In your experience, what do clients find to be the most challenging aspect of undertaking CBT for OCD? What are some strategies they can use to get through difficult exposures?
The most challenging aspect is feeling the horrible symptoms of anxiety. Anxiety is brutally painful. My job is to prevent the compulsions which mean that my patient will feel pain. This is hard to watch but I know they will feel better sooner rather than later. Most of us (OCD treatment providers) don't start with the difficult exposures thus the patient will experience a lower level of anxiety. They learn how to feel the anxiety without doing anything but FEEL and in time the symptoms go down (a process called habituation). Once they realize that the anxiety will lessen on its own, I then have my patients tackle a more difficult exposure.
What are the ingredients that go into an effective exposure exercise?
You need a trained therapist and a motivated patient. I try to prepare my patient as much as possible so they know what will happen. The key is not to bail out of the exposure too soon. Patients must rate their anxiety (0 to 100) and wait for the symptoms to come down by 50%. The exposure is then done repeatedly. If someone stops early and engages in a compulsion, the obsession will strengthen and the exposure for that situation is rendered useless.
How do you decide when home visits might be necessary to conduct exposure exercises?
I decide to do a home visit after doing exposures in the office is completed. Also, I go to the home if someone is practicing at home but still having difficulty. I like doing home visits as I get a better sense of that person in their home environment. It is not always necessary it is just my preference.
Is there any evidence that medications designed to relieve anxiety interfere with exposure therapy? What do you typically say to clients who are taking anti-anxiety medications and who want to undertake CBT?
In order to engage in exposure therapy, the client needs to be able to feel their anxiety. If medications take all of their anxiety away, I can't really do the exposure. Most people will feel some anxiety on their medications so typically it is not a problem. It is problematic; however, if someone is on benzodiazepines to totally mask his anxiety. With that said, I try to work closely with the psychiatrist who is prescribing medications.
Family members often want to help but are unsure what to do. What advice do you have for family members who want to support a loved that is being treated with CBT for OCD? Should family members be actively involved in treatment or even attend sessions?
Family involvement is absolutely important. Typically family members want to be supportive and are often the ones giving in to the patients' anxiety. Enabling a patient is essentially doing a compulsion for the patient and this makes the OCD worse. More often, a family member is just trying to help out. I find it necessary to get the family involved as they are the ones who are going to help with exposure therapy in the home.
For people who are interested in self-help, are there any books that you would recommend for people with OCD?
My absolute favorite books are Getting Control and Imp of the Mind and both are written by Lee Baer. Two of the best websites are Obsessive Compulsive Foundation and OCD Chicago.
