Social Worker Elizabeth McIngvale on treating OCD & Anxiety with erp

An Interview with Clinical Social Worker Elizabeth McIngvale

Elizabeth McIngvale, Ph.D., LCSW is the Director of McLean OCD Institute in Houston, and a Lecturer at Harvard Medical School. She specializes in obsessive compulsive disorder as well as anxiety disorders.

Tori Steffen:  Hi everybody. Thank you for joining us 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 like to welcome with us today clinical social worker Elizabeth McIngvale. Dr. McIngvale is the director of McLean OCD Institute in Houston, and a lecturer at Harvard Medical School. Dr. McIngvale specializes in obsessive compulsive disorder as well as anxiety disorders. She founded the Peace of Mind Foundation and ocdchallenge.com, which is a free self-help website for OCD, which is live in six languages and serves nearly 4,000 individuals. So before we get started today, Dr. McIngvale, could you let us know a little bit more about yourself and what made you interested in studying OCD and anxiety disorders?

Elizabeth McIngvale:  Yeah, absolutely. So I'm actually a clinical social worker. I do have my PhD, but not a clinical psychologist. And I think for me, I really entered the field because of lived experience. I've lived with OCD since I was a young adolescent and went through intensive treatment that saved and changed my life. I then really led into advocacy and started doing a lot of advocacy work around talking and giving back in different ways, which led me into this field. So I ended up doing my undergrad master's and PhD in social work and really was just, and continue to be just really excited to be able to do for others what people did for me.

Tori Steffen:  Awesome. Yeah. Thank you for sharing that. Well, getting down to the basics around our topic, could you explain for us what exposure and response prevention, or ERP, is?

Elizabeth McIngvale:  Yeah. It's actually exactly how it sounds. So it's an exposure with response prevention. So what we mean by that is that from an OCD perspective, individuals with OCD have intrusive thoughts, triggers, things that scare them, and they engage in a lot of compulsive behaviors. And these compulsions or rituals are done to try to alleviate the distress caused from the obsessions. So when we talk about ERP, what we're encouraging patients to do is an exposure. So they face their fear, maybe they touch a doorknob that feels contaminated to them or they do some other exposure, but we're going to ask them to engage in response prevention. So we want them to prevent the response they usually do. So we want them to prevent rituals. So if you typically would wash your hands after you touch something contaminated, we want you to touch that doorknob and not wash your hands. So response prevention is that not ritualizing part. That's really important.

Tori Steffen:  Got you. Okay. That makes sense. Is exposure therapy similar to ERP in any way or how might they differ from one another?

Elizabeth McIngvale:  Yeah. It's a great question. Obviously there's a ton of overlap, and it's very similar in the sense that you are facing your fears, you're doing exposures. We see exposure therapy be really useful in trauma work, in social anxiety work, for phobias, you name it. But what we know is that individuals with OCD, if they're doing exposures, but they're also ritualizing, they're reinforcing their OCD. So for OCD, the big difference is that it's still exposure work, which is very similar, but we have to no longer do the ritual. If we follow the exposure with a ritual, we reinforce OCD versus being able to reinforce treatment and treatment outcomes.

Tori Steffen:  Okay. Awesome. Yeah, that definitely makes sense. And what are the main goals of ERP as a treatment? Are there any specific things that a clinician expects to see?

Elizabeth McIngvale:  Yeah. I mean, obviously we want to see a decrease in the anxiety in the disability and in the hold that someone's OCD has on their life. But across the board, the bigger pictures, we really want to start to change individual's relationship with anxiety and their relationship with their OCD. So we want to be able to teach them that anxiety and OCD isn't dangerous. It feels really dangerous because of how we respond to it, and that actually if we change the way we respond, we get to change the power that it has. So I think the bigger goal of ERP is that individuals understand how to change their relationship with anxiety, how to change their relationship or the way they feed their OCD so that this treatment can not just apply to any future OCD or anxiety triggers, but also to life as well.

When we think about fear in general, we either feed our fear or we fight our fear, and sometimes we think that what we're doing makes sense because it gives us short-term relief, but it actually just makes the fear bigger. If my daughter is afraid of a dinosaur in a room and I get rid of the dinosaur so I don't have to deal with her anxiety, I'm actually reinforcing that dinosaur's scary and that you aren't capable of being around it and being calm. Where instead, if I do exposures, I teach her to lean in and to not be afraid of it and to be with it, she can change her relationship with fear. She starts to realize that, "When I'm scared I don't have to run from it. I don't have to ritualize to make it go away. In fact, I can approach it," and that fear will go away.

Tori Steffen:  Okay. Awesome. Yeah. It sounds like almost a training of coping mechanisms in a way.

Elizabeth McIngvale:  It is a little bit. I think the thing we want to be careful about when we think about coping mechanisms is a coping mechanism often makes us think that we're going to give you a tool to make you feel better. Actually, what we're really doing is trying to allow you to change your relationship with distress. So when you have distress, we don't want to just get rid of it or make you feel better, we want you to learn that you can sit through it and you don't have to respond to it, and it doesn't have to be dangerous.

Tori Steffen:  Okay, great. Thank you for explaining that. So when might a clinician know that ERP is the right treatment option for a client?

Elizabeth McIngvale:  So ERP should always be the first line treatment for OCD, it is the most evidence-based and has the most research to support it. So we always want to start with exposure and response prevention. When we're treating a patient with OCD, of course, the most common treatment is a combination of ERP and medication, and that's often the route that most individuals will go, but we definitely always want to start there. We never want to start with other modalities that are not as proven because I mean, we want to start with what we know has the best chance of success and the best chance of helping our patients. What I will say is that it's really important if you're an outpatient clinician or a clinician who specializes in ERP, if a patient is not making progress, it's really important to sit back and understand why instead of to just keep trying the same thing we're doing.

So some of the reasons why, it could be that a patient... It appears they're trying to do ERP, but maybe they're actually holding on, maybe they are still ritualizing, maybe they're doing mental rituals or avoidance behaviors, and they're still feeding OCD or anxiety somehow. Maybe they need a higher level of care, maybe their OCD is so severe, so debilitating that they're not able to do ERP on an outpatient basis in the sense that if they just come and do it for 45 minutes with you every week, but they go home and they're ritualizing, we're not going to see progress there either. So they may need some support, maybe they need a more intensive treatment program. So lots of things to think about when we're doing ERP with our patients as well.

Tori Steffen:  Okay. Awesome. Could you provide an example for us of an ERP treatment for a client that has a specific phobia, maybe fear of dogs?

Elizabeth McIngvale:  I mean, I think that typically for phobias, we're going to do more exposure therapy than ERP, so it's really going to be getting them to approach that dog. So we might start with looking at pictures, watching videos, and eventually we want to get them working up to being able to hug their family dog, be with their dog, live by their values. I want them to tell me why being able to be close to dogs is important to them, or the reasons that if they don't do it will impact their life in a negative way. We want to really push on those values. I guess if it was an OCD fear, so for example, if the dog is contaminated, we want to do the exposure of getting them close to touching the dog and the response prevention of not washing their hands or not changing their clothes or not engaging in cleaning rituals that they may normally do.

Tori Steffen:  Got you. So it's important for them to understand that even if the dog is contaminated, it's not going to kill them or give them a disease. Would you say that that's true?

Elizabeth McIngvale:  Yeah. So it feels like that's what you'd want to tell the patient. You'd want to give them that reassurance, but actually we want to lean more into the fact that like, hey, people touch dogs all the time and there's value behind it. It's more important for us to focus on doing an exposure and touching our dog, but we don't want to reinforce that, I'm safe. It's okay. Nothing's going to happen. People don't get sick because the reality is that people could get sick. I can't guarantee if you touch a dog, you're not going to get sick. I also can't guarantee that if you touch a dog, you will get sick. So we want to focus less on confirming or denying our certain fears and more on living by our values and not responding to our fears, letting that fear be there that, well, what if I get sick? Being able to acknowledge that and not respond to it. So not try to make sure you don't.

Tori Steffen:  Okay. Awesome. Thank you for clarifying that. What does the process of habituation look like in therapy? How is it usually conducted?

Elizabeth McIngvale:  Yeah. So habituation is a term we don't really use as much anymore in ERP. Habituation traditionally is the thought process that when you face your fear, when you do something challenging, while it will be triggering, eventually your anxiety will subside, you will habituate. It's like you go into a locker room that smells, if you choose not to leave, eventually you'll get used to the smell. The smell doesn't go away, but you habituate to the smell that you were experiencing. And that's really the thought process behind habituation, especially for OCD, is that if you face your fear and don't do anything about it, eventually your anxiety will drop and you'll see that you didn't need to do that ritual to feel better.

We have transitioned in recent years to what we call inhibitory learning, and the point of inhibitory learning is for us to recognize two things. The number one thing is that not everybody habituates the same, and so we don't want to give you the thought process of like, you're going to just sit in habituate, because some people, it takes a couple of hours or their anxiety lingers, and I want them to be able to go do what they want to do and be able to live their life, not sit there and feel like I have to wait to habituate first. But the second, which is more important, is what is the message of habituation versus what we call inhibitory learning? Habituation is an old school model where you might sit and touch something that's contaminated if this is contaminated, and the thought process was you just sit there and you sit with the distress until it goes away.

The problem with that is that what we're teaching you is that you can't move on until you feel better, and we're putting a lot of emphasis on the anxiety and distress. On like okay, the success measure is if you start to feel better, that means that you can face this habituate. What inhibitory learning says and what we're learn, what we learn and really want to practice is that actually you can face challenging things. You can lean in all the way and you can still move on while you're experiencing some distress.

So we want the emphasis to be much less on the distress because again, we don't want you to believe the distress is dangerous, and we don't want to send that message that the distress is really important. It's actually not that important, and it will subside if you don't feed it. But what we don't want to do is sit and wait. We want to make sure that we're emphasizing the distress less, and we're more living by our values. So you're touching this contaminated thing. You're still slowing down to lean in to feel the distress, to think about the fear and choosing to move on and go do other things even if the distress is still lingering.

Tori Steffen:  Got you. Okay. That definitely makes sense. What can a client expect to experience when ERP is working correctly for them?

Elizabeth McIngvale:  I mean, alleviation across the board, they should start to see their intrusive thoughts come with less frequency and with less intensity, and they should start to feel like they're able to get back to their life and functioning the way they want to. They should be able to envision living by their values and OCD not having a grip. My biggest piece is that I want all my patients to be at a place where OCD no longer makes any decisions for them or their life, and instead they're making those decisions for themselves.

Tori Steffen:  Okay. Awesome. How can a clinician tailor ERP for a client? So for example, how might ERP differ for a client with OCD versus panic disorder?

Elizabeth McIngvale:  Yeah. So again, remember with panic disorder, you're going to be doing more exposure therapy because there's not going to necessarily be as many rituals. There will be avoidance. So we're going to get patients to avoid less, start living their life, and we're going to encourage them to engage in exposure therapy. We may also be doing some CBT skills with panic disorder because there may also be a lot of distorted thinking, or maybe there is some ruminating after certain events that we want to help break that cycle. But there's not as many outward rituals with panic disorder, and so the emphasis is much more on exposure compared to OCD. It's going to be much more focused on exposures and preventing those rituals or responses.

Tori Steffen:  Okay. Awesome. How can a clinician train a client to continue ERP or exposure therapy on their own, even outside of therapy?

Elizabeth McIngvale:  Yeah. This is a great question, and really this is about that bigger piece we talked about early on is what do you want patients to get out of ERP? What we don't want them to get is just that they succeeded because their symptoms went down. While that feels like that's successful, what's really successful is that their symptoms go down and they understand the why, and that learning actually took place. So the goal with ERP treatment is that patients understand across the board that they've truly changed their relationship, their responses to anxiety and to OCD.

And if they've done that, then they get to do what I call ERP as a lifestyle where all the time you're having opportunities to face anxiety, to feel it, to lean in, versus to respond to it in a way that you run from it, or you try to get rid of it with a ritual. So ERP should be something that it shouldn't have to feel like sometimes when you're first stepping down from treatment, you need to do more dedicated ERP, but eventually it should just come innate. It should be natural that I'm responding to my life, to my values, not to my OCD, which means I'm doing active ERP all the time. But it shouldn't have to feel like it's active ERP, if that makes sense.

Tori Steffen:  Okay. Yeah, that definitely makes sense. Is it ever possible for ERP not to be effective?

Elizabeth McIngvale:  Absolutely. I think that we definitely see ERP not to be effective if there's a lot of comorbid conditions. I think for me, one of the big things I want to know is if ERP isn't effective, why? We want to understand the why, and oftentimes it's because the patient's not ready or able to do ERP yet. So just because ERP is not effective right now, it doesn't mean it won't be in the future. For example, if a patient is dealing with a lot of distress intolerance difficulties, they're struggling to emotionally regulate, they may need DBT skills first so that they can do ERP. ERP probably wouldn't work right then for them. If their emotion regulation skills were really poor, their insights really poor, but it may be able to in the future.

Tori Steffen:  Okay. That's great to know. How might a clinician move forward? Let's say ERP isn't working for the client, and yeah, that definitely makes sense with DBT. Is there any other ways that you might move forward in that scenario?

Elizabeth McIngvale:  Yeah. I mean, I think the biggest thing when ERP isn't working is to make sure that your patient's ready for ERP. So we need to slow down. We need to think about motivational interviewing, we need to think about rapport building. We need to make sure that they understand why we're asking them to do this, that they're bought into it. No patient should be doing ERP because we're telling them to, they should be doing ERP because they see the value in it and they want to be doing it.

Tori Steffen:  Okay. Awesome. Well, do you have any final words of advice for us, Dr. McIngvale, or anything else you'd like to share with the listeners today?

Elizabeth McIngvale:  I think the biggest thing is just to remember that help and hope are always available, and what I want to make sure people know is that there is evidence-based treatment for any diagnosis you're going through. Make sure you figure out what that is and that you find somebody who has specialty training and background in that area.

Tori Steffen:  Awesome. Great advice.

Elizabeth McIngvale:  Okay. And for OCD resources, please always check out iocdf.org, which is an incredible nonprofit for OCD and host an annual conference, and is a great way to continue to get connected with the community.

Tori Steffen:  Awesome. Well, thanks so much for sharing your knowledge with us today, Dr. McIngvale. It was great speaking with you.

Elizabeth McIngvale:  You as well. Thank you.

Tori Steffen:  Thank you guys, and thanks everybody for tuning in.

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.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Travis Osborne on OCD & Hoarding

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.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Hamilton Fairfax on OCD & Mindfulness

An Interview with Psychologist Hamilton Fairfax

Hamilton Fairfax, Ph.D. is consultant counseling psychologist in the National Health Service (NHS) in the UK. He has developed Adaptation-based Process Therapy (APT), an integrative group-based approach for complex clients, especially those with a personality disorder diagnosis and another medical condition. His work also focuses on the benefits of mindfulness for those with OCD.

Preeti Kota:  Hi, everyone. Thank you for joining this installment of the Seattle Psychiatrist Interview Series. I’m Preeti Kota, a research intern Seattle Anxiety Specialists. We are Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us psychologist, Dr. Hamilton Fairfax who joins us from England today. Dr. Fairfax was a recipient of 2014 Society’s Professional Practice Board’s Award for Practitioner of the Year for his development of innovative therapeutic techniques when working with clients with complex needs. He specializes in adaptation-based process therapy, APT, an integrative group-based approach for complex clients and OCD. Before we get started today, can you let our listeners know a little bit more about you and what made you interested in becoming a psychologist as well as in mindfulness and OCD?

Hamilton Fairfax:  Yeah, of course. Thank you for inviting me.

So, I'm Hamilton. I'm a consultant counseling psychologist in the NHS, the National Health Service, which in the UK is a publicly funded health care system. And I'm working in Devon, which is in the far west end of England. And I'm in charge of psychology and psychological therapies for adults, secondary mental health care clients and that's people who've got severe enduring difficulties.

What's the next bit? Oh, it's why did I want to become a psychologist? Yeah. Good question. I started off doing theology and philosophy and classics and I suppose probably because I'm very bad at philosophy, I got a bit frustrated that it was all really interesting, but I wanted some practical ways of helping people and I think that was my interest all the way along was trying to find ways of trying to be helpful to people and I haven't got many other skills to do so and I ended up being a psychologist and that's still debatable in terms of the skills thing as well.

In terms of mindfulness, I was probably first introduced to it as a concept about 20-odd years ago through DBT and I pursued it from there. And the main focus on OCD is in the work that we were doing. We see anybody here with a complex, any diagnosis of complex care. And in that particular team I was working at the moment, at that time there was a really, really long waiting list and a lot of people with OCD. So, it was a case of how can we see people with the resources we have? And that led to, I'd be thinking as well about limited thoughts and mindfulness and just seemed like let's give it a go for an OCD group, mindfulness based.

Preeti Kota:  Great. So, just to begin generally, what is OCD?

Hamilton Fairfax:  Really difficult question there, isn't it? I guess traditionally, that would be seen as part of an anxiety disorder. I think it's a bit more than that. So, I suppose OCD is the idea of sort of a compulsive need to perform some behavioral or thinking rituals to help neutralize, prevent, or manage really distressing, intrusive thoughts in somebody's mind. And I guess it's on a continuum as well that I feel is about most mental health difficulties, that it's on the continuum, it's dimensional, we've all got a bit of something that it gets more and more extreme. And what OCD really is is awful. It's really, really life bothering and distressing for people. And I think the World Health Organization's still have it high on their worst conditions to have. So, OCD and it's worse because can be completely debilitating for people.

Preeti Kota:  Mm-hmm. Yeah, definitely. Why do you think many clients failed to engage or complete treatment for OCD when using the techniques of cognitive behavioral therapy or exposure and response prevention? Also, if you want to go into what those are generally.

Hamilton Fairfax:  Yeah, sure. So, it's a really good point, isn't it? Because I think they have some studies certainly in the UK saying that sometimes people weren't diagnosed with OCD for up to 15 years from their first presentation because there is something quite shameful that people can feel about OCD. Logically, they know this isn't the case, but they just feel compelled to do it. So, there's something often very shameful about that.

Also, when you start to tell people about exposure and response prevention. So, that is developing a series of graded ways of confronting your fear, that could be really scary. So, if you really think that something really bad could happen if I don't wash my hands 50 times and someone comes along, "Right, the treatment we're going to give you is we're going to make you stop washing hands 50 times and we're going to do it week after week after week in slow steps," it could be really, really off-putting for people to do that. So, there's a lot of fear and I think some people perhaps have read about things and they think, "Oh, no. I've got worries about contamination. I'll have to stick my hand down the toilet." They see these kind of videos out there. So, I think there's something about education in that as well.

And it's a really, really hard condition to treat. So, people won't tell people in huge details about what their thoughts are. Sometimes these thoughts and behaviors are really embarrassing for them. Sometimes they're really shameful and sometimes they're really scary. So, if you've got intrusive thoughts, for example, about being a pedophile, telling people that can have some really difficult consequences and people will respond differently to you. So, that's very, very difficult.

And I guess what we know from people with OCD is often, say, they'll present maybe the top of an iceberg of their difficulties and it would be for the therapist to really, really drill down into what's really going underneath that. And that takes time that you need to build a relationship, not just necessarily steam in with the behavioral side of things. So, it takes time to build that trust. And if you don't address the core, the roots, you might change certain behaviors but they could substitute different behaviors, which happens a lot from the evidence. Sometimes it can be 50, 60% of people relapsing or having a different kind of OCD. I think those are some of the reasons why it can be difficult.

Preeti Kota:  Hmm. Is one in particular CBT or ERP more effective or ...

Hamilton Fairfax:  If so, in the UK we have something called NICE, which is the National Institute for Clinical Health and Excellence. So, that's basically an organization that looks at the RCT forms of research and recommends treatment on that for the more common mental health conditions. So, they would argue that cognitive behavioral therapy with exposure and response prevention would be the best way of treating that. But, of course, the more complex people become, the more you need a bit more sophistication.

Preeti Kota:  Hmm. Yeah, definitely. What about mindfulness do you think makes it an effective solution for OCD?

Hamilton Fairfax:  Yeah. I think there's several things that helpful. One, I mean, it's incredibly portable. I think there's a book on mindfulness, isn't it? I think they're called “Wherever You Go, There You Are” in the sense that if you're being mindful, your body and who you are is always around. So, there's something you can practice and try out wherever you are in the world. I think, as well, I got particularly interested in cognitive mechanism suggested behind OCD called thought-action-fusion. And that's the idea that to have the thought is exactly the same as if you've done the behavior. And there were two types of thought-action-fusion. One's called moral thought-action-fusion, which is, if I have a thought that I'm a pedophile, what kind of person does that make me? I must be that evil person. And then it sets off.

So, the thought is just as bad as being that thing and there's a likelihood thought-action-fusion. If I keep thinking about the plane could crash, it could crash. So, I need to do something about it. It's almost like I'm making it crash. So, this way of the thought-action-fusion is really awful because it really starts that behavioral response automatically. So, I think something good about mindfulness is it begins to start to have a break between that thought-action-fusion. It begins to say, "Hang on, hang on. Okay. Yeah. That happens, but let's just stop and try and get that meta mindful position and try and break that link between thought-action-fusion."

Preeti Kota:  Do you think it's also ... Sorry.

Hamilton Fairfax:  It's also ... Sorry. Go ahead.

Preeti Kota:  Do you think thought-action-fusion is something that we have as an automatic bias or something we develop?

Hamilton Fairfax:  Good question. I'm guessing it's both. I think it has a function as well but that, over time, you feel more... I suppose it depends on the nature of the thoughts, as well, behind it if something is so horrific, either morally- or likelihood-wise, it might become more an ingrained pattern. Good question, though. It's difficult one to answer, but I think it's probably down to individuals-

Preeti Kota:  Yeah.

Hamilton Fairfax:  ... and what happened.

Preeti Kota:  And I'm sorry.

Hamilton Fairfax:  Yeah, yeah. No worries. I think also what's useful about mindfulness and the treatment of OCD is that it really helps engage in a behavior. So, for example, if you think checking the door loads of times is going to help prevent something happen. If you do it mindfully, if you mindfully check the door, you have to say, "Okay, I'm going to mindfully do this. I'm going to observe myself moving the handle and feeling what the metal feels. Oh, I'm surprised. Oh no, no, bring it back to that task." It really makes that person engage in that behavior. So, you're going to be obsessed with mindfully in a sort of paradoxical way. That helps because what we know about OCD, the way that it affects certain brain areas, but also anxiety and distress in general, is it hits our executive functions and our memories. So, it's very hard to do that.

So, when you begin to doubt yourself. "Oh, did I do it 15 times? Actually, no. I do remember really moving the handle." So, you get this whole sensory as well as to format memories as it lays down the links, which makes it more, "Okay. Maybe I didn't ... No, I don't need to go back and check, because I do remember doing it." So, it has that utility as well.

Preeti Kota:  Yeah. Are there specific types of mindfulness that are more beneficial than others, such as meditation over yoga?

Hamilton Fairfax:  I guess they are different practices. So, yoga obviously would be more physical-based. And I suppose the, it's the intention behind what you're doing it. I mean, there's different kinds of traditions in mindfulness and there's loving kindness meditation as well. But I guess they're doing different things in some way. So, I would always say, "Whatever kind of mindfulness you are doing, what's the intention behind doing it?" I mean, to be mindful is not to be relaxed. Far from it, often. You're really sort of immersed in the experience of feeling, "Oh, my god. What's all this about?"

So, it's not a relaxation technique at all. And the same with yoga. It embodies you, which is really important. That's what mindfulness can do as well. Embody you, but I guess with yoga there's an explicit meaning behind the practice.

Preeti Kota:  Can you elaborate on what you mean behind the intention of doing the practices?

Hamilton Fairfax:  Yeah. So, I'm thinking, well, and a poor example, some people will think, "Okay, so mindfulness is about being relaxed," and it isn't, but if your intention is, "I'll do this and I'll feel more capable of managing my distress or getting out there in the world," that's a bit difficult because mindfulness, I guess, personally for me, I don't feel is a set of skills. I think it's a way of being and that's a very different way to approach it. So, I think that's what I mean by the intention.

So, if we set the intention in treating OCD with mindfulness in the sense that, "Okay, what I'd like you to do is just really be aware of when you touch the desk 10 times. I really want you to feel it. I want you to notice." So, you're really actually priming the person about why you're doing what you're doing. You're being really explicit. "Okay." And then you'll say, "What will happen is we'll do this. Your mind will wander. You'll feel racy. You will have those in compulsive thoughts. That's alright. All I want you to do is practice bringing your head back and forth to that sensation." So, it's something again there about why you're doing what you're doing. I think that's what I mean by intention.

Preeti Kota:  Okay. In treating OCD, is mindfulness best suited as in addition to traditional therapy, in addition to medication or involving both?

Hamilton Fairfax:  I would say it depends completely on the person. How I've used it is all of the above. Most people I see will be on medication and they'll need more than just mindfulness practice. It needs to be contained within a wider psychological formulation. So, I'd say complete depends on the individual. I think I'd go back to intention again, but if you're wanting to talk to people about mindfulness in a therapeutic way, it needs to be part of a formulation that's explicit and co-constructive and like, "We're doing this because, and this is what I'd like you to ..." So, I think it depends on the person. I wouldn't separate it.

Preeti Kota:  So, when you're deciding based on the individual, is that related to the severity of the OCD or ...

Hamilton Fairfax:  In terms of medication, yes. So, sometimes medication can be helpful, sometimes it can't. I think I don't I'd ever just do be mindfulness, use mindfulness with somebody, but it would need to be part of the ... I wouldn't say as adjunct. I just say it's part of the therapeutic process.

Preeti Kota:  Okay. How long do the techniques of mindfulness last after completing a mindfulness program? Is it something you have to continue practicing often?

Hamilton Fairfax:  Well, you see, this is where we're bad practitioners in the NHS, because often we don't do follow-ups. But, actually, some of our groups, we did manage to do that. I can't remember if there's a paper written on it, but I think it was 12 months we did, certainly six months. And mindfulness people continue to feel better. When we asked them what was the thing they found most helpful in the group, which was cognitive behavioral as well as ERP and mindfulness, it was mindfulness. So, they carried on practicing the mindfulness.

In terms of what do you have to do? Yes, you do have to keep doing it because it gives you that authenticity. If you're asking someone to sit with their thoughts and manage that meta and the struggle of not getting it right, whatever that means. You need to have your own experience of doing that. It doesn't have to be... Sorry.

Preeti Kota:  Oh, no. You continue.

Hamilton Fairfax:  No. No. I was going to say it doesn't have to be wedded to any particular religious belief or whatever, but you do need to have that authenticity. So, you know what it's like to struggle.

Preeti Kota:  Is it the thing that … casually or something like dedicate time to each day?

Hamilton Fairfax:  I'm sorry. I lost you there over the Atlantic. I couldn't quite hear that.

Preeti Kota:  It's okay. Is mindfulness something that becomes more of an automatic habit or a scale or is it something that you have to dedicate time explicitly to practice each day?

Hamilton Fairfax:  Right. See this is why, depends on who you are as a person and what you need to do to remind yourself to do it. So, I'm very bad, because I suspect as a practitioner I need to be reminded to do these things. I need to have a commitment to do it, not me. I have to do it for an hour or anything like that. But there's also something, back with our client, it's very portable. You can do mindfulness. You find a form of mindfulness practice that suits you. For example, I quite like mindful walking, just really sort of noticing what it means to walk, which can make you feel really unbalanced.

But, so, I think it does take a commitment to actually doing it on an ongoing way. Does it become automatic? I think we're human beings, we resist these things and sometimes they become more familiar and sometimes they don't. Just depends where we are, but it does take a commitment.

Preeti Kota:  Okay. Do mindfulness and OCD affect similar brain areas neurologically?

Hamilton Fairfax:  Tricky and this is where I'll probably get in trouble with all my neuroscience colleagues. I'm not a neuroscientist, but what I'm aware of is that I think what mindfulness does in some of the studies I've seen, it certainly helps, I think it's thick in some of the prefrontal cortex. And I think it's been linked with a lot of the regulation of the limbic system and small amygdalas, I think. So, that would.

And with what we know of OCD, we know, again, the prefrontal cortex, the caudate nucleus, and the singlets are all sort of implicated, particularly that sort of relationship between the frontal cortex and the basal ganglia and the caudate nucleus. That sort of idea that here's the front bit that says here's our choice decision-making and here's the sort of more movement-y bit and that sort of error checking bit that gets skewed in OCD. That's a terrible, terrible neurological description. But anyway, so what I think that mindfulness does is that I think it calms down the reactivity of the system. So, I don't think it necessarily targets brain areas as such. Perhaps it just helps reduce the energy in those certain areas.

Preeti Kota:  Okay. So, I mean this might be too neurological of a question, but it doesn't really rewire the brain. It kind of just-

Hamilton Fairfax:  Well, I think that's interesting because if you go with... I mean, yeah, neuroplasticity I don't but I think, absolutely, because if you do something enough times you are going to rewire that kind of connection. So, absolutely. But I think that's true of any of our experiences. So, yes, I'm sure, I think therapy does help to do that kind of neuroplasticity change.

Preeti Kota:  And that's probably most likely in the prefrontal cortex that does that?

Hamilton Fairfax:  Again, I think you need someone who's much better qualified than me to do that. But, I guess, I think about brain functioning in terms of systems and yeah, across regions, but also systems. I don't know if it's just in the prefrontal because I guess you got the temporal lobes with the memory and all sorts of things. So, I think it might be more diffuse than that. I think that's what mindfulness might do as well. I think it's probably diffuse neural. But again, talking to someone who knows what they're on about.

Preeti Kota:  Okay. Is there a genetic basis for OCD, and also, is there a genetic basis for the ease of practicing mindfulness? Does it come automatically to someone more than another person?

Hamilton Fairfax:  Yeah. The best I've ever come across. I mean, you haven't looked at it for ages, was that 50/50 in terms of genetic bias of OCD. It might be slightly more than that.

It also means, yeah, on that continuum of OCD, we've got tick disorders, we've got neurological things, we've got other things. So, I think it's in maybe about 50/50. In terms of genetic for practicing mindfulness. I guess it's more about personality and temperament than genetics for being why to do it, I guess. I mean, that's a hard one. That's back to the nature/nurture. So, I don't know about that. But what we do know about mindfulness it’s been practiced for thousands of years in cultures across societies and across cultures. So, everyone can do it. Yeah. So, I don't really know about a genetic thing. I wouldn't have thought so but we're animals as well.

Preeti Kota:  Mm-hmm. Are there certain personalities that you were referring to personality-wise, that it depends? Are there certain path personalities you think are better at mindfulness?

Hamilton Fairfax:  Just on my experience and sort of just in gut feeling, I guess again, it's those people who are openness to experience who are sort of perhaps slightly more extroverted. You don't need to do that. But openness to experience that are willing to give things a go that are psychologically minded, that can make connections between things, that like to do new things. I suspect they'll probably be more willing to engage. But that certainly doesn't mean that people who are more reserved or more introverted can't do it.

Preeti Kota:  Yeah, I would actually expect people who are more introvert to be better because they're already kind of in tune or with themselves I guess.

Hamilton Fairfax:  Or a perception of themselves. And I guess that's the thing that we do with the mindfulness is are you introverted or someone called you... I mean, it could be. You could be absolutely right. There's something about that almost as diagnosis of introverted or extroverted but you probably could unpack through mindfulness.

Preeti Kota:  Mm-hmm. Yeah, definitely. Does mindfulness involve dissociation in that it practices separating the self from sensory experiences?

Hamilton Fairfax:  No, I don't think so at all. I think it's quite the reverse. I think it is about engaging with sensory experiences, either very explicitly, such as smell this coffee literally, or smell these. We did an exercise in one of these groups which was smelling Quavers, which in this country, is an incredibly fragrant, almost sick-making crisp that smells very strongly of cheese. So, we thought, "Fantastic. We're doing Quavers, not raisins," because they're far too traditional. But to do that, we were asking people to really engage with this Quaver. So, it felt funny and it really strongly smelled. So, they had to engage with that crisp and having all these thoughts going on and actually nobody really wanted to eat it, because the more you engage with it, the smell took over.

So, that's just an example I think of... It's not. It's about immersing yourself in the experience but having that step back that observes. It's not dissociative. It's an observing mind, it's an observing way of being. So, you need to know all these kind of things and it asks you to be in your body, because if you're sitting there thinking, "Oh, god, I didn't know my stomach felt like that when I'm having this thought." Okay, just observe it. Just hold on to it. Carry on with what you're doing. So, I think it really invites you to be far more embodied. And you can use mindfulness with psychosis as well. I know some can be quite worried about that, but there's some really good evidence of mindfulness in psychosis.

Preeti Kota:  Hmm. Can you just elaborate on the differences between mindfulness and disassociation, because I feel like mindfulness also involves kind of taking perspective, but I don't know much about dissociation.

Hamilton Fairfax:  Dissociation are often a highly understandable and effective way to deal with trauma. But what you're doing in dissociation is literally cutting off from an experience. You're putting your head somewhere else out of that environment. Whilst you're being mindful, you are engaging yourself in that environment. Yes, you're trying to have a meta-perspective to observe it, but you are fully immersed.

Preeti Kota:  Okay.

Hamilton Fairfax:  You're fully present, well dissociation to cut off.

Preeti Kota:  Okay. And then, do certain emotions or situations increase one's tendency to urge surf or act impulsively? And if you want to generally go over what urge surfing is as a concept.

Hamilton Fairfax:  Yeah. Well, I think it takes me back to my DBT days. So, this idea that you'll be flooded with, it's about emotional regulation often. So, you'll be flooded with feelings that just takes you to certain kinds of ways. And how mindfulness and DBT with certain other ways as well is to sort of stop and say, "Yeah, here's that flood of emotions. You can surf the wave, you don't have to be swamped under it."

So, mindfulness is a way of sitting back, setting the board on the wave as opposed to drowning under it. And in terms of acting impulsive, I guess that's what we're trying. That's the antidote that you're surfing it, you're riding it, you're not ignoring it, you're being aware that you feel pissed off or angry or whatever it is, but you're not letting it take you over.

Preeti Kota:  Okay.

Hamilton Fairfax:  And in certain situations do that, I think anything that's traumatic will do that. In terms of the emotion dysregulation. So, if you ask somebody who might have been diagnosed with personality disorder, which I prefer to say, "Complex trauma," there's lots of hardwiring for your environment where you are going to be highly sensitive to certain environments that you might feel abandoned, rejected, or under assault. And that could trigger you instantly into that sort of emotional overload, that storm of affect.

Preeti Kota:  Okay. How long does the emotions of trauma affect the tendency to urge surf?

Hamilton Fairfax:  How does it ... Go on. Say that again?

Preeti Kota:  How long do the emotions of traumatic situations affect one's tendency to urge surf?

Hamilton Fairfax:  How long? I guess it really depends on the situation and what's happening. If, for example, someone is self-harming and that's been what they've done before and we know that the positive thing of self-harming is that the cutting helps express a feeling, helps regulate an emotion, what we're wanting to do is try and change that behavior differently. So, it will depend, again, on the individual. It'll depend again on the context. In terms of a timescale, it's difficult. If that's how you've had to manage your life to survive for decades, it's going to be an instant thing.

Preeti Kota:  Okay. And then, for cases not directly relating to trauma, are there daily emotions or more common emotions that trigger urge surfing or impulsivity?

Hamilton Fairfax:  So, yeah. I mean I think anything that's ... There's small-t trauma, not necessarily sexual abuse and all the rest of, but small-t traumas, things that sort of interfere with our quality of life will lead to arousal of affect. And again, it is going be dependent on the person, what triggers you in that way. And again, the triggering is not necessarily always extreme. So, we're talking about I suppose the fight/flight's freeze way of understanding situations and how that relates to your emotions.

Preeti Kota:  So, it doesn't necessarily have to be negative emotions in terms of arousal, it can also be positive?

Hamilton Fairfax:  Sorry. I missed the first part.

Preeti Kota:  So, it doesn't necessarily have to be negative emotions just in terms of arousal. It could also be positive emotions that ...

Hamilton Fairfax:  Absolutely. Absolutely. If you're a big sport fan or a music fan, you know can really be easily taken over impulsively in the moment and sometimes do things you wish you hadn't or whatever or just be in a different place. Absolutely. So, it's just all mindfulness and I suppose other techniques is other ways of therapy is just trying to rebalance.

Preeti Kota:  Okay. Just also getting on a little bit of a tangent. For positive emotions, since it feels very good to be very happy, how would one be motivated to practice mindfulness to kind of tame those kinds of emotions? Because I feel like more … some people with maybe bipolar, with before you have something might not want to do that.

Hamilton Fairfax:  Yeah. I heard most of that I think, but tell me if I haven't answer your question properly. So, something here about how do you convince people with really high positive emotions that they want to stop doing that and try and be it more balanced?

Preeti Kota:  Yes.

Hamilton Fairfax:  Really ridiculous. Particularly people with bipolar disorder, cyclothymia and often when you meet the people that actually miss those high states, because there's something really addictive about not caring and just being happy in the moment. But I suppose what you need to do, again, is to look at the consequences of behaviors and they can often be really, really bad and they can often influence the bipolar shift the other way sometimes.

So, I think what it is, again, it's all about balance. It's not about destroying those high states. It's building relationships therapeutically with that person and saying, "Look, we want you to be in control of your feelings. That doesn't mean you have to be a robot. So, it doesn't mean you have to do these kind of things." But, like with OCD, we all have it a bit, but when it interferes with the quality of our lives, then it becomes a problem. And that's all we'll be saying to our bipolar people as well, I guess. These things, these emotional states interfere with the quality of your life and the quality of other people's lives. So, that's why we just need to bring this down a bit.

Preeti Kota:  What about-

Hamilton Fairfax:  Sorry, go ahead.

Preeti Kota:  It's okay. What about for people with OCD who just experienced such a high level of satisfaction from performing certain behaviors that they're just not motivated to practice mindfulness, to kind of change those behaviors even though it's affecting their life?

Hamilton Fairfax:  If someone doesn't want to change their behaviors, nothing we can do about that. But I'm guessing the fact that they've come in to talk about it would be some chink of saying, "Something's not okay here." I don't know if I fully answered that question. What was the first part of that?

Preeti Kota:  I think it was how people with OCD could be motivated to resist the satisfaction they get from performing the compulsive behaviors.

Hamilton Fairfax:  Yeah, okay. Yeah. That's an interesting one. I guess the people I tend to see aren't satisfied. It's all they're far from it. So, although there's a sort of, "I've done this. Things are okay." They're not happy because it's controlled their lives for 20 odd years or longer. So, there's a sense of satisfaction, but it becomes something really, really very toxic and they're there because this isn't okay. Or they can live with it, but no one around them can. So, that's a chink in as well. Or they don't want their children to pick up their behavior. There's some knowledge, there's some awareness that they don't want anyone else to have what they're doing.

Preeti Kota:  Okay. And then you're talking about the spectrum of OCD before, how some cases are very extreme and some are mild. So, on that spectrum, I guess what range can mindfulness help with, even mild is there?

Hamilton Fairfax:  Oh, yeah. You see how massively optimistic. I think you can help in all presentations because, again, it's about, the formulation, it's about the intention behind it. It's a very helpful way to get into exposure and response prevention in a certain way. Because the first thing you're doing is I'm gluing thoughts and saying, "Look, all I'm going to ask you to do is spend 30 seconds just sitting with that." So, it's a way of inducting people. So, I think you can work at any level of extremists and we've certainly had people, the OCD groups who were really intensive OCD units in the UK, real lifelong people, 40, 50 years plus of OCD. Had some lady who was so concerned about contamination that she would unscrew her floorboards throughout the house and clean the screws every single day. So, it's really quite extreme things and people benefitted from that.

Preeti Kota:  Mm-hmm. That's great to hear. So, what advice do you have for beginners trying to get into mindfulness?

Hamilton Fairfax:  Don't be put off and don't think you have to be a guru or anything like that at all. You don't have to be Buddhist. You can be. Don't have to be. It's just the way of being and the idea about being a beginner is what we all are. Because it's not about failing or succeeding, it's just noticing and being kind to yourself. So, please, please, please be kind to yourself. We're all beginners. There's a path of mindfulness practice, which is seeing as if for the first time, and that's a really good reminder because we become automatic with our perceptions. And so, if you all begin it, great. You're doing it. It's not about pass or fail. It's just about practice and just noticing what's happening.

Preeti Kota:  And do you also have advice for when someone with OCD relapses or even just someone without OCD trying to practice mindfulness but struggling and they're just harsh on themselves and they get kind of demotivated or unmotivated?

Hamilton Fairfax:  Really kind of compassionate. And also this is a good thing about having your own practice. It's just say, "Me, too. It's a bugger, isn't it? It's really difficult." And so, then you sit with them and think, "Okay, so what were you trying to do?" Well maybe they got into thinking, "I must be mindful, I must be mindful this time and this time. Well, I'm not doing my mindfulness." And just trying to work out what's getting in the way. And sometimes it just might be they've got really busy lives. So, just sort of stop and be compassionate and find out what's happening.

I guess one thing with OCD, I did notice with mindfulness is we saw one gentleman who had really, really severe mindfulness, was in several inpatient units, specifically for OCD. And what we noticed with him, I think he was able to say eventually, is that, when he was given instructions like CBT or whatever, he would internalize them as a ritual.

So, with the mindfulness, when we were talking about wise mind and the rest of it, it became an obsessive ritual. So, he would say things like, "Right, I'm doing my mind," while he wasn't being mindful. So, there's something to watch in that as well, just to make sure that people are doing, and that's why it has to be experiential and talking about the practice.

Preeti Kota:  Yeah, definitely.

Oh. Lastly, is there anything else you would like to share with our listeners or any final words of advice?

Hamilton Fairfax:  Yeah, this is for people with OCD and people treating OCD. Yeah, I just have enormous amount of hope. As I said, in these groups and I haven't run them all. Other people run them as well. People with 60 year histories of OCD, people who have had their life controlled by it - it can change. And you can tell your therapist anything. They're really unlikely to be flustered. Even if it's something you're really, really fearful of, we're here to help you. But it's the massive amount of hope that there can be change in OCD or any mental health difficulty.

Preeti Kota:  Great. I love that. We ended on a very optimistic note. Well, thank you so much for being here.

Hamilton Fairfax:  No problem.

Preeti Kota:  I definitely learned a lot and it was great to have you.

Hamilton Fairfax:  Thank you very much for inviting me.

Preeti Kota:  Of course. Bye.

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.

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Editor: Jennifer (Ghahari) Smith, Ph.D.