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Therapists and counselors can develop exposure and response prevention (ERP) therapy treatment plans to help treat obsessive-compulsive disorder (OCD).

Treating Obsessive-Compulsive Disorder with ERP Therapy

Estimated watch time: 32 mins 

Available credits: none

Presentation Materials:

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems.

Michael: 
Good afternoon, everyone. My name is Michael Crisanto. I’m a clinical outreach specialist here at Advanced Recovery Systems. We operate nine different dual-diagnosis treatment facilities focused on substance use disorder and mental health treatment. We operate nine different facilities throughout the country, and our community outreach team is really dedicated to helping families and individuals get into the treatment options that they need and facilitating that process as much as we can. Today, we have someone that’s part of that team. It’s going to be Jordan Katz. 

At The Recovery Village at Cherry Hill Cooper, Jordan is dedicated to helping clients, families and organizations find quality treatment options. Before joining Advanced Recovery Systems in 2020, Jordan spent six years in public relations and marketing in New York City and nearly five years in behavioral health, specializing in the treatment of OCD, anxiety disorders and phobias in Houston and Philadelphia. Jordan holds a BA in public relations from Hofstra University and a master of social work from Baylor University, where she graduated with top honors and was named outstanding MSW student of the year. She’s a licensed social worker in New Jersey and Pennsylvania. 

Jordan is a published researcher and maintains an active role in clinical research related to OCD, mental health stigma and access to care. She’s excited about the opportunity to engage with the community to raise awareness, provide education and encourage hope in order to improve the lives of those living with substance use disorders and or mental health disorders. I have the privilege of working with Jordan Katz, so thank you so much for being here, Jordan.

Jordan:
Thank you, Michael. So, good afternoon, everyone. Today, my goal is to help everyone understand what OCD — obsessive-compulsive disorder — is, and to give a brief overview of treatment for OCD. OCD, of course, is characterized as a mental health disorder in the DSM-5, the Diagnostic Statistical Manual. It has its own captor, OCD, and related disorders, but in the DSM-4 and prior, it used to be categorized as an anxiety disorder. The hallmark of the disorder is still very much around anxiety. So, I think it’s important to talk about what OCD is because it’s a chronic debilitating disorder that just doesn’t make people want to clean things or put things in order. OCD is a neurobiological disorder, meaning you’re born with it. 

It’s not contagious but is triggered at different points in life, mostly with big life changes or life events. So, you see it a lot in adolescents from graduating middle school, going to high school, graduating from high school, going to college, and we also see it in postpartum OCD. So, triggering happening after you have a baby. Really, there are three components to OCD: obsessive, compulsive and the disorder. Obsessive, of course, comes from the thoughts that are recurrent, unwanted, intrusive. These are not thoughts that people enjoy or get pleasure from. They are very anxiety-provoking, disturbing, and they really affect the individual’s ability to function in everyday life. They’re not thoughts that they like. So, when an individual gets an obsession, they will do anything they can to get rid of the thought because it is so disturbing. And that’s where they see the compulsions come into play.

So, compulsions are these repetitive rituals where one feels anxious, and the only way to get rid of it is to do the compulsion.  And it is temporary, right? So, maybe you have an obsession, you engage in the compulsion and there is this sense of that relief until the next thought comes and the next thought comes and it becomes this cycle. The D in disorder, of course — there are specific criteria. For OCD, someone needs to be engaging in compulsions for more than an hour a day. And again, this really affects an individual’s ability to function. It’s completely disturbing and distressing. You know, OCD is a serious chronic mental health condition. It’s not something to be made fun of, to be taken lightly, to be used as an adjective. I can’t tell you the goosebumps that I get when I hear someone say, “I’m so OCD,” or, “She’s so OCD,”  because, really, every facet of quality of life is significantly influenced and can impact someone’s ability to function.

That said, while OCD is very debilitating, there is a wonderful treatment out there, and that’s where we get into exposure and response prevention. So, exposure and response prevention. While you’re talking about this today — is that among psychotherapies? It is absolutely, without question, the most effective treatment that we know of — that the data can point us to at this moment — for OCD. If you look at studies, and I want to take a long time with this data, but in general, you can expect — if you’re doing exposure and response prevention treatment — around 70% of people to improve. And improvement means that symptoms are cut by about 30% to 50%, which, as you know, is a pretty good treatment. Recovery — really not having OCD anymore — that’s close to 40%, which, again, is pretty darn good for psychotherapy research. 

Limitations of ERP. So, just right off the top, some people don’t improve. That 30% figure almost always refers to people we cannot get to engage in the treatment, which as you’re going to hear in detail, essentially involves doing the thing that you’re afraid of — if it will not actually hurt you — again and again, systematically exposing someone to their fears over and over, which is very, very difficult to do. So, the research points to about 25% of patients that just refuse treatment. And in some studies, that number jumps up to as high as 40%, and 20% drop out of treatment. So, there’s a high refusal and dropout rate because, in general, this is a hard concept for people. To face your fear again and again — it’s really not what people typically want to do when they’re presenting to therapy.

So, this webinar really intends to give you a sense of — if you were to do ERP — exactly what you would be doing. If you’ve not done ERP, or if you’re someone who collaborates with therapists who treat OCD or any other contact, I hope you’ll find this a helpful guide as to what should be happening in exposure and response prevention treatment. In general, we would divide the exposure and response prevention into four phases. The first phase is the initial assessment of the patient. In treatment for OCD, there are some specific things you really want to know to be able to do a successful ERP treatment, and I’ll talk about those in a minute. Two would be building the hierarchy, which guides the treatment — almost like a roadmap. Phase three would be actually doing the exposure and response prevention treatment. And phase four is relapse prevention and maintenance, and research typically points to about 17 to 22 sessions.

So, the assessments. You obviously would start with a clinical interview, and I just wanted to mention the gold standard measures. The main one is the Y-BOCS. So, the Yale-Brown obsessive-compulsive scale is used in almost every research study, and as OCD therapists, we often talk about the Y-BOCS. That’s one measure; if you have OCD patients, I would definitely recommend using the Y-BOCS. So, the dimensional obsessive-compulsive scale is another measure that can give you different subtypes of OCD — for example, contamination OCD, sexually intrusive thoughts, violent, intrusive thoughts, and scrupulosity, which of course is the religious form of OCD. If you see a lot of OTD patients, the DOCS is definitely helpful. 

In general, in your interviews, you’ll want to ask about that. What cues or triggers the OCD? When do people have obsessions? When do they do their compulsions? What situations, what time of day? What mood state? Do you want to get a pretty high level of detail in order to plan your treatment? What are they afraid of? We often talk about subtypes of OCD where sometimes, people are afraid that if they can not engage in a compulsion, something specific will happen. So, if I touch the desk and do not wash my hands after, I could get sick and die. Other people may not have a specific fear of consequence; they just have a feeling of doom or a general feeling of disgust or things being not just right. Rituals are, of course, the things that people do to deal with obsessions. So, like we talked about: Washing hands, checking, reassurance, seeking and mental rituals are things patients might do in their head to alleviate anxiety.

They might view pictures, or mental reviewing. And then there’s avoidance — just really not getting around the cue or to the trigger. And again, all of these are really important to detail, and it’s important to understand each patient’s OCD before starting the treatment. Again, observing and self-monitoring are also good ways to assess too, because who knows their disorder better than the patient themselves? So, having that detail as well is helpful. This slide details some specific language you can use when doing your assessment. It kind of expands on what we just talked about in the previous slide, but it’s a way to, again, assess your patient and really dig deep into their OCD.

Here is an example of a good mapping out of cues, feared consequences, rituals and avoidance. We’ll go through these examples together. So, the first is in the situation of having to touch a faucet in a public bathroom, and the individual begins to be afraid that he will contract HIV and then die. So, a really specific feared consequence. You can sometimes find out that the individual might also have thoughts with regard to dying. It might be, “My kids might be left alone,” or there might be images of being in a grave or of actually dying. Rituals for this person would be that he washes his hands excessively — 10, 11, 12 times — and he uses hand sanitizer all throughout the day. You often see this as the hallmark of OCD — those red, raw, bloody hands, which are very frequent, especially with contamination OCD. 

And then, of course, avoidance. So, avoiding public bathrooms, avoiding anything bathroom-wise that looks dirty. So, this could be a really good map or start of an ERP treatment. Another situation we’ll go through briefly is holding a knife in the kitchen, which might create an obsession about stabbing one’s husband, killing him and going to jail. In this instance, the ritual might be mental reviewing. You know, “I’ve had my hands on the knife this whole time. My husband hasn’t been in the room. He’s sitting on the couch. I’m not looking at him and he looks fine.” And then it’s also avoiding using knives.

Let’s talk about how to educate people about OCD. It’s good to go through what our obsessions and what our compulsions are with your patient and to help emphasize that obsessions are unwanted and intrusive. And that you understand that the patient is not getting any enjoyment from the obsessions. Really, you want to make this a very safe place. I know, as a clinician myself, you want to make this a very safe place for your patient to discuss their obsessions, especially when you’ve got sexually intrusive thoughts or violent intrusive thoughts. There is a lot of shame around this. And discuss themselves. So really, helping them understand that you understand that they do not get any enjoyment from these thoughts and also to discuss the cycle of OCD, right? How the compulsions are feeding the anxiety.

I really like this model to help explain OCD a little bit. So, the model looks at intrusive thoughts, ones that are cued by a situation and some that aren’t — some that just occur and it’s a really tough time. For people with OCD, the thoughts just come in all the time; they trigger anxiety, guilt, and there’s often a negative interpretation about the thought. You know, “Does the fact that I thought about stabbing my husband and I’m worried about it mean that I actually want to? What does it mean about me that I’m thinking about this?” which essentially triggers more anxiety, guilt, and then compulsion and avoidance. Ultimately, the more patients understand the model, the better they help to plan and implement their own treatment. We also want to help really educate people that if they do not engage in their usual OCD response, they will begin to feel better. Anxiety does come down. It does not remain indefinitely. Ultimately, you want to help your patient learn that anxiety is a normal part of life — that everybody feels anxious at some point in their life.

People will not die when they feel really anxious; they might cry and they might get upset and they might have somatic symptoms, but anxiety will not cause death. And the negative consequences when treating OCD fear is ultimately expensive, and those negative consequences are very unlikely to happen or they don’t happen. You know, I can use a public bathroom and very likely not contract HIV. I can use a knife around my husband and not stab him sometimes. So, that would be the first phase, and that can take a long time or be one session, depending on the patient and the therapist. 

So, hierarchy would be next. The hierarchy is just basically making a list in order of the cues and triggers and developing a set scale. A subjective unit of distress is really a zero-to-10 scale of stress and anxiety. You teach the patient, ultimately, how to rate their own anxiety and distress. And I will say here: In this PowerPoint, I used a one-to-10 scale, but there are some clinicians who might use one to 100. There are some programs that use one to seven; really, it’s at your comfort level, but ultimately, we’re teaching the patient that there are levels to their anxiety. G is essentially an ordered list where you’d include on it situations, thoughts and images — about 10 to 20 items with information from your assessment. 

Use obsessions and have the patient rate it. “So, assuming that you were not ritualizing, how anxious would you feel if you walked in a public bathroom and didn’t wash your hands?” If the patient would rate that a four, then you might ask, “How anxious would you be if you actually used a public bathroom and didn’t wash your hands?” That might be a nine or a 10. “How anxious would you be if you imagine going into a public bathroom and didn’t wash your hands?” Well, maybe that’s a two, so essentially, you’re rating all kinds of different examples and the hierarchy becomes your guide for pre-med. I will say, ultimately, you want your patient to know that you would never ask them to do any activity that you yourself would not do. If you, as an ERP therapist, would not lay in toilet water and wipe it around your body, or if you would not roll in the trash, or if you would not hold a knife to your wrist or have a patient stand behind you and imagine pushing you down the stairs, then you maybe, you know, shouldn’t be an ERP therapist. But do not assign that to your patient unless you would do that yourself.

Let’s go back to our first example from slide seven and expand on it. Really, this is just an expanded version of that patient who was afraid that he might contract HIV and die. So, the biggest note here is just the hierarchy development and looking at the lower-level exposures, which in this instance might be shaking hands, moving up to mid-level, which might be using a public restroom, going to a grocery store and buying food. And high-level exposure — so, using a restroom at a sporting event and visiting an HIV clinic. One thing that’s important to know is on these hierarchies, you do have the same situations or words that can have varying language. For example, a patient of mine had a fear that her mom might die as a result of something he did. Just change the language on the hierarchy from “My mom could die too, my mom might die too, my mom will die.” We’ll help that individual face their fear and habituate to their anxiety.

Once you’re done with hierarchy, which could be very fast — it could take one session or it might take many — you would move on to the actual exposure and response prevention. Exposure, of course, is when you elicit on purpose the thing that is feared. Again, we only elicit things that are not actually dangerous. In OCD, that’s pretty easy.  In OCP obsessions, you know, they are often a bit extreme — like contracting HIV from a sink faucet. Oftentimes, it’s obvious to the patient and you that’s not going to happen. So, with OCD, you’ll elicit fear to the faucet, the knife, the image, and you’ll want to start with something on the hierarchy that’s rated about a four for difficulty — you know, not too much, not too little. We want the patient to feel the anxiety and to really engage in the exposure.

Again, it’s really important to assume the the patient in the exposure did not do the compulsion. So, you want to then bring that situation to life, ideally in person in the office, so that you can help coach and guide your patient through it. Because remember: The treatment is about facing your fears. And research data does show us that if you do exposure with your patient together, your outcomes are just a lot better. You would ask your patient to rate their distress level about every five minutes, and you really just hang out with the fear. You encourage the patient to focus on it.  Where I used to work, we would have just sit with it, and every patient understood that that meant to sit with your anxiety. Because remember: Once we sit with it, once we focus on it, it will come down eventually. And you rate your OCD about every five minutes. You want the patient to expose the whole time and focus on their anxiety — what they’re thinking about, what their body feels, the image or thoughts about what’s happening.

Just really focus on it and make sure they’re not ritualizing by accident, especially with mental rituals. An example of that is — let’s say you had someone with contamination OCD, had the doorknob, and then you wanted that patient to sit with their dirty hand and focus on the anxiety. Important to know — and to help the patient understand that they’re not ritualizing by imagining Clorox bleach on their hands or soap on their hand because that essentially is a mental compulsion. And this is why we spend so much time in the beginning on education. The patient knows what a ritual is. They will often point it out to you and say something like, “Well, I didn’t realize it, but I was just reassuring myself while I was doing this exposure.” You want to help your patient and do the full exposure — not ritualize and focus on the fear of consequences.

So, assuming your exposure goes well, what you should expect is that people get afraid. They get too stressed, and if they stick with it, they start to get less distressed and less afraid. Something I would talk to my patients about is — and this is true — I do have a fear of heights. And I would say that with my fear as an exposure, I went to a water park and did one of those huge slides where I walked all 20 stories, walked all the way up the stairs, and went down the slide. I would definitely have anxiety going up the stairs the first time, but if I did it a second time, I might not have as much anxiety as I did the first time. I went again and again and again, I might not feel as anxious over time about climbing the stairs and going down that large slide. And really, when that happens — when someone’s anxiety decreases — lessons are learned about how much the consequence happens or doesn’t happen and how much they can tolerate their own anxiety and their own power. And really, as a therapist, it is incredible to watch someone make strides like that. But sometimes, it just doesn’t seem to work.

What if the anxiety doesn’t decrease? And sometimes, it just takes a while for exposure to work. Sometimes, the patients are ritualizing or distracting themselves, so they’re doing the exposure on the surface. Really, just talking about that possibility with the patient — that that’s something that could happen. Sometimes, you might not have the right cue or trigger. Remember, when we go through the hierarchy development, we are asking patients to imagine what their anxiety level will be for all of those exposures.  But when they start doing the exposures, it might be a lot easier than what they assumed, or the alternative is that it might just be too hard to start with. Again, we want to start with the threes because it’s nothing anxiety to feel — like, it can go down within a reasonable amount of time. Starting too much can get discouraging. We do not want to flood our patients. This is not flooding: Again, this is systematically exposing our patients.

So, imaginal exposures, and that’s exposing a thought, an image in one’s imagination. And we use that when we need to prep for in vivo or live exposures. Maybe someone’s not ready to touch someone, something we imagined touching. Sometimes, we will want to imagine a consequence that won’t actually happen. So, the example before of the patient holding the knife and having the thought that she might stab her husband — that thought itself is not dangerous, and you can do exposure to it. The thought I might stab my husband, the image I might stab my husband,  consequences about the distant future about going to hell — you might engage exposure around it and imagine it. So, whenever possible, combined live exposure and imaginal — the research shows outcomes might be better. But what I mean by that is, for example, a patient driving at night while thinking to themselves, “I might run over someone.” That’s in vivo combined with imaginable.

After the exposure, you really want to emphasize homework. Homework and practice is just so essential to the treatment. Actually thinking about where the fear cues happen, right? Home versus the office. So, you want the patient to record their anxiety and really make sure they’re doing the exposures at home. And you can get really creative with some of the exposures for homework. I always, especially for contamination OCD patients, I would ask them to, let’s say, contaminate a towel at home and bring it in the office so we could contaminate the chair, for example. Little creative tricks that make the treatment really effective.

Just to wrap up, you want to keep relapse prevention in mind, always. OCD is a chronic condition, but it’s manageable. When talking with my patients, I would say I always try to liken it to something like diabetes or asthma, which are also chronic conditions. Whereas someone with diabetes might have insulin shots, the individual with the OCD has exposures. You know, we want our patients to ultimately become their own therapist.  When someone is ending treatment, you want to help them think about how they’re going to handle it in the future. But always say to my patients — not about if you’re triggered; it’s when you get triggered. Really, relapse prevention and maintenance skills are almost, if not more, as important as the exposure piece, right? 

If you are interested in treating OCD with ERP, I would highly recommend getting specialized training. I will tell you that when working with my patients at the PHP and IOP level when we looked for patient clinicians, I always would say make sure you ask them if they engage in ERP. And if they don’t — if they say they treat OCD but don’t engage in ERP — hang up the phone. And the reason for that is very well-meaning therapists can actually be helping the patient to engage in more compulsions and more rituals when not utilizing ERP. Some of the other treatments that are very effective for other mental health disorders are not effective for OCD. So, I would highly recommend getting additional specialized training if you are interested in treating OCD.

So, I am a researcher. I always like to show my references. 

Michael:
Contact information — you guys should have Jordan’s contact information. If you do have any further questions, feel free to email her. I’m going to end things here, but thank you all so much again for attending. Have a great day. Thank you. 

Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

This presentation provides a basic overview of obsessive-compulsive disorder (OCD) and demonstrates how to effectively treat it with exposure and response prevention (ERP) therapy. This presentation is ideal for therapists, counselors and community members.

After watching this presentation, the viewer will:

  1. Understand the basics of obsessive-compulsive disorder
  2. Learn the fundamentals of exposure and response prevention (ERP) therapy
  3. Understand how to effectively create and plan ERP treatment for individuals with OCD

Presentation Materials:

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems.

Michael: 
Good afternoon, everyone. My name is Michael Crisanto. I’m a clinical outreach specialist here at Advanced Recovery Systems. We operate nine different dual-diagnosis treatment facilities focused on substance use disorder and mental health treatment. We operate nine different facilities throughout the country, and our community outreach team is really dedicated to helping families and individuals get into the treatment options that they need and facilitating that process as much as we can. Today, we have someone that’s part of that team. It’s going to be Jordan Katz. 

At The Recovery Village at Cherry Hill Cooper, Jordan is dedicated to helping clients, families and organizations find quality treatment options. Before joining Advanced Recovery Systems in 2020, Jordan spent six years in public relations and marketing in New York City and nearly five years in behavioral health, specializing in the treatment of OCD, anxiety disorders and phobias in Houston and Philadelphia. Jordan holds a BA in public relations from Hofstra University and a master of social work from Baylor University, where she graduated with top honors and was named outstanding MSW student of the year. She’s a licensed social worker in New Jersey and Pennsylvania. 

Jordan is a published researcher and maintains an active role in clinical research related to OCD, mental health stigma and access to care. She’s excited about the opportunity to engage with the community to raise awareness, provide education and encourage hope in order to improve the lives of those living with substance use disorders and or mental health disorders. I have the privilege of working with Jordan Katz, so thank you so much for being here, Jordan.

Jordan:
Thank you, Michael. So, good afternoon, everyone. Today, my goal is to help everyone understand what OCD — obsessive-compulsive disorder — is, and to give a brief overview of treatment for OCD. OCD, of course, is characterized as a mental health disorder in the DSM-5, the Diagnostic Statistical Manual. It has its own captor, OCD, and related disorders, but in the DSM-4 and prior, it used to be categorized as an anxiety disorder. The hallmark of the disorder is still very much around anxiety. So, I think it’s important to talk about what OCD is because it’s a chronic debilitating disorder that just doesn’t make people want to clean things or put things in order. OCD is a neurobiological disorder, meaning you’re born with it. 

It’s not contagious but is triggered at different points in life, mostly with big life changes or life events. So, you see it a lot in adolescents from graduating middle school, going to high school, graduating from high school, going to college, and we also see it in postpartum OCD. So, triggering happening after you have a baby. Really, there are three components to OCD: obsessive, compulsive and the disorder. Obsessive, of course, comes from the thoughts that are recurrent, unwanted, intrusive. These are not thoughts that people enjoy or get pleasure from. They are very anxiety-provoking, disturbing, and they really affect the individual’s ability to function in everyday life. They’re not thoughts that they like. So, when an individual gets an obsession, they will do anything they can to get rid of the thought because it is so disturbing. And that’s where they see the compulsions come into play.

So, compulsions are these repetitive rituals where one feels anxious, and the only way to get rid of it is to do the compulsion.  And it is temporary, right? So, maybe you have an obsession, you engage in the compulsion and there is this sense of that relief until the next thought comes and the next thought comes and it becomes this cycle. The D in disorder, of course — there are specific criteria. For OCD, someone needs to be engaging in compulsions for more than an hour a day. And again, this really affects an individual’s ability to function. It’s completely disturbing and distressing. You know, OCD is a serious chronic mental health condition. It’s not something to be made fun of, to be taken lightly, to be used as an adjective. I can’t tell you the goosebumps that I get when I hear someone say, “I’m so OCD,” or, “She’s so OCD,”  because, really, every facet of quality of life is significantly influenced and can impact someone’s ability to function.

That said, while OCD is very debilitating, there is a wonderful treatment out there, and that’s where we get into exposure and response prevention. So, exposure and response prevention. While you’re talking about this today — is that among psychotherapies? It is absolutely, without question, the most effective treatment that we know of — that the data can point us to at this moment — for OCD. If you look at studies, and I want to take a long time with this data, but in general, you can expect — if you’re doing exposure and response prevention treatment — around 70% of people to improve. And improvement means that symptoms are cut by about 30% to 50%, which, as you know, is a pretty good treatment. Recovery — really not having OCD anymore — that’s close to 40%, which, again, is pretty darn good for psychotherapy research. 

Limitations of ERP. So, just right off the top, some people don’t improve. That 30% figure almost always refers to people we cannot get to engage in the treatment, which as you’re going to hear in detail, essentially involves doing the thing that you’re afraid of — if it will not actually hurt you — again and again, systematically exposing someone to their fears over and over, which is very, very difficult to do. So, the research points to about 25% of patients that just refuse treatment. And in some studies, that number jumps up to as high as 40%, and 20% drop out of treatment. So, there’s a high refusal and dropout rate because, in general, this is a hard concept for people. To face your fear again and again — it’s really not what people typically want to do when they’re presenting to therapy.

So, this webinar really intends to give you a sense of — if you were to do ERP — exactly what you would be doing. If you’ve not done ERP, or if you’re someone who collaborates with therapists who treat OCD or any other contact, I hope you’ll find this a helpful guide as to what should be happening in exposure and response prevention treatment. In general, we would divide the exposure and response prevention into four phases. The first phase is the initial assessment of the patient. In treatment for OCD, there are some specific things you really want to know to be able to do a successful ERP treatment, and I’ll talk about those in a minute. Two would be building the hierarchy, which guides the treatment — almost like a roadmap. Phase three would be actually doing the exposure and response prevention treatment. And phase four is relapse prevention and maintenance, and research typically points to about 17 to 22 sessions.

So, the assessments. You obviously would start with a clinical interview, and I just wanted to mention the gold standard measures. The main one is the Y-BOCS. So, the Yale-Brown obsessive-compulsive scale is used in almost every research study, and as OCD therapists, we often talk about the Y-BOCS. That’s one measure; if you have OCD patients, I would definitely recommend using the Y-BOCS. So, the dimensional obsessive-compulsive scale is another measure that can give you different subtypes of OCD — for example, contamination OCD, sexually intrusive thoughts, violent, intrusive thoughts, and scrupulosity, which of course is the religious form of OCD. If you see a lot of OTD patients, the DOCS is definitely helpful. 

In general, in your interviews, you’ll want to ask about that. What cues or triggers the OCD? When do people have obsessions? When do they do their compulsions? What situations, what time of day? What mood state? Do you want to get a pretty high level of detail in order to plan your treatment? What are they afraid of? We often talk about subtypes of OCD where sometimes, people are afraid that if they can not engage in a compulsion, something specific will happen. So, if I touch the desk and do not wash my hands after, I could get sick and die. Other people may not have a specific fear of consequence; they just have a feeling of doom or a general feeling of disgust or things being not just right. Rituals are, of course, the things that people do to deal with obsessions. So, like we talked about: Washing hands, checking, reassurance, seeking and mental rituals are things patients might do in their head to alleviate anxiety.

They might view pictures, or mental reviewing. And then there’s avoidance — just really not getting around the cue or to the trigger. And again, all of these are really important to detail, and it’s important to understand each patient’s OCD before starting the treatment. Again, observing and self-monitoring are also good ways to assess too, because who knows their disorder better than the patient themselves? So, having that detail as well is helpful. This slide details some specific language you can use when doing your assessment. It kind of expands on what we just talked about in the previous slide, but it’s a way to, again, assess your patient and really dig deep into their OCD.

Here is an example of a good mapping out of cues, feared consequences, rituals and avoidance. We’ll go through these examples together. So, the first is in the situation of having to touch a faucet in a public bathroom, and the individual begins to be afraid that he will contract HIV and then die. So, a really specific feared consequence. You can sometimes find out that the individual might also have thoughts with regard to dying. It might be, “My kids might be left alone,” or there might be images of being in a grave or of actually dying. Rituals for this person would be that he washes his hands excessively — 10, 11, 12 times — and he uses hand sanitizer all throughout the day. You often see this as the hallmark of OCD — those red, raw, bloody hands, which are very frequent, especially with contamination OCD. 

And then, of course, avoidance. So, avoiding public bathrooms, avoiding anything bathroom-wise that looks dirty. So, this could be a really good map or start of an ERP treatment. Another situation we’ll go through briefly is holding a knife in the kitchen, which might create an obsession about stabbing one’s husband, killing him and going to jail. In this instance, the ritual might be mental reviewing. You know, “I’ve had my hands on the knife this whole time. My husband hasn’t been in the room. He’s sitting on the couch. I’m not looking at him and he looks fine.” And then it’s also avoiding using knives.

Let’s talk about how to educate people about OCD. It’s good to go through what our obsessions and what our compulsions are with your patient and to help emphasize that obsessions are unwanted and intrusive. And that you understand that the patient is not getting any enjoyment from the obsessions. Really, you want to make this a very safe place. I know, as a clinician myself, you want to make this a very safe place for your patient to discuss their obsessions, especially when you’ve got sexually intrusive thoughts or violent intrusive thoughts. There is a lot of shame around this. And discuss themselves. So really, helping them understand that you understand that they do not get any enjoyment from these thoughts and also to discuss the cycle of OCD, right? How the compulsions are feeding the anxiety.

I really like this model to help explain OCD a little bit. So, the model looks at intrusive thoughts, ones that are cued by a situation and some that aren’t — some that just occur and it’s a really tough time. For people with OCD, the thoughts just come in all the time; they trigger anxiety, guilt, and there’s often a negative interpretation about the thought. You know, “Does the fact that I thought about stabbing my husband and I’m worried about it mean that I actually want to? What does it mean about me that I’m thinking about this?” which essentially triggers more anxiety, guilt, and then compulsion and avoidance. Ultimately, the more patients understand the model, the better they help to plan and implement their own treatment. We also want to help really educate people that if they do not engage in their usual OCD response, they will begin to feel better. Anxiety does come down. It does not remain indefinitely. Ultimately, you want to help your patient learn that anxiety is a normal part of life — that everybody feels anxious at some point in their life.

People will not die when they feel really anxious; they might cry and they might get upset and they might have somatic symptoms, but anxiety will not cause death. And the negative consequences when treating OCD fear is ultimately expensive, and those negative consequences are very unlikely to happen or they don’t happen. You know, I can use a public bathroom and very likely not contract HIV. I can use a knife around my husband and not stab him sometimes. So, that would be the first phase, and that can take a long time or be one session, depending on the patient and the therapist. 

So, hierarchy would be next. The hierarchy is just basically making a list in order of the cues and triggers and developing a set scale. A subjective unit of distress is really a zero-to-10 scale of stress and anxiety. You teach the patient, ultimately, how to rate their own anxiety and distress. And I will say here: In this PowerPoint, I used a one-to-10 scale, but there are some clinicians who might use one to 100. There are some programs that use one to seven; really, it’s at your comfort level, but ultimately, we’re teaching the patient that there are levels to their anxiety. G is essentially an ordered list where you’d include on it situations, thoughts and images — about 10 to 20 items with information from your assessment. 

Use obsessions and have the patient rate it. “So, assuming that you were not ritualizing, how anxious would you feel if you walked in a public bathroom and didn’t wash your hands?” If the patient would rate that a four, then you might ask, “How anxious would you be if you actually used a public bathroom and didn’t wash your hands?” That might be a nine or a 10. “How anxious would you be if you imagine going into a public bathroom and didn’t wash your hands?” Well, maybe that’s a two, so essentially, you’re rating all kinds of different examples and the hierarchy becomes your guide for pre-med. I will say, ultimately, you want your patient to know that you would never ask them to do any activity that you yourself would not do. If you, as an ERP therapist, would not lay in toilet water and wipe it around your body, or if you would not roll in the trash, or if you would not hold a knife to your wrist or have a patient stand behind you and imagine pushing you down the stairs, then you maybe, you know, shouldn’t be an ERP therapist. But do not assign that to your patient unless you would do that yourself.

Let’s go back to our first example from slide seven and expand on it. Really, this is just an expanded version of that patient who was afraid that he might contract HIV and die. So, the biggest note here is just the hierarchy development and looking at the lower-level exposures, which in this instance might be shaking hands, moving up to mid-level, which might be using a public restroom, going to a grocery store and buying food. And high-level exposure — so, using a restroom at a sporting event and visiting an HIV clinic. One thing that’s important to know is on these hierarchies, you do have the same situations or words that can have varying language. For example, a patient of mine had a fear that her mom might die as a result of something he did. Just change the language on the hierarchy from “My mom could die too, my mom might die too, my mom will die.” We’ll help that individual face their fear and habituate to their anxiety.

Once you’re done with hierarchy, which could be very fast — it could take one session or it might take many — you would move on to the actual exposure and response prevention. Exposure, of course, is when you elicit on purpose the thing that is feared. Again, we only elicit things that are not actually dangerous. In OCD, that’s pretty easy.  In OCP obsessions, you know, they are often a bit extreme — like contracting HIV from a sink faucet. Oftentimes, it’s obvious to the patient and you that’s not going to happen. So, with OCD, you’ll elicit fear to the faucet, the knife, the image, and you’ll want to start with something on the hierarchy that’s rated about a four for difficulty — you know, not too much, not too little. We want the patient to feel the anxiety and to really engage in the exposure.

Again, it’s really important to assume the the patient in the exposure did not do the compulsion. So, you want to then bring that situation to life, ideally in person in the office, so that you can help coach and guide your patient through it. Because remember: The treatment is about facing your fears. And research data does show us that if you do exposure with your patient together, your outcomes are just a lot better. You would ask your patient to rate their distress level about every five minutes, and you really just hang out with the fear. You encourage the patient to focus on it.  Where I used to work, we would have just sit with it, and every patient understood that that meant to sit with your anxiety. Because remember: Once we sit with it, once we focus on it, it will come down eventually. And you rate your OCD about every five minutes. You want the patient to expose the whole time and focus on their anxiety — what they’re thinking about, what their body feels, the image or thoughts about what’s happening.

Just really focus on it and make sure they’re not ritualizing by accident, especially with mental rituals. An example of that is — let’s say you had someone with contamination OCD, had the doorknob, and then you wanted that patient to sit with their dirty hand and focus on the anxiety. Important to know — and to help the patient understand that they’re not ritualizing by imagining Clorox bleach on their hands or soap on their hand because that essentially is a mental compulsion. And this is why we spend so much time in the beginning on education. The patient knows what a ritual is. They will often point it out to you and say something like, “Well, I didn’t realize it, but I was just reassuring myself while I was doing this exposure.” You want to help your patient and do the full exposure — not ritualize and focus on the fear of consequences.

So, assuming your exposure goes well, what you should expect is that people get afraid. They get too stressed, and if they stick with it, they start to get less distressed and less afraid. Something I would talk to my patients about is — and this is true — I do have a fear of heights. And I would say that with my fear as an exposure, I went to a water park and did one of those huge slides where I walked all 20 stories, walked all the way up the stairs, and went down the slide. I would definitely have anxiety going up the stairs the first time, but if I did it a second time, I might not have as much anxiety as I did the first time. I went again and again and again, I might not feel as anxious over time about climbing the stairs and going down that large slide. And really, when that happens — when someone’s anxiety decreases — lessons are learned about how much the consequence happens or doesn’t happen and how much they can tolerate their own anxiety and their own power. And really, as a therapist, it is incredible to watch someone make strides like that. But sometimes, it just doesn’t seem to work.

What if the anxiety doesn’t decrease? And sometimes, it just takes a while for exposure to work. Sometimes, the patients are ritualizing or distracting themselves, so they’re doing the exposure on the surface. Really, just talking about that possibility with the patient — that that’s something that could happen. Sometimes, you might not have the right cue or trigger. Remember, when we go through the hierarchy development, we are asking patients to imagine what their anxiety level will be for all of those exposures.  But when they start doing the exposures, it might be a lot easier than what they assumed, or the alternative is that it might just be too hard to start with. Again, we want to start with the threes because it’s nothing anxiety to feel — like, it can go down within a reasonable amount of time. Starting too much can get discouraging. We do not want to flood our patients. This is not flooding: Again, this is systematically exposing our patients.

So, imaginal exposures, and that’s exposing a thought, an image in one’s imagination. And we use that when we need to prep for in vivo or live exposures. Maybe someone’s not ready to touch someone, something we imagined touching. Sometimes, we will want to imagine a consequence that won’t actually happen. So, the example before of the patient holding the knife and having the thought that she might stab her husband — that thought itself is not dangerous, and you can do exposure to it. The thought I might stab my husband, the image I might stab my husband,  consequences about the distant future about going to hell — you might engage exposure around it and imagine it. So, whenever possible, combined live exposure and imaginal — the research shows outcomes might be better. But what I mean by that is, for example, a patient driving at night while thinking to themselves, “I might run over someone.” That’s in vivo combined with imaginable.

After the exposure, you really want to emphasize homework. Homework and practice is just so essential to the treatment. Actually thinking about where the fear cues happen, right? Home versus the office. So, you want the patient to record their anxiety and really make sure they’re doing the exposures at home. And you can get really creative with some of the exposures for homework. I always, especially for contamination OCD patients, I would ask them to, let’s say, contaminate a towel at home and bring it in the office so we could contaminate the chair, for example. Little creative tricks that make the treatment really effective.

Just to wrap up, you want to keep relapse prevention in mind, always. OCD is a chronic condition, but it’s manageable. When talking with my patients, I would say I always try to liken it to something like diabetes or asthma, which are also chronic conditions. Whereas someone with diabetes might have insulin shots, the individual with the OCD has exposures. You know, we want our patients to ultimately become their own therapist.  When someone is ending treatment, you want to help them think about how they’re going to handle it in the future. But always say to my patients — not about if you’re triggered; it’s when you get triggered. Really, relapse prevention and maintenance skills are almost, if not more, as important as the exposure piece, right? 

If you are interested in treating OCD with ERP, I would highly recommend getting specialized training. I will tell you that when working with my patients at the PHP and IOP level when we looked for patient clinicians, I always would say make sure you ask them if they engage in ERP. And if they don’t — if they say they treat OCD but don’t engage in ERP — hang up the phone. And the reason for that is very well-meaning therapists can actually be helping the patient to engage in more compulsions and more rituals when not utilizing ERP. Some of the other treatments that are very effective for other mental health disorders are not effective for OCD. So, I would highly recommend getting additional specialized training if you are interested in treating OCD.

So, I am a researcher. I always like to show my references. 

Michael:
Contact information — you guys should have Jordan’s contact information. If you do have any further questions, feel free to email her. I’m going to end things here, but thank you all so much again for attending. Have a great day. Thank you. 

Thank you for watching this video. We hope you enjoyed the presentation.

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