For therapists: 25 Ways To Screw Up E&RP For OCD

Most therapist training involves a lot of telling you, the trainee, what you SHOULD do when dealing with the patient. In addition to that approach, I find it useful to also instruct in the inverse. To that end, here is a list of 25 things that you should NOT do when helping your patient create a hierarchy or choose daily assignments for their OCD treatment. If you find yourself doing some of these, take heart: in my 20 years as an OCD specialist, I have done all of them, and learned from my mistakes.

  1. Let the patient choose to work on the “most important” hierarchy items first. [Remember, the hierarchy is designed so that the patient will escalate efforts based on the amount of anxiety or uncertainty tolerated, not on the importance of the item]
  2. Assume you know what the patient is ready to work on. [The SUDs scale is meant to be subjective, which means that only the patient will know what he or she is ready to work on, despite your best insights into their anxiety. ALWAYS ask the patient, rather than tell them, about what they are ready to proceed with]
  3. Let the patient choose to work on something that they can’t completely control. [The best hierarchy items are exposures that the patient can cause to happen, paired with rituals the patient can cause NOT to happen. Having to wait for an exposure to happen by chance, like for someone else to sneeze, means that the exposure may or may not happen in the planned way you and your patient have designed]
  4. Let the patient work on something they can only repeat once. [If an exposure only happens once, or once a week, like only in church on Sundays, then the patient will not get enough repetitions in a short enough time to experience habituation. Ideally, each exposure assignment should be done every day for a week]
  5. Let the patient choose to “just not check this week”. [Remember, ERP requires both planned exposure and an associated ritual prevention. Ritual prevention alone is not sufficient, because it does not guarantee a planned exposure, and it leaves open the possibility of a substitute ritual in place of the one prevented]
  6. Let the patient “just intentionally have the thought this week”. [As above, ERP requires both planned exposure and ritual prevention. In this case, exposure alone is not sufficient, because any compensating ritual the patient might do will inhibit habituation of the fear]
  7. Let the patient choose to work on something that, by design, gets harder and harder during the week. [Having an exposure it gets harder by the day, for instance with someone with contamination concerns not dusting the furniture and noticing dust accumulate, means that the anxiety will get higher toward the end of the week, rather than having the item habituate. It's much better to create an artificial situation that presents a limited and reproducible amount of anxiety on a daily basis]
  8. Have the patient inhibit the wrong ritual for the exposure. [Only the patient will know which ritual they use to alleviate the distress from a given exposure, and sometimes, they will not even be sure until they monitor it. If you have the patient inhibit a ritual that SEEMS likely, like not washing their hands after touching a dirty object, you might miss that they will actually be doing some mental ritual for that particular exposure instead]
  9. Miss a likely substitute ritual for the planned exposure. [For example, if you have someone enter and then leave a room and inhibit the ritual of checking the door lock as they leave, you might also have to instruct them not to review mentally what they just did in place of physically checking]
  10. Let the patient use “This is only my assignment, it doesn’t count” as a substitute ritual. [Used this way, this kind of statement is actually self-reassurance. Remember, the exposure is meant to create some distress for them to tolerate; any statement that artificially alleviates that distress will work against the benefit of your exposure]
  11. Unintentionally reassure the patient by telling them something like “remember, it’s just your OCD.” [This kind of statement is fine to administer in order to get the patient to take the risk in the first place. However, if it reassures them so much that they no longer detect any risk in their activity, the exposure will have no value. Check in with the patient by asking them if this kind of statement eliminated their uncertainty about the task, or if it just permitted them to take the risk]
  12.  Unintentionally reassure the patient by doing the first exposure with them when their main problem is doubting (some exposures only). [Some patients will tell you that they can take any risk as long as you demonstrated for them. In this case, the likelihood is that the real risk is in their not knowing the "correct way" to do that particular exposure, so you might need to have them create the exposure on their own in order for them to face their doubts]
  13.  Unintentionally allow the patient to “borrow faith” from another person during the exposures. [This is actually a way of getting passive reassurance from another person. For example, if the exposure for your patient is to have them drive near a sidewalk full of pedestrians and take the risk that they might hit someone, having another person in the passenger seat at the time might give them a form of reassurance, because in their mind, the other person would react if someone got hit. They may need to be alone in the car in order to face this risk]
  14.  Let the patient choose to be exposed by acts of circumstance or fate. [If a patient is exposed by fate or circumstance, there is no guarantee that the exposure will occur, and the intensity the exposure might vary from time to time. For instance, if the patient wants to choose an exposure like "anytime someone on the bus sneezes, I won't cover my mouth," they can't be sure that they will be exposed to a sneeze on any given day. Further, certain people sneezing may be far more triggering than other people sneezing. The inconsistency in occurrence and intensity of exposures prevents, or at least slows down, habituation]
  15.  Miss some “cover-all” ritual that the patient might perform later. [Often people will perform a kind of "neutralizing ritual", for instance saying the word "neutralize", at the end of the day to make up for any rituals they forgot to do. This is actually about being certain or even being perfect. Not doing this "cover all" ritual might either be an item by itself on the hierarchy, or included in every other ritual prevention listed on the hierarchy]
  16.  Assume that the SUDs scale numbers in the office are the same as they will be in the outside world. [Unless you or your office are somehow the target of your patient's obsession, most exposures in the office will feel less intense than the equivalent exposure in the outside world. This may be due to the patient perceiving your office as some kind of "containing environment" or an otherwise safe place. Try to advise your patient that the intensity of the exposure may be different outside your office, and they should adjust the exposure accordingly]
  17.  Let the patient mistakenly try ALL of the exposures on their hierarchy the first week. [By design, the hierarchy should be a list of items from very low to very high in anxiety or uncertainty; by definition, the upper half of these items are written so that they are too difficult to tolerate in the beginning. Having someone attempt exposures in this range can lead to feeling overwhelmed on the part of the patient, and may even produce a conviction that this approach is too difficult for them to manage. Remind your patient the completion of the hierarchy may take as many weeks as there are items on the hierarchy]
  18.  Don’t remind the patient to practice each of their chosen exposures EVERY DAY during the week. [Exposure treatment works through repetition. Without doing exposures every day, it will be much more difficult for patients to experience habituation to their fears. If a patient chooses to work on four different exposure assignments, he or she should do each of those four every day for the week]
  19.  Let the patient assume that the one-hour safety net is just for them to “gut it out” for an hour and then give in to their exposure. [Each exposure assignment is designed to create a mild to moderate increase in uncertainty or anxiety. That increase should taper off to baseline levels in a matter of a few seconds to a few minutes, or at most an hour. If your patient still feels anxious from the exposure at the end of the hour, it means that the exposure was too hard for them, and they should discontinue it into something easier. That one-hour period is not meant as a routine time that they must be anxious before giving into a ritual. When their anxiety abates, they should no longer need to do the ritual]
  20.  Let the patient do several exposures in a row without letting the anxiety from the first one diminish before starting the next one. [After an exposure, anxiety should spike and then begin to taper off, eventually getting back down to baseline levels. Experiencing the falling phase of that curve is required for habituation. If a patient does a second exposure before their anxiety has returned to baseline after the first exposure, the benefits from the first exposure will be lessened or lost]
  21.  Don’t check in with the patient to find out how they did the assignments, or how far the anxiety extinguished. [Because patients want to do their treatment well, they are at some risk for saying what they think their treatment provider wants to hear; if you simply ask them how things went, they are at least somewhat likely to respond with "fine". They may not tell you that they struggled, or that they simply didn't do the assignment. Over time, this can lead to them being very far behind there reported status, all the while keeping you in the dark. Ask them each week where they struggled, how the anxiety abated, and which days were more difficult than others]
  22.  Create exposure assignments that are not specific, or that vary from day to day. [Unless the OCD itself varies from day to day, which is rare, choosing assignments which vary day-to-day will inhibit habituation. The point of habituation is to move the person from feeling anxious aboutthe trigger, to feeling bored by the trigger. Boredom only comes from repetition, and this can not happen when assignments vary or are novel]
  23.  Let the patient keep trying the same assignment even though they have not been able to tolerate it for two weeks already. [If a patient has not been able to tolerate an assignment for two weeks running, it's a clear sign that something is wrong, most likely that the assignment was to difficult. It's much better to choose something easier that the patient will actually be able to do]
  24.  Encourage a parent to choose an assignment for their child on their own. [Many parents have a difficult time understanding the irrationality of OCD fears. Even the most understanding parents cannot know the relative anxiety or Suds Score of an exposure for their child. Parents may assist children in choosing there assignments, but, like therapists, must ALWAYS ask their children if they are ready for a particular assignment]
  25.  Expose a patient yourself without their permission. [Exposing a patient without their permission is very much like choosing an assignment for them; it comes with the additional risk of surprise to the patient, and it is complicated by the fact that you may not know what your patient is ready for. This can be very detrimental to your working relationship. NEVER expose a patient without their permission]

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