R. Hatton Therapy

My Mission

My mission is to diagnose and treat individuals with OCD and related issues and to provide the friends and family members of those individuals with the education they will need to better understand OCD and support those they care about struggling with OCD.


Please call or email today, and I will be glad to answer your questions. My phone number is 858-703-7620 or you can contact me here.

   Articles about OCD & Other Related Topics

Further Information & Announcements


FREE SUPPORT GROUP
Every 2nd and 4th Friday of the month (every year in June, July, August, November, and December we meet the 2nd Friday ONLY7-8:30pm a FREE support group is offered to individuals struggling with OCD and other related disorders, family members of those listed above, as well as any interested professionals. Located at Mesa Vista Hospital's Day Treatment Lounge, (858.278.4110) 7850 Vista Hill Ave. Kearny Mesa, CA.

OCFOUNDATION CONFERENCE
The 22nd annual conference is in Chicago, IL. Plan to join us on July 29- July 31, 2016. We are looking forward to another great time to meet people and learn more about OCD and those impacted by it. Go to the OCFoundation Website for further information.


 

I'm so OCD (but are you really?)

Many of us have heard the term “she’s OCD about…” or “I’m so OCD about…”, so I wanted to take time to explore what exactly it means to actually have OCD. Those who really struggle with this disorder often feel misunderstood when others take this disorder so lightly – it diminishes just how devastating the disorder can truly be.

So what is “OCD”? It is a mental health disorder that is currently classified as an anxiety disorder. I want to define what OCD is, but then also spend a little bit of time explaining what OCD is, and what it isn’t. OCD stands for Obsessive Compulsive Disorder, and all three words here are important. “Obsessions” are intrusive, unwanted, frightening or disturbing thoughts, images, nonsense words, or even music/sounds. Obsessions cause a significant amount of distress when a person experiences them, which make take form in feelings such as guilt, disgust, anxiety, or fear. I am not talking about the following kinds of obsessions in this case: the perfume by Calvin Klein; one’s “obsession” with somebody like Brad Pitt; or having your kitchen completely done in roosters and roosters only! Some examples of true obsessions you may be familiar with are “What if that’s contaminated?” (as in The Cat in The Hat Comes Back); “What if I leave the door open and then I get robbed?” (As Good as it Gets); “What if I lose something?” (Monk); “What if something isn’t perfect or cleaned well enough” (Emma on the TV show Glee).

“Compulsions,” also known as rituals, are behaviors that one may see should one struggle with this disorder. I say “may see” because some rituals are not physical but are mental instead. A ritual is a physical or mental action taken specifically to reduce the distress one experiences from an obsession. Most of the time the ritual seems related to the obsession (i.e. one’s fear of germs might require extra washing), but sometimes the ritual may seem completely unrelated to the obsession (i.e., one might run the faucet all day to ensure the spouse’s safety). I am not talking about the following kinds of compulsions in the case: compulsive eating, gambling, or shopping, etc.; being particular about the color or order in which your clothes hang, how your nail polish is color coordinated; or wanting things done a certain way for any reason other than the distressing feelings mentioned above. These things may seem ritualistic or compulsive at times, and they might be a way of relieving general anxieties, but they are not usually what one would engage in to decrease the distress from a specific obsession. Some examples of true rituals are excessive cleaning, excessive checking, counting, or seeking out reassurance from others/internet or ones self.

The last component here is “disorder”. Many people can be a little obsessive and/or compulsive at times, but they would not be given a diagnosis of OCD. One can determine that these kinds of symptoms are diagnosable as OCD when the symptoms interfere with one’s functioning or they cause significant distress to the person with the symptoms. It is important to note that most people with the kinds of symptoms described above understand and recognize that their symptoms are irrational, which means they know that their symptoms are not thoughts they desire to have and the rituals are excessive (and at times nonsensical). There are times when a person may have poor insight into the irrationality of their symptoms, but this is more commonly seen with children.

I will close for now by saying that should you, or somebody you know, truly struggle with OCD, there is hope for living a better life. The average time a person takes before seeking help is 14-17 years! It is my hope that by increasing awareness that this number will drop and more people will be provided with the much-needed help that is available to them!


 

What High School Physics Can Tell Us About

 

CBT Treatment For Hoarding

Hoarding as an OCD symptom category has lately been a focus of increasing attention. Several books on the subject have recently been published, local coalitions of mental health and legal entities are forming hoarding task forces to help deal with the social impact of hoarding, and the DSM-V committee is considering moving hoarding to it’s own diagnostic category as a cousin of OCD rather than as a subset of it. Many would say that it’s about time. Most hoarders live with their places quite cluttered, their living space significantly diminished by accumulated items, and their shame about the condition of their surroundings leading them to become socially isolated. Some of us refer to this as CHAOS (Can’t Have Anyone Over Syndrome). Additionally, the piles of stuff can create health and safety hazards, and occupants go tripping through their homes along the pathways between the piles of things they intend to address some day. They might be said to be living in the land of the Someday Isles (or is it the Someday Aisles? or even the Someday I’ll-s?). The frequent plan in the minds of hoarders is that there might, or even will be, a future use or plan for the items at hand, even though time passes with little or no action on those plans.

Our understanding of the difficulties faced by hoarders in recovery is currently in a growth phase, though it lags somewhat behind our understanding and treatment of many other parts of the OCD spectrum. We do know that some hoarders are faced with the problems of going out and acquiring too much (excessive acquisition), some have difficulties discarding things that have come into their lives through passive means (like the mail), and some deal with both issues. These are often complicated by problems with decision-making (”what if I make the wrong choice, and I need this after all?”) and/or prioritizing (“I have to do this, but I have to do that first, and before I do that…”). Like people with other forms of OCD, they have difficulty tolerating uncertainty (“How do I know for sure that I won’t need this?”), and they often have a harder time than average dealing with a sense of loss.

CBT for OCD

For other forms of OCD, our current best treatment includes the SSRI-class of medications, and the type of cognitive-behavioral therapy (CBT) known as Exposure and Response Prevention (ERP). The latter is primarily designed to help sufferers develop a higher tolerance of uncertainty and anxiety by exposing them to the feared situation (e.g., contamination, seemingly risky situations, etc.) and having them prevent doing the safety maneuver (ritual) that would make them feel a temporary sense of relief. For many people this process works quite well. The spike in anxiety after the exposure tends to go away by itself (without a ritual) after a few seconds to a few minutes, and with repetition the person’s fears of that situation extinguish. Using this process with a series of exposure tasks, experienced from least anxiety producing to most, results in a significant reduction of OCD symptoms for many people.

Problems in using the ERP model in treating hoarding

In treating hoarders using ERP, the same model is often intended, but the implementation often ends up being less directed. All too frequently the efforts of the family, the community, the hoarder, and even the therapist become directed toward cleaning up the mess and discarding the belongings. Treatment can easily get sidetracked from the intention of building up tolerance to anxiety and to uncertainty in favor of not acquiring things or of simply discarding things. This sometimes ends up with a cleaner or more orderly living environment (since often the most dominant focus of social treatment is the reduction of harm and the creation of a safe living space), but often does not treat the mental health part of the hoarding problem itself. Although people hoard for many different reasons, and the problem is a complex one, one reason for this is straightforward:  hoarding is not simply a problem of having too much stuff; it’s really a problem of the way one thinks about stuff. To paraphrase George Carlin, our houses have become places where we keep our stuff while we go out and get…more stuff! Additionally, certain cognitive interventions (such as learning to prioritize or schedule) are necessary to supplement routine ERP for hoarding. We would like to present a model of thinking that would allow the efforts of exposure to be better directed than they often are.

A short diversion: High School physics – kinetic vs. potential energy

The High School physics teacher for one of us (JH), Mr. Zetterholm, might be proud to know that I still remember this part of my physics class after so many decades: back then, energy was divided into two sorts, kinetic energy and potential energy. Kinetic energy is the energy of action, or of use. An item falling from a shelf releases kinetic energy when it crashes to the floor (or perhaps more useful, the hammer delivers its kinetic energy when it strikes the head of the nail). On the other hand, potential energy is the energy of storage, or of future use. The item sitting on the shelf has potential energy, because it COULD be converted into kinetic energy if it is pushed off of the shelf. It always struck me that potential energy was an interesting concept, but not a very practical one (sorry, Mr. Zetterholm), because it requires one to put energy INTO the system in order to convert one form into the other (you have to make an effort to push the item off the shelf). The conversion of potential into kinetic requires paying a price in terms of energy input.

Kinetic vs. potential value

What might this have to do with hoarding treatment? Let’s replace the notion of energy with the notion of value. An item can have kinetic value (we define this as the value of use) if it’s being used in a relevant time frame. It can also have potential value (the value of storage, or of future use) if it is not being used presently but MIGHT be some day. Much of the hoarder’s home is often filled with items that have potential value – IF one has time for that project, IF it can get to a good home, IF one can ever get around to repairing it…. These things often do not have any kinetic value, and they sit there for long periods of time without any such value. As with energy, most of the time the potential value of these items can only be converted into kinetic value by putting energy INTO the system, by fixing it or attending to it or by donating it. One very common problem with hoarding is that people think they will have the time and energy to put into these items but rarely ever do!

Tolerating the loss of potential value

In order to use ERP to help hoarders build up the same kind of tolerance to their fears that those with other forms of OCD do, we might have to specifically target having people tolerate a loss of potential value, at least for people hoarding out of low loss-tolerance. It wouldn’t be helpful for them to experience loss of kinetic value by tossing out things they are actually using. Nor would it be AS useful (although it might be a required starting point) for them to put their energy into donating things, giving them away, or selling them on eBay as a way of lowering the potential value loss. This would be the equivalent of someone with contamination fears wiping down the dirty item first before touching it, if the response prevention is to not wash their hands afterward. Donating becomes simply a substitute ritual designed to lessen the impact of the exposure. Experiencing the loss of potential value, and learning to let that feeling of loss diminish over time, is a significant part of hoarding treatment. Loss of potential value might mean evaluating that an item might be useful someday or to someone, and then putting it in the trash anyway. It might mean putting something in the trash instead of into the recycling container (loss of potential benefit to the environment). It could also mean going to a store WITH money, looking for items they believe they will want or that someone else could use, and tolerating walking out of the store empty-handed. These should be the targets of our exposure therapy, at least for the group of hoarders having these concerns.

We should be thinking about the potential value of something vs. kinetic value of that thing. So High School physics turns out to be useful in the hoarding field. Who knew?

 

How to Choose the Right Behavior Therapist



Choosing the right behavior therapist is a bit like choosing the right suit. There are so many important things that are similar (and all important), that it's worth spending a little time discussing them. And, although I write this with a bit a humor to make it easier to read, I'm every bit as serious about everything I say as you are about getting treatment for your OCD.  

First, when suit shopping, you want to find a good quality suit. Likewise, the person with whom you are going to work one your most difficult issues should be a competent therapist. That means, in all U.S. states and in most countries, having both at least a Master's Degree as well as a license to practice therapy (or be on their way to having one, since some people still completing their intern training are already well-experienced therapists). Anyone can call themselves a counselor (even lawyers!), but a therapist is a legal term, with specific requirements. They should be able to tell you about their education, their training and the legal board overseeing their license. They should have several years of experience doing therapy, and should be able to tell you where and when they practiced. They should even be able to give you the names of their previous supervisors (or, in the case of a well-trained intern, their current one), since most therapy training is done with supervision. A competent therapist may be a psychiatrist, psychologist, a nurse, a Licensed Clinical Social Worker, a Marriage and Family Therapist, or any other recognized licensed member of the helping professions. However, just because one has a "higher degree" like an M.D. or a Ph.D. doesn't mean that they're necessarily better therapists or better trained than their counterparts with "lower degrees;" it only means they are more educated (this is NOT the same as more experienced!). Just as many different suits may be of good quality, they may come from different places or be of different designs.

Second, a suit has to do what you need it to do. For instance, a business suit would not do for a “black-tie affair,” and a summer suit may not do in the Fall and Winter. A good therapist may not know much about behavior therapy unless they studied it specifically. Most therapists here in the States are “generalists” by training, and may have heard about behavior therapy but never practiced it. Or, they may believe that behavior therapy involves relaxation training and nothing more. Nothing could be further from the truth. This is a bit like saying “you’ve seen one tree, you’ve seen them all.” In fact there are many different types of behavior therapy, used for very different purposes. For OCD, you’ll be looking for a behavioral therapist that uses Exposure and Ritual (or Response) Prevention (E&RP), the ONLY kind of behavior therapy with proven effectiveness on OCD symptoms. If you have a related Spectrum Disorder (like an Impulse-Control Disorder or tic disorder then you’ll be wanting to make sure the behavior therapist knows Habit Reversal Training as well). But don’t just ask the therapist if they know the technique; that would be like calling a clothing store and asking if they had nice suits. Ask the therapist to describe how they do exposures, how they do ritual preventions, how they structure assignments (they should be able to tell you that you’ll need to reinforce behavioral work daily in between therapy visits), and they should be able to discuss the hierarchy of symptoms with you. They should be familiar with at least as many of the different symptoms of OCD as you are, and should be able to discuss the Yale Brown Obsessive Compulsive Scale with you, at least in terms of discovering the extent of your OCD. Also, a good behavior therapist should be willing to leave their office to do certain exposures with you. If the therapist tells you that they NEVER leave their office for the sake of an “on-site” exposure, that’s a clue that it’s time for YOU to leave their office.

Third, a good suit needs to be tailored to you, at least for alterations. The good behavior therapist needs to be able to tell you what they can offer in terms of individual, family or group treatment, support groups, interactions with other professionals (especially your physician if the therapist is not one). They should be willing to tell you how long they’ve been doing therapy, how long they’ve been working with OCD patients, whether they specialize in working with adults or children, and how many OCD patients they’ve seen in that time. As importantly, they should be able to tell you what they CAN’T offer. No one can offer everything, and you deserve the honesty that this answer provides.

Finally, a good suit has to fit you well. Many good behavior therapists may know OCD, may be competent with E&RP and may be recommended by a friend or other professional. However, if you don’t “click” as a working pair, you won’t be able to do the work as effectively. You might be able to get this feeling about the therapist from your first meeting, or from hearing them at a public lecture. But most of the time, it takes a few sessions before you know if you’ll be comfortable working together. Make sure the therapist is willing to re-evaluate with you your working relationship after 4-6 sessions. But also remember, you might end up with someone that you trust and respect, but don’t necessarily like well enough to want them to inherit the family estate. The important thing is, can you form a trusting relationship with this person, and can they help you learn and practice the skills you need to effectively manage your OCD symptoms? Hopefully, the answer will be yes.

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