CONCENTRATED THERAPY
With short, intense sessions, some patients finish programs in just weeks
Six middle- and high-school students sat around a table on a Monday afternoon, watching a psychologist write three letters on a whiteboard:
O-C-D.
“What does OCD stand for?” the psychologist, Avital Falk, asked the group.
“Obsessive-compulsive disorder,” answered a timid 12-yearold boy wearing a blue blazer and red tie.
“What makes it a disorder?” Falk asked.
“Because it’s messing up our lives,” said Sydney, a chatty 14year-old with long red hair.
These young people have OCD, an illness characterized by recurrent, intrusive thoughts and repetitive behaviors, or other problems with anxiety. They also are participants in a novel treatment program at Weill Cornell Medicine in New York.
Typically patients with OCD see a therapist once a week for an hour over several months, but this program consists of two-hour group meetings three times a week, plus up to four additional hours of individual therapy per week. Some patients complete the treatment in just two weeks.
The program, which began in 2016, is part of a new wave of concentrated, intensive therapy programs for psychiatric disorders. The Child Mind Institute in New York launched a two-day “boot camp” for teens with social anxiety last year. The Houston OCD Program in Texas operated its first weeklong treatment program for adolescents during spring break for local schools.
In Atlanta, Emory University is in its third year of a two-week therapy program for veterans with post-traumatic stress disorder, funded by the Wounded Warrior Project. Similar offerings for veterans are now available at UCLA Health in California, Rush University Medical Center in Chicago and Massachusetts General Hospital in Boston.
The approach is gaining popularity in part because of new research showing that for both adults and children, the concentrated approach is generally just as effective, and in some ways more effective, as treatment that is spread out over several months. A meta-analysis of randomized, controlled trials published last year in the journal Behaviour Research and Therapy found remission rates of 54 percent for children in intensive, concentrated cognitive behavioral therapy (CBT) for anxiety disorders and 57 percent for those in standard CBT, a difference that was not statistically significant.
Just 2.3 percent of patients who did the concentrated therapy dropped out during treatment, compared with 6.5 percent for standard CBT. At Emory, only 5 percent of veterans in the twoweek PTSD program left before finishing, according to a paper published in the fall of 2017.
Another meta-analysis (this one of both randomized, controlled trials and studies without a control group), published in 2015 in the Journal of Obsessive-Compulsive and Related Disorders, found that OCD patients who were treated with intensive, concentrated therapy were more improved after treatment ended than those who received traditional weekly or twice weekly CBT. At a followup point of about three months, both groups were equally improved.
The intensive treatments seem to work best for anxiety-related disorders. They usually consist of CBT, in which patients repeatedly expose themselves to the very situations they fear.
Supporters of the approach said that while it may involve a similar number of total hours as weekly therapy, relief is quicker. Thomas H. Ollendick, a psychology professor at Virginia Tech, who helped pioneer a one-day treatment for phobias and has studied a oneweek treatment for OCD, said this can be crucial for people whose illnesses are preventing them from attending school or work.
And with concentrated treatment, Ollendick said, “you don’t have a week in between to unlearn what you learned in the session or have additional experiences that can lead you to think, ‘Oh, I better be afraid.’”
The concentrated format allows therapists to deliver evidencebased treatment to more people, since it is easier for patients who live in places without access to high-quality therapy to travel for a one- or two-week program, said Donna B. Pincus, director of the Child and Adolescent Fear and Anxiety Treatment Program at Boston University, which runs five- to eight-day intensive treatment programs for panic disorder, separation anxiety disorder and phobias.
Even patients who live nearby may find it easier to take off a week of work or plan treatment during a school break, rather than deal with the logistics of weekly therapy.
“People are pulled out of their everyday lives for two weeks — they are not dealing with work and spouses and kids,” said Barbara O. Rothbaum, a professor of psychiatry and behavioral sciences at the Emory University School of Medicine. “It really is a kind of a bubble for them to do this work.”
The intensive, concentrated approach also has downsides. The price tag for the Houston spring break program, for example, was $2,500 for the week. Many programs do not accept insurance. Sometimes insurance companies will reimburse for only a small portion of treatment or will require patients to first prove that less intensive therapy has failed before coverage kicks in.
Patients also need to be motivated and ready and willing to move quickly into exposure work, noted Boston University’s Pincus.
Some patients use the concentrated therapies to kick-start treatment or as an adjunct to longerterm therapy.
Christina Uzzi, 14, of Fair Haven, N.J., usually does weekly therapy via Skype with her psychologist at the Child Mind Institute. She also did two of the two-day social anxiety “boot camps” at the institute last summer before starting eighth grade at a new school.
The long days gave her hours to practice things that are hard for her, like asking strangers for directions and public speaking, with the help of her therapist and a group of other teenagers with similar fears.
The boot camp “was a big boost all at once,” said her mother, Jennifer Uzzi. “I think she definitely improved to be able to chitchat with people and order in a restaurant.”
Going through Emory’s twoweek PTSD program with a small group of fellow veterans helped Detrice Burriss, 52, stick with therapy and stay motivated, she said. Each day, her group would meet for breakfast or coffee before therapy.
“It was almost like I’ve got to be in formation at 9 o’clock. I’ve got to go, or they are going to be looking for me,” said Burriss, who developed PTSD after an IED hit a vehicle in front of the one in which she was riding in Iraq in 2009.
Several researchers in the United States point to the work of scientists in Norway, led by Gerd Kvale and Bjarne Hansen, as the source of much of the American surge in excitement around intensive, concentrated treatment. Therapists there have treated more than 700 patients with OCD, panic disorder and social anxiety disorder with a four-day protocol.
Patients meet in small groups, but each works with his or her own therapist. The core of the treatment is two eight- to 10-hour days of “exposure and response prevention,” in which patients actively approach the situations that induce their anxiety and avoid engaging in any behavior to reduce the anxiety.
The treatment seems to have a long-term impact. In a study published this month in the journal Cognitive Behaviour Therapy involving 77 people with OCD, 53 of them (or 69 percent) recovered from their disorder four years after the treatment. Only one person dropped out of the therapy.
At the Weill Cornell program, the participants, ages 10 to 15, practice exposures in a mock class. Falk gives them assignments to induce anxiety based on their individual triggers. She told the 12-year-old in the red tie and blazer — who is petrified of not acting “right” out of fear it will cause something bad to happen — to “be really inappropriate and rude, and eat in the middle of class and make a mess.”
She instructed a 12-year-old girl in a Harry Potter “Butterbeer” T-shirt to write about what she did on her recent birthday. The child has many compulsive behaviors involving writing and often has to erase and rewrite, something that causes problems in school.
For a 10-year-old with braces and a purple streak in her hair whose OCD is triggered by not knowing certain things, Falk instructed the other kids to “tell me something secret and rude” that she could not hear.
As class got underway one day, the boy, at Falk’s urging, ditched his tie and blazer. He was eating an orange. “Make fun of me,” encouraged a 14-year-old who has spent most of the session doodling.
The girl with the writing compulsion put down her pen and wailed. “Oh my God. It looks like an ‘I’ with a top hat on it,” she said, staring at her paper.
Falk looked it over. “I can understand it perfectly,” she said. “Let it go, which is going to be better for you long term.”