Q I have a 15-year-old daughter who has OCD. She has recently been treated for OCD but still has a tremendous amount of obsessions and compulsions to manage. They are based on her bodily fluids, and revolve around the toilet, shower, laundry, clothes — things that the fluids could have come in contact with. My gut feeling has always been that if someone would work with her in our home she would make more effective progress. Your website is the first place I have seen that strongly recommends in-home sessions. Can you elaborate on when in the therapy process this occurs and what needs to be in place to ensure that it as successful as possible?
In-home sessions for children with OCD aren’t as common as they should be, and that can become a barrier in treatment.
A lot of times OCD symptoms that occur at home also occur outside of home — a child washes her hands repeatedly whether she’s at home or at school or at a restaurant. We can work on those symptoms in the office with exposure and response prevention (ERP), and the skills a child learns to handle those obsessions can transfer or generalize to other settings, including the home.
But there are two cases in which skills learned successfully in the office might not carry over to home.
First, sometimes there is something preventing the transfer of skills. Maybe it’s because home is a safe haven for the child’s OCD. She works hard to manage her obsessions elsewhere, and home is where her OCD has free rein. Or it’s too scary to manage them at home because her symptoms are more intense there, perhaps even in specific areas of the house.
But for some kids there may be symptoms that only occur at home. In that case you’re not going to get a lot of benefit from working on them in the office because it’s not going to feel real for the child. It’s like the difference between reading about a workout and then trying it at the gym versus having a personal trainer there with you.
If a child is having particular trouble with her symptoms at home, she may need in-home support to learn to handle them. And that doesn’t mean parents hounding or prodding; the child needs situation-specific therapy to learn how to do it at home.
But before beginning in-home sessions, it’s important that your daughter learn how ERP works and get some experience practicing it in an office setting. Laying the foundation is important because if she hasn’t done that, it would be too scary to start at home. She needs to build up her skills and her confidence in her clinician first, and then tackle her obsessions and compulsions at home.