Let's learn about cognitive behavioural therapy with exposure response prevention

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In lesson 1 you learned about obsessions and how these cause distress. In lesson 2 you learned that compulsions reduce distress for a little while but are not a long-term solution. In lesson 3 you learned about the OCD cycle and how giving into compulsions keeps this going round and round. When you stop doing compulsions this breaks the OCD cycle. But you have to stop a little bit at a time, not all at once. I'll show you how in this lesson, first by helping you understand cognitive behavioural therapy and then Exposure Response Prevention (ERP). 

Let's learn more about cognitive behavioural therapy

First, the word cognitive means thinking. The word behavioural is what you do in response to your thoughts and feelings. The word therapy means a therapist helps you change how you think about your unwanted thoughts. 

When you do CBT your thinking changes for the better. When your thinking changes for the better your feelings change for the better too. Thinking and feeling better makes you feel confident. Confidence helps you think better about uncertainty and also about resisting compulsions and deciding to do the behaviours you want to do and not what OCD wants, so this is a positive response. 

CBT also includes exposure response prevention or ERP for short. 

Let's see what this means.

Exposure Response Prevention

When you start to resist compulsions you learn to challenge your OCD fears by first making a list of what these are. This list is called a fear ladder or hierarchy. You then use your ladder to do exposure response prevention one step at a time. The word exposure means agreeing to face the fears on your list one by one. This takes a lot of COURAGE and you would usually do this with a therapist who helps your parents and carers assist you. The words response prevention means you make a big effort NOT to respond as you have been doing, which is doing compulsions, but to resist doing the compulsions instead, like you learned in my 3-step challenge in lesson 3. I believe you have the courage to do this... so let's go ahead and learn more...

Johnny's Contamination Hierarchy
Before you get a large piece of paper and a pencil to write your list of fears, notice on the ladder above how Johnny's fears are all about contamination. If he had a second obsession, like having intrusive thoughts that makes him think he might do something dangerous, he would list the fears for this on a separate hierarchy. Having separate lists makes it easier to do ERP.

For Johnny's contamination fears, notice how the first thing on his list is what makes him the least anxious and the thing at the top is what makes him the most anxious. The ones in the middle are then worked out in order by using an anxiety scale. An anxiety scale means you gauge your fears from 0-10 or 0-100 and on a fear ladder you usually start with 3.5 or 35. So let's go with 0-10 in which case the first thing on Johnny's ladder makes him more anxious than normal at 3.5 and the one at the top makes him extremely anxious at 10. This is why he begins doing ERP for the first thing on his list because he will be less distressed by this 3.5 one; if he were to do the one at the top first that would be way too much for him. So he has to climb the ladder in small steps to get to 10. 

Some children's fears start higher than 3.5 for the first thing on their list and some are rated the same. For example, touching objects at someone else's house and touching doorknobs and rails outside his home are each rated at 5 on Johnny's hierarchy. 

The goal in ERP is to get each fear below 3.5

 When all your fears are below 3.5 you will notice that you no longer need to do compulsions for the obsession because your fears will be dulled. Dulling your fear means becoming less sensitive to the obsession which means you don't respond to the triggers so much. Let's say seeing the bin is a trigger for Johnny and touching it makes him feel dirty or fearful of catching germs. When doing ERP in small steps, his fears about feeling dirty or catching germs weaken. This helps him to take risks, such as washing his hands fewer times. When he does this he is learning all the time to live with uncertainty. This means he puts CBT into practice, such as changing how he thinks about his obsession; for example, "I might catch germs, but I might not either." He then learns that anyone can get sick, but it's not because of OCD, it's just what happens from time to time, and then people generally get better. So living with uncertainty helps Johnny learn that just because he has thoughts about germs doesn't mean he will catch them; and he also learns that even if he did get sick like people do from time to time, he would cope until he starts feeling better again.

Now let's look at Johnny's ERP goals in the diagram below

Johnny's compulsion for the first thing on his list is to wash his hands repeatedly. Usually he washes them 5 times after touching the bin. He is learning a new response which is to wash them 4 times. When he can do this with less distress, he can then wash them 3 times and so on until the urge to wash his hands weakens. When the urge loses its strength he becomes less sensitive to his fear. Being less sensitive is when your fear becomes dulled remember. Therapists call this habituation or becoming habituated to your fear. When Johnny becomes habituated he then starts to wash his hands appropriately again, meaning once only (say before dinner) or sometimes not at all, like after he opens the bin to pop in what's left on his plate. 

Becoming habituated

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Becoming habituated is like getting into a cold swimming pool. When you've been in the pool for a few minutes it doesn't feel so cold anymore. But the water doesn't change temperature, you just get used to it so that you no longer feel the coldness. The same happens with anxiety. The more you resist doing compulsions, the more you become habituated, meaning you feel much less anxious or fearful about the things listed on your ladder. 

Caring Carol's golden-sand-timer technique

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When Johnny did his ERP he used my 3-minute golden-sand-timer technique. This was to help him time and monitor his daily ERP sessions. His first exposure time was for 6 minutes, which meant he had to turn his golden-sand-time over when the sand had reached the bottom. 

Now if your first exposure time is for 6 minutes and say you are resisting the compulsion to wash, check, make something straight, repeat something, ask for reassurance, avoid, escape, pray, or something else, you would turn the timer over twice, like Johnny and then afterwards you would note the time on your progress sheet or in a diary. A progress sheet can also be called an ERP log because it logs information. 

When you feel okay doing 6 minutes you can then do 9 minutes, and then 12, and continue like that, and each time you would note the time increase on your ERP log.

The goal is to reach 1 hour or longer without doing any compulsions, including asking for reassurance. This is because reassurance is like any other compulsion remember, meaning the more you ask the more you feel the urge to ask again and again.

You can get bigger sand timers with more sand when you are ready for longer exposures, or shorter ones if you want to start your exposure with 1 minute or 2 minutes. They come in lovely colours too, like red, blue and purple. Sand-timers are not only a clever way to note down your exposure times throughout the week, they can also be a Mindful distraction when you watch the sand fall to the bottom. 

What is Mindfulness? 

First, a Mindful distraction isn't an avoidance compulsion. This is because Mindfulness involves acceptance. What you learn to do is let your thoughts, feelings, urges and images come and go without thinking they have a special meaning about you, someone else, or the situation. When you use your timer for exposures you can learn to be Mindful. 

Mindfulness can also be done in other ways, like when it's time to go to sleep and you're worrying about things. So what you would do is three things that start with the letter A - these are Acknowledge the unwanted thoughts are there; Accept they are there; and then Allow them to come and go without worrying about what they mean... you can listen to calming music too and eventually you learn to fall asleep much easier. 

It's now time to learn more about anxiety and how to monitor your distress levels.

Distress levels

Notice on the thermometer that when your distress becomes manageable, it is below 3.5. This rating means you don't usually need to do ERP for your feared situation any longer. It might take a week of doing ERP for the first fear on your hierarchy, less than a week, or two or three weeks to get your anxiety below 3.5. It's different for everybody, so it's okay not to feel rushed, just go at your own pace, and until you're ready to move up. 

When you find you no longer need to do ERP for the first thing on your list, each day you are still encouraged to do your appropriate behaviour (e.g., washing your hands once only, or not at all; or whatever your new response is) while working on the next fear on your ladder. 

Basically, as soon as you feel ready to go to your next fear on your ladder grab your sand-timer or other timer to help you keep track of the time. Next, get your ERP log and note down your distress levels before you start your exposure, half-way through your exposure, and at the end of your exposure. When you reach below 3.5 you are then ready to climb your ladder and go again with the next fear on your list.

Draw or print your anxiety thermometer

To measure your anxiety level you can print or draw a thermometer, like the one above. 

Each time you do ERP put a tick beside the number that indicates your distress level. You can then log this to help you monitor your progress. Don't worry if things don't go to plan straight away, just keep practicing and you'll get there eventually!

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Quiz Time! 

Let's see how well you can remember what you've just learned!

 Caring Carol says please ask your grown-up to help you find the answers! 

  1. What does CBT stand for and what does it mean?
  2. What does ERP stand for and what does it mean?
  3. Can you explain what Johnny learns about living with uncertainty?
  4. What is the time-span (main goal) for resisting compulsions for an exposure on your hierarchy: 1 hour, 1 minute or 1 second? 
  5. What does habituation mean?
Caring Carol says WELL DONE on coming to the end of your fourth lesson!

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Now it's time for your final lesson. Just click on the link when you're ready and I'll see you there!

Parent and caregivers summary box

ERP logs and a diary can be effective because it helps children monitor their weekly progress and working on setbacks. Resisting compulsions is helpful when
broken down; for example, your child can resist doing a compulsion first for 6 minutes, then 9 minutes, and so on. When you do this and practice it with them regularly they learn to recognise that anxiety does go away all by itself. A discussion with your child for this lesson is to help them understand that increased anxiety during an exposure normally reduces after about 15-30 minutes, and no longer than an hour. If it's a little bit longer, don't worry, it will come down eventually, since anxiety can only reach a peak before decreasing naturally. This is when your child starts to realise that OCD threats do not come true if a compulsion is not given into; subsequently, they then start to learn to cope with uncertainty. What happens next is that their obsessions start to weaken. When this happens, OCD doesn't bother them so much anymore, and so making their own choices becomes less of a challenge.