Psychotherapy with adolescents is a difficult proposition. Research suggests that adolescents do not do as well as adults in psychotherapy and that they tend to dropout or refuse treatment more often. The cognitive-behavioral treatment for obsessive-compulsive disorder (OCD) is no exception. I have had some stellar successes with adolescents as well as some abysmal failures. Often, adolescents are willing to give cognitive-behavior therapy or exposure with response prevention (ERP) a try but aren’t particularly motivated. Perhaps they’ve come to therapy to satisfy their parents or to avoid taking medication or just to check me out. In any case, for these adolescents, therapy never seems to progress as well as adolescents who are fully onboard with the treatment. Over the years, I have struggled to find an acceptable approach to discontinue the treatment of an adolescent when it’s clear that the treatment is not working. I have developed several guidelines that may be helpful to other clinicians who face this issue from time to time.
Collect outcome data to track progress. The best way to know if a therapy is progressing is to collect outcome data. I always have the adolescent complete a Yale Brown Obsessive Compulsive Scale (YBOCS) prior to each meeting. Because some adolescents tend to under report their symptoms, I ask parents to complete a log each week in which they (1) report the frequency and duration of the rituals they observe, and (2) rate their adolescent’s general level of distress (from 0 to 10). In addition, I note the adolescent’s compliance with each agreed upon out-of-session ERP task. Data such as these assist the clinician to begin the difficult discussion to discontinue a treatment that is not working. I discuss the data with both the adolescent and parents and together we decide whether to discontinue treatment and try a treatment alternative — medication, another cognitive-behavior therapist, or another treatment modality (intensive out-patient or inpatient).
Discontinue treatment too soon rather than too late. When a treatment is not progressing, I recommend discontinuing the treatment before the adolescent loses confidence in the treatment, in the therapist, and in himself. A treatment that drags on too long can leave the adolescent doubting its effectiveness. Also, an adolescent who half-heartedly engages in treatment cannot truly succeed. Soon she says to herself, “Nothing is going to help me. What’s the use, no matter what I do I can’t improve,” leading her to feel hopeless and depressed with little motivation to try again. Adolescents are more likely to return to therapy in the future if they remain hopeful about the treatment and themselves.
Schedule periodic meetings. I seldom completely terminate the treatment of an adolescent. Instead, I schedule periodic (every 4-6 months) meetings with the adolescent and his family to monitor progress and look for opportunities to engage him in treatment. During the session, I obtain a YBOCS score and review the parent’s logs of the adolescent’s observed symptoms and global distress. I ask whether the adolescent has suffered any new consequences because of his or her OCD (e.g., she was unable to attend a party because of her contamination fears, he had arguments with his girlfriend about being chronically late because of his excessive checking). I also use the session to tune up the family plan and change any maladaptive responses the family members may have to the adolescent’s OCD symptoms. I remind the adolescent that cognitive-behavior therapy is an effective treatment for OCD and that he or she can begin therapy again at any time. In this way, I keep OCD, its consequences and the option of treatment present in the adolescent’s mind.
Develop a family plan to decrease accommodation. I recommend developing a plan for the family (parents, siblings and other relatives) to decrease accommodation to the adolescent’s OCD symptoms. In collaboration with the adolescent, we develop an agreement that clearly spells out what the family members will and will not do. For example, if the adolescent often seeks reassurance from family members about his fears, we negotiate how family members can speak to the adolescent about the reassurance seeking without offering reassurance itself. The adolescent often has clear ideas about how this should be handled and by whom. Perhaps the adolescent wants dad to walk away whereas she wants mom to remind her that reassurance seeking is part of OCD. If the adolescent is unwilling to participate in developing the family plan, I meet with the family alone to develop the plan. Often, I meet with parents between periodic meetings with the adolescent to help them manage the family non-accommodation plan.
Encourage participation in an OCD self-help group. Self-help groups, such as those sponsored by the OC Foundation (www.iocdf.org), can be an important part of cognitive-behavioral treatment for OCD. Often, adolescents are ashamed and embarrassed by their symptoms and think that they are the only young person who has ever struggled with the condition. Self-help groups normalize the OCD experience for adolescents while providing opportunities for adolescents to learn from other adolescents. Hearing an adolescent speak positively about his or her experience with cognitive-behavior therapy carries far more weight than what I or parents might say. I encourage the adolescent and his or her family to attend at least one self-help group meeting between scheduled check-ins with me. An OC self-help group is another way to keep OCD and its consequences present in the adolescent’s mind.