Katherine didn’t understand why this pandemic hit her so hard. In fact, she was embarrassed that it did. “I mean, my routines and orderliness can be a little overboard, but I’ve never had difficulty getting by day-to-day. I cry at the drop of a hat and just don't know what to do." I was so honored that she admitted she was struggling, because in that honest vulnerability, she is now getting help.*

In this time of COVID-19, there is a common expectation: the misconception that "healthy" means we won't feel anxious - or the opposite: success is defined by feeling completely safe, confident, or certain. That's crap.
​
Though it’s nice to feel less anxious, it’s not always reality, even if we’re doing all the right things. I mostly work with clients by helping them learn to stay focused on things of value, regardless of how they feel. Overall anxiety reduction is a result of various factors and is rarely immediate. In time, with supportive factors, anxiety often will go down. Jesus himself felt greatly distressed and overwhelmed, at times, too, if you didn’t know. He wept, sweated, pleaded, was scared, bled, and got angry and frustrated. He understands because he can actually relate - physically and emotionally. He gets Katherine's suffering - and yours, too.
Life involves not only facing bad things that don't happen, but also bad things that do. The question is, are you trained and ready? Can you still keep your focus even when the world around you and inside of you seems to be in chaos? Here are some quick tips to help you stay grounded in reality.


1. Be assertive. Routines have changed. We have to communicate to make the covert overt, like telling your loved one if you need a break to recharge (they can't read your mind!).
2. Be careful of untrue thoughts. Unrealistic thought patterns negatively impact our entire life, like All-or-Nothing Thinking. For example, "Since I’ve been eating poorly it doesn't make a difference if I exercise.” Katherine, mentioned earlier, fell into this trap by believing she was doing a terrible job simply because she felt overwhelmed. Mental health is based on grasping reality to the extent we can. Watch your thoughts and line them up with reality as much as possible.
3. Don't over-consume on substances. Caffeine and alcohol are certainly the most popular substances to monitor.
4. Downtime/Mindfulness/Quiet. The importance of giving our brain pauses and rest cannot be overstated. During a crisis, we need more intentionality to slow down unhealthy processes that are automatic or deeply ingrained. Learn to be mindful, slow down the process, and/or meditate on something beneficial- like how much God cares for you and promises to never leave or forsake you. Benefits range from increased focus and function to decreased stress and disease.
5. Emotions, Thoughts, and Behaviors - Tune In. Be aware of your thoughts, emotions, and behaviors. God gave you these - learn to pay attention to them and discover how to respond - sometimes in ways you might not expect.
6. Exercise. Exercise is highly connected to mental health. If you’re stuck in the house, there are ways to get creative. Make a game with a fitness tracker! Compete with others! Set up prizes for yourself or children! Get outside where possible and get moving.
7. Get Support. Use trustworthy support. Few things in life (if any) are done well without support. One place to get support is through an online or in-person Live Second Group.
8. Have fun! We all need reminding to pursue fun. Even the term ‘recreation’ is based on the concept 'recreate '- “to give new life.”
9. Medication. Medication can play a necessary role in well-being. You don’t need to feel shame if you can use a physiological boost for your brain health. Consult a health professional if this would be the right option for you.
10. Normal structure. Our brains integrate information we don't need to remember and becomes second nature. So when you change your routine massively, you will feel out of balance. That’s okay! Try to make use of old structures while learning to develop new ones!
11. Nutrition/Diet. Be careful not to overindulge on carbs and sugars - the snacky & sweet food you may feel the urge to “pound,”which can offer quick energy and pleasure, but overconsumption won’t benefit you. In fact, it will impact you negatively.
12. Prayer. Open communication and presence with the God of the universe is what we access through prayer! His power is what I need; it's really good to follow a big God who is over all our circumstances.
13. Prioritize. Limit inputs of information and stimulation or your brain will do its best to force limits and push you back into what’s called “homeostasis” (or balance), which can lead to feeling burnout and depression.
14. Serve others. Loving our neighbor as ourselves is beautiful. Not only does it help them, but we also can find much encouragement and joy. Learning and growth is often solidified when we can teach, pass along, and serve. Win-win.
15. Sleep. As one of the most important contributors to all aspects of health, good sleep is a necessary foundation to good health.
16. Spend/Save/Give money. Work from a budget. Spending money can be satisfying. Giving it away is powerful to others and ourselves. Taking on unnecessary debts, overspending and being miserly or hypervigilant all lead to stress in different ways.
17. Socialize. We are social beings. Direct contact releases neurotransmitters! But so can positive interactions in this time where we can’t touch much. Wow! For the time being, technology, phones, letters, or writing on messages on cardboard goes a long way.
18. Spirituality/Faith. What do you live for? What do you believe? And are you living congruently with it? Are you allowing yourself to ask questions and pursue guidance, support, and practices around what is good and true and beautiful and lovely? To discover more about what it looks like to follow Jesus watch this.
19. Sunlight. Not only is sunlight important in Vitamin D production, natural light is linked with numerous processes ranging from sleep to mood and much more. If you must be indoors or have limitations on natural light, find ways to maximize it.
20. Supplements. There is good evidence that several supplements can aid in mental health; some linked most commonly to mental health are Vitamin D, B Complex, and Omega-3 Fatty Acids (always follow your doctor’s advice).
21. Your context is your context. Don't compare. "Comparison is the thief of joy." When we look at where we are, don't let expectations crowd out what you're supposed to be about.
Keep in mind this is educational content and not intended as a substitute for professional advice, treatment, or diagnosis. Any of these tips will come across as too simple for someone suffering highly.

​ Exposure and Response Prevention (ERP), the gold standard treatment for OCD, can be fairly straightforward once understood.  However, certain nuances are crucial for facilitating learning, growth, and maximal fear disconfirmation (fancy terms for successfully overcoming fearful responses).  Here are 10 tips- click on the picture for a downloadable version:
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1. Be prepared to feel uncomfortable- a healthy mind is not made in comfort.
2. Structure- it’s important to know how OCD functions, all the clever ways it can sneak past you, and specific strategies that confront the heart of compulsions, which drive obsessional anxiety and disruption to life. Prepare and have a back-up plan.
3. Repeat in mixed contexts. The strongest training requires going beyond one practice or context.
4. Varied- challenge yourself to face varying levels of anxiety- and multiple situations.
5. Track your anxiety level and urges to ritualize.
6. Attempt to not fight fear- it only reinforces it.
7. Avoid subtle avoidance strategies. These also reinforce fear.
8. Test negative predictions. Real-life ERP experiments inhibit faulty/erroneous misappraisals when you experimentally reveal you CAN face your fears. How did you do? Did the worst thing happen?
9. Stick with exposures until your prediction has been tested experientially. You are rewiring your brain for resiliency!
10. Practice alone! Develop strength on your own, not just with others (therapist).

​

Adapted from: Abramowitz, J. S., & Jacoby, R. J. (2015). Obsessive-compulsive disorder in adults. Boston, MA: Hogrefe Publishing.


OCD is an extremely debilitating disorder as a whole, ranking as one of the top ten medical and mental illnesses in the world- right alongside such things as Heart Disease, Major Depression, and COPD, according to the World Health Organization. With 2 out of 3 people reporting severe impairment at some point in their lives (e.g., work, relationships, school), you can count on OCD to create an ever increasing set of problems- without effective treatment. Furthermore, around 90% have at least one comorbid mental disorder, such as Major Depression, Panic Disorder, or a Substance Use Disorder. OCD has a tendency to make sufferers “hostages"- feeling stuck in an ever-narrowing loop of behaviors and/or thoughts that usually seem nonsensical to the person themselves, which tends to drive even more shame. Families and support are collateral damage. It is crucial to identify the threat and connected suffering of OCD in order to fully address its impact- and to have the proper perspective and motivation in getting necessary treatment. ​

Attempt to really understand your loved one’s suffering, and understand how to help, howa not to help, and how to stay healthy yourself. Finding effective support and treatment is crucial. You don’t have to have diagnosable OCD to be an incredible advocate. Myself and a majority of my OCD specialist colleague/friends do not have diagnosable OCD.
Knowing treatments that are effective helps to stay grounded and focused. In short, a specific subset of CBT (Cognitive Behavioral Therapy) known as ERP (Exposure and Response Prevention) is the Gold Standard in treatment. SSRI medications (and clomipramine, a TCA) are used as the first line psychopharmacological treatments. 
 Supportive psychotherapy is not evidence-based first-line treatment for OCD. You may love a counselor who is very supportive, but if they’re not doing some sort of exposures or behavioral experiments, and there’s not a noted clinical reason why they cannot, consider an OCD specialist, because they are not following clinical practice guidelines. Again, check out my Intro Brochure​ and ERP for OCD Presentation for more on the research and specifics.

Taking OCD seriously involves seeing it- and you may help your loved one see it more clearly through your loving support. When it is beneficial to a client, I almost always recommend involving a supportive loved one at some point in treatment. We would consider it odd or unusual not to involve a family member in many other medical treatments. A major challenge with mental illness is making the unseen seen.  ​

Support needs to strike a balance between being overly-accommodating and overly-emotionally expressive (outbursts, hostility, negativity, etc.). The well-researched terms we use to describe these are Family Accommodation (FA) and Emotional Expression (EE). Break the Cycle!! Don’t Do Compulsions for them (by proxy). Begin (with a plan) to minimize your accommodation. Typically in therapy, I help to incrementally get rid of accommodation altogether without “pulling the rug out” too fast (i.e., in one day). Therapeutically, all client rituals must ideally be terminated to maximize outcomes. Helping a loved one ritualize only feeds the cycle. Don’t Give Reassurance. To do this well, you often need to be involved in the prior steps this article elucidates. It can be tricky to know what is reassurance and what is not. Ask questions of your loved one. If they are not open to sharing, you may have to do your best to set your own boundaries, make an informed guess, and base your limits on your own personal boundaries until they're willing to communicate further. Part of feeding obsessions involves engaging the content of obsessions with logic, emotion, and reactions. The person with OCD must learn to live their goals and values without following the content of obsessions. Be careful not to get pulled in, either through accommodation or emotionality. Offer to go to therapy with your loved one if they are willing. You can also gain much support by doing your own therapy, as well! Part of support may be helping covering costs of therapy.
 Just to be clear- you get to have your own emotions, whatever they are! But EE refers to when these emotions are expressed in harmful ways.
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If you have made it this far to read this article, you are quite likely a key support of someone who has OCD. It is then very likely that you care and want to make a difference. You rock. Keep up the good work. 
​ ​

An editor for the American Counseling Association reached out to me about OCD from a Specialists' perspective.  (I was so proud of them for doing their research with multiple specialists!!). The following are excellent questions that may help inform their ACA magazine article in February 2020.  Whether they utilize any of these or not, I hope they are helpful for you as they cover important questions to consider with regard to treatment.  



"What presenting issues might bring these clients into counseling?" 

• Intrusive thoughts!  Many of my clients initially seek out counseling because they have been plagued by intrusive, unwanted thoughts.  They wonder what this says about them, even though there is often some sense of it being senseless and out-of-context (we call it ego-dystonic).  
• "Tipping point" behaviors- people start to notice problems in routines that begin taking too long, physical  pain caused from washing, mental stress from extensive rituals (needing to "feel" a certain way, pray a certain way, walk through doorways multiple times, pick 7th item at the grocery store, and so on).
• Family, friends, and spouses are a great source of support (and pressure, at times), which can help lead to a client first coming for a session.  Some of my clients (more often than not, in the pediatric population) have low motivation for themselves, and it is a concerned loved one who (hopefully lovingly, sometimes not) asks them to seek treatment.

"What are some “red flags” for counselors to listen for that might indicate OCD in a client who came in for something else (anxiety, ADHD, etc.)?"
If a counselor begins hearing the exact same things, worded or behaved in similar ways, this is a good indicator to watch out for.  Many of my clients are good at exactly quoting themselves on what they've said before.  Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.

At its core, it's not remarkably difficult to identify criteria in OCD (in most straightforward cases) if a counselor brushes up on what they're looking for (dust off that DSM-5!). 

Furthermore, if a client isn't improving from certain methods (especially things like Cognitive Restructuring in CBT), this is "Getting Stuck 101" and needs further assessment.  Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence based way and approached the same as regular old automatic negative thoughts. This is not typically helpful. 

"What counseling methods/techniques can be helpful when working with clients with obsessive behavior and/or OCD? Please explain how this/these method(s) work well for this client population. If possible, please talk about a case example (without identifying information) who worked with you and showed improvement. What were his/her presenting issues, what methods did you use and what issues did you focus on in counseling sessions?"
Exposure and Response Prevention (ERP) is the GOLD standard treatment (which is a very specific subset of CBT).  It is indicated as the starting point for all OCD treatment.  This is a strong statement, but it is backed by the research (the most RCTs by far) and organizations like the IOCDF, APA, and so forth.  SSRI (and Clomipramine, a TCA) medications are also first-line psychopharmacological treatments, though with less effect on average than ERP.  Both combined can be helpful, though may not necessarily increase the overall benefit of just ERP alone. Another first-line treatment for OCD (though not the "gold standard") is Cognitive Therapy with Behavioral Experiments.  Along with medications, it is seen as sometimes a more agreeable option for those who are hesitant to engage in exposure therapy (which intentionally and repeatedly provokes distress in order to respond differently- i.e., without compulsions).

Adjunct therapies, medications, and treatments are utilized.  In the interest of brevity, research has discovered the integration of Acceptance and Commitment Therapy (ACT), Motivational Interviewing (MI), and other techniques can be helpful to provide well-rounded treatment and/or facilitate the practice of ERP.

To share a classic example [identifying factors changed to protect confidentiality- this type of case is remarkably common], one woman came to me with severely distressing thoughts about harming her children (no history of harm or abuse).  She knew it was irrational, yet it felt so real to her; the more these intrusive thoughts continued to appear, the more difficult it was for her to determine her intent from confusing feelings and "impulses" to stab her kids.  Upon receiving a diagnosis of OCD, I thoroughly assessed history with symptoms, and educated on the CBT model for understanding OCD treatment with a rationale for CBT and ERP. We discussed medication options, to which the client was willing to pursue with their Psychiatrist.  The client was very cooperative due to a high willingness and intrinsic motivation to be able to engage at home with her two children and spouse. As can be very typical, the stress also took a toll on most every area of life, making work difficult. Once we began ERP, we started with doable exposures while learning how to stay present with triggers and distress- without compulsing.  Upon successful practice of more manageable triggers on their hierarchy, they- with the incredible support of their spouse and church and loved ones- made a jump in their exposure work that began with "scripts" (imaginal exposure stating/writing distressing thoughts and quickly progressed to holding knives and stating these feared thoughts aloud) and transitioned to  practices situationally at home, holding knives and saying scripts aloud (in separate rooms appropriately not in front of their young children).  The incredible support around this client, along with a sense of strong purpose, helped facilitate (this is part of ACT) the integration of ERP into daily life. They would be considered recovered at this point, scoring so low on the Y-BOCS (gold-standard assessment in rating severity) that their symptoms are sub-clinical. In relapse prevention planning, they understand the chronic nature of OCD and the necessity of staying on top of their good progress, with the plan to follow-up at occasional intervals for "booster sessions."  I gain so much joy from stories like these.


"People with an OCD diagnosis may be taking medication and seeing other professionals (psychiatrists, psychologists). How could a counselor work in tandem with these other professionals? Please include a case example, if possible."
Coordinating care can be difficult, but worth it for the best client care!  Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life.  Working within the space and limits that exist, I have found that outside of those very few therapists and Psychiatrists I can have near immediate communication with, it is still very helpful and feasible to at least request/give one way communication to a provider.  In complex cases, it is almost unheard of for me to not outreach another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers' schedules and communicate what we can- how we can. This often looks like me leaving a Psychiatrist a voicemail after release is given- and not hearing back- but at least they have the information. It may be coordinating with another therapist who is treating other concerns. Early on, I used to welcome other counselors working at the same time on separate diagnostic concerns. Though I may work with someone now who is seeing another professional for something like, say, Depression, it is usually quite imperative that I make known to the patient and also the other provider the pitfalls of feeding compulsions through reassurance, ruminating, and so forth. This is a great opportunity for education of those who are not specialists in OCD.  But OCD being as debilitating as it is (2 out of 3 people experience severe impairment at some point in their life), I need to work hard upfront to educate especially the patient about how hard they will need to work (and not undermine) their exposure therapy. Also, many other comorbidities can often improve significantly just by treating the OCD first.  

"How, particularly, are counselors a “good fit” for helping clients with obsessive behaviors? How can they help people with OCD differently than a psychologist would?"
It has been my personal experience that my colleagues who are counselors (Master's level, typically), bring to the table incredible creativity and "outside the box" thinking.  Many of the hands-on resources, videos, blogs, and social media that exist to help the sufferer of OCD often come from Master's level clinicians. I believe there is great flexibility many of my counselor colleagues have (which is a positive and a weakness all at the same time, sometimes lacking the rigors of adhering to the evidence based treatment protocols).

There are actually quite a few more Master's level clinicians than Psychologists, and there is a great need for more clinicians offering great treatment.  Counselors can help fill this gap.

"As a practitioner who specializes in working with OCD, is there anything else you would want counselors who don’t specialize in this area to know?"
For many reasons, I love work with clients who have OCD.  I have found they are some of the kindest, hardest working, conscientious individuals on this planet.  This is where I believe many of their personality strengths arise once moving through pathology. It is a joy every day to see recovery, growth, and maturity bloom out of suffering.

"Any main take-aways to share?"
OCD Treatment can be so rewarding! It has very effective treatments for most, very clear evidence, incredible improvement that can be witnessed in a short period of time, and there are wonderful opportunities to get invested in this world with a community of professionals, sufferers, and supporters who are incredible. 

Sincerely,
~Justin K. Hughes

“Why can’t I stop thinking about this?”  “Why can't I stop?  I know it doesn't make sense.” 

William went to the Middle East after his unit was deployed from Ft. Hood.  Most of what he heard about soldiers’ experiences were rumors and media stories- he had no way to be prepared for what would happen.  After nearly 6 months of swallowing sand stirred up by 110 degree winds, William had 5 days left until he would return home.  Momentarily losing his hearing, all his senses were shaken when an IED tore shrapnel through his three closest friends.  They were dead.  Just like that.  After being rushed by helicopter for triage medical care, William soon discovered he only narrowly missed death- the same shards of nails and rocks that killed his friends were found inches away from where he stood. 
Returning home is where cleaning up the fragments took the longest.  After being debriefed and allowed medical and family leave, Bill struggled getting back to civilian life.  Some of the most difficult times he faced were trying to overcome his own unexpected reactions to situations, usually late at night where he would awake from a noise, pulling his wife down from the bed onto the floor to take cover.  When he became calm, he was covered in sweat, visually stunned by recalling what had happened weeks before- and so embarrassed to be dragging his wife- literally- into the center of his problems. 

This is trauma.  This is the story of William’s PTSD (post-traumatic stress disorder).  Hopefully his story can help bring understanding to struggles faced by those dealing with trauma and respect for our service men and women. 

It’s not very difficult to have some sense of empathy for William’s situation.  It’s often much harder to understand another very real and very overwhelming problem.  It is called Obsessive Compulsive Disorder (OCD).  You may be curious why this article spends so much time talking about PTSD, only to discuss OCD.  Two reasons.  OCD actually has some similar features and neurobiology to PTSD, and secondly, if we are to listen to the struggles of others, often we must start with something we do grasp a little more readily.

Whether a person is triggered into feeling distress from trauma or obsessions, their brain is becoming hyperactive in warning of a threat.  This wonderful system when working properly can be nightmarish when the reactions surface out-of-context.  Think of the panic you would feel if you saw someone almost being run over by a car- your fight/flight/freeze response would activate and prepare the body and mind.  Now imagine it occurring at random times and being uncontrollable.  

Despite popular references of, “I'm so OCD” and “He really likes the house OCD clean,” [FYI, OCD is not an adjective] this diagnosable mental health condition is a serious disorder- and far beyond a person’s immediate ability to just “stop it.”  Because the anxiety and distress a person with OCD feels is so bothersome and intrusive, they naturally seek to alleviate it- sometimes with elaborate mental rituals to “do away” with the anxiety (e.g., counting, prayer, neutralizing statements) and sometimes with physical compulsions and avoidance to feel better (e.g., “I feel anxious when someone touches my clothes and need to change and wash them immediately”).  To some people, this sounds "crazy."  But in our age of neuroscience (and OCD is remarkably well established), we cannot deny scientifically the paint and suffering involved in the sufferer's life.  Their mind- and often body- SCREAM with discomfort until they do something to alleviate it.  And the compulsion works!  Momentarily, at least for a bit.  It problematically, though, reinforces the learning, connections, and neural pathways linked to disorder as opposed to reinforcing healthy, non-compulsive behavior. 

To stand up to OCD, a person needs to ultimately eliminate all compulsions.  What do we make of this?  Do we expect the person with PTSD to just jump back in to just get on with their lives?  Nope.  Let me be clear with OCD (and this is also true of PTSD).

There is hope and very effective treatment.  

We don’t have to understand, ultimately, to love.  As many as 1-3 % of the population wrestle with this.  Look around- that’s someone in your neighborhood or at the restaurant where you ate.  Will you lend a helping hand to those who suffer?  I will.

Yours truly,
Justin K. Hughes

​Check out more resources on my page dedicated to them:

This video and guide below were specially formulated to help you be mindful in an "Exposure-Friendly" way.

This one's a bit different from the average mindfulness practice you might be familiar with.  The reason it's called "Exposure-Friendly" is that it is specially designed to help a person be mindful of whatever they are experiencing, not just attempting to feel better.  This is a hallmark of exposure therapy: being able to tolerate distress without engaging in pathological responses (rituals, safety behaviors) that negatively reinforce fear.  Distractions and relaxation when facing our fears can backfire (see the research at the end of the Guide).  So if we need a different set of tools to face fear, here's one of them.  I hope it helps.

Blessings,

~Justin

I didn’t think much about it.  Once I began to shift from a trim guy in my young 20’s to borderline overweight/obese by my late 20’s, I was introduced to research on the deleterious effects of consuming so much added sugar in my diet.  But I also gained maybe the most crucial part of any health advice: the support to live it out.

The most significant early clinical and research voice for me was Dr. Mark Hyman, Director, Center for Functional Medicine at the Cleveland Clinic.  I was watching a documentary on Netflix in 2015[2] that featured him significantly.  It added to my already growing knowledge and personal experience, which especially helped me a) stop compartmentalizing nutrition (150 calories from Coke ≠ 150 calories from vegetables) and b) look more closely at what I put in my body.  

Bolstered by personal recovery in multiple areas of my life, and leaning on my wife who was super supportive of me, these convergences facilitated what I hadn’t been able to do prior:

• I almost entirely cut out added sugar from my daily diet at first, and now use sparingly with a limited number of desserts.  
  • I lost 45 pounds in about a year and a half, the first 5-10 pounds was just cutting out sugary sodas.  
  • I slowly cut consumption (small things to begin, like not eating past 10:30 pm at night), and then really worked on eating vegetables.  If I wanted a snack, I’d learn to find vegetables, nuts, and fruits). I found foods I enjoyed that I could eat basically as much as I wanted.
  • I began to look BIG-picture at food with an observant eye- and discovered (shocker!) that even my favorite salads possessed added sugar, and not just in the dressing.  Places like McDonald’s and Chik-fil-A add sugar into different items in their salad toppings and breadings (can anyone say candied pecans?).  Stores like Costco sell a lot of “organic” items, but when I look at the packages and see the ingredients lists on most items, I still find a lot of added sugar, sodium, etc.  
  • I still enjoy dessert!  I just had two slices of cake at my sister-in-law’s wedding!  And I loved it.

One of my discoveries is that existing advice often conflicts, and (as with all things) can be driven by profit, greed, and ambition.  Instead of getting embroiled in all these details, I began to think critically for myself and make a plan with support. Here’s the simplest advice that’s now supported relatively across the board:

Recommendations for Added Sugar:
CDC (U.S.)

• In a 2,000 calorie diet, 50 g of added sugar is the max recommended (10% of total energy intake).

WHO (World Health Organization) Recommendations[3]

• Strongly recommends less than 10% of total energy intake as free sugars, 
• And conditionally less than 5%.

Part of a healthy body, mind, and spirit involves an honest look at what we put in our bodies.  Nutrition is, of course, one of the most important realities of daily life. Much success and suffering comes from our consumption and discipline around food- and in that regard, it’s not much different from other areas of life such as our thoughts and beliefs, exercise, generosity, and work and rest.

I’m nowhere near an expert in the food realm, and this post is more personal in nature.  I hesitated writing it for a while so as not to make another one of those ‘Look at me now!’ posts.  The last thing I want is for anyone reading this to feel shamed by a braggadocious post on self-improvement.  I personally didn’t have a bunch of shame about my weight prior, nor would that have helped. I want to thank my sister-in-law, Camille, for encouraging me that people might benefit from my personal story.  I hope it helps.  

As a therapist, I walk with people every day through CBT and counseling to take action.  Traditional medicine, articles, and diets all serve their purpose.  My job is to help people make change, personalized to them, in the context of reality- that we must all live in, or not- only to our detriment.  

If you take nothing else away from this, here are the keys I want to share:

• You (and others) are inherently valuable.
• Nutrition is a significant part of life that, when it goes well or poorly, affects all other aspects of life.
• Consider introspection over your relationship to things like added sugar that, when over-consumed, creates major problems.  
• Goals are great, but change has to be doable.  Unrealistic expectations are a killer of motivation and long-term success!
• I’m here as a resource if you need me!
• Everyone is different, but all of us have to live by the principles of reality.  The more realistic we are about looking and facing it squarely, the more congruent our lives will be.

Sincerely,

Justin


[1] Added sugar is different than sugar as it naturally occurs, like in fruits and vegetables.  See Harvard Health's post here.
[2] “Fed Up”- not that I endorse everything in it, but there were a couple key lessons that I have incorporated from this documentary.
[3] This whole resource is quite fabulous with lots of good research and narrative.  I nerded out with it!

Addiction is confusing.  It is confusing to seasoned professionals.  Let’s just admit it. 

It is not a specified diagnosis under the DSM or ICD; it’s only broadly referential to a sometimes amorphous categorization.

• Under the DSM-IV in 1994, only one vote separated the task force on substance abuse from using the term “addiction” instead of “dependence.”

Society doesn’t help give any clarity.  One of my favorite taco joints in Dallas’s tagline is, “Welcome to your new addiction.” That misses the point.  People say all sorts of wild, off-handed things.  "I’m addicted to sparkling water," “I’m so addicted to this band." Addiction is not an adjective.
​
Take a look at a broad array of definitions (some even from reputable research organizations), which emphasize sometimes different things:

• “Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences.” -NIH’s National Institute on Drug Abuse
• “Abnormally dependent on some habit….” -Dictionary.com
• “The state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes severe trauma.” -Dictionary.com
• “…Continued use/act….becomes compulsive and interferes with ordinary life….” -Psychology Today
• “Addiction is a primary, chronic disease.” -American Society of Addiction Medicine (ASAM)
• “Compulsive substance use despite harmful consequences” -American Psychiatric Association
• “Addiction is a psychological and physical inability to stop consuming a chemical, drug, activity, or substance, even though it is causing psychological and physical harm.” -Medical News Today
• “Cannot control” - HBO
• “Addiction involves craving for something intensely, loss of control over its use, and continuing involvement with it despite adverse consequences.” -Help Guide with Harvard Health
• “Addiction is a condition in which a person engages in the use of a substance or in a behavior for which the rewarding effects provide a compelling incentive to repeatedly pursue the behavior despite detrimental consequences.” -Psychology Today
• “…can’t stop….even when you know the drug is causing harm.” - NIH’s Drugabuse.gov

Clarity through the confusion
While still in the middle of a ‘call to arms’ in clarifying Addiction is, we ultimately have a very stable understanding of the symptoms/criteria of problematic behaviors, and most of the time, how to treat them.

• Let’s look at the premier addiction society’s- The American Society for Addiction Medicine (ASAM)- short definition (which, by the way, only lists “characteristics” vs. actual criteria).  
  • "Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.  Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death."
  • The long definition is impressive, but complex. 

Substance Use and Addictive behaviors do exhibit many consistencies despite the actual substance or reward behavior pursued, and they respond to similar treatments.  Regardless of the organization, the following are usually consistent details across definitions:

• craving a substance or behavior
• with loss of control
• despite significant adverse consequences,
• with an inability to abstain or moderate.  

"Types" of Addicts
There is an extensive history of attempts to categorize addiction, through “typologies.”  Prior to scientific research, which began with E.M. “Bunky” Jellinek, there were many attempts to understand the mystery of addiction, but mostly from an observational or anecdotal standpoint.  

• AA in 1939- we see Dr. William D. Silkworth at Towns Hospital attempting to typify addictive struggles.  AA offered a new solution, albeit targeted towards the most severe “hopeless” cases. They differentiated between:
  • “Real alcoholic” who is “hopeless” d/t loss of all control (AA, pp. 20-21)
  • “Hard drinker”
  • “Moderate drinkers”
• The Jellinek Curve was created shortly after in the 1940’s. (Accessed from  https://www.in.gov/judiciary/ijlap/files/jellinek.pdf)
• Since then, there are many other attempts to classify the differences that exist and to account for the heterogeneity that exists.

We don’t have any consensus yet, but why is it important to know what type or level or continuum a person is on?  At a minimum, we need to understand where a person falls on a continuum if we are to treat effectively.  

Here is one continuum of use problems (Adapted from Earleywine, M. (2016). Substance use problems (pg. 2). Göttingen: Hogrefe.):

• Abstinence
• Initiation
• Infrequent, non-problematic use
• Regular, non-problematic use
• Problems, subclinical
• Abuse (early problems clinically)
• Dependence
• Disorder (mild)
• Disorder (moderate)
• Disorder (severe)

Effective Treatment
As I like to say, "Don’t drive your lawnmower on the freeway."  Just like you wouldn’t do this (I hope), don’t assume that therapy alone, or a doctor alone, or worse, doing nothing- alone- will be enough “horsepower” to get you where you need to go.  

Effective treatment requires applying the factors necessary to get the job done.  The person who abuses a substance occasionally on weekends will need to be treated different than the person who is “hooked” on something.

Two categories of professional treatment exist, with incorporation of several additional supportive factors:

1. Behavioral
2. Pharmacotherapy

Besides treatment, supportive factors often include, but are not limited to:

1. Drug Testing / Accountability for using and acting out
2. Support groups / meetings
3. Family and friend involvement
4. Fun and enjoyment
5. Service of others and engaging life with purpose
6. General health and well-being

​
My plea:
Take addiction seriously.  Don't know whether your are addicted or not?  Find out. 

Addiction is a complex- bio-psycho-social-spiritual- issue.  Problems with drugs, alcohol, or behaviors on a spectrum of addiction cause substantial disability, even death.  And here's the kicker- people who have problems with these often experience lapses in judgement and poor insight into having a problem.

Start with a strong assessment by a competent professional who is trained and experienced.  Look for evidence based treatments (think CBT or Motivational Interviewing). Advocate for truth and be assertive.  Ask hard questions of your provider. When providers get shifty or start to recommend some unusual treatment when you need a first line treatment, exercise caution.

I'm Justin K. Hughes, MA, LPC, and I specialize in the treatment of Addiction through CBT and Motivational Interviewing (MI).  As always, please like or follow me, using whatever platform you prefer.  Also, subscribe for meaningful content regularly!

According to Dictionary.com, their word of the year is "Misinformation."  Defined as "false information that is spread," misinformation occurs "regardless of whether there is intent to mislead."

Misinformation, and its brother, disinformation, can be harmful.  Clearly.  Though much of the current state of discussion around this concerns external affairs.  Much of what we are responsible for at least begins internally (how we respond and engage).

Aligning our thoughts, beliefs, and behavior with reality- what's true and realistic- is a crucial "mechanism of action" that helps facilitate positive outcomes.  This is particularly true in the method of therapy I use- CBT (Cognitive Behavioral Therapy), 

We know that cognitive distortions [click for pdf list] only prevent us from succeeding and growing.  These errors are harmful especially when they are consistent approaches to thought, such as All-Or-Nothing Thinking (I missed my workout today; I might as well skip this week), Mental Filtering (I know they said they enjoyed meeting me, but they must not like me because they talked more to other people), and jumping to conclusions (I just know that she got off the phone quickly because she thinks I'm an idiot!).  The deeper these go, the more impactful they are and harder to break.  

So in a world of misinformation, make sure you first tell yourself the truth, whether it's difficult or comforting.  In this time of the year that is special, wonderful, challenging, or downright awful for some, what can you do?

Be realistic.  Tell yourself the truth, and to others.  Align your thoughts, beliefs, and actions with commitment, purpose, and meaning (and if you're not sure what yours is, find it with help!), and try to get as close to what's honest and accurate.  Be a good researcher (humble).  Don't get snowed by misinformation.  Give the gift of realistic, truthful thinking.  Your brain will thank you (and probably everyone else will, too).  

Merry Christmas, and Happy Holidays!

Yours truly,
~Justin

Want a surefire way to experience more gratitude?  Be grateful.  

I'm not trying to sound trite; those who practice gratitude are more grateful.  I struggle to apply this discipline myself.  But when I do, I see the world differently.  Enjoy the following video (thanks to my brother for passing along).  

Happy Thanksgiving.  

Do I want this, or do I not?  Is this my actual desire, or what I don't want?  Does this thought or desire define me?  What if it's terrible or horrible?


Sometimes the things I think about are because I value them or desire them.

Sometimes the things I think about are because I don't value them or desire them.

What the heck?  


Egosyntonic and Egodystonic are two psychological terms to describe phenomena of thoughts/urges that are synonymous and antonymous to what a person desires or wants.  Sometimes our thoughts reflect very much what we desire or want, but around 90% of people endorse having "intrusive thoughts," or unwanted thoughts.  

It is crucial to do a good functional analysis on a thought/behavior to determine whether someone is doing something in order to pursue- or to avoid- the very same thing.  

You may have just gotten an activity tracker over the holidays, or maybe you’ve already jumped on the bandwagon of wearable tech.  Not only do activity monitors like Fitbit, Apple Watch, and Spire track steps, heart rate, sleeping, and more, you can turn your tracker into an ally for mental health.

Here’s how.  

Being able to track and monitor your thoughts, mood, emotions, symptoms, and sensory experiences is arguably one of the central tenets of most schools of therapy.  It is nowhere more prominent than in Cognitive Behavioral Therapy (CBT), where awareness of internal processes is a first step to changing outcomes.  For years, techniques such as journaling and monitoring have been used, but this new technological age adds a few extra tools that can be a boon for awareness.  But you also have to build the emotional intelligence and discipline to catch what’s going on and translate that into meaningful action.  Following are some tips.  (Remember that some people will have more stress by using a monitor- if so, practice these same tips without help from Mr. Fitbit).

1. Be aware.  Occasionally throughout the day, check in with yourself (or a buddy!)  Ask if your heart rate, breathing, sleeping, thoughts, or mood fits the goals you have (see #3).  Pay attention to little details.  Was my heart rate elevated over the holidays because of my activity level, or stress?  Did I sleep less last week because of something planned, or because of insomnia?  Was I irritable at work?  Did I feel anxious around people?  If you want to change something, you have to identify what you’re working with first.  Allow yourself to take note without spending too much time on any one thing.  
2. Let an external tracker add to your awareness.  Utilize the unconscious observations your tracker makes to correspondingly assist in your own mindfulness.  Those of you who have had the helpful feedback of a trusted support can attest to the value of observations made outside of yourself.  I, for one, appreciate the occasional fashion police!  :)
3. Identify the goal.  What are you trying to accomplish?  Better sleep?  Getting less stressed at work?  Being clear about this in a reasonable way gives you a target to aim for- and helps you see if you need extra resources in getting it done.  (See my Setpoints resource to help further.)  
4. Identify solutions.  Once you have tracked your experience and know the goal, then you can apply solutions.  Heart rate at 110 while sitting at work?  Try some deep breathing and a de-stressing activity.  Notice you’re not taking many steps?  Take 3 minutes to get up and move.  Sleep getting off track?  Develop some sleep hygiene techniques.  And so on and so forth.  
5. Be social.  Whether you are extroverted/introverted or outgoing/shy, connecting in some way with others is essential to your health.  Trackers give lots of options to do this in fun, cute, and challenging ways.  

Make it fun, and happy healthy tracking!  Sincerely,

Justin