2 - (IOP 16) The “When, What, Why, and How” of Scripting in OCD Treatment: Elements to Achieve Effective Change in an Exposure and Response Prevention (ERP) Framework

Scripting can serve as a powerful therapeutic tool, particularly for the treatment of obsessive-compulsive disorder (OCD). It follows an exposure and response prevention (ERP) framework, which is an evidence-based form of cognitive behavioral therapy utilized in the treatment of various mental disorders. Scripts may be used for imaginal exposures targeting obsessions that cannot feasibly or ethically be induced, or they may serve to bolster treatment in conjunction with other exposure methods. Despite widespread use, little formal work has been introduced to synthesize an understanding of why (and when) script writing is beneficial, what scripts should (and should not) contain, and how ERP coaches may achieve a more effective session overall.

Granted that many obsessions and rituals predominantly live in the patient’s mind (and even those with a tangible stimulus are subject to an intrusive mental component, by definition), appropriately engaging with thoughts and inhibiting compulsive mental behaviors can be difficult. Furthermore, the nature of the obsessional content may pose barriers to access for exposure purposes. This conundrum requires creative exposure methods that have the ability to target the core of these thoughts. Existing manuals commonly educate treatment personnel on what scripting aims to accomplish broadly without more precise insight into the rationale as to why it may work mechanistically. Furthermore, instructive guides and example scripts are difficult to generalize with the “ingredient” components identified in isolation. Just as OCD presentations vary vastly—often with subtle, idiosyncratic nuance—the tools with which we engage for treatment must be equally adaptable and versatile.

In this presentation of a forthcoming methods article, we will briefly discuss the usage of scripting for imaginal exposures in ERP for OCD. The bulk of our conversation will aim to (a) clarify the contents of script writing, (b) present variations in scripting that can increase effectiveness, alongside their respective rationale, (c) describe how coaches can identify common mental or “hidden” components present in the ERP session, and (d) conclude with an acknowledgement of important session dynamics that may arise and future work that may be pursued. Insights offered are courtesy of experience, education, clinical practice, and supervision from the OCD Institute at McLean Hospital in Belmont, Massachusetts, one of the world’s leading partial and residential facilities specializing in the use of ERP for treatment refractory OCD, related disorders, and comorbid disorders.