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451 What Successful OCD Treatment Looks Like for Children (with Dr. Aureen Wagner)
00:47:26
This episode breaks down what effective, child-friendly OCD treatment looks like—showing parents and clinicians how to build bravery, reduce accommodation, and tailor ERP to a child’s developmental stage.
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- [00:02]
A
Welcome back. Today we are covering what successful OCD treatment looks like for children here at your anxiety toolkit. In my private practice, we specialize in OCD treatment, but we make very specific modifications when we are treating kids with OCD. And today I have Orine Pinto Wagner, PhD, a clinical child psychologist and expert in cognitive behavioral therapy, who is who developed the child friendly worry hill CBT approach. I am so excited. This is going to be a masterclass for folks who have children and wanting to really create beautiful, effective treatment for kids with OCD. So thank you so much for being here, Dr. Oren Wagner.
- [00:51]
B
Thank you, Kimberly. It's my pleasure to be here. This is one of my favorite things to do because I'm very passionate about treating kids and teens with ocd. And so I'm happy to talk about it and happy to share that hope and optimism that comes with this world of treatment of ocd.
- [01:10]
A
You are the one to do this. Every time I am doing an episode where I feel like I could find someone so much better than me, I want them on and you are that person. So let's get straight to it. When we are treating kids, I'm going to make the assumption and I know already we've actually note for the listeners, we've actually recorded this already once before and we had massive audio issues. So I'm so grateful for you, Dr. Wagner, for being here two times to give me your amazing wisdom. Thank you for that.
- [01:49]
B
I'm sure it's going to be better this time around. And it's like I was saying to you earlier, it's exposure therapy for both of us.
- [01:56]
A
It is. It truly, truly is. And a massive practice of radical acceptance on my end.
- [02:02]
B
Yes. Okay.
- [02:03]
A
We have kids who are struggling. How might we modify treatment for children? First, maybe can we talk about does it look different for kids and adults when they're having OCD symptoms?
- [02:20]
B
Do the symptoms look different, do they look similar?
- [02:23]
A
Or what are the similarities and differences for children compared to adults?
- [02:28]
B
Sure. It might surprise a lot of people to know that actually the core fears and themes of OCD are universal across age groups and cross cultural that in those terms, children and teens fear the same things as adults, which broadly fall into few categories such as a fear of harm, illness, death, contamination, feelings that things have to be just right or, you know, feel symmetrical or equal fears of having done something wrong, you know, committed sins or, you know, done wrong by somebody and then having unwanted, violent, sexual or aggressive thoughts. Those themes are actually common across the lifespan, but how they manifest really depends on A child's age and developmental capacity. So for instance, whereas a teenager or an adult with intrusive sexual thoughts might be more specific and descriptive about them, a child might just convey something broad and vague because they often cannot explain or cannot articulate their fears. So for instance, an eight year old might just say, oh, I have bad thoughts, I have love thoughts, or I think I did something bad, but they aren't able to be specific. But beyond that, again, surprisingly, those themes are across the lifespan.
- [03:57]
A
So from start to finish, and you can break it down, or we can go like, what are the steps we take with children when we are using exposure and response prevention, cognitive behavioral therapy? What are the first stages of treatment that we would take a child through to help them understand what's going, going on for them in their brain?
- [04:18]
B
So just like symptoms are similar across the lifespan, the core techniques of treatment are also the same. We treat children and teens with the same techniques as we treat adults, but we have to adapt them developmentally. And as you know, Kimberly, we both practice cognitive behavioral therapy with exposure and response prevention as the core key technique that helps people with ocd. And exposure means facing your fears. This, by the way, is the gold standard of treatment for ocd, the most effective treatment. But as you might imagine, if a child has fears, it's counterintuitive to them to want to face their fears. It's the last thing they want to do. The intuitive thing is to want to run away from the fears or to ask a parent for help to escape. So in terms of adapting, so it's this delicate balance between trying to get a child to trust that you're helping them overcome fears, but also making them do something very difficult and counterintuitive. So I spent a lot of time cultivating treatment readiness in a very systematic way. And just a few core ideas here. The first thing is for kids to understand that their fears are not true. They are false alarms in the brain. And, you know, kids from middle school and upwards really relate well to that, as do adults. That your brain is telling you there's danger when there really isn't. It's like a fire alarm that goes off, but maybe somebody just blew off the birthday candles for littler kids. I work with the preschoolers and the elementary schoolers and I call them worry tricks. Your mind is playing tricks on you. Like if I said, look, there's a spider on your head and they get that, they brush it off, they laugh, they know anyway. So once they have that conceptualization that this is not real danger, it's just a trick or a false alarm. Then you see it's 180 degree paradigm shift in how they react to it. Because the treatment is really not about changing the worries or changing the fears. It's about changing how you react to the fears. Once you know they're not real, you react completely differently. When you know there's a real fire, you run out of the building. But when you know there's no fire, you don't have to run out of the building. So once they get that, it's like an aha experience. It's an eye opener. And then I help them understand that if they do the rituals, then it's kind of like running out of the building when there's no fire. And it's actually just going to keep making their OCD worse. They have to understand that cycle of escape that perpetuates ocd. And then once they get that, they know that then to face their fears, they have to be brave and they have to catch those worry tricks, catch those false alarms. And to do that, they'll take on brave challenges. And I really emphasize bravery and self efficacy because people with OCD generally feel helpless about their thoughts. They feel like they're just passive victims to their thoughts and children don't know what to do about it. So emphasizing bravery, you're going to be really brave. And facing your fears is like riding a bicycle up and down a worry hill. It's tough at first. You're huffing, you're puffing to get to the top of that hill. But it's only when you stick it out, you get to the top and then you get to come down the other side of the hill. And that's when you can say, I was brave and I did it. And guess what? There's two very important things you're gonna learn when you get down to the other side of the hill. One, that your fears did not come true because, see, they were false alarms to begin with. And second, that you are way braver than you thought you were. Okay? And you can handle riding up and down that worry hill.
- [08:08]
A
This is so beautiful, isn't it? When you can teach somebody that empowerment that they don't have to run away. Let's talk about the parents and how they have to navigate this, because the parents on their end probably can see the irrational thoughts and see it from their perspective, but they get bought into the panic of those moments and they too want to, you know, remove their child from the discomfort that they feel. So when you're Treating children. What role do the parents play? How much do you engage in the parents, Train the parents, coach the parents.
- [08:50]
B
Parents are actively and integrally involved in the treatment from start to finish. Children live with their parents. So parents have to, you know, they're the ones who kind of bring the child to treatment. They're the ones who care for the child. So it's very important to have parents very actively involved. And so I involve them in the education, in cultivating treatment readiness. So I want the parents to hear what I'm saying to their child when I'm teaching their child about how to conceptualize the false alarms and the worry tricks and the cycle of escape. Parents are very much there as well. And I'm modeling for the parents the language that I use, the way I put it to the kids. And I encourage them to then go home and talk to their child in the same ways to reinforce those ideas and those messages. But it's very important to also define boundaries in the treatment. I talk about collaboration, not coercion. CBT is a voluntary treatment, so we don't force anyone to do it. But we each have different roles. I say I'm the coach, I'm the guide, I'm the teacher. I'll be the best coach I know how. But in the end, I can't ride that bicycle for you. Only you can ride that bicycle. And I say your parents can't ride that bicycle for you either. Their role is to support you, to rally for you, to cheer for you on the sidelines. But they're not riding the bicycle either. And in doing so, I'm defining the parents role as well. I'm sort of saying to them, you have done a wonderful job supporting your child, but you cannot force your child to do this because they will get scared and dig their heels in. But we will go about this in a systematic manner. And I'll tell you how you can support and rally for your child. But you have to give your child some autonomy and some space to be able to do these things. Because that's where the self efficacy comes from, from doing difficult things for oneself.
- [10:51]
A
What would you do in the case where, let's say the child needs to attend a doctor's appointment or something that, you know, we usually wouldn't co. Like you said, we wouldn't coerce them, we wouldn't force them or even torment them with their exposures. But what do we do in the instances, let's say if a child has a fear of needles or. But they really need to get their Vaccinations for school, let's say, or they need to get a blood test because they haven't been feeling well. How might you structure or modify the treatment for something that does have. Or maybe it's like an amp. They have to fly to see their grandparents and they're very afraid to fly. How might you manage a deadline for exposure?
- [11:37]
B
Yes, of course, that becomes trickier. But I tell parents we have to prioritize things. So I encourage them to sort of sort out the priorities into three buckets. A, B and C. What are those top priorities that are non negotiable? That's A, and then B is. It's important. But you know what, we're not on a deadline. We have some time. We can work on negotiating, compromising, working out a plan. And then priority C is the small stuff. Don't sweat the small stuff. So priority A would be things like going to school, you have to go to school, or you do have to get to the doctor's office because there's an important medical need, or you have to go to the hospital, or you have to eat a meal you haven't eaten in a day and a half. So as parents, we encounter these kinds of priorities all the time. And so we do our best to kind of support and encourage. But at some point when something needs to be done, we just kind of have to, you know, take them along and make it happen in the, in the gentlest, most supportive way possible. So. But there are ways to, you know, make that easy. And I ask kids, what would make it easier for you to go to the doctor's office? I ask them. They will often come up with great ideas, you know, and sometimes it'll be like, well, if I could have ice cream afterwards, then that'll be a motivator, right? Or if I could close my eyes, or if my mom would hold me, or if such and such. They'll come up with ideas, you know, what would make it easier to go to school? You know, you have to go to school, but what would make it easier for you? Correct. And if there's worries and fears, then let's work on them, let's talk about them. But you know, you kind of have to go to school, so we have to figure out how to make that happen.
- [13:24]
A
Right. And so you would allow the child, I'm just clarifying, just for the parents and the therapists listening, you would allow the child to maybe even engage in some compulsive safety behavior to get them to do the thing they have to do. And then once that's happening, how might you negotiate or prioritize the reduction of the quote unquote compulsion or safety behavior that they're needing to be able to go to school? Does that make sense?
- [13:58]
B
Yes. We call that gradual exposure. Basically what it means is we are taking steps towards the desired final goal. Let's say a child has to go to school or the doctor's office and it's too scary for them to do it all at once. But in the meanwhile, if we can offer them little safety behaviors like you said. Oh, as a matter of fact, I just have a client right now I'm working with who was terrified to be at school and wanted his mother to sit in the parking lot where he could watch her car from the window. And she said before she came to see me, I did it because that's the only way he would go to school. And I said that was fine. Because your goal was to get him to school. And that was the stepping stone that allowed him to get to school. So that's a temporary accommodation or a support. Now, you don't want to be doing that all year. Yeah, but it did get him to school. And now what are we going to do? We're going to step it back. Correct. So you're going to stay for five hours or, you know, he can text you once or twice, and then we're going to peel back that support or wean him off that support. So think of it as a weaning process. You might want to give a child a good amount of support to get them to do something initially, and then gradually as they do it, they feel braver, they see nothing bad happened, those two things happen again, their fears don't come true, and then they are more willing and calmer and ready to let go of some of that support.
- [15:28]
A
Right. So in those moments, what role and how much do you use rewards as a way to help negotiate out those harder exposures? Is that something that you, you know, we know about intrinsic and extrinsic motivation. How much of the work that you do, how much do you incorporate those rewards as a way to get them to be brave?
- [15:56]
B
Every child is different, so I base it on each individual child and family. Ideally, we would want a child to just have the intrinsic motivation, the internal sense of reward, and not need the external. So I gauge that at the outset, there are some kids who are so tired of having ocd, very motivated, just want to feel better and they're willing to do it. And so then I don't even Bring up the external rewards, but the internal rewards are feeling good about it, feeling successful, feeling like you've conquered something difficult. Again, that sense of self efficacy is extremely internally rewarding to anyone. However, some kids, just the much younger ones who don't, they're not old enough to grasp or really understand the intrinsic reward or they aren't able to delay gratification. Young kids are much more present oriented. They may need a little bit of something to make it easier for them. Right. So generally the way I go about that is to use a currency system such as bravery tickets or bravery points. And again, it's all conceptualized as bravery. And each time you catch a worry trick or a false alarm or you do your brave challenge, you get to put a bravery ticket in the jar or a bravery point and then at the end of each day you can redeem those for everyday privileges. You don't have to like. And I tell parents, don't go buying things, don't have to break the bank, but it's a sense of like having done something. And maybe you get 15 extra minutes of bedtime, stay up late or read an extra book or play a board game. Family and activity rewards are better than just buying things. So those are the ways, you know, the things that kids like to do anyway. Now sometimes at the end of the week they can get a bigger treat or the end of a month when they get X number of points, when you get 25 bravery tickets, then you can get a bigger reward. And it's amazing that if you ask kids what they want, some of the things they'll pick would never occur to you. I've had kids, a little five year old who said I want to get blueberries in my cereal. That was a top reward. It would have never crossed my mind. So again, asking kids, they know themselves to some extent, right? So we get their input.
- [18:18]
A
There are some parents and I wonder if a lot of people have this question. I know my staff who are interns have asked this question is how would you, you prioritize or what are your thoughts around giving bravery points versus them losing a privilege? Some parents will come to us and say if you've, you know, they didn't do their bravery points so we took away their tech time or we took away their TV time. What do you exhale told parents in that situation?
- [18:49]
B
You know, that is such a common scenario. Parents, I'm not sure why, seem to be much more oriented towards taking things away. When a child's misbehaving or not doing their expectations versus Rewarding them. And perhaps it's something to do with us as a society just being laden with so many rewards. We live in a very stimulating environment with lots of daily rewards. But I tell parents to actually come at it from the opposite direction. Instead of letting your child freely have lots of things accessible and then when they don't meet the expectations, you say, I'm taking this away. I'm not giving you that. That leaves you all with a bad taste in your mouth that's unpleasant. You don't want to be punishing, they get upset. Why do that? Instead, flip it around, come from the opposite direction. You have to earn your day to day privileges. There's no screen time until you finish your homework. There's no dessert until you eat dinner. That's grandma's rule. That's like how we used to do things. So I tell parents and then guess what? Everyone feels much more good, much more successful, right? Oh, I got this done. So now I get to have my TV show. Whereas otherwise a parent is saying no TV show for you. And then that creates more conflict and negativity, right?
- [20:11]
A
Absolutely. How much time do you spend at the beginning of treatment doing psychoeducation, coaching the parents before starting exposures? I know in your amazing book and I'd love for you to share people, you know, you've got a big release of your book coming out, which I'm so excited about. Can you share with us what the psychoeducation or that coaching education component of treatment, what it looks like for you when you're doing this with families?
- [20:40]
B
Sure. It doesn't actually take that long. I usually do it within a session or two. And that first session I'm even doing an assessment or an evaluation. But in that process too, I can incorporate some ideas for families to take away even after the first visit. Because I found that people really need to have something to take away even after the first visit. So I start with the basic idea of we know that the fears of OCD are not true. That's a known thing, known fact. But our mind sometimes gives us false alarms or plays worry tricks. And so if you can even start to think about it that way, that will really help you be able to let go sometimes. And even that basic idea in the first session really makes a difference for people. But then in my second session, I have a structured program that I call cultivating treatment readiness. And I actually have a flip chart that, you know, there's a physical spiral bound chart that has all these messages that I'm trying to Teach them. But I can also do it on the screen digitally. And basically I'm walking them through an overview of what OCD is, what makes OCD worse and what makes it better. So I'm like walking them through all the steps of the treatment. I use analogies, I use child friendly language. So for instance, when I talk about when we have danger thoughts, we're going to be scared. I have the analogy of the noise at the window and I show them that picture. If you're lying in your bed at night, you hear a noise at the window. If you think it's a burglar, how are you going to feel? Scared. Me too. But what if you thought it was the wind or the trees? No big deal. So the point being it's not the noise that gives you your feelings, but it's what you think about the noise. And when you think danger, you feel scared. So I use a lot of analogies and examples to walk them through. And this is very much of a Socratic dialogue. And it's a dynamic process where I'm continuously engaging the child and the parents who by the way, are in this session completely. The parents sit in on all of this. So they're learning as much as their child. And I'm engaging them continuously in questions and, you know, relating it to their actual life experiences. So it's not an abstract, general thing, a generic thing, but it's really how it applies in their life.
- [23:08]
A
Right. And the, the flip chat that you have, am I true you can access that in your book?
- [23:16]
B
In my treatment manual, yes. The treatment of OCD in children and teens. It's called a professional's kit because it involves a manual that's about 300 pages long that goes into depth about treating OCD of different types of. But then the flip chart is called Teaching tools and there's about 34 of them that you know, you can go through for also different kinds of OCD like intrusive thoughts and just write ocd. And then there are also other tools like feeling thermometers and worry hill ride cards that, you know, again, are tangible things that kids, you know, touch and feel and use all their senses to engage with the treatment.
- [23:55]
A
Yeah, I love that as a clinician and that you have those flip charts and other clinicians can access it because I find kids really do like those visuals and parents tend to feel more confident when they can see it and see that you're explaining it too. So I love them so much. How might you get buy in from a child who really can't see that their OCD is just an error of their thinking and that they're not willing to even challenge that. Is there any tips that you have for us clinicians or parents when your child heels are dug in?
- [24:36]
B
Yes, and that's a fairly common situation because again, kids are afraid. They don't understand ocd. So they may truly believe it sometimes that if they don't do, if they don't wash their hands, they're gonna get sick and end up in the hospital. Or if they don't confess their bad thoughts to their parent, they then they might be smitten at night and die or something bad will happen. They truly believe that. So I think what's very important is to really, you know, when a child is reluctant, it is intuitive for parents to want to add more pressure, to coax more, to get, want them to do it even more. And we as therapists can do the same thing. We might actually get more forceful or insistent when a child is reluctant. But I actually have found that you actually have to step back and do what's counterintuitive. Instead of pushing harder, you want to step back a little bit. I call it going through the paces. Plan an approach, determine, ascertain the reasons, address the reasons for reluctance, correct those, remedy those reasons, empower the child. And if none of that works, then stop enabling or accommodating. And so I walk parents through all those steps. And so I really want to give a child a little bit of time to be able to think about why they're reluctant. And often it really comes from fear and misconceptions about the treatment about ocd. Older children are embarrassed and ashamed and secretive and they don't really want to talk about all this. They want to feel normal. So once you can uncover those things, then you can kind of address them and work with the child. I normalize fears. I say lots of people have these things. Nothing to be ashamed of. It's not your fault, it's not your parents fault. Everyone has something to deal with, right? And this is your thing. Some kids truly believe their fears. So like, I'll really get sick and die. So I come up again with these little clues or, you know, tips for kids. And I say, when you think about that, I want you to look around you. I call it the look around you clue. When you look around you, does anyone else in your family seem to be worried about that same thing? Are they washing their hands about as much? And if they're not, do they seem really terrified? Or if you're in your classroom and you're afraid, you look around you. Do the other kids look scared? What does that tell you? That's the clue. If no one else around you is scared about that thing, then that tells you that it's a false alarm. And if you know it's a false alarm, then if you keep doing what it tells you, it's going to get worse. But instead, that's your opportunity to catch that false alarm and be brave and face your fear.
- [27:25]
A
Yeah. Amazing. That's really, really helpful. And do you encourage them to give it a name, draw it out? Like, I know a lot of clinicians do a lot of work around giving it a name and drawing pictures of it and how having a narrative with it. How much of the work do you include in that way?
- [27:43]
B
Not a lot, actually. I think it's fine to do that if a therapist would like to do that. And that's actually how, when OCD treatment really sort of came out for children, the notion of externalizing and naming the OCD became a little bit of a distancing tool, that it's not me, it's my ocd, and it's doing these things to me. But I find that a lot of kids don't actually need that, and you can do just fine without it. But to me, the analogy of the false alarm and the worry trick is that externalizing step. It's sort of saying, I have this little, you know, my mind is playing tricks on me, but it's not necessary to give it a separate name. Right. I have actually had a handful of younger kids who actually got scared by the idea that maybe there was a worry monster in their brain. Because, you know, when therapists help children identify the worry monster, the worry boogeyman or whatever, a couple kids will get freaked out. Like, you know, they don't like this entity, a third party living in their brain. So that's something to keep in mind with younger kids as well.
- [28:50]
A
Yeah, that's a good point.
- [28:52]
B
Yes. It's okay to do it if that's what works. But be aware that if a child seems uncomfortable, you don't need to do that.
- [28:59]
A
Right. How can we help children face exposures without completely overwhelming them? I know you talked about gradual exposure. How might you determine the pace and the speed?
- [29:14]
B
Very much by engaging the child. So this becomes a collaborative process. I very much ask the child, what do you think? What do you think you'd like to do? So now that you understand this is a false alarm, what do you think you could do to Be brave and again, let them come up with steps. And if they're giving you a step, chances are they're more likely to be able to do it because it was their idea and they're invested in it. Correct. Now, sometimes they may not want to come up with a step. Then I guide them or help with that. Sometimes they might overestimate what they can do. No big deal. We just backtrack a little bit. Not a big deal. So there's a lot of clinical flexibility with the treatment. You don't want to be rigid and hard and fast about, oh, you have to do this step today and that step tomorrow. That generally doesn't work as well. So you have to be able to pace it with the child's readiness. And if they have success, then you definitely want to build on the success. And again, by reinforcing. What are the two main things you learned about this? It didn't come true, it's a false alarm, and you are braver than you think you are. And then gradual steps.
- [30:24]
A
It's amazing. I actually have a bit of a clinical question for you that just came up in one of our supervision sessions since we recorded the first time. And I'm wondering what your thoughts are. So what do you do? And I'm curious more about the setup of treatment is, let's say you're meeting with the child and the parents and then the parent is sort of back channeling you, maybe via email, to say, like, there is so many more things that they're doing. The child will not disclose them. Or maybe they're even lying to the clinician about, you know, no, I'm actually doing really well, but the parents are saying like, no, there's like, do you meet with the parents separately to have those conversations? Do you prefer the parents to do that in person? I know some parents are afraid of, like, ratting their child out and a child gets very upset. So how might you deal with a circumstance where the parents are reporting a difference in symptoms that the child is.
- [31:22]
B
So what I do for that. That's why I think it's very important to define the roles upfront. And I'm very straightforward and open from the beginning about how we're going to proceed with treatment. So I encourage parents to tell me in session rather than send me back channel notes like you said, and I'll give them an opportunity to come speak with me privately for the first 10 or 15 minutes of the session before I meet with the child or the teen so that they can share those things with me. Then I might meet with the child or teen either privately, if they're old enough, but if they're younger, the parent's there the whole time. And then I make sure I let the child or the teen know that I am talking to their parents. So the child should know up front. And I say, look, I'll always be meeting with your parents also for a little bit of time to ask them how they think things are going from their point of view, from their perspective, and they may see things differently from you. But I wanted to be open about that. But I need to hear from both sides. And then once you know, the youth already knows, there's no secret that I'm not hearing from the parents, then let's say a parent were to tell me the child is not being honest or doing more than they're telling me, then I would gently broach it with the child. And I would say, so you tell me, how are things going? What seems to be going better for you? What's easier, what's been harder? What seems to be hard to do? And I've also already set up this idea that there's no blame and no shame involved in this treatment, but that we do need to be straightforward in order for it to work well. So if things are not going well, it would be better if you just told me, I'm not going to shame you or blame you. And then when they have that sense of trust about it, they're more willing to be open. But I'll say, you know, as I mentioned to you, I check in with your parents and your parents said you actually are spending a lot longer in the bathroom than you said you were. What do you think of that? Do you agree with them? And a child might say, no, I don't. That's they're lying. And I'd say, why would they do that? Why would they say that? You know, what do you think they're seeing that you don't agree with? So I'll give them an opportunity to kind of close that gap in the difference in the perceptions.
- [33:38]
A
Thank you. What about, I mean, one of the biggest questions I have seen from other clinicians is more related to teens in that they come and they sort of grunt their way through the session. Do you proceed as you would and just do the exposures and say, it's okay, we don't need to chit chat, we're just here to get the job done? Or what is your approach to an older teen who doesn't want to talk and sort of is grunting their way through sessions or not speaking at all.
- [34:11]
B
Yes, and that's again, common enough. But I don't really force a teen to do the work because I think they're just going to go home and dig their heels in or they will not be honest about it. So what's the point? Instead, I would rather spend time trying to gain rapport, to understand where their reluctance is coming from and to again, align with them, you know, be on their side and try to remedy whatever the issues are. But all said and done, if none of that works, then I work directly with the parents and I say, okay, your child, you know, and a child might. A teen might flat out say, I'm not doing this right. So then I say, okay, then I can work with the parents and I'll work directly with the parents on reducing their accommodation and, you know, how much they're supporting the child's ocd. So the parents start to peel back their accommodations, and then the teen begins to feel the brunt of the OCD a little bit more and maybe then more willing. And if that also doesn't work, then I just work directly with the parents to take back their own lives and not let OCD control the whole family. Because, you know, families often change a lot of things to accommodate ocd. We don't go out anymore. We don't eat this kind of food. We all have to wash our hands, you know, for 10 minutes to accommodate our child because they'll have a meltdown. So those are the things that parents are going to stop doing in a very systematic way, but always with the teen's knowledge. So I say no surprises. Don't surprise your child or teen. But when we make a plan, we'll always communicate it to them. We'll give them a choice, you know, to participate or not participate. If they choose not to participate, then you go ahead with the plan anyway. That's how we go about it.
- [35:59]
A
Great. Okay, I have just a couple more questions. How much homework do you usually give to families and children throughout the week outside of therapy? With exposures.
- [36:13]
B
Homework is less about the amount of time than the frequency of the practice. And I call it practice. By the way, kids have a visceral negative reaction to homework, so this is just another task with homework. They've had enough homework at school. But practice, Kids don't seem to have a negative sense of practice because they're usually engaged in some kind of extracurricular skill development, a sport or music. And they all know. They all know right away, what does it take to get better at soccer practice. What does it take to get better at dance practice or, you know, piano practice? They get that. So I call it practice. And in, in that context, they also then understand what makes you better or practice once a week, once a month, or every day. Every day. Right. Twice a day versus once a day. So helping them understand that the regularity, the frequency of doing something is what's going to just make it easier and easier over time. And all said and done, the practice will really come down to sometimes it's 10 or 15 minutes a day, sometimes it may be a half an hour. There's variability in that depending on the type of practice that's being done. So again, a lot of clinical flexibility where it's not the exact number of minutes, but the frequency and the regularity to keep the skill going or alive.
- [37:37]
A
Amazing. Last question. Is there anything that I haven't asked that you feel that parents, families, clinicians really need to leave this episode with to really like, round it out? Is there a question I didn't ask, a topic I didn't cover, or something that you just want to repeat for us so that we are all moving in the right direction?
- [38:03]
B
I think you asked wonderful questions, Kimberly. So it's not whether you didn't ask a question, but I do have a message that I want listeners to have, and that is that there is a lot of hope and optimism to be had about the recovery or treatment of ocd. OCD is a legitimate illness. It's not anyone's fault, it's not a defect. There's no blame and shame in it. And cognitive behavioral therapy with exposure and response prevention has a lot of scientific backing as the most effective treatment. It's been around for 25 or more years. And, you know, if you find the right therapist who does cbt, do your homework to make sure you find someone who really knows what they're doing. There is a lot to be gained from it. And, you know, kids can go back to the normal trajectory of their lives because OCD often derails children and teens from, you know, academic, social and peer related tasks. And they can recover all of that and live a relatively normal life. So that would be my message of hope and optimism.
- [39:08]
A
Amazing. Thank you so much. I told you it was the last question, but I lied. Do you, as you're finishing treatment and the client is coming back to their daily living, do you do booster sessions? Do you encourage family booster sessions? Is treatment something you taper down from? Just kind of give us an idea of what you would practice on the back end of treatment, all of the above.
- [39:35]
B
So when treatment starts, we want to do it at least once a week, sometimes twice a week on an outpatient basis. Now some people need more intensive treatment and that's a different idea that you would go see somebody every day or live in a residential treatment facility. But as an outpatient therapist, I see someone once a week or maybe twice a week as the need might arise. And that might go on for six to eight to 10 weeks. And then once a child is experiencing a good amount of success and knows the process, it's really more about do they know how to go through this process of identifying the fear, recognizing the false alarm or the worry trick, saying, oops, wait, I don't need to listen to that, I don't need to do that ritual. And I'm going to face my fear and be brave and ride that worry hill. And I learned I could do it, no big deal. Once they've had that sequence happen enough times, then they begin to internalize that process. And we want to cultivate self reliance. Ultimately that's the goal of cbt, is to teach people to do it for themselves. We don't want them to be dependent on us as therapists. We want people to be able to have that self efficacy in doing it for themselves. So once we reach that point again, no fixed number of sessions, then we start tapering. I might meet once in two weeks, once in three weeks, a month, keep phasing it out and then booster sessions once in three months or six months or as the need should arise. I do prepare children and families very actively for the idea that OCD can come and go over time. It's not something that's cured in 100% gone way. You'll always have a propensity of vulnerability, a tendency towards ocd.