"giving in" to OCD

[bigmighty]

I'm confused about/interested in something. I have spoken with two psychiatrist ERP specialists who have pandas patients. Both indicated to me that the worst thing a person with any OCD tendency can do is to "give in" to the desire to perform a ritual or behavior. Apparently, doing a behavior can give an actual serotonin rush that is rather addictive and makes a person want/need to do the behavior the same way repeatedly to get the brain chemical pay-off. The belief is that ERP is something like helping a person to quit smoking. Even if you wear a nicotine patch, you still crave the physical activity of holding the cigarette and inhaling. In addition to having been addicted to the nicotine, you are addicted to the accompanying smoker behavior and get an actual calming rush when you go through the physical motions related to smoking. So it is very hard to stop.

 

I am under the impression that continuing to do any OCD behavior is embedding the behavior and making it much more difficult to stop doing in the future. I have been told that, even if the medical side of treatment is 100% successful for PANDAS patients, they still have an extreme amount of emotional work to do in order to unlearn the rituals they actually chemically crave - even after they are treated and "well."

 

I just listened to an audio clip on Saving Sammy website. Sammy mentions that the most challenging part of recovery was ERP - and stopping himself from doing his compulsions (6 1/2 - 7 minutes?). But he also states that the best help his family was able to give him while going through his illness was that they left him alone and gave him the space and time to perform all of his desired rituals and compulsions (2 minutes). So, the professionals are telling me that we need to nip everything in the bud and not get the rituals embedded in the first place, even if the child is still medically sick. But the recovered child is saying that the only thing that a parent could do that would be helpful to the sick child is basically to do the opposite of that - to let the child have time and space to do the compulsions.

 

How would one know when a child with multiple embedded OCD Pandas-caused behaviors is well enough to make the switch from "parents need to be supportive and let me perform my rituals" to "child is now ready to start attempting to eliminate behaviors?" Since it seems that most children with embedded OCD behaviors would WANT to hang onto them, wouldn't there always be resistance to ERP? As parents, do you just magically know when your child is ready to make this transition?

 

 

audio clip -

 

http://www.savingsammy.net/sg_userfiles/Sammy_QA.mp3

[airial95]

We have had the same discussion with our therapists too. And they also used the drug addict analogy to explain to us how the OCD - once the medical trigger is eliminated - can become ingrained.

 

For us - we use the ERP techniques every day. When he's not fighting an infection or exposure - they're very useful. He doesn't like it - of course he wants to continue his rituals/compulsions. But a heroin addict probably doesn't like rehab either, and would rather keep using than fight to get clean.

 

When he's in a flare, the ERP is completely ineffective. And the level of meltdown/anxiety associated with the effort is multiplied tenfold. But we still give it a try. For us, we look at it as consistency. Whatever we would do when he's "healthy" we will do when he's not. (That goes for dicipline too - he may not sit through a whole time out, but we'll put him back several times before letting it go to make the point - and it's worked.)

 

He still fights us out of an exacerbation - but he does come around. Our biggest issues are around food. He will ALWAYS eat what we give him - even if the quantity is off (our biggest issue) - eventually - when he's out of a flare - and it continually improves until we even have some drama free meals! If he's in a flare, the tantrum won't stop, and he'll skip that meal entirely because it's "wrong". We still won't give him a snack (against our rules - you don't eat the meal, you don't get a snack), but when dinner time comes along, we know to still give the push - no you're not getting just 4 peas, but we will eventually make him a new plate so he eats. When we start to see him slowly responding to the pushes - we know we can push harder.

 

Keeping the consistency with the techniques has been useful to us in other ways. The first sign of the "real" anxiety, we know we might need to get the whole family tested for strep - so it's become a good early indicator for us.

 

I think by showing him that WE aren't going to give in to his OCD and we are going to take control also gives him some encouragement that maybe HE can do it too.

[eljomom]

big question is how do you know it is still from pandas (ongoing) or just an engrained ritual?

[laure]

This discussion really saddens me. For our dd10, we did initially try to get her to fight the OCD, bought all the books, went to a counselor, etc. All that came of it was a lot of anger and tears. She also lost confidence in herself and felt like there was something wrong with her. Fortunately we had some good advice from others who had gone through treatment using abx alone, and decided to back off on the CBT. It was a lot easier just loving her and letting her know it was not her fault, and letting her just get through the day as best as she could. In this way she was able to attend school last year, and continue with sports and music lessons, although we cut back a bit because of the stress of it all, with contamination OCD taking a lot of her time and energy. After the proper abx and treatment, (and diagnosing lyme/bartonella/babesia was huge in adjusting these things), her OCD literally evaporated as fast as it began. Now we talk about it and she says, "I don't know what it was about "x" but it just doesn't bother me anymore." My take on it is, this is an infection, and we need to treat it like one. You wouldn't ask a person with pneumonia to stop coughing.

Sorry if I am sounding too strong, but we barked up the wrong tree for a long time, and it hurt.

[emmalily]

I think this is very important and, as the PANDAS patient, I have a very firm opinion on it. *I do not mean to offend anyone and this is only my opinion and experience*

 

Please, please, please consider not forcing the ERP until you are quite sure you have done everything possible to address the medical side.

 

I agree with Sammy, things improved for my family as a whole when they stopped pushing me to master my OCD while still sick and allowed it to play out. Before that life was h*** for all of us because they kept trying to put me in situations I couldn't handle and got upset when it blew up, and I got upset that I couldn't do it. The damage this did to my self-confidence is truly the hardest thing about all of this and I am still recovering from it, even though we all now know none of it was my fault. I could not even begin to address the OCD until my brain was functioning somewhat normally. Think of it this way: ERP tries to use healthy thoughts to control out of control thoughts. This assumes that the brain is capable of producing healthy, helpful, controlling thoughts. But with PANDAS, the brain literally is not functioning enough to produce healthy, normal thoughts. That's the whole point of it--the basal ganglia is irriated, interrupting the thought processes. So I ask you, where are those healthy thoughts supposed to come from? This could be the mental equivalent of asking your child to heal their broken leg by running on it.

 

Therapy of some type, whether done just within the family or with a psychologist, is very important to healing. ERP and CBT techniques probably will have to be applied at some point if the OCD was serious enough. And using some in the middle of exacerbation is great if you can manage it. But, in my experience, there is definite shift between OCD caused by PANDAS and OCD that is habit. They feel very, very different. I understand many of you have young children and that it may be difficult to get answers from them about if things feel different but I would urge you to try that before going into the ERP too strong while they might still be physically ill.

 

Again, I really, really do not want to offend anyone. I just wanted to give the most honest account of my experience as I could. By all means, trust your gut and the professionals you work with; I hope I've offered some insight to bring to those discussions.

[peglem]

I think this is very important and, as the PANDAS patient, I have a very firm opinion on it. *I do not mean to offend anyone and this is only my opinion and experience*

 

Please, please, please consider not forcing the ERP until you are quite sure you have done everything possible to address the medical side.

 

I agree with Sammy, things improved for my family as a whole when they stopped pushing me to master my OCD while still sick and allowed it to play out. Before that life was h*** for all of us because they kept trying to put me in situations I couldn't handle and got upset when it blew up, and I got upset that I couldn't do it. The damage this did to my self-confidence is truly the hardest thing about all of this and I am still recovering from it, even though we all now know none of it was my fault. I could not even begin to address the OCD until my brain was functioning somewhat normally. Think of it this way: ERP tries to use healthy thoughts to control out of control thoughts. This assumes that the brain is capable of producing healthy, helpful, controlling thoughts. But with PANDAS, the brain literally is not functioning enough to produce healthy, normal thoughts. That's the whole point of it--the basal ganglia is irriated, interrupting the thought processes. So I ask you, where are those healthy thoughts supposed to come from? This could be the mental equivalent of asking your child to heal their broken leg by running on it.

 

Therapy of some type, whether done just within the family or with a psychologist, is very important to healing. ERP and CBT techniques probably will have to be applied at some point if the OCD was serious enough. And using some in the middle of exacerbation is great if you can manage it. But, in my experience, there is definite shift between OCD caused by PANDAS and OCD that is habit. They feel very, very different. I understand many of you have young children and that it may be difficult to get answers from them about if things feel different but I would urge you to try that before going into the ERP too strong while they might still be physically ill.

 

Again, I really, really do not want to offend anyone. I just wanted to give the most honest account of my experience as I could. By all means, trust your gut and the professionals you work with; I hope I've offered some insight to bring to those discussions.

Thank you! This is so helpful! I feel better about the "letting it go" and just letting her get through the day as best she can. We've got unusual circumstances in that my child not only cannot have a conversation with me about what's going on, but she has almost no "normal" to go back to since she's had this since infancy. We do not always know when she's sick-but when she really loses it and CANNOT cooperate or fight the fear, we find out that she IS sick. When she's well (or a bit better, anyway) she can communicate better and interact somewhat, and is willing to fight the OCD, but even then it can get very overwhelming for her to fight it all the time, since its become so endemic in her life. Sometimes she just has to have a chance to relax (us too) and come back to the battle after she's had a break.

[eljomom]

emmalily---thank you for your honest thoughts here. I'm sorry I don't remember, but can you nutshell what your symptoms were, for how long, and what treatment you received. You can PM me if you'd like. Thanks!

 

I think this is very important and, as the PANDAS patient, I have a very firm opinion on it. *I do not mean to offend anyone and this is only my opinion and experience*

 

Please, please, please consider not forcing the ERP until you are quite sure you have done everything possible to address the medical side.

 

I agree with Sammy, things improved for my family as a whole when they stopped pushing me to master my OCD while still sick and allowed it to play out. Before that life was h*** for all of us because they kept trying to put me in situations I couldn't handle and got upset when it blew up, and I got upset that I couldn't do it. The damage this did to my self-confidence is truly the hardest thing about all of this and I am still recovering from it, even though we all now know none of it was my fault. I could not even begin to address the OCD until my brain was functioning somewhat normally. Think of it this way: ERP tries to use healthy thoughts to control out of control thoughts. This assumes that the brain is capable of producing healthy, helpful, controlling thoughts. But with PANDAS, the brain literally is not functioning enough to produce healthy, normal thoughts. That's the whole point of it--the basal ganglia is irriated, interrupting the thought processes. So I ask you, where are those healthy thoughts supposed to come from? This could be the mental equivalent of asking your child to heal their broken leg by running on it.

 

Therapy of some type, whether done just within the family or with a psychologist, is very important to healing. ERP and CBT techniques probably will have to be applied at some point if the OCD was serious enough. And using some in the middle of exacerbation is great if you can manage it. But, in my experience, there is definite shift between OCD caused by PANDAS and OCD that is habit. They feel very, very different. I understand many of you have young children and that it may be difficult to get answers from them about if things feel different but I would urge you to try that before going into the ERP too strong while they might still be physically ill.

 

Again, I really, really do not want to offend anyone. I just wanted to give the most honest account of my experience as I could. By all means, trust your gut and the professionals you work with; I hope I've offered some insight to bring to those discussions.

[emmalily]

emmalily---thank you for your honest thoughts here. I'm sorry I don't remember, but can you nutshell what your symptoms were, for how long, and what treatment you received. You can PM me if you'd like. Thanks!

 

I think this is very important and, as the PANDAS patient, I have a very firm opinion on it. *I do not mean to offend anyone and this is only my opinion and experience*

 

Please, please, please consider not forcing the ERP until you are quite sure you have done everything possible to address the medical side.

 

I agree with Sammy, things improved for my family as a whole when they stopped pushing me to master my OCD while still sick and allowed it to play out. Before that life was h*** for all of us because they kept trying to put me in situations I couldn't handle and got upset when it blew up, and I got upset that I couldn't do it. The damage this did to my self-confidence is truly the hardest thing about all of this and I am still recovering from it, even though we all now know none of it was my fault. I could not even begin to address the OCD until my brain was functioning somewhat normally. Think of it this way: ERP tries to use healthy thoughts to control out of control thoughts. This assumes that the brain is capable of producing healthy, helpful, controlling thoughts. But with PANDAS, the brain literally is not functioning enough to produce healthy, normal thoughts. That's the whole point of it--the basal ganglia is irriated, interrupting the thought processes. So I ask you, where are those healthy thoughts supposed to come from? This could be the mental equivalent of asking your child to heal their broken leg by running on it.

 

Therapy of some type, whether done just within the family or with a psychologist, is very important to healing. ERP and CBT techniques probably will have to be applied at some point if the OCD was serious enough. And using some in the middle of exacerbation is great if you can manage it. But, in my experience, there is definite shift between OCD caused by PANDAS and OCD that is habit. They feel very, very different. I understand many of you have young children and that it may be difficult to get answers from them about if things feel different but I would urge you to try that before going into the ERP too strong while they might still be physically ill.

 

Again, I really, really do not want to offend anyone. I just wanted to give the most honest account of my experience as I could. By all means, trust your gut and the professionals you work with; I hope I've offered some insight to bring to those discussions.

 

Hi, no problem. Most simply explained, PANDAS for me looks like a lot of OCD and some physical symptoms (neurological attacks (as yet not quite understood by doctors), GI problems, some movement issues but not tics). My OCD consists of intrusive, repetitive thoughts. There was some evening up and contamination OCD. Lots of food restriction. Seperation anxiety pertaining to my mother was huge problem in my huge exacerbation (I was 17 at the time, had already gotten my license and been out living my own teenage social life and suddenly wanted my mommy). In hindsight I have had several PANDAS exacerbations in my lifetime, one at 5, one at 11, one 14 that rolled into a huge one at 17. That persisted until diagnosis with PANDAS at 19. I'm 21 now and recently had a small one in the last couple of months after going almost a year clear, but seem to be rebounding fine. I've only used antibiotics to treat active infections, and then remained on certain ones prophylactically. We tried to use homeopathy on the symptoms alone before diagnosis but success was limited. I now use some natural supplements in conjunction with antibiotics (probiotics, of course, curcumin for inflammation, etc). I would certainly use IVIg or PEX if I couldn't get the same results with antibiotics again, and would definitely be willing to try homeopathy again. I had one meeting with a CBT therapist during the beginning of treatment and carried out the ideas from that on my own with help from my family. There certainly were plenty of habits to break. We took it very slow and did not have huge success with it until I had been on antibiotics for almost a year. Hope this is helpful.

[airial95]

I think that the age of the child also has a bearing on how/when to use the ERP/CBT. Our son was less than 2 years old at the time of his sudden onset - 26 months at dx. We started therapy with him just after he turned 3. The therapy in a kid that young is a bit different - in that we weren't really changing his actions or thoughts - but OUR reaction to them. A LOT of his early OCD revolved around things WE had to do either for him, or in a certain way - so it was a bit different for us.

 

I also think that in a younger child, there is more risk of it becoming ingrained than in older kids that can actually remember what it was like "before" - or even communicate better. I think it was someone at the Rothman Center that said the concern with OCD in very young children (and to some extent the tics) is that they are forming so many new neural pathways each day that they can be "written" wrong, and that is one reason why we were still struggling with the residual OCD even when he was "healthy".

 

As to the question "how can you tell when it's PANDAS related vs. residual" - you're probably not going to like my answer - but we just know. The way he cries is different, the words he yells, how he reacts physically - we've gotten to recognize it very clearly. And yes - that does make a difference in how hard we "push" him. We use the techniques in both situations to keep consistency - but we do give in when we see it might be PANDAS related.

 

Another thing our therapist has had us do - which I think is important and haven't mentioned before - is we only work on 1 thing at a time. If we're working through the bedtime ritual - we give in on EVERYTHING else until the bedtime ritual is gone/improves, then we might move on to the teethbrushing issues. We worked in the order of "easiest to hardest". We tackled some of the things that we felt would be easiest for him to succeed with and went from there. So it's not like you're telling him to get over all the OCD at once.

 

I know I've been on the boards almost 2 years now - but my PANDAS son just turned 4 a little over a month ago - I sometimes forget to mention that, and I think it is relevant sometimes in discussions like these.

[MomWithOCDSon]

Many of you know that we've been at this OCD and ERP thing for a long time. Emmalilly, I really appreciate your insightful response; we've heard some of the same things expressed by our DS over the years, though I'd no idea until this topic was posted that Sammy Maloney had been through some of the same stuff.

 

Given our long history with this . . . basically "fighting" OCD for years before we knew we were actually dealing with PANDAS, and then gaining lots of ground with PANDAS treatment but still being encouraged to continue to fight the "residual OCD" via ERP . . . I've sort of come to the following conclusions for our case. Like Emmalilly said, though, these are personal musings and perceptions and not intended to be forced on anyone else. Just our experience(s):

 

1. ERP is wonderful and, in our case, absolutely necessary. That being said, issues of the mind are, I think, entirely in the realm of "You can lead a horse to water, but you can't make him drink." So whether it's the initial, dramatic PANDAS episode or a subsequent exacerbation that brings on the OCD, if your kid is not ready, he's not ready. Forcing the issue . . . i.e., forcing the child to partake in ERP exercises . . . before his brain has settled down sufficiently to make any use of new information and skills . . . is likely a losing proposition.

 

2. BUT . . . the trick is still exposing your child and your family to those ERP "principals" of not allowing the OCD to define who the child is, how the family is to behave, etc., even if those principals can't be put into practice right away or in all situations. The best gifts ERP therapy gave our family were 1) identifying for us definitively that DS wasn't making these poor decisions and choices willingly, but that the OCD was in control in that moment of poor decisions/choices, so blame the OCD, not the kid, and 2) showing us how to not aid and abet the OCD to the extent that it took over more and more of DS's life as we rode out the worst of the PANDAS inflammation/glutamate storm until he could actually make use of some of the ERP skills. I hear what Sammy and Emmalilly are saying, and I know from experience, too, that trying to demand my DS use ERP techniques of his own, rather than going through a ritual or compulsion, is a non-starter. But that's not the same thing as saying that Mom and Dad and Big Brother or Little Sister should join DS, participate in his rituals and permit the OCD to control them too. I've learned to give DS his space, especially when he's ramped up and needs to work out things on his own, but ERP therapy has given me the skills and the strength to say "no" to the OCD when it tries to coerce me into, say, opening the door for DS because DS doesn't want to touch the knob, or adjust the pillows on the couch until they are "just right" according to DS's OCD, or turn the light on and off the correct number of times, etc. I'm sorry, but OCD really is like kudzu, and it will spread where it is watered and given room. So even when the child isn't functioning at a level of health in which he/she can use the ERP skills in every situation, we as their guides, loved ones, etc. can still help draw the line that the OCD cannot cross. Otherwise, you run the risk of giving the message that the OCD thoughts/fears are valid ones that need to be heeded and harbored.

 

3. As DS has gotten older, his ability to intellectualize lingering elements of his OCD has improved, so he can rationalize a lot of behavior that most people would still see as wholly irrational. Mostly, he's now left with some scrupulosity . . . the need to behave -- and sometimes to ensure that others around him behave -- with the highest moral and ethical standards. It can be beyond irritating because I, for one, am far from perfect. Frankly, ERP has done little to nothing to help with this. A good bit of it, I think, is tied up with his very age-appropriate teenage need to cut free the apron strings, be accountable for himself, and make his own choices; it's just that this form of OCD really ups the stakes for him in terms of making those choices, but he doesn't want DH or me too involved because he's almost 15 and he wants to do things and think things through for himself, dagnamit!

 

4. So, while we still adhere to the basic tenants of ERP therapy with DS on these remaining issues, we have more recently moved on to a different therapy, also recognized by the IOCDF, called Acceptance and Commitment Therapy, or ACT. This is a form of CBT that appeals to the intellectual side of our DS and, in short, asks that he Accept thoughts as thoughts and nothing more, including Fearful Thoughts (or Fears), and Commit to the idea that what matters is what you do or don't do with those thoughts/fears. That the thoughts/fears themselves have no industry or power unless you provide them with actions.

 

5. I also think that Sammy and Emmalilly are on to something that we only fairly recently decided was at play in our home, even though they haven't articulated it specifically. There is research that suggests that the blood brain barrier's permeability can be impacted by stress -- basically that stress and anxiety can leave it open, thereby permitting more access to the brain of those very things that are triggering the anxiety and stress to begin with! So, trying to prod, coerce, cajole, bribe, drive or even encourage an already stressed-out kid to comply with ERP techniques that are difficult in and of themselves may only exacerbate the problem, literally and medically. So, now we'll lay out the ERP and/or ACT realities of a given OCD-driven situation, but if DS is worked up and basically already in "fight or flight" mode over it, forget it. No pressure, no insistence on our part. Given the time and space to work it through on his own, he usually does.

 

6. The final thing, though, is that when we talk about our DS or Emmalilly or Sammy, we are talking about older kids; younger ones don't have the same resources or experiences from which to work when the OCD rears its head. And I would hate to think about where we would be today if some of that ERP groundwork had not been laid for us or DS when he was younger. I just think it would've made things much harder.

 

Thanks again for the Sammy and Emmalilly perspectives! Really helpful when facing my DS!

[airial95]

2. BUT . . . the trick is still exposing your child and your family to those ERP "principals" of not allowing the OCD to define who the child is, how the family is to behave, etc., even if those principals can't be put into practice right away or in all situations. The best gifts ERP therapy gave our family were 1) identifying for us definitively that DS wasn't making these poor decisions and choices willingly, but that the OCD was in control in that moment of poor decisions/choices, so blame the OCD, not the kid, and 2) showing us how to not aid and abet the OCD to the extent that it took over more and more of DS's life as we rode out the worst of the PANDAS inflammation/glutamate storm until he could actually make use of some of the ERP skills. I hear what Sammy and Emmalilly are saying, and I know from experience, too, that trying to demand my DS use ERP techniques of his own, rather than going through a ritual or compulsion, is a non-starter. But that's not the same thing as saying that Mom and Dad and Big Brother or Little Sister should join DS, participate in his rituals and permit the OCD to control them too. I've learned to give DS his space, especially when he's ramped up and needs to work out things on his own, but ERP therapy has given me the skills and the strength to say "no" to the OCD when it tries to coerce me into, say, opening the door for DS because DS doesn't want to touch the knob, or adjust the pillows on the couch until they are "just right" according to DS's OCD, or turn the light on and off the correct number of times, etc. I'm sorry, but OCD really is like kudzu, and it will spread where it is watered and given room. So even when the child isn't functioning at a level of health in which he/she can use the ERP skills in every situation, we as their guides, loved ones, etc. can still help draw the line that the OCD cannot cross. Otherwise, you run the risk of giving the message that the OCD thoughts/fears are valid ones that need to be heeded and harbored.

 

 

This is EXACTLY what I was trying to get at!! Thanks!!!

[bulldog24]

My son has PANDAS with a lot of OCD.

I personally have struggled with SEVERE OCD in my life but thankfully its in remission.

I would say from MY personal OCD experience, That constantly forcing someone to not have rituals and compulsions COULD be worse and counterproductive. I think for me it would make my anxiety much worse, making the OCD worse.I have seen this with my son. It could also make your child hide there OCD and do these things in hiding. Thats a very lonely place. For our situation, I let my son do what he does unless he is hurting himself, like obsessive handwashing was making him bleed...

 

but if he wants to count how many steps it takes to go from the living room to the kitchen so be it. I might try a distraction. but I wouldnt let him feel what he was doing was WRONG. adults with OCD know what they are doing makes no sense, so telling them to knock it off just makes them embarrassed and stressed. A child with a brain malfunction prob has no clue why they are counting or sorting etc..

Just my 2 cents. I put my 27 years of SEVERE need to be hospitalized OCD in remission myself when I was ready.

[smartyjones]

Just my 2 cents. I put my 27 years of SEVERE need to be hospitalized OCD in remission myself when I was ready.

 

 

i do not have OCD myself. . . i agree with what you say AND i think it's important for the parent to help set the stage for the child to be ready. my child is young - 7; had pandas onset at 4.5. i believe now his emotional ag/frustration level is somewhere around 4 or 5, so i set my expectations as such when he is having trouble. of course, that's a learned skill and one dh and i struggle with all the time.

 

 

i think it's important but so hard to learn to discern. . . i think it's the parents job to lead the horse to water, but no, you can't make him drink. but i've found it most successful if the leading is appropriate and personalized. but oh so hard to discern -- what's appropriate leading vs. pushing vs. drinking for him vs. leaving him to find the water himself.

[dcmom]

I certainly agree you cannot, and wouldn't want to force a child to abstain from doing their rituals.

 

I have seen how when the ocd hits my kids are in a sheer panic.

 

But- I do feel it is important to continuously work on the ocd with erp. This does not mean not allowing the rituals. What this would mean is, sometimes when ocd is really strong, starting with teeny tiny baby steps, and rewarding them.

 

For example- try delaying the compulsion (even for 5 seconds), try switching up the compulsion, shortening the compulsion, etc. Something even really small, that with a little pushing, they CAN do, and then rewarding them for it.

 

Or doing teeny tiny exposures to the fear (which would be different than eliminating the compulsions). Drawing pictures, writing stories and watching videos on Youtube can be helpful for this.

 

Even starting by working through the workbook what to do when your brain gets stuck is a start.

 

I don't think it helps anyone not to do any therapy. I think even the TEENIEST bit of erp can give the kids a sense of control, and set the expectations for the point that they are able to work on it.

 

It is a balancing act- for sure.