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?"
"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.
~Justin K. Hughes
Those who know me know that I see people as individuals and hate to make generalizations. However, it seems to me that those suffering from OCD are among the kindest and most understanding people I have ever met.
Thanks to Jonathan Hoxmark on Unsplash for this beauty!
Perfectionism and OCD
What is perfectionism? Oxford dictionary defines it as “refusal to accept any standard short of perfection.” That’s automatically problematic. Perfectionism leads to a circumscribed focus, stress, and suffering for not only individuals, but for loved ones nearby who feel the weight of being perfect.
Is this the same as OCD? Nope. OCD and perfectionism often get confused. They both can affect and drive distress in one another, but they are separate. OCD involves unwanted (intrusive) thoughts, urges, and impulses that cause distress; furthermore, compulsions are repetitive behaviors or thoughts that attempt to reduce distress or prevent something bad from happening. Perfectionistic manifestations of OCD, often referred to as “just right / not just right” fit this categorization. Separately, in Perfectionism, someone pursues “perfect” thought, behavior, or action initially out of interest or enjoyment (rather than to suppress an intrusive thought/urge/impulse, like in OCD). There are typically problems that go with this, however. So a difference between the two is that OCD is ego-dystonic and Perfectionism is typically ego-syntonic (you can check out my video here explaining the difference).
Examples of perfectionistic thoughts and behaviors[4,5]:
I am a "recovering" perfectionist. And it’s a problem when I’m not, well, “recovering” from it. One of the mechanisms that keeps perfectionism going is the belief that it is helpful (this is a “Positive Belief” about perfectionism, and it is a cognitive distortion). When I succeed at a task- and especially if I get a lot of praise, it is a natural reinforcer that I must be doing well. However, if I spent 8 hours researching, writing, and proofing this blog today, that is problematic for me at this point in life (and I easily can spend that much time). What is a problem or not sometimes depends on the person and their situation- maybe a journalist would spend that much time or even more, but I am a full-time clinician with a family, church, volunteer involvements, and hobbies. If I make this post “perfect,” in my perfectionism, I will seriously miss out on other things.
This pursuit of perfection doesn't stop with one blog post. It will always generalize if allowed. So if I let it, the pressure of perfection will continue (and does, at times) to move on to other things like caring for my home, caring for people in my life, my relationship with others, my diet, exercise, my spiritual walk, my car, money, and so on. And being honest with you, these things are tied up in anxiety and simultaneously selfishness- attempting to control these things rather than to engage with them/others in a meaningful way by learning to lean into the fear and live based on what is valuable.
Parenting is probably the single biggest event that pressed me with the realization I need really challenge my perfectionism. There are two stark realities to me in life: I can either do my work/relationships/home life/etc. “perfectly” and end up in an ever narrowing scope of anxious overwhelm trying to keep all the balls in the air, OR learn to tolerate the distress that comes doing things "not just right" and focus on the big picture, growing towards what I love and value. And the reality usually is that in time, this fear habituates when not engaging in avoidance, rituals, or control strategies.
Whether in therapy or personal life, to change how I behave and think and respond in life, I need to be aware/monitor what it is that needs to change (good therapy, support, and resources such as on my website can help). Even if I know what needs to be done, if I can’t effectively observe and catch it when it occurs, I will not be able to change it. Next, I will need tools and strategies to effectively grow and mature. In therapy, some of these are Exposure Therapy, Cognitive Restructuring, and more. In essence, at the point of the problem I must be able to insert the solution- and consistently. Lastly, I want to continue to monitor and gain feedback to incorporate learning and solidify growth. I don’t want to oversimplify this- if you are having a problem with any of the areas I have discussed, please reach out to a competent trusted person and/or therapist.
Today I gave myself the time limit of 3 hours- start to finish- to research, write, upload and post. And it’s simultaneously stressful and joyous at the same time. I’m going to do a behavioral experiment and keep doing it- “testing” whether or not my choice(s) in leaning into my fear of failure a) doesn’t end up as bad as it feels like it will, and/or b) I was able to handle or face it anyway. We’ll have to see- I'm leaning in!!!
Justin K. Hughes
 First of all, it’s a whole mess to even get into a truly perfect standard- if I make and continue to make mistakes, I am not perfect. I cannot even begin to conceive what perfect is, then, since I would make a mistake in defining “perfect.”
 The Diagnosis of Obsessive Compulsive Personality Disorder (OCPD) may apply when a person pursues perfectionistic behavior to pathologically disordered levels.
 Grayson, J. (2014). Freedom from obsessive-compulsive disorder: a personalized recovery program for living with uncertainty. New York: Berkley Books.
 Minirth, F. B., & Meier, P. D. (2015). Happiness is a choice: enhance joy and meaning in your life. Grand Rapids, MI: Spire.
This post is intended for Christians looking to deepen their faith and mental health.
The Bible has a lot to say about fear and anxiety. In fact, some variation of “do not be afraid” is the most common directive in Scripture, occurring in some fashion more than ‘do not steal,’ ‘do not kill,’ and even ‘love your neighbor.’
How do anxiety and fear work? When we study these constructs in research, we are understanding mechanisms through which the body/brain is informed to face a threat or danger. We can argue these responses are inherently good, with their purpose being survival, protection, and preparedness. Its activation results in the sympathetic nervous system being primed: adrenalin and noradrenalin are produced, cortisol increases, heart rate increases, blood flow moves to muscles and away from extremities, speed and depth of breathing increases, and many other physiological changes occur. I’m grateful to have these responses- when they are in context. Out of context, they suck, to put it bluntly. Problems like panic attacks, worry, phobias, obsessiveness, skin/hair picking/pulling, preoccupation, social fears, avoidance, and more can be quite terrible.
One of the things I love most in my walk with Christ is context. Direction.
“The Lord is at hand; do not be anxious about anything, but in everything by prayer and supplication with thanksgiving let your requests be made known to God” (Philippians 4:5b-6, ESV).
What is being said here? Partly, “Do not be anxious about anything.” Since anxiety is a feeling of imminent threat- or in other words, it’s at hand- it’s very interesting that immediately before this phrase in Scripture we have another observation revealing a different type of imminence: “The Lord is at hand.”
In the context of the Lord being near we are told, “Do not be anxious.” This Greek word for ‘be anxious,’ μεριμνᾶτε (transliterated as “merimnate”), means to be divided and distracted, fearful, and caring for things that are out of context.
Sounds a lot like anxiety disorders, right? Yep. Or even just day to day worry/anxiety? Yep. When a person feels anxiety and fear and misinterprets this as significant, a person’s entire life and values can shift to focus on whatever is the subject of their fear, whether classified medically as a disorder or not. This can lead to a preoccupation with avoiding something or someone (spiders, relationships, sex, social situations) to obsessively checking to make sure everything is okay (car, stove, locks, bodily sensations, health, perfectionistic behavior), or pursuing something (money, security, approval of others)- and MUCH more.
To help work through these things and avoid pathological responses, I believe we need supports like therapy, help from friends, breathing techniques, mindfulness, exposure techniques, etc. This only underscores our complexity (we are “fearfully and wonderfully made” yet simultaneously all messed up) and highlights what we are told in Scripture about our limits. We can rightly use these tools to help us, just as we do nutrition, medicine, community, and so forth. But there is one thing these tools can’t do on their own: attach us to the very God of the universe and give us a lasting hope and focus- with meaning and purpose at the highest level.
So God gives us a jewel of a passage in Philippians 4 where we are kindly reminded what our attention is to be on (context), and a little bit of how we can live it out (practice). It is well known within the anxiety treatment world that even the most effective therapies (here’s looking at you, classic CBT, which I love and specialize in) often need supports to connect to larger beliefs, values, and commitments (ACT, DBT, and MI are some of the most common modalities). If we don’t connect a person to larger motivations and goals than “I just want to feel better,” it is often near impossible for a person to grow with sustainable change for the long term because they don’t have a sufficient reason and value to keep them invested. God gives us this.
Want more? Well, there’s two tips in the next two verses, Philippians 4:8-9
“Anxious for nothing” will take a lifetime to put into practice. I’m grateful to have the opportunity.
 Continued misinterpretation and repetitive experience of these symptoms worsens disorder, like in Panic Disorder, GAD, Phobias, OCD, PTSD, and more.
 Bible Hub. (n.d.). 3309. merimnaó. Retrieved July 13, 2019, from https://biblehub.com/greek/3309.htm
 I think it’s very important to note that we have to be very careful with saying anxiety/fear is sin- and what we mean by this. A lot of Christians get tripped up on this, and many, ironically, become more anxious. The extent of this point would likely require an entire book, so I will not take the space here to elaborate.
 Psalm 139:14; Genesis 1:26-27
 Jeremiah 17:9; Romans 3:23
 Psalm 73:26; 2 Corinthians 12:9-10
 Oh yes, there’s a whole lot more in Scripture on this topic. Let's not reduce a couple sentences into a "how-to-manual."
In Vivo Exposure
Directly facing feared objects or situations, examples include:
Getting on a flight, touching a doorknob that feels “contaminated,” not going back to check a lock, or going to a social gathering.
Good exposure attempts to match the content and detail of a person's fear as close as possible. So, for example, if a person fears “going crazy” in a social setting, the best exercise will be working up to facing that, not just exposing to the thought or word. On the other hand, if the fear is that a person will have inappropriate impulses (to harm, sexually, etc.), sitting with the intrusive thought and being present will serve best.
Imaginal exposure involves accessing the content of fears and anxieties through cognitive means. For example, a fear that someone will fail, make the wrong decision, harm someone, die, or choose the wrong relationship are not accessed by activating these life occurrences. They are addressed imaginally.
There are many ways to practice Exposure imaginally, but the most common are writing scripts, stories, listening to recordings, watching videos, or using visualization.
To be clear, Imaginal exposure often is the most confusing and hardest to grasp of exposure practices, as it seems to be creating negative thoughts or “bringing” unrealistic and negative thoughts on- the seeming antithesis of most of psychology and cognitive therapy. But what is really done here is only facing what a person is already experiencing, thinking and feeling.
Intentionally bringing up physical sensations that are feared, such as:
Heart racing, shortness of breath, sweaty palms.
Ways to do this when a person's health allows are breathing through a cocktail straw, breathing rapidly, or sitting up quickly.
Virtual Reality (VR) Exposure
With the advent of new technology, we have a recently emerging type of exposure. Some may class Virtual Reality into imaginal exposure, but it can be seen as a cross between in vivo (situational) and imaginal. This is especially helpful with treating disorders such as Flying Phobia, where the access to an actual plane and flight to practice can be cost-prohibitive and difficult.
What is Exposure Therapy?
Exposure therapy is a psychological treatment that is practiced in Behavioral and Cognitive Behavioral Therapy (CBT). It is indicated as a first line treatment for a number of disorders such as
Exposure therapy helps clients to systematically confront fearful stimuli along with changing fearful responses. This relearning increases confidence and decreases disruption in life. Over time, discomfort and fear typically decreases through active engagement rather than avoidance, suppression, neutralization, or ritualization.
The evidence base is very strong for its use and effectiveness, though it is currently only applied a minority of the time in clinical settings.
How Do You Do Exposure Therapy?
The principles of exposure may be simple, but the specifics- personalized to any one individual- involve many working parts.
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!
$1.6 Billion. That's 1,600 x 1 MILLION Dollars. For the person who won roughly that amount in South Carolina (and the rest of us):
Would it surprise you that your emotional well-being really doesn't improve by becoming wealthy? There’s been a host of research in recent years that look into happiness and money. Possibly the most commonly known one is the National Academy of Sciences study on well-being and money.
This study’s now famous $75,000 mark suggests that a person’s emotional well being (how they feel day-to-day) AND their evaluation of life (their overall perspective of how they are doing) improves up to the point of earning $75k per HOUSEHOLD in the United States. Beyond this mark, emotional well-being doesn't significantly improve, though a person will evaluate their life as better if they earn beyond this mark. To quote their findings, “We conclude that high income buys life satisfaction but not happiness, and that low income is associated both with low life evaluation and low emotional well-being” (Kahneman, et al. 2010).
So what do "happy money" spenders do? Research by Elizabeth Dunn and Michael Norton in Happy Money: The Science of Happier Spending (2014) reveals how money is spent makes the crucial difference in happiness.
Are you making the most of what you have? Are you caught up in materialism and consumerism? Today is always a great day to do something different.
Justin K. Hughes, MA, LPC
A Psychotherapists' thoughts on healthy living.
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