Aug. 4, 2009 -- When clients come to a cognitive behavioral therapist with an anxiety disorder, such as obsessive-compulsive disorder, the focus of the therapy is an intervention called "exposure and response prevention," or ERP. It means just what it sounds like -- a person repeatedly approaches or is "exposed to" the very thing that makes him or her anxious or uncomfortable, and then attempts to stop themselves from engaging in behaviors that are designed to lower that anxiety.
Cognitive behavioral therapy (CBT), in contrast to traditional "talk" therapy, is shorter in duration and focuses not so much on early life experiences or unconscious processes, but rather on "here and now" problems, and on the education and coaching of clients as they learn new ways to think and behave in order to solve those problems.
In OCD, obsessions, or anxiety-producing intrusive thoughts or images, are usually followed by compulsions, or behaviors that the person does on purpose to lower that anxiety. For instance, if an obsession takes the form of "that thing is dirty/contaminated" the compulsion would be to avoid touching that thing, or to wash excessively if you did touch it. ERP would then involve the person touching "contaminated" things on purpose, followed by specific efforts on the part of the person to NOT wash.
In ERP, with repeated and lengthy "exposure trials," the person "learns" to let go of these fears through a process called "desensitization." Essentially, after exposing themselves repeatedly to a feared thought, thing or situation over and over again, they get used to it, and it bothers them less and less over time.
Because this is initially a very scary process, clients with OCD do these exposures as slowly or as fast as they feel they can handle, thereby allowing them to feel in control of the therapy. In addition, ERP is usually done one small step at a time, so that clients can "build up their strength" much like one would do by lifting weights, starting with lighter weights first and then "graduating" to heavier and heavier weights as they build their strength.
This metaphor of weight lifting is just one of the many stories that I use when conducting therapy. To help clients and their families understand ERP, which at first can sound very scary and quite strange, I use different stories to help them understand how this process works.
OCD: Easy to Describe, Difficult to Understand
Storytelling and metaphor use is often the best way to present subtle and confusing ideas in a succinct and concrete way. It is a wonderful way to go beyond merely describing something or even explaining it. Narratives serve to illustrate not just an idea, but the very foundation of an idea. By hearing a story, the listener shares an experience with the narrator which enables him to understand what is being discussed in a way that mere description cannot accomplish. It is a way to get inside the mind of the narrator.
OCD is relatively simple and easy to describe, but it is extremely difficult to fully understand. Once presented with information about this psychiatric disorder, we are left with the questions, "OK, I get what happens, but how can that be? How does that make sense? Why are people thinking and doing those crazy things?"
As strange as OCD symptoms are, they don't hold a candle to the treatment. The cognitive behavioral treatment of OCD involves some of the most bizarre and outrageous interventions that you are ever likely to encounter in a therapy office. Most OCD clients are very surprised or even stunned when it is explained to them what they need to do in order to help make themselves better. They sometimes think the therapist is crazier than they feel.
And so something beyond telling is required. Explanations don't seem sufficient when you are being instructed to think and behave in a way that seems contradictory to your goals. It is often hard to "think outside the box," to think nonlinearly.
In the arts, whether we are referring to dance, music, sculpture, painting, writing, poetry, theater, or film making, there are countless examples of an emotion, a struggle, or an experience of some kind, which is communicated indirectly and expressed through the artistic medium. This artistic representation, when done effectively, allows the audience to better understand what is being communicated than if the idea being presented was done so by mere instruction. And so it is with describing the diagnosis and the treatment of OCD.
In terms of children and OCD, parents might not be sure when they should begin to worry. Children, especially younger children, tend to be superstitious, magical in their thinking, and compulsive and repetitive in their behaviors.
They may demand to be told the same bedtime stories night after night, insist that they line up their stuffed animals in a particular order, have a meltdown if the peas touch the mashed potatoes on their dinner plate, and play games such as "step on a crack break your mother's back." These are all healthy attempts to feel a little more in control of one's life when you are a little person living in a world completely dominated by grownups.
But when these rituals become non-functional and non-flexible, when they cause undo and chronic distress to the child as well as the family, then parents might need to consider professional intervention. No one instance or behavior alone may constitute the diagnosis, but if the child is completely unable to control his or her behavior, and is completely inflexible about altering it, and the behavior is excessive to the point of significantly interfering with functioning, whether at school, at home, or during a specific activity such as bathing, eating or getting ready for bed, then that is the time to seek professional help.
Finding the Right Therapist Key to Successful Treatment of OCD
The good news is that help is available, and that we in the mental health field have gotten pretty good at helping most people with OCD to a significant degree. We don't have what one would call a cure (yet), but rather we teach children how to manage their OCD, and help parents help their kids to achieve the same goal. They may even get to the point where they seem to have no symptoms, even for a long time, but chances are that the OCD will re-emerge at a later time, especially when the child is stressed due to illness, lack of sleep, or a life change such as a move of residence or the death of a loved one, including a pet.
Treatment for many children usually consists of a combination of medication and cognitive behavioral therapy. Typically, these medicines fall in the class of SSRIs (Selective Seretonin Reuptake Inhibitors), but other medications are used as well, or instead of these, especially if there has not been a therapeutic response to the initial medication trials. Many children are able to utilize therapy without the addition of medication.
Key to success is CBT treatment. But finding a good therapist may not be easy. You want someone who identifies themselves as a CBT therapist, and one that uses ERP as a treatment protocol. Interview your prospective therapist. Ask how many OCD children they have worked with, and how they treated them. If you don't hear ERP and CBT in the answer, or if you hear things like "relaxation training," move onto someone else.
The first stop to finding a good therapist is the national OC Foundation, which has a Web site at www.ocfoundation.org. They have a referral list for the whole country. Most established therapists have a Web site these days, and it is a good thing to check them out and see what they have to say about the clinician.
If your child has OCD, no matter that the symptoms are severe or that it has been going on for a long time- there is a good chance that they, and you, will get significant relief from treatment, and in a relatively short period of time (weeks, not months), especially if they have never been treated before, or have never had CBT treatment before. There is every reason to be extremely hopeful. The key is to find the right therapist, and psychiatrist, if medication is needed.
There are also some Intensive Outpatient Programs (IOPs) across the country, and a small handful of inpatient hospitals that cater specifically to OCD, though many do not treat children. Again, the www.OCFoundation.org provides information on these resources as well.
Finally, if your child has had a very severe and acute onset of OCD symptoms, and especially if this was preceded by a strep infection, there is the chance that your child has type of OCD triggered by an autoimmune illness. This type of OCD is treated with antibiotics as well as CBT. Check with your physician first.
Allen Weg, Ed.D, is a licensed psychologist, vice president of the New Jersey Obsessive-Compulsive Foundation and has a private practice, Stress and Anxiety Services of New Jersey, Pa., in East Brunswick. He and his associates specialize in the cognitive behavioral treatment of anxiety disorders for children, adolescents and adults. More than three-quarters of the clients seen have a primary diagnosis of OCD.
He is the author of the upcoming book, "OCD and Storytelling: The Use of Metaphor in Treatment," published by Oxford University Press.