Intensive vs. Self-Directed OCD Treatment |
Friday, 15 April 2011 13:23 |
TO STAY HERE, OR TAKE OUT?INTENSIVE VS. SELF-DIRECTEDOUTPATIENT TREATMENTBy 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:
The disadvantages of Therapist-Directed Intensive Treatment are:
The advantages of Self-Directed Treatment are:
The disadvantages of Self-Directed Treatment are:
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 |
Disclaimer
Please Note: Then information in this site is presented as a public service to our patients and friends. It is not a substitute for a careful evaluation by a qualified mental health professional. If you are already under treatment, do not make any changes in your regimen without consulting your doctor. |
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