Until recently I had never heard the term “flooding” in reference to obsessive-compulsive disorder, but over the past couple of months I’ve connected with three parents of OCD sufferers who have all used it in the same context.
For those of you who aren’t familiar with flooding as it relates to OCD, it involves the use of Exposure and Response Prevention (ERP) therapy. But instead of OCD sufferers creating a hierarchy and then working with their therapists to determine which exposures should be tackled first (also known as graduated exposures), they are “flooded” with the exposures that cause them the most fear and anxiety; the ones at the top of their hierarchy. As with any exposure, they need to remain in the situation, refraining from compulsions, until the anxiety subsides. To clarify the difference between flooding and graduated exposures, the analogy of going for a swim is often used. If you jump right into the icy cold water, you feel the shock of the cold, though you will eventually acclimate. This is comparable to flooding. Entering the water slowly, perhaps dipping your toes first and then dabbing your arms, is similar to a graduated exposure. There is less shock to the body and it is likely more tolerable.
Back to the parents I mentioned. In each case, their teenaged or young adult children experienced flooding while attending residential treatment programs for OCD. None of the parents felt it was helpful, and at least two are convinced this treatment backfired, and their children regressed. This is not surprising to me. Whereas graduated exposures afford OCD sufferers a measure of control over their treatment, flooding does not. And exposing someone with OCD to their worst fears immediately? At the risk of sounding melodramatic, I think it borders on being inhumane.
So why was flooding used in these cases? As far as I know, the only reason is that because health insurance coverage limited the length of the OCD sufferer’s stays, there was only enough time to use flooding, not graduated exposures.
There is so much wrong with this picture. Unless I am missing something, flooding does not appear to be in the best interest of OCD sufferers who have reached out for proper treatment. Neither is not being allotted enough time by insurance companies to get the help they deserve. We still have so much work to do in the fight against OCD.
ocdtalk 
Thanks for bringing this to our attention. It seems like a totally wrong approach to choose a treatment based on how long health insurance will provide coverage. The understanding of treatment of mental health in general needs so much work. And it’s hard for me to stomach that money has to be the basis of so many treatment decisions.
Flooding doesn’t seem like a good idea to me either. i can imagine feeling completely overwhelmed and lost if that had happened to me.
Thanks for sharing, Tina, and I totally agree. I’m thinking that for many people, no treatment at all would be preferable to flooding.
Well said. In 3 years of treating OCD, I came across only a single case where flooding was appropriate (and effective). The research on ERP supports the gradual exposure approach. So frustrating when health insurance ends up dictating so much of treatment.
Thanks for your comment, April. If you don’t mind sharing, I’d love to know in what situations flooding is appropriate and effective. Understanding OCD and its treatment is no easy task, so your insights would be valuable!
in this particular case, her reaction to any trigger cased a level 10 reaction. it was as if there was no anxiety hierarchy. we tried to start small but her reaction was just so strong that we decided together that she’d rather just go all in if she was going to do it. this was all contamination ocd. she decided she would be willing to go 5 straight days in the same clothes and not avoid touching things like she usually would. ultimately, it worked for her to be in this sort of sustained exposure rather than go only for a few hours a day. she had a rather stubborn personality (she’d admit this) and so i think we found flooding to be a productive way to channel that trait.
the only other time i’ve seen flooding be helpful is in the case of phobias.
Thanks, April. How interesting!
Good morning Janet, I just read this post and it is so very accurate. I have not heard it called “flooding” before now but that is exactly what happened to my daughter. She was seeing a therapist who obviously was unaware of how to work with ERP therapy and she jumped to the top of the ladder in her heirarchy and it backfired and scared her completely, ruined their therapeutic relationship (if there even was one), and discouraged her from wanting to try the therapy again. The flooding felt more like “drowning” to my teenage daughter.
Which upsets me more knowing how vulnerable and frightened a teenage mind is that how can they start with the highest anxiety and expect a good outcome? Fact is you cant:( so I looked for the best therapist with experience, and it was out of our own state, I will thank dr. Gillihan for his expertise, kindness, patience, laughter and everything he did to help her. Words can’t express our gratitude for his care and time that WORKED:) she will always have to tackle her OCD but she has the proper tools given to her to do it, and when it is done right ERP works. My advice, find the right person with ERP experience and you will always be keeping yourself above water, what a great feeling!:)
Thanks so much for sharing, time2cher. Your comment is both upsetting and heartening at the same time. Upsetting that your daughter needlessly experienced such trauma due to an incompetent therapist, and heartening that you found the right help and she is now doing well.The bottom line, as you say, is that ERP done right works. Also, I love your analogy to flooding feeling like drowning….I’m guessing that’s exactly what it feels like.
Interesting about that insurance limits might be why the treatment directors choose flooding… I think you would do better to give people a taste of success, sending them home with hope and tools to continue to grow.
Your words make total sense to me, Abigail. Thanks for your insight. Of course the best thing would be if people were allowed to get as much treatment as needed!
I think part of the problem is that the public, including insurance companies, still don’t really recognize OCD and other mental illnesses as genuine medical conditions.
An insurance company that I dealt with actually referred to the OCD therapy I needed as “elective treatment” and refused to cover it. So I guess my wanting to overcome my OCD so I can actually leave the house, function, and live a normal life is “elective.” Disgusting, really.
I’m so sorry you had that experience with your insurance company, Teri, and disgusting is a good way to describe it. I think it all goes back to the misconceptions of what OCD really is. This treatment of those who suffer from mental health disorders is so unacceptable. I appreciate your sharing.
A very good post. I think it underscores the need to be very clear with people in treatment about why we do exposures and to obtain their consent and understanding before we proceed. When I was receiving training from the IOCDF, my supervisor recommended in one case that I go right for one of the most difficult issues one of my cases was experiencing. The supervisor explained to me that, because the particular fear and related ritual were so damaging to the patient’s quality of life, we could get a huge life improvement if she were willing to do work with that fear. So, my job as clinician was to make a very good case for going right to one of the most difficult areas. We spent a good deal of time talking about what it would mean, what the exposure would look like, how the patient might feel and all the various ins and outs. The patient and her family opted to do the exposure. The exposure went very well and afterward, patient and family continued to practice it. The benefit to her life, in terms eliminating the time spent in the ritual, was huge to the entire family. But, again, I think the key was explaining to everyone involved what we would be doing, why, how, etc., and obtaining their consent before ever proceeding. In terms of the swimming pool analogy, I actually use that with people I work with. I explain that there are different ways to acclimate to a cold pool – some people choose to jump right in and some need to go in a step at a time. The approach to treatment has to match the individual, and some people just like to cannonball right in.
Thank you for your insight, Angie. To me, your experience is so different from what my post is all about. As you say, your course of action was explained to, and discussed with, your client and family. The OCD sufferer in question had some control and could have decided not to “cannonball.” It was her choice to proceed, not something that was forced upon her. This approach was attempted because it was deemed to be in her best interests, not because there were time restraints. In short, the “flooding” was done for all the right reasons!
I guess I have a difficult time understanding doing an exposure or flooding someone without their permission and understanding. So your point stands; it just seems inhumane and contrary to all training I’ve had.
in my ocd training (also by IOCDF indirectly), it was stressed that you NEVER do exposures without warning or previous discussion. to do so compromises the therapy. if only all therapists respected the oath we agreed to regarding not providing treatment we aren’t qualified to give.
Thank you Angie and April for letting us know this is NOT how ERP should happen, and not how it’s taught to professionals.
Janet,
Do you have any recommendations for OCD treatment centers?
Thanks,
Steve
there is a quality directory at http://www.ocfoundation.org
believe it lists outpatient providers as well as centers that offer intensive outpatient and residential services. rogers memorial just opened a large residential facility for OCD specifically. there are also good centers in houston, st. louis, and the new england area.
Thanks for the information, April. Hope you find it helpful, Steve.