Home and Community Based ERP

Denise Egan Stack, LMHC

I have been treating people with Obsessive Compulsive Disorder (OCD) in home and community based settings (HCBT) for over fifteen years. Throughout this time, I have found HCBT to be an effective way to treat people with OCD, especially if a patient has failed several trials of outpatient behavior therapy or is transitioning from an intensive treatment setting. While HCBT offers the behavioral treatment that would be provided in an outpatient setting (development of hierarchy, goal setting, homework assignments/review, skills training, relapse prevention plan), it offers a number of added benefits over standard outpatient behavior therapy.

In HCBT the therapist assess OCD symptoms in a patient’s natural environment, which is often not possible in office based therapy. This ensures a more comprehensive behavioral assessment because it does not rely on patient self reports made outside of the anxiety provoking moment/environment. For example, a patient with contamination obsessions and washing/avoidance rituals at home might walk the therapist room to room through his or her house, noting all triggers and providing an accurate SUDS rating when in actual contact with the trigger. HCBT therapists have an opportunity to probe more directly and thoroughly in the patient’s natural environment, inquiring about possible avoidances or reassurance statements based on observations in the moment, which provides a more accurate picture of what the patient experiences when triggered or performing rituals. This, I believe, results in better exposure and response prevention (ERP) planning, and, thus, greater compliance with the plan.

Unlike most office based behavior therapy, patients in HCBT receive behavioral coaching during ERP in the environment in which their symptoms naturally occur. For example, someone engaging in ERP to address obsessions related to a fear of causing harm may be coached on walking through a busy subway station without engaging in checking rituals. Many patients who have failed outpatient courses of behavior therapy have reported that ERP assignments were just too difficult to perform on their own and that therapist guided ERP helped them overcome that obstacle. In my clinical experience, this assistance increases motivation for actively engaging in treatment, as well as the likelihood for habituation and compliance with homework assignments, and helps to ensure appropriate application of cognitive interventions. Once a patient has habituated to an item on the hierarchy and is able to perform ERP on his/her own for homework, the coaching is faded with respect to that item and the HCBT focuses on the next item on the hierarchy.

There are other practical advantages to conducting treatment in the home setting. For one thing, HCBT provides an excellent opportunity to consistently include family or other significant people into the patients’ treatment, something that is harder to bring about in traditional outpatient settings. Often times in my practice, family members are included in a part of most therapy sessions in order to learn about OCD, ERP, how to become an effective behavioral coach, how to manage reassurance-seeking questions or other family involvement in rituals, and how to manage expressed emotion in relationships. In my experience, this level of family involvement is essential; it increases treatment compliance and relapse prevention, especially for children and adolescents, because OCD symptoms tend to stress everyone in the family system, not just the patient.

HCBT sessions, consisting of 90-120 minute appointments one to two times per week, are generally longer than most outpatient behavior therapy sessions in order to provide enough time for behavioral planning, skills training, in vivo ERP and family meetings. As patients master items on their hierarchy and manage gains independently, treatment is faded and frequency and duration of sessions decrease. For example, I am currently working with someone who, at the beginning of therapy, had recently transitioned from an intensive treatment setting. We initially met three times a week for 90 minutes to work on skills training, family education and in vivo ERP. She has now successfully habituated to all items on her hierarchy and we have begun meeting once a week for 60 minutes to work on relapse prevention.

While HCBT is not necessary for all cases of OCD, it is an effective intervention for treatment resistant cases, when individuals are transitioning from intensive treatment settings, or for people are unable to leave their homes. If you think you might benefit from this type of treatment, please discuss this with your current therapist.