Episode 221: Understanding Obsessive Compulsive Disorder with Dr. Rindee Ashcraft

I'm Ben Reiman, and this is Behaviorspeak. In this conversation, Dr. Rindy Ashcraft shares her insights on OCD and anxiety treatment, discussing the effectiveness of exposure and response prevention as a primary treatment modality. She emphasizes the importance of understanding OCD symptoms, the role of genetics, and the need for proper trading for therapists. Dr. Ashcraft also highlights the significance of community support and the impact of accommodating behaviors on OCD symptoms. This discussion covers various aspects of OCD treatment, including body-focused repetitive behaviors, and future directions in therapy. Welcome, Rindy. Thank you. I'm excited to be here today. Yeah, grateful to have you. Before we get started, I just want to acknowledge I am producing this podcast on the territories of the climate, Leo Somoco, and Kolmox First Nations, and I'm grateful to be here. So, Rindy, tell me a little bit about yourself. I am a psychologist just outside of Seattle. I specialize in working with OCD and anxiety, and all of the related disorders. So that's the body-focused repetitive behaviors, and body-morphic disorder, and all the variety of anxiety disorders. I have a group practice right outside of Seattle called Polaris Family Behavioral Health, so now I train a bunch of people to do the same thing. I spend a lot of time talking about OCD and all of its disorders, and just educating people, and really love talking about and advocating for treatment of OCD and anxiety with a wide variety of age groups. Yeah, I enjoy it quite a lot. How did you get into this work? It was actually completely accidental. When I was going through grad school, I was going to work with in the forensic realm. My first graduate degree is a forensic psych degree, and then I ended up doing trauma work, and was really enjoying that, and a colleague said, "You know what? You need to try." Because you will love this. You need to try working with OCD. You love working with kids. You got to try OCD, and she sent me a case, and I've never looked back. I've never had so much fun as I do when I'm working with OCD, both because the therapy is just interesting and entertaining, and never what I will expect. And because when I'm doing this work, I get to see people feel better, sometimes really fast. Not always, but the primary treatment modality I use is exposure and response prevention, and somewhere between 70-75% of folks respond to ERP. And that's just a phenomenal response rate. Sorry, my dog's very attention excited right now. When you're doing something, and you see people get better, sometimes really fast, and you're having fun with what you do, and you're seeing the people you work with have fun, it's just everything about that was just a great fit for me. And I haven't looked back. I haven't looked back. Is that sort of unique to OCD and that the treatment works so well? Is that not common in a lot of these psychiatric disorders that folks are working with? I think that there are other treatments that also work fairly well, and I think there's a lot of exposure-based works actually that tend to be pretty effective, and there's a lot of other treatments that can be fairly effective. And there's a lot of treatments that it takes a long time to see progress, and sometimes the progress you see isn't, it's not as notable. So when I was doing trauma work, yeah, we absolutely saw progress, and sometimes potentially even the same percentage of people, the thing about OCD that can be different is that typically people with OCD, they know that what's going on doesn't, it's not something they like. It's not something, you know, that with OCD, the fears that they have are the distress, their obsessions are typically not something, they know it's not rational, the vast majority of the time. And they know that what they're doing about those fears, or the thing that distresses them, they know it doesn't make sense as well. Not always, again, of course, but when you are able to step in and have this treatment, you're helping take away something that can be so much bigger. That's probably the wrong word, but that just is how it feels because OCD can be so disabling. It can be so disabling, and so it feels like you are making a bigger difference faster, and that's just incredibly rewarding. And so do you find that then that for the most part makes your clients sort of, because I know a lot of things, a lot of folks struggle with just getting clients to want to participate in treatment, and do you find that that's not as big of an issue for you? It can absolutely still be an issue. When we are doing exposure based work, you know, it has a bad name. When people develop its researchers who develop the names of the therapy and exposure and response prevention is not a particularly exciting name. It doesn't sound razzle dazzle. The marketing is not good. So it doesn't sound great. And the idea of going out and doing the thing that terrifies you, it can still be really hard, because even though you know it doesn't make sense, there's a part of your brain that definitely says, for example, if I flip this light switch, it will kill my parents. And that's a big risk. So on the one hand, they know it doesn't make sense. And on the other hand, the risk can be so high, and it can be so scary that the motivation can still be something we have to work with. Yeah. So maybe a little bit on sort of what is OCD? What makes something OCD versus me just doing something a few times or doing something, or you know, sometimes I'm a pretty forgetful guy. I think that kind of goes hand in hand with 780 HD. And so what makes me just being unsure if I turn stove off versus someone else who's, you know, got something diagnosable. What makes one have OCD? There's a few different things we tend to look at when we are looking at OCD. A big question is, what happens if you don't do it? If you have a routine when you leave it just like, you know, checking around the house. Did I remember to turn up the stove? Did I remember to lock the back door? Whatever. What happens if you don't follow that routine? Does that cause a lot of really intense feelings of distress? Or does your brain say, eh, whatever, it's probably fine. Not a big deal. If it causes a lot of really intense distress, it's more likely to fall into the OCD world. And then also we look at time. If it causes a lot of intense distress, then it takes a lot of time out of your day, by which we mean more than an hour. And we're probably looking in the OCD world. And of course, as with every diagnosis, it's got to get in the way of functioning. So once someone gets that diagnosis, what's usually the next step? Do they usually come to someone like you for this type of therapy? Or are they off there? Are they prescribed medication? Or what direction are they set typically when they find out there? Well, unfortunately, OCD, getting that diagnosis is hard. OCD is one of those diagnoses that recently people have started to learn more about, which is amazing. But that's relatively new. But once people get that, what's the ideal? Then, yeah, potentially they're getting meds, they're coming to see someone like me, they're getting treatment, and they're often running. That's not actually what normally happens. Normally, what happens is there's, I think we're down to an average of a nine to 12 year delay between onset of symptoms and getting appropriate treatment. It's a pretty OCD can be debilitating. I mentioned the one hour, and it can take up your entire life. It can be 12 to 24 hours. People wake up with nightmares. It can be pretty bad. So, and ideally, there's people like me in lots of places. And so it's easy to find someone like me, but that's not necessarily true. So often people go and get medication. And then hopefully can find someone like me, but sometimes it's a little bit harder to find someone who's appropriately trained. And unfortunately, OCD is something where if you go to a therapist who is not appropriately trained, it's normal cognitive behavioral therapy can make OCD worse. Because if you are introducing the normal relaxation skills, those can become rituals and can really be problematic in the OCD cycle, which is not ideal. Certainly not what any therapist is intending to have happen, but if you have a therapist who has not been educated and how to treat OCD, they just don't know any better. Because the education just isn't something that is provided in most grad schools about how to appropriately treat OCD. Because it's relatively new that we figured out what to do. So it's no one's fault. It just is. Can you give me an example of how that might happen or someone's being taught some relaxation techniques, how that would then turn into a problem? So the normal OCD cycle of let's say a normal OCD fear for an adult could be a stereotype is germs. Someone gets really uncomfortable with germs. They don't want to make other people sick. So they're really careful about germs. So they wash a lot. They wash their hands. And this is getting in their way because they're washing their hands too often. Now, they're going to have a lot of other rituals because OCD doesn't typically just target one thing, but for this example, let's stick with that one. If they go to a regular therapist, that therapist is going to absolutely see this person's really anxious because they are. There's a lot of anxiety that's happening because they don't want to make other people sick. They're terrified. They're going to make other people sick. Of course they are. That sounds awful. Who wants to make a bunch of other people sick? And so they might say, hey, before you wash your hands, why don't you practice some deep breathing or use some muscle relaxation. OCD doesn't actually care what your ritual is. It's happy to add rituals. It's very happy to say, so we're going to do deep breathing and wash hands. That's fine. I don't care. We're going to do muscle relaxation and wash hands. Sure. We'll make the ritual longer. No problem. That's totally fine. And so now you've got two parts of the ritual. And so what was just a hand-washing ritual is now a relaxation and a hand-washing ritual. Or let's say you struggle with falling asleep. And so which you have OCD about sleeping perfectly. If you don't sleep perfectly, you're going to have a bad day the next day. Which many of us have been told forever. We need to have a good night's sleep. That's a really normal thing for OCD to develop. You go to a therapist who says, hey, mindfulness. You should do some mindfulness videos, mindfulness breathing. Do that for 20 minutes before you go to bed. It's going to be great. You'll sleep better. No problem. The problem with OCD is that it's going to say excellent, but you have to do that 20 minutes of mindfulness perfectly. But how do you do mindfulness meditation perfectly? That's really hard to do. And how do you measure that? And to do the OCD ritual perfectly, then you do the mindfulness meditation. But then somewhere in the middle, you might have a thought wander in because our brains have thoughts wander in. And then, well, that means obviously you have to restart. So you go back and you start again. And then you're a little bit more anxious because you're restarting. And it's getting later. And your sleep is going to be more disturbed. And so you start again. But another thought wanders in. And so you have to go back and restart. And the cycle repeats over and over because OCD is telling you that this mindfulness meditation has to be done perfectly. And that's so challenging. And so all of a sudden, this practice that if you don't have OCD can be incredibly helpful for helping people fall asleep at night and sleep more deeply. Please, you know, it's a great relocation technique and a great way to sleep better if you don't have OCD interfering with it really can get in the way if you have OCD interfering with it. That makes a lot of sense. And then of course, doesn't right. What I'm talking about OCD is that it has this way of distorting logic that makes it not act like normal logic. I definitely want to spend a good chunk of time talking about the therapy modality. But I'd like to ask you a few questions about first off, do we know much about sort of what causes OCD and or things folks might be able to do to kind of prevent OCD? We know that genetics causes like 45 to 60% of OCD. And we know OCD has been around a long, it's this, it happens, it's across race, it's been around, like if you look back, there are documented descriptions of OCD that look almost exactly like the OCD we have now going back like a thousand years. So it's really that genetic piece is pretty solid. It's for prevention. It's tricky. There aren't necessarily great ways to say prevent it. Are there things that people can do to limit the chance that they will have it be a huge problem in their life? Absolutely. We talk about living the exposure lifestyle can end up being kind of fun too. It means that you allow yourself to build risk into your life. So you let yourself do things that might terrify you. The idea of speaking on a podcast is terrifying to me. So I am here today because taking risk is an important thing for me to be doing. Right. But it doesn't have to be huge risks like that. It can be little risks like wearing your hair differently or wearing an item of clothing that's a little bit outside what you would normally wear. Or we talk with kids and kids, we talk about smiling at someone in the hall that you wouldn't normally smile at or trying a new food that you wouldn't normally try. If you don't have to be huge risks that you're taking, I'm not talking bungee jumping. Right. It's just trying something new and building that into your life is a regular normal part of your life. Sure. Yeah. That makes sense. It doesn't prevent it, but it does make it easier to fight. Should you need to? I'm thinking about sort of the bungee jumpers and, you know, the X Games kids and things like that. Are these folks would you do? Do we know sort of folks like this or maybe correlated with sort of lower incidences of OCD or is there any relationship there? Do you know? Actually, I don't know. I do know when when I was little, there was a show called Double Dare. That's a similar to your factor. Sure. The host had OCD and it really was all about doing gross things. So do we know? No, because typically the OCD is not going to target. It doesn't necessarily target the stuff that's easy for you to do. So if that's something that you already do, it honestly, I think it just makes it easier to fight if it pops up. If that's something that's already in your skill set. And now where does medication fit into OCD treat medication can be a huge added treatment modality. There are some amazing med typically SSRIs are the first line of med treatment. It is if you're going to if you have OCD, it's really important to make sure you're doing your own research on dosage because typically for SSRIs. So dosage is a little bit different than for then when you're being treated for other things. And so it's really important that you're able to advocate for yourself because sometimes unfortunately the education hasn't necessarily caught up with what the research on how it should be prescribed. If that makes sense, so we know that SSRIs are really effective, but we also know that in order for them to be effective for OCD, they typically need to be prescribed at much higher doses than they would typically be for other things. And sometimes prescribers have not haven't had the opportunity to learn that yet because again, the education just hasn't caught up. That's really important to just make sure you educate yourself. You talked about sort of this sort of stereotypical OCD and some of the things that the movies and other places have talked about and the washing the hands of checking that sort of thing. What are some other kinds of ways that OCD presents that folks might not be aware of and maybe not maybe not even realize are part of that OCD spectrum? That's such a great question because those stereotypes are actually not the most common ways that OCD presents much more common are what I was hinting at earlier that this idea that you might hurt someone else. We call it like aggression is kind of how it gets looked at where you might hurt yourself, where you might hurt someone else either physically, you might hurt their feelings, you might accidentally insult them and that fear that you could potentially hurt someone can be so terrifying because if you really value not hurting people. That really pokes and that's the thing is OCD does tend to find a value and make that thing the thing that you are most scared of. We do in fact even find that there are some folks who it's a fear that they might accidentally kill themselves they're not suicidal but they might have a fear that they might kill themselves. Right now we're seeing a really we're hearing a lot about orthorexia which is not quite OCD but it's in that same vein. It's almost OCD about food where people have a really strong obsession about how they're eating and what their food needs to do so they want to make sure that there's no contaminants in their food no chemicals in their food and it's the same type of thing where most of us it makes sense that we want our food to be good food we want our food to be healthy food. If you find that that is restricting you to the point where you can't eat other things and it's hurting you it's an eating disorder that is certainly more present now than it has been in a really long time and more present at older populations it's similar it's used to be arphid now we're seeing functionally arphid in older people. By which I mean adults other really common OCD themes are this idea of things needing to be just right and feeling just right but how do you measure what just right is you can't it can be very challenging because of not having what we call a core fear you just know that things feel wrong and if it feels wrong you can't do it. And having to explain to people well I know I can't read that book I can't tell you why a lot of people have probably heard over the years at some point about scrupulosity or a fear that you might offend religion that you have to follow religion to a specific degree. Following within that is the idea that things have to be really fair or that you have to be really moral even if it's not necessarily religious we're also seeing a lot of health anxiety which can absolutely end up being OCD where you do a lot of checking what symptoms do I have. And is that OCD and so going back to the doctor over and over again to check are you sure it's not this is that could it be that and doing a lot of body scanning but I see this is there yeah those are some examples and there's so many more OCD can target anything you care about. I like to take a minute just talk a little bit more about the aggression one because I think just a sort of maybe dispel some fears folks have about you know even trying to get that treated because you know I think it's easy to go into a clinician and go checking things or you know I'm not sure about things or I'm trying to get things just perfect here and there. But it's probably harder to go to a clinician and go and having thoughts of hurting people and you you suggested to me before the interview that I should check out Maria Bamford's key notes and and I checked out the shorter one and it was just it was during COVID I think it folks are familiar with just the comedy Maria Bamford she's awesome but she's she's she has some some great anecdotes and really tells the story really well she talks about this harm OCD. And so then I started googling like Maria does a key note and realized you know this was a thing so they actually so there's two pieces to that so the first one is they've actually done research on the many of us have those thoughts those like flash through our brains and like the driving off the bridge one. Or the like mind tend to be like when I'm driving down the road and like and you see like the that divider and so I that's one of mine like can I actually do it. And of course I'm not but thoughts like that are like and especially for new moms you're going to throw your kid down the stairs you're going to throw your kid off our bridge 95% of people have these and the researchers concluded the other 5% we're lying. They're so incredibly common our thoughts are made up of electricity and chemical shooting up and down our brains and kind of like at night when our muscles twitch and we just can't control it. Sometimes our thoughts do the same thing just it's just not a they don't mean anything it's just muscles or just chemicals and electricity that shoot through our brain because there's so many different pathways in our brain and everyone has those thoughts happening. The thing about OCD is that when that happens and it's about something you value OCD attaches meaning and so OCD says you're terrible. And there's some other disorders where you also may attach meaning as well but OCD absolutely attaches meaning says you're terrible and attaches all kinds of rituals that prevent you from driving off the bridge. And often the rituals don't make sense. So you might in order to make sure you don't drive off a bridge or throw your kid over the side of the bridge. You might do who knows what I've heard some very I've heard many many different rituals because the ritual sometimes absolutely are connected like before you get in you you know just check in with someone so that they know I should be here by about this time so that if you don't get there by about that time someone will know which that kind of makes sense it's a little connected for it's a little dance before you get in the car. Why is that connected? It's not it's just that our brain moves together. Part of the advantage of talking with an OCD therapist is if you have a fear that you might accidentally stab someone not a desire to stab someone but a fear that you might we totally understand that we've absolutely heard that before that's not a fear that's going to bother any kind of OCD therapist because it's a really normal OCD fear super normal if you have a fear that you might accidentally kill yourself it's so scary to have that fear and that's a really normal OCD fear which doesn't make it less scary but does mean that it's okay to talk about it to your OCD there if that makes sense. And it really speaks to the importance of training that you're talking about and being trained because you know the fear of killing myself could really start a chain of events that you know ends where I end up spending 10 days in a hospital within moments because you know the untrained therapist is reporting me he's talking about suicide we got to put him under a watch you know you know all that sort of that sort of chain of events can can occur quite quickly if if the therapist and also probably have that person never go back to a therapist again. So right for something where you were never wanting to kill yourself there's never a desire to do it and it gets extra complicated when because it does happen where sometimes man OCD is hard OCD is irritating and sometimes it's so heavy that there are thoughts of wanting to kill yourself where you really do sometimes just you don't know if you can do it and you have the fear of doing it. And so being able to talk with someone who's trained to like tease all of that out and able to say we can give you coping skills because you know you're not going to or this is when it is time to go to the hospital as opposed to someone who doesn't understand where the nuances it's important. So let's talk about the exposure therapy so maybe a little bit about you said this is sort of a relatively new therapy for OCD so so how did this become what is it and how did this become a treatment for OCD. So exposure therapy is relatively new and I should say so exposure therapy probably is 35 or 40 years old and probably at least in my area in the last 10 years the number of people I'm down in Seattle probably in the last 10 years the number of people who are trained in it has tripled. And it's kind of exciting this is a time when there are more treatments for OCD that are being researched. This is a very exciting time to get treatment for OCD because the options there are more options than there were. There's something called I CDT which if exposure therapy doesn't work it's a type of cognitive therapy that can also be helpful. I tend to prefer exposure therapy because I think it's a lot of fun and I really like to have fun in therapy and frankly OCD hates to be left at. I'm a fan of doing things OCD doesn't like because OCD takes away a lot from people and so I'm good with laughing at it. Yeah I'm really good with laughing at it and I forgot your original question so go back to that please. Yeah just sort of you kind of answered the first part about when folks started using it the second part was what is it. So functionally what happens is we figure out a couple of different things we figure out what a person's core fear is we figure out what they're doing to avoid the core fear. And we figure out all of the all of the pieces in between. Then we find ways to do it. So we've been talking about aggression and fear that you might kill yourself if that's what the fear if that's part of the fear. And if the core fear is let's say that people don't see you that no one will notice if you were not here then we would come up with a list of different exposures that would include playing with knives. We have a whole bunch of big knives at the office that would include taking knives and like rubbing them all over arms putting wherever you're concerned you might accidentally stab yourself we would put them all over our bodies in those areas. We would depending on how hard that is we would draw knives. We might again depending on how hard these things are we might say the word nice depending again on how hard things are we might just start with the letter K. We might write a suicide note we might plan a funeral. We very likely would do some research on customs around death and what different customs for death look like in different parts of the world and just lots of different ways of looking at death and suicide for this person. We also because the core fear is not being seen would encourage as best we could taking steps to be seen a little bit more if that means being more social that means no depending on where they are I work with a lot of kids and teens if that means talking in class a little bit more. If that means inviting friends over a little bit more if the person's an adult if that means talking with your boss a little bit more if that means going to more social groups spending time outside of the house doing classes whatever kind of event you can that you are. With people more so they will see you and with all of these we're going to do these without whatever safety rituals were the compulsions there's several keys to whatever we do with exposures because those sounds scary it's always with consent this is never something that gets forced on people because that doesn't make sense if we can we're going to make it fun so. Yeah we're going to play with knives we're probably going to at some point be cutting up chocolate and eating it because chocolate's delicious and that's a really good way to be comfortable with knives is to be using them in a way. That brings pleasure and we're probably going to at some point be watching some knife skill building videos and again absolutely this is never something forced on anyone this is always with consent. If the person says no we're going to because it's not fair it's not reasonable for them to be doing exposures that are our goal is for them to come back and do it again right our goal for them to get better not for them to have a panic attack. And not come back so we really work hard to make sure that yeah we're absolutely doing hard things but we're doing hard things that they are engaged with that they're excited about ish and that they are. Sitting with that knife at their wrist long enough that it gets a little bit boring because you would be surprised if you don't actually want to kill yourself. And you take a knife and you put it at your wrist and you sit there for 10 minutes it starts to get a little bit boring for most people and then all of a sudden like you start wanting to talk about something that is not the knife at your wrist right and then we get to start saying what look at you look at what you can do and you didn't realize it it's exciting that's amazing yeah another area you talked about that you have a lot of interest in is are some of these. Body focused disorders and body focused repetitive disorders and that makes me think about something we run into a lot in the analysis so maybe we run into all these things. But one thing in particular that always we always think they're going to hit a wall with is skin picking and yeah and and and and hair. Yeah and maybe fighting nails right and biting the skin next to the nails the cuticles and yeah and maybe even picking scabs yeah yeah all of those yeah. So how does that fit in in in in in OCD is there like how do you got to conceptualize a skin picking and then how do you go about treating skin picking. So the body focused repetitive behaviors are considered like a cousin of OCD and the thing about them that there's lots of different reasons why people do them. But for many people one of the reasons why people do them not one of the reasons there's others one of the reasons why people do them is because it's functionally it's a coping skill. If you feel bad and you pick it your skin you feel better it's not a healthy coping skill but it is a coping skill so certainly when we're treating them because it is a coping skill it makes them tricky. When we are treating them the first thing we want to do is a functional analysis why are people picking is that the reason there's others as well it can look like OCD it can look like well I have to pick it this because it feels wrong and it has to feel right. Which can be very much an OCD thing it can also be a I have a sensation and the sensation means I have to pick so knowing that piece obviously changes the treatment but for many people I feel bad and so I will pick if that's the case we work really hard to introduce a lot of other possible alternate coping skills. That can be hopefully as effective at reducing whatever feelings that coping skill was alleviating and ideally helping a person start to use them beforehand it's tricky though because there is something about skin picking on any of the body focused repetitive behaviors that you just feel good after them. You feel shame later or many people feel shame later but immediately after you feel good you feel relief so we work really hard to find coping skills that can almost parallel those as close as possible so a lot of our parallel coping skills like if there's hair you know those balls that have like all the hair things that come out. We really love those kush balls I think they are a lot of kush balls wiki sticks for skin picking really love like glue on the hand or there's other that are almost like similar to similar to picking things and then we really work hard to raise awareness because some people pick and they don't even notice because it's just so it becomes habitual and we raise awareness by using. By using things like band aids not everywhere but a bandage on whatever you pick with because most people have a specific finger for example they pick. So you notice I was about to pick with my finger but there's a banded there so I can't that's a reminder i'm going to go use this other coping skill instead and very often i'm definitely a behaviorist so we'll try and pair that with positive reinforcement. If you are able to replace that coping skill x number at times you get some kind of reward because yeah you did it. It's really it can be really really hard to fully change that because it does have the immediate it feels good when you get even though there is shame later. When you talked about sometimes it's not about coping that it's just about this physical sensation is that is that a different approach then yes and actually frequently it's multiple frequently of like all three. So we want the coping for one and then the if it's the sensation we practice sitting with the sensation. So we will practice in session making yourself it's because it's brain is so powerful the nominal you can make your ear it's if you think about your ear itching or you can make your whatever part of your body have a sensation where you want to pick or pull and then you make a different part of your body have that sensation. To kind of help relearn how much control you have you practice having that without picking very obviously very exposure based but sitting with that sensation and not picking and we absolutely because one of the things that can happen is once you start picking. The skin needs to heal and you have more of those sensations and so we work really hard to not pick for a while so the skin can heal. Yeah, it can be really hard to sit with that sensation though and not pick while it heals. Yeah, but it's worth trying. I'm smiling because the moment you said it that one spot in the center my back got itchy where I cannot reach and don't want to try right now but yeah it's easy. And I said your ear itches and of course my ears started to it course yeah wanted to ask a little bit about because a lot of my listeners are behavior analysts and a lot of my listeners work with folks with intellectual disabilities often folks that are non vocal aren't speaking and a couple things come up. One I think is sometimes may be a bit of confusion and this isn't so much the behavior analyst issue probably more the the diagnosis is around sort of deciding whether it's OCD or repetitive behavior and it can thoughts on that. It's so funny because generally speaking OCD is incredibly under diagnosed except for one population that would be folks with autism. The only place where it's over diagnosed and it's and of course you can also have both and so when I think about repetitive behaviors I tend to think about it in terms of if there's a repetitive behavior and it's both. And autism. How do you know which is that specific behavior and I go back to the original. How do you know if it's OCD question why is the person doing the behavior are they doing the behavior to stop a distressing thought are they doing the behavior because it's and so I've worked with a number of folks who have both and they often will have repetitive behaviors that are typically the family describe them as. Play or pleasant pleasure or bowl. And that may not be how most of the listeners end up describing their repetitive behaviors that's how it's frequently been described to me and that repetitive behavior isn't it's not done to get rid of a fear it's done because the person likes it. It's done because they because if they couldn't do it it's not that they would be anxious they would be sad because that's our fun time or there and you know I kind of think about it as like a most kids enjoy quality time doing something pleasant for themselves and they can delay it and it's not a big deal but at some point in the day they want to do it. The one matters less but if it's OCD the one the one really matters is this making sense. The dilemma that I've run into a lot in the past is is around treatment and particularly in particular with these folks that aren't able to speak to us have you had any experience in that area. If I've consulted with some folks who are nonverbal I don't know and I've treated some folks who are nonverbal it the treatment isn't really all that different there's a couple of different things we can do. So the first one is if you have a really good idea that what you're looking at is an OCD behavior one of the things that often happens when someone has OCD or anxiety is that the people around them change their behaviors so that person doesn't feel anxious or uncomfortable. So for example you might find that you have someone who they have no food issues but when the food touches it makes the kid uncomfortable and so the parents slate the food on three plates because they don't want the kid to be uncomfortable. We call that behavior accommodating when we have a kid who doesn't have motivation or who isn't verbal that's typically the route we take is gently removing the accommodation and depending on where they're at in terms of how impaired they are. They are will do it slowly but we will just move towards the food on one plate because if there's not a reason for the food to be on three plates other than them being anxious about it telling a kid that they can't handle an emotion doesn't help the kid. It typically just hurts them and it's useful for kids to know that their parents believe they can handle feelings and yeah that we actually end up doing a lot of work with families to remove those accommodations that tends to be a pretty important part of treatment. Because I think about sort of you know the exposure work and how you need that consent piece and what ends up happening is you're not not changing you are certainly telling the kid and you may not be having the food touch but you're not giving three plates and we definitely try to work to make sure that when we remove accommodation. So for example with three plates as an example we probably wouldn't go straight to all the food on one plate and it's touching that's a huge jump and we probably would want to make sure that that kid could get up and could get another plate if they need to. We want to make sure that we can find a balance so that the kid can get their own second plate if they need to in this example. But the parents aren't getting the second plate the parents aren't forcing anything but the parents are changing their behavior. They're not forcing anything they're just not yeah because it's okay for the kid to not have food touch that's absolutely fine. However the parent doesn't need to make it easy. It almost seems like in some of those cases some of the obsessive behavior is on the part of the parents. They may have put in really rigid restrictions or accommodations for things that may have been a little over the top and could probably fade back to something and still have some success. And the parents you know parents they worry. They're kids they've seen their kids struggle with emotion my house is not on fire never. And over time small changes get bigger and bigger and bigger and kind of like we shape behavior for more positive gains. Their behavior has been shaped so now there's three flights. So we're trying to go the other way the thing that happens though is the parents have inadvertently communicated to the kid that they don't think that the kid can handle one plate. And of course that's not the intention but that is what being communicated. Yeah I mean it sounds like there I mean there there can be a lot done with asset when consent maybe can't be given because they don't speak or write or whatever. Because I'm thinking about less about children we work a lot with with adults and who have been kind of displaying these OCD type behaviors for decades. And what happens is it's not what you're calling accommodations have now turned into kind of full on restrictions and restrictive practices and you know locking things up and limiting access to things. Something I've seen a lot in some of these sort of group home kind of contexts are these sort of what's the term they use. The term for it but but sanitized or whatever but essentially rooms that have nothing in them at all in order to prevent folks from moving dangerous things or whatever and so on. And we call it all we put it all under the umbrella of accommodation it is accommodating the individuals anxiety or a city. And absolutely your absolute we I talk about it typically related to kids and teens and it's absolutely not just kids and teens it's any family member who has anxiety or OCD can be accommodated. And actually one of the biggest predictor of anxiety or OCD not getting better is how much their behaviors accommodated. So we work really really hard to help reduce that because we're pretty passionate about people getting better. Yeah yeah well let's shift over to sort of training so you talk you've been spending a lot of time in your practice trying to get more folks can educated in how to work with OCD so what what. And you said that sort of typically folks that are maybe getting training to be psychologist don't get this training in university and so I guess number one is that changing and to if not how does one become specialized in OCD with what's involved there. I don't know if that's trained if that is changing a ton I hope it is I hope it is I think there are certainly more education specific opportunities like internships and postdocs etc. and that has definitely changed definitely changed and we're just talking about OCD more that has definitely changed in really exciting ways there are so many more therapists who specialize in OCD. And I only started doing this 15 years ago in the Seattle area and there are so many more OCD specific therapists in our area now it is the nominal but I didn't get trained in grad school I did it all after grad school so it's not necessary to do it in grad school. It would be lovely if you know we got the training there but it's definitely possible outside of grad school. The most ideal way to do it is to go through the international OCD foundation they have a behavioral training institute which has just a phenomenal training program. Unfortunately there's like a three year wait list for that so that's not how most people go there are other training programs that people have found online that people are using. And honestly the community of OCD therapists once you get into it is just wonderful they're just delightful. The OCD conference that happens every year it's in Chicago this year is probably the nicest group of clinicians you will ever meet. It's the best conference people go to it is it has both it has clinicians it has researchers it has adult clients it has families everyone at one conference and because it's still a relatively small community it's just nice everyone still really knows each other people are just nice it's really lovely. I really love the community and love that once you are trained it's really easy to reach out and say I have questions can you help me is it typically psychologist doing this work or are there folks from different disciplines all kinds of different disciplines probably mostly a lot of master's level folks I feel like in the field there's a lot of master's level folks doing the work. Just because there are more master's level clinicians generally and a lot of master's level people do amazing work there are definitely a lot of psychologists doing the work as well. And they we obviously do pretty good work too but there's also just a kind of master's level clinicians doing really good work it seems pretty broad yeah that's pretty great. So what's next for you in your practice and goals for the future. So actually we're really excited we are doing a lot of new things right now one of the things that our practice is really focused on is building community and trying to try new things and see where it takes us. So we are putting together a summer intensive for kids where one week where people come and spend a week working with other kids to do a lot of exposures and hopefully leave feeling better and we're also starting a couple of different support groups. And where people we don't have a lot of support group there's Seattle has is a funny place where one side of the lake has a bunch of support groups the other doesn't we're starting support groups we're starting a social anxiety support group and an OCD support group which is exciting and we are also getting ready to start a couple of community nights so like an art night or a poetry night. Where people can come and do OCD art or OCD poetry and then share it cool excited about those things and just have it be about the community yeah take away the stigma that's absolutely the goal we want to make the community. It is a great community nationwide and so having people get to enjoy that just in the northwest is great so we're excited to see where that goes. I can see how much you love this work grindi I mean it's really hard not to once you get started it's such great work great people. It's really fun thanks for sharing so much about OCD with us appreciate it. I mean I really appreciate it if you enjoyed this conversation there are two other episodes of behavior speak that I think you might find interesting. If you enjoyed this episode please consider leaving a review on Apple podcasts Spotify or wherever you get your podcasts and please follow us on Instagram at behavior speak.