Metacognitive therapy for obsessive–compulsive disorder: A pilot study

Highlights

• MCT produced significant reductions in both OCD-symptoms and comorbid depressive symptoms.

• MCT resulted in high proportions of clinically significant change on the Y-BOCS.

• Recovery rates appeared at least comparable to those reported for ERP.

Abstract

The first-line psychological treatment for OCD, exposure and response prevention (ERP), has been shown to lead to statistically significant improvements in 75% of patients. However, as only about 60% of treatment completers achieve recovery, and 25% of patients are asymptomatic following treatment, there is room for improvement. One promising approach is metacognitive therapy, which targets metacognition, a key cognitive process involved in the development and maintenance of OCD. This open trial examined the effectiveness of MCT among 25 consecutively referred outpatients with OCD. At posttreatment and follow-up, MCT produced significant and large reductions across all outcome variables, with high proportions of clinically significant change (patients recovered at posttreatment, 74%; at follow-up, 80%) on the Y-BOCS. In addition, the majority of patients (63% and 80% respectively) no longer fulfilled the diagnostic criteria for OCD. The encouraging results from this open trial justify a controlled trial in which the effectiveness of MCT is evaluated against ERP.

Introduction

Obsessive–compulsive disorder (OCD) is characterized by recurrent obsessions and/or compulsions that cause marked distress and interfere with daily functioning (APA, 2013). In the absence of treatment the course of OCD can be chronic. Until the 1960s, this relatively common condition was considered unresponsive to psychological treatments. However, with the introduction of exposure and response prevention (ERP) the prognosis for OCD improved substantially (Meyer, 1966). The procedure is based on learning theory, which suggests that classical conditioning is responsible for the development of obsessions, whereas operant conditioning processes maintain anxiety and compulsive behaviors (Fisher & Wells, 2005). As a consequence, ERP consists of (a) exposure to anxiety provoking stimuli and (b) prevention of compulsive responses that reduce anxiety.

Widely regarded as first-line psychological treatment for OCD (Olatunji et al., 2010, Öst et al., 2015), several studies and meta-analyses have shown ERP to lead to statistically significant improvements in 75% of patients, only about 60% of treatment completers achieve recovery, whereas only approximately 25% of patients are asymptomatic following treatment (Fisher & Wells, 2005). As only treatment completers were included in these analysis, and approximately 30% of patients refuse ERP or dropout from treatment, overall recovery rates may be lower (Clark, 2004). Furthermore, there appears to be a clear dose-effect relationship for ERP, i.e., the greater the number of treatment hours, the greater the percentage of recovered and asymptomatic patients (Fisher & Wells, 2005). As such, optimal ERP requires considerable amounts of therapist time, with typically 15–20 treatment sessions of 90 min (Foa & Kozak, 1996). These data show that there is room for improvement in both the effectiveness and cost-effectiveness of OCD-treatment. It has been suggested that progress might be made by basing treatments on key cognitive processes involved in the development and maintenance of the disorder (Frost & Steketee, 2002), such as metacognition (Purdon and Clark, 1999, Wells, 1997).

Metacognition refers to knowledge or beliefs about thinking and strategies used to regulate and control thinking processes (Flavell, 1979). The metacognitive model of OCD specifies two subcategories of belief that are fundamental to the maintenance of the disorder; (a) metacognitive beliefs about the meaning and consequences of intrusive thoughts and feelings, containing themes of thought action fusion (TAF), thought event fusion (TEF), and thought object fusion (TOF), and (b) beliefs about the necessity of performing rituals in response to obsessions. Resulting from the metacognitive model, treatment focuses on modifying patients’ beliefs about the importance and power of thoughts and rituals using verbal reattribution and behavioral experiments, with the aim to alter the patients’ relationship with their thoughts as opposed to challenging the actual content of intrusive thoughts (Fisher & Wells, 2008).

To date, two studies have provided support for the efficacy of MCT for OCD. Using single case methodology in four consecutively referred patients with OCD, Fisher and Wells (2008) found clinically significant improvements for all patients treated individually with MCT, whereas Rees and van Koesveld (2008) found that all eight participants in an open trial of group metacognitive therapy for OCD demonstrated improvements on all outcome measures, with even recovery achieved for seven of the eight patients on the Y-BOCS. Together, these findings suggest that MCT might be an efficacious treatment for OCD. However, it should be acknowledged that the evidence is only preliminary given the small sample sizes in both studies and the lack of control groups. Given the promising potential for the treatment of OCD, the present study was conducted to further evaluate the efficacy of MCT in a larger sample of clinically referred patients with OCD. It was hypothesized that MCT would result in significant and large reductions in both symptoms of OCD and comorbid depression, and in metacognitive beliefs about intrusive thoughts. If effective, the next step would be to conduct a large study comparing MCT with ERP, the current treatment of choice for OCD, in an outpatient clinical sample of patients with OCD.