Obsessive Compulsive Disorder 101

0:06 OK, good evening and welcome. Thank you so much for joining us tonight for the webinar, Obsessive Compulsive Disorder, 101 presented by doctor Robert …. My name is Katie Delaney. I am the Family and Medical Outreach co-ordinator at the New Jersey Center for Tourette Syndrome and … for short. I’ll be your facilitator for this evening now before I introduce doctor Zambrano. 0:39 Here are a couple of housekeeping notes. All participants are muted. 0:46 Do you have a question? Please type it in the bottom of your question box and click Send. If you have questions after tonight’s session, you can post your questions on the Wednesday webinar blog, which is access from our homepage at WWW dot NJ CTAS dot org. Under the Heading Programs. This blog will be monitored for the next seven days. 1:10 The New Jersey Center for Tourette Syndrome and Associated Disorders, its directors, and employees, assume no responsibility for the accuracy, completeness, objectivity, or usefulness of the information presented on our site. 1:25 We do not endorse any recommendations or opinions made by any member or physician, nor do we advocate any treatment. 1:35 You are responsible for your own medical decisions. 1:38 Now, it is my pleasure to introduce our speaker for the evening, doctor Robert Zambrano. Doctor Zambrano is a clinical psychological. 1:49 Doctor Rhonda is a clinical the clinical director at stress and anxiety located in East Brunswick New Jersey. Previously. She was part of the Rutgers Psychological Clinics staff for their Tourette Syndrome program. Doctor … specializes in working with children and adults with OCD, depression and other anxiety disorders as well as Tourette syndrome. She has been certified by the behavioral therapy. She has been certified by the Behavioral Therapy Training Institute which is provided by the International OCD Foundation. We’re so happy to have you here tonight doctor …. The floor is all yours. 2:31 Thank you very much Katie and thanks everybody for being here. Just give me a second. 2:35 I’m going to switch over um, and hopefully we can all see my screen. 2:44 And let’s see, it’s slideshow and should be full screen loading. So, everybody can see Katie we can see OCD 101. 2:54 Yup, you’re all good. 2:56 Thank you very much. OK, so like Katie mentioned, I’m the Clinical Director of Stress and Anxiety Services of New Jersey. We have two offices, one in East Brunswick and one of Florham Park. Although most of our therapists, these days are working via Telehealth. 3:09 So if anyone’s interested in more information about our practice, you can go to our website, which is WWW dot stress and anxiety dot com. 3:17 Oh, you know what? 3:18 Before I move forward, I forgot to have my little cluck thingy ready in front of me. 3:23 So I don’t go overtime because I know we want to save some time at the end for Q and A And I also have to send off, turn off this thing where I’m reading all these texts for my wife all of a sudden. So. Bear with me guys. 3:37 Sorry, so livestock. 3:40 OK, so our learning objectives for today is we want to know what is and is not OCD. 3:46 We want to understand the mechanisms that maintain OCD and learn about the gold standard for OCD treatment which is a sneak preview of cognitive behavioral therapy And coincidentally, the kind of therapy that I happened to do. 4:00 Number four, we want to learn about strategies for coping with the distress that can come from not engaging in compulsive behaviors. 4:09 So OCD is obsessive compulsive disorder, and let’s break down what that means. So we’re gonna start with obsessions. 4:15 So an obsession is an unwanted thought image or impulse that causes market anxiety, or distress, and attempts to ignore, suppress, or neutralize are part of OCD. It’s not simply excessive worry about real-life problems. 4:33 So it’s not what we would call generalized anxiety. 4:37 It is often irrational kind of thoughts that pop into our head that overwhelm and frighten us. 4:43 And it’s recognized as a product of one’s own minds. So, usually, not always people with OCD can say, I know this thought doesn’t make sense. I know it sounds strange and farfetched I know it’s impossible, so they’ll often preference their explanation, preface their explanation of what … 4:58 is, with statements like that, but then go into what are the the thoughts that they’re having the beliefs are happening? 5:05 Compulsions composes are repetitive behaviors or mental acts, um, that are functionally related to the obsessions, and we’ll talk in a moment about what do I mean by. 5:15 And those behaviors are aimed at reducing distress or preventing a dreaded event, so the main feature of a compulsion, is trying to neutralize the anxiety that comes from the doubts that that obsessions produce. The uncomfortable feelings you uncomfortable thought. So the compulsion is aimed at neutralizing. 5:35 those sensations. 5:36 OK, and so, disorder, we’re going to talk a little bit tonight about why this word is highlighted as well in OCD. 5:43 So if the obsessions and Compulsions cause distress, dysfunction or disorder, then it’s OCD. 5:50 Alright, So as I said earlier, we’re going to talk a little bit about the difference between what sometimes people refer to as OCD and what actually is clinically diagnosable as obsessive compulsive disorder. 6:01 But first, we’ll talk about some types of obsessions right now. Keep in mind. There’s lots of them. 6:05 And so I didn’t want to take up a lot of time listing all of the different kinds of obsessions that exist. 6:10 But if people are interested, you can Google. 6:14 The you can Google the Yale Brown, obsessive compulsive scale, or that’s called the white box. 6:20 So Y dash, B O C S, or the Children’s Version, which is the sidewalks, so C Y dash, V O C S. 6:27 And that gives you a pretty comprehensive checklist of different kinds of obsessions that people have different kinds of compulsion that people have, right. It also gives you a scoring system for rating, how intense are the obsessions and how disruptive, or the compulsions, right. So typically, when you’re working with somebody seeking treatment for OCD, these might be the kind of assessments that they ask you to complete. 6:49 And I think it’s really valuable to help clients see these, so they have a sense of, you know, what I’m suffering from is not unique. 6:56 It’s not unheard of, it’s not that rare. See? It’s right on that checklist that I’m showing you. So I think there’s value in doing that. As well as sort of getting a baseline of at the beginning of treatment. How intense are the symptoms? 7:09 And then measuring that throughout the course of treatment to just make sure that we are able to have observable change in symptoms, but anyhow in terms of types of obsessions that you might find on the white box or the sidewalks. 7:22 There’s contamination obsessions, perfectionism, obsessions, symmetry obsessions. So that’s a need for things to be. Even or straight. 7:32 Homosexual, OCD is more common than people thought, so that is a person who, let’s say, that might be heterosexual, who suddenly developes, obsessive thoughts, that they might be gay. 7:42 In fact, we can also have heterosexual OCD. 7:45 So a gay person, suddenly, having doubts, intensive doubts, sort of intrusive thoughts, that they might be straight, right? And so we’re not talking about the kinds of things that sometimes kids experience, maybe when they’re approaching adolescence or teenage years, where they have some can, you know, they’re, they’re unsure about their sexuality. 8:05 These are usually people who have pretty firmly established and that they are either heterosexual or homosexual. 8:11 But, then, suddenly, one day, these obsessive type of thoughts, sink in, and produce a lot of fear and discomfort. 8:18 There’s also relationship OCD. So, relationship OCD is kinda the kinds of thoughts. Like do I really love this person? 8:24 and then overthinking that, trying to feel the love which then you know might produce a lot of anxiety. If you start to have doubts, do I really love this person? Now, for children, that’s usually usually the object of relationship OCD might be your parents. Do I really love mommy or daddy? What if I don’t love them? I feel guilty about that so I’m constantly checking to see if I, you know, how do I actually feel about them. 8:47 And then that over analysis produces a lot of fear and becomes a compulsive behavior. 8:52 Fear of harm to self of others or others, this is a really important one, as well, because sometimes people might misconstrue what this is. 8:59 And so, I’ve worked with many people over the years, who might have intrusive thoughts about harming somebody, right? 9:04 And the thought horrifies emmitt distress, it causes them distress, um, or fear that they might harm themselves, right, So that can be an obsession, fear of loss, of essence. 9:15 So that is sort of the, the fear that, somehow I will change at its most extreme. 9:20 I’ve had cases where people believe that literally, if I touch, um, a picture, I will literally become that person. My body will transform and become someone else. 9:30 At its most common, fear of loss of essence is more like, somehow, fundamentally change, right? 9:37 That maybe I’ll go from a person who’s really kindhearted and friendly to a person who’s mean if I don’t do certain compulsions. And then the last one that I’m listing here tonight. But again, keep in mind, there’s so many more. 9:47 These are just some of the more common ones that we are aware of is our scrupulosity or religiosity. So this is an excessive fear that you may have offended God or done something immoral or unethical. 10:01 So let’s talk about the types of compulsion that can line up with that. So if you have a fear of contaminations than one of your compulsions won’t be excessive washing or cleaning. So taking long showers, washing your hands a lot, using a lot of lysol or cleaning sprays to clean surfaces or kill germs. 10:17 Sometimes people even use this to contamination fears that aren’t related to germs. So I’ve worked over the years with people who have contamination, not because they’re afraid of getting sick. 10:26 But maybe the idea that somebody else is distasteful to them or grows to them, and if they touch something that they touch, it makes them feel uncomfortable. 10:34 So the brain, an object with lysol as if that’s somehow kinda knowing that discomfort, if that makes any sense. 10:43 Avoidance is a very common compulsion that people don’t talk much about. 10:46 So, again, an example of this is a person believes that an object is contaminated, they might avoid touching it, right. Repeating behaviors, right, so having to do things over and over again. Sometimes it’s a byproduct of just sort of having an intrusive thought that if I don’t do this, something bad’s gonna happen. 11:04 Sometimes it’s more of a feeling, right? It feels wrong if I don’t do something a certain way. So I’m going to keep doing it over and over again until it feels right. 11:12 Checking compulsions, right, so going back and making sure that you did something correctly. 11:18 So a common one might be a person who’s afraid that they didn’t lock the door, might go back and check their door over and over and over again. 11:25 Even though it’s clearly established the doors lock, they might go back several times to the point where maybe they’re late for something touching compulsion. So, an example, I used to work with somebody many years ago who would have to touch their nose in a certain sequence because their OCD would tell them the obsession. The intrusive thought was, if I don’t, my loved one will die of cancer, right? So they would engage in this behavior, not because, obviously, touching your nose doesn’t actually prevent people from getting cancer. 11:58 But it really made the thought for the discomfort go away. It gave the person the illusion of control over a thing. 12:03 That wasn’t happening by the way, This particular client, um, didn’t the loved one didn’t have cancer? 12:10 But the thought was so distressing that they engaged in a behavior that gave them the illusion of control, counting rituals, right? 12:17 So, sometimes people might have to count to a certain number before they before they complete an action. 12:24 Because their OCD says, if you don’t something bad will happen. 12:28 Or they may have to count objects so counting can become a compulsion mental rituals like prayer. Well, that would line up with scrupulosity or religiosity, right? 12:36 The idea of I may have offended God, so I’m going to have to pray for forgiveness or I might have two only. 12:43 I can’t perform certain behaviors unless I’m only having a pure thought. 12:47 Right? Now the problem with that is, you know, think of it like a pink elephant phenomenon, right? 12:51 If we tell ourselves not think about pink elephants, what do we think about? 12:55 We think about pink elephants. 12:56 If we tell ourselves we’re only allowed to have pure thoughts, then sometimes we might start to have impure thoughts, right? 13:04 So sometimes people who have mental rituals related to compulsion, to religiosity might have to only think pure thoughts before they can complete a ritual mental review. This might be like trying to remember to retrace your steps, right? 13:17 So if a person is afraid of contamination, they might try and they might suddenly have a doubt. 13:23 Did I touch that toilet seat, right, That that looked dirty. Did I clean it thoroughly before I sat down? 13:30 They might mentally review like maybe the bathroom that they used an hour ago, they might go through their head and try to remember how many squares of toilet paper did I use? 13:39 Did I did, I get every single nook and cranny of the toilet paper? So, again, there might be re re reliving or mental reviewing as a compulsion. 13:48 And, again, this is just a sliver of the kinds of things that people with OCD could experience. 13:55 Now, I really did want to make sure that we talked tonight about the difference between somebody saying something like, I’m so OCD versus they actually have the diagnosis of obsessive compulsive disorder. 14:07 So people who say this are often referring to tendencies or habits, but it’s probably not OCD and it actually minimizes how much people who actually have OCD suffer. 14:15 Right. 14:17 Some people would even say that it’s kind of offensive to a person who actually has OCD and suffering tremendously for somebody say, oh, I’m so CD or I have OCD. 14:25 Right? 14:26 So some examples of probably, probably Nado CD, I should say. 14:30 Even though person says, I’m sorry, CD might be being organized, nothing wrong with being organized, Right, liking things a certain way. 14:37 You know, in and of itself, there’s nothing wrong with things being a certain way being friendly. That doesn’t mean you have OCD. Right? Generalized anxiety. So a person could be a worrier. 14:45 They might, So they’ll say, I’m obsessing about about that test that I, that I did poorly on the day before. 14:54 I’m obsessing about, you know, will I get into the college? I want to go to, right? 14:58 That’s more of an anxiety thing than it is an OCD thing because there’s no clear compulsion. 15:05 There’s no sort of irrational behavior aimed at eradicating the anxiety. Right? And of course, there’s a lot of us know tics and stereotype movements are not OCD, right? And it can be confusing because sometimes it’s hard to differentiate. So for those of you who don’t know, stereotype movement, they are often seen and folks on the autism spectrum. So these can be sort of rhythmic, movements like flapping your arms rocking back and forth, et cetera right. Now. That’s not to say that couldn’t be a compulsion. 15:30 Right. But typically, we wouldn’t identify that as OCD if people were doing that as part of a different disorder that they might be struggling. 15:38 Alright. 15:39 To give you an example of what do I mean by sort of tendencies or preferences, I actually have one of my own. 15:45 I prefer things to be even, right? 15:49 And so I have this weird little tendency, I actually literally just did it about two weeks ago, where anytime I buy dress shoes, I always buy a black pair and a brown pair. 15:59 And I take turns. 16:00 So, the next time, I’m going to wear a dress shoes today were black dress uce tomorrow. 16:05 If I were to wear a dress shoes, I would wear the brown bear, right? So, I like things to be even, I like each shoe to have its own turn so that I’m being fair to both pairs of shoes. 16:14 Now, again, this doesn’t cause me distress. 16:17 This doesn’t cause me disfunction, So, if, today, if tomorrow, I decided, know what, I’ll wear the black shoes or somebody, if tomorrow somebody said, Oh, please make sure you wear black shoes because of the event requires it. 16:29 That wouldn’t bother me. I wouldn’t struggle with it. 16:31 It wouldn’t cause me a lot of distress or anxiety or dysfunction. 16:35 But let’s say if I did have OCD right? And maybe if that was my OCD I might be paralyzed by like I can’t wear the black shoes tomorrow because something terrible happened if I do. So that’s the difference, right? 16:47 So I have a, I have a tendency, I have a preference, um, but there’s no distressed component to that. So even though we could say, Oh, there’s there’s an obsession with evenness, and the compulsion is taking turns with the shoes, it doesn’t in any way functionally interfere with me and I can easily not do it. 17:07 Again, now let’s talk about I have OCD so X Some examples of actual OCD might be spending hours, organizing and agonizing over doing it correctly and being late for things because you don’t feel like you can stop. 17:19 That’s a clear example of a person struggling with OCD, ranging objects in a certain way and melting down if someone moves it, because it took you forever to get it right. 17:30 That would be an example of OCD. 17:32 Washing your hands. So often that your skin is damaged or using chemicals to clean things and the thing gets ruined. I’ve worked with many clients over the years, and they often think that they’re the only ones. I’ve worked with many clients, who have, had gone through numerous computers because they’re constantly cleaning the keyboard, because it feels contaminated. 17:51 But then some of those chemicals seep, in, underneath the keyboard and damage. 17:57 The, I’m not a tech guy. So, I guess we call it the motherboard underneath. So that would be an X because again, an example of the compulsion causing a lot of distraught disorder distress destruction. In this case, right, So, a lot of these. 18:11 Some more examples of I have OCD fearing that certain thoughts offend God, so you pray all day long or repeat actions until your thoughts are pure. 18:20 Fearing you could lose control and harm someone so you’ll stay away from sharp objects, avoid being alone with loved ones and are constantly trying to figure out if you are actually dangerous to somebody. 18:31 I’ve seen a lot of that over the years actually really enjoy treating it because, you know, it’s great to see people who suffer so much get a lot better, fear that you said something racist. 18:42 So you try to remember every word you said during conversation. Now, again, this would typically be a person who isn’t racist, doesn’t say racist things. 18:50 But their OCD might say, hey, during that conversation, are you sure you didn’t say something racist? And there’ll be so distressed by the idea that they start mentally reviewing, trying to remember the entire conversation word for word. At its worst they might start texting people, Hey, during our conversation, did I say anything that offended you or that sounded weird, right? So, things like that would be compulsive. 19:11 And again, sort of an a clear example of OCD fear that you don’t really love someone. So you keep trying to figure out how you feel or constantly need to prove it to yourself. Right. now it’s really hard to be in touch with your feelings of love if you’re also having a panic attack. Right. 19:28 So sometimes when people have OCD, the idea that maybe I don’t love this person causes such intense anxiety and panic that they can’t access those loving feelings and it almost in their mind fuel’s the idea of maybe I don’t love them and then they go back into compulsive trying to figure it out. 19:44 Right. one of the things that, you know, we we really try and teach our patients to understand is OCD is all about doubt, right? 19:50 And so, the key to the therapy is helping them learn how to tolerate that or practice tolerating data, I should say. 19:57 So, I like to call this slide, The perfectionism example. Some of you may have noticed, some of you might not have that throughout the slides. 20:06 So far, there have been a few grammatical errors, spelling errors, inconsistencies in formatting, right. 20:17 And some of them are intentional, some of them I may have missed, or some of them I kinda noticed, but I was just too lazy to fix. 20:25 So, if you noticed it, or it annoys you, that doesn’t mean you have OCD. 20:30 Alright, I’m pretty sure that somebody must have noticed that I misspelled perfectionism on one of the previous slides, right? 20:37 Now, if you were the one creating the presentation, and it took you several hours extra, to prepare it, because you are checking rechecking, constantly, making sure that you didn’t make any errors, right. 20:49 Excessively bothered by formatting errors, and things not looking right. 20:55 Um, then, that might be, again, a clear example of OCD. 21:00 So, and by the way, just another plug for a New Jersey Center for Tourette syndrome. 21:06 I am just one of the many participants in the Wednesday webinar series, one of the really brilliant doctors in our practice, doctor Divorce Sure. Recently, a few weeks ago gave a presentation on perfectionism which is, again, a specific form of OCD. 21:20 And she talks a lot about what a major struggle that is for some kids with OCD and in adults with OCD as well. 21:28 one of the things that I really like to talk about with folks who struggle with perfectionism is that we’re trying to teach them to pursue excellence rather than perfection. And we talk about how the pursuit of perfection really interferes with your ability to be accidentally excellent, because it’s overwhelming it’s burdensome, it takes excessive amounts of time. 21:44 Often perfectionists can’t get homework done in time because they spend so much time trying to make sure it’s perfect. I’ve had Perfectionist, who won’t hand in homework because they’d rather get a zero than hand in something that isn’t perfect. 21:56 Right? 21:56 So, again, we talk about how perfectionism actually gets in the way of pursuing excellence rather than making you perfect. So, for more on perfectionism, go to a new … dot org. And look up their webinar series. 22:09 So, as I mentioned earlier, IMA Cognitive Behavioral Therapist Proceeding. And we wanted to talk a little bit briefly about the efficacy. 22:16 So, CBT for OCD has been around for approximately 50 years and is the most empirically supported form of psychotherapy for OCD. 22:24 So what does that mean? 22:24 There’s been a lot of studies because it follows a certain protocol, Right, And so, when therapies follow specific steps, there’s a treatment manual, there’s a protocol, you can compare it to a placebo, you can compare it to medication. 22:37 You can compare it to other Therapy’s, it also have replicable, um, format’s, right. 22:43 And so, consistently over years, various studies have shown that 65 to 80% of clients who complete treatment show a statistically significant reduction in symptoms on average treatment can last up to 16 sessions and most experienced significant improvement by session eight. 22:59 But results in treatment and treatment lengths can vary. But again, the really important point is that there is no other form of psychotherapy that has this, must research behind it, that says, this is really effective. And so, that’s why it’s considered largely the gold standard and don’t take my word for it. 23:16 If you guys were to Google treatment for OCD, you’re going to see a lot of ****. 23:23 References to CBT cognitive behavioral therapy. You’re also going to see a lot of references to something that I’m about to talk about. 23:30 Might be the next slide I’ll talk about in a few slides. Sorry. 23:33 So, we also, of course, when we work with kids, we want to equip them with tools. So, a really, simple tool is a fear thermometer, right? So, we want to ask kids that we work with, How difficult is it to do something? 23:45 Right? And we give them ratings so one being no problem. three, I’m a little uneasy five. Maybe I can resist but I’m not sure seven, I don’t think so nine. It’s really hard. 10. 23:54 No way possible, right? 23:56 Some kids have a hard time, or actually perfectionist might overthink, right? 24:01 The scale, right? I don’t know, maybe it’s a five, but maybe it’s a four. Maybe it’s a two, I don’t know. 24:06 And so, with kids like that, I might give them more of a, like, uh, green, yellow, red, right? 24:13 Or cold getting warm or hot, But we can find different, creative rais ways to help them rate. How difficult would certain things be? 24:22 For them, how difficult are certain things? Typically normal behaviors, but might that might be made difficult for them. So if again, going back to an example, I’ll probably reference a lot tonight. 24:33 If you have a fear of contamination or germs, I might ask somebody how difficult would it be for you to touch that door **** and not wash your hands? 24:41 Um, and I want them to give me a score, and if they say that’s a 10, then I might ask them some easier versions, What about this, what about this? And so we really want to have a robust hierarchy with lots of different options in terms of different behaviors that we can work towards. 24:57 So speaking of hierarchy, so again, I might have clients and parents, of course, you’re gonna be a big help with this because especially with younger kids, they may have a harder time explaining themselves or listing or even acknowledging or understanding of. They have OCD. So I would want them to list maybe like, let’s start with the 5, 5 situations that cause me distress, anxiety or the urge to ritualized and again, with kids, I might use more kid friendly. 25:21 Terminology. 25:22 So I wouldn’t say urged or ritualized but I might talk about habits that they’d have to engage in like you know, washing your hands after you touch a pen that belong to somebody else. Right? 25:33 How much anxiety? 25:34 Would it cause you to touch that pen, right? You can see at the bottom part, describe five rituals. Again, I might use habits you engage in and how much time they take and how often you do them. This is a good thing for us to list because it also aids motivation. We want to help people really get in touch with like how time consuming and how difficult it is. 25:54 So, if somebody puts, look upon this list, it takes me an hour to shower because I can’t get out until I feel perfectly clean. 26:02 And then they might say after I shower and I am perfectly clean, I have to be extremely careful before I go into my bedroom because if I accidentally bump up against something, now I’m contaminated and I either have to take a shower again or I can’t go into my bedroom because I run the risk of contaminating my bedroom. 26:16 Alright, so again, it’s really great to have kids and adults list, you know? 26:22 What are the rituals? How time consuming? Are they how disruptive are they? And so it really sets the stage for what we want to do. 26:28 And that’s anthropomorphizing OCD why I said that word correctly. I can almost always struggled to nail it. 26:35 Yes. 26:36 So what is anthropomorphizing? 26:38 It’s teaching kids to see their fears as a bully that’s bossing them around. 26:42 And we often have the kids give that Boolean name and teach the child that we’re going to be bossing back. 26:48 And we boss back by ignoring what the bullies telling us to do or do the opposite of what the bully tells us to do right. So I think SpongeBob is still popular, but, if not, OK, sorry, for the data reference, But this is a drawing of one of the characters in SpongeBob called plankton and plankton. If you’ve ever watched SpongeBob has like this nefarious, scary, deep voice. 27:09 And, you know, he has all these plots to steal the crabby patties and what have you. But then, one of the things we try and help kids realize is … is actually very small. 27:18 He’s not strong enough to actually do any harm, but he talks a big game. So that’s against kind of how we want to frame OCD. 27:26 So sometimes we have people draw things in therapy. So these were donated by clients over the years, who gave us permission to share these slides. 27:33 So this person drew a monster is a very New Jersey term for any of you who are watching from Outside of Jersey Scotch. Right, so I’m not Italian. The name sounds of time, actually, Columbia, but I’ve been told by my town inferences, which is something that’s like annoying, or, you know, a pest. 27:50 Right? So there’s scotch. You do what I say, says, Scotch. 27:55 Mister pushy, By the way, this was drawn in February 2000 by somebody who I think was like 7 or 8 at the time. So this kid is probably in there. Like, late twenties, early thirties. Yeah, I’m not good at math. 28:09 But I’m not a perfectionist. So who cares? So? Here’s mister Pushy, He’s roaring. 28:15 He’s an animal formation, he’s got claws and sharp teeth and spikes all over. So again, we really want to help kids identify this is our enemy, This is the person who is pushing us around passing us around telling us what to do. We’re gonna push them back, We’re going to boss back, we’re not letting him or her control us anymore. 28:34 So, again, we want to help them stand up to the bully. 28:38 And, so, we often use metaphors in storytelling a lot in our practice. 28:43 So we might use the metaphor of: If a bully threatens you for money, what do you do? 28:47 What happens if you give it? 28:50 Now, the problem is if you give the bully money, he learns, or she learns. If I threaten you every day, I’ll get more money out of you. 28:57 They’re usually not reasonable, They don’t go, Oh, this nice lab gave me a dollar. I think I’ll take it and put it in my piggy bank and never bother him again. It’s a hub. All these operate. 29:06 Right. Now, sometimes because bullies are scary. We we can say, Well, I could hide I could avoid, which again is a compulsion. 29:12 But what we know is avoidance is a compulsion that doesn’t do anything to prevent the bully from being a major factor in our lives. And that means we have to spend the rest of the school year. If we stick with the metaphor hiding from the bully and that’s really unpleasant, that’s really anxiety provoking, Right? So we instead talk about what happens when you fight back. 29:30 Right? And it turns out the bullies don’t like going after the kids who fight back there a lot more work. 29:35 Right. That doesn’t mean, you know, might not get punched. So sometimes fighting back hurts, it’s difficult, it’s uncomfortable. 29:41 But we want to teach kids that in the long run. it’s the best thing to do so that the bully doesn’t control our lives. 29:48 So again, this is another drawing. On the right is the bully saying, go wash your hands. And this is the child saying, no, I won’t listen to you. 29:56 So with younger kids, I think that again, these are really good examples that sort of set them up for the work we want them to do. 30:03 I also use storytelling a lot. 30:04 So, one of the stories I share is, you know, what would you say and this is about sort of responding to your your OCD with logic, which never works, right? So, if you’re OCD says you’re the Queen of France. Right? 30:16 Well, I could try and convince OCD that I’m not the queen of France. I can say, Well, how could I be the Queen of France? 30:22 I’m a guy, right, and I was born in Plainfield New Jersey and my parents or Columbia. And we’ve never even been to France like, How could I possibly be, the Queen of France, and OECD is just gonna look at me and go, Man, you’re the queen of France. And then I could say, Well, let me show you my birth certificate. See, I was born to paint them Jersey. Like I told you. Right now, you’re the Queen of France, and it’s never going to stop. 30:40 So the more we talk with OCD, the more we interact with it. All we’re doing is we’re getting its attention. And that’s what the bully wants from us. It wants us to do what it, what we tell it to do, and it wants a lot of our attention. 30:51 So we don’t want to keep this conversation going. 30:54 So metaphorically speaking, what we do is sometimes when OECD says, Oh, you’re the queen of France, it says Something that we know, sounds irrational and illogical. 31:02 We have to learn to just say, Yeah, maybe, and we walk away. 31:06 So that’s an example of sort of resisting trying to eliminate doubt. 31:10 Instead, we, we respond with a doubting phrase. Maybe. Yeah. We’ll see. I don’t know. 31:16 We’re not trying to gain certainty because OCD is the desperate attempt to get certainty around doubt. 31:22 I doubt that I might have, I’m feeling this doubt that I might get diseases from touching pens and door *****. So I’m going to wash my hands until the doubt goes away. 31:31 Versus just being able to say, I acknowledge it’s really, really, really unlikely that I’ll get aids from that doorknobs, so I’m going to touch it. And if OCD goes, you’re gonna get aids. 31:40 As creepy as it sounds, we’re not going to wash your hands, and we’re just gonna say, yeah, maybe don’t feed the cats. 31:47 Our fears behave like Meowing Katz asking to be fed. 31:50 If we feed the cat, it comes back the next day and brings its friends. 31:53 So what, you know, So often, I ask, kids, well, What should we do? If the cat has learned that when it meows, you’re going to feed it? And every kid will say, Oh, you have to stop feeding it. 32:07 Now, that doesn’t mean the cats go away right away. 32:10 Maybe the first few and I say, meow even louder because they’re just thinking, Hey, this person forgot to give me my cat food. I need to get their attention. 32:17 But I tell people that if we stick to our guns, I gotta get rid of that term, by the way. 32:23 If we, if we commit to not giving in eventually, the cat goes away and, again, that’s like a metaphor for OCD when we don’t give in to compulsions right When we don’t keep keep giving the CAAT what it wants. 32:36 The OC or in this case, I’m sorry, the when we don’t give OCD the compulsion is when we don’t give it what it wants. It does weaken and eventually fades away. 32:43 That doesn’t mean we cure OCD. 32:45 It might something new might pop up, but at least now we know how to respond to it more effective. 32:50 So all of this that I’ve been talking about is what we call exposure and response prevention. 32:55 So in a lot of research when I was in grad school you would always see ERP and more recently they often write E X RP but again both stands for Exposure and Response Prevention. Right. Sometimes people say exposure with response prevention as well. 33:10 So basically whatever OCD tells you to do, you do the opposite. 33:14 So you trigger your anxiety on purpose and you don’t do compulsions to make the anxiety go away. 33:21 Alright, so that might sound weird. 33:22 Why would I trigger my anxiety on purpose, right? 33:26 and so we have to do a really good job of explaining why it’s going to help, how it’s going to. 33:31 Right, So what are some forms of exposure? 33:35 So I often explain the difference between scheduled exposure versus serendipitous exposure. 33:39 So scheduled exposure might be, let’s say, the person who believes that if I don’t touch, mind knows three times every time the phone rings that someone will die. 33:52 Well, schedule exposure might be, I’m going to call you at a certain time, and you can’t touch your nose, Right? You’re just going to have to sit there and deal with the anxiety you experience. Because, again, we’re going to try to remind, especially with younger children, who may not get it. 34:06 We’re going to try and mine them. 34:07 Touching your nose has nothing to do with whether or not somebody lives or dies. It’s really about OCD, being a mean bully who’s messing with you and trying to get you to do silly things. 34:17 Trump by scaring it. 34:19 But we’re going to be brave and we’re not going to give in and do irrational things that don’t make sense. 34:24 But when we do schedule exposure, we’re gonna pick the fight with the bully. 34:27 We’re going to trigger the discomfort, but not give into it. 34:30 Now, serendipitous is more like when it happens by accident. 34:33 So, I had a great example not too long ago where a client that they worked with who has contamination, OCD, tripped, and accidentally touched a wall that he thought somebody might have sneezed on, right? So he hadn’t planned on it, right? 34:48 In fact, he was to usually kind of stays away from the walls because he just, in his mind, can surfaces are contaminated, but he tripped his hand, touched it. And I was really proud of him because he made a decision not to wash his hands, and, in fact, he went around and like, he used his pen, he touched his book bag. 35:06 He spread the contamination, right? So he went, once he, once he did that, he realized, Oh, I can handle these feelings. 35:13 Right now, in terms of, you know, so not just, how do you know when exposure can occur but there’s three types of exposure. We often talk about. one is in vivo. 35:22 That’s when, again, we literally do the thing that makes us uncomfortable, Right? So, if you have germ fears, you touch the thing that you think has germs, right? 35:30 If you have negative thoughts and you want to type tapir knows, I make you think the negative thought on purpose and don’t touch your tap. You know, so we’re, we’re doing, we’re making, you do the thing that makes you uncomfortable and we’re not allowing you to do or you’re choosing, I should say, you’re choosing not to do the compulsion. 35:47 Right? So that’s in vivo exposure. 35:49 Imagine all, is it is an add on. So, we might imagine the thing that makes us really uncomfortable says, as dark as this might sound, the person who’s afraid that a loved one will die if they don’t tap their nose. 35:59 I might have the client close her eyes and imagine that loved one dying. 36:03 And they’re just standing there with their arms folded. You know, it’s their fault, because he didn’t touch their nose, right? Again, we only do this if we have a strong sense that people know, this doesn’t make sense, and, you know, they understand, it’s just an uncomfortable thought, this couldn’t actually happen. 36:18 Right? Now, as a side note, we don’t want to talk too much about that, because we don’t want to re-assure them that it’s definitely going to happen. 36:25 We’re just sort of starting with the idea of, I know it’s not going to happen, and now I’m just going to do it anyway. And I’m not going to re-assure myself. 36:33 Now, scripting. Similar to manual exposure, you might write a story. Sometimes, we refer to as a flooding scripts. 36:38 So again, the person might write a story and read the story, repeat the story several times about, Again, that, like, I didn’t touch my nose when I could have, and I was right all along, that I had some sort of magic power, and because of that, my loved one passed away, and it’s all my fault, and everybody’s going to hate me. And I’m a terrible person, because it would have been so easy for me to touch my nose. So we’re really laying it on thick. 36:59 We’re really telling the horror story that the person tries to avoid by engaging in compulsions, right? 37:06 So these are all different forms of exposure and response prevention. 37:12 So why would I do something that makes me feel bad? 37:15 And the answer is because it helps By facing our fears, our bodies get used to the uncomfortable sensations. 37:20 This is often called habituation and desensitization. So I have a slide here, the images of people jumping into an ice. 37:27 I guess like an ice hole somewhere, right. Make sure I pronounce that properly ice hole. 37:32 So, and so, the metaphor that I give, folks, that I work with when explaining exposure therapy, as I said, have you ever jumped into a swimming pool that was a little bit too cold? And they say, Sure. And I’ll say, What does your body wants to do? And they’ll typically tell me, I want to jump out to call it, I don’t like how it feels. 37:50 And I say, Well, what happens if you stay in the pool anyway? 37:53 And they say, Eventually, I get used to it. So it’s not that the water gets warmer. It’s that our bodies habituate are desensitized to the cold water. 38:01 Right now I’ll ask them the opposite. What happens if you jump out of the pool? 38:05 Right. Well, then, I’ll never get used to the temperature of the water, if I keep jumping out. 38:12 So, when kids do compulsions, they deny themselves the opportunity to see that, that the anxiety won’t persist forever. It can go away without resorting to rituals. 38:20 That feared outcomes about getting sick from using a public washroom, for example, for example, are highly unlikely to occur. 38:29 Now, one of the most important questions that we ask, after having somebody do their ERP exercise is, what did you learn from that experience, right? They’ll often talk about how awful it was. You know, I felt really bad. I really hated it. 38:41 I don’t want to do that again, but we can also say, But what you learned is you’re resilient. You could handle the uncomfortable feelings. 38:49 If we’re lucky, by the end of this session, they might be able to say, I’m not that anxious anymore. I feel OK. 38:54 Right, but if they’re even if they leave the room, feeling still anxious, I know they’re going to come back next week, hopefully, And, I might ask them: So, what was the week like? Were you in a state of terror for the entire Week? And almost all Wilson, always. 39:07 They’ll say, no, not really, it got a little bit better, like, maybe the next day. 39:11 And so, even then we can say Great, that proves that exposure works, right, that you can do difficult things, You don’t have to do Compulsions which strengthens and feeds your OCD and you can tolerate that discomfort. 39:25 So that’s what we can learn. 39:27 So, we don’t want to teach them about the vicious cycle of OCD. 39:30 So when we have OCD, we might be exposed to a trigger, some kind of intrusive thought, Or some sort of thing makes us think the uncomfortable thought, and our anxiety starts to decline. 39:42 Now if we engage in avoidance behavior, that would be a compulsion, our anxiety does drop quickly. 39:47 But the thing is, we never had the opportunity to habituate to desensitize and the next time that trigger happens. 39:53 The whole process happens again and nothing changes. 39:56 Right? 39:57 So I say to my clients, I understand why you do compulsions, who wouldn’t initially, right? I feel really uncomfortable. I wash my hands, I don’t feel uncomfortable anymore. I feel really scared. I tap my nose, and I spend three times and less scared anymore. Makes sense, It’s so easy to do, right? 40:12 But the problem is CDF spirals out of control and demands more and more of your time and it becomes more disfunctional more disruptive, and it extends to more and more triggers. Right? 40:21 So it’s actually really important that we helped them get over this peak. Now, what happens when they do? 40:29 So this is the outcome of repeated exposure and response prevention, and again, response prevention is important because that’s when we bailout. 40:36 So let’s say the first time we do exposure, we climb that curve. 40:39 The peak, the panic peaks, but then it comes down. 40:44 Alright, And it starts to get easier and we start to see that, OK, I can handle having anxiety. Even if it’s really intense But I don’t have to do a compulsion to make it go away, I just have to wait it out. 40:55 And then if we keep doing it repeatedly, it just gets easier and easier. 40:59 You see the kerb doesn’t peak quite as much, and it doesn’t take quite as long for the anxiety to go down. So again, that’s habituation. 41:08 So how do we deal with the anxiety? That’s a really hard thing, right. We’re asking people to do something that makes them really uncomfortable. 41:16 So we start by making sure we aren’t unintentionally sustaining it. That’s really important. So often clients will tell me, I did exposure, doctors and Brown, and I didn’t feel better. I didn’t desensitize it felt horrible. And I ended up washing my hands or tapping my nose or doing some sort of irrational compulsion. Right? 41:32 And and you know, Sometimes they say and I waited hours and it didn’t go away, it didn’t get better. Right? So one of the first things I want to ask them is, might they be doing a compulsion that again because this is called exposure and response prevention, not exposure and go wash your hands right away. 41:47 Right. But often people don’t realize they’re doing compulsions right. So maybe if they’re seeking reassurance, if they touch a door **** and they’re asking their parents, are you sure I’m gonna be OK? You don’t think, I’m gonna get aids, right? Now they think they’re thinking about it, They’re talking about it, they’re obsessing about it. They’re fueling their fear, right? 42:03 They’re staying engaged with the anxiety rather than sort of just allowing themselves to experience it and watching it fade away. 42:11 Right. 42:13 And so when people do compulsions I, the metaphors I use is they say, I’d rather you not do exposure. 42:19 Sure, if you’re going to do a compulsion afterwards, it’s like eating a bag of oreos while running on a treadmill, right, It’s counter-productive if you’re running into trouble because you want to get in shape, but you’re eating that bag of oreos at the same time. 42:30 What’s the point? Right? I mean, Oreos are pretty awesome. 42:32 But, uh, it probably is counter-productive to our goals, right? Now, what do I mean by don’t shake the snow globe? Right? 42:40 one of the things that we try and teach people is not, how do I make the anxiety go away? 42:44 Because that that sells the idea that you should make your anxiety Goe that anxiety is a bad thing that you can’t handle versus it’s a natural, normal part of our brains design. And that all we have to do is sit still. 42:58 Right. So think of how think of a snow globe, right? 43:02 Usually, when you see a snow globe just sitting there, all the snow is on the bottom. 43:05 But if you pick it up and you shake it, then we see the snow all over the place, right? 43:11 And that’s kind of how our emotions can be when our OCD is triggered, right? It really shakes us. And now we’re kind of in a swirl, the snowstorm of emotion, right? 43:20 The problem is, if we’re doing compulsions or forth doing mental rituals, or where preoccupied with the anxiety and fixating on it, what we’re really doing is we keep shaking the globe over and over and over again. 43:33 And we know what happens when we keeps shaking snow globes. 43:36 The snow never is allowed to settle, right? 43:40 And so again, this is a, this is a thing that I try and teach my clients, is that you may be unintentionally shaking that snow globe without realizing it, by trying to re-assure yourself by trying to resist your and suppress your feelings. 43:53 And even a simple relaxation technique honestly can be an attempt to suppress feelings. 43:58 So instead, we try to teach people to deal with it differently. So I teach them to ride the wave. 44:03 So instead, we might teach them to patiently sit and watch their feelings using mindfulness techniques, right. 44:10 So if I have somebody to exposure and they say, OK, I feel really anxious. I really wanna go wash my hands. I said, well, just look, let’s see if you can sit with me. Let’s see if we can delay just a little bit longer. 44:18 And I’ll ask them, where do you feel the anxiety? 44:21 And they’ll say, oh my heart is pounding, my stomach is in knots. I feel nauseous, OK. Let’s sit there for like a minute, and I’ll pull up my timer, my stopwatch. 44:29 So I want you to sit there for a minute. I want you to really focus on those feelings. 44:33 I want you to notice your heart pounding, I want you to feel that, not in your stomach and just Explore it, almost like an explorer Who’s curious about it? 44:42 Right? 44:44 And what that does is it switches up the relationship. 44:49 Instead of trying to suppress it, or be afraid of it, they’re kind of just, like, willing to experience it, and watch it, and if they do it long enough, then I might say, after that one minute, OK, Now let’s just sit here with those feelings so you don’t have to focus on it, like I asked you to, for that whole minute and good job. 45:04 You did a great job sitting there with it for a minute. You usually don’t do that. 45:09 I had you really, really focus on it, and you, you’re still here, you’re still OK. 45:13 Now, let’s kinda just switch to While you’re feeling this, tell me what else you can feel. 45:20 What else do you notice? So they might say, well, my stomach is still in knots, OK, what else? Well, the room’s kind of cold, OK, what else? 45:28 My throat is kind of dry, OK, What else? 45:30 My lips are a little chapped, OK, with us. 45:34 I’m sitting on this chair and it’s really cushioning, OK, what else? 45:37 Now, if you’re an old person like me, my hip feels kinda sorry. But if it’s a young kid, it might be like, what do you smell? What do you see? What are you here? 45:44 Now we’re not trying to distract them. So I don’t want you guys to get confused. It’s not about distraction. It’s about OK. 45:50 We’re going to sit here with these really uncomfortable feelings. 45:52 But they’re not the only feelings that are present. They’re not the only thoughts or sensations that are present. 45:58 Right? 45:59 And that but in doing this, sometimes people just notice that, oh, my stomach doesn’t hurt as much anymore, my heart’s, not pounding as hard as it used to, right? 46:10 And it also has the added benefit of sort of maybe by focusing more on what’s present, we don’t go into the place where we’re thinking about what we just did too much, right? And so, it maybe just sort of allows the snow globe to settle. 46:24 On the other hand, sometimes we can add an exposure to the exposure. 46:28 So, sometimes adding a magical exposure and or scripting helps desensitization happen more quickly right? So person might touch the door **** and again think, Oh, no, that door **** was covered? You know, that door, and I’m gonna give me aids. That’s a thought This distressing right, so I might say OK, let’s touch the doorknob when you’re when you were at that part of the hierarchy? 46:46 And let’s maybe kinda just go all in. 46:49 You’re going to close your eyes and imagine, and now I have aids and, you know, I imagined the doctor telling me, oh, you shouldn’t have touch that doorknob, right? Because it was covered needs, in your hand, had a huge gash on it that you somehow didn’t notice. And now, you know, And, again, I know this sounds really intense, Obviously, we’re going to do it in an age appropriate way, depending on who we’re working with. 47:07 Alright. But the idea is we can add an exposure to exposure. We can imagine something, we can tell a story. 47:12 Sometimes we tell the story in a very vivid way, but it helps us get in touch with how ridiculous the story might sound, or how far fetched and unlikely it is. 47:21 We’re almost out of time before Q and A So in terms of OCD treatment goals, we want to teach people not to suppress anxiety or make it go away, but rather we’re learning how to function in spite of the anxiety and trusting that it goes away on its own, and, heck, even if it doesn’t. 47:36 Then we’re not as quickly as you wanted to. Then, when we learn, we’re resilient. 47:41 I can manage some level of anxiety and still function and do all the things that are meaningful to me that I want to do. And I’m not going to let OCD stop. 47:48 Right? So again, our goal is to manage, not eliminate uncomfortable. 47:53 Some rules for exposure for families. This is really important. 47:56 It’s helpful to assess how much a child believes their obsessions as this can be a major obstacle to ERP. So there’s no way I’m gonna get somebody to touch the doorknob if they 100% actually think they’re going to die. 48:07 But if I can get them to say, I know it’s farfetched. 48:09 It’s really unlikely and I’m willing to take the risk, right? 48:14 Usually, people only are willing to take the risk if they can acknowledge the risk is pretty small, Right? And I often use the metaphor of, like, well, did you drive in a car today? Most days, people do, right? 48:24 And I asked them, could you have died in a car accident today? 48:27 Right. And they ultimately say, Yeah, that happens. It’s possible. And we’ll say, So you took a risk. 48:32 You took a risk of something terrible happening, and it turns out for us to live normal lives that we have to be able to take risks every day. 48:39 And I would think that there’s a greater chance that somebody will die from a car accident than they will from a doorknob. 48:44 So, again, these are the kinds of sort of ways that we help people get in touch with, know how unrealistic their obsessions are. And maybe that motivates them to take these risks. Because they’re not really risks. 48:55 They’re so in infinitesimally unlikely to happen that that we try and get them to take that leap of faith. 49:04 Families may have to figure out if they are somehow enabling avoid behaviors or rituals, and work on slowly pulling out of such behaviors. 49:11 And we then provide the child with specific deadlines. 49:13 So, one example, again, might be the parent who, the child who’s afraid that something terrible happened to their parent. So the parent maybe sleeps in the same room with them to, you know, because they’re too afraid to be separated. 49:27 Right. That’s an enabling behavior that sustains the fear. 49:30 The parent who buys the child, tons and tons of paper products and cleaning products, so that they can clean the house excessively to the child’s standards. 49:42 I get why parents do it, they don’t want their children suffer. But, in the long run, it gets in the way of the therapy, and then enables and feeds. The OCD. Now, child should never be forced to do ERP. 49:51 ERP should never be a surprise. 49:52 So if a person has no again, a superstitious fear, for example, like that. 50:01 If I drive past a great graveyard, somebody I love will die, Right? I wouldn’t say the parents should, like drag the child into the car and then we’re going to drive history, Graveyards, like it or not. 50:11 That should be something that we’re trying to get the child to agree to work on. 50:15 Right? So ERP should never be force. It should never be surprised. 50:17 But maybe, again, we can create situations by not enabling it where the child is kind of, has no other choice, right? But to, OK, I’m going to have to confront this. And we also want to make sure that everybody understands that … OECD only wins. 50:31 If you don’t try to fight it, we’re going to have a lot of missteps. We’re going to have a lot of struggles. 50:36 It’s not always going to be a straight line to improvement, but we have to be station patient, and have realistic goals. 50:43 Don’t take no for an answer. If if the child says I can’t do it, then S find out what they can do. 50:47 Can’t touch that doorknob, OK? 50:49 What if I touched the tissue to the doorknob? Could you then touch the tissue? Can’t do that. 50:53 What if I touch the tissue to the doorknob, and then touch depend to the tissue and then, touch the dependent touch the tissue that touch the doorknob, touch to to another tissue? 51:02 If we try hard enough, I can find something that the child will say, this makes me uncomfortable, but it doesn’t overwhelm me. And that’s usually a good starting point. 51:11 If the child can’t 100% percent prevent themselves from engaging in a ritual, then the goal is to delay or alter the ritual. 51:17 Whenever possible, inject humor and celebrate all successes. 51:20 Be sure you are always pointing out the progress you’re chubs making. No step is too small so long as we keep moving forward. 51:27 Right. So this is really important for parents, because you could get frustrated, how long it’s taking. But if we’re seeing forward movement, if we’re seeing progress, we want to encourage it while continuing to push. I believe you can do so much more. 51:38 Let’s keep at it. So our job is to motivate and push, but not force. 51:42 Um, against somebody’s will. 51:48 If there’s motivation issues, we want to help children understand what anxiety stops them from being able to do, right, not being able to do these things. Makes me feel Blanck. 51:56 Some things I’d like to do when I’m less anxious are link, Right, So so, again, helping them sort of really see what an … 52:03 is and how much better life can be after, they’ve dealt with it properly. 52:06 We want to empathize with the child’s fears but give them the confidence that you believe that they can get better, and you will help in this process. 52:12 You may have to include a system of rewards for participating in those in ERP therapy. 52:18 So, that brings us to the end of the presentation. You guys have copies of my slides, so, some suggested readings. My boss, the head of our practice. Doctor … Weg, wrote a really fantastic book called OCD Treatment Through Storytelling. We in our practice you. 52:32 This a lot, Irene Wagner who I have some slides from her previous presentation. She writes a really good book for younger children called Up and down the Worry Hill. 52:43 There’s also OCD in children and adolescents, a cognitive behavioral treatment manual. This is an excellent guide for therapists who want to understand more about how to treat OCD. 52:54 But I’d highly recommend John March, also, a big name in our field, talking back to OCD. 52:59 And this is more sort of for, like, uh, adolescence. 53:03 So that brings me to the end of this portion of the presentation. 53:10 And thanks for listening everybody. So do we have any questions? First and foremost, thank you so so much. 53:18 We greatly, greatly officiate you coming and facilitating this webinar. So we do have a couple of questions. Awesome. Our first question is how can you tell if it is OCD or a phobia? 53:34 My son seems like he has a fear of fruit. 53:38 If someone touches an apple, they have to wash their hands after before touching something that she will touch. 53:45 Hmm. Hmm, hmm. 53:47 It sounds like a contamination OCD, right? 53:50 So, if, if I understood Katie correctly that that, if someone else touches the apple, then, you know, they have to wash. Your hands are clean The surface right? So, phobia would be more like, if I’m exposed to the apple or the fruit And it brightens me. 54:04 But there’s no actual compulsion involved, no like cleaning behavior. 54:09 If it’s just if it’s just a avoidance, then I’d say that’s more of a phobia. 54:12 If it’s I am now making people clean or doing some again, some sort of ritualistic type of behavior to negate that anxiety, then it’s OCD. 54:22 OK, thank you. 54:24 Yeah, next question is I find that talking to myself gets me through. You say you don’t talk to it. I logic myself out of stuff to a point. To a point I can function please comment on this given your comment on not talking to it. 54:40 Sure. 54:41 I think if you have OCD and your logic in your logic in your way out of it let’s refer back to that slide where we talk about the D and the disorder right. If that’s if it’s a simple phrase that you can say, OK, I know that’s not realistic. I would never do that. Or that’s, that’s impossible or unlikely. 54:57 I don’t have a big problem with that. Right. If you’re constantly doing it throughout the day, right. 55:02 If you’re constantly having to re-assure yourself spending a lot of time thinking about, so the point too, that you’re driven to distraction or it gets in the way of getting stuff done, then we could say, well that’s problematic, because it’s a compulsion, right? Versus at some point we have to just be able to say. that is so far fetched. That is so unlikely, just like, and that’s the Queen of France story. 55:22 Right. 55:22 If somebody accuses me of being the queen of France, um, I don’t have to prove anything to them. 55:28 I know I’m not the Queen of France. 55:30 It’s ridiculous for me to have to present evidence, And I know maybe it, maybe my desire is, I want this person to stop calling me the queen of France. 55:38 So I’ll present all my data and information over and over again, and maybe maybe that person will shut up and go away. 55:45 Right? 55:45 But then I’m going to have to do it again the next time he shows up, Right? So perhaps at some point, I have to just be willing to say. 55:53 And I have to be really disciplined about just sort of again knowing This is so unlikely this so far fetched is outside of the realm of realistic probability that I did. It really is OK to ignore it even though it feels uncomfortable. 56:08 Right. 56:08 Anything more we would consider compulsion awesome. Thank you. So, our next question is: What do you recommend about working through 12 Step programs with co-occurring OCD slash moral scrupulosity focusing on OCD first. 56:25 Hmm, hmm, I’m not sure. I know what the, the questioner means about a 12 step program. 56:32 Um, so, sorry, I didn’t get a really effective response. 56:38 We can come back to that, I can also post it under, with a little bit more information on the webinar live, so I’m just going to go to the next one. 56:48 Do we know a thing or after the fact, I might answer some questions? 56:52 We used to do the oldest. 56:54 Yeah, no, definitely. 56:56 So, I’m so sorry I hate to disappoint, but I can, maybe I’ll flesh out that question, when maybe it’ll be easier to process when I see it in writing. 57:03 So sorry, lovely listener. 57:08 OK, so next question is, My son picks the skin on the sides of his fingers He does not respond. Here when she is finger picking, how do I interrupt him while he is doing it? Or after. 57:23 When he shows me all the blood, he cries as he is fighting his skin because of all the pain, how do I get his attention? Or should I just keep letting him back to his fingers? Probably not. What I would say is that’s called a body focus, repetitive behavior. I actually have that, I pick up my skin. 57:42 Um, and so I was gonna sound like a plug, but our practice is one of the few where everybody who works for us is trained by the, by the trichotillomania Learning Center, on how to treat body focused, repetitive behavior. So one of them is triggered …, that’s a hair pulling, the disorder. I didn’t have that, it just had bad genetics. 58:03 Excoriation, thanks for that, It’s always good to have, at least somebody in the audience like excursion X creation is what is what this person is talking about. So, excessive skin, picking, or biting that leads to bleeding, and sometimes even infection. 58:17 So, at my worst, right. I sometimes have to put band-aids on my finger, so, in answer to your question really quickly with …. 58:27 and I think that we might have a presentation on that on the webinar series, as well. If not, I’d be happy to do one. 58:33 But with …, we want to really understand the origins of what’s making the person engage in that behavior. 58:39 So for myself, if I’m sitting still for too long or I’m anxious, that behavior seems to increase, were others, it’s more if their skin feels rough. They can’t tolerate this sensation. So they’ll have to pick out it to make the Roughness go away. 58:52 Right. So it’s helpful to understand the origins of why people do this now. It’s not OCD, right? But it’s very similar in presentation. 59:00 So that’s probably why a lot of a practice like mine That specializes in OCD also does …, right? 59:07 So some of the interventions you can call it to your son’s attention in terms of the behavior, not in the scolding way but more like hey, here are some tools I want us to try using so that you don’t hurt yourself Because I know you don’t like it when you bleed. It probably hurts your fingers. My fingers get pretty sora around the edges when I do it too much. 59:25 So they actually become kind of sensitive, and I don’t like how it feels, right? So, we want to sort of, tap into his or her motivation. 59:31 Here’s why we want to work on this, right? And then, the next step is, how do we work on it, right? 59:36 So that, that’s why it’s really important to know what’s behind it, if the person only does it in their bedroom. For example, we might say, OK, in your bedroom, maybe you need a fidget object, something to play with. 59:46 Right? Because maybe you do it when you’re just idle and you have nothing to distract you, and you’re bored. 59:51 All right, So having, That’s why I always have a baseball, by my side. Like, if I start picking, I don’t wanna like bite my fingers during a session with a client. So if I notice the urge, I’ll just grab an object. and so when I hold this, it’s a little bit harder for me to pick, because I usually pick with these two fingers, right? 1:00:08 But if I’m if something’s occupying my hand, it’s harder to pick. 1:00:12 Or, I might put band-aids around the ruf skin, so I can know if there’s something blocking me from engaging in the picking behavior. Now, some people, they hate being blocked. It feels bad, drives them crazy, because their brain has a desire to pick at something. 1:00:25 So, for some of those, these folks, we might give them toys that like they can pick out, right? 1:00:31 So I’ve had countless dolls who have been mutilated by children picking at the doll scanner, pulling out all their hair, but it gives them some sort of replacement behavior to maybe what their brain is craving. 1:00:44 Or like having popping, those like little packing bubbles that you can pop or breaking pieces of spaghetti if they like a snapping feeling so. So we try and understand again, what are their needs and how can we address them? 1:00:57 How can we block the behaviors, never with shame, never with yelling or punishment, the more like, Hey, this is not great for you, this doesn’t feel so good. 1:01:08 Let’s, let’s use these techniques, and we maybe even a reward that, right? Hey, I walk past your bedroom, and I saw you were sitting reading a book, and you had band-aids on your fingers or you were holding your baseball. 1:01:20 That’s a really great job. You get a sticker and five stickers earns some sort of reward, right? So we want to reward using techniques that make them less likely to pick. 1:01:29 So, anyway, sorry if I turn this into a BFA FRB presentation, but I really like that stuff too. 1:01:33 Know, you’re totally fine. I know that it is 8 30 right now. And some of you might need to hop off if you, I can stay and, Rob, if it’s OK. Can I ask you a few more questions? 1:01:49 OK, beautiful, um, so if you do need to log off, I just wanted to remind you, once again thank you for attending, that there is an exit survey. Please take a moment to complete it, and that the webinar blog is now open and available for the next seven days on the … 1:02:06 website, which is WWW dot N, J C T S dot org, and you will be receiving an archived recording of tonight’s webinar, and, in addition, that will also be posted to our website. So with that being said, the question, I’m gonna go back to a question earlier. 1:02:28 That said, what do you recommend about working through 12 step programs for that they met, like, alcohol, alcohol, anonymous, mm programs with co-occurring OCD slash morass, group velocity? And, like, would you focus on OCD first? Is that make a little bit more sense? 1:02:46 Yeah, I think a lot. 1:02:48 Thank you for clarifying. So yeah, I can answer that, because we’ve dealt with that many times, over the years, Right. If a person, you know sometimes a person with OCD or really any kind of major issue might be what we call doing. what we call self medication, Right? 1:02:59 They drink, or a drug as a way of dealing with their anxiety, right? 1:03:06 And we would explain to our clients that that interferes with your ability to make progress via this therapy because if the therapy is all about allowing yourself to feel your uncomfortable feelings, right? Then anything that’s aimed at suppressing it is counter-productive, right? So if the substance abuse issue was severe enough, I would definitely say, let’s not move forward with this treatment. Not that I’m getting rid of. 1:03:29 You are abandoning you, but to say, you need to sort of get the substance abuse under control for you to benefit from this therapy. 1:03:35 Now, sometimes people will say, well, the reason I am drinking and Drugging so much is because my OCD is so intense, right? 1:03:43 But still my preference would be for them to sort of know, if it’s with, we’re talking like nightly blacking out. Right there where they’re actually in danger. 1:03:52 I would want them to go to some sort of facility to detox. Right. 1:03:56 But let’s say if it wasn’t as severe, but it wasn’t interfering with therapy if the client was just unable to stop on their own, then I would be willing to do a co-occurring therapy where I’ll handle the OCD. 1:04:08 And somebody else, who’s a substance abuse therapist or maybe having to go to AA and do a 12 step program would definitely be appropriate. 1:04:15 Um, so yes, that’s a great, really important question. 1:04:19 OK, beautiful. So another question that we have is, I have a six year old who has really been struggling with Tourette’s and has multiple OCD issues, such as A lot, such as hand washing to the point of bleeding, touching, organizing blocks as certain way? then his brother messes it up, causing major melt. 1:04:42 Yes, yes. A medication through a doctor, that’s located in Morristown but I feel he needs more help. How can we get him into your practice for an evaluation? 1:04:52 Sure, and so, what I would say is, you can always go to our website, that stress and anxiety dot com, but we’re not the only game in town. And my, my main interest, of course, is making sure that whoever needs help gets the help they need. 1:05:03 one of the unfortunate things, because I want to be completely transparent, is, there are, you know, it’s a lot harder to find a therapist who’s willing to work with younger children. 1:05:13 Full disclosure, I don’t tend to, as a clinical director, I have a lot of responsibilities. I’ve got my own kid at home, so it’s so working with younger kids is a little too close to home for me lately. 1:05:23 So I usually stick to 10 years old and above and about half of my practice feel the same way, right? Younger kids come with their own distinct challenges, right? 1:05:31 So, one of the things that you might encounter is it’s a little bit harder to find somebody who specializes in OCD that works with young children. And we consider somebody who’s six young. 1:05:41 We’re not the only game in town. So, one of the things I would definitely recommend is you can go to the International OCD Foundation’s website. 1:05:48 So that’s I, O, C, D, F dot org. 1:05:51 And on there, you can find lots of listings of different people who do the kind of therapy we do, right. And so that’s one route, there’s also New Jersey. 1:06:00 I’m a I’m a volunteer for An on the board of New Jersey, OCD New Jersey. So, our website that website is … dot org. You can find a listing of folks there who also again, work with kids with OCD. 1:06:13 Right. 1:06:13 So cast as wide a net as you can because it’s not always easy to find somebody, right. 1:06:19 So, you know, typically my guess would be, most six year olds are going to have to come in after school or on the weekends, so those are hours that are, you know, harder to come by. So there’s a good chance you might be on a waiting list. So, cast a wide net but get on waiting lists as soon as possible. 1:06:33 Like I said, there’s lots of good places where really good practice. We’re known for doing OCD work but we’re not the only ones. I’ve referred to other places as well if our Waiting List happens to be too long. 1:06:43 So, yeah, but I mean, but I think it’s really great that you’re looking for help, because these things get really complicated. 1:06:49 And so working with an expert who can, you know, help get this under control earlier rather than later, is really important. 1:06:57 OK, and so we have two more questions. one of them is My daughter has Tourette’s and OCD. She has many triggers like certain words or sounds that makes her tick. Can you provide any information on how ERP therapy is used for this and if it is successful? 1:07:15 Right. Huh. That’s interesting because again, this you know in OCD our job is to Antagonize the OCD, right? Let’s activate those feelings, right? 1:07:25 And then, you know, not suppress, not do compulsion, right? Now, I’m trying to think of the name. 1:07:31 I know with Tourette’s there used to be treatment mast something I’m forgetting like mass practices like that, right. 1:07:40 But by and large, when I work with kids with Tourette’s, I don’t really try to antagonize the OCD unless we’re practicing using competing responses. Right. So maybe with then session, I might sort of say, OK, what if there is something specific that might trigger the urge to engage in a tick behavior? 1:08:00 OK, we’re going to sort of practice what does our game plan for using, what we call habit reversal Training Or a competing response. So, for those of you who don’t know, competing responsive. Let’s say if a person’s tick is, shrug their shoulders upwards like this. Right. Right. 1:08:18 The competing response would be, if they feel the urge to shrug their shoulders upward, it might be some, kinda just sort of pulling your shoulders downwards like this, like, I am right now. 1:08:27 So if I felt the urge to do that, I might sort of do the opposite of that urge and hold that muscle in place, right. And so what we’re really doing is we’re training ourselves not to listen to the urge and to do the opposite until that urge fades away. 1:08:42 So, conceivably, when I know if I’m working with a client, I could have them practice this, right? We’re going to trigger the urge, right. You know, it’s coming out, so let’s say if it’s a word, like. If every time I say mustard right? 1:08:54 the person like, starts flicking their Shoulders IMHO, OK, ready Mustard and they’re gonna feel that urge and I want them to just do this and hold it, right? So it sounds a little bit like exposure and response prevention. The only difference is instead of just sitting there and allowing yourself to feel the uncomfortable feeling, we’re going to train ourselves not to engage in the tick behavior. 1:09:14 So that’s a kind of in a nutshell, I mean, it’s a lot more complicated than that. 1:09:18 But in a nutshell, that’s how we might use it. 1:09:22 A situation Where we know there’s a clear trigger. 1:09:26 That would be pretty, pretty similar to C B, I T, correct? Totally CB at it. Yeah, so that’s a stupid intervention. Yeah, I was because I didn’t know how sophisticated the audience there, so I’m trying to stay away from like jargon. Yeah, that kind of sea bed, which is comprehensive behavioral Intervention for ticks. 1:09:45 OK, and no worries whatsoever. I know previously it was called Habit Reversal. 1:09:50 Reversals basically a component within seabed. 1:09:53 Yes. OK, and so our last question, Rob, and thank you so much for, for staying a little bit later to answer. Our last question is, What is the name of the scale for OCD and how does one order? 1:10:09 You can find a PDF for free, pretty much anywhere. So, if you would like, Oh, OK, here. 1:10:15 So, if you go to Google, Right, and you just type Y box. 1:10:18 So, for Adults, Y, dash, B, O C, S, and then PDF, you’ll find it for free, right? And for the children, it’s just sidewalks. 1:10:29 See Y, dash, B O C S. 1:10:34 And then type literally PDF. You’ll find it for free. It’s not that, that’s not hard to find. 1:10:40 Um, So yeah They’ve they’ve been out for a long time. They have not only a checklist, but scoring sheet, I’d say leave the scoring to the experts, but the checklist, you know, might be kind of pretty comprehensive in terms of, OK, these are different compulsion people. These are different obsessions people have. 1:10:55 These are different portions of the web, and it can be valuable for people to be able to look at one of the things, because I tried to trim some of the fat of the presentation. Because, like, I always put, too many slides you, all, you might also want to Google Family Accommodation Scale. For those of you who have children with OCD, it’s a really good questionnaire in turn, and again, you can find the appropriate family accommodation scale. 1:11:15 Um, it’s a good question here that sort of asks you questions about like, you know, what are the kinds of things that you do that might be enabling the OCD. 1:11:25 OK, thank you so so much, Rob, so that up for tonight, or wrap this up for tonight once. Again, thank you all so so much for joining us tonight for our webinar on Obsessive Compulsive Disorder, 101. 1:11:41 There’s an exit survey. Please take a moment to complete. The webinar blog is open now and available for the next seven days on the N J CTAS website for any additional questions that were not covered tonight or any questions that you might have within the next couple of days. 1:11:58 That website is WWW dot N J C T S dot org. Also, an archive recording of tonight’s webinar will be posted to the site, And, in addition, you will also, when we send our follow-up e-mail, it’s usually around 24 hours after the webinar. 1:12:17 You will also have a link that has the recording as well. 1:12:22 So, our next presentation will be Treatment Approaches to Help Manage Painful texts, which will be presented by doctor Peter Morison on Wednesday, November 16th, at 7 30 PM Eastern Standard Time, Tonight’s webinar, Thank you, doctor Zambrano, for your presentation, and thank you, everyone, for attending. I hope you have a wonderful night.