Development of a protocol for videoconferencing-based exposure and response prevention treatment of obsessive-compulsive disorder during the COVID-19 pandemic

Table 4 Modifications in technique required for conducting videoconferencing-based exposure and response prevention treatment for obsessive-compulsive disorder

VC-ERP components	Modifications made to the VC-ERP
Detailed psychoeducation	Carried out using manuals in English and the local language for clinicians, patients, and caregivers. The content was simple, brief, and provided clear explanations. Psychoeducation sessions continued throughout the treatment
Monitoring of symptoms and progress	Simultaneous monitoring was carried out by the patients, caregivers, and clinicians through VC sessions, Google sheets, or WhatsApp messages that were regularly updated. Constant feedback about the progress of treatment was provided to the patient
Relaxation exercises	Benson’s relaxation technique was preferred because of its brief and simple format. Autogenic training or modified Jacobson’s progressive muscular relaxation exercises were taught if required. Written instructions in English and the local language and audio-visual aids for teaching were available for clinicians, patients, and caregivers
Duration of VC-ERP sessions	Though prolonged exposure is the goal because of its greater efficacy, it was quite difficult to have VC sessions of more than 30 min. Thus, the minimum duration was set at 30 min with the opportunity to prolong the sessions according to the patient’s convenience
Frequency of VC-ERP sessions	The frequency of sessions varied from weekly sessions to one session every 10-14 d. Flexibility was essential in deciding the duration and frequency of sessions. Several other factors were considered, particularly patient/caregiver preferences, the stage of ERP, the severity of symptoms, and the availability of clinicians
Supervision of VC-ERP sessions	The patient’s camera was not only focused on the patient but also covered a significant portion of the room so that clinician could detect any surreptitious compulsions or neutralizing acts. The camera was never switched off during the sessions
Engaging patients during the VC-ERP sessions	Clinicians, patients, and caregivers were all actively involved during the VC-ERP sessions. Every effort was made to minimize distractions. Neutralizing acts were noted and discussed later during processing. The clinician engaged with the patients at regular intervals to make sure that they were focusing on the treatment and to check the level of anxiety during sessions. However, constant talking was avoided because this might distract the patient
Ensuring patients’ tolerance of anxiety	Patient comfort with the level of exposure and their ability to tolerate anxiety was of overriding importance. They were never forced to engage in something that made them uncomfortable during the ERP sessions. Rather, each step was undertaken after proper education and fully ensuring the patient’s agreement and cooperation
The slower pace of VC-ERP	VC-ERP was expected to progress at a much slower pace than in-person ERP. This was explained to the patients and caregivers and usually did not present a problem
Privacy and confidentiality	Privacy was essential, and patients were informed about the people present in the room (e.g., technicians) when the session was being conducted. The patient was only accompanied by the designated caregiver at home. Any recording was done only with the patient’s explicit consent. All material relating to the treatment was stored securely
Safety	Patients were required to be accompanied by caregivers during the sessions. Anxiety levels were constantly monitored, and sessions were terminated if the patient was uncomfortable. If there were other concerns about the safety of the patient (e.g., risk of self-harm or violence), closer monitoring was instituted for such highrisk situations. Caregivers were also educated to manage such high-risk situations. For persisting safety concerns including symptom exacerbations during VC-ERP, patients and family members were helped to attend outpatient or emergency services
Treatment of comorbidities	Other modalities such as medications or occasionally ECT were used to treat primary or secondary comorbidities. The VC-ERP was adapted to meet the needs of patients with comorbid symptoms. Techniques utilized included temporarily suspending the sessions when comorbid symptoms increased, offering increased support at this time using the VC platform, promoting greater involvement of caregivers, and combining VC sessions with in-person sessions
Using hybrid modes of treatment	Hybrid care involved conducting some of the initial ERP sessions on an in-person basis and the later sessions by utilizing VC. Similarly, for each new step of the hierarchy, the initial session was an in-person one followed by VC sessions. This often mitigated the problems of poor understanding and variable motivation noted in exclusive VC-ERP treatment. Requests from patients and caregivers for in-person sessions were catered to as far as possible
Self-exposure	In exceptional instances when caregivers were not available, therapist-guided self-exposure was tried. A greater level of patient motivation was required for self-exposure and the pace of ERP was slower

ERP: Exposure and response prevention; VC-ERP: Videoconferencing-based exposure and response prevention. ECT: Electroconvulsive therapy.