Episode 45 Effective Treatment for OCD with ERP, with Dr. Roseann Capanna-Hodge

Jan 12, 2022

Do you treat patients with OCD? Why can you not treat OCD like anxiety? How does ERP work alongside CBT for effective OCD treatment?


Dr. Roseann is a mental health trailblazer, founder of The Global Institute of Children’s Mental Health, and Dr. Roseann, LLC. She is known for brain-based solutions for struggling kids and her work has helped thousands reverse the most challenging conditions, such as ADHD, anxiety, mood, autism, learning disability, Lyme, and PANS/PANDAS using PROVEN holistic therapies such as neurofeedback, biofeedback, and psychotherapy.

She is the author of the first-ever book on teletherapy activities for child and adolescent therapists, “Teletherapy Toolkit” and “It’s Gonna be OK!” She gives parents step-by-step solutions for their struggling kids with her books and remote neurofeedback program. A media personality, she is often featured on dozens of media outlets: Fox, CBS, NBC, PARENTS, and New York Times.

Visit her personal website and childrensmentalhealth.com.

Connect with her on FacebookInstagram, TwitterYoutube, and Pinterest.

Find out More about Roseann’s Get Unstuck Summit!

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  • OCD
  • ERP
  • CBT and OCD treatment


OCD, obsessive-compulsive disorder, is not always related to anxiety and it cannot be treated as anxiety.

OCD is about the over-activation of the nervous system, the obsessive thinking, the compulsive behaviors that are deeply rooted in behavioral habituation … people inadvertently reinforce people’s OCD all the time. (Dr. Roseann Capanna-Hodge)

People may comfort others who suffer from OCD instead of reminding them that they are capable of self-regulating as well.


Exposure and response prevention is about educating the client in the neuroscience behind behavioral changes and enabling them to self-regulate based on behavioral changes.

[The clients] get the insight, they understand, then they understand how to break free from the accommodation. They learn how to talk back to their OCD and their worries or intrusive thoughts. (Dr. Roseann Capanna-Hodge)

Clients are given the tools to overcome their OCD by learning about what their triggers are.

Later in therapy, clients interact with safe exposure to those triggers and learn behavioral strategies to overcome the OCD and compulsive needs for rituals.

CBT and OCD treatment

Cognitive-behavioral therapy is an important aspect of OCD treatment. However, it needs to work in unison with behavioral strategies and not only be based on talk therapy.

You are using [CBT] in a way that is relevant to the OCD and you’re really focusing on the exposure. With CBT we’re doing cognitions and behaviors … but CBT alone is not as effective as when we incorporate the exposure part. (Dr. Roseann Capanna-Hodge)

If you work with clients who suffer from OCD, consider taking on training in ERP because it adds another necessary and integral dimension to their treatment.

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Resources Mentioned And Useful Links:

Visit Dr. Roseann’s personal website and childrensmentalhealth.com

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The Get Unstuck Summit

BOOK | Dr. Roseann Capanna-Hodge – It’s Gonna Be OK: Proven Ways to Improve Your Child’s Mental Health

BOOK | Dr. Roseann Capanna-Hodge – Teletherapy Toolkit: Therapist Handbook for Treating Children and Teens

BOOK | Maria Rickert Hong – Brain Under Attack: A Resource for Parents and Caregivers of Children with PANS, PANDAS, and Autoimmune Encephalitis

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Welcome to the Holistic Counseling Podcast, where you discover diverse wellness modalities, advice on growing your integrative practice, and grow confidence in being your unique self. I'm your host, Chris McDonald. I'm so glad you're here for the journey. .

Welcome back to today's episode of the Holistic Counseling Podcast. This is Chris McDonald. I'm your host and expert in all things related to holistic counseling. If you're a new listener, I want to say welcome. I invite you to come join my amazing Facebook community called the Holistic Counseling and Self-care group. In this group, you can connect with other like-minded providers and gain holistic tools and insights to help you on your holistic journey.

I am so pleased to bring back my guest from episode 35, Dr. Roseanne Capanna Hodge. She gave a wonderful interview on the use of neuro-feedback and biofeedback. So check it out in case you missed it. You really want to go back and listen. Dr. Roseanne is a mental health trailblazer, founder of The Global Institute of Children's Mental. She is changing the way we view and treat children's mental health. She is known for brain-based solutions for struggling kids and her work has helped thousands reverse the most challenging conditions. Today's discussion will be on ERP or Exposure and Response Prevention Therapy. Welcome to the podcast, Roseann.


I am so grateful and excited that we're having this interview. We're going to talk about something that people don't know a lot about, OCD.


Exactly. This treatment too, I think a lot of people may not be familiar with it.


Most definitely. I think people, besides it being super sometimes hard to diagnose, easily missed we don't know really how it's treated and that includes not just people who are searching for solutions, but often clinical therapists have misinformation about how OCD should be best be treated. I'm all about science backed solutions. So you've got to look to the science to see what actually turns the dial for OCD, especially because it is a very treatment-resistant condition.


Oh, for sure. So can you share with my listeners a little more about yourself and your work?


Yes, so I am a therapist, a psychologist, an author, and I really just, as you said, I'm on this mission to change the way we view and treat mental health, particularly for children and families during this really extraordinarily stressful time but even prior to that. So I have been teaching people about solutions for struggling kids for 30 years and all of my work is holistic-based. I've actually never, ever, I've certainly drained in traditional methodologies, but all of my clinical practice has been using effective natural solutions, like specific types of psychotherapy and neuro-feedback and biofeedback and nutrition and supplements, which is why I have such great results with my clients because I'm looking to the research to look at what actually creates change.


So what makes OCD so difficult to treat?


I think the first thing about what makes OCD difficult to treat is that these individuals are often missed and OCD, we often think of it as those compulsions, those outward behaviors and rituals that you see like hand washing and counting and checking. But it always starts with obsessive thinking and a lot of people, even though they may have rituals, they're internal. So it's a very internal disease. So that makes it hard to diagnose and hard to treat, because we don't know how long it's been around. So that's one part of it.

Then the other part of it, and I'll give you some great stories about how hard it was to identify people, but the other part of it is that from a neurological basis, why it's so hard to treat is that yes, you have an over-activity of neurotransmitters, too many excitatory neurotransmitters, you have your central nervous system in what we call stressed out, sympathetic dominant state, but there's something called a negative reinforcement loop. With OCD when somebody has an intrusive thought or compulsive behavior, there's something that's a trigger.

So, for example, true story had a kid that his obsessions were about storms. So anytime a storm was going to happen, he would naturally have an acceleration of anxiety and intrusive thoughts and compulsions. So he would say to his mom, whether there was a storm or not, though Chris, every day, he would sit at the, you know a need for reassuring questions is a common component, whether you're an adult or a child, but even more so if you're a teenager or a child. So he would say, mom, is there going to be a storm today? So he would activate, and his mother would give him a reassurance, no, it's not going to.

What would happen is if you can visualize, if you're listening, he would have a spike and then his mother reassuring him would cause the anxiety to go down. The problem with that's actually feeding his anxiety because he then on a neurological subconscious level relies on the reassurance to calm his anxiety. It actually causes it to increase. So every time she reassures him, it goes down, but then the spike goes further up the next time. So it's called a negative reinforcement loop. Now is she handled it differently. This is what ERP's all about. We can talk about this. She said, "Hey, Joey, what happened yesterday? Or what is the answer to that?"

Or she said something that forced coping. What's going to happen is his anxiety's going to spike up further. But since he employed his own coping strategies, and he wasn't accommodated, his anxiety will be less the next time. So it goes up further, then goes down further. So every time he's going to lower the threshold, we'll get his baseline down where, when we accommodate, we move the baseline up. It becomes harder and harder. So that's one of the hardest parts about treatment. Then the third part that makes treatment really hard is there's not a lot of people doing appropriate evidence-based treatment for OCD. They're doing a lot of talk therapy or the same therapy they do for anxiety, which is not the same.


I just want to stop you right there because I appreciate that clear discussion on that, because I've treated some clients with OCD, but I've never thought of it that way about the negative reinforcement loop. Why have I not heard of this? This really helps to understand in my mind if I'm treating somebody with this.


Yes. Oh, I mean, it's a big deal. I have a great blog about it with a visual because even just to see the visual to understand you're actually feeding it. So when we talk about their anxiety, that in itself is an exposure. When we work with the client and please know everybody, I was doing this too, for many, many years, I was doing anxiety treatment for people with OCD, is a completely different treatment and we'll break out what is exposure, response, and prevention. We'll get into all that. But what would happen is they would come in and I would be like, "Wow that must have been really hard. Let's talk about ways to breathe through that," which is not a terrible treatment, but we didn't exactly address the underpinnings.

It's really, really easy if you're not asking the right questions, you're not doing a deep intake to miss what OCD is. Here's a great example. And please know, whenever I share examples, I've changed the story to protect people's identity. So I recently had somebody who came in, have heard this story 50 times. So the client came in and they're like, he just got OCD. I was like, "Okay, let's look back." I always say, when did the anxiety start? Because OCD, unless it's pans pandas, which is sudden onset of OCD in this case, OCD can be a variety of mental health issues, from a toxic or an infectious disease trigger and it just turns on with no precipitating mental health issue, which can happen. It does happen all the time.

But what happens with typical OCD it starts with anxiety. It starts with worry. And we all have different ways that we manage our worry. Some are healthy and some are unhealthy and some unhealthy response, I think a lot of adults can relate to, would be things like drinking alcohol or emotional eating, or sitting in bed or even binge watching Netflix all the time or avoiding people. But then for some people, what happens is they move to this constant looping thoughts and when it flips to OCD is when you're spending an hour or more a day having obsessive thinking, compulsive or obsessive thoughts and behaviors or rituals. So it's got to be an hour or more a day is when ---


So it's not just a casual, oh, I keep checking to see if the door is locked five times?


Exactly. And even that if you have a ritual around you can't leave your house, unless you've gone back and checked five times that's interfering with your daily life. But where is that also showing up? So in the case of this mom, when we went back, what we uncovered is there were a ton of rituals. There were rituals around bedtime that the parent participated in. They didn't see it as a problem then, because he did well in school, he had friends and they just participated in the ritual. So he didn't "freak out," as they said, as he is now, them using their words.

Then there were a bunch of other things related to how he did certain things related to sports and rituals around eating and things. Again, it wasn't, they were absolutely OCD, but since he wasn't so emotionally reactive as he is right now, and I'm also getting, as we're returning in the 2021, 2022 school year, I'm getting a lot of school refusals, so he started school refusing because of his OCD and his rituals. So we were able to piece together that he actually had OCD for about three years with ---


Wow, Just like a lot of investigative work.


Yes, a lot of investigative, right questions. It's the right questions.


Right questions.


You want to do, Yale has a great intake form for OCD that's available online, and people can do that as a therapist. So it's really understanding what to look for. And that, many people, what their obsessions and compulsions are, OCD yes, we think hand washing, but the majority of people have obsessive, they can have very dark thoughts, thoughts about harming themselves or other. They're not going to, but they have an obsessive worry about it. I am worried I'm going to kill myself. I am worried I'm going to hang myself. These are things people have told us. They have no plan, no intention, but there is a thought that comes in.

They can worry, they can have thoughts about demons, thoughts about knives, sexual things with never having been sexually victimized in any way. These are intrusive thoughts that have no logic behind them. I think that's one of the big differences about OCD there's often no logic where in anxiety, there tends to be a bit of truth. I'm worried about tests, school tests, because they're imported. Now in OCD it could flip to that you're worried and you have a series of rituals around these tests, and it's taking two hours a day. You believe that if you do a prayer ritual for 43 minutes, and it could be that specific that you will then get a good grade. If you don't do that for 43 minutes, and let's say, you're interrupted, you will get a bad grade. Do you see that distinction and the rationality? So really, really important to understand, and that that's so hard. Then therapists, we got trained. How much of OCD training did you get? Not much.


No, not much at all.


And it kind of got lumped in with anxiety, but yet we didn't know how to treat it. What happened is doing, being that, if you listen to the other episode about neuro-feedback, I deal with a lot of very challenging, layered cases. I also get some pretty straightforward cases, like a nice little case of ADD.


A nice little case.


But most of mine are just like super layered


Yes, you can take on the hardest cases


I take on the hard cases. So what happened was when I started working with people with OCD, I was like, oh my gosh, how am I going to help them? Because OCD is about the over-activation of the nervous system, the obsessive thinking compulsive behaviors that are deeply rooted in behavioral habituation. And as I gave you that example of the negative reinforcement cycle, people inadvertently reinforce people's OCD all the time. You don't even know you're reinforcing in the case of a kid or partner or a loved one because I have lots of adults who literally can't live their lives, are completely eclipsed by the OCD and people around them comfort them.

Instead of saying, hold on, you got through this yesterday, let's go through the three steps you did yesterday, and then you get them to learn how to cope. So that is so important. What exposure, response, and prevention is it's an amazing asset because when I started to realize, wait a second, I wasn't getting people better at the same rate, 90% or better when people come to me, consistent with research about neuro-feedback. I was lucky if I had 30 to 40% of people with OCD get better just with neuro feed feedback. You need to behaviorally dismantle the behaviors.


So can you talk my listeners through it? So how does it usually start?


So what we do is we do a combination of neuro-feedback. We get the nervous system regulating. At the same time, we do exposure and response prevention. So ERP is about educating the client in the neuroscience, so what I talked about, this negative reinforcement cycle. They get the insight, they understand, then they understand how to break free from accommodation. They learn how to talk back to their OCD and their worries, or intrusive thoughts, their compulsive behaviors or rituals. They're given those tools but how that happens is in the psychoeducation process, we're learning about what are your triggers?

In the case of the boy, it was the weather. Anything related to weather you could have a benign conversation about the weather, boom, triggered obsessive thinking and a series of rituals for him. What then happens is in a therapy session, you learn through safe exposures. You expose somebody in that case. What would be a safe exposure? Well, you could pull up the weather for the week and in the session or one day you could do a start with something easy, like sunny weather, and then say, okay, let's check the weather right away.

Lots of anxiety, has an obsessive belief that he will be harmed or killed if there is any type of lightning or bad weather in particular. So then it would be like, look, it's raining outside. Let's look outside, whatever it is, and then realize I'm not going to pass. And every time you do that, he then realizes and challenges his belief system, his rational, compulsive, obsessive thinking, and then he then gains control. So it's teaching him, you're safe, you're in control and you're practicing that.

You're giving them tools and really, really, really, really critical to the efficacy of exposure and response prevention, especially when there's kids involved, is the people in your life learning how to not feed the barking dog, how not to accommodate, because we inadvertently do it and having that consistency in the practice themselves within those ERP sessions so that they can do it outside of the session. It is the most evidence-based type of cycle therapy for ERP, I mean, for OCD. ERP is very structured. There's a rigidity to the treatment that lends itself beautifully with OCD because the person is rigid in OCD. It's sort of like a step by step methodology with a lot of teaching of coping skills and tremendous amount of psychoeducation.


So I'm guessing that those that have OCD would probably like that too, to have that structure.


They do love the structure. People with OCD can, you know, there's two kinds of people with OCD in terms of like, it's just like any other therapy and all the therapists that listen, there's people that are ready and there's people that are not. And even the people that are not, if they're sick and tired of that OCD, that anxiety, whatever is their affliction, they are willing to do the work. So you have to be willing to do the work and in the case of parents supporting a kid, they are usually the determining factor in if a kid's going to get better or not, because I'm going to tell you that probably a third of parents who attempt OCD they stop because they can't handle it.

So as I always talk to my parents about working smarter not harder, so they're already working real hard. They get caught in a behavioral cycle with their kid that's OCD. The OCD is ruling the household, and it's a tyrant. OCD is like a tyrant I've never seen, sometimes even more so than addiction. That's how hard OCD can be to break. And they don't want to have another, what that feels like them at first is an initial hill. So they have to learn how to break their part. And obviously, we talk about feeding the barking dog and like, it's just shifting your language so that you shift towards not accommodating and teaching coping skills.

And it's hard. It's not easy, but it is unbelievably effective. If people are compliant the rates of efficacy are quite rare in terms of like in psychotherapy, but they do appreciate the formality of it, the consistency of it. And you need a consistency when breaking a behavior and ERP does a great job of it and therapists have to like it. You can't all of a sudden start talking about out feelings about something else. You have to stick to the ERP because your job is to dismantle those behaviors. So it requires rigidity on the therapist part as well.


That's true. So how is it different? I know you talked about traditional therapy is not effective usually for OCD. So how's it different from like CBT? I know that's a very common modality.


So it does blend in some CBT. It absolutely does, but you are using it in a way that is relevant to the OCD and you're really focusing on the exposure. With CBT know we're doing cognitions and behaviors, and that's absolutely part of what you have to do, but CBT alone is not as effective as when we incorporate the exposure part. It requires a finesse. My book Teletherapy Toolkit, we have a whole section on ERP and OCD because it is something we're not learning about. I certainly would, if you have a population of people with OCD or you're willing to work with that, there's some great trainings out there.

You can log onto IOCDF and it's worth this kind training, because I even like doing exposures, obviously with people with anxiety, with different areas. We all get stuck on thoughts. Sometimes they can just eclipse your rational thinking and quickly turn on this obsessive compulsive bent. And no, you don't have to have genetic OCD to have OCD. In fact, it is the least common form of OCD that I see. It often just morphs on its own and also can be very inflammation-based, which we're starting to see talk way more about a mental health that people have inflammatory conditions, which are turning on things like OCD.


Wow, I had no idea.


Oh, absolutely. I mean, there's even, we know that through postmortem studies with autism, 72% of brains with autism have inflammation and about a third of people with autism have OCD. So there's so much comorbidity and inflammation is one of the primary causes of mental health issues. You're just not hearing about it because good old pharma wants us to think everything is biochemical and genetic, because then there's a pill for it.


That's true. That's why I love holistic counseling too, because we do look at the whole person and could there be other factors that are causing some of these issues


Could there be treatments that we're doing, which is so important why you're having these conversations.


To really open people's minds, right?


100%. Absolutely. I mean there's probably a therapist right now thinking, oh my gosh, I've got two people, three people on my caseload right now that have OCD and I am not giving them the best type of treatment, which is how I found ERP. I was like, I got to do something different because I'm not okay with people not having significant change. I knew that I was getting more and more people with OCD and if I was going to serve them, then I needed to do a better job in the psychotherapy part. Otherwise I was going to have to start finding somebody else to refer them to.

Unfortunately there's not a lot of providers that do ERP, which can be quite advantageous. I mean, people come to us from all over to do ERP. So if you're a therapist looking to niche down this is a wonderful area to niche down. There's such a desperate need. If you're somebody who likes order, which I do, because I come from neuro-psych testing this is a wonderful therapy because it really does unwind the behavior right in front of your eyes in a way that is so different from talk therapy.


How involved is the training for that?


Well, they have trainings that are, if you go to IOCDF, I think it's UMass, has a training that's about a month virtually. It's a great training and it gets you started and after a month you can start really incorporating some of these things. I mean ---


That's not too bad.


No. And of course I hired a clinical supervisor and we did our whole practice, got the training a number of years ago. I knew we are only a holistic practice. So I found a holistic ERP provider to train our staff. So that I wasn't going to hear medication, medication, medication, because there's not a lot of good research to support the medication. We know with OCD you've got to do psychotherapy that addresses the behavior. It just is not as effective. It's not.


That's why I was wondering too, if this can be used with other holistic modalities.


It's a wonderful adjunctive. I know some of your recent podcasts, you've had stuff about essential oils. I love essential oils. I have them right out right in front of me. Certainly I always use it with either neuro-feedback or something called PEMF, which is Pulse Electromagnetic Frequency, which calms the central nervous system or biofeedback. I use it with that.

But also there's wonderful supplements. I have great blogs about supplements for OCD that are evidence-based. So there are many, many resources and tools, yoga, I'm just trying to think of just whatever feels right to a person that doesn't feed the OCD component of it can be a great add on. The great part about holistic therapies, Chris is that they often work synergistically only just together, but they often boost each other because once you focus on regulating that nervous system, everything can work at a higher, the way that it's supposed to be. I say higher level, but really it's the way that it's supposed to be.


Getting back to that homeostasis, right?


That's right.


Hopefully, that's the goal. It's not easy to get there.


It's not easy to get there. And once you get there, you got to keep going.


I know, and maintain, oh my God.


You got to maintain. That's what the beauty of holistic therapy is. There's so many tools and resources that you can be in control of. I love, as therapists when we teach our clients these things because they're not learning it unless they seek it out. So it's a wonderful opportunity to create lifestyle changes for our clients.


So Roseanne was there anything else you wanted to share about what we talked about today?


I would just say that if you, if people are talking about, you know with OCD we can't approach it with feelings. That is not where they're at. We have to really meet them on the thinking level because it's intrusive thoughts. When you're asking them to connect to the emotions part of it's like talking Chinese to them when we're supposed to be speaking French. So really focus on psychoeducation, teaching them to talk back to their worries, their intrusive thoughts, their compulsions, and really supporting the thinking and sensation part of it. Emotions come later but they're so caught up in these looping intrusive thoughts that they're going to always think therapy is ineffective if we approach it from feelings. So consider ERP and I highly recommend all the therapists out there to get onto IOCDF website to learn more about it.


Can you send that link? I'll put it in the show notes.


Yes, I will.


That would be great. So what's the best way for listeners to find you and learn more about you?


So I'm Dr. Roseann everywhere. D-R-R-O-S-E-A-N-N.dot com. I'm on YouTube, Instagram, TikTok, you name it, as Dr. Roseann.


She is everywhere. I was telling her before we recorded too, that she has so many interviews that you can learn so much from her. And your book is out too.


Yes, I have my book, It’s Gonna be OK! It really talks a lot about how to reduce and reverse mental health system issues and conditions and symptoms just using only proven holistic therapies. So it's written technically for parents, but I want you to know that this is really for everybody. I know a lot of therapists buy it.


Well, thanks for coming back on the podcast.


I'm so grateful to be here.


This has been great. I want to thank my listeners for tuning in to today's episode. Let's continue to build this holistic community. You can help by sharing this episode with a friend and remember to subscribe, rate and review wherever you get your podcast. And once again, this is Chris McDonald, sending each one of you much light and love. Until next time, take care.

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