The most common mistake in OCD therapy
When clients hire an OCD specialist, I can imagine they might have some expectations like “let’s get started with the ERP RIGHT NOW because this is flipping expensive.” But I have to reconcile this with the most common compliant I hear in my practice from clients who have been to OCD specialists prior to seeing me which is something like “It all felt so mechanical and impersonal. I wasn’t ready to do exposures right away and I felt like my therapist was mad/disappointed in me for not doing more exposures.”
Of course, this is NOT everyone’s experience. There’s a reason that local OCD clinics charge $250 a session and have months long waiting lists and it’s not because they are ineffective.
I think that if anything, the premium nature of high quality OCD therapy might make therapists anxious to get started and they end up out ahead of their client, driving treatment faster than some clients want to go. Truth is, this is one of my big worries about raising my fees to match my colleagues - that I’ll feel even more pressure than I already put on myself to “be effective/efficient/fast,” and inadvertently end up being less effective.
Slow down
My number one tip for all therapists who are trying to implement ERP in their practices is to take a nice deep breath and slow WAAAAAY down. You should feel NO pressure to go any faster than is indicated for effective treatment and effective treatment requires significant client buy-in and partnership. Even if your practice is entirely insurance based, insurance companies know that despite what treatment manuals may describe, “REAL LIFE” ERP can take more than 12-16 sessions to be effective. We can easily write a good treatment justification for longer treatment, so long as you, as the therapist, are confident in why you’re spending time on the foundational parts of therapy that lead to effective ERP.
What do I mean by slowing down?
Remember all of that motivational interviewing stuff in grad school? It’s a basic therapy skill and still important, even in super-specialized OCD treatment. In early treatment, no matter how “fancy” you are as a specialist, you must do everything to get you client in front of you, leading you towards change. You work to help them see all of their reasons for change and all of the awful and terrible costs of staying the same and what their current coping is costing them. Yes, ERP therapists do that too - or we SHOULD do it well, before we start exposures. Having a super sparkly evidence-based treatment does not reduce the need to do good-therapy basics.
How do you build a really good foundation for ERP?
Make sure the client has a reasonable understanding of how OCD develops and a good narrative of how their OCD formed.
Help the client secure the support of friends and family in reducing accommodations and reassurance.
Build a strong therapeutic alliance (still accounts for a good proportion of change in therapy, last time I checked).
Define and develop mindfulness of OCD coping behaviors and help the client understand how their’s work. Help them be the expert of their own OCD, so they can see it happen as it’s happening.
Check in on their reasons for change. ERP is hard work. Why would you want to do this? What will you get if we do a good job?
Help your client design the exposures with an intrinsic reward of being able to do something important to them as a natural result of the successful exposure.
Help them notice their own OCD coping behaviors in action - especially the covert ones, so they’re full participants of ERP and fully engaged in the fear.
Be a team, constantly reviewing and revising the plan to target important, medium-difficult exposures until the really big ones look relatively easier.
Teach them to integrate ERP practices into their everyday life so that anytime OCD starts to tighten up, they know how to loosen it on their own.
If you’re stuck while doing ERP, it might not be the ERP you’re stuck on but rather another basic therapy skill like relationship building, collaboration, motivational issues, etc. Look there first and then look at your ERP strategies.