This is an overview of the principles and practices of the intensive treatment programme for the treatment of OCD. There are descriptions of how exposure and response prevention (ERP) is used in practice, along with criteria for referral and treatment.
Prior to 2013, a small number of Scottish patients with difficult-to-treat OCD had to travel to specialist inpatient treatment centres in England because inpatient ERP was not available in Scotland. This separated them from their families, their support system(s), and their local services.
From 1 April 2013, the Advanced Interventions Service has been able to offer intensive/ inpatient treatment programmes for Scottish patients with OCD. This is funded by NHS Scotland and is free to NHS Boards in Scotland.
We believe that any gains from intensive ERP will only be maintained with a clear treatment plan that can continue after discharge, and we aim to be working with referring NHS Boards before, during, and after any inpatient programme to ensure maximum benefit. In some cases, we may recommend additional treatment prior to admission and we will work with members of the referring team to help support this.
We would expect that referrals would come from consultant psychiatrists who continue to be involved in the ongoing care of the patient. Please read more about making a referral below.
Psychological treatment of Obsessive-Compulsive Disorder
Individuals with OCD who are referred to the Advanced Interventions Service initially participate in a detailed review of their current and past experience of the condition and their previous treatment history. Assessment involves: face-to-face interviews with staff from the service; measures of how severe the symptoms are made using rating scales; and a detailed examination of their case notes. Particular attention is paid to the type of psychological therapy they have received and their response to it.
Normally, to meet the criteria for treatment resistance, the person should have had two attempts at psychological therapy from a suitably experienced (and, ideally, accredited) Cognitive Behavioural Therapist. Each of the attempts should have included at least twenty hours of Exposure and Response Prevention. If, at the end of this treatment, the person continues to have significant symptoms which are impairing their ability to function then they may be considered to be resistant to standard psychological treatment.
The results of this initial review are discussed with the individual and treatment recommendations, which may include drug and psychological interventions, are explored. In certain circumstances the individual may be offered further treatment in Dundee. This treatment may be offered on an out-patient basis or involve treatment while an inpatient.
The key ingredients for successful Exposure and Response Prevention (ERP)
Exposure and Response Prevention, sometimes known as Exposure and Ritual Prevention has been described as one of the most successful psychological treatments currently available. This type of treatment is based on experimental research of human and animal models of OCD. The results of this research enables clinicians and people suffering from OCD to understand the underlying mechanisms that produce such distressing, time consuming and often prolonged suffering. In addition the rationale for the treatment is made explicit, i.e. people understand an explanation how their OCD "works" and the steps needed to overcome it. Contemporary ERP for treatment resistant OCD, delivered on an outpatient or inpatient basis, involves systematic, therapist assisted (or guided) prolonged exposure to situations or stimuli that provoke obsessional fear accompanied by abstaining from compulsive behaviour.
For example, a person who has contamination obsessions and who is driven to hand wash excessively (the compulsive behaviour) would experience treatment in the following way:
- The therapist and the patient would agree a plan of specific exposure exercises that target important areas of the OCD that interfere with the patients day-to-day functioning. There are several important rules which ensure the success of this type of therapy; not least that person knows in advance what is required of them. Typically the exercises start with less difficult or distressing situations, e.g. touching a clean sink or tap, and then progress to more difficult tasks such as touching unwashed basins or taps. Eventually therapy is delivered in the persons own home where often the most troubling symptoms occur. Planning with the person, delivering the exposure in certain ways, dealing with easier targets early and graduating to more difficult tasks later on, and treating people in their own homes are the systematic part of therapy.
- Touching the feared object is the exposure part of therapy. As previously stated, successful treatment involves making sure that certain carefully thought-out rules, derived from the model of OCD, are adhered to.
- In the case of someone with contamination obsessions and hand washing compulsions, when the patient abstains from hand washing this is called 'response prevention'. Response prevention does not simply involve the therapist stopping the person carrying out hand washing, but depends on the patient being convinced that by resisting the urge to hand wash during the exercise they can reduce the levels of discomfort that they feel in the long run.
Is this Cognitive Behavioural Therapy (CBT)?
The answer to this question is complicated because the Cognitive Behavioural Therapy (CBT) approach to OCD often includes some aspects of treatment that are very similar to ERP. In addition much of the literature about the nature and treatment of OCD uses "CBT" as an umbrella term that includes ERP.
Our current understanding of OCD acknowledges that cognitive factors do contribute to the severity and prolonged course of the condition. Such factors may include: unhelpful beliefs about responsibility; the importance of certain thoughts to the individual; and perfectionism. Typically, we focus on Exposure and Response Prevention but also explore the contribution of the person’s thoughts and beliefs about themselves and the issues they are concerned about. Some, but not all people, find this aspect of treatment helpful.