Episode Transcript
Intro: This is #OurAnxietyStories, the Anxiety Canada podcast. This is the place where people from all walks of life share their stories of anxiety and related disorders to remind you that you are not alone. If you have an anxiety story you’d like to share, contact us at anxietycanada.com/ouranxietystories.
Mark Antczak: Hi, I'm your host, Mark Antczak, registered clinical counselor and clinical educator, and you're listening to Anxiety Canada's OurAnxietyStories podcast, the OCD series. Each week, we'll dive into personal stories, expert insights, and practical tips to help you understand and manage OCD. Whether you or someone you love is affected by OCD, this podcast aims to provide support, education, and a sense of community. Join us to navigate this journey together one podcast at a time.
Today, I'm chatting with Dr. Robert Selles, a registered psychologist who provides treatment to individuals and families in British Columbia through his practice headquarters, Mental Health. Dr. Selles completed his PhD at the University of South Florida, residency at Brown University and Postdoc Fellowship with the Provincial OCD Program at the University of British Columbia and BC Children's Hospital. Dr. Selles has extensive clinical research expertise in the area of OCD, anxiety disorders, tick disorders, and body-focused repetitive behaviours. He's published over 40 scientific articles regarding these conditions, their impacts on individuals, youth, and families, and optimal approaches to treatment. Dr. Selles has been a member of Anxiety Canada's Scientific Advisory Committee since 2017. Thank you so much, Robert, for joining us today.
Dr. Robert Selles: Thanks for having me. Excited to be here.
Mark Antczak: So I'm really curious, because we know there a lot of clinicians have different motivations behind diving into the world of OCD. I know I certainly have my own story behind that, but I'm curious, what brought you into it, or what was the thing that drew you to OCD research?
Dr. Robert Selles: When I first was looking into going into psychology work, I was really interested in family systems, and how families manage challenges that come up. At the time, I didn't know a whole lot about OCD, I wasn't particularly familiar with it, but I found an advisor, Dr. Eric Storch, who worked extensively in OCD and anxiety disorders and had a good fit in that program. And once I started working with individuals and families who struggle with OCD, I really fell in love in working with those people. Because OCD has such a dramatic impact on individual's lives, it can cause so much distress and impairment, and at the same time, there is so much potential for change and hope that the interventions we have can work really well.
And that engaging in the intervention, supporting people to change their behaviour, and find new ways of handling these typical problems, and facing their fears was something that was really active and participatory and experiential, and I really loved that about that. I enjoy talking with people and supporting people through their emotions, but it's also fun to say, "Okay, how are we going to tackle this, and can we try that right now?" And I loved that about OCD work.
Mark Antczak: I resonate with that so much because when I think about the nuance in OCD treatment and how we have all these approaches that are quite standardized, even just being able to see the subtle differences and how things can change so significantly from person to person, the creativity and treatment planning and just being able to really get that specific, "Oh, this one's a little bit different than that one that I worked with three and a half years ago. What can I do a little bit differently?" So I can fully appreciate that.
Dr. Robert Selles: Yeah, I love about OCD that our principles are actually fairly easy to follow, they're fairly simple, but then the exact application of those principles has a ton of variety. So I go into sessions knowing that I will generally know what we need to be doing, but exactly what that will look like might change a lot between person to person.
Mark Antczak: Absolutely, that's such a great way of putting it, simple concepts, very creative, and sometimes difficult ways to apply it, I guess, you can say. Well, given the fact that this is a podcast, today's episode is really catered towards families and parents who are trying to support their kids who have OCD. Maybe we can start with something that's a little bit more basic where you can go in and describe how would parents notice OCD showing up for their kids, and how could they know if it is OCD or if it is just anxiety, I guess?
Dr. Robert Selles: Sure. I think the first thing to understand is that like most behaviours that become problematic for kids or adults, OCD behaviours in small amounts don't necessarily indicate a problem, that there are lots of things that young kids and older kids do that may overlap somewhat with what we know OCD tends to look like, that if it's there in low levels, if it doesn't get in the way, if it's not associated with a lot of distress, isn't necessarily an issue. So, being a little bit particular or being a little bit concerned about whether or not something is clean or not doesn't necessarily indicate that OCD is there. But to answer your question, I'll think about two things that parents might be looking out for. The first is the most common ways that OCD tends to show up.
And there's lots and lots of variety in the exact fears and the exact behaviours that show up, but when researchers have looked at all of those things and try to simplify them, simplify them, simplify them down to the biggest, broadest categories, you see three main ones for OCD, you see a lot of concerns about something being contaminated. And that could be that it's germs, or that it's dirty, maybe that it's disgusting, it could be worries about getting sick, or just feeling gross. And then individuals try to address that with lots of things that would remove that. So hand washing, or cleaning, or trying not to come into contact with it in the first place. So maybe there are things that they don't want to touch or places that they don't want to go because that would make them feel contaminated, or dirty, or might make them sick. So that's category one.
Category two is really unwanted thoughts, disturbing thoughts, things that show up in the mind and don't really fit in with the day-to-day worries or anxieties that maybe most kids have. So if we think about how you might... lots of kids might be a bit worried about whether or not their friends like them, a bit worried about something that they think is really important, like how they're going to do on a test or in an upcoming soccer game. But kids with OCD might start having thoughts that feel really different from the types of worries that they might normally have, they might be really specific about something bad happening, they might feel really inappropriate, or thoughts that they just really don't want to be thinking about. And when individuals have these types of symptoms, we often see them associated with efforts to cancel out the thought in some way, like make the thought go away by doing something, or prevent something bad from happening, or do anything they can to essentially make that thought not be true or not come true.
And this often comes up too with lots of questions maybe that parents get, is everything going to be okay? Do you think it would anything would happen and things like that. And sometimes it happens a lot in the individual's mind as well, that they're just thinking about those things and trying to cancel things out with their thoughts. The final category is that individuals often experience something called a not-just-right experience or an incomplete experience. You can think about it almost like an itch. It's a sensory experience where your body just doesn't quite feel comfortable. And typically, what individuals have when that feeling comes up is an urge to fix it, to make it right. And so you see lots of different behaviours where things have to be a particular way or have to be done multiple times.
Often, it's really strict, it has to be done this many times, or this often, or it exceeds the amount over time, it keeps growing. It was three times, now it's five times, now it's seven times, and it just never seems enough to get to that feeling of satisfaction. So lots of kids might have bedtime routines that they like to follow. A kid who's starting to develop OCD or might have OCD might have a really extensive bedtime routine with a lot of very particular ways things have to be done, gets really distressed if they're not done that way, it seems to be escalating and growing into more things over time and things like that. So, that brings me to part two, which is, how do you distinguish a kid who maybe has some general concerns or some things versus a kid who's developing OCD? And we're looking at that bigger picture of, is it getting in the way? Is it associated with distress?
Does it seem particularly rigid or particularly disconnected from ideas or behaviours that we would think are quite typical for kids? Has this been happening for a while? Is it starting to take up the child's or the family's energy and time? Are things getting worse? Are we bothered by the fact that this is happening? And is it causing problems at school, disrupting sleep, causing conflicts with family members, and these sorts of things? Because the final part of OCD is disorder. And so we all have different things that we like things a certain way, or different worries that we have, and that's part of being human, and including part of being a kid, but when the way in which we're handling those things isn't working, it spirals more and more out of control into disorder territory.
Mark Antczak: Right. Yeah, and that's really how we often give that explanation to adults when we are trying to explain where does typical worry start and where does disordered worry that turns into anxiety start. And that, I guess, leads into the next question because one thing I was reflecting on... because I work primarily with adults as you know, it seems like there is a bit more of a narrow focus on the types of themes or the types of obsessions that kids or youth can have as compared to adults. And it narrows itself into those three primary categories, which is that contamination piece, the specific kind of abnormal thoughts, which I'm going to ask you to narrow down a little bit more, maybe explain that a bit more, but also that just right feeling, which is, "Oh, something has to be done really specifically."
For example, I had a case a couple of years back, "I got to get all the suds out of my hair because the shampoo just can't stay in there," kind of thing. So could you describe that second theme a little bit more in detail? Is it more harm-based? Is there any kind of things that kids won't typically air into or you'll see quite rarely?
Dr. Robert Selles: Not necessarily. So I think in kids, as well as adults, things can present in any multitude of ways. I find those categories are just an easier way of giving a sense of what OCD might look like, because like you say, it really can present in a lot of different specifics. But if we think about a child presenting with an intrusive thought that could be about anything, often, we can still identify that that relationship between a thought that's really unwanted or bothersome and then some sort of effort to get rid of that thought or cancel it out. So, harm is definitely a common way that presents something bad might happen, I'm going to hurt someone, or someone is going to get hurt, the house might get burned down, things like that are really common. There can be an association too with everything falling apart, or things going wrong, and more general like that. Sometimes when people say, "I just feel like something bad will happen," they don't know, they're not saying this specific event, it's just this broader sense of dread and uncertainty that's really uncomfortable. So that's a common thing that comes up as well.
Often, the types of thoughts are still tied somewhat to the developmental level of a child. So intrusive sexual thoughts can be something that children present with, but the nature of how they're intrusive for an 8-year-old versus a 16-year-old might be quite different. An 18-year-old or a 16-year-old might be imagining more specific graphic things that are very disturbing to them, whereas an 8-year-old might just even be getting images of naked bodies or something that they find quite distressing because they're reacting to that being something that's bad or inappropriate and trying to get rid of that. So there is really no specific content area that can't happen for kids or can't come up. So, the same ones that you think about in adults of harm, sexual thoughts, religious concerns or worries, other types of taboo type thoughts are also really common in kids.
Mark Antczak: Right. Okay. So really revolving around that notion of how much distress is this causing, what degree of dysfunction is this causing for the child as well, and just seeing the nature of the thoughts, how specific, how repetitive, and how they react to them in an adaptive way or in a way that leads to either of those first two categories, distress or dysfunction?
Dr. Robert Selles: Right. Exactly.
Mark Antczak: All right. So regarding, I guess, age of onset, so what's the earliest you would see OCD start to show up for kids? Or is there a typical age that you would see this?
Dr. Robert Selles: A lot of families come in and talk about how they've seen some signs or indicators from really early on, 3, 4, 5 even, that their child wanted things a particular way or had a particular aversion to one thing or another. But often, at that point, it is too early to really say this is OCD or not. Often, those same families are saying, "You know, we kinda just thought of it as a bit of a quirk," or, "My mom had a similar thing. And so we just figured it runs in the family." And that's an appropriate response at that point. Again, if those things aren't causing major issues and aren't really getting in the way. When we talk about age of onset, and the way that that's been defined in the research, we're often talking about the onset of disorder. And typically, we see that at more a transitional age. So, 10 is a common age in which you start to shift a little bit from maybe having some symptoms that might look a bit like anxiety or a bit like OCD that begin to start to emerge more into something that becomes a disorder.
The transition often from elementary to middle, or middle to high school, these periods of higher levels of stress, the potential impact of changing bodies and minds, these are moments where it seems like OCD is a little bit more commonly emerging into what we would call a disorder. For any individual family listening to this though, that's not a magical age, I have seen every possible age be the time that OCD emerged. It just gives a bit of a sense that, for kids, it might be happening somewhere in that range. And then often, for adults, it emerges later in life too. That may be in that transition into independence, university, or first jobs, or moving out on their own, another kind of stressful transition, and a point when the mind is changing that that might be when OCD emerges.
Mark Antczak: Got you. Okay. So when there's a lot of change happening, I guess, change is also linked to a lot of that uncertainty, which we know is very much linked... that intolerance around uncertainty that can birth OCD in a sense as well.
Dr. Robert Selles: I think about it a little bit as our minds like to solve problems and to keep us safe, and OCD is a very driven problem solver, it just tends to get stuck on trying to solve problems in unhelpful ways. But if we think about having maybe some tendencies ahead of time to want to manage our emotions, or control our circumstances, or get certainty in certain ways, and then life becomes stressful, the baseline anxiety is higher, we don't know how to handle that feeling of being out of control, OCD shows up and says, "Well, maybe this is why we feel so out of control, and maybe we could fix it by doing this thing. Maybe it's because there's germs everywhere and if we just wash our hands, that'll make it go away." And all of a sudden, that begins to evolve into a bigger and bigger pattern.
So sometimes people say, "I went to this one talk at school where they told us about how germs are so bad and you have to wash your hands, and that was the moment I developed OCD." And others say, "I don't know, it was a hard year and I was feeling stressful. And these thoughts popped up, and then I started doing these things, and it just spiraled out of control over time." So that can be one of those things that happens, is the mind's trying to support you, it thinks it has an idea of something that works, but it's just not working out a lot.
Mark Antczak: Yeah. It is really interesting how sometimes, when you're doing that intake assessment, you could almost pinpoint the specific moment where maybe the first seed was planted, but often, it's a collection of a lot of moments or a collection of a lot of circumstances that leads you to be a bit more vulnerable to it. And so the explanation of an intrusive thought, because you started getting into that piece, I imagine there's a lot of parents here who are starting to suspect that their child may have OCD. So how would you encourage a parent to explain what an intrusive thought is? And maybe we can then segue into talking about the role of reassurance because we know that is a pretty vital component when it comes to enabling and also treating OCD.
Dr. Robert Selles: Right. Yeah. The first thing to remember with intrusive thoughts, because when you encounter them, they will seem very abnormal, so the first thing to remember is that they are actually very normal experiences. Everyone has thoughts that show up that they don't think on purpose. Most of the time, those thoughts are random, they're not bothersome, but sometimes, they can be a bit weird, or strange, or scary, when you're standing over a balcony, that you get this thought that you might jump over it, and just these things that pop up in our mind in different situations. And when we react to those thoughts in a way that doesn't interpret them as important, that doesn't view them as distressing, often, they just fade. They show up and they go away.
But, these thoughts can be particularly problematic when they are interpreted as distressing or bothersome, and often, when they are connected to something we really care about. So, when we think about explaining this to a kid, it might be helpful to have an analogy, something that a kid can connect with. Because talking about thoughts is quite abstract, especially for a young child who might not even be fully aware of their thinking, they just know that they have a feeling, and they're distressed, and they want to resolve it.
So, I was thinking a little bit about this and I thought, well, most kids probably know their way around a phone, or they spend some time on an iPad. So that might be a useful analogy to use. And so if you imagine that you're on a phone, most of the time, you go on it intentionally, you go on different apps, you play games, you watch videos, and that's most of the time how we think and act as well, we do things intentionally and do what we want.
But sometimes, on your phone, midway through doing something, maybe another app that you have installed sends you a pop-up notification, or maybe you get an advertisement on something. And it tells you something, it maybe tells you, "Go activate this discount or check out this new notification." And if that's interesting to you, maybe you want to do that, you'll click on it, and if it's not, you might just stick with whatever it is that you were doing. Our thoughts are the same. Sometimes we remember something out of the blue, "Oh, I was supposed to do that," and if it's important, we might go and do it, and if it's not, we might continue with what we're doing. Now, and a really intrusive thought and a problematic one is a really terrible pop-up ad that says, "Your phone is infected with spyware and you have to download this thing to get rid of it."
And so now, you're taking it seriously, you're thinking, "Oh, no, it's really true." And you're clicking on it, and you're going into this app, and you're doing all of these things that say that they're going to fix the problem, and it never seems to work. You do it for a while and it says, "You did it," and then you go back to that other thing you were doing and a new one pops up, and it says, "Actually, no, you didn't do it. You got to come back." And so kids are having these thoughts and they're spending all of their time trying to resolve them and fix them, and then they're not spending any of that time doing the things that they initially wanted to be doing, or just are good for kids to be doing, it's all caught up in this cycle of trying to make these thoughts go away.
And so what we want kids to understand is that what we're looking to do is just let that pop-up pop up. And just like on a phone, if you let it hang out there for a while, often, it just will naturally go away. But if we're clicking on it and we're engaging with it, we end up stuck in that cycle.
Mark Antczak: I guess the same way OCD fixates on the things that are most important to you, the algorithm is really good at giving you pop-ups that are going to tempt you the most to engage with them. So that's a really great analogy because it really showcases how OCD will find a hook point, it'll really find the weak spot and it'll say, "Hey, this is really urgent, you need to deal with this or else." And for a lot of people, we're all getting those, but there's only a small percentage of folks that are particularly susceptible to that, they're going to click it, engage with it, and then have all those negative consequences come afterwards.
Dr. Robert Selles: Yeah. Yeah. And it really is when those thoughts target that something that feels so valuable and important. And again, our brains don't want us to lose the things that we care about, and OCD both offers the threat and the solution, and that's what is really sticky. It feels like OCD is maybe just the threat, but it's also the idea that you can solve the threat with OCD's strategies that becomes part of its problematic cycle.
Mark Antczak: Totally. It's like, "Hey, we're going to alert you to this scary thing and we're also going to give you the solution." And in the fine print, they're saying, "Warning, this will come with more threats if you engage with it," kind of thing.
Dr. Robert Selles: Yeah, it's like the worst antivirus software or something that actively is installing viruses as it removes them, and you have to do all the work of it.
Mark Antczak: Totally. And yeah, I think that point too of just being able to explain these are normal experiences, these kinds of thoughts have them, like mom and dad, we have these exact same kind of thoughts, but the difference is we're not going to give them meaning, we're not going to give them any attention. They don't have to mean anything. And I guess that's a really tough concept for some kids when they're so fresh, this idea of worry, getting used to this surge, not fight-or-flight response, it involves a lot of that kid-oriented education, I guess. Right?
Dr. Robert Selles: Yeah. And you're speaking to an important balance, which is that we still want to validate that the feelings are real. The feeling that this is threatening or that it's important is undeniable. We're not trying to dismiss by simply saying, "Oh, just don't be anxious about that," because the kid is going to say, "But I am." It's really understanding, "Yes, you're feeling all of those feelings because your brain is telling you that this is really important, and if we can practice responding to it in a way that doesn't put as much importance on it, then that'll help with those feelings."
Mark Antczak: Right. So okay, let's give a little point of view here, you're a parent and you see your child just like brushing their teeth excessively before bed, maybe they're stuck in prayer, if there's a religious background, maybe they have to arrange something really specifically in their room and it's becoming a nightly habit, maybe that same child is also asking for a lot of reassurance. So we're acknowledging that these are all compulsions, and we know compulsions ultimately fuel these obsessions, how could you respond to a child to be able to explain, "Hey, these things, they make you feel safe, but they're actually really not helping you"? How do you explain that within the context of reassurance-giving to still validate without enabling, I guess?
Dr. Robert Selles: For sure. I think with reassurance in particular, what we're often seeing is this struggle that is common among OCD, with fear, uncertainty, and particularly doubt, that what kids are looking to do is to get an external perspective that helps them resolve those uncomfortable states. So they want to know maybe that they won't get sick, or that something bad won't happen. And they don't trust their inner self to resolve that, to feel for sure that something bad won't happen. They can't find that sense of confidence to move through that moment, and so they're seeking support from someone that they trust or respect to provide that to them so that they can resolve that uncomfortable emotion and move on. And in general, having assurance from a trusted person can help us regulate our emotions and encourage us to persist in difficult circumstances-
Mark Antczak: And how do you differentiate the two? Because reassurance and assurance, I don't know if a lot of people know the difference there.
Dr. Robert Selles: Yeah. Yeah, for sure. So we think about assurance as an occasional, single, one or two things that generally support someone, and in particular, supports them towards engaging in that difficulty in a way that helps them move forward and passed it. So today, before we started, I mentioned, "Hey, I'm feeling a little bit nervous about doing this podcast." And you said, "You know what? Other people have told us that too, I think it's going to go really well. Just do your best." That was some assurance, and it was helpful. It helped me feel a little bit more calm and ready to do today's podcast.
Reassurance might start to look like a more repetitive cycle. Maybe if I come back and say, "But how do you know for sure? How do you know I won't make a mistake?" And I'm looking in particular to resolve particular uncertainties or particular areas of doubt, ones that you actually can't know or predict. You can't know that I won't make a mistake or say something really silly.
You could encourage me to try my best and we'll roll with whatever happens, but you can't actually tell me that nothing bad will happen. And that's often a clue for parents as well, are you answering questions that really you can't answer? Because if so, you are signaling technically a false sense of safety around something that's uncertainty, and therefore, your child will become dependent on you for that false sense of safety. So when we think about reassurance, what we're really looking to try to do is encourage... is be honest, be validating of the emotion, "I know this is really scary. I know this is really uncomfortable. I understand why this upcoming event is so important to you and how it would be really, really crappy if you were to get sick. I know that you don't want that to happen, Unfortunately, I just don't know. We don't ever know for sure when something like that is going to happen. All we can do is try to find our way through it and do our best."
So we're looking to come with a response that instead of giving an answer that realistically we can't know for certain, to give an answer that allows for a little bit of uncertainty, that recognizes why this is difficult for the child and is validating, and in that way, and provides some encouragement to respond to those uncomfortable feelings and that uncertainty in a way that helps move forward and move through it.
Mark Antczak: Right. Yeah, it's such an important point. Because when we talk about the cycle of OCD, it's like, okay, the intrusive thought pops up, the subsequent emotion or the emotion right after nails, so it's that pit in your stomach, it's that immense sense of anxiety, and it's a really uncomfortable thing to feel like that. So, you try and seek that sense of certainty and you say, "Mom, please tell me everything's going to be okay. Is the person going to break in? Am I going to get sick? Something bad going to happen?" If you just say, "No, nothing's going to happen," one, you're not giving them, as you said, that sense of, "You know what? Something bad could happen, but it's not likely." Probability over possibility, an important lesson that I think we often talk about in therapy. But then they also attach to that sense of, "Oh, relief. Okay, I can completely lean into this feeling," until it comes sneaking back and you need to repeat the cycle and over again.
Dr. Robert Selles: Yeah. And that really is the red flag for reassurance, is just that it keeps coming back to that same cycle, the same questions... When it becomes particularly problematic, often, it's multiple questions within the same moment. So, initially, maybe it's the one response, "No, everything's going to be fine," is enough, but then it starts to become, "But how do you know? But what if it isn't? But what about this?" And so parents are really tend to find themselves exhausted, they're interrupted during their other activities, they don't feel like they can support their child towards regulating their emotions effectively anymore, they become dysregulated because the child is so anxious, and distressed, and persistent, and that's really bothersome as well. And all of your interactions, instead of being about things that are interesting, or fun, or loving, become interactions about OCD and OCD's questions, and that doesn't support the relationship well.
Mark Antczak: Right. Right. Yeah. We can definitely dive more into some of those pieces around the fatigue that caregivers and parents experienced in this moment, but acknowledging time here, if I could just even ask, do you have any tips that parents could practice when there is excessive reassurance-seeking? What are a couple of pragmatic pieces? We've already talked about the validate, acknowledge the emotion attached to it, reminder of the, "We can't know, but it's unlikely," what are some other things that you would encourage folks try?
Dr. Robert Selles: I think those are the big two, with the third being then encouraging the child towards facing the situation and testing things out. We can think about fears as our brain, again, trying to protect us and let us know about a potential threat. And, in particular, in situations where parents are fairly confident that nothing bad will actually happen, they can then encourage the child to say, "Let's find out together, let's do an experiment. Your brain is telling you this, let's see if that's really the case." And to then come back and reflect a little bit on that learning, "Remember yesterday you were asking me, 'Is everything going to be okay?' What ended up happening?" "Oh, things were okay." "All right. Interesting. What can we learn from that?" And often, we're trying to support kids getting to the stage where they can see their thoughts are just thoughts, they aren't amazing magical prediction machines, like sometimes they feel like they are.
And it doesn't mean we dismiss every single thought that says, "Maybe something bad will happen or maybe that's a bad idea," some of those thoughts are important. And as a parent too, you'll likely know those. If your kid's saying, "Hey, I want to go run out into the street in the middle of traffic," you're probably not going to say, "Let's test that out." But OCD usually makes it pretty clear that there are some of these things that we can provide some encouragement to say, "I know this is hard. I'm not exactly sure what will happen, but let's see if we can try out together."
Mark Antczak: Totally. Yeah, no, that makes sense. So let's pretend here now you're trying all these things, you're reading books, you're listening to all these podcasts, and your child is just repeatedly struggling. The assurance versus reassurance piece isn't working. You're trying to do your best, but they're just progressively getting worse. At what point do you know you need to seek out a professional, and how would you make sure that you're seeing a professional that, for lack of a better word, is trained to be able to treat OCD?
Dr. Robert Selles: Yeah. The first question, I think it's a lot of preference. You could seek out a professional really early on. If you want that help, you want to talk to someone, you want to get their opinion, you don't have to wait to the point where you have tried to do everything on your own. You can get that-
Mark Antczak: No threshold required?
Dr. Robert Selles: No, that is absolutely understandable. And certainly, I've met with families who have come really early and I've said, "You know what? We're actually not in a bad stage yet. Here are a few things you could try, here are a few resources you could work on." And you send them off, and maybe down the road they end up coming back. But that's a good intervention too, a brief check-in with someone to help just get a little bit of clarity. Because sometimes too, it's hard to know, is this typical kid behaviour? Is this OCD? Is this this or that? Sometimes kids throw tantrums around things, and sometimes they're because of OCD, and sometimes they're just because kids like to put up a stink, and it can be helpful to have a bit of input on that. But beyond that, I think if you've been trying things for a while, you feel like you're not able to follow through consistently... Consistency is a really big thing, because we know, for example, from slot machines, they're so reinforcing because of their inconsistency.
And so if the way in which parents are responding to OCD feels really inconsistent, they don't feel like they're able to make that progress and see the benefits that that would be a good indicator, that it might be helpful to have someone else on board. It is a complicated thing to address. And particularly when you're in the thick of it, it's really hard to see how to manage it. There's a reason why therapists and psychologists also go and seek professional help for themselves, it's because we can't necessarily think our way out of the things that we're struggling with. Sometimes we need a bit of support to come up with a plan and to implement it and be consistent. So if things are escalating, if you're finding it really hard to be consistent, then that indicates a more urgent need for support.
Mark Antczak: Got you. Okay. So when you feel like you're falling out of your depth, when you feel like you're really trying but things are progressively getting worse, or even if you notice things early on and you're like, "You know what? Let's just nip this in the bud, let's get a second opinion," all of those markers are appropriate times to go and see a professional.
Dr. Robert Selles: Yeah. And I think too, it depends on your region and how many services you have locally. Sometimes it can be a bit of a wait. So, I think if you're trending in that direction, it doesn't hurt to reach out and to get the process started a little bit.
Mark Antczak: Right. Okay. Seguing into that, follow-up question surrounding how you find a professional that we know can treat childhood OCD. What are some of the questions you could ask a professional to do your due diligence and make sure that they're not just taking on a case that they think they could work with?
Dr. Robert Selles: Sure. Yeah. OCD, like we talked about at the beginning of the episode, has some pretty simple principles but can be a little bit complicated when you are implementing it. And, in particular, it is a bit of a different approach for a clinician that involves supporting individuals to become more uncomfortable and feel more distressed. And a lot of therapists, their baseline approach is doing things that help people be less uncomfortable. And so that's a really big thing that you would want to have a sense of, is how does this person address this problem? Are they just going to talk with my child around it? Because what we know is that just talking about OCD or just trying to think logically about OCD does not lead to meaningful change. And in particular, what the research supports is the primary evidence-based treatment for OCD, is cognitive behavioural therapy, but in particular, that focuses on the process of exposure and response prevention. And that is a complicating sounding word if someone hasn't heard it before. I think about it in two ways. One is facing fears, that you're working towards facing those uncomfortable thoughts and situations.
But even more simply, I think about it as living life as if you don't have OCD. And if we come back to that pop-up analogy, the goal is to work towards not responding to those things. So, we are allowing pop-ups to happen. We are putting ourselves in situations where we know that they probably will, and then we're working to live in a way that doesn't involve responding to them and getting caught up in all of those compulsions. And so it makes sense why that works because, really, it's just building individual skills of being that person who isn't caught up in the OCD cycle.
Mark Antczak: Right. So, do you have experience working with kids that have OCD? Are you trained in ERP? Maybe do you have some acceptance and commitment therapy training, going off that reference of, "How would you live without your OCD?" Because I guess going off that algorithm... or metaphor that you shared earlier, you can't stop the pop-ups from happening, the same way you can't stop the intrusive thoughts from happening. So we have to learn how to face them, how to not react to them basically.
Dr. Robert Selles: Yeah. I think as a parent, what I would want to hear is I would want to hear some practical ideas, and skills, and approaches that demonstrate that this clinician understands the cycle of OCD and the ways that it can be interrupted. And so that would be the main thing that I'm looking for there.
Mark Antczak: Right. One of the last questions I have for you here, Robert, is just surrounding medication, because we know it's a very controversial topic, especially when we talk about younger populations. What would you say to a parent who's had a clinician or if some kind of paediatrician suggest medication and they're feeling really ambivalent about it? What would you say?
Dr. Robert Selles: I think, generally, practice guidelines always say patient preference is really important. I'm going to clarify before we continue talking, just that I am a psychologist, not a psychiatrist, so I'm not going to provide a lot of specific recommendations around medications outside of my practice area. But I'll speak a bit to how I try to talk to families about that decision.
The main thing to understand first is that based on extensive research, CBT with ERP, so that's the exposure and response prevention, is the first line treatment. It's the most recommended. It has the most evidence for the most amount of people for being associated with the largest reductions in symptoms and has the least amount of risks. At the same time, medications, serotonin reuptake inhibitors, often referred to as antidepressants, also have good evidence that they can be quite helpful, including in children and teens.
And so medications can be an important option if families feel comfortable or interested in trying them out, and otherwise, they're often an option that we're thinking about if symptoms are quite severe, so the impact of symptoms is very intense and causing a lot of disruption, or if CBT has been effectively done for quite some time and is not seeming to produce meaningful change.
Medications do have risks, they have risks of different side effects and things like that. And often, the paediatrician or whoever's prescribing is going to be looking out for those and trying to help manage them. And there may be some that you just aren't... If it makes you really ill or things like that, then that's probably not a good fit. But in making the decision to think about trying medication, it's important to balance the risks of having a side effect with the risks of not effectively treating this disorder that maybe, is impacting the ability to go to school, or to make friends, or to engage in age-appropriate self-care, these things that are so fundamental to developing as a person.
And if we leave those things untreated and they spiral and they're really, really bad, that is a side effect, that is something that we have to balance with those other risks. So what I encourage families to do often is, if they haven't tried CBT yet, that's often a good place to start. We can start there. You don't have to immediately go and seek out medication. But, if they're interested and they want to know more, they feel like it could be helpful or something that they want to try, I encourage them to speak to their doctor about their options, and the risks, and benefits.
Mark Antczak: So acknowledging that it is an option, it doesn't have to be the first option, but it's always about weighing that cost-benefit analysis, is me saying no to this option that we're at, we've tried all these other things, is me saying no to this is going to come at a greater cost if my child is limited from doing important things like socializing, forming friendships, navigating and growing up different pieces there. It's tough decision, I imagine, case to case.
Dr. Robert Selles: Yeah, for sure. And I think the other important thing to come in mind as things are particularly severe is that if you are hoping to access higher levels of care, so what might be things like a residential or a day treatment program, or things that are going to be really intensive because the symptoms are so bad, that often the entry criteria for those types of programs is that you have tried these medications before. So, again, that doesn't mean that people have to start there, but if you're really struggling, they are a meaningful evidence-based part of the treatment recommendations. And so it is going to be something that is part of the recommendations down the road.
Mark Antczak: Got you. Such an important point. Yeah, I really appreciate you clarifying that. And I guess just some final words of encouragement here. We know OCD, especially in kids, can make a lot of parents feel very, very hopeless, really fatigued. They might feel like they've been turning left, right, and center and they're coming up with dead ends. What would you say to parents who are in that space where they're like, "Oh, my God, I don't know what I'm supposed to do." What words of encouragement would you provide or any pragmatic advice?
Dr. Robert Selles: Yeah. I think it's really understandable, OCD is challenging and it brings up a lot of challenging emotions. It's overwhelming to see your child struggling, and OCD probably has also made your lives as parents really, really hard too. You didn't ask for the situation, that's not what you hoped for your child, for your family, but it's where you're at. And so the question becomes one that I'm going to put back on parents a little bit, that says, "So you're here. You're here in this struggle, and how do you want to handle this? Maybe take a moment to imagine yourself a year from now and you're reflecting back and you feel good. You don't necessarily feel good because everything's resolved, or perfect, or better, you feel good because you know you handled these tough moments in the best way possible."
I would ask them to lean into that, to lean into that feeling and think a little bit about like, "How did I think about this situation? What mindset did I adopt? What choices did I make? What things did I prioritize? Where did I turn to for support? How did I treat myself in those tough moments, and how did I treat my child?" Because what we're facing is that in difficult situations, regardless of how stuck we are, we have a choice to face the reality and the pain with courage, to try to act in ways that are consistent with who we want to be and the future we seek, or we have the option to give up, and we know where that leads. That's what leads us into that hopelessness and that sense that nothing can change.
So it's that choice, and it's the same choice the child is facing when they feel overwhelmed by OCD and this urge to engage in compulsions, that's that same choice that they're facing. And so there is so much hope here. There is so many families who have been so, so stuck and who have found their way, and sometimes it has been through digging really deep, and getting the exact right services, and working really hard. Sometimes families have done that and it still hasn't quite worked. And then some situations, and the child's life, and their brain develops in ways and they clue in that it's not helpful, and they start to get more engaged and things start to shift. It's hard to say exactly when it's going to happen or how perfectly and neatly it will all wrap up, but there is in those moments just that choice of, "How do I want to face this?"
And if you as the parent can model handling and responding to that emotion in ways that reflect trying your best to navigate through it, and that promote an idea or concept called active hope. And so what active hope is the idea that you create hope by engaging in things that are consistent with what you hope to have happen. And so if you can model that idea of, "Yes, this is hard, yes, this is overwhelming," and we are still going to try to do the things that we know are associated with the outcomes that we hope for, that provides a really meaningful example and model for your child.
Mark Antczak: "There's hope." Those are beautiful words to finish on, Robert. Thank you so, so much for joining today. I suspect that we're going to bring up a lot of questions from anyone listening, and we really do appreciate all your insight and expertise today.
Dr. Robert Selles: Thanks for having me.
Mark Antczak:
All right, folks, well, thank you for listening to OurAnxietyStories, the OCD series. If you'd like to support this podcast or Anxiety Canada, go to anxietycanada.com. We'll see you next time.
Outro: Thank you for listening to #OurAnxietyStories, the Anxiety Canada podcast. To share your own story or to find resources and support this podcast, visit us at anxietycanada.com.
