The Evidence Base For Behaviour Therapy

The French neurologist Pierre Janet described exposure therapy for obsessions and compulsions more than a century ago. At the beginning of the twentieth century psychoanalytic theory proposed that obsessions and compulsions were the result of unconscious conflicts. However treatment using this principle was ineffective and until the late 1960s OCD was widely considered to be untreatable. Case reports demonstrated that OCD symptoms could be reduced by a combination of exposure and response prevention (Meyer, 1966). The treatment required the client to be exposed to the fear producing stimulus and to be prevented from carrying out the fear-reducing rituals. The first controlled studies of exposure for the treatment of OCD (Marks, Rachman, & Hodgson, 1975; Rachman, Marks, & Hodgson, 1971) would not be accepted as methodologically sound by today's standards. However they were an important part of the process of generating an evidence base.

Behaviour therapy has been shown to reduce symptoms compared with relaxation (Abramowitz, 1997) and anxiety management training (Lindsay, Crino & Andrews, 1997). Foa & Kozak (1996) reviewed 12 outcome studies and found 83 % of patients who completed exposure and response prevention treatment were post-treatment responders. Stanley & Turner (1995) concluded that about 75 % of OCD patients show substantial improvement after 12 to 15 sessions of behaviour therapy. O'Sullivan & Marks (1991) reviewed nine follow-up studies of OCD exposure and response prevention treatment completers. The follow-up duration was between one and six years with a mean follow up of three years. Seventy-nine per cent of patients had improved or were much improved and symptom improvement was maintained irrespective of the length of follow up. However, these results are for treatment completers. About 25 % of OCD patients offered ERP refuse it (Kozak, 1999) and others drop out or do not improve with ERP. Hiss, Foa & Kozak (1994) found using specific OCD relapse prevention techniques was effective in promoting gains at follow up.

Clinical trials often measure efficacy in particular sub-groups of the general OCD population, for example in-patients or patients with no co-morbid psychiatric diagnoses, but this cannot be directly extrapolated to typical clinical practice. Franklin et al. (2000) addressed this issue and found comparable outcome in 110 routine clinical patients receiving exposure and response prevention with the outcome reported in randomised controlled trials (RCTs). Abramowitz (1998) conducted a meta-analysis to investigate the clinical significance of treatment gains following exposure therapy in OCD. This showed that after treatment the average patient's functioning was more similar to that of the general population than to individuals with untreated OCD. However the patients were not 'cured' by treatment as they did remain more symptomatic than members of the general population.

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