Ask the Experts

hello hello hello hi welcome everyone today is Wednesday May 1 it's the first day of May uh for us Millennials it's gonna Bay May according to Justin Timberlake so that's uh always the today's the day that you can uh play that obnoxious meme to death um so I I kind of hide from the internet until tomorrow because I'm like I really just don't want to see that Meme Over and Over that's back when he had his ramen noodle hair which kind of freaks me out uh a little bit so we're definitely definitely gonna gon to skip on that but it's May um it's Taurus season I'm May 26 birthday so that's Gemini season so may is a good month it's also maternal mental health um so you know that's super important in the OCD space we know that perinatal OCD is a time that really impacts um women with OCD so happy maternal mental health day um and I'm excited to be here so we're gonna to do a little bit of housekeeping stuff and then I'm going to introduce my guest Liz mcinville my co-host uh will definitely be here she runs one of the busiest OCD residential so sometimes she gets called to emergencies the ocdi in Houston Texas but she'll be on in a second um but just to get some housekeeping out of the way so this is one of the live streams we have live streams twice a week um consistently so Tuesday evenings at 4M my time 7 pm on the East Coast where Mona and Cat are and then on Wednesdays at 9:00 a.m. on the west coast and then 12 noon on the East Coast where Mona and Cat are um so this one is we have lunch and learns today is an ask the expert so we're really bringing on people that can sort of give you information whether you're a new clinician or a seasoned clinician you're a parent or loved one of somebody with OCD where you have OCD and anxiety yourself we always try to bring you different experts to talk about different aspects of the disorder and the treatment or and today's no different so we're excited to jump in before we jump in we always have to talk a little bit about housekeeping so this live stream is really intended to be educational we want to give you resources Community Education and hope what we can't do in this capacity is be a crisis center so if you are in crisis please make sure to dial 911 go to the the nearest um emergency room or you can dial 988 or go to 988 lifeline.org so those are ways that you can get safe and make sure that you uh connect with your clinician as well and then lastly this is being live streamed and recorded on mult platforms if you come in late or you want to share this with someone you can go to youtube.com iocdf where all of these are uploaded along on the ocf Facebook so we're gonna jump in so I'm gonna introduce my guests so first do you like Katherine or cat better uh let's go with cat okay sounds good that's my initials by the way just not a very exciting little fun fact but that's why I chose cat for sure for sure all right so Katherine AK cat Boger pH D abpp is a board-certified Child and Adolescent clinical psychologist who has devoted her career to helping children and teens with anxiety and obsessive compulsive disorder she is passionate about improving care for youth with these disorders and decreasing their suffering through Innovative research-based treatment approaches in 2013 she co-developed the mle anxiety Mastery Program MP at McLean Hospital nationally recognized for providing empirically supported in ensive anxiety and OCD treatment she also served as an assistant professor in Psychology at Harvard medical school and has published peer-review Journal articles delivered Regional and National talks including a tedx talk and provided training to hospitals schools and the community she is the author of a children's book step by step about facing fears and being brave in 2021 Dr Boger am I butchering your last name no you're doing great a lot of people try to say B and but he it well that's where I shop at tar so I was almost going to say B but I I wasn't feeling too bougie um co-founded instride Health with the mission of increasing access to insurance-backed research-based care for children adolescents and young adults with anxiety and OCD so welcome welcome welcome to the stream cat thank you so pleased to be here I am happy to have you as well and then Dr Mona Potter is the co-founder and chief medical officer of instride Health she is board certified child and adol ENT psychiatrist with two decades of clinical and training experience in the Mass General mle Hospital System she has worked across all levels of care and with the range of diagnostic presentations and has developed a strong appreciation for the incredible impacts the right treatment and support can have on pediatric anxiety and OCD immediately proceeding in stride she served as an assistant professor of Psychiatry at Harvard Medical School medical director of mle Hospital's Child and Adolescent Psychiatry outpatient services including the McLean anxiety Mastery Program associate training director for the MGH McLean Child and Adolescent Psychiatry fellowship and is on the leadership team for the mle institute for technology and Psychiatry building on her experience and expertise not only as a Child and Adolescent psychiatrist but also as a parent Dr Potter was motivated to co-found in stride to improve access to insurance-based care that works for Pediatric anxiety and OCD welcome welcome thank you my my vocal cords got to work out there yall doing so much making me look like I have nothing going on in my life thanks a lot no as I was listening to you I was thinking we GNA shorten our bios a little bit yeah let's do some cutting we have we have some talents being concise might not be one of those cat it's all good well we're super excited to have you like I said it's always good having different experts on to kind of share with us you know just what options are out there I mean I think first and foremost so many people are in areas struggling to find care struggling to find higher levels of care um so that's super important so one of the things I want to start at is you did talk about in stride having an intensive program can you tell people watching a little bit what is an intensive program and when does somebody need a higher level of care what are some of those signs whether it's a clinician that should refer out to a higher level care or a parent or a person with OC that might benefit more from a higher level of care I'll jump in there you know I think that the the traditional once a week 50 minute model it works for many people and and it can move the needle I think that when anxiety when OCD reaches a certain level of severity so the level of impairment in somebody's functioning has gotten to a certain point it can be hard to get Traction in that once a week model and so if you think about you know the care we provide a CB with a big b meaning the behavioral piece is really what is driving the outcomes and there's so much of an emphasis on exposure work and when a kid for example is not attending school when they're not interacting with their family when they're not engaging with peers doing their extracurriculars because of the severity of their symptoms coming into session talking about the week planning for the exposure doing the exposure somehow magically getting out in the world and having that exposure you know then generalized by being in a store being in a school Etc and then processing is incredibly hard to do in that once a week model and so um with intensive treatment what we're doing is providing multiple touch points a week of therapy and so this is a lot of exposure work the cognitive work the emotion piece um doing that out in the world we provide exposure coaching to help generalize the learning and help engage kids in the care help them practice their exposures in multiple settings uh groups and then so that kids feel less alone and they have other kids who can kind of cheer them on talk about their experience normalize and then Med management so the idea being that you're really getting wraparound care your providers can work together uh to help you get back on track more quickly and really build that momentum because for a kid or a teen who is struggling at that level they've really fallen off the developmental curve the losses start building up quickly so the sooner you can get them back on track the more you can build that momentum the more you're staving off other issues down the road well said and Mona can you tell us a little bit about in stride where you located what are some of the services you provide and what is the treatment approach that you all take there yeah so um so in stride just cat and I were just talking this morning um we we we work together at mlan um for what was it cat um 12 15 years before co-founding in stride and when we first started um at mlan in our anxiety program there we had this vision for saying we just want to be able to just make sure that anybody and everybody who has anxi who's who has an anxiety or OCD diagnosis gets the treat gets kind of access to treatment that they need and um and what we found was that um that be that in an academic center um you're able to to provide really great treatment but what we were finding people were having to relocate in order to get that treatment or people were having to pay out of pocket because what we were doing was a little bit different from kind of the traditional feif for service model um and so we built and stride directly from kind of what we were seeing on the ground and what we where we felt there was a gap knowing that there's incredibly effective treatment that again as cat was saying that exposure based treatment really makes a difference um not getting the right treatment um also like it it's can be devastating um and so for us this is absolutely something where we want to make sure we're doing right by every child and family we're pediatric um clinicians and so again we think about the CH the child teen young adult who comes to us but also the system in which they work or in the system in which they live so um we've built and stride as really what we call a systems based care cat kind of described it it's um we work with kids teens young adults age 7 to 22 who were diagnosed with with anxiety and or OCD oftentimes they they go hand inand and um we we use a evidence-based treatment CBT at our core with um with again a big emphasis on that behavioral aspect making treatment very active oftentimes what we see is that it's very easy to talk about what we're going to do differently and talk about the the pain that it causes the losses that happen and there is a supportive aspect to that but the change really comes with showing that that brain showing your brain that um engaging in those things that are uncomfortable or engaging in things that OCD tells you you cannot do actually helps create that dissonance between what is true and what OCD is telling you and actually helps shift the behaviors helps you move towards the life that you want to live rather than the life that OCD is kind of causing leading you to live um and that's just easier said than done so it really is about that intensive phase being like we are in this with you we are all together we know how hard it is you are highly motivated for a different life um and actually following through on the things you need to do to do it is really hard and so that's where having not only that therapist like that therapist support teaching you and working with you hand inand but also that coach saying I'm holding you accountable like I'm G to cheerlead I'm going to make sure that you don't feel alone through this and um i' would say that the Psychiatry piece is like I'm a psychiatrist um traditionally it's like oftentimes like we're all just busy and it's really hard to coordinate and so I would have somebody come to me and say it's just getting worse I I don't know and my tool is a medicine and so it's like well here let me give you medicine so oftentimes we see kids coming in on lots of medication with um and it's hard to know what's been helpful or um and so for us it's a really talking about the medication as helping you access the the treat the therapy so we're trying to dial down that intensity of the emotions intensity of the OCD so that you can engage in those approach behaviors you can engage in that in that exposure work and taking the feedback from the therapist and Chris you should interrupt me because what we I I once I get going I just go well have a couple no no thank you so much for the information I was gonna say one of the things that you spoke to you know as somebody with OCD um I always think the way that I think of the C and the B and CBT is I've always felt like you know looking and reflecting back on my treatment I always felt like there needed to be more of a cognitive piece I think my my OCD was so intense to the point where logic was out the window I mean I one of my fears was getting drunk and I might lose control and harm someone and I remember one time just driving by a billboard for Kors light and thinking could I get drunk from that and actually pulling over and sleeping in my car to sleep off the alcohol right so I think cognitive is so important but I like what you said about the emphasis on B because to me what b stands for is like you're backing it up like you're putting your mouth you know your money where your mouth is ex ex agree that and when I first started um with treating OCD I would get in all kinds of back and forths with that the irrational like like let's let's catch that thought let's check it let's change it and I'd realize I mean kind of similar to substance abuse like motivational it's like the more struggle you get into the more that person is feeling tied to those thoughts and it's like oh my goodness I got to stop doing this struggle here and like let's absolutely identify when OCD is showing up when OCD is telling you um like is interpreting the world for you and um so I'm multaneously I can't I it's not my job to convince you it's wrong it and there are ways in which it is trying to protect you and so it's messy it's messier than sometimes we think it is and that's why I think that behavioral piece the action oriented part is an important part to go along with that that cognitive well the prettier half of the hosts of this show just arrived hi Liz hi y'all so sorry I'm late so happy Chris could get started today um I'm so excited for this live stream so sorry that I'm hopping in a fourth of the way but um really excited to be here yeah one thing I wanted to ask you cat we got a question early on and I think this is good for a lot of people because they hear us talk about like a lot of our centers treat both OCD and anxiety and so we got a question Amanda at 1202 from Dr Hassan who said is it common to have OCD and general anxiety disorder together what is a PR Pro prognosis in such a case so do you see both of those arrive at in stride and other treatments centers and what is the prognosis and how is it different yeah no it's a great question and so the the short answer is yes we we see a fair amount of comorbidity OCD with a variety of anxiety disorders Andor depression and I think the good news is that we take a trans diagnostic approach and so instead of saying we're going to have one protocol for OCD and one for Gad and one for specific phobia and one for separation Etc and that could just go on and on and on we have a trans diagnostic curriculum where we're hitting on core mechanisms so we're hitting on cognitive inflexibility emotional avoidance behavioral avoidance with all of our interventions and because we work with kids and really specialize in moderate to severe we also have complicating factors de so we recognize when anxiety when OCD gets more severe that um they're going to other complexities for example School avoidance then we want our therapists to be equipped to both use a trans diagnostic curriculum but also have the understanding of how would you navigate this case in light of the fact that this kid has been out of school let's say for six months totally and I would love for some of our viewers if y'all can just explain what trans diagnostic means just because some some of our viewers are not clinicians and um would be so useful for them to understand because the reality is is not just most of our viewers but most of the patients any of us treat especially when we're treating you know above moderate levels of severity they carry multiple diagnoses yeah no it's a great question so essentially it's crossing different diagnostic presentations and our trans diagnostic curriculum crosses the anxiety disorders and OCD if that makes sense and we do do a comprehensive clinical evaluation up front and really what we're understanding there is like what are our primary targets specifically when it comes to exposure so when we're building that fear and avoidance hierarchy what are going to be the Target on that on that hierarchy or hierarchies because often we know that kids can have multiple uh hierarchies but at the end of the day we have the sort of the same core component so we're doing for example the cognitive work and we give options of are we going to go for this kid in a more diffusion route are we going to go more in reappraisal route and for some people there's actually for example with various anxiety disorders it's helpful to have both approaches and they kind of choose in the moment but everybody gets mindfulness everybody learns how to just sit with and be with their emotions for example and exposure is a given yeah oh go on no I was just gonna say you know I think two things I wanted to to mention based on kind of discussion so far and the first is that you know every diagnosis has an evidence-based intervention and it's really important for our listeners that you know we we've talked a lot about this we've talked about how do we differentiate how do we know where to start how do we know which intervention to use but this is so important because actually like even if a patient is living with Gad and OCD treatment looks similar but it also has some very different components right and the way the way we approach it the way we focus on response prevention for OCD right all of these different things play a big role and so it's really important I always tell everyone that you do want to really spend time in that assessment phase to understand what is my presentation right what what does my disorder look like and as somebody you know we run obviously a residential level of care for adults we sometimes learn more and more two three four weeks in right two weeks in three weeks in we're saying hey there's also this going on and like let us like further assess for this and understand and so I say that just because you know I'm curious how often you guys bring on a kiddo you or an adolescent not Kido necessarily always but you bring bring on somebody that you're like okay this is what it looks like but maybe two three weeks in especially in intensive treatment how often are you saying hey like this is also coming up this is treatment interfering and we need to make sure you're getting treatment and focusing on this it's such a great question too because part of the treatment process is building awareness and so I think we have kids who come in and they're actually not aware of the different ways in which their anxiety manifest or the O their OCD manifests and so as treatment goes on uh the awareness increas increases the family's awareness increases so absolutely our conceptualization will shift we do at the outset a really comprehensive conceptualization where we're identifying what are the contextual factors in the family what are the diagnoses what are the goals and specifically what are our targets for the patient and targets for the family I think that oftentimes that family piece can be missed and when you work with kids and teens it's really important to get everyone aligned around where you're headed why you're headed there what matters to this specific family and how are you trying to to move the needle and then you can keep reevaluating as you go I would love to hop into that because that is my next question is tell us about family involvement what's it like in y''s treatment model and also just with your background and experience talk a little bit about why it's so important and why families need to be actively involved in treatment because what we know is that especially for the age group you're treating right you can't treat the the individual not treat the family system that they're part of yeah I I'll say a couple things and then cat I this is this is your jam so I'll I'll let you take over but um the the family piece is the part so when we were first developing this program at mlan that was the piece that we enhanced and added more than any other component of our treatment and even when you look at the research I mean that that family involvement again that system that that environmental piece and how that environmental piece interacts is so important um and as a parent I'm sorry I mean it's like when your children are really struggling your own mental health like there there's also that own kind of how am I doing and what am I modeling and piece of things and um and when you have multiple children what works well for one child might not work as well for another and so so again there's so many different reasons that that we highly value that that parental piece in there yeah I would just add that the care we provide is purposely Tim limited the idea being that we are not trying to create Perpetual patients kids who are like I'm going to be in therapy for the next 10 years instead our goal is to give kids give the system surrounding the kids give the families give the schools a new way to respond to the anxiety and the OCD so we're really activating that environment so that Beyond instride they don't need instride they're their own care team and they know when they have those you know bumps in the road because the road to recovery it's it's bumpy so when they hit those bumps both the child but also the family knows how to respond in those moments how to be effective and they also know to just expect those bumps that those are going to be a given in the process so everybody is not up in arms when they encounter the bumps so I can I can tell you how we work with families if that's hopeful uh so yeah that'd be great yeah we include families on multiple levels so we have H an initial parent and caregiver skills group so it's an eight-week group and we're teaching the fundamentals so we're teaching about validation about removing accommodation about labeled praise Etc and then beyond that we have an ongoing parent and caregiver Practice Group because as a parent myself I know it's one thing to talk about the skills and strategies it's a whole other ball game to try to implement it is messy it's really hard Extinction bursts are brutal and so the idea is that you can then as a parent come back to group and say all right I tried this thing this part worked this was really really hard and messy what feedback you have and both a group leader but then also the other parents and caregivers can give support because I think when you're a parent and your child is struggling it feels it's really isolating you feel like you're the only one and so having encouragement from other people is so so powerful and just having those like reminder tips you know like I always tell people guys like I'm a behavioral therapist for a living right this is what I do it's what I live and breathe and like I need help with my kids you guys I just I just rehired a sleep consultant this week because three or two three-year-old oh we transitioned to a big kid B and I thought I was gonna die and um it's funny like Granite I don't need as much like we had one meeting and like we are good to go because she's like well you're just following everything I said I'm like yeah like I can follow what you tell me I'm a behavioral therapist but sometimes like even those of us that know this we're trained in it you it is so hard when we're talking about your own child crying and screaming and anxious and shaking in front of you for you to like know exactly what to do so I I love that they get those skills but then they also have opportunities to re-engage as needed and to come back and say okay I'm stuck with this one or here's a new one OCD through at us can you help guide me yeah there's nothing that brings up our own emotions like our kids right it's one thing to to think about applying skills when everything is like cool and Cal it's whole another thing when we're in Emotion mind and now we're trying to remember what was that skill or strategy because it's out the window what one of my kids had a tonsil surgery in the last two weeks and I teach validation every day I like was tired overwhelmed and this morning I like skipped right over validation I went right to like you're okay you're fine I'm like what am I doing I teach the opposite again I I think that's where it's really helpful to have not only the reminders the accountability but just some peer support and recognizing this is hard and we're all doing the best we can 100% and you talked a lot about family involvement can you talk about we we get a lot of newer clinicians that's who I get a lot of messages from that watch the live streams for newer clinicians what are the differences I mean your program really focuses on child teen adolescent OCD and anxiety um for clinicians or for psychiatrists what are some differences maybe than treating the adult population what are some things that your program does different to cater to that age range yeah I mean I think the family component is is a big one but I would say the school piece also so these kids spend a lot of their day in school and um and that's another place where it's great opportunity to practice the new skills uh because what we see oftentimes is um school people wanting to be kind and and supportive and and build good relationships and in that context they they help with the avoidance which as we know really might might make things feel better in the moment but actually perpetuates and and kind of strengthens the OCD in the long run so it's it's kind of teaching and and encouraging uh kind of something that doesn't quite feel right from a relational perspective and um so a lot of times we'll get kids coming into us who are who are um having a harder time engaging in school um either because they'll either go and spend a lot of time in the nurses clinic or in the guidance office office or texting parents to say bring me home or ultimately having a hard time even getting to school and um and so there's a lot of work we'll do with with the teams at school to say all right here's here's what I mean to the your point was here's our assessment of what's happening and here's what we all need to do even though it doesn't feel kind in the moment um if we're all on the same page and I'm doing this deliberately this is this is in the long run much Kinder um so that's I would say a huge Point piece that um is Central to to what we do the the other piece I would add is that when you're an adult going into treatment you're making that decision because the struggle is big enough that it's worth it for you to take the time to meet with a stranger to open up for kids they often feel like it's like parent mandated when they're going into treatment this is not their first choice there are a lot of other things they would rather be doing and so similar to to work with adults we have to make it meaningful to them and for for kids that can mean something different so of course we're connecting with kids around their values around what matters to them we also take a strength Spas approach so we're identifying like what is really cool about this kid what makes them you know what what matters to them and what are they proud of and we're really connecting around those things and then I'd say we try to make it very active so it's virtual but it's not virtual like what we're all doing right now this is like I mean I was going to say this is stagnant this isn't stagnant because this is a fun conversation that's okay dang we just got got stated on our own show that that hurts take them off the list of guests yeah you can take me right off right now just he's like it's not as boring as this live stream we do fun stuff this is a super engaging fun conversation and with these kids we have them put their their headphones or their earbuds in and they're out in the world or maybe they're shooting baskets with their coach virtually or they're going for a walk or they're doing their inter receptiv or they're in school reaching out to their coach because they're having a panic attack in the bathroom but it's really active it's really engaging and they're they're interfacing with their fears out in the world they're not just in the office talking about it yeah which I I love so much you know and I think that um this leads into a few questions I want to make sure we cover and then we have a lot of live questions so I'd love for us to hop to those so that we can make sure we get to those but you know I think that there is so much belief that oh virtual is just like this boring computer where it's actually like no virtual is like when we can't be in person doing active exposures together we can now do that virtually and that's so incredible right a lot of clinicians don't have the flexibility to be able to go into the community with their patients and do those sort of things where you guys can and that's awesome so I want to talk for a second about y'all's program and then ask a couple questions because um for all of our viewers there's a couple reasons I wanted to make sure that both um Mona and Cat were on today number one is they are incredible they come from you got everyone on our program that you know we all know about mlan we know about McLean's background and history and and their incredible programming and you know obviously in the OCD world right first ever OCD Institute was developed by Michael jenck and Diane and Denise over at mlan and you know there's just so much that comes from there so we know you guys I told cat this I was like I know you're a sound incredible clinici which is amazing but this is one of the first programs I know of if not the only program that I actually know of that does evidence-based intensive virtual care for OCD that accepts Insurance that's really OCD and anxiety specific and there's a couple things I always tell people number one you have to be with a trained clinician who really has training and background not somebody who went and did a three-day training like yes that's great that's better than nothing but if you need more intensive treatment I want you asking where was someone trained what was their background what was their experience have they had experience with a more severe population right that's really important um and number two right are they doing evidence-based treatments right those are those are some of the big things and so I am just so excited to be able to talk to our community about not just your program but also the fact that you guys are in that work and that this is an intensive option available so I would love for you to just tell us like who you serve how people can find you guys and of course like what insurance and payments look like because one of the things we get is that many of us myself included have not had the um the luck if that's what we want to call it h to be able to accept Insurance you know unfortunately Insurance Anders have can't agree to our rates um I try every day I fight with them every day it's not fun um Mike jeni has a lot of his famous conversations of throwing phones against the room you know while talking to insurance because of the difficulties but y'all been able to figure it out for this population and group and that is just so incredible and is such a resource everyone needs to hear about so would love for y'all to tell us a little bit specifically about who you serve how they can find you and what uh payers you guys are in network with go for it Mona sure um yeah so we um we're pediatric specialty so we work with kids teens young adults 7 to 22 we will sometimes stretch up in age depending on kind of comfort level kind of what's going on um stretching down is a little harder because um a lot of our work is also group work and and individual work and and so um but with the younger kids oftentimes the parents are even more involved in in treatment um and you can find us just by going to inst stride. health and it's our website and we're we're we're trying to make it we've we've done really we've worked really hard on our inside um work and and now we're starting to to work better on kind of the our external so our website is you're going to notice that it's going to get updated and improved but I think it's a reasonably easy userfriendly just go and click Start here um but I'll say that the insurance piece has been the biggest learning curve for me it was a it was one of the big reasons we we spun it out of academic Medicine of of mlan because um we needed to be able to go straight to the the insurance companies and negotiate directly with them for this very specific program and and I'll say it's been kind of I I I've done a lot I've done a lot of that work with our team and and I find it really fun and challenging because it is um this is something we believe in and something that should be delivered and also that we have to do it in a sustainable way for us because if we don't then we're going to have to compromise on the care we're delivering which is not okay it's it's just not okay these are kids and families and um and so we are slowly but surely making our way in network so we are not in network with all commercial payers yet um we each conversation is is a conversation that um that involves many different parts of the payer and then operationally we have to integrate them into our system we we um we do a very unique collaboration um or um contract with each payer so it's it's not a small deal and it does take a team of amazing operational um workers um players teammates at at instride and so I'll say that um are we we're trying to do a good job of listing out all of the different insurances we take on our site so that it's very clear and again it's been cool because like we started with optim United and some and blue some of the blue crosses depending on the states and we're we're slowly but surely expanding plan is also to get get in with Medicaid um we've started those conversations as well and we're working on the regulatory piece so that is that's also happening so if anyone ever wants to talk insurance or give us advice as to how to we will take it we are humble yes I'll talk it you'll be giving me advice like coffee no Honestly though I will say you know we do get a lot of requests for webinars on the insurance piece both for clinicians and individuals that I would love for us to do an updated one Chris and we might have you on Mona just because we would love because you know we talk we majority of our patients were self-pay all of our patients for the most part are using insurance it's just whether you they're using it for an N Network exemption or a single case agreement you know is dependent on the case but you know and so a lot of people don't know that that even self-paid program there's ways to use insurance but then how as a program can you try to get in network at a rate that you don't have to compromise the clinical care right everyone knows I'm not willing to compromise that so here we are figuring it out doing scholarships and everything else to make it work so yeah what states are y'all in right now and expansion goals so that anyone listening can know and can go go straight to your website for help oh okay let's see I'm like Alexis where are you um so Massachusetts so most of um most of New England and we're kind of expanding so part of it is and we want to be really we want to be able to offer service um across the board to anyone who needs it and we never want to compromise on quality and um and every state is different and we want to be integrated into the local um so we started in Massachusetts where where we obviously train and grew up professionally um and and um so Massachusetts was our home and then we've kind of expanded out from there so we are now in um New Hampshire New Jersey Rhode Island Connecticut New York Maine Pennsylvania think you hit it okay excellent and and we have we have States if you I think we have states that were and then geographically we're kind of going out and branching out from there how we decide one of our biggest um decision points in branching out is also just how can we can we have at least 50% of the commercial lives covered um can we be network with um with the majority of the um insured people in that state because also really hard is when a family reaches out and has an insurance we don't take um and we what we do is we we'll call the insurance and we'll say hey we'll work with you to to try to to on single case agreement perspective so we're trying but that's part of what's driving us in in how fast we're expanding amazing I love it and last question before we hop into live questions is how do you assess for the right level of care so so how do you guys make a good determination of like actually we think you would do great with traditional outpatient care you don't necessarily need our level of care or someone's in your level of care or even from the onset you're like oh you really need a higher level of care right where you're referring to OC junor or to us or ocdi or whoever like tell us a little bit about that I can jump in and I'm going to feel free to interrupt at any point so as part of our comprehensive clinical evaluation we also assess for level of severity and at the outset and then that then dictates the amount of time that someone will spend at each phase of our treatment and so it's not like a one-size fits-all so if you have somebody who has more moderate symptoms they're going to spend less time for example in our first more intensive phase than someone who has more severe symptoms and of course it's all individualized by patient but we have sort of projected uh Pathways by level of severity and what's interesting is that we've had kids with more mild presentations and I think our definition of mild is a little bit different than maybe sort of the standard definition of mild so mild might be like one or two diagnoses for example and maybe a round of of Outpatient Therapy but not years of outpatient therapy or not higher levels of care for example and so they could do a once a week model and expand it over a longer period of time or they have the option of coming to us and doing something more intensive and compressing that time period perod and so they may for example be in treatment for four months in total and see the gains that they might have realized over like a year plus or two plus so that's that's really an option for families I think that the kids who have more severe presentations these are the kids who tried the weekly model they've been in it for years they're just not getting that traction or they've been in higher levels of care or they're sort of hovering on the border of higher levels of care and I think the challenge for some of these kids for example is if they're sort of like bumping in and out of the ER or impatient is that if they go to like your traditional impatient unit they may actually look where there's no exposure it's not sort of specific to anxiety and OCD they may look better for a period of time because they're away from all the triggers in their life that cause their symptoms so then they discharge and their symptoms crop back up and they're sort of stuck in this vicious cycle so we're really trying to keep them out of the higher levels of care yeah and so so how um you know for you if you if a patient because we get this question a lot if a patient's in your level of care at what point would you say you you know they do need a higher level of care is it you're not seeing a reduction four to six weeks in you know what what what's kind of y'all's yeah so I would say for for kids who have more active safety issues that's one thing so for example we plenty of our kids have passive suicidal ideation that kind of comes to the territory with kids who again are just feeling hopeless and despondent and like nothing is working and if it gets to the point where now it's more active suicidal ideation where they have intent they have plans they have means then we would consider a higher level of care um Mona what what else am I missing here yeah I would say that um it's it's how the OCD is showing up and how they're feeling and their their environment are feeling able to to then push to to kind of work through it and so um it's so we we will work we have all kinds of different tricks of parlees in terms of Engagement and motivation again like especially being a a child or a teenager a lot of their lives are not their choice they have like they have to go to school they don't get to choose their job they don't like a lot of a there's so the motivation to actually do the things that they need to do might not be quite as strong as for an adult where there are other incentives motivating you to get back into life um and so we'll try all kinds of different motivational techniques but if we're finding that a kid is just really stuck and might need some might need a structure around them to help them get into a routine and help them just even get going on trying these exposures we might say um a higher level of care might be indicated um hopefully a briefer stint on the higher level of care knowing that they that once they get that momentum they can come back and start doing that work uh kind of on an outpatient basis so that they're integrated into their lives and and practicing this in their real lives so I think that that's kind of the other time where where we really do and to your point was practice we practice measurement based care right we're we're colle we have clear goals and we we're we're tracking data and we're saying are are you trending in the right direction it's going to be up and down it's not going to be this beautiful like curb of everything goes down or line that everything goes down but generally we want to know that that like you're this child is able is engaging in these exposures is Enga is coming in and and talking and and and able to identify how OCD is showing up and trying different approaches and with if that's happening then then that's hopeful that you're going to move in the right direction if not then you do want to catch that early and make sure that you're intervening and and shifting your approach one thing I would add Mona is that we also have the option for a parenton approach so most of the time when a child has low motivation or low willingness to engage our coaches are like our secret sauce to activate and engage a kid and every once in a while a kid is just like not going to do it and that is just not happening no matter all the tricks that we try it's just not happening so then we can work primarily with the parents um and they're working on Shifting the environment which then creates that like exposure is life environment for the kid love it love it exposure is life um my favorite thing when people say Liz what will Erp look like long term what does Erp look like next in treat and I'm I like Erp doesn't look like anything it looks like you living your life like we're not calling it Erp anymore we're calling it like your life like you're going to go live your life and that is Erp right we don't need a treatment plan anymore once you discharge and I love that I love that you guys are you're treating you know after treatment the goal is like you don't need treatment you need life so treatment after treatment should be living your life it should not be continued treatment and I just want to send that message I I keep hearing Chris you know how feel but I keep hearing so many people talking about like struggling forever and you know the road is always going to be bumpy and we have to expect that and like that is not the truth you guys with effective treatment you can get Freedom it doesn't mean it's it's perfectly linear as soon as you step down from treatment but long term treatment is that you live your life not that you are expected to have to be in treatment forever to be in and out of the system and to continue to need to always have these like interventions you know for for your struggles well of things we often talk about um and this is the kind of thing that I think sometimes kids feel like rolling their eyes up but it's really true is that the bumps in the road those are learning opportunities so anytime you encounter that bump because life in general it's bumpy for anyone whether or not you have anxiet or OCD but each time you hit that bump it's an opportunity to yes I can take a pause and make a deliberate choice in how I'm going to respond both if I'm the patient myself or the client and if I'm the parent right so they have an opportunity to practice their skills and so I'm like bring on any bumps in life because then your brain can keep learning can keep creating those new neural Pathways 100% um Chris is gonna like he's looking at me because he's like we have 13 minutes left we have so many questions sorry okay okay so we're gonna do rapid fire because I love rapid fire where we just kind of we ask it and we're direct so Chris I'm throwing the first one to you what are the panel's thoughts of including icbt and RBT into OCD treatment instead of capitalizing on the traditional Erp route especially if they're not ready or not progressing with Erp yeah one thing I wanted to say to answer this question and I think it was it was really well talked about at this panel I hear a lot of times clinicians that do a traditional like 50 minute session model saying Erp doesn't work and at my treatment center we do have a higher level of care we have an IOP one-on-one IOP we've sent a lot of clients to lizz's uh uh treatment center and those clients that were like not able to do Erp thri in those environments so what I would say before abandoning Erp is I I I want to shout this from the rooftops is the right level of care is so important we get so many clients that come to our IOP that have failed Erp and I'll sit with them they have a 32 ybox score and they can barely leave their house and I'm like no clinician no matter how many books you've written can do that much change in one or even two 50-minute sessions it has to be a higher level of care so whenever I get questions when somebody's hey Erp didn't work for me the first question I always ask is what was the top level of care and it's always weekly sessions and I'm like that's why it didn't work as a clinician I've been trained in icbt I've done training we had a a clinician that worked at the DBT Center of Orange County that trained me in DBT R uh DBT got trained in in uh motivational interviewing I've done trainings in acceptance and commitment therapy I what I always fall back on is for me and for my clients and from the research Erp always has to be a part of treatment there has to be a behavioral change we can understand what's going on in our brain and any of these other mechanisms I've talked about you can understand your value based you can learn to be motivated and buy into treatment but the end of the day we've done so many behavioral things to feed the OCD we have to start doing behavioral things that get us back into life so I'd always be cautious if somebody is trying to get you to do like Erp is gone in the treatment modality I've heard some people like some of these other um you know mod ities that that we just mentioned but I'm always uh challenged to find a person with ocu who's like I only did this and never did Erp and I got better 100% are we allowed to just say like plus one plus one plus one I mean again it's the thing is you know I think that I always tell people my one of my favorite webinars was one Chris we did with me and um John hersfield and I said that like guys for 10 years of my life I would have been someone saying Erp doesn't work for me but it wasn't that Erp didn't work for me it was that I wasn't ready for Erp and I was doing it with one foot in one foot out and yes you know I wasn't actually doing Erp and so I'm not saying that's the case for everyone because again if there's comorbidities yeah Erp doesn't work for eating disorders right like I mean there's some evidence now but you know what I mean like certain substance use we're going to use a specific substance use intervention and so there's always caveats but I want us to really be like before we say Erp doesn't work I want us to be able to answer the question of why is Erp not working is this values based Erp is this you know Erp that makes sense but also like are we really doing Erp are we doing it all the way or are we kind of doing it and hoping it'll work but we're still ritualizing or still holding on yeah I that's exactly what I would want to know so I would want the person to describe to me what the exposure look like so for example I often hear about Erp without the RP and I'm like doing it or to your point Elizabeth like I I think it's the how of exposure so are you doing it sort of like white knuckling the whole time or are you really leaning in and letting go and and I think that piece matters so so much and again is it values based Erp is this Erp that you want to do because you see the value in it and you see how it lines up with those strengths that you have those things you're wanting in your life or is it Erp that you're being told to do but like you don't really see why you should do it yep all right Mona we've got so many questions for you so we're gonna hop to the next one yeah I'm gonna rapid fire Mona so there's there's three medication at 129 from simple what's the more advanced treatment for OCD other than an SSRI so if somebody's uh on an SSRI and let's say it's not working is there other medication interventions that someone can try well I would say the first the first thing I will say is the same thing as you said for ER P um is I I ask what was your SSRI trial and um because what we've seen is that the the one of the main reasons ssris don't work is non-compliance with the actual prescribed um the actual prescription so not taking it as prescribed taking it intermittently missing some doses or or um kind of intermittently taking it so one is just have have you taken the SSRI as prescribed and then looking at the the dose progression and the timing what we know is that they're slower to work and and so we're we're looking for them to to take have effect up to 24 weeks after starting I again Peak is around four to six weeks but they can they can take time and then what does it mean for the SSRI to work we're not necessarily looking for them to take away all emotions to take away the OCD to take away the that is we're looking for a decrease in volume so that you can then engage in the exposure work and so some of it is what is your goal and how are you defining um what Works means so I I'll start with all of that because ssris can be very effective and and we'll often start with one if that doesn't work will go to another SSRI before moving to different ones the snri category um again they're they're similar so but I would say that um now so I'm a pediatric psychiatrist so I'm so used to off Lael and simultaneously have to give the disclaimer that this is I'm like just be mindful when like when we're prescribing a lot of this it is off label so we go by expert like we we talk with each other we want to be really careful and and think through um how we're prescribing but we will sometimes use a tricyclic like um camine like as a as an adjunct so if we have an SSRI that's been partially helping we might do a low dose um as as an augmentation or we might go to the atypicals with augmentation there are some newer medications that have come about again I'm I'm in the child world so I'll say we're a little bit more reluctant to to to use some of these medications in the dev ing child brain without without kind of being able to see longitudinally how it impacts K we get Gass about ketamine a lot so I've lots of thoughts about that but I think we're supposed to do rapid fire so that can be another let's do it let's talk let's talk psychedelics come on at 12:21 Joey C asks can what is the role of benzodi aapes and OCD treatment can it make OCD worse it's a that's a great question and um and so again where so there's not great evidence for use of of benzo aines with OCD um or with anxiety in general but what I will say is that clinically so again this is off label this is clinically how I this I'm giving you my thoughts um how where I found it most helpful is in that initial Bridge phase of saying if when somebody is just having a hard time accessing getting even getting into the therapy room to have that conversation about where they're going to start um it can be something that might help um lower that in the intensity of of the of the barrier to get in and um and I I will usually say this is a two to four week Bridge or like let's see how let's see what impact it has and decide whether or not we keep it the nice part about avenzo it's quick on quick off especially depending which one you choose to use so you kind of quickly know what impact it's going to have I do not like using it um at when we're use when we've got somebody heavily involved in exposures it it hits the Gaba system that's that that impact memory there's some concern that when we're when we're talking about um new learning like you have your you have your your kind of OCD your old learning your fear memories your cycle um we're trying to create new learning in the brain and does a benzo impair that um that cons consolidation of new memory so does it potentially make the treatment stick less strongly I think there is some some concern there and so again or is it a safety behavior um is it one where um oh I've got my benzo I I take it and I can do these things and I feel better but in but you're not developing the new relationship to OCD that we want you to and so again again remember right what we're trying to teach you behaviorally is that you can do hard things exactly and you know AB benzo teaches you the opposite no matter what right because it's really teaching you that like you can't tolerate anxiety you you you you don't have the ability to feel that distress and you need something to feel better and so I find clinically like so many of our folks right that come that are you know is not just do they have to get off benzos but also then we have to like really help them shift their whole mentality around medication Reliance to feel better versus actually can we ride the wave of anxiety so if we had to sum it up in like a few rules I'll say that I would if if we're going to use it it's it's incredibly short term and fully in the in in the um in effort to help um actually access therapy and engage in therapy um and then take it off and not as a PRN so not as a as a as a rescue but instead as a again to take down the intensity so that you can start engaging and once you're engaging take it off if if you even use it again we we we're pretty Limited in how much we do Kat I have a question at 12:31 from Amy tips for encouraging a young adult child to finally get Erp treatment well that's a great question I think it it goes back to what we were talking about earlier is that values piece and figuring out how to make treatment really meaningful for that person so it's less about you're doing this because your parent or your friend told you to do it or you feel like you should or you need a certain reduction on the Y box but because you want to get back the life that you were living before you want to get back the things that matter to you you want to get back to being the person that you were and you want to get back to the driver's seat of your life and so really taking the time upfront to lean in around the values piece and to really connect with this person to build their motivation we we do an activity at the outset around um we call it the my life activity where we have somebody draw a pie chart and in that pie chart they're depicting the different areas of their life and how much space they're each taking up so they will include anxiety or OCD in that and oftentimes what we're seeing is that anxiety or OCD at present is like five six of the pie chart and that wedges out everything else so like school and friends and family and work and extracurriculars and all the things that really used to matter are like this small wedge of the entire pie and then we say what do you want your life to look like and now all of a sudden all those other things are coming back online and so then treatment becomes about well then how do we get those things back online how do we open up the slices the big the important slice of the pie for you well said I'm going to Rapid Fire to Liz last question uh from h G at 12:30 since OCD could run in families but is also conditioned Behavior do you recommend any early intervention programs for children who have a parent with OCD wow great question um you know I know we've never gotten that I was like we got ask yeah I haven't gotten that question I think my first advice would be that I want to make sure the parent is really well treated because again you know I see anxiety in my kid right my daughter's three I've seen some early OCD signs of like things needing to be up and her being triggered if they're not in the right place and what's going to happen but because I I'm so well treated like I can intervene really quickly right and help do some active fun exposures that hopefully OCD won't progress and so I think that if the parent is really well treated and really knows the tools you're going to be teaching your kid right because you're living that model of we can do hard things and and fear doesn't have to win and and that's kind of how you raise your child in your household but I certainly think if there's any signs and symptoms the earlier we can intervene the better right we know that as with any condition well sad yeah very wellcome okay well we will let y'all um wrap up with final words but I just want to say thank you for everything thank you'all for coming on but also thank you for what you're doing I think it is um really remarkable to have a new resource that is going to be so accessible to so many people who need it offering evidence-based care so this is something we get asked for all the time and I'm just super excited and honored to be able to have youall on to be able to talk about a resource that's finally available and has been needed for a long time thank you all and thank you for the incredible work that you're all doing in St this education so so valuable and so powerful and looking forward to seeing you at iscf yes yes yes thanks so much all right Chris take it away yeah no just super super happy to have you thank you so much I mean what people want is more resources more access to care uh and we were excited bring you on and give people a new resource and I just hope everybody watching I think the thing I want everybody to take away is like if you are working with someone for three years once a week and just not seeing the results that you want please look into a higher level of care we've all on this panel have seen lives changed from that so please please please look into that uh and we hope to see you in July at the Orlando conference last week in July registrations open sign up and come hang with us make sure you sign up my last plug that I love that y'all mentioned earlier for um you know inride in any programs is that so many times I get asked the question question like well how do I know I should pause and focus on treatment and what I always tell people is that sometimes an opportunity to do intensive treatment in a short format is going to feel so much shorter even though it feels longer up front than in the long run right having therapy go for two five however many years so if there's opportunities to condense and get that treatment and get back on your feet quicker I think the Learning Happens better right we we get to practice it more often and frequently but also it just sets you up for so much more in the long run right so always think about kind of imagining that like intensive intervention that we get those amazing results faster versus this longer process so always make the time for treatment you guys it will change your life and get to a place where you don't have to spend your life doing Erp you get to spend your life Liv living life and that's what we want to teach you thanks you guys thanks for being with us today thank you so much

Channel: International OCD Foundation

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Id: 3CP_bG11byo

Length: 59min 57sec (3597 seconds)

Published: Thu May 02 2024