- Email: [email protected]
Cognitive–behavior therapy of obsessive–compulsive disorder in private practice: An effectiveness study
Anxiety Disorders 15 (2001) 277 ± 285
Cognitive±behavior therapy of obsessive± compulsive disorder in private practice: An effectiveness study$ Ricks Warrena,b,*, Jay C. Thomasb a
The Anxiety Disorders Clinic, Lake Oswego, OR, USA b Pacific University, Forest Grove, USA
Received 15 March 1999; received in revised form 15 April 1999; accepted 5 April 2000
Abstract A controversy exists over whether or not the results of randomized controlled trials (RCTs) are generalizable to routine clinical practice. The present study examines the effectiveness of cognitive ± behavior therapy (CBT) for obsessive ± compulsive disorder (OCD) in a private practice setting. Twenty-six consecutive clients referred to a private anxiety disorders specialty clinic began treatment for OCD. Of the 19 (73%) clients who completed treatment, 84% were treatment responders. Clients, treatment, and outcome of the present study are compared with those of representative RCTs, and it is concluded that there are more similarities than differences. It is concluded that CBT can be effectively delivered in routine clinical practice. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Obsessive-compulsive disorder; Private practice; Effectiveness study; Cognitive behavior therapy
Portions of this paper were presented in Sookman, D., Yaryura-Tobias, J., & Warren, R. (1997). In C. A. Pollard & C. N. Carmin (Chairs), Issues in the integration of drug and cognitive behavioural treatments for OCD: a clinical roundtable. Symposium conducted at the meeting of the XXVII Congress of European Association for Behavioural and Cognitive Therapies, Venice, Italy. * Corresponding author. The Anxiety Disorders Clinic, Suite 225, 4550 Southwest Kruse Way, Lake Oswego, OR 97035, USA. Tel.: +1-503-635-8710; fax: +1-503-635-0583. E-mail address: [email protected] (R. Warren). $
0887-6185/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 8 8 7 - 6 1 8 5 ( 0 1 ) 0 0 0 6 3 - 9
278
R. Warren, J.C. Thomas / Anxiety Disorders 15 (2001) 277±285
1. Introduction The controversy over empirically supported treatments (ESTs) (Chambless & Hollon, 1998) has important implications for the relationship between research and practice, job satisfaction of practitioners, managed care directives, and ultimately the welfare of consumers (Barlow & Hofmann, 1997). While behavior therapists have long advocated use of ESTs, there is opposition within the ranks challenging the relevance of research to clinical practice (Fensterheim & Raw, 1996). Garfield (1998) has cogently expressed concern that, in the rush to establish ESTs, the importance of therapist skill and patient variability may be diminished. One central argument against widespread advocacy of ESTs is skepticism as to generalizability of treatment conducted in research protocols to everyday clinical practice (Seligman & Levant, 1998). In other words, while randomized controlled trials (RCTs) are used to support efficacy of ESTs, few studies have evaluated effectiveness of these treatments in routine clinical practice. Relevance of results obtained from RCTs are questioned due to a number of presumed differences, including therapist training and supervision, manualization of treatment, fixed number of treatment sessions, and the kinds of patients treated. Due to these presumed differences, RCTs are considered to possess internal but not external validity (Persons & Silberschatz, 1998). In spite of understandable skepticism, given these presumed differences in RCTs and actual clinical practice, studies supporting the transportability and effectiveness of research-based treatments to routine clinical practice are beginning to emerge. For example, Wade, Treat, and Stuart (1998) found panic control treatment (PCT; Barlow & Craske, 1989) to be effective in treating panic disorder in a community mental health center, and Warren and Thomas (1998) found PCT effective in a private practice setting. Persons, Burns, and Perloff (1988) successfully implemented cognitive therapy for depression with private practice patients. In addition, Westbrook and Hill (1998) reported on successful long-term outcome of cognitive ± behavior therapy (CBT) for adults with a variety of focal problems in a National Health Service Clinic in Oxford. Franklin et al. (1998) recently reported results of an effectiveness study of exposure and ritual prevention for patients at the Allegheny University of the Health Sciences (AUHS), Department of Psychiatry Obsessive ± Compulsive Disorder (OCD) Clinic. Patient demographic characteristics, OCD severity, and treatment outcome were comparable for AUHS clinic patients, RCT study protocol patients, and several representative RCTs conducted at other universities. It could be argued, however, that while Franklin et al. (1998) demonstrated transportability of CBT for OCD from the research protocol to clinic patients at AUHS, the travel distance was limited. Effectiveness studies conducted with other therapists, clients, and settings are needed to test the boundaries of transportability. Over 15 years ago, Kirk (1983) stated that, ``A question of continual concern to research workers, however, is the extent to which such findings can be
R. Warren, J.C. Thomas / Anxiety Disorders 15 (2001) 277±285
279
generalized to everyday clinical practice'' (p. 57). Kirk reported on the behavioral treatment of a series of 36 OCD patients referred to a National Health Services Behavior Therapy Clinic. She concluded that over 75% were moderately improved or better, and that 81% of patients appeared to seek no further treatment between 1 and 5 years of follow-up. We are not aware of any further report of CBT for OCD in routine clinical practice. Kirk's (1983) report appeared before the Yale-Brown Obsessive ± Compulsive Scale (Y-BOCS) was developed and became the gold standard for measuring OCD treatment outcome. Kirk noted that, in her study, no standard measures were used, and instead, a global rating based on patient self-monitoring and self-ratings and therapists' assessments based on discharge letters were the outcome measures. The purpose of the present study was threefold: (1) to explore the effectiveness of CBT in a private practice setting, using Y-BOCS scores as the outcome measure; (2) to explore similarities and differences between our clients and typical patients in RCTs; and (3) to explore the adaptability of variants of ERP, frequency and length of sessions, use of cognitive therapy techniques designed particularly for OCD, and substantial reliance on self-controlled exposure homework assignments. 2. Method 2.1. Subjects Twenty-six clients (15 males, 11 females) were referred to The Anxiety Disorders Clinic (TADC), Lake Oswego, OR, for the treatment of OCD. Nineteen (73%) clients completed treatment. Sample characteristics of completers are presented in Table 1. Co-morbid conditions included major depressive disorder (n = 1), major depressive disorder and GAD (n = 3), oppositional disorder (n = 1), and schizoid personality disorder (n = 1). Of the 13 clients who had received previous treatTable 1 Sample characteristics of completers N Sex Age Marital status Education Income Age of onset Duration of OCD Co-morbidity On medication Previous treatment
19 12 males (63%) x = 30.1 12 single (63%) x = 15.2 years x = 53,292 x = 17.9 x = 63.3 months 6 yes (32%) 13 yes (68%) 13 yes (68%)
7 females (37%) S.D. = 8.07 7 married (37%) S.D. = 3.00 S.D. = 36,807 S.D. = 9.02 S.D. = 56.75 13 no (68%) 6 no (32%) 6 no (32%)
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ment for OCD, the following treatment modalities were reported: behavior therapy alone (zero), medications plus behavior therapy (one), medications alone (seven), medications along with supportive therapy (five). Using the four symptom dimensions reported by Leckman et al. (1997), 12 (63%) clients had ``harmful, religious, and sexual obsessions and related compulsions,'' including fears related to HIV and brain tumors, leaving car doors unlocked and garage doors open, accidents and loved ones' safety, accidentally poisoning family food, feces, being molested, being gay, and being a pedophile. Two clients in this category had obsessions with minor overt compulsions. Six (32%) clients had ``contamination obsessions and cleaning compulsions,'' including fears related to germs, HIV, semen, household cleaners, urine and feces, and supernatural beings. One client had ``symmetry, ordering, counting, and arranging obsessions and compulsions,'' including vacuuming, making child's lunch, and making the bed perfectly. No client had ``hoarding and collecting obsessions and compulsions.'' 2.2. Procedures All clients were routine consecutive referrals to TADC from 1992 to 1998. TADC is a private practice group specializing in the treatment of anxiety disorders, located in Lake Oswego, OR. The clinic staff includes four psychologists, one licensed professional counselor, and a mental health nurse practitioner. TADC is currently in its 12th year of operation. The clients in the present study were referred by their psychiatrist (n = 6), primary care physician (n = 2), psychologist (n = 2), OC Foundation (n = 2), friends, relatives, or local agencies (n = 7). 2.3. Assessment The outcome measure for this study was the self-report version of the Y-BOCS (Goodman et al., 1989). The self-report Y-BOCS (Baer, Brown-Beasley, Sorce, & Henriques, 1993; Warren, Zgourides, & Monto, 1993) appears to be psychometrically equivalent to the original interview version and has been suggested by Steketee, Frost, and Bogart (1996) as a time-saving and less costly alternative to the interview format. 2.4. Treatment Treatment was conducted by the first author, usually with weekly sessions, with a mean of 16.4 hrs of treatment. Exposure and response prevention (ERP) were the core elements of treatment (Kozak & Foa, 1997; Steketee, 1993) with formal cognitive procedures often included (van Oppen & Arntz, 1994). Clients with obsessions with few overt rituals were treated with writing and/or looped tape exposure and cognitive interventions (Freeston et al., 1997). For clients with overt compulsions, two cases included in-office in vivo exposure, and three patients received therapist-assisted out-of-office in vivo exposure. Exposure in
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Table 2 Means and standard deviations for pre- and post-self-report Y-BOCS scores for completers (N = 19) Pre Obsessions Compulsions Total
Post
M
S.D.
M
S.D.
11.5 11.5 23.0
1.95 4.56 5.62
6.7 4.9 11.6
2.45 3.26 4.98
vivo in the client's home was included in one case. The majority of clients (n = 13) received cognitive therapy and planning for self-controlled exposure (Emmelkamp & Kraanen, 1977). Imaginal exposure was conducted only for clients with feared disasters. 3. Results Table 2 presents pre- and post-self-report Y-BOCS scores for completers. Treatment was associated with a significant reduction in Y-BOCS obsessions, compulsions, and total scores, t(18) = 7.30, 7.22, and 7.28, respectively, P < .000001. Effect sizes (d) were 1.66, 1.65, and 2.19, respectively. Improvement rates ranged from 12% to 91%, with a mean of 48%. Using a 35% reduction in Y-BOCS total scores as indicative of responder status, 84% were responders. Using Jacobson and Truax's (1991) ``C'' index, 84% of clients showed clinically significant change on obsessions, 53% on compulsions, and 84% on total Y-BOCS scores. Seventy-five percent of clients obtained functional status on obsessions, 53% on compulsions, and 58% on Y-BOCS total scores.1 There were no differences in degree of change between clients taking medications and those who were not. Of the limited data available for comparison, dropouts (n = 7) were older (x = 41.00, S.D. = 10.10) than completers (n = 19) (x = 30.00, S.D. = 8.10) [t(24) = 2.90, P < .01]. Not surprisingly, dropouts received fewer sessions (x = 5.4, S.D. = 5.2) than completers (x = 16.4, S.D. = 8.8) [t(18.6) = 3.92, P < .0009]. 4. Discussion Results of this case series support the effectiveness of CBT for OCD in an outpatient private practice setting. As Kirk (1983) concluded from her behavioral
1
Self-report Y-BOCS scores for non-clinical subjects used to calculate functional status were taken from Warren et al. (1993). Mean scores were 2.13 (S.D. = 3.21) on the obsession subscale, 1.55 (S.D. = 2.85) on the compulsion subscale, and 3.68 (S.D. = 5.46) for the total score.
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treatment of OCD patients in routine clinical practice, it appears that findings from controlled studies can be generalized to everyday clinical practice. How similar were our ``real patients'' to patients who participate in RCTs? Marital status, mean age, age of onset, hours of treatment, education level, and dropout rate appear comparable (e.g., Abramowitz, 1998; Antony, Downie, & Swinson, 1998; Foa, Steketee, Grayson, Turner, & Latimer, 1984). In addition, pretreatment OCD severity (total Y-BOCS score) was also similar (Greist, 1996). There also appears to be differences between clients in the present study and those participating in research protocols. Our sample contained more males (63%) than females (37%), a sex ratio which is roughly the reverse of the average in RCTs. In addition, mean duration (5.2 years) of OCD symptoms in our sample appears shorter than those reported in RCTs (x = 10.28) (Abramowitz, 1998). It is difficult to determine how our co-morbidity rate of 32% compares to rates in RCTs, as this information has rarely been reported. However, exclusion criteria often do not include rule outs for Axis I or Axis II conditions, and a recent study reported significant co-morbidity. Forty-seven percent of study patients were diagnosed with at least one additional Axis I disorder, and 53.1% met criteria for a personality disorder (Hohagen et al., 1998). Greist (1996) reviewed results of 18 studies examining efficacy of behavior therapy for OCD where the Y-BOCS was used to measure outcome. Including Foa, Franklin, and Kozak (1998) to this collection of studies, the mean percent improvement on Y-BOCS scores at post-treatment is 46%, ranging from 16% to 66%. The Y-BOCS result of the present study, 48% improvement, is consistent with those reported in the controlled studies. As Abramowitz (1998) concluded from his meta-analysis, CBT does not cure OCD. While obtaining clinically significant gains from treatment, patients still remain more symptomatic than the general population. The results of the present study are consistent with this finding. There are obvious limitations inherent in this clinical case series. As the first author was the sole therapist, generalization to other therapists in clinical practice without comparable training and experience is constrained. Based on the whole of the reported research on CBT and OCD, we believe that other qualified therapists using the same method should achieve positive results. However, the magnitude of effect and degree of change may well vary from those achieved here. Lack of a control group prevents unequivocal attribution of improvement in OCD to the treatment provided. On the other hand, ineffectiveness of previous non-CBT psychological treatments, low rates of spontaneous remission in the face of longstanding symptoms, and low placebo response (Foa & Kozak, 1996) suggest that CBT was related to therapeutic outcome. Another limitation was the sole reliance on the self-report Y-BOCS, with the absence of other measures of pathology. Finally, absence of follow-up assessment prevents assessment of the durability of the treatment effects. Despite these significant limitations, CBT authorities are increasingly noting the dearth of effectiveness studies and the resulting controversy over whether
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results of RCTs are relevant to real life clinical practice. The present study supports Kirk's (1983) conclusion that ``the encouraging reports of controlled studies of behavioural treatment can be generalized to everyday clinical practice'' (p. 62).
Acknowledgments We extend thanks to our clients who made this research possible.
References Abramowitz, J. S. (1998). Does cognitive ± behavioral therapy cure obsessive ± compulsive disorder? A meta-analytic evaluation of clinical significance. Behavior Therapy, 29, 339 ± 355. Antony, M. M., Downie, F., & Swinson, R. P. (1998). Diagnostic issues and epidemiology in obsessive ± compulsive disorder. In: R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive ± compulsive disorder: theory research and treatment ( pp. 3 ± 32). New York: The Guilford Press. Baer, L., Brown-Beasley, M. W., Sorce, J., & Henriques, A. (1993). Computer-assisted telephone administration of a structural interview for obsessive ± compulsive disorder. American Journal of Psychiatry, 150, 1737 ± 1738. Barlow, D. H., & Craske, M. G. (1989). Mastery of your anxiety and panic. Albany, NY: Graywind. Barlow, D. H., & Hofmann, S. G. (1997). In: D. M. Clark, & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy ( pp. 95 ± 117). New York: Oxford Univ. Press. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7 ± 18. Emmelkamp, P. M. G., & Kraanen, J. (1977). Therapist-controlled exposure in vivo versus self-controlled exposure in vivo: a comparison with obsessive ± compulsive patients. Behaviour Research and Therapy, 15, 491 ± 495. Fensterheim, H., & Raw, S. D. (1996). Psychotherapy research is not psychotherapy practice. Clinical Psychology: Science and Practice, 3, 168 ± 171. Foa, E. B., Franklin, M. E., & Kozak, M. J. (1998). Psychosocial treatments for obsessive ± compulsive disorder: literative review. In: R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.), Obsessive ± compulsive disorder: theory research and treatment ( pp. 258 ± 276). New York: The Guilford Press. Foa, E. B., & Kozak, M. J. (1996). Psychological treatment for obsessive ± complusive disorder. In: M. R. Mavissakalian, & R. F. Prien (Eds.), Long-term treatments of anxiety disorders ( pp. 285 ± 309). Washington, DC: American Psychiatric Press. Foa, E. B., Steketee, G. S., Grayson, J. B., Turner, R. M., & Lattimer, P. R. (1984). Deliberate exposure and blocking of obsessive ± compulsive rituals: immediate and long-term effects. Behavior Therapy, 15, 450 ± 472.
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Franklin, M. E., Abramowitz, J. S., Kozak, M. J., Levine, J., Sacks, M. B., Brigidi, B. D., & Foa, E. B. (1998). An effectiveness study of exposure and ritual prevention for adult obsessive ± compulsive disorder. Poster session presented at the annual meeting of the Association for Advancement of Behavior Therapy, Washington, DC. Freeston, M. H., Ladouceur, R., Gagnon, F., Thibodeau, N., Rheaume, J., Letarte, H., & Bujold, A. (1997). Cognitive ± behavioural treatment of obsessive thoughts: a controlled study. Journal of Consulting and Clinical Psychology, 65, 405 ± 413. Garfield, S. L. (1998). Some comments on empirically supported treatments. Journal of Consulting and Clinical Psychology, 66, 121 ± 125. Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive ± Compulsive Scale: I. Development, use, and reliability. Archives of General Psychiatry, 46, 1006 ± 1011. Greist, J. H. (1996). New developments in behaviour therapy for obsessive ± compulsive disorder. International Clinical Psychopharmacology, 11, 63 ± 73. Hohagen, F., Winkelmann, G., Rasche-Rauchle, H., Hand, I., Konig, A., Munchau, N., Hiss, H., Geiger-Kabisch, C., Kappler, P., Schramm, P., Rey, E., Aldenhoff, J., & Berger, M. (1998). Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: results of a multicentre study. British Journal of Psychiatry, 173 (Suppl. 35), 71 ± 78. Jacobson, N. S., & Truax, P. (1991). Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12 ± 19. Kirk, J. W. (1983). Behavioural treatment of obsessional ± compulsive patients in routine clinical practice. Behaviour Research and Therapy, 21, 57 ± 62. Kozak, M. J., & Foa, E. B. (1997). Mastery of obsessive ± compulsive disorder: a cognitive ± behavioral approach. San Antonio, TX: The Psychological Corporation. Leckman, J. F., Grice, D. E., Boardman, J., Zhang, H., Vitale, A., Bondi, C., Alsobrook, J., Peterson, B. S., Cohen, D. J., Rasmussen, S. A., Goodman, W. K., McDougle, C. J., & Pauls, D. L. (1997). Symptoms of obsessive ± compulsive disorder. American Journal of Psychiatry, 154, 911 ± 917. Persons, J. B., Burns, D. D., & Perloff, J. M. (1988). Predictors of drop out and outcome in private practice patients treated with cognitive therapy for depression. Cognitive Therapy and Research, 12, 557 ± 575. Persons, J. B., & Silberschatz, G. (1998). Are results of randomized controlled trials useful to psychotherapists? Journal of Consulting and Clinical Psychology, 66, 126 ± 135. Seligman, M. E. P., & Levant, R. F. (1998). Managed care policies rely on inadequate science. Professional Psychology: Research and Practice, 29, 211 ± 212. Steketee, G. S. (1993). Treatment of obsessive ± compulsive disorder. New York: The Guilford Press. Steketee, G. S., Frost, R., & Bogart, K. (1996). The Yale-Brown Obsessive ± Compulsive Scale: interview versus self-report. Behaviour Research and Therapy, 34, 675 ± 684. van Oppen, P., & Arntz, A. (1994). Cognitive therapy for obsessive ± compulsive disorder. Behaviour Research and Therapy, 32, 79 ± 87. Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically supported treatment for panic disorder to a service clinic setting: a benchmark strategy. Journal of Consulting and Clinical Psychology, 66, 231 ± 239.
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Warren, R. & Thomas, J. C. (1998). Is panic control treatment effective in a private practice setting? In T. Tokarz (Chair), Protocol-based treatments in a U.S. hospital system, Canadian Health Service, and private practice: contrasting experiences. Symposium conducted at the annual meeting of the Association for Advancement of Behavior Therapy, Miami, FL. Warren, R., Zgourides, G., & Monto, M. (1993). Self-report versions of the Yale-Brown Obsessive ± Compulsive Scale: an assessment of a sample of normals. Psychological Reports, 73, 574. Westbrook, D., & Hill, R. (1998). The long-term outcome of cognitive behaviour therapy for adults in routine clinical practice. Behaviour Research and Therapy, 36, 635 ± 643.
Cognitive±behavior therapy of obsessive± compulsive disorder in private practice: An effectiveness study$ Ricks Warrena,b,*, Jay C. Thomasb a
The Anxiety Disorders Clinic, Lake Oswego, OR, USA b Pacific University, Forest Grove, USA
Received 15 March 1999; received in revised form 15 April 1999; accepted 5 April 2000
Abstract A controversy exists over whether or not the results of randomized controlled trials (RCTs) are generalizable to routine clinical practice. The present study examines the effectiveness of cognitive ± behavior therapy (CBT) for obsessive ± compulsive disorder (OCD) in a private practice setting. Twenty-six consecutive clients referred to a private anxiety disorders specialty clinic began treatment for OCD. Of the 19 (73%) clients who completed treatment, 84% were treatment responders. Clients, treatment, and outcome of the present study are compared with those of representative RCTs, and it is concluded that there are more similarities than differences. It is concluded that CBT can be effectively delivered in routine clinical practice. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Obsessive-compulsive disorder; Private practice; Effectiveness study; Cognitive behavior therapy
Portions of this paper were presented in Sookman, D., Yaryura-Tobias, J., & Warren, R. (1997). In C. A. Pollard & C. N. Carmin (Chairs), Issues in the integration of drug and cognitive behavioural treatments for OCD: a clinical roundtable. Symposium conducted at the meeting of the XXVII Congress of European Association for Behavioural and Cognitive Therapies, Venice, Italy. * Corresponding author. The Anxiety Disorders Clinic, Suite 225, 4550 Southwest Kruse Way, Lake Oswego, OR 97035, USA. Tel.: +1-503-635-8710; fax: +1-503-635-0583. E-mail address: [email protected] (R. Warren). $
0887-6185/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 8 8 7 - 6 1 8 5 ( 0 1 ) 0 0 0 6 3 - 9
278
R. Warren, J.C. Thomas / Anxiety Disorders 15 (2001) 277±285
1. Introduction The controversy over empirically supported treatments (ESTs) (Chambless & Hollon, 1998) has important implications for the relationship between research and practice, job satisfaction of practitioners, managed care directives, and ultimately the welfare of consumers (Barlow & Hofmann, 1997). While behavior therapists have long advocated use of ESTs, there is opposition within the ranks challenging the relevance of research to clinical practice (Fensterheim & Raw, 1996). Garfield (1998) has cogently expressed concern that, in the rush to establish ESTs, the importance of therapist skill and patient variability may be diminished. One central argument against widespread advocacy of ESTs is skepticism as to generalizability of treatment conducted in research protocols to everyday clinical practice (Seligman & Levant, 1998). In other words, while randomized controlled trials (RCTs) are used to support efficacy of ESTs, few studies have evaluated effectiveness of these treatments in routine clinical practice. Relevance of results obtained from RCTs are questioned due to a number of presumed differences, including therapist training and supervision, manualization of treatment, fixed number of treatment sessions, and the kinds of patients treated. Due to these presumed differences, RCTs are considered to possess internal but not external validity (Persons & Silberschatz, 1998). In spite of understandable skepticism, given these presumed differences in RCTs and actual clinical practice, studies supporting the transportability and effectiveness of research-based treatments to routine clinical practice are beginning to emerge. For example, Wade, Treat, and Stuart (1998) found panic control treatment (PCT; Barlow & Craske, 1989) to be effective in treating panic disorder in a community mental health center, and Warren and Thomas (1998) found PCT effective in a private practice setting. Persons, Burns, and Perloff (1988) successfully implemented cognitive therapy for depression with private practice patients. In addition, Westbrook and Hill (1998) reported on successful long-term outcome of cognitive ± behavior therapy (CBT) for adults with a variety of focal problems in a National Health Service Clinic in Oxford. Franklin et al. (1998) recently reported results of an effectiveness study of exposure and ritual prevention for patients at the Allegheny University of the Health Sciences (AUHS), Department of Psychiatry Obsessive ± Compulsive Disorder (OCD) Clinic. Patient demographic characteristics, OCD severity, and treatment outcome were comparable for AUHS clinic patients, RCT study protocol patients, and several representative RCTs conducted at other universities. It could be argued, however, that while Franklin et al. (1998) demonstrated transportability of CBT for OCD from the research protocol to clinic patients at AUHS, the travel distance was limited. Effectiveness studies conducted with other therapists, clients, and settings are needed to test the boundaries of transportability. Over 15 years ago, Kirk (1983) stated that, ``A question of continual concern to research workers, however, is the extent to which such findings can be
R. Warren, J.C. Thomas / Anxiety Disorders 15 (2001) 277±285
279
generalized to everyday clinical practice'' (p. 57). Kirk reported on the behavioral treatment of a series of 36 OCD patients referred to a National Health Services Behavior Therapy Clinic. She concluded that over 75% were moderately improved or better, and that 81% of patients appeared to seek no further treatment between 1 and 5 years of follow-up. We are not aware of any further report of CBT for OCD in routine clinical practice. Kirk's (1983) report appeared before the Yale-Brown Obsessive ± Compulsive Scale (Y-BOCS) was developed and became the gold standard for measuring OCD treatment outcome. Kirk noted that, in her study, no standard measures were used, and instead, a global rating based on patient self-monitoring and self-ratings and therapists' assessments based on discharge letters were the outcome measures. The purpose of the present study was threefold: (1) to explore the effectiveness of CBT in a private practice setting, using Y-BOCS scores as the outcome measure; (2) to explore similarities and differences between our clients and typical patients in RCTs; and (3) to explore the adaptability of variants of ERP, frequency and length of sessions, use of cognitive therapy techniques designed particularly for OCD, and substantial reliance on self-controlled exposure homework assignments. 2. Method 2.1. Subjects Twenty-six clients (15 males, 11 females) were referred to The Anxiety Disorders Clinic (TADC), Lake Oswego, OR, for the treatment of OCD. Nineteen (73%) clients completed treatment. Sample characteristics of completers are presented in Table 1. Co-morbid conditions included major depressive disorder (n = 1), major depressive disorder and GAD (n = 3), oppositional disorder (n = 1), and schizoid personality disorder (n = 1). Of the 13 clients who had received previous treatTable 1 Sample characteristics of completers N Sex Age Marital status Education Income Age of onset Duration of OCD Co-morbidity On medication Previous treatment
19 12 males (63%) x = 30.1 12 single (63%) x = 15.2 years x = 53,292 x = 17.9 x = 63.3 months 6 yes (32%) 13 yes (68%) 13 yes (68%)
7 females (37%) S.D. = 8.07 7 married (37%) S.D. = 3.00 S.D. = 36,807 S.D. = 9.02 S.D. = 56.75 13 no (68%) 6 no (32%) 6 no (32%)
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ment for OCD, the following treatment modalities were reported: behavior therapy alone (zero), medications plus behavior therapy (one), medications alone (seven), medications along with supportive therapy (five). Using the four symptom dimensions reported by Leckman et al. (1997), 12 (63%) clients had ``harmful, religious, and sexual obsessions and related compulsions,'' including fears related to HIV and brain tumors, leaving car doors unlocked and garage doors open, accidents and loved ones' safety, accidentally poisoning family food, feces, being molested, being gay, and being a pedophile. Two clients in this category had obsessions with minor overt compulsions. Six (32%) clients had ``contamination obsessions and cleaning compulsions,'' including fears related to germs, HIV, semen, household cleaners, urine and feces, and supernatural beings. One client had ``symmetry, ordering, counting, and arranging obsessions and compulsions,'' including vacuuming, making child's lunch, and making the bed perfectly. No client had ``hoarding and collecting obsessions and compulsions.'' 2.2. Procedures All clients were routine consecutive referrals to TADC from 1992 to 1998. TADC is a private practice group specializing in the treatment of anxiety disorders, located in Lake Oswego, OR. The clinic staff includes four psychologists, one licensed professional counselor, and a mental health nurse practitioner. TADC is currently in its 12th year of operation. The clients in the present study were referred by their psychiatrist (n = 6), primary care physician (n = 2), psychologist (n = 2), OC Foundation (n = 2), friends, relatives, or local agencies (n = 7). 2.3. Assessment The outcome measure for this study was the self-report version of the Y-BOCS (Goodman et al., 1989). The self-report Y-BOCS (Baer, Brown-Beasley, Sorce, & Henriques, 1993; Warren, Zgourides, & Monto, 1993) appears to be psychometrically equivalent to the original interview version and has been suggested by Steketee, Frost, and Bogart (1996) as a time-saving and less costly alternative to the interview format. 2.4. Treatment Treatment was conducted by the first author, usually with weekly sessions, with a mean of 16.4 hrs of treatment. Exposure and response prevention (ERP) were the core elements of treatment (Kozak & Foa, 1997; Steketee, 1993) with formal cognitive procedures often included (van Oppen & Arntz, 1994). Clients with obsessions with few overt rituals were treated with writing and/or looped tape exposure and cognitive interventions (Freeston et al., 1997). For clients with overt compulsions, two cases included in-office in vivo exposure, and three patients received therapist-assisted out-of-office in vivo exposure. Exposure in
R. Warren, J.C. Thomas / Anxiety Disorders 15 (2001) 277±285
281
Table 2 Means and standard deviations for pre- and post-self-report Y-BOCS scores for completers (N = 19) Pre Obsessions Compulsions Total
Post
M
S.D.
M
S.D.
11.5 11.5 23.0
1.95 4.56 5.62
6.7 4.9 11.6
2.45 3.26 4.98
vivo in the client's home was included in one case. The majority of clients (n = 13) received cognitive therapy and planning for self-controlled exposure (Emmelkamp & Kraanen, 1977). Imaginal exposure was conducted only for clients with feared disasters. 3. Results Table 2 presents pre- and post-self-report Y-BOCS scores for completers. Treatment was associated with a significant reduction in Y-BOCS obsessions, compulsions, and total scores, t(18) = 7.30, 7.22, and 7.28, respectively, P < .000001. Effect sizes (d) were 1.66, 1.65, and 2.19, respectively. Improvement rates ranged from 12% to 91%, with a mean of 48%. Using a 35% reduction in Y-BOCS total scores as indicative of responder status, 84% were responders. Using Jacobson and Truax's (1991) ``C'' index, 84% of clients showed clinically significant change on obsessions, 53% on compulsions, and 84% on total Y-BOCS scores. Seventy-five percent of clients obtained functional status on obsessions, 53% on compulsions, and 58% on Y-BOCS total scores.1 There were no differences in degree of change between clients taking medications and those who were not. Of the limited data available for comparison, dropouts (n = 7) were older (x = 41.00, S.D. = 10.10) than completers (n = 19) (x = 30.00, S.D. = 8.10) [t(24) = 2.90, P < .01]. Not surprisingly, dropouts received fewer sessions (x = 5.4, S.D. = 5.2) than completers (x = 16.4, S.D. = 8.8) [t(18.6) = 3.92, P < .0009]. 4. Discussion Results of this case series support the effectiveness of CBT for OCD in an outpatient private practice setting. As Kirk (1983) concluded from her behavioral
1
Self-report Y-BOCS scores for non-clinical subjects used to calculate functional status were taken from Warren et al. (1993). Mean scores were 2.13 (S.D. = 3.21) on the obsession subscale, 1.55 (S.D. = 2.85) on the compulsion subscale, and 3.68 (S.D. = 5.46) for the total score.
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treatment of OCD patients in routine clinical practice, it appears that findings from controlled studies can be generalized to everyday clinical practice. How similar were our ``real patients'' to patients who participate in RCTs? Marital status, mean age, age of onset, hours of treatment, education level, and dropout rate appear comparable (e.g., Abramowitz, 1998; Antony, Downie, & Swinson, 1998; Foa, Steketee, Grayson, Turner, & Latimer, 1984). In addition, pretreatment OCD severity (total Y-BOCS score) was also similar (Greist, 1996). There also appears to be differences between clients in the present study and those participating in research protocols. Our sample contained more males (63%) than females (37%), a sex ratio which is roughly the reverse of the average in RCTs. In addition, mean duration (5.2 years) of OCD symptoms in our sample appears shorter than those reported in RCTs (x = 10.28) (Abramowitz, 1998). It is difficult to determine how our co-morbidity rate of 32% compares to rates in RCTs, as this information has rarely been reported. However, exclusion criteria often do not include rule outs for Axis I or Axis II conditions, and a recent study reported significant co-morbidity. Forty-seven percent of study patients were diagnosed with at least one additional Axis I disorder, and 53.1% met criteria for a personality disorder (Hohagen et al., 1998). Greist (1996) reviewed results of 18 studies examining efficacy of behavior therapy for OCD where the Y-BOCS was used to measure outcome. Including Foa, Franklin, and Kozak (1998) to this collection of studies, the mean percent improvement on Y-BOCS scores at post-treatment is 46%, ranging from 16% to 66%. The Y-BOCS result of the present study, 48% improvement, is consistent with those reported in the controlled studies. As Abramowitz (1998) concluded from his meta-analysis, CBT does not cure OCD. While obtaining clinically significant gains from treatment, patients still remain more symptomatic than the general population. The results of the present study are consistent with this finding. There are obvious limitations inherent in this clinical case series. As the first author was the sole therapist, generalization to other therapists in clinical practice without comparable training and experience is constrained. Based on the whole of the reported research on CBT and OCD, we believe that other qualified therapists using the same method should achieve positive results. However, the magnitude of effect and degree of change may well vary from those achieved here. Lack of a control group prevents unequivocal attribution of improvement in OCD to the treatment provided. On the other hand, ineffectiveness of previous non-CBT psychological treatments, low rates of spontaneous remission in the face of longstanding symptoms, and low placebo response (Foa & Kozak, 1996) suggest that CBT was related to therapeutic outcome. Another limitation was the sole reliance on the self-report Y-BOCS, with the absence of other measures of pathology. Finally, absence of follow-up assessment prevents assessment of the durability of the treatment effects. Despite these significant limitations, CBT authorities are increasingly noting the dearth of effectiveness studies and the resulting controversy over whether
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results of RCTs are relevant to real life clinical practice. The present study supports Kirk's (1983) conclusion that ``the encouraging reports of controlled studies of behavioural treatment can be generalized to everyday clinical practice'' (p. 62).
Acknowledgments We extend thanks to our clients who made this research possible.
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