Therapy for Co-Occurring Disorders (COD)

My distinctive therapeutic specialization is the application of Transdiagnostic Treatment for Co-Occurring Disorders of OCD & Anxiety, Mood, Eating, Substance Use, or Trauma.

Transdiagnostic (integrative) treatment for comorbid conditions, meaning conjunctively treating all symptoms derived from more than one diagnosis, is well-supported as the most efficacious care with which you can engage.

The wealth of research following integrative care patients has produced several notable positive outcomes such as: improved mental functioning, reduced substance use, substance abstinence, decreased hospital/inpatient admissions, improved life satisfaction and quality of life, and higher client satisfaction.

If you see a clinician specialized in only one area, treating symptoms solely within their specialized area of focus, then only a portion of your full clinical picture is being addressed. You might experience a feeling of “whack-a-mole” with your co-occurring diagnoses, meaning while one condition is being treated, other condition(s) re-emerge after years of stabilization, or worsen if ongoing or previously untreated.

What is Transdiagnostic Therapy?

Transdiagnostic treatment means we simultaneously address the shared underlying core mechanisms and processes perpetuating multiple diagnostic conditions.

At the core of most mental health disorders within my areas of focus are two pervasive problems:

1) a distorted relationship with thoughts

2) an avoidant relationship with feelings

Though this is a drastically simplified and reductive truth, it allows for us to much more efficiently and effectively parse out the most direct and relevant therapeutic issues and interventions. It also helps us to zoom out from from the complex and sometimes chaotic symptomatic presentation.

Mental health disorders often co-occur because they are operating to protect the individual from many of the same core fears/beliefs and accompanying intrusive thoughts, in creative and variant maladaptive ways.

Being a specialized practitioner means I am not the best choice for any and all diagnostic presentations. However, within the co-occurring intersections of my specializations, I am confident that with your collaboration I can help expand your tolerance for painful symptoms, reduce psychological suffering, and increase your quality of life. I will do my best for and with you until optimal functioning is returned, whatever we determine that to be.

Diagnostic Co-Occurring Disorder Evaluation

If you are interested in participating in a comprehensive diagnostic evaluation for COD, please reach out to me. This is a stand-alone service I provide with no continuing therapeutic commitment expected or required. Continuing care and level of care treatment recommendations are provided upon completion of this evaluation.

Co-Occurring Disordered Thinking Sounds Like:

“I don’t feel “right” unless I eat a certain way, or in a certain order, or at a certain time.”
“I’m not doing well at my ED, but I can be perfect at my OCD.”
“My OCD needs ritual, and I can itch that scratch using this drink or high (or restriction).”
“I can drink/use tonight if I restrict food calories today.”
“I ate imperfectly today. I may as well use substances imperfectly (to excess) today as well.”
“I can’t tolerate my ED and/or OCD thoughts without self-medicating or engaging in rituals.”

Co-Occurring Disordered Behaviors Look Like:

Using drugs or alcohol to suppress or cope with obsessional thinking or to serve compulsive urges
Using food or exercise to suppress obsessional thinking or to serve compulsive urges
Food avoidance or rules that serve both the ED and OCD contamination obsessional fears
Food avoidance or rules that serve both the ED and BDD obsessional thoughts
Trans-diagnostic “Triple R”: Rules, Rituals, Reassurance-Seeking across the disorders

What is the Prevalence of Co-Occurring Diagnoses?

OCD & Anxiety Disorders, ED, SUD, and Mood and Trauma disorders highly co-occur, meaning they are showing up at the same time, creating a more complex subset of clinical interplay. It is also important to normalize the co-occurring nature of mental health diagnoses as vastly more common than exceptional. In fact, the below numbers are likely statistically lower than actual numbers, due to the lack of specialization among treatment providers in treating co-occurring disorders, resulting in under/un-diagnosed ED’s, SUD’s OCD, etc.

80% of clients with PTSD will have one or more additional mental health diagnoses
50% of individuals with a substance use disorder also have a co-occurring eating disorder
30% of individuals with an eating disorder will develop a co-occurring substance use disorder
ED co-occurs in at least 14% of the OCD population

Prevalence Statistics for OCD & SUD:

Individuals with OCD are more likely to develop a Substance Use Disorder. More than 1 in 4 individuals seeking treatment for OCD are self-medicating unmanageable OCD symptoms using substances of choice.
In the adult population with OCD diagnoses, as high as 40% have been identified as meeting criteria for a Substance Use Disorder.
70% of the OCD diagnosed population display symptoms consistent with a behavioral or process addiction, as compared to only 58% of the population not meeting OCD diagnostic criteria.
Under-reporting of substance use remains an inherent condition of the behavior, so careful assessment and increased awareness by clinicians is indicated as an area for improvement.

How Does Sara Watts Treat Co-Occurring Diagnoses (COD’s)?

The most effective therapeutic interventions for COD’s are those that are transdiagnostic.

Of the treatment approaches I utilize, the great news is that most of them are transdiagnostic. CBT, DBT ACT, and UP are all transdiagnostic treatment approaches. ERP is not inherently transdiagnsotic, but has been shown to have good efficacy when applied outside of OCD, especially around anxiety and eating disorders. ERP can be compromised by active SUD’s, just as it can be compromised by many other avoidance and safety-seeking behaviors. ERP can still be applied when there is an active SUD. A harm reduction agreement is indicated, and would be most beneficial when applied during the times of planned exposures to situations of avoidance and distress.

We can simplify the focus of these therapeutic interventions by recognizing that at the core of many co-occurring diagnoses is a shared element of emotion avoidance. And more often than not, COD’s also overlap around an overvaluation of thoughts and a learned and practiced intolerance of emotions.

It is important to clarify that every mental health disorder can inflict variant levels of struggle or suffering. No mental health disorder “trumps” another as being more severe or less treatable than another. All mental health disorders fall along a spectrum of severity, and every individual is different in terms of the impacts of their respective disorder(s).

Am I Too Complicated for Treatment in Outpatient Therapy?

Co-occurring conditions are not untreatable or a treatment problem for you to solve. And, comorbid conditions do require specialized therapeutic intervention provided by a clinician trained in all areas of your clinical needs.

Whether or not you are a good fit for being treated at the outpatient level of care is not determined by how many diagnoses you have. Rather, the appropriate level of care is determined by symptom severity and to what extent these symptoms impact functionality in fulfilling your life roles within a manageable physical, mental, and emotional state.

Co-Occurring Mood Disorders

Mood disorders are one of the most common co-occurring diagnoses.

Mood disorders commonly take the form of Major Depressive Disorder, Bipolar Disorder, or Persistent Depressive Disorder. Depressive symptoms include persistent feelings of sadness, loneliness, helplessness, or low self-esteem, sleep and/or appetite disturbances, irritability, loss of interest in formerly enjoyable activities (anhedonia), fatigue, suicidal thoughts, forgetfulness, and increased difficulties with concentration or decision-making.

In bipolar disorder, in addition to depressive episodes, we will see (hypo)/manic phases of elevated or irritable mood, grandiosity, decreased need for sleep/insomnia, and increased impulsivity.

Many of the above symptoms overlap with symptoms found among alternative diagnoses such as Trauma Disorders, Anxiety Disorders, and ADHD. This is one of the reasons it is so important to work with a licensed healthcare provider to determine which symptoms are primarily sourced from which diagnoses, and from there establish the most effective treatment plan and interventions.

Medication is highly recommended, but not required for the successful treatment of mood disorders.

How Does Sara Watts Treat Co-Occurring Mood Disorders?

My main interventions for mood disorders include CBT, ACT, and Behavioral Activation.

Behavioral Activation involves identifying and incorporating both enjoyable activities and essential acts of daily living into a person’s everyday routine, goal-setting, problem-solving, and tracking strategies. Tracking strategies might relate to sleep, mood, motivation, or level of engagement.

How Do We Apply Behavioral Activation (BA’s) in Our Therapeutic Work?

identifying and overcoming potential or actual barriers that are preventing engagement with enjoyable activities
incorporating individual values and committed actions as motivators
establishing a system of structure and routine, partnered with a healthy course of psychological flexibility and self-compassion

How Do I Treat Co-Occurring Trauma Disorders?

Trauma disorders frequently co-occur with all of my clinical specializations.

Trauma symptoms can present chronically or acutely in the form of feelings of guilt, shame, or fear, negative thoughts about oneself, hyperarousal or feeling on edge, intrusive thoughts or flashbacks, sleep and/or appetite disturbances, physical pain, emotional dysregulation or detachment, and avoidance or people, places, or things.

When working with co-occurring trauma, I incorporate CBT and DBT trauma-focused protocols, as well as elements of Prolonged Exposure into my trans-diagnostic treatment approaches. I also continually invest in training around a sub-specialization of religious trauma, and am a member of the Religious Training Institute. When indicated, I provide formal trauma treatment using the evidence-based intervention Written Exposure Therapy.

What is Written Exposure Therapy?

Written Exposure Therapy is a well-researched brief 5 session exposure-based trauma protocol.

The client engages in written exposure work targeting one specific trauma. It is recommended to target either the most traumatizing or the most memorable traumatic event first. The client spends the majority of the therapy session writing, and engages with a check-in and check-out with the therapist before and after writing. Like most other trauma interventions, Written Exposure Therapy aims to reframe thought distortions, and bring a more integrated and balanced perspective of the self and the world into alignment.

Written Exposure Therapy has been shown to have lower dropout rates and higher efficacy as compared to longer term trauma interventions.

If I determine that PTSD or a trauma disorder is of primary focus or requires longer term primary trauma treatment, I will provide referrals to my colleagues specializing in primary trauma disorders. Typically, primary trauma interventions are between 8-20 sessions. Upon completion, clients are welcome to return to me to continue work around the other co-occurring diagnoses, or if the trauma specialist is equipped to address your other co-occurring diagnoses, you are welcome to continue your work with them.

Learn About Co-Occurring Disorder Therapy with Sara Watts

If it would help, I would be pleased to offer a 15 minute complimentary call to introduce myself and my approach to Co-Occuring Disorder Therapy.

Please feel free to contact me today.

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