OCD Treatment Considerations for Autistic Individuals

Rebecca Sachs, PhD

Rebecca Sachs, PhD

About the Author

Rebecca Sachs, PhD, is a licensed psychologist and an expert in the top recommended treatments for Anxiety, Autism, and OCD. She believes in empowering individuals and their families with knowledge and skills. Board Certified in Behavioral and Cognitive Psychology, Dr. Sachs was recently awarded a federally funded grant through the New York State Office of Mental Health, aimed at helping train community-based service providers better serve children and youth who are dually diagnosed with mental illness, like OCD, and a developmental disability. She has a private practice in New York and is co-Director of Successful School Transitions, a comprehensive program for school refusal. In addition to these roles, Dr. Sachs is mom to an energetic and determined 6 year old and step mom to the coolest 15 year old around!


See Dr. Sachs’s companion article:

One of the most effective treatments for Obsessive Compulsive Disorder (OCD) is Cognitive Behavior Therapy (CBT) with Exposure and Response Prevention (ERP). Cognitive Behavioral Therapy (CBT) is a treatment that teaches clients specific skills and focuses on the ways that a person’s cognitions (i.e., thoughts), emotions, and behaviors are connected and affect one another.  Most CBT-for-anxiety and OCD programs generally cover the following elements:

  1. psychoeducation about anxiety and OCD;
  2. somatic management (teaching the client to identify bodily cues for anxiety, increasing awareness of somatic sensations associated with distress);
  3. cognitive restructuring;
  4. teaching coping self-talk, relaxation and problem-solving;
  5. developing a hierarchy of feared situations/those that trigger obsessions;
  6. gradual exposure to those feared situations/those that trigger obsessions; and
  7. developing a positive reinforcement system to reward the client/for client to reward themselves for completing or attempting exposures.

*The most critical intervention in CBT to use when treating OCD is exposure, which means exposing clients to the discomforting stimuli or situations that evoke obsessions and the related obsessional distress. Exposure involves confronting the distressing situation, whether that situation is real (“in vivo” or in-person exposure, such as confronting a dirty object with germs, like a used tissue) or imagined (imaginal exposure, such as imagining a germs on your hand). The Response Prevention part of ERP refers to making a choice not to do a compulsive behavior once the anxiety or obsessions have been “triggered.” All of this is done under the guidance of a therapist at the beginning — though the client and family can eventually learn to do their own ERP exercises to help manage OCD symptoms. 

It is well established that when modified and tailored for Autistic youth, with and without co-occurring intellectual disability, this therapy is efficacious in treating OCD as well as anxiety. There is growing research evidence (and my personal clinical experience) that this is also the case for Autistic individuals across the lifespan and not just youth. Exposure has been shown to be the active ingredient in treating these conditions. However, when doing CBT with ERP with Autistic clients, it is important to include neuro-affirming modifications that are tailored to each individual’s needs.

Cognitive Behavior Therapy

Some general modifications to CBT when working with Autistic clients are:

  • Increase structure, predictability, and choice
  • While a hallmark of general good CBT practice, it is even more important when working with Autistic clients to: collaborate on agreed upon goals that are relevant to the client (including youth) 
  • Tailor the therapy environment to accommodate Autistic differences
  • Ensure the client has a functional way to communicate
  •  Use concrete and visual teaching strategies and relay information in a multi-modality fashion that include written information (vs relying solely on speaking)
  • Simplify cognitive activities and deemphasize speaking activities
    • Social stories to teach psychoeducation & cognitive restructuring
    •  Video modeling and/or role-play to teach coping strategies
    • Worksheets/questions with multiple-choice lists instead of open-ended questions
  • Make abstract concepts into concrete “hands-on” activities (e.g., role-play)
  • Use literal language
  • Use modeling (including video)
  • Incorporate “special interests” and passions into treatment delivery (not just as rewards)
  • Use a reward system with highly meaningful and personalized rewards, but also be attentive to the possibility that a reward system may inadvertently feel like pressure (vs motivating) to the Autistic client
  • Longer/more sessions to allow for more opportunities for repetition and practice 
  • Slow the pace of treatment to allow for breaks and information processing differences
  • Teach skills and make adjustments/accommodations to address autism-specific difficulties that contribute to distress/anxiety*(These skills will also benefit NT individuals, but may not always be included in CBT)
    • Teach, practice and encourage  Functional Communication skills
    • Teach and prompt coping skills (e.g., coping self-talk, relaxation) 
    • Teach, practice and prompt Problem-Solving skills
    • Teach, practice and prompt  Adaptive/Daily Living skills
    • Teach, practicum, and prompt Executive Functioning (EF)  skills and use of EF modifications
    • Teach, practice, and prompt Self-Advocacy skills and willingness to accept help
  • Increase focus on generalization
    •  Increase caregiver/family involvement
    • Increase school involvement when working with youth.

Exposure and Response Prevention

While all the above modifications apply to delivery of exposure therapy, below are specific and critical modifications to ERP when working with Autistic clients:

  • While a hallmark of good exposure therapy, it is even more important when working with Autistic clients to: collaborate on agreed upon goals that are relevant to the client (including youth) and which they feel ready to address
  • Not all fears need to be faced! Every compulsive behavior does not need to be immediately targeted.
    • Not every behavior needs to be changed and not every fear needs to be confronted.
  • Is this distress/avoidance truly harming the client’s quality of life?
  • Before starting exposure work- even hierarchy creation:
    • Incorporate Functional Communication Training (FCT)/have a functional communication systems, so there is a way to ask for a break
    • Establish trust, (not only rapport building) with client
    • Address alexithymia and understanding the emotional experience (including physical sensations)
  • During exposure work:
    • Ensure a sensory- safe space
    • Reduce/eliminate non-exposure related demands (eg. social-emotional, verbal, executive functioning, sensory, and  interoception demands)
    • Create a hierarchy that focuses more on “willingness to approach” vs. “how distressing”
    • Consider not using Subjective Units of Distress (SUDS) when doing exposures or changes to a simplified/more visual way of rating (eg. feelings thermometer, 0-5, low-medium-high)
    • Be prepared:  hierarchy creation may itself be an exposure 
    • Clients should be prepared and know exactly what to expect during an exposure (eg. visual agenda, clear expectations, social stories, priming)
    • Find ways to start very low on exposure hierarchy and move slowly from one exposure to the next
    • Consider starting with ritual delay and restriction versus response prevention
    • Incorporate counter-conditioning when relevant (especially with clients with co-occurring ID). *counter-conditioning is pairing distressing stimuli with positive “anti-distressing” stimuli non contingently during the exposure.

References

Moskowitz, L.J., Zaheer, I., Smith, A., Benitez, N., Ross, R., & Sachs, R. (under review). Adaptation of CBT to treat co-occurring mental health problems in autistic youth. In. M. Terjesen & R. DiGiuseppe (Eds.), Essentials of CBT with Children. Wiley.

Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., & Hepburn, S. (2012). Group cognitive behavior therapy for children with high-functioning autism spectrum disorders and anxiety: A randomized trial. Journal of Child Psychology and Psychiatry, 53, 410-419.

Walters, S., Loades, M., & Russell, A. (2016). A systematic review of effective modifications to cognitive behavioral therapy for young people with autism spectrum disorders. Review Journal of Autism & Developmental Disorders, 3, 137-153. 

Resources

For Whose Benefit? Evidence, Ethics, and Effectiveness of Autism Interventions

What is Cognitive Behavioral Therapy?

Obsessive-Compulsive Disorder: Fact Sheet

Exposure and Response Prevention (ERP)

Videos: Natasha Daniels, Anxiety & OCD Therapist

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