Why Intensive Treatment for Obsessive-compulsive and Anxiety disorders works

There was a time when successful treatment of OCD was considered almost impossible. In his summary of the current state of OCD treatment in 1960, psychiatrist Charles Breitner (1960) wrote “most of us are agreed that the treatment of obsessional states is one of the most difficult tasks confronting the psychiatrist and many of us consider it hopeless”.

The origins for ERP wind their way all the way back to Pierre Janet, a French psychologist and neurologist and contemporary of Sigmund Freud. Janet coined the term “exposure” and used it to describe a process in which he repeatedly presented individuals with challenging stimuli and used encouragement and firmness to promote more helpful responses to these challenging stimuli. As the story goes, Janet became a celebrated psychologist, becoming chair of the psychology department at Sorbonne, doing research in a number of areas and publishing numerous influential papers. But his work on exposure therapy did not fare as well and it took the blossoming of the behavior therapy movement in the 1960s to revive and re-interpret Janet’s work. In the late 50’s and early 60’s, researchers and clinicians struggled with treating individuals with OCD. The Australian psychologist Joseph Wolpe was a pioneer in the application of learning theory to individuals with chronic anxiety. At the time, the field of behavior therapy was growing and spreading and Wolpe’s work was instrumental in establishing behavioral treatment and exposure (specifically something called systematic desensitization). But early attempts with OCD did not yield much success until Victor Meyer, a British psychologist and former fighter pilot published a case study report of his work in a psychiatric hospital, in which he actively enlisted nursing staff to help OCD patients to prevent doing compulsions (Meyer 1966).

Some time after Meyer, other the research labs led by Stanley Rachman, Paul Emmelkamp and Edna Foa started publishing studies on what eventually became called exposure and response prevention (ERP). Behavioral scientists started to migrate treatment to outpatients, typically done in sessions once a week. But relatively quickly, it became clear that daily treatment for a short period of time was extremely effective and in addition, for some patients, once a week of ERP did not seem to be sufficient (Steketee, 1987). Since those early days, intensive treatment has become a mainstay for treating OCD, yielding improvements in weeks rather than years.

A 2015 paper suggests that intensive treatment may produce stronger treatment effects than once a week treatment. Hjalti Jonsson and colleagues compared four studies that were head-to-head comparisons of intensive (5x a week) vs weekly treatment. Each of these studies standardized the number of treatment hours so that every patient got the same number of treatment hours. But some got them in an intensive/daily format, and some got them once or twice a week spread out over an extended number of weeks. Their findings show a significantly stronger treatment effect (also called effect size) for intensive treatment.

Why might this be? Perhaps practicing learning new skills (like how to manage overwhelming anxiety) is well suited for frequent “squeezed together” practice, rather than practicing in spread out sessions. Keep in mind that spaced, weekly sessions can help considerably, but working in a concentrated fashion might be even better.

References

Breitner, C. Drug therapy in obsessional states and other psychiatric problems. In Diseases of the Nervous System. 1960 Vol 21, pgs 31-35.

Emmelkamp P & Rabbie, DM. Psychological treatment of obsessive-compulsive disorder. Book Chapter in Biological Psychiatry. 1981

Foa, E. Steketee G., and Ozarow, BJ. Behavior Therapy with Obsessive-Compulsives. In Obsessive-Compulsive Disorder. 1985, pgs 49-129.

Jónsson H. and colleagues. Intensive cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. In Journal of Obsessive-Compulsive and Related Disorders. 2015 Vol 6, pgs 83-96.

Marks, IM, Hodgson, R, & Rachman, SJ. Treatment of Chronic Obsessive-Compulsive Neurosis by in-vivo Exposure A Two-Year Follow-up and Issues in Treatment. In The British Journal of Psychiatry. 1975 Volume 127, Issue 4, pgs 349-364.

Meyer V. Modification of expectations in cases with obsessional rituals. In Behaviour Research and Therapy. 1966 Vol 4, 273–280.

Steketee G Behavioral Social Work with Obsessive-Compulsive Disorder. In Journal of Social Service Research. 1987 10:2-4, 53-72

Why video sessions work

A common and reasonable concern for people starting with us is whether remote, video sessions for psychotherapy and cognitive-behavioral therapy (CBT) in particular are helpful. It turns out there is a good amount of research on these specific questions that demonstrate that video sessions actually work very well.

In a comprehensive review of 103 research studies, Fernandez and colleagues report that “video” psychotherapy is as effective as in person therapy, regardless of the type of talk therapy (Fernandez, Woldgabreal et al, 2021); but even more that that, CBT based video therapy seems even more effective. In their paper, the study authors emphasize that video therapy seems to be particularly well suited to CBT.

In the past year, we have exclusively focused on video based CBT treatment for OCD, specifically exposure and response prevention (ERP). We regularly get phone calls and emails from people who think that remote therapy wouldn’t work well for OCD. In our experience this is not at all the case and this is consistent with published studies showing the effectiveness of remote therapy for treating OCD. Bethany Wootton published a meta analytic review in 2015 on exactly this topic. She looked at results from 18 studies and found that remote treatment (video or telephone) led to significant improvements in OCD symptoms that were similar to in person treatment.

Wootton describes a few advantages of video based CBT. The first is that distance from the office is no longer a factor. Pre 2019, it would not be usual for people to come to the clinic after an hour long drive. If you lived 2-3 hours from us, you were out of luck. I had one client whose commute time was 2 hours to come see me. Yikes!

Another important factor that is specific to treating OCD is that we get to see clients in their home environment. This can be helpful because we get to conduct exposures in people’s home. Although it’s not true for everyone, but typically OCD flourishes in the home environment so working on it directly in that environment is really useful.

A third important piece is that we get to use the computer. Spreadsheets, whiteboards, sharing documents to read over are all really useful. We can do that in person too, but via video it becomes much easier. This is really great for tracking homework in that we can mutually go over what’s working and what’s not working in terms of getting homework done.

There are downsides however. The most basic one is privacy. Some people live in homes or apartments where privacy can be difficult. Privacy is vitally important to therapy because we have to have a talking area where you feel comfortable airing things out. And some of the things you air out may not be flattering to yourself or to others. But to get some honest work done, we need to put this stuff on the table. Feeling like you don’t have a private area can pose significant problems with that. These issues often have work arounds. People can use headphones, or can ask family members to not be in the house for the hour.

Some people can get distracted doing video therapy. They get text messages, email notifications, they get tempted to surf the web. The good news is that this is workable and an assertive therapist can point out that they notice the client seems distracted. Usually calling this out a couple times does the trick.

Lastly, some folks are just not tech savvy and are not interested in becoming more video or tech savvy. Ultimately, this is understandable. It is your choice.

The COVID-19 boom in video meetings, overall in my opinion, for therapy, has forced us to invest and really try out doing video therapy and to take advantage of its unique positives it offers while also making us aware of its problems. But even before COVID-19, a number of research studies clearly have shown that video CBT works very well; in fact so well, that it should not be considered a second tier alternative to in person therapy but on par with in person therapy.

REFERENCES

Ephrem Fernandez et al. Live psychotherapy by video versus in‐person: A meta‐analysis of efficacy and its relationship to types and targets of treatment In Clinical Psychology & Psychotherapy. 2021 Apr 7. doi: 10.1002/cpp.2594.Online ahead of print.

Bethany Wootton. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis. In Clinical Psychology Review. Volume 43, February 2016, Pages 103-113