SOWK 5430 Anxiety Disorders

SOWK 5430 Anxiety Disorders


Hello class, Doctor Mike Burford here, I want
to talk with you a little bit today about our psychopathology class, today
we’re going to cover anxiety disorders and obsessive-compulsive disorder and again I want to remind you that the
disorders that I cover are the ones that I frequently see or have seen in the psychotherapy
clinic, I also have two of the books, the two books that I have either required or requested
that you use in our class, this of course is the DSM 5, that I have asked you to get and of
course it’ll be useful in helping you make diagnoses and all that and again
this is the book that you will use when you’re in practice most likely to help you with diagnostics. The other book is a recommended book, it’s not
required but this is the Barlow book, that is in your syllabus and the Barlow
book is really good in that it provides information not only about diagnosing, but it also provides great information about treatment
protocols and treatment approaches and I really value this book, it’s a great scientific book and I hope
that you get this book and use it as a reference in your career, I know I
certainly use it in mine. One of my mentors had that book lying on his desk
one day and I asked to look at it and liked it and sure enough decided that
I needed to get that and I have used it many times since then. Okay so again today I want to talk about anxiety
disorders and obsessive compulsive disorder. I want to remind you that the
information from these slides are, most of the information is taken
from the DSM, with of course the exception of
treatment information. Now let’s talk a minute about anxiety, I commonly see people with anxiety in the clinical office, just today
as a matter fact, earlier today I had a couple of people in that suffer from anxiety and anxiety is their
primary diagnosis. By the way I will say something to you, that is a bit unscripted that I had not
thought about until now in terms of sharing with you, but if
you have a person that comes in and they present with maybe two or three disorders, maybe they have
two or three problems and they say well you know the main thing that I’m interested
in is working with anxiety or depression
or what have you, now in the long run it could be that
you end up treating all three of the problems that they present, but oftentimes it may be that somebody comes in and says well okay I
have for instance I have an anxiety
problem and they have anxiety disorder and that would be the thing that bothers them the most, that
would be the thing that they identify that they want to address and so even
though they may also have some other problems you would focus on
the anxiety problems and get that squared away
and then later on once that’s done perhaps give them the option of addressing
the other issues. When someone comes into your office and
they’re talking about having problems with anxiety they may use phrases like I had a nervous breakdown, I have heard that a
bunch of times, I heard that growing up actually, they may tell you that they have
quote-unquote bad nerves that their nerves are acting up, I’ve had some of them come in and say
that they’re going through spells and I think to myself well okay
what do they mean by spells, what do they mean by a nervous
breakdown, what do they mean when they say their
nerves are acting up and even when somebody comes in and says that they have
anxiety, what I want to know is what is it
exactly they mean by anxiety, their definition of anxiety and mine maybe two
different things and the same thing with all these common vernaculars they use, nervous
breakdown, problems with nerves, having spells and all that, I will say
you know, what does a spell mean, tell me about your spell, what does that look and feel like, the same thing with the nerves
and the nervous breakdown Generally though what they’re talking
about of course is having anxiety and experiencing overwhelming anxiety and of course I
never belittle them for using phrases like my nerves are bad or or I’m having a spell or a nervous
breakdown and one of the other things that I wanted
to bring to your attention, what I’ve noticed over the years and
working with clients is that it is indeed helpful to take a here and now approach
and what I’ve learned is that people that come in and that say they have anxiety
or they report anxiety symptoms, is that they tend to
be future-oriented, they tend to be concerned and worried about what might
happen and oftentimes in their mind what might
happen is a bit far-fetched, their catastrophizing, taking an
event and imagining it at its worst and of course it causes them to have distress and feelings of anxiety and depression
of course would be the opposite, people who come in to see me, who report depression, significant
depression tend to be the type of people that focus on the past, they live in the past, a lot of times they don’t have a whole
lot going on in the here and now, that’s not always true, but oftentimes
people coming in with depression and they’re living in past relationships
or past experiences, past abilities those kind of things, as opposed to living
in the here and now and engaging things in the here and now and so I think that mental health can be
found in the present, in the here and now, does that mean that we don’t take into account things that have
happened in the past and learn from them, of course not, we learn from the past, at
least hopefully we do and it also means that we
would be amiss not to plan for the future to some degree, but as a general rule, I teach people to
live in the here and now and that’s where the most mental
health is found, in my opinion. Okay let’s talk a little about
generalized anxiety disorder. Generalized anxiety disorder is one of
the two most common disorders that I see in my client base, that and depression, major depressive disorder, so what do we know about generalized anxiety?
Well we know that, well I should say
generalized anxiety disorder, well we know that it’s a disorder that
causes a disruption in one’s ability to function appropriately, we identified as having excessive anxiety and worry about
various things, not one thing in particular, but a
variety of things and so when I asked one of my clients about
their anxiety and to describe it, oftentimes they will say things like that
they have anxiety continuously, that they’re always worried
every day, most of the day and they’re worried about a variety of things and have even had some tell me, once we were getting into their therapy,
that if there is nothing to worry about, they will
create something to worry about, they will ruminate about something until it
becomes an issue, a problem and they’ll do that with
several different things, so that they have a whole plateful of things that they’re
worried about and anxious about, anxiety may include restlessness and fatigue, poor concentration, people with
generalized anxiety maybe irritable, oftentimes there’s a
sleep disturbance and a lot of times they will tell me that
they feel like their body is a spring coil under pressure, so they have muscle tension,
sometimes they feel like, they tell me they feel like that they’re about to explode, that they have a ton of
energy and they need to get up and move around. These people also tend to have
difficulty controlling worry, you heard the term worry wart and all that, well chances are a person that may be termed a worry wart is a
person that suffers from generalized anxiety and again it’s present most every
day, usually all day and its present for
at least six months, a person that has generalized anxiety
disorder has been generally anxious for at least six months, so what I found
in working with people with
generalized anxiety disorder, is that oftentimes they have been anxious since
childhood, they can identify first thoughts and feelings of anxiety, when they were a child and its persisted throughout their life and with those type of people, it may be reasonable that they have an
anxious temperament and that indeed they will probably have some anxiety for the remainder of their
life, my goal in such case is to reduce suffering as much as
possible and to help give them tools so that they can reduce and manage their anxiety, that
doesn’t seem to go away and its treatment-resistant, so again what I do is provide a little
psychoeducation with people with generalized anxiety and say well hopefully we can get rid of all
this anxiety, but if not we will at least reduce it and make it
manageable and give you some tools to help you live a better life. Now of course like I said before with generalized
anxiety disorder, is a disorder that disrupts functioning ability. Now sometimes I give the diagnosis of unspecified
anxiety disorder and for people that have unspecified
anxiety disorder, they have anxiety symptoms and they have
functional impairment, but they do not meet full criteria for other anxiety disorders or more
specifically generalized anxiety disorder or it may be that I don’t have enough information to say
that this person has generalized anxiety disorder, it may be that I need to give a
provisional diagnosis or could be for whatever reason,
maybe I don’t ever get the full story, which would be rare, but I guess that could
happen, but anyways unspecified anxiety disorder is
sometimes useful if we don’t have enough information
yet about the client or if they don’t meet full criteria for
instance maybe they have all the criteria for
generalized anxiety except for the six month time period that is
required, maybe they’ve had it for four months or three months or five months or
something to that effect. Let’s talk about panic disorder for a
minute, I wonder how many have you that are in
class, that are watching this video have experienced panic attacks and if you have you probably know it, physical symptoms can be very severe, I have heard it described as a feeling of the walls are closing in, a feeling
that their heart will beat out of their chest, I have heard people tell me in a panic
attack they can actually hear their blood pumping in their body, they sweat, sometimes they get abdominal cramps
and stomach cramps that kind of thing, sometimes they shake and they get
dizzy oftentimes and oftentimes it can escalate, a pack attack can escalate into the
person feeling like they’re having a heart
attack and oftentimes end up in the emergency room, complaining of heart symptoms
and thinking they’re having a heart attack and it turns out that their heart checks out to be just fine and
it’s a panic attack. Panic attacks can be very severe and sometimes are not so severe, but a lot of times they are, they can range in duration,
sometimes there just a couple of minutes and I’ve had clients tell me that they last for
them up to 30 minutes and perhaps even more and then for the panic disorder what has to happen is that of course
a person has panic attacks and then they become persistently
worried about experience of more panic attacks
because panic attacks can occur spontaneously and there seems to be
no rhyme or reason for instance you could be at the
grocery store, a panic attack may hit, you can be standing in your living room
and a panic attack may hit, you can be outside in the
garden and a panic attack hit or driving a car, sometimes they hit with no rhyme or
reason, on the other hand occasionally I have had a
client tell me that panic attacks would
occur when they’re doing certain behaviors, for
instance I remember a client that I had that told me that when she was driving a car
they were more likely to occur, especially when she got to a certain
part of town or maybe the road was a little more
narrow or may be traffic was a little more heavy, so what happens is that a person that has repeated and recurrent panic
attacks sometimes begin to get worried
about when they’re going to have that and that worry impacts their life,
for instance it may be that a person with panic
attack and persistent worry and fear of having
a panic attack, decides that well you know I’m not going to leave home
because of it because it’s humiliating for me to have a panic
attack out in public or it may be that they avoid the grocery
store, I had one client several years ago who would have panic attacks in the grocery
store and it got to where she just simply refused to go to the
grocery store, somebody else will go to the grocery store in her family and in fact just talking about a grocery
store in my office would cause her to experience discomfort, so that is panic
disorder, so now I want to talk a little about
specific phobia. Now how is specific phobia different from
generalized anxiety disorder? Well okay generalized anxiety as you have just heard is general, people worry
about a variety of things, so with specific phobia there is a specific thing that a
person is arm in fear of or has anxiety about, it could be a certain object or a
certain situation and that fear is excessive and
inappropriate, so for instance if I have a fear of spiders for instance, we would not necessarily consider that a
disorder you know, unless I let it disrupt my life and I refuse to leave my bedroom for instance
because I was afraid that I would encounter a spider, then we could say
that I have a specific phobia of that, but in general if I am functioning pretty
well, but you know I have a fear of spiders then we certainly couldn’t say that, that was a specific phobia, that was in need of clinical attention alright. For specific phobias we need an
excessive, inappropriate fear or anxiety about a specific object or situation and the phobic object or situation produces immediate fear or anxiety,
it’s an immediate irritant and the person tries to avoid situations or avoid those objects that would cause the fear or the anxiety, so they
go out of their way to avoid such things, now generally specific phobia lasts for six months or more, so if it
lasts less than that, according to the DSM we would not
necessarily diagnose with specific phobia, but if it lasts
six months or more, then we can say that yes this person has
specific phobia. Now I want to say something else too, the DSM
is a guideline, your clinical opinion can at least to
some degree overrule hard, fast guidelines in the DSM, for
instance I have been a therapist, a psychotherapist, for around 15 years or so, I was counting that up just last night, but I have been around long enough to where
I know some of the diagnoses very well and I
know the flavor of those and on occasion I get somebody in
that mostly meets the criteria for
something, but there may be something that doesn’t quite fit, but I’m
still able to say well you know this person has that flavor of that disorder and I believe
that is what that person has, based on practice wisdom and some of the other things that
are found in the DSM and maybe some current research and all that. On occasion it’s appropriate to use your
clinical wisdom and maybe overrule some things in
the DSM if necessary, but you have to be really careful
doing that, that’s not something you want to do lightly, if you want to make an accurate
diagnosis. Now again specific phobia there has to be an impairment in
functioning again, that’s the definition of a true disorder. I want to share a case
with you that I had years ago and I’m going to change
things a little bit so as to provide, protect confidentiality. I am going to tell you about the case of Tommy and of
course Tommy is not the person’s real name, but I remember when I met Tommy he and his parent presented to me and tommy was a little boy who was afraid of candy bars, oddly enough and what happened is that Tommy had got a chocolate candy bar and had tried to
eat it one summer’s day in the car and the chocolate had melted and
Tommy ended up with chocolate all over his face and his hands
and his arms and his shirt and everything he touched of course had
chocolate on it and so there was a big chocolate catastrophe for lack of a
better description. Tommy developed a phobia of chocolate because in his mind it was on nasty, messy substance that he would have to deal with to the nth degree if he were around it and it got to the point with Tommy that
he not only a refused to eat chocolate, but he avoided completely if he was in
the store he would have to make a wide,
wide circle around the chocolate candy aisle, would not even walk
past it, but would have to move around it in a circular fashion
and try to stay as far away from it as he could get. Tommy’s phobia got so bad that, that he forbade anyone in his family to
use the word chocolate, and if somebody said chocolate he would
cover is ears like this and act as if he had heard some terrible and horrendous thing and he would make a big production out of it and would demand that the
person that said the word chocolate, would demand that they promised to never
say that word again, he would banish the word chocolate and would admonish me in therapy, when I used
the word chocolate, so that was Tommy he had a specific
phobia, he wasn’t afraid have any other type of candy, but it was chocolate, chocolate candy
bars that he would he would be afraid of. Tommy had some other problems too, I was going to tell you
a little bit about Tommy’s outcomes, but he had some other problems that had to
be addressed and one of which was pervasive and severe and so Tommy is able to be around chocolate now or was when I last saw him, was able to
say chocolate, still didn’t eat chocolate, which is fine, but at least he was able
to go in the store were there was chocolate and walk down the aisle where
there was candy bars and all that and didn’t make a big issue if somebody
else used the word chocolate. imagine how
disruptive that would be in the work environment or the school environment, you as students when you’re sitting in your
class, imagine what would happen if you
stood up in and announced that nobody in the class needed to use the word chocolate
or the word pen or pencil or whatever have
you, that wouldn’t go over too well and chances are your success might be
hampered and certainly true in the workplace. Now I want to talk about obsessive
compulsive disorder a little bit and by the way there are other
disorders in the OCD section and in the
anxiety section of the DSM, but again I’m covering the ones that I
see frequently, for instance I’ll mention just briefly trichotillomania,
where a person habitually pulls out hair, whether from their head or their eyebrows,
over the years I’ve seen, I’m thinking of three people that
I’ve seen that have done that, two were adolescents, one was an adult and it is pretty uncommon to see that
kind of behavior and trichotillomania is usually
secondary to some other, at least in my experience, some other disorder, it can be interesting and all
that, especially when you first see it, somebody may have a patch of hair
that’s you know out and I remember for instance one client that I had, a female client and she had long dark hair, she had beautiful hair, but there was
a patch that was missing and she would kind of cover it up the way
she would comb her hair, style her hair, but she could move her hair back and you could see this
big patch of hair that was missing, where she had pulled pieces of hair, pulled hairs out over time and I remember another little boy that I
had and he would pull is eyebrows out
and half the time he would not even realize, apparently that he was
doing it, but he would come in and part of his eyebrow
would be gone or sometimes the complete eyebrow would be gone, fascinating stuff, but with Obsessive Compulsive
Disorder, OCD you guys have probably heard quite a
bit about it, but with OCD we have obsessions that are recurrent, persistent thoughts and urges and/or urges and or images that are intrusive and
cause anxiety and distress. Attempts are made to ignore or suppress
such thoughts, urges and images and then there are
compulsions, which are rigid and repetitive behaviors
or cognitions and they’re aimed at preventing or
reducing anxiety, so these behaviors are aimed at reducing or perhaps preventing anxiety with people that suffer from OCD. The DSM guidelines require that the obsessions and compulsions take
more than one hour a day or cause impairment
in social, occupational or other areas of functioning, so for more than one hour a day, a
person needs to have obsessions and compulsions to garner a diagnosis of
Obsessive-Compulsive Disorder. The interesting thing for me to tell you about is that I have, on my case load right now, I have three
people that have Obsessive-Compulsive Disorder and what I can tell you about people
with OCD, is that, at least the ones that I’ve seen have
been in treatment for a while, have usually had providers previous
to me, OCD is in my opinion and from my experience
difficult to deal with and I’ll talk more about all that
shortly when I get into the treatment aspects of OCD. One of the things that you want to be careful about when you’re
diagnosing OCD is the differential diagnosis, you in particular want to rule out substance
abuse because like most other disorders
they can mimic signs and symptoms of substance
abuse and by the way there’s an interesting
little phrase, signs and symptoms, can somebody tell me the difference between
signs and symptoms of a mental disorder, well signs are what other people see, for instance if
I’m sitting with you and I see that you’re fidgety and that you can’t sit
still at all and that you have trouble focusing and that kind of thing, then I may say well
this person has signs of ADHD combined type for instance, whereas if you’re telling me your symptoms, if you’re telling me the
things that are bothering you in relation to
whatever particular disorder, for instance you may say well gee Mike I have
trouble sitting still, always have to be fidgeting with something, I get in trouble a lot because I can’t be still , I am into everything coming and going it is like I’m driven by a
motor, I can’t concentrate very well, I’m always on tangents about things, just really have trouble with focus and all that then as a person that has those things you’d be talking about your symptoms, as opposed to signs of your disorder, so the difference between
signs and symptoms, there is a difference and you’ll
probably hear signs and symptoms used a lot when you
become clinicians. Okay I want to talk briefly about whether OCD traits, OC traits I guess I
should say, are pathological. For instance I have known people who before they go to bed at night would check the door a couple of times to
make sure it’s locked, they might go unlock the
door and then maybe thirty minutes later they go into
the kitchen, they’re going to grab some popcorn, maybe a soda or something and they say while I’m here let me
just glance over and make sure the doors locked or perhaps they check the stove a couple of
times before they got to bed or before they leave. Is that Obsessive Compulsive Disorder?
Not necessarily, again we think about the definition of a
disorder, right and I know you guys are probably
getting tired of me talking about that, but it’s important that you know the
difference between traits and a disorder, the disorder of course is something that
disrupts one’s ability to function. Now if I am checking the door so frequently that I
can’t perform other duties in the home than
that is a problem or if I’ve got in the car and I’m a mile
down the road and I have to turn around and go back to
make sure I checked the door, yeah that’s a problem, especially if
it causes me to be late for work or late for a meeting or with a friend or
a dinner or what have you, so what I’m saying is that it’s
quite possible to have traits of Obsessive Compulsive Disorder, but not actually
have the disorder, you know for instance the person
that needs to check the kitchen door a couple of times, maybe they look at it while they are getting their
popcorn or maybe while they are get a drink of water, you know they look at it, is that
pathological? Not necessarily, it’s not disrupting
their life. I can use myself as an
example, you know sometimes I’ll be out digging in the garden or you know my wife and I have a
pretty extensive flower garden and we’ve got some vegetables too, sometimes
I’ll be out there trying to relax a little bit and I’ll come in wash my hands and
then 10 or 15 minutes later I’ll
decide to make a sandwich or something and want to make sure that I wash my hands
again, to make sure all the dirt is off my hands or maybe I have been out there petting
the dog and it slobbers on me or whatever and I will come in and maybe wash my hands and
then maybe shortly thereafter wash them again, is that Obsessive-Compulsive Disorder? No, doesn’t disrupt my life at all and I do like to be clean, as hopefully
you do as well, anyways lets talk real briefly here about treatment, again
you have more about treatment protocols and all
that when you have some of your other classes, but I do briefly want to talk about treatment, so for treatment for anxiety disorders, commonly Cognitive Behavioral
Therapy is used, basically what you do is
identify and challenge erroneous thoughts and
beliefs, help people reframe and look at things a little differently
and replace thoughts and beliefs that
are harmful or incorrect. CBT can be a very powerful tool, just last week I had a client that came to me that has been suffering
with guilt probably for three decades now. Longer than that now that I’m
thinking about it, but anyways for many, many, many years, for a
long time and that guilt was based on thinking in a belief that she had, that was incorrect and so for years she had this secret and this
guilt that she carried and it was very heavy
for her and it was all based on incorrect information and so we were able to identify that and to gently challenge that belief and I was able to provide her with
information, accurate information that was used to displace the incorrect
information that she had, so isn’t that something though, that somebody would
suffer for all those years based on erroneous thoughts and beliefs and that’s not uncommon actually and so CBT can be very effective with
with helping that, also I like to use Existential
Psychotherapy when appropriate, to be
existentially minded and look at things in terms of the big
picture and various other things so that would take us off track of what
we need to be doing today so if anybody is interested in hearing more
about Existential Psychotherapy I could talk with you forever about it and would be happy to
make an appointment and have you to sit down with me and we can have some interesting discussion
about that, also psychoeducation goes a long way, especially with like panic attacks, I’m thinking of a client that I had now,
have now that had some serious panic attacks and I was able to
provide psychoeducation to her and to help her do some self talk, along the lines of
well hey I know what this is, this is a
panic attack, it’s not a heart attack, it’s not you know the world ending, it’s not that
the walls are closing in, none of that’s true, what I have is a panic attack and I know things
about panic attack, Doctor Burford has taught me about panic
attacks, I know that this is time limited, I know that I’m going to be okay, once this
passes and in fact I’m really okay now, I don’t feel okay, but I’m going to get through this just fine,
this is a time limited thing and all I have to do is hang on for a
little bit and this will pass and then I teach them to know and recognize that is what it is,
that it’s not some big monster and then eventually clients began to
think well okay this is just another one of those silly panic attacks, not a big deal, I’m going to chill out for a minute and
wait for it to pass and then what happens over time is that
the panic attacks become less severe and less frequent because the person begins to realize that well
really this is not anything to be worried about, this is a nuisance more than
anything and then the symptoms and all that tend to
subside with time, especially if psychotherapy is done to address other anxiety issues or likely to be experienced and so it all kind of works hand in hand and by
the way seldom do I see somebody with panic attacks and panic disorder that
doesn’t also have Generalized Anxiety Disorder, I am not saying that they have to happen together,
but in my practice it seems like they co-occur very
frequently, so between psychoeducation and Cognitive Behavioral Therapy or
Existential Psychotherapy, we can usually get Anxiety Disorder and Ipanic attacks, panic disorder under control quite nicely, although it does take a little time,
also psychoactive medications can be useful, providers, you know the physicians, the psychiatrists, family doctors, nurse practitioners, physician’s assistants, those
types of people that can prescribe meds, they are very wary of prescribing benzodiazepines
for anxiety, things like zanax, valium and
klonopin. I have seen cases where, some of those like zanax
might be needed for a short term, but it’s certainly not something the mental health people like for clients to
be on for long periods because obviously they’re addictive and kind of like a band-aid, in order to help somebody muddle
through until more permits things can be done to help with change things like psychotherapy. An example I guess for the appropriate use of
zanax would be if somebody has a loved one die and they’re just overwhelmed to the point that they are not
functioning and there in a panic basically and not
panic in terms of a panic attack, but just a panic and perhaps they need something for a
couple of days to help them get through. Now as a provider I can tell you that
I never cease being amazed by the ingenuity of people that come in
that are trying to get benzodiazepines prescribed
to them. I’ve often had people try to get me to
prescribe them, I’m not a physician, I can’t prescribe
medication. I’ve had people get mad and walk out
when they realize that, I wasn’t going to be able to
prescribe medication for them, I have had people say to me yea I know that you can’t do it, but I know
that you’re probably buddies with that person down the hall that can and by the way can you refer me to that
person and can you tell them that I need this medicine. Sometimes I do refer them, but I
certainly don’t tell a physician that I think that somebody
needs medicine, that’s their job to figure that out, but I can tell you that they’re very wary of prescribing
those and they should be, we have lots of people out there that are drug seekers and
again they can be very clever, I’ll tell you a real brief
story, I remember many years ago I was working
on a psychiatric unit and part of my job, I was working night
shift and part of my job was to go down to the ER and do evaluations on people
that came in with mental crisis and oftentimes they would be drug
seekers and I remember one person that came in and she was a woman, middle-aged
woman and she told us that she had been beaten and raped and was yes she was a person that frequented the streets and had a rough life style, she was forthcoming with that, but said that she had been beaten up and had
been raped and granted you know you can look at her and tell that
somebody had beat on her and her eye was all puffed up and her lip you know had been bleeding and her hair
was a mess and you know various scrapes and contusions
on her arms and that kind of thing and so I felt really badly for her and wanted to do the very best I could to
help her and so I went to the physician, the
ER physician and I said well look you know this gals the real deal and you know I think that we can
pretty much trust what she has to say and so he ended up prescribing her I don’t remember what it was, some
kind of benzo that he prescribed, we found out later that
this girl made a point of going to the different
ERs and had a very believable story and
all that and so I got duped, you know she tricked me and I don’t feel really
badly about that because it will happen sooner or later to you because if you think about it, we’re
in a bit of a precarious spot, we want to help somebody
and would like to give people the benefit of the doubt, we are there to try to relieve suffering,
but we also have to be wise that sometimes things aren’t as
they’re presented and that there’s another motive and it is not to get well and healthy, that’s also true for people
sometimes that come in that have been accused of a crime and they have a court
date coming up and there trying to, their lawyer sends them over to get
therapy and says well we need to show the judge that your getting therapy so you’ll get a lighter sentence or you know we need to show that
your in therapy and that you’re a pretty good person and yea you need custody of the kids versus
the other spouse or the other parent, whatever the case and so a lot of times what will happen is that someone will come in
and they will act like
they want therapy and the reality is they are there because they intend to have their lawyer
subpoena you to court or maybe they want you to write a letter
in support of their mental status to the court, those
kind of things, so be wary not everybody that comes
to you for therapy is there because they want to be, indeed some may be
court-mandated to be there and also something about
that in just a second, but a lot of people there, not a lot, but
some people there will come in because of alterior motives and so you need to be mindful of that. I tell people up front, when I talk with them about confidentiality
and having to report suicidal ideation or you know if their intending to hurt
themselves I have to report that and I have to report homicidal ideation and I
have to report if abuse is occurring whether they are the
perpetrator or a victim and all that, I give them information about all that up front, I also tell them a little about me so they
know who their working with, I tell them what to expect in
psychotherapy and how things tend to work and I tell them about the importance of a
therapeutic relationship and communication all that, but one of the things that I tell them is that I may get subpoenaed to court,
you know perhaps by your lawyer, if you have one, ifthere something going on or perhaps by somebody else’s and it may be that I
have to go and testify and I let them know that I don’t like to do that and that
when I go, I do my very best to protect their
confidentiality and in fact I tell them that if they’re
looking for someone to go to court, they need to go to a different
therapist because I don’t want to do that and my intention is to be as protective of their information as
possible in court, and I haven’t had to do that many times,
I can tell you that going to court is generally a very
unpleasant experience, you willl have lawyers that are clawing
at you and trying to make you into someone that
is lying and doesn’t know what they’re
talking about and that kind of thing, so a nasty experience or at least it can be, I guess some
people enjoy that are pretty good at it, I guess people that are
into forensic psychology and all that, but I don’t enjoy it and
most therapist that I know do not enjoy it
either, however if you think that you might, there are people that are forensic clinicians that would probably be
happy to talk with you and help you go down that path for a career, anyways there was something I was going to say
to you about, that I mentioned earlier, I have
forgotten what it is and I apologize for that. Treatment for
Obsessive-Compulsive Disorder, by the way if somebody sees the
tape and says oh that must be what it was that he was going to tell us, send me an email and I’ll be happy to
address that in the next video. Obsessive-Compulsive
Disorder treatment, one of the things that I try to do is, I try to teach
coping skills, things like Jacobson’s
progressive relaxation techniques, things like mindfulness meditation, things like breathing exercises, the reason that I
teach those is because I want my clients to have some skills to help manage and perhaps deescalate
their anxiety, when they do other things that I’m
asking them to do, regarding OCD, such as being abstinent from certain
behavior, earlierwe said that a certain behavior keeps anxiety at bay and so if I’m asking a person not
to engage in that behavior, then obviously their anxiety may go up, at which time they’ll need some of those
coping skills that I just mentioned, so the number one thing is to lay a
foundation of coping skills, so that they can use as necessary and
CBT we talk about extinction were trying to cause behaviors to become
extinct, we’re asking that people space out times that their doing certain
behaviors, for instance I had a client that needed to check his vehicle to make sure it was
safe and he would do that excessively and so I got him to where he was doing
that in intervals that were further and
further apart and eventually to be abstinent
from that, also it’s useful to repetitively
talk about the issue, nothing against horses, but you’ve
heard the phrase beat a dead horse, well there’s at least been a few studies that show that, that’s
useful in causing behavior to become extinct, is to
talk about it and talk about it and talk about it and
talk about it and also I give homework, I send people out and I say okay press the issue and let’s see how far between you can get these episodes
of behavior and I want to tell you that even
slight gain can be very useful for someone
suffering from OCD, just the slightest change can make a big
difference because these people tend to be suffering greatly, and it can really mess up their life, OCD and their family and so you want to involve loved ones, I’m thinking of two people right now that I’m treating in psychotherapy and
we have their loved ones involved in their recovery and also of course
psychoactive medications may be an option and finally I want to remind you of the use of the DSM in this video that’s where I have pulled most of the
information for this video and the last slide you’ll notice is
a reference slide, which is appropriate form for doing PowerPoint presentations if you use somebody else’s material, in fact you
could even put little footnotes at each
slide, but I chose not to do that because I’m telling you verbally before and after the slides, in the slides
that I’m using the DSM, so they’re is information on anxiety disorders and obsessive compulsive disorders and study hard, I know you have a lot of work to do, welcome to graduate school, learn a
lot and I will see you next video.

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