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Data:
Session duration: 60 minutes. Location: virtual. Client appeared exhausted and reported worsening compulsions, stating, "It's taking over my whole day now." Client described intrusive thoughts about contamination, frequent handwashing, avoidance of certain objects, and increasing difficulty focusing at work. Client noted growing avoidance behaviors, including avoiding public bathrooms and now avoiding going out entirely due to anxiety about germs. Therapist explained the relationship between avoidance, compulsions, and OCD, and introduced ERP as a treatment approach. Together, therapist and client began constructing an ERP hierarchy, with tasks ranging from touching a doorknob at home without washing to using a public restroom without washing hands. Therapist and client rehearsed response prevention language to use during high-anxiety moments, emphasizing that anxiety is uncomfortable but not dangerous and will pass.
Assessment:
Client is showing significant distress and impairment related to OCD symptoms, including intrusive thoughts, compulsions, and avoidance behaviors, which are interfering with daily functioning and work. Client responded to psychoeducation about ERP with a mix of nervousness and hopefulness, indicating some readiness to engage in treatment. Initial steps toward building an ERP hierarchy and practicing response prevention strategies were productive.
Plan:
Client will attempt one item from the lower end of the ERP hierarchy twice this week and use response prevention language during urges to engage in compulsions. Therapist and client will meet next week to review progress with exposures and refine the hierarchy as needed. Continuation of ERP-focused treatment is planned.
We had a 60-minute virtual session today. Daniel logged in looking exhausted and said the compulsions have been getting worse. He said quote 'It's taking over my whole day now' unquote. He described how he's been having these intrusive thoughts about contamination, and the more he tries to push them away, the stronger the compulsions get. He's washing his hands dozens of times a day, avoiding touching certain things, and it's starting to affect his work because he can't focus. He said the avoidance has been growing, he used to just avoid public bathrooms, but now he's avoiding going out at all because he's so anxious about germs.
We talked about how avoidance and compulsions actually make OCD stronger over time, even though they feel like they're helping in the moment. I explained how ERP works, gradually facing the feared situations without doing the compulsion, which teaches the brain that the anxiety will come down on its own. We started building an ERP hierarchy together, rating different situations from least to most anxiety-provoking. At the bottom was something like touching a doorknob at home without washing right away, and at the top was using a public restroom and not washing hands after. We agreed to start small and work our way up.
We also rehearsed some response prevention language for those high anxiety moments. I told him that when the urge to wash comes up, he can remind himself that the anxiety is uncomfortable but not dangerous, and it will pass. We practiced it a few times so it would feel more natural. His homework is to pick one item from the lower end of the hierarchy and try it twice this week, and to use that response prevention language when the urge comes up. He seemed nervous but also a little hopeful, like there's finally a way forward. We'll meet again next week to see how the first exposures went and adjust the plan as needed.
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