Verbatim for Exposure and Response Prevention

Identifying information

Name: John

Age: 56

Gender: Male

Language: English

Occupation:

Education:

Religion:

Marital State: Married

Economic strata:

Informant: Self

Referral: Self

Information: Reliable

Presenting problem:

John often worries that he may have left the doors and windows of his house open before
leaving. He sometimes drives back from work to check his house. He closes the doors and
windows in a specific way before sleeping every night, due to which he has arguments with his
wife.
History of the presenting problem:

John has always been an anxious person. About 10 years ago, he started worrying that he would
contract HIV by touching an infected doorknob in his house. Because of a few life stressors, his
anxiety worsened. He now has multiple obsessions and compulsions, e.g. washing hands
repeatedly to prevent infections, checking the doors and windows of his house to make sure they
are locked, submitting work assignments late because he wants them to be perfect, and so on.

Sr.No. Verbatim Process comments

T1 Hi John, how are you feeling today? The therapist greets the client.

C1 I am feeling fine. The client has a neutral

expression.

T2 In the previous session we started talking about The therapist summarises the
your fear that you will leave the doors and previous session.
windows of your house open by mistake and
someone will break in.

C2 Yes. The client nods.

T3 Okay, so today we are going to use a technique The therapist introduces ERP.
called exposure response prevention. To begin
with, we are going to discuss different levels of
this situation that make you anxious, and we are
going to find out how distressed you feel in each
one of them. Eventually, we shall try to stop you
from giving your usual compulsive checking
response. What do you think about that?

C3 I mean yeah, we could try this thing. So what do I The client looks down at the
do? floor while talking.

T4 Tell me what makes you most anxious about The therapist begins by
leaving your doors and windows open. What is the inquiry about the most
worst-case scenario? anxiety-provoking situation in
the hierarchy.

C4 I am out at night, maybe having drinks at my The client continues to use

friend’s place, and I have forgotten to close one hand gestures, eyes are
window. opened wider.
T5 Alright. Now tell me something that would be a bit The therapist makes notes and
less anxiety-provoking than this. moves to the next situation in
the hierarchy.

C5 Um, maybe I am out for work all day, nobody’s The client looks into the
home, and like two of the front windows are open. distance while talking.

T6 I’ll write that down. You’re doing great, give me The therapist makes notes and
one more, with lesser anxiety. encourages the client to move
to the next situation.

C6 Okay, I guess I am at work on a Saturday, I know The client speaking with an

I’m gonna be back by lunchtime, but I have kept even tone.

T7 Alright, so now it’s a half-day. Now let’s go to the The therapist makes notes and
next one, we will try to go up to ten. moves to the next situation in
the hierarchy.

C7 The next one would be, like all of the windows are The client has a neutral
open, and I go out for a stroll in the neighborhood. expression.

T8 Alright. I’ll write that down. So what would be a The therapist makes notes
bit less anxiety-provoking? What next? and moves to the next
situation in the hierarchy.

C8 I am chatting with my neighbor or sitting on their The client shifts in his chair.
porch in the morning, and I can see that my front
door is open.

T9 Alright then. Now take it down a notch, what The therapist makes notes and
would be a bit less troubling? moves to the next situation in
the hierarchy.

C9 I am walking around on my lawn, or just sitting The client maintains a neutral

there, while the door is unlocked. But I can see the expression.
door, so if someone tries to break in I can do
something. But it’s still kind of uncomfortable.

T10 Okay, so you have control over the situation but The therapist paraphrases
it’s still uncomfortable. What next? make notes and moves to the
next situation in the
hierarchy.

C10 I am at home, it’s nighttime, I am watching TV, The client looks more relaxed
and I feel like I may have forgotten to lock the compared to before
main door from inside.

T11 What would make you a bit less anxious than that? The therapist takes notes and
 moves on to the next item in
the hierarchy.

C11 I am in my house, I am sleeping at night, and I The client sits back in the
may have forgotten to lock the door. chair, resting his back against
the back rest.

T12 Okay, you’re doing great, keep going, let’s come The therapist makes notes na
further down on the list, what is even less anxiety dmoves on to the next
provoking? situation in the hierarchy.

C12 I don’t know, what else…maybe I am taking a nap The client starts to yawn
at home during the day, maybe uh…on a Sunday. toward the end of the
And I have forgotten to lock the door. sentence.

T13 Okay, now just give me one more. The least The therapist makes notes nad
anxiety provoking situation on your list. moves on to the next item in
the hierarchy.

C13 That would be…me being awake, in my house, The client pauses in the
during the day, and the doors and windows all are beginning, perhaps struggling
open. to come up with a situation.

T14 Okay, now that we have listed all the situations, I
want you to take a look at this list and rate the
level of distress that you experience in each
situation on a scale of 0 to 100. Try not to give the
same rating for two situations. Okay?
The therapist asks the client
to give subjective units of
distress for each situation.

C14 Alright. The client is iven the list of

situations and he writes the
ratings next to each situation
using a pencil.

T15 Okay, now close your eyes. Let’s imagine the last The therapist starts imaginal
situation on this list. You are in your home, sitting exposure to the least anxiety
in your bedroom. You think to yourself, “Did I provoking situation on the
lock the front door from inside?” Maybe you have hierarchy.
locked it, but you don’t know for sure. How do
you feel?

C15 I feel really tense, I should go and check the door The client frowns, his eyes
to make sure it is locked. are closed.

T16 Right, how would you rate your distress on a scale The therapist asks for
of 0 to 100? subjective units of distress.

C16 60, maybe 65? Yeah somewhere close to that. The client sounds unsure.
T17 Okay, now take a deep breath. Try to sit still. Do The therapist begins response
not allow yourself to get up and check the door. prevention.

C17 Okay The client nods, still

frowning.

T18 Have you noticed that it has been 2 minutes, but The therapist attempts to give
you haven’t gotten up to check the door in your
imagination?

C18 Yeah, I guess. That’s something. The client nods and opens his
eyes.

T19 Alright. So in the next few sessions, we will take The therapist informs the
one situation after another and try to stop your client about what he can
checking response to these situations. How does expect in the next few
that sound to you? sessions.

C19 I guess it could help, we can give it a shot. The client sounds unsure but
hopeful.

Sr.No. Situation Distress level

1 Leaving one window open while he is out all night. 100

2 Leaving two windows open when he is at work full 99

day.

3 Leaves two windows open when he is at work until 95

lunchtime.

4 Leaves all windows open while he goes out for a few 90

hours in the neighborhood

5 Leaves the door open while he visits his neighbors. 89

6 Leaves the door open while he walks around on his 85

lawn
 7 Leaves the door open while he is home at night, 80
sleeping.

8 Leaves the door open while he is home at night, 79

awake.

9 Leaving the door open while he is taking a nap 75

during the day.

10 Leaving the door open while he is at home, awake, 60

during the day.

Consolidated report:
John was a 56-year-old male who was in distress because he used to feel anxious about
somebody breaking into his house because he left the doors and windows open. Hence he
constantly engages in checking behavior, sometimes going to extreme lengths like driving back
from work to check on his house. During the session, the client and the therapist and the client
discussed the situations that make John anxious, organized them in a hierarchy from the least to
most anxiety-provoking situations, and gave subjective units of distress for each one of them.
Then they started with imaginal exposure to the least anxiety-provoking situation. The therapist
asked John to try and prevent his compulsive response and made him aware that he could sit for
almost 2 minutes without performing checking behavior. Then the therapist ended the session by
telling him that they would proceed to do the same procedure with the other situations up the
hierarchy.

Introspective report:
I found it difficult to describe to the client what I mean by the “next item in the hierarchy”. I
wasn’t sure if the client was understanding the concept of an anxiety hierarchy. I was also
skeptical about the effectiveness of imaginal exposure. It is a high possibility that the client was
performing the compulsive checking behavior in his imagination and that he lied that he hadn’t,
perhaps to avoid embarrassment. I would find it easier to practice the technique using in vivo
rather than imaginal exposure.