What is more useful Exposure and Relapse Prevention or Cognitive
Therapy in the treatment of OCD?
Contents
Abstract
Introduction
Definitions of key terms
OCD
Topic and Inclusion criteria
Method Used
Structure of Paper
Paper Review
Philosophical basis
1. Van Oppen et al. (1995)
Aims of the Paper
Hypotheses
Design
Results
Critique
2. McLean et al. (2001)
Aims of the Paper
Hypothesis
Design
Results
Critique
3. Cottraux et al. (2001)
Aims of the Paper
Hypothesis
Design
Results
Critique
4. Whitall (2005)
Aims of the Paper
Hypothesis
Design
Results
Critique
5. Belloch et al. (2008)
Aims of the Paper
Hypothesis
Design
Results
Critique
Synthesis
Reducing sample bias
Anomalies
McLean et al. (2001)
van Oppen et al. (1995)
Conclusion
References
Abstract
Introduction
Definitions of key terms
OCD
Topic and Inclusion criteria
Method Used
Structure of Paper
Paper Review
Philosophical basis
1. Van Oppen et al. (1995)
Aims of the Paper
Hypotheses
Design
Results
Critique
2. McLean et al. (2001)
Aims of the Paper
Hypothesis
Design
Results
Critique
3. Cottraux et al. (2001)
Aims of the Paper
Hypothesis
Design
Results
Critique
4. Whitall (2005)
Aims of the Paper
Hypothesis
Design
Results
Critique
5. Belloch et al. (2008)
Aims of the Paper
Hypothesis
Design
Results
Critique
Synthesis
Reducing sample bias
Anomalies
McLean et al. (2001)
van Oppen et al. (1995)
Conclusion
References
Abstract
This study reviews the 5 most salient papers in the debate
between the use of ERP and CT in the treatment of OCD. These were drawn from a
literature search across academic databases and cross checked with the Nice
Guidelines.
All studies have their philosophical basis seen as realist,
with its strengths and weaknesses. The strengths of the papers are brought out
in that they show that ERP is as useful as CT however this is weakened by the
measurement, performance and sample biases I draw out, which decrease both
their internal and external validity.
The key critiques are
1.
OCD is a distress of meaning
2.
Y-Bocs has its flaws
3.
Key data missed:
a.
Client attitude
b.
Levels of homework performed
4.
Assessment techniques
5.
Weak generalizability to the overall OCD
population
The papers are then synthesised, aiming to aggregate their
performance bias and to reduce the impact of the two anomalies one which shows
CT as more effective, one that shows ERP as more effective.
Given the realist bias of the papers and the meaningful basis
of OCD, which I argue for in this paper, there is a call for finding out when
should a specific technique be used as opposed to trying to provide the general
rules for a treatments objective validity.
Introduction
Definitions of key terms
OCD[1]
a.
Defined in DSM 4[2],
which paraphrased leads to:
i.
Obsessions
1.
Recurrent and persistent thoughts, impulses or
images experienced as intrusive causing anxiety or distress.
ii.
Compulsions
1.
Repetitive behaviour in response to the
obsession which aims to neutralise its content and affect
iii.
Disorder
1.
Significantly interfering with a person’s
functioning.
2.
ERP[3]
a.
First documented by Meyer (1966). It is used to treat
people’s dysfunctional fear by exposing them to their feared object and
preventing their avoidant responses. This
enables the patient to see there is nothing to fear.
The underpinning behavioural theory comes from Mowrer’s (1939) two stage
theory of fear and avoidance; fear is learnt by classical conditioning and
maintained by avoidant behaviour.
ERP breaks classical conditioning by exposing the client to their feared
object and seeing that the anxiety will diminish of its own accord. After
repetition of this the anxiety is no longer created, which is known as
habituation
3.
CT[4]
a.
This approach sees OCD as being created\maintained
by dysfunctional interpretations of the intrusive thought\image and comes from
the work of Clark & Beck (2010, p. 446) and Salkovskis (1985).
4.
Useful
a.
Used in the title to represent both the efficacy
and effectiveness of ERP vs. CT. “Efficacy trials determine whether an
intervention produces the expected result under ideal circumstances.
Effectiveness trials measure the degree of beneficial effect under ‘real world’
clinical settings” (Gartlehner et al. , 2006, p. 3).
Topic and Inclusion criteria
I chose this topic as I wanted to understand when working
with a patient with OCD which approach would be more beneficial, so looked for
the most relevant papers that compare behavioural and cognitive approaches.
Method Used
I performed a literature search against the Psychinfo, EBSCOhost
and Medline databases using the following search terms (OCD, Cognitive,
Behavioural and ERP). I cross checked my results with the NICE (2006) to ensure
the papers that I was using were also those that met NICE’s high methodological
criteria for inclusion.
Structure of Paper
First I look at the philosophical basis of all papers; then
each will be critiqued chronologically. Some critiques apply to other papers,
so I will name them in italics in parentheses, e.g. (Y-Bocs critique).
The papers are:
1.
van Oppen et al. (1995)
2.
McLean et al. (2001)
3.
Cottraux et al. (2001)
4.
Whittal et al. (2005)
5.
Belloch et al. (2008)
Having reviewed each paper, the results are then
synthesised. Conclusion is drawn through what has been learnt and omitted and
what in research terms needs to be done to improve the treatment of OCD.
Paper Review
Philosophical basis
All the following papers philosophical basis are realist
with its corollary medical model explanation of mental distress. This means
there exists such a thing as OCD, as there is liver cirrhosis, which is
recognisable should enough rational people have sufficient information.
They have all tried to rule out the impact of subjective
data of the participants such that they could have objective results meaning
that ERP\CT could be applied to OCD in anyone and have these results. Their language of OCD has an objective
implication. They talk about the treatment of OCD as if it is a something
irrespective of the person who has it. They talk of OCD symptoms with the
implication that there is an underlying thing, i.e. OCD, which you can have
symptoms of.
The difficulty with this position is that OCD is understood
from the criteria of DSM4, which is a
psychological taxonomy and has no metaphysical implications.
OCD is a distress of meaning seen in cognition, behaviour
and emotion. You can’t tell if someone has OCD when they are asleep. Meaning is enabled synchronically and
diachronically. Diachronically, meaning is produced through the learning
history of a person’s life. Synchronically, it is produced via its context
within a person’s overall meaning structure, in the same way that a dictionary
explains one word by referring to another.
A realist position has advantages and disadvantages. An
advantage is that it simplifies the complexity of a person’s meaning making and
produces something definitive to be treated. The disadvantage is that it can
miss what is the sufficient condition[5] to
a person’s distress if it doesn’t fall within this general understanding.
1. Van Oppen et al. (1995)
Aims of the Paper
Compare CT and ERP in the treatment of OCD.
Hypotheses
1.
CT would be more effective at treating
obsessions.
2.
CT would benefit checkers who have strong
dysfunctional beliefs about responsibility.
Design
Sample
Size
71
Attrition
14 (CT 7, ERP 7)
Drawn from
Previous clinical participants at their centre:
People who:
1.
Didn’t want to take part in a previous drug
trial.
2.
Had been previously put on an 8 week waiting
list.
3.
Had been treated with anti-depressants.
Method
Participants were randomly allocated to either the CT or ERP
group. 16 sessions were given via a manualised approach for both groups in an
individual format. Weekly group sessions were held with the therapists where
problems that occurred during treatment were discussed.
CT used diaries for identifying and challenging
thoughts. CT was mainly focussed on
challenging dysfunctional beliefs of responsibility and catastrophisation.
ERP used behavioural experiments to cognitively restructure
after session 6. ERP used a homework task between session and graduated
exposure, the exposure was self-exposure.
Measurement
Key Measures used
Y-Bocs, PI-R
Measurement method
Participant\clinician rated
Results
Both CT and ERP were effective and CT was more effective
than ERP. There was no difference found between the checkers OCD subgroup for
either CT or ERP, however this could be explained by the low number of people
in this subgroup. CT was not seen as more effective at treating obsessions.
Critique
Strengths
1.
Participant exclusion criteria of:
a.
Anti-depressants
i.
We can understand the results to be for a
monotherapy approach. (Monotherapy
critique)
b.
Whether the participants had CBT in the prior 6
months.
i.
Knowing the levels of CBT knowledge and
psychological mindedness can help rule this out as a significant variable.
2.
Hypothesis
a.
Having a hypothesis allows us to not just find
out an outcome but why, meaning it has higher external validity as we
understand more the causes of the outcome.
Weaknesses
1.
Sample Bias
a.
DSM 3 diagnosis for OCD was used as inclusion
criteria.
i.
This doesn’t include obsession with no
compulsion or covert compulsion which is included in DSM 4. If DSM 4 is used to
define our OCD population this would weaken the generalizability of these
findings.
b.
All participants had been involved in previous
work at the centre. There could be varying levels of trust\optimism that
participants have depending on their experience within the centre. This would affect the samples orientation to
treatment.
2.
Performance Bias
a.
The therapists had weekly meetings to address
difficulties.
i.
This can provide support, modelling, increase a
sense of competition and the “exam” conditions of the study, for the therapists.
These factors could see the therapists performing in ways unrepresentative of
their standard practice. Whilst this can be useful for understanding the
efficacy of ERP\CT it would weaken the effectiveness of this study.
3.
Measurement Bias
a.
The assessors of the outcomes weren’t blind;
they were the therapists in the study, rating their clients via structured
interview. Thus the scores might be skewed by what the participants thinks of
their therapist (No blind assessor
critique).
b.
Y-Bocs is a central to the findings, but its
validity is questionable, i.e. is it measuring the right thing.
i.
It aggregates :
1.
Interference\distress, which are of concern to
the client, with time spent\resistance and control which only have significance
for the client if they cause interference or distress.
2.
Obsession and compulsion where the client may be
only distressed with one.
ii.
In the compulsion section it marks resistance
and control high, indicating a stronger aspect of OCD. Now there is ambiguity
here as we know from the "green rabbit" (Clark, Ball, & Pape, 1991),
you can’t control thoughts. So if this question is answered about the primary
intrusion then the results would be opposite indicators to client’s distress.
iii.
Woody et al. (1994) noticed very poor test-retest
reliability on the resistance to obsessions\compulsion question
4.
Distribution
a.
The distribution of the OCD population was not
stated. This means we do not know how we can generalise to the wider
population, as we don’t know if our sample is representative (Distribution critique)
5.
Do no harm
a.
The SD[6]
of the Y-Bocs\ADS[7]
scores increased for both CT and ERP. This
could indicate a worsening of outliers’ condition. This information should be
available as we would want to ensure a treatment approach doesn’t increase any
patient’s distress. (Do no harm critique)
6.
Omitted data
a.
Participants levels of motivation, psychological
knowledge and belief.
i.
Given CBT
is collaborative empiricism, without understanding what these aspects are we
would struggle to generalise from these findings. The sample might be highly
motivated, believed in the approaches given and knew a lot about psychology and
it was these factors that were instrumental in the outcome. (Psychological Data critique)
b.
Frequency and compliance of homework
i.
If one group were doing little homework then it
could affect our comparison between ERP and CT as more effective treatment is
being given. If both groups were doing a lot of homework then this could affect
the overall outcome (Homework critique).
2. McLean et al. (2001)
Aims of the Paper
1.
Compare the efficacy of CBT vs. ERP for OCD in
group treatment.
2.
Establish which treatment is more effective in
the change of OCD specific dysfunctional
cognitions.
3.
Identify predictors for treatment outcomes in
both treatments.
Hypothesis
None
Design
Sample
Size
76 treatment starters
Drawn From
Recruited from advert and medical practitioner referral
Attrition
14 accepted but refused treatment (12 CBT, 2 ERP). 10 dropped out during treatment
(8 ERP, 2 CBT).
Method
Random allocation to 3 groups:
1.
38 were wait-listed for 3 months.
2.
19 were allocated to ERP group.
3.
19 allocated to CBT.
Manualised treatment was delivered by 2 therapists to groups
of 6-8 participants.
Measurement
Key Measures: Y-Bocs
Measurement Method: by participant
Results
CT and ERP treatment groups were superior in outcome to the
waiting list group both at the end of treatment and at 3 month follow up. ERP
was marginally more effective at end of treatment and follow up although both
treatments were clinically equivalent at the end of treatment. ERP had more
patients at the recovered criteria at follow up than CT. Only 1 of 7 belief
measures showed improvement with either CBT or ERP.
There was no demographic information or patient behaviour
that could predict improvement in Y-Bocs scores apart from their level of Y-Bocs
scores.
Critique
Strengths
A waiting list group was used which attempts to show that
people wouldn’t have improved by themselves therefore it is the treatment offered
that achieved the improvement. Of course this is only an attempt as many things
happened to the waiting list group as they waited, living their lives and we
don’t know what they are.
Weaknesses
1.
Sample Bias
a.
Above average education level
1.
22% graduated from high school
2.
30% post-secondary school education
3.
14% graduated from 2 year post-secondary course
4.
29% graduated from 4 year post-secondary course
ii.
Without
knowing what the general education aspects of the overall OCD population are,
it is hard to know whether this provides a sample bias or not, but to the
overall population it is unrepresentative
b.
48% of the participants were taking psychotropic
medication for their OCD
i.
We cannot say ERP is better than CT as a monotherapy
2.
Measurement Bias
a.
No blind
assessor critique
b.
Y-Bocs
critique
3. As
per the Do no harm critique, the SD
increases in the BDI scores.
4.
Omitted data
a.
Psychological
Data critique
b.
Homework
critique
c.
Hypothesis
i.
No hypothesis means we can only draw general
conclusions, at best ERP is effective. Without a hypothesis stating why this is
the case means that should ERP not work, we wouldn’t know why and therefore
generalizability is lessened (Hypothesis
critique)
3. Cottraux et al. (2001)
Aims of the Paper
Compare CT against BT[8] in
non-depressed patients.
Hypothesis
CT would yield better outcomes in the long term because it
modifies schemas which BT doesn’t.
Design
Sample
Size
65
Attrition:
5 (3 BT, 2CT)
Drawn From
3 centres in university hospitals
Method
65 people randomized into 2 groups for 16 weeks receiving 20
hours of either CT or BT. Patients were informed that they were part of a
trial. Therapists were either psychologists or psychiatrists with a CBT
diploma. All had 20 hours of OCD training.
Behavioural experiments were used in CT to cognitively restructure. Homework was set for both groups. BT used ERP led by therapist in session and in
vivo as homework.
Measurement
Key Measures
Y-Bocs
Measurement Method
Blind Assessor and Participant
Results
Response rates between CT and BT were similar at post-test
and follow-up. BT was significantly more improved by CT at week 16.
Critique
Strengths
1.
Measurement
a.
Increasing the validity of the scores through
i.
Blind assessor
ii.
Behavioural assessment tests, which don’t depend
on client
self-report
Weaknesses
1.
Sample Bias
a.
All participants had severe OCD (Y-Bocs >16)
whose depression was mild (HRD[9]<=12).
OCD sufferers can be understood in terms
of the distress they feel and the impairment on their functionality. If we understand that their distress can
either be depression or anxiety plus functional impairment and there is no
necessity which affect they suffer, then this study would only be generalizable
to those in with anxiety. Of course their
depression\anxiety scores could be the result of comorbidity. However the
finding of this study is their BDI does reduce so it seems reasonable to
conclude that some aspect of their BDI would be dependent on the distress from
their OCD.
b.
Distribution
critique
2.
Measurement Bias
a.
Y-Bocs critique
3.
Omitted data
a.
Psychological
Data critique
b.
Homework
critique
c.
Demographics: we were only given age, sex, OCD
duration, Axis 1 comorbidity, so insufficient information to see if there was a
sample bias, e.g. education.
4. Whitall (2005)
Aims of the Paper
Compares ERP and CT in individual format
Hypothesis
None
Design
Sample
Size
71 started treatment
Attrition
12 (4 CT, 8 ERP)
Drawn From
Participants selected from self-referral or referral from
health professionals.
Method
Participants randomly allocated to the CT or ERP group and
treated. No waiting list condition as McLean et al., (2001) indicated that OCD
symptom severity remained stable during the 3-month delay. Experienced therapists treated 38 clients and
interns treated 11, over a 12 week period 1 hour per week. ERP focussed on
habituation, CT on challenging the dysfunctional appraisal of intrusions and
could use behavioural experiments if needed.
Measurement
Key Measurements
Y-Bocs
Measurement Method
Blind assessor\participant
Results
For 59 treatment completers, there was no signiļ¬cant
difference in Y-Bocs scores between CT and ERP at post-treatment or at 3-month
follow-up.
There was a significant association between employment
status and dropping out. Dropouts were 40% students and 50% unemployed
people.
Critique
Strengths
1. Monotherapy critique
Weaknesses
1.
Sample Bias
a.
High degree of education:
i.
44% having a university degree and 27% having post-secondary
degree qualification
b.
High degree of homework compliance and therefore
motivation
i.
Mean being at 4 out of 6, where 6 is: “has done
more than is asked for”.
5. Belloch et al. (2008)
Aims of the Paper
Compare ERP and CT for OCD patients, and see usefulness of
each in changing cognitive beliefs at post-treatment and one year follow up.
Hypothesis
None
Design
Sample
Size
33
Attrition
4
Drawn From
Two Spanish public mental health clinics
Method
33 OCD patients were randomly assigned to ERP or CT. ERP
applied was in vivo, gradual and therapist-guided. The CT challenged all the
cognitive domains considered relevant for OCD, using cognitive techniques. The
therapists delivering treatment were experienced in working with anxiety and
depressive disorders.
Both groups ran over a 6 month period
ERP: 20 sessions and had daily homework.
CT: 18 sessions and had daily homework.
Measurement
Key Measurements
Y-Bocs, BDI, ATQ[10]
Measurement method
Blind assessor/Participant
Results
Y-Bocs improvement and recovery rates were slightly superior
for CT than for ERP (ERP: 69.23% and 61.53%, respectively; CT: 81.25% and
68.75%, respectively. At the one-year follow-up, 53.85% of the treated patients
remained free of symptoms in ERP, and 65.5% in CT. Finally, the two treatments
were equally effective in modifying dysfunctional beliefs, and the outcomes at
the end of the treatments were maintained, or even increased, one year later.
Critique
Weaknesses
1.
Sample Bias
a.
86% were on medication
b.
Education is low to medium
c. Distribution critique
2.
Measurement Bias
a.
Y-Bocs
critique
3.
Omitted data
a.
Psychological
data critique
Synthesis
To synthesise the findings of these papers I will pick out
the key points in tabular form such that I can refer back to them.
Name
|
Date
|
Treatment
Format
|
Sessions
Hours
|
Treatment
length weeks
|
Sample
Bias
|
Homework
frequency
|
|
CT
|
ERP
|
||||||
Van
Oppen et al.
|
1995
|
Individual
|
16
|
16
|
16
|
No
covert compulsions
Education Medium to High |
Implied
weekly
|
McLean
et al.
|
2001
|
Group
|
9
|
9
|
12
|
48%
on medication for OCD
64% overt compulsions |
Weekly
|
Cottraux
et al.
|
2001
|
Individual
|
20
|
20
|
16
|
Mild
depression
|
Implied
weekly
|
Whittal et
al.
|
2005
|
Individual
|
12
|
12
|
12
|
Education
High
Motivation High |
Implied
weekly
|
Belloch et
al.
|
2008
|
Individual
|
18
|
20
|
24
|
Education
low to medium
82% on medication for OCD |
daily
|
Name
|
Date
|
Started
treatment
|
Attrition
|
Y-Bocs
|
Y-Bocs
|
Conclusion
post treatment
|
|||
CT
|
ERP
|
Pre
|
Post
|
||||||
CT
|
ERP
|
CT
|
ERP
|
||||||
Van
Oppen et al.
|
1995
|
71
|
7
|
7
|
24
|
25
|
13
|
17
|
CT
more effective than ERP
|
McLean
et
al.
|
2001
|
76
|
3
|
10
|
21
|
21
|
16
|
13
|
ERP
more effective than CT
|
Cottraux
et al.
|
2001
|
64
|
2
|
3
|
28
|
28
|
12
|
12
|
CT as
effective as ERP
|
Whittal
et al.
|
2005
|
71
|
4
|
8
|
23
|
21
|
10
|
10
|
CT as
effective as ERP
|
Belloch
et al.
|
2008
|
33
|
2
|
2
|
26
|
24
|
6
|
8
|
CT
as effective as ERP
|
Of the five papers
1.
1 finds CT more effective
2.
1 finds ERP more effective
3.
3 ERP and CT as effective as each other
Reducing sample bias
The low generalizability of the studies due to sample bias can
be counteracted by aggregating 3 studies. Looking at Cottraux et al. (2001),
Whittal et al. (2005) and Belloch et al. (2008) combined, we can make a
stronger case for the equivalence of CT and ERP.
In Belloch et al. (2008) there is a low to medium
educational of the sample whereas within Cottraux et al. (2001) and Whittal et
al. (2005) there are high ones, which
then would lead us to reduce the individual sample bias of any one study.
Whilst 82% were taking psychotropic medication for their OCD
in Belloch et al. (2008) none were in Cottraux et al. (2001) again reducing
sample bias.
Anomalies
How do we deal with the anomalies to the 3 papers saying ERP
is as effective as CT?
McLean et al. (2001)
Group ERP showed itself to be more effective than CT, but it
also had the highest attrition rate across any of the studies. McLean et al. (2001) explains the success of
ERP in due to ERP being more effective in a group setting, due to “modelling
and peer pressure” (McLean et al. , 2001,
p. 201). However whilst this might be true is there more that we can
learn from this? One hypothesis could be that the high attrition rates suggest
that the treatment was seen to be demanding and the resulting participants were
motivated to meet these demands in search of treatment.
McLean et al. (2001) had high rates of attrition in ERP relative
to both CT in his study and in comparison to the other studies. The theory
underneath ERP could help us to understand this, and understand why the group
format was effective. Within ERP habituation is the goal. ERP works using
graded and gradual exposure, and theory would suggest that the higher up the
graded task list a participant goes then the greater the beneficial outcome
would be. It is conceivable then that the combination of group setting,
participant motivation and ERP delivered meant that participants challenged
higher up their graded task list and therefore became more habituated. I can only speculate this is the case as McLean
et al.(2001) did not report on this, I wonder if there had have been a
hypothesis in his paper and a prediction, if this type of data would have been made
available.
Should it be the levels of habituation that determined the
effectiveness of ERP, then this would open up a whole different slant for
research. It would be seen that some
level of participant fortitude would be needed to achieve this, which could be
enabled by levels of participant motivation, psychological mindedness and
belief in the process. It could be enabled by a group format to encourage; it
could be enabled by the strength of the therapeutic alliance that gives the
participant the trust to do something, facing their fear, which is inherently
uncomfortable.
van Oppen et al. (1995)
Here CT is more effective than ERP, Belloch et al. (2008)
argued this was the case due to the use of self –exposure in ( van Oppen et
al., 1995), which is deemed to be less
effective than therapist led exposure, although all the studies set homework
which is self-exposure as well as therapist led exposure.
However there are some other factors that may be at play
here:
1.
This was the first controlled study against CT,
did this inspire the therapists to prove something with their pioneer spirit?
2.
Was the fact that half of the participants had
already been involved in a previous CT trial significant? Did it increase their
knowledge and orientation towards CT? Again the omission of this data leads me
to only be able to pose questions here rather than statements, but the worth of
this is, to open up the areas that should be studied in future papers.
3.
The CT group had 64% living together married and
the ERP group 55% single. Whilst this has been deemed a no significant
difference between the ERP and CT, in absolute terms this obviously represents
a difference and would then pose the question of whether co-habiting with this
sample group was significant to getting the results that were achieved in CT.
A tentative synthesis of these five papers is that we can we
can reduce some of the sample bias via aggregates, the 2 anomalies can be
reduced in significance when we see that van Oppen might well have got higher
levels of habituation than the other paper’s use of ERP and van Oppen might
have had a performance bias in its pioneering spirit.
Conclusion
This paper, whilst showing the results of 5 papers has
critiqued their internal and external validity. The internal validity via
1.
Measurements biases
a. Y-Bocs critique
b. Blind Assessor critique.
2.
Performance bias
a.
Homework frequency/compliance
The external validity
has been critiqued through
1.
Sample bias
2.
Lack of understanding of the distribution and
demographics of the general OCD population.
In the ”Philosophical basis” section above the meaning basis
of OCD was shown. Therefore what I
believe is more salient, than an attempt for objective validity, is to
understand first that ERP and CT can be effective, then under what
circumstances they can be used. These circumstances I believe would be factors
about the client, the therapist and their relationship.
These papers should have focussed more on the conditions
under which CT or ERP is effective for OCD as efficacy for ERP and CT has
already been shown, e.g.
1.
Lindsay et al (1997) show the efficacy of ERP
2.
Cordioli et al (2003) show the efficacy of CBT
It should be noted however, “There is as yet little evidence
for either cognitive therapy or CBT from RCTs against control conditions” (Nice,
2006, p. 101), indicating worth within these papers for what they show of CT.
Given CBT is collaborative empiricism this means that both
the therapist and patient are vital in the effectiveness of any treatment.
Questions then about the therapeutic alliance, about a client’s motivation,
belief in the process, psychological mindedness are all vital to understand the
effectiveness of any treatment. Unfortunately the studies under review appear
to treat ERP and CT like an aspirin that can be given in any manner according
to the manual, to any person and they will have the same effect.
The final point about generalizability, albeit an
unfortunate one, is that to know our levels of generalizability we need to know
the demographics of the OCD population. The prevalence of OCD is high “In the
UK, the prevalence of OCD is 1.2% of the adult population between 16-64 years
of age”, (Nice, 2004, p. 2). However a large percentage of these people don’t
seek treatment. Mayerovitch (2003) found, from a sample of 7124
of people classifiable with OCD, 64% of
them hadn’t sought treatment.
The problem here is at best we can identify the distribution
and demographics of 36% of the OCD population. My hope is that through doing
this and increasing the effectiveness of the treatment the other 64% come
forward.
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[1]
Obsessive Compulsive disorder
[2]
Diagnostic Statistical Manual
[3]
Exposure and Response Prevention
[4]
Cognitive Therapy
[5] A sufficient condition is
one which if satisfied, assures the statement's truth
[6]
Standard Deviation
[7] Anhedonic
Depression Scale
[8]Behavioural
Therapy
[9] Hamilton Rating Scale for Depression
[10] Automatic
Thoughts Questionnaire
