Obsessive-Compulsive Disorder (OCD) Treatment
at SBCS
using Exposure and Response Prevention (EX/RP or ERP)
Offered by Diana Harden, LCPC
Trained by faculty from the Center for Treatment and Study of Anxiety through University of Pennsylvania
What is Obsessive-Compulsive Disorder (OCD)?
Obsessive-Compulsive Disorder (OCD) is a mental health condition characterized by recurring, unwanted thoughts (obsessions) and repetitive behaviors (compulsions). Individuals with OCD feel compelled to perform these behaviors to alleviate anxiety caused by their obsessions, impacting daily life and functioning.
An estimated 2-3% of the US population has Obsessive-Compulsive Disorder (OCD). Obsessions are defined as overly distressing/intrusive thoughts, images, impulses or, feelings that are often unpleasant, irrational, sometimes unexplainable and are difficult to get rid of on your own. Compulsions (also referred to as rituals or responses) are learned behaviors and patterns that a person might use to lessen the anxiety and distress associated with the obsessive thoughts/images/feelings, etc.
Compulsions are not often successful in reducing anxiety for most people with OCD and therefore lead to more ritualizing, thus creating more unhelpful patterns in temporarily reducing anxiety. The rituals can often be irrational, intended to prevent harm of any sort, exaggerated or even cause a client to avoid a daily life activity altogether to avoid perceived consequences. Compulsions can be more overt (i.e. handwashing, or counting) or mental (i.e. repeating a phrase or prayer continuously)
Obsessions and compulsions are often interfering with a person’s day to day activities, interpersonal relationships, work/school, and leisure. Exposure and Response Prevention (EX/RP) is a data driven CBT (cognitive-behavioral therapy) treatment model for OCD. EX/RP is highly interactive and mostly defined by creating a working list of different obsessions and compulsions (also known as responses or rituals) that a client presents with. Clients will work in treatment with clinician to identify the most distressing obsessions (thoughts, images, feelings, etc.), paired rituals and design exposures specifically tailored to that client’s needs.
An example of an obsession, ritual and paired exposure could be:
Obsessive Thought: "If I'm out in public and touch a door knob used by many people, I will bring those germs home to family and cause harm."
Ritual/Compulsion: Client will repeatedly wash their hands for longer than necessary due to fear of contamination of their family.
Exposure: Client will be challenged to wash their hands only once for 20 seconds per CDC guidelines.
**Please note: this is just an example. All exposures are agreed on by client and therapist. Every client will be different as every client will have different obsessions and compulsions. Exposures are set up in a hierarchy format and worked through based on specific client needs.
EX/RP not only provides the client with a level of distress tolerance and acceptance, but also helps the client work against and eliminate the rituals/responses.
What to expect with EX/RP Treatment
(1) Clients will first be evaluated for the severity and presence of OCD behaviors using the following assessments (1 session)
Y-BOCS (Yale Brown Obsessive-Compulsive Scale (Goodman, Rasmussen, et al.)): guided by clinician to determine severity of obsessions, compulsions, avoidance, and time spent on obsessions and compulsionsOCI-R (Obsessive- Compulsive Inventory- Revised): self-report from client administered prior to sessionsPHQ-9 (Patient Health Questionnaire): to assess depression presence and severityGAD-7 (General Anxiety Disorder): questionnaire to assess anxiety presence and severity
(2) After severity/presence of OCD is determined, clients and clinician will engage in treatment planning to determine obsessions, compulsions, and avoidance. Self-monitoring outside of session is used, along with the assessments to determine the different rituals the client is performing and time spent performing the rituals. (up to 2 sessions).
(3) Client and clinician will spend the next sessions exploring exposures—the client will agree on exposures to try with the guidance of the clinician, building up to the most distressing exposures. Clients will try exposures within session and then on their own (outside of therapeutic sessions) and will engage in daily self-monitoring, journaling/logging of distress, compulsions/rituals performed, and lowering of distress not using compulsions/rituals. The overall goal is for the client to expose themselves to the discussed obsessions and not engage in the ritual to reduce anxiety. (up to 15 sessions)
How effective is EX/RP Treatment for OCD?
A review of 12 treatment studies involving 330 patients found that 83% of patients who completed EX/RP therapy were classified as responding favorably to treatment (Foa and Kozak’s, 1996)
In 16 studies reporting long term follow-up with 376 patients, 76% were considered to have successfully maintained their gain.
If clients are committed to the treatment, including out of session invitations to log, journal and practice exposures- outcomes can be very favorable.
“OCD is a crippling disorder that can leave most with a hopelessness about their future. OCD is often referred to as the “doubting disorder” and often leaving people in a place of isolation. I hope with our collaborative treatment using EX/RP you can regain some of your hope and learn the life long skills to manage your thoughts and intrusions. While I cannot promise this process will be easy, I will be here to support you in a therapeutic way. Learning to accept the doubt and uncertainty is one of the challenging features of OCD - but in most cases this can be worked against with repetition and commitment.”
$275/90 minute assessment session$275/90 minute follow-up session$225/60 minute follow-up session
Due to the unique and interactive nature of EX/RP treatment for OCD, some sessions may need to be longer in order to effectively engage in exposures for the client’s benefit. You and your clinician will agree on the length of sessions so that you are aware of the time and cost needed. Please consult with your clinician at any time should you have any questions or concerns about session logistics.
TELL ME ABOUT FEES AND INSURANCE?
SBCS is not paneled with any insurance plans but can offer you what's called, "out-of-network" (OON) benefits. Not everyone has this as part of their benefits package so please call your healthcare plan and ask these questions:
Do I have out-of-network benefits?
What percentage of my therapist's fee does my plan pay for?
MOST OON Benefit PLANS REIMBURSE BETWEEN 50-90% OF OUR FEES.
At times, insurance plans request upfront billing codes your therapist will be using. You can share this list of codes for their approval:
90791 Psychiatric Diagnostic Assessment (from 1-4 sessions depending on the problem)
90834 Psychotherapy, 45 minutes
90887 Collateral visit
When using OON benefits, your clinician would provide you with a document monthly called a "superbill" which is like an invoice but contains the service codes, dates of treatment, and monies paid during therapy. You would submit this to your plan directly and your plan would reimburse you directly as well.
You can get in-network therapy if this is out of your budget. Your plan can identify providers who are in-network should you need to use your benefits.
HOW ARE MY RECORDS STORED?
We at SBCS utilize a HIPAA compliant, encrypted, electronic medical record called SimplePractice that holds all of our client's mental health records safely in it. You will get a link to a client portal where you fill in demographic information and can access documents like invoices and superbills on your own.
HOW DO I PAY MY THERAPIST?
SimplePractice has a credit card processing system named Stripe embedded in it. If choosing to work with a therapist at SBCS, you would upload your credit card number and your therapist will charge after each session or late cancellation for the fee. Your therapist will only have access to the last 4 digits of your card and it is completely secured.
DO YOU HAVE A CANCELLATION POLICY?
All clinicians at Space Between Counseling Services have a 24- business hour cancellation policy. You will be responsible for an entire session fee if the change is made in less than 24 business hours' notice. Exceptions may be made for emergencies such as sudden illness or accidents, at your therapist’s discretion. It should be noted that insurance does not reimburse for canceled sessions and HSA and FSA cards can't be used in these cases.