The role of between‐session homework in cognitive‐behavioral therapy for comorbid obsessive‐compulsive disorder and autism: A case vignette

Abstract

ObjectiveCognitive‐behavioral therapy (CBT), which includes a decided emphasis on exposure and response/ritual prevention (ERP) and between‐session practice of treatment principles, has consistently demonstrated efficacy for the treatment of obsessive‐compulsive disorder (OCD) and is a gold standard, recommended first‐line treatment. CBT with ERP has been successfully adapted to fit the needs of autistic individuals with OCD. The present article provides a brief overview of CBT for OCD and outlines special considerations and adaptations needed when working with patients with OCD and comorbid autism, with an emphasis on the importance of between‐session homework.MethodA case vignette is presented.ResultsThis case study illustrates the role of homework in the exposure‐based treatment of an adult autistic individual with comorbid OCD.ConclusionImplications of this case vignette are discussed, and recommendations are offered for clinicians working with autistic individuals with OCD, especially in regard to bolstering completion of between‐session ERP homework.

Between‐session homework and processes of change

“…Perfectionism is not the goal. As emphasized in the case studies, therapists need to be attuned to the client's experience and the therapeutic process and progress, to propose BSH that is within the client's experiential and developmental grasp (e.g., Warwar, 2023) or tolerable level of anxiety (e.g., Church et al, 2023), through a scaffolding process that over time facilitates increased independence on the client (e.g., Murphy et al, 2023) and progressive internalization of new skills (Wachen, 2023). Hammersmark and colleagues (2023) also demonstrate how clients in group therapy may aid and facilitate each other in designing BSH.…”

“…For example, lack of engagement could be due to limited socialization to the treatment model and frustration, especially in the early phase of treatment (e.g., Hammersmark et al, 2023;Murphy et al, 2023), which highlight the need to have a continuous emphasis on the rationale for the treatment and BSH specifically (Callan et al, 2019). Emotional barriers, such as worry and distress (Hammersmark et al, 2023;Magistrale et al, 2023;Warwar, 2023), or difficulties with identifying emotions and anxiety levels (Church et al, 2023) were other potential barriers. Again, authors recommended devoting sufficient time to ensure that clients had understood the rational underlying a specific BSH, by asking for feedback, in-session practice, discussing potential barriers and difficulties to BSH, and writing down specific tasks and rationale.…”

“…Specifically, all authors noted how BSH may help clients (1) build awareness or insight (a stance of curiosity toward inner mental life; new perspective on thoughts and though processes, etc.) through specific task such as psychoeducation and sharing of rationale (Church et al, 2023;Hammersmark et al, 2023;Magistrale et al, 2023;Murphy et al, 2023;Wachen, 2023;Warwar, 2023), writing about unresolved feelings toward a significant other (Warwar, 2023), writing an impact statement (Wachen, 2023), using work-/task sheets (McEvoy et al, 2023;Murphy et al, 2023;Wachen, 2023), experimenting with new behaviors (e.g., Magistrale et al, 2023), or experiential tasks (e.g., Hammersmark et al, 2023); as well as (2) change behaviors by extending in-session work and (new) behaviors into clients' daily lives through the practice of new skills (e.g., exposure, activity scheduling, trying out new ways of relating, thought worksheet, etc. ; Church et al, 2023;Hammersmark et al, 2023;Magistrale et al, 2023;Murphy et al, 2023;.…”

“…through specific task such as psychoeducation and sharing of rationale (Church et al, 2023;Hammersmark et al, 2023;Magistrale et al, 2023;Murphy et al, 2023;Wachen, 2023;Warwar, 2023), writing about unresolved feelings toward a significant other (Warwar, 2023), writing an impact statement (Wachen, 2023), using work-/task sheets (McEvoy et al, 2023;Murphy et al, 2023;Wachen, 2023), experimenting with new behaviors (e.g., Magistrale et al, 2023), or experiential tasks (e.g., Hammersmark et al, 2023); as well as (2) change behaviors by extending in-session work and (new) behaviors into clients' daily lives through the practice of new skills (e.g., exposure, activity scheduling, trying out new ways of relating, thought worksheet, etc. ; Church et al, 2023;Hammersmark et al, 2023;Magistrale et al, 2023;Murphy et al, 2023;. Admittedly, there are various ways of conceptualizing change-processes in psychotherapy (e.g, Castonguay et al, 2019;Ryum et al, 2014;Valen et al, 2011), but the case studies demonstrate how numerous techniques may target similar, general change-process (e.g., increasing awareness; experimenting with new skills, etc.).…”

“…Fifth, Church et al (2023) presented the case of a male client diagnosed with obsessive-compulsive disorder (OCD) and comorbid autism, treated with CBT with exposure and response prevention. While this intervention is considered "the gold standard" treatment of OCD, the case illustrates some important considerations and adaptions needed when working with comorbid autism, and strategies to enhance client engagement with BSH.…”