Tell me about ERP therapy

[Phasmid]

I have reached the point where I need to stop kidding myself thinking that my son does not need therapy after all the PANDAS crap has done to him. His self esteem is in the toilet and I see very bad things coming with this. Plus, he has resumed pulling brows. New neuro. classifies trichotillomania as an anxiety-type OCD. I can't imagine I will make it through the IVIG appeal process so I am going to get him started in therapy. I have read a few postings about ERP but don't know anyone's experience with it.

 

Would you mind please sharing about what the therapist does, how long it takes to work, does it work, how does your child take having to go (my son is going to blow a gasket when he finds out)....

 

thank you

[MomWithOCDSon]

Hi Phasmid --

 

Our DS (now 14) started CBT/ERP for OCD when he was just 6. I think the most critical thing is that you find a good therapist who both 1) knows what they're doing, and 2) has a good rapport with your son.

 

Exposure Response Prevention (ERP) is, in its simplest terms, about facing a fear (exposure) and not engaging in the typical/standard coping behavior (response) -- in your son's case, hair pulling -- in order to manage the anxiety that fear causes. So, for example, for my DS, he went through a phase of his OCD that was all about contamination. It wasn't germaphobia in terms of being afraid he'd catch something or get sick; he just thought that touching certain things . . . like a toilet seat, a sink faucet or tap . . . was "icky."

 

In therapy, the therapist would make a "hierarchy" list of things that my DS thought were contaminated, ranging from #1 = lowest concern to #10 = highest concern. Then he (and we at home) started working with him to knock off that hierarchy. So, in a session, for instance, DS didn't like touching the door that led into/out of the common area mens washroom because other people touched it and what if they didn't wash their hands properly or long enough or whatever after using the washroom. So the therapist would walk him down the hall to the offending door and ask him, initially, to just touch it. Then he would be asked to "feel" his fear/anxiety for the moments after that. They would then take it a step further, and they would walk down the hall and instead of just touching the door, the therapist would ask DS to actually open the door, using a flat palm, in full contact with the door. And they'd do the exercise over and over again until DS was opening the door from both the outside and the inside without using a paper towel or a sleeve, or running off to rewash his hands immediately thereafter. Once #1 was "conquered," then we moved on to #2 on the hierarchy list and so on.

 

Does it work? Yes. Is it easy? No. That's one reason the rapport with the therapist is so important because your kid needs to trust that person, you know? Plus, in my experience, some compulsions are harder to "get to," much less eradicate, than others. As an older kid now, his OCD has nestled into some "obsessive thinking" which even our experienced therapist is finding challenging. But we do gain little pieces of territory nonetheless, as we work the exercises.

 

Generally, our sessions are 45 minutes long. Sometimes we go over or actually mutually agree to work in a dual-session block occasionally, but I would think that with a younger kid, 45 minutes is about all they could handle without tuning out or getting overloaded. Depending on what's being tackled and how the kids responds, you might be in the room for part of the session too, or for all of it. Once the therapist and your DS know one another a little better, though, I would expect that they would spend some sessions almost entirely alone, only calling you in to sum up their explorations and goal-setting, etc.

 

In the depths of exacerbation, we've taken our DS to therapy as frequently as 3 times each week, but those were atypical circumstances. When he's really dealing with some OCD behaviors both at home and at school, he goes once each week or once every two weeks, with us "working the program at home" in between. When he's been well and subclinical in terms of his OCD, we've gone as long as 3 or 4 months between sessions, scheduling one just to "brush up" on OCD management skills before embarking on a new school year or DS undertaking some new, potentially anxiety-producing situation.

 

Depending upon the depths of the fears/anxiety that are driving your little DS to pull his eyebrows, I would expect, probably, once weekly sessions for maybe 6 to 8 weeks initially. Then, depending upon how well he's doing and how successful you are at getting him to follow through with the therapy techniques at home, you could potentially agree to start cutting back a little and come in less regularly.

 

I would really suggest that you check out some of Aureen Wagner's books regarding pediatric OCD. She has books for parents and for kids ("Up and Down the Worry Hill") that explain things pretty well, in terms that are very accessible.

 

Good luck to you!

[dcmom]

Phasmida-

 

I agree the tools of ERP are invaluable. My daughters have been pretty open to it.

 

We lucked out with our therapist in Dc, fist one we tried was great, really cool, laid back personality, really worked hard to establish trust with the kids. Now have moved to NJ, and having a rough time finding someone we like- have been to two. Both rushed right in with an almost confrontational style. Not all therapists do ERP, not all therapists will fit your style, and not all are created equal- so be picky, it's a lot of $$.

 

The last thing, I think I have seen some articles that discuss the most effective form of therapy for trich is called habit reversal training. (a good friend's daughter started pulling last tear). I am sure you have seen, but there are a couple of informative websites on trich, as well.

 

Good luck- I understand your heartache.

[airial95]

We're doing it with our 3 yr old. For us, it's been great, but as Nancy said, it's not easy. Since our guy is so young, the therapist works withnus as well as him, helping us change how we respond ton the OCD. In the beginning there were unimaginable meltdowns, but we all had to suffer through them. And it's has been working. Our therapist also made a priority list, but we approached it a bit differently -we first tackled the things that were most disruptive (in our case his need to take the dogs to the bathroom and clean up all the dog poop), once we got that, we started to the small stuff and are working our way up. With each consecutive tantrum he had because of the exposures, they did get shorter and shorter.

 

We like it because it gave us as parents a clear, unified direction of how we can help him, and he does get so proud when he succeeds.

 

As far as how he takes to going, he loves it!!! We see a therapist in the behavior group in Murphy's office, so she's also well versed in PANDAS as well. He loves his "miss Jessie" and when things get rough, he often channels strength by wanting to "make miss Jessie proud".

[Phasmid]

Thanks for your reply! I will read it over again tonight. The whole idea of going through this is exhausting to think about. Worth it if it works.

 

 

[lynn]

We have tried both weekly therapy and the one week intensive. Of the two, the one week intensive was most helpful because it really jump started the ERP stuff and was very on track and helpful. The once a week therapy was not as helpful and we think that what happened is that 1) the therapy degenerated into a once a week gripe session for DS and was prevented by him from addressing the issues and 2) the therapy actually made him more activated because it confirmed his belief that there was a problem without addressing it and getting to a solution. However, the problem could be that there was just a bad DS/therapist match there. For us, the main symptom is inability to do any homework due to anxiety and fear of failure and furious, acted out anger at anyone who tries to encourage homework completion.

 

In the intensive, the therapist set up two rules: 1) If hitting or even "poking" is directed at either parent, we must immediately leave, and if DS tries to stop us from leaving the room, we must leave the house (practically speaking, we must go to the downstairs apartment and visit grandmother.) This has worked very well (in the 3 days since we finished.)

2) Every day when DS comes home he has to make a schedule--30 minutes for English, followed by 5 minute break, 45 minutes for geometry, 5 minute break, etc. The schedule is supposed to be his bulwark from anxiety, since all he has to do is move through the schedule and we don't have to intervene. This has not worked as well and we are tinkering with it (e.g., DS didn't understand that he was supposed to finish each subject in the time he allotted himself; DS, as always, is pushing the envelope as far as how long breaks will be; DS does not want to actually start his schedule until 9 pm, which results in inconvenient 2 am bedtime.) Hopefully we can get this one on track since when we practiced it in therapy it seemed to really take care of the anxiety.

 

If this doesn't get back on track, we will resume weekly therapy with a new therapist--but long story short, this is a great treatment and gives really good insight into not only OCD behavior but also dynamics in which the parents may be adding to the problem--quite embarassing, but at least now we know!

[kferricks]

I have seen ERP work on so many kids & teens. My DD went to a specialized clinic 4 days a week for 2 1/2 hrs. It did not help her because she was in a major exaboration for months. Before I knew she had P.A.N.D.A.S. She was just too sick. But, it really helped me and DH. We learned how NOT to get sucked into her new OCD. We were already involved in so many rituals that I just could'nt do 1 more..I was done, but her OCD just kept mutating into another form.

The ERP helps the kids become numb to the bad feelings associated with whatever there OCD is. They made a separate page for each TYPE of ocd. bad thoughts, just right, contamination, anorexia etc. On each page numbers 1 - 10. Put on as many as they can think of for each number with 10 being the scariest for them. You start off with the easiest, so that they can easily see that they can succeed and build confidence. You give each item a fear # from 1 - 10 with 1 being just a little scarey or annoying.

 

The kid takes a piece of paper and writes what the exposure will be, and what they feel the (#) level of fear will be. The exposure starts as soon as the kid takes the paper and beings to write and should be done at approx the same time every day. The only talking or interference should be you asking what is your fear # now? So say the fear is writing with a pen. You would put the pen infront of him and just let him look at it and sit with those feelings until they come down at least two #. Then it is over till the next day, same time. When the beinging # is at least 2 lower than the previous day, move on to touching it, repeat, then move on to holding, then drawing a line etc. It does take a long time but with each thing mastered no matter how minor, it builds thier confidence. Just don't let him go up the later too fast or they may take on too much and end up at the begining.

Also, make sure you have the time before starting an exposure. Most of them often last around 45min....

 

Hope this helps,