Our First OCD Peer Consultation and Education Group
Our inaugural meeting was held on June 1. For those who couldn’t join us, we discussed the value of considering the theory underling ERP in case conceptualization and problem solving, as well as how adjunct therapeutic approaches (e.g., ACT, IFS) might be optimally integrated with ERP.
Most of us are aware that ERP is modeled on Pavlovian (or “associative”) conditioning to harness “extinction learning” (e.g., the dog comes to learn that the bell no longer signals food). Starting in the 1980s, it became increasingly clear that associative learning is a cognitive process in which expected outcomes stored in memory are central to OCD and its treatment. Foa and Kozak’s landmark 1986 paper – Emotional Processing of Fear: Exposure to Corrective Information – described “fear networks” linking innate fear programs (fight or flight) to real-world circumstances in a memory structure. The fear structure is considered “pathological” when safe objects and situations are incorporated into a fear network. Modifying a pathological fear structure requires two key elements: 1) activating the fear network by exposure (note the fear structure is impervious to change when not activated); and, 2) introduction of incompatible (or “corrective”) information when the fear network is activated (note this corrective information can be anything from the failure of the expected bad outcome to occur to the unexpected decrease in fear and anxiety over time in the absence of the ritual). There are three clinical indicators of successful ERP: 1) a strong fear reaction during the exposure (this must happen for the corrective information to be incorporated into the fear structure); 2) within session habituation/fear reduction in the absence of the ritual (recent research finds this condition is not always necessary but is typical in successful sessions); 3) between session habituation/fear reduction to the same exposure in the absence of the ritual (this must be present). If any of these indicators are absent (especially 1 and 3), you must assess and adjust the treatment. This theory and approach are supported by the neuroscience of memory formation/consolidation and modification through re-consolidation.
We also discussed incorporating various therapy modalities (e.g., ACT, IFS) in the practice of ERP practice. Whether coaching patients to notice and accept their discomfort during exposures (as in ACT) or helping them focus in on the part of themselves specific to the exposure while temporarily sidelining other parts (as in IFS), these adjunctive therapies are helpful when they are in the service of achieving the two key elements of ERP (above).
If these topics are of interest to you and you would value getting to know your colleagues, please join us for our next peer consultation group! We hope to host them monthly, assuming there is sufficient interest.