 Good evening everybody and welcome to this MHPN webinar on an interdisciplinary approach to caring for people living with obsessive compulsive disorder. We've got a fascinating case to consider tonight and a great panel to do it with and as always we're looking to you for your questions that you've asked before the webinar but also during the webinar so that the panel can respond to those. I will begin by acknowledging the traditional custodians of the land seas and waterways across Australia on which our webinar presenters and participants are located. We do pay our respects to Elders past present and future for the memories, the traditions, the culture, hopes of Aboriginal and Torres Strait Islander Australia. We currently have roughly, what are we, over 500 people already connected and others are still joining us so it's a good number for what should be a really good evening. My name's Steve Trumbull and I'll be the facilitator tonight. I'm a general practitioner by training but my major role is as head of medical education at the University of Melbourne, Melbourne Medical School, which has graduated another 360 brand new doctors today so that's good news. I will apologise for my background, you probably noticed it's a virulent green, the chroma key is not working. There is a storm over Melbourne at the moment for those of us who are in Melbourne so if the power goes out, talk amongst yourselves until we rejoin you but hopefully things will hold in. The team's done a wonderful job bringing it all together again. The panellists biographies were disseminated with the webinar invitations so I won't go through those in detail but I will just say a quick hello to each of the members starting in the order of the presentations we'll be hearing with Dr Scott Glear West who I first met 36 years ago. Hello Scott, you're a psychiatrist here in Victoria and the question I'm going to ask you is obviously about obsessive compulsive disorder. What's the prevalence of the condition and have you found it increasing significantly during the pandemic? Thanks Steve, thanks for everyone for inviting me. The general stats for OCD have been done in a whole range of countries across the world suggest that prevalence is about 2%, bit more, bit less. As to whether it's increased, no one really knows I've got to say. I think the general feeling of people who work in the areas perhaps it is but then this might relate to all anxiety disorders and certainly presentations this year seem to be up interestingly not so much last year perhaps when people sort of I think stayed at home and sort of snuggled down and but they're all coming out now maybe can't manage things quite so well so yeah I could be we could be seeing more we're certainly seeing more people with related disorders to skin picking, hair pulling that sort of stuff as well so we'll wait to see there's going to be a lot of research on this subsequently I'm sure. Absolutely and we I'm sure will discuss it when you get to the questions have been a number of questions about people's return to workplaces and schools and the impact of the hand washing regimens the hand hygiene regimens and whether that's driving people's behaviors so great to have you Scott good to see you. The next person I'll introduce you to is Dr Selene Gilgich who is a clinical psychologist now you're also enjoying the delights of Victoria at the moment Selene welcome to the webinar and the question I'm going to ask you I must say I'm genuinely curious about this what interest to do so much about obsessive compulsive disorder that you decided to make this aspect of mental health care the focus of your career. Thank you so much for having me what interested me in working with OCD was while I was a student working with Scott and his team at the inpatient program at the Melbourne Clinic on my final clinical placement I very quickly realized that there wasn't a lot of advocacy for people with OCD in Australia it wasn't very well known there were a lot of gaps in people's knowledge wasn't that very well understood and so what sparked that passion in me was not only enjoying working with the clinical population and you know and I was very lucky to be supported by such an amazing team and learn so much the other thing that sparked that ignited that passion was wanting to be able to do more in that area and seeing that gap so I think it was a bit of a really good timing to be able to be in such a position at the end of my clinical placement all those years ago not 36 years ago but 11 years ago so it's it was yeah it was really really eye-opening for me and that's something that hasn't died down all these years later yeah fantastic it's a joy to have something that you truly passionate about to drive you at work every day so that's fabulous now Johanna Lynch you very wisely live in Queensland well done well done you and you like me or a general practitioner what the hell are you doing as a GP you're going out and doing a PhD what what drove you to be so interested in a question that you've undertaken a PhD in it I think it's actually been driven by my patients who I saw cycling in and out of the mental health system whereas a GP I wanted to work out how to hold them a little bit more as a whole person and I saw their life stories and their relationships kind of sidelined in how we thought about them when we were thinking about their mental well-being and so that drove me back influenced a lot by what I'd learned in trauma and attachment and through my patients life stories their compulsions and their addictions and the patterns that I saw in those that led me back to to try and see if there was a wider pattern we could use to help GPs and other clinicians to see the whole person fantastic and so that's really very much the trust of your approach to practice the whole person that's right I kind of think that's a special thing that GPs do in their day-to-day work that they don't even notice that they do and that it can be a gift to the whole system if we were better able to articulate what we do fantastic well great well thank you for being with us tonight and we will definitely get to hear more about that during the presentation and the discussion what I want to do now is introduce the participants to the webinar platform I see a number of familiar names in the the list of people who've been with this before but I'll take you quickly take you through it most of the navigation buttons that you need are located at the top right of your screen so there you can use the purple button to access the chat box so please chat with each other in the chat box and we'll keep an eye on that if anything comes up that we need to address will certainly do that if you have a more formal question though please use the blue hand button to enter your question and then that will come through to the panelists and if we can get to it we certainly will you can download the slides and other resources that the panelists have contributed tonight by the light blue button which is there with the little down arrow on it the there's a help button which is always good news if you need assistance you can message read back the conference providers directly or ring the number which I think might be there it's not that's okay if anybody is anxious you can write the number down 1-800-733-416 so what we'll be doing is we'll be moving on to the presentation in just a moment each panelist will give a brief presentation which is specific to their particular discipline followed by question and answers between the panel and we're very much going to aim at these learning outcomes which you can see there and mainly it's looking at the biological environmental factors that increase the risk of developing OCD along with other comorbidities we'll discuss the assessment diagnosis and treatment we'll particularly talk about those treatments which is successful as you would hope when treating OCD but also as always we want to talk about the importance of collaboration and making appropriate referrals when providing care to people who live with obsessive compulsive disorder so you will have already seen the case study that's been circulated relating to DeWutter our patient or client and there's quite a lot going on in her life she has got to the point though where she's betwixting between as far as the provision of her mental health care is concerned and she's anxious about moving on to a new provider of mental health care because she's moved geographically within the state so we're going to start actually with her psychiatrist person who's been more or less a consistent theme through her life doesn't see the psychiatrist very often but the psychiatrist has probably got the best overview of DeWutter's case at the moment so that's you Scott Blair West you're the psychiatrist in the evening so if you could take us through your approach to dealing with DeWutter's needs great look thanks Steve so look my first thought is so I'm going to talk about sort of initial ideas a little bit about the model that we use and then a bit about the more medical psychiatric treatments and my colleagues are going to touch on more of the psychological side of thing and I'll make a few comments about all of those sort of things as we go so look my first thought is we need to we need to make a diagnosis first which you might think is pretty clear cut in this case but it's not always so so in DeWutter's case there's lots of concern about contamination lots of excessive washing and hand washing etc so this is what I've what I've given you here is a way of sort of making a diagnosis of OCD in this case but also in others so we need recurrent anxiety-provoking thoughts images and urges seen as intrusive involuntary exaggerated excessive and against one's own belief system most OCD people have intrusive thoughts a few people have intrusive images as well particularly people with violent content so this is people who fear they're going to harm others and sometimes people who have intrusive sexual content as well I always think diagnosis really should be focused on the the obsessions the thoughts and the images so secondly we we have repeated compulsive behaviors pretty obvious in this case not always obvious and in the latter the latter comments there I've given you some of the particular content so the content of obsessions contamination disaster violent thoughts relating to doubt fear of loss sexual intrusion religious OCD and we also see people now who have issues with their relationships in the sense that they have thoughts I'm not sure I love that person or equally and vice versa I'm not sure they love me and then the list of compulsions that tend to go with those things as well the thing the point I wanted to make at the end here is that we see a lot of people now doing compulsions in their head so don't assume that someone doesn't have OCD if they don't do a physical compulsion this is really important and in fact often as people get a bit older they tend to do things more in their head than they do physically so let me go on all right so this is my first step in in in helping people understand and trying to to help the the treatment process get started so this is the model that that I use and a lot of people do use starts with triggers things that start off the process so for her it'll be touching things in most cases and she will have an intrusive thought in response to that what if I'm contaminated in some cases it might even be I just feel dirty we have then so that's an intrusive thought that just pops into the person's head the appraisal is how they appraise that thought and characteristically OCD people give a lot of meaning to those thoughts now you might have these thoughts but you might give them short shrift you might sort of be able to push them to one side and not respond for her she'll be thinking probably one of two ways one is this is terrible I'm going to get contaminated I'm going to harm other people by spreading contamination alternatively she might just dislike the feeling of being contaminated that's a feeling of being disgusted in that sense and that will lead to anxiety shame guilt and then the compulsive behaviours which in this case involve washing and cleaning so this is our this is one of the first steps in the process and so as I've said there the treatment options are listed there now I should apologize they're definitely in the wrong order the first one is correct we start with education we start with talking about OCD we hopefully develop that model but really ERP should be well above drugs and we should be trying to approach people with psychological approaches like exposure and response prevention before we use medication there'll be some people where it'll only work with medication and we need to do that we need to use the pills first off mainly people who are severely unwell or significantly depressed so the top three are the gist of pretty much all OCD treatments we can sometimes add in some cognitive therapy that's a fairly specific approach that I think Celine might talk a touch about I'm going to talk a little bit about augmentation and combination medication strategies and we can touch on the novel therapies later on if we have a bit of time in questions so all right so medications now I've got to say up front there have been no breakthroughs really here in the last sort of 2030 years really since the introduction of the serotonergic antidepressants and my jargon there SSRI stands for selective serotonin reuptake inhibitor antidepressants SNRIs are another variety of those and CMI is chlamypramine which is the only tricyclic antidepressant that works and that's pretty much the order that we do it in we will subsequently in some cases add augmentation with other drugs and I've listed the three sort of areas that we might use there 5ht is serotonergic drugs da is dopaminergic drugs glue is glutamatergic drugs now these drugs sometimes have some benefit the most useful ones really are the dopaminergic ones these are drugs that are used or have been developed for psychosis but in very small doses we find that they can be quite good as augmenting drugs for SSRIs I would normally only use these when we're getting a bit of response from the SSRIs or that the the first benacation but we're not really getting enough and we want to see if we can boost it a touch I'm getting the bell here I've got one to go so I'll continue on to that so look finally these are the comorbidities and this is just a point to make comorbidity is common you should almost assume comorbidity and certainly I suspect Duarte has had issues with depression in the past I wouldn't be at all surprised if she has issues with social anxiety and generalized anxiety as well but there's a range of other conditions and symptoms that are also relevant there as well and as I said you must consider that sort of stuff social anxiety is the thing I'd be asking you to consider mostly so that's it from me Steve I'll hand back to you great thanks very much indeed Scott and there's certainly plenty that we'll discuss in the in the chat part later on so thanks for leading us into it but we now will move on to looking at it from Celine's point of view so Celine you've seen in the case study where she's really quite anxious about finding or starting up with another psychologist however she's being referred to you so let's hear your approach thank you so much um so when a client likes Duarte comes to see me it's really not unusual that she would have worked with someone before or is often referred by a psychiatrist or a GP and in those instances really what we want to do and so when I I guess when a client comes to see us quite often a diagnosis is made sometimes our diagnosis is unclear because a client will come with a more general um diagnosis such as query anxiety or depression but seeing as we're talking about Duarte and she's already had her diagnosis I want um during that first session really it's about getting to know her and really understanding her as a person but also understanding the function of her OCD symptoms and what that does for her so the first thing we focus on as clinical psychologist is really formulating our client and what that means is understanding some of these things that we've got listed here such as what was Duarte's particular vulnerability to developing OCD and we consider things like genetic history um family history family dynamics um her relationship with um her family growing up etc um what are the origins of her OCD behavior so what what was some of the first things she noticed right back at the beginning what was going on for her at the time what are the current problem areas what is her OCD narrative so that's the other thing we want to know in terms of current problem behaviors or areas in terms of what is what is the OCD saying to her in a sense um for lack of a better way of describing it that's perpetuating her symptoms what are her supports we also want to know because people are not they don't exist on their own they live in a system and I think Johanna's going to explore this a little bit more later um in terms of who is her support who does she have as professionals who in her family is there to help her rather than enable her um and then using all that information to formulate a treatment plan and as Scott talked about the gold standard treatment that we use is exposure and response prevention I myself don't err on the fight of cognitive therapy per se from a traditional CBT perspective um if we think about cognitive behavior therapy traditionally what we tend to do is teach people ways to reframe um their intrusive thoughts and their faulty beliefs or the assumptions that they're making we teach people to look for evidence and so on and so forth but what we find with people with OCD is a lot of the time um when we try and reframe in that way clients will often say yeah but I know it doesn't make sense I know that this is really unlikely but when I'm in that moment of doubt I just can't help it and so doubt is a really really big feature of anxiety in people with OCD and if we think about how the brain works and we think about that fight freeze response when people are feeling anxious and we have um frontal lobes being shut down because the amygdala is taking over um people become really reactive and so what we see is this process here so we see this process of the person being triggered they're making an assumption so this is very similar to what Scott talked about earlier but what happens is they become extremely reactive their frontal lobe is shutting down and as we know our frontal lobes are responsible for things like reasoning reasoning logical thinking and all that kind of stuff and so people can't access it in that moment in time and their behavior becomes quite reactive which is what we see in obsessions and in sorry in compulsions um so what we want to do in treatments or exposure and response prevention is encourage people to be aware of what their triggers are so we explore that together and typically we use through the exposure through exposure therapy we use a graded hierarchy so basically it's a step ladder from least anxiety provoking to most anxiety provoking triggers and we start somewhere at the bottom and we teach people how to tolerate distress and discomfort because it becomes about what our aim is to teach our client how to regulate their emotions because a lot of the recent research is showing us with people with OCD that it's not necessarily a thought problem it's not about the content of their thinking it's about the way that they're not regulating their emotions and using compulsions in a maladaptive way to help regulate the emotion so we're conceptualizing it more now as an emotion regulation difficulty rather than a thought-based problem so um obsessions are really important from a diagnostic perspective but from a treatment perspective we really want to focus on emotion and emotion regulation and teaching people how to tolerate that distress how to sit with their discomfort how to really be open to their thoughts and feelings so that they can then be in control to resist their their compulsions and slowly take those away and through that process people learn that their feed consequence doesn't happen so the evidence is gained kind of at the end but it's our role as clinicians to really hold our clients so that they can see through that process of learning how to ride that intense wave of emotion it's like um surfing the urge to scratch an itch really um which a lot more complex obviously in people with OCD but it's learning how to sit with that and giving themselves a chance to see that if they can ride that wave of emotion the thought is just a thought at the end of the day one of the biggest no-nos is reassuring our clients or enabling our clients and so I think just kind of coming back to Joada and her case the other thing that you might want to consider is working on and looking at whether the family is accommodating her behavior and addressing some of those as well so just kind of thinking about how to you know the function of her OCD how that's impacting her teaching her how to regulate her distress so she's not relying on compulsions looking at how she can build her own independence with that but also looking at how her family can support her in a way that isn't enabling okay I think that's it for me there's certainly been some questions about the role of family and how family can support um and also there's been a question about what you said about hierarchy within treatment you mean you have things stacked up I guess the people can go for whichever shelf they need to depending on how that it must be an extraordinary feeling for people who are riding that wave oh it's it's amazing it's a rollercoaster I get so scary at the start but when they allow themselves to kind of get to the end of that wave it's incredibly rewarding okay that's great tonight thanks for that uh so then the general practitioner role and uh we'll go to you now thanks Johanna if you could tell us a bit about your perspective from a whole person understanding yeah thank you Steve I thought I'd start a little bit with a really insightful comment that Duarte said about herself saying I feel like an addict and I have to clean to calm my feelings of distress and as as a GP I think that noticing what she thinks about her problem is a key element of that initial connection with her so that we're with her um and trying to see it from her point of view and I guess then my I see my task is trying to help understand what is this thing that she's calling distress and how wide is it involved in her life and to keep myself holding a really wide view while she has turned into having a very narrow view on certain things and really focusing her attention on this feeling of not wanting to get contaminated or not wanting to hurt someone when she thinks about her grandson and her parents so I guess my my sense is of Duarte is I can see somebody who's very thoughtful very caring towards her people in her life and quite focused and kind of highly values noticing and predicting and trying to prevent bad things happening and all of those are lovely things about her and quite sophisticated thoughtful things about her that I would want to help her see rather than seeing herself as though something shameful or wrong with her and then if I look at this framework my my goal is to try and notice things in her environment that would increase or decrease her distress things in the social climate around her as well as in her personal relationships with the people that we've heard about in the story with her parents with her husband and with her sons and grandson and I guess I'd also be very interested as a GP in her body and wanting to notice that there's anything that might be increasing her sense of emotional dysregulation in her body and that would include some practical things like her thyroid and her nutrition and the amount of time she spends in the sunlight and exercise and those kind of practical things that are part of seeing her and then I'd be interested in her inner experience which is where a lot of our conversation has been about today and the sorts of things that bother her inside that she has memories and thoughts and images and physical feelings that bother her and influence her life and I'm also really interested in her sense of self and how much these symptoms that she's had have become a part of how she sees herself in the world and if there's anything we can help her to have a more settled sense of who she is in the world including how she sees her kind of spiritual world or meaning and belief system. I have a little framework to think through this and in Dewata's case I'm really interested she's a migrant she might have people in other parts of the world that she's worrying about or thinking about or missing especially during COVID and we're noticing her experience with just the what we're all experiencing through this time in COVID of an increased awareness of germs and other people's influence on our well-being and even how much freedom we have to move changing how we feel in the world and then really interested in the quality of her relationships so I'd be interested in how she's getting on with her husband how she feels when she goes to visit her parents how much stress she feels when she's being a grandmother and all those experiences as she travels through this journey and again in this case she talks a lot about sensations at the beginning of her OCD journey the experience of wound dressing and blood and gore that really kind of triggered off this and so I'd be really noticing how Dewata experiences her sensations and whether she has a capacity to see a wider view of herself and whether or not there's a sense of being able to calm herself and if there's any skills she already has from her previous psychologist I'd be interested to connect to those and again noticing how she can sense herself in the world a big part of this journey one thing I've got to mention earlier is I notice she's also had past therapists and she's fearful of future therapists and so those relationships are also part of what might be distressing her at the moment so if we look for resources we're trying to find safety and help Dewata feel safer in the world and help that to help her body feel safer which in turn will do what Celine has been talking us through around emotion regulation so we want to reconnect her to a strength past hobbies friendship group she hasn't seen for a long time because of COVID connect to somebody she hasn't talked to for a long time in her overseas life or somebody she forgot in that was a real resource to her in a past story and draw on those helpful relationships and memories and activate her connections to her self and to others and to the wider world including just enjoying being in her own home finding a chair in her house that she feels really comfortable in enjoying being in her garden slowing down how she sees the world when she's going at the pace of her grandchild and then a key piece which I think we would all agree in this is to build her capacity for soothing her own physiology and her capacity to tolerate the uncertainty of emotions as they rise and fall in her body and that will be a key area as a GP we can teach simple grounding skills that can become a resource throughout a person's life help her see her own patterns that help her to feel safe in the world and sort of assure her of staying with her on the journey as she engages with this task and in in Duarte's case if I she's having trouble engaging with a GP clinic at the moment what I would be hoping we could do is help Jeff to get her an online appointment as a first point of call to build towards her being able to come into the clinic and to help her know that she's going to have some regular appointments with you the way she doesn't have to be unwell to come but she's got regular connection that will keep that engagement going I have a framework that kind of thinks this through based on trauma informed practice as a strengths-based framework and that our goal is to build Duarte's sense of safety overall that's that's a kind of wide framework and to help her to grieve some of the things that really distress her in her current life and in the past and to help it have that sense that she's safe enough to grow safe enough to learn new ways to calm herself safe enough to learn new things in the world that take her attention away from the things that are currently her attention's focused on safe enough to move from where she's currently feeling a bit stuck and then a reframing of Maslow that was part of my thesis is saying that Duarte has some range of different needs but if we think centrally it's that we wanted to have a calm body emotions are bodily experiences there a way our body talks to us and explains the world to us through our senses and sometimes we don't know how to interpret that we don't know how to understand that and especially when we're aroused or hyper-vigilant we are extra good at noticing every small change in our world around us and so helping Duarte learn how to decrease her vigilance in the world she is is a big part of the journey and then i'd say we've she's got a deep need to say that she's not going to hurt them by being herself and that's a that's a need i would see for her as grandma and safe on the inside from the the harassing of thoughts and images and i guess senses that she's worried by that's a key goal for Duarte's well-being long-term and then that sense of her living somewhere where she feels safe to be and at the moment there's a bit of stress with her parents and so and and whether to go and clean and the pressure of that and the stress of COVID and normalizing that a little bit that the whole community is feeling this pressure that she has and it's not something especially wrong with her at the moment that is part of this journey and of course always having this sense that she like everyone else can learn to cope with the things that our lives give us and that there's a a growth that's possible for her that comes from a sense of being safe in the world so that's it from me Steve over to you thanks Joanna and thank you all i think you've given fabulous presentations with a lot of compassion and recognition of the needs of the person with the condition although i think that really the the thunder's been stolen a little bit in the chat box by Amanda who has written in the public chat about her own experiences of being diagnosed with OCD as a youngster and the fact that CBT didn't help and that to hear Yusseline say that it's all about emotional regulation all about being with the condition and riding the condition rather than necessarily wrestling it into the ground and there have also been questions about whether we go back to the causes of this did you want to speak a little bit further on that i'm so glad to hear that that was a breath of fresh air because i think a lot like that is whenever every time i sit with a client and go through that is without a doubt every single time that is a comment that every single client makes i'm glad that that resonated with you as well um we do in a sense it does help to understand and kind of go back to to the why and i think not from and i know it sounds like probably like a very psychologically thing to say like we want to kind of go back to childhood or teenagers or whatever that might be but i think the reason for that is because quite often but not always and i think scott might be able to hope maybe agree with or disagree with this as well but we'll see what he says um in a sense that when a lot of the time when our things are going on in our environment what happens is um sometimes we can feel a bit out of control or we can feel overwhelmed and we start to try and um we start to have this desire to want to feel better because no one likes feeling distressed or uncomfortable and so we start to experience sometimes when we're really really stressed or distressed or overwhelmed with for some people who have a predisposition can start to experience intrusive thoughts more often than those in the general population because intrusive thoughts are a part of everyone's thinking they're actually quite normal to experience what's not regular is the intensity and frequency at which someone with OCD experiences them so we have a naturally occurring phenomena that starts to occur more often in people with OCD in the beginning in response to um environmental factors um and sometimes you know um points in life can kind of trigger that as well there are a couple of clusters when we see people who are um entering puberty and then we see another cluster later in adolescent years like 17 class we see those two kind of clusters of age of onset so either physically developmentally there are some there's some stuff going on or environmentally um and really understanding that because what what we sometimes see is OCD actually acts as a symptom of what's going on underneath and so it does sometimes um it is worthwhile going back to the start and figuring out what that is and helping the person learn to understand that and cope with it but then also learn how learn more adaptive and healthy ways of regulating their emotions so they're not relying on rituals and compulsions. Great thanks for that so Scott do you have anything to add to what Celine just said? Well look I think um the the origins of OCD remain a little bit shrouded I mean we I mean it's the case with all you know psychological psychiatric conditions I mean look the simplest way of of answering the question is it you know is it biological and or or psychological uh is yes it is it's both um so let's sort of you know consider that um my sort of view on this really is that if you have a significant genetic component if you've got a lot of family history then maybe you don't need very much at all to trigger it off if you don't have as much maybe you need more and the that's I think probably the best way to to think about it um yeah that's probably what my my comment at that point yeah all right thanks for that um there've also been questions asked I can't think who it was who made the comment about um being careful not to reassure the patient I gather that was uh it must have been you I think Celine saying not just to dismiss the person's concerns mm-hmm can you just expand a little bit more on that what what what their point was? Yeah so a really common compulsion in people with OCD is seeking reassurance um and they might want to seek reassurance for themselves it's also been hours and hours on Google or they'll ask family members for reassurance multiple times um and so as a clinician one of the things that we want to do in treatment during exposure response prevention um is to not feed into that reassurance trap because um it just it feeds the compulsions and only provides temporary relief it doesn't provide it doesn't give a decline a chance to actually learn how to sit with their distress so if a client is saying something for example um in Duarte's case um like have I cleaned this enough for argument's sake that might be a question are you sure that I can stop cleaning this that might be another question and so a typical answer will be well I don't know maybe you have maybe you haven't let's just try and sit with that doubt and uncertainty and see what happens as opposed to going yeah that's fine you've cleaned it like five times already so option a is preferable over option b okay good to know um Steve if I can make a comment about that look um this is where families sort of get pulled in because and and therapists too I mean it's really easy to I mean Celine just said you know we wouldn't we would never say um something like that we would never say that's enough that's enough but it is incredibly hard not to do that sometimes and and and some patients are very very well clever they're sneaky they can sort of they'll ask it in one way they'll say oh and they'll ask it in a slightly different way but the dilemma we have is that as Celine sort of hinted that um compulsions everyone performs compulsions but the problem with compulsions is that they're not very efficient and sometimes you do it and you have to do it again and you have to do it again and you have to do it again and you know this is why some people develop you know I've got to do everything four times or four times four um but this is also where family comes in too because they they do it and they have that uncertain feeling which I think what is what Celine was saying before about what they've got to learn to to sort of cope with um but they hate it and I mean we're all like that we hate feeling uncertain we'd love to be we'd love to have have a guarantee about things we'd love to know yep this is the situation um and so in the end we have to sort of resort to sneaky little things like saying well yeah that could be enough or I'm 99 percent sure that you'll be okay and you won't get cancer um but and you might say well that's that's being a bit mean but you know it it's but what we're trying to do is get people to stay with that doubt and that uncertainty and and not scratch it in a sense my one of my favorite sort of analogies or metaphors is it's like a mozzie bite you get a mozzie bite and you think oh I've got to scratch it but what we know is that eventually we've got to not scratch it and we just got to let it be there and be painful until it sort of fades um so that's sort of what we're hoping in these situations yeah it does make sense like I don't know how people are going the the video is breaking up a little bit Scott look briefly like Thonos from the Avengers there for a moment but he's back with us again if people are having trouble I'm sure it will hold together for the rest of the webinar anyway look one thing Johanna I'm thinking of you the one of the major roles for the GPs obviously making really good referrals a few questions have come up about how you find people likes Len and Scott with a particular interest and the expertise in things such as ERP as an approach to OCD how do you go about finding the right therapist for a particular client I think that's built over time I think GPs are the kind of we are based in our place and so we we work out who our local key referral pathways are and sometimes we get negative feedback and don't refer again as a result and so with a little bit of a feedback loop to guarantee the quality of the people we refer to of course there's times when we actually don't know of somebody new in our neighborhood and that's where we have to also go searching and ask our colleagues for who they would recommend in this space and often patients will bring to me somebody they've heard through word of mouth and that also introduces me to someone with some skills I don't know yes so you build your build your network that way that makes a lot of sense look I'm just picking up on a question which has come up from a couple of people which goes back I guess to this question about enabling behaviors I mean we obviously don't want enabling behaviors from the the treating clinicians but again from family I'm just wondering what sort of words people might use when talking to families who are obviously living this experience with their family member their loved one what what words can you give them to help them not enable these these behaviors Colleen I think was first first out of the box I'll make mine quick the things we often teach our family members is validate what your loved one is going through and then convey confidence in their ability to cope with what they're going through so you're being a coach and a cheerleader on the side rather than getting pulled in and as Scott mentioned remembering you are human it's never going to be perfect it's a learning it's a learned skill all of this is even as clinicians but if you can remember those three things validate their emotional experience and convey confidence in their ability to cope you can think of phrases that will be able to help your loved one get through that moment great all right thank you I would add to that the idea that we're wanting them to feel safe enough to feel and so that's not safe as in molly coddled and reassured all the time it's safe as in safe enough to try something new and take appropriate risks and so that kind of framework that you're the overarching goal is to help them to feel like they can cope with what they know with the images that come into their mind with the thoughts and feelings that they experience and that you're with them on the journey as they ride that wave is part of how we would do that it must be difficult living in that environment in fact janice has asked a question about her dissonance I guess she sees in how people can be so obsessive about some aspects of cleanliness germs on covered handles and things like that and yet you know not change the bed for a year bags of rubbish there can be some sort of incongruities in the way people are interacting with their environment any thoughts about that and how that they might help resolve that well yeah okay um yeah look Steve some in some cases people with OCD have they sort of compartmentalized how their OCD affects them so they keep certain areas sort of free of it but in in in the area where it involves them it really takes over and so you can have people who have an area in the house for example that is perfectly clean and the rest of the place is is is full of junk for example and you can have someone who's very pedantic in one circumstance about washing or checking but you know has to in a sense almost make an excuse in another one and it's one of the I mean what we were talking about before I think sometimes for family you need to do a little tutorial I guess on how OCD works and you might need to explain to them how reassurance sort of acts as a as a compulsion but you might also need to explain to them that that this sort of inconsistency is pretty much pathodontic of OCD so and you can get people who are who are absolutely pedantic about one circumstance and often might relate to a family member and yet they break that rule themselves you know a minute later and that family just scratched their head about this they just you know they struggle to to sort of get their head around that how can you do that in this situation not in that and again that's there's probably some coaching and discussion with family members about that to sort of help them tolerate it sometimes it's incredibly difficult and family members feel like they almost have to choose between you know do I accommodate this person or do I resist what they want me to do all the time which inevitably leads to a often well often leads to a lot of conflict all right thank you for that I'm just wondering again I should warn people that the storm is really getting serious here but we are holding in there as the thunder crackles in the background this is actually a pretty impressive effect I might do this more often look while while we have the satellite there are a number of questions coming up I'm going to actually ask Scott while we've got you Scott you you mentioned that you might come to this but it's newer approaches I guess or almost experimental approaches there've been a couple of questions asked about transcranial magnetic stimulation and deep brain stimulation can you talk just a little bit about that I must say I haven't heard about those in my neck of oars sure sure um look what what we've talked about is I mean the essence of treatment is still explanation a CBT method primarily exposure with some often with some act ideas and medication plus or minus TMS is a is a technique that's been developed in the last 20 years and I'm not going to try and explain it fully because I don't even understand it myself fully but essentially it's a large magnet that is placed next to the person's head and it's turned on and it changes there's a magnetic field within the magnet which changes the magnetic field of the neurons in the brain and again I cannot explain how it works but there's some pretty good evidence that it works in depression and it's been used a lot and it's been rolled out a countrywide really in in the last five ten years pretty much every private psych hospital and a lot of public ones have them now the evidence in depression is good the evidence in OCD is really patchy there's research being done particularly in Melbourne by Paul Fitzgerald's group but at in Campbellwell but the research is I mean I've referred probably 20 people for TMS for OCD and the results I've seen have not been particularly impressive now I suspect if we had Paul Fitzgerald here he'd say well look that's because we haven't refined it yet we've still got some hopes and I think they do still have some hopes deep brain stimulation is like the end of the line and this is for the squeamish you should sort of mute at the moment but DBS is a treatment that was developed for Parkinson's disease and is very effective for Parkinson's essentially what it involves is placing electrodes drilling holes in the skull placing electrodes through the brain matter into certain part of the brain on both sides the nucleus accumbens the electrodes are attached to a like a pacemaker and that's turned on and those parts of the brain are stimulated repetitively and there's some evidence that that works in a proportion of people with really severe OCD it's as you can imagine it's a really complicated treatment it's expensive it's done fairly infrequently it's a last resort treatment and it works probably for about 50 percent of the people who have it and for some of those it's absolutely you know a revelation it's not so good when when you talk to the other 50 percent who aren't getting better and you've had what is seen as like the the most important treatment around but so look that that's really a last resort treatment it's there's potential for it but it's never going to be a mass treatment I think at the moment the Royal Melbourne has funds to do two operations per year so it's going to be always infrequent That's extraordinary thanks for the update on that it sounds hair-raising as you say there's also been a number of questions including before the webinar about people who are neurodivergent on autistic spectrum disorder having an intellectual disability and whether there are any thoughts from any of the team about whether the approach might be different when you're dealing with somebody with those co-existing conditions children adults I guess the approach in terms of the form of treatment isn't different but the way we deliver the treatment differs so for people who are um diagnosed with an autism spectrum disorder for example um we have to first pick apart compulsions that are that will repetitive behaviours that seem like compulsions but are part of the ASC and because often they serve a function of helping to regulate and self-serve and are not bothersome and then look at what constitutes intrusive thoughts and more typical OCD like behaviours because you will see that and a lot of the time either the young person or the adult will tell you I don't want to be experiencing these thoughts and one of the functions of intrusive thoughts is that they are inconsistent with one's values and beliefs we um we call that being ego dystonic which is exactly what that means being inconsistent with one's values and beliefs and so we have to through the assessment process really carefully tease that apart and then modify how we deliver the treatment um whether there are any special interests or what not from an ASC perspective using that I'm modifying the language um using a lot of games and that kind of stuff with young people working more with parents um with young people as well so getting more parents involved a lot more um and so on and so forth so we still use ERP but we just modify the delivery while you're mentoring ERP there have been a couple of questions about further training in ERP where might people go or what would be sort of a good approach to upskilling in that area am I allowed to plug my training we're not on the abc so I can go first um I do a lot of training for professionals um also have a book um to help people learn more about treating OCD but there's so much out there like there's a lot of overseas providers um I know Ellie Lieberwitz who works from Yale University works a lot with he's got a wonderful program at the moment that teaches uh clinicians how to work with parents especially when young people are refusing treatment and it's got really wonderful results so the young person doesn't actually have to be going through ERP it's working with parents to reduce family accommodation and it's got really wonderful results in achieving outcomes and helping the young person reduce their symptoms of OCD as well and also through that process encouraging them to actually engage in treatments so he's got a lot of um workshops that are going at the moment um and there's a lot of other training around as well yeah yeah all right so certainly worth looking for there's plenty of opportunities by the sound of it yeah talking just a moment ago about younger people and there've been a number of questions about older people with OCD and Joanna I think a question or comment was made earlier it might have been Scott actually but I think a comment was made about um that older people tend to experience their OCD symptoms more in the more in the head rather than being visible behaviors yeah I think my assumption there is that they've got better and make it making it less intrusive on other people and less obvious they manage it more with mental processes that that would be my way of seeing that that mentioned that Scott mentioned the comment he made what would you add Scott look I think most people with OCD are quite embarrassed by it and they will do almost anything to to hide it and in fact if you see someone doing obvious OCD behaviors in public you know they are really sick and they are really really struggling because they've lost that ability to sort of sort of you know control it manage it um and I think you're right Joanna part of this is is trying to do it more in here so it's less visible externally and and I think um I don't know if there's been a lot of studies on this but it does seem to as people get a bit older they they sort of learn I suppose to do that um and and their rituals become more ones of sort of internal analysis of the situation so I mean I remember I had a patient um who would his fear was that he would hit someone driving home on the road when he went went home every night so he would drive home um and he wouldn't drive around in circles which they often do but he would get home and sit in his garage for as long as it took to mentally try and review the whole trip so he tried to have get a mental image in his head like a video of the whole trip in order to you know tell himself reassure himself essentially that he hadn't hit anyone um and you can imagine how difficult that would be particularly if it was a very long drive which in his case it was um so yeah I think that's um I and you know there's all sorts of little subtleties that people do you know when they check a door for example they can they can sort of listen to it they can you know look at the door jam they can sort of you know um they don't have to actually touch it at all um and uh as I said I think as people get older they they get they get um better at that and in some ways a bit in some in some cases a bit sneakier at that too yeah I mean I would see a lot of these um compulsions are sort of sophisticated ways to try and calm yourself down um and often for very clever people who are who are troubled by something that's partly because they're such they're so capable of seeing um bad things happening in their minds uh and thinking of multiple options of what might go wrong uh and so the idea that they're trying to work out a sophisticated way to manage an experience they're having on the inside that's not going to bother other people um whether it's counting or or you know thinking thoughts in a certain order or looking for patterns in on the wall or images around them um these these kinds of things for me I just see these people as they're trying to cope with something and they're using their amazing minds to try and solve that problem um and then perhaps their bodies actually could become their friends that their bodies could help them to know that they're in a safe place with safe people around them uh and that their sensations could be broadened so in the person who's in the house where they're not noticing the rubbish in the dirty bed but they are noticing that fleck of dust on something if we're broad and they're noticing so they can see the sunlight as well as the clouds outside and smell something and feel the breeze on their their arms and remember something their friend gave them last week and have that wide sense that when we're well we have this kind of wide sense of noticing our world uh and this narrowing is part of what's the distress for them uh so I I guess I would see this also beautiful sophisticated ways we can use their amazing minds to connect them back to their bodies uh so their experience in the world is less frightening and narrow in its focus it looks Suzanne in the questions as asked a question relating to somebody whose life's been turned upside down and is exhibiting behaviors I guess as a consequence of a major loss of grief uh she's talked about an older person who starts exhibiting a verbal discussion of a sexual nature shortly after their partner dies and just wondering you know how that is can sort of be um I was going to say dealt with but that sounds suppressive or repressive but I mean is this sort of an approach before having to go for professional help if somebody's had their their universe rattled in that sort of way yeah I I think that's a tricky one it's it's a little bit driven by how distressed they are by what's happening and how and much it's impacting other people around them and I guess how how amenable they are to shifting the topic off that topic and widening it in the moment but I'm sure there are wiser things that both Celine and Scott could add to that that um thought Suzette yeah I'm not entirely sure what that that that um question is about to be honest um I think it might relate to another case which is probably going to lead us away from the case we're considering one thing I did want to talk about though was the issue about the focus on hand hygiene as a result with here in Victoria everybody heading back into the shops kids back at school heaven for fiend even many students on university campuses again how do we recognize what's become this sort of government mandated focus on hand washing with people who were trying to um ride their their compulsions to hand wash it's it's quite an issue actually um we had a young woman did a hospital program recently who had the classic sort of you know reddened hands and and really I mean you just look at them and you feel you cannot feel her pain really because you she she would have been washing her hands a hundred times a day plus look this is going to be a problem and it's going to be a problem in in uh you know CD management for some years I think because um you know there are going to be a lot of people washing their hands a lot and using you know nasty sort of chemicals like bleach and the like as well the interesting thing I've found is that many of the people who are washing their hands a lot um actually are not so much concerned about contamination well I guess they are there but they're mainly concerned that they're going to get COVID and give it to someone else so actually this is more an issue with harm rather than with contamination because they're not so concerned themselves about getting COVID but they're certainly concerned about about giving it to others the interesting thing I'll let Celine have a have a word in a sec the interesting thing is that last year a lot of my patients who were hand washes um didn't actually wash their hands any more than they than than than usual because they basically said look that's not my OCD um and they were able to stick to the rules pretty well and I think they'll be generally okay um so the ones that I've seen have had problems have been more people with harm issues and and maybe you didn't have significant contamination stuff before Celine well yeah I totally agree a lot of my clients have also been saying the same sort of thing they're more worried about making other people sick so it's triggering a sense of responsibility which ties into that harm um but also one of the things that often you know and a lot of clients um definitely last year were like I'm being told to do things I'm trying not to do what is going on and I think the most disconcerting thing as an OCD therapist is having to stop your clinic with glen 20 and all this other stuff um and I it almost felt like car not for the last decade or so of making people with this the urge to not have to wash their hands and stuff but anyway I'm digressing um absolutely one of the things that I often tell my clients especially if it is relevant for them and they are struggling is to not do the extra because if there's anything we know about compulsions once he's never enough there's always this really strong urge to keep going until it either feels right or the pattern is complete or whatever that looks like for that client and so the client will still have to sit with some form of urge because they'll wash their hands once and they'll want to keep going often or they'll want to complete the pattern and so I often say to my clients follow the guideline but don't do the extra um and then sit with your urge to want to do more knowing that you can't because if you've done what what the guideline is recommended by um our higher powers indeed indeed thank you all very much we're moving into the summing up phase now but before we do I think that we've probably had the comment of the night from Dr Norman Schum who seems to have captured the whole mental professional network concepts by saying that in my clinical practice I found that the stronger the therapeutic relationship the better the outcome almost no matter which strategy or approach I apply so I mean that's always been my view as a GP that it's the operator as much as the technique in many many cases not dismissing the importance of good technique I can see you nodding there Celine what are what are people's thoughts on that comment before we move to the summations absolutely that is like in ERP trust is so important because you're asking people first of all ERP is a very counter-intuitive treatment to what we would normally do with our clients who present with general anxiety or other types of anxiety disorders and other conditions so that level of trust is and rapport that you have with your client is first and foremost the most important thing um I think that's a really wonderful comment and wholeheartedly agree and if we look at um I think it's Walpole's research um who talks about that relation the one key thing that is the most important predictor for success is therapeutic relationship so 100% agree with that yeah great all right well thanks for that let's now agree with half of it I agree with the first part and not so much the second part I think I think that therapeutic relationship is vital um but well you're not going to get a great response to OCD by doing psychoanalytic psychotherapy for example so you know there has to be a there has to be some focus on the specific in that context so the careful choice of technique but it's not going to work if that relationship is not there I suppose yeah absolutely the patient I'd have to say is a GP pills work a whole lot better if the person providing them is trusted yes yeah too late in the evening it's going to be throwing these things around so let's hear from each of you we'll start with you Scott with your reflections and summary I guess of what we've talked about tonight from your perspective okay thanks Steve um look it's it's great to be here to talk about this um OCD's been something I've worked in for a long long time um and look I think we're getting better um when I started um you know I think there were so many people with OCD who were coming in having had the problem for 10 20 years or more um we're still seeing those people but we're seeing a lot of people now coming in in their late teens early 20s um with you know much earlier so the the understanding of it's better um and I think we're doing better as well um so the the comment that someone asked about before as to how to get training in it is complicated because there aren't a whole lot of you know specific training programs I'd have to say that I learned a lot of my um uh understanding of how OCD works and ERP understanding for meeting self-help books and there's a couple of fantastic self-help books I think I've put it I've given a couple of links to some of them to two of them um the other thing that's worth thinking about is um you just got to talk to a lot of people with OCD that actually is a big issue um and just try and understand how it works for them and if you're interested go to a conference and but go to a specific conference if you really want to get OCD stuff sounds great now talking to people is obviously something you do a lot of Selene your reflections on tonight's conversation um I think like it's just so wonderful to be able to do this on such a large-scale forum um because I think you know there sadly isn't that much but as Scott said it is getting better and so I guess the biggest takeaway from all of this is to really try and think as holistically as possible in terms of not just from a treatment perspective but also listening to your client as well and making sure that your client is able to walk with you along that treatment journey and to not leave them behind um and to always make them feel safe enough to know that they're still in control of their treatment and they can still advocate for their needs no matter where they're at so I guess we have to remember to meet meet our clients where they're at in terms of what their needs are absolutely no thank you so much for that and Joanna the last last words from you your reflections well I just thank everyone for a lovely conversation bringing all our points of view and something I love about mhpn that we bring our diverse trainings and together we're something better together uh I I guess I was really struck as we were talking and seeing the chat box of the sense of the silent suffering of those with OCD in our community and their families and um so I I guess I I'm thankful for everyone who's spending time tonight listening and learning for the work they're going to do in each location where they're working or around the country I also wanted to say look I love the way that Scott put it that these are people with OCD and the way Celine said we have to formulate what this whole person's life story and their community and their their experience overall is and so we don't accidentally make the same mistake the patient is of the OCD becoming their focus uh so in each time we care for these people to remember that they're people who've got amazing strengths and who have worked out sophisticated ways of staying safe in the world for themselves and the people they love and uh that we have a role to help them see that there are possibilities for healing uh in on that journey and if some of that's up to us to go and get trained and I'd highly recommend trauma-informed practice in this space because it brings in the idea that life story relationships and our embodied experience are part of what impact our mental well-being and our relational well-being uh and so I would see some of the emotion regulation focus we've had in our conversation tonight could be directly attributed to some of the raising of awareness in that area about how our bodies get aroused and our perceptions get distorted and our sense of sort of arousal in in our altered perception of our world contained have experienced our lives and so those broad skills could they'd be used for your range of patients that include obsessions as one of the ways that they cope but also addictions and withdrawal and avoidance and all the other ways that people try to cope with being physiologically aroused and distressed in their world and I just loved being with the panel tonight thanks for having me what a fabulous way to finish so thank you so much indeed to our panelists and also to a very active group of attendees it's amazing how connected you do feel through this platform with the people the thousand people who are watching at home so please do ensure you complete the exit survey before you log out either by clicking the pie chart icon in the lower right corner of your screen beside the sewage bubble or wait for the message to pop up when the webinar ends now there will be a statement of attendance issued within four weeks and you'll also get the link to the online resources for the webinar within a few weeks reminding you about the various other activities coming up the cultural considerations in social and emotional well-being of Aboriginal and Torres Strait Islander children and families which is 10th of November we have trauma-informed care in older Australians on the 18th of November and generalized anxiety disorder 6th of December you can see the podcast program there as well and if you would like to join in with other professionals at a local level then please do contact the project officer in your area there's a map online there at the website or contact Jackie at the network's email address there so we're at 8.30 and before I close though as always and particularly tonight so we're talking so much about what it must be like to live with this particular condition I would like to acknowledge the lived experience of people with the condition and other mental illnesses and the people who care about them in the past and those who continue to live with mental illness in the present so thank you so much to everybody for your participation this evening I wish you all the best and I hope you have a really good evening and heading into the festive season I've got in first before anybody else thank you all very much good night thanks Dave thanks everyone thank you