Thus, many people with OCD ask for constant reassurance during therapy. Fourth is skill acquisition whereby practice makes competence and competence reduces the need for fear. I use different forms and handouts in cognitive-behavioral therapy (CBT) for OCD and anxiety disorders. You press the elevator button several times in a row. Guidelines for Exposure sheet 4. First, I have added a cognitive therapy (CT) component to treating OCD, making my philosophy a cognitive-behavioral therapy (CBT) approach.  The premise behind adding cognitive therapy to ERP is the belief that there are “errors” in thinking that generate the anxiety in the first place.  It is believed that everyone makes these errors in thought from time to time, but that someone with OCD tends to make them more often and have a harder time self-correcting them.  An example of a type of thinking error that an OCD sufferer would make is an overestimation error.  Here an individual is overestimating the likelihood of a bad event occurring (e.g., believing that you will contract HIV from touching a doorknob and not washing your hands).  Cognitive therapy helps one identify and better self-correct these errors in thought.  I believe that cognitive therapy or what others and I call “thought challenging” is a good addition for most of my OCD patients.  I have developed worksheets that provide individuals the structure and framework for learning how to better identify and ultimately better self-correct the errors in thought that they make.  Clearly, I believe the main emphasis should still be on ERP, but the CT plays an important role.  I would say that my protocol is 80-85% ERP and 15-20% CT. Second, in talking with colleagues from other OCD treatment facilities, it appears that my exposure hierarchies tend to have more specific exercises on them.  An exposure hierarchy is a master list of all the exposure exercises that an individual will perform to reduce their OCD symptoms.  These exercises are then ordered in some fashion from least to most difficult to do (i.e., in a hierarchical fashion).  I have patients rate potential exercises on a zero (i.e., “no anxiety whatsoever”) to seven-point scale (i.e., “the most anxiety you could possibly imagine experiencing”) in terms of how anxious they think the exercise would make them feel if I actually had them perform the exercise.  My average hierarchy probably has 100 exercises on it.  Many other clinicians I have talked to have far fewer exercises (e.g., 20-25) on their hierarchies.  The reasons for these differences are varied and not entirely clear.  Some clinicians feel they can successfully “bunch” or combine exercises (i.e., combining two or more exercises into one entry on the hierarchy) in an attempt to make exposure therapy more time efficient.  Others have stated that they believe the process of generalization (i.e., anxiety will habituate or go down in certain OCD areas without directly exposing one’s self to those areas) will occur (e.g., by touching light switches an individual’s fear of touching doorknobs will also substantially reduce). 3. As the client faces distressful items, they are concurrently prevented from engaging in corresponding rituals or distracting ‘safety behaviors.’ ERP can be conducted in session—in the therapy room, with a therapist; or In Vivo—in real-life situations with a therapist. These behaviors may resemble OCD, but what sets them apart from the disorder is that they do not overwhelm you or cause significant distress and disruption in your life. This worksheet allows the individual to recognize the figures that make him anxious, causes of obsessions and compulsions. Part of traditional CBT treatment for OCD is exposure to situations which trigger obsessions (classically accompanied by the prevention of the associated compulsion). To access forms, worksheets, and handouts, look for the relevant Treatments That Work or Programs That Work title below. We aim to connect people dealing with OCD and anxiety with the resources and information they need to thrive. The exposure hierarchy lays out a roadmap for the rest of treatment. Many of us have occasional repetitive, intrusive, or strange thoughts. How OCD Treatment Will Change Due to the COVID-19 Pandemic, Harm Obsession OCD: Beyond Hand Washing and Orderliness, Psychology Today © 2021 Sussex Publishers, LLC, 5 Recent Findings About Dark Personalities, How Mindfulness Can Improve Relationships, What Dogs Can Teach You About Your Own Personality, Why Change Is Hard Even When We Know It’s Needed, The One Diagnosis All Therapists Should Understand, Mental Rituals in Obsessive-Compulsive Disorder, Scrupulosity OCD Treatment Shouldn't Be a Hard Sell, Obsessive-Compulsive Disorder: Research Update. BeyondOCD.org does not provide medical advice, diagnosis, or treatment. Facts about OCD information sheet 2. First is physiological habituation, a process whereby nervous system arousal (which is necessary for the experience of anxiety) is reduced upon prolonged exposure to the same stimulus. For OCD, the technique for facing fears is called exposure and response prevention (ERP). When complete, the worksheet can serve as a guide for your therapeutic work with your client. It is possible that you may have heard of Cognitive Behavior Therapy (CBT) before. By Bradley C. Riemann, Ph.D. – Director, OCD Center at Rogers Memorial Hospital. These can then be tackled in order of increasing difficulty. Obsessions tend to cluster around common themes: Contamination worries, doubting/harm fears, symmetry/completeness urges, and unacceptable thoughts (blasphemous, violent, sexual). Once the hierarchy is set, ERP sessions will tackle each item on it, working gradually up the levels of distress. In this case, to paraphrase Marks, quantity often creates quality. The client needs to summon their courage and perseverance, and accept the fact that short-term pain is the price of acquiring long-term health and wellbeing. Avoiding your fears never helps and in fact may even make them worse. For Adam, these eventual catastrophes were legion. ERP works best when the exercises are specific and well designed, when the client’s anxious arousal is intense, and when the ‘dose’ of exposure is substantial and systematic. Second is inhibitory learning, a process whereby new associations inhibit (rather than extinguish) old ones. Be Strategic! To create a fear hierarchy, a person will identify an obsession that they're struggling with. Overall, the psychosocial treatment protocol for obsessive-compulsive disorder (OCD) has been well established and empirically supported.  Exposure and ritual prevention (ERP) has been found to produce successful management of symptoms in roughly 85% of OCD cases.  This strategy was first described by Meyer in 1966 and has since been studied and refined by many outstanding researchers and clinicians (e.g., Edna Foa). You wear your lucky tie to the job interview. Exposure Therapy Practice form 6. Conquering Your Fear The best way to overcome fears is to face them in small steps. Sessions are often longer than usual (90-120 minutes), and twice or thrice weekly sessions are common. When distressing thoughts come to occupy and overwhelm them, they will often attempt to suppress the thoughts directly, a futile effort sometimes known as the ‘white bear problem’ (if we try not to think of a white bear, we end up thinking about it). Treatment will usually begin with a thorough assessment of symptoms. However, over time most behavioral therapists have added their own “personalized spin” to ERP and in some cases added other types of therapy to the mix.  In this article I will discuss the ways that I have “tweaked” the basic approach to treating OCD.  As you will see, there are far more similarities to the basic protocol than differences but there are some divergences that are worth noting. International OCD Foundation PO Box 961029, Boston, MA 02196 617.973.5801 Exposure with response prevention: Exposure and response prevention (ERP) is a treatment for obsessive compulsive disorder (OCD) in a patient is exposed to their feared situation and encouraged not to engage in their typical neutralizing response. ERP is a sort of psychological workout. CBT refers to a group of similar types of therapies used by mental health therapists for treating psychological disorders, with the most important type of CBT for OCD being Exposure and Response Prevention (ERP). Exposure and response prevention (ERP) is the most effective way to treat any kind of OCD. In Vivo Exposure for OCD OCD & Contamination: Washing & Cleaning Compulsions/Rituals OCD & Contamination: Reasons Why People Do Rituals/Compulsions OCD Treatment: Back to Basics Pure-O OCD Rituals: Starting Over, Resetting, & Undoing Scrupulosity Exposure … As in any workout, you tend to get out of it what you’ve put in. Don’t Ritualize. Feel free to use them in your own work: 1. Identify avoidances, situations that the client avoids so as not to feel anxious or have intrusive thoughts, images, or urges. The second step is a process known as psycho-education in which, as the name implies, the client will receive accurate information about OCD, including prevalence statistics, common symptoms, available treatments and their effectiveness. During the treatment of OCD, this cycle will be identified and broken. Habituation occurs when a person stops responding or paying attention to a stimulus, such as a thought, object, place, person or action, with repeated exposure. These rituals of cleaning, checking, ordering, or counting are a means of anxiety avoidance. Identify the client’s rituals, what they do to decrease their anxiety, get rid of the thoughts, images, or urges, or minimize the likelihood of a feared consequence. ERP is done by: o Exposing yourself to situations that bring on obsessions (triggers) o Not engaging in the unhelpful coping strategies (compulsions or avoidance). Obsessions and compulsions may be thought of as extreme, grotesque permutations of common and benign thoughts and behaviors. Question: I recently watched the harm OCD webinar (really enjoyed it-thank you) and I was wondering whether or not I could get some ideas or suggestions for hierarchy items-exposure for fear of molesting their child-pedophile OCD. One form of treatment that focuses on the disruption of this cycle is called exposure and response prevention therapy. A symptom hierarchy is a central tool in exposure therapy, and it provides a birds’ eye view of what needs to be accomplished in treatment. People with OCD often spend much energy and time ‘looking for trouble’ so to speak, acutely attuned to the cloud in the silver lining. Each item in the hierarchy will receive a SUDS rating (0-100), ranking items in order from least distressing to most distressing. The short-term pain of ERP is a better deal than living with the long-term punishment of untreated OCD. Noam Shpancer, Ph.D., is a professor of psychology at Otterbein College and a practicing clinical psychologist in Columbus, Ohio. For each title, we have listed direct links to appendices containing free, downloadable forms. ERP is also aversive by design. This worksheet serves as a guide to organize feared and uncomfortable situations that your client faces each day. This is the OCD Exposure Hierarchy Worksheet. One therapeutic approach that helps with this process is exposure and response prevention (ERP) for OCD. See below for a recent question Light on anxiety received after our Harm OCD webinar. Generally, ERP treatment will proceed in an orderly sequence of stages. Response prevention is the key component here. Washing your hands routinely after you go to the bathroom is not OCD. We hope that by the end of this part of the group you’ll have an idea of when exposure can be helpful and how to use it. It works through pain, not away from or around it. The therapist and patient develop a hierarchy of avoided activities that the patient practices through in vivo exposure between sessions. ... of a SAMPLE fear hierarchy of exposures for a particular patient seeking treatment at an anxiety specialty center. Get the help you need from a therapist near you–a FREE service from Psychology Today. treatments for OCD CBT that relies primarily on behavioral techniques such as exposure and response prevention (ERP) is recommended because it has the best evidentiary support *American Psychiatric Association. With regard to compulsions, the goal of ERP is for the client to learn, through experience, that they don’t need rituals to manage anxiety well. As a part of this treatment, your clients will be gradually exposed to their triggers, which results in their anxieties, obsessions, and compulsions diminishing. Like many other avoidance strategies, they work well in the short term. To deal with the distress caused by fearful thoughts and images, people with OCD turn to increasingly elaborate rituals and safety behaviors. Third is psychological empowerment, whereby the client learns from experience that they can manage distress, thus developing greater self-efficacy regarding coping. Some have questioned the speed and efficiency of this approach, believing that it will take individuals much longer to complete their hierarchies if they start “so low” in them.  On the contrary, it appears to be a “tortoise and the hare” kind of phenomenon.  Despite starting lower in the hierarchy, I believe individuals complete treatment in roughly the same amount of time that others do in treatment facilities that don’t emphasize the need for graduated exposure as much.  What I lack in terms of starting place in the hierarchy I make up in needing fewer repetitions to achieve anxiety habituation with a particular exercise and thus being able to move on to new exercises faster.  It should also be noted that the individual whom I am working with has a strong say in where we start in their hierarchy.  Some opt to start higher, but most see the “method” behind what some of my colleagues teasingly call the “madness” behind this approach and start in that manageable anxiety range.  In summary, I believe emphasizing the graduated nature of exposure ultimately allows more individuals to seek and complete treatment in roughly the same amount of time. Alas in the long term they become a problem themselves. Although some generalization does take place in exposure therapy, in my experience it is rarely enough to completely eliminate the need to work on an entire OCD area (e.g., light switches completely generalizing to doorknobs and thus eliminating the need to address).  Thankfully, generalization is present to an extent but I see it usually within an OCD area (i.e., there is no need to touch every light switch to overcome a fear of them) not as much between them.  I have individuals demonstrate their mastery over every OCD area.  Despite the observed generalization effect in my patients, I also tend to develop separate exposure exercises within each area (e.g., light switches) to address the differences most patients perceive between certain circumstances (e.g., differences between light switches in bedrooms and ones in bathrooms).  In summary, I believe these are the reasons my hierarchies are larger in terms of number of items than most behavioral therapists.  I believe that the more specific the exposure exercises are the more functional (i.e., anxiety reducing) they will be in the long run.  Obviously, this is a bit of a balancing act and too big of a hierarchy can really slow someone’s progress.  It also does not help an individual’s confidence to give them a hierarchy the size of a phone book! 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