Helpful ERP Therapy Considerations for the Autism Spectrum & OCD

Obsessive Compulsive Disorder can often co-occur with the Autism Spectrum Condition. In fact, 17.4-37 % of autistic individuals also can have OCD at the same time (vanSteensal, et., al 2011; Zabowski & Storch, 2018). For the purpose of this blog post, I will refer to autism in identity first language. It’s important to remember to check with our individuals and families who are on the spectrum and explain if needed the differences between person-first and identity-first language. In doing so we can ask them what they prefer to better explain their experiences. A person-first approach would be saying “a person with autism” and identity first approach is seeing autism as part of who the person is “I am autistic”. At Spectrum Connections Therapy, I prefer not to pathologize autism per the medical model for diagnosis but rather support that autism is just a different way of experiencing the world vs. how a neurotypical experiences the world.

Autism Spectrum Condition

Most recently based on data collected from 2020 and just published by the CDC, 1 in 36 eight-year-olds are now identified as autistic. Current research shows autism affects more boys than girls, but I feel this is likely because it can be entirely missed in girls as it presents a bit differently. The Autism Spectrum is a neurodevelopmental condition that affects social, communication, and behavioral functioning. In other words, autistics have some processing differences in how they experience the world. These differences include: thinking, interpreting social information, emotional processing skills, sensory/motor differences, and interoception challenges (difficulty interpreting physiological cues such as feeling hungry, or tired). However, despite these processing needs, the treatment for OCD is essentially the same for autistics. However, modifications will be needed to account for some of these individualized needs and I recommend looking for a therapist who can make these appropriate accommodations for successful treatment.

Autism and OCD

Autistics tend to have restrictive and repetitive behaviors (RRBs) or limited interests, and this is one of the criteria that meets an autism diagnosis. Common RRBs can be lining up toys, opening and shutting things, sensory behaviors, touching things a certain way, counting, and so on. These RRBs can function as a way to feel safe, calm, and good. The RRBs also can maintain a sense of predictability for the autistic when navigating a neurotypical world that can often be overwhelming for them. At Spectrum Connections Therapy, I maintain a neurodiversity-affirming and trauma-informed approach to treatment that supports safety. These restrictive and repetitive behaviors are more rule-oriented in nature and are not necessarily needing treatment in therapy unless they are really getting in the way of daily functioning. Someone with OCD may also have restrictive and repetitive behaviors but those in OCD serve the function of reducing anxiety or a feared outcome. It will be important to find a therapist who can work to identify what are autism-specific behaviors and traits versus OCD loops that function to reduce anxiety and that need specialized treatment with ERP.

Autistic Modifications to Support Exposure Therapy

When working with an autistic individual and/or family who is seeking treatment for OCD, it’s important to find a therapist who can work to individualize treatment and provide accommodations and modifications for OCD treatment and autism spectrum condition. The gold-standard treatment for OCD is the use of Cognitive-Behavioral Therapy (CBT) along with Exposure and Response Prevention (ERP) Therapy. At Spectrum Connections Therapy I specialize in issues related to OCD and autism. Some appropriate modifications and considerations for therapy may include:

  • Using a strengths-based approach set up the environment to promote success, engagement, motivation, and executive functioning abilities.
  • Autistic clients tend to be more visual learners and processers, so using visual schedules, using timers and/or countdowns, and strategies where time management planning and organization are supported,
  • Therapy should promote a sense of structure and predictability with the use of concrete examples and strategies. Visual schedules and plans versus verbal instructions, worksheets with multiple choice examples vs. open-ended questions, the use of social stories to promote social thinking, emotional awareness activities, and alternative thinking strategies. Therapy should also use role plays to learn new coping skills, and positive self-talk and also to support in-session exposures as part of anxiety and OCD treatment.
  • The therapist should provide opportunities for choices and promote a sense of agency for individuals in the session.
  • To increase motivation and engagement, the therapist should individualize and incorporate special interests into the session to make therapy meaningful and rewarding.
  • The therapist should also model and prompt helpful behavior (e.g., brave behaviors to beat our OCD brain bully or anxiety monster).
  • In addition to CBT and exposures, therapy may need to include direct teaching of other skills such as activities of daily living, social skills, emotional regulation skills, and executive functioning skills. All sessions should be individualized based on the client’s current needs.

If you’re interested in learning more about OCD treatment and autism, please don’t hesitate to contact me. More importantly, if you or your child have been diagnosed with OCD and need help learning how to manage your symptoms I’m here for you. Together, we can work through the techniques necessary to take control of your anxiety and OCD. I will also hold space to support and celebrate your autism spectrum traits and help you connect to a more joyful and meaningful life while affirming your identity. With the right support in place, you and your loved ones can learn to thrive. Please feel free to contact me for a free 20-minute phone consultation to hear more about how I can help.

Be well,

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