Group Versus Individual Treatment in Obsessions without Compulsions

Transcription

1 Clinical Psychology and Psychotherapy Clin. Psychol. Psychother. 12, (2005) Group Versus Individual Treatment in Obsessions without Compulsions K. O Connor, 1 * M. H. Freeston, 2 D. Gareau, 1 Y. Careau, 1 M. J. Dufour, 1 F. Aardema 1 and C. Todorov 3 1 Centre de recherche Fernand-Seguin, Montreal, Canada 2 University of Newcastle, UK 3 Louis-H. Lafontaine Hospital, Montreal, Canada The principal goal of the current study was to compare the efficacy of two treatment formats, group and individual, of an empirically proven manualized cognitive behavioural treatment (CBT) package, for obsessions without overt compulsions. It was hypothesized that individualized treatment would be more effective both in terms of post-treatment group mean improvement and end state functioning. A secondary goal was to assess the relationship between cognitive and behavioural change during treatment and link it to symptom change. Both group and individual CBT format produced a significant clinical change, but as expected individual treatment produced the greater change in symptoms and in obsessional belief. Also, the individual format showed a clear superiority over the group format in the reduction of anxiety and depression. Severity of OCD symptoms showed little relationship with strength of obsessional beliefs at the start of treatment, but change in beliefs was strongly correlated with behavioural improvement post-treatment. The results of the study suggest that the impact of a group format may lie in the value of shared social support and motivational effect of peer feedback, but at the expense of individualized targets. Copyright 2005 John Wiley & Sons, Ltd. INTRODUCTION Cognitive behavioral treatment (CBT), based largely on exposure and response prevention (ERP), has become established as the treatment of choice for OCD, either alone or, especially in more severe cases, in combination with psychopharmacological treatment (March, Frances, Carpenter, & Kahn, 1997). Meta-analyses on studies investigating exposure and response prevention treatments find large effect sizes that show 75 85% of patients * Correspondence to: Kieron O Connor, Ph.D., M.Phil., Centre de recherche Fernand-Seguin, 7331 Hochelapa Street, Montreal, QC H1N 3V2, Canada. kieron.oconnor@crfs.umontreal.ca improve (Steketee & Shapiro, 1993; Hiss, Foa, & Kozak, 1994). However, there remain a number of unresolved issues. First, CBT for OCD is typically among the longest and the most costly of all the anxiety disorders (Turner, Beidel, Spaulding, & Brown, 1995). Second, adequate treatment is not widely available because only a limited number of professionals can deliver the treatment, particularly to the sizable subgroup of patients who do not show overt compulsive rituals and do not present common symptoms such as washing or checking. Third, a large number of patients refuse, or drop out during, treatment, largely due to the key role of exposure in current treatments. Fourth, although treatment gains are impressive for a significant proportions of patients, some benefit less and remain symptomatic; others do not maintain initial Copyright 2005 John Wiley & Sons, Ltd. Published online in Wiley InterScience ( DOI: /cpp.439

2 88 K. O Connor et al. gains (Steketee, 1993). In conclusion, despite a consensus that effective treatment does exist, there is still a great deal to be done to make available treatment more effective and available. Obsessions without associated overt compulsions represent one of the largest subgroups in OCD. A review found that 62% of multipatient treatment studies, on which the claims of OCD treatment efficacy are based, did not include any patients with obsessions only (Ball, Baer, & Otto, 1996). Obsessive thoughts have been, and are still generally considered, refractory to both pharmacological and psychological treatments. A cognitive behavioural account of OCD (Salkovskis, 1985) proposed that unwanted intrusive thoughts, a universal experience, are appraised as having particular negative implications for some predisposed individuals. When they are so appraised the person engages in a series of strategies to neutralize the thought and decrease discomfort and the subjective sense of responsibility. This model led to outlines for treatment strategies (e.g. Salkovskis, 1985; Salkovskis & Westbrook, 1989). Work at Université Laval (e.g. Ladouceur, Freeston, Gagnon, Thibodeau, & Dumont, 1993) led to a manualized treatment for obsessions without overt compulsions. In an initial study by the Laval group using a multiple baseline design across subjects the CBT intervention (cognitive restructuring and ERP) for obsessive thoughts was found to result in a decrease in discomfort provoked by the obsessive thoughts and improved professional and interpersonal functioning in all three participants (Ladouceur, Freeston, Gagnon, Thibodeau, & Dumont, 1995). In a further study using a single case design treatment consisting solely of cognitive therapy, five out of six patients showed a significant improvement in Y- BOCS scores before and after treatment (Freeston, Léger, & Ladouceur, 2001). The first random trial investigating CBT for obsessional thoughts compared a CBT intervention (cognitive restructuring and ERP) with a wait-list control group (Freeston et al., 1997). Patients in the active CBT condition showed significantly greater improvement compared with the wait-list control group on measures of obsessive compulsive symptoms, interference, and anxiety. The majority of those who completed treatment showed clinically significant change on the Y-BOCS. These gains were maintained at 6 month follow-up. This study showed convincingly that psychological treatment of this obsessional subgroup is feasible. However, treatment was long (40 hours including assessment), although this is typical of current practice in OCD in general in North America (Turner et al., 1995). Longer treatment decreases treatment availability. Experience with the treatment package developed for obsessive thoughts both in single case studies and in standard clinical practice indicates that the treatment may be shortened. Treating mental disorders in a cost-effective way is a top priority in the context of increasing demand and decreasing resources for health-care services. One way of improving the cost-efficiency and availability of treatment is by offering therapy in a group format, allowing more cost-effective use of the therapist time and availability (see Teasdale, Walsh, Lancashire, & Mathews, 1977). Well established treatments have been adapted to the group treatment for panic disorder (e.g. Nagy, Krystal, Chraney, & Merikangas, 1993), agoraphobia (e.g. Mackay & Lidell, 1986) and specific phobia (e.g. Jerremalm, Jansson, & Ost, 1986). Therapeutic factors unique to group therapy such as vicarious learning, interpersonal learning, and group cohesiveness are advantages for many patients (Kobak, Rock, & Greist, 1995). The group format also helps normalize the experience of OCD and improve patient morale, and can lead to better compliance (Fals-Stewart & Lucente, 1994). Normalizing the experience is particularly important for OCD without overt compulsions, because the dominant symptoms are often ego-dystonic and particularly upsetting, such as thoughts about harming loved ones, personally unacceptable sexual thoughts, blasphemous thoughts, etc. Several uncontrolled studies involving exposure and response prevention (ERP) have shown group treatment to be effective in reducing OCD symptoms (Bouvard, Milliery, & Cottraux, 2002; Enright, 1991; Espie, 1986; Krone, Himle, & Nesse, 1991; Himle, Rassi, Haghighatgou, Krone, Nesse, & Abelson; 2001; Stengler-Wenzke & Angermeyer, 2002; Thieneman, Martin, Cregger, Thompson, & Dyer-Friedman, 2001; Van Noppen, Steketee, McCorkle, & Pato, 1997). A controlled trial by Fals- Stewart, Marks, and Schafer (1994) detected no differences between individual and group treatment both post-treatment and at 6 month follow-up, although individual therapy showed a faster reduction in symptoms in the course of treatment. The above studies often showed modest, but significant, improvement with group therapy. Although the results of group treatment are generally promising, it is not clear whether patients treated in this format obtained the degree of improvement that is possible with individual CBT.

3 Treatment of Obsessions without Compulsions 89 Post-test scores remained quite high on standardized measures; and many patients completing these trials would still meet entry criteria for pharmacological trials. The efficacy of CBT has been compared with traditional behaviour therapy (ERP) in the group treatment of OCD in two studies (Whittal, McClean, Taylor, Sochting, & Anderson, 1997; McLean et al., 2001). In the first study inferior results were obtained for CBT compared with ERP. The second study showed clinically significant difference between treatment groups post-treatment, but at 3 month follow-up more participants from the ERP group showed recovered status. The authors state that the modest gains were probably due to difficulty in adapting the cognitive techniques to a group format setting because of the diversity of symptoms in OCD. Thus there is a need for additional application of the efficacy of group treatment in general, and there is yet no test of the efficacy of group treatment when overt compulsions are absent. Group treatment may ultimately prove to show less efficacy than individual therapy in absolute terms, but be more cost effective when therapist input is considered. Given the relatively low availability of expert psychological treatment for CBT due to high cost and few therapists, the cost-effectiveness and increased access to therapy that group treatment can offer may be a more important consideration. The current study aims to contribute to the improvement of cognitive behavioural treatment of OCD. It compares two treatment formats of an empirically proven manualized treatment package. The trial contrasts group treatment modality with an individual treatment. The first goal was to compare the efficacy of the two treatment formats as a function of both statistically significant change and clinically significant change. It was hypothesized that patients in both conditions would improve significantly, but that individualized treatment would be more effective both in terms of group means and in terms of high-end state functioning. The second goal of the study was to (a) assess cognitive change during treatment and its link to symptom change, and (b) identify predictors of cognitive change and outcome. METHOD Recruitment Recruitment for the study was carried out between 1998 and 2001 under the auspices of the OCD research program already in place at the Centre de Recherche Fernand Seguin. The recruitment involved telephone screening, face to face diagnostic interview, and administration of structured interviews. Although obsessions without associated overt compulsions are experienced by a significant minority of OCD patients, the present study required a uniform group of patients with only obsessions and no or minimal overt compulsions. Consecutive referrals were randomly allocated to either a group or individual format. In total, over a 3 year period, we were able to recruit 43 such cases (21% of our total recruitment) who met inclusion criteria. Amongst these, however, there was a high rate of refusal (38%). Main reasons for not wanting to participate in the group format were anxiety about sharing problems with others, social anxiety, lack of personal attention and fears of acquiring new obsessions from others in the group. Although we planned to run three groups of 10 participants over the 6 month treatment period, delay in recruiting for the group format allowed only two groups to be treated. The final sample size consisted of 26 participants. Entry criteria were (a) primary diagnosis of OCD, (b) dominant obsessive thoughts with few or no overt compulsions, (c) no change in medication type or dose during the 12 weeks before treatment for antidepressants (four weeks for anxiolytics), (d) willingness to keep medication stable while participating in the study, (e) no evidence of suicidal intent, (f) no evidence of current substance abuse, (g) no evidence of current or past schizophrenia, bipolar disorder or organic mental disorder and (h) willingness to undergo randomization. Measures Diagnostic Measures Baseline diagnosis used three structured interviews to provide adequate description of clinical features. First, all patients were diagnosed using the Anxiety Disorders Interview Schedule for DSM-IV, a structured interview that diagnoses anxiety disorders and exclusionary conditions (ADIS-IV, Brown, Di Nardo, & Barlow, 1994). Reliability of diagnosis was checked for 30% of the cases. Second, participants were administered the Yale Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989a, 1989b).

4 90 K. O Connor et al. Main Dependent Variables The main dependent variables assessed symptoms and cognitions that were direct targets of the intervention and were used to establish treatment efficacy. The Yale Brown Obsessive Compulsive Scale (Y-BOCS) was administered by an independent clinician and defined as the primary outcome variable. The Y-BOCS can be used to assess overt and covert neutralizing separately (Vézina et al., 1995). Studies confirm the validity and reliability of the principal scales (ICC = , r s = 0.90) (Steketee, 1993; Taylor, 1995). Inter-rater reliability was established for 15% of ratings. An independent assessor administered the Y-BOCS at pre-, mid-, post-treatment, and follow-ups. The Padua Inventory (Sanavio, 1988) is a comprehensive 60-item self-report inventory of obsessions and compulsions. The total scale (a =0.95) and the subscales (a = ) are reliable. The Cognitive Intrusions Questionnaire (CIQ) (Freeston, Ladouceur, Thibodeau, & Gagnon, 1991) assesses content, form, and appraisal of obsessions as well as neutralization strategies used with the target obsession. Psychometric properties of the subscales are good (a= ). The Interpretations of Intrusions Questionnaire (III; OCCWG, 1997, 2001, 2003) covers three dimensions related to the faulty appraisal of a target obsessive thought and consists of 31 items. Strength of belief in the appraisals ranges from 0 I did not believe this idea at all to 100 ( I was completely convinced this idea was true. The Beck Anxiety Inventory (BAI) (Beck, Epstein, Brown, & Steer, 1988) is a 21-item anxiety symptom checklist rating symptom intensity for the last week (a =0.91). The Beck Depression Inventory (BDI) (Beck, Rush, Shaw, & Emery, 1979) is a 21-item measure of depressive symptoms (a = 0.91). Self-Monitoring Patients were also asked to self-monitor, in a daily diary, the duration of obsessions, degree of distress experienced during the obsession and strength of obsessional beliefs linked to obsessional thoughts. Types of obsessional belief varied from person to person, but generally related to catastrophic reactions produced by the presence of obsessional thoughts such as I will lose control over myself if I don t suppress this thought, I will feel responsible if this thought does not go away and this thought means I am a terrible person wanting terrible things to occur. Treatment Protocol The treatment program consisted of the same manualized treatment protocol administered over the same time period (approximately 20 weeks) in both group and individual format. Cognitive Behavioural Group Treatment for OCD In the initial phase, before the start of group therapy, patients were seen individually for four 1 hour evaluation sessions to ensure adequate preparation. This included a cognitive behavioural assessment, explanation of self-monitoring and specific preparation for the group treatment by answering questions about the group format. The group sessions were 2 hours in length. The second phase (group sessions 1 5) covered introduction to the cognitive behavioral account of OCD where five groups of beliefs were addresses by first explaining their roles in maintaining cognitive biases leading to faulty appraisal of threat and thus symptom-maintaining behavior: overestimation of the importance of thoughts, overestimation of danger, overestimation of the consequences of anxiety, responsibility and perfectionism. Next, patients were trained in identifying their key beliefs and how they could be challenged using Socratic dialogue, and the downward arrow technique. This then led to a discussion of exposure and response prevention, which in the CBT model is conceptualized as a way of disconfirming the beliefs by reality testing. The third phase (group sessions 6 7) involved exposure and response prevention using either in vivo or tape-loop exposure according to hierarchies developed during the evaluation sessions. The fourth phase (group sessions 8 10) continued with ERP while making explicit links to the cognitive targets identified above, thus maintaining an emphasis on cognitive correction throughout treatment. The last phase (sessions 11 12) focused on relapse prevention based on programs developed by Hiss and collaborators (1994) and Emmelkamp, Kloek and Blaauw (1992), which included a written individualized guide (the OCD emergency kit) and a telephone follow-up after completion of the group session at 3 week intervals for a 12 week period. Individual Treatment Participants received the same treatment package as the group treatment with three differences: (1) In the fourth initial session, group preparation was skipped. (2) Individual patients

5 Treatment of Obsessions without Compulsions 91 received 14 1 hour and two 1 1 / 2 hour sessions. (3) Treatment was standardized in that that all patients received the six components above, but individualized in that cognitive correction and ERP components were used flexibly in a more integrated way. Each patient received 20 hours therapist time in the individual protocol (3 hours assessment + 16 hours therapy + 1 hour telephone follow-up). the course of treatment between the group (n = 1) and individual format (n = 2). A total of nine participants completed the group therapy versus 17 in the individual treatment. This difference in numbers between the group and individual conditions was due to a greater refusal in the group condition. There were no significant differences between groups on any of the demographic or clinical measures. RESULTS Participant Characteristics Participants characteristics are shown in Table 1. The total sample consisted of 15 males (57.7%) and 11 females (42.3%). The average age was 40 years (SD = 12.9; range 20 64). Marital status was distributed as follows: single (15.4%), married or cohabitating (53.8%) and separated or divorced (11.5%). Education level showed an average of 14.8 years of schooling for the entire group. Types of obsession in our sample were broken down as follows: religious or sexual intrusions (15%), doubting or questioning obsessions (27%), health concerns (19%), fear of harming self or others (39%). There was no difference in drop-out rates in Outcome: Main Dependent Variables Outcome analyses of the effects of therapy was only performed on those who completed treatment (means before and after treatment are shown in Table 2). Both individual and group formats showed a significant decrease in obsessional symptoms as measured by independent Y-BOCS evaluations pre and post (see Figure 1). There was a significant treatment effect (F(1, 23) = 86.1; p < ). A significant interaction effect indicated that the individual format showed superior outcome (F(1, 23) = 13.45; p < 0.001) in terms of symptom reduction on the Y-BOCS. On average, participants improved 68% in individual treatment as compared with 38% in the group format. The scores on the Padua Inventory decreased signifi- Table 1. Participant characteristics (n = 26) Variable % Gender Male 62.0% (n = 15) Female 38.0% (n = 11) Education 0 12 yrs 19.0% yrs 71.5% more than 18 yrs 9.5% Occupation Student 4.8% Employed 62.0% Homemaker 14.0% Retired 9.5% Unemployed 4.7% Marital status Single 19.0% Married or cohabitating 66.7% Divorced or separated 14.3% Type of obsession Religious/sexual 15% Doubting/questioning 27% Health concerns 19% Harming self/others 39% Table 2. Means and standard deviations of measures for each group, before and after treatment Pre-treatment Post-treatment Questionnaire X SD X SD Y-BOCS Individual Group Padua Inventory Individual Group Beck Depression Inventory Individual Group Beck Anxiety Inventory Individual Group Cognitive Intrusions Questionnaire Individual Group Interpretations of Intrusions Inventory Individual Group

6 92 K. O Connor et al. Y-BOCS 25 Individual 20 Group Pre Post Figure 1. Mean Y-BOCS scores pre- and post-treatment BAI Figure 2. Individual Group Pre Post Mean BAI scores pre- and post-treatment cantly (F(1, 22) = 22.83; p < 0.001). However, no interaction effect was observed for Padua scores (F(1, 22) = 0.16; p = 0.70), possibly due to its focus on compulsive symptoms. There was an overall treatment effect on measures of anxiety (F(1, 22) = 6.60; p < 0.001). However, a significant interaction effect (F(1, 22) = 5.01; p < 0.05) indicated that anxiety decreased only marginally in the group treatment, whereas a large reduction in anxiety was found for the individual treatment (see Figure 2). Very similar results were found for depression scores with a significant treatment effect (F(1, 22) = 6.86; p < 0.001) and interaction effect (F(1, 22) = 6.86; p < 0.05) (see Figure 3). Looking overall at change in questionnaire measures of obsessional appraisals, the CIQ showed an overall treatment effect (F(1, 19) = 50.14; p < ), but no group versus individual interaction (p < 0.84). Likewise, the measure of interpretations, the III, showed a significant treatment effect (F(1, 18) = 14.88; p < 0.01), but no group versus individual interaction effect (p < 0.72). Thus, both groups showed a tendency to make less negative appraisals of their aversive obsessional thoughts, post-treatment. Outcome: Self-Monitoring Variables Behavioral and subjective self-monitoring variable were measured by the participants in a daily diary. Recording took around 5 minutes a day. The following types of variable were measured: daily duration of obsession (minutes per day), degree of distress (0 100) about obsessions, and resistance to the obsession (0 100). Strengths of idiosyncratic obsessional thoughts were also measured over treatment phases (0 100). Differences before and after treatment were calculated by taking the average score of the first 10 days in the diary and BDI Figure 3. Duration (minutes) Pre Post Individual Group Mean BDI scores pre- and post-treatment st period 2nd period 3rd period Group Individual 4th period Figure 4. Duration (minutes a day) of obsessions and compulsions during treatment for group and individual formats the average score of the last 10 days in the diary for each of the measures. Repeated measures analyses of duration revealed that whereas both groups showed a treatment effect (F(3, 57) = 12.6; p < ) only the individual treatment showed a linear reduction in duration over the successive phases of treatment (see Figure 4). However, there was no significant interaction effect (p = 0.39). In terms of reduction in

7 Treatment of Obsessions without Compulsions 93 distress associated with the obsession, the same pattern emerged, with both the individual and group formats showing significant change (F(3, 51) = 29.1; p < ). The individual group showed the most consistent change over successive treatment phases, but there was no significant interaction effect (p = 0.44). Resistance to mental covert neutralizing also improved in both groups posttreatment (F(3, 57) = 27.7; p < ). However, there were no significant interaction effects for duration, distress or resistance between the group and individual therapies. The process measures based on idiosyncratic obsessional beliefs were divided into two parts: strength of obsessional belief itself, and conviction in the necessity to act compulsively on the belief. In the former case repeated measures analysis revealed a significant treatment effect (F(1, 19) = 26.3; p < ) as well as a significant group by treatment interaction effect at baseline and after treatment (F(1, 19) = 4.8; p = 0.041). Strength of obsessional belief decreased by 77% in individual therapy as compared with 39% in the group format. In the case of the need to act on obsessional beliefs, there was a main treatment effect over both groups (F(1, 19) = 33,7; p < ), and a trend appeared showing a group interaction effect (F(1, 19) = 3,7; p < 0.07) with greater decrease in the individual treatment format. The effect of treatment on the idiosyncratic obsessional beliefs specifically targeted by the treatment and recorded in the daily diary was clearly more pronounced than the treatment effect on overall measures of obsessional appraisals assessed by the CIQ. Relationship Between Symptom and Process Measures The daily diary measures and symptom measures were highly correlated through all treatment phases. Duration, distress and resistance to neutralizing were highly correlated in treatment phases 1 3. Y-BOCS scores correlated most significantly with duration and distress variables. The Y- BOCS did not however correlate with changes in obsessional belief in any treatment phase. During phases 1 and 2 the two measures of belief did not initially correlate with duration, nor with distress nor resistance to neutralizing measures, although they correlated highly among themselves. However, during phases 3 and 4 there was a strong correlation between strength of beliefs and duration of obsession and degree of distress. We calculated change scores for the outcome and process variables in order to determine the relationship among them (Table 3). The relationship between symptom outcome measures and beliefs over the course of treatment was examined through correlational analysis. Change in strength of belief and necessity to act were highly correlated, but overall there was an absence of relationships between process and outcome measures. However, change in strength of belief almost reached significance with change in Padua scores (p = 0.058) Six-Month Follow-Up Both groups maintained gains in Y-BOCS (F(2, 24) = 14.7; p < ) at 6 month follow-up, but with no further decrease in post-treatment scores. Y- BOCS mean at follow-up was 7.1 (SD = 7.7) for the individual treatment format and 10.0 (SD = 10.1) for the group format. DISCUSSION The proportion of individuals recruited with obsessions without overt compulsions from consecutive referrals to an OCD clinic was 21% of Table 3. Correlations between change scores in process variables and outcome measures Y-BOCS III Padua Duration Belief strength Neccessity to act Y-BOCS * III * Padua Duration Belief strength ** N = 26. * p < 0.05; ** p < 0.01.

8 94 K. O Connor et al. the total recruitment, which is in accordance with prevalence estimates from other sources (Emmelkamp, 1982; Rachman, 1985). Of those who were eligible for the study, 38% refused treatment in a group format, thereby further decreasing the influx of patients for a group therapy versus individual treatment. Reasons for the refusal included anxiety about sharing problems with others, social anxiety, lack of personal attention, and fears of acquiring new obsessions from others in the group. Anxiety about sharing problems and social anxiety may be due to the often shameful content of obsessions and symptoms, and while positive benefits would be expected from a group therapy for related problems such as isolation, fear of judgement and stigma (Kobak et al., 1995) it may also be a limiting factor in the recruitment of a purely obsessional patient group. The results of the current study indicate that both group and individual CBT formats show promise of producing significant statistical and clinical change in obsessions without overt compulsions, a group traditionally refractory to treatment. It thus replicates the earlier study by Freeston et al. (1997). The mean percentage reduction in symptoms in both formats (individual therapy 68% versus group therapy 38%) is better than or comparable to reported studies in the literature, and demonstrates the effectiveness of the current treatment protocols. Individual treatment produced the greater change in symptoms and in obsessional beliefs. Also, a more consistent change in duration of obsessions and compulsions was observed for participants in the individual treatment. The individual format clearly permitted more focus on, and hence change in, idiosyncratic obsessional targets than did the group format. Particularly pronounced was the finding that anxiety and depression were far more effectively treated in the individual format than in the group format. Severity of OCD symptoms showed little relation to strength of obsessional beliefs at the start of treatment, but change in beliefs was strongly correlated with symptom improvement post treatment. Single case studies of process confirm that relation between beliefs and emotion varies over treatment phases, and this is important to consider when monitoring progress and planning intervention during treatment (Rhéaume & Ladouceur, 2000). Other studies applying group format to a wider range of OCD with overt compulsions have likewise reported successful symptom improvement in a group format (see Whittal et al., 1997, for an overview). In a study by Fals-Stewart et al. (1994) individual therapy was compared with group behaviour therapy. They found a significant improvement in both groups in Y-BOCS scores with no difference between individual and group therapy. In a more recent study by McLean et al. (2001), group ERP was found to lead to a significantly better improvement than group CBT at both post-treatment and follow-up. They propose that perhaps group CBT does not allow for an individually tailored approach to address the cognitive processes important in achieving successful outcome. However, individual treatment consisting solely of exposure in vivo has also been found to lead to changes in cognitions and the importance of addressing cognitions in successful treatment outcome remains contentious (Emmelkamp, Van Oppen, & Van Balkom, 2002). The uniqueness of the current study lies in the comparison of a standard treatment in group or individual format with a sample of participants suffering only from obsessions. The current results permit us to conclude that although the impact of a group format may lie in the value of shared social support and the motivational effects of peer feedback, this may be at the expense of focus on individualized targets. Hence, these results are consistent with those found by Whittal, & McLean. (2001), where group CBT appeared to be less effective than individual CBT. Also, motivational factors and availability of patients remains an issue, and group therapy for this particular patient group may be not be feasible in small or nonspecialized settings. REFERENCES Ball, S.G., Baer, L., & Otto, M.W. (1996). Symptom subtypes of obsessive compulsive disorder in behavioural treatment studies: a quantitative review. Behaviour Research and Therapy, 34, Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Bouvard, M., Milliery, M., & Cottraux, J. (2002). Un programme de thérapie cognitive et comportementale en groupe dans le trouble obsessionel compulsif: résultats préliminaires. L Encéphale, 38, Brown, T.A., Di Nardo, P.A., & Barlow, H.H. (1994). Anxiety Disorders Interview Schedule for DSM-IV. Albany, NY: Graywind.

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