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The Worry Hill - Page 2


Building Treatment Readiness

Children who aren't properly prepared for how ERP works and what it entails are more likely to become ambivalent or afraid, withdraw from exposures, and refuse to do practice exercises. When they understand how exposure and habituation work, they're more willing to tolerate the initial anxiety experienced during ERP, because they know it'll increase and then subside.

The four steps in building readiness to undergo the added anxiety engendered by CBT—Stabilization, Communication, Persuasion, and Collaboration—are illustrated in Maria's journey to recovery.

Stabilization comes first. When I met Maria, she was shy and embarrassed as her parents described her symptoms and their futile struggle to get her to see reason. "I know I'm washing too much," she said quietly, "but I just can't stop." Her parents, like most parents seeking help for their child's OCD, expressed a sense of urgency. They asked if they should be actively fighting the OCD by "getting tough" with their daughter and refusing to give in to her rituals. I said that our first focus was on stabilization and that it wasn't the right time to withdraw support for Maria, who was already overwhelmed and struggling to function each day. Instead, I encouraged them to function in "survival mode"—to be flexible in their expectations, accommodate their daughter temporarily at home and school, and cut back on discretionary commitments to reduce her stress and conserve time and energy for future treatment.

In this first session, I focused on setting the foundation for treatment and getting everyone on the same page. I began with a clear description of OCD. "Everyone has worries, Maria. But when you have OCD, your brain sends you a lot of worry messages that get stuck in your mind, even when there's no reason to be worried. It's like it would be if you rang the doorbell and the button got stuck: the doorbell would keep ringing. OCD is like a 'worry bell' in your brain that gets stuck. The worry thoughts that OCD puts in your brain are called 'obsessions.' The things you do over and over again to make the obsessions go away are called 'compulsions' or 'rituals.'"

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