Change in obsessive beliefs in therapist-directed and self-directed exposure therapy for obsessive-compulsive disorder

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Highlights

  • Change in maladaptive beliefs may be important for successful treatment outcomes.

  • We compared belief change in self-directed and therapist-directed exposure for OCD.

  • Results demonstrated greater belief change in the therapist-directed condition.

  • It may be helpful to add cognitive training to self-directed exposure protocols.

Abstract

Self-directed treatment may be a cost-effective adjunctive or stand-alone intervention for obsessive-compulsive disorder (OCD) and related problems. Current cognitive-behavioral theories suggest that disconfirmation of maladaptive beliefs about feared stimuli is a mechanism of change in exposure-based treatments. It is unclear whether self-directed exposure therapy results in the same degree of change in maladaptive beliefs as traditional therapist-directed exposure. The current study used data from a published trial of self-directed and therapist-directed exposure therapy for OCD (N = 41; Tolin et al., 2007) to compare change in obsessive beliefs between the two treatments. The original trial found superior treatment outcomes for patients in the therapist-directed condition as compared to the self-directed condition. Piecewise linear growth modeling demonstrated that therapist-directed exposure resulted in greater change in obsessive beliefs from pre-treatment through 6-month follow-up than did self-directed treatment. Post-treatment obsessive beliefs mediated post-treatment OCD symptoms in both treatment conditions, suggesting that treatment effects were at least in part due to change in obsessive beliefs. The findings suggest that therapist-directed exposure leads to greater cognitive change than does self-directed treatment, and are discussed in terms of cognitive-behavioral theory and potential ways to promote belief change in therapist- and self-directed treatment.

Introduction

Exposure and response prevention (ERP) is an evidence-based treatment for obsessive-compulsive disorder (OCD; Foa et al., 2005; Franklin & Foa, 2011; Öst, Havnen, Hansen, & Kvale, 2015), which involves direct exposure to feared stimuli combined with instructions to abstain from performing compulsive behaviors. Although effective, ERP can be difficult for some patients to complete. A recent meta-analysis found, on average, that 15% of patients refuse ERP entirely, and another 15% drop out of treatment prematurely (Öst et al., 2015). Specific barriers to ERP include cost, time commitment (for both patients and clinicians), and provider availability, among others.

As a possible alternative or adjunct to traditional treatment, in our earlier work we examined the efficacy of self-directed ERP in comparison to traditional therapist-directed treatment (Tolin et al., 2007). Self-directed treatment may address a number of barriers associated with ERP, including cost, clinician availability, and unwillingness to commit to the expectations of a full treatment (e.g., weekly sessions, completing daily homework). However, results demonstrated that self-directed treatment was less effective than therapist-directed ERP. Patients in the self-directed condition showed less change in OCD severity, global illness severity, and functional impairment. In our previous paper, we speculated that therapist-directed exposure was superior to self-directed treatment for several possible reasons, including education and understanding about OCD, therapist modeling of treatment procedures, enhancing motivation by addressing ambivalence about treatment, and accountability. These results are consistent with the literature on self-help interventions for anxiety disorders, which suggests that self-directed treatment is more effective when therapist support is provided (Spek et al., 2007).

Cognitive and behavioral theories of the mechanisms of exposure therapy may provide additional insight into our study findings. The inhibitory learning model (Craske et al., 2008, Craske et al., 2014), emotional processing theory (Foa & Kozak, 1986), and cognitive theory (Beck and Clark, 1997, Hofmann, 2008) all purport that the mechanism of action in exposure-based treatments is disconfirmation of exaggerated or catastrophic beliefs about feared stimuli. Indeed, research has shown that cognitive change predicts (Smits, Rosenfield, McDonald, & Telch, 2006) and mediates (Hofmann, 2004, Vögele et al., 2010) outcomes in exposure therapy for anxiety disorders, although relatively few studies have found evidence of causal mediation (Smits, Julian, Rosenfield, & Powers, 2012). The literature is somewhat unclear for patients with OCD. Specific domains of obsessive beliefs, including overestimation of threat, inflated responsibility, importance and control of thoughts, perfectionism, and intolerance of uncertainty have been implicated in the etiology and maintenance of OCD (Obsessive Compulsive Cognitions Working Group, 1997, Obsessive Compulsive Cognitions Working Group, 2001, Obsessive Compulsive Cognitions Working Group, 2003, Obsessive Compulsive Cognitions Working Group, 2005), yet several studies have failed to find evidence of cognitive mediation of symptom change in exposure therapy for OCD (Olatunji et al., 2013, Su et al., 2016). Further research is needed to clarify the potential mediating role of cognitive change in ERP.

To be able to obtain disconfirmatory evidence, patients need to have a specific and nuanced understanding of their catastrophic beliefs and then collect information that directly targets those beliefs. The self-help intervention used in our prior study did not provide specific training in this process, and as such may have resulted in less belief change and poorer treatment efficacy than the therapist-directed condition. By contrast, patients in the therapist-directed group may have benefitted from the expertise of their clinicians in identifying and targeting their beliefs, resulting in greater belief change and better treatment outcomes in the therapist-directed condition.

The purpose of the current study was to examine cognitive change in ERP using data from our previous trial of therapist-directed and self-directed ERP for OCD (Tolin et al., 2007). We were interested in formally testing our hypothesis that therapist-directed treatment resulted in greater belief change than self-directed treatment, as speculated above and theorized by inhibitory learning, emotional processing, and cognitive models of anxiety disorders. We compared change in obsessive beliefs between the two conditions using piecewise linear growth modeling (Raudenbush & Bryk, 2002), a multilevel modeling approach that allows for differences in slopes of change that may occur in the treatment phase as compared to the follow-up phase, when presumably less change occurs. Importantly, this approach allows for missing data; the models included all data points, regardless of whether participants completed all assessment points. In the original study (Tolin et al., 2007), we used the last observation carried forward (LOCF) approach for missing data, which has been shown to inflate Type I error rates and result in biased estimates of pre-post changes in treatment trials (Gueorguieva and Krystal, 2004, Mallinckrodt et al., 2001). The LOCF approach assumes that patients’ current symptom severity is the same as the severity of their symptoms at the last assessment point they completed. However, patients may discontinue their participation in treatment for a variety of reasons, including decreases in symptoms that would not be reflected using LOCF.

Consistent with the findings of the original study (Tolin et al., 2007), we hypothesized that patients in the therapist-directed condition would demonstrate greater belief change from pre-treatment through 6-month follow-up than would those in the self-directed condition. To help clarify mixed findings regarding cognitive change as a mechanism of CBT response, we also examined whether obsessive beliefs mediated outcomes in the trial. We hypothesized that cognitive change would mediate outcomes in both treatment conditions, but that greater overall change in beliefs would occur in the therapist-directed group.

Section snippets

Participants

This study used data from a randomized-controlled trial of self- vs. therapist-directed ERP for OCD (Tolin et al., 2007). Inclusion criteria were a primary diagnosis of chronic (i.e., over one year's duration) OCD of at least moderate severity, defined as a score of 16 or higher on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, Delgado et al., 1989; Goodman, Price, Rasmussen, Mazure, & Fleischmann, 1989) and a score of 4 (moderately ill) or higher on the

Sample characteristics

The sample consisted of 15 women and 26 men with a mean age of 38.18 (SD = 13.10) years. In addition to a primary diagnosis of OCD, 17 participants had a comorbid anxiety disorder, 11 a comorbid depressive disorder, and nine a comorbid personality disorder (obsessive-compulsive, n = 4; avoidant, n = 3; dependent, n = 1; not otherwise specified, n = 1). Twenty-one patients were randomly assigned to receive therapist-directed ERP, and 20 patients were assigned to receive self-directed treatment.

Discussion

The purpose of this study was to compare change in obsessive beliefs between therapist-directed and self-directed exposure therapy for OCD. Using 2-piece linear growth modeling, we found greater change in OBQ scores from pre- to post-ERP in the therapist-directed condition as compared to self-directed treatment, with gains maintained through 6-month follow-up. These results are consistent with our original outcome trial (Tolin et al., 2007), in which greater change in OCD symptoms was observed

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  • Author Note. This work was supported by the Patrick and Catherine Weldon Donaghue Medical Research Foundation (01-022). No other declarations of interest.

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