Download Group versus individual treatment in obsessions without compulsions

Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 12, 87–96 (2005)
Group Versus Individual
Treatment in Obsessions
without Compulsions
K. O’Connor,1* M. H. Freeston,2 D. Gareau,1 Y. Careau,1
M. J. Dufour,1 F. Aardema1 and C. Todorov3
1
Centre de recherche Fernand-Seguin, Montreal, Canada
University of Newcastle, UK
3
Louis-H. Lafontaine Hospital, Montreal, Canada
2
The principal goal of the current study was to compare the efficacy of
two treatment formats, group and individual, of an empirically
proven manualized cognitive–behavioural treatment (CBT) package,
for obsessions without overt compulsions. It was hypothesized that
individualized treatment would be more effective both in terms of
post-treatment group mean improvement and end state functioning.
A secondary goal was to assess the relationship between cognitive
and behavioural change during treatment and link it to symptom
change. Both group and individual CBT format produced a significant clinical change, but as expected individual treatment produced
the greater change in symptoms and in obsessional belief. Also, the
individual format showed a clear superiority over the group format
in the reduction of anxiety and depression. Severity of OCD symptoms showed little relationship with strength of obsessional beliefs
at the start of treatment, but change in beliefs was strongly correlated
with behavioural improvement post-treatment. The results of the
study suggest that the impact of a group format may lie in the value
of shared social support and motivational effect of peer feedback,
but at the expense of individualized targets. Copyright © 2005 John
Wiley & Sons, Ltd.
INTRODUCTION
Cognitive–behavioral treatment (CBT), based
largely on exposure and response prevention
(ERP), has become established as the treatment of
choice for OCD, either alone or, especially in more
severe cases, in combination with psychopharmacological treatment (March, Frances, Carpenter, &
Kahn, 1997). Meta-analyses on studies investigating exposure and response prevention treatments
find large effect sizes that show 75–85% of patients
* Correspondence to: Kieron O’Connor, Ph.D., M.Phil.,
Centre de recherche Fernand-Seguin, 7331 Hochelapa Street,
Montreal, QC H1N 3V2, Canada.
E-mail: [email protected]
improve (Steketee & Shapiro, 1993; Hiss, Foa, &
Kozak, 1994). However, there remain a number of
unresolved issues. First, CBT for OCD is typically
among the longest and the most costly of all the
anxiety disorders (Turner, Beidel, Spaulding, &
Brown, 1995). Second, adequate treatment is not
widely available because only a limited number of
professionals can deliver the treatment, particularly to the sizable subgroup of patients who do not
show overt compulsive rituals and do not present
common symptoms such as washing or checking.
Third, a large number of patients refuse, or drop
out during, treatment, largely due to the key role
of exposure in current treatments. Fourth, although
treatment gains are impressive for a significant
proportions of patients, some benefit less and
remain symptomatic; others do not maintain initial
Copyright © 2005 John Wiley & Sons, Ltd.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.439
88
gains (Steketee, 1993). In conclusion, despite a
consensus that effective treatment does exist, there
is still a great deal to be done to make available
treatment more effective and available.
Obsessions without associated overt compulsions represent one of the largest subgroups in
OCD. A review found that 62% of multipatient
treatment studies, on which the claims of OCD
treatment efficacy are based, did not include any
patients with obsessions only (Ball, Baer, & Otto,
1996). Obsessive thoughts have been, and are still
generally considered, refractory to both pharmacological and psychological treatments.
A cognitive–behavioural account of OCD
(Salkovskis, 1985) proposed that unwanted
intrusive thoughts, a universal experience, are
appraised as having particular negative implications for some predisposed individuals. When they
are so appraised the person engages in a series of
strategies to neutralize the thought and decrease
discomfort and the subjective sense of responsibility. This model led to outlines for treatment
strategies (e.g. Salkovskis, 1985; Salkovskis &
Westbrook, 1989). Work at Université Laval (e.g.
Ladouceur, Freeston, Gagnon, Thibodeau, &
Dumont, 1993) led to a manualized treatment for
obsessions without overt compulsions. In an initial
study by the Laval group using a multiple baseline
design across subjects the CBT intervention (cognitive restructuring and ERP) for obsessive
thoughts was found to result in a decrease in discomfort provoked by the obsessive thoughts and
improved professional and interpersonal functioning in all three participants (Ladouceur, Freeston,
Gagnon, Thibodeau, & Dumont, 1995). In a further
study using a single case design treatment consisting solely of cognitive therapy, five out of six
patients showed a significant improvement in YBOCS scores before and after treatment (Freeston,
Léger, & Ladouceur, 2001). The first random trial
investigating CBT for obsessional thoughts compared a CBT intervention (cognitive restructuring
and ERP) with a wait-list control group (Freeston
et al., 1997). Patients in the active CBT condition
showed significantly greater improvement compared with the wait-list control group on measures
of obsessive–compulsive symptoms, interference,
and anxiety. The majority of those who completed
treatment showed clinically significant change on
the Y-BOCS. These gains were maintained at 6
month follow-up. This study showed convincingly
that psychological treatment of this obsessional
subgroup is feasible. However, treatment was long
(40 hours including assessment), although this is
Copyright © 2005 John Wiley & Sons, Ltd.
K. O’Connor et al.
typical of current practice in OCD in general in
North America (Turner et al., 1995). Longer treatment decreases treatment availability. Experience
with the treatment package developed for obsessive thoughts both in single case studies and in
standard clinical practice indicates that the treatment may be shortened.
Treating mental disorders in a cost-effective way
is a top priority in the context of increasing
demand and decreasing resources for health-care
services. One way of improving the cost-efficiency
and availability of treatment is by offering therapy
in a group format, allowing more cost-effective use
of the therapist time and availability (see Teasdale,
Walsh, Lancashire, & Mathews, 1977). Well established treatments have been adapted to the group
treatment for panic disorder (e.g. Nagy, Krystal,
Chraney, & Merikangas, 1993), agoraphobia (e.g.
Mackay & Lidell, 1986) and specific phobia (e.g.
Jerremalm, Jansson, & Ost, 1986). Therapeutic
factors unique to group therapy such as vicarious
learning, interpersonal learning, and group cohesiveness are advantages for many patients (Kobak,
Rock, & Greist, 1995). The group format also helps
normalize the experience of OCD and improve
patient morale, and can lead to better compliance
(Fals-Stewart & Lucente, 1994). Normalizing the
experience is particularly important for OCD
without overt compulsions, because the dominant
symptoms are often ego-dystonic and particularly
upsetting, such as thoughts about harming loved
ones, personally unacceptable sexual thoughts,
blasphemous thoughts, etc.
Several uncontrolled studies involving exposure
and response prevention (ERP) have shown
group treatment to be effective in reducing OCD
symptoms (Bouvard, Milliery, & Cottraux, 2002;
Enright, 1991; Espie, 1986; Krone, Himle, & Nesse,
1991; Himle, Rassi, Haghighatgou, Krone, Nesse, &
Abelson; 2001; Stengler-Wenzke & Angermeyer,
2002; Thieneman, Martin, Cregger, Thompson, &
Dyer-Friedman, 2001; Van Noppen, Steketee,
McCorkle, & Pato, 1997). A controlled trial by FalsStewart, Marks, and Schafer (1994) detected no differences between individual and group treatment
both post-treatment and at 6 month follow-up,
although individual therapy showed a faster
reduction in symptoms in the course of treatment.
The above studies often showed modest, but
significant, improvement with group therapy.
Although the results of group treatment are generally promising, it is not clear whether patients
treated in this format obtained the degree of
improvement that is possible with individual CBT.
Clin. Psychol. Psychother. 12, 87–96 (2005)
Treatment of Obsessions without Compulsions
Post-test scores remained quite high on standardized measures; and many patients completing
these trials would still meet entry criteria for pharmacological trials.
The efficacy of CBT has been compared with
traditional behaviour therapy (ERP) in the group
treatment of OCD in two studies (Whittal,
McClean, Taylor, Sochting, & Anderson, 1997;
McLean et al., 2001). In the first study inferior
results were obtained for CBT compared with ERP.
The second study showed clinically significant difference between treatment groups post-treatment,
but at 3 month follow-up more participants from
the ERP group showed recovered status. The
authors state that the modest gains were probably
due to difficulty in adapting the cognitive techniques to a group format setting because of the
diversity of symptoms in OCD. Thus there is a
need for additional application of the efficacy of
group treatment in general, and there is yet no test
of the efficacy of group treatment when overt
compulsions are absent. Group treatment may ultimately prove to show less efficacy than individual
therapy in absolute terms, but be more cost effective when therapist input is considered. Given the
relatively low availability of expert psychological
treatment for CBT due to high cost and few therapists, the cost-effectiveness and increased access to
therapy that group treatment can offer may be a
more important consideration.
The current study aims to contribute to the
improvement of cognitive–behavioural treatment
of OCD. It compares two treatment formats of an
empirically proven manualized treatment package.
The trial contrasts group treatment modality with
an individual treatment. The first goal was to
compare the efficacy of the two treatment formats
as a function of both statistically significant change
and clinically significant change. It was hypothesized that patients in both conditions would
improve significantly, but that individualized
treatment would be more effective both in terms of
group means and in terms of high-end state functioning. The second goal of the study was to (a)
assess cognitive change during treatment and its
link to symptom change, and (b) identify predictors of cognitive change and outcome.
METHOD
Recruitment
Recruitment for the study was carried out between
1998 and 2001 under the auspices of the OCD
Copyright © 2005 John Wiley & Sons, Ltd.
89
research program already in place at the Centre
de Recherche Fernand Seguin. The recruitment
involved telephone screening, face to face diagnostic interview, and administration of structured
interviews.
Although obsessions without associated overt
compulsions are experienced by a significant
minority of OCD patients, the present study
required a uniform group of patients with only
obsessions and no or minimal overt compulsions.
Consecutive referrals were randomly allocated to
either a group or individual format.
In total, over a 3 year period, we were able to
recruit 43 such cases (21% of our total recruitment)
who met inclusion criteria. Amongst these,
however, there was a high rate of refusal (38%).
Main reasons for not wanting to participate in the
group format were anxiety about sharing problems
with others, social anxiety, lack of personal
attention and fears of acquiring new obsessions
from others in the group. Although we planned to
run three groups of 10 participants over the 6
month treatment period, delay in recruiting for
the group format allowed only two groups to
be treated. The final sample size consisted of 26
participants.
Entry criteria were (a) primary diagnosis of
OCD, (b) dominant obsessive thoughts with few
or no overt compulsions, (c) no change in medication type or dose during the 12 weeks before
treatment for antidepressants (four weeks for
anxiolytics), (d) willingness to keep medication
stable while participating in the study, (e) no evidence of suicidal intent, (f) no evidence of current
substance abuse, (g) no evidence of current or
past schizophrenia, bipolar disorder or organic
mental disorder and (h) willingness to undergo
randomization.
Measures
Diagnostic Measures
Baseline diagnosis used three structured interviews to provide adequate description of clinical
features. First, all patients were diagnosed using
the Anxiety Disorders Interview Schedule for
DSM-IV, a structured interview that diagnoses
anxiety disorders and exclusionary conditions
(ADIS-IV, Brown, Di Nardo, & Barlow, 1994).
Reliability of diagnosis was checked for 30% of
the cases. Second, participants were administered
the Yale–Brown Obsessive–Compulsive Scale
(Y-BOCS; Goodman et al., 1989a, 1989b).
Clin. Psychol. Psychother. 12, 87–96 (2005)
90
Main Dependent Variables
The main dependent variables assessed symptoms and cognitions that were direct targets of the
intervention and were used to establish treatment
efficacy. The Yale–Brown Obsessive–Compulsive Scale
(Y-BOCS) was administered by an independent
clinician and defined as the primary outcome variable. The Y-BOCS can be used to assess overt and
covert neutralizing separately (Vézina et al., 1995).
Studies confirm the validity and reliability of
the principal scales (ICC = 0.91–0.94, rs = 0.90)
(Steketee, 1993; Taylor, 1995). Inter-rater reliability
was established for 15% of ratings. An independent
assessor administered the Y-BOCS at pre-, mid-,
post-treatment, and follow-ups. The Padua Inventory (Sanavio, 1988) is a comprehensive 60-item
self-report inventory of obsessions and compulsions. The total scale (a = 0.95) and the subscales
(a = 0.75–0.91) are reliable. The Cognitive Intrusions Questionnaire (CIQ) (Freeston, Ladouceur,
Thibodeau, & Gagnon, 1991) assesses content,
form, and appraisal of obsessions as well as neutralization strategies used with the target obsession. Psychometric properties of the subscales are
good (a = 0.79–0.92). The Interpretations of Intrusions
Questionnaire (III; OCCWG, 1997, 2001, 2003)
covers three dimensions related to the faulty
appraisal of a target obsessive thought and consists
of 31 items. Strength of belief in the appraisals
ranges from 0 ‘I did not believe this idea at all’ to
100 (‘I was completely convinced this idea was
true’. The Beck Anxiety Inventory (BAI) (Beck,
Epstein, Brown, & Steer, 1988) is a 21-item anxiety
symptom checklist rating symptom intensity for
the last week (a = 0.91). The Beck Depression Inventory (BDI) (Beck, Rush, Shaw, & Emery, 1979) is a
21-item measure of depressive symptoms (a =
0.91).
Self-Monitoring
Patients were also asked to self-monitor, in a
daily diary, the duration of obsessions, degree of
distress experienced during the obsession and
strength of obsessional beliefs linked to obsessional
thoughts. Types of obsessional belief varied from
person to person, but generally related to catastrophic reactions produced by the presence of
obsessional thoughts such as ‘I will lose control
over myself if I don’t suppress this thought’, ‘I will
feel responsible if this thought does not go away’
and ‘this thought means I am a terrible person
wanting terrible things to occur’.
Copyright © 2005 John Wiley & Sons, Ltd.
K. O’Connor et al.
Treatment Protocol
The treatment program consisted of the same manualized treatment protocol administered over the
same time period (approximately 20 weeks) in both
group and individual format.
Cognitive–Behavioural Group Treatment for OCD
In the initial phase, before the start of group
therapy, patients were seen individually for four
1 hour evaluation sessions to ensure adequate
preparation. This included a cognitive–behavioural assessment, explanation of self-monitoring
and specific preparation for the group treatment by
answering questions about the group format. The
group sessions were 2 hours in length. The second
phase (group sessions 1–5) covered introduction to
the cognitive–behavioral account of OCD where
five groups of beliefs were addresses by first
explaining their roles in maintaining cognitive
biases leading to faulty appraisal of threat and thus
symptom-maintaining behavior: overestimation
of the importance of thoughts, overestimation of
danger, overestimation of the consequences of
anxiety, responsibility and perfectionism. Next,
patients were trained in identifying their key
beliefs and how they could be challenged using
Socratic dialogue, and the downward arrow technique. This then led to a discussion of exposure
and response prevention, which in the CBT model
is conceptualized as a way of disconfirming the
beliefs by reality testing. The third phase (group sessions 6–7) involved exposure and response prevention using either in vivo or tape-loop exposure
according to hierarchies developed during the
evaluation sessions. The fourth phase (group sessions 8–10) continued with ERP while making
explicit links to the cognitive targets identified
above, thus maintaining an emphasis on cognitive
correction throughout treatment. The last phase
(sessions 11–12) focused on relapse prevention
based on programs developed by Hiss and collaborators (1994) and Emmelkamp, Kloek and Blaauw
(1992), which included a written individualized
guide (the OCD emergency kit) and a telephone
follow-up after completion of the group session at
3 week intervals for a 12 week period.
Individual Treatment
Participants received the same treatment
package as the group treatment with three differences: (1) In the fourth initial session, group preparation was skipped. (2) Individual patients
Clin. Psychol. Psychother. 12, 87–96 (2005)
Treatment of Obsessions without Compulsions
91
received 14 1 hour and two 11/2 hour sessions. (3)
Treatment was standardized in that that all
patients received the six components above, but
individualized in that cognitive correction and
ERP components were used flexibly in a more integrated way. Each patient received 20 hours therapist time in the individual protocol (3 hours
assessment + 16 hours therapy + 1 hour telephone
follow-up).
Outcome: Main Dependent Variables
RESULTS
Participant Characteristics
Participants characteristics are shown in Table 1.
The total sample consisted of 15 males (57.7%) and
11 females (42.3%). The average age was 40 years
(SD = 12.9; range 20–64). Marital status was distributed as follows: single (15.4%), married or
cohabitating (53.8%) and separated or divorced
(11.5%). Education level showed an average of 14.8
years of schooling for the entire group. Types of
obsession in our sample were broken down as
follows: religious or sexual intrusions (15%),
doubting or questioning obsessions (27%), health
concerns (19%), fear of harming self or others
(39%). There was no difference in drop-out rates in
Table 1.
the course of treatment between the group (n = 1)
and individual format (n = 2). A total of nine participants completed the group therapy versus 17
in the individual treatment. This difference in
numbers between the group and individual conditions was due to a greater refusal in the group
condition. There were no significant differences
between groups on any of the demographic or clinical measures.
Outcome analyses of the effects of therapy was
only performed on those who completed treatment
(means before and after treatment are shown in
Table 2). Both individual and group formats
showed a significant decrease in obsessional symptoms as measured by independent Y-BOCS evaluations pre and post (see Figure 1). There was a
significant treatment effect (F(1, 23) = 86.1; p <
0.0001). A significant interaction effect indicated
that the individual format showed superior
outcome (F(1, 23) = 13.45; p < 0.001) in terms of
symptom reduction on the Y-BOCS. On average,
participants improved 68% in individual treatment
as compared with 38% in the group format. The
scores on the Padua Inventory decreased signifi-
Participant characteristics (n = 26)
Variable
Gender
Male
Female
Education
0–12 yrs
12–18 yrs
more than 18 yrs
Occupation
Student
Employed
Homemaker
Retired
Unemployed
Marital status
Single
Married or cohabitating
Divorced or separated
Type of obsession
Religious/sexual
Doubting/questioning
Health concerns
Harming self/others
%
62.0% (n = 15)
38.0% (n = 11)
19.0%
71.5%
9.5%
4.8%
62.0%
14.0%
9.5%
4.7%
19.0%
66.7%
14.3%
15%
27%
19%
39%
Copyright © 2005 John Wiley & Sons, Ltd.
Table 2. Means and standard deviations of measures for
each group, before and after treatment
Pre-treatment
Questionnaire
X
SD
Y-BOCS
Individual
22.2
3.6
Group
18.7
9.3
Padua Inventory
Individual
70.6
35.0
Group
84.5
37.0
Beck Depression Inventory
Individual
16.9
7.7
Group
16.5
7.8
Beck Anxiety Inventory
Individual
18.6
10.3
Group
19.5
11.6
Cognitive Intrusions Questionnaire
Individual
206.4
31.3
Group
230.1
32.1
Interpretations of Intrusions Inventory
Individual
1464.8
554.8
Group
1390.0
833.9
Post-treatment
X
SD
8.0
10.8
2.8
6.8
32.0
52.4
16.9
24.6
6.5
15.3
6.2
8.9
8.2
18.7
5.8
12.4
139.1
163.2
48.5
35.8
535.3
650.0
508.6
425.6
Clin. Psychol. Psychother. 12, 87–96 (2005)
K. O’Connor et al.
25
Individual
20
Group
Individual
25
Group
20
15
BAI
Y-BOCS
92
10
15
10
5
5
0
0
Post
Pre
Post
Mean BAI scores pre- and post-treatment
Individual
18
16
14
12
10
8
6
4
2
0
Group
Pre
Figure 3.
Post
Mean BDI scores pre- and post-treatment
300
Group
Individual
250
200
150
100
50
4th
period
2nd
period
0
1st
period
cantly (F(1, 22) = 22.83; p < 0.001). However, no
interaction effect was observed for Padua scores
(F(1, 22) = 0.16; p = 0.70), possibly due to its focus
on compulsive symptoms.
There was an overall treatment effect on measures of anxiety (F(1, 22) = 6.60; p < 0.001).
However, a significant interaction effect (F(1, 22) =
5.01; p < 0.05) indicated that anxiety decreased only
marginally in the group treatment, whereas a large
reduction in anxiety was found for the individual
treatment (see Figure 2). Very similar results were
found for depression scores with a significant treatment effect (F(1, 22) = 6.86; p < 0.001) and interaction effect (F(1, 22) = 6.86; p < 0.05) (see Figure 3).
Looking overall at change in questionnaire measures of obsessional appraisals, the CIQ showed an
overall treatment effect (F(1, 19) = 50.14; p < 0.0001),
but no group versus individual interaction (p <
0.84). Likewise, the measure of interpretations, the
III, showed a significant treatment effect (F(1, 18) =
14.88; p < 0.01), but no group versus individual
interaction effect (p < 0.72). Thus, both groups
showed a tendency to make less negative
appraisals of their aversive obsessional thoughts,
post-treatment.
Figure 2.
Duration (minutes)
Mean Y-BOCS scores pre- and post-treatment
BDI
Figure 1.
3rd
period
Pre
Outcome: Self-Monitoring Variables
Figure 4. Duration (minutes a day) of obsessions and
compulsions during treatment for group and individual
formats
Behavioral and subjective self-monitoring variable
were measured by the participants in a daily diary.
Recording took around 5 minutes a day. The following types of variable were measured: daily
duration of obsession (minutes per day), degree of
distress (0–100) about obsessions, and resistance to
the obsession (0–100). Strengths of idiosyncratic
obsessional thoughts were also measured over
treatment phases (0–100). Differences before and
after treatment were calculated by taking the
average score of the first 10 days in the diary and
the average score of the last 10 days in the diary
for each of the measures.
Repeated measures analyses of duration revealed
that whereas both groups showed a treatment
effect (F(3, 57) = 12.6; p < 0.0001) only the individual treatment showed a linear reduction in duration over the successive phases of treatment (see
Figure 4). However, there was no significant interaction effect (p = 0.39). In terms of reduction in
Copyright © 2005 John Wiley & Sons, Ltd.
Clin. Psychol. Psychother. 12, 87–96 (2005)
Treatment of Obsessions without Compulsions
93
distress associated with the obsession, the same
pattern emerged, with both the individual and
group formats showing significant change (F(3, 51)
= 29.1; p < 0.0001). The individual group showed
the most consistent change over successive treatment phases, but there was no significant interaction effect (p = 0.44). Resistance to mental covert
neutralizing also improved in both groups posttreatment (F(3, 57) = 27.7; p < 0.0001). However,
there were no significant interaction effects for
duration, distress or resistance between the group
and individual therapies.
The process measures based on idiosyncratic
obsessional beliefs were divided into two parts:
strength of obsessional belief itself, and conviction
in the necessity to act compulsively on the belief.
In the former case repeated measures analysis
revealed a significant treatment effect (F(1, 19) =
26.3; p < 0.0001) as well as a significant group by
treatment interaction effect at baseline and after
treatment (F(1, 19) = 4.8; p = 0.041). Strength of
obsessional belief decreased by 77% in individual
therapy as compared with 39% in the group
format. In the case of the need to act on obsessional
beliefs, there was a main treatment effect over both
groups (F(1, 19) = 33,7; p < 0.0001), and a trend
appeared showing a group interaction effect
(F(1, 19) = 3,7; p < 0.07) with greater decrease in the
individual treatment format.
The effect of treatment on the idiosyncratic
obsessional beliefs specifically targeted by the
treatment and recorded in the daily diary was
clearly more pronounced than the treatment effect
on overall measures of obsessional appraisals
assessed by the CIQ.
phases. Duration, distress and resistance to neutralizing were highly correlated in treatment
phases 1–3. Y-BOCS scores correlated most significantly with duration and distress variables. The YBOCS did not however correlate with changes in
obsessional belief in any treatment phase. During
phases 1 and 2 the two measures of belief did not
initially correlate with duration, nor with distress
nor resistance to neutralizing measures, although
they correlated highly among themselves.
However, during phases 3 and 4 there was a strong
correlation between strength of beliefs and duration of obsession and degree of distress.
We calculated change scores for the outcome and
process variables in order to determine the relationship among them (Table 3). The relationship
between symptom outcome measures and beliefs
over the course of treatment was examined
through correlational analysis. Change in strength
of belief and necessity to act were highly correlated, but overall there was an absence of relationships between process and outcome measures.
However, change in strength of belief almost
reached significance with change in Padua scores
(p = 0.058)
Six-Month Follow-Up
Both groups maintained gains in Y-BOCS (F(2, 24)
= 14.7; p < 0.0004) at 6 month follow-up, but with
no further decrease in post-treatment scores. YBOCS mean at follow-up was 7.1 (SD = 7.7) for the
individual treatment format and 10.0 (SD = 10.1)
for the group format.
DISCUSSION
Relationship Between Symptom and
Process Measures
The daily diary measures and symptom measures
were highly correlated through all treatment
The proportion of individuals recruited with
obsessions without overt compulsions from consecutive referrals to an OCD clinic was 21% of
Table 3. Correlations between change scores in process variables and outcome
measures
Y-BOCS
Y-BOCS
1.00
III
Padua
Duration
Belief strength
III
Padua
Duration
0.21
1.00
0.08
0.51*
1.00
0.43*
0.10
0.27
1.00
Belief strength Neccessity to act
0.24
0.05
0.40
0.28
1.00
0.21
0.11
0.31
0.25
0.95**
N = 26.
* p < 0.05; ** p < 0.01.
Copyright © 2005 John Wiley & Sons, Ltd.
Clin. Psychol. Psychother. 12, 87–96 (2005)
94
the total recruitment, which is in accordance
with prevalence estimates from other sources
(Emmelkamp, 1982; Rachman, 1985). Of those who
were eligible for the study, 38% refused treatment
in a group format, thereby further decreasing the
influx of patients for a group therapy versus individual treatment. Reasons for the refusal included
anxiety about sharing problems with others, social
anxiety, lack of personal attention, and fears of
acquiring new obsessions from others in the group.
Anxiety about sharing problems and social anxiety
may be due to the often shameful content of obsessions and symptoms, and while positive benefits
would be expected from a group therapy for
related problems such as isolation, fear of judgement and stigma (Kobak et al., 1995) it may also be
a limiting factor in the recruitment of a purely
obsessional patient group.
The results of the current study indicate that both
group and individual CBT formats show promise
of producing significant statistical and clinical
change in obsessions without overt compulsions, a
group traditionally refractory to treatment. It thus
replicates the earlier study by Freeston et al. (1997).
The mean percentage reduction in symptoms in
both formats (individual therapy 68% versus
group therapy 38%) is better than or comparable
to reported studies in the literature, and demonstrates the effectiveness of the current treatment
protocols.
Individual treatment produced the greater
change in symptoms and in obsessional beliefs.
Also, a more consistent change in duration of
obsessions and compulsions was observed for participants in the individual treatment. The individual format clearly permitted more focus on, and
hence change in, idiosyncratic obsessional targets
than did the group format. Particularly pronounced was the finding that anxiety and depression were far more effectively treated in the
individual format than in the group format.
Severity of OCD symptoms showed little relation
to strength of obsessional beliefs at the start of
treatment, but change in beliefs was strongly correlated with symptom improvement post treatment. Single case studies of process confirm that
relation between beliefs and emotion varies over
treatment phases, and this is important to consider
when monitoring progress and planning intervention during treatment (Rhéaume & Ladouceur,
2000).
Other studies applying group format to a wider
range of OCD with overt compulsions have likewise reported successful symptom improvement
Copyright © 2005 John Wiley & Sons, Ltd.
K. O’Connor et al.
in a group format (see Whittal et al., 1997, for an
overview). In a study by Fals-Stewart et al. (1994)
individual therapy was compared with group
behaviour therapy. They found a significant
improvement in both groups in Y-BOCS scores
with no difference between individual and group
therapy. In a more recent study by McLean et al.
(2001), group ERP was found to lead to a significantly better improvement than group CBT at both
post-treatment and follow-up. They propose that
perhaps group CBT does not allow for an individually tailored approach to address the cognitive
processes important in achieving successful
outcome. However, individual treatment consisting solely of exposure in vivo has also been found
to lead to changes in cognitions and the importance
of addressing cognitions in successful treatment
outcome remains contentious (Emmelkamp, Van
Oppen, & Van Balkom, 2002).
The uniqueness of the current study lies in the
comparison of a standard treatment in group or
individual format with a sample of participants
suffering only from obsessions. The current results
permit us to conclude that although the impact of
a group format may lie in the value of shared social
support and the motivational effects of peer
feedback, this may be at the expense of focus on
individualized targets. Hence, these results are
consistent with those found by Whittal, & McLean.
(2001), where group CBT appeared to be less effective than individual CBT. Also, motivational
factors and availability of patients remains an
issue, and group therapy for this particular patient
group may be not be feasible in small or nonspecialized settings.
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