Bevan 2010

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173
The
British
Psychological
British Journal of Clinical Psychology (2010), 49, 173–191
q 2010 The British Psychological Society
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A qualitative study of the acceptability

of an intensive format for the delivery
of cognitive-behavioural therapy
for obsessive-compulsive disorder
Anna Bevan1, Victoria B. Oldfield2 and Paul M. Salkovskis1,2*

1
King’s College London, Institute of Psychiatry, London, UK
2
Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Trust,
London, UK
Objectives. An intensive format may be both useful and effective for the delivery of
cognitive-behavioural therapy (CBT) for obsessive-compulsive disorder (OCD).
However, the acceptability of an intensive treatment format from the perspective of
service users is unknown. This study examines service user perspectives on the
acceptability of an intensive versus a standard weekly treatment format.
Design. The study comprises a detailed comparative qualitative analysis of the
perspectives of service users who have completed either intensive or weekly CBT
for OCD.
Methods. Six treatment completers in each format (matched for age, gender, and
symptom changeover the course of treatment) were asked to reflect on helpful and
problematic aspects of their treatment format, and to consider the differences between
treatment formats. The interviews were transcribed and analysed in detail using
thematic analysis.
Results. Individual differences were apparent in preference for treatment format.
Weekly treatment completers were concerned that intensive treatment could be
overwhelming or too brief for real change to take place. However, intensive treatment
completers valued the high pressure and pace and felt that it improved motivation,
engagement, and eventual outcome.
Conclusion. An intensive treatment format for the delivery of CBT for OCD can be
highly motivating and acceptable to service users who have chosen to undertake it.
Good quality follow-up and crisis support may be particularly important following
intensive treatment.
* Correspondence should be addressed to Professor Paul M. Salkovskis, Centre for Anxiety Disorders and Trauma,
South London and Maudsley NHS Trust, London, UK (e-mail: p.salkovskis@iop.kcl.ac.uk).
DOI:10.1348/014466509X447055
20448260, 2010, 2, Downloaded from https://bpspsychub.onlinelibrary.wiley.com/doi/10.1348/014466509X447055 by Universitat De Barcelona, Wiley Online Library on [16/08/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
174 Anna Bevan et al.
Obsessive-compulsive disorder (OCD) is a chronic and potentially disabling condition

with an estimated lifetime prevalence of 2.5% (Karno, Golding, Sorenson, & Burnman,
1988). It is characterized by recurrent and distressing intrusive thoughts, images, or
urges; and by repetitive behaviours or mental acts which the sufferer feels driven to
perform in response to intrusions (American Psychiatric Association, 1994),
contributing to high levels of distress and interference to normal functioning. OCD
may be extremely persistent and treatment-refractory (Rasmussen & Eisen, 1997)
although a range of effective treatments have been developed, including cognitive-
behavioural therapies (CBTs; Cordioli et al., 2003; Freeston et al., 1997; Krochmalik,
Jones, & Menzies, 2001). CBT is currently recommended as a first line of treatment by
the National Institute for Clinical Excellence (NICE, 2005) guideline for OCD.
Outpatient psychological treatments including both behaviour therapy and CBT are
commonly provided in short sessions on a weekly basis (e.g. Beck, 1995). Although
more recently this mode of treatment delivery has been adopted in most disorders
including OCD (probably for reasons of convenience), early OCD treatment using
behaviour therapy was commonly offered on an intensive and/or inpatient basis
(e.g. Thornicroft, Colson, & Marks, 1991), and there are good reasons to reconsider
more intensive treatment formats for OCD. Providing treatment over the course of a
shorter time period may be valuable in cases where immediate clinical improvement is
important, as when job or relationship loss is threatening. There may also be practical
advantages in intensive treatment, for example, when travel time to the clinic is an issue,
or when time cannot be regularly taken off work. It has also been suggested that
intensive treatment may be particularly useful in treatment-refractory OCD (Krochmalik
et al., 2001; Storch, Gelfand, Geffken, & Goodman, 2003). The NICE (2005) guideline
for OCD recommends that research efforts should be directed towards investigating
intensive versus spaced individual treatments, particularly for service users who have
not responded to previous treatment.
A new intensive format for the provision of CBT for OCD has been developed within
a national service for the treatment of OCD, and is currently being evaluated (Oldfield,
Salkovskis, & Taylor, 2010). Weekly treatment is delivered as standard within the service.
In many ways, the intensive treatment is very similar to the standard weekly treatment.
In both cases, the model, rationale, and procedures employed are identical and are
based on a cognitive-behavioural conceptualization of OCD (Salkovskis, Forrester,
Richards, & Morrison, 1998). The two treatment formats are also identical in terms of
the number of therapy hours provided, the amount and quality of follow-up (up to three
additional booster sessions at monthly intervals), the written materials employed, and
the practice of audiotaping sessions for service users to listen to as part of their
homework. The main difference between the two formats is the time-frame in which the
intervention is carried out. Within the standard weekly format hour-long sessions are
provided at weekly intervals for 12 weeks; while within the intensive format 12 h of
treatment is flexibly provided over 5 days with a weekend between. In the weekly format,
homework is given and tapes reviewed on a weekly basis. In the intensive format, this
takes place daily. In addition, one therapist provides the weekly treatment, while two
therapists conjointly conduct each session of the intensive treatment.
Although treatment in the two formats is identical in terms of the model it is based
on, the rationale it employs, and the procedures it uses, it is possible that differences
exist between the formats in terms of non-specific or common therapy factors (Frank,
1982; Kazdin, 1986; Weinberger, 1995). A number of such factors have consistently
been shown to have a moderate effect on outcome regardless of treatment modality,
Acceptability of intensive CBT for OCD 175
including the quality of the therapeutic alliance (Martin, Garske, & Davis, 2000),
treatment credibility (Kirsch & Henry, 1977), and service user expectations for outcome
(Devilly & Borkovec, 2000). Completion of homework tasks has been related to
outcome in CBT (e.g. Addis & Jacobson, 2000); while a recent study found that aspects
of service users’ motivation to engage with treatment were associated with outcome in
CBT, interpersonal therapy, and pharmacotherapy (Zuroff et al., 2007). It is likely
that different treatment formats provide different experiences for service users in terms
of many of these issues, such as the nature of the therapeutic alliance, the extent to
which the treatment appears likely to make a lasting difference, and ease of complying
with homework requirements, and it is possible that such differences may impact
both on service users’ satisfaction with their treatment and potentially on their success
in therapy.
As an addition to evaluations of treatment efficacy, the views of service users can
provide a complementary perspective and possible insights into why treatments work
or fail to work. Qualitative methods are particularly appropriate for investigating
subjective experience, perspectives, and meanings (Elliott, 1995) and may offer
uniquely useful insights into factors affecting change, such as service users’ experience
of the therapeutic alliance, engagement with treatment, or motivation to undertake
difficult homework tasks. A better understanding of service user perspectives and
preferences through the use of qualitative methodology is likely to assist the
development of highly acceptable services, and in turn, impact on service effectiveness.
To our knowledge, no study has previously examined service users’ perceptions of
the acceptability of intensive CBT for OCD. The current study employed a qualitative
methodology in order to gain a better understanding of service acceptability issues with
a view to future service development.
Method
Participants
Two groups of participants were recruited; a group of service users who had completed
intensive treatment with the clinic, and a matched group who had completed the
comparable weekly treatment. The weekly format was the default format for treatment
provided in the clinic. Service users on the waiting list for weekly treatment were
contacted and offered the opportunity to undergo intensive treatment as part of a larger
outcome study that was being conducted. The current study drew its participants from
the pool of treatment completers from this larger outcome study. From the pool of all
intensive treatment completers, individuals were selected according to the distance
they lived from the clinic (to make travelling in for the interview feasible) and
subsequently contacted. In total, eight service users were contacted and six agreed to
take part. A matched group of weekly treatment participants was then recruited.
Treatment completers who had completed treatment within the same time frame as the
intensive group, had been treated by the same team, and had not had additional
treatment over and above the number of hours given in the intensive treatment were
selected. From this pool, participants were matched to the intensive sample by gender,
age, and improvement on the Obsessive-compulsive inventory (OCI; Foa, Kozak,
Salkovskis, Coles, & Amir, 1998) from baseline to post-treatment using the OCI distress
score (see Table 1). The matched group were not selected on the basis of the distance
from their home to the clinic but, like the intensive participants, all lived within an
Table 1. Participant characteristics
Participant Gender Age OCI (baseline) OCI (post-treatment) OCI (improvement)
Intensive treatment
Peter M 32 114 43 71
Carole F 30 45 14 31
Sarah F 34 125 33 92
Janet F 30 50 27 23
Rosa F 19 112 35 77
Mark M 40 72 51 21
Weekly treatment
Gareth M 31 88 0 88
Lisa F 19 78 12 66
Ann F 37 100 59 41
David M 36 72 9 63
Kate F 23 96 75 21
Laura F 31 69 43 26
hour’s journey time. One potential participant was not contacted for ethical reasons,
and another had moved away. In total, six participants were contacted and all six agreed
to take part.
It should be noted that allocation to treatment format was not randomized and
differed between the two groups. All those offered intensive treatment had been given a
choice between the two formats, and all selected an intensive approach. Five of the six
weekly participants were not offered a choice of format, due to the fact that they had
already begun weekly treatment before the starting date of the outcome study. One
(David) was offered a choice and preferred the weekly treatment.
Each group consisted of four women and two men. The mean age of the intensive
participants was 30 years (median 31, range 19–40) and the mean age of the weekly
participants was 29 years (median 31, range 19–37). All participants in both groups
were discharged during 2005 (within a year of their interview). The mean baseline OCI
score was 86.33 (median 92, range 45–125) for the intensive participants and 83.83
(median 83, range 690–100) for the weekly participants, and the mean post-treatment
OCI score was 33.83 (median 31, range 14–51) for the intensive participants and 33
(median 27.5, range 0–75) for the weekly participants. The mean OCI improvement
score was 52.5 (median 51, range 21–92) for the intensive participants and 50.83
(median 52, range 21–88) for the weekly participants.
Five of the six intensive format participants reported that the onset of their OCD had
occurred in early childhood (prior to age 11). The sixth had suffered from 10 years of
OCD. Of the weekly format, three participants reported onset in early childhood, and
the remaining three reported 7, 9, and 20 years of OCD, respectively. All participants
from the intensive format reported current or past problems in addition to the OCD,
including depression, self-harm, alcohol abuse, and generalized anxiety disorder. Four of
the six weekly participants also reported past or present comorbid problems including
depression, self-harm, alcohol abuse, panic disorder, and eating disorder. One
participant from each format had not had any form of psychological treatment prior
to their assessment by the service. The remaining 10 had undergone a range of therapies,
including bereavement counselling, psychodynamic psychotherapy, psychosynthesis,
hypnosis, Christian counselling, inpatient treatment, anxiety management group work,
non-specific group work, non-specific counselling, and one-off sessions with a

psychiatrist. In terms of therapies specifically directed at the OCD symptoms,
three participants from the intensive format had previously had a course (or courses)
of CBT for OCD, and one had had family therapy aimed at the OCD. Two participants
from the weekly format had had a course or courses of CBT for OCD; one had had
a course of exposure with response prevention, and one had attended a group for
people with OCD.
Materials
A semi-structured interview schedule was developed. Initial questions were open-
ended, asking how participants had found the therapy overall, and which aspects of
treatment they felt were potentially helpful and problematic in each format. This was
intended to allow participants themselves to define which issues were important, and to
provide as close a picture as possible of their own understandings (Strauss & Corbin,
1990). In addition, therapists who had worked in both formats were consulted during
the development of the interview schedule. Therapists raised some particular issues,
including the potentially overwhelming impact of having two therapists, and concerns
about whether the shorter intensive time scale allowed therapists to develop a
formulation which covered all important issues and felt appropriately relevant to service
users. These suggestions were incorporated into the schedule by asking participants
more specific questions about how responsibility was shared between themselves and
their therapists, whether the therapy had felt relevant, and whether important issues
had been left out. These questions were asked later in the interview to avoid shaping
participants’ responses to the early questions. Finally, participants were asked whether
they felt anything important had been left out of the interview, and whether there was
anything they would like to add.
Procedure
The interview schedule was piloted with a treatment completer from each therapy
format. These participants were asked for their comments, and subsequently a question
about how confident participants felt about controlling their symptoms in future was
included in the interview schedule.
Potential participants were contacted by telephone and the study was explained to
them. If they agreed to take part, an appointment was made for them to come to the
clinic to be interviewed. Written information was sent to them in the post. Written
informed consent was obtained on their arrival at the clinic. The purpose of the study
was explained, and the position of the researcher clarified. It was explained that
although the study was being undertaken at the request of the clinic, and the general
results would be fed back, the researcher was independently employed and would
observe confidentiality with respect to individual disclosures. Participants were also
reminded that disclosing any dissatisfaction with the service would be particularly
useful in terms of service development. These precautions were taken in order to
minimize the likelihood that participants would avoid disclosing dissatisfaction due to
the clinic setting. The two treatment formats were described. Interviews lasted from 20
to 40 min, and were audio-recorded and later transcribed verbatim by the same
researcher. Participants’ travel expenses were reimbursed.
Qualitative analysis
The methodology employed was thematic analysis (Braun & Clarke, 2006),
approaching the data from an essentialist or realist theoretical standpoint assuming
that a valid account of participants’ experiences and views can be accessed via the
ways in which they talk about them. The analysis had two aims: first, to identify
patterns inherent in the data that reflected a shared understanding of issues arising
within each therapy format, and secondly to provide a comparative analysis of these
patterns across the two formats. Given that the study’s focus was on group
comparison, codes relating to idiosyncratic concerns of single participants were not
included in the overall analysis unless they related to a category which reflected the
experience of at least one other participant (regardless of therapy format). Analyses
initially focused on the transcripts from the intensive participants only. Each
transcript was read a number of times and coded for categories arising from the data.
Once identified, codes were grouped together in meaningful clusters. This process
was repeated for each transcript from the intensive format, with efforts being made to
approach each interview afresh and keep codes grounded in the data. Subsequently,
clusters of categories from each transcript were grouped together and examined for
shared experience (i.e. relating to the experience of two or more participants),
leading to the creation of general categories. All transcripts were then recoded for
these categories, and all the data related to them collected together and examined
more closely in order to refine the coding scheme. Once the intensive format coding
scheme had been created, the whole process was repeated with the transcripts from
the weekly participants. Again, efforts were made to approach this data afresh, and to
question assumptions made on the basis of the coding of the intensive transcripts.
On comparison, the two completed coding schemes contained very similar
categories, and an overall scheme was created. Only one unique category emerged
from the coding of the weekly data (‘stress’ – see the Results section). A matrix was
created, representing all incidences of each category for each participant in each
format, in order to help to organize the categories and to look for patterns in the data.
Finally, all transcripts were reread in order to check that all relevant data had been
coded, and to test the coding scheme by searching for different interpretations
(Strauss & Corbin, 1990).
Validity
Following the analysis two audits (e.g. Lincoln & Guba, 1985; Smith, 1994) were carried
out. A second researcher (an experienced OCD therapist) was provided with the raw
transcripts, the coded data, the matrix of codes, and the first draft of the results, in order
to review the process and to check that the interpretations made were warranted on the
basis of the data. However, all researchers and therapists involved in the design of this
study had a cognitive-behavioural orientation and prior assumptions relating to OCD
and to its treatment. In order to check that these assumptions did not lead to
unwarranted interpretations, an anthropology student with no background in mental
health was asked to conduct an independent audit, and was provided with the same
materials. Both auditors were asked to pay attention to the appropriateness of both the
coding scheme and the interpretations made on the basis of it. Minor changes to
terminology were made on the basis of these audits.
Results
Overview
Five categories emerged from the analysis of the interview transcripts. These are shown
with sub categories and codes in Table 2. The first two categories, ‘background’ and
‘perception of outcome’ provide context and a basis for understanding participants’
viewpoints on their therapy and therapy formats, but are not discussed in detail. The
remaining categories ‘views of therapy’, ‘preference for treatment format’, and
‘accessibility’ are discussed in turn with an emphasis on group similarities and
differences. Pseudonyms are used throughout.
Table 2. Categories arising from thematic analysis

Background
Perception of outcome
Views of therapy
Relavance
Perceived quantity of therapy
Ongoing support
Therapeutic alliance
Preference for treatment format
Time between sessions (benefits)
Time to learn
Time to reflect and practise
Time to make sure everything covered
Five days not long enough
Time between sessions (drawbacks)
Thinking too much
Daily support
Concentration
Efficiency
Longer sessions
Stress
Motivation
Momentum
Perceived power of treatment
Accessibility
Background
In line with assessment measures, participants described incapacitating OCD symptoms
over many years. Most participants described a number of previous experiences of
treatment, and about half described feelings of hopelessness or despair prior to
beginning treatment. No participants believed that their symptoms would have
improved without treatment, and several reported fears such as becoming
unemployable, losing their partner, or passing the OCD on to children if they had not
had therapy at the time that they did.
Perception of outcome
At the time that they were interviewed, seven participants (Peter, Carole, Sarah, and
Janet from the intensive format; and Gareth, Lisa, and Ann from the weekly format)
reported feeling currently in control of their OCD symptoms, for example, being able to
respond to any resurgences and to overcome them. Rosa from the intensive format had
not yet overcome her symptoms to the extent that she would have liked. The four
remaining participants (Mark from the intensive format; and David, Kate, and Laura from
the weekly format) described having relapsed since completing treatment, although
none of these felt that their symptoms were as bad as they had been prior to having
the therapy. Laura was seeking re-referral to the clinic, and David intended to use
the materials from his therapy to work through the OCD on his own. Mark and Kate did
not describe future treatment plans.
Views of therapy
This section summarizes participants’ views of their therapy overall. Key issues arising
from the analysis included the relevance of therapy, the perceived quantity of therapy
received, ongoing support once therapy was complete, and the therapeutic alliance.
All participants in both formats, including those who were still struggling with
symptoms, were extremely positive about their overall experience of CBT:
Mark (intensive): I thought the therapy was excellent, basically. It – it was designed very
well, the way it was put across to me, how we discussed about the intrusion of OCD, and –
and what have you was – was just very accurate, you know, very direct, to the point about it.
I don’t know what else to say, really, it was just – it was just ideal. It was how – it was how I
could wish for it to have been, really.
Relevance
The perceived relevance of therapy is clearly an important issue, in terms of outcome,
motivation to engage, and satisfaction with treatment. All participants in both formats
felt that their therapy had been extremely relevant:
Lisa (weekly): CBT gave me an opportunity to see – well, you know, these are the kind of
symptoms, but actually there’s huge thought processes that is going on, and in that context
that makes sense.
When asked whether they felt that everything important relating to their OCD had been
covered, five participants from each format replied that it had, some remarking that if
anything had been missed they would have pointed it out:
Rosa (intensive): I don’t think anything important was missed out. Because I had a chance
– I had – if I did think it – anything – as soon as I thought of it I said it.
However, one intensive participant described having felt anxious about this at the time
of her therapy:
Sarah (intensive): I think it was just me really feeling : : : a bit panicky that I might not have
covered everything because it was so intensive. But reflecting on it now I can’t think of any
examples which I have since thought of, oh, that part of the OCD wasn’t covered.
Janet (intensive) and Kate (weekly) felt that they had not got to grips with the
underlying causes of their OCD:
Kate (weekly): I haven’t really attacked the reason – and maybe this is on a very
subconscious level, why I had the thoughts in the first place. Why I developed them.
In addition, Sarah (intensive) and Lisa and Kate (weekly) would all have liked to have
had more therapy time to spend on issues other than OCD:
Sarah (intensive): It would have been quite perhaps useful to see how CBT could be used
if I sort of felt myself going along the depressed route as well, I think that would quite
useful, because I do believe they are sort of interlinked.
In summary, all participants from both formats felt that their treatment was relevant.
Although two participants felt that they had not got to the bottom of the underlying
reason for their OCD, and three participants would have liked to have had the
opportunity to cover issues other than their OCD, there was no indication that people
who had completed intensive treatment had a greater sense that important issues had
been excluded.
Perceived quantity of therapy

Of the 12 participants, 10 felt that the quantity of therapy they had received had been
sufficient, although some found moving out of therapy anxiety-provoking:
Laura (weekly): It was quite worrying, but I felt quite confident that I had enough
understanding of : : : how – sort of the tools and how to – to use them, really, and – and you
know, why – why it happened.
One participant from each format felt that they would have preferred to receive more
therapy. Kate (weekly) had come to this conclusion ‘in retrospect’ but Janet (intensive)
reported feeling this at the time:
Janet (intensive): I guess the only thing I can say is that when it got to the end of the
therapy, even though I felt a hell of a lot better, I felt as if I maybe could have done with just
one more week to – to go over things again, and make sure I fully understood everything.
In summary, although Janet from the intensive format was the only participant to report
having felt that she would have liked more therapy at the time of leaving it, there did not
seem to be any more general indication that intensive treatment felt less adequate in
quantity than weekly treatment.
Ongoing support
The issue of whether there had been enough follow-up was raised only by participants
who had completed intensive treatment. Sarah and Janet (intensive) both volunteered
that they would have liked a further follow-up appointment a year or 6 months after
completing therapy:
Janet (intensive): You know, I’ve kind of been capable of dealing with it for a whole year, it
would just be nice to sit down with somebody again and – and discuss, you know, how I’ve
done that, and whether there’s anything that I could improve on.
Mark, also from the intensive format, would have preferred regular ongoing support,
while the remaining three intensive participants (Peter, Carole, and Rosa) felt that they
had had enough follow-up:
Carole (intensive): Even in my follow-ups, I think : : : I think they were – they weren’t – I
think they could have been longer if I needed them to be, and I just didn’t.
On a related note, the majority of the intensive participants (Carole, Sarah, Janet, &
Mark) and one weekly participant (David) described the importance of having been
told that they could ring their therapist for support once they had been discharged.
Four of the five had never rung the number, but found it helpful to know that they
could do so:
Sarah (intensive): I think it would have been really really frightening to feel I was being – I
was completely abandoned at the end of it. Especially after the intensive. So just from – just
saying, you know, look you’ve got our number, that was really important, just that – just that
one sentence.
In summary, follow-up sessions and the potential for ongoing support in the shape of a
telephone number appeared to be particularly crucial issues for people who had their
treatment intensively.
Therapeutic alliance
Issues relating to the therapeutic alliance arose during the course of all interviews, and
all participants in both formats were very positive about it. Aspects of the alliance which
were described as important included being able to raise concerns, the friendliness of
the therapists, and, in particular, feeling understood:
Laura (weekly): It was somebody that really totally understood what the problem was,
and someone that was sort of really approachable and – and you know, kind –
something
– and sort of like when I was seeing like other people, it – you know, you just felt that
you – you know, just had to sort of agree with them, whereas with this, you know,
you could say, well actually, you know, I’m going to find that really hard to : : :
No intensive participants suggested that having two therapists was problematic or
overwhelming. Carole, Rosa, Sarah, and Mark (intensive) all felt that having two
therapists was unambiguously helpful due to the different perspectives available:
Sarah (intensive): It was really useful I think having two. Two therapists for sure, because
if one wasn’t maybe so sure what I was talking about the other one knew, and then if one
was writing notes the other one was carrying on, and – because I had quite a lot of
questions, as well, and it was – they both maybe had slightly different opinions about things.
In summary, there was no indication that any participant from the intensive format felt
overwhelmed by having two therapists, and on the contrary the majority of them
described this as a helpful aspect of the intensive treatment.
Preference for treatment format

Participants were asked to consider what they felt had been helpful and what had
been problematic about their own format, and to try to imagine what they felt would
be helpful and problematic about the opposite format. Aside from the number
of therapists, the main categories which emerged were the amount of time available
between sessions, the length of time spent working with therapists during
any one session or day, and perceived stress and motivation considered to be
inherent in the two formats. These categories are discussed in turn in the following
sections.
Time between sessions

This issue inevitably came up in all discussions of the relative benefits of the two
treatment formats. However, participants held very different opinions as to whether
having more time between sessions, as in the weekly format, was helpful or unhelpful.
The perceived benefits of having time between sessions are described first, followed by
a description of the perceived drawbacks.
Time between sessions (benefits)

The greater amount of time available between sessions in the weekly format was seen as
a benefit by all weekly participants. Perceived benefits included having time to learn,
having time to reflect and practice, having time to make sure that everything important
was covered during the therapy, and a sense that 5 days could not be long enough to
produce lasting change.
Time to learn. David and Ann (weekly) both felt that the weekly format offered better
opportunities to take all the information in:
David (weekly): I think my – my brain doesn’t work that quickly sometimes, so I
think by the end of the week it would only sort of be starting to sink in that I was
there at all, you know.
Time to reflect and practice. Five of the six weekly participants (David, Gareth, Lisa,
Laura, and Ann) mentioned having time to reflect on what they were learning and to
practice skills as a benefit:
Gareth (weekly): I suppose one plus – if I had to think of an answer off my head – was
reflection time. Just to think about what happened in that session, and think – well, you
know, because a week goes quite quickly, as well, you think, ah it’s next Wednesday I’ve got
to – so it does give you a bit of time to reflect and practise anything that you took from that
particular lesson at home. Gives you time to practise it indoors.
Perhaps, surprisingly, however, of the intensive participants only Sarah felt that time
between sessions to reflect and practice would have been unambiguously helpful.
Time to make sure everything is covered. Gareth (weekly) pointed out that having
treatment on a weekly basis gave him time to ask outstanding questions and make sure
everything was covered:
Gareth (weekly): On the weekly thing you’ve got time. You’ve got time to ask questions,
sometimes you might think, oh, well what about that? I didn’t – you can just mention it in
the next session. Oh, you know, I was thinking about this as well, and I forgot – or I forgot to
mention it last session, so no, there’s always time to ask questions, and go in the right way,
sort of thing.
On a similar note, Lisa (weekly) pointed out that weekly treatment could cover
changing situations, while Rosa and Sarah (intensive) also raised this issue as
potentially helpful.
Five days not long enough. Finally, David and Gareth (weekly) felt that the intensive
5 days might simply not be long enough for lasting change:
David (weekly): I think if it was just a week long, a week wouldn’t be long enough for
me to have faced the fears I had. And it would all have – it would all be over too soon, I
wouldn’t have had enough time to build up to the things I knew I had to do to get rid of it.
Time between sessions (drawbacks)

From another viewpoint, having time between sessions was seen as problematic.
All six intensive participants gave reasons for preferring not to have a week to reflect
between sessions. These included preventing ‘thinking too much’ (obsessive
rumination or procrastination), receiving daily support from the therapist, increased
concentration on the problem, and increased efficiency in terms of time.
Thinking too much. The category of ‘thinking too much’ includes issues relating
both to obsessive rumination and to anticipatory anxiety leading to procrastination.
Peter, Rosa, and Mark (intensive) all felt that one of the benefits of intensive treatment
was that it prevented them from thinking too much between sessions:
Peter (intensive): I think if I had a week I think possibly there would have been the sort of
element, oh, I’ve got a week to do it, and I might leave it a couple of days and have a think
about this – sort of procrastinate about it a bit, and then kind of, you know, possibly chicken
out.
As this might suggest, three weekly participants (Kate, Lisa, and Ann) described
occasions when ‘thinking too much’ between sessions had been problematic:
Lisa (weekly): By the time we got to the next session – kind of a week – I’d had time to
think about it and perhaps get a little worried about it, and a bit more reserved, whereas
initially I was very very up for kind of – I – I’d wanted it for so long that – that I was – was
kind of raring to go initially, and then became a bit kind of oh, I’m not sure about this by the
next one, so perhaps that was a disadvantage.
Daily support. Peter, Rosa, and Janet (intensive) all believed that seeing their therapist
on a daily basis had helped them to do their homework, which they might otherwise
have avoided:
Janet (intensive): I feel that some of the things that, you know, you had to do, like the
exposure therapy, and stuff, that having to – you know, go home and practise this stuff,
come the next day, I was kind of in such a state and so anxious that knowing I was going to
get to see my therapist the next day was the best thing, I think. Because if I’d had to go
another week, I probably feel as if I would have given up.
This view was also endorsed by Kate (weekly), while Lisa (weekly) also felt that daily
support could have been helpful at a time when she was feeling particularly low.
Concentration
Carole, Rosa, Sarah, and Mark (intensive) described being able to concentrate fully on
the OCD as being helpful:
Carole (intensive): I think because it – because it was – because it was so concentrated, I
didn’t really think about anything else for those two weeks. And it meant that – I think if I’d –
if I’d had to come and go and come and go, it wouldn’t have worked as well. I think it worked
better because you have to think – you concentrate on nothing else.
From the weekly format, Kate also felt that ‘following through things immediately’
would have helped her.
Efficiency. Carole, Sarah, and Janet (intensive), and Gareth (weekly) valued the
efficiency of the intensive treatment. For example, Sarah felt that weekly sessions would
have been ‘Just a bit of a pain, I guess, having a long-term commitment. Eating into sort
of work life and domestic life’.
To summarize, there were individual differences in beliefs regarding the helpfulness or
unhelpfulness of having a week between sessions. These could be broadly categorized
by format, with each group perceiving greater benefits in the format that they
themselves had undergone.
Longer sessions
Another attribute of the intensive treatment involves having a longer amount of time in
each day to work on issues with the therapist. Rosa and Mark (intensive) both felt that
having longer sessions in intensive treatment was helpful in preventing them avoid
difficult issues during therapy itself:
Rosa (intensive): If there’s things that you don’t want to discuss, not – not consciously,
but things that you don’t want to discuss, you sort of hide it away in your brain after an hour,
if you feel that you’ve got – got a bit too close to something. So – and then the next week
you’d have to – either myself or the therapist or whatever would have to start again going
into that bit. But when you’re in there for like a couple of hours or whatever it is at a time,
you’re forced to – it’s not that I’ve got something that I don’t want to tell them, it’s that I
don’t know myself, and it forces you to sort of dig deeper.
Kate (weekly) also felt this would have helped her to ‘confront things’, and both Kate
and David (weekly) felt that an hour was not always long enough:
David (weekly): There were times I could have – I could have – I could have spent – you
know, a good half a day with my therapist. Just talking about the problem, just thrashing it
out, you know. You know, there was some days I could definitely have done with that.
In summary, the issue of longer sessions was clearly less salient than was the issue of
time between sessions. Only two participants from each format raised it, but all four felt
that having longer than an hour in session was a benefit.
Stress and motivation

A less concrete difference between the treatment formats concerns the perceived
emotional effects on service users of the greater ongoing pressure and momentum of
the intensive format relative to the weekly format. Again, although participants were
not asked about this issue, all participants referred to aspects of it. Participants’ opinions
fell into two broad categories: stress and motivation. These are discussed in turn.
Stress
All weekly participants felt that intensive treatment would be extremely stressful, and
four of the six (David, Gareth, Laura, and Ann) suggested that the stress might be so
intense as to impede motivation or progress in treatment:
Laura (weekly): The anxiety levels would really sort of shoot up. And then I think, oh, you
know, would I be concentrating on the therapy, because I’d be too busy : : : coping with
the anxiety levels.
Surprisingly, perhaps however, feeling stressed or overwhelmed by the brevity or high
focus of their treatment were not issues raised frequently by intensive participants.
Only one participant from this format (Sarah) said that she felt that intensive treatment
was more stressful than weekly:
Sarah (intensive): Perhaps I would have felt more comfortable having the chance to ask a
few more questions and not felt so rushed and keep thinking oh God I’ve only got one day to
go. Maybe – I think it would have been a bit less stressful.
Janet (intensive) actually felt that weekly treatment would have been more stressful
than intensive, due to the lack of daily support; while Mark (intensive) felt that the
pressure of the treatment was an important part of the process of effectively tackling
the problem:
Mark (intensive): I don’t think you really feel overloaded, the OCD feels a bit overloaded,
which will then pressure you, you know, itself, because the OCD’s what’s under attack.
No intensive participants stated that the pressure of intensive treatment had been
overwhelming or had impeded their progress.
Motivation
In contrast, all of the intensive participants mentioned ways in which they had found the
intensive format motivating. These included the momentum and the perceived
thoroughness and power of the therapy in the intensive format.
Momentum. Five of the six intensive participants (Peter, Carole, Sarah, Janet, &
Mark) described the speed and momentum of the therapy as helpful and motivating:
Peter (intensive): I can only guess, if you did the same therapy over a longer period,
once a week, I don’t know if you’d get the same sort of feelings of, you know, sort of really
being fighting it.
This viewpoint was also taken by Kate (weekly):
Kate (weekly): When you first start a treatment, it’s usually very – and I’ve started a lot of
treatments – very frustrated, you’re at the point of – you know, despair in a way, that you
really just want to sort it out quickly.
Perceived power of treatment. Peter, Carole, Rosa, and Mark (intensive) all talked
about the intensive treatment format in ways that implied it was a more powerful,
thorough or energetic approach than weekly treatment:
Peter (intensive): When you do it full-on like that, I think it’s sort of – I think you’re sort of
almost fighting the anxiety more full-on and more positively.
Rosa (intensive): In one way it’s like exploding the whole OCD thing in the fi- in the five
days, that’s what you do. But when you’re doing the weekly thing it’s more – you’re still
treating it gently.
When discussing helpful aspects of the intensive format, participants who had
undertaken it used descriptions including ‘the kick up the bum I think that I needed’
(Peter); a ‘jump-start’ (Rosa); ‘the full hit’, as opposed to a ‘part repair’ (Mark); and
‘bombarding an enemy’ (Mark). Kate (weekly) also perceived intensive treatment as
more thorough:
Kate (weekly): I think you have time to explore possible difficulties more fully, and : : :
that it would seem like a – a thorough way to do it.
Although motivation is a difficult concept to define, and feelings of momentum, power,
thoroughness and energy in confronting the problem difficult to disentangle,
participants who had completed intensive treatment frequently raised aspects of
these issues when discussing the benefits of their own format. These feelings, in
retrospect at least, appeared to be more salient to them than feelings of stress or
pressure. Only one intensive participant (Sarah) felt that the stress of the intensive
format was a drawback, and she stated that this drawback was outweighed by the
benefits of keeping up the momentum of therapy. This is in contrast to the weekly
participants, all of whom felt that intensive treatment would be more stressful than
weekly treatment, and several of whom believed that this would have potentially
deleterious effects on their state of mind, or on their ability to concentrate on the
therapy and make the most of it.
‘Which format would you choose now?’

Participants were also asked which treatment they would choose now if they were to
have it again. From the weekly format, David, Lisa, Laura, and Ann stated a definite
preference for weekly treatment. Kate would definitely have preferred intensive
treatment, and Gareth said that he would prefer intensive treatment if he could be sure
that it was equal in effectiveness to weekly treatment. From the intensive format, all six
participants stated a definite preference for intensive treatment.
Accessibility
Only two participants from each format raised the logistics of attending treatment as a
personally important issue. Kate and Lisa (weekly) both felt that weekly treatment was
easier to fit in with work or study:
Kate (weekly): I think in terms of fitting it in with my work, once a week was good.
However, Carole and Sarah (intensive) felt that intensive treatment was easier to fit in
with work, and also ensured privacy:
Carole (intensive): I just took a week off and pretended I was on holiday, and – so no-one
had – because I didn’t want to have to tell – you know, because – because a lot of my OCD
was – happened in work, I didn’t want to feel that – you know, I don’t think anyone would
have judged me on it, I just didn’t want to feel the pressure of oh God, are they watching
me?
In summary, this did not seem to be an outstandingly important issue for either group of
participants in comparison to many other issues raised. However, this may be a more
important issue for service users living further away, who may have more pressing
practical reasons for preferring a given treatment format.
Discussion
All participants in both formats, including those who were still struggling with
symptoms, were extremely positive about their overall experience of CBT, and both
intensive and weekly participants found their treatment very relevant. The majority of
participants in each format felt that all important issues had been covered during their
therapy; there was no indication that the intensive treatment was perceived as less
adequate in quantity than weekly treatment. However, ongoing support (in the shape of
follow-up sessions and permission to ring the therapist if needed after the end of
treatment) was frequently raised as an important issue by the intensive participants.
Although a preference for ongoing support may also reflect individual differences and
personal circumstances, it seems likely to be a particularly crucial issue following
intensive treatment.
Both intensive and weekly participants were equally positive about the therapeutic
alliance, although participants from the intensive treatment format raised the issue
of having two therapists as a benefit of intensive treatment. Having two therapists
was viewed as providing valuable extra perspectives, and was not described as
overwhelming or problematic in terms of the power balance.
The perceived accessibility of the two formats was rarely mentioned as an issue.
This may be a more important issue for service users living further away, who may have
more pressing practical reasons for preferring a given treatment format, but due to
the selection criteria employed in the present study this remains a speculation.
When participants were asked to discuss the benefits and drawbacks of the two
treatment formats, two broad perspectives arose. Reasons for preferring weekly
treatment included the benefits of having time to learn, reflect and practice, and to ensure
that all important issues were covered. In addition, those preferring weekly treatment
were concerned that intensive treatment might be too stressful, and might even prevent
them from progressing in therapy. Conversely, reasons for preferring intensive treatment
included the efficiency of intensive treatment; the benefits of having no time to think,
worry or ruminate; having daily support from the therapist; being able to concentrate
fully on the therapy without distractions; and the relative ease of confronting deeply
buried issues during daylong sessions. In addition, those preferring intensive treatment
described having found the perceived power, momentum, thoroughness and energy of
the intensive treatment motivating rather than stressful or overwhelming.
All six of those who had undergone intensive treatment said that they would choose
it again. Two members of the weekly format would also choose the intensive treatment,
whilst the remaining four preferred the weekly format. It should be noted that the
intensive participants, by the nature of the study, had already chosen their treatment
format. The majority (five out of six) of participants from the weekly format did not have
a choice of treatment. This could be a reason for the divided preferences of the weekly
participants.
Many of the issues raised by participants can be considered in the light of non-
specific therapy factors identified in previous research as contributing to treatment
outcome. Devilly and Borkovec (2000) have identified expectancies for treatment as a
predictor of treatment outcome, and issues contributing to treatment expectancy were
raised by both weekly and intensive participants. For example, participants from the
weekly format expressed doubts as to whether an intensive week would be long enough
to secure lasting change, while intensive participants expressed beliefs as to the
superior power of the intensive format. Although it may be that participants’ beliefs
developed retrospectively to treatment, any such beliefs existing prior to or during
therapy could affect engagement with treatment in a particular format, and perhaps
impact on treatment outcome.
In terms of treatment credibility, participants were not asked specifically to
comment and did not tend to volunteer opinions regarding such issues as to how logical
the treatment appeared to them, although they unanimously felt that the therapy was
relevant and appropriate to their problems. However, a theme that arose despite no
questions being asked about it was the importance of feeling that the problem was
accurately understood. Feeling that the therapist is fully able to understand the problem
may be an important factor in treatment credibility and expectancy for change.
In terms of motivation, some interesting issues were apparent. Motivation to engage
in therapy has often been conceptualized as existing within the service user, or perhaps
in interactions between service user and therapist (e.g. Zuroff et al., 2007) rather than as
a result of interactions between service user and treatment conditions. All participants
in this study had high levels of motivation to change. However, many of them reported
difficulties with following through on that motivation, in terms both of completing
homework and of identifying distressing beliefs whilst in therapy. These participants all
had something to say about the impact of their treatment format on their motivation
levels (for example, that having daily support from the therapist facilitated homework
completion; that longer sessions facilitated more disclosure; or alternatively that having
more space between sessions facilitated motivation by being less overwhelming).
The impact that therapy characteristics may have on initial motivation is a question of
interest, particularly in terms of service development.
The quality of the therapeutic alliance is perhaps the most-studied of the common
factors (Martin et al., 2000), and is believed to have a consistent impact on treatment
outcome regardless of treatment modality. There has been considerable debate as to
how the alliance should be defined, including which factors or processes are of
importance in predicting outcome (e.g. Hovarth & Luborsky, 1993); and whether such
factors work in the same ways across treatment modalities (DeRubeis, Brotman,
& Gibbons, 2005). In the current study, participants spontaneously reported a number
of benefits of their relationship with their therapist: feeling understood (which may
relate to treatment credibility and expectancies for outcome); feeling supported (which
facilitated homework completion and toleration of high levels of anxiety); and the
usefulness of having outside perspectives on the problem.
In summary, there are some indications that there may be interesting relationships
among non-specific factors impacting on therapy outcome. It appears probable that
aspects of such relationships may be heavily context-specific, as in the present study;
and detailed investigation of their interactions in context (e.g. within a given service or
similar services) may provide a useful research strategy in addition to general theories
spanning treatment modalities. In addition, such investigation could provide clinically
useful data on how best to maximize the positive impact of these factors in terms of
treatment acceptability, adherence, and outcome within the services studied.
Qualitative analytic techniques may be well placed to initially examine such
relationships in detail, and are capable of contributing both to broader theories and
to small-scale service development research.
An important limitation of this study relates to the generalizability of the findings.

The study was limited to a small number of participants treated at a single site, and only
treatment completers were included in the study. A future study recruiting service users
who chose to discontinue therapy could provide particularly useful insights into the
factors which make therapy difficult or unacceptable to some users. Another limitation
relates to the fact that the intensive participants had all actively chosen their treatment,
while the majority of the weekly participants did not. It is very possible that choosing
one’s treatment may impact independently of outcome on its perceived helpfulness, and
hence limit the comparability of the two formats. Finally, this study is based entirely on
retrospective report, and issues seen as important retrospectively may differ from those
most salient at different times during therapy. Considering service user perspectives at
various time points throughout therapy could be an illuminating approach, potentially
enabling services to enhance treatment credibility and acceptability at all stages of
delivery.
In conclusion, this study demonstrates that there are individual differences in
preference for treatment format, and that what one service user perceives as helpful
(for example, time to reflect) another may perceive as unhelpful. Given this, service
users who chose to undertake their treatment within an intensive format perceived
many benefits in that format. Far from perceiving it as overwhelming, inadequate in
quantity or too fast in pace, participants experienced their intensive treatment as
powerful, efficient, thorough, and motivating. As is true in therapy in general, a strong
therapeutic alliance may be very important in helping clients to make the best use of
intensive treatment, and the potential for continued support, either in terms of follow-
up sessions, or permission to contact the therapist if times get bad, may be particularly
crucial following intensive treatment. In summary, when initially considered credible by
the service user, delivered by a trusted therapist, and including adequate follow-up and
subsequent support, intensive treatment can be a highly motivating and acceptable
format for the delivery of CBT for OCD.
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Received 24 November 2007; revised version received 27 March 2009

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A qualitative study of the acceptability

Anna Bevan1, Victoria B. Oldfield2 and Paul M. Salkovskis1,2*

174 Anna Bevan et al.

Obsessive-compulsive disorder (OCD) is a chronic and potentially disabling condition

Acceptability of intensive CBT for OCD 175

176 Anna Bevan et al.

Table 1. Participant characteristics

Participant Gender Age OCI (baseline) OCI (post-treatment) OCI (improvement)

Acceptability of intensive CBT for OCD 177

non-specific group work, non-specific counselling, and one-off sessions with a

178 Anna Bevan et al.

Acceptability of intensive CBT for OCD 179

Table 2. Categories arising from thematic analysis

180 Anna Bevan et al.

Acceptability of intensive CBT for OCD 181

Perceived quantity of therapy

182 Anna Bevan et al.

Preference for treatment format

Acceptability of intensive CBT for OCD 183

Time between sessions

Time between sessions (benefits)

184 Anna Bevan et al.

Time between sessions (drawbacks)

Acceptability of intensive CBT for OCD 185

Stress and motivation

186 Anna Bevan et al.

Acceptability of intensive CBT for OCD 187

‘Which format would you choose now?’

188 Anna Bevan et al.

Acceptability of intensive CBT for OCD 189

190 Anna Bevan et al.

An important limitation of this study relates to the generalizability of the findings.

Acceptability of intensive CBT for OCD 191

Received 24 November 2007; revised version received 27 March 2009

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