Using Motivational Interviewing to Enhance Treatment Outcome in People With Obsessive-Compulsive Disorder

https://doi.org/10.1016/j.cbpra.2009.06.009Get rights and content

Abstract

Obsessive-compulsive disorder (OCD) is a leading cause of health-related disability. There are two evidence-based treatments for OCD, pharmacotherapy and cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP). Although effective, outcome from both treatments is often limited by patient lack of adherence to the treatment procedures. In this article, we present the rationale for using motivational interviewing (MI) to increase EX/RP adherence. We then review two published studies that used MI in different ways to foster EX/RP participation. Finally, we describe 6 cases in which we explored whether MI could help ready OCD patients who had refused or failed prior evidence-based treatment of any kind. Together, these data illustrate the promise and obstacles of employing MI to promote treatment adherence in OCD. We conclude by discussing future directions for researchers and for clinicians when using MI in this population.

Section snippets

Conceptualizing Treatment Resistance as Ambivalence

EX/RP teaches people new strategies to cope with obsessions and compulsions (Kozak & Foa, 1997). Specifically, patients are taught to confront what they fear (“exposure”) and to refrain from performing compulsions when doing so (“response prevention”). Exposures involve live confrontations with feared situations (e.g., touching objects in public bathrooms for a patient with contamination fears) and imaginal confrontations with feared consequences (e.g., imagining killing someone for someone

Published Studies Using MI With OCD Patients to Foster EX/RP Participation

To date, there are two small published studies that used MI in different ways to foster EX/RP participation. In the first study, Maltby and Tolin (2005) developed a brief, 4-session readiness intervention that was intended to decrease EX/RP refusal among patients with OCD. The readiness intervention consisted of 4 individual visits with a therapist over 1 month and was comprised of several different components: (a) psychoeducation focused on OCD and the empirical data supporting the efficacy of

Summary

Together, these six cases illustrate several points. First, OCD patients who are unwilling to seek a referral with a mental health professional for evidence-based treatment were willing to participate in this protocol that offered them an opportunity to speak about their ambivalence but did not require them to commit a priori to any specific treatment for OCD. All completed every session, and those who compulsively hoarded asked for more. Second, although each patient expressed clear reasons

Future Directions

MI has been used in different ways to foster treatment participation in OCD patients. As reviewed above, the study by Maltby and Tolin (2005) indicated that a multimodal intervention that includes MI procedures provided prior to EX/RP can increase acceptance of EX/RP, but is insufficient to prevent subsequent dropout. Preliminary data from Simpson and colleagues (2008) suggest that MI can be integrated into standard EX/RP and used during the introductory sessions of EX/RP as well as during

Acknowledgement

This work was funded by a 2005 NARSAD Young Investigator Award and by NIMH (R34 MH071570) to Dr. Simpson. We thank Ms. Jessica McCarthy and Rena Staub for patient management, Mr. Andrew Schmidt for data management, Dr. Ivan Balan for conducting ratings of therapist sessions, Dr. Frank Schneier for helpful comments on an earlier draft, and Stephen and Constance Lieber for supporting the first author as a NARSAD Lieber Investigator.

References (36)

  • FirstM.B. et al.

    Structured Clinical Interveiw for DSM-IV Axis I Disorders-Patient Edition

    (1996)
  • FoaE.B. et al.

    Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder

    American Journal of Psychiatry

    (2005)
  • GoodmanW.K. et al.

    The Yale-Brown Obsessive Compulsive Scale. II. Validity

    Archives of General Psychiatry

    (1989)
  • GoodmanW.K. et al.

    The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability

    Archives of General Psychiatry

    (1989)
  • GroteN.K. et al.

    Engaging women who are depressed and economically disadvantaged in mental health treatment

    Social Work

    (2007)
  • HamiltonM.

    A Rating Scale for Depression

    Journal of Neurology, Neurosurgery, and Psychiatry

    (1960)
  • HettemaJ.M. et al.

    Motivational interviewing

    Annual Review of Clinical Psychology

    (2005)
  • HuppertJ.D. et al.

    Cognitive behavioral therapy for obsessive-compulsive disorder: an update

    Current Psychiatry Reports

    (2005)
  • Cited by (32)

    • Intermittent Motivational Interviewing and Transdiagnostic CBT for Anxiety: A Randomized Controlled Trial

      2020, Journal of Anxiety Disorders
      Citation Excerpt :

      Similarly, treatment ambivalence in PTSD has been described as the dialectic of wanting support, while also wanting to evade difficulties related to shame, trust, and trauma-related fear, and avoidance of trauma stimuli (Resick, Monson, & Rizvi, 2008). Treatment ambivalence has been found to be particularly common in both OCD and PTSD, as CBT treatment requires individuals to withstand considerable levels of anxiety in the face of feared stimuli without engaging in safety behaviors or avoidance (Resick et al., 2008; Simpson & Zuckoff, 2011). Many treatment seekers even worry that exposure-based treatments could exacerbate anxiety symptoms (Purdon, Rowa, & Antony, 2004; Westra, 2012).

    • Improving treatment outcome in obsessive-compulsive disorder: Does motivational interviewing boost efficacy?

      2019, Journal of Obsessive-Compulsive and Related Disorders
      Citation Excerpt :

      This low dropout rate is inconsistent with previous research where dropout rates from ERP tend to average 25% (Maltby & Tolin, 2005) although it is consistent with the low dropout rate from another study on MI as an adjunct to group CBT for OCD (Meyer et al., 2010) and in a study using MI before CBT in a mixed anxiety sample (Westra & Dozois, 2006). Previous studies suggest that MI may increase the likelihood that participants will choose to proceed with ERP (Maltby & Tolin, 2005), increase initiation rates of attending transdiagnostic CBT (Barrera, Smith, & Norton, 2016), and provide a supportive and client-centered environment to discuss understandable ambivalence about treatment (Simpson & Zuckoff, 2011), suggesting that MI may be especially productive at retaining participants. However, the low dropout rate and consistent rate between MI and relaxation in the current study precludes any conclusions about the impact of MI (as compared to another pretreatment intervention) on dropout in our sample.

    • Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature

      2017, Cognitive and Behavioral Practice
      Citation Excerpt :

      This homogeneity is a strength in terms of drawing conclusions about treatment efficacy, but may hinder external validity and inferences that can be drawn about effectiveness (Kazdin, 2003). Six of the reviewed studies did not report whether participants had comorbid psychological problems (Maltby & Tolin, 2005; McKay & Bouman, 2008; Merlo et al., 2010; Murphy et al., 2009; Simpson and Zuckoff, 2011; Titov et al., 2010). For the studies that did report comorbidities, depression, dysthymia, and anxiety disorders were the most common additional diagnoses.

    View all citing articles on Scopus
    View full text