Exposure & Response Prevention (ERP) Group Treatment

This treatment will work most effectively and gains will be optimized if the principles, skills, and exercise it teaches are universally understood and applied.

To foster good communication with our community partners (e.g. residence workers, school staff, community agency personnel, family members), the following information is provided to support the treatment we are providing at this time.

We hope it is of benefit; our clinic is also always receptive to feedback. Community partners requiring a programming consultation from our team may feel free to contact our clinic secretary for this purpose at 519-858-2774 ext. 2025. These consults are typically conducted in teleconferencing format and are booked most Tuesdays at 2:30 p.m.

With guardian consent and patient agreement, any involved community partners as listed above are encouraged to attend at least some treatment sessions.

Medications should remain stable (i.e. no changes) for the duration of treatment;

If this creates a problem, please notify our clinic to discuss.

Following Session One:

  • At this early stage, don’t make sudden changes in your management of the youth’s behaviour. As a first step, try to pinpoint interactional patterns that foster and promote anxiety in the youth. Group participants themselves will also be encouraged to do this. Just note these patterns as a starting point, with a view to changing them in later weeks. Try to avoid giving advice or prematurely fighting OCD. And don’t blame yourself for previous misplaced criticism or for inadvertently enabling the child’s OCD in the past. This is a new beginning!
  • In Session One group participants and their parents will have learned about our future strategy for “bossing back” OCD and about mapping, the use of special cognitive/behavioural “tools” and exposure exercises. Encourage the youth to talk about what he/she has learned and be a positive cheerleader in promoting optimism about the possibility of future success.
  • Introductory handout sheets (e.g. “Tips For Parents”) and an OCD bibliography were given to group participants in Session One. Read these to orient yours
  • elf to our treatment perspective. In general, throughout the group, try to actively learn about OCD through books, articles, videos and online websites.
  • In order to help group participants “externalize” OCD, they were encouraged to choose a funny nickname for their OCD in Session One and during the week following. Support them in being creative, but avoid being critical if they simply choose to stick with the name “OCD”. The main thing is to make OCD the problem, not the child, by regularly externalizing OCD when you talk about compulsive behaviour. To facilitate this shift in perspective, we liken OCD in group to a “brain hiccup” or a “leaky brake”.

Following Session Two:

  • Participants were taught to map their OCD by sorting their obsessions- compulsions into different regions: “OCD’s Terrain” (where OCD always wins); the “Youth’s Terrain” (where he/she always wins); and, finally, the “Work Zone” (where there’s a tug-of-war between OCD and the youth). The work zone is where treatment will focus.
  • The “Fear Thermometer” was also introduced in Session Two as a way of measuring the intensity of anxiety generated by obsessions. From now on, when the youth is anxious, try to be consistent in asking about his/her intensity level on the fear thermometer (1-10). This allows both of you to gauge the current strength of obsessive anxiety and facilitates adult-youth communication as well as problem-solving.
  • In Session Two group participants began completing a symptom hierarchy list of their various obsessions & compulsions.  In the coming week(s), feel free to help them identify symptoms that they may have missed or taken for granted, but always do this in a supportive and non-critical manner, and only if the youth is open to your assistance.

Following Session Three:

  • Group participants finished mapping their OCD in Session Three. Any initial successes in bossing back OCD were discussed in session, reinforced and rewarded.  Praising and rewarding positive steps, particularly the “effort”  made by the youth to counter OCD, no matter how small, should be continued between sessions by parents, teachers and significant others.
  • Continue to make a habit of externalizing OCD in your discussions with the youth. Use his/her nickname for OCD whenever possible. This turns you into the youth’s ally and makes OCD the “enemy” to be challenged through treatment. For example, avoid saying “There you go again: you’re compulsively arranging your food on your plate”; rather, try to say something like “Boy, OCD is sure giving you a hard time today, ordering you to arrange your food like that.”
  • Our “Tool Kit” was presented in the third session. Three specific “tools” were learned by group participants for coping with the anxiety generated by OCD (and for helping to successfully complete exposure/response-prevention assignments): “Constructive Self-Talk”(think positive!), “Realistic Appraisal” (show me the proof OCD!)  and “Cultivating Detachment” (that’s my OCD, not me!). It is recommended that significant others, involved in the youth’s life, find out about these concepts, learn how they are utilized, and incorporate them in future discussions with the youth.
  • A first trial exposure task was assigned in Session Three. This task involves the youth tolerating the anxiety generated by his/her particular obsessions until it gradually reduces, but without engaging in the usual compulsions. This is to be done each day and must be one that the youth can successfully navigate to ensure success. Group participants were helped to understand that they must repeatedly face and encounter their fear in order to habituate to it (like getting used to a cold swimming pool or a scary rollercoaster). It means doing the opposite of what seems intuitive, so the youth will need lots of support. As well, because exposure assignments are hard work like any other chore, rewards from parents, teachers and significant others are crucial in helping to maintain motivation.

Following Session Four:

  • Group participants were helped to start thinking about specific ways in which OCD bosses their family around. This was in preparation for our bigger “family discussion” in Session 6.
  • Although treatment is now underway, don’t hurry, direct or badger the youth in order to help them make faster progress.. Every child advances at their own pace. Learning to effectively manage OCD is like learning to drive a car, play baseball or swim: no one can do it “for” you! Certainly feel free to supportively encourage the youth to take risks, but don’t push them beyond their capacity to cope.
  • Three more “tools” were learned in Session Four: “Breaking OCD’s Rules” (do it later, less, slower, or different!), “Repetition” (what OCD is saying starts to sound silly!), and “Contrived Exposure” (boss back when you’re strong!). Incorporate these in discussions with the youth, like you did with the first three, to enrich your discussions and to ensure that he/she feels you are “onside” and understand their situation.

Following Session Five:

  • A final “tool” was learned by group participants in Session Five: “humour” (laughing at OCD makes it weak!). This tool, in actuality, was used informally throughout the initial ERP sessions because joking about OCD is such an effective way of neutralizing its power and achieving distance from it. So, as group therapists, we use it frequently and encourage participants to use it regularly to deflate the “empty threats” of OCD. It’s a handy tool to employ at home, at school and in the community (as long as humour is always directed toward OCD and not the youth!).
  • ERP exposure tasks may be tried out “in person” (or “in vivo”) in this session so that immediate support and feedback can be provided to the youth. These may be assignments that are proving to be too difficult to do alone at home. Follow-up encouragement after the session, emphasizing newly learned strategies, will facilitate progress. A new exposure assignment, somewhat harder than the initial one, will have been chosen by the youth from his/her hierarchy list by the end of Session Five. Practice will need to continue to occur daily for success to be achieved.

Following Session Six:

  • Our Family Session gave group participants and their family members strategies for bossing back OCD at home. Parents, siblings and significant others were encouraged to avoid the extremes of Indulgence (“assisting” with rituals or offering misplaced “reassurance”), on the one hand, and Disapproval (becoming angered/frustrated), on the other, when interacting with the youth.
  • Things that are helpful include: maintaining a sympathetic attitude; demonstrating by example that anxiety is “no big deal” and that “facing your fears” makes sense; encouraging the youth to break OCD’s rules (without, however, being pushy); promoting open discussions about feelings/worries; encouraging the youth to take reasonable risks (and modelling this yourself); and giving rewards for any effort made in countering OCD (no matter how small).
  • As a support person to the youth, it helps to discourage avoidance, escape, flight and denial – but always in a kind and empathic manner. Try to communicate the importance of “Exposure” (fighting fears) as opposed to Avoidance (fearing to fight).
  • As a support person to the youth, if you have OCD or any other anxiety- related problem, get help for yourself by accessing appropriate treatment.

Following Sessions Seven To Eleven:

  • This phase of group therapy involves consolidating gains, fully utilizing the Tool Box, and fine-tuning exposure/response-prevention skills. Family members and significant others can help by taking on a more active “coaching” (teach/lead) role at this time if the youth is amenable. Otherwise, just keep doing as much cheerleading (supporting) as possible.
  • The youth will be completing ever more difficult exposure exercises during this phase of treatment. As a result, the Youth’s Zone (or Terrain) should be getting bigger, as he/she conquers previous anxieties and desists from engaging in ritualistic behaviour. At the same time, OCD’s Zone (or Terrain) is getting smaller and is being transferred to the Work Zone (or Transition Zone) where it can now become a focus of treatment.
  • Family members and significant others should continue to reinforce both effort and success by providing Rewards, celebratory Ceremonies, and positive Notifications (i.e. advertising various triumphs).

Following Session Twelve:

  • This is Celebration Time! The ERP Group has finished. The youth is now skilled at using the tools involved in exposure/response-prevention and has experienced some significant successes. Provide as much support and positive reinforcement as possible at this point because he/she is going out into the world to continue the battle on their own and therefore needs all the assistance they can get.
  • Tool card laminates have been distributed to the youth in Session Twelve as well as a special certificate marking the completion of treatment. Acknowledge the enormous amount of work that went into this accomplishment.
  • In Session Twelve the therapists talked about the possibility of Relapses (a substantial and persistent return of symptoms) and the unlikelihood of their occurring because of the skills and tools the youth has learned to use in group. Nipping symptoms in the bud is emphasized as part of relapse- prevention. In contrast to genuine Relapses, it is much more common, particularly in times of stress, for Slips to occur (these are brief and temporary symptom flare-ups). As a support person, you can be helpful in a given situation by pointing out to the youth the difference between a Slip and a Relapse. This will assist him/her to avoid making a mountain out of a molehill by anxiously over-reacting to a small setback. It is also beneficial to regularly problem-solve with the youth in a proactive way regarding how OCD might try in the future to trick them and cause them to backslide.
  • Keep reading and learning about OCD and encourage the youth to do the same.