This document discusses guided self-help for obsessive compulsive disorder (OCD). It begins by outlining the aims of exploring what guided self-help is, if it is effective for OCD, and how it is applied. It then provides background on OCD, describing obsessions and compulsions. The document discusses the rationale for alternative delivery systems for OCD treatment due to lack of therapists and long waitlists. It presents the stepped care model and treatment options. Low intensity interventions like brief CBT using structured self-help are described. Evidence is presented that self-help with minimal therapist contact can be effective for OCD. Application of self-help involves assessment, family involvement, self-help materials, ongoing monitoring, and exposure/

1. Guided self help for
Obsessive Compulsive
Disorder
Professor Karina Lovell

2. Aims of the workshop

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What is guided self help?
Does guided self help work in OCD?
How is guided self help applied with
someone with OCD

3. Obsessive compulsive disorder

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OCD is a major disorder and under recognized
public health problem.
Obsessive-compulsive disorder can occur at any
age but most often presents for the first time in
adolescence
Lifetime prevalence (1.9-3.0%)
There is evidence that without adequate
treatment the disorder tends to have a chronic
fluctuating course

4. Obsessions
Obsessions are repetitive, recurring thoughts,
ideas, images or impulses that are
experienced as intrusive and are usually
distressing or anxiety provoking. Such
thoughts are often centered on dirt and
contamination, accidental harm, illness,
aggression, sex, orderliness and perfection.

5. Compulsions
Compulsions: (rituals) are repetitive and
intentional acts and serve to reduce anxiety
the thoughts provoke. The person
recognizes that their behavior is excessive or
unreasonable.

6. Obsessions and compulsions
Obsessions
 Bodily fluids
 Asbestos
 Unspecified germs
 Disease specific
 Radiation
 Animal specific
Compulsions
 Washing excessively
 Avoidance
 Reassurance
 Magical numbers

7. What is guided self help
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A self-administered intervention
Involves a health technology (book,
computer, audio tape)
Facilitated by a health professional
Role of facilitator is to guide, support,
review and monitor

8. What is guided self help


GSH is one of many interventions deemed
a low intensity intervention
Others include, telephone, computer
delivered, groups and internet delivery.

9. Rationale for alternative
delivery systems

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Does not meet policy recommendations
Lack of therapist’s
Traditional service delivery
Poor access
High waiting lists

10. Stepped-care model

The model provides a framework in which to
organise the provision of services in order to
identify and access the most effective
interventions

Stepped care attempts to provide the most
effective but least intrusive treatments
appropriate to a person’s needs

The recommendations in the NICE guidance are
structured around the stepped-care model

11. STEPPED CARE MODEL
STEP 6 Inpatient care or intensive treatment
programmes. CAMHS Tier 4
STEP 5 Multidisciplinary teams with specific expertise in
management of OCD. CAMHS Tiers 3 and 4
STEP 4 Multidisciplinary care in primary or secondary care.
CAMHS Tiers 2 and 3
STEP 3 GPs and primary care team, primary care mental health
worker, family support team. CAMHS Tiers 1 and 2
STEP 2 GPs, practice nurses, school health advisors, general health
settings. CAMHS Tier 1
STEP 1 Individuals, public organisations, NHS

12. Treatment options for adults with OCD
Mild functional
impairment
Brief CBT (+ERP)
< 10 therapist hours
(individual
or group
formats)
Moderate functional
impairment
Offer choice of:
more intensive CBT
(+ERP)
>10 therapist hours
or
course of an SSRI
Severe functional
impairment
Inadequate
response at 12
weeks
Multidisciplinary
review
Offer combined
treatment of
CBT (+ERP)
and an SSRI
Patient cannot engage in/CBT
(+ERP) is inadequate

13. Low intensity interventions definition

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Less than 10 hours of therapist time
per patient
CBT includes exposure and response
prevention (ERP)
The intensity of the intervention is
dependent upon the degree of
functional impairment and patient
preference

14. Low intensity interventions

Brief individual CBT (including ERP) using
structured self help

Brief individual CBT (including ERP) by
telephone

Group CBT (including ERP)

15. Recommendations identified
as key priorities

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All people with OCD should have
access to evidence-based treatments:
CBT including exposure and
response prevention (ERP) and/or
pharmacology
But, limited availability of CBT
Therapists
 Waiting times
 Access


16. Recommendations identified
as key priorities


CBT (including ERP) should be
offered in a variety of formats
Treatment programmes for formats
other than standard individual CBT
exist but have not been widely
disseminated (including guided self
help, telephone and groups)

17. Small group work

In small groups discuss your views on the
stepped care model recommended by the
NICE guidelines and the advantages and
disadvantages of guided self help.

18. Low intensity treatments – self-help
materials with minimal therapist
contact - The Evidence

Fritzler et al (1997) found that a third of
people with OCD made clinically significant
improvement with a CBT based self-help
manual and minimal therapist contact

Lovell (2005) uncontrolled study found self
help manuals and minimal therapist contact
with people with OCD promising

19. Low intensity treatments:
The Evidence
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Lovell (2000) pilot study (CBT)
Taylor (2003) open study ( CBT with self help
book)
Griest (2002) RCT ( CBT- computer
accessed by telephone and work book)
Lovell (2005) RCT compared CBT by
telephone or face to face with adults with
OCD

20. Meta-analysis of treatment intensity for
CBT

Grouping Therapist hours/patient into bands
Treatment intensity Study
N
SMD
CI
arms
Low (<10 hrs)
11
261
.93
0.75 - 1.11
Medium (10-30)
22
461
1.44
1.29 - 1.59
High (> 30)
10
157
1.65
1.38 - 1.91

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Medium, High > Low
Low works, medium and high work better

21. Self help materials
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Wagner A. Up and down the worry hill: a children's book about obsessive
compulsive disorder and its treatment. New York: Lighthouse Press, 2002—
An illustrated book designed to help parents and professionals to explain
obsessive-compulsive disorder to younger children through the story of
"Casey," a young boy with the disorder
Wever C, Phillips N. The secret problem. Sydney: Shrink-Rap Press,
1996—A cartoon book that describes obsessive-compulsive disorder in
clear and simple language to help children, teenagers, and parents to
understand it and its treatment
Hyman B, Pedrick C. The OCD workbook: your guide to breaking free from
obsessive-compulsive disorder. Oakland, CA: New Harbinger Publications,
2005—A self help manual for adults and older adolescents, which guides
the patient through exposure with response prevention; includes advice for
family members
Veale D, Willson R. Overcoming obsessive compulsive disorder. London:
Constable & Robinson, 2005—A self help book suitable for adults and older
teenagers
Lovell, KOCD self help manual (available on request)
Schwartz JM. Brain lock: free yourself from obsessive compulsive
behaviour. New York: Harper Collins, 1997—A self treatment manual
suitable for adults and older adolescents

22. Application: self-help with
minimal therapist contact
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Patient centred assessment
Involvement of families
Self help materials (which ones?)
Ongoing monitoring (process and
outcome measures)
Collaborative working
Includes exposure and response
prevention
20-40 minute sessions

23. Small group work
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Discuss the self help resources that you
have used and would recommend?
Identify a spokesperson to feed back to
the larger group

24. Questions

25. Thank you for listening
Karina.Lovell@manchester.ac.uk