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

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!

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.  

I hate to admit it.  Mom and Dad, please don't laugh too hard when I say....this.... I sometimes miss being told what to do.  There.  I said it.  

I remember the drill of childhood.  "When did you last eat?  Here, have some food."  "Looks like you could use a hug."  "You're getting cranky; it's time for a nap."  

In my super-mature “I'm-smarter-than-a-child” mentality, I miss some of the plainest truths in life.  One of these is the importance of rest.  It’s the weekend before Christmas, and all through my house are temptations to “achieve” and find my worth in what I do and the approval of others.    

I’m trying to step back and rest.  And I often will remind myself, “I’m more efficient when I rest.” What’s funny about that statement is that I still am finding an excuse for resting.  What would it be like if I stop running the show for a moment?  Slowing down the crazy pace of life is not only a discipline, it is an act of faith- one that acknowledges that I don’t control all and know all.  And I don’t have to carry the universe on my shoulders.  That’s freeing.  I hope you “achieve” some great rest during this time of the year.  Merry Christmas and Happy Holidays!!

​Yours truly,
​
Justin

You’re surrounded by setpoints every day.  They literally keep you alive.  One of them is your set body temperature.  If your body drops or rises a mere 15% beyond your core temperature, death occurs.  Think of a setpoint like a reference point, a sort of boundary.  Medically, it’s called homeostasis.  The body regulates internal functioning (temperature, blood flow, oxygen) despite external circumstances.  The body is always seeking homeostasis.  So is the brain.  And you can intentionally take charge for your mental, emotional, and relational health.

Examples
In our bodies, we break out in a fever when something is wrong- which is one way the body makes conditions unfavorable to viruses and bacteria- because they are temperature sensitive.  In addicts, their brains have faced an onslaught of dopamine rushes- and the brain counters it by producing less dopamine to balance out- even sometimes ELIMINATING dopamine receptors.  This is the brain naturally seeking to turn down a party that’s gotten too loud.

The system
Balanced functioning (homeostasis), whether biological, technological, or psychological, will involve three interdependent elements that help reach homeostasis- all centered on a setpoint:

1. Receptor– A sensing component that observes changes in the environment. The receptor then sends information to the Control Center.
2. Control Center– determines an appropriate response, having a set range in place (setpoint).  Then the control center sends this information to an effector.
3. Effector– Structures that receive signals from the control center and correct deviation by negative feedback, thus putting a system back into its normal range.

Remember from above how dopamine in the brain works with substance abuse?  But we can actually gain the upper hand by being active in our decisions- including making setpoints for ourselves.

Get negative
In order to bring a system back to normal, negative feedback is used to regulate it.  So when I say, “get negative,” or course I’m not telling you to have a negative outlook on life.  What I AM saying is that a system that is out of control will only be put back in control/order by it being regulated by setpoints, carried out by either an internal or external force- and this is negative feedback.
Okay, have I been sufficiently nerdy?  Let’s get practical!!

Sample exercises  
Check out how William uses all three processes of homeostasis as a married entrepreneur with children, who is also dealing with some alcohol abuse (#2 in each is the setpoint).

Entrepreneur-
1) Financial accounts are reconciled daily by William (outside help oversees them weekly).  2) The business plan was developed with a setpoint of no greater than $100,000 debt.  Crossing $50,000 debt signals a problem and requires meeting with the board.  3) If the setpoints are not honored, the board has full power and autonomy to enact established strategies.

Temperature-
1) William’s two year old, Thomas, is running a fever- revealed by his behavior, and then it was gauged with a thermometer.  2)  If 24 hours pass with a fever over 100 F- or at any point it goes beyond 103 F- the setpoint has been crossed.  3) Visit the doctor immediately.

Remodeling-
1) Extra money was left over- discovered in the budget by William’s wife, Katie.  2)  They determine no more than $10,000 will be spent on a kitchen remodel.  The goal is $8,500; beyond the goal is a warning flag.  3) At the $8,500 mark, a conversation will be held with the contractor to hold to the budget.

Alcohol Use-
1) After running into various troubles with alcohol, William considered his personal/family values and health recommendations.  2) A setpoint was made: only 2 drinks or less daily.  3) If this line is crossed, the commitment is to have an entire month sober.  If this cannot be done, it is agreed on with his support team to increase treatment (e.g., go to a group, go to counseling).
​
Got the hang of it?  These steps can be applied to about anything, though I mostly use the Setpoints Exercise (click on the link below to access!) to help increase ownership and boundaries with addictions.  It’s a straightforward way to get honest with anything you are facing, the amount of help you need, and what supports can get you there.  This concept has helped assist many of my clients to face problems squarely, and in turn, to be more successful and realistic in addressing life challenges.  Give it a try!

In Latin, Quid Pro Quo means, “something for something.”  You scratch my back; I scratch yours.  Tit for tat.  It’s how the world runs.

Or is it?

In the business world, this often works.  Social psychology calls it “reciprocity.”  In relationships, well, this is where it gets fuzzy.  Relationships require sacrifice regularly; they require that you stick around, presuming it’s reasonable to do so.  In business, if someone doesn’t offer you a good deal, you can move on.  If you keep doing this with relationships, you will bankrupt your heart and anyone close to you quicker than ever thought possible. 

Relationships involve the molding and holding of hearts.  Business involves the flow of money.

I want to call to the table that many principles that work for business DON’T in relationships, which is partly why someone can be extraordinarily successful in the business world but trade in relationships as often as changing underwear.  The concept of reciprocity is fascinating, and I regularly utilize it in respectful ways when I consider how to engage in business, such as when I “add value” to interactions with businessmen and women by offering helpful counseling materials.  This, in turn, increases my odds of getting a favorable response.  Nothing wrong with it.  I attempt to not do it ONLY for this reason.  However, when I expect a certain response- demand it, even- I am not respecting a person’s freedom, uniqueness, or spontaneity.  And this is precisely the problem when quid pro quo is present as a foundation in relationships.

Everyone from Hendrix to Gottman to Eggerichs (see references below) point out the necessity of proactive initiative in love- an active, intentional doing what’s best for another, choosing love over “balancing the budget.”  In fact, the eminent researcher Dr. John Gottman states the myth of quid pro quo in The Seven Principles for Making Marriage Work (2002): “But it’s really the unhappy marriage where this quid pro quo operates, where each feels the need to keep a running tally of who has done what for whom” (p. 15).  

Isn’t this the definition of selfishness?  And it tears relationships apart.  I don’t know of anyone who says, “Yes, being completely selfish is good; I want to live by the principles of selfishness and teach my kids to do the same.”  No one really debates this.  How quickly it takes over, though!  My role as counselor isn’t to point a finger; it’s to help uncover what’s holding people back.  Consider how you might be “losing while winning,” holding grudges, keeping a record of wrongs.  These things are the opposite of contentment- and love.  "Love keeps no record of wrongs," (1 Corinthians 13:5d) as is often quoted at weddings.

Don’t wait for a person to do good to you.  That’s the whole importance of the Golden Rule and the Greatest Commandment.  If you wait around for the other person to “play by the rules” in loving you, prepare to be unsatisfied.  There will come a time (in EVERY relationship) when loving another becomes hard: when the "high" of newness wears off, when the attractiveness of another becomes the norm, when that little quirk that you thought was wonderful turns out to annoy the heck out of you.  If it’s left up to reciprocity, we’re screwed.  In friendships, romantic relationships- ANY relationship.

If a relationship fundamentally relies on quid pro quo, it will prove an unhappy ending.  Find out how to love others despite what they bring to the table, and reap the overflowing results.  If one person brings a feast to the table, just because the other doesn't bring one won't mean you can’t enjoy yours- and just maybe win them over in love.

Sincerely yours,
Justin


For more information:
Business Networking That Works...It's Called Quid Pro Quo (Forbes)
Getting the Love You Want (Drs. Harville Hendrix and Helen LaKelly Hunt)
Influence and Persuasion (Robert Cialdini)
Love and Respect (Dr. Emerson Eggerichs)
The Seven Principles for Making Marriage Work (Psych Central summary)