The First-Line Treatment of OCD: Client Level Considerations
By Mike Heady, LCPC
Co-Director/Owner, Anxiety and Stress Disorders Institute of MD
Faculty, IOCDF Training Institute
I’ll begin by stating that it is an exciting time to be in our field. Our understanding of OCD and its treatments is growing fast, and I am so curious to see what the next 20 years will bring. Recently, our community of clinicians has been wrestling with new developments from Transcranial Magnetic Stimulation (TMS) to Psilocybin and Exposure Response Prevention (ERP) to Inference-Based Cognitive Behavioral Therapy (I-CBT). I think, ultimately, this is a good thing for us and for those who are suffering, as treatment options are more available than ever before. Since I am not a physician nor am I versed in the intricacies of TMS or Psilocybin, I will focus my attention on the psychological treatment developments for OCD, specifically I-CBT.
In recent years, I-CBT has been mentioned, suggested, and advocated to other clinicians as another treatment option for OCD. I acknowledge that I was among the first (along with Carl Robbins) to publicly make these suggestions on social media to mental health providers who specialize in OCD in the U.S. As with any “new” treatment, it has been met with a variety of responses including excitement, curiosity, skepticism, criticism, and rejection, to name a few. Change and acceptance as we know, often follows a kind of process that Prochaska and DiClemente noted as stages of change. It is the process of change and acceptance within our community of OCD specialists that I wish to address.
How we clinicians come to support, learn, and utilize treatments with clients is complex. While research data are necessary to guide us, it alone is not sufficient. Several articles have elaborated on a wonderful visual of a three-legged stool where each of the legs represents the 3 aspects of evidence-based practice. The first is empirical support, the second is clinical experience, and the third is client preferences or values. These legs represent guideposts for us to consider when helping our clients. Each leg puts the other in context because each leg alone does not provide an adequate decision tree for treatment on its own. It is only in considering aspects of all three legs of the evidence-based practice stool does true evidence-based practice emerge. Using only one leg and removing the other two will often lead to unbalanced care, whether for an actual stool or for mental health treatment. Borrowing a quote from the brilliant and humorous psychologist, Alec Pollard, “Our clients are rude. They insist on being themselves instead of conforming to my treatment model.”
While the conversation about empirical support and data is very important, if we do not put it into context with clinical experience and client preferences/values, we risk the very thing Alec ingeniously warned us about: treatment being about our personally favored approach and not about what is best for the client who is sitting in front of us. The message that ERP is the only evidence-based treatment for OCD persists today. In 16 years of practice, I have come across dozens of clients who have had either one or more courses of ERP fail to improve their functioning or not reduce their symptoms sufficiently for them to want to try a course of ERP again. I have had clients who adamantly refused exposure-based treatments like ERP for numerous reasons including that it was not in line with their values or preferences. All of these reasons for client hesitancy toward ERP create an access to care problem and a problem for our community of clinicians. How are we to respond to these clients? I have heard many kinds of responses from “try harder,” to “try different,” “add on motivational interviewing,” and “address self-compassion.” All of these are reasonable ideas, yet they remain intended to increase engagement with exposure-based treatments like ERP. What if instead of recommending more of the same, we suggested a treatment that is not exposure-based? How might we come to support that recommendation for these clients?
If the research data is what we most heavily weigh when making this type of recommendation, we should be up-to-date on the current body of literature and we should carefully consider our previous assumptions when it tells us hard truths like those reported in these comprehensive reviews and analyses on the current status of OCD treatment. The general takeaway from Öst et al., 2015, Steketee, et al., 2019, and Reid et al., 2021, is that ERP is effective for OCD. ERP shows clinically significant change in 50% of trial participants. However, when comparing ERP to other active psychological treatments, the superiority of ERP is more in question than many of us in the field realize. I strongly encourage you to actually read the articles listed. Their conclusions, I think, warrant humility within our clinical specialization. Even the most relaxed definitions of treatment outcome (participants’ treatment response) show no more than 70% efficacy for ERP. It reasonably follows that the remaining 30% of participants did not respond to treatment and 50% did not experience clinically significant change. Those statistics are humbling. If we extrapolate these research findings to clients who present to our offices for treatment, 30-50% of our clients will not experience significant improvement or relief from their OCD symptomology. If we add context to this by considering world population numbers, that is tens of millions of people who will continue to suffer from OCD even after seeking ERP.
First line treatments, also known as Empirically Supported Treatments (ESTs) as determined in the U.S. by the American Psychological Association (APA)’s Division 12, are those which have passed a certain level of research-based support. Research determining what treatments will receive an EST designation needs to be rigorous and as unbiased as possible. It stands to reason that one way to get close to a goal of denoting certain treatments as first-line treatments is to establish specific criteria. All of this is important for credibility however, it is a ‘top-down” approach. Meaning, this approach takes group data and requires an individual clinician to apply it to their individual client. We as clinicians often also must think with a “bottom-up “approach with our clients. We must consider care at the level of the client, their previous treatment experiences, their values and preferences, and our assessment of their current needs, while simultaneously being aware of and guided by the “top-down” group research data of ESTs. I assert that there must be nuance and flexibility in this process if we are to be effective treatment providers.
I am advocating for a return to context of the individual client in our office utilizing the three pillars from the three-legged stool visual as it applies to the client level. ERP is currently deemed to be a first-line (EST) treatment for OCD with strong empirical support. Is that true for those who refuse exposure treatments? Is that true for those whom exposure failed? Is that true for those whose preference/values contraindicate certain exposures? These questions highlight why the other two legs of the stool are so important and add meaningful context to our day-to-day decisions in our individual offices. What is first-line treatment from the client’s perspective?
Regarding I-CBT for a moment, I’d like to review and clarify any misconceptions about the current state of the research data. To date there are approximately 100 peer-reviewed published articles related to I-CBT. This includes theoretical, experimental, cross-sectional, longitudinal, psychometric, replication, clinical trials, and randomized controlled trials (RCTs). If we break this down further, there are 11 clinical trials and 3 of the 11 are RCTs. Those RCTs are from two separate labs, the OCD-RL--Montreal Mental Health University Institute Research Center (MMHUI-RC) affiliated with the University of Montreal and Innova Research Centre—GGZ Centraal, in the Netherlands. In fact, multiple independent labs from around the world are studying I-CBT and its components and have been for many years. The clinical trial research data show that I-CBT performs as well as ERP for OCD. Additionally, research on I-CBT is consistently showing that it is superior to ERP for those with overvalued ideation as well as for those who refuse exposure-based treatments. However, it has not yet been proven in a research context that it is equivalent to ERP. Trials demonstrating equivalency are referred to as non-inferiority trials and two of those are currently underway now and occurring in separate labs. If we put all of this in the context of the APA requirements for its submission to be considered for a designation as an empirically supported treatment, I-CBT needs only to analyze all of the existing research data in a meta-analysis. There is more than enough data to perform this meta-analysis at present, however the current researchers prefer to let the non-inferiority trials finish first so that data from those trials can be added to the meta-analysis. The data from the non-inferiority trials will add important results to the analyses, statistical power, and also provide valuable information for the APA committee as well as individual clinicians and researchers to consider as they weigh the results and merits of I-CBT in action.
Considering those clients who refuse exposure-based treatment or those who have overvalued ideation, or those for whom ERP failed to sufficiently help, how do we decide what is clinically best for those clients? What resources can we use in making clinical decisions about the most appropriate treatment approach for them? What data exists for us to make informed clinical decisions that take into account our client’s treatment history, current needs, and stated preferences? What treatment might we and the client deem first-line for them?
My point is that we must consider context and a client’s particular vantage point. There are circumstances that would warrant trying a treatment other than ERP as a first-line choice with a client who has OCD. We see this already with the popular and often-recommended parent-based treatment Supportive Parenting for Anxious Childhood Emotions (SPACE). SPACE is not technically an empirically supported treatment according to APA and no researchers have performed a meta-analysis on it at this time. However, we as a community of anxiety and OCD specialists, make clinical decisions based on our understanding of the potential benefits of the treatment and consider the client’s preferences/values and needs as a context for what evidence-based practice means with regards to SPACE. Clinical decisions and client preferences are commonly used to make judgements regarding treatment. As another example, each time we choose to utilize an inhibitory learning model of ERP, we are straying from strict adherence to EST as there are currently no published OCD-based clinical trials for it. When we treat Body-Focused Repetitive Behaviors (BFRBs) with the popular Comprehensive Behavioral Model (ComB) we are relying on clinical experience and client preference, not the APA designation, as it is not an established EST for BFRBs. There are many such examples of how clinicians utilize a particular treatment model with a client despite there not being clinical trial data testing it, let alone a meta-analysis. At the individual client level, mental health treatment is nuanced and flexible. It is adaptive to a client’s wants and needs, taking into consideration individual differences and treatment history, and allowing for an experienced clinician’s clinical judgments about which treatments have enough evidence or justification to use in an ethical and conscientious way, rather than rigidly considering only a treatment with an EST label from APA. From my perspective, when a client expresses a preference or a value or history that contradicts the “top-down” first-line treatment option, it is reasonable to pivot and consider treatment options that have research support that might make it “first-line” for this client specifically. As the aforementioned three-legged stool visual denotes, treatments can be “evidence-based” without the specific EST designation from the APA, when we carefully consider empirical support, clinical experience, and client preferences.
So, until I-CBT is specifically labeled as an EST, and therefore specifically designated a first-line treatment option by the APA as well as other international bodies (I suspect the data will substantiate such designation in the very near future), we need not wait to learn and utilize it with clients that are suffering now. We can ethically and conscientiously utilize I-CBT as an evidence-based treatment. We also might consider that we are therapists who treat OCD. We are not ERP therapists or I-CBT therapists or ACT therapists, but therapists. This shift positions our clients first and our models second rather than our models first and our clients second. Our clients deserve to be considered first.
References:
Öst, L. G., Havnen, A., Hansen, B., and Kvale, G. (2015). Cognitive behavioral treatments of obsessive-
compulsive disorder. A systematic review and meta-analysis of studies published 1993-2014. Clinical
psychology review, 40, 156–169. https://doi.org/10.1016/j.cpr.2015.06.003,
Reid, J. E., Laws, K. R., Drummond, L., Vismara, M., Grancini, B., Mpavaenda, D., and Fineberg, N. A. (2021).
Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-
compulsive disorder: A systematic review and meta-analysis of randomised controlled trials.
Comprehensive psychiatry, 106, 152223. https://doi.org/10.1016/j.comppsych.2021.152223.
Steketee, G., Siev, J., Yovel, I., Lit, K., and Wilhelm, S. (2019). Predictors and Moderators of Cognitive and
Behavioral Therapy Outcomes for OCD: A Patient-Level Mega-Analysis of Eight Sites. Behavior therapy,
50(1), 165–176. https://doi.org/10.1016/j.beth.2018.04.004
Selected I-CBT Clinical Trial Publications:
O’Connor, K., Aardema, F., Bouthillier, D., Fournier, S., Guay, S., Robillard, S., Pelissier, M.-C., Landry, P.,
Todorov, C., Tremblay, M., and Pitre, D. (2005). Evaluation of an Inference-Based Approach to Treating
Obsessive-Compulsive Disorder. Cognitive Behaviour Therapy, 34, 148-163.
Visser, H. A., van Megen, H., van Oppen, P., …, van Balkom, A. J. (2015). Inference-based approach
versus cognitive behavioral therapy in the treatment of obsessive-compulsive disorder with poor insight:
A 24-session randomized controlled trial. Psychotherapy & Psychosomatics, 84, 284-293.
Aardema, F., O’Connor, K., Delorme, M-E., and Audet, J-S (2017). The inference-based approach (IBA) to
the treatment of obsessive-compulsive disorder: An open trial across symptom subtypes and treatment
resistant cases. Clinical Psychology and Psychotherapy, 24, 289-301.
Aardema, F., Bouchard, S., Koszycki, D., Lavoie, M., Audet, J-S, O’Connor,K. (2022). Evaluation of
inference-based cognitive-behavioral therapy for obsessive-compulsive disorder: A multi-center
randomized controlled trial with three treatment modalities. Psychotherapy and Psychosomatics.
Comprehensive List of Peer-Reviewed Published Articles on I-CBT (IBT and IBA):
