Group Therapy in Adults with Obsessive-Compulsive Disorder: A Review

In the treatment of OCD, several therapeutic approaches have been developed, including individual, group and/or pharmacological therapeutic methods. However, group therapy on OCD has received little research attention in comparison with other therapeutic methods and some studies demonstrated that OCD can be treated in group settings. In the literature, mentioned group therapies to treat OCD involve behavioral therapy, cognitive therapy, ERP (exposure and response prevention), cognitive behavioral therapy, ACT (acceptance and commitment therapy), supportive groups and individual therapy with family member involvement. In relation to their effectiveness, research indicated inconsistent findings. Therefore, the aim of this study was to address and to review whether group treatments on OCD are efficacious. This review focused on cognitive-behavioral group therapy (CBGT), ERP, and ACT.


Introduction
OCD is defined as having obsessions and/or compulsions. Obsessions, which are persistent and iterative thoughts, impulses, or images, are experienced as intrusive, disturbing, uncontrollable, and undesirable. However, compulsions are repetitious behaviors or mental acts that an individual is driven to enforce due to an obsession or because of her/his own rules that s/he must rigidly apply or that must be strictly applied. Some other obsessive-compulsive and related disorders are featured by preoccupations. Some encompass recurrent body-focused repetitive behaviors (such as skin picking and hair pulling). Obsessive and compulsive symptoms frequently last one hour per day basis and cause significant distress and/or the person's or her/his family functioning is prevented [1]. OCD mainly consists of four symptom patterns that are contamination, pathological doubt, intrusive thoughts, and symmetry [2].
The disorder is a distressing and disabling condition for many individuals and includes recurrent obsessions that generally require compensation attempts through repeated and stereotypical compulsions (such as hand washing, checking things or putting them in order over and over or counting, praying, silently repeating certain words again and again). This behavior pattern often affects life quality in a negative way [3] and leads to a great deal of functional impairment [4]. It is usually a chronic condition which typically begins in adolescence and continues throughout life in general [5]. Affecting 2.5% of the general population, OCD is also the sixth most common psychiatric disorder [6] and is one of the top causes of disability related to illnesses worldwide [7]. Besides the lifetime prevalence in OCD among adults in the USA is nearly around 1% to 3% [8] and one study found that approximately more than 25% of people in the USA experience obsessions or compulsions at some point in their lives [6]. And if left untreated, it apparently leads to deterioration in social and vocational life [9]. Therefore, it should be treated to decrease the symptoms, to enhance the life quality of people and their well-being.
There are a number of therapeutic approaches that individually aim to treat OCD and its symptoms. Along with this, it is documented that OCD can also be treated by group therapy. OCD-related group therapies are mainly CBT followed by ERP and ACT-cognitive-behavioral approaches. However, group therapies on OCD have relatively received little attention and research indicated inconsistent findings. Thus, the need to address OCD group studies in order to describe the current literature regarding group OCD, to evaluate the advantages and disadvantages of the studies, to develop novel treatments, and to assess the effectiveness of the studies has emerged. In this review, it is aimed to evaluate OCD group treatments and to discuss their effectiveness and since cognitive-behavioral approach is the subject of most of the studies, the article focuses on it in particular as well as ERP and ACT.

Literature Review
Because of the fact that the disorder is a multifactorial disorder having various cognitive, emotional and behavioral dimensions, in the treatment of OCD, there are several therapeutic approaches that are approved to be effective in reducing obsessive-compulsive symptoms, to promote a better life and to decrease the rate of relapse. In this regard, among others especially pharmacotherapy, cognitive-behavioral therapy (CBT) and exposure response prevention (ERP) have been found to be effective to treat its symptoms in an array of studies [10]- [15].
Apart from individual practice data showing that the effectiveness of therapeutic methods on OCD, some studies demonstrated that OCD could be treated

Cognitive-Behavioral Therapy (CBT)
Group therapy has its origins in psychodynamic models of psychopathology and developed before CBT. In group therapy, it is viewed that group members' interactions are the tool of change [32]. From the perspective of CBT, it is seen that individuals who have OCD inaccurately interpret situations, objects or thoughts being intrusive as hazardous. By way of cognitive and behavioral treatment strategies, CBT aims at changing/diminishing dysfunctional thoughts that produce anxiety and reducing/replacing behaviors that maintain symptoms [33] [34]. Some studies have proposed that cognitive therapy was an efficient alternative in many cases [35] [36].
In group-CBT, the cognitive-behavioral model given to the group is more than the interaction between the members. It is structured and directive, time-limited and collaborative as in individual CBT [30]. However, group-CBT pays also attention to the therapeutic factors occurring in therapy. Group-CBT encompasses: 1) cognitive restructuring through behavioral experiments, 2) normalizing through identification with others, 3) "in-vivo" exposure, positive reinforcement and vicarious learning in a safe environment, 4) the experience of mastery.
With respect to the effectiveness of CBT, there has been an array of studies.
For example, Cabedo et al. [19] compared the efficacy of individual and group cognitive-behavior therapy for OCD treatment. They took into consideration the change in the severity of OCD in both the short and long term. Forty-two individuals having OCD attended the treatment programs and were assigned to group CBT (n = 24, in four groups) or to individual. Sixteen and twenty-two participants completed the treatments. The Y-BOCS were evaluated at pre-and post-treatment and at the one-year follow-up. At post-treatment the individual CBT treatment had higher recovered rate than group CBT and at follow-up the recovery rate decreased to 62.5% in individual CBT and to 31.8% in group CBT.
That is, group CBT is effectively decreasing OCD symptoms and one year later the post-treatment changes remained unchanged. The finding that group OCD is less effective than individual CBT for OCD is supported by NICE [37].
Conversely, Çelik et al. [38] have reported that group CBT is decreasing the symptoms of obsessive-compulsive disorder in undergraduate students in Turkey. Along with this, in a 1-year follow-up study the results of CBGT were evaluated. The reduction in symptom severity observed at the end of the treatment S. Bulut, M. Subasi Open Journal of Medical Psychology was retained during one year. Eleven of forty-two patients relapsed in the follow-up term [39]. The CBGT's effectiveness is supported by this study but larger and long term-randomized controlled trials are necessary so as to validate this finding.
In a similar context, Haraguchi et al. [23]  Additionally, a study investigated the effectiveness of group-cognitive behavioral therapy versus SSRIs (fluoxetine) for obsessive-compulsive disorder. According to the conclusion, response rates to both treatments were congruent and lower than reported data in the literature. It may be because of the broad inclusion criteria and the resulting sample being more similar to the real setting [44].

Exposure and Response Prevention (ERP)
As well as CBT, ERP systemically and deliberately assists the person to get close his/her most feared thoughts or situations and refrain him/her from an activity which intentionally reduces anxiety [13]. Recently, ERP has grown into a valuable option of treatment. Exposure means exposing to stimulus that invokes fear and response prevention describes behavioral avoidance which relieves rituals, compulsions, and behaviors relevant to safety. In Foa and Kozak's meta-analysis [13], which encompasses 12 ERP studies and 330 OCD patients, it is reported that among patients there is an 83% response rate. However, ERP has high drop-out rates and low-level commitment.
In a pilot study, whether intensive ERP group treatment for OCD was effective was addressed. Six individuals whose OCD symptoms were basically different from each other engaged in the study and they had a long history of OCD, four having the disorder since childhood or early adolescence years. With prolonged exposure training on second and third day, the treatment which was designed as one long session, was conducted for four successive days. All of the patients stated high acceptance for the treatment format, content and protocols.
When compared, there were 17.8 points reduction on Y-BOCS between pre-and post-treatment and at follow-up in six months the point just negatively increased 0.6 point [16]. This study implies that intensive group ERP seems to be a promising treatment for OCD and larger studies are also needed.
In a similar vein, Haland et al. [17] carried out a study about the effectiveness of ERP-focused group therapy for patients with OCD, which lasted 12 weeks in a community-based outpatient clinic in Norway. The participants involved 54 patients who have been diagnosed with OCD. The assessment scales were administered before treatment, after treatment and follow-ups ranging from 3 and 12 months. Analyses indicated that the offered group behavioral therapy to OCD patients dramatically improved ratings of OC symptoms along with depression and anxiety. The improvements were retained in both follow ups but the delayed effect of therapy wasn't observed after 12-month follow-up. The results point out that behavioral group therapy can be delivered to OCD patients as well as comorbid disorders. It can be concluded that this study supports the pilot study performed by Havnen et al. [16].

Acceptance and Commitment Therapy (ACT)
In one study conducted in Iran, the effects of adding group acceptance and commitment therapy (ACT) to individuals who have been diagnosed with obsessive-compulsive disorder (OCD) were investigated and they were already taking an optimal dose of SSRIs (selective serotonin reuptake inhibitors). The study was performed with forty-six Iranian women, on SSRIs, who were randomized to group ACT + SSRI or continued conditions. SSRI dosages were retained stable throughout the study. The results of the study showed considerable reductions on the Yale-Brown Obsessive-Compulsive Scale Self (Y-BOCS-SR) in both conditions at post-treatment. At follow-up, there were significant reductions in the ACT + SSRI condition when compared to only SSRI treatment.
These results demonstrate that group ACT is a fruitful treatment for OCD and a successful alternative to SSRI treatment [31]. However, the study included some limitations that: • the study was just confined to females, • the sample size was small, • there were just two months for follow-up to assess clinical outcomes, • the study was implemented by self-reporting, • random assignment and assessments were applied after all participants were on SSRIs.

Conclusions
OCD is a disabling and debilitating disorder and causes dysfunctionality in several domains of the person's life [1]. Various therapeutic models have been developed to treat OCD symptoms in a person-centered approach [10]- [15]. As well as individual therapies, group therapies are also practiced to effectively deliver mental health services to the patients having the disorder and to decrease OCD symptoms [16]- [28]. Group-CBT, being in the first place, and other group treatments, ERP and ACT, have been found to be efficient when compared to the individual practice, medical treatment, and waitlist. However, the literature has inconsistent findings about group effectiveness on CBT. This may be due to confounders consisting of symptom alienation, embarrassment of expressing obsessions/compulsions, comorbidity, sociodemographic conditions such as age, gender, race, ethnicity and so forth.
With all that, as discussed and addressed above, research point out that CB group treatments as well as ERP and ACT on OCD are a practicable and an al- Group and therapist(s) factors should also be considered and be evaluated in research processes.