Back in 1990, not long after I had started the Western Suffolk Psychological Services treatment group, I found myself facing a dilemma. We found ourselves with more patients than we could treat. This was a desirable situation for a practitioner, but a very undesirable situation for sufferers. We were using the traditional intensive outpatient 5-day-per-week model at that time, seeing patients for daily 90-minute treatment sessions supervised by a therapist. A full-time therapist could only have a caseload of perhaps six patients at a given time. Given that one-in-forty people is afflicted with OCD, this clearly left many sufferers in our immediate area out in the cold. Turning away these people plainly seemed wrong. In addition, there had always been things I disliked about intensive treatment.
Since an intensive program lasted three to four weeks, it was too disruptive if a patient had a job and family and could not easily time off from everything. In many cases, the three to four weeks were not sufficient, especially where there were dozens of compulsions and numerous obsessions. Also, insurance companies were not usually supportive of long courses of intensive treatment (if at all). It rapidly used up insurance coverage if there were yearly limits, and if a patient had no insurance coverage, it was extremely expensive, requiring large sums to be paid in a short period of time, putting it out of the reach of many people.
Another thing I disliked about intensive treatment was that the constant supervision could inhibit the development the feelings of self-efficacy and control that come with doing things on your own. Knowing that a therapist was constantly watching as patients did anxiety-provoking things could be reassuring in a way that slowed a patient's improvement. Patients could say to themselves, "There's nothing to worry about, because the therapist has to be responsible, and wouldn't really ask me to do an assignment that would harm me or someone else." Thinking this way, patients didn't feel as much anxiety, weren't really confronting their fears, and therefore weren't getting the full benefits of therapy.
It also seemed to me that the three-or four-week time limit of intensive programs sometimes put pressure and stress on patients, and could make them feel that they were a failure if they could not fully recover by the end of the time period. Conversely, the time limit could also create unrealistic expectations on the patient's part, or on the part of their family members, who believed that recovery would be complete by the end of the intensive treatment period, when often it was not. I was certain there had to be a better way to treat OCD sufferers. A solution soon appeared in the form of several intriguing behavioral treatment studies I found when seeking other treatment models. In 1977, Drs. Paul Emmelkamp & Joost Kraanen (in Holland) published the first study that demonstrated the effectiveness of Self-directed Treatment (SDT). In this study, no difference was found between self-directed exposure and therapist-controlled exposure, and in fact, self-directed exposure was consistently superior to the therapist-controlled exposure at a one-month follow-up. In another study by Emmelkamp & De Lange (1983), self-directed exposure was tested against spouse-aided exposure, and both were found to be equally effective. Dr. Isaac Marks and others (1988) in England showed that self-directed exposure was as effective as therapist-controlled exposure, despite the fact that the therapist-directed treatment group received 5 times more treatment. Finally, in 1989, Dr. Paul Emmelkamp and colleagues showed again that self-directed exposure was as effective as therapist-controlled exposure.
In SDT, as we began to practice it, patients came to the office on a once-per-week basis for a 45-minute session. Their progress and what they had experienced the previous week was monitored at their sessions, and they were given feedback and new assignments where appropriate. Sessions were also used to build motivation, meet with family, discuss other life issues, and to do cognitive therapy.
I could quickly see that there were several clear advantages to SDT. To begin with, if patients depended upon an insurance plan, they were more likely to be reimbursed for treatment. Also, costs were spread over a much longer period easier if patients were paying out of pocket. On a more technical level, it allowed sufficient time for those who had numerous symptoms to have their symptoms treated in-depth and more completely when visits were spread over a longer period. It allowed more time for a greater variety of assignments to be carried out, and to be done a greater number of times, leading to the development of greater tolerance of feared situations. It permitted the therapist to become better acquainted with a patient, their world, and their symptoms over a longer period of time, and allowed the detection of other significant problems that also needed to be confronted in therapy. Some symptoms can be quite subtle, and may not be apparent at first. Further, there was more time for teaching maintenance and relapse prevention skills that kept patients well long after therapy had finished. There was also sufficient time for significant others to attend sessions to be educated about the disorder, and to be given more of a role in treatment when necessary. Finally, I found that the lack of an exact time limit discouraged patients from pressuring themselves about recovering by a particular date, and also helped family and friends to be more patient and realistic about seeing the therapy as a process and not an event. It allowed those who worked outside the home or who raised children time to fulfill their responsibilities while working on recovery, sparing the family added stress and further expense.
Another advantage of SDT was that it had patients doing assignments on their own at home which was a lot closer to real life, and more like what things would be like after treatment. This, I believe is crucial, as it instills a sense of personal responsibility, teaches patients how to be their own therapists, and to develop their own resources. Becoming your own therapist is, after all, the chief goal of treatment. In line with this, SDT boosted personal feelings of effectiveness and self-control by allowing patients to be responsible for doing assignments without supervision. It was clearly much better for them to be able to say that they did an assignment on their own, rather than due to a therapist supervising them. I believe that ultimately everyone has to essentially face their OCD themselves (with the exception of the most seriously ill) if they are to make the best recovery. No one can do your work for you. It is crucial that each sufferer be helped to develop the feeling that they are personally responsible for the management of their illness. In working on their own, SDT put patients in a position to confront their own anxiety and hyperresponsibility, as they could not now blame anyone for making them do their homework. The therapist may have assigned it, but they had to make themselves do it.
Convinced that this was what we had been looking for, we began by implementing the approach with our incoming patients. We found, was that in line with the European studies, our patients did every bit as well or better than those treated with the intensive approach. We could also deliver services to many more members of the OCD community, as a full-time therapist could see six times as many patients as before.
Having worked according to this model for the last two decades, and having the experience of personally treating over 1000 cases in this way, I feel that it was clearly the right decision. Some claim that Intensive treatment works faster, but when you figure in all the follow-up sessions that are required, it really isn't. The only clear disadvantage I have discovered for SDT is that it may not be suitable for the most seriously ill, who need constant supervision and structure in order to follow instructions. When I do get patients whose symptoms are too severe for them to benefit from SDT, I refer them, without hesitation, to intensive inpatient programs.
I would take issue with therapists who despite available evidence, still routinely offer intensive daily outpatient treatment to every patient. This is impractical. Many individuals are functioning well enough to come to an office and take home assignments and don't need to come for treatment five days per week. They seem to make no allowance for different levels of severity. Obviously, you may have to work with whatever is available locally; however, I advocate for adjusting the level of treatment to the needs of the patient, and against simply putting people into one-size-fits-all programs. I believe that by doing this, many more OCD sufferers can be helped with the resources we currently have, and at lower cost.
If you would like to hear more of what Dr. Fred Penzel has to say about OCD, you can take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can find out more about it at www.ocdbook.com .