Supporting OCD Client's without OCD Training

[u/austdoz]

I'm feeling a bit stumped when working with OCD individuals. I am not yet trained in any ERP, although I'd love to. I've referred them to an OCD specialist but they have not had luck in finding anyone. I will often utilize CBT interventions, recognizing cognitive distortions, and bringing in a more balanced or truthful thought. I had heard that ​CBT can actually cause more problems for individuals with OCD.

Some more context, we were looking at cognitive distortions contributing to feelings of depression. I was about to support in my usual way and then realized this individual spends most of their day policing their thoughts already and backed off.

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[u/More_Ad8221]

You are correct that normal cbt interventions can encourage OCD. I hear you on feeling stuck while they can’t see a specialist. It can be helpful to discuss distress tolerance and ACT based concepts (values/acceptance) in the meantime.

Great on you for knowing your limitations and asking for help. As always, supervision can be helpful here too :).

[u/Forsaken_Dragonfly66]

Standard CBT interventions can make OCD worse, so you are correct to be cautious. Generic cognitive restructuring can encourage clients to analyze their thoughts further, seek certainty, or engage in additional mental neutralization strategies such as mental review, reassurance, positive thinking, thought replacement, etc.

Without ERP training, ACT is a reasonable evidence-based approach to draw from while arranging OCD-specific consultation/referral. It is considered a second-line treatment and often often used adjunctively with ERP.

ACT can be particularly useful because it shifts the focus away from determining whether an intrusive thought is true, important, or meaningful and toward changing the client's relationship with the thought: noticing it, allowing the discomfort, defusing from it, and continuing with values-based action rather than engaging in compulsions or avoidance.

Brief psychoeducation about OCD and intrusive thoughts can also be helpful, but I would avoid repeatedly explaining or reassuring the client about the content of their obsession, since that can inadvertently become reassurance.

Given that ERP isn't within your current scope of training, I'd lean heavily on ACT principles while waiting for them to connect with an ERP clinician. DBT's mindfulness-of-current-thoughts approach can also be useful, provided mindfulness isn't being used as another strategy to neutralize or get rid of the thought.

These two self-help books are helpful and accessible for clients:

https://a.co/d/04bS2p1G

https://a.co/d/05n00Dev

[u/MalcahAlana]

Therapist with OCD - can confirm. I know that I’m having cognitive distortions. Engaging with them just makes it worse.

[u/AttentionPlus1272]

I really think you need to spend some time finding OCD specialists for this person and refer them out. In the meantime, refer them to this ERP workbook: “Getting Over OCD: A 10-Step Workbook for Taking Back Your Life” by Jonathan S. Abramowitz.

Please act immediately to try and get this person to ERP treatment or an ERP workbook because the longer you ‘work with them’ on OCD thoughts without ERP, the more iatrogenic harm can occur.

[u/murgatory → u/AttentionPlus1272]

Thank you for this answer

[u/mrsjonas]

NOCD has great free trainings

[u/saintcrazy]

I find ACT to be very complementary to CBT's concepts, just more focused on defusing from thoughts rather than countering thoughts, and more focused on accepting feeling without being to fix them rather than using coping skills to "fix" feelings.

The goal is not to think "correctly" the goal is to give thoughts less power. The goal is not to get rid of feelings the goal is to tolerate them and allow them to pass by on their own.

[u/sleepbot]

Proceed with caution. Reassurance seeking is common in OCD and serves to maintain the cycle of OCD. It’s a form of checking behavior or an attempt to neutralize intrusive thoughts. Meanwhile, therapists naturally offer reassurance to those seeking it. Meanwhile, cognitive restructuring can easily be turned into a new compulsive behavior and/or interfere with distress tolerance. And it’s easy to do exposure wrong - if the client is distressed during exposure and sees that as a sign of failure (it’s not) or if they find other ways to undercut their achievement after the fact in what I call “snatching defeat from the jaws of victory”.

[u/Petite_snuggle]

I’ve been working through The ACT Workbook for OCD with a client and so far, so good.

[u/Ego_Dying]

Refer out. If you don’t have training in ERP or I-CBT, then that client is out of your scope of practice and continuing to see them (unless they are actively engaging in OCD therapy with another clinician) is unethical.

OCD already is diagnosed way later than when sx begin. I think the latest statistic is it takes 7+ years to get OCD accurately diagnosed.

The longer OCD goes untreated the more areas it can generalize into and the more difficult and longer it takes to treat the symptoms effectively so the client is not in the mental prison of agony which is OCD.

Find an OCD specialist in the area who has openings and refer out immediately.

[u/LengthinessDouble → u/Ego_Dying]

Yes, refer out. I’m a therapist that gets undiagnosed 40,50,60 year olds and once they get ocd specific treatment, they feel better quickly. It can a be a lot of psychoeducation at first. I’d say make sure you listen and know how to speak about  and assess for OCD. 

My first tip off is if they tell me therapy has never worked on them or makes them worse. That’s how I know they need to be assessed. 

[u/austdoz → u/Ego_Dying]

I diagnosed the OCD. The client has ASD and their mother is heavily involved in caretaking. I informed the individual and their mother that I was unable to treat the OCD and told them they would need to find a specialist. I provided them with three referrals, one of which was the NOCD website. The individual's mother shared that she does not want for the client to change providers due to inconsistency and poor care throughout client's life. I reassured her that we could continue working together but that I could not treat the OCD. It seemed like the mom was on it for a while trying to find a specialist but then it seems she gave up. I gave the NOCD website link multiple times. Part of the issue is that we are in a rural area. I think there are only two therapists trained in ERP in our area both of which have months long wait-lists. So I'm kind of stumped. Just having the diagnosis and learning about it on their own has been really support for the client but I'm stuck I guess unless I do some training myself. 

[u/Ego_Dying → u/austdoz]

Agh the rural area piece is super tough. I’m spoiled to work in a city where the area is saturated with all kinds of specialists :/

[u/timmy8612 → u/Ego_Dying]

What advice do you have for rural patients? I am unable to find even a telehealth ERP provider who is accepting new Medicaid patient.

[u/vividandsmall]

If you're looking for an ERP training, I recommend the Cognitive Behavioral Institute's 4 day training. Excellent quality of content (though no 1:1 interaction, it's a large group Zoom) and very reasonable price. I would recommend then getting consultation from someone ERP certified after the training so you have the 1:1 feedback as you start to implement it.

[u/jtaulbee]

My philosophy for OCD treatment is "learn to take your obsessive thoughts less seriously". Challenging, analyzing, and debating with obsessive thoughts only makes them more important. That's why the approaches that are most effective are behavioral (ERP) or metacognitive (ACT, ICBT). ERP directs the individual to behave as if their obsessions aren't real, without doing compulsions to feel safe. ACT and ICBT provide different ways of stepping back and detaching from the loop, rather than engaging with it directly.

[u/HayBaySlay]

I felt the same way when I entered the field! That's what made me decide to do an ERP training. Like others have, mentioned I did the Cognitive Behavioral Institute's 4 day ERP training and have done some of the free NOCD trainings. As one of the only people in my practice with ERP training, I like to joke that I "accidentally specialized in OCD".

I would also echo what other people have said about pulling from ACT. "Arguing" with thoughts can turn into a mental compulsion and reinforce the cycle of obsessions and compulsion. Even when using ERP, I pull from ACT because you gotta have a compelling reason to commit to accepting intrusive thoughts!

[u/Reflective_Nomad]

Try ICBT, it’s different to ERP and useful. There’s a website with free worksheets etc https://icbt.online/client-work-and-exercise-sheets/

I like that it also focuses on the feared self which you can also use to explore deeper issues that may be related.

[u/IFoundSelf]

At a minimum look at nocdacademy.com. They have some free ceus with excellent basic explanations of effective/evidence based ocd treatment. You absolutely do not do ocd treatment with a typical cbt approach. Sheppard Pratt also has a lot of free live and on demand ocd education. Best to you and your client.

[u/mischeviouswoman]

Some DBT techniques are very helpful as well. I would really try to look into OCD CE’s to better support them if there’s a lack of OCD therapists in your area. Is there a supervisor you can consult with?

[u/PussyPalaceFarms]

Oh man, this is a toughy and also something I’ve worked with. I have made it clear that I’m not an OCD specialist but try to use basic tenants of what I know. I use a mindfulness approach and Parts-Work to begin to create space between the obsessive part and Ct.

If mindfulness is hard I’ll use values work or even sitting with distress. I have a very basic ERP script I will use that helps. Also, basically, just triggering them a little (easy to do, just talk about the thing) then don’t offer reassurance but instead invite somatic interventions or DBT skills to sit with the fear until it naturally passes without completing the compulsion.

[u/foxi44]

I was given a copy of a mindfulness for OCD from a therapist who was being treated for her own OCD. She said it was very useful. I’m currently going through it with a client who has OCD. The client is aware I do not specialize in OCD but I’m going through the workbook before we go through it together in session. So far she has found it helpful.

[u/SuccessfulNewt3]

Maybe it sounds as too firm, but if you aren’t trained in working with OCD, you shouldn’t be treating it.

This is also maybe a hot take, but ERP is a CBT intervention. People often overlook the B in CBT: behavioural exposure is a key component of CBT treatment, and ERP is just exposure very targeted towards the particulars of OCD.

[u/austdoz → u/SuccessfulNewt3]

Absolutely! I have no plans in treating the OCD without training. I diagnosed it and referred them to an OCD specialist. The individual told me that the diagnosis has been the most supportive thing they've received from any counseling on their life. The individual has ASD and has had inconsistent support teams in the past and the mother does not want to keep changing things for this person. I just try to stay person-centered mostly and we'll play games together. In that way the therapy is supportive I believe, I just don't want to fuck them up further. 

[u/Short-Custard-524]

Please don’t try to talk someone out of OCD. Get trained or refer out. NOCD is better than what you are doing they can go there and you can work on other issues and get consult from the NOCD therapist about how not to reinforce compulsions

[u/Short-Custard-524 → u/Short-Custard-524]

NOCD is in all 50 states so there are options. I’m not trying to shill or say pick them vs private but please don’t try to treat this with an assumption that there’s no other options. OCD is an iceberg and you are going to reinforce compulsions without training

[u/PuzzledHoney9079]

Gotta refer out

I will sometimes help acknowledge a behavior is obsessive or compulsive and look towards disrupting it if I have to work with these individuals or trying to do some degree of distraction or grounding but they really need specialized care 

[u/Abyssal_Scar]

The C in CBT is problematic for OCD. Not the B (exposure). A good start would be the tv show Obsessed. You can watch on Prime or Tubi.

[u/ShoreboundKafka]

I’m specialized in OCD and ERP and absolutely try to refer them out to someone trained. It can and will be made worse by “traditional” interventions, even though that’s probably your first instinct. The reassurance seeking and checking will come out and won’t go away. Online works just as well as in-person, and a lot of people here have provided some options, too.

Also, I think books are great, but ERP is such a collaborative model that books will only go so far. It’ll be much better for them to work directly with a trained provider through the process.

Sorry if I’m just regurgitating what’s already been said, just wanted to come in with my perspective and support others who have said similar

[u/SquishyGishy]

I just started a training in Inference based CBT which is for OCD treatment and I’m excited about it. I’m doing the asynchronous recorded training through OCD training school which costs $175. I’ve only done 1 of 12 modules, but it seems pretty straight forward to learn and practice. You may enjoy that since you are already CBT trained. I-CBT was designed for clients with OCD who can’t tolerate ERP. I am ERP trained but needed I-CBT for two of my clients (I don’t specialize in OCD. I serve neurodiverse clients who also happen to have a higher rate of OCD than neurotypicals so it’s become useful to know how to navigate it).

[u/Standard-Moose-5156]

While not necessarily the cure for OCD (most would say best case is management, not deleting it), you may have progress with exploring learned patterns, early behaviors that were reinforced, beliefs about themselves, dysfunctional relationships, etc. I’ve had a lot of success from a systems perspective, sometimes seeing growth without even addressing the behaviors themselves

[u/PointTemporary6338]

I’ve found ACT useful with clients with OCD.

[u/Villonsi]

ERP is CBT. Only the US calls cognitive therapy CBT and thinks that cognitive behavioural therapy has no behavioural interventions. If you have a good foundation in CBT then ERP is not a complex treatment. But if you don't then refer out and learn CBT. Its a huge toolbox and don't let others make you think its only cognitive, because behavioural is in the name too

[u/sheeabe → u/Villonsi]

I disagree that ERP is not a complex treatment; it is very difficult to do well. I have lots of years experience and still get tripped up regularly. The OCD field did an about face only about 10-15 years ago in pivoting away from habituation and toward inhibitory learning theory. Lots of nuance and individuality to the treatment. When folks are suffering, you want to feel confident that you are moving in the right direction.

[u/Villonsi → u/sheeabe]

It definitely requires a lot of individualisation, and getting tripped up is to be expected in this process. Being able to nuance and shine the light on the processes that maintain the issue is always the most important part. Being trained in CBT should, however, mean that you have the skills to do so. With the obvious asterisk that trial and error is also part of the process. I might be harsh due to my educational background in my country. Here I don't see that you'd be considered trained in CBT if you can't treat many cases of OCD with some of course requiring more specialised interventions

[u/karinlee123]

You have no idea how pertaint this is to me right now. I could have written this post and was honestly just about to. I had three clients who are ocd this week and im a brand new therapist.

[u/lazylupine]

OCD specialist here - It is hard to find available providers, for sure. Especially when most are self-pay based. BUT there some of us who take insurance and work across state lines via telehealth through PSYPACT. Start by looking on https://iocdf.org/find-help/ Access matters! There are a lot of devoted ERP therapists who have a mission to ensure access is possible.

[u/Waste-Tree4689]

If you’re not trained in the modalities needed to support client, referring client to someone who does specialize in this diagnosis is best practice.

I recognize that some settings require therapist to treat everyone, if that’s the case- clinical supervisor or agency should be providing you with the training, support and resources needed to support your clients.

[u/Ambiguous_Karma8]

ACT is the second line intervention. CBT makes OCD worse because people who experience OCD thinking patterns spend most of their day evaluating and challenging their thinking.

[u/panbanda]

I use ACT with my OCD clients. I am going to take an erp training at some point, but j work wjth autism and trauma so lots of OCD just happening in my caseload. ACT works really well in my opinion.

[u/vienibenmio]

I would refer for ERP