​During my time as an intern at Cornerstone, I have learned a lot about OCD. Recently, in our intermediate Outpatient Program (iOP) the amygdala came up, and I noticed how often it comes up and how important I feel it is to discuss the amygdala when it comes to Exposure Response Prevention. When we are feeling our distress level rise, and we start to feel anxiety or panic, something in our brain tells us we are in danger, and we need to stop what we are doing. This is the amygdala, once we start to feel the need to start rituals/compulsions, this is OCD.

The amygdala is a part of the brain’s limbic system. The limbic system is deep inside the brain near the cerebral cortex above the brainstem. This is where the brain figures out our behavioral and emotional responses. However, the amygdala is key to how we process strong emotions, and form memories, usually related to fear. The role of the amygdala is to keep us safe by alerting us when danger is near. The amygdala is there to protect us. However, it is easy for our amygdala to get confused. 

When our anxiety level raises and we approach level five and above we tend to get frightened, even though it doesn’t feel like it. During these events, our amygdala stores them for later as a fearful memory, when we are approached with the same situation, or one like it, our amygdala puts out a red alert. The issue here is the amygdala cannot tell the difference between real dangers out in the world versus our internal fears. This is why self-awareness is so important!

Hello! Let me introduce myself; I’m Cecilia Garrett, but everyone (even my mother) calls me Ceci. I am excited to join the team here at Cornerstone OCD & Anxiety in a dual role as Clinical Director and as a clinical social worker. I just earned my MSW in clinical social work from Campbellsville University in Kentucky this May.
 
Although I’m a new graduate, I am bringing with me nearly a decade's worth of community-based experience with seniors, housing relocation, and nonprofit management related to hoarding behaviors. Additionally, I have extensive experience in practice management and entrepreneurship. I founded a nonprofit in Spokane, Lightening the Load, which was a faith-based organization that offered paraprofessional-led groups and in-home coaching to individuals who self-identified as having hoarding behaviors.
 
At Cornerstone, I’m going to be working to strengthen our team, services, and to build our new group of programs called the Hoarding Wing. You may be aware that “Cornerstone” is an architectural element, so we have decided to stick with that as we named the new hoarding-focused programming, hence the Hoarding Wing. Our OCD-focused services include intermediate outpatient groups called “Foundations.”
 
Why a wing? Why not just a room?
Hoarding disorder (HD) is a unique disorder because of the environmental impact that surrounds those who fight valiantly against the unhelpful beliefs (cognitive distortions) that tend to underpin HD. Often the first contact is from a concerned family member or friend. Adult children and spouses often spend decades attempting to get their parent/spouse to admit that there is a problem or to seek help. Family members may be overwhelmed and lack the resources and training to help. 
 
We desire to view HD through a holistic lens, looking at the individual with HD, their needs, as well as those of their family members, housemates, and even community. Although skilled mental health treatment for HD is a necessity, addressing the impacts of HD may include working with family members to heal trauma wounds, make repairs to housing, or advocating for extensions to stabilize housing or stop eviction proceedings. 
 
We recognize that the environmental impacts that often accompany HD as well as symptoms of comorbid disorders that many with HD endure means that compassionately and professionally dealing with hoarding means creating programs for loved ones who have been affected in addition to those that support and treat the individual with HD. As a result, we are planning programs for families (and adult children specifically) impacted by HD. We don’t view families as part of the problem, but as a helpful addition to addressing hoarding holistically even when that means first, we must address the wounds and relational ruptures that co-occur in these families and relationships.
 
Additionally, HD has a unique outcome that has often been sensationalized by the media; even when the person with HD is removed from their house, evidence of the problem remains. Clutter. Sometimes that clutter is so severe that it becomes more appropriate to call it squalor. It is important to clarify here that clutter is an external symptom. Clutter is just evidence, after the fact, that faulty cognitions spurred on by strongly held personal values have positively reinforced new acquiring while anxiety has stopped the process of dissemination, redistribution, or letting go of acquired items. 
 
Things—like newspapers, craft supplies, tools—are unable to act on their own. Thus, the problem lies within the person and these person-centered behaviors act upon the environment. It would be so much easier if the physical symptom, clutter, were easily resolvable without the person present and invested in the process. Successful change requires us to remain vigilant that the challenge lies within the person even if it manifests itself so tangibly in the physical environment.
 
Treating the person with HD focuses then on two very separate fronts—internal thought processes and externally obvious behaviors. Attempts to deal with either separate from the other are generally unsuccessful. Removing the person and clearing out the accumulated possessions is a temporary fix at best and often results in the new intensified acquisition of possessions. The cost of such cleanouts is exorbitant. 
 
At times, individuals, families, and communities may be forced to engage in such cleanouts due to personal and public health and safety issues. We reserve these levels of intervention for those exceptions; most individuals with hoarding behaviors exist with lower levels of clutter and should not be approached with an aggressive style of intervention. For these individuals, specialized treatment that is based upon cognitive-behavioral therapy (CBT) is a viable option to help them take on unhelpful beliefs and begin to choose new responses and behaviors.
 
It is our hope as we plan and design services to address hoarding to give equal weight to those impacted by a loved one’s hoarding as we do to treating those with the diagnosis of HD. We believe that the best outcome requires us to see the unique challenges of family members, offer care to the person who is seeking services. Ethically, we cannot treat someone who is not seeking help. Relationally, it is essential to hear and validate the multiple experiences of those impacted by an individual’s hoarding. 
I am trained in both the specialized form of CBT for treating HD in the individual as well as in EMDR for dealing with traumatic components that may impact this work. Additionally, I am pleased to offer EMDR to adult children who find themselves experiencing symptoms of depression, anxiety, and other lasting effects of growing up with a parent with HD. In time, we will be offering group counseling for individuals and family members. 
 
Imagine trying to stuff all these elements into a single room. It would be too much! So, we believed it was necessary to call hoarding-related services something larger. Welcome to the Hoarding Wing!

Motivation—I know, it is something we all want, yet seldom have, unless you are David Goggins. When you hear the word motivation, you may roll your eyes and say, “yeah, yeah, I know it’s important for work or losing weight”. But, motivation can be used in a multitude of ways and it is really important when talking about therapy and OCD treatment. In exposure-response prevention therapy, your therapist is asking you to sit in the distress and face what you fear, not exactly what the layman envisions when seeking help from a psychotherapist. 

If you are reading this post, you may not know it, but you used motivation to seek out help. Individuals with OCD or anxiety spend an immense amount of time, energy, and brainpower to contain the unwanted thoughts, feelings, or behaviors that they fear. Why not divert that attention and energy to therapy, to physical health, to overcoming your anxiety? 

You may be yelling at your computer screen saying, “it is not that easy! You make it sound like a piece of cake”. And while it may sound impossible to find the motivation to intentionally be in pain with exposures, you already have the energy capable of facing the fear. Let us start simple, what are the different types of motivation?

Motivation can be categorized into two main types: Intrinsic or internal and extrinsic or external. 
Intrinsic motivation is when individuals do something because they are interested in it or enjoy it. The reason you are doing the thing is that it comes from within you. The outcome of intrinsic motivation looks like joy, gratification, relief, or a sense of competence. An example of intrinsic motivation would be if you enjoy dinosaurs, so you teach yourself about the intricacies of dinosaurs. 
Extrinsic motivation is when individuals do something because they are told to do it, or they have the need to achieve a goal, want to get a reward, avoid a disadvantage, or want to gain power or affiliation. An example of extrinsic motivation would be doing an assigned chore because your parents said that you would be grounded if you did not finish them. It could also look like losing weight because you want the attention of others. 

There are positive and negative motivators, but you can use both in treatment. A negative motivator in treatment could be not wanting sores on your skin from picking or washing your hands. It could also look like a fear of being alone because your partner does not want to marry someone who is constantly checking the door. A negative motivator could be a fear or a threat, but it can be reined in during therapy. Do you want to suffer from intrusive thoughts for the rest of your life? No. So what should you do instead? Do your homework, do exposures, exercise, eat relatively healthy, socialize, sleep, drink water. All these tasks contribute to the well-being of your treatment. 

A positive motivator in treatment could be giving yourself a goal of doing ten exposures in a week and rewarding yourself with an ice cream date. An intrinsic positive motivator example is seeking the satisfaction of reading the entire Grayson book for homework.  Positive motivators are great because you are motivating yourself to do something you may not want to do or maybe painful, but you are doing it for something that feels good or makes you happy. 

How do you become motivated to overcome OCD, anxiety, BDD, etc.? 
The great thing about motivation is that it can be increased by a few small tasks. Some ways to increase your motivation are: 

•Start small – do not shoot for the moon when you do not have a rocket ship. Create attainable and measurable goals/tasks to achieve. 

•Connect to your values- reminding yourself of values is a crucial component of motivation. Values can be family, friends, faith or it can be valued taking care of yourself or valuing being a kind human. When you wake up less motivated and it is raining outside and your goal is to go on a run, how can you get motivated? Review and get in touch with your values. 

•Reach out for support—if you are feeling alone in your therapeutic journey, reach out to a friend or your family and ask if they would be willing to come up with some exposures for you to do. Asking for help is an important aspect of therapy and advocating for yourself

•Accountability—accountability can look like multiple things. You could have an accountable friend to who you report; your therapist can keep you accountable for doing homework, or you can keep yourself accountable by keeping a journal and tracking progress. 

•Expect life to throw hurdles your way—Life has a funny way of keeping us on our toes. If we can expect and prepare for hurdles that will inevitably show up, we will not be surprised or taken aback when they do show up. Instead, we will be prepared to tackle the hurdles. 

•Celebrate wins!—it can be inherent to focus on the failures or setbacks and ignore the wins. Remember to celebrate even the smallest wins. Share your success with others, treat yourself, recognize the accomplishment and remember what the win feels like to know you are moving in the right direction. 


If you find it difficult to motivate yourself or you are having a really bad day, look up motivational videos on Youtube. Here is a good one:

​During a lecture given by Michelle Craske on inhibitor learning, she states, “extinction is really the inhibition of one threat expectancy association with another new association that’s not involving threat.” The primary mechanisms involved in inhibitory learning are the amygdala and prefrontal cortex. State of the art research concludes that fear extinction is a result of the prefrontal cortex successfully inhibiting the amygdala. Anxiety is correlated with the inability of the prefrontal cortex to successfully inhibit the amygdalae. Improving ways in which individuals train and acquire inhibitory learning skills remains ongoing.

Intentional behavior characterized by motivation in alignment with individual values (as opposed to somatic dictates) evidences the functionality and engagement of the prefrontal cortices which serve to contextualize (and perhaps thus extinguish) primal fears within abstracted frameworks. Many clients regard growth as a value and element of health, although abstractions like “growth” are difficult to measure. The model of consciousness proposed by Dr. Michio Kaku could serve as a template for understanding how conscious states ranging between spikes and inhibition diverge and exchange.

Dr. Kaku’s model of consciousness distinguishes between three neurological systems (reptilian, mammalian, and human) that process sensory data at different levels of abstraction and complexity. The “reptilian” brain corresponds to OCD research into the amygdala and limbic system. Further analysis and research into how the prefrontal cortex processes information could potentially advance our understanding of how creative regions in the brain inhibit more automatic ones. The culmination of this research could potentially help illuminate how the prefrontal cortex inhibits the limbic system through CBT and ERP treatment. That research suggests the development of the prefrontal cortex as relevant to how clients learn to override and extinguish fear-based inputs (i.e. inhibitory learning) makes sense. Effectively treating OCD may involve the engagement of abstract processing which contextualize exposures and distinguish various thought patterns.    

​Being halfway through my second month at Cornerstone and writing this blog-post; gave me an opportunity to reflect on some of the writing I did as part of my application process. The subject matter came out of videos and interviews of people who are actively engaged in the ERP lifestyle and those that are in early treatment. Now, my perspective on OCD continues to be on how challenging treatment is the daily work that goes into recovery. 

Every session and supervision session I participate in is a reminder of how much work goes into recovery for clients. And there are a couple of fundamentals that I keep coming back to as a reminder. An important foundational piece for my understanding is the difference between trauma anxiety and intrusive thoughts and OCD intrusive thoughts. Trauma intrusive thoughts are those of experiencing or witnessing, things seen or done (I think of it as thoughts from the outside). With OCD, the thoughts come from the inside, without an experiential component. Metaphorically, from out of nowhere with little or no warning. 

Living with uncertainty is something we all do; life is a series of probabilities. There is an X percent chance that a plane will crash, a Y percent chance that a road trip will end abruptly because of an accident. But we still take a plane to Europe or Asia for vacation and the car to the theatre. We do not calculate probability; we just do it consciously or unconsciously, accepting the degree of uncertainty or ignoring it completely.  OCD is the quest for the grail of certainty that can never be found. For the client, the grail is the acceptance of uncertainty.

Being witness to Exposure/Response Therapy is humbling. To be with a person or group that intentionally situates themselves in a position of anxiety, a degree to which they agree beforehand for a specific amount of time is inspiring. And in the words of a therapist from one of the videos “…it’s almost unbearable to watch.” Fortunately for me, I also get to see the results over time when clients are living the “ERP Lifestyle” and how it is worth the time, energy, and struggle for the result. It is a privilege to be part of the quest.

I am not loving how tired I am right now. One little thing and I'm spent. Never a better time to make some of the big changes we need to make around the old office.

As of today I'm planning to take two weeks off of work and let all the fabulous people I've gathered around me to take really great care of me and my clients. I think this will allow me to make my commitments to the interns and associates for their supervision. If you told me a year ago that I would have confidence in my staff to this measure I would not have believed you. I have such faith in their office and counseling skills. Please trust them like I do!

At this time the best help you can give me to recover from Covid is to transition your care to one of my staff therapists, associates, or interns. Covid has shown us that we can work remotely and that insurance companies can be flexible. Work with our office and please consider one of these options.

Option 1. Since we are a teaching facility, this might be a great time to transition your care to one of our interns or associates who are under my supervision. They all have open schedules, and some are able to take insurance.

Option 2.  Sign up for our next Intermediate Outpatient Group (IOP).  We have had such success with out Intensive Outpatient Groups that we are restructuring them to be less time commitment but still have the same program and successes we’ve seen in the current IOP. 

Sometimes we rest and sometimes we're forced to rest.  These changes aren't really new for us but just moved up in the timeline.

Thanks for your prayers. I'll post here to keep you up to date.

Just getting back from the Annual IOCDF Conference and I am, once again, blown away by the whole thing. It is so hard to put into words the feeling that I get while I'm there.
I see people do miraculous, courageous, ridiculous stuff every single day. I am constantly in awe of my clients' ability to confront intense anxiety, take it on, and then thoroughly defeat it. The strength it takes to daily live with this level of anxiety is mind-blowing.
But then you go to the conference. WOW!! I know it can take weeks or months to get into see me or one of my colleagues. I know all of us who treat OCD commiserate about how there is only one of us to go around, and how devastating it is to tell someone they're going to have to wait. And then you meet people at the conference who literally have no therapists who treat OCD in their state, or who have only just this month figured out it is OCD. And there here!
Making the trek to another state is incredible. But the magic that happens once they arrive and are among "their people" is even more incredible.
I recall Jon Grayson once explaining that a client can ride the wave for a year after the conference. I don't doubt it.

And I am SO excited that the 2020 Conference will be in Seattle!!!  What a blessing. I have been looking forward to this for two years. I can't wait to welcome all my OCD-related friends to our home town. I can't wait for all my clients to experience what just a few have been able to see.

Most healthcare professionals do not understand obsessive compulsive disorder. Graduate schools do not go into great depths in diagnostic courses to shed enough light on this complicated disorder. An OCD specialist learns to evaluate a new client using very specific questions, surveys, and symptom checklists. For a variety of reasons many people go misdiagnosed for years before finding adequate help or giving up.

Most of my clients who suffer with OCD are functioning in the world, but life is difficult. Not only do they spend most of their days fighting distress, they venture to hide it. I find it rare that my clients announce their OCD in public to explain their behavior. I might be generalizing but I think those who excuse quirky behavior by saying “I’m so OCD” really do not have the slightest idea how terrible OCD really is. Everyone has unwelcomed or intrusive thoughts. The intrusive thoughts OCD brings are accompanied by intense anxious or otherwise distressed emotions. The need to alleviate those emotions is the driving force behind the compulsions.

Most of my clients are aware that their compulsions don’t make sense. House fires rarely start from the toaster left plugged in. It is nearly impossible to know if refraining from washing hands after touching money will make someone or their family member sick. Tapping the table a certain way will not save lives. Looking at knives will not compel stabbing a loved one. Stepping on cracks will not break mother’s back, and yet very few of my clients will step on cracks.

The distress is real. It is intense. The urge to do compulsions is overwhelming. The statements, “I have to” or “I can’t” are true. The inability to refrain from compulsions is not a lack of will power or a character issue. The fight-or-flight response in the brain is a biological process. No amount of logic works when the amygdala is engaged to stay alive. And the amygdala is not aware that crooked wall-hangings will not kill us.
​
There are as many manifestations of OCD as there are sufferers. A common thread for most OCD is the need for certainty. When we treat OCD we ask clients to embrace uncertainty, and to be willing to accept distress. This is a difficult and very important decision for clients as they start treatment.
Clients who find the most success reaching management or remission of OCD are those who comprehend exposure and response prevention, engage in therapy, do their homework regularly, and include medication .