TO STAY HERE, OR TAKE OUT?

INTENSIVE VS. SELF-DIRECTED

OUTPATIENT TREATMENT

 By Fred Penzel, Ph.D.

There are currently two major models for how outpatient behavioral therapy for OCD is conducted. The first model, and perhaps the better known of the two, is Intensive or Therapist-Directed Treatment, and is taken from the original treatment that was conducted when behavioral therapy for OCD first began. It involves daily treatments of about ninety minutes in length for a period of three to four weeks. A therapist is present throughout the exposure, and directs and guides the patient through exposure exercises. There is about 30 years worth of scientific literature on the efficacy of this approach, and it has been an accepted means of treatment throughout that time. I was originally trained in the use of this model, and practiced it faithfully for a period of about 8 years in just about every home, office, and public setting there is.

The other model is known as Self-Directed or Home-Based Treatment, and has actually been around longer than many people realize. It first evolved in Europe in the 1970's, possibly as a response to the needs of socialized healthcare, where resources for each patient were more limited, and costs had to be contained (sort of like here, these days). According to this approach, patients are seen on a once-per-week basis at a therapist's office, and are sent home with homework assignments to carry out on their own. Their progress is monitored at their sessions, they are debriefed on what they accomplished the previous week, and given feedback, and new assignments, where appropriate. Sessions are also used to build motivation, discuss other life issues, and to do some cognitive therapy as well.

There are studies that also attest to the efficacy of this approach. In 1977, Drs. Paul Emmelkamp & Joost Kraanen published the first study that demonstrated its effectiveness. 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) 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.

Over the last 12 years, I have become an advocate for the self-directed approach to treatment. In 1990, while doing a literature search for a talk I was putting together, I ran across the studies by Dr. Paul Emmelkamp and others, and this coincided with the opening of my own OCD clinic. I had been finding it frustrating that the insurance companies were beginning to balk at paying for daily exposure treatments, and I was also finding it frustrating that I could only work with a small number of patients perhaps about 10 to 12 per week at any given time, although there were very large numbers of people in my area seeking treatment and not being able to find it. Using the European model, I could reach over 50 people per week. Having worked according to this model for the last decade, and having the experience of treating close to 400 cases in this way, I feel that it has some particular advantages as compared to therapist-directed treatment. The following is an outline comparing the advantages and the disadvantages of the two approaches.

The advantages of Therapist-Directed Intensive Treatment are that:

• It can lead to rapid change and get you off to a running start
• It is useful for the most severe cases to be in an environment that can be temporarily totally controlled to prevent relapse or non-adherence to instructions a kind of brief, total immersion.
• It can help in cases where you really want to recover, but just feel too anxious, demoralized or helpless to bring yourself to follow instructions on your own.
• It can be practical if you do not have any appropriate sources of therapy near where you live, and have no option except to travel to where an intensive program is located, for briefer, more concentrated treatment.

The disadvantages of Therapist-Directed Intensive Treatment are:

•  It is over after a few weeks, possibly leaving you without support or help with maintenance and open to relapse if you went to a program far from home and do not live near a source of post-discharge follow-up or booster therapy sessions. I have seen this happen to a number of people. If you are getting this treatment locally, this is obviously not a problem.
• It is too disruptive if you have a job and family and cannot easily take a month off from everything. If you are doing this locally, this may be less of a problem.
• In many cases, the three to four weeks are not sufficient, especially where there are dozens of compulsions and numerous obsessions to be dealt with. Insurance companies are not usually supportive of long courses of intensive treatment (if at all). 
• It rapidly uses up insurance coverage if you have yearly or lifetime limits, leaving you uncovered after discharge or even sometimes without enough time to carry out the full treatment.
• If conducted far from home, it can leave you unprepared to face symptoms that occur in your own real world environment, since the treatment is conducted in a safer, more controlled setting where many feared things from home cannot be brought or reproduced for exposure therapy purposes.
• The ever-present supervision may keep you from developing the feelings of self-efficacy and
• It may allow patients to avoid confronting the full range of the anxiety and feelings of responsibility and guilt that accompany their symptoms. It is easy to simply tell yourself that if anything bad does happen, it is the therapist's fault, and not yours, because they made you do whatever it was.
• If you have no insurance coverage, it is extremely expensive, requiring large sums to be paid in a short period of time (sometimes in advance) that may be out of the reach of many ordinary people.
• The three-or four-week time limit of many programs can put unnecessary pressure and stress on you, and may make you feel that you are a failure if you cannot recover sufficiently by the end of the set time period.
• Conversely, the time limit can also create unrealistic expectations on your part, or your friends and family members who believe that recovery will be complete by the end of your intensive treatment, when often it is not.

 The advantages of Self-Directed Treatment are:

•  It allows you to be treated in your own home setting, a place where symptoms have originated, and where the work of therapy really needs to take place, assuming help is nearby.
• Doing assignments on your own at home is a lot closer to what post-therapy self-maintenance will be like, and this teaches you how to be your own therapist and develop your own resources.
• It boosts personal feelings of effectiveness and self-control by allowing you to take your assignments home and be responsible for doing them without supervision. It is clearly much better for you to be able to say that you did an assignment because you made yourself do it, rather than because a psychologist or other staff person was standing over you. I believe that 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. Along with behavioral change, it is vital that each sufferer be helped to develop the feeling that they are personally responsible for the management of their illness.
• It forces you to confront your own anxiety and feelings of hyperresponsibility, as you are not now in a position to blame anyone for making you do the homework. The therapist may have assigned it, but you had to make yourself do it.
• If you are submitting your therapy visits to a health insurance plan, they are more likely to pay for treatment. It is what they are familiar with, and they won't fight about it.
• Costs are spread over a much longer period which is somewhat easier if you are paying out of pocket.
• It allows sufficient time for those who have numerous compulsions and obsessions to have their symptoms treated in-depth and more completely when visits are spread over a longer time span. It allows more time for a greater variety of assignments to be carried out.
• It allows more between-visit time for assignments to be done a greater number of times, and for the development of greater tolerance of feared situations to occur.
• The lack of an exact short term time limit discourages you from perfectionistically pressuring yourself about recovering by a particular date, and also helps family and friends to be more patients and realistic about seeing the therapy as a process and not an event.
• It allows those who work outside the home or those who raise children to keep up their responsibilities while working on recovery, sparing the family added unnecessary stress and even further expense.
• It permits the therapist to observe and become acquainted without you, your world, and your symptoms over a longer period of time, allowing him or her to spot other problems that also need to be confronted in therapy, which could have a negative impact on your recovery if not treated. Some symptoms can be quite subtle, and may not be apparent at first.
• It allows more time for teaching maintenance and relapse prevention skills that will keep you well long after therapy has finished.
• There is sufficient time for spouses and other family members to attend sessions to be educated about the disorder, and to be given a role in treatment when necessary.

The disadvantages of Self-Directed Treatment are:

• It may not be suitable for the most seriously ill, who need constant supervision and structure in order to follow instructions.
• You may not have anyone nearby to see for outpatient therapy, making a visit to an intensive treatment program away from home necessary (although follow-up will still be a problem).

There are a fair number of therapists who routinely offer intensive daily treatment on an outpatient basis to every patient who comes their way. This seems to me to be impractical. Many individuals are functioning well enough to come to an office and take home assignments in the first place, and don't need to come for treatment five days per week. There would seem to be no allowance made for different levels of severity. Also, if a patient is so ill that they really need daily supervision in order to succeed, then they probably would be better off in an inpatient setting getting intensive treatment. One could make a valid case that intensive outpatient treatment is a less costly way for the seriously ill (who can make it to an office) to be treated. There is really no argument about this. Daily ninety-minute sessions are still very expensive, but certainly less so than inpatient treatment. The one exception to all of this is that insurance will sometimes cover inpatient treatment, but it will not always cover intensive outpatient treatment.

In my own practice, I routinely use self-directed treatment, and that seems to suit the needs of the majority of patients. I will see them at most two times per week (although even this is not usually necessary). When I do get patients whose symptoms are too severe for them to benefit from this approach, I refer them to more intensive inpatient programs.

Obviously, you may have to work with whatever is available locally; however, I am trying to make a case for adjusting the level of treatment to the needs of the patient, and against simply putting people into one-size-fits-all canned programs. I believe that by doing this, more OCD sufferers could be helped with the resources we currently have, and at lower cost.

If you would like to read more about what Dr. Penzel has to say about OCD, 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 learn more about it at www.ocdbook.com