Cognitive Versus Behavior Therapy in the Group Treatment of Obsessive—Compulsive Disorder Peter D. McLean Department of Psychiatry University of British Columbia Maureen L. Whittal Department of Psychiatry University of British Columbia Dana S. Thordarson Department of Psychology University of British Columbia Steven Taylor Department of Psychiatry University of British Columbia Ingrid Söchting Department of Psychology University of British Columbia Hospital William J. Koch Department of Psychology University of British Columbia Hospital Randy Paterson Department of Psychology University of British Columbia Hospital Kent W. Anderson Department of Psychology University of British Columbia Hospital ABSTRACT This study examined the effects of cognitive—behavior therapy (CBT) compared with traditional behavior therapy (exposure and response prevention [ERP]) in the group treatment of obsessive—compulsive disorder. Of the 76 participants who started treatment, 38 were wait-listed for 3 months before treatment to assess possible course effects. Both treatments were superior to the control condition in symptom reduction, with ERP being marginally more effective than CBT by end of treatment and again at 3-month follow-up. In terms of clinically significant improvement, treatment groups were equivalent on the conclusion of treatment, but 3 months later significantly more ERP participants met criteria for recovered status. Only 1 of 7 belief measures changed with treatment improvement, and the extent of this cognitive change was similar between CBT and ERP groups. Discussion includes consideration of optimal formats for the delivery of different types of treatment. Historically considered resistant to psychological interventions, obsessive—compulsive disorder (OCD) is a common mental disorder that often causes considerable distress and functional impairment. Meyer (1966) was the first to report OCD treatment success using exposure and response prevention. Subsequent researchers' experimental work clarified the nature of OCD (e.g., Foa & Kozak, 1986 ; Rachman & Hodgson, 1980 ) and gave further direction to a succession of controlled clinical trials (see Steketee, 1993 , for review) that used behavioral therapy. These trials returned encouraging results and established exposure and response prevention (ERP) as the psychological treatment of choice for OCD. Van Balkom et al. (1994) reported an average effect size for behavior therapy of 1.46, which was significantly more therapeutic than placebo conditions in both self- and assessor-rated measures. Despite immediate results in the range of a 70% average decline in symptoms for those who completed this form of behavioral therapy ( Foa, Steketee, & Ozarow, 1985 ), a minority of participants did not improve with treatment and others declined treatment or dropped out, largely because of the requirements of treatment Journal of Consulting and Clinical Psychology © 2001 by the American Psychological Association April 2001 Vol. 69, No. 2, 205-214 For personal use only--not for distribution. Page 1 of 169/5/2001http://spider.apa.org/ftdocs/ccp/2001/april/ccp692205.html(i.e., exposure and ritual prevention). Considering treatment refusers, dropouts, and those who do not benefit immediately from treatment or who subsequently relapse, researchers have estimated the proportion of OCD participants who can be considered successfully treated by behavioral therapy through to long-term follow-up to drop to about 55% ( Stanley & Turner, 1995 ). In addition, behavioral therapy has proved to be relatively ineffectual in treating obsessions with covert compulsions ( Rachman, 1997 ). A number of cognitive theorists have proposed that OCD can be conceptualized and treated cognitively. Specifically, because intrusive and distressing thoughts, along with associated beliefs and assumptions, play such a prominent role in the manifestation of OCD, it is felt that targeting dysfunctional cognitions will provide a more comprehensive treatment than ERP. Salkovskis (1985 , 1998) detailed a cognitive theory of OCD proposing that intrusive thoughts, images, or impulses are misinterpreted in characteristic ways that foster attempts to suppress the intrusive thoughts and the urge to neutralize the distressing effects of the thoughts through cognitive or behavioral compulsions. Central in Salkovskis's cognitive model is the faulty appraisal that promotes the notion of exaggerated personal responsibility for events that will bring harm to oneself or, more typically, to others. Faulty appraisals are thought to derive from maladaptive assumptions learned over the life course. Other researchers in the field have identified appraisals that may be distinct from inflated responsibility. For example, Rachman (1997) and Freeston, Rheaume, and Ladouceur (1996) have elucidated faulty appraisals characteristic of obsessions with covert compulsions, and the international Obsessive Compulsive Cognitions Working Group (1997) has identified a limited list of faulty appraisals for field testing in the development of a cognitive-assessment measure. By addressing the appraisals and beliefs associated with OCD, therapists suggest it is possible that clinical outcomes will improve, as such beliefs are directly engaged in treatment. OCD sufferers who refuse or drop out of ERP treatments may also find cognitive treatments more acceptable, thus also enhancing clinical outcomes. Several controlled trials have been conducted that compared various forms of cognitive therapy and ERP interventions, alone or in combination ( Emmelkamp & Beens, 1991 ; Emmelkamp, van der Helm, van Zanten, & Plochg, 1980 ; Emmelkamp, Visser, & Hoekstra, 1988 ; Freeston et al., 1997 ; van Oppen et al., 1995 ). Generally, these behavioral and cognitive treatments for OCD have been found to be comparable in efficacy, but various design limitations restrict conclusions. Most of these studies had small sample sizes, and all but two ( Freeston et al., 1997 ; van Oppen et al., 1995 ) used early cognitive treatments that did not address the faulty appraisals thought to be particularly relevant to OCD. Although Freeston et al.'s (1997) study was the only one to use comprehensive cognitive measures to assess OCD-related beliefs, it did not include a behavioral comparison group and was restricted to participants with covert rituals. The studies delivered treatment on an individual basis. Recently, Himle (2000)
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