JOSH FEDER: Welcome to the Carlat Psychiatry Podcast. This is another special episode from the Child Psychiatry Team. I'm Dr. Josh Feder, MD, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of the Child Medication Factbook for Psychiatric Practice, 2nd Edition, 2023, and the other book, Prescribing Psychotropics. 

MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of The Carlat Psychiatry Report.

JOSH FEDER: We were so happy to interview Dr. Robert Friedberg, PhD. He's a clinical child psychologist doing private consultation and training on cognitive behavioral therapy to individuals and institutions. The reason why I had hoped to get us together is to talk about office-based OCD CBT. So, obsessive-compulsive disorder cognitive behavioral therapy for clinicians who aren't necessarily doing a whole lot of psychotherapy. Back in the day, we did a little bit more in psychiatry—we did psychotherapy training. And I still do a lot of therapy. And by the way, the American Academy of Child and Adolescent Psychiatry just did a policy statement that encourages trainees in child psychiatry to get psychotherapy training. But in any case, back then, I got a little bit of training in cognitive behavioral therapy in the style of Aaron Beck for depression. And then John March came in probably 15 or 20 years ago with his book Talking Back to OCD, which was a handbook for working with kids and adolescents and their families with OCD. It's hard to find a therapist. The question I have is, is it possible for general clinicians who are prescribers—and that can include psychiatrists, pediatricians, nurse practitioners, or others who are prescribing— is it possible for them to learn office-based CBT? 

ROBERT FRIEDBERG: It depends on the person's interest, their competency, their practice setting. You know, I think if you are only seeing folks for 10, 20 minutes, and that's more difficult, the treatment of OCD via exposure-based treatment, but certainly it's possible that you know, there's nothing that would absolutely prohibit it, probably other than the time constraints, potentially reimbursement constraints, those type of things. 

JOSH FEDER: Well, you know, in terms of the current circumstances, what do you see as the limitations to finding good cognitive behavioral therapy for OCD? 

ROBERT FRIEDBERG: One of the things that is absolutely indispensable with OCD is the exposure-based component of CBT. For any of the anxiety disorders, if you do the CBT package without the exposure, it loses its effectiveness. Even among practitioners who self-identify as CBT-oriented, few of them are doing exposure. The real big part of this is finding a clinician, regardless of their discipline, who does the exposure with the kids.

JOSH FEDER: Are there like list serves or things where you can find people who are able to do it in a competent way? 

ROBERT FRIEDBERG: Yes, there are some websites that are helpful. Probably the most comprehensive one is the Association for Behavior and Cognitive Therapy, ABCT. If you search that on the search engine, when you get to their website, it'll say, find a therapist. Then you can search your geographic area, and you'll see that when you click on someone, whether they do exposure. Then another one is the American Psychological Association Division 53 website, and again, it's the same type of thing. There's a button for find a therapist, and that's the same sort of directory. And then there's a third one, which is at the Beck Institute. Again, same type of thing. You go to the web page, and it says locate a therapist.

JOSH FEDER: Do you have a sense of how social determinants impact availability of care for kids with OCD? Do we have any numbers on how much harder it is for those populations?

ROBERT FRIEDBERG: There's nothing particular about OCD treatment that makes it more or less accessible to traditionally marginalized populations. 

JOSH FEDER: Do you have any sense of the effectiveness of those kinds of online or app approaches? 

ROBERT FRIEDBERG: Really, where they have the benefit is in the facilitative skills part of the exposure treatment. So, in teaching kids, in orienting them to OCD, to teaching them some basic coping skills, some talkback strategies, those are nice augmentations. Where it loses its effectiveness is that you can't do the exposure via the app. 

JOSH FEDER: Maybe we should talk just a little bit more about the concept of exposure and how important it is.

ROBERT FRIEDBERG: In a very simple sense, exposure is an experiential procedure that helps any patient encounter what they fear and realize that the threat that they have expected from encountering that fear is not present and that they have learned then to tolerate the distress associated with the previously avoided situations. So, in the example of kids with OCD, it might be touching contaminated surfaces and realizing that the contact with the surface is not going to kill them or that leaving kids with symmetry obsessions and compulsions, leaving something that's awry or not aligned, and it not being perfectly symmetrical won't lead to some dreaded consequence, whatever that might be, that's what exposure does. There's an article that said that many practitioners may shy away from it is just by the notion of the word exposure. So it's now being essentially re-termed, or the idea is to re-term it as something called SAFE, S A F E, C B T. With SAFE being Supported Approach to Feared Experiences. That may be less of a scary term than exposure. And that sums up, in kind of what I said, is that you're really coaching them to, in a gradual manner, safely approach, with support, what they feared and avoid. When exposure first came out as the gold standard, probably 30 years ago or a more, the prevalent model was something called the emotional processing model. The person confronts the dreaded circumstance, and then they tolerate that until the distress goes down. Until they had, essentially a 50% decrease in subjective distress and anxiety, and that worked well. But it wasn't as effective as we in CBT liked. So, around 2008, a new movement started taking hold established by Michelle Craske, PhD at UCLA, and it is called the Inhibitory Learning Model of Exposure. The level of distress can remain the same as long as the person tolerates. So it's essentially learning to accept that you're going to be distressed in the situation where you're touching a toilet seat or leaving the crooked picture frame and not making it symmetrical, right? The key is that you tolerate the distress. Let me give you a case example. I just supervised this case. It was a kid who had a contamination fear, and they did graduated exposure where they—the kid— was going to touch perceived contaminated surfaces. First time the patient held on to the surface for a period of time, while holding a couple of tissues as sort of a barrier, and then they faded out the tissues and they just held it bare-handedly. The key part was they held it for a long period. The anxiety stayed the same. But you have to make predictions ahead of time, collect data in terms of what they're observing or experiencing during the encounter with the exposure, and then debrief afterward. And you want to try to reduce safety signals. The main part of safety signals is avoidance or to kind of neutralize the obsession or compulsion. You're looking at being able to tolerate the distress that you want the person to be able to have skills to tolerate the distress when they're in the encounter. 

JOSH FEDER: How would you structure the assessment: telling them about it and carrying it out? What would the simple nuts and bolts be of this kind of procedure?

ROBERT FRIEDBERG: You have to do the exposure to have generalization and durability. So first is sort of orienting them to exposure and to OCD. Yeah, that can take 15 minutes. And again, John March, MD has a manual to do that.  He talks about drawing the OCD, naming the OCD that is all part of it. You want to, though, again, tell them that eventually we're going to, you know, practice touching surfaces, thinking blasphemous thoughts, whatever the OCD symptom is. Psychoeducation, and then you teach them some of the distress tolerance skills. You're definitely going to probably do some cognitive restructuring with the talkback skills. Perhaps some mindfulness techniques could involve some acceptance of the distress. Those type of things can be done in piecemeal in 20-minute bits. Now, the exposure part is where there's going to be some variability, and there are going to be things that are going to affect that 1 is the severity of the case. The other is the provider's ability with doing exposure, and how difficult the item is on the hierarchy that you're working with. Naturally, probably, you know, when you're doing the hierarchy or when you started sort of the moderate in the middle level, the early ones might get some success in 20 or 30 minutes when it's higher levels of distress. I have never done an exposure shorter than 40 minutes. 

JOSH FEDER: Is there a standard way that you recommend people do that in terms of following symptoms? Are we talking about serial Y box scores? 

ROBERT FRIEDBERG: You can do Y box scores. You can also have more individual functional metrics, which would be based on your hierarchy.

JOSH FEDER: Do you know of any research about the effect sizes of doing these treatments and how durable they are with and without medication — that sort of thing? 

ROBERT FRIEDBERG: A lot of your listeners are probably going to be familiar with the POTS study in the early 2000s they looked at three arms. They had CBT, they had Sertraline, and they had combined CBT and Sertraline arm. What they found was CBT had a 39 percent remission rate. The combined CBT and Sertraline was 53%. That led people to say that for moderate to severe cases, you're best with combined treatment. Then OST did a meta-analysis, and 12 years later, they compare the effect sizes of essentially the SSRI and the CBT, and they were roughly equivalent 0.53 for the CBT and 0.4. For the SSRI, and then in a recent one, just looking at CBT, this is a nice review and clinical psych review. In 2021—this probably reflects the change in the exposure models that Wegeland GJH et al— they found effect sizes of CBT to be over two. So that's a fairly robust effect size. 

JOSH FEDER: What do you think about the capacity of a general prescriber to learn how to do reasonably competent OCD treatment for office use?

ROBERT FRIEDBERG: It really kind of depends on the individual. I would love to see prescribers if they're interested to do that. There are really great training platforms to learn that, and some of these people who have the platforms do individual consultations... I would not rely on a book or journal article to learn how to do it. There are a couple of really master OCD people, and one is Jonathan Abramowitz, PhD. And he even has a website where he walks both clinicians and practitioners of all sorts through the process. Eric Storch, PhD, is also another one. He has two sets of great books, you know, Exposure Treatment for Children and Adolescents with OCD. Has, you know, the chapters of the different vicissitudes of working with OCD. Really helpful, and then he has another one, which is a training book for how to supervise it or how to learn it. There are other platforms that train you. Beck has a curriculum where, essentially, you go through some didactics on how to treat OCD. And then, you get 10 individual consultations, where you do video consultation with your case, and you getfeedback on all of that. 

JOSH FEDER: Thanks for those resources. It sounds like you think about OCD and anxiety disorders together, while the DSM back in 2013 separated OCD from the others. Do you have thoughts about that? 

ROBERT FRIEDBERG: OCD is so clearly a disorder. Neurobiological in origin, whereas social anxiety and GAD probably less so. But the key part is that there is such a high level of anxiety around the kid's obsessions and compulsions that it's difficult for me to separate them out from anxiety disorders. But again, I take your question as a chance to launch into the role of intolerance of uncertainty across disorders. And so one thing that's common in OCD and anxiety and eating disorders, even in kids on autism spectrum, is high levels of this thing called intolerance of uncertainty. That's why the checking and the rechecking and the fixing of the different things that are out of line if they're symmetrical is that it's the doubt. Did I do it? Did I really lock that? Did I really get all that stuff off my hands? Will I really not stab these people? All of those type of things. I can't be sure that I won't. And so that's becoming a real transdiagnostic treatment focus. And the good thing is, and this is based on the work of Abramowitz, is that the inhibitory learning model seems to directly target that intolerance of uncertainty.

JOSH FEDER: That's really interesting. Back when DSM5 came out in 2013, at the same time, NIMH came out with the research diagnostic criteria, talking about things that cut across diagnostic categories like anxiety or depression, and this seems to fit that model.

ROBERT FRIEDBERG: Absolutely, there are actually some studies are looking at IU and ...

JOSH FEDER: What can you tell people that will help them in the middle of a busy clinical day to help try to partner with the child. And, the catchphrase is lets you and me..., whether it's the parents saying to the kid or me saying it to a patient, lets you and me be a little bit brave today, a little bit brave together, so that we're kind of walking through this, kind of getting you, your feet a little bit wet. Because the opposite, being a little bit less brave, is the beginning of a process where the person becomes more and more afraid and less and less functional.

ROBERT FRIEDBERG: I do that. There's a great parenting resource for kids, which is called, Freeing Your Child from Anxiety by Tamar Chansky, PhD. I rely on that to do some psycho-ed with parents because it has, in particular, the first chapter is giving your child wings and roots. So, because often time with OCD and with the anxiety disorders, the parents have an urge to either accommodate or be too strict, and this gives them some balance. 

JOSH FEDER: That sounds super helpful. I'm wondering what other thoughts you might have, just as we conclude today. 

ROBERT FRIEDBERG: It's one of the things that behavior therapists lament. You have this really powerful intervention, and it's too infrequently employed outside of academic or training clinics. And people have, I think, a lot of myths and fears about trying to do it, but I think the key part is if you get the training, the supervision, or consultation, I think that exposure work is the most rewarding thing that I have done as a clinician.

JOSH FEDER: We hope you enjoyed today's podcast. You can read more about this topic in our October/November/December 2023 newsletter. Hopefully, people will check it out! 

MARA GOVERMAN: Everything from Carlat Publishing is independently researched and produced. There's no funding from the pharmaceutical industry. 

JOSH FEDER: Yes, the newsletters and books that we produce depend entirely on reader support. There are no ads and our authors don't receive industry funding that helps us to bring you unbiased information that you can trust. 

MARA GOVERMAN: As always, thanks for listening, and have a great day.