Anxiety Disorders/OCD IOP

The Anxiety Disorders/OCD IOP (Intensive Outpatient Program) at Doorways is a group therapy program for teens who are struggling with the following issues or symptoms:

  • School avoidance/ refusal
  • Specific phobias (fear of vomiting, fear of spiders/animals, fear of elevators, etc.)
  • Panic attacks, panic disorder
  • Generalized anxiety disorder
  • Obsessive compulsive disorder (OCD)

The Anxiety Disorders/OCD Intensive Outpatient Program is held three days per week.

Our IOP groups are contracted with Aetna, Blue Cross Blue Shield, Cigna, and United Behavioral Healthcare.

For more information about IOP, contact our IOP coordinator at 602-997-2880 or [email protected].

Here’s a typical session at our Anxiety Disorders/OCD IOP.

The first hour of our IOP is group sharing time. Members share and celebrate their successes and challenges with anxiety since the last group and offer each other feedback.

Then the remainder of the group we engage in fun and creative tasks to help adolescents face their fears.

These serve a purpose in challenging the social anxiety and OCD symptoms that keep adolescents from functioning in their world.We might play a game of charades, lip-syncing contests or practice doing every day activities that they might avoid.

We also go offsite and participate in activities that normally would cause us to feel extreme anxiety, but by doing it as a group in a safe setting, we learn how to overcome those feelings. For example, we recently went to a pumpkin patch and participated in a maze to challenge particular fears. We also go to malls or restaurants and plan social activities.

Do You Have a Teen with OCD?

Do you have a teen with OCD?

Launched in 2009 by the International OCD Foundation (IOCDF), OCD Awareness Week takes place annually during the second week in October. OCD stands for Obsessive-Compulsive Disorder and OCD Week aims to raise awareness and understanding about this condition so that more sufferers can receive appropriate and effective treatment.

What is Obsessive-Compulsive Disorder?

OCD is a common mental condition. An individual with OCD has constantly recurring thoughts (obsessions) that may lead to behaviors that they have no control over (compulsions). These behaviors will be repeated over and over and the sufferer will be unable to stop. It’s not just about a habit like biting your nails or sometimes thinking negative thoughts. OCD in teens can affect their lives to such an extent that they have trouble living a normal life at home or in school.

What are Examples of OCD Obsessions and Compulsions?

An obsessive individual might be someone who thinks they’ll be unlucky if they don’t put their clothes on in the exact same order every morning. A compulsive habit might be someone washing their hands exactly seven times after touching something dirty. A teen may try to involve family members in their obsessions. For instance, they may insist that their parents and siblings also wash their hands the way they do. Although teens might not want to think or do these things, and may even understand that they don’t make sense, they feel powerless to stop.

How Common is OCD Among Teens?

The International OCD Foundation (IOCD) estimates that approximately twenty teenagers in a large high school may have OCD. Compulsive rituals can be somewhat time-consuming, making teens late for school and activities. When parents try to “reason” a teen out of their compulsive behavior, this results in arguments and tension. Some teens may worry that they’re going crazy and work hard to hide their OCD from others. This prevents them from behaving naturally and causes a great deal of inner stress and exhaustion.

What Causes OCD?

Unfortunately, research has not been able to pinpoint the exact cause or causes of OCD. However, studies have suggested that differences in the brain and genes of those affected may play a role. OCD may result from problems in communication between the front part of the brain and the brain’s deeper structures. These brain structures use a chemical messenger (neurotransmitter) called serotonin. What is known is that, in some sufferers, the brain circuitry involved in OCD becomes more normalized with medications that have an effect on serotonin levels (serotonin reuptake inhibitors, or SRIs). The same effect has been observed in OCD sufferers undergoing cognitive behavior therapy (CBT).

  • Can OCD be Inherited? – It does seem that OCD can run in families. This backs up the contention that genes are likely playing a partial role in the development of the disorder.

Where can I get Help for my Teen with OCD in Phoenix?

OCD is a type of anxiety disorder. If your teen (aged thirteen to seventeen) has been diagnosed with OCD, they may benefit from joining a Doorways Intensive Outpatient Program (IOP) for Anxiety Disorders/OCD. A Doorways IOP consists of a small group led by a trained counselor and operates on an open enrollment basis. This means that your teen can be enrolled at any time. We want to help your teen with OCD so contact us for more information.

Everything You Need to Know to Help Your Teen Manage OCD

The adolescent years can be difficult, but if you have a teen with obsessive-compulsive disorder (OCD) you are faced with additional obstacles as a parent. Know that you are not alone on this journey. According to the Anxiety and Depression Association of America (ADAA), OCD affects about one in one-hundred school-age children. Once you gain an understanding of OCD, know that there are treatment options available for your adolescent.

Doorways Arizona Blog: Everything You Need to Know to Help Your Teen Manage OCD

What is OCD?

OCD has two components. One component is the obsession. This is when the person has ongoing fears and thoughts and images that are upsetting to them. The compulsion aspect is the urge to do certain things repeatedly to get rid of the thoughts and help reduce the anxiety these thoughts are causing. These actions only provide temporary relief and can actually reinforce the obsession. Further, these actions cause interference with daily activities. Common Obsessions and Compulsions:

  • Fear of contamination or germs leads to compulsively cleaning and/or washing
  • Fear of violating religious rules leads to a compulsion with religious observances
  • Fear of having something valuable lost leads to compulsively hoarding
  • Fear of danger or harm leads to compulsively checking
  • Feels the needs for things to have symmetry which leads to compulsively arranging things
  • Feels the need to be perfect which leads to needing reassurance and making sure they are doing things perfectly

Causes and Risk Factor

According to Kids Health, the exact cause of OCD is not yet known by scientists and doctors. What is believed is that there is a relationship between the levels of serotonin in the brain and that if serotonin levels are blocked the brain creates these “false alarms” or danger messages and instead of the brain getting rid of these messages it obsesses about them which causes unnecessary fears.

There is strong evidence that OCD can be hereditary. Many find if they have it so do at least one of more members of their family. However, just because this gene may exist does not mean that a person will develop OCD. There is just a stronger chance for it to develop. Keep in mind, that if OCD is genetic, then it is not caused by the family of the adolescent with OCD.

According to ADAA, other instances of OCD occurring are following a strep infection and also a major life change or stressful event. Examples are:

  • Move to a new community or new home
  • Having a new sibling
  • A loved one dying
  • A new school year
  • Other illness
  • Vacation Time
  • Divorce

How to Talk to Your Teen About OCD

Your teen might be relieved that you want to talk about their OCD or they might be reluctant. According the International OCD Foundation, parents should first do research to learn more about OCD, as well as therapists and also medications to treat OCD. Then approach your adolescent in a non-judgmental way to talk about their OCD and seeking professional help.

Diagnosing

To diagnose OCD, a mental health professional with knowledge of OCD will perform an interview to see if your adolescent has OCD. They will likely ask questions in regard to the obsessions and compulsions. Examples of questions:

  • Do you have thoughts, images, worries, ideas or feeling that either scare or upset you?
  • Do you feel it necessary to organize things in a certain way?
  • Do you repetitively go over things?

Upon being diagnosed, treatment can begin for your adolescent. What does treatment for OCD look like?

Treatment

Initially your adolescent will begin working with the therapist to learn about OCD and what to expect from treatment. The types of therapy they will then begin are cognitive-behavioral therapy (CBT) and Exposure and Response Prevention (ERP) coupled with cognitive therapy. These are the most effective treatments for OCD. What this means is that the therapist will give your adolescent tools to outsmart the OCD and help manage the OCD with proven tactics. In most cases, you can expect the treatment to take weeks or months. Gradually your adolescent can expect to be exposed to their fears and asked to stop doing the compulsion. An example would be for a person afraid of germs being asked to touch an item in public like a door knob and then wait an extended period of time to wash their hands. Then gradually increase the time between touching the object and then washing their hands. Over time your body will be trained to act differently to the fear.

If your adolescent seems to exhibit symptoms of OCD contact the team at Doorways for an evaluation and if we find that they do have OCD, then we can recommend the best course of treatment for your adolescent.

 

Perfectionist vs OCD

It is easy to confuse the different between perfectionist vs OCD. You see the acronym OCD being used in social media every day.  Here’s an example from Twitter: “52 Home Organization Tips for Your OCD Side.” Unfortunately, this casual characterization of OCD minimizes the seriousness of the real disease.

Perfectionist vs OCD

What is OCD?

Obsessive Compulsive Disorder (OCD) is a disease that afflicts people in two ways. First, the person experiences various unwanted urges, thoughts, or impulses that usually result in some level of stress. Second, the person performs some type of habitual routine as a way to alleviate the effects of those thoughts, leading to the compulsion aspect of the disease.

OCD is a serious disorder that prevents people from functioning normally. The compulsion gets in the way of basic, day-to-day responsibilities. As a result, OCD can lead to personal, professional, and academic problems.

The Difference Between OCD and Perfectionism

It’s easy to characterize people who are perfectionists as having OCD. However, while extreme perfectionism may be a symptom of OCD, the reality is that for most people, the quest for perfection is nothing like being afflicted with OCD. There are several ways in which perfectionism and OCD differ.

 

People Afflicted with OCDPeople Who are Perfectionists
Experience thoughts, urges, and impulses that   are unwanted and involuntaryHave a completely voluntary desire to make everything “just right”
Do not gain satisfaction from performing their habitsEnjoy a brief sense of accomplishment knowing that they’ve done the right thing or met a goal
Engage in specific, habitual behaviors as a     means of relief from thoughts, urges, or     impulsesPractice good habits that they’ve developed with the strength of character
Practice unhealthy habits such as checking that   the stove is off over, and over, and over again,   even leaving an event to go home and check the ovenPractice healthy habits such as making sure that the oven is shut off and then going on with their day
Practice habits that have a detrimental impact     on their day-to-day responsibilitiesPractice habits that complement their day-to-day responsibilities
Practice habits that are distressingPractice habits that are rewarding
Practice habits that are irrationalPractice habits that are perfectly rational
Want to get rid of the thoughts driving them to compulsionWelcome the thoughts driving them to perfection
View their habits as a nuisanceView their habits positively
Want to get rid of their habitsWant to keep their habits

At first glance, you might think that people who have OCD are just like perfectionists. That’s an easy error for an untrained eye.

However, the two are nothing alike. People who are afflicted with OCD are suffering from a disorder that has an adverse effect on their ability to function properly. People who are perfectionists, on the other hand, rely on their good habits to improve their lives and the lives of others.

People who have OCD need treatment. Perfectionists may go overboard on occasion, but the perfectionism does not interfere with their ability to function in their daily lives.

If you are a parent or a guardian of a young person that you suspect of having obsessive compulsive disorder, we can help.  We have providers who are some of the best OCD experts in the US, and specialize in working with teens and young adults with OCD.

If your young person has not been diagnosed with OCD the first step would be to contact us for an evaluation.  Once we have confirmed whether or not a person has OCD, then we will make recommendations for the best course of treatment.

There is help for OCD.  Call us! 602-997-2880.

OCD in Young Adults

Obsessive Compulsive Disorder (OCD) afflicts people of all ages. However, it can be particularly difficult for young people who are just beginning their journey as independent adults.

Obsessive Word Cloud

What is OCD?

OCD is a mental disorder that influences a person’s mind as well as his or her actions. As the name implies, there are two distinct parts to OCD: obsession and compulsion.

The obsession part of OCD is a thought, urge, image, or impulse that’s recurring in the patient’s mind. In many cases, the thought is unwanted and leads to severe anxiety. Obsessive thoughts also can lead to feelings of fear, doubt, or disgust that further complicate the patient’s mental health. Obsessive thoughts are time-consuming and prevent people from leading fulfilling, healthy lifestyles.

A compulsion in OCD can be thought of as a response mechanism. It’s a habitual practice that people afflicted with the disorder use to cope with the obsessive thoughts. Even though patients realize that a compulsion offers only temporary relief, they engage in the practice anyway, leading to further development of the habit and complicating treatment.

 

How It Affects Young People

OCD affects every adult differently. However, when young people are just beginning to live their lives as independent adults, it can be particularly debilitating to a proper social and mental development. This is especially true in a college setting that’s often best enjoyed with multiple social encounters and interactions

Further, OCD can be particularly troubling for college students who are required to live in a dormitory environment. That’s because OCD patients are often fearful of contamination from other people or everyday objects. As a result, college students afflicted with the disorder might find themselves in a severe state of anxiety after they move into a dormitory.

Also, people who have OCD try to avoid situations that they fear might trigger an obsessive thought. That can inhibit healthy lifestyle development in a collegiate environment if students who have the disorder withdraw from social functions.

 

The Story of Anna

Young people who have been diagnosed with OCD should know that they are not alone. A 25-year-old woman from the UK, who goes by the name of Anna, was kind enough to share her story with others who might find themselves in a similar situation.

Anna says that she can’t remember a time when she wasn’t worrying or carrying out specific rituals. When she was younger, the phobias started with a fear of monsters. She would habitually check to ensure that the toilet was flushed and all the faucets were off because she was afraid that something would come out of the water.

She was a child afraid of monsters. That seems normal enough, right?

Wrong. In Anna’s case, a normal fear turned into an onset of OCD. It affected her life because she never outgrew it, as children tend to do when it comes to the concern about creatures lurking under the bed.

When she was a child, her classmates caught on to her OCD and asked her why she always washed her hands. That’s when she started to hide her disorder symptoms for fear of being “different.”

At the age of 10, she developed an intense fear of dying after being taught about heaven and hell. She literally became obsessed, in the strictest sense of the word, about losing her life and not going to heaven. As a result, she took great pains to ensure that she didn’t get hurt. She also made sure, as much as possible, that she didn’t hurt other people as well, fearing that she would die and go to hell if she harmed anybody else.

Anna’s onset of OCD became particularly intense when she entertained the awful thought of taking her own life so that she wouldn’t spread her germs to other people.

Her mother took her to therapy, but Anna was too ashamed of her thoughts to share them openly. That delayed her treatment for years.

When Anna reached 18 and landed a new job, she realized it was time to reevaluate where her life was headed. She had just dropped out of the university after less than a year and now says that her OCD threw her life “into disarray.”

She found a path to obtaining her degree in her own time, by studying during evenings and weekends. She claims today that pursuing her university education was one of the best choices that she ever made.

Anna is now in counseling and believes that she has emerged from “all the angst and stress of not being able to cope with my OCD.” She’s engaged to a man that she describes as “wonderfully patient and caring.”

Her OCD still emerges periodically, but Anna has developed a confidence about treating it. She says that her counselor has helped recognize the difference between obsessive thoughts and her own thoughts.

Now, Anna says, she can begin to help herself.

 

Treatment for OCD

Thanks to recent advances in Cognitive-Behavioral Therapy (CBT), OCD in people like Anna is considered treatable.

One avenue of treatment is called Exposure and Response Prevention (ERP). That involves what professionals describe as “exposure therapy” and is currently considered the most effective treatment for the disorder.

A variant of ERP, known as “imaginal exposure,” is used to not only treat OCD but also anxiety disorders and OC Spectrum Disorders. Imaginal exposure, as the name implies, exposes the patient to stories related to his or her obsessions. It’s been demonstrated to reduce the magnitude and frequency of obsessive thoughts.

Another treatment possibility for OCD is called Mindfulness-Based Cognitive-Behavioral Therapy. It’s an approach that teaches patients to accept their thoughts and avoid responding with the compulsive behavior.

 

OCD is a mental disorder that can be particularly challenging for young people. As they suffer from constant, unwanted thoughts, they attempt to engage in compulsive behavior as a coping mechanism. That leads to a lifestyle that is at odds with healthy development in early adulthood. Fortunately, there is treatment available to those who realize that it’s a problem and are willing to do something about it.

 

4 Ways to Support Your Teen With OCD

Obsessive Compulsive Disorder

If your teen has OCD, here are some ways you can help support them. (photo credit: BigStockPhoto.com)

Before a mental health disorder is diagnosed, everyone in the family can feel helpless and out of control to the point that finding a name for what is happening can start to feel like the answer.  Unfortunately, knowing what is causing the problem isn’t enough to solve it.  The real work of dealing with many disorders, including Obsessive Compulsive Disorder (OCD) comes after the diagnosis.  When your initial relief at knowing what is causing the problem begins to fade you will need to start the real work of helping your teenager learn to manage this condition and of changing your own behavior to best support them.  Here are some of the things you can do, now that you have the “what” to help define how to move forward.

1.     Educate Yourself

The most supportive thing you can do for your teen is to learn everything you can about their disorder.  This helps you better understand the struggles they are facing while also helping you understand what is the disorder and what is not.  It can be easy in the time period directly following diagnosis to blame the disorder for everything that isn’t “right” but in so doing you may miss other problems that need treatment or become frustrated when management strategies don’t “fix” everything.

2.     Identify Accommodations You are Making

More so than many other mental health disorders, OCD can become a family problem because other family members often do things to accommodate the person with the condition.  In the moment, these things can seem to be the best thing because they are helpful, supportive, and even participative.  Accommodating behaviors can include washing your hands whenever the person requests it, helping them to avoid uncomfortable tasks like cleaning the bathroom by doing it for them, providing unlimited access to cleaning supplies, or performing rituals to ease their anxiety and feed their compulsions.   For parents, identifying how they are enabling their teens OCD in these ways can be challenging.  Most parents only want the best for their child.  This generally means providing an environment that promotes happiness, comfort, and safety.  It can be difficult to follow-thru on what is “best” for them when it feels like that action is making them feel unhappy, uncomfortable, or insecure.

3.     Reducing Accommodations

Once you have identified what you and other members of the family are doing that is enabling the OCD the next step is to try and reduce or minimize those actions as your teen learns new ways to manage their condition.  This will take time and will be unpleasant for everyone at different times.  Remind yourself that all you are seeking to do is to treat this member of your family the same way you treat everyone else while supporting their recovery.  It can be very beneficial to seek the advice of a mental health provider as part of this process.

4.     Get Help

Learning to manage OCD and how to provide a healthy, supportive environment for that person is difficult to do without assistance.  Finding a provider that can work with your teen individually and with your family as a whole should be at the top of your list.  Building this kind of relationship is one of the most important things you can do to support your child.  This provider can help your teen learn new strategies for managing their thoughts and behaviors while also guiding your family unit through the first part of your journey to wellness.

Phoenix Teen Counseling: Mental Health 101: Teen Troubles

The teenage years can be troublesome and traumatic.  Faced with a myriad of pressures from every direction, teenagers often feel that they need twist and morph themselves into someone else in order to fit into other people’s molds.  This is made more difficult because they are only beginning to discover who they are and what they want.   They feel pressured to look a certain way, get good grades, fit in with friends, make the team, get the part, and be popular and sometimes that pressure can be too much.  Teens also have to deal with other issues like family financial problems, divorce, and illness.  Although the majority of teenagers make it through these tumultuous times to become well-adjusted adults, some teens struggle enough that they need professional help.

For parents, understanding when a teenager’s behavior is normal teen angst and when it is not is one of the biggest challenges.  In order to get teens the help they need to successfully navigate whatever challenges they are facing, parents need to know what to look for, what to expect, and when to seek help.  Here is a list of the most common mental health issues teens experience to help parents know when it’s time to seek outside help.

Mood Disorders

Bipolar Disorder – A teen with bipolar disorder has periods of mania and periods of depression.  When they are in a manic period, they may be extremely happy, hyperactive, and/or irritated.  They get by on very little sleep, get involved in multiple projects and activities, and may participate in risky behavior.  When they are in a depressive period, they display the signs of depression.

Depression – When teens are clinically depressed, they experience feelings of sadness and irritability along with several other symptoms that can include changes in appetite or sleep, rapid weight loss or gain, fatigue, loss of interest in previously enjoyable activities, problems concentrating, feeling hopeless, and suicidal thoughts.

Anxiety Disorders

General Anxiety Disorder – Feelings of anxiety are common in teens, but in some cases these feelings can rise to the level of a disorder.  Teens may worry excessively about situations, events, or activities to the extent that it interferes with their normal life.  Symptoms include feeling restless, having trouble sleeping, being irritable, and being unwilling or unable to participate in everyday activities.

Obsessive-Compulsive Disorder (OCD) – Teenagers dealing with OCD have distressing thoughts or impulses that occur over and over and repetitive behavior patterns like hand washing, counting, and hoarding that interrupt their ability to live their life normally.

Eating Disorders

Anorexia Nervosa – Teens with anorexia nervosa do not eat enough to maintain a healthy body weight.  Signs and symptoms include being significantly underweight, dry skin, low blood pressure, depression, moodiness, and unwillingness to eat around others.

Bulimia – Teens with bulimia participate in a cycle of bingeing and purging, eating a large amount of high calorie food and then inducing vomiting.  Bulimics may also use laxatives, exercise, diuretics, and diet pills to prevent weight gain.  Signs of bulimia include obsessing over weight, exercising hours at a time, eating in secret, spending time in the bathroom directly after eating, and low self esteem.

Trauma and Abuse

Teens who have been physically, emotionally, or sexually abused or who have lived through a traumatic event may need assistance to overcome the lasting damage these circumstances can cause.  Teens may experience Post-Traumatic Stress Disorder (PTSD), anxiety, depression, substance abuse, suicidal tendencies, and self harm.

Suicidal Tendencies

According to the American Academy of Child & Adolescent Psychiatry, suicide is the third leading cause of death amongst teenagers.  Warning signs include depression, frequent thoughts of and conversation about death, substance abuse, previous attempts, and traumatic events.

Is Obsessive Compulsive Disorder Affecting My Teenager?

Person washing his hands

Does your teen struggle with OCD?  (Photo credit: Wikipedia)

It can be difficult in this age of acronyms to know when your teenager’s behavior is appropriate for their developmental stage of life of when it’s something that a parent should be concerned about.   With anxiety disorders like Obsessive Compulsive Disorder (OCD), it is even harder to find.  The difference between the two is the impact it has on the child’s daily life.

What is Obsessive Compulsive Disorder?

Obsessive Compulsive Disorder (OCD) is an anxiety disorder that causes those who suffer from it to experience persistent anxiety, fear, or distressing thoughts and/or exhibit a ritualized behavior as a method to control their anxiety.  For example, a child might be so afraid of germs, they wash their hands every 15 minutes.  The obsessive nature of these thoughts and their compulsion to perform the ritual interfere with the teenager’s daily life.

Someone who is afraid of germs may develop a ritual that involves washing their hands a certain number of times at certain points over the course of the day.  A child who is worried about their house burning down may develop a ritual involving checking their smoke alarms and fire extinguishers to ensure they are operating.  It is important to remember that someone with Obsessive Compulsive Disorder does not believe they can control their compulsions and that these rituals offer only a temporary respite from their anxiety.

People with Obsessive Compulsive Disorder, both children and adults, may realize that their behavior is out of the ordinary but this is not always the case in children.   OCD may be accompanied by other conditions including depression and eating disorders and affects the same number of males and females.  In many cases, Obsessive Compulsive Disorder first presents during adolescence or the teen years.

What Causes Obsessive Compulsive Disorder?

Obsessive Compulsive Disorder is a brain disorder.  Research has shown that it does tend to run in families but there is no clear indication of why one person develops the condition and another doesn’t.  But the truth is clear, that OCD is no one’s fault, and especially does not occur because of something a parent did, or did not do.

What are the Symptoms of Obsessive Compulsive Disorder?

A person suffering from Obsessive Compulsive Disorder will display many of the following symptoms:

  • Repetitive thoughts that are distressing or cause anxiety about several different things.  Common obsessive topics include germs, dirt, crime, sexual acts, cleanliness, violence, or hurting others.
  • Ritual behavior patterns associated with their obsessions that they complete over and over to alleviate the anxiety.  Rituals can involve actions like repetitive hand washing, locking and unlocking doors or windows, counting, and performing things in a specific way again and again.
  • Performing rituals can be distressing and are not a source of comfort or pleasure although they do alleviate feelings of anxiety temporarily.
  • Obsessive thoughts and rituals occupy at least one hour a day and impact the person’s daily life.

Symptoms may come and go over time and it is not uncommon for people suffering from OCD to use avoidance techniques to try and keep their anxiety from being triggered.

How is Obsessive Compulsive Disorder Diagnosed?

As with many mental health conditions, start with your medical provider who can rule out any physical conditions that may be contributing or causing the symptoms.  This doctor can refer you to a mental health practitioner for diagnosis and treatment.

How is Obsessive Compulsive Disorder Treated?

Traditional treatment for Obsessive Compulsive Disorder involves both medication and exposure therapy.  This type of therapy is often combined with cognitive behavioral therapy to provide desensitization and alternative coping strategies.  Recent research supported by the National Institutes of Health’s (NIH) National Institute of Mental Health shows that children and teens respond most effectively to treatment with antidepressants in conjunction with therapy.

If you are concerned that your child or teen is experiencing obsessive thoughts and compulsive behaviors, work with a professional who can assess your child’s behavior and advise you on the appropriate course of action.