Involving Family Members in the Treatment of OCD

This review focuses on previous research with families of adults and children with obsessive‐compulsive disorder (OCD). Three primary areas of research are covered: (i) characteristics of family members and the family environment; (ii) the prediction of treatment response based on family variables; and (iii) the inclusion of family members in treatment. Much of the research supports a hypothesized model of family response to symptoms of OCD that ranges on a continuum from overly accommodating to overly antagonistic. Further research indicates that responses at either extreme of this continuum are associated with poorer response to both exposure and response prevention (ERP) and pharmacotherapy. Finally, results of preliminary treatment outcome studies suggest that family‐based interventions aimed at reducing such responses and/or including family members in ERP as coaches or co‐therapists may enhance patients' response to treatment. Based on current theory and research, suggestions for future research and general recommendations for involving family members in treatment are made.     

Potentials and Limitations of Cognitive Treatments for Obsessive‐Compulsive Disorder

Exposure and response prevention (ERP) is a well‐established treatment for obsessive‐compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure‐based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Potentials and limitations of cognitive treatments for obsessive-compulsive disorder

Exposure and response prevention (ERP) is a well-established treatment for obsessive-compulsive disorder (OCD). However, it is not completely effective for many patients, and some do not benefit from or tolerate this treatment. Over the past 3 decades there has been growing interest in using cognitive interventions, either as adjuncts or alternatives to exposure-based treatments such as ERP, to address these shortcomings. Cognitive therapy and cognitive behavior therapy for OCD have both demonstrated greater efficacy than no treatment at all, and appear to have a lower incidence of dropout than ERP. Unfortunately, however, for the average OCD patient, cognitive interventions have not improved treatment efficacy; that is, cognitive interventions, either alone or combined with ERP, are no more effective than ERP alone. Reasons for this disappointing result are considered, and indications for the use of cognitive interventions are discussed. Future research directions are suggested in order to evaluate more fully the merits of, and indications for, cognitive methods for treating OCD.     

Psychological Flexibility as Shared Process of Change in Acceptance and Commitment Therapy and Exposure and Response Prevention for Obsessive-Compulsive Disorder: A Single Case Design Study

Changes in psychological flexibility were tracked in a combined protocol of exposure and response prevention (ERP) and acceptance and commitment therapy (ACT) for adults with OCD to assess if changes in psychological flexibility processes were unique to ACT intervention (e.g., not impacted by ERP). Using a nonconcurrent multiple baseline design, four participants received sessions of ERP and ACT while data was collected on psychological flexibility processes of change and OCD symptom severity. Results indicate treatment response for three of four participants based on OCD scores. Contrary to predictions, data suggest both ERP and ACT have positive effects on psychological flexibility. Implications of these findings are discussed in relation to recent research on ACT and ERP for OCD. This study also illustrates a type of research design that can be accomplished in clinical practice.     

A Brief Motivational Intervention for Treatment‐Refusing OCD Patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive‐compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self‐identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4‐session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait‐list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4‐week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop‐out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop‐out as well as directions for future research are discussed.     

A brief motivational intervention for treatment-refusing OCD patients

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive-compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self-identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4-session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait-list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4-week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop-out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop-out as well as directions for future research are discussed.     

D-Cycloserine for Treatment Nonresponders With Obsessive-Compulsive Disorder: A Case Report

Despite being the most effective treatment available, as many as one third of patients who receive exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) do not initially respond to treatment. Recent research suggests that the n-methyl d-aspartate (NMDA) receptor partial agonist D-Cycloserine (DCS) may speed up the course of ERP for OCD rather than enhance it. Thus, it is unclear whether DCS would benefit patients who have proven nonresponsive to ERP and serotonin reuptake inhibitors. The present study evaluated the ability of DCS to enhance ERP for 2 patients with OCD who previously had failed to show adequate response to treatment using time-series analysis. Both patients experienced greater reductions with DCS augmented ERP than they did with prior treatment; however, 1 patient relapsed by the 1-month follow-up. DCS augmented ERP might be an effective method for boosting outcomes in individuals who do not readily respond to ERP.     

Irritability in Children and Adolescents With OCD

Irritability is a common, impairing transdiagnostic symptom in childhood psychopathology, though it has not been comprehensively studied in pediatric obsessive-compulsive disorder (OCD). Further, the central cognitive behavioral treatment component for OCD, exposure and response prevention therapy (ERP), has been recently proposed as a treatment for irritability. This study aimed to evaluate whether certain clinical characteristics are associated with irritability in pediatric OCD and whether irritability reduces following ERP. Participants were 161 youth (ages 7–17) with OCD and a caregiver participating in a randomized controlled trial of D-cycloserine or pill placebo augmented ERP. Participants completed validated assessments during treatment. Irritability was significantly and positively associated with depressive symptoms, defiance, functional impairment, and family accommodation, but was not associated with pretreatment OCD severity, symptom dimensions, obsessive beliefs. Irritability significantly declined following treatment, with over half of youth with any pretreatment irritability experiencing clinically significant change, though this change was not related to OCD improvement. Results suggest that irritability may be a marker of psychiatric comorbidity, parental accommodation, and impairment in youth with OCD. Implications for the exposure-based treatment of irritability are discussed.     

Therapists’ Thought-Action Fusion Beliefs Predict Utilization of Exposure in Obsessive-Compulsive Disorder

Although exposure and response prevention (ERP) is considered the gold standard for the treatment of obsessive-compulsive disorder (OCD), it is rarely used in clinical practice. Therapists’ beliefs about ERP affect its utilization, as previous research suggests, but the role of therapists’ cognitive biases is unclear. In particular, susceptibility to thought-action fusion (TAF) may be related to the underutilization of ERP in OCD.Therapists (N = 353) were divided into those recommending (ERP+, n = 228) and not recommending ERP (ERP−, n = 125) as treatment for an OCD case example. TAF in therapists was assessed using behavioral and self-report measures (TAFS).TAF was higher in the ERP− than the ERP+ group, with a small to moderate effect size (0.2 ≤ d ≤ 0.4). ERP− therapists showed more avoidance and neutralizing behavior and a stronger emotional response than the ERP+ therapists during the experimental task. Moreover, higher TAF as measured by the TAFS was associated at a small magnitude with lower likelihood of using ERP in the therapists’ actual clinical practices.Therapists’ cognitive biases should be addressed in their training in order to increase the dissemination of evidence-based treatment (i.e., ERP) and thus improve the treatment of OCD.     

Family and psychosocial predictors of obsessive compulsive disorder in a community sample of young adolescents

A two-stage epidemiologic study conducted between 1986 and 1988 in the southeastern United States investigated family and psychosocial predictors of obsessive compulsive disorder (OCD) and subclinical OCD in young adolescents. In the first stage, a life-event schedule and a family adaptability and cohesion scale were administered to a community sample of 3,283 adolescents. In stage two, the Schedule for Affective Disorders and Schizophrenia in School Age Children and the Children's Global Assessment Scale were administered to 488 mother-child pairs. In multivariable models family cohesion was the only significant correlate of OCD (odds ratio=0.95, 95% confidence interval 0.91–0.98). Gender, race, age, socioeconomic status, guardian status, adaptability, undesirable life events and desirable life events were not found to be significant predictors of OCD in models adjusting for cohesion. Note of the above variables were significantly associated with subclinical OCD. However, separate analyses of the 41 individual life events indicated seven specific events were significantly associated with OCD or subclinical OCD. These findings are at odds with the theory that overinvolvement of family members is a risk factor for OCD, though an association with overly rigid family structure cannot be eliminated based on these data. Further exploration of family characteristics is warranted.     

A randomized controlled trial of self-directed versus therapist-directed cognitive-behavioral therapy for obsessive-compulsive disorder patients with prior medication trials

Cognitive-behavioral therapy incorporating exposure and response prevention (ERP) is widely considered a first-line psychosocial treatment for patients with obsessive-compulsive disorder (OCD). However, a number of obstacles prevent many patients from receiving this treatment, and self-administered ERP may be a useful alternative or adjunct. Forty-one adult outpatients with a primary diagnosis of OCD, who reported at least 1 current or previous adequate medication trial, were randomly assigned to self-administered or therapist-administered ERP. Patients in both treatment conditions showed statistically and clinically significant symptom reduction. However, patients receiving therapist-administered ERP showed a superior response in terms of OCD symptoms and self-reported functional impairment. We discuss several potential reasons for the superiority of therapist-administered treatment, and propose a stepped-care integration of self-administered and therapist-administered interventions for OCD.     

Are all safety behaviours created equal? A comparison of novel and routinely used safety behaviours in obsessive-compulsive disorder

Contamination fear is one of the most common symptoms of obsessive-compulsive disorder (OCD). Exposure and response prevention (ERP) is effective for OCD, but a significant minority of treatment-seeking individuals refuse ERP entirely or drop out prematurely. Research suggests that safety behaviour (SB) may enhance the acceptability of ERP; however, questions remain about how to incorporate SB into existing treatments. Clinical participants with OCD and contamination fear (N = 57) were randomized to receive an exposure session with no SB (ERP), a routinely used SB (RU), or a never-used SB (NU). Significant reductions in contamination fear severity were observed in all conditions. Although omnibus comparisons were only marginally significant, pairwise comparisons revealed some condition differences. NU demonstrated significantly lower self-reported contamination fear severity at post-exposure, as well as marginally higher treatment acceptability ratings. Findings suggest that exposure with SB may be effective and acceptable, and are discussed in terms of cognitive-behavioural theory and treatment of anxiety and related disorders.     

Does Exposure and Response Prevention Behaviorally Activate Patients With Obsessive-Compulsive Disorder? A Preliminary Test

Exposure and response prevention (ERP) and behavioral activation (BA) are effective treatments for obsessive-compulsive disorder (OCD) and depression, respectively. Patients with OCD often exhibit depression; furthermore, ERP for OCD is associated with reduced depressive symptoms. To our knowledge, no study has examined whether ERP itself functions to behaviorally activate patients with concurrent OCD and depressive symptoms. This prospective study was designed to test the hypotheses that (a) OCD exposure hierarchy completion, increased BA, and depressive symptom reduction would all be related, and (b) pre- to posttreatment changes in BA would mediate the direct effect of OCD hierarchy completion on posttreatment depressive symptoms, even after controlling for pretreatment depressive symptoms, pretreatment BA, pre- to posttreatment reductions in OCD symptoms, treatment duration, and antidepressant medication use. Patients (N = 90) with a primary diagnosis of OCD who received residential ERP for OCD completed a self-report battery at pre- and posttreatment. Exposure hierarchy completion, increases in BA, and decreases in depression were all significantly correlated (rs ranged .33 to .44). The effect of hierarchy completion on posttreatment depressive symptoms was fully mediated by pre- to posttreatment changes in BA. Findings highlight the potential for ERP to exert antidepressant effects by behaviorally activating patients. Limitations, clinical implications, and future directions are discussed.     

Office-based vs home-based behavioral treatment for obsessive-compulsive disorder: a preliminary study

The current study investigated whether exposure with response prevention (ERP) for obsessive compulsive disorder (OCD) is more effective when administered in a participant's home or other natural environments where symptoms tend to occur, than in a therapist's office. Twenty-eight outpatients with a principal diagnosis of OCD were randomly assigned to receive ERP in their therapist's office vs. wherever their symptoms usually occur (e.g., at home, at work, in public places, in the car, etc.). Participants received 14, 90-min sessions of ERP with an individual therapist. Participants were assessed at pretreatment, post-treatment, and at 3- and 6-month follow-up. Assessments included both self-report as well as clinician-rated indicators of OCD symptom severity, depression, and functional impairment. Results suggested that participants improved significantly, regardless of where treatment occurred. There were no differences in efficacy between the home-based and office-based treatment for OCD. Implications of these findings are discussed.     

“Phobie à deux” and other reasons why clinicians do not apply exposure with response prevention in patients with obsessive–compulsive disorder

Meta-analyses suggest that exposure with response prevention (ERP) is the most efficacious treatment for obsessive–compulsive disorder (OCD) and treatment guidelines for the disorder accordingly recommend ERP. Despite this, many therapists, including those with a cognitive-behavioral therapeutic background, do not perform ERP in patients with OCD. The present study aimed to elucidate the reasons why. German therapists (N = 216) completed an anonymous online survey, the newly developed Reasons for Not Performing Exposure in OCD Scale (REPEX), that inquired whether, to what extent, and how they perform ERP in the treatment of OCD. We also asked their reasons for not applying ERP in the past. Most therapists considered ERP an efficient treatment for OCD. Marked differences emerged between physicians and psychologists, however. The former used exposure less often and for a shorter period, preferred in sensu to in vivo exposure, and conducted exposure less often in the personal environment of the patient than did psychologists. Both groups were familiar with clinical guidelines to a similar extent. A factor analysis of the REPEX scale revealed five factors. Patient lack of motivation, preference for exposure to be self-help as well as alleged organizational difficulties were endorsed most often. The latter was correlated with the age of the therapist and was far more often affirmed by physicians. Fear of side effects was named by a subgroup of clinicians; in the context of patient ambivalence, this may foster “phobie à deux”. Unlike prior research, lack of expertise was rarely identified as a reason not to use ERP. Recommendations for improving adherence to guidelines are discussed.     

Directions in Specialized Cognitive Behavior Therapy for Resistant Obsessive-Compulsive Disorder: Theory and Practice of Two Approaches

This paper discusses specialized approaches developed for patients with obsessive-compulsive disorder (OCD) who are resistant to cognitive behavior therapy (CBT). Following a review of theoretical and outcome research, two approaches developed to resolve persistent OCD are described and illustrated. Cognitive therapy (CT) designed to address characteristic dysfunctional beliefs has shown promising results (Wilhelm et al., 2005; Wilhelm & Steketee, 2006). CT modules focus on understanding and correcting OCD-related beliefs (e.g., inflated responsibility, need for certainty, perfectionism) pertinent to each patient’s symptoms, using specialized strategies and behavioral experiments to test and modify maladaptive hypotheses and related negative emotions. CT appears to be acceptable to many patients and may reduce refusal rates and improve collaboration during exposure and response prevention (ERP). It is not yet clear whether this method improves outcomes for patients who have not responded to previous ERP. A schema-based CBT approach developed by Sookman and Pinard (1999, 2007) for resistant OCD of different subtypes aims to broaden the scope of CT, to improve patients’ capacity to fully engage in ERP, and to reduce susceptibility to relapse. Available results with previously CBT-resistant patients suggest this approach may improve learning during CT and collaboration in ERP, resulting in recovery for some patients. Criteria are outlined for defining CBT resistance and assessing treatment response using various outcome measures and stringent criteria. The ultimate goal of expert intervention for OCD is remission. The authors propose theory, practice, and research directions to help ameliorate symptoms and related difficulties in resistant OCD.     

Treating Obsessive-Compulsive Disorder in Intimate Relationships: A Pilot Study of Couple-Based Cognitive-Behavior Therapy

Although cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) is an established treatment for obsessive-compulsive disorder (OCD), not all patients respond optimally, and some show relapse upon discontinuation. Research suggests that for OCD patients in close relationships, targeting relationship dynamics enhances the effects of CBT. In the present study, we developed and pilot tested a 16-session couple-based CBT program for patients with OCD and their romantic partners. This program included (a) partner-assisted ERP, (b) techniques targeting maladaptive relationship patterns focal to OCD (e.g., symptom accommodation), and (c) techniques targeting non OCD-related relationship stressors. OCD, related symptoms, and relationship functioning were assessed at baseline, immediately following treatment (posttest), and at 6- and 12-month follow-up. At posttest, substantial improvements in OCD symptoms, relationship functioning, and depression were observed. Improvements in OCD symptoms were maintained up to 1 year. Results are compared to findings from studies of individual CBT for OCD and discussed in terms of the importance of addressing interpersonal processes that maintain OCD symptoms.     

App-guided exposure and response prevention for obsessive compulsive disorder: an open pilot trial

Although effective treatments for obsessive–compulsive disorder (OCD) exist, there are significant barriers to receiving evidence-based care. Mobile health applications (Apps) offer a promising way of overcoming these barriers by increasing access to treatment. The current study investigated the feasibility, acceptability, and preliminary efficacy of LiveOCDFree, an App designed to help OCD patients conduct exposure and response prevention (ERP). Twenty-one participants with mild to moderate symptoms of OCD were enrolled in a 12-week open trial of App-guided self-help ERP. Self-report assessments of OCD, depression, anxiety, and quality of life were completed at baseline, mid-treatment, and post-treatment. App-guided ERP was a feasible and acceptable self-help intervention for individuals with OCD, with high rates of retention and satisfaction. Participants reported significant improvement in OCD and anxiety symptoms pre- to post-treatment. Findings suggest that LiveOCDFree is a feasible and acceptable self-help intervention for OCD. Preliminary efficacy results are encouraging and point to the potential utility of mobile Apps in expanding the reach of existing empirically supported treatments.     

Year of Zoom in a Year of Doom: Lessons Learned Delivering ERP Remotely During the COVID-19 Pandemic

In response to the COVID-19 pandemic and consequential shutdown measures, many mental health professionals started providing therapy to patients exclusively via telehealth. Our research center, which specializes in studying and treating obsessive-compulsive disorder (OCD), historically has provided in-person exposure and response prevention (ERP) to adults with OCD, but shifted to telehealth during the pandemic. Unlike in other modes of talk therapy, ERP’s emphasis on therapist-supervised exposures presented unique opportunities and challenges to delivering treatment entirely via a virtual platform. This paper provides case examples to illustrate lessons we learned delivering ERP exclusively via telehealth in New York from March 2020 through June 2021 and offers recommendations for future study and practice. Though we observed a number of drawbacks to fully remote ERP, we also discovered advantages to delivering ERP this way, meriting additional research attention.     

The Treatment of Mental Contamination: A Case Series

The recommended treatment for obsessive-compulsive disorder (OCD) is cognitive behavior therapy (CBT) incorporating exposure and response prevention (ERP), which is effective for approximately 50% of patients. However, there has been little advance in treatment outcomes since the introduction of ERP in 1979. It has been suggested that some progress can be made in treating contamination obsessions and washing compulsions by addressing feelings of dirtiness and contamination that arise without physical contact with a tangible contaminant. To date, the treatment of these “mental contamination” fears in OCD has not been systematically explored. This paper reports on a case series of 12 participants with OCD who received 10 to 20 sessions of a CBT-based treatment for mental contamination. At the end of treatment, 7 participants no longer met the diagnostic criteria for OCD and mental contamination and these gains were maintained at 6-month follow-up. The clinical implications of these findings are discussed.