By Patrick McGrath, PhD, & Charles Brady, PhD, ABPP
This article was initially published in the Spring 2015 edition of the OCD Newsletter.
Dr. McGrath is President of OCD Midwest and is the Director of the Center for Anxiety and Obsessive Compulsive Disorders Alexian Brothers Behavioral Health Hospital in Hoffman Estates, Illinois. He is a member of the Scientific and Clinical Advisory Board and the Conference Planning Committee of IOCDF, as well as the President of OCD Midwest. He is the author of a stress management workbook called “Don’t Try Harder, Try Different,” as well as “The OCD Answer Book”.
Dr. Brady is the vice president of OCD Midwest, and directs the Lindner Center of HOPE’s OCD and Anxiety treatment program. He is Board Certified in Clinical Psychology by the American Board of Professional Psychology. He has made numerous presentations at national conferences and has published scholarly articles about the diagnosis and treatment of OCD. He is also vice president of OCD Midwest, a regional affiliate of the IOCDF.
“What is the part of your job that you like the least?” Eager students love to throw this question out during job shadowing or training experiences. We often respond by saying that turning down individuals with OCD and related disorders who have been unable to find a trained OCD therapist is one of the most painful parts of our job. For many experienced OCD therapists, a practice filled beyond capacity is an all-too common situation. We regularly hear gut wrenching stories of lives that are commandeered by OCD and of sufferers unable to find OCD-trained therapists who can provide treatment that can help them reclaim their lives. This is one of the reasons we helped to set up OCD Midwest (an IOCDF Affiliate serving Illinois, Indiana, and Ohio), to help increase access to effective care by those who desperately need it. This is also a core mission of the International OCD Foundation, and why they began their Behavior Therapy and Training Institute (BTTI) that has helped train over 1,000 therapists to date about how to accurately diagnose and effectively treat OCD.
To help address this ongoing need for training and support in the local area, OCD Midwest decided a few years ago to develop a program for clinicians with an interest in treating clients with OCD and related disorders to improve their skills and boost their confidence in providing successful evidence based treatments. Our strategy was to pull together a group of OCD experts to provide accessible training opportunities and small group consultations, in the hope that we could build a network of competent and enthusiastic OCD clinicians, consequently increasing access to quality care in the Midwest.
Currently, our training team consists of five therapists. Patrick McGrath has been leading anxiety disorder trainings for professionals for the last 5 years through Alexian Brothers Behavioral Health Hospital in Northern Illinois. Charles Brady and Jennifer Wells, from the Lindner Center of Hope, run a monthly, small group case consultation series in Southwest Ohio (now in its third year!). And Rodney Benson and Robin Ross have been running a small group consultation group in the Chicago area for the past few years.
In this article, we outline the basic strategies we employ when training therapists and, in particular, how to run an effective case consultation group. To begin, we have a few initial suggestions we share with all of the therapists we work with right off the bat:
- Accurate Assessment. People with OCD will tell you things that they may have had hidden for years due to their beliefs that their thoughts, images, and impulses are so awful or vile that anyone hearing them will be disgusted by them or think that they are very strange. Therefore, we often share with our new trainees many of the presentations of OCD that we have heard in our careers to help them become familiar with the themes of OCD. This will also help them with more accurate diagnosis as the content of obsessions can sometime sound like symptoms of other disorders.
- Use key phrases. We often have key phrases that we use with our clients to reinforce the idea that OCD is a problem of anxiety and cognition — not of reality. For example, the thought: “I have life threatening disease” is not the same as having a life threatening disease. So, we want therapists to remind their clients that, “a thought is just a thought,” or, “just because you think it does not mean it is true.”
- Learn to tolerate uncomfortable feelings and uncertainity just as you ask your clients to do. Therapists who are comfortable with traditional supportive therapy may struggle with the idea that kind reassurances they may be offering can actually hinder their clients’ recovery. These therapists benefit in our consultation group and trainings from the support and encouragement we offer them in making this vital shift in therapy style.
- Read some, train some, and read and train some more. There are great books about OCD out there, and attendance at a BTTI or at the IOCDF’s Annual OCD Conference are a must if you are going to work with individuals with OCD. And, as Drs. Ross and Benson have underscored, attendance at a few consultation groups or trainings does not make you an OCD expert — it is simply a way to open the door to further training.
How a Therapist Consultation Group Works
When we first started the consultation group, we found that it was helpful for us (the group leaders) to first present a few cases that we have worked on to lay a foundation for how we were going to be talking about OCD and OCD treatment. In this way, we are giving them a comprehensive treatment model to consider and replicate in their own work. We then ask for a volunteer in the group to present a case (client privacy is always protected by using fake names and changing any identifying information about the client), and the whole group works together on creating a diagnostic picture. In fact, we go through all of the OCD diagnostic criteria to be sure that it is truly OCD.
We then all work together on developing ideas for the initial treatment sessions. In other words, once the assessment is done, where do you start and how do you go about doing the treatment. One place to start is to help the therapist put together an inventory of all of the symptoms the client is reporting. We coach the therapists about how to explain Exposure and Response Prevention (ERP) therapy to their clients. We then talk about how to work collaboratively with their clients to design ERP exercises, as well as where to start. Sometimes you begin with the least threatening situations and sometimes you start on the aspects of the client’s OCD they are most willing or motivated to work on.
We do a lot of “role playing” with the therapists in the group. For example, we discuss and role plays scenarios about how you conduct an exposure, and how you negotiate with the client about not engaging in compulsive behavior. During these role played sessions we are also looking for whether the therapist is not pushing the client hard enough or maybe too hard (we follow the rule that we would NEVER have a client do an exposure that we would not be willing to do right alongside of them). During the role plays, sometimes the exposures go well and sometimes they don’t. We want therapists to be prepared for all possible outcomes. If an ERP backfires, we want to coach the therapists about how to keep a client motivated to continue. We teach flexible problem solving strategies to our therapists by talking about how to modify their approach or how to target a symptom from a different perspective so that another chance might allow for a successful experience.
From our experiences we can offer a few additional tips for those who may be thinking of starting a consultation series:
- Client privacy is paramount. Be sure to hold the group in a private location where you can talk freely about clients. While therapists are used to following rules around confidentiality it is important to remind them to not discuss outside of the group what is discussed in the group. Additionally, all therapists are asked to change identifying information about their clients when presenting cases.
- We remind the therapists attending the group that if they have talked about a client in the past, it is important to for them to provide updates about that client in future groups, so that the group is able to talk about successes and challenges with implementing what they’ve learned.
- DO NOT let just one person take up the whole group or else you will start to lose your other participants. If people need more time than what the group can offer, you may want to consider working out a private consultation schedule with them.
- Keep the group manageable — if it is larger than 5 people per group leader, not everyone will be able to present a case. Structure your time in order to review past presented cases as well as allowing for several new ones. Do not try to cram in too much or the discussion will not go into enough detail to prove productive to people who want to really learn the nuts and bolts of ERP for OCD.
- Don’t just rely on word of mouth to spread the word about your group. For the Cincinnati series, the most successful publicizing tool was the Listserv provided by the Ohio Psychological Association. When we give talks in the community, we also mention these consultation groups so that clinicians in the audience become immediately aware of the opportunity.
As a result of the tandem efforts of the OCD-Midwest members in Chicago and Cincinnati, several benefits are apparent. Not only is access to quality care more rapid, but there is also a growing sense of community and camaraderie among local OCD therapists, which is fueling further enthusiasm and commitment of these professionals to help individuals and families who suffer due to OCD. The case consultation series has been a strong positive experience for the less experienced OCD therapists as well as the series leaders. When asked about the benefits of participation, Dr. Rick Reckman, a private practice psychologist in Cincinnati responded, “As a long-time clinician with an interest in developing a new practice area, I have found that meeting with other therapists in our community has increased my confidence and broadened my repertoire in treating clients with OCD. When learning something new, it is very helpful for me to be able to talk through how I am approaching a case and draw on the expertise and experience of people I know and trust.”
Finally, we wanted to underscore that it is not only the therapists we train that benefit from the consultation groups — we also learn from them and it helps us to become better therapists, as we have to always be working on improving ways to explain OCD and ERP. If you are looking to start a case consultation group in your area, we would be happy to work with you more closely — feel free to give us a call or send us an e-mail.
To learn more about the OCD Midwest Case Consultation Groups, you can contact Charles Brady at firstname.lastname@example.org, and Patrick McGrath at email@example.com.