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The Worry Hill - Page 6


I deliberately don't begin ERP until the child voluntarily expresses readiness. I gave Maria my telephone number to call within the next week and let me know if she'd like to go ahead. I received a call from her the next day. "Okay, I'm going to try it. I'm ready to beat my OCD! " I applauded her for her decision, and reiterated that we'd work as a team to conquer her OCD, with no pressure from her parents or me. Had Maria not been ready to participate, I wouldn't have proceeded with ERP, but instead would have spent more sessions with her and her family to understand the source of her reluctance, and to address those issues in therapy first. Sometimes children just aren't ready for ERP, and then this phase of treatment has to be deferred until they are. In some instances, medication may reduce the severity of anxiety symptoms, thereby making the possibility of ERP less daunting to the child.

Rather than slow treatment and recovery down, building treatment readiness makes the entire process go faster. After a few sessions of readiness-building, children with moderate to severe symptoms can often begin to master OCD within 4 to 8 sessions of ERP—for a total treatment duration of 12 to 20 sessions.

The RIDE

Once the child has learned about ERP, it's time for her to experience the relationship between gradual exposure and habituation. This shows her that if she can wait it out without doing her rituals, what she fears happening won't actually come to pass. Once she experiences this, her anxiety will dissipate naturally.

The 4-step RIDE acronym (Rename the thought; Insist that you are in charge; Defy OCD by doing the opposite; Enjoy your victory) comprise the steps for successfully tackling the Worry Hill. The Defy step is the most critical, as this is the core exposure strategy. In essence, the RIDE teaches youngsters to stop, think, take control, and respond assertively to OCD, rather than default to an automatic compliance with it. The combination of the acronym, logical steps, and visual features of the Worry Hill make the ERP process easy to grasp, remember, and recall, even in the midst of anxiety.

In our third session, Maria, her parents, and I sat down together and made a list of all the things Maria was afraid to do because of her fear of hepatitis, along with a list of all the rituals she employed to deal with her fears. Using a 10-point scale called a Fearmometer, she then rated how "scary" it would be to face each fear on the list. We then created an exposure hierarchy or "Fear Ladder," with the least scary items at the bottom of the ladder and scariest items at the top.

Toward the bottom of Maria's Fear Ladder were ERP tasks such as reading articles about hepatitis, describing the symptoms and causes of hepatitis to her parents, and repeating the word hepatitis several times in a conversation. In the middle of the ladder were items such as touching her parents on a clothed part of their body with unwashed hands, and touching herself on unclothed areas of her body with unwashed hands. At the top of the ladder were touching her parents with unwashed hands, using only 10 squares of toilet paper instead of an entire roll, sitting on chairs after using the toilet, and asking her parents to sit in the chairs that she'd just "contaminated."

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