Published in: - Eprints



Published in:

Clinical Psychology, 2002 (Feb), 10, 6-10.

Group therapy for Obsessive-Compulsive Disorder.

Kenneth Gordon

West Hampshire Trust

Address for correspondence:

Psychology Services

59 Romsey Road

Winchester

Hants. SO22 5DE

Tel. 01962 825600

Fax. 01962 825601

e-mail: ken.gordon@weht.swest.nhs.uk

Introduction

There have been sporadic reports in the literature about groups in which cognitive-behavioural therapy was offered to people with Obsessive-Compulsive Disorder (OCD), often with good results (e.g. Krone, Himle & Nesse, 1991). These tend to have been seen as an adjunct to individual therapy and a way of involving families (Enright 1991, Tynes, Salins, Skiba & Winstead, 1992, Van Noppen, Rasmussen, Eisen & McCartney, 1991), or to prevent relapse (Epsie, 1986), or as an economical alternative to the same therapy delivered on a one-to-one basis (Fals-Stewart, Marks & Schafer, 1993).

However, there are reasons to believe that a group setting may be potentially better than individual sessions for people with OCD (Van Noppen, Pato, Marsland & Rasmussen, 1998). It is on that basis that we have tried to develop an effective programme over the last three years in Winchester: offering group therapy rather than just therapy in a group. This work has been carried out by the author in conjunction with a series of colleagues and trainees, to whom grateful thanks are due. The following paper reports on aspects of the group programme which may be of help to others developing similar programmes elsewhere.

The rationale of group work for people with OCD

There are a series of group processes which have the potential to facilitate cognitive-behavioural programmes for people with OCD. Firstly, people with OCD are often particularly reluctant to come forward for help, because they recognise their behaviour as illogical, and feel a sense of shame in admitting to their problems. This has been seen as one cause of the uncertainty over the true incidence of the disorder. The group process offers a way of overcoming this, through the sense of 'universality' which discussion of shared problems creates (Yalom, 1975). Hand & Tichatzky (1979) therefore stress the importance of group cohesion in obsessional patient programmes.

Van Noppen et al. (1998) endorse this, but also cite several other ideas from Yalom's work as potential 'curative factors' for people with OCD. These are 'imparting information' (from each other, as well as the therapist), 'instillation of hope' (through seeing others benefit), 'imitative behaviour' (where risk-taking is encouraged when others are seen to do so) and 'altruism' (in that helping others build their self-esteem helps re-focus attention on external, rather than internal issues). They add to this list 'competition', describing the urge to try harder when with others in the same boat, and, as a further factor, mutual contracts ('If you do this, then I'll do that'). In a related vein, Krone et al (1991) suggest public goal setting is of particular value.

At a more prosaic level, and given that the group described here works within a cognitive-behavioural framework, it is also important that the group is a social setting which provides an immediate way of exposing members to some of the most frequent obsessional fears, namely passing on (as well as catching) disease, or more generally, being responsible for the well-being of others. In vivo exposure in a group should therefore be highly effective.

These points will be discussed below, alongside a number of more general observations from our experience of running OCD groups.

The group programme

Although our groups began by using a 20-week format, the most common pattern has been to run for 12 weeks, with a later follow-up meeting. We have completed five such groups to date. The structure of each weekly, 90 minute meeting is to begin with feedback on progress, move to a specific topic for the week, and end with the development of personal targets for the week. For each 12-week group we cover the sequence of topics shown in Table 1. These are based on building group cohesion, followed by an early introduction of exposure with response prevention, reinforced each week through goal setting, and the later introduction of cognitive interventions.

(INSERT TABLE 1 ABOUT HERE)

Outcomes

These groups have not been formally evaluated, but goal attainment ratings by 17 participants suggest that our clients feel, on average, that they are 62% improved by the end. We also have before / after data for 15 of the more recent clients using the Padua Inventory, a measure of obsessional symptoms (Sanovia, 1988, Macdonald & de Silva, 1999). The extent of change on this scale can be interpreted using the modified 'effect size' statistic used by Westbrook & Hill (1998) to analyse the outcome of routine therapy within the Oxford clinical psychology service. Change in mean score after therapy is expressed as a ratio of the standard deviation obtained pre-therapy, giving a figure which can be compared across different questionnaires or groups. The Oxford group published effect sizes of 0.74 (Beck Anxiety Inventory) and 0.36 (Beck Depression Inventory), with 0.78 as the figure for a problem rating scale. Our effect-size on the Padua to date is 0.83, which seems encouraging.

The group in practice

The 'curative factor' of universality is certainly engendered in session one: there is an almost tangible sense of relief as people begin to share their symptoms, fears and behaviour patterns, and a strong sense of cohesion often emerges. In our experience, this process is more marked than in other CBT groups, and should facilitate the altruism, hope and (healthy) competition which Van Noppen et al. (1998) describe.

The group also has some greater difficulties than other CBT programmes, perhaps because of the nature of obsessional disorders. Goal setting is one concept which seems surprisingly hard to get across, and considerable time is needed within the programme to try to realise the benefits of public goal-setting claimed by Krone et al. (1991). Perhaps this is because people with obsessional problems find it hard to abandon detail in favour of broad themes, and can become stuck, agonising about which particular aspect of their disorder it is best to tackle. It can also be difficult to ensure that tasks are framed in positive terms (attempting genuinely new behaviour), rather than negatively (simply doing slightly less of the old behaviour). In this sort of debate, the group can work against the therapist, who has perhaps less authority than they would in the one-to-one therapy situation.

This bears on the issue of risk taking in groups. OCD consists in large part of an attempt to nullify perceived risks, whether of disaster, blame or illness. Therapy therefore has to help the client learn to accept risk. If a group can achieve this, it will be a powerful method of therapy. However, the social psychological literature suggests that using group processes to facilitate risk-taking is not a simple matter.

Research on the 'shift to risk' phenomenon in the 1960's seemed to show that people are able to take greater risks when working as a group than they do alone, and that these risky decisions apply not only to the group's work, but to individual decisions discussed within the group. Unfortunately, later research made it clear that although groups take more extreme positions than individuals, this polarisation may be in either direction: towards risk or towards conservatism (see Baron & Byrne, 1993). The direction depends partly on the original view of the majority of members, so a group for people with OCD could easily result in the group members becoming more risk-averse through hearing each others' point of view.

The ethos of taking risks is therefore crucial, but difficult to establish. In our group, the therapists may model appropriate behaviour, for example through the coffee and tea provided at the start of the evening. Because contamination fears are common, the therapists may be the only ones drinking in the first couple of weeks, but the presence of the cups and kettle gives a natural opportunity to open a discussion of 'risking' a drink, and usually if one client does so, others will rapidly follow. Once members are persuaded to try such new ways of acting, the anxiety reduction seems more rapid than in individual therapy, possibly because of the sense of mutual support.

Similarly, it seems to need a role model from amongst the group members for exposure sessions to really take shape. This is in line with the social psychological literature which suggests that, for individuals to have an influence on a group, they must act consistently, and be seen as part of the group rather than an outsider. In this context, a range of severity within the group can be helpful, with less severely affected clients often acting as an encouragement or model to others.

Another type of 'imitative behaviour' (Van Noppen et al. 1998) is provided in the video we show in session 3. This shows a woman having exposure/response prevention therapy and clearly tolerating a good deal of distress so as to overcome her fears. We use this to discuss what might be an acceptable level of distress during homework, using subjective units of discomfort (SUDS) ratings. This can be one point where the 'competition' idea (Van Noppen et al., 1998) is seen, with people almost outbidding each other for the level of discomfort it is worth enduring.

Pace is a problem which needs to be kept in mind from the start. Clients may find a sense of safety in negotiating to take only very small steps forward, or letting a target drift from one week into the next. Healthy competition and social support can be used to maintain the momentum. One way we do this is by beginning each session with a review of successes, which the group are encouraged to celebrate with each other. We only later discuss any 'snags'. The session which reviews reasons for change (based on motivational interviewing concepts) is also designed to keep the momentum up at points where the initial enthusiasm may falter.

One recent addition to the programme, which is still being developed, is an exercise based on research into magical thinking and its relation to disgust (Rozin, Millman & Nemeroff 1986, Rozin, Markwith & Ross 1990). Briefly, it involves eliciting ratings of the person's willingness to use or consume an innocuous object appropriate to their individual obsessions (an electrical appliance for someone who checks, a glass of bottled water for someone with fears of germs, etc.). They also rate how risky the object actually is. The item then has an official-looking label attached stating that it is dangerous (e.g. "Fire hazard, do not connect to electrical supply!"), and it is returned to the person, so their ratings can be repeated.

In general, the rating of actual danger is unchanged, but the reluctance to use the object rises markedly. This experiential exercise makes the distinction between thinking with 'head versus heart' very clear, and appears to be of help in re-framing beliefs about danger. Again, the group context is important, as each individual can be 'objective' about others' fears and therefore recognise the cognitive distortions they themselves are using.

Amongst the cognitive therapy strategies, we have a good response to the 'responsibility pie' exercise, which evaluates all the factors which could contribute to the disasters for which the obsessional currently blames themselves (cf. Salkovskis 1999). A key feature here, and in other exercises, is the work we do in pairs, which allows each person to take the 'therapist role' for their partner, with associated vicarious learning of a different viewpoint. The most powerful session can, however, be the one using the 'downward arrow' method of eliciting underlying fears which maintain the person's presenting negative thought patterns. Almost always, this session produces a consensus that the basic fear is of being alone, abandoned or shunned by others. For some clients, this is understandably a very moving or distressing session, where the benefits of the group process (particularly 'universality' and altruism') become particularly apparent.

Conclusions

This article has provided some reflections on clinical group therapy for OCD. Whilst using fairly standard cognitive-behavioural procedures, we attempt to mobilise the group process to increase the impact of therapy. There are potential benefits over individual work, but also some possible pitfalls, and the groups require a fair degree of energy, creativity and flexibility to go well. Nevertheless, we hope that this article will raise interest in the development of similar, experimental, group programmes elsewhere.

Table 1: Group Programme for OCD

|WEEK |CONTENT |

|1 |Introductions. |

| |Brainstorm: the nature of OCD. |

|2 |Review of baseline records. |

| |Discussion of goals. |

|3 |Video & discussion of exposure with response prevention (E/RP). |

| |Setting initial targets (in pairs) |

|4 |Review of homework achievements & snags. Troubleshooting. |

|5 |Homework review. |

| |Exposure in vivo during group. |

|6 |Cognitive therapy: downward arrow exercise. |

|7 |Review of cognitive records. |

| |Cognitive therapy: the responsibility pie. |

|8 |'Magical exposure' exercise. |

|9 |Progress review. |

| |Motivational 'balance sheet'. |

|10 |In vivo exposure in group. |

| |Open discussion on themes chosen by group. |

|11 |Relapse prevention strategies. |

|12 |Feelings about the group ending. |

| |Final summary, 'What I've learned'. |

| |Self-help information. |

|16 |Progress review & feedback on questionnaires. |

|Follow-up |Helpful strategies review. |

References:

Baron, R.A. & Byrne, D. (1993) Social Psychology: Understanding Human Interaction (7th Ed.). Allyn & Bacon, Needham Heights, Massachusetts.

Enright, S. (1991) Group treatment for obsessive-compulsive disorder: an evaluation. Behavioural Psychotherapy, 19, 183-192.

Epsie, C.A. (1986) The group treatment of obsessive-compulsive ritualizers: behavioural management of identified patterns of relapse. Behavioural Psychotherapy, 14, 21-33.

Fals-Stewart, W., Marks, A.P. & Schafer, J. (1993) A comparison of behavioural group therapy and individual behaviour therapy in treating obsessive-compulsive disorder. Journal of Nervous and Mental Disease, 181,3. 189-193.

Hand, I. & Tichatzky M. (1979) Behavioral group therapy for obsessions and compulsions: first results of a pilot study. In Hand, I. & Tichatzky M.(Eds.), Trends in Behavour Therapy, New York, Academic Press p. 269-297.

Krone, K.P., Himle, J.A. & Nesse, R.M. (1991) A standardized behavioral group treatment program for obsessive-compulsive disorder: preliminary outcomes. Behaviour Research & Therapy 29,6. 627-631.

Macdonald, A.M. & de Silva, P. (1999) The assessment of obsessionality using the Padua Inventory: its validity in a British non-clinical sample. Personality and Individual Differences, 27, 1027-1046.

Rozin, P., Millman, L., & Nemeroff, C. (1986) Operation of the laws of sympathetic magic in disgust and other domains. Journal of Personality and Social Psychology, 50, 703-712.

Rozin, P., Markwith, M., & Ross, B. (1990) The sympathetic magical law of similarity, nominal realism and the neglect of negatives in response to negative labels. Psychological Science, 1, 383-384.

Salkovskis, P. M. (1999) Understanding and treating OCD. Behaviour Research & Therapy, 37 (Special Issue), S29-S52.

Sanovia, E. (1988) Obsessions and compulsions: the Padua Inventory. Behaviour Research & Therapy, 26, 169-177.

Tynes, L.L., Salins, C., Skiba, W. & Winstead, D.K. (1992) A psychoeducational and support group for obsessive-compulsive disorder patients and their significant others. Comprehensive Psychiatry 33,3. 197-201.

Van Noppen, B.L., Pato, M.T., Marsland, R. & Rasmussen, S.A. (1998) A time-limited behavioural group for treatment of obsessive-compulsive disorder. Journal of Psychotherapy Practice & Research, 7,4. 272-280.

Van Noppen, B.L., Rasmussen, S.A., Eisen, J. & McCartney, L. (1991) A multifamily group aproach as an adjunct to treatment of obsessive-compulsive disorder. In Pato, M.T. & Zohar, J. (Eds) Current Treatments of Obsessive-Compulsive Disorder. Washington DC, American Psychiatric Press, 115-134.

Westbrook, D. & Hill, L. (1998) The long term outcome of cognitive behaviour therapy for adults in routine clinical practice. Behaviour Research & Therapy 36, 635-643.

Yalom, I.D. (1985) The Theory and Practice of Group Psychotherapy (3rd Edn.) Basic Books.

OTHER REFERENCES OF INTEREST:

Morrison, N. (2001) Group cognitive therapy: treatment of choice of suboptimal option? Behavioural & Cognitive Psychotherapy 29(3), 311-332

McLean P.D., Whittall M.L., Thordarson D.S., Taylor S., Sochting I., Koch, W.J., Paterson R. & Anderson K.W. (2001) Cognitive versus behaviour therapy in the group treatment of obsessive-compulsive disorder. J. Consulting & Clinical Psychol. 69(2), 205-214.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download