EXPERT PSYCHOLOGICAL TREATMENT SPECIALIZING IN ANXIETY

Spectrum360 is a new kind of treatment approach for OCD

Spectrum360 is an intensive outpatient program (IOP) built to provide evidence-based, science-informed treatment for obsessive-compulsive disorder (OCD). Currently we are doing remote therapy via video and so far we have found this to be very effective.

Spectrum360 features cognitive-behavior therapy (CBT) and exposure and response prevention (ERP), offering updated versions of these treatment modalities through integration of mindfulness-based third-wave CBT and cutting edge findings from research in behavioral neuroscience (eg fear conditioning, inhibitory learning). Clients in our program work together, one-on-one with our expert team of psychologists and therapists. We do not do any group work. OCD is not a simple issue to treat; there are a variety of types of obsessions and also a variety of co-occuring mental health issues (like depression, social anxiety, post-traumatic stress disorder) that individuals are dealing with. Because of this, we tailor treatment to each client and prefer not to use generic or generalized treatment approaches.

Our Program

Spectrum360 is unique in several ways. We do a team-based treatment approach. Each client works with three treatment providers. Recent research indicates that variety is extremely important for new learning to strengthen during and after exposure therapy. Working with just one psychologist is useful but not optimal. Therefore our clients collaborate with three psychologists daily in our program, with each doing ERP.  Because OCD is complex, we prefer that our IOP clients do not work with counselors or coaches to do ERP but instead work with experienced psychologists.

 Assessment

We track progress using several structured interview assessments and self-report measures. Specifically, we use the Yale-Brown Obsessive-Compulsive Scale, 2nd version (YBOCS-II) and the Clinical Global Impressions Scale (CGI) together, as suggested by the expert consensus findings for OCD reported by Mataix-Cols and colleagues (2016). The updated version of the YBOCS-II interview provides an estimate of the severity of OCD symptoms and the CGI is a rating system used by psychologists and psychiatrists to evaluate client improvement. We also use a self-report measure, the Obsessive-Compulsive Inventory-Revised version (OCI-R). We use these measures periodically through treatment to get a picture of progress. Together these measures provide us with guidance about the effectiveness of our approach and where road blocks might still lie.  People are people and not a cluster of symptoms, so we don’t over-rely on these measures, but they are helpful. Because people who seek out IOP level of care usually struggle with a variety of mental health issues, we use a variety of additional research validated assessment measures based on the issues people are dealing with (eg depression, poor sleep, social anxiety, generalized anxiety, panic attacks etc).

Family & social relationships

 What impact does one’s family, significant other and friends have on OCD treatment? It depends, but usually the impact is powerful. OCD can be confusing and very disruptive. Sometimes family members and loved ones are committed to helping, but their help can inadvertently wind up fueling more compulsive behaviors and more avoiding. Sometimes in order to “just get things done”, family members wind up doing things for the person with OCD.  This leads to a progressive restricting of the OCD sufferer’s activities, responsibilities and eventually lead to worse and worse quality of life. This can also stoke growing resentments as families take on more and more responsibilities for their family member. At Spectrum CBT, we try to involve family, significant others and/or friends in the treatment process. This includes discussions about two typical cycles of behaviors – accommodation and conflict, that often co-occur in families.  We work together with family so that we see a clearer picture of what is happening at home and also can develop a family plan to help family members have specific coping and behavioral approaches to “take care of themselves” while also helping the client.

What is OCD?

Obsessions

Obsessive-compulsive disorder (OCD) is a complex mental health disorder that has three distinct parts to it. The first part are obsessions; to understand them better, first think of all the thoughts that come and go in our minds. There are memories, wishes, dreams, plans, goals, things you notice, things you think about. Thoughts can feel like they are in the form of a verbal conversation with yourself, they can also be visual images, scenes, stories. Some thoughts have are like click-bait. They can lure us in with a curiosity-generating headline. Many thoughts pop into our awareness. We don’t control their arrival. Some thoughts are boring, some are funny, some are enchanting, some are frightening. Some are downright awful. Some thoughts are wispy and come in and pass out of our awareness quickly; others are sticky and like brambles on a sock are hard to get rid of. Some are like tar; they just stick, others just keep coming back over and over. Thoughts can be like movies – some are comedies, some are action-adventure, some fantasy, and some are horror. Obsessions are pop in thoughts that are hard to get rid of, sticky, come back over and over and unfortunately, fall into the horror category of thoughts. They are frightening, often disgusting. Everyone has weird, gross, scary pop-in thoughts. Psychologists call them intrusions; unwanted, frightening and/or disgusting thoughts that intrude into our awareness. It seems many, many people have intrusions. Studies done with nonclinical research participants confirm this. Approximately 70% of adults report intrusive thoughts about leaving the stove on and causing a fire, 55% of adults report feel sudden impulses to say something insulting to a stranger, 48% having thoughts of impulsively running over a pedestrian. Remember, these thoughts are unwanted and feel repulsive to experience (see Purdon & Clark, 1993 & Byers, Purdon & Clark, 1998). Obsessions are intrusions on steroids. They are more intense, more disturbing and much harder to get rid of. For severe levels of OCD, people report having obsessions for more than three hours a day and extreme levels of OCD, people report having obsessions that are twelve or more hours a day.  The focus of the obsessions are incredibly diverse, but what they all have in common is doubt – the uncertainty about the risk of some horrible outcome arising.

OBSESSION Subtypes

As we go through this list of obsessions, you hopefully will get a sense that this is a catalogue of the variety of vital human fears that everyone struggle with. What makes these fears obsessions is not the content, but the way these thoughts express themselves; forcefully, repetitively and intensely.

Contamination

Obsessions about contamination (being contaminated or spreading contamination) are a major subtype and often the version of OCD that most people think about when you mention the term OCD. The origin of the word comes from Latin – contamino, meaning to pollute, stain or defile.  Contamination obsessions can be thoughts about harm coming to me or others through germs, viruses, bacteria, chemicals, radiation, blood, feces, urine, saliva or other bodily fluids. These thoughts arrive into awareness with significant distress, anxiety and importantly disgust. The latter being a misunderstood emotion that refers to feeling repulsed and nauseated. “Stomach turning” is a way to describe the shuddering, gross feeling of disgust.

Violence and injury

 Doubting about hurting others – accidentally or intentionally are another major category of obsessions. Obsessions about running over a pedestrian, stabbing someone, causing harm by neglecting to turn off the stove or causing an electrical fire, superstitious fears that I might cause harm by having a “bad” thought.

Perversion

Another major concern is about having unwanted, undesirable sexual thoughts. Obsessions can be about being perverted, or a deviant, thoughts about molesting children or committing rape. These thoughts, like other categories of obsessions, are highly disturbing.

Religious or metaphysical

Obsessions relating to religious beliefs are another major category of obsessions. Thoughts about violating a religious codes, angering God, being damned to hell, angering “fate”, harm coming because you put bad thoughts out into the universe, attracting bad energy or evil spirits to you can all be examples of obsessions in this category.

Physical/body related

This is a broad ranging category, but a way to think about it is a disruption in interoception. How we sense what is going on in our own bodies is called interoception and having obsessions about what is going on in our bodies is a way of thinking about this category. It can include fears of illness growing and developing in your body, obsessions about specific sensations (eg nausea, headaches, twitches, moles, pains) and it can also include neurological obsessions, like thoughts about remembering things properly, thinking properly, blanking out. It can also involve fears about relatively involuntary behaviors such as choking, and stopping breathing.

Knowing

The last category on this list is tricky one. This is the general area of knowing – or a need to know about ______. You fill in the blank. It might be about your significant other’s interest in you, whether you are a good person. Troubling obsessions can even be about topics that you yourself or others around you may not think are that big of a deal – like “was Michael Jordan the best basketball player ever?” Yet these thoughts become paired with significant emotional distress. It can also be about obsessions about “do I even have OCD? How do I know for sure?”

Central features of obsessions

I am borrowing heavily from and expanding a bit from the work of David A. Clark. In my experience there are six central features of obsessive thoughts: unpleasantness; intrusiveness; unacceptability; subjective resistance; uncontrollability; and threatening to one’s values or sense of self.  The thoughts are unpleasant. They are distressing, causing anxiety, sometimes panic, sometimes intense disgust and/or self loathing. Intrusiveness refers to a quality of the thought that it invades consciousness frequently and powerfully “steals” our attention. It calls us to action. The thoughts are unacceptable. I do not want these thoughts in my mind; they are either not allowable, not welcome. Subjective resistance refers to the call to arms. Something must be done about these thoughts or whatever situation the thoughts are referring to. I have to, I must engage in a form of controlling, solving, fixing, cleaning or undoing. These obsessions feel uncontrollable. There is a sense that I have weakened control over these thoughts and I have to get better at controlling them. Lastly, these obsessions are threatening to my values or my sense of self. If I cause harm to happen, it would mean that I am a horrible person. If I let this thought exist in my mind, it would mean that I am a deviant, corrupt or gross.

 Obsessions are thoughts, images, impulses that come to us, into our mind. There are other categories that I have left out, and for that I apologize, but let’s move on. Along with obsessions come strong urges to act. The carrying out of these urges are the next major aspect of OCD: compulsions.  

Compulsions

Compulsions are highly repetitive actions that we perform to reduce our distress or to generate a sense that we just prevented a horrible outcome. They are not “good” for us. Hand washing 3-4 times a day for about 20 seconds each time is good for us. Hand washing for 2 hours a day is burdensome, difficult, impacts our family and social life, impacts our school work or occupation. It is not good for us. Wondering if my significant other is cheating on me can be useful; it would be important to know. Wondering if my significant other is cheating on me for about 3-4 hours a day, including sending 10-20 texts “checking-in” with my significant other, discussing cheating likelihood with friends and family excessively is not good.

 Basically any action can be engaged in compulsively. From putting on your shoes, to walking through a doorway to thinking about the weekend. Engaging in the compulsive action typically leads to a weakening of the unpleasant feelings and the urge to act. Like when if you are thirsty, drinking water reduces the unpleasant feeling of thirst. Often people with OCD will notice that at first the unpleasant feelings reduce after performing a compulsion, only to have the bad feelings arise quickly only moments or a little while later. Sometimes, people don’t notice any reduction in feeling anxious, but at least the urge to act subsides after performing the act. Kind of like an itch subsides for a bit after you scratch, but it rises up again.

 Neutralizing is an important aspect of compulsions. We ALL neutralize thoughts. Knocking on wood is a good example of neutralizing. Neutralizing is a type of action whose goal is to cancel the effects of a bad thought or action. Compulsive neutralizing is a fixed, ritualized way of canceling bad thoughts or actions. Repetitive praying, counting, confessing, re-doing a behavior and other repetitive gestures can all be compulsions. Another major general aspect of compulsions is reassurance seeking. Repeated, excessive verbalizations like “am I going to be ok?” or “did I lock the back door?” are common compulsions. Reassuring can also be a “closer” behavior that is a way of closing out another repetitive behavior like washing or cleaning. The very act of reaching out for reassurance confirms that the obsession is bad and dangerous. Sometimes people ask for reassurance just to ask and they don’t particularly care if you don’t answer. Avoidance is another major aspect of compulsive actions. A major aspect of all anxious behaviors is to avoid a threat or situations that are associated with that threat. For example, if I have obsessions about being a child molester, I might avoid walking by schools, spending time with family members who have small children. If I have fears about bodily waste, I might avoid using public bathrooms. Unfortunately, avoiding can beget more avoiding, so my life becomes more and more restricted and limited. Also in OCD, I might start avoiding things and get triggered by things that remind me of the threat, even if they are symbolic and not closely related to the threat. A former client with OCD struggled with saying the word “beehive” because the letters HIV were in the word and so just saying “beehive” would trigger intense fear that he had HIV.

Although compulsive actions can be almost any behavior, there are a set of common behaviors that can become compulsive. The following table is not exhaustive, but hopefully illustrates the range of actions that can be compulsive.

Common Compulsions*

 Washing

Cleaning

Checking (door locks, faucets, electrical cables, driving back to check if you ran someone over)

Confessing

Reassurance seeking

Repeating routine actions (putting on shoes, sitting down, walking through a door way)

Reading & re-reading texts, emails, book chapters, contracts

Ordering or arranging objects over and over

Repeated counting, praying, chanting

Scanning (for contaminants, sharp objects, disapproval from others)

Staring, blinking, swallowing, adjusting one’s position

* Remember, everyone does these behaviors, but what makes them compulsive is that they are done excessively and in a rigid, fixed-like manner.