A group-based treatment for clients with Obsessive Compulsive

Disorder (OCD) in a secondary care mental health setting: Integrating

new developments within cognitive behavioural interventions � An

exploratory study

HAMILTON FAIRFAX1* & JANE BARFIELD2

1Clinical Psychology Services, The Riversvale Centre, Barnstaple, Devon Partnership NHS Trust, and 2Tawside Community

Mental Health Services, Riverside, Barnstaple, Devon Partnership NHS Trust, UK

Abstract

Aims: This paper presents a model of a group-based intervention for the treatment of clients with Obsessive Compulsive

Disorder (OCD) referred to secondary mental health care services, which has been developed by the authors over the last

five years. Method: Groups are not a common form of treatment design for this client group, however the available literature

is briefly reviewed and the common issues that informed the design are identified. Following this additional technique of

neuropsychological theories, Mindfulness, and socialisation are presented and a brief rationale for their inclusion provided.

Quantitative and Qualitative outcome measures of the most recent group are discussed with respect to the utility and validity

of the model. Conclusion and implications for practice: It is concluded that the group has good ecological as well as outcome

validity and provided a method of linking together evidence-based practice (EBP) and practice-based evidence (PBE)

movements.

Keywords: Obsessive compulsive disorder; OCD; group-based intervention; mindfulness; neuropsychological

theories; evidence-based practice; practice-based evidence

Introduction

The National Institute for Health and Clinical

Excellence (NICE) Guidelines (NICE, 2005) for

the treatment of Obsessive Compulsive Disorder

(OCD) published in the UK, indicate that Cognitive

Behavioural Therapy (CBT), in combination with

appropriate medication or CBT by itself, should be

the evidence-based treatments offered to clients.

OCD has a significant psychological research base

(e.g. Rachman, 2002; Salkovskis & Warrick, 1985)

and several specific treatment programmes exist

(such as the Maudsley inpatient unit). Behavioural

techniques such as Exposure and Response Preven-

tion (E-RP) are found to one of the most effective

interventions in the treatment of OCD (Christensen,

Hadzi-Pavolovic, Andrews, & Mattick, 1987; Foa,

Steketee, & Ozaron, 1985).

OCD, particularly long standing difficulties, has

been recognised as one of the hardest psychological

problems to treat (Rachman, 1998). An informal

audit of referrals to the local Community Mental

Health Team (CHMT) in 2003 found that over a

one year period OCD accounted for around a third

of referrals. Furthermore, OCD represented a sig-

nificant group in clients described as having endur-

ing mental health needs. Given the high demand for

appropriate treatment and the lack of available

resources, a group-based intervention was designed

and piloted.

The group has been running for more than four

years (seven groups), and a formalised group proto-

col has recently been established. Current develop-

ments in outcome research have indicated the value

of more clinically informed evaluations, referred to

as Practice Based Evidence (PBE) (Lucock et al.,

2003; Margison et al., 2000). This advocates the

benefits of a ‘bottom up’ approach to research, based

on findings from actual clinical practice as opposed

*Corresponding author. Email: hamilton.fairfax@nhs.net

Counselling and Psychotherapy Research, September 2010; 10(3): 214�221

ISSN 1473-3145 print/1746-1405 online # 2010 British Association for Counselling and Psychotherapy

DOI: 10.1080/14733140903171212

to the ‘top down’, Randomised Control Trial

(RCT)-led design of the Evidence Based Practice

(EBP) advocated in the UK by NICE (2004).

It will be argued that the OCD group suggests a

method of adapting a good evidenced-based inter-

vention such as CBT to a challenging client group

with good clinical validity. In so doing, we are

countering criticisms that CBT interventions are

inflexible, not generalisable to difficult clinical po-

pulations and only successful with a limited group of

‘high functioning’ clients (Cromby, 2006; James,

2007).

This paper outlines the current group protocol,

provides a rationale behind the design and interven-

tions, and presents evaluation data from a three

month follow up group. As an exploratory study the

data is from a small sample (N�5), and this

particular group presented was chosen as represen-

tative of the most developed version of group

protocol. The results are discussed with reference

to the integration of certain techniques used, and

conclusions are made regarding the benefits of

group-based intervention and how PBE can compli-

ment evidence-based research.

Group-based OCD interventions

There is substantial literature indicating the positi-

ve effects of employing CBT techniques through

group intervention for a variety of problems types

(Emmelkamp & Kuipers, 1985; Juster & Heimberg,

1994). However, there has been comparatively little

research investigating the application of these prin-

ciples in a group setting with OCD. Prior to the

design of the first group a literature search was

conducted using PsychInfo and Medline databases.

Of the relevant research identified, several were

based in adolescence populations (Thienmann

et al., 2001; Van Noppen et al., 1998).

In one of the few comparative studies (Fals-

Stewart, Mark, & Shafer, 1993) individual and

group interventions were found to be as equally

effective at reducing symptoms (as measured by

the Yale-Brown Obsessive Compulsive Inventory).

Although individual therapy indicated a faster rate of

improvement, follow up studies of both found

continued symptom reduction at three month and

one year follow up. Further longitudinal support for

OCD groups was found by Epsie (1986), and Braga,

Cardioli, Niederauer, and Manfro (2005) at one year

follow up of their group.

The length of the OCD groups identified ranged

from seven sessions to 14 sessions. In all OCD had

to be the main complaint but secondary difficulties

such as anxiety, some conduct problems, and

depression were also included. The average length

of sessions was around 90 minutes.

From a consideration of the available literature it

was possible to identify the following general com-

ponents common to OCD groups (listed below in no

particular order):

1. Closed groups

2. Behavioural treatment with a primary emphasis

on E-RP

3. Psychodeucation about OCD

4. Homework

5. Cognitive techniques of labelling and externa-

lising

6. Family involvement

From their group, Krone, Himle, and Nesse (1991)

further found that public goal setting and peer

encouragement helped behavioural targets to be

met.

Based on current literature and recent develop-

ments in OCD treatment, three further components

were integrated into the group design � neuropsy-

chological findings, mindfulness and socialisation.

Application of neurological research

Neurological investigations have implicated the role

of the basal ganglia, in particular the caudate nucleus

and executive function (Bannon, Gonsalvez, Croft,

& Boyce, 2006; Cavedini, Ferri, Scarone, & Bellodi,

1998; Freidlander & Desrocher, 2006; Greisberg &

McKay, 2003; Matrix-Cols, Conceraodo, & Leck-

man, 2005; Muller & Roberts, 2005; Roth, Milovan,

Baribeau, & O’Connor, 2005).

Of the few treatments based on these, Schwartz

(1996) has developed a specific treatment for OCD

primarily centred on the function of the caudate

nucleus. He argues that this structure acts like a

processing centre for impulses from the frontal lobe.

Together with the putamen, the caudate nucleus

(collectively referred to as the striatum), processes

executive, motor, and emotional responses. With the

anterior cingulate gyrus, (another structure that is

associated with the basal ganglia), the caudate

nucleus is also involved in the detection of errors in

brain circuits.

It has been suggested that a malfunction in this

system results in the frontal areas becoming

A group-based treatment for clients with OCD 215

overstimulated and using excessive energy. It is

thought that this could account for the stuck feeling

of ‘something being wrong’ and ‘doubting’ often

reported by sufferers of OCD, a process Schwartz

has referred to as ‘Brain Lock’. He proposed the four

‘Rs’ techniques to help shift this process, Relabelling,

Reattribution, Refocusing, Reevaluation.

In terms of group treatment it was felt that these

neurological findings could be used in a re-evaluative

capacity, and as the basis for cognitive re-attribution

techniques. For example, understanding the physio-

logical component of OCD may help to reduce

stigma, provide an account for the feelings of the

individual’s ‘mind not being their own’. Within this

framework, issues of control of behaviour and

thought could also be addressed.

Mindfulness

Mindfulness has increasingly been applied to mental

health issues in the West (Baer, 2006). It has been

used with a variety of clients groups such as pain

management (Kabat-Zinn, 1996), stress reduction

(Grossman, Niemann, Scmidt, & Walach, 2004),

personality disorder (Linehan, 1993), brain injury

(Bedard et al., 2003) and depression (Segal, Wil-

liams, & Teasdale, 2002). Mindfulness encourages a

non-judgmental engagement with one’s thoughts

through the development of awareness and the

controlled use of attention. With OCD it was felt

that the application of Mindful awareness, non-

judgement and control of attention, could help

challenge the ruminative nature of thoughts as well

as the compulsive urge to respond to them (for

further discussion see Fairfax, 2008).

Socialisation

Finally it was thought that loneliness and socialisa-

tion was a significant but largely unaddressed issue

within mental health difficulties such as OCD. This

was based on the recovery literature (Ryan &

Pritchard, 2004), commentators such as Smail

(2002) and discussions with clients who felt unable

to admit their symptoms and the distress it has

caused to family, friends, or medical professionals.

Kobak, Pock, and Greist (1995) suggested that

not only would a group treatment be cost effective,

but it could also contribute further ‘therapeutic

factors’ (such as support from others) that may

enhance the efficacy of CBT techniques (Westbrook,

2001). It was therefore felt that socialisation outside

of the group could enhance this through cohesive

group identity, reduce stigma through sensitisation,

and further provide the opportunity for ER P

experiments. Non-treatment-based group meetings

and the establishment of a support group was

therefore encouraged by the group leaders.

Group members met on several occasions outside

of the group once it had ended. As this was a client

led initiative, the group leaders did not evaluate this

process. From anecdotal evidence (e.g. client’s

report), it would appear that it helped to reinforce

techniques, add social and therapeutic support and

reduce stigmatisation, although no robust data was

collected to support these observations.

Method

Group structure

Based on the above literature the group design was

closed and thematically structured around basic

CBT principals (e.g., Session 1 psychoeducation

and understanding emotion, Session 2 and 3, under-

standing and challenging thought, Session 4 beha-

vioural challenges, Session 7, managing physical

symptoms Session 8 and 9 relapse prevention).

However, these themes were repeated throughout

the group, and specific themes or skills are revisited

in the final session (e.g., issues of responsibility or

guilt). Sessions lasted for 90 minutes and included a

15 minute break. It was decided to limit the group to

10 members to reduce feelings of anxiety and retain

a more intimate group process that could help with

disclosure and ER-P.

Group leaders

The group leaders were a psychologist and a com-

munity psychiatric nurse, both with experience of

treating OCD.

Assessment

Clients referred to the CMHT with OCD as the

primary diagnosis were assessed individually by both

group leaders. Inclusion was not problem specific,

e.g. only including particular rituals such as washing

or checking. Clients who had received previous

treatment for OCD were also included in the group.

Clients completed three measures at assessment.

The Obsessive Compulsive Inventory Revised (OCI-

R) (Foa et al., 2002), has an established research

base in the detection of OCD. Scores above 21 on

216 H. Fairfax & J. Barfield

this measure suggest the presence of OCD, and the

OCI-R also provides an indication of specific group-

ings of OCD-related behaviour (e.g., washing,

checking, hoarding, neutralising). Clients also com-

pleted the Yale Brown Obsessive Compulsive Scale

(Y-BOCS) which provides a measure of symptom

severity for obsessive and compulsive symptomatol-

ogy separately as well as providing an overall score

(subclinical to severe). It is a well used measure of

change in the OCD outcome research.

Clients additionally completed the Depression,

Anxiety and Stress Scale (DASS) (Lovibond &

Lovibond, 1995). Individuals with scores significant

on either the OCI-R or the Y-BOCS were invited to

join the group. The vast majority of clients who

accepted scored significantly on both measures.

However, some clients with extremely specific rituals

occasionally did not meet the cut-off on the OCI-R

but were included in the group. The rationale for

this is discussed in greater detail later. The Y-BOCS

and the DASS, have good pre- and post-reliability,

and were re-administered along with the OCI-R at

three month follow up.

Exclusion was based on Yalom’s (1975) identifica-

tion of poor candidates for a group; those with brain

damage, paranoia, hypochondria, current psychoses,

anti-social personalities and current substance

abuse.

Outline of group sessions

A general description of session content and aims is

provided by Table I below. Family meetings are

offered at the beginning (after the first two sessions),

and near the end of the group. A one week break is

included, usually occurring after session 5 or session

6. The rationale for a break is to help practice skills,

allow time for skill acquisition, encourage family and

friend involvement in the process, develop support

Table I. Outline of group structure

Session no. Outline of content

1 . Orientation to the group structure and CBT model

. Begin to normalise OCD as a way to manage emotional distress that has become a problem in itself.

. Gain an understanding of how OCD operates, its possible aetiology, and current place in individual’s lives

. Neuropsychological theories and group process.

. Have some basic ways of relating differently to OCD (e.g. four ‘Rs’ techniques)

. Five minute rule, in context of basic E-RP

. Begin process of exposure through some group disclosure of individual difficulties with OCD

2 . Challenging the nature of thoughts, questioning the instinct to believe them as ‘true’, having a better

understanding of the process of feeling and response to thoughts, introducing Thought-Action-Fusion (TAF)

. Introducing Mindfulness as a way of sitting with thoughts and not responding to them

. Explore this process in the context of superstitions used by group members, looking at differences in behaviour

and thoughts and feelings behind it, exploring the origins of superstitions and how this affects current

behaviour. Highlighting the differences in individual’s endorsement of belief systems and validity of thoughts

3 . Re-Introduce CBT model and its relationship to the structure of the group.

. Continue with challenging thoughts.

. Speaker invited form previous group to share experience and encourage using skills. Experiment with thought,

(e.g. cursing co-leader’s dog). Re-introduce TAF

4 . Explanation of and Response Prevention (ERP) Begin to establish behavioural hierarchies Encourage group

bonding process outside of the group to develop support network and challenge feelings of social isolation

5�6 . Continue developing behavioural hierarchies making sure goals are appropriate and discussion of how they will

be achieved and what skills/ social support is needed. Review CBT and other skills Begin E-RP

7 . Managing the process of confronting behavioural goals, responding to difficulties and set backs

. Managing physical symptoms Introduce relaxation skills

8 . Identify repeating themes and explore through CBT and Mindfulness

9 . Planning for life with reduced OCD

10�11 . Relapse prevention

Family Groups

(two sessions)

. Provide families with an understanding of OCD Allows families to express feelings about the impact of OCD on

their lives Explore ways of helping with the process, particular reassurance and managing anxiety

Individual session . The group leaders meet with client’s individually one month after the group to explore any difficulties and

‘coaching’.

Three-month

follow-up

. Reviewing process

. Revisiting skills

A group-based treatment for clients with OCD 217

and encourage re engagement in community activ-

ities by encouraging group socialisation.

Ethical consideration

Ethical approval for this study was granted by the

Ethics committee of the Research and Development

Department, Devon Partnership NHS Trust. In-

formed consent was obtained from the clients for

outcome data to be presented in this research. It was

agreed that clients would not be able to be identified

from the data, and therefore any possible identifying

information, e.g. names, age, gender, when they

attended the group, was omitted from this research.

Clients were also given the right to withdraw from

the study, or to refuse to complete outcome mea-

sures. All results were shared with participants at the

follow up group. This is consistent with local trust

ethical guidelines.

It is of interest that by the end of the group clients

were keen to be involved in any process that high-

lighted services for OCD, e.g. participating in

videoed discussions for training purposes, returning

to other groups as ‘experts’. We have found this to be

a consistent outcome for all groups and speculate

that this may be a result of the group dynamic and

increases in social motility and interpersonal con-

fidence, although we do not have any objective data

to support this conclusion. We are currently in

discussion with former group members to set up a

client-led support group.

Results

The results of the pre- and post-outcome measures

are presented in Table II. Given the purpose of this

paper and the small numbers involved, detailed

statistical analysis was not felt appropriate. Table II

therefore includes the descriptive outcome data for

each test.

In some instances data was unable to be collected,

e.g. the client was too distressed to complete the

measures, tests were not returned. The results

presented therefore represent a small sample but

reflects the clinical realities of evaluating a treatment

for a challenging population.

Clients also completed a group evaluation mea-

sure at the end of the 12 week group. Copies of the

Table II. Pre- and post-outcome measures

Client identification Measure Pre Post (three months)

a OCI-R 36 n/a (not returned)

Y-BOS 30 (severe) 16 (mild/moderate)

DASS Depression (moderate)

Anxiety (severe)

Stress (severe)

Depression (normal)

Anxiety (mild)

Stress (normal)

b OCI-R 36 7

Y-BOS n/a (client distressed) 7 (sub-clinical)

DASS n/a (client distressed Depression (normal)

Anxiety (normal)

Stress (normal)

c OCI-R 33 n/a (not returned)

Y-BOS 25 (severe) 10 (mild/sub-clinical)

DASS Depression (normal)

Anxiety (normal)

Stress (normal)

Depression (normal)

Anxiety (normal)

Stress (normal)

d OCI-R 26 13

Y-BOS 26 (severe) 16 (mild)

DASS Depression (severe)

Anxiety (moderate/mild)

Stress (severe/moderate)

Depression (normal)

Anxiety (normal)

Stress (normal/mild)

e OCI-R 36 8

Y-BOS 26 (severe) 5 (sub-clinical)

DASS Depression (moderate)

Anxiety (severe)

Stress (moderate)

Depression (normal)

Anxiety (normal)

Stress (normal)

218 H. Fairfax & J. Barfield

questionnaire are available on request. Findings

suggested that clients overwhelmingly found that

being in a group with other people suffering from

OCD was of significant benefit. It helped to normal-

ise their feelings, challenge isolation, disclose diffi-

cult feelings and emotions, and to support

behavioural challenges.

Analysis of individual ratings for each item found

that listening to other people with OCD, neuropsy-

chological theories and Psychoeducational were

rated highest, followed by anxiety ladders (beha-

vioural hierarchy), Mindfulness, Family Groups and

ER-P. Criticisms of the group included the group not

being long enough and environmental issues (e.g.

comfort of the room).

Discussion

The outcome data presented in Table II show a

general trend of significant improvement three

months from the end of the group; with the majority

of post Y-BOCS scores within the mild or subclincal

range. None of the post performances on the OCI-R

met criteria for significance, and scores on the DASS

were in the mild or normal range.

However, as discussed above, the overall signifi-

cance of the results is reduced by the sample size and

some missing data. Furthermore, it could be argued

that as the OCI-R is designed as a brief screening

tool (Foa et al., 1998), it may not be sensitive to

measuring change and therefore inappropriate for

this purpose. Although the DASS is a widely used

and validated test (Crawford & Henry, 2003), it does

not have a comparable research base like measures

such as the Beck Depression Inventory (BDI-II).

Some research has criticised the DASS for over-

endorsing the Depression scale when scores are

highly rated (Brown, Chorpita, Korotitsch, and

Barlow, 1997).

Given the sample it is not possible to comment on

variables such as age or gender. In the future a much

larger sample with a more comprehensive assess-

ment package (e.g. perhaps including personality

measurement, quality of life measures, and objective

assessments of general function such as the SCID)

should be considered.

Implications for practice

The results add some support to the hypothesis that

the group format encourages participant disclosure

and engagement in ER-P. The integration of

Neuropsychological theories, Mindfulness and Fa-

mily Groups were also highly rated by participants,

and may present further evidence to the suggestion

that they support and contribute to the evidence-

based CBT ethos that underlies the group. Further

research could test these hypothesised relationships

more formally; for example how Mindfulness may

support E-RP. The current study adds some support

to the suggestion that Mindfulness may help to

develop an internal locus of control through the

use of mindful awareness and control of attention,

but more quantitative correlational research would

be recommended to establish how this and the other

client-endorsed interventions may relate to symptom

improvement.

It could also be beneficial to explore more com-

munity-based options such as developing a local

support network, a client run self help group, and a

family support group in the general treatment of

OCD.

Conclusion

This exploratory study presents evidence to consider

working with the challenging diagnosis of OCD

within a group framework in a secondary care

service. This has organisational benefits in terms of

cost, time management and skills sharing. It further

includes particular clinical benefits in being able to

generalise evidence-based interventions, and chal-

lenge the sense of isolation, ‘abnormality’, and social

exclusion reported by clients with the condition.

In keeping with PBE, this study has good ecolo-

gical validity, being based in a complex cohort of

clients that are representative of referral to secondary

care psychological services. A particular strength of

the group is that it provides a potential method of

synthesis between EBP and PBE, illustrating how

both positions can combine to provide a more

effective model of psychological treatment.

References

Baer, R.A. (2006). Mindfulness-based treatment approaches. New

York: Elsevier Academic Press.

Bannon, S., Gonsalvez, C.J., Croft, R.J., & Boyce, P.M. (2006).

Executive functions in obsessive-compulsive disorder: state or

trait deficits. Australian and New Zealand Journal of Psychiatry,

40, 1031�1038.

Bedard, M., Felteau, M., Mazmanian, D., Fedyk, K., Klein, R.,

Richardson, J., Parkinson, W., & Minthorn-Biggs, M. (2003).

Pilot evaluation of a mindfulness-based intervention to improve

A group-based treatment for clients with OCD 219

the quality of life among individuals who sustained traumatic

brain injuries. Disability and Rehabilitation, 25 (13), 722�731.

Braga, D.T., Cardioli, A.V., Niederauer, K., & Manfro, G.G.

(2005). Cognitive-behavioural group therapy for obsessive-

compulsive disorder: a one year follow up. Acta Psychiatrica

Scandinavica, 112 (3), 180�186.

Brown, T.A., Chorpita, B.F., Korotitsch, W., & Barlow, D.H.

(1997). Psychometric properties of the depression anxiety

stress scale (DASS) in clinical samples. Behaviour Research

and Therapy, 35 (1), 79�89.

Cavedini, P., Ferri, S., Scarone, S., & Bellodi, L. (1998). Frontal

lobe dysfunction in obsessive compulsive disorder and major

depression. Psychiatry Research, 78 (1�2), 21�28.

Christensen, H., Hadzi-Pavolovic, D., Andrews, C., & Mattick, R.

(1987). Behaviour therapy and tricyclic medication in the

treatment of obsessive-compulsive disorder: a qualitative re-

view. Journal of Consulting and Clinical Psychology, 55, 701�711.

Crawford., J.R., & Henry, J.D. (2003). The depression anxiety

stress scale (DASS): Normative data and latent structure in a

large non-clinical sample. British Journal of Clinical Psychology,

42, 111�131.

Cromby, J. (2006). Fundamental questions for psychology.

Clinical Psychology Forum, 162, 9�12.

Emmelkamp, P.M.G., & Kupiers, A.C.M. (1985). Behavioural

Group Therapy for anxiety disorders. In D.R. Upper (Ed.),

Handbook of behavioural group therapy (pp. 443�469). New

York: Plenum Press.

Epsie, C.A. (1986). The group treatment of obsessive-compulsive

ritualizers: behavioural management of identified patterns of

relapse. Behavioural Psychotherapy, 14, 21�33.

Fairfax, H. (2008). The use of mindfulness in obsessive compul-

sive disorder: suggestions for its application and integration in

existing treatment. Clinical Psychology and Psychotherapy, 15,

53�59.

Fals-Stewart, W., Mark, A.P., & Shafer, J. (1993). A comparison

of behavioural group therapy and individual behaviour therapy

in treating obsessive compulsive disorder. Journal of Nervous

and Mental Disease, 181, 189�193.

Foa, E.B., Steketee, G.S., & Ozaron, B.J. (1985). Behavioural

therapy with obsessive-compulsives: from theory to treatment.

In M. Mavissakalian, S.M. Turner & L. Michelson (Eds.),

Obsessive-compulsive disorders: Psychological and pharmacological

treatment (pp. 49�121). New York: Plenum Press.

Foa, E.B., Kozak, M.J., Salkovskis, P.M., Coles, M.E., & Amir, N.

(1998). The validation of a new obsessive-compulsive disorder

scale: the obsessive-compulsive inventory. Psychological Assess-

ment, 10 (3), 206�214.

Foa, E.B., Huppert, J.D., Leiberg, S., Langer, R., Kichil, R.,

Hajack, G., & Salkovskis, P.M. (2002). The obsessive-compul-

sive inventory: development and validation of a short version.

Psychological Assessment, 14 (4), 485�496.

Freidlander, L., & Desrocher, M. (2006). Neuroimaging studies

of obsessive-compulsive disorder in adults and children. Clinical

Psychology Review, 26 (1), 32�49.

Greisberg, S., & McKay, D. (2003). Neuropsychology of ob-

sessive-compulsive disorder: a review and treatment implica-

tions. Clinical Psychology Review, 23 (1), 95�117.

Grossman, P., Niemann, L., Scmidt, S., & Walach, H. (2004).

Mindfulness-based stress reduction and health benefits: a meta-

analysis. Journal of Psychosomatic Research, 57 (1), 35�43.

James, O. (2007). Affluenza. London: Vermillion.

Juster, H.R., & Heimberg, R.G. (1994). Cognitive behavioural

group therapy for social phobia. The Clinical Psychologist, 47,

18�20.

Kabat-Zinn, J. (1996). Full catastrophe living. London: Piatkus.

Krone, P.K., Himle, J.A., & Nesse, R.M. (1991). A standardised

behavioural group treatment program for obsessive-compulsive

disorder: preliminary outcomes. Behavioural Research Therapy,

29, 627�631.

Kobak, K.A., Pock, A.L., & Greist, J.H. (1995). Group behaviour

therapy for obsessive compulsive disorder. Journal of Specialist

Group Work, 20, 26�32.

Linehan, M.M. (1993). Skills manual for treating borderline

personality disorder. New York: Guilford.

Lovibond, S.H., & Lovibond, P.F. (1995). Manual for the

Depression Anxiety Stress Scales. Sydney: Psychology Founda-

tion.

Lucock, M., Leach, M., Iveson, S., Lynch, K., Horsefield, C., &

Hall, P. (2003). A systematic approach to practice-based

evidence in a psychological therapies service. Clinical Psychology

and Psychotherapy, 10 (6), 389�399.

Margison, F.R., McGrath, G., Barkham, M., Mellor Clark, J.,

Audin, K., Connell, J., & Evans, C. (2000). Evidence-based

practice and practice-based evidence. The British Journal of

Psychiatry, 177, 123�130.

Matrix-Cols, D., Conceraodo, R., & Leckman, J.F. (2005). A

multidimensional model of obsessive-compulsive disorder.

American Journal of Psychiatry, 162 (2), 228�238.

Muller, J., & Roberts, J.E. (2005). Memory and attention in

obsessive-compulsive disorder: a review. Journal of Anxiety

Disorders, 19 (1), 1�28.

National Institute for Health and Clinical Excellence (NICE)

(2004). Emerging best practices in mental health recovery.

Accessed 15 November 2008 from: www.tin.nhs.uk/EasySite/

lib/serveDocument.asp?doc�1828&pgid�780

National Institute for Health and Clinical Excellence (NICE)

(2005). Obsessive compulsive disorder: core interventions in

the treatment of obsessive-compulsive disorder and body

dysmorphic disorder. (Download available from: www.nice.

org.uk/CG031).

Rachman, S. (1998). A cognitive theory of obsessions: elabora-

tions. Behaviour Research and Therapy, 36, 385�401.

Rachman, S. (2002). A cognitive theory of compulsive checking.

Behaviour Research and Therapy, 40, 625�639.

Roth, R.M., Milovan, D., Baribeau, J., & O’Connor, K. (2005).

Neuropsychological functioning in early and late onset obses-

sive obsessive-compulsive disorder. Journal of Neuropsychiatry

and Clinical Neurosciences, 17 (2), 208�213.

Ryan, T., & Pritchard, J. (Eds). (2004). Good practice in adult

mental health. London: Jessica Kingsley Publishers.

Salkovskis, P.M., & Warrick, H. (1985). Cognitive therapy of

obsessive compulsive disorder: treating treatment failures.

Behavioural Psychotherapy, 13, 243�255.

Segal, Z., Williams, M., & Teasdale, J. (2002). Mindfulness-based

cognitive therapy for depression: a new approach to preventing

relapse. New York: Guilford Press.

Schwartz, J. (1996). Brain lock. New York: Regan Books.

Smail, D. (2002). Commentary. De-psychologizing community

psychology. Journal of Community and Applied Social Psychology,

11, 159�165.

220 H. Fairfax & J. Barfield

Thienmann, M., Martin, J., Cregger, B., Thompson, H.B., &

Dyer-Friedman, J. (2001). A manual-driven group cognitive

behavioural therapy for adolescents with obsessive-compulsive

disorder: a pilot study. Journal of American Child and Adolescent

Psychiatry, 40 (11), 1254�1260.

Westbrook, D. (2001). Obsessive-compulsive disorder. A guide for

patients and their families. Clinical Psychology Department,

Warneford Hospital, Oxford.

Van Noppen, B.L., Pato, M.T., Marsland, R., & Rasmussens

S.A. (1998). A time limited behavioural group for treatment of

obsessive compulsive disorder. Journal of Psychotherapy Practice

and Research, 7 (4), 272�280.

Yalom, I. (1975). Theory and practice of group psychotherapy. New

York: Basic Books.

Biographies

Hamilton Fairfax is a Chartered Counselling

Psychologist working in Adult Mental Health in

the Devon Partnership NHS Trust. His interests

include OCD, Personality Disorder, Trauma,

therapeutic process, Mindfulness and Neuropsy-

chology.

Jane Barfield is a Community Psychiatric Nurse

and Senior Mental Health Practitioner also working

within the Devon Partnership NHS Trust. Her

interests include OCD, psychosis and CBT.

A group-based treatment for clients with OCD 221

Copyright of Counselling & Psychotherapy Research is the property of Routledge and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.