Practitioner’s Corner
THRÖSTUR BJÖRGVINSSON, PhD, ABPP
Outcomes of Specialized Residential Treatment for
Adults with Obsessive-Compulsive Disorder
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Cognitive-behavioral therapy (CBT) utilizing
exposure and response prevention for obsessive-
compulsive disorder (OCD) has typically been
studied in the context of time-limited treatment
conducted in outpatient settings. However, in
practice, patients vary in their response to such
treatment, and some require more prolonged
participation to obtain optimal benefit. An inten-
sive residential program is one alternative for
patients who do not improve in traditional out-
patient treatment. This naturalistic study evalu-
ated 46 patients with a primary diagnosis of OCD
who received intensive residential treatment
between 2004 and 2008. Patients entering the
program completed assessments at admission
and at discharge. Results indicated statistically
significant improvements on all outcome meas-
ures, with 60.9% of patients meeting criteria for
clinically reliable change in OCD severity and
37% achieving high end-state functioning.
Specialized residential treatment seems effective
for treatment-refractory OCD, although future
controlled trials with larger samples are needed.
(Journal of Psychiatric Practice 2013;19:429–437)
KEY WORDS: cognitive-behavioral therapy, obses-
sive-compulsive disorder, treatment-resistant, treat-
ment effectiveness, residential, exposure and response
prevention
Obsessive-compulsive disorder (OCD) is a pervasive
anxiety disorder characterized by the presence of
obsessions and/or compulsions. Once considered rel-
atively rare, the lifetime prevalence of OCD has
been found to be between 2% and 3%.1,2 OCD often
has a profound effect on an individual’s quality of
life, and a third of those who suffer from OCD are
unable to work.3 Moreover, the World Health
Organization ranked OCD among the 20 most debil-
itating illness-related conditions for individuals
15–44 years of age.4
Journal of Psychiatric Practice Vol. 19, No. 5
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JOHN HART, PhD
CHAD WETTERNECK, PhD
TERRI L. BARRERA, PhD
GREGORY S. CHASSON, PhD
DANA M. POWELL, PhD
SUSAN HEFFELFINGER, PhD
MELINDA A. STANLEY, PhD
Pharmacological and behavioral treatments for
OCD are well established.5 The most prominent
pharmacological interventions used to treat OCD are
serotonin reuptake inhibitors.6,7 In addition, aug-
mentation strategies using other classes of medica-
tions (e.g., atypical antipsychotics, mood stabilizers)
have shown some efficacy, but the long-term effects
of any pharmacological interventions are unknown.6
Regardless, a significant number of patients do not
respond to medication, and relapse rates after med-
ication discontinuation vary but are typically high,
ranging from 45% to 89%.8,9
Exposure and response prevention (ERP), which is
a form of cognitive-behavioral therapy (CBT), is an
effective treatment for OCD,10,11 producing an aver-
age reduction in symptoms of 48% when treatment
is conducted in outpatient settings.12 A large, multi-
site trial demonstrated that ERP alone and ERP
plus clomipramine produced similar outcomes,
although both were more effective than clomipra-
mine alone, and all treatment conditions were more
At the time of the study: BJÖRGVINSSON, POWELL, and HEF-
FELFINGER: The Menninger Clinic and Baylor College of
Medicine, Houston, TX; HART and BARRERA: The Menninger
Clinic; WETTERNECK: University of Houston-Clear Lake; CHAS-
SON: Towson University, Towson, MD; STANLEY: Baylor College
of Medicine and Michael E. DeBakey VA Medical Center, Houston.
Currently: BJÖRGVINSSON: the Houston OCD Program and
McLean Hospital/Harvard Medical School; BARRERA:
University of Houston; POWELL: Michael E. DeBakey Veterans
Affairs Medical Center; HEFFELFINGER: the Houston OCD
Program.
Copyright ©2013 Lippincott Williams & Wilkins Inc.
Please send correspondence to: Thröstur Björgvinsson, PhD,
ABPP, Director, Houston OCD Program, 1401 Castle Court,
Houston, TX 77006. tbjorgvinsson@houstonocd.com
This material is based upon work partially supported by the
Department of Veterans Affairs, Veterans Health Administration,
Office of Research and Development, and the Houston VA Health
Services Research and Development Center of Excellence
(HFP90-020). The views expressed are those of the authors and
do not necessarily reflect the position or policy of the Department
of Veterans Affairs, the United States government, or Baylor
College of Medicine.
DOI: 10.1097/01.pra.0000435043.21545.60
September 2013 429
 Practitioner’s Corner
effective than placebo.13 ERP has also demonstrated
superior maintenance of gains at follow-up relative
to medication.14,15
Unfortunately, the impressive efficacy rates of
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ERP for OCD are slightly misleading, as studies
report refusal rates of 25%–30% and treatment
dropout rates of 28%.16 Therefore, a significant num-
ber of patients with OCD do not benefit from outpa-
tient treatment alone, suggesting a need for more
intensive and comprehensive treatment to poten-
tially improve response rates. A number of variables
may contribute to poor treatment response, includ-
ing comorbid severe depression and personality dis-
orders, symptom severity, and motivational
factors.17,18 High expressed emotion, hostility, and
criticism in the family environment are also associ-
ated with poorer behavior therapy outcomes, as are
nonadherence and unwillingness to collaborate fully
in ERP.19,20 Problems with treatment adherence
may in part be related to motivational factors asso-
ciated with the lack of a positive therapeutic
alliance.21,22 While the exact underlying factors are
not clearly understood, it is widely accepted that
some patients are refractory to outpatient treatment
and there is a need for improved treatment delivery
methods.
One such delivery method is specialized residen-
tial treatment. Treatment of this type may be bene-
ficial when a patient is unable to complete ERP
without close supervision, is severely depressed, or
does not have cooperative family members or signif-
icant others to support treatment at home.23 In addi-
tion, OCD is often comorbid with other psychiatric
disorders, requiring more complex and time-con-
suming treatment planning and delivery.24
Specialized residential treatments may also be a
viable alternative when generic inpatient treatment
fails (because generic inpatient programs generally
focus on stabilization and not on specialized treat-
ment of OCD) or when no specialized outpatient
behavior therapy for OCD is available.
One major advantage of residential treatment for
OCD is that it can help remove environmental bar-
riers for the patient with treatment-refractory OCD.
Clinical levels of severity are associated with serious
interpersonal problems.25 Due to the debilitating
effects of OCD, there is often a high degree of care-
giver burden for family members, especially when
the patient is dependent on his or her family for
financial and emotional support.26 Family accommo-
430 September 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
dations, defined as behaviors of relatives or friends
that assist the individual with OCD in completing
rituals or avoiding obsessional fears, occur in up to
89% of those who suffer from OCD.27 These behav-
iors often lead to further family distress and higher
levels of hostility and criticism, both of which con-
tribute to poorer treatment outcomes and a greater
chance for relapse.28 Although treatment ultimately
needs to focus on helping the patient adapt to his or
her home environment, intensive treatment away
from an accommodating environment may be useful.
Another significant advantage of treating OCD in
a residential setting is the availability of staff 24
hours per day and 7 days per week to help block rit-
uals and provide support for patients to complete
challenging ERP sessions. A residential environ-
ment also allows for physical aids (e.g., locked bath-
rooms) to help reduce rituals, such as hand washing
or body checking. In addition, the specialized resi-
dential milieu setting provides powerful peer sup-
port, relief from the isolation that many of those
with OCD experience, and opportunities to better
recognize symptoms and learn more about treat-
ment through the modeling of peers. Having easy
access to staff may increase medication adherence
and facilitate the resolution of medication side
effects and/or effectiveness of the medication regi-
men. Close medical supervision also allows the
treatment team to attempt unconventional medica-
tion augmentation strategies that may be difficult
to implement in an outpatient setting (e.g., d-
cycloserine).29
Despite the potential benefits of specialized resi-
dential treatment, very few studies have addressed
its effectiveness, because controlled trials are diffi-
cult to conduct in naturalistic settings due to the
financial and time commitments required of
patients, as well as patients’ complex clinical pre-
sentations involving acute (e.g., potentially lethal)
and highly comorbid symptoms across a wide range
of psychopathology. However, to date, at least three
naturalistic studies have suggested that specialized
residential or inpatient care for OCD is effective.
First, a study of 403 residential adults with treat-
ment-refractory OCD found that mean OCD severi-
ty was reduced by 30% after intensive residential
treatment.30 Significant improvements also
occurred in depression severity and psychosocial
functioning. Second, in a smaller study of 23 adoles-
cents, 70% of patients treated in a specialized resi-
Journal of Psychiatric Practice Vol. 19, No. 5

dential program experienced clinically significant
improvement.31 Third, Boschen and colleagues
reported on the effectiveness of specialized inpatient
treatment for 52 adult patients with OCD.32
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Clinically significant reduction in OCD severity was
evident in as much as 52% of the sample. However,
enrollment in the Boschen study was so exclusion-
ary that results may not generalize to other resi-
dential or inpatient programs for OCD. For example,
in the Boschen et al. study, patients were required to
present with profoundly severe OCD, as well as a
history of two unsuccessful trials of serotonin reup-
take inhibitors, two unsuccessful CBT trials, and
failure of pharmacological augmentation strategies.
Lastly, patients could only be admitted with suffi-
cient justification for 24-hour nursing assistance
(e.g., they presented as suicidal or homicidal). These
stringent criteria exclude a substantial number of
patients with severe OCD who might benefit from
specialized residential treatment.
Björgvinsson et al. suggested that specialized res-
idential treatment may be helpful in reducing com-
mon clinical and cognitive correlates of OCD (e.g.,
trait anxiety and obsessive beliefs) among adoles-
cents,31 yet no studies to date have investigated
these correlates over the course of residential treat-
ment with adult patients. Thus, the current study
set out to address this void in the research litera-
ture. In addition, while the Boschen et al. outcome
study provided evidence of clinically significant
change using a standard index, such as the Reliable
Change Index (RCI),33 the results may not general-
ize to other specialized inpatient or residential pro-
grams for OCD, given the study’s inclusion
criteria.32 Thus, one goal of the current study was to
replicate the evidence for clinically significant
change in a broader clinical sample. We present data
from adult patients with primary diagnoses of OCD
treated in The Menninger Clinic OCD Treatment
Program, a specialized residential facility. All
patients had significant psychosocial dysfunction
and poor response to outpatient therapeutic inter-
ventions. Anecdotally, most patients had made pre-
vious attempts at CBT with a strong focus on ERP.
We expected statistically and clinically significant
decreases in OCD severity, depressive symptoms,
trait anxiety, and obsessive beliefs, as well as an
increase in quality of life. A secondary exploratory
analysis of correlates of OCD symptom change was
also conducted.
Journal of Psychiatric Practice Vol. 19, No. 5
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Practitioner’s Corner
METHODS
Participants and Procedures
Participants completed an assessment battery with-
in the first week of admission and again during the
week prior to discharge. The residential program and
treatment delivery are described elsewhere.31
Approval for this study was granted by the Baylor
College of Medicine Internal Review Board.
A total of 120 adults with a primary diagnosis of
OCD (conferred by the treatment team, consisting of
staff psychiatrists and psychologists with expertise
in the diagnosis and treatment of OCD) were admit-
ted between August, 2004, and February, 2008. For
46 of these patients, discharge precluded completion
of the assessment battery. Reasons for the discharge
included transfer to another unit (e.g., inpatient) for
treatment of other psychiatric symptoms, financial
concerns, nonadherence with unit structure, and the
decision to pursue alternative treatment elsewhere.
An additional 22 patients were unable to complete
the assessment for various reasons, including OCD
symptoms that directly interfered with question-
naire completion (n = 10; e.g., fears of contamination,
doubts about accurate completion of items), data-
coding errors (n = 8), and patient refusal (n = 4). Six
other patients, 3 with significant cognitive impair-
ment and 3 with prominent psychotic symptoms,
were also excluded. Thus, analyses in this study were
conducted with 46 adult patients with a primary
diagnosis of OCD who completed the Yale-Brown
Obsessive Compulsive Scale–Self Report (Y-BOCS-
SR)34 at both admission and discharge. The Y-BOCS-
SR was the first measure that patients filled out at
discharge, but not all patients completed all meas-
ures at discharge as they moved down the list of
measures to complete. For example, of the 46
patients who completed the Y-BOCS at admission
and discharge, only 26 completed the Schwartz
Outcome Scale (SOS-10)35 at both admission and dis-
charge.
The mean age of the sample was 32.5 years (stan-
dard deviation [SD] = 11.2; range, 18 to 55 years).
The sample was primarily Caucasian (89%) and
included 18 men and 28 women. Most of the sample
(89%) had comorbid diagnoses (mood disorder 78%,
anxiety disorder 26%, personality disorder 22%, alco-
hol/substance-related disorder 17%, eating disorder
4%, attention-deficit/hyperactivity disorder 4%,
September 2013 431
 Practitioner’s Corner
developmental disorder 4%, somatoform disorder
2%, dissociative disorder 2%, and OCD spectrum dis-
order 2%). Patients stayed in treatment an average
of 6.2 weeks (SD = 7.5; range = 2–12 weeks). To be
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included in the study, patients needed to receive at
least 2 weeks of treatment.
Measures
Outcome measures assessed severity of obsessive-
compulsive symptoms, obsessive beliefs, anxiety,
depression, and quality of life.
Obsessive compulsive symptoms. Severity of obses-
sive-compulsive symptoms was measured with the Y-
BOCS-SR,34 which includes 10 items, each rated using
a five-point Likert scale ranging from 0 to 4, with
higher scores indicating greater severity. The 10
items, which assess distress, frequency, interference,
resistance, and symptom control for both obsessions
and compulsions, yield three scores, an Obsessions
Severity Score (range = 0–20), a Compulsions Severity
Score (range = 0–20), and a Total Score (range =
0–40), with a Total Score of 16 commonly used as the
clinical cut-off.29 The Y-BOCS-SR Total Score has
demonstrated good test-retest reliability (0.80), and
convergent reliability between the self-report and
interview versions (0.75).34 Internal consistency in the
current sample ranged from acceptable (Y-BOCS-SR
Obsessions ␣ = 0.72) to good (Y-BOCS-SR
Compulsions ␣ = 0.86 and Total ␣ = 0.81).
Obsessive-compulsive beliefs. Obsessive-compul-
sive beliefs were assessed with the Obsessional
Belief Questionnaire (OBQ-44),36 a 44-item measure
revised from the original 87-item version measuring
obsessional beliefs. In addition to the total score, the
OBQ has three subscales: Responsibility/Threat
Estimation (RT), Perfectionism/Certainty (PC), and
Importance/Control of Thoughts (ICT). RT refers to
the tendency to feel overly responsible for surround-
ing events and to over-estimate the likelihood of
threat in a given situation. PC pertains to the need
for perfection and certainty of outcomes in a variety
of situations. ICT addresses the weight one places on
how thoughts define us and whether they need to be
controlled. Responses are on a seven-point Likert
scale, and higher scores are associated with stronger
obsessive beliefs. The OBQ-44 has sufficient criteri-
on-related and convergent validity, and the measure
432 September 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
successfully distinguishes between samples with and
without OCD.36 Internal consistency in the current
sample for the OBQ (␣ = 0.72) total score was ade-
quate, and subscale alphas were excellent (OBQ-RT
␣ = 0.96, OBQ-PC ␣ = 0.94, and OBQ-ICT ␣ = 0.92).
Anxiety. Anxiety was measured with the State-Trait
Anxiety Inventory,37 which is a 40-item measure
made up of a 20-item state anxiety scale and a 20-
item trait anxiety scale. Scores on both the state and
trait scales range from 40 to 80, with higher scores
indicating higher levels of anxiety. This study used
only the trait anxiety subscale scores, which have
demonstrated good test-retest reliability.37 Internal
consistency for the trait subscale in the current sam-
ple was excellent (␣ = 0.91).
Depression. Depressive symptoms were evaluated
with the Beck Depression Inventory (BDI),38 a well
known 21-item self-report measure of depression.
Although a newer version of the BDI is available
(BDI-II), we used the BDI given its rich clinical
research background and strong psychometric proper-
ties. Scores range from 0 to 63, with higher scores
associated with greater levels of depression. A score of
10 typically indicates at least some clinical symptoms
of depression.39 Concurrent validity and test re-test
reliability of the BDI are good,40 and internal consis-
tency in the current sample was excellent (␣ = 0.87).
Quality of Life. The Schwartz Outcome Scale (SOS-
10)35 is a 10-item self-report scale that measures
individual quality of life over the previous 7 days.
Total scores range from 10 to 50, with higher scores
indicating greater quality of life. The SOS-10 corre-
lates in the expected directions with measures of
psychopathology, hopelessness, and psychological
well-being.35 Finally, the SOS-10 has shown sensitiv-
ity to treatment change in an inpatient psychiatric
sample.30,35,41 Internal consistency in the current
sample was good (␣ = 0.87).
Analytic Approach
Multiple dependent samples t-tests were conducted
on outcome scores at admission and discharge.
Bonferroni corrections were applied in order to con-
trol for inflated Type I error as a result of carrying
out multiple statistical tests. Within-group effect
sizes for each variable were computed using Cohen’s
Journal of Psychiatric Practice Vol. 19, No. 5
 Practitioner’s Corner

Table 1. Descriptive data, t-test results, within-group Cohen’s d, and percentage of patients with
reliable change or high end-state functioning
Admission Discharge RCI High end-state
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Na Mean (SD) Mean (SD) t d n (%) functioning n (%)

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Y-BOCS-SR-Total 46 26.5 (5.9) 19.0 (7.6) 6.68* 1.10 28 (60.9) 17 (37.0)

BDI 34 21.8 (10.6) 11.8 (8.8) 5.95* 1.03 21 (61.8) 12 (35.3)
SOS-10 26 22.1 (9.0) 31.5 (10.3) –4.46* –0.97
STAI-T 36 60.3 (11.7) 50.5 (13.8) 5.42* 0.77
OBQ-RT 31 66.0 (27.0) 53.1 (23.8) 3.14* 0.51
OBQ-PC 31 76.0 (22.2) 61.2 (23.7) 3.42* 0.64
OBQ-ICT 31 41.2 (18.2) 28.7 (16.9) 4.62* 0.71
aDifferential n across measures is due to item level missing data, which resulted in case-wise deletion patterns that were unique

across individual analyses.

*p < 0.006 (p-value based on a Bonferroni correction—alpha of 0.05 divided by 9, the total number of tests)
RCI = Reliable change index; Y-BOCS-SR Total = total score on the Yale-Brown Obsessive Compulsive Scale–Self Report;
BDI = Beck Depression Inventory; SOS-10 = Schwartz Outcome Scale; STAI-T = State-Trait Anxiety Inventory–Trait;
OBQ-RT = Obsessional Beliefs Questionnaire–Responsibility and Threat Estimation subscale;
OBQ-PC = Obsessional Beliefs Questionnaire–Perfectionism and Certainty subscale;
OBQ-ICT = Obsessional Beliefs Questionnaire–Importance/Control of Thoughts subscale

d. Clinical significance of symptom change was eval-
uated for two outcome measures, the Y-BOCS-SR and
the BDI, using two methods: 1) the reliable change
index (RCI)33 and 2) a measure of end-state function-
ing. We calculated RCI for these two measures using
published normative data from non-clinical samples;
we computed confidence intervals to define the
thresholds of reliable change using a standard cut-off
score of two standard deviations (RCI = 1.96).
Patients who demonstrated reliable change and dis-
played post-treatment scores in the non-clinical to
mild range on the same measure (Y-BOCS-SR < 16;
BDI < 10) were categorized as achieving high end-
state functioning on that measure. Secondary analy-
ses were conducted to explore correlates of change in
OCD symptom severity, as well as OCD severity
scores at discharge, as assessed by the Y-BOCS-SR.
Variables of interest included initial OCD and
depression severity, and initial OBQ, STAI, and SOS
scores, as well as symptom change on all measures.
RESULTS
All outcome variables demonstrated a statistically
significant improvement from admission to discharge
(Table 1), and effect sizes were moderate to large.42
RCI scores indicated reliable decreases in symptom
severity in 60.9% of patients on the Y-BOCS-SR and
61.8% of patients on the BDI. In addition, 37% of
patients achieved high end-state functioning accord-
ing to the Y-BOCS-SR, and 35.3% achieved high end-
state functioning based on BDI scores.
Table 2 provides data on the relationship between
potential correlates of treatment outcome and Y-
BOCS-SR change scores and Y-BOCS-SR scores at
discharge. The results indicated that baseline OCD
symptom severity, change in depressive symptoms,
and change in beliefs associated with responsibility
and threat estimation were significantly associated
with OCD change scores. Lower baseline OCD sever-
ity and greater improvement in OCD beliefs and
depressive symptoms were associated with greater
change in OCD symptoms after treatment. In addi-
tion, except for state anxiety (which bordered on sta-
tistical significance at p = 0.06), all symptom changes
correlated with end-state Y-BOCS scores. A greater
change on the Y-BOCS from admission to discharge
was strongly associated with a lower end-state Y-
BOCS score, but all other symptom measures (e.g.,
depression) indicated that a greater change from
admission to discharge was correlated with higher
end-state YBOCS scores.

Journal of Psychiatric Practice Vol. 19, No. 5 September 2013 433

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 Practitioner’s Corner

Table 2. Relationship between potential correlates of treatment outcome and Y-BOCS-SR change
scores and Y-BOCS-SR post-treatment score
Y-BOCS-SR Y-BOCS-SR
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Severity change score Post-treatment score

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Measures na r p na r p

Score at admission
Y-BOCS-SR 46 –0.40 0.006
BDI 43 –0.06 0.71
SOS-10 44 0.08 0.61
STAI-T 41 0.05 0.77
OBQ-RT 40 –0.27 0.09
OBQ-PC 40 –0.19 0.22
OBQ-ICT 40 –0.19 0.24
OBQ-Total 40 –0.25 0.12
Change score
(admission minus discharge)
BDI 34 0.52 0.002 34 0.36 0.04
SOS-10 26 –0.50 0.009 26 0.46 0.02
STAI-T 36 0.33 0.05 36 0.31 0.06
OBQ-RT 31 0.54 0.002 31 0.54 0.002
OBQ-PC 31 0.39 0.03 31 0.41 0.02
OBQ-ICT 31 0.38 0.04 31 0.38 0.04
OBQ-Total c 31 0.49 0.006 31 0.49 0.005
Y-BOCS-SR 46 –0.71 < 0.001
aDifferential n across measures is due to item level missing data, which resulted in case-wise deletion patterns that were unique

across individual analyses.

Y-BOCS-SR Total = total score on the Yale-Brown Obsessive Compulsive Scale–Self Report;
BDI = Beck Depression Inventory; SOS-10 = Schwartz Outcome Scale; STAI-T = State-Trait Anxiety Inventory–Trait;
OBQ-RT = Obsessional Beliefs Questionnaire–Responsibility and Threat Estimation subscale;
OBQ-PC = Obsessional Beliefs Questionnaire–Perfectionism and Certainty subscale;
OBQ-ICT = Obsessional Beliefs Questionnaire–Importance/Control of Thoughts subscale

DISCUSSION symptoms. Over half of these patients (60.7% or 37%

In this naturalistic study of treatment outcomes for
adult residential patients with a primary diagnosis of
OCD, patients reported statistically significant
reductions in OCD symptoms as well as obsessive
beliefs, depression, and trait anxiety. Effect sizes for
reductions in OCD symptoms and depression severi-
ty were medium to large and comparable to or
greater than those reported in previous residential
treatment program studies.30 In addition, patients
reported an increase in quality of life over the course
of treatment. RCI analysis showed that 60.9% of
patients had reliable decreases in severity of OCD
of the total sample) achieved clinically significant
change (i.e., a Y-BOCS-SR score < 16). This is a
notable finding because scores below 16 are commen-
surate with results found in outcome studies using
outpatient groups.29,34 Many outcome studies of OCD
treatment set an inclusion criterion for OCD severity
of a score of 16 or greater on the Y-BOCS. This sug-
gests that our high end-state functioning patients (as
assessed by the Y-BOCS-SR) would no longer be eli-
gible for OCD trials.29,34 Similarly, 61.8% of patients
demonstrated reliable decreases in BDI scores, and
57.1% of these patients reported high end-state func-
tioning according to the BDI (35.3% of the patients

434 September 2013 Journal of Psychiatric Practice Vol. 19, No. 5

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

who completed the BDI on discharge). These clinical-
ly significant reductions on the BDI in this smaller
subset of patients are important, because a primary
goal of residential treatment involves reducing symp-
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tomatology to a level at which the patient can transi-
tion successfully to outpatient treatment. Overall,
rates of reliable change in the current study were
larger than those reported by Boschen et al.,32
although this may reflect differences in the samples.
In the Boschen et al. study, patients were admitted
based on a strict set of inclusion criteria, resulting in
a subset of patients with highly severe and treat-
ment-refractory OCD. Therefore, it is not surprising
that such a group might be slightly less responsive to
treatment.
In our sample, baseline OCD symptom severity, as
well as changes in depression and threat estimation,
were significant correlates of change in OCD severi-
ty. Because the data are correlational in nature, it is
not clear whether clinically significant change
occurred first in depression, or in OCD severity, or
whether change occurred in both simultaneously.
Regardless of the specific relationship between
depression and OCD severity, previous studies have
shown that comorbid depression has a negative
impact on the effectiveness of ERP in outpatient set-
tings.43–45 Interestingly, in our sample, depression
scores at admission were not significantly related to
change in Y-BOCS-SR scores, a result supported by
existing literature concerning groups with treat-
ment-refractory OCD.30,31 This finding can potential-
ly be explained by the nature of intensive specialized
residential psychiatric care. Residential milieu treat-
ment can work flexibly with comorbid depression
and OCD by tailoring treatment in a manner that
increases effectiveness. Within residential programs,
substantial resources are allocated to the full range
of clinical and psychosocial problems faced by
patients. Such resources are not as plentiful in an
outpatient setting, suggesting that certain problems
must be targeted in lieu of others. Furthermore, the
structure of the 24-hour, 7-day/week residential ther-
apeutic community may provide a behaviorally acti-
vating experience for depressed patients through
increased activity and socialization. The integration
of daily structure is not a common therapeutic ele-
ment in outpatient settings.
This study also raises questions about the role of
obsessive beliefs in maintaining OCD. Changes in
obsessive beliefs were associated with changes in
Journal of Psychiatric Practice Vol. 19, No. 5
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Practitioner’s Corner
OCD severity from pre- to post-treatment. Studies
of outpatient CBT have found similar results.46
However, metacognitive beliefs associated with
OCD, particular those concerning the need to con-
trol one’s thoughts and one’s positive beliefs about
worry, were stronger correlates of improvement
compared to obsessive-compulsive beliefs as meas-
ured by the OBQ-44.46 Further research is needed
to tease apart the cause and effect of cognition dur-
ing OCD treatment.
Changes in depression, OCD beliefs, and OCD
severity over the course of treatment were signifi-
cantly correlated with OCD severity at discharge. A
larger change in Y-BOCS severity from admission to
discharge was strongly correlated with less OCD
severity at discharge. This is unsurprising given that
the treatment program was designed specifically to
address OCD severity. However, all other secondary
symptom indices (e.g., depression) indicated that
more change from admission to discharge was associ-
ated with higher OCD severity at discharge. It is pos-
sible that patients with more severe presentations of
secondary clinical correlates (e.g., depression) change
the most in treatment, but still end therapy at a high-
er level of severity compared with those who present
with less severe clinical correlates. This finding may
also reflect a statistical artifact—regression to the
mean—since those with more severe clinical corre-
lates, such as depression, may exhibit larger drops in
severity, moving towards the mean. Further research
is needed to clarify this finding.
This study had several limitations. First, the sam-
ple size was relatively small, precluding more sophis-
ticated statistical analyses, including the use of
control variables (e.g., time in treatment).
Furthermore, given the naturalistic setting of the
study, a comparison group and randomization were
not possible. Fewer instances of treatment dropout,
and a lower percent of missing data, would have
enhanced the generalizability of the findings, but the
attrition rates in the current study were comparable
to other outcome studies of intensive residential
treatment for OCD.30 Retaining patients in treat-
ment is a ubiquitous problem faced by mental health
care providers.47 In addition, residential care often
attracts patients who refused or dropped out of more
traditional treatment approaches. Thus, it is a
strength of residential care that it can facilitate
treatment completion among patients who are prone
to treatment refusal or dropout. Another potential
September 2013 435
 Practitioner’s Corner
limitation is that some patients required staff assis-
tance to complete assessment batteries due to severi-
ty of symptoms (e.g., doubting obsessions, re-reading
rituals), and it is possible that observation of respons-
Downloaded from http://journals.lww.com/practicalpsychiatry by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIH
o4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 08/16/2023
es and interaction with the patients had an impact on
patients’ self-report. It would be advisable for future
naturalistic studies to document reasons for non-
completion in a more systematic fashion. The accura-
cy of self-reports of symptoms may also be limited,
and future research would benefit from incorporating
multiple methods and informants when measuring
OCD and clinical correlates. Finally, outcome studies
of specialized residential treatment for OCD would
benefit from follow-up data to determine the long-
term effectiveness of the treatment approach.
In conclusion, this study suggests that residential
treatment is effective in reducing severity of obses-
sive-compulsive symptoms and beliefs, depression,
trait anxiety, and poor quality of life. Most impor-
tantly, these improvements occurred in a sample
that is characterized by outpatient treatment fail-
ure. Thus, intensive residential treatment for OCD
may bring about meaningful improvement when all
other treatment has failed, offering hope for patients
with treatment-refractory illness.
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