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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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FRIDAY<br />

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FRIDAY<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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6/14/13 <br />

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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6/14/13 <br />

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 />

-27-<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 />

-63-<br />

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 />

IOCDF 2013 Ask an Attorney<br />

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 />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

7<br />

IOCDF 2013 Ask an Attorney<br />

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 />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

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 />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

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 />

IOCDF 2013 Ask an Attorney<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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Marilynn Mika Spencer<br />

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 />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

2 1<br />

IOCDF 2013 Ask an Attorney<br />

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 />

IOCDF 2013 Ask an Attorney<br />

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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Marilynn Mika Spencer<br />

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 />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

2 7<br />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

2 8<br />

-71-


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 />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

2 9<br />

IOCDF 2013 Ask an Attorney<br />

Marilynn Mika Spencer<br />

3 0<br />

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 />

Marilynn Mika Spencer<br />

3 1<br />

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THE SPENCER LAW FIRM<br />

2727 Camino del Rio South • Suite 140 • San Diego, CA 92108<br />

(619) 233-1313 telephone • (619) 296-1313 facsimile • spencerlaw@spencerlawoffice.com<br />

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 />

Marilynn Mika Spencer<br />

Ask an Attorney!<br />

IOCDF 2013 Annual Conference<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 />

Ask an Attorney!<br />

Marilynn Mika Spencer IOCDF Annual Conference 2013<br />

-74-


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 />

Ask an Attorney!<br />

Marilynn Mika Spencer IOCDF Annual Conference 2013<br />

-75-


THE SPENCER LAW FIRM<br />

2727 Camino del Rio South • Suite 140 • San Diego, CA 92108<br />

(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 />

Ask an Attorney!<br />

Marilynn Mika Spencer IOCDF Annual Conference 2013<br />

-76-


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 />

MHA-SF 14th Annual International Conference on Hoarding & Cluttering<br />

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THE SPENCER LAW FIRM<br />

2727 Camino del Rio South • Suite 140 • San Diego, CA 92108<br />

(619) 233-1313 telephone • (619) 296-1313 facsimile • spencerlaw@spencerlawoffice.com<br />

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 />

Ask an Attorney!<br />

Marilynn Mika Spencer IOCDF Annual Conference 2013<br />

-78-


THE SPENCER LAW FIRM<br />

2727 Camino del Rio South • Suite 140 • San Diego, CA 92108<br />

(619) 233-1313 telephone • (619) 296-1313 facsimile • spencerlaw@spencerlawoffice.com<br />

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 />

Ask an Attorney!<br />

Marilynn Mika Spencer IOCDF Annual Conference 2013<br />

-79-


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 />

Marilynn Mika Spencer<br />

Ask an Attorney!<br />

IOCDF 2013 Annual Conference<br />

-80-


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 />

Marilynn Mika Spencer<br />

Ask an Attorney!<br />

IOCDF 2013 Annual Conference<br />

-81-


THE SPENCER LAW FIRM<br />

2727 Camino del Rio South • Suite 140 • San Diego, CA 92108<br />

(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 />

-109-<br />

3


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 />

4


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 />

-111-<br />

5


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 />

1


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 />

2


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 />

-115-<br />

3


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 />

-116-<br />

4


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 />

5


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 />

-118-<br />

6


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 />

7


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 />

8


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 />

9


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 />

10


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 />

1


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 />

-125-<br />

2


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 />

-126-<br />

3


6/14/13<br />

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 />

-127-<br />

4


6/14/13<br />

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 />

-128-<br />

5


6/14/13<br />

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 />

-129-<br />

6


6/14/13<br />

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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7


6/14/13<br />

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 />

-131-<br />

8


6/14/13<br />

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 />

-132-<br />

9


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 />

-133-<br />

1


6/24/13 <br />

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 />

-134-<br />

2


6/24/13 <br />

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 />

-135-<br />

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6/24/13 <br />

% 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 />

-136-<br />

4


6/24/13 <br />

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 />

-137-<br />

5


6/24/13 <br />

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 />

-138-<br />

6


6/24/13 <br />

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 />

-139-<br />

7


6/24/13<br />

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 />

-141-<br />

9


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 />

-143-<br />

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 />

-144-<br />

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 />

-145-<br />

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 />

-146-<br />

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 />

-149-<br />

17


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 />

-150-<br />

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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6/14/13 <br />

“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 />

SATURDAY<br />

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6/14/13 <br />

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 />

-165-<br />

3


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 />

SATURDAY<br />

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6/14/13 <br />

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 />

-167-<br />

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6/14/13 <br />

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 />

-168-<br />

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6/14/13 <br />

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 />

-169-<br />

7


6/14/13 <br />

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 />

-170-<br />

8


6/14/13 <br />

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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Comorbidity of OCD <strong>and</strong> Eating Disorders<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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6/14/13 <br />

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 />

7 <br />

8 <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 />

-194-<br />

3


6/14/13 <br />

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 />

-195-<br />

4


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 />

-196-<br />

5


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 />

-197-<br />

6


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 />

-198-<br />

7


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 />

-199-<br />

8


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 />

-200-<br />

1


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 />

-201-<br />

2


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 />

-202-<br />

3


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 />

-203-<br />

4


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 />

-204-<br />

5


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 />

-205-<br />

6


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 />

-206-


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 />

-207-<br />

2


6/14/13 <br />

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 />

-208-<br />

3


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 />

-209-<br />

4


6/14/13 <br />

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 />

-210-<br />

5


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 />

-211-<br />

6


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 />

-212-<br />

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 />

-213-<br />

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 />

-214-<br />

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 />

-215-<br />

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 />

-216-<br />

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 />

-217-<br />

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 />

-219-<br />

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 />

-228-


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 />

-231-


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 />

-232-


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 />

-233-


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 />

-236-


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 />

-240-


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 />

-241-


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 />

-242-<br />

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 />

-246-<br />

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 />

SUNDAY<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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6/14/13<br />

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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6/14/13<br />

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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6/14/13<br />

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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6/14/13<br />

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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6/14/13<br />

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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6/14/13<br />

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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6/14/13<br />

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 />

SUNDAY<br />

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6/14/13<br />

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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6/14/13<br />

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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6/14/13<br />

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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6/14/13<br />

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 />

SUNDAY<br />

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6/14/13<br />

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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6/14/13<br />

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 />

SUNDAY<br />

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6/14/13<br />

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 />

-265-<br />

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-278-


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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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

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