What Can I Expect When Starting ERP Therapy For OCD?
You may have been in therapy in the past, or this may be your first time. You may have even done Exposure and Response Prevention therapy (ERP) before, but an OCD flareup may have led you to seek treatment again. Wherever you are in your mental health journey, you might be feeling a little nervous about meeting with a new provider and unsure of what to expect.
I will give you a run-through of how I typically structure ERP treatment so that you can have a general sense of what to expect. Take this as a guide, as there may be modifications depending on client needs and circumstances. Likewise, every therapist has their way of approaching ERP therapy, so there may be variations if you seek care with another OCD specialist. If you’re still researching therapists, learn more about why you may want to consider an OCD specialist.
Some of what you can expect when starting ERP therapy for OCD:
Information Gathering And Assessment
Our first few sessions will be focused on getting to know you and understanding what you’re going through. I will ask about your history, background, symptoms, and symptom interference with your daily living. I will also assess for safety issues and suicidality. As an OCD specialist, I am trained to distinguish between true suicidality and Suicidal OCD, which is a common OCD subtype. Depending on your experience, we may come up with a safety/crisis management plan that will be easily accessible to you during intense moments.
A good assessment is important to obtain an accurate diagnosis and for treatment planning. I will often use the guidance of a diagnostic tool called the Diagnostic Interview for Anxiety, Mood, and OCD and Related Neuropsychiatric Disorders (DIAMOND) to help in this assessment phase. I like to keep sessions conversational so it doesn’t feel like you’re just answering questions the entire time. But I also keep it balanced to ensure that I cover what I need on my end. I may interject with a follow-up to something important that you said or to keep us on track. I will provide you with your diagnosis (or diagnoses if it is the case that you meet criteria for something other than or in addition to OCD), answer questions you may have, and provide you with education and helpful resources. I will also instruct you on self-monitoring symptoms to increase awareness around triggers and compulsions. I will ask that you keep a self-monitoring log as we move closer to starting treatment. Self-awareness is an essential part of treatment and making change.
OCD Measures
Measures can be very useful in screening and assessment. One of the measures that we will do is the Yale-Brown Obsession Compulsive Scale (YBOCS). The YBOCS is a commonly used tool to assess for obsessions and compulsions and to measure the severity of symptoms. It is a two-part instrument, with the first part being a checklist of some of the most common obsessions and compulsions. We will go through this checklist together so that you can identify what you have experienced in the past and what you are experiencing presently.
Going through this process can be validating for clients who can see that their symptoms are not as unusual as they had thought. It can also help clients identify obsessions and compulsions that they did not recognize as being part of OCD. The second part of this tool is a 10-item questionnaire that will ask about symptom frequency, interference with functioning, level of difficulty managing them, etc., and provide us with a total score ranging from 0-40. Each score will fall into a specific symptom severity range (subclinical, mild, moderate, severe, extremely severe.)
Upon completion, I will share your score and severity range and we will discuss the best way to move forward with treatment. Sometimes clients who are extremely impacted by their symptoms and fall in the higher ranges may need a higher level of care. If that’s the case, we will discuss getting you connected to the care that would be most beneficial to you. If we continue working together, we’ll use this score as a baseline and reassess later on to see how it has changed. Our goal will be to bring that score down to the subclinical/mild range throughout ERP treatment.
Initiation Of ERP Therapy
After those few initial sessions, we may be ready to initiate treatment. We will start with hierarchy building before moving on to exposure exercises. We will create an exposure hierarchy based on triggers you’ve noted in your self-monitoring. An exposure hierarchy is a listing of exercises that trigger your obsessions and are ranked according to the level of anxiety/distress that they provoke. ERP therapy will involve learning new skills to resist compulsions and help you shift your relationship with anxiety. This will take place gradually so that you’re starting with easier exercises before moving to the more difficult ones. We will move at your pace so that you can begin building skills and confidence. Your hierarchy will change throughout treatment and eventually, some of those items that were ranking high on your hierarchy may not rank as highly anymore.
Moving forward, treatment will involve doing exposure exercises in sessions and engaging in daily exposure practice in between sessions. Practice outside of sessions will be essential in helping to reinforce the learning that is taking place since most of your time will be spent outside of our sessions.
Important Considerations
Keep in mind that the above is a flexible guide and timeline. The way things move along will depend on your specific needs and circumstances. Sometimes we will need to address other issues that could get in the way of doing exposure work. For example, if there is a co-existing condition taking precedence, we may focus on managing that first. Many clients will notice initial shifts in symptom management within the first few months of exposure work. But again, progress and length of treatment will vary by client. It will depend on the different factors influencing your unique clinical picture (i.e. symptom severity, consistency with practice, other life stressors, other co-occurring diagnoses, etc.)
