An Interview with Clinical Psychologist Travis Osborne
Travis Osborne, Ph.D. is the Clinical Director at the Evidence Based Treatment Centers of Seattle (EBTCS), as well as the Director of the Anxiety Center and Co-Director of Research and Outcomes Monitoring at EBTCS. Dr. Osborne specializes in the treatment of anxiety and related conditions, including OCD and hoarding disorder.
Tori Steffen: Hi everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Tori Steffen, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today clinical psychologist, Travis Osborne. Dr. Osborne is the clinical director at the Evidence Based Treatment Centers of Seattle (EBTCS), as well as the director of the Anxiety Center and co-director of Research and Outcomes Monitoring at EBTCS. Dr. Osborne specializes in the treatment of anxiety and related conditions, including OCD and hoarding disorder. He has multiple appearances on the television show, Hoarding, Buried Alive on the Learning Channel TLC, and he is also a longtime consultant to the Seattle OCD and Hoarding Support Group and is a training institute faculty member of the International Obsessive Compulsive Disorder Foundation, IOCDF. So before we get started today, Dr. Osborne, could you let us know a little bit more about yourself and what made you interested in studying various obsessive compulsive spectrum disorders, including OCD and hoarding?
Travis Osborne: Yeah, well thanks for having me today. So as you mentioned, so I'm a clinical psychologist, so the biggest part of my job is actually working with clients who have anxiety and related conditions. And the center where I work, in addition to being an anxiety specialty center, is also known for being an OCD specialty center. So when I joined that, when I joined EBTCS about 16 years ago, I actually had never treated clients with OCD before. I had treated anxiety, but I hadn't treated OCD. And so pretty quickly had to learn the treatment for OCD and get up to speed.
So I actually attended a training with the IOCDF International OCD Foundation, which you mentioned a minute ago that does these really great three day intensive trainings to teach clinicians how to treat OCD from an evidence-based perspective. And they're really doing a lot of good work to try to train as many therapists as possible to treat OOC because there's a huge lack of specialists trained in that treatment. So pretty early in that work went through that training, really fell in love with both the treatment but also working with OCD in particular.
One of the great things about the treatment, which we might end up talking a bit about today, exposure and response prevention is that's incredibly effective. Research has actually founded it to be one of the most effective forms of psychotherapy across all disorders. So it works well, which is exciting. And OCD is a really complex disorder. The symptoms can be very difficult for people to manage and figure out how to overcome on their own. So it's super rewarding to be able to deliver a treatment, has a lot of science behind it, and actually see the vast majority of people that do it get better. So fell into that work and then it's become one of the bigger parts of the work that I do over time.
Tori Steffen: Awesome. Yeah, that sounds like a very rewarding field.
Travis Osborne: Yeah, for sure.
Tori Steffen: And I'm sure it's nice to have more specialists for the OCD and hoarding, so that's awesome. Well, getting down to basics, could you explain for our listeners what OCD is?
Travis Osborne: Absolutely. So OCD used to be classified as an anxiety disorder, so that's kind of how it was thought of in the field for decades. And then around 2013, a new version of the classification system for psychological disorders came out. It's called the DSM-5 for a Diagnostic and Statistical Manual of Mental Disorders, version five came out. And in that version there was a major reorganization of several conditions and OCD and hoarding were a part of that major reorganization. And after a lot of research and work by the committees that put this together, there was a decision made to move OCD out of the anxiety disorders into its own new category called obsessive compulsive spectrum disorders. And as part of that decision, there was also a decision to make hoarding disorder formally its own disorder. So previously it had been considered a type of OCD, there was a lot of research suggesting that was not quite right, which we could talk about today.
And it also became its own disorder. So OCD kind of now anchors this whole new category that's been created. And so what OCD is, is a combination of intrusive thoughts and those can be words or images or kind of movies playing in one's mind that are very distressing, cause anxiety or related emotions. And then people do a whole range of rituals or compulsions, which are behaviors that are done repetitively over and over again in an attempt to bring down their anxiety and distress. And OCD can present in an infinite number of ways, but there are seven or eight kind of really common kind of subtypes, ways that it can show up, but really can be just about anything as long as you see this combination of these repetitive thoughts that are really bothersome and then these repetitive behaviors as an attempt to reduce that distress.
Tori Steffen: Gotcha. Okay. That definitely breaks it down for us. And then hoarding disorders, since those are two separate things, could you explain for us that one a little bit?
Travis Osborne: Yeah. So as I mentioned prior to 2013 hoarding had always been considered a subtype of OCD. So if you had hoarding behaviors, you came to a mental health professional, you would've gotten a diagnosis of OCD and they would've just said that the subtype that you had involved hoarding behaviors. Unfortunately, what we discovered is, I've mentioned a little while ago that the treatment for OCD works very well. It's an incredibly effective treatment. And so we had several decades of research showing that this treatment, ERP or exposure and response prevention works great for OCD when they started doing some more fine grain analysis of what happens when we looked at just the subgroup of people in those research trials that had hoarding symptoms, what they found is those folks were actually doing terribly. So the treatment was not working for them very well at all, but it was working for all these other OCD presentations.
So it kind of started giving us the hint that something is different about these symptoms and the way that we're treating it isn't working for these folks. So a fair amount of work in the '90s, early 2000s went into flushing out some more specific diagnostic criteria for a separate hoarding disorder diagnosis would look like. And then also developing a completely different treatment approach for the disorder given that ERP was not working very well. The other thing that was discovered is that if OCD, if hoarding was a subset of OCD, we should see really high rates of other OCD symptoms in people with hoarding if it really was a type of OCD. What they found is only about 18% I think it is, of people with hoarding actually meet criteria for other OCD behaviors.
So it's a pretty small group. So there was all this research that started coming out, but these are different things. So in 2013, hoarding disorder actually became its own standalone disorder. So that's not that long ago, it's less than 10 years ago. So if you think about that in the history of mental health field, that's a pretty new classification of disorder. Obviously the symptoms have been around forever. What that means though is that the treatment research and the research on hoarding is lagging decades behind disorders like OCD and depression and anxiety, things like that because it is a pretty new kind of standalone disorder. And so what the criteria for hoarding disorder look like is people basically holding onto or saving a large number of things regardless of their actual value, having considerable difficulty getting rid of things and often only get rid of things if sort of pressed by others.
So it could be other people living in the house or landlords or other outside entities that might be involved and a fair amount of distress when faced with actually having to get rid of things. And then what that leads to is a tremendous amount of clutter in people's homes and an inability to use their homes as they're designed. So perhaps the kitchen table is so cluttered you can't actually eat at it. Maybe your kitchen counters are so cluttered you can't use them to prepare food. Your bed might be so cluttered you can't sleep in it, so you really can't use your home as it's intended. And so when we look just at the symptoms, they're actually pretty different than what OCD looks like. OCD, we have these recurrent thoughts and then these recurrent behaviors that people are doing in response to those thoughts.
And although hoarding could be seen as a compulsive behavior, it's a much more varied and complicated picture. And then you also have all these physical belongings that make it very different too. So the good news is a new treatment has been developed, that treatment is showing good promise, certainly much better promise than what we were doing before. But it has also really helped us understand that these are two very separate disorders. People can have both, but the majority of people that have one don't have the other. It's a relatively small number of people that have both.
Tori Steffen: That's pretty interesting. It sounds like there's a lot of differences in the way that they present themselves as far-
Travis Osborne: For sure.
Tori Steffen: ... as symptoms go. Are there any ways that OCD and hoarding disorder are connected?
Travis Osborne: I think the shared connection, and I think this is reflected in this new category of DSM that I mentioned of obsessive compulsive spectrum disorders. So they're both sort of under that umbrella, which is a recognition that there are some shared components. I think the component that probably would be arguably the most shared is that the compulsion, if you will, in hoarding is saving things. So not getting rid of things. And then for some people excessively acquiring things. So not all people with hoarding acquire things at a really rapid rate or excessive rate, but some do. And I think that as described as a compulsive type behavior, you could argue sort of fits, but there's actually I think actually more differences than similarities, kind of reflecting the division of them. For example, in OCD, the emotion that tends to be most predominant when people have their obsessive thoughts or encounter triggers for their OCD is anxiety usually, or fear.
There are other emotions too, but that's the most prominent. And anxiety is not necessarily the most prominent emotion in hoarding, it could be loss, feelings of sadness and loss when you get rid of things or anger when people suggest that you do get rid of things or try to help you get rid of things or push you to get rid of things. And so there's just a lot more variability in the emotions that come up, what those emotions look like. Whereas in OCD we see a lot more kind of narrower range of it typically looks like fear and anxiety, some other emotions sometimes. So they're pretty different in terms of the emotions that pop up too.
Tori Steffen: Okay. That definitely makes sense as far as how they can be differently understood. So I saw an article on the EBTCS site that noted most OCD symptoms can begin in childhood. Do signs and symptoms of OCD tend to defer among children and adults?
Travis Osborne: That's a great question. So the vast majority of people with OCD do show symptoms in the childhood or teen years. It can come on in adulthood, but that's more rare. And when most adults look back, even if they didn't have kind of full-blown OCD, they can see the traces of those behaviors. What's interesting is the symptoms themselves look pretty similar in childhood and adulthood.
So the subtypes that I mentioned of OCD that are pretty common are kind of the same subtypes show up in kids as show up in adults and what the big broad categories of those look like is contamination concerns where people probably the rituals are engaging a lot of hand washing or showering or washing their clothes, cleaning that kind of stuff, doubting whether you've done something. So did I check the stove? Did I check the lights? Did I check the car? The fear being that something bad could happen if I didn't do those things. And then the checking behaviors that can go along with that.
Obsessive thoughts about harm are really common. It's one that's not talked about a lot, but they're very high number of percentage of people who have what we call harm obsessions, which could be worries that they're going to harm other people in some way or concerns that they're going to harm themselves. And then usually lots of avoidance of situations where that could be potentially possible. Another major subtype is sexual obsessions, people having unwanted sexual thoughts. And we see this in kids and teens just as much as we see them in adulthood as well. And then what we call just right obsessions, which are needing things to be a particular way. And that could be anything from needing things to be symmetrical or done a certain number of times or done a particular way or doing something until you get a feeling that it's right. And then you can see a lot of repeating of behaviors until you get it right, in some sense.
Probably forgetting one of the subtypes. But those are the main kind of subtypes. And then from there, OCD can really be about, oh, the other one is called scrupulosity. So this kind of either religious or morally themed obsessions about, "Have I done something wrong? Have I done something sinful?" And then lots of rituals usually that are related if it's religious like praying or confessing or things like that. If it's more moral, it could be asking reassurance about whether somebody else feels like maybe you did do something wrong or whether you did X or Y or trying to evaluate whether you have made some kind of mistake or transgression or things like that. And so what we see in kids is the same subtypes, but maybe the way they show up just isn't as developed as it might be in an adult brain. But the things that kids with OCD worry about essentially are the same things that adults with OCD worry about.
Tori Steffen: That's very interesting. It sounds like anxiety and then fear are probably the main symptoms that show up for OCD. Are there any that we're missing from there?
Travis Osborne: So sometimes people can have disgust and disgust can show up in different types of contamination. So people feel like if food is rotten or if they feel like it's spoiled. Or some people with contamination concerns won't handle raw meat or eggs because they worry about salmonella or they worry about other diseases. They can actually feel fear, but also just like, this is gross, this is just kind of a disgust response. So disgust can definitely come up. And then I think guilt and shame can come up a lot when people have harm and sexual obsessions, so worries that they're going to hurt people or behave sexually in a way that's inappropriate. People can feel a lot of shame and guilt about those thoughts as well. So fear is kind of the biggest one and then disgust and shame and guilt can sort of pop up too.
Tori Steffen: Okay, great. What kind of treatment options are available for those with OCD and hoarding disorder or maybe just OCD and/or hoarding disorder?
Travis Osborne: Yeah, yeah. So for OCD two, clear treatments, one would be medication. So medication has been very repeatedly proven to be helpful with OCD, particularly the SSRI medications, which are also used for things like depression and other kinds of anxiety. Those can be extremely helpful for folks. The caveat is oftentimes for people with OCD, the doses of those medications need to be higher than for depression or other types of anxiety. And not all medication providers have that training. And so don't always know to try higher doses if lower doses aren't working, the medication can be very effective. And then the therapy that's most effective, as I mentioned, is something called exposure and response prevention, ERP for short, that's a treatment that was developed in the '80s and has 30 plus years of data behind it. There's probably somewhere between 40 and 60 randomized control trials evaluating that treatment with kids, teens, adults, very robust database.
And what ERP involves is having people systematically approach the things that trigger their OCD, make them feel anxious, and then have them practice not doing their rituals, not avoiding in response to it. And doing those two things together kind of helps people learn new ways of facing their OCD symptoms and breaks the cycle of OCD that people get stuck in. It's hard to do because it involves facing your fears, but what I usually tell clients is that, "It's no harder than living with OCD because if you have OCD, you're also feeling fear all the time anyways. At least with treatment, if you're feeling fear, it's in the service of you getting better as opposed to your OCD you're feeling fearful all the time, but you're just stuck in this endless kind of loop."
So the treatment for hoarding so far, we do not have any medications that are a clear home run for hoarding symptoms that is unique in the psychiatry psychology world. We do have medications for most disorders and we don't have a clear medication for hoarding. So what we think about for medication with hoarding is treating other conditions that might go along with it. So if someone is hoarding and also has depression or has a problem with hoarding and also has anxiety or an attention deficit disorder, we think about using medications to treat those other conditions because sometimes they make it harder for the person to do all the work involved of going through all their belongings and getting rid of stuff. There's no medication yet specifically for hoarding.
Then the treatment, the therapy that's been found to be most helpful for hoarding is a type of cognitive behavior therapy or CBT that has been specifically developed for hoarding that teaches people strategies that address the three components of the problem, which would be acquiring if they're bringing things into the home, the saving, not getting rid of stuff, and then the clutter that develops in the home.
So there's different strategies to help people tackle each of those things. And it's a pretty hands-on treatment, like ideally it's actually done in people's homes. So therapists often go into people's homes, actually help them go through their belongings, learn how to make decisions about what to keep and what to get rid of, and then actually practice going through that process until it becomes less distressing and they get better, better and better at it. Can take a while as you can imagine if a home has a lot of things in it, that process can take a long time, but for now it's the only treatment that we have that has some research behind it.
Tori Steffen: Well, it's good to hear that there is the research out there and techniques that can help people with both hoarding disorder and OCD. So thank you for explaining that. That was very educational. Well, a past interview of yours with NPR notes that one goal in treating OCD as you mentioned is to limit that amount of ritualizing. Can you explain for us how that's usually accomplished in the treatment process?
Travis Osborne: Yeah. So that part of the treatment is the response prevention part. So the exposure is facing the thing that makes you anxious and the response prevention is the trying to not ritualize or avoid in response to that. So I think there's lots of ways. Some people we can get them on board with just stopping certain rituals and they're able to do that in response to very specific situations. They might not be able to stop the whole thing, but if we're working on something, they might just be able to say, "Okay, I will work on just not doing this ritual and I will ride out this wave of anxiety that I'm having." Not everyone can just do that.
So other ways that we help people is usually rituals are pretty repetitive. Someone's washing their hands, they might be washing their hands multiple times. Usually the rituals take up quite a bit of time. So if there's a way we could say, let's say somebody always washes their hands like five times, can we go from five to four? Can we go from four to three? Can we go from three and fade out the hand washing over time? That's one way we might do it. Or maybe they're just at the sink for 20 minutes and they're just washing the whole time. Can we go from 20 to 15 to 10 to 5 getting down to what would be a normal 10 20 second hand washing? Sometimes we have to shape things in the right direction, slowly cut things out.
For other people; let's say some people get really stuck when they're leaving the house. They have a whole sequence of things that they have to check before they leave to make sure everything is safe. So maybe they check the lights and the stove and the door locks and make sure they unplugged anything that was plugged in anywhere and they go through this whole sequence before they leave.
In that case, what we might do is eliminate one step at a time. So for this week, could we eliminate this particular thing and you're going to do the rest of it, and then next week could we add another thing? Could we slowly cut down that? And so we have eliminated all of those things, but what we're always looking for is how to create a pathway for people to get to where we want to go at a pace and a way that they feel is doable. So if someone can just say, "I could just stop doing that," then we'll do that. If they can't do that, then we'll start thinking, "How do we get you from where you are to where we want to get you and how do we slowly break that down into smaller and smaller steps?"
Tori Steffen: Okay, yeah, that definitely makes sense how that could be helpful to phase people out if needed. So that's great. And one thing we also touched on earlier is the success rates for treating OCD. They're often much higher than other mental health problems. Do you have any ideas what might cause the differences between the success rates?
Travis Osborne: Yeah, that's a good question. So anxiety disorders, broadly speaking, have pretty high success rates. So I think part of it is as a field we understand fear a lot better than we understand a lot of other disorders. And I think our science has helped us figure out what are the strategies that worked for fear. And what's interesting is intuitively we all know that to get over fear, you have to do it. So the way you get over fear is by doing it. So it's like you're afraid of swimming, what you need to do is get in a pool. If you're afraid of flying, what you need to do is fly more. We know that as humans, but it's so hard to do that a lot of people just end up avoiding and not actually doing it.
So I think because we have some pretty good basic science around fear, what's actually happening in the brain around fear, what happens when you don't avoid that has really led to the development of treatments like exposure therapy, which turned out to be really effective because they're really linked to the science of what happens with fear and treating fear. And I think with other disorders we're still trying to understand better what's happening in the brain? What's some of the basic science of what's happening, and then how do we link treatments to those things? And then some other areas I think we just don't have that quite figured out as well. So exposure turns out to be a really powerful intervention that works well, which I think is why we see such big effect sizes in the studies that show that it works.
Tori Steffen: Gotcha. That's great that we have those scientific backed up techniques on how to treat that.
Travis Osborne: Yeah, I mean one of the things that's incredible to me is prior to the 1980s, OCD was really considered a form of severe mental illness that was largely considered untreatable. We did not have treatments really that worked well for OCD and it was considered a chronic untreatable or not very successfully treated illness. Then the '80s we had these two breakthroughs, we had the breakthroughs of SSRI medications that started to be found to be really effective. And then we have the development of ERP exposure therapy in the early '80s as well. What's amazing to me is just in the span of 30 years, 20, 30 years, we went from OCD being essentially a untreatable severe mental illness to the disorder that has some of the highest success rates in the whole field, all driven by science, all driven by evidence based procedures, which I think also just underscores the need for science backed treatments like that basic science that helped us understand what's happening in the brain when fear is activated, what happens when we do exposure and stick with the fear, how that changes things.
All that sort of led to the development of a treatment that now is highly, highly effective, which is super cool and exciting. And how in that span of... well, some people's lifetimes, I've treated clients who were much older who when they were kids, teens, early adults, there was no treatment for their OCD then by the time they were older, there now was a treatment for their OCD and then they finally got the treatment that they needed and it worked really well for them, which is pretty life changing.
Tori Steffen: Absolutely. Yeah, that's really good to hear that a lot of people have been helped by that. So hopefully those scientific findings can keep coming and helping us for other disorders as well. So in an article, you mentioned that hoarders can sometimes perceive themselves as collectors. Could you explain maybe the difference between a hoarder and a collector for the audience?
Travis Osborne: For sure. Yeah. I think the term hoarding and hoarder are so negative and have so many negative connotations in our culture. That makes a lot of sense to me that if somebody is struggling with clutter, it's way more comfortable to see oneself as a collector than as having a problem with hoarding. So I think people will gravitate toward that term because it's just not a term that has a lot of negative sort of bias and kind of stigma attached to it. When we look though at what collecting looks like and what hoarding looks like, they're totally different things.
So most people who are collectors, it is true, they might have a lot of possessions and they might have categories of things that they collect a lot of whatever, whatever it is they collect, whether it's baseball cards or fashion or artwork or cars or whatever it is they collect, they probably have a lot of those things and they may have a hard time actually getting rid of things that they collect because they're pretty attached to their collections, they like their collections and they've spent a lot of money and time on their collections.
So parting with those things could be pretty hard. However, they don't tend to have any issues with acquiring other stuff. They don't tend to have any issues with getting rid of other stuff. And most people who collect are super proud of their collections and will go to great lengths to display them in their homes, keep them really organized and beautiful. They get a lot of joy from sharing their collections with other people, showing people their room that has baseball memorabilia in it or whatever it might be. It's something that they get pride from, share with others, and there's a lot of joy around that.
In hoarding what we see is the complete opposite. So there's rarely organization, there's a lot of clutter and difficulty to navigate or find things. And most people with hoarding do not want anyone coming into their home. So whereas a collector might love having somebody over and sharing their collection with somebody, somebody with hoarding typically does not want anyone seeing the state of their home that would cause severe shame, distress, they actively work to actually keep people out of their homes and keep people away from their homes.
And most people with hoarding, some people with hoarding do only hoard specific things, but a lot of people with hoarding the stuff is the collecting is or the acquiring, accumulating is pretty broad based. They have too much of all over the place, too much of everything and it's not usually as specific to something like a collection. And then of course they also have the broad base difficulty with parting with things. So I think what the home looks like is pretty different between collecting and hoarding and then the fact that people with collecting want to share it, want to show it off, get a lot of joy from that versus the sort of shame and keeping people out away I think are some pretty big differences.
The other thing is that for most collectors it's not getting in the way of their lives and hoarding really gets in the way of people's lives. They usually can't socialize in their homes. They often can't have family or friends over to their homes. They can't find things. Sometimes in more severe situations there's health hazards or for older adults like falling hazards and tripping hazards. It actually gets in the way of living makes life harder. Whereas collecting usually doesn't make life harder typically.
Tori Steffen: Right. Yeah, definitely some pretty big differences there between the two. So while treatment options are best and ideally done under the guidance of a licensed mental health professional, what are some things adults can do on their own to, or even children as well to potentially reduce or lessen any symptoms of OCD and hoarding disorder?
Travis Osborne: Yeah, well for folks here in Seattle, and this is true in other major cities too, there actually is a free OCD and hoarding support group here in Seattle. That is an awesome resource, particularly for adults but also for family members and friends. So parents of kids or teens with OCD or hoarding behaviors, ocdseattle.org is the website for that. They have free meetings that are a huge source of support and help for folks. So looking for local support groups that are often easier to access sometimes than therapy, maybe less scary to access than therapy sometimes can be good. There's also great self-help books. That's so readily available online now, the internet has helped with that.
The IOCDF or international OCD foundation that I mentioned earlier has tons of not just resources, but they have an annual conference every year that's open not only to professionals but also people with OCD and hoarding disorder. They now actually have separate hoarding conference as well. Those are really helpful resources and they also run some other programs throughout the year that can be of help. And like I said, some great self-help books as well. I think all of those are kind of resources that can be useful to folks. I think the reality is most people with hoarding and OCD are going to need some form of professional help typically because it's just a very complicated problems to solve, but some people can often get a lot out of those other resources too.
Tori Steffen: Okay, that's good to know. I'm glad to hear that there's those resources out there. So thank you for sharing that info. But yeah, like you mentioned, it's with the success rates, I'm sure it's most ideal to seek out professional help.
Travis Osborne: Yeah, for sure.
Tori Steffen: Well, Dr. Osborne, do you have any final words of advice or anything else that you'd like to share with our listeners today?
Travis Osborne: I think just the key thing that like OCD has come so far in the past 30, 40 years. I mean, we really have great treatments if folks are willing to do them and just the awareness that folks should have that we are still figuring, hoarding out because it just became its own disorder just under 10 years ago, has really put the research behind. So we're moving in a good direction, but I suspect in another 10 or 15 years we're going to have even better treatments than we have today.
Tori Steffen: Awesome. Yeah, I'm definitely hoping as well that the research continues for that. Well great. Well thank you so much Dr. Osborne. It's been really nice talking with you today and thank you for your contributing to our interview series.
Travis Osborne: You're welcome. Thanks for having me.
Tori Steffen: Absolutely. And thanks for everybody for tuning in and we'll see you later.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.