Intensive Treatment at AustinOCD
Note: The following FAQ is an edited version of an interview we gave for the newsletter of the International OCD Foundation in the summer of 2008.
Could you describe your intensive treatment program?
Intensive treatment at AustinOCD is very similar to what we do in our regular outpatient treatment for OCD, except that it's more intensive, with more hours per day and more days per week, and it involves one-to-one therapy with a number of our specialized therapists rather than with just one therapist. The cornerstone of our approach is cognitive behavioral therapy (CBT), and the CBT technique we use most is exposure and ritual prevention (ERP). We also evaluate for medications and can make recommendations for their use (starting, adjusting, or discontinuing), but medications often take several weeks to take effect, so we don't depend on medications to have an effect during someone's stay here.
AustinOCD is an outpatient facility, so we don't have a place for people to eat or sleep. We provide intensive outpatient treatment for adults and older adolescents. The insurance companies sometimes refer to this as an intensive outpatient program (IOP). We prefer not to call it a program, since that suggests a pre-existing curriculum or treatment plan that we plug people into regardless of their individual situation. We're a small enough operation that we can tailor-make a program for each individual.
People usually come for between one and three weeks and stay in one of several nearby extended-stay hotels, where they have a suite, kitchenette, high-speed internet, etc. We generally recommend that intensive treatment clients come with at least one family member.
One to three weeks sounds like a very short time. Is that really long enough?
No one coming for treatment should expect to be anywhere near symptom-free after such a relatively short stay. But it is possible to achieve a 50% drop in YBOCS (Yale-Brown Obsessive-Compulsive Scale) symptom severity in that time, and that's what we shoot for. We don't always achieve that; sometimes we don't even achieve a 25% drop. Our intensive treatment is meant to be a major push, a jump-start, toward treatment that will then continue on an outpatient basis. In many cases, the progress achieved after the intensive phase is greater than that achieved during the intensive phase. Of course, clients will still need professional guidance after they get home, but we hope to increase their knowledge, confidence, and commitment so that everyone can follow through when they get home. We still aim for a 50% reduction in symptoms over the following several weeks or months.
What does the therapy consist of?
Typically, a client coming for intensive treatment would meet with the director or another senior therapist for two hours of individual therapy each morning, Monday through Friday, and then for up to four more hours of individual therapy each afternoon with a predoctoral intern. Some of the therapy takes place in our office, and some takes place "in the field," at shopping malls, for example, or outdoors, whatever may be most appropriate and effective for that particular treatment. Clients need to learn to confront real-life triggers and practice their new skills. Our interns, from the University of Texas clinical psychology PhD program, are well trained in this kind of "in vivo" therapy, and of course we work closely with them and supervise them. The family members also have the opportunity to meet with each of these therapists during their stay with us. We have a team approach, and patients and their families are important members of that team.
Are family members always present during therapy sessions?
No, not always. We provide opportunities for each patient to speak alone with each of their therapists throughout their stay, and they might meet one-on-one with a therapist most of the time. In some cases there is a great deal of family participation, and in other cases much less. It all depends on the individual situation.
Family and relationship issues are extremely important, which is a major reason we recommend that even adult clients come with a family member. OCD is obviously hard for the OCD sufferer to live with, but individuals with OCD can also be hard to live with. Anger and resentments build up. We try to get everyone on the same page and working together. Friends and family members, of course, typically (and quite naturally) have tried to reassure the client about their obsessive concerns, but reassurance is rarely helpful and usually makes the OCD worse. We train family members how to be supportive without providing reassurance about obsessive concerns. We also encourage the family to move toward healthy and enjoyable activities, without having OCD be the centerpiece of their interactions with each other, and to practice this during their stay with us.
What would determine family participation?
There are a number of reasons why we might want more family participation, such as when family members have been sucked into the person's OCD world, say, by providing excessive reassurance, or by going along with OCD-driven requests, for example that everyone needs to shower and change clothes whenever they come into the house. Also, the client and the family may prefer more family involvement. There are also times where the family is over-involved and needs to back off.
What kinds of cases work well in intensive treatment, and what kinds don't work well?
Most types of OCD work well, including what used to be known as "pure O" (for pure obsessional). Body Dysmorphic Disorder (BDD) cases often do well in intensive treatment. The cases that don't work well are ones that are tightly bound to the client's home situation. Someone who obsesses about things not being right with their house, for example, may find those concerns disappear when they move away from home temporarily. Hoarding is also more difficult to treat away from the settings in which the behavior occurs.
Is group therapy part of your treatment?
No, group therapy is not part of our intensive treatment. We're a small facility, and we usually see only one intensive treatment patient or family at a time, so there is no group for them to meet with. Sometimes it feels like group therapy when the senior therapist, the intern therapist, the family therapist, the client and family members are all in the room!
What about follow-up?
Follow-up is crucial. We prepare for follow-up (often called discharge planning or aftercare planning) even before the person arrives. Tremendous progress can occur while they're here with us, but intensive treatment in any facility must be followed up with continued outpatient therapy after the person leaves, or any gains made will most likely be lost. Follow-up can be difficult if there are no trained OCD therapists near the person's home, which is in fact a common reason for people to come to our center. Consequently, we often wind up providing continued outpatient therapy by telephone.
Is that legal?
Yes, it's legal, ethical, and can be remarkably effective. Obviously, it's better to have face-to-face meetings, where you can see people's facial expressions and other non-verbal behavior, but it's not necessary. There are blind therapists who are very competent. Insurance may not reimburse for telephone sessions, however.
What is your success rate?
That's difficult to compute. Some of the best treatment centers in the world, like the OCD Institute at McLean Hospital in Belmont, MA, have relatively modest success rates, since they often treat the very toughest cases. If someone has never had good CBT/ERP before, our success rate is very high. But if they've seen several competent therapists with little or no success, we may have to find an approach that the others had missed. Sometimes we do and sometimes we don't.
We had one intensive treatment case that we thought was a dismal failure. We just couldn't get anywhere; it was like pulling teeth. We simply weren't able to find a way to get the client to do any of the exercises we recommended. We terminated treatment after a week, because it would have been a waste of time and money to continue. Then a year or so later we got an email from the mother, thanking us, saying that when her daughter got home from Austin, she began to do the ERP we'd recommended and got much better. The mother reported that she was now entering graduate school and doing great. So, even though we measure gains at the end of the intensive treatment phase, once a person gets back home with new tools and confidence, we expect to see continued growth and success.
How much does your program cost?
Our standard charge is $1100 for the first day and $900 for each additional day for adults coming for intensive treatment. We may charge more when significantly more staff time is required either for assessment of more complex cases or for treatment. We provide treatment for up to five days (Monday-Friday) a week. Followup phone calls, which are often recommended, are charged separately at our usual hourly fees. See also: Which AustinOCD therapist would be best for me? for more information on therapist's fees.
Is your intensive outpatient treatment covered by insurance?
Sometimes. It's important to arrange this ahead of time. After the treatment is already paid for, insurance companies have less incentive to approve it. We don't belong to any HMO networks or panels, and people generally get reimbursed less for going "out of network" to see us. But one person came to us from out of state, going out of network, and his insurance company reimbursed him all but a $25-a-day copayment. He may have had exceptional negotiating skills, or maybe he was able to talk to someone at the insurance company who realized that it would save them money in the long run to get it treated properly than to pay for years of ineffective treatment. For tips on how to get insurance companies to pay for OCD treatment, see Fight For Your Rights, as well as Will my health insurance cover AustinOCD's fees?
How does your intensive outpatient treatment differ from an inpatient or residential treatment program? Why would someone choose one over another?
All forms of intensive treatment, whether outpatient, residential, or inpatient, are obviously going to be intense. We generally offer more individual therapy -- up to 6 hours a day -- and less in terms of group therapy, than inpatient or residential programs. Because we don't need a large support staff, however, such as 24-hour nurses, laundry, cafeteria, groundskeepers, etc., we can keep our fees down. A residential or inpatient setting would be a better choice if the person has significant potential for suicide or violence, or if they have a complicated medical or psychopharmacological picture that needs to be closely monitored.One advantage of the AustinOCD program is that it allows people to enjoy their visit to Austin at the same time they're making progress in treatment. Even if someone is highly motivated to make a lot of progress, there's a limit to how much therapy anyone can do in any one day. Most people don't do the full 4 hours per day with the intern that we offer; instead, they might take only 2 to 3 hours. But then they might find some interesting places around town to do their homework exercises. We encourage people to take breaks from their therapy every day and on the weekends to enjoy Austin, which is the capital of Texas, of course, in the beautiful Texas Hill Country, and a college town, and especially known as the Live Music Capital of the World, so there's always a lot going on for just about anyone's interests.