Description of Treatment
The program is based on empirically supported research, asserting that intensive specialty treatment, utilizing evidence-based treatment protocols, is effective in treating severe obsessive compulsive disorder, obsessive-compulsive spectrum disorders, anxiety disorders (such as social anxiety, panic disorder, and generalized anxiety disorder), and other coexisting conditions. To achieve maximum benefit for patients, the program adheres to the following assumptions:
1. We use state-of-the-art evidence-based cognitive-behavioral and psychopharmacological treatment modalities.
2. We encourage normalization by patient participation in decision-making about treatment and by providing treatment in a caring environment.
3. We design and provide services in a way that supports, educates, and empowers the patient.
4. We attend to the individual’s physical, emotional, social, and economical problems.
5. Our long-term goal is to establish healthy functioning individuals and families.
A diagnostic assessment is completed within two weeks of admission by the clinical team. The team utilizes observations, specific interventions, patient and family history, parent and patient reports, psychological testing, and past treatment records in formulating the diagnostic assessment. Given the complex presentation of severe OCD and anxiety disorders, 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 treatment and are shared with the patient and, when appropriate, with loved ones involved in the patient’s care.
Core Treatment Program
The Houston OCD Program’s clinical team specializes in OCD and anxiety disorders treatment to target the issues impacting the patient’s life. Treatment planning focuses on symptom reduction and prevention with the patient’s active involvement in the treatment design. Discharge planning begins upon admission to assure community reintegration and tenure, as well as planning for future treatment to address the long-term care needs of the patient.
An extensive battery of measures in the field, with well-documented reliability and validity, is used throughout the course of treatment and to inform decisions about treatment level and discharge. Furthermore, a weekly assessment is administered to assess treatment progress and aid in treatment decisions. Patients are provided with weekly progress monitoring feedback.
The Treatment Team
A treatment team is assembled for each patient, including a cognitive-behavioral therapist, a residential counselor, and a psychiatrist (when needed). Involvement of other specialists (e.g., dieticians, chemical dependency counselors, specialty consultations, etc…) varies in time and intensity based on the patient’s clinical status and intensity of care.
The psychiatrist meets regularly with residents, and with intensive outpatients when indicated. Many patients who seek out this level of treatment have failed multiple medication trials. Hence, previous medication trials are reviewed and assessed for adequacy, and when appropriate, alternative regimens are instituted.
The cognitive-behavioral therapist, who designs the individual treatment plan with the patient, provides initial assessments and evaluations. They will also conduct individual behavior therapy sessions as well as optional family sessions.
The direct delivery of care, 24-hours a day, seven days a week is provided by a team of two to three residential counselors. The staff is trained to help patients to enhance response prevention by blocking their rituals (or pertinent anxiety reducing behaviors) and assisting in “ritual free” activities of daily living, as well as to implement behavior therapy techniques through the provision of support and coaching to utilize effective coping skills, reduce isolation, and encourage normal social interaction.
Behavior Treatment Plans and Treatment Contracts
Individualized treatment plans, or Behavior Treatment Plans, are mutually developed and agreed upon between the patient and their cognitive-behavioral therapist, and re-evaluated on a weekly basis. The foundation of the treatment contract is the Behavior Treatment Plan, which outlines core problems, specific obsessions, compulsions, avoidances, goals and specific interventions. This contract builds upon the patient’s hierarchy that is designed with patients, as well as addressing the unique opportunities derived from the delivery of round the clock care. The Behavior Treatment Plan includes information about how to assist the patient through their daily living activities with minimal rituals and, most importantly, how to implement staff- assisted and self-directed exposure and response preventions sessions. The Behavior Treatment Plan represents a collaborative endeavor, as patients are active in designing and implementing the Plan.
The Behavior Treatment Plan is supplemented by the Treatment Contract. In this contract, the patient has the leading role in designing their objectives for the week and implementing the contract. On the Treatment Contract, patients 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. Each patient sets very specific objectives for the week that aims to help him/her tackle some of the OCD/anxiety triggers and meet the goals set out in the Behavior Treatment Plan. Following each week of treatment, the staff and patients review the Treatment. Patients are encouraged to engage in a self-assessment, as well as receive weekly feedback from fellow patients and from the treatment team about progress toward their goals. Based upon our clinical experiences and supported by preliminary research findings, these group feedback sessions are a powerful therapeutic vehicle in providing motivation for the patient to change and encouraging empowerment over their treatment and recovery. This is especially true for patients with very severe and treatment refractory OCD/anxiety who have previously failed in outpatient treatment. This format also provides opportunities for modeling by “senior” patients, accountability to peers and staff, as well as a very clear format to provide constructive feedback about treatment effort success.
Delivery of CBT, Milieu and Group Therapy
The program’s setting fosters an atmosphere for change, while maintaining the milieu and a safe environment where patients and staff work collaboratively toward treatment goals. The staff is attentive to the unique challenges that OCD and anxiety disorder symptoms put on patients and their families. The cognitive-behavioral therapist conducts individual behavior therapy sessions. Residential Counselors assist the patient in following his or her Behavior Treatment Plan, especially aiding in implementing challenging exposure and response prevention sessions. Daily group therapies utilizing a variety of primary and supplemental treatment approaches are also incorporated into the patient’s treatment. Patients 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 treatment program are the daily exposure and response prevention (E-RP) sessions and daily self-directed E-RP sessions. While patients begin and end each session in a brief group, the patients engage in E-RP individually. In the group, patients report their “Subjective Units of Distress Scores” (SUDS; scores document beginning, peak, and ending distress levels) along with other relevant facts about their E-RP session. E-RP sessions are initially completed with staff assistance, while gradually increasing the patient’s independence on completing the exposures during self-directed E-RP sessions.
All additional therapeutic groups are designed to complement the evidence-based E-RP sessions, to build upon the patient’s skill sets and resilience, as well as to foster support from peers.
Family Education and Support
Throughout treatment, staff members provide psychoeducation about OCD/anxiety and the impact it has on family relationships. They also coach family members on how to work with loved ones, without providing accommodations or minimizing any enabling behaviors, and how to help boost their loved one’s recovery from symptoms. It is especially important, in the work with patients who live at home, to include the family in the treatment. Hence, in addition to the work described above, the cognitive-behavioral therapist typically has at least one meeting of either face-to-face or a phone therapy session with both the family and patient each week.
Discharge and aftercare planning are an ongoing process, which begins at the onset of treatment. This is completed in both group and individual contexts. As patients near completion of treatment, therapeutic passes from the program to the home are scheduled to promote the application of CBT skills, and to facilitate ways to challenge the OCD and anxiety triggers in their home environment. Every effort is made to find an experienced cognitive-behavioral therapist at discharge, if the patient was not seeing one at admission, in an effort to ensure future success.
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Björgvinsson T., Hart, J., & Heffelfinger, S. (2007). Obsessive-Compulsive Disorder: An Update on assessment and Treatment. Journal of Psychiatric Practice, 13, 362-372.
Davidson, J., & Björgvinsson, T. (2003). Current and future treatments of obsessive-compulsive-disorder. Expert Opinion on Investigational Drugs, 12(6), 993-1001.
Osgood-Hynes, D., Riemann, B., & Björgvinsson, T. (2003). Short term residential treatment for obsessive-compulsive disorder. Crisis Intervention and Brief Treatment, 3, 413-435.