Who we treat

Cost

Length of Stay

Number of beds & staffing

Treatment philosophy

Program leaders

Program description

Treatment details &
clinical protocols

Adhering to treatment

Making treatment work

Program life

Daily treatment:
Adolescent Program

Daily treatment:
Adult Program

Family involvement

Psychoeducational groups

Discharge planning

What patients say

Admissions

Packing for your stay

Obsessive-Compulsive Disorders Treatment Program

Treatment details & clinical protocols

Who we treat
The Obsessive-Compulsive Disorders Treatment Program at Menninger offers specialized hospital treatment programs for adolescents and adults that provide intensive cognitive-behavioral therapy, medication and milieu-driven treatment. Programs are suited exclusively for youth and adults with severe obsessive-compulsive disorder, OCD spectrum disorders and other anxiety disorders that may be accompanied by related psychiatric conditions.

The adult program serves patients, 18 years of age and older, who struggle with severe OCD. The patients in the adult program usually have attempted outpatient treatment with little to no benefits. They usually have had OCD for many years and have tried numerous medications. The individual's symptoms severely interfere with his or her ability to attend to activities of daily living, make decisions and complete everyday tasks.

The adolescent program serves patients, ages 12 through 17, who are experiencing difficulties in most areas of their lives due to OCD symptoms, as well as family, school and social difficulties. Typically, these patients are either failing school, unable to attend school or have significant difficulty attending school due to the nature of their symptoms.

Many patients, in addition to suffering from OCD, struggle with other anxiety symptoms, such as social anxiety and panic, and varying degrees of depression. Many patients also have a diagnosis of one of the OCD spectrum disorders, such as body dysmorphic disorder, trichotillomania, hypochondriasis or Tourette syndrome.



Treatment approach
The program is based on the conviction that intensive specialty treatment employing evidence-based treatment protocols is effective in treating severe obsessive-compulsive disorder, other anxiety disorders and coexisting conditions. In the attempt to achieve maximum benefit for patients, the program adheres to the following assumptions:

1. The treatment program utilizes state-of-the-art cognitive-behavioral, evidence-based and psychopharmacological treatment modalities.
2. The treatment program encourages normalization, patient's participation in decision-making and provision of services in the least restrictive environment. All services are designed and provided in a way that supports, educates and empowers the patient.
3. Successful treatment requires attention to the individual's physical, emotional and social, needs, as well as to financial resources for treatment.
4. Each patient has significant strengths that are supported and developed.
5. All services and treatment involve the creation of a supportive environment that incorporates goals and objectives of the patient and, when appropriate, the family. The treatment environment is designed to further the long-term goal of establishing healthy functioning individuals and families.
6. All standards of care and quality assurance are consistent with the policies and procedures of The Menninger Clinic.

Upon admission
A diagnostic assessment is usually completed within two weeks of admission by the clinical team. The team utilizes observations, specific interventions, patient and family history, parent and patient reports, psychological testing and past treatment records in formulating the diagnostic assessment. Given the complex presentation of severe OCD, a careful and thorough diagnostic assessment is crucial for future treatment to be effective. Team members share assessment findings with one another during a multidisciplinary team meeting. These findings comprise the foundation of future treatment and are shared with the patient and, when appropriate, with parents.



Core treatment program
The Menninger OCD Treatment Program utilizes a multidisciplinary clinical team whose members specialize in OCD treatment to target the issues destabilizing the patient. Treatment planning focuses on crisis management, symptom reduction and prevention. Discharge planning begins upon admission to ensure effective community reintegration, as well as ensuring future treatment to address the long-term care needs of the patient.

Conventional measures in the field, with well-documented reliability and validity, are used throughout the treatment, and the data complements decisions about treatment level and discharge. These measures that are given at admission and discharge include the:

• Yale-Brown Obsessive-Compulsive Scale
• Obsessive-Compulsive Inventory,
• Beck's Depression Inventory, Basis-32
• Multiaxial Anger Inventory
• State Trait Anxiety Inventory I and II
• Fear of Negative Evaluation Survey

Treatment setting
The OCD Treatment Program is located on the Menninger campus and provides unique opportunities to regulate the patient's environment. Each room has it own shower and washroom. Furthermore, if it is clinically necessary, the treatment center can be locked as a way to support patients in treatment. These measures are rarely used, but are sometimes required initially in treatment for adolescents or for suicidal patients.

Given the fact that the OCD Treatment Program is located on the Menninger campus, it also provides the opportunity for patients to participate in specialized treatment with other programs. These services include anger management, dialectical behavior therapy, spirituality counseling, chemical dependency counseling and individual supportive therapy—to name a few.



Multidisciplinary treatment team
A multidisciplinary treatment team is assembled for each patient. Cognitive-behavior therapists, a psychiatrist, an activity therapist and nursing staff serve on the team. Involvement of a chemical dependency counselor, neuropsychologist and other specialists vary in time and intensity based on the patient's clinical status and intensity of care.

The psychiatrist meets with the patient at least weekly. The Center’s psychiatrist reviews previous medication trials and assesses for adequacy and, when appropriate, prescribes an alternative medication regimen.

The cognitive-behavioral therapist, who designs the individual treatment plan with the patient, provides initial assessments and evaluations.

Unparalleled direct delivery of care 24 hours a day, seven days a week is provided by the treatment team. The team’s role is to aid treatment delivery, especially to enhance ritual prevention for patients with severe and treatment refractory OCD. In addition, nursing staff members administer the medication and monitor compliance. The nursing staff is trained to help patients with OCD block their rituals, to assist ritual free activities of daily living and to implement behavior therapy techniques.



Behavior treatment plans & treatment contracts
Individualized treatment plans are negotiated between the patient and the treatment team and re-evaluated on a weekly basis. The core of the treatment contract is the behavior treatment plan, which delineates core problems, specific obsessions, compulsions, avoidances, goals and specific interventions.

This plan that is designed with patients builds upon a hierarchy of symptoms and includes the unique opportunities that 24-hours hospital care provides. The plan covers specific information about ways to assist patients through their morning routine with minimal rituals, evening routine and, most importantly, how to implement staff-assisted exposure and ritual prevention sessions. Staff and the patient collaborate to evaluate the plan each week. Patients are active in designing and implementing their care delivery and deciding what OCD symptoms to address weekly.

The behavior treatment plan is supplemented by a program-specific treatment contract. In this contract, the patient has a leading role in designing the objectives for the week and implementing the contract. On the treatment contract, patients are encouraged to proactively address discharge-related issues, e.g. health, vocation/education, family and personal relationships, post-program treatment and other quality of life issues.

The patients also set specific objectives for the week to help them tackle some of their OCD symptoms and meet the goals set out in the behavior treatment plan. At the end of each week, the staff and patients review the treatment contract in the areas of symptom reduction and management, healthy living and aftercare. Patients receive weekly feedback about their progress toward the goals, in a group designed for that purpose, from fellow patients and from the treatment team.



CBT, milieu & group therapy
The program's setting fosters an atmosphere for change, while maintaining the milieu and a safe environment where patient and staff work collaboratively toward treatment goals.

The staff is attentive to the unique challenges the OCD symptoms put on patients and their families. The cognitive-behavior therapist conducts individual behavior therapy sessions. Nursing staff and behavior management counselors assist a patient's effort to follow his or her behavior treatment plan, especially implementing challenging exposure and ritual prevention sessions. Supportive staff interactions, as well as groups and activities, are scheduled to maximize the patient's ability to follow their behavior treatment plan. All patients and staff participate in a group forum community meeting to foster atmosphere for change, support, and provide opportunity to influence program procedures.

The cornerstones of the Menninger OCD Treatment Program are the daily two-hour exposure and ritual prevention (E-RP) group sessions, as well as the minimum required number of self-directed E-RP sessions. The E-RP sessions take place in a group format, but each E-RP is completely individualized. The group format refers to the fact that the patients gather in a group and report their Subjective Units of Distress Scores (SUDS) at the beginning of the session, as well as working out which patients need individual staff support in blocking their rituals or implementing the E-RP. At the end of the E-RP session, patients get together as a group and report their highest SUDS score of the session, their current SUDS score and various facts about their success in implementing the E-RP for that day.

The cognitive-behavior therapist works closely with the patient to build on the progress made in the behavior plan through E-RP and other interventions. The plan serves as a road map to recovery for patients. Both staff and patient are responsible for the integrity of the E-RP session. Due to the nature and severity of the OCD that many of our patients struggle with, every effort is made to preserve the integrity of the E-RP session.

It is expected that as many OCD staff as possible partake in the E-RP session and provide individual assistance to those patients who have historically been unable to complete E-RP sessions independently. The goal is that patients will eventually be able to complete all E-RP sessions independently. A major factor for facilitating a patient's ability to conduct their E-RP sessions independently is the emphasis staff put on setting time aside for the self-directed exposures (see adult and adolescent daily schedules). For self-directed exposures, patients select OCD symptoms they are reasonably certain that they can complete independently in a focused E-RP session.

All other specialized groups in the program are designed to complement the evidence-based E-RP sessions and build patients’ skill sets and resilience, as well as foster support and opportunity to practice what they have learned.

Treatment interventions and group work are based on the diagnosis and symptoms that each patient presents. They provide a unique opportunity to create support and reduce distortions of patients.



Family education & support
A unique and important feature of the program is the bimonthly, full-day family workshop. The workshop enables families to provide support and share resources with each other. Due to the enormous strain OCD symptoms often put on all family interactions, family members are strongly encouraged to attend the workshop.

Families and patients alike have told Menninger staff how important and helpful the workshop has been in increasing understanding of the struggles OCD patients go through and empowering both families and patients.

Full-day family workshop

• Assess academic needs,
• Provide individualized instruction for the patient’s needs and
• Increase the patient’s academic skills and knowledge while credit is earned toward graduation.

In addition, the School Program staff assists the treatment team in understanding how school performance may be related to difficulties the patient experienced before admission and which interventions make the greatest impact on school performance.



Discharge planning
Discharge planning is an ongoing process. As a patient nears completion of treatment, therapeutic passes from the hospital to the home are scheduled to promote the application of CBT skills and facilitate ways he or she can challenge their OCD in the home environment. Every effort is made to find an experienced cognitive-behavior therapist at discharge, if the patient was not seeing one at admission, in an effort to foster success.



Specialized groups
Exposure & Ritual Prevention
Group therapists will assist patients in implementing exposure-ritual prevention (E-RP), the key component of behavior treatment for OCD. Anxiety ratings, using the Subjective Units of Distress Scale (SUDS), are monitored at the beginning and throughout the group with the goal to achieve habituation within the group session.

Objectives:

1. Patients learn to implement exposure and ritual prevention in OCD treatment.
2. Patients learn to achieve habituation through ritual prevention.

Behavior Therapy Skills
Patients will learn the ABC model of behavior therapy, exposure and ritual prevention (E-RP) and other behavior techniques, especially as they relate to OCD. Group discussion, role-play and behavior therapy skills will increase the patient's ability to cope and problem solve.

Objectives:

1. Patients learn basic ABC model and advanced behavior therapy techniques.
2. Patients will practice skills outside of group and receive feedback from group leaders and members.

Cognitive Therapy
This group reviews the basics of cognitive therapy—cognitive distortions, mood monitoring and cognitive restructuring, especially as they relate to OCD. The group leader will facilitate discussion and direct patients in role plays in order to enhance cognitive restructuring and problem solving, as well as utilization of other cognitive therapy skills.

Objectives:

1. Patients learn the basic cognitive therapy model and advanced cognitive restructuring techniques.
2. Patients will practice skills outside of group, using thought records specifically designed for this group.

Motivational Group
This group reviews the basics of motivational interviewing and the stages of change in therapy. Patients evaluate their commitment to cognitive-behavioral treatment through group discussions, identifying adaptive long-term goals and personal examples.

Objectives:

1. Patients learn basic motivational interviewing and stages of change.
2. Patients explore their commitment to change through education and interaction.

Relapse Prevention
Patients are educated about the differences between relapses and slips and are taught skills to maintain emotional and behavioral stability. Role-play, group discussion and psychodrama exercises enable patients to practice their relapse prevention plans.

Objectives:

1. Patients identify symptoms and high-risk situations for relapse.
2. Patients develop individualized relapse prevention plans.

Family Issues
This group addresses issues and conflicts that families of OCD sufferers often experience. Education and group discussions will center on family dynamics and the patient's interactions with family members.

Objectives:

1. Patients learn how OCD symptoms affect family interactions.
2. Patients learn to identify triggers for family conflicts, how to reduce conflicts and increase support.

Affect Management
Patients will learn how to express difficult emotions, e.g. anger, anxiety and sadness, and how to effectively deal with them, especially as they arise from OCD symptoms and symptomatic behaviors.

Objectives:

1. Patients learn adaptive ways to effectively address anger, anxiety and sadness.
2. Patients learn how to identify emotional triggers.

Assertiveness & Social Skills
Patients will enhance treatment outcomes by increasing assertiveness, social skills and communication through education, role-play and discussion.

Objectives:

1. Patients learn these skills as an integral component to recovery.
2. Review basics of listening, modes of expression, self-disclosure and assertiveness.

Treatment Contract Setting
Patients design a new treatment contract for the coming week by setting measurable and achievable goals.

Objectives:

1. Patients learn to incorporate constructive feedback in setting their goals.
2. Patients learn to set realistic, measurable and achievable goals.

Treatment Contract Review
Using the client as a colleague model to foster commitment and motivation for change, patients assess how well goals were met.

Objectives:

1. Patients learn about the client as a colleague model, to become proactive and to take responsibility for their treatment.
2. Patients learn how to achieve short- and long-term goals through accountability and constructive feedback from staff and group members.

Self-Assessment and Treatment Planning
The patients set specific daily treatment goals to obtain overall treatment success and increase the likelihood that they will meet goals set for the week in their behavior treatment contract.

Objectives:

1. Patients learn to structure activities in order to enhance treatment outcomes.
2. Patients learn to incorporate constructive feedback about goal settings.
3. Group provides patients with techniques to structure their daily goals post-treatment.

Supportive Group Psychotherapy
This group provides the opportunity for patients to discuss and share emotional and psychosocial problems, as well as gain insight into their emotional struggles.

Objectives:

1. Group work aids in modification of maladaptive beliefs that have incurred through the course of the illness.
2. Process fosters group cohesiveness, hope and universality.

Art Therapy
Art therapy provides a nonverbal means of exploring and communicating through the use of art as a metaphor.

Objectives:

1. Patients are offered an alternative from of communication.
2. The session ends with a behavioral goal or objective.

Diagnostic- & Symptom-Specific Groups
Diagnostic- and symptom-specific groups will be offered based on the needs in the patient population. Symptom presentation and struggles are often similar. In order to enhance treatment efficacy and provide mutual support, symptom-specific groups are provided. Patients learn effective ways to deal with specific symptoms through education and have the opportunity to share experiences through group discussion. These groups are:

• Scrupulosity
• Social Phobia
• Symmetry and Perfectionism
• Addictions
• Intrusive and Violent Thoughts
• Body Dysmorphic Disorder

Objectives:

1. Patients learn about specific symptoms.
2. Patients learn specialized interventions to reduce obsessions and compulsions.

Managing Depression
The group leaders focus on educating patients about the various factors that contribute to and maintain depression. Through utilization of cognitive-behavioral therapy skills, patients practice implementing cognitive behavioral techniques in managing and reducing the symptoms of depression.

Objectives:

1. The patient will gain a better understanding of the manifestations of depression.
2. The patient will gain knowledge of and practice coping strategies for the management of depression; especially learning to implement CBT strategies.

Dialectical Behavior Therapy (skill-building)
This group teaches the skills developed by Marsha Linnehan. The skills that are focused on include mindfulness, distress tolerance, emotion regulation and relationships. The information is presented specific to patients with OCD.

Objectives:

1. The patient will understand mindfulness and how it can be used in enhancing their life management skills.
2. The patient will gain skills that they can use in understanding and managing emotions.

Problem-solving Group
The group focuses on several questions each week asking what if the patient was in a certain circumstance. It is a fun and interactive way for patients to explore their own thinking and see how others would react in the same situation.

Objectives:

1. The patient will practice their skills of group interaction.
2. The patient will be able to explore his or her own thinking processes in relation to others.

Teen Talk Group
Each week the group selects a topic that is relevant to being a teenager and discusses it. It is an opportunity to share the challenges of being a teenager and explore how peers manage similar issues during their development.

Objectives:

1. The patient will have increased comfort in talking with peers about issues pertinent to them.
2. Patients will be given the opportunity to learn by sharing experiences, through group discussion and role-plays.

Specific Challenges in Implementing Exposure & Ritual Prevention
Patients will learn about different behavior therapy techniques to enhance the efficacy of their exposure and ritual prevention session. Patients brainstorm with an experienced behavior therapist about solutions to common challenges in following through with OCD treatment.

Objectives:

1. Patients learn different ways to enhance the efficacy of exposure and ritual prevention.
2. Patients will practice specific behavior skills within and outside of group and receive feedback from group leaders and members.

E-RP Community Re-integration Outing
Purpose:
To provide the patient with the opportunity to perform exposure-response prevention in the community setting with the support of the activity therapist. To provide opportunities and experiences for the patient that promote the development and application of new knowledge, skills and attitudes necessary for successful participation in daily community living. The four concentrated areas are:

1. Application of skills
2. Socialization
3. Problem solving
4. Resource guidance

Goals:

1. To facilitate and increase patient participation in everyday activities and leisure pursuits.
2. To encourage and assist patients in their adjustment to their physical, cognitive and emotional limitations.
3. To provide experiences that require the use of independent thinking, problem-solving and organizational skills.

Physical Fitness
Open gym hours are available in the evening.

Purpose:

To provide an opportunity for patients to improve physical fitness, stress reduction and cardiovascular endurance.

Rationale:

Patients can benefit by improving their ability to follow verbal and visual instructions, increase exposure-response prevention, fitness level, balance, coordination, range of motion, ability to stay on task and self-esteem through improved body image.

Goals:

1. Use this opportunity to perform exposure-response prevention if appropriate.
2. Demonstrate maintenance or improvement in fitness level.
3. Demonstrate an ability to identify a reasonable fitness program following discharge.

Social Skills

Purpose:

To help the patient understand his/her role in interpersonal relationships and how their behaviors either strengthen or weaken relationships and treatment outcomes.

Rationale:

Many patients are not aware of how their behaviors affect relationships and treatment outcomes.

Goals:

1. Identify characteristics of behavior that are detrimental to interpersonal relationships.
2. Identify characteristics that are valuable in interpersonal relationships.
3. Begin to look at ways to modify behaviors.

Arts, Crafts & Kitchen
Open Craft Room hours are available and encouraged for adults in the evening.

Purpose:

To provide an opportunity for patients to develop creative leisure skills through various cooking, art and craft projects.

Rationale:

Patients can benefit from exposure to a leisure and craft medium, which can provide gratification as a leisure option following discharge. Patients can also learn basic skills that can lead to interest in more challenging craft activities.

Goals:

1. Redirect attention from the disease to meaningful, enjoyable experiences.
2. Improve self-esteem through learning new skills.
3. Provide opportunities for experiences of fun and enjoyment.

Self-esteem Group

Purpose:

To provide patients with an opportunity to explore issues related to self. Through self-assessment, the patient will identify coping skills, positive and negative traits and self-esteem traits.

Rationale:

The first goal in the recovery process is to address the distorted thinking, feelings and behaviors that resulted from the sources of low self-esteem.

Goals to improve:

1. Self-awareness: The ability to identify his/her own feelings.
2. Empowerment: The individual's ability to see himself/herself as being able to influence people and events around him/her.
3. Awareness of others: The individual's awareness of his/her trust of others.
4. Affirmations: The individual's ability to state his/her beliefs and goals.
5. Bonding/cohesion: The individual's ability to see himself/herself as being connected to a group.

Perfectionism
To allow the patient an opportunity to explore the cycle of perfectionism. To provide the patient with the opportunity to perform exposure-response prevention in a peer setting. The group will focus on irrational beliefs, advantages and disadvantages and rational behaviors needed to overcome perfectionist tendencies, social support system benefits and steps to overcome perfectionism.

Goals:

1. Identify perfectionism characteristics of behavior, which are detrimental to interpersonal relationships.
2. Identify characteristics of perfectionism that reduce people's ability to function.
3. Begin to look at ways to modify behaviors that reduce perfectionism.