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CBT/ERP


lynn

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DS14 just had his first appointment with a cognitive behavioral therapist. The Dr wants him to make a list of what makes him angry, as well as starting HW with the most difficult subject (chemistry, obviously) first. The problem is that now everything makes him angry with accompanying meltdowns, and starting with his hardest subject just means that at 11pm he is still on chemistry with geometry, global history and english still to go. This, therefore, has been the week from ######. While there is a little flu going around this area and it is cold outside, there really doesn't seem to be any reason for him to be flaring right now. Could the therapy be having a paradoxical effect? Should I ditch the therapy or the therapist? Has anyone else had this problem? Wish all of these problems didn't include getting no sleep--I was just on a conference call and seem to have fallen into slumber, although I was told that no one heard any snoring :o...not a good idea .

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Is your ds in exacerbation at the moment? During exacerbations, CBT/ERP was utterly useless for our ds (also 14 now). It made him more anxious and magnified his OCD. Our therapist finally gave up, saying that it was not possible to make progress in an office setting, and just gave us some guidelines on how to attempt ERP at home. That started to work better once our son's PANDAS symptoms in general began remitting on the "Saving Sammy" dose of augmentin XR.

 

Hope you see progress soon. For us, though, we backed off the CBT/ERP until our ds was capable of coping with it enough to make some progress rather than just becoming more discouraged.

 

Meg's Mom is a CBT/ERP "guru." Maybe she can offer some constructive advice?

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Meg's Mom is a CBT/ERP "guru." Maybe she can offer some constructive advice?

Um I think that would be desperate mom, with no way to function, actually :wacko: , but thanks for the compliment.

 

Lynn, I am a little confused by your post. So yes, ERP can make things a little worse when it starts - a talented therapist can help with this as well - but I am not sure this is an ERP therapist? Maybe just CBT? What is your son's anger caused by primarily - is it a reaction to OCD compulsions? I apologize for not knowing this already. If this is an OCD based issue, then the changes you have made thus far would not seem to be appropriate first steps. If you let me know this, then I can give you a little more advice. There are a LOT of therapist that can do CBT, but do NOT understand OCD, or the ERP therapy that is necessary. We do a small non-profit that helps to train therapists for children on this very topic - because finding a really good therapist can be very challenging! There are more for the teen group, however, than for very young children. I will tell you that we dumped a number of therapists before finding a great one, who was indispensible to us.

 

Also, I second WorriedDad on asking about the phase of the illness you are in? I think some level of ERP can be done at almost anytime, but what that level is will be strongly dependent upon how well the child has been treated medically. And depending on the issues and the severity, having a really talented ERP therapist is key.

 

So does he have OCD? And was he already doing pretty well compared to the peak of the illness (pre-treatment)?

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We are doing ERP/CBT right now with our son. And it does get worse before it gets better. We were told by our therapist to expect that. My understanding is that with ERP the goal is to trigger their OCD anxiety and have them "suffer through it" (for lack of a better way of putting it) until their anxiety levels slowly start to reduce on their own over time. After multiple exposures to the trigger, the amount of time for the axiety to recede should decrease.

 

Our therapist stressed the importance of tackling just one thing at a time. If we're focusing on his obsession with the number 3 - that is ALL we will work on for a few weeks until that is under control better. We "give in" to all of the other compulsions. Then we start working down our list one by one until we have touched on every thing. The fun part is the changing nature of OCD. Just as you get one thing under control - a new one pops up. (Which we were also told was normal.)

 

Our therapist had a different approach than yours however, aside from tackling the most disruptive rituals first (our drop off at school), she had us start with some of the more mild compulsions. The fallout wasn't as severe, and my son when he succeded in working through the anxiety himself was very proud, to the point where he wants to keep trying.

 

We have seen some of the things we've "fixed" flare up again during exacerbation, but knowing that we kicked it once has helped us not lose hope.

 

In my opinion, if you start with the toughest first, you may be setting up for failure and frustration on your son's part.

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Even though it is important to be consistent with sticking with what you are trying to overcome at the time, at some point if the anxiety is too extreme and not calming down at all, one may want to reconsider what tendency they are trying to overcome and choose something else, something that may be a little easier. Or is the therapist making him go "cold turkey" too fast? We pretty much had to wean my son and do baby steps. I agree with the others that if your child is still well into an exacerbation, therapy may not help at this time. Also, your therapist should be open to hearing what you have to say and re-evaluate the game plan if it is not working out for the family. Do you have an email or phone number for the therapist to explain what is going on now that you've tried to implement his plan? Lack of sleep (by child and parent) will not lay a good foundation to attempting to overcome any OCD. I would at least talk to the therpist and see what they have to say once you voice your concerns and tell them what's going on.If they insist on sticking to the plan even though it is obviously causing so many problems, then it's time to find someone else. Nothing's wrong with ditching a therapist if it's not a good match.

Edited by Vickie
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Hi Meg's Mom--

 

 

Lynn, I am a little confused by your post. So yes, ERP can make things a little worse when it starts - a talented therapist can help with this as well - but I am not sure this is an ERP therapist?

 

The term ERP was thrown around during our initial interview. This is a Manhattan office that specializes in OCD (and goes on television!!)so I figured they would be ERP.

 

What is your son's anger caused by primarily - is it a reaction to OCD compulsions? I apologize for not knowing this already. If this is an OCD based issue, then the changes you have made thus far would not seem to be appropriate first steps. If you let me know this, then I can give you a little more advice. There are a LOT of therapist that can do CBT, but do NOT understand OCD, or the ERP therapy that is necessary. We do a small non-profit that helps to train therapists for children on this very topic - because finding a really good therapist can be very challenging! There are more for the teen group, however, than for very young children. I will tell you that we dumped a number of therapists before finding a great one, who was indispensible to us.

 

It appears that the anger is caused by anxiety over OCD compulsions. Mostly anyway.

 

Also, I second WorriedDad on asking about the phase of the illness you are in? I think some level of ERP can be done at almost anytime, but what that level is will be strongly dependent upon how well the child has been treated medically. And depending on the issues and the severity, having a really talented ERP therapist is key.

 

He was about 20% down from his absolute worst point, now he is right back up there at the peak. Although, oddly, the exacerbation he is in now allows him to do much better in schoolwork than the worst he was at, which was at the beginning of the school year. He is getting back a little of his self confidence (arrogance) about being able to ace tests (sadly sometimes inappropriately.) The biggest problems he has right now are inability to start homework because of rituals and fear, and anger at his parents when they try to help him get started.

 

I really appreciate your responses--I was feeling so depressed!

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We are doing ERP/CBT right now with our son. And it does get worse before it gets better. We were told by our therapist to expect that. My understanding is that with ERP the goal is to trigger their OCD anxiety and have them "suffer through it" (for lack of a better way of putting it) until their anxiety levels slowly start to reduce on their own over time. After multiple exposures to the trigger, the amount of time for the axiety to recede should decrease.

 

Our therapist stressed the importance of tackling just one thing at a time. If we're focusing on his obsession with the number 3 - that is ALL we will work on for a few weeks until that is under control better. We "give in" to all of the other compulsions. Then we start working down our list one by one until we have touched on every thing. The fun part is the changing nature of OCD. Just as you get one thing under control - a new one pops up. (Which we were also told was normal.)

 

Hi Airial

 

I agree that he may have bit off too much right at first. Problem is that I don't think the therapist really understood the depth of DS's problem--he can sound so rational and calm with strangers, and he really liked the therapist. In addition, we may not have done the other part--giving in to everything except the one he is working on. In particular, DS has an OCD where he slaps me that I just can't stand. It was gone, now it is back, I've been pushing back, could be a problem...? this is such a horrible disease.

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Also, your therapist should be open to hearing what you have to say and re-evaluate the game plan if it is not working out for the family. Do you have an email or phone number for the therapist to explain what is going on now that you've tried to implement his plan? Lack of sleep (by child and parent) will not lay a good foundation to attempting to overcome any OCD. I would at least talk to the therapist and see what they have to say once you voice your concerns and tell them what's going on.[/quote]

 

I agree I will have to talk to the therapist--in his defense this is less than a week out. I will talk to him after the weekend, during which time I intend to SLEEP IN !!

 

Lynn

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Lynn --

 

Our DS is nearly 14 (next month) and has had significant OCD behaviors. We, too, have him in ERP therapy with a well-known and respected therapy group; this is our second therapist, though, after having discovered (somewhat belatedly) that our first therapist was fairly well versed in CBT, but wasn't really implementing true ERP in a consistent way.

 

Our DS has healed to the extent that he's now doing well in school again and generally handles homework reasonably well, also. However, we initially had a LOT of homework avoidance behavior . . . meltdowns, distractions, breaking pencils, scribbling on the page, unnecessary and repeated erasures, ripping up papers, etc. . . . and he still has a day every now and then in which the homework just seems overwhelming to him and he goes into avoidance mode again, dragging the process out longer and longer until the afternoon and even the evening wither away and he's barely gotten anything done.

 

Like your therapist, ours suggested tackling the subject our DS most dreaded first when it came to homework; interesting enough, this was the subject he is actually BEST at: math. Sometimes it works and, with our coaching, he can muscle through it. Generally, he's intimidated by a perception that the assignment is too lengthy and/or tedious (he'll count the problems and scan them for complexity and get overwhelmed), and that's when the true avoidance kicks in. Other days, it is a losing proposition and it does seem to wear further on his sense of self-worth and capability. So when we see the process devolving, we make an "executive decision." We determine that he will complete SOMETHING on that hardest subject, whether it's the problem he's currently on or, if things are going a little more smoothly, maybe he'll do the five problems on the one page. But then, after that, we're going to move on to another subject. We talk about how this is a good answer because he cannot foresake all his other subjects in favor of this one . . . they deserve some of his time and attention, too . . . and he has been responsible and bossed back the OCD by making some headway on that tough subject before moving on to the others. If he has extra time after having tackled his other homework, we'll circle back around to the math and see if he can knock out another problem or two before we call homework done for the night.

 

For a while, too, the homework was such a trigger for him that it became an actual therapy exercise for him; we'd send him and his homework to the therapy session together so that the therapist could see the true ferocity of our DS's fear and avoidance, and could therefore better design the techniques and responses that would be in keeping with the behavior.

 

I will echo that it was tough going in the beginning. That urge to avoid, to flee, is really, really strong in our kids. And it takes tremendous strength and determination on their part and ours to ride out that wave of desperation and stick with moving forward, even if it's only an inch or only a single problem or a single page, rather than give in to the avoidance and ditch that undertaking for something that's less of a trigger . . . now. But the thing about the insidiousness of OCD is that, if you give it that inch, it will stretch its tendons into a mile, and tomorrow instead of fearing chemistry or math, your child may decide that Spanish is the evil subject, or geography. So making a gain, however small, before moving on to something else or switching gears, can be so important in terms of building their confidence and helping them gain leverage against the fear.

 

In the end, I know exactly where your therapist is going with this; he's trying to have your DS get on top of the avoidance behavior, nip it in the bud, and experience success so that the avoidance won't feed upon itself. But you may need to stage it a bit and build in some smaller steps and some flexibility, rather than making it an all or nothing proposition. Even if this therapist is the cat's meow, you know your son best, and you're the one up to your eyeballs in the heat of the moment, so the three of you have to work together to formulate techniques and responses that actually work in the trenches. But you can do it!

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You guys are just amazing. I told DS14 last night that we are not working on hitting this week so he has a free pass on it right now and it visibly reduced the anxiety level. Since then he has half heartedly started up a few times, but when I said again that hitting was not our point of attack this week, it stopped. Then, this morning I was helping with homework and I told him to do one chemistry problem and then do the rest of his homework because it needed to be addressed also and it was hard for him, but he was able to stop working on chem and do the rest of his subjects. Don't know about the rest of his chem, but at least the rest is done:) Thank you all, you are such a font of knowledge

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Sounds like you did all the right things - and you have gotten all great advice. There are so many parents here that have been successful with ERP. There are times to "go all the way" on things, but they are usually when everyone is in agreement to do so, and after tools are successfully learned. At first, slow and steady is the key - and as you found, letting the child have a lot of say in what will be worked on is so important. They are the ones doing the really hard work, and respecting that lets them have some control in all this. Knowing that they don't have to do it all at once, and that no one is going to be disappointed by some failure - in fact it is expected - really helps them focus and takes some of the pressure off.

 

I would guess that your therapist just doesn't know him well yet - so I'd give him a few more sessions. But I like to write an email before I get there, giving them some background on what worked & what did not work. Then you have more freedom to discuss in front of your child when you get there, but don't have to say it all. For example, you may want to tell him that your son is more debilitated that he may appear or may want to admit at this time.

 

I also think setting up a reward program is important, and setting time limits on how long he will work on things that are specifically related to OCD! And I agree with all the parents here - it is SO important that they get enough sleep during all this.

 

After your next few weeks, if you have specific areas that you want to get suggestions on how to break down a ritual, let us know. Otherwise, you are already doing great, and it will take a while, and it will entail some frustration, but he will emerge stronger & more confident.

 

I expect that the "list the things that makes you angry" may be a first step towards building a heirarchy - especially if most of the things that make him angry are OCD related. So when he gets angry, you may want to try saying something like "I know this is really hard, and I am proud of you for working on this. I guess this will be a good thing to put on your "makes me mad list". I think that is a really good thing for us both to learn". We found that identifying what is OCD, vs what is the child, helps so much for everyone, especially the child. We tried to point this out without being angry or demeaning about it, and making the list for the therapist was very helpful. I was shocked by how very very long the list was, and how much I was missing. I was pretty tuned in to her OCD, and was still missing a ton of subtle rituals that were eating up her day.

 

Good luck with all this - we all feel for you and know where you are. It gets better!

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