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Problem:
Client logged into the session appearing exhausted and reported worsening compulsions. Client stated, "It's taking over my whole day now." Client described intrusive thoughts about contamination and noted that efforts to push them away increase the compulsions. Client reported washing hands dozens of times daily, avoiding touching certain objects, and experiencing difficulty focusing at work. Client shared that avoidance behaviors have escalated, progressing from avoiding public bathrooms to avoiding going out entirely due to anxiety about germs.
Intervention:
60-minute virtual session. Therapist explained how avoidance and compulsions reinforce OCD over time. Therapist introduced ERP and its process of gradually facing feared situations without performing compulsions. Together, therapist and client began building an ERP hierarchy, ranking situations by anxiety level, from touching a doorknob at home without washing to using a public restroom without washing hands. Therapist also rehearsed response prevention language with client for high-anxiety moments, emphasizing that anxiety is uncomfortable but not dangerous and will pass.
Response:
Client appeared nervous but expressed some hopefulness about the ERP approach, indicating a sense of possibility for progress. Client engaged in building the hierarchy and practicing response prevention language, demonstrating initial understanding of the concepts.
Plan:
Client assigned homework to attempt one item from the lower end of the ERP hierarchy twice this week and to use response prevention language when experiencing the urge to perform compulsions. Therapist and client plan to meet next week to review progress with exposures and adjust the plan as needed.
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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