 10. “It doesn’t bother me much at <br />
all.” <br />
• Conclusion -‐ Neither predic8on came true. <br />
• New Hypotheses <br />
– The thought of throwing things away is worse than <br />
the doing of it. <br />
– If I throw something away that I am deathly afraid <br />
of discarding, it will not feel as bad as I think, <strong>and</strong> <br />
the bad feeling won’t last as long as I think. <br />
-147-<br />
15
6/24/13 <br />
Downward Arrow <strong>and</strong> Behavioral <br />
Experiment <br />
Other Cogni8ve Strategies <br />
• Underst<strong>and</strong>ing the numbers <br />
• Taking another perspec8ve <br />
• Evalua8ng advantages <strong>and</strong> disadvantages <br />
• Dis8nguishing need from want <br />
Cogni8ve Restructuring <br />
Probability <br />
◦ What’s the likelihood that something bad would actually <br />
happen What would that be <br />
◦ What is the evidence <br />
Severity <br />
◦ How bad would it be <br />
Ability to Cope <br />
◦ How well will you be able to manage <br />
Distress <br />
◦ How upset would you feel <br />
◦ How long would that last <br />
◦ Can you tolerate that feeling <br />
% Reduction<br />
0%<br />
-5%<br />
-10%<br />
-15%<br />
-20%<br />
-25%<br />
-30%<br />
-35%<br />
Controlled Trial: <br />
Saving Inventory-‐Revised <br />
Partial<br />
ETA 2<br />
= .223<br />
12 26<br />
Session<br />
CBT<br />
Wait list<br />
Partial ETA2 = .475<br />
29% reduction<br />
SATURDAY<br />
Steketee et al., 2010, Depress&Anx, 27, 476-‐484 <br />
-148-<br />
16
6/24/13 <br />
Treatment Responders (%) <br />
Other Interven8on Strategies <br />
90 <br />
80 <br />
70 <br />
60 <br />
50 <br />
40 <br />
30 <br />
20 <br />
10 <br />
0 <br />
Self-‐ra8ng <br />
Therapist <br />
Post <br />
Followup <br />
• Group CBT – 20 sessions, clinician led <br />
• Buried in Treasures Workshops – 15 <br />
sessions, non-‐professional led <br />
• Bibliotherapy – a few benefit <br />
Steketee et al., 2010; Muroff et al., 2011 <br />
Conclusions <br />
Conclusions <br />
• Hoarding disorder is common, chronic, <strong>and</strong> <br />
debilita8ng for sufferers <strong>and</strong> family members <br />
• Hoarding has unique biological, cogni8ve, emo8onal, <br />
<strong>and</strong> behavioral features <br />
• Tradi8onal medica8ons <strong>and</strong> treatments for OCD have <br />
not been very helpful <br />
• Specialized CBT reduces hoarding symptoms <strong>and</strong> <br />
improves on previous treatments <br />
• Individual treatment produced good outcomes <br />
• Group CBT <strong>and</strong> facilitated Buried in Treasures <br />
workshops also produced good outcomes <br />
• Need to improve treatments to increase the overall <br />
impact <br />
• These modali8es offer opportuni8es for stepped care <br />
model <br />
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6/24/13 <br />
Referral Op8ons <br />
• Informa8on, assessment instruments, therapy <br />
manuals, referral, resources, hoarding task forces – <br />
www.ocfounda8on.org/hoarding <br />
• Support groups – www.messies.com; <br />
www.childrenozoarders.com <br />
• Mental health & family therapists – www.abct.org; <br />
www.adaa.org <br />
• Professional organizers who specialize in chronic <br />
disorganiza8on <br />
hVp://www.challengingdisorganiza8on.org/ <br />
• Hauling (for example, 1-‐800-‐GOT-‐JUNK) <br />
• Cleaning services – local area <br />
Thank You! <br />
R<strong>and</strong>y O. Frost: rfrost@smith.edu <br />
Gail Steketee: steketee@bu.edu <br />
SATURDAY<br />
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18
Perfecting Perfectionism<br />
Perfecting Perfectionism <br />
Jeff Szymanski, Ph.D. <br />
Executive Director, <br />
International OCD <strong>Foundation</strong> <br />
Clinical Instructor, Harvard Medical School <br />
Author, “The Perfectionist’s H<strong>and</strong>book” <br />
Steven D. Tsao, Ph.D. <br />
Clinic Coordinator <br />
Center for the Treatment <strong>and</strong> Study of Anxiety <br />
University of Pennsylvania <br />
First things 0irst…. <br />
what do we actually mean <br />
By “<strong>perfectionism</strong>” <br />
Jesse M. Crosby, Ph.D. <br />
Postdoctoral Fellow <br />
OCDI OfHice of Clinical Assessment <strong>and</strong> Research <br />
McLean Hospital / Harvard Medical School <br />
Types of Perfectionism <br />
Absence of mistakes or 0laws <br />
We often consider something to be <br />
“perfect” when we can no longer 7ind <br />
any errors, mistakes or 7laws. <br />
Types of Perfectionism <br />
Personal St<strong>and</strong>ards <br />
Sometimes when you’ve done <br />
something “perfectly”, it means that you <br />
achieved a particular st<strong>and</strong>ard you set <br />
for yourself. <br />
-151-
Types of Perfectionism <br />
Types of Perfectionism <br />
Meeting an Expectation <br />
Order <strong>and</strong> Organization <br />
One might also de7ine <strong>perfectionism</strong> as <br />
having matched an expectation that <br />
someone else has set. <br />
Order, organization, <strong>and</strong> having <br />
“everything in its place” <br />
is yet another way to think <br />
about <strong>perfectionism</strong>. <br />
Types of Perfectionism <br />
Types of Perfectionism <br />
SATURDAY<br />
Ideals <strong>and</strong> “Just Right” Experiences <br />
Sometimes we “know” that something <br />
is ideal because it hits us “just right”; <br />
it looks, feels, <strong>and</strong> sounds right. <br />
Absolutes: <br />
knowledge, certainty, safety <br />
To have absolute, complete, <br />
comprehensive knowledge about <br />
something – to be convinced that this <br />
is the right direction to take -‐-‐ is very <br />
satisfying <strong>and</strong> reassuring. <br />
-152-
Types of Perfectionism <br />
Being the best <strong>and</strong> the <br />
“best of the best” <br />
What’s Wrong with Perfectionism <br />
“Absence of mistakes, order, certainty, ‘best <br />
of the best’…wait a minute, what’s wrong <br />
with wanting these things <br />
Why is it a bad thing if I am detail-‐oriented, <br />
organized, <strong>and</strong> driven to excel <br />
Though, I am also accused of being <br />
controlling, rigid, <strong>and</strong> self-‐defeating as <br />
well…” <br />
Perfectionism Paradox <br />
If your intentions are good… <br />
wanting to excel <br />
<strong>and</strong> the outcomes you want seem reasonable… <br />
to feel competent <strong>and</strong> satisBied <br />
why would your <strong>perfectionism</strong> back7ire <br />
<strong>and</strong> result in unhappiness <strong>and</strong> unwanted <br />
results <br />
The Challenge of Perfectionism <br />
• Many people consider their <br />
<strong>perfectionism</strong> to be one of their most <br />
valuable attributes <strong>and</strong> critical for <br />
success in achieving their life goals. <br />
• When <strong>perfectionism</strong> works it can have <br />
big payoffs – real <strong>and</strong> promised. <br />
-153-
The Challenge of Perfectionism <br />
• However, when <strong>perfectionism</strong> bogs you down <br />
<strong>and</strong> gets in your way, you typically get advice <br />
from others that sounds a lot like… <br />
Lower the bar <br />
Is your <strong>perfectionism</strong> a good <br />
thing or does it get in your <br />
way <br />
• This is unacceptable to many perfectionists. <br />
• As a result, people continue to hold onto their <br />
<strong>perfectionism</strong> because it works – at least some <br />
of the time -‐ even when they know it also can <br />
also back7ire. <br />
Or both <br />
Or <br />
It depends…<br />
Unhealthy Perfectionism <br />
SATURDAY<br />
Let’s start by trying to <br />
distinguish between <br />
“healthy” <strong>perfectionism</strong> <strong>and</strong> <br />
“unhealthy” <strong>perfectionism</strong>… <br />
In general, unhealthy <strong>perfectionism</strong> is operating when <br />
your behavior, choices <strong>and</strong> strategies are driven by: <br />
• A fear of failure <br />
• Chronic concerns about making mistakes <br />
• Constant doubting of yourself <br />
• Repeated attempts to live up to others’ <br />
expectations of you <br />
• Always falling short of self-‐made goals <br />
• Your costs outweigh your payoffs <br />
-154-
Healthy Perfectionism <br />
In general, healthy <strong>perfectionism</strong>… <br />
– Pays off more often than it costs you <br />
– Encourages you to achieve high but <br />
achievable st<strong>and</strong>ards that lead to <br />
feelings of satisfaction <strong>and</strong> increased <br />
self-‐esteem. <br />
Perfectionism on a Continuum <br />
From Unhealthy to Healthy <br />
Diagnostic <br />
Personality Traits <br />
OCPD: OCD: Self Doubting: Ambitious: <br />
Rigid Symmetry Procrastination Sets high goals <br />
Pervasive Just right Hide from others Conscientious <br />
Ineffective Paralyzed Preoccupied Learns from <br />
with mistakes mistakes <br />
Perfectionism Assessment:<br />
Where Would You Rate Yourself<br />
Unhealthy<br />
Healthy<br />
Developing Your Own <br />
Perfectionism Pro0ile <br />
1. My goals <strong>and</strong> outcomes match. _________ _________<br />
2. I am flexible <strong>and</strong> adaptable. _________ _________<br />
3. I devote time <strong>and</strong> energy to<br />
my strengths. _________ _________<br />
4. I am good at prioritizing. _________ _________<br />
5. I am good at meeting deadlines. _________ _________<br />
6. I am organized <strong>and</strong> efficient. _________ _________<br />
7. My concerns about making<br />
mistakes pays off.<br />
_________ _________<br />
8. I recognize my strengths <strong>and</strong><br />
weaknesses.<br />
_________ _________<br />
9. I have a positive attitude<br />
toward upcoming projects. _________ _________<br />
-155-
Perfectionism Assessment:<br />
Where Would You Rate Yourself<br />
Unhealthy Healthy<br />
10. My focus is on success, not<br />
worrying about failure. _________ _________<br />
11. I am balanced in self-evaluations. _________ _________<br />
12. I am comfortable with making<br />
decisions.<br />
_________ _________<br />
13. I engage in problem solving<br />
versus self-criticism. ________ _________<br />
14. I am a collaborative team player. ________ _________<br />
15. I am good at taking constructive<br />
criticism.<br />
_________ _________<br />
16. I ask others for help when<br />
needed. _________ _________<br />
17. I am driven by own goals, not<br />
by the need to please others. _________ _________<br />
Perfectionism in society <br />
• “Gentlemen, we will chase perfection, <strong>and</strong> <br />
we will chase it relentlessly, knowing all the <br />
while we can never attain it. But along the <br />
way, we shall catch excellence.” -‐ Vince <br />
Lombardi <br />
• “The relentless pursuit of perfection” – <br />
Lexus <br />
• A perfect game in baseball <br />
• “Picture perfect” <br />
Perfectionism payoffs <br />
SATURDAY<br />
Developing motivation to <br />
change <br />
• Think about a time when your <br />
<strong>perfectionism</strong> paid off <br />
– What happened <br />
– How did it feel <br />
– Did other’s notice What did they say <br />
– Did it lead to other rewards <br />
-156-
The cost of <strong>perfectionism</strong> <br />
• Think about that same example, but now focus <br />
on the downsides <br />
– What happened that you didn’t like <br />
– How much time did you spend on it <br />
– What other things got neglected or pushed aside <br />
while you were working on this <br />
– How did it feel <br />
– How did it impact other people, especially those <br />
closest to you <br />
– What did it make you think about yourself <br />
1. Cost-bene0it ratio <br />
• Thinking of the payoffs <strong>and</strong> the costs, which <br />
one do you experience more often <br />
– Do the payoffs happen more than the costs <br />
– Do you spend more time dealing with costs than <br />
basking in the glory of payoffs <br />
• Regardless of your ratio, ask yourself “How <br />
satisHied am I with this ratio” <br />
– What area of <strong>perfectionism</strong> are you most <br />
dissatis7ied <br />
2. “Finding” lost successes <br />
• A story from the pharmaceutical world… <br />
• Striving to achieve a goal through <br />
<strong>perfectionism</strong> may blind you to valuable <br />
information or perhaps other successes! <br />
– Tunnel vision <br />
• Broadening your scope can help you <br />
immediately catch missed opportunities to <br />
feel satis7ied, competent, <strong>and</strong> proud. <br />
3. Perfectionism as a habit <br />
• “I don’t know another way” <br />
• Trying to achieve perfection has known <br />
outcome (your payoff-‐cost ratio) <br />
• What’s the outcome when you try to be <br />
“high average” or “80% perfect” <br />
– We can only 7ind out by experimenting <br />
• If it feels “wrong” or “different” it’s working! <br />
-157-
Audience participation <br />
• For the next minute, I want you to think <br />
about anything in the world except… <br />
Warm jelly doughnuts <br />
4. When it works, it works. When it <br />
doesn’t, it doesn’t. <br />
• Trying very hard leads to failure <br />
↓ <br />
↑ <br />
• Beating yourself up for failing leads you to try <br />
even harder! <br />
• Perfectionism may not be working <strong>and</strong> your <br />
efforts to “force” it to work may be making it <br />
worse <br />
– How many times does a strategy have to fail before <br />
you decide to drop it <br />
• Insanity = doing the same thing, but expecting <br />
a different outcome <br />
Motivation Summary <br />
• Think of your ratio of payoffs v. costs, especially <br />
if you’re dissatis7ied with the ratio in some area <br />
• Consider the successes you’re missing or <br />
ignoring because of the narrow focus of <br />
<strong>perfectionism</strong> <br />
• Work up the courage to try something radically <br />
different from <strong>perfectionism</strong>. The outcome may <br />
surprise you. <br />
• Be honest with yourself about strategies that <br />
aren’t working, even if they feel like they can, <br />
should, or will. <br />
SATURDAY<br />
-158-
Let’s Focus on Two Problematic <br />
Areas of Perfectionism <br />
1) High St<strong>and</strong>ards <br />
2) Rigidity <br />
• Expectations <br />
• Ideals <br />
• Just right <br />
• The best <br />
• Better <br />
• The “shoulds” <br />
• The right way <br />
• Exact <br />
• Perfection <br />
High St<strong>and</strong>ards <br />
Rigidity <br />
Two Targets <br />
• In7lexibility <br />
• All-‐or-‐nothing <br />
• Excessive self criticism <br />
• Judgment of others <br />
• Conditional acceptance <br />
• Never good enough <br />
• Never satis7ied <br />
• Rule based <br />
• Absolute consistency <br />
• Narrow <br />
High<br />
St<strong>and</strong>ards<br />
High<br />
St<strong>and</strong>ards &<br />
Rigidity<br />
Rigidity<br />
-159-
Practice <br />
Targeting High St<strong>and</strong>ards <br />
• Choose a role/responsibility that you have <br />
at work or at school. <br />
• Write down your st<strong>and</strong>ards. <br />
• Rate the importance of those st<strong>and</strong>ards. <br />
• How important are these st<strong>and</strong>ards in <br />
relation to your values <br />
• Is this a value that could be adjusted <br />
• How would you change it <br />
Practice <br />
• Are they too high <br />
• Are they misguided <br />
• Are they unrealistic <br />
• Are they consistent with what we really value <br />
in our life <br />
• Have you lost sight of why you were engaged in <br />
the task <br />
• What are the consequences of performing at a <br />
lower st<strong>and</strong>ard <br />
Two Targets <br />
SATURDAY<br />
• Focusing on ALL the outcomes… <br />
• Exp<strong>and</strong>ing our perspective… <br />
• Nine dots… <br />
High<br />
St<strong>and</strong>ards<br />
High<br />
St<strong>and</strong>ards &<br />
Rigidity<br />
Rigidity<br />
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• Are we there yet <br />
• The road trip… <br />
Practice <br />
Targeting Rigidity <br />
• Developing 7lexibility <br />
• Moving beyond “all-‐or-‐nothing” <br />
• The role of values <strong>and</strong> priorities <br />
• Striving vs. achievement <br />
• The importance of direction <br />
• Rule based behavior compared to <br />
contextual behavior <br />
Practice <br />
Two Targets <br />
• Solids <strong>and</strong> liquids… <br />
• Growth from mistakes… <br />
• Unconditional acceptance… <br />
High<br />
St<strong>and</strong>ards<br />
High<br />
St<strong>and</strong>ards &<br />
Rigidity<br />
Rigidity<br />
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For More Information… <br />
Jeff Szymanski, Ph.D. <br />
jszymanski@ocfoundation.org <br />
www.drjeffszymanski.com <br />
Steven D. Tsao, Ph.D. <br />
stsao@mail.med.upenn.edu <br />
Jesse Crosby, Ph.D. <br />
jcrosby@mclean.harvard.edu <br />
SATURDAY<br />
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Addressing Relapse in CBT for OCD<br />
6/14/13 <br />
Outline <br />
Addressing Relapse <br />
in CBT for OCD <br />
Op:mizing Long-‐Term <br />
Treatment Outcomes <br />
• Overview of CBT for OCD <br />
• Case presenta:on – “Lisa” <br />
• Explana:ons for Lisa’s relapse <br />
• Methods for op:mizing long-‐term outcome <br />
Jonathan S. Abramowitz & Ryan J. Jacoby <br />
University of North Carolina at Chapel Hill <br />
CBT Model of OCD <br />
• Obsessional thoughts <br />
– Basis in normal intrusive thoughts & doubts <br />
– Misinterpreted as significant or threatening <br />
– Intolerance of uncertainty <br />
– Provoke anxiety <br />
• <strong>Compulsive</strong> rituals <strong>and</strong> avoidance behavior <br />
– Performed to reduce obsessional anxiety <strong>and</strong> get <br />
assurance of safety <br />
– Reinforced by short-‐term anxiety reduc:on <br />
– Long-‐term maintenance of obsessional fear <br />
CBT for OCD <br />
• Derived from the conceptual model <br />
• Treatment techniques <br />
– Assessment <strong>and</strong> psychoeduca:on <br />
– Self-‐monitoring <br />
– Cogni:ve therapy <br />
– In vivo <strong>and</strong> imaginal exposure <br />
– Response preven:on <br />
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“Lisa” <br />
• 27 yr old married woman <br />
• YBOCS = 26 (severe), no comorbidity <br />
• Obsessions about being possessed by the devil <br />
• Compulsions: Reassurance-‐seeking, mental <br />
rituals, excessive praying <br />
• Avoidance: reminders of hell, death, possession, <br />
devil, serial killers, “murder,” her high school <br />
• Onset: years earlier when she learned a high <br />
school classmate had murdered his wife <br />
Lisa’s Treatment: Sessions 1 & 2 <br />
• Informa:on-‐gathering <br />
– Triggers, thoughts, rituals, avoidance <br />
– Main fear: I’ll be possessed & become a serial killer <br />
• Educa:on about the CBT model of OCD <br />
– Lisa felt comforted to know everyone has bad <br />
thoughts <br />
• Ra:onale <strong>and</strong> explana:on of ERP <br />
– Lisa thought the ra:onale made sense <br />
Conceptual Model of Lisa’s OCD <br />
Beliefs about the meaning of feared s3muli <br />
“Thoughts are significant <strong>and</strong> meaningful” “I should have control over my thoughts” <br />
Aen3on toward threat <br />
Devil, possession, death-‐related sHmuli <br />
Normal intrusive thoughts <br />
Thoughts about demonic possession (“What if I become possessed”) <br />
Misinterpreta3on of thoughts <br />
“I could be possessed”; “I can’t take the chance”; thinking=truth <br />
Obsessional fear <br />
<strong>Compulsive</strong> rituals to reduce anxiety & feel safe <br />
Avoid, reassurance, praying, thought suppression/control <br />
Emo:onal Processing Theory (EPT), <br />
Habitua:on, <strong>and</strong> Exposure Therapy <br />
• EPT emphasizes the importance of within-‐ <strong>and</strong> <br />
between-‐session habitua:on <br />
– Provoke ini:al anxiety (SUDS) <br />
– Remain exposed un:l anxiety subsides naturally <br />
SUDS <br />
90 <br />
80 <br />
70 <br />
60 <br />
50 <br />
40 <br />
30 <br />
20 <br />
10 <br />
0 <br />
10 20 30 40 50 60 <br />
Time (mins) <br />
Session 1 <br />
Session 2 <br />
Session 3 <br />
Session 4 <br />
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Lisa’s Exposure Hierarchy: Session 3 <br />
Item SUDS <br />
School <strong>and</strong> names/pictures of classmates 40 <br />
Words (“devil”, “murder”) <br />
50 <br />
Names of serial killers 65 <br />
Cemetery/funeral home/funeral 75 <br />
Documentaries about serial killers <br />
80 <br />
Images of being possessed <strong>and</strong> killing family members 85 <br />
Horror movies (The Exorcist) 95 <br />
• Response preven:on: gradual; depending on <br />
exposures <br />
Exposure Sessions: Session 4+ <br />
• Therapist emphasized the importance of <br />
habitua:on within <strong>and</strong> between sessions <br />
• Each prac:ce provoked anxiety <br />
• Anxiety fell to mild levels with repeated <br />
prac:ce <br />
• Generally successful in resis:ng urges to <br />
ritualize <br />
• Very compliant with ERP in general <br />
Use of Cogni:ve Therapy <br />
• Used informally to help Lisa engage in <br />
exposure prac:ces <br />
– Examine the evidence for/against Lisa’s percep:on <br />
of risk with each exposure situa:on <br />
• Lisa took notes from cogni:ve therapy <br />
discussions <strong>and</strong> oken read them over to help <br />
her complete exposure exercises on her own <br />
– She used cogni:ve techniques to help anxiety go <br />
down during exposures <br />
Lisa’s Progress <br />
• Consistent but very gradual <br />
– Very gradual progression up the fear hierarchy <br />
• Concerns about exposure <br />
– “Am I going too far” <br />
– “What if I am really possessed” <br />
– “Will too much exposure turn me into a killer” <br />
• Lisa felt relieved aker each exposure was over <br />
– Self-‐reassurance that anxiety would always go down <br />
• “I know I’ll be OK because anxiety will always go away” <br />
– Felt successful because anxiety went away <br />
– No obvious generaliza:on across exposures <br />
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6/14/13 <br />
Confron:ng the Greatest Fear <br />
Lisa’s Lapse <strong>and</strong> Relapse <br />
• Session 14, Lisa planned to watch The Exorcist with <br />
her husb<strong>and</strong> at a showing on campus <br />
• Prepared by reassuring herself that anxiety would go <br />
down <br />
• Reviewed her cogni:ve therapy materials <br />
• Lisa became overwhelmed during the movie <br />
– Couldn’t reassure herself that everything would be OK <br />
(“just thoughts”; “anxiety going down”) <br />
– Had to leave the theater before she had a “breakdown” <br />
Factors involved in Lisa’s Relapse: <br />
Insights from Learning Theory <br />
• Over-‐reliance on habitua:on as an indicator of <br />
improvement <br />
• Use of exposure to disconfirm obsessional fear <br />
• Lack of varia:on in exposure prac:ces <br />
• Misuse of cogni:ve therapy <strong>and</strong> educa:on <br />
• OCD symptoms increased rela:ve to how she had <br />
been doing (“lapse”) <br />
– Fear of possession, more rituals <br />
• Stopped exposure <strong>and</strong> began avoiding again <br />
• Cancelled several sessions before stopping <br />
treatment <br />
– Therapist urged Lisa to con:nue <br />
– Lisa felt it was hopeless, <strong>and</strong> that she needed a break <br />
• 2-‐wk follow-‐up phone call confirmed Lisa’s <br />
relapse (significant, las:ng return of symptoms) <br />
Implica:ons of EPT for Lisa <br />
• It was assumed that Lisa had improved if <br />
– Self-‐reported anxiety (SUDS) reduced during an <br />
exposure trial <br />
– Exposure to the same s:mulus evoked less anxiety <br />
from one trial to the next <br />
• Prior to watching The Exorcist, Lisa was <br />
experiencing liple anxiety during exposures <br />
<strong>and</strong> she was not performing rituals <br />
– Her treatment goals seem to have been achieved <br />
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Is Performance During Exposure a <br />
Reliable Indicator of Learning <br />
• Although habitua:on usually occurs during exposure, <br />
it's not a good predictor of outcome <br />
– Fear expression during learning is not the same thing as <br />
fear learning <br />
• Decline in anxiety across similar exposures may <br />
predict, but is not necessary for, long-‐term <br />
improvement <br />
– Successful response to exposure can occur in the absence <br />
of habitua:on <br />
Habitua:on <strong>and</strong> Lisa’s Relapse <br />
• Reliance on habitua:on likely played a role in relapse <br />
– Lisa’s performance on prior exposures did not predict <br />
performance on the Exorcist exposure <br />
• Lisa con:nued to viewed anxiety/fear as a problem <br />
– She used exposure to control it <br />
– She viewed the surge of high anxiety as a sign of failure <br />
• Reinstatement: When exposure to an uncondi:oned <br />
s:mulus (anxiety) re-‐awakens fear of related cues <br />
– If treatment had ins:lled greater fear tolerance, <br />
reinstatement might have been avoided <br />
Craske et al. (2008) <br />
Using Exposure to Disconfirm Fears <br />
• Stated goal of ERP was to minimize anxiety by <br />
disconfirming the fear of becoming possessed <br />
– Aker each exposure, Lisa said she “knew” her fear was <br />
senseless <br />
– This relief reinforced Lisa’s belief that she couldn’t tolerate <br />
uncertainty <br />
– Exposure became a way of re-‐assuring herself <br />
– Slow pace of therapy might have been a sign of the need <br />
to establish safety <strong>and</strong> comfort <br />
Lack of Varia:on in Exposures <br />
• Lisa prac:ced exposure mainly in the therapist’s <br />
office <strong>and</strong> at home as opposed to in varied <br />
contexts <br />
• Lisa never combined imaginal <strong>and</strong> in vivo <br />
exposure <br />
• Thus, she did not develop tolerance for <br />
experiencing obsessional anxiety in different <br />
situa:ons <br />
– Prac:cing in a broader range of environments <strong>and</strong> <br />
combining exposure media might have helped with <br />
generaliza:on of learning <br />
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Misuse of Cogni:ve Therapy <strong>and</strong> <br />
Educa:on <br />
Misuse of Cogni:ve Therapy <strong>and</strong> <br />
Educa:on <br />
• CT targets were overes:mates of risk of <br />
becoming possessed <strong>and</strong> probability of <br />
becoming evil <br />
– “There’s no evidence that I am possessed” <br />
– “There’s no evidence I will become evil” <br />
• Educa:on focused on assuring Lisa that her <br />
intrusive thoughts were “just thoughts” <br />
Re-‐thinking Pathways to Long-‐term <br />
Success: An Inhibitory Learning Approach <br />
• Lisa used cogni:ve therapy <strong>and</strong> educa:onal <br />
material to help her get through exposures <br />
– Reviewed it before <strong>and</strong> during exposures <br />
– The material became a safety cue <br />
– Emphasis on immediate fear reduc:on kept her <br />
from learning the importance of tolera:ng anxiety <br />
<strong>and</strong> uncertainty <br />
– She experienced anxiety <strong>and</strong> uncertainty as a sign <br />
of failure <br />
Genera:ng Non-‐Threat Associa:ons <br />
SATURDAY<br />
• Original fear associa:ons remain intact during <br />
exposure while new safety learning is formed <br />
– The old <strong>and</strong> new associa:ons compete with one another <br />
• Important to maximize the likelihood that safety <br />
learning will inhibit access <strong>and</strong> retrieval of fear <br />
associa:ons <br />
• The degree to which fear vs. safety associa:ons are <br />
expressed following treatment depends on inhibitory <br />
learning, rather than fear expression <strong>and</strong> habitua:on <br />
• Mismatching expectancies <br />
• Elimina:ng safety behaviors <strong>and</strong> cues <br />
• Combining fear cues during exposure <br />
• Linguis:c processing <br />
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Frame ERP to Mismatch Expectancies <br />
• When the expecta:on that a fear trigger produces a nega:ve <br />
outcome is disconfirmed, an alterna:ve non-‐threatening <br />
associa:on is generated <br />
– Tricky in OCD because obsessional fear is oken cued by <br />
uncertainty about long-‐term or unknowable disasters <br />
– Conduc:ng exposure to feeling uncertain can help diminish the <br />
significance <strong>and</strong> intolerance of uncertainty <br />
• Implica:ons <br />
– Set up exposure to violate expectancies about uncertainty <br />
• Instead of tracking SUDS, track length of :me Lisa can manage <br />
feeling uncertainty without ritualizing <br />
• Violate Lisa’s expecta:ons that she can’t manage uncertainty, <br />
anxiety, obsessions <br />
Elimina:ng Safety Behaviors <strong>and</strong> Cues <br />
• Response preven:on enhances the genera:on of <br />
non-‐threat associa:ons <br />
• Allows the pa:ent to learn that feared situa:ons, <br />
thoughts, <strong>and</strong> uncertainty are tolerable even <br />
without rituals <br />
• Therapist can be an unintended safety cue <br />
• Implica:ons <br />
– Target more than just rituals—any ac:on to reduce <br />
anxiety, doubt, or remove an obsession <br />
• Reassurance-‐seeking, thought suppression, neutralizing, etc. <br />
– Ensure that Lisa prac:ces ERP in mul:ple contexts <br />
without the therapist or other “safety person” or cues. <br />
Combining Fear Cues During Exposure <br />
• When an expected nega:ve outcome fails to occur <br />
despite the presence of mul:ple fear cues, <br />
inhibitory learning is greater than when only a <br />
single fear cue is present <br />
– “Deepened ex:nc:on” (Rescorla, 2006) <br />
• Implica:ons <br />
– In OCD, exposure can involve confron:ng external fear <br />
cues along with imaginal exposure to the feared <br />
consequences of (or uncertainty about) doing so <br />
• Lisa: Exposure to driving past her old high school while <br />
imagining becoming possessed <strong>and</strong> eventually ac:ng in <br />
evil ways <br />
Linguis:c Processing <br />
• Puung feelings into words disrupts the <br />
feelings being verbalized <br />
• Implica:ons <br />
– Might be beneficial to have OCD pa:ents label <br />
their feelings during exposure <br />
• “I am very scared that being at my old school will cause <br />
me to become possessed” <br />
• “I feel very unsure of whether I will become possessed <br />
<strong>and</strong> one day murder my child.” <br />
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Enhancing the Retrieval <br />
of Non-‐Threat Associa:ons <br />
• Maximize variability during ERP <br />
• Exp<strong>and</strong>ing the interval between sessions <br />
• Aid context retrieval <br />
Exp<strong>and</strong>ing the Inter-‐session Interval <br />
Maximize Variability During ERP <br />
• Prac:ce in varied contexts makes short-‐term learning more <br />
difficult, but enhances long-‐term reten:on (Bjork & Bjork, <br />
2006) <br />
– The more diverse the condi:ons under which learning <br />
takes place, the greater the number of retrieval cues that <br />
are generated <br />
• Implica:ons <br />
– Prac:ce ERP under as many different condi:ons as <br />
possible <br />
– Use r<strong>and</strong>om (rather than gradual) exposure <br />
– Vary imaginal exposure (uncertainty, worst possible <br />
outcome) <br />
– “I’ll be OK because I know anxiety will go away” becomes <br />
“I’ll be OK because I know I can tolerate anxiety” <br />
Aiding in Context Retrieval <br />
SATURDAY<br />
• Temporally spacing learning trials results in <br />
beper long-‐term reten:on of what was <br />
learned <br />
– More opportuni:es to strengthen long-‐term <br />
memory by forgeung <strong>and</strong> prac:cing re-‐learning <br />
associa:ons <br />
• Implica:ons <br />
– Exp<strong>and</strong>ing spaced scheduling <br />
• 2x/week 1x/week every other week, etc. <br />
• Prac:cing ERP in as many different contexts as <br />
possible <br />
– Enhances accessibility <strong>and</strong> retrieval of new safety <br />
learning <br />
• Implica:ons <br />
– Prac:ce ERP in as many contexts as possible <br />
– Aim for prac:ce in situa:ons where symptoms are <br />
likely to be triggered <br />
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Implica:ons for Psychoeduca:on <strong>and</strong> <br />
Treatment planning <br />
• Providing the treatment ra:onale <br />
– Explain the importance of using ERP to learn fear <br />
tolerance to prevent relapse <br />
– Label the occurrence of obsessions, anxiety, <strong>and</strong> <br />
uncertainty as opportuni:es to prac:ce distress <br />
tolerance as opposed to signs of failure <br />
– “Bring it on” autude! <br />
– Be on the lookout for pa:ents misusing ERP <br />
Implica:ons for Using Cogni:ve <br />
Techniques <br />
• Avoid trying to convince the pa:ent that <br />
obsessional thoughts are illogical, senseless, or <br />
unlikely to come true <br />
– This overemphasizes short-‐term anxiety reduc:on <br />
– Can’t be proven anyway! <br />
• Beper targets for cogni:ve therapy <br />
– Likelihood of tolera:ng anxiety, uncertainty <br />
– Catastrophic misinterpreta:ons of intrusive thoughts <br />
– Dysfunc:onal beliefs about the need <strong>and</strong> ability to <br />
gain absolute certainty <br />
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OCD Taboos - Strategic Responses to Sexual <strong>and</strong> Violent Intrusions<br />
6/14/13 <br />
OCD TABOOS: Strategic Responses to <br />
sexual <strong>and</strong> violent intrusions <br />
Sco@ Blair-‐West MD <br />
Christopher Mogan PhD <br />
Throstur Bjorgvinsson PhD ABPP <br />
C.Alec Pollard PhD <br />
Case 1: Mother with intrusive thoughts <br />
of harming her daughter <br />
Sco8 Blair-‐West <br />
Director, The Melbourne Clinic <br />
InpaCent OCD Program, Australia <br />
IOCDF CONGRESS ATLANTA, GA 2013 <br />
Case -‐ Jenny <br />
Jenny <br />
SATURDAY<br />
• 43 year old woman, lives with husb<strong>and</strong> <strong>and</strong> 6 year <br />
old daughter in Melbourne suburb, previously <br />
worked as teacher <br />
• Husb<strong>and</strong> -‐ trainee surgeon, married 2005 <br />
• Moved from Brisbane to Melbourne, Jan 2012 <br />
• First seen by Clinical psychologist, June 2012 <br />
• Seen by me Sept 2012 <br />
• OCD symptoms from age 10 – sporadic intrusive thoughts <br />
that teachers were a@racted to her <br />
• Age 15 – thoughts in love with school friend’s mother, “what <br />
if I was a@racted” <br />
• 15-‐17 – ongoing thoughts, poor academic performance <br />
• Completed school, worked for 7 years as bank teller, sudden <br />
onset of intrusive thoughts of harming person si`ng in front <br />
of her on train, age 21, during this ame <br />
• Rapid generalizaaon harm to family <strong>and</strong> others – highly <br />
anxious, nightly prayers, religious rituals, harm self to keep <br />
contact with partner, requests for reassurance <br />
3 <br />
4 <br />
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Jenny <br />
Jenny <br />
• Referred to psychiatrist, meds – Clomipramine <br />
• Next 3 years (21-‐24), thoughts of harming family by <br />
punch, hit, slap, similar compulsions, reassurance <br />
seeking <br />
• Age 24-‐35 – improved with medicaaon (CMI 200mg), <br />
CBT/ERP avoided – “coasted along” with occasional <br />
flaring of symptoms, especially harm <strong>and</strong> sexual <br />
a@racaon thoughts <br />
• First pregnancy 2006, complicated by thyroid disease <br />
• Withdrawn from medicaaon prior to conceiving <strong>and</strong> no <br />
meds throughout pregnancy <br />
• Daughter born June 2007, induced @ 40 weeks, 12 hour <br />
labour, NVD, birth weight 6.5 lbs, N development <br />
• Few symptoms during pregnancy or for 2 mths pp <br />
• Sudden onset “What if I harm her” <br />
• Rapid increase in thoughts, anxiety, review of thoughts <br />
<strong>and</strong> acaons, checking, franac requests for reassurance, <br />
harming self to keep husb<strong>and</strong> from leaving <br />
5 <br />
6 <br />
Jenny – subsequent progress <br />
Jenny – current status <br />
• Rapid return to medicaaons despite breast-‐feeding, <br />
iniaally 3 different SSRI’s (F, Cit, S) <br />
• Late 2007 – 2 admissions to PND unit – no specific <br />
OCD treatment, CBT more focussed on depression <br />
• 2008-‐2009 – severe symptoms, back to CMI <br />
• Late 2009 – ceased medicaaon when a@empang <br />
second pregnancy return of severe symptoms <strong>and</strong> <br />
depression two further admissions (2010) <br />
• Ongoing treatment incl outpaaent ECT <br />
• Intrusive thoughts of harming daughter <strong>and</strong> family plus <br />
doubt over her acaons <strong>and</strong> moavaaons <br />
• Some other OCD intrusions <br />
• Frequent reviewing of thoughts, images, video of acaons <br />
• Frequent requests for reassurance <br />
• “Tesang procedure” – deliberately bringing on thoughts to <br />
prove to self that she would be repulsed, revolted by <br />
thoughts. Source of reassurance iniaally, subsequently <br />
ritualised <strong>and</strong> then source of doubt <strong>and</strong> anxiety. Catch 22 <br />
scenario if felt less anxiety – “if I’m not repulsed then <br />
maybe I’ll do it!” <br />
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Talking points <br />
1. Would earlier <strong>and</strong> more intensive treatment <br />
(preferably with ERP) make a difference in the long <br />
term Is this harder to achieve with sexual obsessions <br />
And when paaent seems to be funcaoning well <br />
2. What about stopping meds before, during <strong>and</strong> aner <br />
pregnancy Risks versus benefits <br />
3. How do you successfully do ERP in paaents who <br />
ritualise constantly <br />
Case 2 <br />
9 <br />
Father with sexual intrusions re contact <br />
with infant daughter <br />
Christopher Mogan <br />
Director, The Anxiety Clinic <br />
Richmond <br />
Australia <br />
Model for Case 2 <br />
SATURDAY<br />
• 35 year old man with a strong family history of <br />
contaminaaon, order <strong>and</strong> symmetry, high avoidance, <br />
contaminaaon worries re pregnant wife …increased h<strong>and</strong>-washing,<br />
fear of harm. <br />
• Employed as an electrical engineer in large mula-‐naaonal <br />
company. Previous 10 years, avoided bins, door h<strong>and</strong>les, <br />
sharing drinks, fear of transferring germs wife; increasing <br />
moral/ethical concerns –woman in shop touched his h<strong>and</strong> <br />
giving change – “Was that sexual contact Should I have <br />
prevented it Am I a monster”. interest in pornography as a <br />
uni student. <br />
• Early 2010 – wife pregnant, recall of event when surfing the <br />
net, felt guilty, would not hug wife for fear of “crossing the <br />
line”, harming unborn child. Baby born 2011 – sweaang <strong>and</strong> <br />
shaking at any contact, st<strong>and</strong>ing near, changing the baby. <br />
11 <br />
SituaCon <br />
trigger <br />
LiOing <br />
baby to sit <br />
on lap <br />
Obsession <br />
intrusion <br />
“What if this <br />
creates a <br />
sexual <br />
connecCon <br />
with my <br />
daughter” <br />
Appraisal <br />
Interpret-‐ <br />
aCon <br />
“Maybe I want <br />
this. <br />
I have to watch <br />
myself like a <br />
hawk. <br />
Maybe I’m really <br />
a paedophile, a <br />
monster” <br />
I couldn’t cope <br />
with even the <br />
slightest chance <br />
of harming her.” <br />
Anxiety <br />
or <br />
NJR <br />
Anxiety <br />
<strong>and</strong> guilt <br />
Compulsion <br />
Neutraliz-‐ <br />
aCon <br />
Agitated & <br />
lengthy analysis <br />
<strong>and</strong> reviewing <br />
of the event, <br />
Reassurance-‐ <br />
seeking, <br />
hypervigilant in <br />
all acCons <br />
12 <br />
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Appraisals of intrusions <br />
• Doubt that might have acted on urges in the past review <br />
<strong>and</strong> analysis of behaviour <br />
• Worry that may act on thoughts <strong>and</strong> urges in the future <br />
avoidance of situaaons .. What if I lose control Worry that <br />
may be wrongly accused of acang on such urges <br />
reassurance-‐seeking <br />
• Evaluaaon ‘I am a bad person suppression <strong>and</strong> control <br />
a@empts. What if I have moved the child towards my <br />
genitals <br />
• Need to be vigilant, to re-‐examine my thoughts <strong>and</strong> acaons <br />
to be@er underst<strong>and</strong> possibiliaes. <br />
• Disabled by the heightened anxiety, the distress of any <br />
possibility of harming his daughter. <br />
13 <br />
Treatment <br />
explanaaon of the model: anxiety confused <br />
thinking overwhelming feelings avoidant <br />
<strong>and</strong> disrupave behaviors. <br />
Key trigger – Sense of disgust with self at any <br />
possibility of sexual behavior with daughter. <br />
CBT model based on evidence not impulse <br />
Program of exposure/behavioral tasks aimed at <br />
habituaaon of the felt anxiety that preceded the <br />
birth of daughter. <br />
Graded, repeated, intense, prolonged exposures. <br />
14 <br />
Paaent collaboraaon in exposures <br />
• Model based on prolonged exposures <strong>and</strong> <br />
conanuous engagement with daughter. <br />
• Going towards the anxiety, not away from it. <br />
Se`ng targets like the panicky feelings that <br />
come before a@ending to baby. Increasing his <br />
own agency by appropriate engagement in tasks. <br />
Breakthrough exposures – (1) Increased play with <br />
daughter; (2) not avoiding spontaneous contact; <br />
(3) Reading with child si`ng on lap. <br />
15 <br />
Discussion <br />
1) Diagnosac issues: Before coming to OCD <br />
Program, paaent was referred for assessment <br />
by a Forensic Psychologist -‐ Pedophilia. <br />
2) Does prior interest or browsing of porn sites <br />
suggest likelihood of increased risk for <br />
inappropriate contact with an infant or child <br />
3) When assessing for OCD, should specific <br />
quesaons about sexual urges to be asked by the <br />
therapist <br />
16 <br />
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6/14/13 <br />
Bill <br />
Adult with a range of obsessional <br />
intrusions – religious, sexual <strong>and</strong> harming <br />
Throstur Bjorgvinsson <br />
Director, Houston OCD Program <br />
Bill <br />
• A married male in his 40s who had a successful law <br />
career previous to the worsening of his OCD <br />
symptoms. <br />
• He sought treatment aner he was unable to work <br />
due to the nature of his intrusive obsessions. <br />
• He described a normal childhood, one of four <br />
siblings, <strong>and</strong> reported that he was close to his <br />
parents <strong>and</strong> siblings. <br />
• He married his high school sweetheart <strong>and</strong> she was <br />
encouraging him to seek treatment. <br />
Bill <br />
18 <br />
SATURDAY<br />
• His symptoms began to emerge about 10 years prior <br />
to seeking treatment when he first noaced intrusive <br />
<strong>and</strong> disturbing thoughts that he could not avoid. <br />
• He reported four types of obsessions: 1) religious, 2) <br />
intrusive sexual thoughts, 3) fear that he might harm <br />
or had harmed someone, <strong>and</strong> 4) fear of <br />
contaminaaon. <br />
• His religious obsessions were mostly associated with <br />
the devil. For example, any numbers that were <br />
remotely similar to “666” had to be neutralized or <br />
they would lead to something horrible. This <br />
included going to hell or harm coming to him, his <br />
wife, or his family. He had to neutralize (this was his <br />
compulsion) by changing the number 6 to the <br />
number 7, such as adding a 1 to each number <strong>and</strong> <br />
making it “777” as a way to neutralize the intrusive <br />
associaaon with the devil. <br />
19 <br />
20 <br />
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6/14/13 <br />
Bill <br />
• His intrusive sexual thoughts involved a flickering <br />
thought of sexually abusing his nieces <strong>and</strong> nephews, <br />
something that he found abhorrent <strong>and</strong> very difficult <br />
to tolerate. His way to cope with these obsessions <br />
was to avoid going to family gatherings, something <br />
that he used to enjoy in the past, <strong>and</strong> avoid places <br />
where he might run into children. <br />
Bill <br />
• His harming obsessions included intrusive images of <br />
him killing his two dogs with a shovel. This caused <br />
him tremendous distress <strong>and</strong> he would insist on <br />
removing all tools when he was close to the dogs <br />
<strong>and</strong> not be len alone with the dogs among other <br />
things. <br />
21 <br />
22 <br />
Conceptualizaaon <br />
• Intrusive sexual or harming thoughts significant distress <br />
avoidance/neutralizaaon/distracaon temporary relief <br />
conanued distress upon triggers <br />
– Fears: “I must have liked it because I didn't’stop it,” <strong>and</strong> “I must have <br />
brought this on by thinking ‘bad’ thoughts” <br />
• Underlying fear: “If I think the ‘wrong’ thoughts, something <br />
bad might happen”<br />
An Adolescent with Intrusive, <br />
Blasphemous Thoughts <br />
C. Alec Pollard <br />
Director, St Louis Behavioral Medicine <br />
InsCtute <strong>and</strong> St Louis University <br />
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6/14/13 <br />
Descripaon of the Paaent <br />
Symptoms <br />
• 16 yr-‐old boy, “Damien” <br />
• Lived with parents <strong>and</strong> an 18 yr-‐old sister <br />
• Raised Bapast, “moderate” <br />
• Hx of subclinical perfecaonism; symptom <br />
onset at age 13 <br />
Preparaaon for ERP <br />
• Intrusive thoughts: 1) harming family <br />
members; 2) thoughts that would offend God <br />
• Avoided: provocaave TV/movies, etc., church, <br />
family when possible <br />
• Compulsions: prayer/scripture review, <br />
reassurance-‐seeking <br />
• Fear: If I have these thoughts, I will be <br />
punished by God <br />
Exposure <br />
SATURDAY<br />
• Educaaon about OCD <br />
• Cogniave Tx: PISA Worksheet to help Damien <br />
clarify his beliefs <br />
• Consultaaon with minister <br />
• Developed ERP plan <br />
• Met with parents: educate about OCD, assess <br />
recepavity, obtain “blessing” <br />
• Recorded on digital voice recorder blasphemous <br />
thoughts: <br />
-‐ “F*** God” <br />
-‐ “I want to give my soul to the Devil” <br />
-‐ “I love Satan” <br />
• Listened to recording for extended amounts of <br />
ame <br />
• Exposure to thoughts constant as moved up <br />
hierarchy of contexts: e.g., therapist’s office <br />
(low), near a Bible (medium), at Church (high) <br />
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6/14/13 <br />
Response Prevenaon <br />
• During exposure: resisted all rituals. Periodically, <br />
read his coping script. <br />
• Coping script emphasized living with <br />
uncertainty, moavated him to resist rituals. <br />
• Outside of exposure: Follow new rules for <br />
“normal” religious behavior within Bapast faith <br />
tradiaon: <br />
-‐ Daily, brief prayer <br />
-‐ Scripture reading once a day – 10 minutes <br />
-‐ “Reassurance Time” 5 minute daily, phased <br />
out <br />
Outcome <br />
• Resumed a@endance at church <strong>and</strong> family <br />
gatherings <br />
• Thoughts did not disappear, but less reacave <br />
• Able to follow normal religious pracace, with <br />
a few “slips” – especially when new thought <br />
emerged <br />
• More difficulty on weekends – less structure <br />
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We’re All in This Together - the Power of Group Therapy for OCD<br />
6/14/13<br />
We’re All in this Together<br />
The Power of Group Therapy for OCD<br />
Scott M. Granet, LCSW<br />
The OCD-BDD Clinic of<br />
Northern California<br />
The Power of Group Therapy:<br />
Jennifer’s Story<br />
The IOCDF 20 th Annual Conference<br />
Atlanta, GA<br />
July 21, 2013<br />
Study Comparing Individual Vs.<br />
Group Treatment for OCD<br />
Study Comparing Individual Vs. Group<br />
Treatment for OCD Cont.<br />
<br />
Individual versus group cognitive behavioral<br />
treatment for obsessive–compulsive disorder:<br />
Follow up (Spain)<br />
<br />
Psychoeducation, ERP, cognitive techniques, <strong>and</strong><br />
relapse prevention utilized<br />
<br />
<br />
<br />
38 subjects meeting DSM-IV-TR criteria for OCD<br />
Completed 20 sessions of IT <strong>and</strong> GT; CBT based<br />
All were given medication; CBT began 12 weeks<br />
after start of medication<br />
Jaurrieta, N. PhD, et al. (2008). Individual versus group cognitive behavioral treatment for<br />
obsessive–compulsive disorder: Follow up. Psychiatry <strong>and</strong> Clinical Neurosciences, 62, 697-704<br />
<br />
<br />
No significant difference in improvements in IT<br />
vs. GT groups<br />
Maintained progress at follow-ups of 1, 3, 6 <strong>and</strong><br />
12 months.<br />
SUNDAY<br />
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6/14/13<br />
Study Comparing Individual Vs. Group<br />
Treatment for OCD Cont.<br />
Another Study<br />
<br />
Y-BOCS Changes:<br />
<br />
32 patients with OCD; 5 groups<br />
Individual average prior: 25.2<br />
<br />
12 weekly sessions; 2 hours in length<br />
Individual at 12 month f/u: 10.0<br />
<br />
CBT treatment<br />
Group average prior: 24.6<br />
Group average at 12 month f/u: 13.7<br />
78.1% of patients showed improvement of ≥ 35%<br />
in Y-BOCS score<br />
Cordioli, Aristides, V., et al. (2002). Cognitive-behavioral group therapy in obsessive-compulsive<br />
disorder: a clinical trial. The Brazilian Association of Psychiatry, 24 (3), 113-120<br />
What Does This All Mean<br />
Group Therapy – Key Concepts<br />
<br />
Support from others with similar problems<br />
<br />
Is group therapy for OCD effective: Yes!<br />
<br />
Helps to combat shame <strong>and</strong> isolation<br />
<br />
Is individual therapy better than group therapy<br />
Not necessarily<br />
<br />
Provides encouragement to do behavior<br />
therapy<br />
<br />
But, some people are better suited for group<br />
than others <strong>and</strong> some manifestations of OCD are<br />
more easily treated in group than others<br />
<br />
<br />
Opportunities for modeling<br />
Group ERP exercises<br />
<br />
Limit telling of “horror stories”<br />
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6/14/13<br />
Group Therapy – Key Concepts Cont.<br />
Criteria for My Group Members<br />
<br />
<br />
<br />
<br />
<br />
More affordable than individual treatment<br />
Can be effective within managed care<br />
restrictions<br />
Can be difficult to manage so many people<br />
with diverse problems, <strong>and</strong> different levels of<br />
functioning<br />
Requires clients who are motivated to do<br />
homework assignments<br />
Providing group structure important<br />
<br />
<br />
<br />
<br />
Diagnosis of OCD, hoarding or hypochondriasis<br />
Primary diagnosis of BDD or Impulse Control<br />
Disorder may be problematic<br />
Ability to participate in group format, be<br />
compassionate <strong>and</strong> supportive towards others<br />
Be motivated to do homework<br />
And the backbone of any group….<br />
Confidentiality<br />
Confidentiality<br />
Confidentiality<br />
Confidentiality<br />
Confidentiality<br />
Confidentiality<br />
Confidentiality<br />
SUNDAY<br />
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6/14/13<br />
Exclusionary Criteria<br />
Structure of My Group<br />
<br />
Actively suicidal<br />
<br />
90 minute session<br />
<br />
Psychotic symptoms<br />
<br />
On-going group. People can join at any time<br />
<br />
Hostility/inability to engage in appropriate<br />
group interaction<br />
<br />
Divided into 3 sections:<br />
* Check-in/review of prior week’s homework<br />
<br />
Chronic resistance to doing homework<br />
assignments <strong>and</strong> working on hierarchy<br />
* Exposure therapy/discussion<br />
* Homework<br />
<br />
Active substance abuse<br />
Examples of In-Group ERP<br />
Examples of In-Group ERP Cont.<br />
<br />
Harm obsessions: patients sit with knives/harm<br />
related pictures near them/watch videos<br />
<br />
Hoarding: Bring in items to be discarded or<br />
recycled/bring in papers to assist with decision<br />
making/bring in pictures<br />
<br />
Checking: go to car in parking lot. Open <strong>and</strong> lock<br />
once <strong>and</strong> walk away. Do this alone or with whole<br />
group present<br />
<br />
Harm/religious/sexual obsessions*: Write script<br />
<strong>and</strong> read aloud in group<br />
<br />
Contamination: Walk around clinic touching<br />
various items without engaging in any cleaning<br />
behaviors/“field trips”<br />
<br />
Symmetry/exactness: Purposely place various<br />
items in a manner that creates anxiety<br />
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6/14/13<br />
Examples of In-Group ERP Cont.<br />
What Else Besides ERP<br />
<br />
Repeating Compulsions: Go for a group walk<br />
around clinic, <strong>and</strong> continue walking when<br />
triggered to repeat an action<br />
Hoarding: Have everyone in group bring in 1<br />
item to be discarded<br />
<br />
Excessive cleaning rituals: Bring in tooth brush<br />
<strong>and</strong> brush for a very limited amount of time<br />
<br />
Discussions on various topics:<br />
*Dealing with family/friends/employers<br />
*Feelings of shame<br />
*Acceptance<br />
*Psychoeducation<br />
*Family meeting<br />
*Coping with anxiety during ERP<br />
Special Considerations<br />
What Advice Would You<br />
Give to Professionals<br />
<br />
No reassurance!<br />
<br />
“Be non-judgmental”<br />
<br />
H<strong>and</strong>ling disruptive group members<br />
<br />
“Be supportive”<br />
<br />
<br />
What if someone expresses thoughts of suicide<br />
How to deal with medication questions<br />
<br />
<br />
<br />
“Make the group members feel comfortable”<br />
“There’s value in being accountable to a group”<br />
The role of humor: be respectful<br />
SUNDAY<br />
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6/14/13<br />
Contact Information<br />
The OCD-BDD Clinic of Northern California<br />
501 Seaport Court, Suite 106<br />
Redwood City, CA 94063<br />
650-599-3325<br />
www.ocd-bddclinic.com<br />
sgranet@ocd-bddclinic.com<br />
The Palo Alto Medical <strong>Foundation</strong><br />
Department of Psychiatry <strong>and</strong> Behavioral Health<br />
795 El Camino Real<br />
Palo Alto, CA 94301<br />
650-853-2875<br />
granets@pamf.org<br />
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For Support Persons Only - Help for the Helpers<br />
6/14/13 <br />
For Support Persons<br />
Only-<br />
Help For the Helpers!<br />
Mary Kathleen Norris, LPC<br />
DFW Center for OCD & Anxiety<br />
2700 Tibbets Dr., Suite 500<br />
Bedford, Texas 76022 (DFW)<br />
Phone: 817-237-9889<br />
Fax: 817-545-8417<br />
www.dfwocd.com<br />
Goals of This Presentation<br />
1. Define the Conflict in Support<br />
2. Look at Personality Styles<br />
3. Develop Positive Reacting Styles<br />
4. Examine the Support Stages<br />
5. Work towards Collaboration <strong>and</strong><br />
Motivation by Love<br />
1<br />
2<br />
The Conflict of Support<br />
Acceptance vs. Change<br />
Acceptance__________vs____________Change<br />
3<br />
Acceptance<br />
Infers:<br />
Saying “yes” to<br />
Agreeing with<br />
Consenting to<br />
Approving of<br />
Something satisfactory<br />
*Acceptance means fully accepting the Sufferer as they<br />
are- including all OCD worries, behaviors, <strong>and</strong> dem<strong>and</strong>s<br />
for others to comply.<br />
4<br />
SUNDAY<br />
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6/14/13 <br />
Acceptance vs. Change<br />
Change<br />
Infers:<br />
To become different<br />
Transform<br />
Lay aside<br />
Alter<br />
Modify to satisfactory<br />
See the inherent Conflict<br />
*Change means the Sufferer discontinues all OCD<br />
worries, behaviors, <strong>and</strong> dem<strong>and</strong>s for others to comply.<br />
5<br />
6<br />
How Do We Resolve the<br />
Conflict<br />
Our Personalities Matter<br />
Personalities of Support Persons<br />
Extremely Competent <strong>and</strong> Capable<br />
Insight into ourselves will help us<br />
Find eventual balance between<br />
acceptance <strong>and</strong> change<br />
High competence of a Support Person tends to<br />
minimize the difficulties in life. May take away from the<br />
Sufferer’s feeling of competence.<br />
7<br />
8<br />
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Our Personalities Matter<br />
Personalities of Support Persons<br />
Overly Protective<br />
With an overfunctioning Support Person, the<br />
Sufferer may feel powerless to make even small<br />
decisions <strong>and</strong> lack a sense of autonomy. Sufferers may<br />
grow to expect the Support Person to defend the<br />
Sufferer from their OCD.<br />
Our Personalities Matter<br />
Personalities of Support Persons<br />
Dictatorial <strong>and</strong> Dem<strong>and</strong>ing<br />
The Sufferer may try to conform as a way to<br />
alleviate dem<strong>and</strong>s. He may go underground, hiding, <strong>and</strong><br />
fearful of the repercussions of being forthright <strong>and</strong><br />
honest.<br />
9<br />
10<br />
Our Personalities Matter<br />
Personalities of Support Persons<br />
The Critic<br />
Our Personalities Matter<br />
Personalities of Support Persons<br />
Passive, Disinterested<br />
Criticisms or putdowns, teasing, <strong>and</strong> sarcasm<br />
characterize this Support Person’s defense mechanisms.<br />
This may erode the Sufferer’s fragile self-esteem or<br />
sense of personal competence. May also result in<br />
feelings of rejection.<br />
The Support Person disengages in problems that<br />
appear challenging. A “to each his own” attitude. May<br />
result in the Sufferer feeling unwanted or ab<strong>and</strong>oned.<br />
May suffer in silence, feeling alone.<br />
SUNDAY<br />
11<br />
12<br />
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6/14/13 <br />
Positive Reacting Styles<br />
Positive Reacting Styles<br />
The Mirrorer- sees that the Sufferer is doing/or<br />
has done an OCD behavior. Comments like “I can<br />
see you are struggling, anything I can do to<br />
coach you”<br />
The Echo- listens <strong>and</strong> hears the Sufferer comment<br />
on a bad experience or difficult day. Reflective<br />
statements like “I hear you <strong>and</strong> I am listening.<br />
Sounds tough, I am here!”<br />
The Supporter- reminds the Sufferer that they<br />
will always be there <strong>and</strong> they are willing to help.<br />
Makes comments like “You know no matter what<br />
we face, I love <strong>and</strong> support you!”<br />
13<br />
14<br />
Positive Reacting Styles<br />
Stages the Support Person<br />
May Experience<br />
The Team Player- looks at this struggle as<br />
something to be faced by more than the Sufferer<br />
alone. Is willing to share the burden <strong>and</strong> helps to<br />
lighten the load. Is cohesive <strong>and</strong> pulls together.<br />
The Victory Emphasizer- thinks of the<br />
positive. Emphasizes strengths, not weaknesses.<br />
Recounts victories when the Sufferer needs to hear<br />
them. Sees the Sufferer as courageous <strong>and</strong> strong.<br />
1. Denial- I don’t want to hear about it, don’t want<br />
to underst<strong>and</strong> it, tries to overlook it, pretends it will<br />
resolve itself.<br />
2. Accept it as the Sufferer’s Problem- I<br />
see it as YOUR problem. YOU need to do<br />
something about it.<br />
15<br />
16<br />
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Stages the Support Person<br />
May Experience<br />
3. Anger- I may make some effort to help (as I<br />
underst<strong>and</strong> help). When that doesn’t work to<br />
eradicate the problem, I become frustrated <strong>and</strong><br />
angry.<br />
4. Marital Discord- I have many conflicts in my<br />
feelings resulting in hostility <strong>and</strong> arguments.<br />
5. Withdrawal- I will seek to pull away as a<br />
defense, both physically <strong>and</strong> emotionally.<br />
Our goal is to develop the<br />
6 th step<br />
6. Collaboration- It’s our problem, we can tackle<br />
this together. As a team, we can do far more than as<br />
individuals. Therapeutic goals move much faster <strong>and</strong><br />
with much better outcomes.<br />
17<br />
18<br />
Balance is the Key to Support<br />
Resolving the Conflict Means<br />
Finding the Balance<br />
Acceptance<br />
The answer<br />
is in the<br />
balance<br />
Benevolent<br />
Dem<strong>and</strong>s for<br />
Change<br />
19<br />
Acceptance<br />
Balance<br />
Resolves the conflict for the supporter<br />
Is what the Sufferer needs<br />
Benevolent<br />
Dem<strong>and</strong>s for<br />
Change<br />
20<br />
SUNDAY<br />
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6/14/13 <br />
What is P-N-P<br />
What is P-N-P<br />
A formula for success<br />
A way to think about balance<br />
Examples of P-N-P<br />
I care so much about how you are<br />
feeling.<br />
P<br />
Positive-Negative-Positive<br />
I hear you saying that you are really<br />
struggling with your OCD. N<br />
I know you are working on rituals <strong>and</strong><br />
making great strides.<br />
P<br />
21<br />
22<br />
What is P-N-P<br />
Motivation by Love vs. Fear<br />
Examples of P-N-P<br />
I am so glad to be home <strong>and</strong> see you! P<br />
I see you are having a hard time with your<br />
OCD symptoms.<br />
N<br />
Tonight we can have time for each other<br />
<strong>and</strong> go for a walk. P<br />
Motivation by Fear<br />
1. May provide tremendous motivation<br />
2. Usually short-term reactions to dem<strong>and</strong>s<br />
3. Has long-term psychological consequences<br />
4. Defensive in nature<br />
23<br />
24<br />
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6/14/13 <br />
Motivation by Love vs. Fear<br />
Motivation by Love<br />
1. May provide tremendous motivation<br />
2. Usually has long-term reactions to dem<strong>and</strong>s<br />
3. Consolidated as positive psychologically<br />
4. Seeking- not defending in nature<br />
Ways to Motivate by Love<br />
Words of Affirmation<br />
Acts of Kindness <strong>and</strong><br />
Thoughtfulness<br />
Quality Time as a Gift<br />
25<br />
26<br />
Summary<br />
Notations<br />
The Support Person can be the vital resource of<br />
strength in an OCD recovery program. As we<br />
learn more about the inherent conflicts of the<br />
Support Person, we learn more about ourselves.<br />
This helps us find the balance in ourselves. We<br />
can then provide the Sufferer additional<br />
strength, helping them find their balance <strong>and</strong><br />
securing a more self-fulfilling life.<br />
The concept of the “dialectical balance” is<br />
from Marcia Linehan’s work in DBT<br />
(Dialectical Behavior Therapy).<br />
SUNDAY<br />
27<br />
28<br />
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7
People <strong>and</strong> Places - Emotional Contamination in OCD<br />
6/14/13<br />
PEOPLE <strong>and</strong> PLACES: EMOTIONAL <br />
CONTAMINATION in OCD: A COMMON <br />
BUT MISUNDERSTOOD <br />
CONTAMINATION PHOBIA <br />
Katharine Donnelly, Ph.D. <br />
Sony Khemlani-‐Patel, Ph.D. <br />
Fugen Neziroglu, Ph.D., ABBP, ABPP <br />
_____________________ <br />
Bio Behavioral Instute <br />
Great Neck, New York <br />
www.biobehavioralinstute.com <br />
516-‐487-‐7116 <br />
WHAT IS EMOTIONAL CONTAMINATION <br />
• Subtype of contaminaon OCD in which: <br />
– person believes specific people <strong>and</strong> places are <br />
contaminated <br />
• Thought object fusion – Belief that thoughts, events, <br />
or feelings can be transferred onto objects <br />
• Feeling “morally polluted” by another person <br />
• Also called “magical” contaminaon <br />
• Characterized by magical <strong>and</strong> supersous beliefs <br />
WHAT IS EMOTIONAL CONTAMINATION <br />
• FEAR OF PEOPLE <br />
1. Fear of “catching” something from another person <br />
• Negave personality trait(s) <br />
• A disability or specific characterisc by contact <br />
– Blindness, mental retardaon, physical disability, <br />
becoming homosexual <br />
2. Aversion to a specific person – general sense of disgust <br />
3. Aversion to a specific person as a result of a significant <br />
traumac interacon <br />
• FEAR OF A GEOGRAPHIC LOCATION <br />
1. Due to a personal experience <br />
• Linked to a trauma or significant event <br />
2. General supersous reacon to a place <br />
• Contact will lead to bad luck, death <br />
COMMON COMPULSIONS AND AVOIDANCE <br />
• Compulsions similar to other OCD <br />
– Washing, checking <br />
– Ordering/arranging <br />
• Avoidance behaviors <br />
– Avoidance of contact with person or place <br />
– Avoidance of numbers, words, places associated with <br />
the person or place <br />
– A^empts to erase the internal thoughts <strong>and</strong>/or <br />
images of an event <br />
– Magical transmission of the contaminant <br />
• Photographs, conversaon <br />
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1
6/14/13<br />
COMMON CORE BELIEFS <br />
• If I have possess negave personality traits, <br />
then I am a bad person <br />
• I have to be perfect <br />
• Having some flaws makes me a flawed person <br />
• Personality can change drascally <br />
• Thinking about something can make it happen <br />
• My thoughts can alter outcomes <br />
EMOTIONAL CONTAMINATION VS. <br />
TRADITIONAL OCD CONTAMINATION <br />
• Characterized by more supersous thinking <br />
– Transmission of the “germs” through magical means <br />
• More shame, embarrassment, <strong>and</strong> fear of being <br />
misunderstood or mislabeled as “prejudice” <br />
• More complex emoonal reacons to the “contaminant” – <br />
anger, resentment, hoslity, disgust <br />
• Disastrous consequence -‐-‐-‐ threat to sense of self <br />
SUNDAY<br />
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2
6/14/13<br />
CASE EXAMPLE <br />
• 67 year old recently divorced female with co-‐morbid <br />
depressive disorder <br />
• Contaminant is deceased brother who had negave <br />
personality traits <br />
• Avoids numbers associated with his birthday, death <br />
day <br />
• History of emoonal abuse by mother <strong>and</strong> ex-husb<strong>and</strong><br />
<br />
• Religious Roman Catholic <br />
• Disabled son <br />
• Supersous <br />
HIERARCHY <br />
10 vising gravesite <br />
9 acng in manner similar to brother <br />
8 speaking about brother in apartment <br />
7 wearing “contaminated” clothes again – associated <br />
with unlucky days <br />
6 looking at photographs <br />
5 speaking about brother in neutral locaon <br />
4 engaging in acvies at specific mes (3 o’clock, 6 <br />
o’clock etc.) <br />
3 engaging in acvies 3 or 6 mes <br />
CASE EXAMPLE <br />
• 18 year old female co-‐morbid Borderline Personality <br />
Disorder <br />
• OCD onset age 17 <br />
• Symptoms manifested exclusively at home <br />
• Father was source of contaminaon; disgust reacon <br />
anything she associated with father (bathroom, <br />
computer etc.) <br />
• Developed ager hospitalizaon prior to which her <br />
father had to physically restrain her <br />
HIERARCHY <br />
• 10 – coming into contact with father or st<strong>and</strong>ing near him <br />
• 9 – using objects frequently used by him <br />
• 9 – using the bathroom that her father uses <br />
• 8 – using items or appliances in the house that her father has <br />
recently come into contact with <br />
• 7 – using items in the house that are frequently used by other <br />
family members who may have come into contact with her <br />
father <br />
• 6 – using items in the home that are infrequently used by <br />
other family members <br />
• 4 – being in the person’s room, which is generally considered <br />
uncontaminated when the individual feels uncontaminated. <br />
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3
6/14/13<br />
CASE EXAMPLE <br />
• 39 year male with co-‐morbid borderline personality <br />
disorder, PTSD, <strong>and</strong> simple phobia <br />
• History of mulple sexual assaults by peers, clergy, <br />
<strong>and</strong> stranger <br />
• Contaminaon to places associated with the trauma <br />
which generalized to the enre town <br />
• Disgust reacon to conversaons about the town or <br />
the trauma <br />
• Rituals involve washing, avoidance of specific <br />
locaons, repeve discussions (“need to <br />
underst<strong>and</strong>”) about the trauma <br />
OCD AND TRAUMA: IS THERE A RELATIONSHIP <br />
• Co-‐morbidity rates between OCD <strong>and</strong> PTSD are unclear (6.2% <br />
in one study; 39% of treatment resistant OCD paents) <br />
• PTSD has a negave impact on treatment outcome for OCD <br />
• Complex relaonship between the two disorders <br />
• Traumac events are ogen trigger for OCD <br />
• Is OCD contaminaon a coping response to a traumac event <br />
– Rituals <strong>and</strong> avoidance provide Illusion of control over <br />
situaon <br />
– Washing to remove the sense of internal dirness/<br />
polluon or the negave emoons or thoughts brought on <br />
my trauma memories <br />
MENTAL CONTAMINATION <br />
MENTAL CONTAMINATION <br />
• Rachman differenates between: <br />
– Physical contaminaGon – disease, dirt, etc. <strong>and</strong> involves <br />
direct physical contact with contaminant resulng in <br />
“feeling dirty” <br />
– Mental contaminaGon (“mental polluGon”) <br />
– “Sense of internal un-‐cleanness which can <strong>and</strong> usually <br />
does arise <strong>and</strong> persist regardless of the presence or <br />
absence of external, observable dirt’’; <br />
– feeling unclean can be triggered by images, thoughts, or <br />
memories (immoral religious, sexual obsessions) <br />
– ogen triggered by life events that are wrong, <br />
inappropriate, immoral <br />
– Linked with feelings of disgust <strong>and</strong> morality <br />
• Emoonal contaminaon may take on <br />
qualies of mental contaminaon especially <br />
when the obsession is linked to abuse <br />
• Thoughts, images, <strong>and</strong> memories rather than <br />
direct contact with the contaminant may <br />
trigger urges to ritualize (wash away the <br />
internal sense of unclean) <br />
SUNDAY<br />
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4
6/14/13<br />
THE ROLE OF BETRAYAL <br />
• “Betrayal is a sense of being harmed by the intenonal <br />
acons, or omissions, of a person who was assumed to be a <br />
trusted <strong>and</strong> loyal friend, relave, partner, colleague, or <br />
companion” -‐ Rachman <br />
• TYPES OF BETRAYAL <br />
– Harmful disclosures of confidenal informaon <br />
– Disloyalty <br />
– Infidelity <br />
– Dishonesty <br />
– Failures to help during significant mes of need <br />
EMOTIONAL CONTAMINATION AND <br />
INTERPERSONAL DYSFUNCTION <br />
• Is there a connecon <br />
• Possible co-‐morbidity with Axis II perhaps <br />
mediated by history of trauma <br />
• Betrayal is form of trauma <br />
• Betrayal leads to feelings of humiliaon, degradaon, <strong>and</strong> <br />
worthlessness which lead to feeling dirty <strong>and</strong> “polluted” <br />
• The “betrayer” can become focus of contaminaon <br />
MAGICAL THINKING IN OCD <br />
• Beliefs about relaonships between events that do not follow <br />
laws of nature or causality <br />
• Coincidental co-‐occurrence of a thought <strong>and</strong> negave event <br />
• Cultural influences <br />
• Religious moral influences from authority figures (parents, <br />
clergy, etc.) <br />
• Magical thinking increases during mes of stress <br />
• Need to control things that ma^er to us as human beings <br />
– Found in cultures all over the world in which ritualisc <br />
behaviors are performed to alter natural events <br />
THOUGHT ACTION FUSION <br />
• Moral TAF – unacceptable thoughts are <br />
morally equivalent to immoral acons <br />
• Likelihood TAF – certain thoughts cause <br />
parcular events or increase likelihood of <br />
events occurring <br />
• Part of the construct of magical or <br />
supersous thinking <br />
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5
6/14/13<br />
THOUGHT OBJECT FUSION <br />
MAGICAL THINKING AND OCD <br />
– Thoughts, events, or feelings can be transferred <br />
onto objects <br />
• Death, bad luck, a person’s personality traits are <br />
transferred onto objects <br />
• Believing that personality characteriscs act like germs <br />
which linger on objects or places <br />
• Objects retain the negave qualies of significant <br />
events <br />
• The more severe the OCD, the more likelihood <br />
to have magical thinking <br />
• The more magical thinking person <br />
experiences, the less tolerant of obsessive <br />
thoughts (more distress associated with <br />
obsessive thoughts) <br />
TREATMENT CONSIDERATIONS <br />
STANDARD CBT TREATMENT TECHNIQUES <br />
• Proper assessment <br />
– Assess level of OVI <br />
– Thorough psychosocial to idenfy possible trauma <br />
<strong>and</strong> betrayal <br />
• Assess for expression of other emoons associated <br />
with obsessive belief (anger, sadness, disgust) <br />
• Role of emoon dysregulaon <strong>and</strong> balancing <br />
validaon with exposure response prevenon in <br />
cases with dysregulaon <br />
• Behavioral experiments to challenge beliefs <br />
• Place oneself on a connuum in relaon to other <br />
people who act on their thoughts <br />
– Best ever person -‐-‐-‐-‐-‐-‐-‐worst ever person <br />
• Cognive therapy to address core beliefs <br />
• In vivo or imaginal exposure to person, place, or <br />
object that has taken on aversive emoonal quality <br />
• Response prevenon <br />
SUNDAY<br />
-218-<br />
6
6/14/13<br />
THE ROLE OF ACCEPTANCE AND <br />
COMMITMENT THERAPY <br />
• Increase willingness to experience negave <br />
thoughts <br />
• Develop a dialogue with unpleasant thoughts <br />
that undermines the control that they have <br />
over behavior. <br />
• Rather, allowing life’s valued areas to <br />
determine behavioral direcon <br />
THE THIRD WAVE <br />
• Goals of these treatments focus on <br />
– living a meaningful existence <br />
– living according to one’s values <br />
– focusing on the present moment <br />
– tolerance of emoons. <br />
CORE PROCESSES OF ACT <br />
• ACT teaches the individual that thoughts <strong>and</strong> emoons <br />
are not necessarily causes of behavioral outcomes <br />
• Unpleasant internal experiences are not harmful as <br />
they are <br />
• Alternaves in lenng go of the struggle with <br />
unpleasant internal experiences. <br />
• Learn more flexible ways of responding to these <br />
events. <br />
COGNITIVE DEFUSION <br />
• In ACT, the therapist a^empts to help the individual <br />
change they way they view, react to, <strong>and</strong> interact with <br />
thoughts <strong>and</strong> feelings. <br />
• Most of the me, an individual with OCD has <br />
repeatedly responded to intrusive thoughts in <br />
maladapve ways, ACT teaches that one can respond <br />
differently without changing the form or content of the <br />
intrusive thought. <br />
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7
6/14/13<br />
MINDFULNESS <br />
• Hayes et al (2006) describe this as, “on-‐going <br />
non-‐judgmental contact with psychological <strong>and</strong> <br />
environmental events as they occur.” <br />
• Mindfulness exercises are used to introduce this <br />
skill <strong>and</strong> aide the person in praccing <br />
acceptance of thoughts <strong>and</strong> feelings. <br />
• Values <br />
VALUES CLARIFICATION <br />
– “chosen qualies of purposeful acon that can <br />
never be obtained as an object but can be <br />
instanated moment by moment” (Hayes et al, <br />
2006) <br />
– values will serve as guides by which to live by <strong>and</strong> <br />
will lead the individual to core process number six; <br />
commi4ed ac5on. <br />
COMMITTED ACTION <br />
ACT AND OCD <br />
• ACT asks the individual to create more flexible <br />
<strong>and</strong> more abundant pa^erns of behavior in the <br />
service of chosen values. <br />
• The goal is to live according to one’s values <br />
rather than live in the service of reducing <br />
anxiety leading to a more meaningful existence. <br />
• Many symptoms <strong>and</strong> defining features of OCD <br />
appear to lend themselves to the use of ACT, <br />
specifically those aspects associated with <br />
emoonal contaminaon. <br />
• Thought-‐acon fusion <br />
• Low distress tolerance <br />
• Perfeconism <br />
SUNDAY<br />
-220-<br />
8
Challenging Kids Challenged Adults - When OCD Has Dual Diagnoses<br />
Challenging Kids,<br />
Challenged Adults:<br />
When OCD has Dual-Diagnoses<br />
OCF Convention<br />
July 21, 2013<br />
Sheryl K. Pruitt, M.Ed., ET/P<br />
-221-
Sheryl K. Pruitt, M.Ed., ET/P<br />
c<br />
Introduction<br />
Sheryl K. Pruitt, M.Ed., ET/P, is the Clinical Director of Parkaire Consultants, a clinic<br />
she founded in 1987 to serve neurologically impaired individuals. Prior to the founding<br />
of Parkaire Consultants, Ms. Pruitt conducted a State of Georgia exemplary Model<br />
Learning Disability Program <strong>and</strong> taught behavior-disordered students in a<br />
psychoeducational setting. Ms. Pruitt served on the Board of Directors of the Tourette<br />
Syndrome Association of Georgia for six years <strong>and</strong> as a member of the Scientific<br />
Advisory Board of the Tourette Syndrome Association of Georgia <strong>and</strong> South Carolina.<br />
Ms. Pruitt was a member of the Scientific Advisory Board for the Tourette Spectrum<br />
Disorder Association of California. She also served on the National Tourette Syndrome<br />
Association’s Education Committee. She was a member of the Professional Advisory<br />
Board for North Atlanta <strong>and</strong> Central Georgia CHADD <strong>and</strong> served on the Board of<br />
Directors for the Association of Educational Therapists. She is also a member of the<br />
Professional Advisory Board of the Tourette Syndrome <strong>Foundation</strong> of Canada. Ms.<br />
Pruitt is a member of the Senior Advisory Board of the Brad Cohen Tourette<br />
<strong>Foundation</strong>. She teaches a State of Georgia Professional Learning Unit Course on<br />
students with neurological impairments <strong>and</strong> the impact of their disorders on education,<br />
behavior, family, <strong>and</strong> socialization.<br />
Ms. Pruitt is a co-author of the books Teaching the Tiger, Hope Press (1995) Tigers,<br />
Too with corresponding supplements titled Tigers, Too: Checklists for Classroom<br />
Objectives <strong>and</strong> Interventions <strong>and</strong> Tigers, Too: Assessment, Parkaire Press (2009-2011)<br />
<strong>and</strong> Challenging Kids, Challenged Teachers, Woodbine Press (2010) <strong>and</strong> is a<br />
contributing author to the Tourette <strong>Foundation</strong> of Canada’s Education Guide on<br />
Tourette Syndrome. She has currently co-authored a chapter on educating people with<br />
Tourette Syndrome for a medical book on Tourette Syndrome, Oxford Press (2013).<br />
Sheryl K. Pruitt has presented both nationally <strong>and</strong> internationally. Her presentations<br />
incorporate not only professional experiences, but her personal experiences living with<br />
children, a spouse <strong>and</strong> herself with these conditions.<br />
Contact Information:<br />
Sheryl K. Pruitt, M.Ed.,ET/P<br />
Parkaire Consultants, Inc.<br />
4939 Lower Roswell Road, Suite C-201<br />
Marietta, GA 30068<br />
Tel: 770-578-1519<br />
Fax: 770-578-0860<br />
www.parkaireconsultants.com<br />
www.parkairepress.com<br />
-222-<br />
SUNDAY
Regulatory Disorders<br />
Challenging Kids,<br />
Challenged Adults:<br />
When OCD has Dual-Diagnoses<br />
OCF Convention<br />
July 21, 2013<br />
Sheryl K. Pruitt, M.Ed., ET/P<br />
Tourette Syndrome<br />
<strong>Obsessive</strong> <strong>Compulsive</strong><br />
Disorder<br />
Other Anxiety Disorders<br />
Mood Disorders<br />
Autistic Spectrum<br />
Attention Deficit<br />
Hyperactivity<br />
Disorder<br />
Sensory<br />
Defensiveness<br />
Sleep Disorders<br />
Stuttering<br />
© Sheryl K. Pruitt, M.Ed., ET/P 2013<br />
© Sheryl K. Pruitt, M.Ed., 1999<br />
The Basal Ganglia<br />
Non-Regulatory Disorders<br />
Learning<br />
Disabilities<br />
Speech<br />
Disorders<br />
Processing<br />
Speed<br />
Executive<br />
Dysfunction<br />
Language<br />
Disability<br />
Visual-Motor<br />
Disability<br />
Memory<br />
Disorders<br />
© Sheryl K. Pruitt, M.Ed., 1999<br />
-223-
<strong>Obsessive</strong>-<strong>Compulsive</strong> Disorder (OCD)<br />
• Intrusive, repetitive<br />
unwanted thoughts<br />
(obsessions), <strong>and</strong>/or<br />
• Repetitive or ritualized<br />
behaviors (compulsions)<br />
• Some compulsions may<br />
not be observable (such as<br />
counting)<br />
H<strong>and</strong>writing Issues in OCD<br />
• Retracing letters, numbers, <strong>and</strong><br />
punctuation marks<br />
• Frequent erasures <strong>and</strong> re-working<br />
to make it “perfect”<br />
• Filling in Scantron circles perfectly<br />
interferes with completing task<br />
© 2011 Challenging Kids, Inc.<br />
© Teaching the Tiger, 1995 .<br />
Tips <strong>and</strong> Strategies for OCD<br />
“I can’t go to school<br />
because I can’t keep<br />
people from touching my<br />
stuff!”<br />
• Reduce h<strong>and</strong>writing.<br />
• Do not give more than<br />
student can finish in<br />
allotted time.<br />
• Remove triggers for<br />
compulsive behavior if<br />
possible, e.g., use of a<br />
word processor<br />
instead of h<strong>and</strong>writing.<br />
© 2011 Challenging Kids, Inc.<br />
Non-OCD Anxiety Disorders<br />
Anxiety may cause a “fight or flight” response <strong>and</strong> lead to<br />
school avoidance or refusal.<br />
Image courtesy of Silicon Valley Brain Spect Imaging, Inc.<br />
• Separation Anxiety<br />
• Generalized Anxiety<br />
• Specific Phobias<br />
• Panic<br />
• Post-Traumatic Stress<br />
• Social Anxiety<br />
• Selective Mutism<br />
© 2011 Challenging Kids, Inc.<br />
-224-<br />
SUNDAY
Tips for Non-OCD Anxiety Disorders<br />
Tourette Syndrome<br />
“I can’t be away<br />
from my mom”<br />
because I am too<br />
scared!<br />
• Do not give more work than<br />
student can finish in allotted<br />
time.<br />
• Assist with social/peer<br />
issues.<br />
• Allow the student to leave<br />
the anxiety-provoking<br />
situation for a designated<br />
“safe place.”<br />
• Tics are brief,<br />
purposeless, repetitive<br />
involuntary movements<br />
or sounds that usually<br />
occur in bouts.<br />
• Tics may be simple or<br />
complex <strong>and</strong> are often<br />
confused with allergies,<br />
habits, or misbehavior.<br />
© 2011 Challenging Kids, Inc.<br />
Tips for Tourette Syndrome<br />
Who turned out the Lights!<br />
“Why does the<br />
teacher think I<br />
would do this on<br />
purpose <strong>and</strong><br />
embarrass myself<br />
in front of my<br />
friends”<br />
• Let student leave the room to<br />
discharge tics in private<br />
place.<br />
• Reduce production dem<strong>and</strong>s<br />
when tics interfere with<br />
performance during times of<br />
tic worsening.<br />
• Allow student to engage in<br />
highly motivating tasks.<br />
© 2011 Challenging Kids, Inc.<br />
This is what your brain looks like “ON” ADHD.<br />
© 1999 Leslie E. Packer, Ph.D.<br />
-225-
Tips for ADHD<br />
Mood Disorders<br />
“What did I do<br />
wrong this<br />
time!”<br />
• Externalize motivation.<br />
• Alternate quiet activities<br />
with opportunities to<br />
move around.<br />
• Externalize instructions.<br />
• Pause or use fillers to<br />
allow sufficient time to<br />
process.<br />
© 2011 Challenging Kids, Inc.<br />
“When I am depressed,<br />
I feel so blue!”<br />
• Dysthymia<br />
• Depression<br />
• Bipolar Disorder<br />
• Cyclothymia<br />
© 2011 Challenging Kids, Inc.<br />
Tips for Mood Disorders<br />
• Accommodate impaired<br />
focus, memory, <strong>and</strong><br />
concentration.<br />
• Allow for “graceful exits”<br />
<strong>and</strong> permanent passes, as<br />
needed.<br />
• Assist with social/peer<br />
issues.<br />
Pediatric<br />
Acute-onset<br />
Neuropsychiatric<br />
Syndrome<br />
PANS, PITANDS,<br />
<strong>and</strong> PANDAS,<br />
Oh my!<br />
Pediatric<br />
Infection<br />
Triggered<br />
Autoimmune<br />
Neuropsychiatric<br />
Disorder<br />
Pediatric<br />
Autoimmune<br />
Neuropsychiatric<br />
Disorder<br />
Associated with<br />
Strep<br />
SUNDAY<br />
"Graceful Exit"<br />
© 2011 Challenging Kids, Inc.<br />
© modified from L.E. Packer<br />
<strong>and</strong> S.K. Pruitt, 1999 Raymond A. Cattaneo, 2011<br />
-226-
Sleep Problems<br />
Tips for Sleep Problems<br />
• Impaired attention <strong>and</strong><br />
memory<br />
• Increased hyperactivity<br />
<strong>and</strong> impulsivity<br />
• Bullying <strong>and</strong> aggressive<br />
behaviors<br />
• More accidents<br />
• Depressed mood<br />
• Screen for sleep problems.<br />
• Allow student to start day<br />
later <strong>and</strong>/or end it earlier.<br />
• Provide parents with sleep<br />
hygiene h<strong>and</strong>out.<br />
• Open the blinds in the<br />
classroom to allow in as<br />
much natural light as<br />
possible.<br />
“Just five more<br />
minutes!”<br />
© 2011 Challenging Kids, Inc.<br />
“Just five more<br />
minutes!”<br />
© 2011 Challenging Kids, Inc.<br />
Sensory Defensiveness<br />
Tips for Sensory Defensiveness<br />
“Make the firm<br />
alarm bell stop!”<br />
Photo Credit C. Wang<br />
• Smelling<br />
• Seeing<br />
• Tasting<br />
• Hearing<br />
• Touching<br />
• Pain<br />
• Proprioceptive<br />
• Vestibular<br />
© 2011 Challenging Kids, Inc.<br />
“Make the firm<br />
alarm bell stop!”<br />
• Screen for occupational<br />
therapy.<br />
• Do not touch the child lightly,<br />
wear heavy perfumes, or seat<br />
student near noise or<br />
distraction.<br />
• Avoid sensory overload<br />
settings; allow child to leave.<br />
© 2011 Challenging Kids, Inc.<br />
-227-
Hey, you forgot<br />
Oppositional Defiant<br />
Disorder!!<br />
Did Not!!!!<br />
Executive Function<br />
Overarches All Areas:<br />
Academic, Social <strong>and</strong><br />
Emotional<br />
© L.E. Packer, S.K. Pruitt, C.I. Wang, 1999<br />
© Leslie E. Packer, Ph.D., 2000<br />
The “Dreaded Book<br />
Bag Diagnostic<br />
Test”<br />
CL UE<br />
SUNDAY<br />
© Sheryl K. Pruitt, M. Ed., 1995<br />
© Sheryl K. Pruitt, M. Ed., 1995<br />
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EXECUTIVE FUNCTION<br />
“He is such a good boy. I just don’t know enough things<br />
to tell him not to do.”<br />
- Ferrell Sams<br />
• Set Goals<br />
• Initiate<br />
• Prioritize<br />
• Pace<br />
• Plan<br />
• Sequence<br />
• Organize<br />
© D.G. Pruitt, S. K. Pruitt, L.W. Walter,<br />
M.P. Dornbush, L.E. Packer, 2008<br />
EXECUTIVE FUNCTION<br />
• Shift<br />
• Use Feedback<br />
• Inhibit<br />
• Self-Monitor<br />
• Problem Solve<br />
• Execute<br />
• Generalize<br />
Executive functions have been<br />
the “hidden curriculum.* ”<br />
It’s time to explicitly<br />
teach them.<br />
© D.G. Pruitt, S. K. Pruitt, L.W. Walter,<br />
M.P. Dornbush, L.E. Packer, 2008<br />
* Richard Lavoie<br />
© Leslie E. Packer, Ph.D., 2002<br />
-229-
Now!<br />
Or<br />
Not Now!<br />
Teach them to do<br />
it now - not later!<br />
© Sheryl K. Pruitt, M.Ed., ET/P, 2001<br />
© Sheryl K. Pruitt, M.Ed., 2000<br />
Two-Step Process<br />
Plan Your Work <strong>and</strong><br />
Work Your Plan<br />
P.L.A.N.<br />
+<br />
Problem defined!<br />
Lay out options!<br />
Act on one!<br />
Now evaluate!<br />
You announced a change in<br />
plans. She’s h<strong>and</strong>ling it quite<br />
well, isn’t she<br />
Prewarn!<br />
Prewarn!<br />
Prewarn!<br />
SUNDAY<br />
© Sheryl K. Pruitt, M.Ed., ET/P, 1999<br />
© Leslie E. Packer, Ph.D., 2002<br />
-230-
Write It or Regret It!<br />
CL UE<br />
Tips for<br />
Executive Dysfunction<br />
• Lend them your frontal lobes.<br />
• Screen for organizational problems.<br />
• Use consistent structure.<br />
• Teach strategies <strong>and</strong> routines.<br />
© Sheryl K. Pruitt, M.Ed., ET/P, 1999<br />
© 2011 Challenging Kids, Inc.<br />
CL UE<br />
Tips for<br />
Executive Dysfunction<br />
• Use color code system.<br />
• Use cognitive cues.<br />
• Highlight important information.<br />
• Teach social skills curriculum.<br />
Memory Functioning<br />
Spared Memory<br />
Short-Term Memory<br />
Immediate Memory<br />
Long-Term Memory<br />
Declarative Memory<br />
Semantic Memory<br />
Episodic Memory<br />
© 2011 Challenging Kids, Inc.<br />
© Sheryl K. Pruitt, M.Ed., ET/P, L.<br />
Warren Walter, Ph.D., 1997<br />
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Memory Functioning<br />
Impaired Memory<br />
Short-Term Memory<br />
Working Memory<br />
Long-Term Memory<br />
Procedural Memory<br />
Prospective Memory<br />
Metamemory<br />
Strategic Memory<br />
© Sheryl K. Pruitt, M.Ed., ET/P, L.<br />
Warren Walter, Ph.D., 1997<br />
©Tigers, Too, 2009<br />
Memory Functioning<br />
Word Retrieval<br />
Is A<br />
Memory Look Alike<br />
© Marilyn P. Dornbush,<br />
Sheryl K. Pruitt, M. Ed.,<br />
Tigers, Too, 2009<br />
Externalize Your Memory!<br />
Tips for Memory Problems<br />
Too much at<br />
one time<br />
• Reduce amount <strong>and</strong> complexity<br />
of material presented.<br />
• Hook new concepts to previous<br />
learning.<br />
• Teach, “Do it now, not later.”<br />
• Teach, “Record it or regret it.”<br />
• Check for comprehension.<br />
SUNDAY<br />
© 2011 Challenging Kids, Inc.<br />
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Slow Processing Speed<br />
(Sluggish Cognitive Tempo)<br />
Inattentive type of<br />
ADHD has slow<br />
processing speed<br />
component.<br />
Slow processing speed is<br />
reported by researchers<br />
to exist in one-fourth to<br />
one-half of students with<br />
ADHD-Inattentive Type.<br />
© Sheryl K. Pruitt, M.Ed., ET/P 2000<br />
Carlson, Mann,2002, Goodyear, Hynd1992<br />
©Tigers, Too, 2009 Nigg,Blaskey,Huang-Pollock,Rappley, 2002,<br />
Weiler, Bernstein, Bellinger,Waber, 2000, Barkley, 2006<br />
Processing Speed Influences:<br />
• Sustained Attention<br />
• Executive Functions<br />
• Memory<br />
• Academic Achievement<br />
• Behavior<br />
• Social Competence<br />
Sluggish Cognitive Tempo<br />
Tips for Slow Processing Speed<br />
• Reduce length of assignments.<br />
• Repeat, rephrase, summarize.<br />
• Cue questions ahead of time.<br />
• Allow extra time for everything!<br />
• The Fast ForWord® Program<br />
©Tigers, Too, 2009<br />
©Dornbush, M.P. <strong>and</strong> Pruitt, S. K., 2009<br />
©Tigers, Too, 2009<br />
©Dornbush, M.P. <strong>and</strong> Pruitt, S. K., 2009<br />
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Treatment for Sluggish Cognitive<br />
Tempo or Slow Processing Speed<br />
Disorder<br />
How Can This NOT Affect Academic<br />
Production<br />
“Stuck”<br />
Unable to prioritize<br />
The Fast ForWord® Program<br />
Unable to stick with it<br />
Disorganized<br />
WHAT plan<br />
Irritable<br />
© 2000 S.K. Pruitt & L. E. Packer<br />
Common Impact:<br />
• Written Expression<br />
• Long Term Projects<br />
• Math Calculations<br />
• H<strong>and</strong>writing<br />
• Homework<br />
Tips for Written Expression &<br />
Long-Term Projects<br />
“He’s just not<br />
motivated.”<br />
• Break tasks into chunks with<br />
intermediate deadlines.<br />
• Use consistent graphic<br />
organizer.<br />
• Treat editing as separate<br />
activity.<br />
• Use electronics to offset deficits<br />
<strong>and</strong> increase motivation.<br />
• Use visual editing strips <strong>and</strong><br />
mnemonics.<br />
SUNDAY<br />
© 2011 Challenging Kids, Inc.<br />
© 2011 Challenging Kids, Inc.<br />
-234-
Tips for H<strong>and</strong>writing<br />
• Reduce copying from the<br />
board <strong>and</strong> amount to be<br />
written at any one time.<br />
• Do not even THINK about<br />
grading for neatness.<br />
• Encourage use of<br />
electronics.<br />
• Turn lined paper sideways for<br />
math calculations if written.<br />
• Extend time for h<strong>and</strong>writing<br />
<strong>and</strong> tests.<br />
© L.E. Packer, 1999<br />
Tips for Math Calculations<br />
• Teach cognitive cues to<br />
preserve sequence.<br />
• Turn lined paper<br />
sideways or use graph<br />
paper.<br />
• Color highlight<br />
operational symbols <strong>and</strong><br />
directions.<br />
• Use editing strips.<br />
© 2011 Challenging Kids, Inc.<br />
Other Strategies to Incorporate<br />
• Extend time.<br />
• Capitalize on<br />
interest,<br />
underst<strong>and</strong>ing, <strong>and</strong><br />
talent to improve<br />
learning.<br />
• Provide testing<br />
accommodations.<br />
• Educate staff <strong>and</strong><br />
peers.<br />
• Accommodate<br />
medication side<br />
effects.<br />
• Use electronics to<br />
offset deficits <strong>and</strong><br />
enhance motivation.<br />
• Create a “Trick<br />
Book.”<br />
Recognize <strong>and</strong> Validate the Student’s Struggle<br />
© 2011 Challenging Kids, Inc.<br />
THE TRAUMATIC TRIAD<br />
• Homework<br />
• Sleep<br />
• Storms<br />
© Sheryl K. Pruitt, M.Ed., 1988<br />
-235-
Medication<br />
Issues<br />
Learning<br />
Disabilities<br />
Too Much<br />
Work<br />
Specific<br />
Symptom<br />
Interference<br />
Executive<br />
Dysfunction<br />
Homework<br />
Problems<br />
H<strong>and</strong>writing<br />
Issues<br />
Sleep<br />
Issues<br />
Visualmotor<br />
Integration<br />
Issues<br />
Poor<br />
School<br />
Support of<br />
Parents<br />
Inadequate<br />
Parent<br />
Support of<br />
Child<br />
From Challenging Kids, Challenged Teachers (2010)<br />
“Just shoot me<br />
<strong>and</strong> put me out<br />
of my misery!”<br />
Tips for Homework<br />
• Screen for homework<br />
problems.<br />
• Post assignments on<br />
Internet.<br />
• Let student use email to<br />
send copies of assignments<br />
home or back to teacher.<br />
• Provide parents with<br />
sufficient support to<br />
underst<strong>and</strong> homework.<br />
© 2011 Challenging Kids, Inc.<br />
What Is The Communication<br />
Child’s<br />
Characteristics<br />
Classroom<br />
Environment<br />
Curricular<br />
Dem<strong>and</strong>s<br />
Home<br />
Environment<br />
School<br />
Behavior<br />
Problems<br />
Teacher<br />
Characteristics<br />
Other Factors<br />
Peer<br />
Characteristics<br />
SUNDAY<br />
© Sheryl K. Pruitt, M.Ed., 1999<br />
Adapted by L. E. Packer from Rathvon (1999)<br />
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Curiosity<br />
vs<br />
Judgment!<br />
© Sheryl K. Pruitt, M.Ed., 1999<br />
Pathways to “Storms” or<br />
“Fight-or-Flight” Behavior<br />
• Depression/ Bipolar Disorder<br />
• Attention Deficit Hyperactivity Disorder<br />
• <strong>Obsessive</strong>-<strong>Compulsive</strong> Disorder<br />
• Executive Dysfunction<br />
• Sleep Disorders or Fatigue<br />
• Learning Disabilities<br />
• Nonverbal Learning Disability<br />
• Social Impairments<br />
• Anxiety Disorders<br />
• Autistic Spectrum Disorders<br />
• Sensory Defensiveness<br />
• Complex Partial Seizures<br />
• Traumatic Brain Injury<br />
• Language Processing Deficits<br />
• Medication Side Effects<br />
© 2008 Challenging Kids, Inc<br />
Storm Prevention<br />
Allow the child a “graceful exit.”<br />
Let child go to someone they trust.<br />
Develop a good relationship with child.<br />
Create an appropriate behavior<br />
management plan that takes into account<br />
medical information.<br />
Naughty or<br />
Neurology<br />
© Sheryl K. Pruitt, M.Ed., 1995<br />
© 1996, Sheryl K. Pruitt, M.Ed.<br />
-237-
Family Meeting<br />
Reparations<br />
© Sheryl K. Pruitt, M.Ed., 1996<br />
© Sheryl K. Pruitt, M.Ed.,1999<br />
Everything in Life is Social!<br />
Instant<br />
Replay<br />
SUNDAY<br />
© Sheryl K. Pruitt, M.Ed., 1997<br />
-238-
Prepare the<br />
child for the<br />
path….<br />
Not the path<br />
for the child!<br />
Tigers, Too<br />
Tigers, Too: Supplements<br />
- Checklists <strong>and</strong> Objectives for the Classroom<br />
<strong>and</strong><br />
- Assessment<br />
Available at www.parkairepress.com<br />
Challenging Kids, Challenged Teachers<br />
Available at www.woodbinehouse.com<br />
© Sheryl K. Pruitt, M.Ed., 2000<br />
Credits….<br />
Thanks go to Leslie Packer, Ph. D. for her constant support<br />
<strong>and</strong> contributions for several of the power point slides<br />
used here today.<br />
Thanks also to Marilyn Dornbush, Ph.D. <strong>and</strong> Warren Walter,<br />
Ph.D. for their contributions <strong>and</strong> support to several power<br />
point slides today.<br />
Thanks especially to my husb<strong>and</strong>, Daniel G. Pruitt, PCC,<br />
SCAC, who has been my supporter, partner in our clinic,<br />
my publisher, <strong>and</strong> a contributor to this presentation.<br />
Dedication<br />
This program is cheerfully dedicated to the<br />
author’s family, who have cleverly managed<br />
to have almost every problem described. Any<br />
problem my husb<strong>and</strong> <strong>and</strong> I did not have I gave<br />
birth to. They are my first, <strong>and</strong> best, teachers.<br />
© Sheryl K. Pruitt, M.Ed., 2000<br />
© Sheryl K. Pruitt, M.Ed., 2000<br />
-239-
Sheryl K. Pruitt, M.Ed., ET/P<br />
www.parkaireconsultants.com<br />
SUNDAY<br />
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How Can the Whole Family Fight OCD With Their Kindergartener<br />
Developmentally Appropriate Rigidity Found in Children<br />
Age<br />
Normal Behavioral Rigidity <strong>and</strong> Rituals<br />
1-2 Strong preference for rigid routines around home routines (e.g., bedtime goodnight). Very aware <strong>and</strong><br />
can get upset about imperfections in toys/clothes.<br />
3-5 Repeat same play activity over <strong>and</strong> over again.<br />
5-6 Keenly aware of the rules of games <strong>and</strong> other activities (e.g., rules in classroom settings) <strong>and</strong> may get<br />
upset if rules are altered/broken.<br />
6-11 Engage in superstitious behavior to prevent bad things from happening, <strong>and</strong> they may show increased<br />
interest in acquiring a collection of objects (e.g., Pokémon cards).<br />
12+ Become easily absorbed in particular activities they enjoy (e.g., video games) or with particular people<br />
(e.g., pop stars); they may also show superstitious behavior in relation to making good things happen<br />
(e.g., performance in sports).<br />
(adapted from Freeman & Garcia, 2009 <strong>and</strong> Evans et al., 1997).<br />
Differential Attention Overview<br />
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Differential Attention<br />
1. Giving positive attention to increase behaviors you want to see<br />
2. Removing attention to decrease the behaviors you don’t want to<br />
see.<br />
Instructions: Please keep a daily record of your involvement in<br />
your child’s OCD symptoms. In the space provided below (feel<br />
free to use additional space if necessary) please record the date,<br />
the specific symptom, <strong>and</strong> how the parent(s) are involved in the<br />
symptom.<br />
There are different kinds of positive attention:<br />
1. Praise <strong>and</strong> encouragement like saying “great job” or giving your<br />
child a hug.<br />
2. Tangible rewards like giving your child a piece of c<strong>and</strong>y or a small<br />
toy.<br />
3. Privileges like allowing your child extra computer time or a later<br />
bedtime.<br />
Tangible Rewards: Key Components of Successful Reward Plan<br />
1. The plan should be simple <strong>and</strong> easy to follow - ideally targeting<br />
specific, easy to observe behaviors.<br />
2. Rewards should be delivered promptly following desired behaviors.<br />
3. Rewards should be frequent enough that child will be encouraged<br />
to work toward them.<br />
4. Rewards should be something child enjoys <strong>and</strong> that parents are<br />
going to feel OK about if children do not get it (e.g., stickers,<br />
playing a game, spending time with someone special, food, small<br />
toy).<br />
5. Rewards have to be delivered consistently.<br />
Differential Attention – Removing Attention/Ignoring<br />
Date OCD Symptom Time Spent<br />
Parent(s) Involvement<br />
1. You should never ignore your child if they are in danger to<br />
themselves or anyone else.<br />
2. Learn to ignore behaviors that you want your child to engage in<br />
less frequently.<br />
3. Ignoring something means that<br />
You cannot speak to your child<br />
Touch your child<br />
<br />
Make eye contact with him/her<br />
4. Once you begin to ignore a behavior you have to ignore in until he/<br />
she stops doing it.<br />
5. Continue to praise your child’s good behavior.<br />
OCD Symptom Tracking<br />
Child Tools - Daily Practice Record<br />
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SUNDAY
Task Description & Reminder of specific strategies to use:<br />
Thermometer Ratings<br />
Date & What was attempted Pre-task 1 min 2 min 5 min 10 min 15 min 20 min<br />
-243-
Reward (describe what can be earned <strong>and</strong> what criteria are for earning it):<br />
Parenting Tool - Scaffolding Steps<br />
Goal: To empathetically encourage approach rather than avoidance.<br />
Step 1: Find out how child feels (e.g., afraid, angry, sad) <strong>and</strong> empathize with them. Help your child to identify his/her feelings <strong>and</strong> emotions.<br />
Listen to what your child is saying <strong>and</strong> let him/her know that s/he has been heard. Help your child use the feelings thermometer to<br />
identify the level of distress that he/she is experiencing.<br />
Step 2: Brainstorm with child how to approach rather than avoid the situation. You will be in charge of activating your child to do the E/RP<br />
task. Generate ideas about how to approach the situation. Talk with your child about his/her concerns <strong>and</strong> help provide a rationale for doing E/RP<br />
(“Avoiding the OCD doesn’t make it go away”). Offer some reasons why doing E/RP would be a good thing versus a bad thing (“You’ll be in charge,<br />
not the OCD”, “the OCD wants you to believe that you can’t do it”) or, if possible, prompt the child to generate some of these ideas. Reinforce the<br />
importance of E/RP – feeling some anxiety will help your child be the boss of OCD. Note: it is important to meet kids where they are in this process<br />
(cognitively, emotionally). Praise your child for generating ideas <strong>and</strong>/or for listening to you.<br />
Step 3: Choose one of the options from Step 2 <strong>and</strong> act on it.<br />
Pick an option, now go <strong>and</strong> do it! Follow through on the exposure task.<br />
Step 4: Evaluate <strong>and</strong> reward.<br />
Review how the plan worked (or didn’t work), <strong>and</strong> reward your child for trying. In addition to the anxious feelings that can be evoked by the E/RP<br />
task, young children can be very sensitive about their performance when trying new things. Parents should anticipate resistance to practicing <strong>and</strong>/or<br />
frustration when the practice doesn’t go as planned. Remind your child that this is a skill, <strong>and</strong> that it will take some time to get “good” at it. Practice<br />
regularly. Be honest about how it goes, <strong>and</strong> learn from your mistakes. Reward your child for making an effort, as opposed to tying the reward only<br />
to the outcome.<br />
Overview of Parenting Toolbox<br />
1. Differential Attention – positive <strong>and</strong> negative attention<br />
· Giving positive attention to increase behaviors you want to see.<br />
1) Praise <strong>and</strong> encouragement<br />
2) Tangible rewards – reward program<br />
3) Privileges<br />
· Removing attention to decrease the behaviors you don’t want to see.<br />
1) Ignoring<br />
2. Modeling – children can learn both good <strong>and</strong> bad behaviors just from watching others.<br />
3. Scaffolding – helps parents help their kids to boss back OCD using a step-by-step method.<br />
SUNDAY<br />
-244-
Using Scaffolding Steps in Unplanned Situation<br />
Goal: To empathetically encourage approach rather than avoidance in more real-life situations as opposed to just during planned E/RP tasks. For<br />
example, when __________________________________________________________________________________________________________<br />
_______________________________________________________________________________________________________________________<br />
_______________________________________<br />
Step 1: Find out how child feels (e.g., afraid, angry, sad) <strong>and</strong> empathize with them.<br />
The difference in this step from last week is that you must work with your child to identify the level of difficulty in this naturally occurring situation<br />
because you want to match the difficulty level of what your child will try to do with what s/he is capable of h<strong>and</strong>ling at this point in treatment.<br />
Step 2: Brainstorm with child how to approach rather than avoid the situation.<br />
Again, the difference from last week is that you do not have the luxury of choosing this situation to match the level of difficulty that your child is ready<br />
to tackle. Therefore, you may need to be creative to determine how to accomplish at least partial “approach” of this situation. Stated differently,<br />
small changes from your child’s typical response to this situation are OK if complete reversal of their previous pattern is not possible. You <strong>and</strong> your<br />
child will need to balance a number of issues (e.g., being in a hurry, being in public where others may be around) at the same time as attempting to<br />
boss back OCD. Partial approach is better than complete avoidance.<br />
Step 3: Choose one of the options from Step 2 <strong>and</strong> act on it.<br />
Pick an option, now go <strong>and</strong> do it! Follow through on the exposure task.<br />
Step 4: Evaluate <strong>and</strong> reward.<br />
It is often the case that tasks that can be successfully completed in a controlled setting like your home are much harder when attempted elsewhere.<br />
Therefore, it is especially important to focus on the effort that your child makes to boss back OCD <strong>and</strong> not necessarily the outcome of those efforts.<br />
-245-
Scrupulosity<br />
6/14/13 <br />
DefiniEon <br />
Scrupulosity: <br />
When OCD Invades Our <br />
Religious & Moral Life <br />
C Alec Pollard, Ph.D. & Jonathan Grayson, Ph.D. <br />
• Scruple: “1. A very small quanEty”; “2. A doubt arising <br />
from difficulty in deciding what is right” (Wesbster’s) <br />
• Scrupulous: “1. ConscienEously honest”; “2. Careful of <br />
details; precise” (Webster’s) <br />
• Scrupulosity (Ciarrocchi, 1995): <br />
-‐ seeing sin where there is none <br />
-‐ a form of OCD <br />
-‐ excessive doubt or concern that a thought or behavior <br />
violates religious doctrine or offends God <br />
June 21, 2013 -‐-‐ IOCDF -‐-‐-‐ Atlanta, GA <br />
Notable Religious Leaders <br />
Affected by Scrupulosity <br />
In contrast to normal religious prac4ce, <br />
scrupulous behavior: <br />
• St. IgnaEus Loyola <br />
• St. Alphonsus Liguori <br />
• MarEn Luther <br />
• John Bunyan <br />
• St. Veronica Giuliani <br />
• Exceeds or disregards religious law <br />
• Focuses on a few trivial areas of religious <br />
pracEce <br />
• Disregards other areas fundamental to the <br />
faith community <br />
SUNDAY<br />
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1
6/14/13 <br />
Examples of <br />
Behavioral Rituals <br />
Examples of <br />
Cogni4ve Rituals <br />
• Cleansing, purifying <br />
• Reassurance-‐seeking <br />
• Confession <br />
• Acts of self-‐sacrifice/punishment <br />
• Reading or reciEng sacred passages <br />
• Praying <br />
• Imagining sacred images <br />
• Reviewing sacred phrases/passages in one’s <br />
head <br />
• Promises to God <br />
• Figuring out the sin <br />
Scrupulosity… <br />
• Affects people from a variety of faith <br />
tradiEons <br />
• Is shaped by the values <strong>and</strong> customs of the <br />
faith community & culture <br />
• Is treatable <br />
Treatment <br />
• Same front line approaches (e.g., medicaEon, <br />
CBT) as other forms of OCD <br />
• However, special issues & challenges <br />
involved… <br />
-247-<br />
2
6/14/13 <br />
References for Consumers <br />
1. Ciarrocchi (1995). The Doub;ng Disease: Help for scrupulosity <br />
<strong>and</strong> religious obsessions. Mahwah, NJ: Paulist Press. <br />
2. Santa (2007). Underst<strong>and</strong>ing scrupulosity: Ques;ons, help, & <br />
encouragement. Liguori, MO: Liguori Books. <br />
3. Osborn, I. (2008). Can Chris;anity Cure <strong>Obsessive</strong>-‐<strong>Compulsive</strong> <br />
Disorder: A Psychiatrist Explores the Role of Faith in <br />
Treatment. Ada, MI: Brazos Press. <br />
4. Scrupulosity Fact Sheet, InternaEonal OCD FoundaEon, <br />
website: www.ocfoundaEon.org <br />
Contact InformaEon <br />
C. Alec Pollard, Ph.D. <br />
Center for OCD & Anxiety-‐Related Disorders, Saint Louis <br />
Behavioral Medicine InsEtute <br />
Address: 1129 Macklind Ave, St Louis, MO 63110 <br />
Phone: 314-‐534-‐0200, ext. 424 <br />
Email: info@slbmi.com <br />
Website: www.slbmi.com <br />
Jonathan Grayson, Ph.D. <br />
Anxiety & OCD Treatment Center of Philadelphia <br />
Address: 1845 Walnut St., 15 th Floor, Philadelphia, PA 19103 <br />
Phone: 215-‐735-‐7588 <br />
Email: jbg1717@gmail.com <br />
Website: www.ocdphiladelphia.com <br />
SUNDAY<br />
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3
Assessment <strong>and</strong> Treatment of Postpartum OCD<br />
IOCDF Annual Conference, July 2013<br />
Licia Freeman, M.A., M.Ed., LMFT, CSAT(c)<br />
www.liciafreeman.com<br />
Obsessions: The same thoughts, images, or impulses come again<br />
<strong>and</strong> again, <strong>and</strong> are distressing, frightening, <strong>and</strong> often shame producing.<br />
The person tries to dismiss them, <strong>and</strong> that just strengthens<br />
them.<br />
Compulsions: Rituals (actions <strong>and</strong> thoughts), developed to gain<br />
temporary relief<br />
Assessment <strong>and</strong> Treatment of Postpartum OCD<br />
1. Etiology:<br />
- Physiology: Abnormalities detected in the frontal lobe <strong>and</strong><br />
the basal ganglia, <strong>and</strong> in some neurotransmitters such as serotonin.<br />
In OCD patients the frontal cortex works extra hard<br />
to tame the impulses of the limbic system<br />
- Environment: An event or thought will often trigger the obsessions<br />
<strong>and</strong> compulsions<br />
- Genetics: Relatives of OCD patients are more likely than the<br />
average person to develop anxiety/depression. Onset of OCD<br />
in late teens<br />
- Psychological: To prevent a psychologically painful idea from<br />
surfacing into one’s consciousness, one focuses on another<br />
painful yet less disturbing idea. Low self-esteem also plays a<br />
role<br />
Causes of OCD:<br />
- It’s both a learned <strong>and</strong> a biological disorder<br />
- Neurobiological disorder – dysfunction in the biology of the<br />
brain<br />
- Stress <strong>and</strong> biological mechanisms play a role in activating the<br />
genes<br />
- Neuropsychiatric illness resulting from a malfunction in the<br />
circuitry of the brain<br />
- Striatum<br />
- Biochemical imbalance in the brain that results in a malfunction<br />
of the brain’s gearshift – the brain gets stuck<br />
- Changing one’s behavioral responses to the uncomfortable<br />
feelings <strong>and</strong> shifting to useful <strong>and</strong> constructive behaviors<br />
will, over time, make the broken gearshift come unstuck<br />
- Fluctuation in hormones – especially progesterone <strong>and</strong> oxytocin<br />
- Personal <strong>and</strong> family history of mood <strong>and</strong> anxiety disorders<br />
- Excessive <strong>and</strong> overwhelming sense of responsibility for another<br />
much more fragile human being<br />
- Glitch in the brain which sends our false message<br />
Uncertainty is at the core of OCD<br />
2. Symptoms <strong>and</strong> Assessment Tools<br />
- Most common types of PPOCD:<br />
Contamination, Checking, Primary Mental Obsessions<br />
- Assessment Tools: YBOCS Symptoms Checklist, YBOCS, EPDS,<br />
PDSS, Perinatal/Postpartum Checklist (make your own)<br />
OCD vs. PSYCHOSIS<br />
OCD<br />
Psychosis<br />
Thoughts repulsive<br />
Thoughts pleasurable<br />
Try to dismiss obsessions Agree with obsessions<br />
Ego dystonic<br />
Ego syntonic<br />
Avoidance<br />
Thoughts consistent<br />
with world view<br />
Aware of irrationality<br />
Thoughts part of delusions<br />
Warped reality<br />
3. Treatment<br />
Goal of treatment not to stop the intrusive thoughts or even to<br />
know what they mean about her, but to learn to let the thoughts<br />
be there without anxiety – that is normal.<br />
- Medication: very effective in decreasing the anxiety level by<br />
suppressing the intrusive urges so that one can be available<br />
for therapy. At least 10 weeks to see the benefits for OCD.<br />
Luvox, Prozac, Zoloft, Paxil, Celexa, Lexapro, especially helpful<br />
- ERP (Exposure Response Prevention)<br />
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Exposure to the feared situation <strong>and</strong> prevention of rituals <strong>and</strong> avoidance. Can be done imaginal or in vivo. SUDS (subjective Units of<br />
Distress)<br />
- Cognitive Behavioral Therapy<br />
Explore interpretations of intrusions <strong>and</strong> assumptions. The goal of the Cognitive interventions is to be sure that the client agrees that her<br />
thoughts directly affect how she feels <strong>and</strong> behaves in neutral <strong>and</strong> obsessive situations.<br />
Helpful techniques: Socratic Questions, Downward Arrow, Cognitive Errors, Survey method, Role Play, Thought Suppression Test, Double-St<strong>and</strong>ard<br />
Technique<br />
- Mindfulness<br />
Visual imagery, Mindfulness awareness<br />
The goal is to non-judgmentally accept uncomfortable psychological experiences<br />
Develop the ability to more willingly experience the uncomfortable thoughts, feelings, sensations <strong>and</strong> urges without responding with<br />
compulsions, avoidance behaviors, reassurance seeking, <strong>and</strong>/or mental rituals<br />
- Deep Brain Stimulation<br />
- Family Therapy<br />
A family disease: all members get sucked in <strong>and</strong> contribute to the perseverance of the problem<br />
Problem-solving skills training for both patient <strong>and</strong> family members – assessment <strong>and</strong> intervention strategies for reducing criticism,<br />
over-involvement, <strong>and</strong> hostility during behavioral therapy<br />
Psycho-education about OCD <strong>and</strong> the process of ERP<br />
Reduction of accommodation of <strong>and</strong> participation in symptoms<br />
Reduction of hostile, antagonistic responses to OCD<br />
Incorporating the relative as a coach or co-therapist in ERP when appropriate<br />
Boundaries<br />
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Cognitive-Behavioral Strategies in the Treatment of Hypochondriasis <strong>and</strong> Health-Related OCD<br />
6/14/13<br />
“It Only Hurts When I Obsess”<br />
Goals Of The Presentation<br />
The Treatment of<br />
Hypochondriasis <strong>and</strong> Health-<br />
Related OCD<br />
Bruce M. Hyman, Ph.D., LCSW<br />
Director, OCD Resource Center of Florida<br />
Fort Lauderdale, Florida<br />
www.ocdhope.com<br />
OCD – DSM IV-R<br />
Health Related OCD<br />
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Obsessions<br />
Unwanted, repetitive thoughts,<br />
images, or impulses that are<br />
experienced as intrusive <strong>and</strong><br />
which generate significant<br />
anxiety<br />
Typical Health Obsessions<br />
Common Obsessionally Feared<br />
Illnesses In OCD<br />
• How do I know for certain I don’t have a serious<br />
or incurable illness<br />
• How do I know for sure if I have been given the<br />
right diagnosis (If patient actually has a nonserious<br />
illness)<br />
• How do I know if I’m not getting the wrong<br />
treatment (for non-serious illness)<br />
• How can I be sure that I won’t negligently do<br />
something that will cause me to become<br />
seriously ill<br />
• HIV-AIDS<br />
• Multiple Sclerosis (MS)<br />
• Alzheimer’s Disease<br />
• Amyotrophic Lateral Sclerosis (ALS)<br />
• Rabies<br />
• Herpes – Type I <strong>and</strong> II<br />
• Condyloma acuminata (genital warts)<br />
• Cancer – all forms, especially brain tumors<br />
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iCompulsions (OCD) or<br />
CyberChondriasis (HC)<br />
• Mining online websites for health <strong>and</strong> treatment<br />
information as a form of reassurance-seeking, to<br />
relieve anxious ideas about possibly having or<br />
eventually contracting a catastrophic illness<br />
• Typically results in an increase in anxiety from<br />
increased somatic preoccupation<br />
• New doubts <strong>and</strong> symptoms often arise from<br />
contact with new information<br />
Hypochondriasis – DSM IV-R<br />
Hypochondriasis (HC)<br />
• Classified as a Somatoform Disorder<br />
• A preoccupation with fears of having a serious<br />
disease<br />
• Idea persists despite appropriate medical<br />
evaluation <strong>and</strong> reassurance<br />
• Preoccupation causes significant distress or<br />
impairment in social, occupational or other<br />
important areas of functioning<br />
• Duration for at least 6 months<br />
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Hypochondriasis – DSM V Changes<br />
• Term “Hypochondriasis” eliminated <strong>and</strong> renamed<br />
“Somatic Symptom Disorder”<br />
• Dx of SSD must include BOTH:<br />
– Persistent medically unexplained somatic symptoms<br />
(lasting longer than six months)<br />
– Distorted cognitions <strong>and</strong> attributions:<br />
• High level of health-related anxiety.<br />
• Catastrophic ideas about the state of one’s health<br />
• Belief in the medical seriousness of one's<br />
symptoms despite evidence to the contrary.<br />
• Health concerns <strong>and</strong>/or symptoms assume a<br />
central role in one's life (ruminative preoccupation).<br />
• When high levels of health anxiety is present without<br />
somatic symptoms, the diagnosis of “Illness Anxiety<br />
Disorder” is given<br />
Hypochondriasis - Clinical Features<br />
• Cognitive Features<br />
– Belief that one has a serious disease or will contract a<br />
serious disease in the future<br />
– Recurrent thoughts <strong>and</strong> images of disease <strong>and</strong> death<br />
• Somatic Features<br />
– Anxiety-related bodily reactions (e.g., palpitations)<br />
– Benign bodily sensations <strong>and</strong> changes (e.g.,<br />
blemishes, mild aches & pains)<br />
• Behavioral Responses<br />
– Repeated checking one’s body for signs of illness<br />
– Repeated reassurance seeking from physicians or<br />
family members<br />
– Repeated requests for medical tests<br />
– Excessive information seeking via books or the<br />
internet<br />
– Avoid or escape disease-related stimuli<br />
Relationship between OCD <strong>and</strong> HC<br />
Is it Hypochondriasis (HC) or<br />
Health-related OCD<br />
• HC present in 9.5% of a sample of OCD patients<br />
vs. 2.6% of controls (Barsky et al, 1986).<br />
• 34% of a sample of 100 OCD patients had<br />
somatic obsessions that compelled them to seek<br />
medical treatment (Rasmussen & Tsuang,<br />
1986).<br />
• 33% of a sample of 21 HC patients were found<br />
to have lifetime histories of OCD (Fallon et al,<br />
1993c).<br />
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Similarities Between HC <strong>and</strong> OCD<br />
Differences Between HC And OCD<br />
• Intrusive thoughts (about illness in the case of HC)<br />
• Repetitive self-checking <strong>and</strong> vital sign monitoring<br />
(body vigilance) as an escape from anxiety<br />
• Frequent reassurance-seeking<br />
• Repeatedly going for medical consults <strong>and</strong> tests<br />
• Recurring doubts about results of medical testing<br />
• <strong>and</strong> examinations<br />
• Overconcern with the possible significance of bodily<br />
sensations<br />
• Both have a 1:1 sex ratio<br />
Where Does OCD vs. HC lie<br />
on a Continuum of Doubt<br />
More<br />
Doubt<br />
Less<br />
OCD<br />
HC<br />
(OCD)<br />
(HC)<br />
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Cognitive-Behavioral Model of<br />
Hypochondriasis/Health-Related OCD<br />
A = Activating health<br />
related event<br />
D = Action taken<br />
to reduce fear, worry<br />
<strong>and</strong> uncertainty<br />
B = Dysfunctional<br />
appraisal of bodily<br />
sensations<br />
C = Heightened fear, worry<br />
<strong>and</strong> uncertainty<br />
• The human body is “noisy”<br />
• Most bodily sensations are mild, transient <strong>and</strong> not<br />
associated with any serious disease - for example:<br />
– Dizziness, faintness, rapid heartbeat from not eating<br />
for a long time<br />
– Rapid heartbeat from eating a meal rich in<br />
carbohydrates<br />
– Arm <strong>and</strong> joint discomfort from sitting or st<strong>and</strong>ing in<br />
one position for a long time<br />
– Stomach pain from overeating or indigestion<br />
– Headaches from being out in the sun too long<br />
– Muscle pain after a lengthy workout in the gym<br />
B = Dysfunctional Appraisal<br />
• Blank-<strong>and</strong>-White thinking–<br />
– “Bodily complaints are always a sign of disease”<br />
– “I’m only certain I’m healthy if I don’t have any body<br />
sensations”<br />
– “Unless I’m absolutely sure that there is nothing<br />
wrong, I must assume the very worst”<br />
• Negative interpretation bias / disqualifying the<br />
positive<br />
– “Just because these doctors says I’m healthy doesn’t<br />
mean I am. They could be missing something.”<br />
• Catastrophizing- attributing horrible consequences<br />
to minor events<br />
– “I have a headache – I must have a brain tumor”<br />
– “My back aches – I must have bone cancer”<br />
• Intolerance of Uncertainty<br />
– “I must have 100% proof that I’m not ill, otherwise I’m<br />
probably sick”<br />
– “I must frequently check my body <strong>and</strong> watch my<br />
health carefully in order to catch the first signs of<br />
serious illness”<br />
– “If I stop thinking about my health, even for a short<br />
time, it’s dangerous”<br />
• Superstitious thinking<br />
– “If I tell myself I’m healthy, I’m tempting fate”<br />
– “Seeing a TV show about herpes by chance at the<br />
very same time that I’m worrying about it is an omen<br />
that I probably have it”<br />
– “Worrying about my health will keep me safe from<br />
illness”<br />
• Emotional Reasoning: feelings = facts<br />
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C = Increased Fear <strong>and</strong> Doubt<br />
D = Action to Neutralize Anxiety<br />
D = Action or avoidance<br />
to reduce fear<br />
<strong>and</strong> uncertainty<br />
A = Increased likelihood of<br />
the next activating somatic<br />
or health-related event<br />
Exposure & Response Prevention<br />
Cognitive-Behavioral<br />
Treatments<br />
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Habituation<br />
Naturally occurring reduction in anxiety<br />
resulting from prolonged exposure to an<br />
anxiety provoking thoughts, feelings,<br />
impulses, as well as the situations in which<br />
they occur. “Nervous system boredom”<br />
“You can’t be bored <strong>and</strong> scared at the<br />
same time” (Fred Penzel, Ph.D.)<br />
Steps in ERP for Health-Related<br />
OCD<br />
Typical Exposure Hierarchy For<br />
Cancer Obsession (Sample)<br />
SUDS (0=none<br />
100=extreme)<br />
Reading medical article on cancer mortality 40<br />
Touching photos of actual cancer tumors 50<br />
Sitting in waiting area of hospital cancer unit 60<br />
Touching sign “Chemotherapy Clinic” with<br />
70<br />
gloves<br />
Touching sign “Chemotherapy Clinic” without 80<br />
gloves<br />
Shaking h<strong>and</strong>s with cancer patient with gloves 90<br />
on<br />
Shaking h<strong>and</strong>s with cancer patient without<br />
100<br />
gloves on<br />
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Sample Exposures For Health<br />
Obsessions<br />
CBT for Hypochondriasis<br />
Obsession<br />
HIV<br />
Hepatitis C<br />
Food<br />
poisoning<br />
Sample Exposure<br />
Watch movie “Philadelphia”<br />
Touch books on “how to manage your HIV” in<br />
public library<br />
Eating meal in restaurant frequented by gays<br />
Sit in hospital waiting room chairs without gloves<br />
Touch beef blood from meat section of market<br />
Touch dried blood on used B<strong>and</strong>-Aid<br />
Eat canned foods out of a slightly dented can<br />
Eat meal from “unclean” restaurant<br />
• Supported by a number of studies (Barsky <strong>and</strong><br />
Ahern, 2004; Warwick, et. al., 1996; Speckens,<br />
et. al., 1995; Clark., et. al., 1998)<br />
• Offering it as “stress management” more<br />
acceptable to HC patients<br />
CBT for HC – Do’s <strong>and</strong> Don’ts<br />
CBT for HC – Do’s <strong>and</strong> Don’ts<br />
Do:<br />
– Acknowledge reality of patient’s bodily concerns<br />
– Explore <strong>and</strong> validate the patient’s reasons for holding the<br />
beliefs they have about their symptoms – “It’s<br />
underst<strong>and</strong>able that you’ve come to this conclusion”<br />
– Acknowledge patient’s doubts about the role of<br />
psychological factors in their symptoms. Present<br />
psychological factors as “an open question to be further<br />
investigated”<br />
– Get to some agreement that psychological factors play a<br />
role in the experience of pain – example of pain felt by<br />
athletes competing; mothers/fathers rescuing a child in<br />
danger<br />
– Discuss pitfalls of “certainty seeking” strategies such as<br />
doctor shopping, internet research, etc.<br />
– Provide alternative, non-illness related explanations for<br />
the patient’s symptoms<br />
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Emotions Can Cause Bodily<br />
Sensations<br />
“I’m such a fool, totally embarrassed”<br />
“I’m so overwhelmed at work! I’ll lose<br />
my job!”<br />
“That a—hole is getting away with<br />
murder!”<br />
“I miss him/her so much! I can’t st<strong>and</strong><br />
it”<br />
“I’m so relieved that Johnny passed<br />
his college entrance exam”<br />
• In addition to the catastrophic explanation, write down<br />
as many non-catastrophic explanations for the<br />
symptoms you are experiencing. Rate the likelihood of<br />
each (0-100%)<br />
• Review the list. Are there non-catastrophic<br />
explanations that are just as ore even more probable<br />
that the catastrophic ones<br />
Seeing TV show on skin cancer<br />
Possible Reasons for Having a Headache<br />
Tolerating Health Uncertainty<br />
• Establish that distress about one’s health is associated<br />
with intolerance of uncertainty<br />
• List all of the ways that client already tolerates<br />
uncertainty in countless ways:<br />
– Drives car – risking car crash<br />
– Goes to bank – risks being caught in holdup<br />
– Goes to work – risks not knowing if house has burned down<br />
– Goes outside – risks being hit by falling objects<br />
– Eats in restaurant – risks getting food poisoning<br />
• The difference: you’ve already habituated to the<br />
uncertainties above. ERP promotes habituation to health<br />
worries.<br />
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The Effect of Attention<br />
(Taylor & Asmundson, 2004)<br />
Behavioral Experiments:<br />
• Purposely focus on sensations in throat – notice<br />
presence of itchiness, scratchiness, or dryness<br />
may lead to coughing or throat clearing<br />
• Purposely focus upon one’s scalp – notice<br />
sensations of itchiness, tension or tingling<br />
• Purposely focus upon one’s eyes blinking –<br />
notice fluttering sensations in eyes<br />
Attention Modification for HC<br />
• Reduces level of body-focused scrutiny<br />
• Shifting focus of attention from internal to<br />
external can reduce detection of bodily<br />
sensations<br />
• Attention Training Technique (Papageorgiou &<br />
Wells, 1998; Wells, 1997) can improve attention<br />
flexibility<br />
Attention Training Instructions<br />
with script <br />
http://tinyurl.com/agmlgka <br />
ATT Monitoring Form <br />
http://tinyurl.com/aqovxrt <br />
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Mindfulness & Acceptance<br />
Approach to Health Anxiety<br />
• Mindfulness - the practice of consciously bringing<br />
awareness to your here-<strong>and</strong>-now experience<br />
• Teaches the principle of allowing your thoughts <strong>and</strong><br />
feelings to be what they are, letting them come <strong>and</strong> go<br />
without “buying in” to them or struggling with them<br />
Case Examples<br />
• Acceptance & Commitment Therapy (ACT) –<br />
encourages greater response flexibility to the experience<br />
of pain, uncertainty<br />
Health-Related OCD<br />
Case Example<br />
Patient: 36 year-old male HS teacher, married, no<br />
children<br />
Presenting Problem: Severe obsessive doubt <strong>and</strong><br />
fears about having either MS or ALS as a result of<br />
h<strong>and</strong> tremors that occurred after grading many tests,<br />
along with some unrelated cramping in calves,<br />
tightness <strong>and</strong> muscle twitches in legs, <strong>and</strong> muscle<br />
cramping in h<strong>and</strong>s. Also believed his left h<strong>and</strong> was<br />
significantly smaller than his right, <strong>and</strong> reported<br />
feelings of muscle pulsations in his h<strong>and</strong>s when<br />
gripping objects. These were all found to be<br />
medically insignificant following several neurological<br />
workups.<br />
Health-Related OCD<br />
Case Example (cont.)<br />
Symptoms:<br />
• Frequent medical visits <strong>and</strong> phone calls to physicians<br />
• Questioning of family members to obtain reassurance<br />
• Constant visual comparing of h<strong>and</strong>s to each other<br />
• Measuring of h<strong>and</strong>s <strong>and</strong> calves to see if they have<br />
shrunk<br />
• Studying his body in mirror for signs of muscle loss<br />
• Repetitive scanning for <strong>and</strong> checking of pulsations <strong>and</strong><br />
cramping sensations in legs <strong>and</strong> h<strong>and</strong>s<br />
• Searching online for information about MS <strong>and</strong> ALS<br />
• Testing own muscle strength (gripping own h<strong>and</strong>s,<br />
walking on tiptoe, etc)<br />
• Checking his own reflexes<br />
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Health-Related OCD<br />
Case Example (cont.)<br />
Cognitions:<br />
• If I am experiencing physical sensations that I can’t find<br />
the cause of, they must be a sign that I have a really<br />
serious health problem.<br />
• How do I know I don’t have a serious neurological<br />
problem such as MS or ALS<br />
• If I have such a serious <strong>and</strong> fatal problem I will have to<br />
kill myself to avoid an even worse death.<br />
Health-Related OCD<br />
Case Example (cont.)<br />
Treatment:<br />
• Exposure <strong>and</strong> Response Prevention, followed by<br />
• Cognitive Therapy to challenge his<br />
misinterpretation of his bodily sensations<br />
• Administration of an SSRI-type antidepressant<br />
(Lexapro 30 mg.)<br />
• I must eliminate my doubts at all costs, <strong>and</strong> have<br />
absolute certainty about the status of my health at all<br />
times.<br />
Health-Related OCD<br />
Case Example (cont.)<br />
Health-Related OCD<br />
Case Example (cont.)<br />
Some typical ERP assignments:<br />
Resist body <strong>and</strong> sensation checking<br />
Watch YouTube videos of MS <strong>and</strong>/or ALS patients –<br />
45 min-1 hr per day OR until SUDS decrease by ½<br />
Refrain from any compulsions during exposure<br />
Stop all reassurance-seeking from physicians or<br />
family<br />
Labeling physical sensations as ALS <strong>and</strong> MS<br />
Agreeing with all thoughts of having these disorders<br />
“Yes, I certainly must have ALS/MS”<br />
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Hypochondriasis - Case Example<br />
Patient:<br />
39 year old divorced white male. One son<br />
from 1 st marriage, age 11, who lives with<br />
him. Employed as a financial writer for<br />
large brokerage firm x 5 yrs.<br />
Presenting Problem<br />
• 2 years - burning sensation in his penis despite<br />
medical tests from urologist <strong>and</strong> neurologist confirming<br />
no medical basis for his complaint<br />
• Anxious worry, fears of not being able to function<br />
sexually<br />
• Persistent hyperawareness of sensations in his groin<br />
area<br />
• Guilt over possibly harming himself from excessive<br />
masturbation<br />
• Extremely doubtful that his pain can be anything other<br />
than the result of physical damage<br />
• Severely depressed as a result of his pain (BDI =33)<br />
Cognitions<br />
• “Maybe there is irreparable physical<br />
damage to my penis”<br />
• “I’m punishing myself for masturbating”<br />
• “If I refrain from masturbating or having<br />
sex, the pain will go way”<br />
• “If I feel pain in my groin, my day is ruined”<br />
<strong>Compulsive</strong> <strong>and</strong> Avoidance<br />
Behaviors<br />
• Mental checking his penis for signs of burning<br />
• Arguing back <strong>and</strong> forth in his mind whether burning is<br />
physical or mental<br />
• Research on the internet into “prostatitis, “pudendal<br />
neuralgia”<br />
• Avoids sexual arousal, masturbation based on belief<br />
that it will make his pain worse<br />
• Avoids looking at his genitals-makes him anxious<br />
• Avoids sitting for long periods of time – causes pain<br />
• Multiple, repeated urological <strong>and</strong> neurological testing<br />
• Seeks reassurance from girlfriend<br />
• Tries hard to NOT think about the problem.<br />
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Treatment<br />
• Stop all compulsive avoidance behaviors <strong>and</strong> certainty<br />
seeking including doctor visits, internet searches,<br />
reassurance seeking, avoidance of masturbation<br />
• Cognitive experiment: “What if it’s not mental” Rx:<br />
Practice making pain worse for 5 minutes per day by<br />
intense focus upon it<br />
• Bibliotherapy: Mindfulness <strong>and</strong> Acceptance (ACT)<br />
• Cognitive defusion – creating distance from his<br />
thoughts (“mindful observer”)<br />
• Daily practice: mindfulness meditation – thought <strong>and</strong><br />
feeling watching; paying attention in the moment for 20<br />
minutes, twice per day<br />
• Attention Training (Wells, 2000) – practice in paying<br />
attention externally vs. internally during various<br />
activities including work, jogging.<br />
• Medication – SSRIs – helped with the depression <strong>and</strong><br />
puts a damper on the anxiety<br />
Outcome<br />
• Significant improvement in mood,<br />
lowered levels of anxiety <strong>and</strong> worry.<br />
More optimistic <strong>and</strong> cheerful.<br />
• Increased capacity to shift focus away<br />
from his groin pain for long periods of<br />
time during the day.<br />
• Sleep much better, interests increasing<br />
(joined novel writing club)<br />
• Not avoiding masturbation or dating<br />
Recommended Reading<br />
• Taylor, S., Asmundson, G.J. (2004) Treating Health<br />
Anxiety- A Cognitive-Behavioral Approach. Guildford<br />
Press.<br />
• Abramowitz, J., Braddock, A.E., (2011) Hypochondriasis<br />
<strong>and</strong> Health Anxiety. Hogrefe Publishers<br />
• Owens, K., Antony, M. (2011) Overcoming Health<br />
Anxiety: Letting Go of Your Fear of Illness. New<br />
Harbinger Publications<br />
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So You Expect Them to Leave Home<br />
So You Expect Them to Leave Home!<br />
OCF Convention 2013<br />
Atlanta, Georgia<br />
Sheryl K. Pruitt, M.Ed., ET/P<br />
Daniel G. Pruitt, CPCC, PCC<br />
-279-
Sheryl K. Pruitt, M.Ed., ET/P<br />
c<br />
Introduction<br />
Sheryl K. Pruitt, M.Ed., ET/P, is the Clinical Director of Parkaire Consultants, a clinic<br />
she founded in 1987 to serve neurologically impaired individuals. Prior to the founding<br />
of Parkaire Consultants, Ms. Pruitt conducted a State of Georgia exemplary Model<br />
Learning Disability Program <strong>and</strong> taught behavior-disordered students in a<br />
psychoeducational setting. Ms. Pruitt served on the Board of Directors of the Tourette<br />
Syndrome Association of Georgia for six years <strong>and</strong> as a member of the Scientific<br />
Advisory Board of the Tourette Syndrome Association of Georgia <strong>and</strong> South Carolina.<br />
Ms. Pruitt was a member of the Scientific Advisory Board for the Tourette Spectrum<br />
Disorder Association of California. She also served on the National Tourette Syndrome<br />
Association’s Education Committee. She was a member of the Professional Advisory<br />
Board for North Atlanta <strong>and</strong> Central Georgia CHADD <strong>and</strong> served on the Board of<br />
Directors for the Association of Educational Therapists. She is also a member of the<br />
Professional Advisory Board of the Tourette Syndrome <strong>Foundation</strong> of Canada. Ms.<br />
Pruitt is a member of the Senior Advisory Board of the Brad Cohen Tourette<br />
<strong>Foundation</strong>. She teaches a State of Georgia Professional Learning Unit Course on<br />
students with neurological impairments <strong>and</strong> the impact of their disorders on education,<br />
behavior, family, <strong>and</strong> socialization.<br />
Ms. Pruitt is a co-author of the books Teaching the Tiger, Hope Press (1995) Tigers,<br />
Too with corresponding supplements titled Tigers, Too: Checklists for Classroom<br />
Objectives <strong>and</strong> Interventions <strong>and</strong> Tigers, Too: Assessment, Parkaire Press (2009-2011)<br />
<strong>and</strong> Challenging Kids, Challenged Teachers, Woodbine Press (2010) <strong>and</strong> is a<br />
contributing author to the Tourette <strong>Foundation</strong> of Canada’s Education Guide on<br />
Tourette Syndrome. She has currently co-authored a chapter on educating people with<br />
Tourette Syndrome for a medical book on Tourette Syndrome, Oxford Press (2013).<br />
Sheryl K. Pruitt has presented both nationally <strong>and</strong> internationally. Her presentations<br />
incorporate not only professional experiences, but her personal experiences living with<br />
children, a spouse <strong>and</strong> herself with these conditions.<br />
Contact Information:<br />
Sheryl K. Pruitt, M.Ed.,ET/P<br />
Parkaire Consultants, Inc.<br />
4939 Lower Roswell Road, Suite C-201<br />
Marietta, GA 30068<br />
Tel: 770-578-1519<br />
Fax: 770-578-0860<br />
www.parkaireconsultants.com<br />
www.parkairepress.com<br />
-280-<br />
SUNDAY
Daniel G. Pruitt, Jr., PCC, SCAC<br />
Introduction<br />
<br />
Daniel has been working as a professional coach at Parkaire Consultants for ten years.<br />
He helps adolescents <strong>and</strong> adults with neurological impairments obtain their goals. He<br />
holds the Certified Co-Active Coach designation (CPCC) from the Coaches Training<br />
Institute (CTI), the Professional Certified Coach designation (PCC) from the<br />
International Coaching Federation (ICF), <strong>and</strong> the Senior Certified ADD Coach (SCAC)<br />
from the Institute for the Advancement of ADD Coaching (IAAC).<br />
He has, for the past four years, been one of the four co-leaders of the ADD SIG on<br />
CTI’s Co-Active Network. He was, for two years, a member of the Board of Directors of<br />
the Institute for the Advancement of ADD Coaching working to establish credentialing<br />
st<strong>and</strong>ards for the ADD Coaching community. He has been a presenter at local, regional,<br />
national <strong>and</strong> international conferences on the subject of how neurological disorders<br />
impact performance <strong>and</strong> what to do about it. He has served on the Professional<br />
Advisory Board for North Atlanta <strong>and</strong> Central Georgia CHADD <strong>and</strong> the Board of<br />
Directors of the Tourette Syndrome Association of Georgia.<br />
He also illustrated <strong>and</strong> contributed to the book, Teaching the Tiger, by Marilyn P.<br />
Dornbush, Ph.D., <strong>and</strong> Sheryl K. Pruitt, M.Ed. He recently started Parkaire Press, a book<br />
publishing company. He published Marilyn’s <strong>and</strong> Sherry’s newest book, Tigers Too, as<br />
well as Leslie Packer’s book, Find a Way or Make a Way, <strong>and</strong> Darin Bush’s book, Tiger<br />
Trails. Coaching is a term that is being used in multiple settings at this time. Dan’s<br />
coaching is for independent adolescents <strong>and</strong> adults who are interested in fixing the<br />
impact of their neurological disorders on everyday life.<br />
Contact Information:<br />
Daniel G. Pruitt, Jr., PCC, SCAC<br />
Parkaire Consultants, Inc.<br />
4939 Lower Roswell Road, Suite C-201<br />
Marietta, GA 30068<br />
Tel: 770-578-1519<br />
Fax: 770-578-0860<br />
www.parkaireconsultants.com<br />
www.parkairepress.com<br />
-281-
SO YOU EXPECT THEM TO<br />
LEAVE HOME<br />
Sheryl K. Pruitt, M.Ed., ET/P<br />
<strong>and</strong><br />
Daniel G. Pruitt, CPCC, PCC<br />
One out of every<br />
three adults with ADHD are home<br />
at age 30!<br />
Russell Barkley, Ph.D., 2006<br />
One out of three people with ADHD<br />
have an anxiety disorder.<br />
Coffey et al, 2003<br />
© Daniel G. Pruitt, CPCC, PCC<br />
Sheryl K. Pruitt, M.Ed., ET/P 2010<br />
NEEDED TRANSITION SKILLS:<br />
TRANSITION:<br />
Necessary Steps<br />
to Independence<br />
• Awareness of Disorder<br />
• Medicine Management<br />
• Sufficient Strategies<br />
• Daily Living Skills<br />
• Electronics Under Control<br />
• Waking Up Independently<br />
• Organizational Skills<br />
• Money Management<br />
SUNDAY<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P 2000<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P 2000<br />
-282-
NEEDED TRANSITION SKILLS:<br />
• Time Management<br />
• Social Skills<br />
• Problem Solving Strategies<br />
• Gets Help When Needed<br />
• Respectful, Positive Attitude<br />
• Effort When Task Is Boring<br />
• Takes Responsibility<br />
TRANSITION SKILLS:<br />
Awareness of<br />
Disorder<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P 2000<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P 2000<br />
Regulatory Disorders<br />
Tourette<br />
Syndrome<br />
<strong>Obsessive</strong><br />
<strong>Compulsive</strong><br />
Disorder<br />
Other Anxiety<br />
Disorders<br />
Mood Disorders<br />
Autistic Spectrum<br />
Attention<br />
Deficit<br />
Hyperactivity<br />
Disorder<br />
Sensory<br />
Defensiveness<br />
Sleep Disorders<br />
Stuttering<br />
The Basal Ganglia<br />
© Sheryl K. Pruitt, M.Ed., 1999<br />
-283-
Non-Regulatory Disorders<br />
Learning<br />
Disabilities<br />
Processing<br />
Speed<br />
Speech<br />
Disorders<br />
Language<br />
Disability<br />
When you say “I have ADHD” what do you mean:<br />
ADHD/Inattentive<br />
ADHD/Hyperactive<br />
ADHD/Combined<br />
Symptoms<br />
to Qualify<br />
6 of 9<br />
6 of 9<br />
12 of 18<br />
Total<br />
Combinations<br />
130<br />
130<br />
31,162<br />
Executive<br />
Dysfunction<br />
Memory<br />
Disorders<br />
Visual-Motor<br />
Disability<br />
© Sheryl K. Pruitt, M.Ed., 1999<br />
Possible coexisting disorders: TA, OCD, ODD, LD, EDF, AxD<br />
[18!/(12!*6!)]*[9!/(6!*3!)] * [7!]<br />
Gr<strong>and</strong> Total = A really Big Number<br />
Again I ask you, what do you mean<br />
Learn to be specific!<br />
EXECUTIVE FUNCTION<br />
Hallmarks of Executive Dysfunction<br />
Difficulties with:<br />
Executive functions are control processes. They involve<br />
inhibition <strong>and</strong> delay of responding. They can be divided into<br />
the realms of initiating, sustaining, inhibiting or stopping<br />
<strong>and</strong> shifting. Another important aspect of executive function<br />
is planning <strong>and</strong> organization, which requires “attention to<br />
the future.”<br />
- Martha Bridge Denckla<br />
• Goal Setting<br />
• Initiating<br />
• Prioritizing<br />
• Pacing<br />
• Planning<br />
• Sequencing<br />
• Organizing<br />
• Shifting Flexibly<br />
• Using Feedback<br />
• Inhibiting<br />
• Self-monitoring<br />
• Executing<br />
SUNDAY<br />
© 1999 L.W. Walter, S.K. Pruitt & L.E. Packer<br />
-284-
Memory Functioning<br />
CL UE<br />
Short-Term Memory<br />
• Immediate Memory<br />
• Working Memory<br />
© Sheryl K. Pruitt, M. Ed., 1995<br />
©Tigers, Too, 2009<br />
© Marilyn P. Dornbush,<br />
Sheryl K. Pruitt, M. Ed.,<br />
Tigers, Too, 2009<br />
CL UE<br />
Tips for<br />
Executive Dysfunction<br />
CL UE<br />
Tips for<br />
Executive Dysfunction<br />
• Lend them your frontal lobes.<br />
• Screen for organizational problems.<br />
• Use consistent structure.<br />
• Teach strategies <strong>and</strong> routines.<br />
• Use color code system.<br />
• Use cognitive cues.<br />
• Highlight important information.<br />
• Teach social skills curriculum.<br />
© 2011 Challenging Kids, Inc.<br />
© 2011 Challenging Kids, In<br />
-285-
TRANSITION SKILLS:<br />
Medicine<br />
Management<br />
© Daniel G. Pruitt, CPCC, PCC, Sheryl<br />
K. Pruitt, M.Ed., ET/P, 2000<br />
Memory Functioning<br />
Spared Memory<br />
Short-Term Memory<br />
Immediate Memory<br />
Long-Term Memory<br />
Declarative Memory<br />
Semantic Memory<br />
Episodic Memory<br />
Impaired Memory<br />
Short-Term Memory<br />
Working Memory<br />
Long-Term Memory<br />
Procedural Memory<br />
Prospective Memory<br />
Metamemory<br />
Strategic Memory<br />
© M. Dornbush, L. Packer, S.<br />
Pruitt, W. Walter, 1997<br />
Externalize Your Memory!<br />
Tips for Memory Problems<br />
• Reduce amount <strong>and</strong> complexity<br />
of material presented.<br />
• Hook new concepts to previous<br />
learning.<br />
• Teach, “Do it now, not later.”<br />
• Teach, “Record it or regret it.”<br />
SUNDAY<br />
• Check for comprehension.<br />
© 2011 Challenging Kids, Inc.<br />
-286-
Taking<br />
Medications<br />
Exercise!<br />
•Underst<strong>and</strong>ing why you need<br />
medicine<br />
• Accepting what it takes to<br />
always have your medicine when<br />
needed<br />
• Medicine organizers<br />
© Sheryl K. Pruitt M.Ed., 1999<br />
© Sheryl K. Pruitt, M.Ed., 1991<br />
TRANSITION SKILLS:<br />
Sufficient<br />
Strategies<br />
The Right Trick<br />
Can Be Magic<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P 2000 © Sheryl K. Pruitt, M.Ed., 1990<br />
-287-
Get A Clue!<br />
1. Create a plan<br />
2. Look at options<br />
3. Use strategies<br />
4. Evaluate<br />
© Sheryl K. Pruitt, M.Ed., l995<br />
Write It<br />
or<br />
Regret It!<br />
© Sheryl K. Pruitt, M.Ed., 1997<br />
© Sheryl K. Pruitt, M.Ed., 1990<br />
TRANSITION SKILLS:<br />
Bathroom Routine<br />
Daily Living Skills<br />
Maintain Routine<br />
Lay Out Everything in<br />
Order<br />
SUNDAY<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P 2000<br />
© Sheryl K. Pruitt M.Ed., 1999<br />
-288-
Washer <strong>and</strong> Dryer<br />
TRANSITION SKILLS:<br />
• Chores are life<br />
• Learn early<br />
• Have multiple supplies<br />
• Do one action each day,<br />
e.g., sort, next day start<br />
a load.<br />
Manages Use<br />
of Electronics<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
Computer Programs<br />
TRANSITION SKILLS:<br />
•Word Processors<br />
•Checkbook Programs<br />
•Voice Activated Software<br />
•Programs for ease of<br />
production.<br />
! Can get “stuck” on a color monitor, e.g. computer,<br />
Nintendo <strong>and</strong> TV. This can lead to an addiction.<br />
© Sheryl K. Pruitt, M.Ed., 1990<br />
Waking Up<br />
Independently<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P 2000<br />
-289-
Sleep Hygiene<br />
• Learn a sleep hygiene program.<br />
• Have someone make sure you are up at the<br />
same time every day.<br />
• Utilize a multiple alarm clock system.<br />
Sleep Deprivation<br />
• 18 hours of sleep deprivation produces<br />
cognitive impairment equal to 0.05 blood<br />
alcohol level<br />
• After 24 hours of sleep deprivation versus 8<br />
hours of sleep<br />
- Performed worse on a cognitive task<br />
- Rated concentration <strong>and</strong> effort higher<br />
- Overestimated performance<br />
© Sheryl K. Pruitt M.Ed., 1999<br />
© Keida Walsh, M.D. & Susan Ball, Ph.D.<br />
TRANSITION SKILLS:<br />
Organizational<br />
Skills<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
Organizing Materials: Do’s<br />
Have A Stash of Supplies<br />
Color Code To Help Organize<br />
© Leslie E. Packer, Ph.D., 2000<br />
-290-<br />
SUNDAY
TRANSITION SKILLS:<br />
Ready !<br />
Money<br />
Management<br />
Fire !<br />
Aim !<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
© Daniel <strong>and</strong> Sheryl Pruitt, M.Ed ., 1989<br />
Teaching The Tiger<br />
Teach About Money<br />
TRANSITION SKILLS:<br />
• Teach concept of money needs over the lifetime.<br />
• Get rid of debit cards <strong>and</strong> ATM cards.<br />
• Utilize automatic withdrawals for savings <strong>and</strong><br />
retirement.<br />
Time<br />
Management<br />
© Daniel G. Pruitt, CCPC,,<br />
Sheryl K. Pruitt M.Ed., 1999<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
-291-
When<br />
you say<br />
YES<br />
it<br />
means<br />
when<br />
TRANSITION SKILLS:<br />
Social Skills<br />
(boss, co-workers, family)<br />
© Daniel G. Pruitt, 2001<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
“The most<br />
powerful social<br />
skills group is<br />
your family.”<br />
Family<br />
Friends<br />
Work<br />
SUNDAY<br />
John Walkup, MD<br />
© Sheryl K. Pruitt, M.Ed., 1990<br />
-292-
TRANSITION SKILLS:<br />
• Tell them what happened<br />
• How it impacted them<br />
• How it impacted others<br />
• What to do next time instead<br />
Problem Solving<br />
Strategies<br />
© Sheryl K. Pruitt, M.Ed., 1996<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
Two-Step Process<br />
Planning involves anticipating the outcome<br />
of your strategy before selecting it.<br />
.<br />
Plan Your Work <strong>and</strong><br />
Work Your Plan<br />
P.L.A.N.<br />
+<br />
Problem defined!<br />
Lay out options!<br />
Act on one!<br />
Now evaluate!<br />
© Sheryl K. Pruitt, M.Ed., ET/P, 1999<br />
© Tigers, Too, 2009<br />
-293-
TRANSITION SKILLS:<br />
Getting Help<br />
When Needed<br />
IDENTIFY<br />
SCAFFOLDING<br />
• Reality check<br />
• Scaffolding list<br />
• Identify pitfalls<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000 © Sheryl K. Pruitt, M.Ed., Daniel G. Pruitt, 2002<br />
Parents Doctors<br />
Friends<br />
Living Encyclopedia<br />
Pharmacists<br />
Teachers/Tutors<br />
Therapists<br />
“…Coaching for the neurologically<br />
impaired focuses… on helping people<br />
with TS, OCD, ADHD, EDF <strong>and</strong> WM…<br />
to identify <strong>and</strong> modify problematic<br />
personal behaviors <strong>and</strong> to develop<br />
more effective self-management<br />
skills.”<br />
SUNDAY<br />
© Sheryl K. Pruitt, M.Ed., 1999<br />
Adapted by Daniel Pruitt from<br />
Thomas E. Brown, Ph.D. in Attention-Deficit Disorders <strong>and</strong><br />
Comorbidities in Children, Adolescents, <strong>and</strong> Adults, 2000<br />
-294-
TRANSITION SKILLS:<br />
This Isn’t It!<br />
Respectful <strong>and</strong><br />
Positive Attitude<br />
Who would you rather be<br />
around or hire in the future<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000 © Sheryl K. Pruitt, M.Ed., 1997<br />
TRANSITION SKILLS:<br />
Works Hard at<br />
Boring Task<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
HOMEWORK<br />
•Set time <strong>and</strong> place<br />
• Prepare materials <strong>and</strong><br />
workspace<br />
• Start, finish, put up<br />
• Parents check completion<br />
• Pack it up<br />
ADULT HOMEWORK<br />
If you think that homework<br />
is boring wait until you see<br />
how exciting it is to have<br />
to do your taxes when you<br />
grow up!<br />
© Sheryl K. Pruitt, M.Ed., ET/P,<br />
Warren Walter, Ph.D., 1999<br />
-295-
TRANSITION SKILLS:<br />
Takes<br />
Responsibility for<br />
Actions, Attitudes,<br />
<strong>and</strong> Decisions<br />
Reparations<br />
© Daniel G. Pruitt, CPCC, PCC,<br />
Sheryl K. Pruitt, M.Ed., ET/P, 2000<br />
© Challenging Kids, Challenged Teachers, 2010<br />
© Sheryl K. Pruitt, M.Ed., 1995<br />
Attitude, Effort,<br />
Taking Responsibility,<br />
<strong>and</strong> Asking<br />
For Help Equals…<br />
SUCCESS!<br />
Prepare the child<br />
for the path….<br />
Not the path for<br />
the child!<br />
SUNDAY<br />
© Sheryl K. Pruitt, M.Ed., 2000<br />
© Sheryl K. Pruitt, M.Ed., 2000<br />
-296-
Tigers, Too<br />
Tigers, Too: Supplements<br />
- Checklists <strong>and</strong> Objectives for the Classroom<br />
- Assessment<br />
www.parkairepress.com<br />
Challenging Kids, Challenged Teachers<br />
www.woodbinepress.com<br />
Credits….<br />
Thanks go to Leslie Packer, Ph. D. for her constant support<br />
<strong>and</strong> contributions for several of the power point slides<br />
used here today.<br />
Thanks also to Warren Walter, Ph.D. for his contributions to<br />
several power point slides today <strong>and</strong> his support.<br />
Many of the photos are copyright Photo Disc or Getty<br />
Images.<br />
Special thanks go to our children <strong>and</strong> gr<strong>and</strong>child for their<br />
support for our work <strong>and</strong> for cleverly managing to have<br />
some of the disorders that we did not have to help us in<br />
our discussion today.<br />
Dedication<br />
This program is cheerfully<br />
dedicated to the author’s<br />
family, who have cleverly<br />
managed to have almost<br />
every problem described.<br />
Any problem my husb<strong>and</strong><br />
<strong>and</strong> I did not have I gave<br />
birth to. They are my first,<br />
<strong>and</strong> best, teachers.<br />
Daniel G. Pruitt, CPCC, PCC<br />
Sheryl K. Pruitt, M.Ed., ET/P<br />
www.parkaireconsultants.com<br />
© Sheryl K. Pruitt, M.Ed., 2000<br />
-297-
Scrupulosity Support Group<br />
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SUNDAY<br />
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WHEN REASSURANCE IS HARMFUL<br />
By Paul R. Munford, Ph.D.<br />
Anxiety Treatment Center of Northern California<br />
Published by The OC <strong>Foundation</strong>, Inc.<br />
People with OCD worry that their obsessional fears will come true. To ease this distress they ask other<br />
people, usually family members or close friends, over <strong>and</strong> over again to reassure them that it won’t happen.<br />
Because obsessional fears are always unrealistic, the family members or friends (<strong>and</strong> even therapists) tell<br />
them there is no need to worry; nothing bad is going to happen. For instance, it is quite common for<br />
people with fears of hurting others to seek reassurance that they are harmless; for people with fears of<br />
engaging in inappropriate sexual acts that they will not lose control; <strong>and</strong> for fears of committing blasphemy<br />
that they will not be punished. Typically, they get the reassurance that they want but its effects don’t last<br />
because the fear returns with the next obsession. These repeated reassurance requests are actually<br />
compulsions because they provide only temporary relief from the obsessions. And, like other compulsions,<br />
they prevent exposure to the fear which is necessary for recovery. Even though offering only temporary<br />
relief, the reassurance is rewarding enough to keep the person repeatedly seeking more of it. Here’s the<br />
first paradox: the more reassurance received, the more reassurance wanted.<br />
It eventually becomes apparent to those in the reassurance exchange that their efforts are not only useless<br />
for managing fear but also lead to interpersonal strife. Reassurance is not helpful; it’s harmful. For<br />
example, I worked with a woman who feared that her three-year old daughter was not her biological<br />
offspring but someone else’s; her baby had been switched in the hospital. During the early stages of fear,<br />
she called the hospital requesting confirmation that the child was hers, <strong>and</strong> was assured that indeed she was.<br />
This satisfied her for a few days; but as the doubt returned, she called again, <strong>and</strong> again, <strong>and</strong> again until the<br />
hospital refused to take any further calls. When she couldn’t get reassurance from the hospital, she turned<br />
to her husb<strong>and</strong>. “Does the child look like us Did you see any other Asian babies in the hospital How can<br />
we be sure the blood tests <strong>and</strong> medical records prove we are the parents” Realizing that his attempts to<br />
comfort her were futile, the father tried to ignore her. This only caused her to redouble her efforts; she<br />
followed him from room to room dem<strong>and</strong>ing that he answer her questions. Her dem<strong>and</strong>s became so<br />
frequent <strong>and</strong> intense that he eventually moved out of the house <strong>and</strong> rented an apartment of his own. At that<br />
point, the mother entered an intensive treatment program where they both received help.<br />
Reassurance requests can become reassurance dem<strong>and</strong>s. This happens when the person threatens emotional<br />
outburst or has temper tantrums if his dem<strong>and</strong>s are not met. The person may insist on hearing certain<br />
words, words said in a certain way, or repeated in a ritualized fashion. Whenn this is not enough, he or she<br />
may dem<strong>and</strong> that others actually perform rituals for the person. For example, I worked with a woman who<br />
was afraid that she was touching children inappropriately, touching them in a sexual way even though she<br />
was unaware of actually doing it. These fears would frequently occur whenever she was close to lots of<br />
children in public places. On the way home, she would question her spouse about any misdeed; <strong>and</strong>, once<br />
home, she worried that someone saw her touch a child <strong>and</strong> reported her to the police. From then on,<br />
sounds from the outside were interpreted as the police descending on her home <strong>and</strong> pounding on her door<br />
at any minute. Again she repeatedly sought confirmation that she wasn’t about to be arrested. Also, she<br />
compulsively opened her apartment door <strong>and</strong> surveyed the street to see if the police had arrived. When she<br />
went to bed she had to routinely repeatedly check all the locks on all windows <strong>and</strong> doors. However, this<br />
wasn’t enough. She would then ask her husb<strong>and</strong> to assure that she had done the checking. When his<br />
reassurances eventually failed to comfort her, she then dem<strong>and</strong>ed that he repeat her checking routine.<br />
As you can see, trying to satisfy dem<strong>and</strong>s for reassurance is like trying to fill a bottomless pit. Now, the<br />
second paradox: once reassurance elimination is underway, the reassured finds his desire for it vanishing until<br />
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eventually he feels no need for it at all. There is also a corresponding decrease in the strength of his obsessions<br />
<strong>and</strong> other compulsions. But all of this is only realized after reassurance has stopped. How, then, should<br />
one respond to reassurance requests from an OCD sufferer<br />
First, the person <strong>and</strong> his significant others are educated about the harmful effects of reassurance. They are<br />
given the explanation that providing reassurance interferers with recovery from the disorder. It does so by<br />
blocking exposure to the fear, which is necessary for the elimination of fear. Remember, exposure is key to<br />
successful treatment.<br />
Second, the person is instructed to abstain from asking for reassurance. A reassurance-seeker’s most<br />
frequent questions are identified <strong>and</strong> she/he is told not to ask these questions. Frequently, there are subtle,<br />
indirect ways that the person obtains reassurance. There may be unknown to the reassurers, but knowingly<br />
practiced by the reassure. For example, one client I worked with would abruptly stop doing whatever she<br />
was doing, sit down <strong>and</strong> space out. Her husb<strong>and</strong> learned that these behaviors signaled that she was caught<br />
up in obsessions; <strong>and</strong> unbeknownst to him, they became a nonverbal request for reassurance that he would<br />
immediately provide by telling her not to worry, that her fears were irrational, that it was only her OCD.<br />
So, in addition to attending to the obvious requests, subtle, indirect ones also need to be stopped. The<br />
statement “I love you” seems caring, but is it when stated by a person who has violent obsessions Most<br />
likely not, if said repeatedly, because it commonly elicits the response “I love you too,” which can be<br />
comforting to a person, guilt ridden by images <strong>and</strong> thoughts of stabbing the reassurer.<br />
Third, it can be expected that some requests for reassurance will continue despite the person’s efforts to<br />
abstain from them. Therefore, those providing reassurance need to work out expressions that are<br />
acceptable to the person for refusing to offer it. One way of doing this is to say. “I think you’re asking for<br />
reassurance. Remember, reassurance is not helpful it’s harmful. Therefore I’m not going to answer.”<br />
However, if this method does not result in the elimination of reassurance request, it could be possible that<br />
the agreed upon statement itself has become reassuring or that the client believes that no harm can occur<br />
because the reassurer would warn him. In this case, the best way to prevent continued reassurance is for<br />
the parties to stop talking about OCD entirely.<br />
Now this elimination of reassurance is to be restricted only to OCD fears. By all means, the comfort <strong>and</strong><br />
support that are given for realistic worries <strong>and</strong> concerns of life should continue in the reciprocal way that<br />
one finds among people who mutually care for each other. In the case of OCD, however, this comfort <strong>and</strong><br />
support comes from the absence of harmful reassurances.<br />
SUNDAY<br />
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APOSTOLIC CHRISTIAN<br />
Counseling <strong>and</strong> Family Services<br />
515 E. Highl<strong>and</strong> Street, Morton, IL 61550 Tel: (309) 263-5536 Fax: (309) 263-6841 www.accounseling.org<br />
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Georgia Center for<br />
OCD & Anxiety<br />
The warm environment, highly-trained clinicians <strong>and</strong> caring staff at the<br />
Georgia Center for OCD & Anxiety enable this specialized outpatient treatment<br />
facility to provide necessary skills <strong>and</strong> knowledge to help those struggling. By using<br />
effective, evidence-based treatments tailored to the unique needs of each person,<br />
our specialists deliver the highest level of care to help clients move forward.<br />
Specializing in the treatment of <strong>Obsessive</strong> <strong>Compulsive</strong> Disorder<br />
<strong>and</strong> <strong>Obsessive</strong> <strong>Compulsive</strong>-related disorders including:<br />
• <strong>Obsessive</strong>-<strong>Compulsive</strong> Disorder<br />
• Generalized Anxiety Disorder<br />
• Illness Anxiety<br />
• Tics / Tourette Syndrome<br />
• Panic Disorder<br />
• Social Anxiety<br />
• Hoarding<br />
• Specific Phobias<br />
• Hair-Pulling / Skin-Picking<br />
• Post-Traumatic Stress Disorder<br />
• Body Dysmorphic Disorder<br />
Dr. Justin Shewell, Psy.D., LCSW<br />
Licensed Clinical Psychologist<br />
Licensed Clinical Social Worker<br />
Graduate, IOCDF Behavior Therapy Training Institute<br />
Kasey Brown, LMSW<br />
Graduate<br />
IOCDF Behavior Therapy Training Institute<br />
TLC Professional Training Institute<br />
TSA-USA Behavior Therapy Training Institute<br />
Children | Adolescents | Adults<br />
www.GeorgiaOCD<strong>and</strong>Anxiety.com | info@GeorgiaOCD<strong>and</strong>Anxiety.com<br />
Office: 706.425.2809<br />
188 S. Milledge Avenue | Suite 2 | Athens, Georgia 30605