5 Steps to Set the Stage for Success
If you are starting or considering Exposure and Response Prevention (ERP) for Obsessive Compulsive Disorder (OCD), congratulate yourself! Researchers have found that people with OCD wait a long time (14 – 17 years on average) before starting appropriate treatment. So getting off to a good start and stacking the odds in your favor for success is worth the time and effort. The following 5 preparations presented below provide an overview of what to expect before you actually start completing planned exposures.
1. Engagement in The Treatment Process
A Good Working Relationship – with your therapist is key to your success. You should respect and trust your therapist, and feel comfortable about communicating openly. At the beginning of the process, if possible, I ask clients with OCD about accommodations they may want when first meeting with me. I attempt to honor their requests so that they can engage in treatment. As time goes on, we will discuss whether those accommodations are facilitating compulsive rituals and how to make changes. But that should happen after we get to know each other, and agree to set off in that direction purposefully. Like all other therapies, ERP is a voluntary process over which the client should maintain a sense of control.
Clarifying Goals and Expectations – helps to build your motivation and commitment. From the start of the intake process, I try to help clients formulate their own goals for treatment, and let them know what to expect during the process. EPR can require substantial time and effort, but most clients believe the results are worth it. Researchers in structured clinical trials often complete a course of ERP within 16 weeks (4 months), but I usually inform clients that 24 weeks (6 months) is a more reasonable initial expectation which allows us to expect the unexpected – extra time on certain activities, time for medications to take effect, and/or the option to pause and address other urgent life events if they emerge.
Takeaway – Select your ERP therapist carefully. Look for a combination of training, experience, and somebody you feel comfortable working with.
Diagnostic Evaluation – to confirm your diagnosis is critical prior to starting ERP. If your case is complex, it may take several sessions complete the evaluation. Unfortunately, I’ve seen several clients who were previously struggling with ERP with another provider because they did NOT have OCD. ERP may not be an appropriate strategy for clients with sensory processing challenges or restricted interests related to autism, rigid thinking associated with OCPD, or other diagnoses besides OCD. A careful diagnostic evaluation is always worth your time and effort.
Prioritizing Needs – helps to sequence and time your interventions. Many persons struggling with OCD also have other diagnoses related to depression, anxiety, body dysmorphia, or substance use. If this is true in your case, you will need a solid plan that makes sense to both you and your therapist about the best way to move forward.
Functional Assessment – of your OCD patterns builds a shared understanding. You and your therapist should have a decent understanding of your patterns – challenging situations or events, typical obsessions (thoughts, images, impulses) and compulsive rituals to neutralize them. A typical one sentence formulation that you should be able to answer is: If X happens, and I’m not able to Y, then I’m concerned that Z.
Client Strengths – should be utilized during your treatment. What are you good at and how did that happen? Who is on your team (family members, friends, co-workers, coaches) and how might they be able to support you in treatment? How have you successfully dealt with challenges or made changes in the past? Reviewing your strengths are an important part of the assessment process.
Monitoring Progress – using a validated instrument will help you recognize patterns and also see the impact of treatment. I administer a rating scale at the beginning of treatment, and before each subsequent appointment to help my clients track changes over time.
Takeaway – Take the time and effort to complete an accurate and comprehensive assessment.
3. COLLABORATION WITH OTHER CARE PROVIDERS – is a best practice to develop a multidisciplinary plan. Most importantly, I want to be able to talk with your medical provider prescribing medications for OCD. It is always your choice to decide whether or not to take medications, and I respect my clients’ decisions. That said, I have observed that most clients with OCD seem to benefit from medications. And some times, taking medications enhances client success with ERP. So, it may be in your best interest to start ERP, medications, or both. Or, you may want to pause ERP and wait until medication treatments have been optimized. The best way to make good decisions about those types of questions is to openly communicate about them.
Takeaway – You and your providers should all work together to maximize the potential benefits of interventions in a thoughtful and purposeful way.
4. DEVELOPMENT OF NON-AVOIDANT COPING SKILLS – will help you learn how to deal with obsessions in ways that purposefully dismantle OCD patterns. One of the goals of ERP is to eliminate the use of rituals as a coping response. Some ritualistic behaviors are unnecessary and can be stopped altogether. For those, you may plan for what to do instead – review a coping script or practice mindfulness – something to enhance your learning. Other ritualistic behaviors may be excessive, but will not be eliminated. For example, if you are ritualistically washing your hands, you will need to develop hand washing guidelines that you can follow. When should you wash your hands? How many squirts of soap will you use? For how long will you wash? You should have a detailed plan of what not to do, what to do instead, and when to do it. Some clients benefit from taking a few “dry runs” to practice the guidelines before starting exposures.
Takeaway – If you are going through the exposures and you don’t seem to be benefiting, revisit this step first with your therapist to consider if some tweaks are needed.
5. IMPROVING ENVIRONMENTAL SUPPORT – that will allow recovery to occur. Often, friends and/or family members become involved in compulsive rituals in an effort to be compassionate and caring. They may need education, encouragement, and/or coaching to make or support changes that are conducive to successful treatment. Alternatively, you may need to make plans for adjusting schedules at school or work, consult with a spiritual leader (clergy), or make changes to your physical environment.
Takeaway – Be open the possibility of making uncomfortable changes that will help you achieve your treatment goals.
I don’t believe that any of the five steps above are unique to my approach. They are generally seen as good clinical practice and completed by most skilled OCD therapists and clinics, even if not done so explicitly. But I stress the importance of these preparations to make the most of ERP. How much time you will need to complete these preparations will depend on your unique needs, but usually can be addressed within 3 to 6 sessions. Keep in mind though, that these processes may be both foundational (building on each other) and recursive (need to return to them if you find yourself stuck).
Jim Carter, Ph.D., Specialty Behavioral Health, Member of IOCD and certified BTTI therapist
Hi! I don’t trust ERP. I wouldn’t have control at all. It’s brainwashing from the therapist. Her or your agenda not my best interest. Doesn’t the client/patient deserve every bit of trust and respect too? Trust and respect are earned not entitled to you. Perhaps it helps but I don’t think it’s for me. I’ll keep OCD and anxiety. At least I know it’s me not becoming your copy of me or being an imposter.
Thank you for comment! You raise some excellent points, especially about respecting and honoring clients’ wishes – I completely agree. Hopefully, a good therapist would be able to discuss all of those issues at the outset, and would only proceed if the client wanted to go that route. One point I would add though is that skillfully delivered ERP (and all therapies for that matter) are collaborative, and based upon the client’s challenges and goals, not the therapist’s goals. In other words, therapy is done “with and for” the client, not “to” the client. When ERP is done this way, the client actually has quite a bit of control in terms deciding which challenges to address, which therapeutic strategies to use (e.g., ritual prevention and/or ritual delay and/or ritual interference and/or response commission), the order and sequence of activities, and the pace and duration of the therapy process. In the end, only the client can decide if a treatment is right for them and worth continuing, so the client has ultimate control in the ERP therapy process.