The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 5
5 - Highly Usable
The intervention has operationalised principles and values, core components that are measurable and observable, a fidelity assessment, identified modifiable components
Core Components
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used in the treatment of a variety of mental health disorders. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours within a person’s environment and how alterations in one domain can impact other domains. CBT therefore helps people to notice, understand and question their thinking, emotions and behaviour to facilitate changes in areas that are unhelpful.
In the context of Obsessive-Compulsive Disorder (OCD), CBT includes cognitive and behavioural strategies that aim to change OCD associated thoughts and behaviours and develop more helpful alternatives. These strategies include: 1) Cognitive strategies that address unhelpful cognitions related to obsessions; 2) Exposure Response Prevention (ERP) - a behavioural strategy specifically designed for OCD management. ERP involves the systematic introduction of anxiety/ obsession provoking triggers. This is for the purpose of confronting fears, increasing tolerance, and reducing the urge to engage in compulsive behaviours.
Core components of CBT (that includes ERP for the treatment of OCD) are:
- Assessment, education, and treatment planning. This includes a) psychoeducation to increase knowledge on the nature of OCD; improve understanding of the CBT/ ERP treatment model by collaboratively developing an individualised formulation, increasing knowledge of the cycle of maintenance of OCD; b) information gathering as it relates to patient symptoms, as well as external and internal triggers; and the content of the patient's obsessions and compulsions; and c) making a treatment plan to systematically approach fears without engaging in rituals;
- Cognitive processing to identify and challenge the range of cognitive processes that maintain the OCD symptoms. This is intended to help patients address unhelpful understanding of situations, and create new beliefs about the meaning of the obsessions;
- Behavioural experiments are also used to explore and test the meanings underpinning OCD to develop new beliefs and insights to help overcome OCD;
- Exposure-response prevention therapy (including in vivo and imaginal exposures) to trigger the anxiety provoking situation in the absence of compulsive response to learn about the habituation of anxiety.
CBT for OCD also includes a homework component which provides opportunities for patients to challenge themselves between sessions, and to generalise the skills learnt to their everyday lives (e.g. symptom monitoring, exposure exercises). Further information on the specific competencies that should be followed when delivering CBT for OCD are outlined in the UCL CBT Competency Framework.
Fidelity
Practitioners delivering CBT for OCD should receive training and ongoing clinical supervision. In particular, practitioners should be aware of the specific theories and approaches underpinning CBT for OCD. Practitioner competence can be monitored and evaluated using appropriate measures, e.g. via recording of treatment sessions and auditing of recorded sessions and rated against a CBT competency assessment tool, such as the Cognitive Therapy Scale-Revied (1) or another similar scale.
Modifiable Components
The number of treatment sessions delivered is dependent on the persons’ degree of functional impairment. Low intensity CBT with ERP, which includes up to 10 therapist hours per patient, is typically delivered to patients with mild functional impairment. More intensive CBT with ERP is typically 16-20 sessions in duration and delivered to patients with moderate to severe functional impairment.
Low intensity CBT (including ERP) can be delivered as brief individual CBT using structured self-help materials; brief individual CBT by telephone, online or as group CBT. People receiving low intensity CBT (including ERP) in group format may receive more than 10 hours of therapy.
CBT (including ERP) for children can involve family or carers and should be adapted to suit their developmental level. Active involvement of parents or carers (e.g. training parents or carers to assist their children with ERP) and specifically targeting family-based factors within the intervention are identified as factors that may contribute to improved outcomes (2,3).
Individual cognitive therapy (without an ERP component) that has been specifically modified for OCD can be considered for individuals with OCD who are unable or unwilling to undergo ERP.
CBT (including ERP) can be delivered in several settings including outpatient settings, hospitals, and residential treatment settings.
Supports - Rating: 5
5 - Well Supported
Comprehensive resources are available to support implementation, including resources for building the competency of staff and organisational practice as a standard part of the intervention
Support for Organisation / Practice
Implementation Support
Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology Adult Mental Health and CAMHS workstreams, including webinars, and supervisor training.
Start-up Costs
There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations.
Building Staff Competency
Qualifications Required
Staff will usually hold an undergraduate degree in a relevant area (e.g. nursing, psychology, medicine) and as a minimum will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).
Training Requirements
Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT is available through the NES Psychology adult and CAMHS workstreams.
Supervision Requirements
Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:
- NES Generic supervision competences training (GSC) (or equivalent)
- NES Specialist Supervision Training: CBT (adult or child focus)
It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills.
Evidence - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Theory of Change
Cognitive theories have been proposed to explain the development and maintenance of OCD.
According to Foa and Kozak’s theory, OCD is characterised by erroneous cognitions that include; a) the overestimation of the likelihood of danger in safe conditions; and b) the exaggeration of the graveness of consequences associated with negative events.
According to Salkovskis’s theory, responsibility is identified a key issue for the onset of obsessions. Catastrophic appraisals of obsessions translate to increased sense of responsibility, which in turn increase anxiety and cause compulsions to exert control over obsessions.
Behavioural theories for OCD include the Mowrer's two-factor theory of fear and avoidance. The theory suggests that, when triggered, anxiety provoking obsessions can prompt avoidant behaviours or compulsions for the purpose of reducing the anxiety associated with the situation. These behaviours reinforce fears, which in turn strengthens both obsessions and compulsions.
Hence CBT, that includes ERP, targets the unhelpful cognitions that are crucial in the transformation of normal unpleasant thoughts into obsessions. It also targets behavioural responses that occur with the triggering of anxiety or obsessions. CBT that includes ERP is therefore expected to help patients challenge their existing fear response, increase tolerance to distress without engagement in unhelpful behaviours, and hence, eliminate avoidance and compulsive behaviours.
Children and Young People - Rating: 5
Children and Young People (CYP) Evidence
A number of studies have evaluated the effectiveness of CBT in CYP. Some of the best available evidence is described below.
A recent meta-analytic study evaluated the effectiveness of CBT with ERP in the treatment of obsessive-compulsive disorder (5). The review included 10 RCTs that involved 537 children and adolescents with an OCD diagnosis. CBT was delivered in group or individual formats.
Another meta-analytic study evaluated the effectiveness of CBT in children and adolescents (aged 4-18 years) with a primary diagnosis of OCD (10). It included nine RCTs (compared to no intervention) with 645 participants. The review included any type of CBT that was defined as CBT by trialists. CBT was delivered in 5-14 planned CBT sessions over 12-14 weeks.
One meta-analytic study also evaluated and compared the efficacy of CBT and SRIs in the treatment of paediatric OCD (7). CBT was delivered as ERP with no cognitive therapy, CT with no ERP (but with behavioural experiments), or the combination (ERP + CT). CBT was offered in individual, group, or family formats, in 12.5 (mean) sessions, over a mean period of 12.7 weeks. Study participants were aged no more than 18 years and had a diagnosis of OCD. Parental involvement is associated with better, more sustainable outcomes (11)
A randomised controlled study evaluated the effectiveness of internet delivered CBT (including ERP) in 67 adolescents (aged 12 to 17 years old) with OCD (12). iCBT was delivered as a clinician and parent- supported programme over a 12-week period.
Another RCT followed up the outcomes from group and individual interventions at 12 and 18mths and included 48 participants. 70% of participants in individual therapy and 84% in group therapy diagnosis free at follow-up at 12 and 18 months (13).
CYP Outcomes Reported
Compared to no intervention (e.g. placebo, waiting list), the following outcomes were observed;
- Significantly reduced OCD symptom severity at post-treatment (5,7,10,12), with even greater improvement observed at 3-months follow-up (12).
- Significantly reduced risk of persisting OCD or significantly improved remission rates at end-of treatment (7,10). Remission rates were significantly increased from post-treatment to follow-up assessment (approximately 9-months later) (7).
- Significantly improved functioning at end-of treatment (10,12), maintained at 3 months follow-up (12).
- Maintenance of recovery in 70% of participants in individual therapy and 84% in group therapy at follow-up at 12 and 18 months (13).
- Significantly reduced anxiety at post-treatment, maintained at 3-months follow-up (12).
Adults - Rating: 5
Adult Evidence
A number of studies have evaluated the effectiveness of CBT (including ERP) in the treatment of OCD. Some of the best available evidence is described below.
A recent meta-analytic study reviewed the outcomes of CBT for OCD in routine clinical care (4). The review included 29 studies (8 randomised controlled trials) that involved 1669 participants.
Another meta-analytic study evaluated the effectiveness of CBT with ERP in the treatment of obsessive-compulsive disorder (5). The review included 26 randomised-controlled trials (RCTs) that involved 1483 adults with OCD diagnosis. CBT was delivered in group or individual formats.
Another meta-analytic study evaluated the effectiveness of low intensity technology-delivered CBT (6). It included 18 RCTs (n=1707), with CBT delivered to include typical CBT elements e.g. cognitive restructuring, ERP or components of third wave CBT. Participants were adults (aged 18 years or over) with OCD diagnosis.
A meta-analytic study also evaluated the effectiveness of CBT in adults with OCD diagnosis (7). It included 37 RCTs with CBT delivered to include elements of exposure and response prevention (ERP) with no components of cognitive therapy, cognitive therapy (CT) with no components of ERP studies, or the combination of ERP and CT. 14.7 (mean) CBT sessions were delivered over a mean period of 12.7 weeks. CBT was delivered face-to-face or remotely, in individual, group or family formats.
One meta-analytic evaluated the effectiveness of CBT for OCD (8). The review included sixteen RCTs (n=756), with 13 of the 16 studies conducted in adults. CBT was delivered in individual or group formats, over 5-23 sessions.
An older meta-analytic study evaluated the effectiveness of cognitive and behavioural approaches in OCD management (3). It included 19 studies, with CBT delivered to include elements of ERP, cognitive restructuring (CR), or a combination of ERP and CR.
One RCT study evaluated the effectiveness of CBT for augmenting serotonin reuptake inhibitors (SRI) in OCD (9). The study included 100 adults, aged 18-70 years, who still had OCD of at least moderate severity despite SRI use for at least 12 weeks prior to entry. 17 sessions of CBT, consisting of exposure and ritual prevention, were delivered twice weekly.
Adults Outcomes Reported
Compared to control conditions (including waiting list, pill placebo, or psychological placebo), the following outcomes were observed;
- Significantly reduced symptoms of OCD (3-9), depression (3,7) and anxiety at post-treatment (7,8). Effect sizes reported remained large at follow-up (approximately 15 months after end-of-treatment) (4,7).
- Significantly improved social adjustment (3,9) and quality of life (9) at post-treatment.
Need
Comparable Population
CBT (including ERP) has been shown to be effective in the treatment of OCD in children, young people, and adults. Its effectiveness has been demonstrated when delivered alone. It has also been shown to be effective when delivered in combination with pharmacological interventions (e.g. SRI) to people with persisting OCD symptoms despite the use of pharmacological interventions.
Desired Outcome
CBT (including ERP) is associated with significant improvements across several outcomes including OCD symptom severity, depression, anxiety, functioning, and social adjustment.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Fit
Values
Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT. In the context of OCD, CBT, which includes ERP, involves cognitive and behavioural strategies that address OCD associated thoughts and compulsive behaviours. Cognitive and behavioural theories that have emerged to understand the development and maintenance of OCD include Foa and Kozak’s theory, Salkovskis’s theory, and Mowrer's two-factor theory of fear and avoidance.
Priorities
CBT (including ERP) for OCD focuses on; 1) cognitive strategies that address unhelpful cognitions and beliefs which are crucial in the transformation of normal unpleasant thoughts into obsessions; 2) exposure therapy, which is the systematic introduction of anxiety/ obsession provoking triggers, and 3) response prevention to reduce the need to engage in compulsive behaviours. CBT (including ERP) therefore aims to help patients confront their fears, increase tolerance, and reduce their urge to engage in compulsive behaviours. CBT (including ERP) can be delivered to children, young people and adults, in individual, group or family formats, either in-person or as a remotely delivered intervention (with varying levels of therapist’s assistance).
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g. psychologists, psychiatrists, or mental health nurses) who have undergone training to support its delivery. CBT can be delivered to patients weekly, typically over 12-15 sessions.
Technology Support
Cognitive Behavioural Therapy can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.
Administrative Support
Low intensity CBT (including ERP) can be delivered in up to 10 therapist hours per patient, and is typically delivered to patients with mild functional impairment. More intensive CBT (including ERP) can be delivered in more than 10 therapist hours per patient, and is delivered to patients with moderate to severe functional impairment. CBT (including ERP) can be delivered remotely or in-person. In-person delivery can be held in several settings including outpatient settings, hospitals, and residential treatment settings. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.
Financial Support
Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
