Using Motivational Interviewing to Enhance Treatment Outcome in People With Obsessive-Compulsive Disorder

Sleep problems and referral intentions in mental health services: service user self-report and staff proxy report surveys

BACKGROUND

Sleep problems are common in mental health service users, but few non-pharmacological therapies are offered. Therapies are being developed and tested, but there may be barriers to these therapies reaching those who need them.

METHODS

Light-Dark and Activity Rhythm Therapy (L-DART), is a new sleep therapy delivered by an occupational therapist, which has been feasibility tested in people with schizophrenia spectrum diagnoses. This paper presents two surveys, conducted with mental health staff and service users, on sleep problems, treatment wishes; and barriers and facilitators to uptake of L-DART or similar therapies. Descriptive statistics, single-level and multi-level ordinal logistic regression were used to examine factors associated with sleep problems and referral intentions.

FINDINGS

Sleep problems were commonly identified by staff and service users, there was demand for non-pharmacological intervention across diagnostic and demographic categories, but staff readiness to refer differed according to NHS Trust and service user diagnosis. Staff and service user reports differed in awareness of sleep disordered breathing and parasomnias, and wish for referral. Staff were more confident identifying sleep problems than addressing them, but more training was associated with greater confidence concerning both assessment and treatment.

CONCLUSIONS

A range of sleep problems are prevalent and recognised in mental health service users, and there is an unmet need for non-pharmacological sleep interventions. Improving suitable resources to support self-management in this group may help; Staff and service users also reported a high readiness to refer or be referred for sleep interventions. Staff training to improve identification of sleep problems, and differentiation between types of sleep problems, would support access to the most appropriate treatments.

A remote cognitive behavioural therapy approach to treating hoarding disorder in an older adult

Hoarding disorder (HD) is characterised by excessive acquisition and distress associated with discarding objects, resulting in significant clutter. At present, cognitive behavioural therapy (CBT) represents the strongest evidence base for treating HD, although some limitations exist. Little research has examined the effectiveness of remote-CBT interventions for HD in older adults. This case study focuses on Mary, an older female adult presenting with clinically significant hoarding behaviours which severely impact her daily functioning and quality of life. Assessment and intervention followed a structured CBT approach. Despite the complicating factor of COVID-19, Mary responded well to a remote-CBT intervention, with progress indicators suggesting modest improvements in personal, social and occupational functioning. These findings support the use of remote-CBT for HD in both reducing frequency and intensity of hoarding behaviours and improving wellbeing.

Key learning aims

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Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update

In this update of a previous review, the authors discuss cognitive-behavioral therapy (CBT) with exposure and response prevention for obsessive-compulsive disorder (OCD). This efficacious modality avoids side effects common to psychotropic medication and reduces risk of relapse once treatment has ended. Psychotherapy involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions, and cognitive restructuring. The family of the OCD patient plays a significant role in treatment. This article includes expanded research on family-focused CBT and treatment of pediatric OCD. The family's accommodation and emotional response to a patient's symptoms may interfere with therapy and perpetuate the disorder. The treatment of pediatric OCD involves the same considerations. However, the form of obsessions and compulsions may differ and therapeutic techniques are modified to make them age appropriate.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Motivational Interviewing Enhances Group Cognitive Behavioral Therapy for Anxiety Disorders

This pilot study tested whether the addition of motivational interviewing (MI) prior to group cognitive behavioral therapy (CBT) for anxiety may improve the effectiveness of the treatment. Prior to group CBT, 40 individuals with a principal diagnosis of an anxiety disorder (40% panic disorder, 25% generalized anxiety disorder, 22.5% social phobia, and 12.5% others) were randomly assigned to receive either three individual sessions of MI or were assigned to a control group that did not receive MI. The pretreatment MI group, compared to the control group, experienced significantly greater reduction in anxiety symptoms post-CBT. These results suggest that brief MI pretreatment enhances the efficacy of CBT on anxiety. A combination of MI and CBT may be particularly promising for the treatment of anxiety, with MI directed at increasing motivation and commitment to change, and CBT directed at helping the client achieve the desired changes.

Intermittent Motivational Interviewing and Transdiagnostic CBT for Anxiety: A Randomized Controlled Trial

Recent meta-analytic findings suggest that Motivational Interviewing (MI) used as an adjunct to Cognitive Behavior Therapy (CBT) for anxiety disorders improves overall treatment outcomes (Marker & Norton, 2018). However, when used as a prelude to CBT, MI significantly increases the length of treatment and numerous studies note that the effectiveness of pre-treatment MI subsides over time. The current study adapted an already established 12-session transdiagnostic CBT protocol (tCBT, Norton, 2012) to include one hour of MI spread across four sessions of tCBT (sessions 1, 3, 8, and 10) at 15 minutes each, with the option of including additional MI if resistance arose in therapy. Thirty-six treatment seeking adults with principal anxiety disorder diagnosis were randomly assigned to receive intermittent MI and tCBT (iMI + tCBT) or tCBT and psychoeducation. Results indicated that the iMI + tCBT condition significantly outperformed the tCBT condition on several primary outcome variables. While no significant difference was found between the two groups on clinician rated scores of participant principal anxiety disorder, differences were found on a composite index of participants' self-report measures of symptom improvement, and on clinician rated scores of global psychiatric functioning. These effects were not moderated by baseline motivation or baseline ambivalence. The study also found that the iMI + tCBT condition showed significantly greater improvement to comorbid conditions and greater reduction in self-report depressive symptoms. The inclusion of MI did not impact participant drop out. This study provides further support for integrating MI and tCBT and highlights that even small doses of MI can improve treatment outcomes, without increasing length of usual therapy. Limitations and future research options are also discussed.

Use of videotaped personal compulsions to enhance motivation in obsessive-compulsive disorder

BACKGROUND

Watching videotaped personal compulsions together with a therapist might enhance the effect of cognitive-behavioural therapy in obsessive-compulsive disorder (OCD) but little is known about how patients experience this.AimsTo performed a qualitative study that describes how watching these videos influences motivation for treatment and whether patients report any adverse events.

METHOD

In this qualitative study, data were gathered in semi-structured interviews with 24 patients with OCD. The transcripts were coded by two researchers. They used a combination of open and thematic coding and discrepancies in coding were discussed.

RESULTS

The experience of watching videos with personal compulsions helped patients to realise that these compulsions are aberrant and irrational. Patients report increased motivation to resist their OCD and to adhere to therapy. No adverse events were reported.

CONCLUSIONS

Videos with personal compulsions create more awareness in patients with OCD that compulsions are irrational, leading to enhanced motivation for treatment.Declaration of interestNone.

Motivational Interviewing as an Adjunct to Cognitive Behavior Therapy for Anxiety Disorders: A Critical Review of the Literature

Cognitive behavior therapy (CBT) is efficaciously and effectively used in the treatment of anxiety disorders; however, as CBT for anxiety routinely utilizes exposure components, clients often experience ambivalence about treatment and their clinicians often must deal with resistance. Motivational Interviewing (MI) is a therapeutic strategy that addresses ambivalence about change in clinical interventions. MI has been applied as an adjunct for treatments such as CBT in order to increase motivation for and commitment to the intervention, especially when components of the treatment may be challenging (e.g., exposure, cognitive restructuring). Though researchers have commented specifically on the use of MI as a supplement to CBT for anxiety disorders, no comprehensive review has systematically assessed the strengths and limitations of extant literature on the topic, nor across anxiety disorders. Findings are summarized from 6 case studies and uncontrolled trials and 11 randomized controlled trials published through March 2016. An integrated critique of this literature also is offered. Limitations and the preliminary nature of the work in this area notwithstanding, it appears that it is feasible to supplement or integrate CBT with MI and that doing so has the potential to improve treatment initiation and engagement, as well as clinical outcomes. A number of directions for future research are addressed, such as determining which MI approaches to implement, with whom, when, and in what contexts.

Assessment and management of treatment-refractory obsessive-compulsive disorder in children

OBJECTIVE

To review the assessment and treatment of treatment-refractory pediatric obsessive-compulsive disorder (OCD).

METHOD

A PubMed search was conducted to identify controlled trials in pediatric OCD. In addition, practice guidelines for the treatment of adults and children were further reviewed for references in treatment-refractory OCD across the lifespan.

RESULTS

Pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT) were found to be effective treatments for pediatric OCD. Evidence suggests that CBT is also effective even in pediatric patients with refractory OCD symptoms. Antipsychotic augmentation, raising SSRI dosage, and several glutamate-modulating agents have some evidence of efficacy in adults with treatment-refractory OCD but have not been studied in pediatric populations.

CONCLUSION

Several pharmacological treatment options exist for children with refractory OCD symptoms. However, little evidence-based data exist to guide treatment for our most challenging pediatric OCD patients. Further research is needed to evaluate the efficacy/side effect profile of commonly used interventions in treatment-refractory pediatric OCD.

Extending motivational interviewing to the treatment of major mental health problems: current directions and evidence

Motivational interviewing (MI) was originally developed for the treatment of substance abuse but is rapidly expanding to other major mental health populations beyond addictions. This brief review considers the use of MI and related motivational enhancement therapies (METs) in the treatment of anxiety, depression, and eating disorders, and concurrent psychosis and substance use disorders. MI-MET has been added and (or) integrated into treatment for these problems in a wide variety of ways, most commonly as a pretreatment to other therapies (psychosocial treatments and pharmacotherapy) or integrated into standard assessment procedures. In each problem domain, the bulk of the current evidence supports the value of adding MI to existing therapies in increasing engagement with treatment and in improving clinical outcomes. This is particularly encouraging in that many of the populations included in these investigations represent severe and treatment-recalcitrant populations. However, research on the application of MI to other major mental health problems beyond addictions is in the early stages, with existing studies having numerous limitations (for example, small uncontrolled studies or lack of adequate control groups, and failure to establish both MI treatment integrity and the unique contribution of MI in integrated treatments). In short, the substantial body of promising preliminary findings strongly support the continued investigation of MI and related methods for these populations in well-designed clinical trials that examine not only the additive value of MI but also mechanisms underlying these effects and individual differences (moderators) indicating the need for MI.

Predictors of treatment outcome in modular cognitive therapy for obsessive-compulsive disorder

BACKGROUND

The present study sought to identify predictors of outcome for a comprehensive cognitive therapy (CT) developed for patients with obsessive-compulsive disorder (OCD).

METHODS

Treatment was delivered over 22 sessions and included standard CT methods, as well as specific strategies designed for subtypes of OCD including religious, sexual, and other obsessions. This study of 39 participants assigned to CT examined predictors of outcomes assessed on the Yale-Brown Obsessive Compulsive Scale. A variety of baseline symptom variables were examined as well as treatment expectancy and motivation.

RESULTS

Findings indicated that participants who perceived themselves as having more severe OCD at baseline remained in treatment but more severe symptoms were marginally associated with worse outcome for those who completed therapy. Depressed and anxious mood did not predict post-test outcome, but more Axis I comorbid diagnoses (mainly major depression and anxiety disorders), predicted more improvement, as did the presence of sexual (but not religious) OCD symptoms, and stronger motivation (but not expectancy). A small rebound in OCD symptoms at 1-year follow-up was significantly predicted by higher scores on personality traits, especially for schizotypal (but not obsessive-compulsive personality) traits.

CONCLUSIONS

Longer treatment may be needed for those with more severe symptoms at the outset. CT may have positive effects not only on OCD symptoms but also on comorbid depressive and anxious disorders and associated underlying core beliefs. Findings are discussed in light of study limitations and research on other predictors.

Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder

Exposure and response prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD). However, patients often do not adhere fully to EX/RP procedures. Motivational interviewing (MI) has been shown to improve treatment adherence in other disorders. This pilot study used a randomized controlled design to examine whether MI can be successfully added to EX/RP and whether this intervention (EX/RP+MI) could improve patient adherence to between-session EX/RP procedures relative to EX/RP alone. Thirty adults with OCD were randomized to 18 sessions of EX/RP or EX/RP+MI. Therapists rated patient adherence at each exposure session. Independent evaluators assessed change in OCD and depressive symptoms, and patients completed self-report measures of readiness for change and quality of life. The two treatment conditions differed in degree of congruence with MI but not in conduct of EX/RP procedures. Both groups experienced clinically significant improvement in OCD symptoms, without significant group differences in patient adherence. There are several possible reasons why EX/RP+MI had no effect on patient adherence compared to standard EX/RP, each of which has important implications for the design of future MI studies in OCD. We recommend that MI be further evaluated in OCD by exploring alternative modes of delivery and by focusing on patients less ready for change than the current sample.