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