Description of Treatment
We use Cognitive Behavioral Therapy (CBT) with our clients. CBT is a form of therapy that helps promote behavior change through understanding of the interplay of thoughts, feelings, and behaviors. Clients are assisted in uncovering unhelpful automatic thoughts and maladaptive behavior patterns that contribute to depressed mood, anxiety, anger, and others negative feelings. Treatment is active and requires collaboration and participation of both the therapist and client. Treatment is also intended to be brief as the client learns skills that can be used to manage anxiety and depression symptoms.
To treat OCD and other anxiety disorders, CBT treatment adds an Exposure and Response Prevention component (ERP). ERP has strong research supporting its effectiveness in treating and overcoming fears. ERP is an active form of therapy that assists clients in facing fears in a supportive and systematic way. We assist clients in creating a hierarchy of their fears, and then they are gradually exposed to those situations. They are assisted in tolerating their anxiety without avoidance, rituals, or other maladaptive responses. Gradually over time, people get used to these situations (also called habituation) and are able to function with greater freedom. This, as research has repeatedly demonstrated, is the most effective treatment that is available to treat OCD and other anxiety symptoms.
Our intensive programs are based on the conviction that intensive specialty treatment, employing evidence-based treatment protocols, is effective in treating severe obsessive compulsive disorder, other anxiety disorders, and coexisting conditions. In the attempt to achieve maximum benefit for clients, the program adheres to the following assumptions:
- We use state-of-the-art evidence-based cognitive-behavioral and psychopharmacological treatment modalities.
- We encourage normalization by client participation in decision making and provision of services in the least restrictive environment.
- We design and provide services in a way that supports, educates, and empowers the client.
- We attend to the individual’s physical, emotional, social, and economic problems.
- Our long-term goal is to establish healthy functioning individuals and families.
A diagnostic assessment is usually completed within two weeks of admission by the clinical team. The team utilizes observations, specific interventions, client and family history, client and family reports, psychological testing, and past treatment records in formulating the diagnostic assessment. Given the complex presentation of severe OCD, a careful and thorough diagnostic assessment is crucial for future treatment to be effective. Assessment findings are shared by team members during a multidisciplinary team meeting. These findings comprise the foundation of future treatment and are shared with the client and, when appropriate, with family.
Core Treatment Program
The Houston OCD Program utilizes a multidisciplinary clinical team who specialize in OCD treatment. Treatment planning focuses on symptom reduction and prevention with the client’s active involvement in the treatment design. Discharge planning begins upon admission to assure community reintegration and tenure, as well as assuring future treatment to address the long-term care needs of the client.
Conventional measures in the field, with well-documented reliability and validity, are used throughout the treatment, and the data complements decisions about treatment level and discharge. These measures include the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Obsessive Compulsive Inventory, Becks Depression Inventory (BDI), Basis-24, Multiaxial Anger Inventory, State Trait Anxiety Inventory I and II (STAI-I & II), Fear of Negative Evaluation Survey (BFNE). These are examples of a few of the measures that are given at admission and discharge. Furthermore, the Y-BOCS, BDI, STAI-I, and BFNE are administered fortnightly (every two weeks) throughout treatment to aid in treatment delivery.
Multidisciplinary Treatment Team
A multidisciplinary treatment team is assembled for each client. A cognitive-behavior therapist, psychiatrist, and residential counselor compose the foundation of the team. Involvement of a chemical dependency counselor and other specialists varies in time and intensity based on the client’s clinical status and intensity of care.
The psychiatrist meets regularly with the client. Most clients who seek out this level of treatment care have failed multiple medication trials. Hence, previous medication trials are reviewed and assessed for adequacy, and when appropriate, alternative regimens are instituted.
The cognitive-behavior therapist, who designs the individual treatment plan with the client, provides initial assessments and evaluations. They will also conduct individual behavior therapy sessions.
The direct delivery of care is provided by a team of residential counselors. Their role is to aid treatment delivery, especially to enhance response prevention for clients with severe and treatment refractory OCD. The staff is trained to help clients with OCD to enhance response prevention, block their rituals, assist “ritual free” activities of daily living, and to implement behavior therapy techniques.
Behavior Treatment Plans and Treatment Contracts
Individualized treatment plans are negotiated between the client and the treatment team, and re-evaluated on a weekly basis. The core of the treatment contract is the Behavior Treatment Plan, which delineates core problems, specific obsessions, compulsions, avoidances, goals and specific interventions. This contract builds on a hierarchy that is designed with clients. This includes having specific information on the Behavior Treatment Plan about ways to assist clients through their morning routine with minimal rituals, evening routine, and most importantly how to implement staff-assisted exposure and response prevention sessions. The Behavior Treatment Plan is evaluated weekly and is a collaborative endeavor. Clients are active in designing and implementing the care delivery and deciding what OCD triggers to address in each given week.
The Behavior Treatment Plan is supplemented by a program specific Treatment Contract. In this contract the client has a leading role in designing the objectives for the week and implementing the contract, as is postulated in the “Client as Colleague” model (see, Heinssen, Levendusky, & Hunter, 1995). On the treatment contract, clients are encouraged to address discharge-related issues while they are in treatment at the Houston OCD Program, e.g. health, vocation/education, family and personal relationships, post-program treatment and other quality of life issues in a proactive fashion. The clients also set very specific objectives for the week that aim to help them tackle some of the OCD triggers and meet the goals set out in the Behavior Treatment Plan. The treatment program is designed such that clients set a specific goal for each day that will help them meet the treatment contract for that particular week. Specifically, the clients set three OCD or other anxiety related goals, two health goals, two aftercare goals, and three self-directed exposure targets. At the end of each week, the staff and clients review the treatment contract in the areas of symptom reduction and management, healthy living, and aftercare. Clients receive weekly feedback about progress toward the goals, in a group designed for that purpose, from fellow clients and from the treatment team. These group feedback sessions are, based on our experience and supported by some preliminary findings (e.g., Heinsen et al., 1995), a powerful therapeutic vehicle in providing motivation for the client to change and accept increasing amounts of control over the treatment and recovery. This is especially true for clients with very severe and treatment refractory OCD who have previously failed in outpatient treatment. This format provides opportunities for modeling by “senior” clients, accountability to peers and staff, as well as a very clear format to provide constructive feedback about effort.
Delivery of CBT, Milieu and Group Therapy
The staff is attentive to the unique challenges the OCD symptoms put on clients and their families. The cognitive-behavior therapist conducts individual behavior therapy sessions. Residential counselors assist the client’s efforts to follow his or her behavior treatment plan, especially implementing challenging exposure and response prevention sessions. Supportive staff interactions as well as groups and activities are scheduled to maximize the client’s ability to follow their behavior treatment plan. Clients and staff participate in a group forum community meeting to foster an atmosphere for change, support, and to provide opportunity to influence program procedures.
The cornerstone of the Houston OCD Treatment Program is the daily exposure and response prevention (E-RP) group sessions (two hours), as well as daily self-directed ERP sessions (SDE). The ERP sessions take place in a group format, but each ERP is completely individualized. The group format refers to the fact that the clients gather in a group and report their “Subjective Units of Distress Scores” (SUDS) at the beginning of the session, as well as working out who of the clients needs individual staff support in enhancing their response prevention or implementing the ERP. At the end of the ERP session, clients get together as a group and report their highest SUDS score of the session, their current SUDS score, and various facts about their success in implementing the ERP for that day.
The cognitive-behavior therapist works closely with the client to create the ever changing and transforming hierarchy of OCD triggers. The hierarchy serves as a road map to recovery for clients. Both staff and clients are responsible for the integrity of the ERP session. Due to the nature and severity of the OCD that many of our clients struggle with, as well as having a history of treatment failure, every effort is made to preserve the integrity of the ERP session. It is expected that as many as possible of the OCD staff partake in the ERP session and provide individual assistance to those clients who have historically been unable to complete ERP sessions independently. The goal is that clients will eventually be able to complete all ERP sessions independently. A major factor in the program to facilitate client’s ability to conduct their ERP sessions independently is the emphasis put on setting time set aside for the daily self-directed exposures. Clients select OCD triggers they are reasonably certain that they can complete a focused ERP session on independently. Additionally, the clients utilize the weekly treatment contracts to specify what self-directed exposures they plan to complete and receive feedback from peers about how realistic, in peers opinion, it is that they will be able to complete those ERP sessions.
All other groups in the program are designed to complement the evidence-based ERP sessions and build client’s skill sets and resilience, as well as foster support and an opportunity to practice what they have learned. Treatment interventions and group work are naturally based on the diagnosis and symptoms that each client presents.
Family Education and Support
Throughout treatment, staff members provide psychoeducation about OCD and the impact it has on family relationships. They also coach family members on how to work with loved ones to fight illness and boost recovery from symptoms. It is especially important in the work with clients who live at home to include the family in the treatment (see, March & Mulle, 1998). Hence, in addition to the work described above, the cognitive-behavior therapist has one meeting of either face-to-face or a phone therapy session with both the family and client each week.
Discharge and aftercare planning is an ongoing process. As clients near completion of treatment, therapeutic passes to a client’s home may be scheduled to promote the application of CBT skills, and to facilitate ways to challenge the OCD triggers in their home environment. Every effort is made to find an experienced cognitive-behavior therapist at discharge, if the client was not seeing one at admission, in an effort to ensure future success.
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