by Andrew Guzick, MS, and Adam Reid, PhD
This article was initially published in the Winter 2018 edition of the OCD Newsletter.
On Increasing Utilization of Evidence-Based Treatment for OCD
I am delighted to introduce Andrew Guzick and Adam Reid’s article on the need to promote therapist use of evidence-based treatments. The authors provide a thoughtful summary of the many challenges involved, but also remind us why it is so important to address the problem. Too many people with OCD still do not receive proper treatment, which, of course, was the reason IOCDF initiated the Behavior Therapy Training Institute (BTTI) over two decades ago. We have come a long way since then, but we have more work to do, as this informative article reveals.
C. Alec Pollard, Ph.D.
Chair, IOCDF Clinical Training Subcommittee
Most members of the IOCDF community understand how challenging it can be to seek out professional help for OCD or a related disorder. Many people do not know where to look, and if they do, they may not have the resources available to access care. Even when those with OCD overcome these barriers and meet with a mental health professional, they are rarely offered the opportunity to try exposure and response prevention (ERP), the most well-supported therapy for treatment of OCD (e.g., Hipol & Deacon, 2013; Peris et al., 2015). Sadly, this appears to be especially true for kids and teens with OCD (Reid, et al., 2018; Whiteside et al., 2016).
Why More Therapists Don’t Use ERP
In a survey of over 250 private practice therapists across the United States, we recently found that ERP was used just 30% of the time to treat kids with OCD (Reid et al., 2018). Comparatively, breathing retraining and muscle relaxation strategies, two techniques with far less research to support their effective treatment of OCD, were used almost half of the time by private practitioners. Unfortunately, it seems that most therapists perceive ERP to be just one more tool in their toolbox, rather than the core treatment element that so many of us have learned to rely on. This even appears to be true among private practitioners who are often promoted as OCD specialists (Hipol & Deacon, 2013; Reid, et al., 2018; Whiteside et al., 2016).
Why are therapists all across the country using ERP so rarely? It’s clearly not due to a lack of evidence, as we have an enormous amount of research that supports the power of this intervention (e.g., Ost, Havnen, Hansen, and Kvale, 2015; Freeman et al., 2018; Peris et al., 2015). While far from perfect, we also know that ERP makes sense and works for people; every year patients and clinicians tell countless stories of overcoming OCD by participating in ERP while at the IOCDF’s Annual OCD Conference. During my clinical work in the residential program at McLean Hospital’s OCD Institute, I have seen ERP change lives even for those with the most severe cases of treatment refractory OCD.
Barriers to Professional Use of ERP
One major barrier is how practitioners think about ERP. Therapists often hold biases against this treatment. Many believe that patients cannot tolerate the stress of exposures, that they may lose control when directly confronting their fears, and that ERP leads to treatment dropout (Deacon et al., 2013; Reid et al., 2018). I imagine many of you would take issue with these beliefs; We know that individuals with OCD are resilient and can handle the distress ERP brings. Furthermore, a quantitative analysis of 37 ERP studies showed that patients who do ERP drop out of therapy at similar rates to those who participate in other forms of psychotherapy (Ost et al., 2015). Additionally, there is no research to suggest that ERP can lead to worsening of symptoms for people with OCD; Exposure and response prevention has the most research support of any therapeutic intervention. The idea that ERP will hinder the therapeutic bond between therapist and patient is also false (e.g., Kendall et al., 2009). In our clinical experience, it seems to actually strengthen this bond for many cases.
Logistical barriers are an emerging challenge to ERP utilization that warrants more research. In a preliminary study we conducted, this was actually the top self-reported reason that community-based clinicians did not utilize more ERP (Reid et al., 2017a)! This is understandable when you consider that if a clinician lacks the flexibility to do 90-minute sessions, it can be very challenging to review homework, process the week, teach skills, design an exposure, conduct the exposure, process the exposure, and assign new homework all within one session. This gets even more challenging if it is necessary to perform an off-site ERP. Additional research on how to optimally design and implement ERP in a time-sensitive way would allow more therapists to practice ERP in the community.
Lack of Education
Our findings suggest a key reason that clinicians use ERP so infrequently and hold these beliefs is that they simply do not have adequate education. Ninety-two percent of the private practice therapists we surveyed reported that they would benefit from more training in ERP, and unsurprisingly, those with more training used ERP more often. The IOCDF should be applauded for doing their part in addressing this major issue; the IOCDF’s Behavior Therapy Training Institute (BTTI) has now trained thousands of clinicians in this treatment with some data to back its effectiveness (Reese et al., 2016).
The Behavior Therapy Training Institute for OCD: A preliminary report
Published in the Journal of Obsessive Compulsive and Related Disorders, January 2016
By Hannah E. Reese, C. Alec Pollard, Jeff Szymanski, Noah Berman, Katherine Crowe, Elizabeth Rosenfield, and Sabine Wilhelm
The IOCDF organized twelve sessions of the Behavior Therapy Training Institute between 2008 and 2011. During these sessions, 350 therapists were trained to utilize cognitive behavioral therapy (CBT), including ERP, to treat patients with OCD. The BTTI sessions also provide a platform for therapists to consult with experts and peers regarding patient cases. Researchers surveyed training participants and found the following:
- Participants reported that, after the trainings, they were utilizing their ERP skills at a “more than moderate” level in their practice
- Participants who consulted with peers and experts after the BTTI session used their CBT and ERP skills with patients more often
- After attending the BTTI, a majority of participants reported that patients with OCD were being referred to them in greater numbers
Read the complete article: https://www.sciencedirect.com/science/article/pii/S2211364915300312?via%3Dihub#!
Beyond the training offered at the IOCDF’s Annual OCD Conference, the BTTI offers intensive, three-day workshops aimed at teaching clinicians how to implement ERP. To address the needs of kids and teens with OCD, they have recently developed the Pediatric BTTI, which specifically addresses the unique needs of this group, such as incorporating supportive family members into ERP. To think of the number of people who have benefitted from the thousands of graduates of the BTTI who are now equipped with ERP skills is a truly outstanding achievement.
Building Successful ERP Training Models
We now know of a few ingredients in training models that most successfully educate clinicians in a new form of therapy. One important component is the opportunity for continued consultation after training is over; for example, clinicians who trained in the BTTI used ERP more frequently if they consulted with experts or with peers after their training (Reese et al., 2016). One-time workshops or seminars do not seem to do the trick (see Reid & McHugh, 2018 for a review). The research also indicates that any graduate or post-graduate education needs to lean on experiential learning over didactic learning (Reid et al., 2017b, see Reid & McHugh, 2018 for a review). In this vein, another helpful model is a “train-the-trainer” method. This approach involves scaffolding in which skilled therapists train more junior clinicians under the supervisor of an even more experienced therapist. This model has the potential to trickle down and reach more clinicians as more therapists become experienced teachers as well.
Perhaps the most systemic change that needs to occur, however, is that the education of psychologists, counselors, social workers, etc. needs to more consistently support evidence-based therapy, or therapy that is supported by science, like ERP. Clinicians often do not trust evidence-based forms of psychotherapy, suggesting that they are too rigid to apply to real-world individuals with unique situations; that their clinical intuition is more valuable than scientific evidence; that behavioral therapies like ERP do not adequately address the underlying causes of mental health problems; or that other untested treatments are likely equally effective (e.g., Lillenfeld et al., 2013). Graduate programs that emphasize science in their education will create a culture in which more therapists are eager to use evidence-based approaches like ERP.
Training More Clinicians in ERP
The development of ERP is arguably the single greatest contribution to the individuals who suffer with OCD, but even those who have the resources to seek out therapy rarely get to try this treatment. Ensuring that as many young people as possible have access to ERP can set countless individuals with OCD on a positive trajectory for the rest of their lives. Successful dissemination of ERP will require an all-hands-on-deck approach, from individuals advocating for ERP on the ground, to organizations like the IOCDF creating opportunities for successful training, to governing bodies and graduate programs ensuring that early education fosters positive attitudes and opportunities for training in evidence-based forms of therapy like ERP.
Over the past several years, the IOCDF’s Training Institute programs, including the BTTI, have provided hundreds of therapists with the opportunity to learn ERP techniques that can be applied in clinical practice. As a result, this program has increased the number of therapists worldwide who are qualified to effectively treat OCD and related disorders. If you are interested in supporting the IOCDF’s efforts to train the next generation of therapists and increase access to effective treatment for all, we encourage you to consider donating to the Foundation’s end-of-year campaign at iocdf.org/donate. Your gift will help the IOCDF continue to grow its provider training programs and ensure that therapists are able to build the skills they need to help individuals with OCD manage their symptoms and lead full and productive lives. For more information about the IOCDF’s Training Institute, visit iocdf.org/training.
Andrew G. Guzick, MS, is a fifth-year doctoral student in Clinical and Health Psychology at the University of Florida (UF). During his graduate training, he has pursued research focused on better understanding ERP at the UF OCD Program, where he has also enjoyed serving as a therapist for individuals affected by OCD, anxiety, and related disorders.
Adam M. Reid, PhD, MSE, completed his doctoral training at the University of Florida in 2016 and subsequently completed an internship and post-doctoral fellowship at McLean Hospital/Harvard Medical School. He currently conducts research at the OCD Institute at McLean Hospital, works in private practice in the Boston area, and serves as a part-time psychologist at Groton School in Groton, MA. He has published over 30 publications and 10 book chapters. His primary research goals are to improve the quality of care, as well as access to this care, for youth with anxiety disorders and obsessive-compulsive and related disorders.
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Reid, A. M., Bolshakova, M. I., Guzick, A. G., Fernandez, A. G., Striley, C. W., Geffken, G. R., & McNamara, J. P. (2017a). Common Barriers to the Dissemination of Exposure Therapy for Youth with Anxiety Disorders. Community Mental Health Journal, 53(4), 432-437.
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