(p. 681) Treating Obsessive-Compulsive and Related Disorders
I am a licensed psychologist who is board certified in clinical psychology. I have been in private practice for over 14 years. My practice is solo and is in the affluent Buckhead area of Atlanta, Georgia. I work approximately 40 hours per week and see approximately 25 to 30 patients per week.
The Niche Practice Activity
I have a niche private practice in the areas of obsessive-compulsive disorder (OCD) and related disorders as well as anxiety disorders. I spend approximately 98% of my time in my practice with patients with these disorders as primary disorders. Within the obsessive-compulsive and related disorders component of my practice, I predominantly see patients with OCD; however, I also see clients with trichotillomania, excoriation disorder, and body dysmorphic disorder. I have some patients with hoarding disorder as well. I also see patients with many types of anxiety disorders, including generalized anxiety disorder and panic disorder.
Developing an Interest and Training in this Niche Activity
My interest in these disorders began when I took a course in cognitive-behavioral therapy (CBT) in graduate school and was able to see the connection between a person’s thoughts, mood, and (p. 682) behavior. I was taught the feedback loop of anxiety and the concepts of schedules of reinforcement. I also took an existential psychology course, an area that was already of interest for me prior to graduate school. I subsequently wrote my clinical dissertation based on extrapolating concepts from Martin Buber’s work into the therapeutic relationship. Merging CBT and Buber’s work has become a foundation for my work today. Buber focused on principles that involved aiding a person to be heard and to work toward his or her ultimate goals, and I have applied these concepts through the therapeutic relationship in my treatment work with patients. I knew that I wanted to pursue private practice prior to graduate school, so I was interested, early in graduate school, in the types of issues patients can struggle with that I might want to work with later in my career to help me inform the type of internship and postdoctoral experience I desired.
I had completed my dissertation when I left for my predoctoral internship year. I had been very focused on Buber’s work at that time and wanted to balance that with more specific CBT training. I chose an American Psychological Association–accredited predoctoral internship that had a broad array of patient populations. The program director, who was involved in my supervision, identified as a cognitive-behavioral therapist and was working on several CBT-based projects. This internship allowed me to practice interweaving Buber’s concepts regarding the therapeutic relationship and the structured evidence base CBT can provide.
I then chose a postdoctoral supervised work experience in a private practice setting such that I could further my development as a psychotherapist. I learned about the business side of being a mental health clinician in a private practice setting to help round out my desire to ultimately have my own practice. This supervisor helped me reinforce the concepts of both the therapeutic relationship and CBT with a variety of patient populations. I was exposed to many clinical issues and began realizing that I particularly enjoyed working with anxious clients and those who had obsessive-compulsive and related disorders.
After I had completed my postdoctoral year I opened a solo private practice. I started with a wide variety of patients who had clinical issues I had experience treating from my training years. I also concurrently worked at a residential treatment facility for two years, during which time I had a private practice. For board certification, I chose a case in my area of interest of combining the clinical issues as well as CBT and Buber’s concepts. The preparation as well as process of this certification in clinical psychology sealed my desire to pursue a specialty in obsessive-compulsive and related disorders as well as anxiety disorders, and to deepen my knowledge and application of evidence-based treatments.
I started attending conferences through the International OCD Foundation (www.iocdf.org) and further researching obsessive-compulsive and related disorders. These activities enhanced my interest even further. These conference opportunities include patients, researchers, and mental health practitioners and have been powerful in providing me with up-to-date and relevant research, treatment, and experiences related to OCD. I was also able to pursue training in the model of Acceptance and Commitment Therapy (ACT) through the conferences and through other trainings; I use this as a treatment approach in my practice as well. These conferences enhance my network of like-minded psychotherapists around the world, which is crucial in this specialty as there are not enough mental health practitioners in the area to meet patient needs. Attending conferences can help reinforce your knowledge and broaden your connections beyond your office.
(p. 683) I decided to pursue further formal training within my area of interest through the International OCD Foundation, which offers a formal program to become certified in treating OCD through the Behavior Therapy Training Institute. This training enhanced the knowledge I had and offered many practical examples.
I also joined what was previously called the Trichotillomania Learning Center (now called the TLC Foundation for Body-Focused Repetitive Behaviors, www.bfrb.org) and completed its Virtual Professional Training Institute training program, a CBT-based program in body-focused repetitive behaviors. This program was helpful in teaching me about trichotillomania and excoriation disorder as well as other body-focused repetitive behaviors and the relevant treatments for these disorders.
I have been a member of a small group of several psychologists who specialize in treating the same population as I do, and this has been a wonderful group for consultation and learning. Further, I have done presentations at a variety of locations on areas and treatments in my niche, and these have been excellent experiences in educating others about the evidence-based treatments available.
Joys and Challenges Related to this Niche Activity
Having a niche area such as this has been an incredibly rewarding experience. I truly enjoy the process of treatment, from the beginning assessment to the psychoeducational component to the actual treatment. Being a direct part of the change process when I can do exposure/response prevention (ERP) treatment in session with patients who have OCD is rewarding. Exposure involves exposing a patient to thoughts, images, or stimuli that induce anxiety, and response prevention focuses on the elimination of compulsive responses. Patients learn to rate their anxiety levels and continue exposures with response prevention until their anxiety levels significantly reduce and they gain greater tolerability for anxiety. For treatment to be maximally effective for any of the disorders I specialize in treating, the patient needs to work on the concepts of treatment outside of session as homework between visits. This type of treatment for OCD can involve leaving the traditional therapy office setting to assist patients in carrying out their ERP treatment when necessary.
There can be difficulties for clients on issues with willingness, commitment, and follow-through with homework, as well as family members evidencing difficulty with treatment concepts. These issues can significantly interfere with treatment progress and thus the ultimate effectiveness of the treatment. The psychoeducational component of treatment is very helpful for teaching patients and their family members (if possible) about the treatment methods employed. It initiates the process of inducing hope that their situation can improve and that there are evidence-based treatments for their disorder. This requires a curiosity and openness as well as readiness to hear this kind of information, and if a patient is unable to do so, treatment can be compromised early on in the process as these issues need to be addressed.
(p. 684) Perhaps the largest issue I have seen in practice is lack of the patient following through with homework. I work to collaborate with patients on assigning homework so that they are as much a part of the process as I am to increase the chances of follow-through. At times, a plan is put in place for patients to check in with me in between sessions to promote homework compliance. The ERP process requires repetition in order for learning to occur and for the anxiety to decrease in intensity, frequency, and duration, so if clients do not obtain this repetition, the effectiveness of treatment is limited.
There are many obstacles that can interfere with homework completion, and these need to be addressed to maximize treatment effectiveness. I try to include the family members who are most involved with the patient’s life from the outset of treatment to provide a “team” of support and so that I can try to redirect any collateral behavior that could be interfering with treatment. One of the largest issues with family members and OCD is that a they can unknowingly be reinforcing the patient’s compulsions. This is addressed early in the psychoeducational phase of treatment as well as throughout treatment. A primary example of this is providing reassurance to an anxious patient who is compulsively seeking reassurance. Another is engaging in rituals for the patient. If the family member does not work on ceasing these behaviors at the right times in treatment, it could alter otherwise effective treatment.
Business Aspects of this Niche Activity
In the past, I was in-network with several insurance panels, but I ultimately decided to no longer remain in-network and have transitioned into a 100% self-pay practice. I had a billing service for the time I was on insurance panels but I no longer require one as I bill at the time of service. One of the main reasons for altering my practice to be self-pay was that patients can need more and different arrangements for treatment than the traditional once-weekly psychotherapy session. At times patients need to meet more frequently than the traditional session frequency that insurance will reimburse. Preauthorizations from insurance companies may be required for providing these treatments. I have more time for patients when I spend less time with insurance companies and their requirements. Further, treatment also involves travel time outside of the office to provide ERP. I have found that having flexibility and addressing each patient’s needs session by session works best for my patients.
Developing this Niche Activity into a Practice Strategy
The International OCD Foundation as well as the TLC Foundation for Body-Focused Repetitive Behaviors are incredibly active with offering training opportunities, conferences, and community (p. 685) experiences that garner much attention. They have been a key aspect for developing the needed competence in my niche area. There is incredible community involvement in my niche area that has also generated many referrals.
My marketing is broad-based and includes schools, pediatricians, general practitioners, dermatologists, and other mental health professionals as well as psychiatrists. I have given talks to a mental health center and to other agencies in the community and have reached out to many doctors in the community to inform them of the type of work I do. I have served on ABPP committees for candidates undergoing examination, and this has connected me with a variety of psychologists who learn about my work. I have met many psychologists at the conferences I have attended as well as psychologists in the community who share my specialty, and these efforts have culminated in many client referrals. Patients also often refer others they know are suffering to me.
I keep in touch with referring doctors throughout treatment (with the patient’s written authorization for consent), which provides collaboration on the patient’s care and helps me maintain the relationships with my network of doctors. I also have a website that describes my specialty, and I have included that website in my profile of the organizations to which I belong. When patients are looking for a psychologist with my specialty, my website helps them learn about my work and provides my contact information.
For More Information
The key books for me regarding the treatment of OCD are by Grayson (2003) and March and Mulle (1998). I would recommend the trainings that the International OCD Foundation, the TLC Foundation for Body-Focused Repetitive Behaviors, and the Anxiety and Depression Association of America provide. I also suggest you attend conferences offered by these organizations. The training provides the foundation, and the conferences allow you to network with like-minded clinicians who can possibly be a part of a consultation group, could serve as referral sources, and could become consultants and friends. I would have been limited in my niche area had I not pursued these avenues.
The websites for these organizations (www.iocdf.org, www.bfrb.org, and www.adaa.org) provide a wealth of information on the disorders I specialize in treating, and they also provide resources, from books to support groups to treatment information. I would recommend reading the books and articles that these organizations suggest because they focus on evidence-based treatments. Further, these organizations send out newsletters with helpful information regarding the disorders if you are a member.
I would also advise joining a strong consultation group that meets at least once per month to discuss all aspects of treating these disorders. There is great variability in cases and nuances of the treatments that are often very helpful to review with others.
Grayson, J. (2003). Freedom from obsessive compulsive disorder: A personalized recovery program for living with uncertainty. New York: Penguin Group.Find this resource:
March, J. S., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual. New York: Guilford Press.Find this resource: