For Therapists: Teletherapy & Treating OCD Online

Adapting OCD Treatment to Telehealth

By Ashley Annestedt, LCSW

In the office setting, treatment and specific exposures will be different depending on the patient’s needs. The same is true for telehealth. However, you can adapt your work in order to make telehealth as effective as possible and utilize it as a tool in your traditional office practice as well.

• Have a backup device available: Consider logging in to your chosen platform on a backup device, such as a phone or tablet. At the very least, have the patient’s number pulled up on your cell. A patient can feel quite abandoned if you lose internet connect, the power goes out etc., especially in the midst of a difficult exposure or dialogue.
• Consider telehealth a tool for all practice settings: If, after COVID, you plan to transition back to your regular office setting, consider using telehealth as an addition to a quality treatment plan. Telehealth is a wonderful opportunity to treat OCD where it lives. Perhaps there are various places in the patient’s home where compulsions occur most often and specific triggers than cannot be easily replicated in the office. Use telehealth for those sessions! An occasional telehealth session also gives you amazing insight into the life of the patient and can provide some clinical perspective that might otherwise be lost in the office. I have example after example of the surprising and helpful information I’ve gathered simply from seeing the environment of a patient.
• Is your physical presence a safety signal?: This is a question I find many therapists fail to consider and/or do not broach in therapy. Your physical proximity to your patient can create a safety signal cycle that may not be shared unless asked directly. In office sessions I have had many patients disclose thoughts such as “I know you won’t let me hurt myself” or “If (fill in the blank feared outcome) did happen, I know you would help me.” The distance that telehealth provides allows you to challenge these cognitions and craft more challenging exposures.
  
• Consider a pet policy: Some of your patients will have casual pets or specific emotional support animals. In either case, patients may use pets as a safety behavior or form of avoidance. If the patient insists on having a pet in the room, discuss the rational and define clear rules.
• Increase your organization/planning: Both you and your patient may need more planning with telehealth sessions than office sessions. As an experienced OCD therapist, you probably have everything you need in-office to curate a valuable exposure but, your patient might not. At the end of each session, inform your patient as to what they may need physical access to for your next session.
• Record the session: Most telehealth platforms have the option to record. If the patient is completing an exposure and you have their consent, record it! Repeatedly watching themselves engage in an exposure task is an exposure in itself. You can also watch it together as a tool for exploring expectancy violation. You can bring awareness to indications of acceptance through their body language on the recording and explore feared outcomes that didn’t manifest, among other ideas.
• Model your own expectations: It’s important to model that telehealth sessions are equally as valuable and important as the office sessions the patient is accustomed to. Hopefully it goes without saying but, the usual standards you hold yourself and your patients to should be happening. Be on time, look professional, provide the patient a quiet and private space. Be flexible with things on the patient end but not overly accommodating.

This section was written by Ashley Annestedt, LCSW, and published with permission. Ashley is a Clinical Social Worker licensed in Alabama, Alaska, Arkansas, Colorado, Idaho, & Tennessee. Her practice is dedicated to the evidence based treatment of OCD, Tourette & related disorders.

Public Health Recommendations & Exposures

In response to the COVID-19 pandemic, public health officials are recommending a range of strategies to help limit and prevent the spread of disease. These include:

• Washing hands regularly with soap and water after being in a public place, touching commonly-used surfaces like doors and handrails, and especially before eating.
• Using hand sanitizer if washing hands is not an option.
• Staying home when you’re sick.
• Heeding the advice of public health workers to “self-quarantine” if you’ve been exposed to someone who has COVID-19.
• Limiting travel and working from home if possible.

Treating OCD with exposure and response prevention requires clinicians to encourage their clients to expose themselves to triggers and resist the urge to engage in compulsive rituals. But what should we do when public health recommendations are in conflict with the exposures clients need in order to make progress in their OCD treatment?

Adjusting the baseline

In more normal times, asking a client to completely cease washing their hands may be an important step in treating contamination-related obsessions. Forgoing a typical and healthy level of handwashing can ratchet up an exposure in a way that has long-term, lasting treatment benefits. Usually the risk from this type of exposure is low, but the presence of a pandemic forces us to think differently about what is an acceptable risk. To keep clinicians, clients, and the broader community safe and healthy, it’s important to adjust the baseline and consider both public health guidance and the individual context for each person. Setting clear limits around that baseline will make exposures possible.

Setting clear limits

The widely repeated recommendation to “wash hands frequently” may be ambiguous and triggering for someone with contamination obsessions. Consider the context for each individual patient: do they live alone or with other people? Does their job require them to work with the public? Do they have regular contact with vulnerable people or other patients in a residential setting? Break it down and set limits that can be used as the basis for exposure:

• Washing hands with soap and water for 20 seconds only — no longer
• Only washing hands once and when the situation truly calls for it: after being in public spaces, before eating, after using the bathroom, or after coughing or sneezing.
• Using hand sanitizer only when soap and water are unavailable, and only when the situation truly calls for it (see above).
• Tailor these limits to the circumstances of each client, and avoid making hard and fast rules for your caseload. For example, for someone who takes the subway to work, agree to limit hand hygiene to sanitizing their hands once when they get off the subway, and washing their hands once with soap and water for 20 seconds before they use the office’s communal coffee pot.
• Consider the context of your clients’ living situations. Those who live alone, for example, naturally have a much different context than those who live in groups, with family, etc.

While following these recommendations may make contamination exposures less anxiety-provoking than they would be with no hand washing at all, remember that these guidelines are likely to represent a significant limitation on compulsions and are time limited in nature, as this crisis situation will pass.

Your clients with other types of obsessions, such as obsessions related to moral scrupulosity, might also be struggling. Travel restrictions, social distancing, and other containment measures are a minefield filled with lots of room for individual judgement and choice. “How do I know my travel is truly necessary?” “I think it’s essential for me to commute to the office today, but how can I really be sure?” “How do I know that I’m not unnecessarily putting others at risk?” Right now, these are all legitimate questions that everyone must consider briefly, and then act upon — your clients included.

• Like with hand hygiene and contamination, the challenge will be setting limits.
• In this case, limits might focus on how much time clients spend considering choices before they act, how much information gathering they perform (e.g., reading an employer’s email or a travel advisory one time only), and preventing rumination and reassurance seeking after they’ve acted.
• Like with hand washing, following public health guidelines in a reasonable manner may still be anxiety provoking enough to allow for you to structure effective exposures to moral scrupulosity triggers related to COVID-19.