29th IOCDF Conference highlights
Directors Jonny Say and Stuart Ralph recently attended the 29th annual International OCD Foundation conference in Orlando, Florida. The conference offers many talks on OCD delivered by world class experts and people with lived experience. It was a great chance for them to learn, and connect with others to share the work done at The Integrative Centre for OCD Therapy.
Below are Jonny and Stuart’s top 5 highlights from the conference (written by them).
Below are Jonny and Stuart’s top 5 highlights from the conference (written by them).
Photo: Stuart Ralph (Left), cardboard Jon Hershfield (Middle), and Jonny Say (Right)
Jonny’s 5 highlights from the conference:
Walking through a sea of therapists and OCD sufferers, the importance of community coming together in person was palpable. I looked around and noticed how many hugs, smiles and kind words were being exchanged. To have the support of a group, validation of struggles and gathering brilliant minds together to talk about OCD recovery was so powerful to witness. For many people, simply getting into a conference like this was ERP (Exposure and Response Prevention therapy). Facing social anxiety, challenging travel fears, the social impacts of OCD. Not to mention, getting together in a large space when people have contamination fears, checking fears, physical compulsions creating barriers and intrusive thoughts around people, all create a huge ERP challenge. This is very difficult for many people and I was in awe of their bravery. Then I saw the power of being around a compassionate community with empathy and validation who are not judging them like potentially back home, people are able to be more open about their symptoms and where they are at in their recovery, whilst gaining praise for their strengths. This is the support of the whole person, a person bigger and beyond their OCD symptoms.
I found the first talk I attended about ‘Intrusive Thoughts and Overvalued Ideation’ to be fascinating. There was a debate at times about whether behaviour change is enough to work on more deep-rooted patterns of OCD or whether there is the need to challenge the overvalued ideation. Dr Jon Hoffman made the case for working out ‘pinky press-ups’ in ERP/behaviour change for OCD. These are the simplest smallest steps (like starting with a pinky press-up when it is hard to do physical exercise) for ERP. But Dr Fugen Neziroglu and colleagues made the case that when clients have strong belief in their thoughts (or overvalued ideation) that we need to cognitively challenge these beliefs upfront, in order to get better engagement in ERP. It was one of those debates where I found myself agreeing with both sides and seeing that they are different tools for different stages and levels of motivation in treatment. I have always been a big advocate for finding the smallest possible step. But in ACT (Acceptance and Commitment Therapy) we think about challenging the workability of strongly held beliefs as well as behaviour change – If I keep reacting to this thought as a belief what will it mean for my life in the long run, what does it cost me and what values and goals does it block? It convinced me of the power of getting top experts in rooms debating and collaborating on these topics, rather than working in silos dismissing other groups and theorists’ ideas as ‘new bottles for old wine’.
I attended a number of brilliant talks on the interaction of OCD and trauma/PTSD. I heard clinicians talking about the high incidences of stressful and traumatic events preceding OCD onset. I heard clinicians describing nuanced interactions between the two disorders. Sometimes there is a static relationship where they are not interacting. But often there is a dynamic relationship where the OCD may be functioning to defend against the fear of trauma repetition, or to provide an illusion of control where the trauma has been out of their control (to mention two possible interactions of many). There were also nuances in treatment such as paying attention to dissociation and not launching into ERP until the client has skills to cope with dissociation or depression potentially triggered by the trauma. Also, about the need to get to the point where trauma and OCD can be worked in parallel in exposure therapies.
Building on this, I saw a second presentation where two brave advocates described their experiences with OCD and PTSD and the dynamic relationships between them. They were incredibly courageous in sharing their painful histories and symptoms and then compassionately sharing what they had learnt about treatment and recovery work. A core component was the need to understand the complex dynamic relationship between trauma and OCD. Then it was clear they were advocating for the need of an integrated approach to treatment where ideally the trauma and OCD can be worked on together in exposure therapy. When this is not done well clients can feel invalidated, they can also feel improvement in one cluster of symptoms (e.g. the trauma) but then an exacerbation in the other set (the OCD). Therefore, just as we do at the centre, developing a comprehensive set of psychological skills to work with the two disorders and mastering their application on both in parallel.
For all the great wisdom at the conference, I was also aware of how far we have to go in maximising existing treatments. I observed debate around core aspects of treatment with little agreement on how to tackle specific components. Most notably mental compulsions. There were advocates for seeing thoughts as all being ‘just thoughts’ and recovery being about facing and learning to function with them, without controlling thoughts. There were others articulating the difference between an automatic obsession and the cognitive process of mental compulsion/rumination. And that we can drop mental compulsions and this is a vital part of ‘response prevention’. Of course, again there is truth on both sides – that sometimes mental compulsions are so automatic it’s about building the ability to experience them and pursue goals and actions. But over time we realise that much of our mental compulsions are an active process of perseveration thinking that we can let go of. This is an area of deep interest for our centre and something we feel we are focusing on, given that many people who struggle with ERP are often doing the exposure part with less of the response prevention. They often need to learn tools to put the RP back into ERP.
Stuart’s 5 highlights from the conference:
Dr Jonathan Grayson made the point that the questions a person with OCD ask themselves in the OCD have broken great philosophers. I loved this view of the ‘what if’ questions that make up OCD. People with OCD often get pulled into the most detailed and philosophical thought processes in the same manner many great philosophers have. As with philosophy questions there is often no concrete answers to these OCD questions. Dr Grayson’s one liner here acknowledged the futility of this level of thinking and honoured how tiring it is.
ERP dosage. I can’t remember who said this but the question of dosage or the amount of ERP came up. The comment was we sometimes throw the CBT baby out with the bath water saying it doesn’t work, when we may have got the dosage wrong. We are under no elusion that ERP is a panacea, but sometimes as this statement says it’s too readily thrown out. One of the factors for it not working may be the dosage. Someone may have been getting weekly therapy when they needed twice weekly, or some may have needed an intensive outpatient treatment, and fewer still inpatient care. Obviously, economics and people’s finances or what insurance can cover, or the NHS comes into play. But it’s definitely something to consider for both clients and treatment providers.
Side note - other factors that may impact the effectiveness of ERP but not exhaustive are: therapeutic alliance (do you like your therapist), is another therapy needed to be integrated such as Acceptance and Commitment Therapy, has the ERP been delivered effectively, treatment motivation etc.
Dr Jon Hoffman mentioned the term “Don’t mind-fulness”. The attitude of “I don’t mind”. This felt like another route into acceptance of the presence of thoughts, feelings and experiences. We know in OCD recovery that what we resist, persists. We resist the troubling thoughts, they persist. We resist the uncomfortable emotions, they persist. We avoid OCD feared situations, they remain feared situations. This is why ACT can be a useful therapy as it helps us make space for uncomfortable things, so that we can respond differently and over time help our brain learn new things. This “Don’t mind-fulness” I felt was a nice quick saying for jolting us back into acceptance of the presence of uncomfortable thoughts/feelings and reducing experiential avoidance.
Calling a thought intrusive makes us guard against it, Dr Jon Hoffman said something similar to this. On the panel talk the idea of what makes a thought intrusive and aren’t all thoughts intrusive as they pop into our mind was debated. I liked the idea that adding the word intrusive to OCD thoughts makes them sound scary, when they are already tough enough to deal with. The scarier the thought, the harder it may feel to practice acceptance of the presence of the thought and make it harder to engage in valued activities. In ACT we teach skills to notice and name the thoughts so that they remain thoughts and not possibilities of doom, as it often feels with intrusive thoughts. I will still use the term intrusive thoughts, but I like the idea of maybe one day finding an alternative name that can help speed up the process of us seeing OCD thoughts as just thoughts. Neither good, nor bad, just thoughts.
Letting the kid pick the therapist. I was watching a panel talk with some parents and their now older children on the panel. They were discussing what had helped, not helped and their advice for navigating the difficulties families face. One of the parents was discussing how the child had not wanted to see a therapist, and one way that helped was the parents finding and making a shortlist of suitable therapists for their child and letting the child pick one or a few to try out from the shortlist. This gave the child a sense of agency over their recovery, and made it feel less like the parents where mandating therapy. It can be scary for kids to go to therapy, meeting some strange person (therapist) in a room or online, doing this activity of therapy which is unlike anything else, and talking about all the scary experiences they are having. I think the more guided agency we can give kids the better.
Hope these highlights help.
All the best