Organized Chaos - Volume 9
Group Treatment For Teens
by Dr. Kerry Collins and Dr. Julie Eichstedt
Children’s Hospital of Western Ontario, London, ON, Canada
“Are you sure I’m going to get better?” “Have you ever met other kids my age with this problem?” “Do you really understand what I’m going through?” These are some common questions asked by teenagers suffering from OCD. Based on our professional experience,we can provide positive and confident responses to them about the value of cognitive-behavior therapy for reducing symptoms and improving their ability to cope with this disorder. However, we have also learned directly from teens that the most powerful intervention for them is meeting other teens with OCD who share the same daily struggles and challenges.
It was several years ago when we first realized the value of starting group treatment for teenagers with OCD. In fact, the decision to develop and offer a group intervention was inspired by a teenage client we were working with around 4 years ago. Stephan (pseudonym) was overwhelmed with intense obsessional thoughts that someone in his family would be harmed if he didn’t perform compulsive rituals. He felt paralyzed in the morning when he tried to get ready for school and at nighttime before bed, describing OCD as a “mind trap” that forced him to complete various checking behaviors. Despite being a skilled student and enjoying time with his friends, his life had dramatically changed since the onset of OCD and it was difficult for Stephan to concentrate on his schoolwork and even leave his home. His parents were very concerned about him and approached their family doctor to get some help. The doctor referred him to our service at the Children’s Hospital of Western Ontario. Being diagnosed with OCD by a professional was an important first step for Stephan in treatment, as it normalized his present experience and empowered him to learn all about the nature and cycle of OCD symptoms.
Stephan was incredibly motivated to gain control over his OCD and this assisted him to make numerous gains in individual treatment. As an initial step, it was very important to assist him to disengage from the OCD mind trap, by separating his own thoughts, feelings, and choices of behavior from those imposed by OCD. This process of externalizing the disorder was facilitated by monitoring and labeling the “OCD Bully.” Stephan felt this term captured his experience of being bossed around by OCD and suffering intense negative thoughts and anxious feelings. Treatment proceeded to learning cognitive challenges for Stephan’s OCD messages and images. Although Stephan made gains through individual treatment, he often felt OCD made him “weird” and “different” from other kids his age. To address his concerns, as well as those of other clients, Dr. Eichstedt and I decided to offer a group treatment for teens with OCD in collaboration with our colleagues. In retrospect, this was one of the best treatment decisions for Stephan; as by the end of the 8-session Group Treatment For Teens group, he reported his OCD symptoms in the minimal range of severity. Moreover, he was able to feel back in control of his life, spend his free time with friends, complete school assignments on time.
The Teen OCD Group at the Children’s Hospital of Western Ontario has proven successful every year since it started and repeatedly teens comment on the value of meeting other teens with OCD. Stephan described feeling like he was part of a supportive team in the group, who together fought the OCD Bully with their coping tools. Satisfaction comments from other teens that have completed the group consistently identify meeting other teens with OCD as their favourite aspect of the group. Descriptions about the positive and friendly atmosphere of the group and helpfulness of sharing treatment with other teens further capture the helpful and powerful aspects of peer support. In fact,we believe the support from other teens in the group is directly related to the accomplishments made by group members during treatment. Teens are able to motivate each other to challenge OCD through their shared experiences and insight into beneficial coping strategies. Parents similarly report that it was important for their son or daughter to complete treatment challenges together with other teens with OCD.
Over the past few years, the group program has been further developed based on feedback from teen clients, their parents, and research developments in the field. The Teen OCD Group is now comprised of 12 weekly sessions, with a family meeting held before and after the group to discuss teen’s symptoms and treatment accomplishments. The number of teens in the group varies each year, but generally around 8 teens participate and range in age from 13 to 16. The treatment provided is cognitive-behavior therapy, primarily based on the work of Dr. John March and colleagues (1998, 2004, and 2006). A major component of the intervention is having teens engage in exposure and response prevention exercises to target their specific OCD symptoms. This involves purposefully facing anxiety-provoking situations (e.g., touching “germs” in the bathroom) and resisting the related compulsive behavior (e.g., washing hands repeatedly). To maintain a positive atmosphere and build teens’ courage, these exercises are completed in game format (e.g., Fear Factor Challenges), with prizes awarded for participation. A parent group is also run simultaneously to provide psychoeducation on OCD, to discuss and teach components of cognitive-behavior therapy, as well as to offer support from other parents and professionals. Teens also join the parent group on two occasions to review coping strategies learned and homework assignments.
Prior to starting the group, an initial family meeting is held to provide an opportunity for teens and their parents to meet the group leaders, as well as have questions/concerns about OCD addressed. Teens vary in their knowledge of OCD and experience with treatment; and it is important that they feel comfortable with, and understood by, the group leader. The group leader provides an overview of what’s involved in the Teen OCD Group (e.g., exposure and response prevention exercises, homework assignments) and neutralizes any fears they might have about joining a group. Past and present OCD symptoms are then identified with the family by completing the Children’s Yale-Brown Obsessive Compulsive scale (CY-BOC; Scahill et al., 1997). The teen is then asked to set goals for treatment by choosing specific obsessive and compulsive symptoms that s/he would like to target in the group. Using a 10–point rating scale (0 = minimal anxiety; 5 = moderate; 10 = severe anxiety), teens rate each OCD symptom and use these ratings to form an anxiety hierarchy for treatment. The hierarchy serves to outline the sequential fashion for targeting OCD symptoms in treatment. OCD symptoms eliciting the least amount of anxiety are challenged first to ensure the teen is successful and confident with the exposure exercise, followed by those symptoms eliciting more intense anxiety. A few other questionnaires are also completed before the group to assess the nature and severity of OCD symptoms (e.g., Leyton Obsessional Inventory; Berg et al., 1988).
Once the Teen OCD Group begins, each session follows a structured format in which specific topics are discussed each week (e.g., symptoms of OCD), coping skills are taught, and group members complete an exposure and response prevention exercise together. Each teen receives his/her own printed group manual containing additional information from each session and sections for completing his/her homework assignments. Yes, an important part of the group is homework and we would like to acknowledge that most teens initially are not very enthusiastic about this part of treatment. However, when the benefits of homework exercises are explained to them (e.g.,OCD symptom tracker,worry logs), they are usually willing to give them a try and do find them beneficial. For example, teens are asked to monitor their daily OCD symptoms with the OCD tracker, identifying the situations in which symptoms were more intense and reflecting on specific triggers (e.g., feeling bored, having an argument with a sibling). Most teens feel this gives them increased insight and control over OCD symptoms, because they learn what internal and/or external factors make them more vulnerable to OCD.
The supportive atmosphere of the group is facilitated by the wonderful personal characteristics of the teens participating, as well as shared activities completed during the group. For instance, at the start of group, the interview game is played in which teens ask each other personal questions (e.g., do you have any hobbies?) and then share what they have learned about each other with the whole group. Group rules are also established collaboratively in order to build a trusting environment. A discussion of OCD symptoms is also facilitated and teens are asked to share their past and present struggles with the disorder. Teens with OCD have similar symptoms (e.g., fear of germs) and they often begin to compare daily compulsive behaviors, such as how many times they wash their hands (usually ranging from 20 to 50 times) and how much hand soap they use. Other OCD-related behaviors are also pointed out and shared among the teens, including carrying hand sanitizer and toilet paper in their school bags, as well as avoiding public washrooms. Treatment also is comprised of a lot of group games and exercises that help the teens bond together. Specific “Fear Factor Challenges” are conducted each session to assist teens to engage in an exposure and response prevention exercise. To address their fear of bathroom germs, the “Fear Factor Challenge” involves touching a range of anxiety-provoking objects, from the door handle, sink taps, hand dryer, toilet flusher, to the toilet seat and water (if the teen dares!). Upon completion, teens resist washing their hands until their anxiety has decreased and they are encouraged to delay washing as long as possible to prove to themselves that nothing bad will happen to them (in contrast to what the OCD Bully tells them). Although the teens experience anxiety during the exercise, they manage to stay positive and focused during the task, making jokes with each other in order to get through it. Other exposure exercises include the “Laundry Game” and “Clean Sweep.” In the “Laundry Game,” the teens form small groups and compete with each other in relay format to grab “dirty” pieces of clothing to fill their team’s laundry basket. Small prizes are awarded to the winning team. The “Clean Sweep Game” was designed to address OCD hoarding behaviors and teens are asked to bring in a variety of personal items that they have been saving over time. The types of items vary among the teens, ranging from years of school assignments and notes, to stuffed animals and birthday cards, to books and rocks. Parents assist teens with their collection of items from home for this exercise by helping them fill and carry in garbage bags or bins of personal items from their bedrooms. For the game, teens in the group are again paired together and asked to help each other to throw away items (or recycle) to challenge their OCD. Ten minutes is allowed for the task and at the end of the time limit, group members vote on the teens who have demonstrated the best reduction of hoarded items.
Additional exposure and response prevention exercises include the “Haunted House” and “Dirty Clothes” challenges. Both interventions target fears of germs by having the teens face anxiety-provoking items and resist washing their hands or changing their clothes. In the “Haunted House,” group members wear blindfolds and are guided through touching a series of “scary” items by the co-leaders. Items are carefully selected based on the teens’ specific OCD symptoms and they do not present any real health risk. Typically, the scary items to be touched include previously used hair bands, bars of soap, body sponges, and towels. Teens monitor their anxiety level and try to touch all of the items with their hands, but often the harder items are touched briefly with one finger. The “Dirty Clothes Challenge” functions the same way. The group members pass a range of previously worn clothing to each other and practice coping with their anxiety. At the top of the fear hierarchy is a sweaty and slightly stinky t-shirt for the teens to touch and put on over their clothes. Although this is a very difficult challenge, several group members have been able to complete this task and even nicknamed the t-shirt the “Sweatmonster 3000.”
One of the benefits of completing exposure exercises in a group context comes from the opportunity it provides to observe either more confident teens tackle the situation; or conversely, watching someone who was previously quite afraid, overcome his/her anxiety. We have found that seeing others participate in these exercises can empower teens to work even harder at challenging their OCD Bully.
Further peer support is facilitated through completion of cognitive exercises in the group. One of the main activities for practicing cognitive restructuring of obsessional thoughts is “OCD Court.” As the name suggests, teens are asked to take their OCD to court and argue against the OCD messages in front of their peers. Each group member takes a turn being the defense attorney, prosecutor, judge, and jury member to decide whether OCD messages and predictions are indeed true. Teens learn to present and discuss factual evidence such as personal experience or statistics to challenge OCD. Messages taken to court include fears of getting a serious illness from coming into contact with germs in the bathroom, worries about contracting mad cow disease from eating ground beef, beliefs that a family member will be seriously harmed if the teen does not complete a compulsion, anxiety about wearing and touching “dirty” clothes, and the need to know and remember all important thoughts. Group members are really able to advocate for each other during this task and show their ability to rationally think through OCD fears using contrasting evidence. OCD is almost always defeated in this task and the teen is then able to apply evidence to fight OCD when it next arises.
At the end of the group, teens again complete several questionnaires to assess the nature and severity of their OCD symptoms. This allows the group co-leaders to measure changes in symptoms and functioning from before to after the group intervention. Teens consistently show significant reductions in the intensity of their OCD symptoms and improvement in their management of OCD on a day-to-day basis. Co-leaders facilitate a discussion of helpful aspects of the group and request teens’ feedback for improvements at the end of group, as well as during follow-up appointments with their parents. Consistently teens acknowledge how helpful it was to be in treatment with other kids with the same problem. They felt understood, supported, and not alone in their battle with OCD. In light of the powerful nature of peer support,we would like to thank all the teens who have participated in the Teen OCD Group to date at the hospital and encourage other teens to seek out group treatment in their community or consider starting your own peer support group.
