Clinicians Only: What I do during an exposure to help increase client motivation and engagement - Solution Focused Brief Therapy combined with Exposure and Response Prevention (ERP)

I’ve always had an interest in brief therapy modalities. I began introducing concepts of Solution Focused Brief Therapy (SFBT) with my OCD and anxiety patients many years ago, but never really have come across other professionals who use SFBT in their ERP work. This article explores how I have used SFBT and combined it with Exposure and Response Prevention to help increase patient engagement and motivation throughout the therapy process.

SFBT is excellent in helping patients focus more on what they are able to think, feel and act in ways that help them move toward their goals. Part of the process of SFBT is to emphasize goals and ways in which clients are already moving toward them. Of course, some of these goals may be inconsistent or incomplete, but highlighting what they’ve done to help move closer to their goals is part of the SFBT process.

What I do during exposure exercises with a client:

Goal setting is particularly important when it comes to SFBT work. During an exposure, I will have my clients speak about their goals for therapy. This is an opportunity for you to correct any misconceptions they may have about their goals for treatment. Sample questions may be ‘What does 10 out of 10 recovery look like when it comes to your OCD?” or “If a miracle happened and your OCD was managed well, what would that look like.” Make sure that the goals are stated in a positive form and realistic. If the client indicates that their miracle would include their OCD going away, you can educate them on what healthy recovery looks like.

A client may say “I would like to feel less anxious” however, this statement lacks detail. The therapist may want to consider asking what they would be doing if they were tolerating the anxiety better or what would be different in their life if they were managing their anxiety better.

Questions that may be helpful for you to ask the client include: What would be different, how would your partner know that things are different in how well you are managing your OCD?

Lastly, goals need to be stated in the active form. Help them focus on what they would be doing differently if they had their OCD managed well. Actively framing the goals helps build tasks for therapy. A goal stated in the active form may be “I will work on exposures daily for at least one hour.”

Example:

If I were managing my OCD well at a 10 out of 10 it would look like me practicing my exposures for at least 1 hour per day. Meditating at least 20 mins per day. Focusing on my school and engaging with my partner more. I would be exercising regularly (at least 30 mins per day) and making sure that I am going to sleep at 10 pm every day.

After I ask the client the question about what a 10 out of 10 would look like in OCD recovery, I ask on a scale of 1-10 (where 1 is poorly managing your OCD and 10 is managing your OCD well) where they are on that scale. If the client responds with a number lower than a 10 (for example a 5 out of 10), it would be worthwhile asking what would they need to do to get to a 6 out of 10 today (one increment higher than their present place value). It’s important that you do ask them what they can do today as it helps empower them to see that there are things that they can do that can help them move closer to their goal.

Example:

If I were at a 6 out of 10 in my OCD recovery I would be doing the exposures we talked about in session that are more tolerable. I would be waking up 10 mins earlier to practice my meditation. I’d be going out for walks every day. I would be listening to my OCD scripts on repeat throughout the day.

I would then ask them what they envision a 7 out of 10 in OCD recovery looks like and have them write it out (two increments higher). Lastly, I would have them write out any barriers that may get in the way of them getting to a 6 out of 10 and 7 out of 10 in their OCD recovery. For each barrier, I will have them come up with a plan of how to manage with each.

The next session:

I would have them revisit each written statement at the next session (likely mid-exposure as well). I’ll also ask them to rerate where they are on a scale of 1-10 in their OCD recovery. They are to repeat the process again by evaluating where they are by reading the 10 out of 10 statement and come up with a new statement based on where they are on the scale. For example. If they are now at a 6 out of 10, I’ll have them revisit the 7 out of 10 statement and make any necessary changes. I will then have them create a new statement for 8 out of 10. Another discussion about barriers would follow.

Many would argue that engaging in such discourse with the client would limit the exposure. I do caution that the practitioner considers when it would be appropriate to use the suggested techniques. If the practitioner believes it would serve as a distraction it may be best to engage with the material at a later time (outside of the exposure). If the exposure situation is created so that the client cannot 'escape' the exposure after the session, I would be more willing to engage the client mid-exposure. For instance, if I had the client take a cloth and rub it on a contaminant and rub that on themselves, their possessions and their surroundings I would be more inclined to implement SFBT techniques during the exposure.

For those interested in how I implement solution-focused brief therapy strategies on an ongoing basis throughout my therapy program, please read below:

There are specific elements that I have taken from SFBT that I found useful when working with ERP clients:

1) A search for progression change

2) Goal setting

3) Use of the miracle question

4) Use of scaling questions

5) A search for exceptions

6) A message including compliments and a task.

Search for Progression Change:

After conducting my assessment with a client, I often encourage the client to be on the lookout for any changes that may occur between the time of our assessment and the next meeting. Many people attending session are likely feeling discouraged and frustrated with their OCD or have likely had OCD therapy in the past that has failed. I often provide reading material after the first session to help them understand more about their OCD and what treatment looks like. It is unlikely that significant change would happen after an assessment appointment, but it is likely that the client has taken some steps that may help them see that they are already doing things to create positive changes in their recovery. Inquiring at the next meeting if a slight change has occurred is imperative to the process. This provides an opportunity to inquire about what they may have been doing differently and how some of their symptoms may have changed. Dewan, Steenbarger, and Greenberg (2004) made the important point that the language in which discussion of how pre-session change proceeds is important: It frames such change as something the client is doing rather than as something happening to the client. Clients often feel discouraged and demotivated when attending OCD sessions, helping them by pointing out that they are already doing something that produces change can help them feel in control.

Questions the elicit change talk could include:

What have you done differently since reading the material I sent?

Have you noticed any changes in your thinking about your OCD that you think would be helpful?

How are you beginning to see your OCD/anxiety differently that could create change today?

If there are no results to be reported, simply reminding them that change does not typically happen all at once is important. However, your goal is to attempt to find ‘change talk’ in their dialogue. Therapists can also use scaling tools to identify change. A follow-up inquiry could be “You mentioned feeling anxious attending the last session. On a scale of 1-10 (1 low anxiety and 10 high anxiety) how anxious were you and what is it at today? If it is lower, the therapist can ask what they specifically have done to help bring it down. If they do report a decrease help them identify action items that they have done that have helped them. The therapist may want to provide encouragement and promote more of the activity that has helped them (if productive for the therapy goal and aligns with OCD treatment protocol). If they performed a ritual or safety behaviour to attend the session it may be helpful to educate them on healthier coping strategies.

Ongoing Sessions:

I often search for change by asking a question at the beginning of our therapy work. I usually ask questions centred around change after they have been exposed to an OCD-related reading. For example, I may ask, “Can you tell me three positives as to how you are seeing the OCD differently, since our last session?” and “What changes have you made since our last session since reading the material I suggested?”.

Ritual Reduction:

Goals are stated in the here and now. When goals are created in the therapy session it is useful to help bridge the gap between what the future goal is and what they can do today. For instance, if the client’s goal is to hang out with her daughter who she believes is contaminated, it may be helpful during the ritual reduction stage to help the client navigate how they can do that this week and become more tolerable to it. Therefore the goal may look like “This week I am going to attempt to sit with my daughter while watching a movie in the living room until the anxiety goes down to zero.” When I do these types of ritual reduction strategies, I always check in with the client to see what they are willing to do this week and build a plan around their agreed ritual reductions. Focusing on specific attainable goals will help the client feel in control and recognize that they can act to create change. I often create a chart to help them observe their progress in ritual and anxiety reduction.

Searching for Exceptions

Searching for exceptions in their dialogue will help the client recognize that they are already doing things to help create change in their life. A client may say that they feel hopeless that they are not tackling their ritual reductions or exposures as they should. A therapist might say “None of us are perfect, but I can’t believe you are not engaging with any of the material that you have been exposed to in some way. Can you tell me more about how that may have happened this week? You may also say “Tell me how you are thinking about the material when you do have a minute to think about your OCD recovery?” At times it may be even helpful to side with them on their ‘extreme self-presentation.’ This may look like agreeing that they don’t seem to have enough time to devote the energy they need to commit to therapy and they come back at a time when they are ready to commit. This may open the dialogue as to what they can do to change if they wish and what they are doing differently between sessions. Some clients may ‘fight’ to stay in therapy once you agree with them that they may not be ready.

Compliments and Reviewing the Task

Compliments are helpful and are used to affirm the client’s strengths. The compliment helps the client by conveying that they have real strengths and that their strengths are being used in sessions already to help achieve their goals. Each session provide a task for the client. Initially, this could be homework or ritual reduction. Later on, this could be an exposure exercise or core belief record (if you are using CBT).

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Greenberg, R. P. (2004). Essential Ingredients for Successful Psychotherapy: Effect of Common Factors. In M. J. Dewan, B. N. Steenbarger, & R. P. Greenberg (Eds.), The Art and Science of Brief Psychotherapies: A Practitioner's Guide (pp. 231–241). American Psychiatric Publishing, Inc..