Exposure and response prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD). However, patients often do not adhere fully to EX/RP procedures. Motivational interviewing (MI) has been shown to improve treatment adherence in other disorders. This pilot study used a randomized controlled design to examine whether MI can be successfully added to EX/RP and whether this intervention (EX/RP + MI) could improve patient adherence to between-session EX/RP procedures relative to EX/RP alone. Thirty adults with OCD were randomized to 18 sessions of EX/RP or EX/RP + MI. Therapists rated patient adherence at each exposure session. Independent evaluators assessed change in OCD and depressive symptoms, and patients completed self-report measures of readiness for change and quality of life. The two treatment conditions differed in degree of congruence with MI but not in conduct of EX/RP procedures. Both groups experienced clinically significant improvement in OCD symptoms, without significant group differences in patient adherence. There are several possible reasons why EX/RP + MI had no effect on patient adherence compared to standard EX/RP, each of which has important implications for the design of future MI studies in OCD. We recommend that MI be further evaluated in OCD by exploring alternative modes of delivery and by focusing on patients less ready for change than the current sample.
Cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP) is a first-line treatment for obsessive-compulsive disorder (OCD), either as monotherapy or combined with pharmacotherapy (American Psychiatric Association, 2007). EX/RP requires patients to confront feared situations (exposures) and to stop ritualizing (response prevention; Kozak & Foa, 1997). When patients adhere to these procedures, EX/RP is highly efficacious (Foa et al., 2005), yet patients often fail to adhere by dropping out of treatment or by not fully implementing the procedures as recommended (Abramowitz et al., 2002, Foa et al., 1983 and Simpson et al., 2006). Reducing dropout and improving patient adherence to EX/RP procedures could potentially improve treatment outcomes substantially.
One conceptualization of why OCD patients enter but then dropout or adhere poorly to EX/RP procedures is that they are “ambivalent” or caught between mutually exclusive courses of action. Specifically, although patients may wish to improve their lives by reducing the time spent obsessing and ritualizing (leading them to seek EX/RP treatment), they may also be unwilling or unable to adhere to the EX/RP procedures designed to achieve that goal (e.g., because they find exposures too aversive or perceive some benefit to their rituals). Motivational interviewing (MI) is a client-centered, goal-oriented method designed to enhance motivation to change by helping patients explore and resolve such ambivalence (Miller, 2006 and Miller and Rollnick, 2002). In MI, the therapist expresses empathy by evoking and reflecting patients’ perceptions of their situation and the advantages and disadvantages of change. Therapists enhance motivation by eliciting and strengthening patients’ articulation of their desire, ability, reasons, need, and ultimately commitment to change and treatment (“change talk”). To accomplish this, therapists develop discrepancy between patients’ current behavior and important values and goals and support self-efficacy by exploring and affirming efforts and abilities to overcome obstacles. Emphasizing collaboration, supporting patient autonomy, and avoiding confrontation and directives, therapists roll with resistance when it arises. The goal is to help patients talk themselves into change.
Used as a prelude or integrated with other treatments, MI has reduced dropout and enhanced treatment adherence in substance use, health behavior, and mental health contexts (Hettema et al., 2005 and Zweben and Zuckoff, 2002). For example, Westra, Arkowitz, and Dozois (2009) provided MI as a prelude to group CBT in patients with generalized anxiety disorder and found that these patients had better homework adherence and treatment outcome than those receiving CBT alone. Lewis-Fernandez and colleagues (in review) integrated MI into medication management for depressed Hispanics and found significantly improved retention and outcome compared to historical controls.
We wondered whether MI could improve EX/RP adherence. Thus, we created an EX/RP + MI intervention that included explicit MI strategies in the introductory sessions to enhance motivation for treatment and an MI module for use during exposure sessions if resistance to treatment emerged. Delivering this intervention to six patients in an open trial (Simpson, Zuckoff, Page, Franklin, & Foa, 2008), we found it yielded comparable outcomes to standard EX/RP. However, this study did not address whether EX/RP + MI differs in its dose of MI or improves patient adherence relative to EX/RP alone. These are key questions since there can be overlap between MI and CBT approaches (Wilson & Schlam, 2004). At the same time, adding MI to a structured, expert-driven treatment like EX/RP might dilute the integrity of MI.
Consistent with recommended stages of psychosocial treatment development (Carroll & Onken, 2005), we conducted a small randomized controlled trial to directly compare EX/RP and EX/RP + MI in adults with OCD. Our aims were to evaluate whether EX/RP + MI was more congruent with MI than standard EX/RP and to determine whether EX/RP + MI led to better patient adherence. To assess MI fidelity, we used the Motivational Interviewing Treatment Integrity scale, a measure widely used in MI clinical trials. To assess patient adherence to EX/RP procedures, we used the Patient EX/RP Adherence Scale (Simpson et al., 2010). We hypothesized: 1) EX/RP + MI would be more congruent with MI than standard EX/RP during treatment segments designed to emphasize MI elements; and 2) EX/RP + MI would lead to better patient adherence to between-session EX/RP procedures. We also explored the effects of the two treatments on OCD outcome, knowing a priori that the small sample had adequate power to detect only large effects.
