First Post on “Think, Act, Be”

Earlier this month I wrote my first blog entry on PsychologyToday.com. You can view it here:

https://www.psychologytoday.com/blog/think-act-be/201501/cognitive-behavioral-therapy

End-of-Year Reflections

On the eve of the new year I wanted to take some time to reflect on the year that’s ending and to look ahead to 2015.

One of the biggest changes that I look forward to is being in full-time clinical practice. When I left the University of Pennsylvania in 2012 I took a visiting assistant professor position in psychology at Haverford College around the same time that I opened my practice. It’s been a wonderful place to teach and do research, and the faculty in my department have been unfailingly kind and generous.

As my practice has grown over the past couple years I’ve realized that as much as I enjoy academia, my heart is in the clinical work. On a daily basis I have the privilege to work with individuals who are determined to get their lives back. Whether it’s sleeping better, finding new ways to cope with stress, facing fears, fighting addictions, strengthening relationships, healing from trauma and loss, or anything else, I get to be witness to the courage that allows us to make tough changes. I couldn’t ask for anything more than to be a part of that process.

This fall I made the final decision to leave Haverford College after the 2014-2015 year, and to focus my efforts on being a therapist. I’m excited to see what lies ahead.

This year also saw the birth of our baby in November. I was grateful for her safe arrival and for the strong support from so many who shared in our joy.

Early 2015 will also bring the publication of Overcoming OCD: A Journey to Recovery which Janet Singer wrote about her son’s recovery from severe OCD through exposure and response prevention (ERP) therapy. I provide commentary throughout the book on topics related to OCD. I also plan to start blogging on PsychologyToday.com in the new year.

I wish you health and happiness in 2015, and many moments of feeling fully alive.

Blogging at PsychologyToday.com (and Changes to This Blog)

Recently I was invited to join the roster of bloggers at PsychologyToday.com.

I plan to write posts for PsychologyToday.com that are similar to what I’ve been doing here, so many of my future entries on this blog will be re-posts from things I’ve written for Psychology Today.

The general page for blogs at PT.com is here.

Once my page is set up I’ll share the link.

OCD Awareness Week 2014: “I’m a Little OCD” Repost

Today marks the beginning of OCD Awareness Week. According to the International OCD Foundation (IOCDF) the goals of this awareness week are to “educate the public about what it means to have OCD and related disorders, to fight stigma of mental health issues, and to help people find the resources and treatment they need.”

My friend and co-author Janet Singer works constantly toward these related goals. I’d like to share the blog entry that she posted most recently, which talks about a common response when the topic of OCD comes up: “I’m a little OCD myself.”

http://ocdtalk.wordpress.com/2014/10/12/im-a-little-ocd/

Thanks to Janet and others who are engaged in similar work, more OCD sufferers can find the kind of help that makes life livable again.

What’s More Important Than Your Fear?

Ambrose Redmoon is credited with saying that “Courage is not the absence of fear, but rather the judgment that something else is more important than fear.” A recent article and video on NYTimes.com beautifully illustrated this truth. The piece features Attis Clopton, who had an intense fear of water. He decided he wanted to conquer his longstanding fear, and so worked with a swim coach to do just that.

Many things stood out to me from watching the video, given the work that I do. First, Attis Clopton had had traumatic experiences with water, and his solution was to avoid water and the fear that came with it. Like Attis, we’re all wounded during our lives in various ways, and we make compromises to keep going. We might avoid certain situations, guard ourselves in relationships, use drugs or alcohol to cope, or cling to a sense of control. These compromises can work, and then at some point may stop working, or not be worth what they cost. Attis finally reached a point where he realized he was alive but wasn’t truly living his life. He knew he had to change.

This need to change provided the motivation that Attis needed. Whenever we make big changes in our lives there inevitably comes a point when we think that maybe the old way, the “safe” way, really wasn’t so bad. At these times we can remind ourselves of why we wanted to change in the first place. Why were we not content to leave things as they were? And what’s on the other side of our fears? For Attis, facing his fear was a huge challenge, so there had to be compelling reasons to stay in the water when he really wanted to flee.

Attis also needed to experience the water, and it was his experience that changed him. It wouldn’t have been enough simply to be told that “water isn’t always dangerous.” That intellectual understanding could only take him so far. What got him over his fears was moving through them. Nothing is more powerful than our actual experience of successfully doing what we’re afraid of.

In many ways Attis’s instructor was like a good exposure therapist. She seemed to understand and empathize with his fear, and at the same time wasn’t willing to let him stay there. She also had a program of exercises that were gradual and systematic, with later steps building on earlier ones–just like we do in exposure therapy.

Once Attis had overcome his fears, he still had a lot of work to do. Even though he was no longer afraid, he didn’t know how to swim. I often find something similar in my clinical work–after the symptoms are under control, there’s still the task of creating the kind of life that the person wants. For example, overwhelming social anxiety can lead to a stunted career in addition to impoverished relationships; after successful treatment, a person has the challenge and the opportunity to build a better life.

Every time we decide it’s worth it to face our fears, we allow our lives to expand. And with that expansion comes freedom–the freedom to live lives that we value, to share love with close others, to face life with all its beauty and uncertainty. The image of Attis Clopton swimming in the ocean perfectly captures that sense of freedom in letting go. We can decide as often as we need to that freedom is worth more than our fears.

The article and video are found here.

Still Checking, Still Not Sure

A common compulsion in OCD is checking to make sure that something was done correctly: turning off the stove, copying an address, shutting the refrigerator, locking the door, and so forth.

We can never know with absolute certainty that we’ve done something right, so many people with OCD end up checking repeatedly, sometimes for hours. The lost time is bad enough, and most people find that they actually feel less certain that they’ve done it right.

How can it be that more checking yields greater uncertainty? A recent study addressed this paradox by having participants perform a computerized task and then check to make sure they’d done it correctly. The study authors predicted that repeated checking would lead to quicker, more automatic checking as well as less confidence in one’s memory of having done the task correctly. 

The study’s results did show that repeated checking resulted in faster checking and less memory confidence. It was unclear whether the faster, more automatic checking caused the greater uncertainty, and more work remains to be done to understand how checking leads to uncertainty. Additionally the participants were undergraduate students, not necessarily individuals with OCD, which calls into question the applicability of the findings to checking in OCD.

What’s the bottom line for OCD sufferers? As most people with OCD-related checking have found, the best solution is not to start checking in the first place. Generally it’s easier to walk away from an urge to check than to “check a little” and then walk away.

Of course, it’s easier to say “don’t check” than it is to resist the compulsive urges. Exposure and response prevention (ERP) for OCD is designed to assist a person’s efforts to break free of compulsive behaviors. Over time it typically gets easier not to check, leading to less distress and more time to do the things a person actually cares about.

 Reference

Elaine C. P. Dek et al. (2014). Automatization and familiarty in repeated checking. Journal of Obsessive-Compulsive and Related Disorders, 3, 303-310.

Pure O?

Obsessive-compulsive disorder, as the name suggests, involves both obsessions–intrusive worries about bad things happening–and compulsions, which are intended to prevent the feared outcomes.

Or does it? Based on the diagnostic criteria in DSM-5, OCD can be diagnosed if obsessions or compulsions are present. Accordingly, a significant number of OCD sufferers describe themselves as “pure obsessional” or “Pure O,” meaning they have obsessions without compulsions.

However, what appears to be “Pure O” typically turns out to involve mental compulsions (like saying a ritualized prayer), which functionally are the same as compulsions that others can see (such as repetitive hand washing). Both types of compulsions are meant to reduce the chance of something bad happening, and to reduce the person’s distress.

Every instance of “Pure O” that I’ve encountered has included the presence of mental compulsions, which is in line with research findings. In a study (1) of over 1000 OCD sufferers, every single person was found to have both obsessions and compulsions–including the 1 percent of individuals who initially thought they had only obsessions. A related study (2) reported that individuals who supposedly have “Pure O” engage in mental compulsions and reassurance seeking.

The study authors strongly recommended that the updated OCD criteria reflect their, and others’, findings. However, for reasons that are unclear the DSM-5 work group that updated the OCD criteria chose not to require the presence of both obsessions and compulsions for an OCD diagnosis.

Does it matter that “Pure O” actually includes rituals, or is it an academic distinction without a difference? In practice it probably matters a great deal. The psychological treatment of choice for OCD is exposure and response prevention (ERP), and preventing the compulsive response is a crucial part of the treatment. If the OCD sufferer (or therapist) doesn’t recognize mental compulsions and reassurance seeking as compulsions, then treatment will not effectively deal with these behaviors. As a result the person is likely to stay stuck with the OCD.

When the compulsions are recognized for what they are, they can be treated just like any other ritual in ERP (see this related post).

References
1. Leonard, R. C., & Riemann, B. C. (2012). The co-occurrence of obsessions and compulsions in OCD. Journal of Obsessive-Compulsive and Related Disorders, 1, 211-215.
2. Williams, M. T., Farris, S. G., Turkheimer, E., et al. (2011). Myth of the pure obsessional type in obsessive-compulsive disorder. Depression and Anxiety, 28, 495-500.

PTSD Awareness Day

June 27th is National PTSD Awareness Day. All of us know people who’ve been through horrifying traumatic events–things like assaults, combat, accidents, and natural disasters. The person may have experienced the event directly or witnessed it, or learned about something terrible happening to a loved one. About 1 out of 10 people who survive a trauma will develop posttraumatic stress disorder (PTSD).

Common symptoms of PTSD include being very upset by the memory of what happened, having nightmares, and other ways in which the trauma memory keeps coming back; trying hard not to think about the memory or be in situations that bring up the memory; blaming oneself for “allowing it to happen” or feeling weak and incompetent; problems sleeping and focusing; anger and reckless behavior; and being constantly “on guard” and easily startled, among others.

Even for people who don’t develop PTSD, these kinds of reactions are really common in the aftermath of a trauma. PTSD involves stress reactions that last longer than a month.

Yesterday I had the privilege of speaking about cognitive-behavioral therapy for PTSD at the SUNY Upstate Medical Center, Department of Psychiatry grand rounds. I tried to emphasize the good news that highly effective treatment is available that can help most PTSD sufferers get their lives back. For example, in a large PTSD treatment study by Dr. Edna Foa and colleagues (2005), the average patient who received cognitive-behavioral therapy (CBT) saw their symptoms go down by more than 70% after 8 to 12 sessions.

The first step toward effective treatment is recognizing the need for it. If you or someone you love might have PTSD, it may be helpful to seek a professional consultation. If treatment is necessary, it’s a good idea to find a therapist who uses evidence-based treatment. You can ask the person what form of treatment s/he uses for PTSD and whether the treatment has research evidence to back it up. CBT programs have the most evidence that they work, and include treatments like prolonged exposure, eye movement desensitization and reprocessing (EMDR), and cognitive processing therapy.

With proper diagnosis and treatment a person with PTSD can expect to feel better and rejoin life.

New Book: Overcoming OCD

When Janet Singer’s son was diagnosed with severe OCD, she discovered like so many parents that effective OCD treatment is frustratingly hard to find. Eventually her son recovered through exposure and response prevention (ERP). Janet is determined to make it easier for parents and OCD sufferers to connect with the help they need. She maintains a terrific blog about OCD and wrote a book about her son’s journey to recovery.

I was very honored that Janet asked me to join her as a co-author, adding commentary throughout the book on various OCD topics. The book was recently accepted for publication and is due out in January 2015. Our hope is that Overcoming OCD will be a helpful resource to individuals with OCD and their loved ones. More information about the book is available on Janet’s blog here.

 

Good Sleep Is Low-Tech

Earlier this month my students and I completed a research study on college students’ sleep. One of the things we asked students was how often they used various forms of technology (e.g., tablets, cell phones) in the hour before bedtime. We found a highly significant correlation between technology use and sleep problems, confirming results from earlier studies showing that technology use is associated with worse sleep.

One recent study that also found links between technology use and poor sleep was the National Sleep Foundation’s 2014 Sleep in America Poll, titled “Sleep in the Modern Family.” The study of over 1100 parents found that kids who used tablet computers in their bedrooms at night got on average almost an hour less sleep. Similar results were reported for use of TVs in the bedroom. Dramatic effects were also found for leaving on electronic devices at night; kids who left on 2 or more devices had nearly triple the rates of parent-reported “fair or poor” sleep compared to those who never left on any electronics. The full report is available here.

These results by themselves don’t tell us if using electronics in the bedroom causes poor sleep. It could be that people who sleep badly are just more likely to turn to their TVs or smartphones when they’re having trouble sleeping–in other words, electronic use might be a consequence of bad sleep rather than a cause. Future work remains to be done to figure out exactly why more technology use equals worse sleep.

Nevertheless, there are reasons to believe that using cell phones and other forms of technology interferes with sleep. For one, the blue light that the screens emit has been found to disrupt sleep. Additionally, it’s not uncommon for people to receive–and respond to–text messages in the middle of the night. If a cell phone isn’t in the bedroom, or is turned off, then there’s no risk of being woken up by it. So the safest option is to banish technology from the bedroom, and enjoy a relaxing and low-tech environment for sleeping.

My student collaborators at Haverford College were recent grads Noemi Agagianian, Tami Mau, Kylie O’Neill-Mullin, and Gabe Olsen.