British Psychological Society Publishes Guidelines on Hoarding

British Psychological Society Publishes Guidelines on Hoarding

In the most recent DSM, hoarding was given its own diagnosis. Prior to that, it was hitched to OCD as subtype. I was glad when the DSM-5 gave hoarding a separate diagnosis, as in my experience, hoarding often presents as different enough from OCD that a separate diagnosis seems warranted. This may also help encourage more research about hoarding disorder, as researchers tend to devote more resources towards problems with an official diagnosis. The International OCD Foundation recently created a linked but separate website for hoarding disorder.

In the June 2015 issues of their journal, the British Psychological Society (BPS) devoted the entire issue to providing up-to-date information about hoarding disorder. It’s a tremendous resource for any professional interested in working with hoarding.

Currently, you can download the issue for free if you sign-up for a membership. However, I found a link that will allow you to download a pdf of the issue directly.

Renouncing “reparative therapy”: A giant in the field admits his humanity

Renouncing “reparative therapy”: A giant in the field admits his humanity

Robert Spitzer, MD, one of the most influential voices in modern psychiatry, readily admits that he has always been drawn to controversy. He definitely has been at the heart of the controversy about sexual orientation and identity since the 1970s. It was during that time that Dr. Spitzer was instrumental in getting homosexuality removed from the DSM-III thereby declassifying it as a “mental illness.” However, the biggest controversy he may have been a part of was his more recent work on so-called “reparative therapies.” And now his recantation of that work may be one the last (he’s 80 years old now) and possibly one of the most important contributions Dr. Spitzer will make. In an inspiring act of courage and scientific integrity, Dr. Spitzer has written a letter to be published in the Archives of Sexual Behavior in which he states, ““I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy.”

The study that Spitzer is referring to is the highly influential 2003 study he conducted and that was published in the Archives of Sexual Behavior (published, it should be noted, without going through the standard peer-review process) in which he concluded that the majority of participants in his study, who were self-selected as being highly distressed about their sexual orientation, reported having changed their sexual orientation from homosexual to heterosexual. The result was a study that has been widely misused for political purposes to state that homosexuality can (and should) be “cured.” While Spitzer has, reportedly, always disagreed with this interpretation of his study, he has now publically denounced the study as being based on flawed science. All of the findings in the study were based exclusively on self-report from a “highly motivated” sample. In addition, this was not a study of the effectiveness of any type of particular therapy–nearly ½ of the participants never even engaged in any therapy at all. Basically, his study, which has been cited for nearly 10 years as “scientific proof” that sexual orientation/identity can be changed, consisted of interviewing people who reported that they had, in the past, been highly distressed about identifying as homosexual and now felt that they were more strongly identified as heterosexual.

Dr. Spitzer is certainly not alone in his criticism of reparative therapies. In fact he is a bit late in his critique. In 1997, the American Psychological Association came out with a resolution specifically stating that there is no scientific merit to claims of therapies being able to change sexual orientation and condemning the practice of such therapies. In 200, the American Psychiatric Association followed suit and published a resolution challenging the “validity, efficacy, and ethics of clinical attempts to change an individual’s sexual orientation.” Just last week the World Health Organization came out with a report stating that these type of therapies are “a serious threat to the health and well-being — even the lives — of affected people.”

The problem with science is that it is conducted by humans, and we humans have our own preconceptions, egos, and agendas that can get in the way of our science. What is heartening is that someone like Spitzer, a giant in the field, can finally take a stand and correct what he has called his “only professional regret.”

PTSD Without Trauma? A Scientific American article examines some controversies about diagnostic criteria for PTSD

PTSD Without Trauma? A Scientific American article examines some controversies about diagnostic criteria for PTSD

When I was delving into the trauma literature for my dissertation several years ago, I noticed a study that—while not particularly relevant to my needs at the time – offered an intriguing finding. Bodkin, Pope, Detke, and Hudson (2007) found equivalent rates of PTSD symptoms between individuals who did (78%) and did not (78%) report a history of trauma. That is, a significant portion of their sample (who had major depression) similarly exhibited symptoms for PTSD, regardless of whether they had had been exposed to a trauma or not.

This was the first time I became aware of an ongoing controversy relating to how PTSD is diagnosed. In our current nosology (as defined in the DSM-IV), a PTSD diagnosis requires a person to have experienced a traumatic event–Criterion A, defined as threat of injury or death to self or others. However, some data seem to indicate that people can can experience PTSD-like symptoms even in the absence of an identifiable Criterion A trauma (as defined by the DSM-IV).  There is a large group of proponents who think this reveals a deep flaw in our diagnostic critera for PTSD.

For a brief summary of this controversy, check out, Rosen, Spitzer, & McHugh (2008; click on this link for the full pdf). As I’ve written about in a previous post, the current task force is considering tightening up the criterion A definition of what is considered a traumatic event.

I bring all this up now because the controversy has reached the popular press. In an April issue of Scientific American (reprinted online in May), Scott Lilienfeld and Hal Arkowitz provide a brief, readable summary of these concerns in their article, “Does Post-Traumatic Stress Disorder Require Trauma?

This is an issue that can be easily misinterpreted by the public. Critics of diagnostic criteria of DSM are not suggesting that PTSD does not exist; rather, the concern is that our understanding of PTSD and the criteria we use to diagnose it are seriously flawed.

I look forward to watching how this debate plays out in the revision process for the DSM-V.

In the meantime, check out the Scientific American article, and follow it up with Rosen et al. (2008).

Changing PTSD Criteria for the DSM-5

Changing PTSD Criteria for the DSM-5

As a member of the Anxiety Disorders Association of America (ADAA), I receive their monthly journal Depression and Anxiety. The September issue—I know this post is a little late, it got caught up in editing—features an article on changes that are being considered for diagnosing PTSD in the upcoming DSM-5. It’s not certain that the proposed changes will make it in there, but they provide some interest food for thought.

What Causes PTSD?

PTSD is pretty unique among diagnoses in that the definition requires an external event (criterion A) that other diagnoses—such as depression and other forms of anxiety—do not. There is no posttraumatic stress disorder without a trauma. But what counts as a trauma?

People such as Harvard’s Richard McNally have criticized the current parameters of what can be considered a traumatic antecedent as being too broad. Some of this controversy came out of 9-11, where people were diagnosed with PTSD after seeing news footage of the collapse of World Trade Center, even though they didn’t know anyone who died or were endangered. Anthropologist Allan Young called this “PTSD of the virtual kind” (quoted in McNally, 2009). The point of this is not to diminish the impact of people’s subjective experiences; rather, that a definition that runs the spectrum from rape, torture, and combat violence all the way seeing something distressing on TV may not be clinically useful.

The authors of the proposed DSM-5 revision tighten up the definition and limit criterion A events to those involving threat of harm or death that are either witnessed by the individual or involve a close relative or friend. Additionally, they cut out entirely the second component—that the person experience “fear, helplessness, or horror.” The authors suggest that this second part is not clinically useful.

Expanding Symptom Clusters from Three to Four

Currently, the DSM clusters PTSD symptoms according to three categories: Re-experiencing (e.g., memories, nightmares, flashbacks); avoidant/numbing (e.g., avoiding internal/external reminders, psychic numbing); and hyperarousal (e.g., easily startled, hypervigilant). By contrast, the authors of this article expand the total number of symptoms from 17 to 2, and they categorize them according to four clusters.

The newly added symptoms are “erroneous self- or other-blame regarding the trauma,” “negative mood states,” and “reckless and maladaptive behavior.” I have no problem with the addition of negative mood states, and I think incorporating reckless and maladaptive behavior helps to capture aspects of PTSD that are often exhibited in military veterans.

I’m concerned, however, with the entire notion of “erroneous” beliefs. This is part of the new symptom category, “Alterations in Cognitions and Mood,” which puts more of a cognitive therapy spin on the diagnostic criteria. I find the word “erroneous” troubling, as it places the therapist in the role of deciding what’s realistic and what’s not. This is a problem I have with cognitive therapy, in general, so I’ll admit my bias here. And in fairness to the authors, they have obviously thought deeply about this change and cite their reasoning. Nonetheless, the label strikes me as less descriptive and more evaluative.

Additionally, the DSM in general tends to draw an imaginary and arbitrary line between thinking and feelings. For example, the new suggestions recast “detachment from others” as “Feeling [italics mine] of detachment or estrangement from others.” The use of the word “feeling” seems imprecise, as it’s impossible to imagine this experience except as filtered through thinking. For example, a dog may feel fear, but I doubt it ever feels estranged from others. This imprecision in the use of language is hardly unique to the PTSD, but pervades the DSM, unfortunately.

What About Complex PTSD?

Coined by psychiatrist Judith Herman, there’s a growing faction of people such as Bessel van der Kolk clamoring for the inclusion of Complex PTSD aka Disorders of Extreme Stress Not Otherwise Specified. They argue that the current definition of PTSD fails to describe victims of severe and prolonged abuse (e.g., some childhood sexual abuse survivors or tortured political refugees). These survivors demonstrate complex clinical pictures which may include features that overlap with borderline personality disorder and dissociative disorders. The authors examined the available research and concluded that there’s not enough evidence to include complex PTSD as a separate disorder. I think this is a reasonable position, and at the very least, provides motivation for advocates to refine their research, which is a little sparse to date.

Final Thoughts

It’s impossible to predict which of these suggestions will make it into the next edition of the DSM. The authors take pains to state that their suggestions remain speculative and should be subjected to further inquiry. At the very least, this article provides a wonderfully concise summary of current PTSD research, and I highly recommend anyone interested in trauma check it out.

Reference:

 

Friedman, M.J., Resick, P.A., Bryant, R.A., & Brewin, C.R. (2011). Considering PTSD for DSM-5. Depression and Anxiety, 28(9), 750-769.

UPCOMING TRAINING EVENTS


Acceptance & Commitment Therapy – An Experiential & Practical Introduction

Jason Luoma, PhD and Jenna LeJeune, PhD
November 13th and 14th, 2021 from 8:30am-4:30pm
at Hilton Garden Inn Portland Airport
This two-day in-person workshop provides a thorough overview of the theory, principles, and techniques of Acceptance and Commitment Therapy. It is intended for those who are relatively new to ACT and for those who have done some reading on their own about ACT but who may not have had the opportunity to participate in more experiential learning, observe models, or receive feedback while using the ACT model. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Brian Pilecki, PhD and Jason Luoma, PhD
November 19th, 2021 from 9am-11am

There is an increasing demand from clients seeking therapeutic support in their personal use of psychedelics. However, many clinicians interested in psychedelic preparation and integration are unsure as to how to provide these services as psychedelics mostly remain illegal. In this workshop, we will outline legal and ethical frameworks relevant to providing therapy to clients around their personal use of psychedelics, as well as describe how harm reduction approaches are suitable for this developing clinical area. Read More.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 18, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

November 12th, 2021Psychedelic Research: Implications for Palliative Care and End-of-Life Existential Distress with Anthony Bossis, Ph.D.

December 10th, 2021Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div., M.S.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD