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| From a RCP publication on Diagnosis and Intervention of Mental health conditions in childhood.(2006) |
PSYCHOLOGICAL INTERVENTIONS
5.1 INTRODUCTION
Psychological interventions have been described for obsessive-compulsive disorder
since the time of Freud. However, despite extensive writing about the disorder, OCD
was generally considered to be virtually untreatable for over 50 years. In 1966 Victor
Meyer described the successful treatment of two people with OCD by what would
now be considered as the forerunner of modern day CBT treatments by changing
cognitions and blocking compulsive rituals (Meyer, 1966). Following on from this,
staff at the Maudsley Hospital developed behaviour therapy (BT) techniques in the
early 1970s that offered hope for the first time and demonstrated efficacy in a series
of small quasi-experimental studies (Marks et al., 1975; Rachman et al., 1971;
Rachman et al., 1973). Other researchers in the UK, Europe and North America
rapidly experimented with a range of behavioural techniques (Emmelkamp &
Kraanen, 1977; Foa & Goldstein, 1978; Rabavilas et al., 1979).
By the early 1980s the common elements of several procedures that had been developed
at different centres evolved into what is now known as exposure and response
prevention (ERP) (see Steketee, 1994 for a review). Given the absence of effective treatments
until the seventies, the early studies were so convincing that most researchers
explored different ways of delivering the treatment components in trials looking at the
differential efficacy of treatment formats rather than conducting randomised controlled
trials to establish efficacy against non-treatment or attention controls. In fact, with one
or two exceptions, most of the controlled trials date from after 1990.
With the rise of cognitive therapy in the eighties (Salkovskis, 1985), a variety of
cognitive approaches have also been developed, mostly in combination with behavioural
techniques (Freeston et al., 1996; Salkovskis, 1999; Salkovskis & Warwick,
1986; van Oppen & Arntz, 1994). While many therapists have continued to offer a
variety of psychological approaches, there has been relatively little written about
other approaches and even less research.
5.2 BEHAVIOUR AND COGNITIVE THERAPIES
5.2.1 Introduction
More than 30 years of published research and a large number of authoritative
accounts have led to a widely held consensus that behaviour therapy is an effective
treatment for OCD. Indeed, the successful treatment of OCD was one of the early
success stories for behaviour therapy. The early experimentation with a diverse range
of behaviourally based procedures has evolved into a therapy with a central
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89
technique, ERP, that can be used in a variety of formats, including book and
computer-based self-help, group therapy, and individual therapy that ranges from
minimal therapist contact or telephone contact through to intensive outpatient and
inpatient regimes (Foa & Franklin, 2000; Himle et al., 2003; Lovell et al., 2000;
Marks, 1997). Cognitive therapies have emerged more recently with the hope that
they would improve the efficacy of behaviour therapy and provide an alternative to
those who have difficulty in engaging in ERP (Salkovskis & Warwick, 1986;
Wilhelm, 2000). Many contemporary treatment approaches combine behavioural and
cognitive approaches, but there are proponents of purer forms of both. It is important
to note that in general, published treatment studies almost certainly do not cover all
symptom presentations equally. Washing/cleaning and checking are probably well
represented, but obsessions without overt compulsions and hoarding are most likely
to be underrepresented except in studies that specifically target these forms. It is difficult
to know the extent to which other less frequent forms are included in treatment
studies, or their response to treatment (see also Mataix-Cols et al., 2002a).
5.2.2 Current practice
During the rapid development of behaviour therapy in seventies, Professor Isaac
Marks established a training programme at the Maudsley Hospital in 1972 to develop
behaviour therapy skills among psychiatric nurses. This programme, and others that
followed, established a strong core of skilled behaviour nurse therapists working in
the NHS (Gournay et al., 2000). The work at the Maudsley and other centres also
influenced professional training for psychologists and psychiatrists, among others,
and so emerged a strong multidisciplinary tradition for behaviour therapy in centres
throughout the UK. Multidisciplinary training in cognitive therapy developed in the
early nineties and in 2004 there were over twenty post-qualification courses across
the UK offering training in cognitive and behavioural therapies (www.babcp.org).
There are, however still gaps in the provision of training and although most are
accredited with universities, accreditation by the British Association of Cognitive and
Behavioural Therapies is not yet widespread. Almost all basic professional training
in psychiatry, psychology and nursing includes some training in these therapies. Thus,
there is a large body of clinicians with knowledge of these approaches, although
there are relatively few with specific expertise and experience in the application of
cognitive and behavioural therapies to the treatment of OCD.
Therapists with the necessary expertise have traditionally been found in secondary
and tertiary care settings. There is an unequal distribution of accredited therapists
across the UK (Shapiro et al., 2003) and the picture is likely to be similar with trained
but non-accredited therapists. However, there are increasing numbers of clinicians with
CBT training in primary care and there are a number of recent training programmes to
enable professionals in primary care with little CBT experience to provide assisted
self-help to people with anxiety disorders (for example, Lovell et al., 2003), including
OCD.
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A recent report from the Department of Health (2004), addresses issues related to
current provision of psychological therapies, training, supervision, and competence.
While not limited to CBT, the report makes a number of recommendations on these
issues and provides guidance on the organisation and provision of training, continuing
professional development, and clinical supervision.
5.2.3 Interventions included in the review
The following interventions were included:
Behaviour therapy
Cognitive therapy
Cognitive behavioural therapy
Rational-emotive therapy.
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