As the adage goes, “too much of a good thing becomes a bad thing.” For most people, their moral and religious beliefs help them live meaningful lives. For individuals suffering from scrupulosity OCD, their moral and religious beliefs become a source of distress and panic that impacts their lives adversely. Scrupulosity OCD typically involves intrusive thoughts, images, and doubts related to their moral and religious beliefs. Their obsessive and compulsive behaviors, internal or external, are aimed at reducing distress by atoning for wrongdoing or checking if they had behaved in an offensive manner. This presentation seeks to raise awareness about scrupulosity OCD and to learn about the different treatment options available.
Ferdinando Palumbo, MSW, LCSW is a New Jersey Licensed Clinical Social Worker in private practice. He completed his graduate studies at the University of Michigan School of Social Work with a focus on clinical social work practice.
0:04 Good evening, and welcome. 0:06 And thank you so much for joining us tonight for the Webinar, Understanding and Treating Scrupulosity OCD, presented by Ferdinando Colombo. 0:17 My name is Katie. 0:18 And I am the Family and Medical Outreach co-ordinator at the New Jersey Center for Tourette Syndrome. I will be your facilitator for this evening before I introduce mister Colombo. 0:30 We have some housekeeping notes, All participants are muted. If you have a question, please type it in the bottom of your question box, and click Send. 0:40 If you have questions after tonight’s session, you can post. 0:43 You can post your questions on the Wednesday webinar blog, which can be accessed from our homepage at WWW dot N J C T S dot org. Under the heading programs, this blog will be monitored for the next seven days, and it would be underneath the archived webinar. 1:03 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. 1:21 We do not endorse any recommendation, or opinion made, by any member or physician, nor do we advocate any treatment. 1:30 You are responsible for your own medical decisions. 1:34 Now it is my pleasure to introduce our speaker for this evening Ferdinand Alonzo. Miserable Lambo is a New Jersey licensed clinical clinical social worker in private practice. 1:46 He completed his graduate studies at the University of Michigan School of Social Work with a focus on clinical social work practice. 1:56 While at the University of Michigan, mister Columbo completed his internships at both the Outpatient Clinic of Catholic Social Services and the University of Michigan’s counseling and say Cycle Psychological Services, excuse me. 2:14 Throughout his career, mister Colombo has been interested in applying cognitive behavioral intervention therapy to obsessive compulsive disorder. 2:25 Post-traumatic stress disorder, anxiety disorders, and phobias body focus repetitive behaviors, and most recently Tourette syndrome and other checking disorders. 2:36 And it was cognitive behavioral therapy interventions. My apologies. So, with that being said, miserable lumbo, we’re so happy to have you here tonight. 2:46 The floor is all yours. 2:49 Thank you so much, And good evening, everyone, and welcome. 2:53 Tonight, we’re going to discuss a topic that many of you might not be familiar with. 3:00 We’re all familiar with the challenges associated with people who they aren’t thinking about morality enough. 3:08 Tonight, we’re looking at people who get stuck in the opposite direction, their brains kinda get stuck on morality. 3:15 Um, so, forgive me. 3:21 So, um, before we get started, a really quick disclaimer, the information contained in this presentation is educational in nature and just provided only as general information. 3:33 It should not be understood as medical advice, diagnosis, or treatment. 3:38 If you or a loved one is experiencing obsessive compulsive disorder or any other psychological challenge, please seek treatment from a competent provider. 3:46 Resources on finding competent providers will be included at the end of this presentation. 3:54 So, what we’re going to talk about tonight is, first we’re going to talk about the diagnosis and treatment gap that exists in obsessive compulsive disorder. We’ll talk about what obsessive compulsive disorder is. 4:08 And then we’ll look at what Scrupulosity OCD is specifically and we’re going to look at some psychotherapy options which have been shown to work for OCD. 4:17 What therapies might not be good options for OCD. 4:22 We unfortunately won’t be talking about medication treatment for obsessive compulsive disorder but there’s many good resources on that are at the International OCD Foundation. 4:34 And then we’ll be looking at some resources for people who experience OCB clinicians who are interested in learning more and on the loved ones and family members of people who live with OCD. 4:50 So, why this presentation? There’s so many different interesting facets of OCD. 4:57 But for me, the the main reason that I selected this presentation was that the research kind of shows there’s a pretty long gap over 10 years. And most recently, we’ve seen over 12 years on average between when OCD symptoms are diagnosable. 5:17 Who when people get properly diagnosed and treated for OCD. 5:23 Recent research has also shown that people who were diagnosed closer to the onset of symptoms, they generally had less severe symptoms and less severe impact of their symptoms, then compared to the group who was longer in that gap. 5:41 So, um, it seems like the general public has a pre-conceived notion or stereotype of what OCD is. 5:50 Perhaps they think of OCD as when someone is washing their hands, compulsively worried about germs or when they’re re-arranging their desk to be in a certain order. 6:03 And while OCD can look like that, it’s also much more complex than that and can have multiple presentations. 6:11 So when researchers reach out to people in the public and try to present them, OCD case vignettes, the general public kind of has trouble discerning what is OCD if it is outside of that stereotype. 6:31 And interestingly enough, researchers have also found that even trained doctors and mental health professionals also had trouble identifying obsessive compulsive disorder outside of those kind of stereotypes. 6:47 So I’m hoping that in presenting this to the public, we can collectively try to work on this gap by recognizing that OCD has multiple presentations. 6:59 And hopefully, we can learn about some of the evidence based treatments that can help people live off fulfilling lives even if they have OCD. 7:11 So to start us off, we should look at what is obsessive compulsive disorder. 7:17 And we’ll see in the diagnostic and Statistical Manual that’s the book that mental health professionals use. 7:23 It talks about the presence of obsessions and compulsions, and we’ll look at kind of what they mean by that and how this might impact people. 7:33 Then we’ll look at some of the ways this presents in some well-known types of OCD and maybe some less well-known types. 7:42 So in the DSM they define obsessions as recurrent and persistent thoughts, urges or images that are experienced at some time during the disturbance as intrusive or unwanted and that a most individualist cause causes marked anxiety or distress. 8:01 Now it’s usually anxiety, but for some folks that marked distress could be a feeling of disgust, a feeling of guilt. 8:10 But the idea is is that these thoughts are unpleasant to the individuals who have OCD. 8:18 Then the second component is, is that the individual attempts to ignore the thoughts or push them away um or trying to neutralize them with some sort of action, which we would call a compulsion. 8:35 Which brings us here to compulsions, these are repetitive behaviors, for example, hand-washing, ordering things, checking things, or mental actions, Praying, counting, repeating words, quietly, that the person feels. 8:52 They have to perform in response to an obsession or by some sort of strict set of rules. 9:01 These behaviors are usually aimed at preventing or reducing the uncomfortable emotion. 9:07 So, whether that’s anxiety or disgust, or preventing some sort of negative outcome, um, but it’s important that these behaviors are mental actions are not connected in a realistic way, with what they, the problem that they’re trying to prevent or neutralize. And we would call these clearly excessive. 9:33 In addition to having either obsessions or Compulsions, or both, these obsessions and compulsions have to be time consuming. Well, look in a little bit about how most of the population experiences thoughts, similar in Nature to people with OCD. 9:48 But that, um, for most people, these thoughts are pretty fleeting for individuals with OCD. 9:54 These thoughts are very time consuming, and the actions they take in response to these thoughts are generally time consuming. 10:03 And additionally, right these obsessions and compulsions have to either cause distress for a person where they have to get in the way of them meeting their goals in their social life or their work. 10:21 So we’re going to look at some obsessive compulsive clusters of symptoms. 10:26 Probably starting with one that we’re very familiar with and then we’ll we’ll get toward Scrupulosity OCD, tonights subject. 10:35 Contamination OCD is probably what most people think of when they think of OCD. 10:41 And we could imagine that a person with contamination OCB might have thoughts like that doorknob across the hall could be contaminated and then that thought could lead them to a compulsion like sanitizing their hands after they touch the door. 10:59 Um, in carmelo, C D, this is a set of symptoms where people are really worried that they could cause harm to themselves or others. 11:09 A very common type we might see is someone who’s driving in a car, they hit a pothole and there they get the really scary and distressing thought of, what if that was a person and then that that scary thought might lead them to the compulsion of circling back to check and see if they committed any act of harm. 11:36 In gender and sexuality OCD A person might have an intrusive font that perhaps they they could identify as a different way than they typically do. 11:47 So maybe a person is a straight male, but he has the intrusive thought that he could be gay. 11:56 Then, typically, there’s an urgency that’s felt with that, where the person tries to solve that by asking for a reassurance or checking by, by looking at individuals to see if they’re attracted you them. 12:15 In the category of relationship OCD and there was just an excellent article in Huffington Post about relationship OCD. 12:22 We noticed that the obsessions and Compulsions are focused on the relationships that are important to that person. 12:30 So a common presentation of this could be someone is in a healthy and loving relationship with a partner, but they experienced the intrusive doubt that perhaps their partner doesn’t love them. 12:44 And perhaps they, they seek reassurance in a compulsive way by asking their partner Do you love me? 12:53 And while some of that is is normal, we’ll see a little bit later that when someone with OCD engages in a compulsion, that answer usually doesn’t satisfy them for long whether it’s two minutes, two days, two months. 13:09 They typically have to go back for reassurance to check. 13:16 And then in another Less commonly known type of OCD, we have sensory motor or OCD. 13:24 That’s where a person becomes kind of intensely aware of natural bodil bodily functions like breathing, heartbeat, blinking and then they either are trying to distract themselves from these sensations. Or they’re trying to do it right. 13:44 In no quotes. 13:47 And this sometimes can get confused for a tick disorder, but it’s a little bit different because this is in response to, you know, and anxiety that that they might not ever stop thinking about their bodily functions. And they’re really trying to resolve that anxiety, which looks a little bit different than tic disorders. 14:13 And then, lastly, we have scrupulosity OCD, where a person gets, you know, intrusive, distressing thoughts about morality, religion, whether they’re a good person or not. 14:24 And then the compulsions are kind of geared toward resolving those doubts, asking for reassurance, repeating acts until they’re right. 14:34 These kinds of things. 14:36 But it’s important to note that these are all OCB, they’re all tradeable by the, uh, the therapy options that we’ll be looking at later. 14:46 But some of these presentations get missed because they’re not as well known as contamination OCB Or, you know, I’ve tried to someone who’s trying to organize things in a certain way. 15:02 So I think one of the important concepts for us to understand is negative reinforcement in obsessive compulsive disorder. 15:11 If we could imagine this blue line at the bottom here, um, as the person’s anxiety gets up, there’s a desire to kind of escape or leave the anxiety. 15:25 So the person engages in some sort of avoidance, or a compulsion, and we see pretty rapidly. That the anxiety goes down. 15:35 Unfortunately, we see that that doesn’t tend to stay that way for very long, and then the anxiety creeps back up often times more rapidly, and then they have to repeat the same compulsion or do other compulsions to try and get the same release. 15:59 So we’ll notice that there’s kinda these jagged peaks and valleys that that happen. 16:05 And the idea is, is that each time a person does that compulsion and gets this reduction in anxiety. 16:13 That they kind of learn that they have to escape their emotions or avoid their emotions, and they get stuck in this cycle. 16:24 This orange line, on the other hand we could imagine, is if someone doesn’t do a compulsion. 16:30 So there are anxiety goes up, and then it goes up higher, and it goes up even higher, which is very uncomfortable. 16:40 But then after it reaches a certain critical mass, the anxiety starts to decrease slowly and eventually does it get back to that baseline. 16:52 The idea here is that in the orange line scenario, that person might learn to, um, live with that discomfort instead of having the agenda of getting rid of the anxiety. 17:07 So we’ll notice that all, almost all the compulsion, is have the agenda of trying to get rid of discomfort. 17:17 So, um, before we get started, I think it’s important to note that intrusive thoughts are very common. The research varies a little bit in what percentage of the population experiences, intrusive thoughts. 17:32 But, um, pretty much, we can say over 80% of people who don’t have OCD also have intrusive thoughts that are similar in content. So, they’re thinking about the same things that people with OCD are. 17:48 But, um, when individuals with OCD have these thoughts, they experience these spots more frequently, more intensely for longer periods of time. 17:59 They’re really worried that these thoughts could have serious consequences. 18:06 So, many of the things that we’ll talk about tonight, you might think of in your own life. 18:14 But that isn’t necessarily evidence that that OCD is present. It just seems that most of the population thinks about these things. 18:26 But, if these thoughts are so common, it kind of raises an important question of, why do people with OCD have so much distress with these thoughts? 18:39 And some researchers in the nineties, they kind of created a working group and they identified six types of beliefs that they believe are associated with these intrusive thoughts getting more stuck for individuals. 18:57 The first type of belief that they noticed is that individuals with OCD seem to have a really inflated sense of responsibility. 19:06 So they they believe that there’s consequences to their actions or Inactions and that they would kind of be very much responsible for that and that this might lead to them getting into a cycle with more compulsive actions. 19:29 The next category that this working group identified was called over importance of parts. 19:35 So for people with OCD, these plots usually don’t feel like a random occurrence or a random firing of the brain, but they often infer that these thoughts mean means something significant. 19:53 And within this category of over importance of thoughts, we have the subcategory of thought, action Fusion. This is a type of thinking trap that that happens in OCD. 20:05 Where some people with OCD are worried that the more they think about something. 20:11 The more likely it is that that negative outcome will occur. 20:16 So, not only did the thoughts feel important, but sometimes there’s a bit of thinking that these thoughts could lead to certain actions or that they’re the same as committing an action. 20:29 The third category that the working group identified is called excessive concern about trying to control one’s thoughts. 20:36 And that’s the idea that people with OCD And it’s probably related to some of these other domains that they, they really try to control one’s their own thoughts, and it feels really important to do that. 20:52 Us. 20:52 The challenge with this is this: The research shows only a very small percentage of the population can force themselves to stop thinking about something. 21:04 For the most part, when we try hard to control our thoughts or push a certain thought away, we usually get more stuck thinking about it. 21:18 And, um, and yeah, this is kind of backfires in a major way for individuals with OCD. 21:26 The fourth category is called overestimation of threat. 21:30 So, folks with OCD, when they are having these distressing thoughts, they’re, they’re jumping often to the worst conclusion or outcome. They’re not worried that the common cold could be on that door, and they could get mildly ill. They’re worried that a very serious disease could be on the door, and that the consequences of this would be really great. 21:58 Um, and that this might contribute to the feeling that, that these thoughts need to be resolved or addressed. 22:09 The fifth category, they labeled intolerance of uncertainty. It’s this idea that being uncertain for individuals with OCD seems to be really unpleasant. 22:20 Scary and there seems to be an urgency to becoming certain and the that that dislike of the uncertainty and that urgency might also lead people to try to resolve their thoughts with compulsions and perhaps getting a bit more stout. 22:44 And lastly, the last category they identified was perfectionism. 22:48 And that’s the idea that individuals with OCD might might approach their thoughts in a perfectionist stick way. So I shouldn’t have thought about that. It’s really bad that I thought about that, let me try and get it just right try and think about the right thing. 23:07 But as we could see, that this would lead people to getting more stuck in their thoughts feeling like these are really important, that they’re responsible, but they have to get it right. 23:18 And we call this the appraisal model. And the idea is that people have beliefs about their thoughts in OCD, that get them more stuck in the thought. 23:30 Some researchers up in Canada have have come up with what they call the inference based model, and we’ll explore that a little bit differently. 23:37 But they would argue that there’s actually a different reasoning process that individuals with OCD um, use. 23:47 And that they don’t usually trust their stem senses and instead focus on possibility and what could have happened. 23:57 And the kind of narrative of what could happen if they they don’t engage in a compulsion. 24:06 So the idea is that people with OCD might start with a conclusion based on a possibility. 24:14 So, for example, I could have been really offensive in talking to Jeremy, even though he didn’t say anything, but I should probably just apologize to him, just in case, um, that the person might start with a conclusion based on possibility, and then kind of backwards engineer, um, the reasoning for it. 24:39 So, these are two ideas of why these spots might get more stuck for people who have OCD. 24:47 So, now that we know what OCD is, hopefully, we can try and look at what Scrupulosity OCD is. 24:53 So Scrupulosity OCB is just the subtype of OCD, where a person is plagued with frequent, obsessive thoughts that they violated or could have violated a religious or moral standard that they hold all look at what some of these obsessions might look life, like, both in a secular contexts and in a religious context. 25:19 The Compulsions and Scrupulosity OCD are typically geared toward trying to gain certainty about whether they did something wrong or not, or whether they’re a bad person making up or atoning for whatever mistake that that they made or could have made. 25:38 And we see that that these individuals try really, really hard to avoid potentially making these mistakes. 25:46 And they spend a lot of time trying to thing about ways that they could be moral people and avoid falling into this. 25:57 This feared version of themselves. 26:01 So we can’t, unfortunately go over all of these, because I’d like for there to be enough time at the end to answer questions. 26:09 But we’ll notice that each of these starts with the word: excessive. 26:13 Again, these are relatively normal things for us to think about, but when they’re getting to a certain level of time, or distress, that, and they’re getting in the way of living our lives, that they’re probably excessive. 26:27 Um, and probably the most common, secular, scrupulous, obsession I see is, um, being really worried about having offended other people. 26:39 And, you know, recently, I’ve been been seeing a lot of people who are really worried that they could be harming the environment, are not doing enough to protect the environment. 26:52 And their brain kinda gets really stuck on those thoughts. 26:57 Um, very recently, especially among youth, I’ve been seeing a really strong fear that they could have said something socially inappropriate, and that they might end up getting canceled for something that they didn’t intend as a offensive, but not understood in an offensive way. 27:20 And since we’re so close to tax season, I thought that this could be a good time to mention that. 27:26 A lot of folks with scrupulosity OCD, they might be really afraid that they could have been dishonest on their taxes and really want to try and resolve that that challenge. 27:42 Some of the corresponding compulsions because the, this compulsion is our response. 27:47 Maybe a person who’s really worried about offending people in social interactions, they might mentally replay those social interactions to try and check to see if they did anything that could have been offensive. 28:02 And with that, they might apologize or confess that, um, having made a mistake just in case so they replay it, right? 28:13 They have a new doubt, and maybe they apologize or tell someone that they, they made this mistake just in case, with the environmental concerns. Maybe this person spends hours, just making lists of things they could do to reduce their, their carbon footprint. 28:34 And the, they, they have the agenda of reducing that discomfort. Right? 28:41 And we’ll notice that in the compulsions, that, that there’s the agenda of getting rid of discomfort. 28:47 We’re trying to fix the, the original problem and trying to avoid a catastrophe. 28:53 Then we might see people who are worried about their taxes, re reading their taxes, reviewing their taxes, asking for someone else to look at it. 29:03 Right? 29:04 But that, it’s important, we understand that there is the relationship between the obsessive thoughts and then the compulsive actions. 29:16 In a religious context, we might see also some of the same ones we saw on the the secular slide will most commonly see intrusive blasphemous thoughts or thoughts that feel really against what a person values that that are maybe disrespectful to that person’s God or gods. 29:38 Um, we might see a lot of concerns about ritualistic purity, so beyond what the other people who share their religious beliefs. 29:52 Feel concern with. 29:55 We might see some concerns there. 29:59 Someone had bad thoughts while praying or listening to sacred music or attending the service. 30:08 And a lot of times we see people engaging in compulsive prayers, but that some of those might be preempted by the obsession of what if I didn’t pray properly enough. 30:24 So, very frequently, in the compulsion category, we see people repeatedly asking their religious leaders, for reassurance or clarification. 30:37 And kinda, like we said earlier, that that explanation doesn’t really satisfy them for a long time, and they ended up having to to come back to it. 30:47 Um, the person might repeat prayers in a way that’s not typical in their faith tradition, and the goal of that repeating of the prayers is to try and decrease their distress or prevent something bad from happening. 31:03 Um, we might see people trying to replace, quote unquote bad thoughts with good thoughts or images. 31:14 End. 31:16 We might see people who are engaging in confessions for things that they aren’t sure or sinful and their religion. 31:25 But there’s there’s kind of that just in case component that they feel they should mentoring network confess it. 31:34 So we’re going to look at some therapy options that I think should give us good reason to have hope these therapy options have a lot of science to back them up and are effective for a large portion of the population. 31:50 So, the treatments that have some empirical and scientific support. 31:55 And this isn’t an exhaustive list, but it’s a pretty comprehensive list. 32:01 We’ll first talk about exposure and response prevention, sometimes called exposure, ritual, prevention, acceptance, and commitment therapy, usually called Act. 32:13 We’ll also look at supportive parenting for anxious childhood emotions or space. 32:20 We’ll look at the inference based cognitive behavioral therapy or inference based approach will usually see that called the eye CBT or IBA. 32:32 So, uh, ERP was the first evidence based treatment for OCD. 32:39 And it was developed in 19 66. Prior to this, it was kind of assume that OCD was untreatable and was. 32:51 A condition that, that will just get worse over time, because the therapies they used at that time, don’t really target what’s going on for individuals with OCD. 33:04 We often call this treatment, the gold standard, but when we say that, we don’t necessarily mean that it’s the best treatment or the only treatment. 33:14 What we mean is that when we look at those later treatments and we say that it’s effective, we’re comparing it to exposure and response prevention. 33:24 Because we know ERP works, so we kinda get to use it as a measuring stick to compare other treatments. 33:34 And treatment focuses on helping the clients face the things they fear in a systemic and gradual way, but also reducing the use of compulsions. Right? 33:49 Because if we just get someone to face their fears, but they’re mentally distracting themselves, or they’re engaging in a lot of compulsion, they’re not having a new learning experience, Right. 34:02 In fact, they’re they’re just learning that the compulsions help them escape this discomfort. 34:11 So, it’s really important to remember that that the goal is also reducing the, the responses, the compulsions, and, uh, ERP therapists worked with clients to create either an exposure hierarchy, or an exposure menu. 34:31 End. 34:32 the, the idea would be that, that we could approach fears in a predictable way while not engaging in compulsions and have that new learning experience. 34:47 Usually ERP therapists try to go from easiest to most difficult when having people face their fears. But there’s some different thoughts on this. 34:56 Some people prefer to have the client ppic where they want to start, whether it’s a hard challenge or an easy challenge. 35:06 And my guess is this for some clients that works better to go from easiest to most difficult. 35:12 For other clients, it might be easier to if what’s important to them and kind of go in order of what they value. 35:24 So, um, we’re going to look at some examples of of exposures For scrupulosity. 35:32 I think this is the part that gets very scary for folks when they hear about ERP, But these are some, perhaps more mild and some less mild examples. 35:44 But a person might write down or record their intrusive thoughts. 35:50 There are some ERP coloring books with themes related to Scrupulosity. 35:54 We’ll actually look at a few pages from a one such coloring book. 36:01 The Therapists’ might encourage the client to tell unimportant white lies. 36:06 one of my favorites to use with my clients is having them tell someone that they ate an apple that day, even if they didn’t, But to try and experience the discomfort of having said something that isn’t true. 36:26 A person who has been avoiding religious services or religious textbooks. 36:32 We might have them face those and not do a compulsion while they’re in their religious services. 36:43 Um, and, uh, you know, sometimes, for the folks who are really worried about reading and rereading, we might have them scroll down to the bottom of the Terms and Conditions, and click Agree, even if they aren’t, sure if they agree or not. 37:02 Then, in a similar theme to the white wise is, maybe having client say, the client say, Um, grammar school level, insults that. 37:13 That, uh, you know, could be offensive to some, but aren’t very serious, as a way of, of understanding that the discomfort associated with being offensive doesn’t last forever. 37:32 So these are some coloring page books from a really talented OCD therapist named Amanda Petrick gardener. And this could be an example of, of exposure for a person if these thoughts are very scary for them. 37:48 And maybe having them color in a way can be a way to interact with these thoughts and not experience such high levels of distress and discomfort, learning to sit with that distress and discomfort. 38:07 So, there’s a really cool blog called Living with OCD dot net And the individual who runs this blog, he decided to make a graph of his ERP treatment and we’ll see that. The blue line is how high his anxiety was in a given week. 38:28 And the orange line is the number of compulsion he engaged in, and we see that. 38:35 In the second week of ERP, the anxiety, and the compulsions actually skyrocketed, right? 38:43 Um, his discomfort got worse, the compulsions got worse, but by keeping up at the ERP, we actually see a pretty steady decline where four weeks after there was over 80% reduction. 39:01 Then we see a little bit later that there’s a few spikes here and there of either compulsions or anxiety, but as he worked on eliminating his compulsion, eventually he got to a place where he was having no anxiety about this and he was not engaging in any compulsions. 39:26 Now, this is very linear on this person’s graph, but, um, things happen in treatment, and a person’s progress might not be as linear as this is. 39:40 Looking at acceptance and commitment therapy. And this is another very cool treatment option. 39:47 Um, the the goal of acceptance and commitment therapy Or act isn’t really two: eliminate the unpleasant thoughts or unpleasant feelings but to try and create an openness to experiencing that. 40:03 Um, and the in at the the therapists will often ask people has you by trying to control your thoughts and unpleasant emotions has has that made the situation better or worse than the long run? 40:22 I think most people with OCD can recognize that As time goes on. 40:30 It typically is more harmful for them to try and control these thoughts and emotions and Act would argue that most of us probably think a little to give too much importance too. 40:46 Our thoughts and we give a little too much importance to feeling comfortable and that this leads to people avoiding or engaging in compulsive behavior That when people engage in avoidance and compulsions, it usually gets in the way of, um, doing the things that are important to them. 41:10 So, um, an act practitioner might might work on accepting the presence of these thoughts and feelings, but trying to get the client to commit to doing the activities which are meaningful to them, even if they’re scared. 41:26 So, some people with Scrupulosity OCD, they might be in church all the time, but some others they might be scared that they’re going to have, um, unpleasant thoughts while they’re in church. 41:42 And they might avoid it, but, but going to church is important to them. An act therapist might work with that client. 41:49 I’m trying to commit to going to, Um, They’re religious services, no matter what thoughts or feelings come up for them. 42:00 And that, usually, as we commit to doing what we value, these thoughts and feelings have a lot less power, And, typically, in act, there’s less of a focus on trying to get rid of these uncomfortable experiences, but the purpose of exposure might be, too, create space, and learn to live alongside this distress. 42:29 And this treatment has been provided both as a standalone treatment for OCD, but also as an enhancement to ERP. And the studies have been very promising to show that it works pretty effectively on OCD. So, this is another potential option for individuals. 42:50 Um, who are looking for evidence based treatment for OCD. 42:57 This is a bullseye that comes from an act for OCD manual by doctors abramowitz and …. 43:06 And they have this bull’s eye in the center of the bullseye, is where someone wants these domains of their life to be where they want their work in education to be, that they want their leisure to be, etcetera. 43:19 Um, and they might ask them to put where they are on this bull’s eye. 43:27 And ask if the compulsions are bringing them closer to where they want to be or further away. 43:35 And that really trying to keep our eyes on the target of where that client would like to be and gearing treatment toward that. 43:49 Next, we have a really exciting treatment for children with OCD. 43:54 I think this will be particularly helpful if you’re a parent and maybe you’re ready to work on your child’s OCD but they’re not ready for individual therapy. 44:06 So this is called supportive parenting for anxious childhood emotions or space. 44:12 And this is, this comes from doctor Elli Liebowitz of Yale. 44:19 And space really targets what’s called family accommodations, bye, working with parents and other primary care figures to offer supportive messages to the child, but also to reduce the engagement in accommodations and compulsions. 44:42 So, for example, a child with OCD and Scrupulosity OCB might ask their parent if they’re a bad person. And the parent can see that. 44:54 The child is very distressed and perhaps that that parent offers reassurance. 45:01 But again, remember that only satisfies the OCD for so long before the, the client needs more reassurance. 45:11 So space therapists work with parents on creating what they call a map and the parents identify all the things that they do or don’t do to avoid and accommodate the OCD. 45:25 And then that space therapists would work with, parents, too, offer messages that, that show no understanding and empathy for the child. 45:37 But also show confidence that they know that the child can, um, experiences, unpleasant emotions and not need the accomodation. 45:48 Um, and it has the parents explain which combination accommodations, they won’t be engaging in any longer. 45:58 That way, the kid knows what to expect and slowly the parents would start reducing even more accommodations. 46:08 And the really cool thing about space and this research is in the process of being published, but it is on the space website is, um, in a pretty large study space was just as effective as individual therapy for children with anxiety and, uh, in that study, about 20% of the participants had OCD. 46:34 So, this seems like a really good option for, for parents who, I have anxious children, but the children aren’t ready or willing to engage in their own therapy while the parents can reduce their participation in the accommodations. 46:57 And the last treatment approach we’ll be looking at is a newer treatment approach that comes from Montreal, University of Montreal, specifically and it’s called inference based Cognitive behavioral therapy. 47:12 And this treatment focuses on on the the faulty reasoning process that they call inferential using. 47:21 Where the doubts are confused with reality. Right? And the doubts lead people to not trust their senses. 47:30 So the model really starts off with education about OCD and how a person goes from a trigger to a doubt from that doubt to a scary story about what consequences could happen. 47:46 Um, and from that, that scary story they, they engage in a compulsion, trying to, to solve the doubt. 47:55 But unfortunately, that typically leads to two new doubts. And they kind of restart the cycle. 48:03 And the client learns through this process to recognize this cycle and kind of develop awareness of when they’re falling into that, that cycle. 48:14 And the goal is to get them to begin to trust their five senses, their common sense, and who they know that they are instead of trusting, what the OECD is telling them they could be if they don’t engage in the compulsion. 48:32 Um, and tries to get them out of this cycle of relying on on possibility and learning to trust what they, they see in front of them. 48:47 Unlike the previous models we discuss, what’s really unique about eye CVT is that this model doesn’t focus on sitting with discomfort. 48:58 It’s not opposed to it, but it really focuses on trying to solve this reasoning process, not the content, not the types of thoughts, but how they came to those conclusions. 49:14 And the preliminary research has shown that this model is similarly effective at, at treating ERP. 49:22 I’m sorry. 49:23 Treating OCD as ERP is but there are also conducting more research to further prove this at the University of Montreal and some universities in the Netherlands. 49:38 And it’s been shown to have a medium to large effect size, which I think is very encouraging does for some clients is really challenging for them to tolerate exposures. 49:50 This might be an additional option, or those individuals. 49:58 I think it would also be good for us to talk about treatments and techniques that don’t have science behind them. For the treatment of OCD at sometimes can make OCD worse. 50:14 In our field, as therapists, we often try to find insight and and look to the past to try and understand what’s happening now, inside oriented talk therapy, while it has other applications and these other, all of these other ones do. 50:33 With the exception of thoughts stopping, Uh, it isn’t going to too really help someone resolve their their OCD and that person might get temporary relief by discussing these things, but it isn’t going to challenge the processes that go on in OCB. 50:56 Similarly, cognitive challenging or restructuring um, has many really good applications. 51:04 And even in OCD, there is a place for it. 51:08 If we’re looking at challenging the idea that someone is very responsible or, but when we debate the content of Obsessional thought, that typically results in other problems. Most people with OCD find themselves in, in this internal debate. 51:26 So, if a clinician is encouraging us to challenge the probability or likelihood of a thought occurring, that probably isn’t going to be very helpful. 51:37 Um, problem solving therapy, where individuals are trying to find ways of addressing their problems that sometimes can make it worse. 51:49 Because if a client has the agenda of getting rid of this anxiety and they’re doing that through compulsions, a problem solving therapist might actually encourage them to engage in behavior that becomes compulsive. 52:08 Um, there were some thoughts about trying to engage and thought stopping in the eighties. They would have people where are these rubber bands on their wrists? 52:17 and if they had an intrusive thought, they would try to snap the rubber band to stop it. 52:23 But the research showed that, that was actually very ineffective and usually made people more stuck in an art. 52:31 So, that definitely isn’t something we would want to count as um of good treatment for OCD. 52:40 Similarly, psychodynamic and psychoanalytic therapy is they have really good applications in other areas. 52:49 But for OCD, it doesn’t quite work very well as a standalone treatment. 52:57 doctor Michael Greenburg in Los Angeles, he’s actually integrating psychodynamic therapy into his exposure and response prevention. 53:07 But, he would also provide the the warning that a psychodynamic treatment in and of itself isn’t a evidence based treatment for OCD. 53:20 And these other options aren’t really good for people living with OCD. 53:29 So, lastly, we have some resources, that you guys should be able to see in your handout. 53:33 We have the International OCD Foundation they have a find help link where you can find some professionals they also have a Faith and OCD Resource Center where you can talk to religious leaders who are very competent in understanding OCD. 53:50 New C D is an evidenced based telehealth platform that focuses only on the treatment of OCD. 53:59 Then we we have, you know, a list of inference based cognitive behavioral therapy providers. Psychology today also has a way of finding providers. 54:09 Um, and the, we see, similar actions for space. 54:18 And there is a link to the coloring book that I showed earlier. 54:24 And lastly, before we get into answering questions, I’d really like to thank all of these individuals. There’s many people. I forgot the bank. 54:31 But this was an effort, and I’m very grateful for the assistance of these individuals in helping me present this. 54:43 So with that, we will go into answering questions, I believe. 54:51 Thank you so, so much, Fred. 54:53 So for our questions, one question that we have is how to how do you differentiate between ticks or Tourette’s syndrome and OCD? 55:05 Yeah, this is a very good question that that the person asks and it can be really confusing, especially since we know that there’s a lot of overlap and comorbidity. 55:19 For me, where the difference is is, people with OCD are typically having distressing fox and the compulsions are in relation to that. 55:30 And the Compulsions are a willful act. 55:32 I, it might happen very quickly, but it’s I’m washing my hands because I had the thought that I could be contaminated with tick disorders. 55:43 There’s a discomfort, which we call a promontory urge, that means a tick is about to happen, but the, the tick is is automatic, it’s not it’s not something that the person is is choosing to do with a specific goal. 56:05 That’s how I would tried to answer that question but it’s a really good question. 56:10 Thank you And for the audience anybody that has questions don’t forget that you can post them under the questions section. 56:18 So another question is: what are your thoughts or what does research say about the use of I’m going to butcher this can I spell it? It’s yes. 56:32 It’s P S I L O C O psilocybin treatment group Velocity. So, to my knowledge I don’t know if there’s been any randomized clinical trials to establish whether psilocybin is effective for OCD. 56:58 I do know that it’s had promising treatment results and PTSD and generalized anxiety so maybe there’s a possibility that it could work but I don’t think the science has an answer to that question just yet. 57:22 What are moral standards that you have challenges being flexible, less? 57:29 Yeah, so that’s a very good question. 57:35 I guess, and in my own life, you know, faith is very important to me, and one of the moral standards that I have is, You know that I don’t want to be a person who gossips, right? 57:50 And that what it can be a little bit sticky for me where I can be like, Oh, this is me talking about something. 57:57 Katie said Is that me gossiping about her, right? 58:02 So it can be hard for me to be a little bit flexible in that arena And, and my guess is that most of us, I have those those doubts. 58:14 But it’s really about how persistent or disruptive these doubts are that that might make it a challenge for people. 58:25 And another question we have is, what is one of the hardest exposures you’ve had a client engage in? 58:33 Yeah, I don’t know if they’re asking about Scrupulosity in general or Scrupulosity in particular rather or OCD in general. 58:44 But, um, My guess is that that we should stick with scrupulosity just because that’s the topic and, um, You know, it’s often very challenging for people to write down their intrusive thoughts, especially if their thoughts are blasphemous, right? 59:00 And we looked at some of those biases that have these thoughts feeling very important and, and Like they matter. 59:08 But I do think while that can be distressing and challenging that that the clients who do that often really do have a reduction in, um, how distressing those, those thoughts are. 59:27 I do have a couple more questions, and it’s it is currently 8 30. 59:34 I know that some people might have to jump off if it’s OK with you, bird for us to stay on and answer a couple more questions, OK. Awesome, so with that being said, if you do need to hop off, there is an exit survey that will pop up. When you exit out of the screen, we greatly appreciate you filling that out and archived. An archived recording of tonight’s webinar will be posted to our website, WWW dot NJ CTS dot org. The Webinar Blogs now open and accessible underneath the archived Webinar. It will remain open for the next seven days for any additional questions that were not covered this evening. 1:00:13 Our next presentation will be introduction a transition services presented by a couple of staff members from the Disability Rights New Jersey. And it will be April 19th, which is a Wednesday at 7 30 PM, Eastern standard time. I hope you guys have a wonderful night. 1:00:30 And with that being said, we got a whole bunch in. 1:00:34 I’m going to continue allies. So another question that we have is, do you involve religious leaders in your scrupulosity exposure? 1:00:43 Excellent question, and forgive me whenever you’re making a presentation. It’s, it’s really tough to decide what information will go in and what won’t. 1:00:54 I think it can be really important to involve religious leaders. 1:00:58 Ideally, though, it would be good for an OECD therapist to screen that religious leader because we could have a really negative effect. 1:01:10 For example, if, if I ask a client to ask a random, religious leader that that religious leader might say, Oh, my goodness, these thoughts are terrible, right? The response do matter. 1:01:22 You need to play more, right, and that’s why I find the OECD Faith Resource Center to be very helpful because these are religious leaders who are respected in their faith traditions. 1:01:35 We’re also very familiar with OCD. 1:01:37 But, um, as a therapist, I would ideally like to explain to the religious leader, the rationale that, that we’re not doing this, for the sake of doing it or for entertainment, but that this is an evidence based treatment. 1:01:52 I do think it can be really good, but we would want the client to agree to only asking their religious leader one time. 1:02:01 Otherwise, we could slip back into those can polish ends up, looking for more reassurance, redoing that, but that’s a really excellent question that that that person had. 1:02:14 Yeah, that was a good question. So, another one is, D B T. Be ineffective modality of treatment for building skills to managing the distress from OCD? Or would this potentially offer a way around dealing with the underlying changes or underlying challenge? 1:02:33 That’s a really excellent question and I suppose it really matters, um, how the person is using those skills. 1:02:43 So a distress tolerance skill, that’s helping someone stay in an exposure and not resort to compulsion. That’s, that’s fine, right? 1:02:53 But a coping skill that a coping skill can become a compulsion if it has that agenda of trying to push away the unpleasant experience and emotion. So I think a lot of it would be, it really depends. 1:03:08 And I tend to be a little bit more on the cautious side about coping skills. 1:03:14 Because CPU does like to grab onto them and kinda twist them into compulsion. 1:03:21 But but OCD can turn anything into a compulsion. So it’s not just coping skills that we have to be on the lookout for. 1:03:33 Another question that we have is, what if a person overly thinks or obsess about one specific issue, then all of a sudden, like it just drops and it’s not really, I guess, a thing? 1:03:47 And then, they do the same thing about a different issue after some length of time. Would that be considered OCD? 1:03:57 It could be. It’s really tough to say and certainly, I couldn’t tell you for certain outside of a diagnostic interview. Right. 1:04:09 But um, with OCD we often do see a dropping of certain themes and thoughts and kind of an investment in others. 1:04:23 And I sometimes playfully refer to it as OCD whack a mole, where 1 1 month right? Religion and spirituality is Is the thing that’s so distressing and scary, but then maybe another month it’s no harm OCD. Did I commit a whole? Enron? 1:04:42 Um, so that could be it OCD, it could also be something else. 1:04:50 And, um, my question about the thoughts would be is if the thoughts are with the goal of resolving a doubt. 1:04:58 That can be rumination, which which is a compulsion, if if the action is trying to resolve the doubt or reduce the anxieties. 1:05:10 Even if it just feels like obsessions. Sometimes people are missing the compulsive piece where they’re actively replaying the thoughts in their head. 1:05:21 That makes a lot a sentence. 1:05:23 And then our last question is I, how do you respond to people who say, I’ve done ERP and it does not work for me. 1:05:32 So I try to respond in a validated way because I think us, therapists and and I hope we all have our hearts in the right place. 1:05:43 Sometimes we approach ERP in less than effective ways, I was actually speaking with some clinicians about this earlier, where maybe we go to aggressively too quickly, or maybe we don’t stick it through consistently enough, and the person kind has mixed results. 1:06:03 What I would ask that person, though, is, is, do they want to try your RFP again? 1:06:08 Or, might they want to try one of these other treatments that we talked about tonight, that that could be just as effective as ERFP? 1:06:19 Um, and, uh, you know, seeing how that person responds. But, I hear that a lot. 1:06:26 And, I do think that, a lot of times, it’s, It might be more about clinician delivery, then, about ERP in and of itself. 1:06:38 Well, thank you so much, too, for staying on, answering a few questions to everyone that stayed for those questions. And the questions are absolutely wonderful. Thank you so much as much. 1:06:53 So, this concludes our webinar on understanding and Treating Scrupulosity OCD. 1:06:58 Just to re-iterate from before, when you close out of this webinar, there’s an exit survey, which we would greatly appreciate you filling out. 1:07:06 An archived recording of tonight’s webinar will be posted to our website, WWW dot NJ CTS dot org. Under Programs any questions? We were not able to get to tonight, or any questions that you might have within the next few days. Feel free to post them underneath the webinar blog, which would be underneath our the archived webinar on our website. And the webinar blog will be open and available for the next seven days if you have any questions for our presenter. Like I said, feel free to post them on the blog and post as often as you would like our next presentation introduced, Introduction to Transition Services, presented by Melissa Zeidler and Jana shamans. 1:07:56 Disability Rights New Jersey is scheduled for Wednesday, April 19th at 7 30 PM Eastern Standard Time. This ends tonight’s webinar. Thank you, My sofa Lumbo for your presentation and thank you everyone, for attending. I hope you all have a wonderful night. 1:08:12 Thank you so much.