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. 2021 Oct 28;34(1):83–90. doi: 10.1080/08995605.2021.1970983

A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans

Terri L Fletcher a,b,c,✉, Derrecka M Boykin a,b,c, Ashley Helm a,c, Darius B Dawson a,b,c, Anthony H Ecker a,b,c, Jessica Freshour d, Ellen Teng b,d, Jan Lindsay a,b,c, Natalie E Hundt a,b,c
PMCID: PMC10013345  PMID: 38536285

ABSTRACT

Exposure and response prevention (ERP) is the gold-standard, evidence-based psychotherapy for obsessive-compulsive disorder (OCD), but few receive it. Video telehealth can increase access to ERP for OCD and may enhance the salience of exposures. This study examined the feasibility, acceptability, and preliminary effectiveness of video telehealth-delivered ERP. We conducted a pilot open trial with 11 Veterans, using mixed quantitative and qualitative methods. Treatment completers (n = 9) had significantly reduced OCD and posttraumatic stress disorder symptoms posttreatment. Patients expressed greater comfort in engaging in ERP at home than in clinics. Therapists reported that seeing patients’ home environments helped them understand their symptoms and identify relevant OCD exposures. Results suggest that video telehealth-delivered ERP is feasible and acceptable to patients and therapists and promising for reducing OCD symptoms. Future research should compare its effectiveness to usual care and evaluate patients’ preferences for treatment delivery.

Abbreviations: ERP: exposure and response prevention; GAD-7: Generalized Anxiety Disorder-7 scale; OCD: obsessive-compulsive disorder; OCI-R: Obsessive-Compulsive Inventory, Revised; PCL-5: PTSD Checklist; PHQ-9: Patient Health Questionnaire; PTSD: posttraumatic stress disorder; VA: epartment of Veterans Affairs; Y-BOCS: Yale-Brown Obsessive Compulsive Scale, self report form.

KEYWORDS: OCD, exposure and response prevention, video telehealth, Veterans, pilot trial

What is the public significance of this article?—This study demonstrated that video telehealth-delivered exposure and response prevention may be helpful in improving symptoms of obsessive-compulsive disorder and symptoms of comorbid posttraumatic stress disorder in Veterans. Video telehealth-delivered exposure and response prevention is feasible and acceptable to patients and therapists and can increase access to care for Veterans with obsessive-compulsive disorder and provide continuity of care in times of public health crisis such as a pandemic.

Introduction

Obsessive-compulsive disorder (OCD) is a severe and debilitating psychiatric disorder that affects 1–3% of the general population (Kessler, Chiu, Demler, & Walters, 2005). OCD is characterized by distressing, unwanted obsessions (i.e., thoughts, images, impulses) and repetitive compulsions (i.e., behaviors or thoughts) to neutralize obsessions and reduce anxiety. Symptoms are often chronic, especially in the absence of effective treatment (Visser, Van Oppen, van Megen, Eikelenboom, & Van Balkom, 2014). Exposure and response prevention (ERP; Foa, Yadin, & Lichner, 2012; Himle & Franklin, 2009) is the gold-standard, evidence-based psychotherapy for OCD. This cognitive-behavioral treatment is based on exposure principles and teaches patients to systematically confront distressing or anxiety-provoking thoughts and situations without performing compulsive rituals to reduce anxiety. ERP is highly effective, with large effect sizes in reducing OCD symptoms (Cohen’s d = 1.13) (Rosa-Alcazar, Sanchez-Meca, Gómez-Conesa, & Mariln-Martinez, 2008).

Despite its effectiveness, few individuals with OCD receive ERP (Torres et al., 2007), in part because many therapists lack sufficient training in ERP (Stanley et al., 2017). Many patients, especially those living in rural and underserved communities, also experience social and logistical barriers to care, including long travel distance and limited time off work (Douthit, Kiv, Dwolatzky, & Biswas, 2015; Glazier, Wetterneck, Singh, & Williams, 2015). OCD symptoms, such as fears related to contamination, can further interfere with participating in therapy in traditional clinic settings. Among Veterans with OCD, only 29% received any psychotherapy in the year following diagnosis, and those who did received an average of only 3.9 individual psychotherapy visits which is substantially below the recommended 8–16 sessions of ERP (Barrera et al., 2019).

Video telehealth can overcome these barriers and help increase the generalizability of exposures by focusing on OCD triggers encountered in the home environment. Preliminary data from case series and pilot open trials support the effectiveness of ERP delivered via video telehealth (Brand & McKay, 2012; Goetter, Herbert, Forman, Yuen, & Thomas, 2014), although further research is warranted. Video telehealth can also provide care continuity during natural disasters or pandemics.

To examine the feasibility, acceptability, and preliminary effectiveness of video telehealth-delivered ERP, we conducted a pilot open trial targeting rural Veterans with OCD, using mixed quantitative and qualitative methods. This study expands on preliminary effectiveness data from the few published case studies by also exploring patient and therapist perspectives on the use of video telehealth to deliver ERP.

Methods

Participants

Inclusion criteria were a primary OCD diagnosis and willingness to participate in ERP via video telehealth; exclusion criteria were significant cognitive impairment or conditions that threaten safety (current psychosis, mania, imminent suicidality, and treatment-interfering substance use). We recruited Veterans from rural and outlying suburban areas around a large metropolitan area. Sixteen patients consented to participate and attended a baseline assessment. Three were excluded for failure to meet full OCD criteria or meeting criteria only for a related condition (e.g., hoarding disorder). One patient withdrew from the study during the baseline assessment citing a lack of time to participate, and we were unable to reach a second patient after the baseline assessment, leaving 11 patients with assignment to a therapist who had at least some treatment sessions. Two participants dropped out of treatment after 2 and 4 sessions respectively. One of these cited his busy schedule as the reason for treatment discontinuation, and the other was lost to contact.

Measures

Structured clinical interview for diagnostic & statistical manual, fifth edition

This structured interview (First, Williams, Karg, & Spitzer, 2016) was administered at baseline to determine whether patients met criteria for OCD and any excluded diagnoses (e.g., psychotic disorder, severe substance use disorder).

Cognitive screener

A six-item cognitive screener testing language and memory (Callahan, Unverzagt, Hui, Perkins, & Hendrie, 2002) was administered at baseline; participants with > two errors were excluded.

OCD symptoms

The Yale-Brown Obsessive-Compulsive Scale, self-report form (Y-BOCS; Goodman et al., 1989) was the primary study outcome. This 10-item questionnaire asks about the frequency and severity of obsessions and compulsions, ability to resist them, and interference from symptoms. A score of 8–15 represents mild OCD, 16–23 represents moderate OCD, 24–31 represents severe OCD, and above 32 represents extreme OCD. The Obsessive-Compulsive Inventory, Revised (OCI-R; Foa, Kozak, Salkovskis, Coles, & Amir, 1998)) was used as a secondary assessment of OCD symptoms. It contains 18 items rated on a 0–4 scale from “not at all” to “extremely.” The recommended cutoff for a likely OCD diagnosis is 21.

Posttraumatic stress disorder (PTSD) symptoms

The PTSD Checklist (PCL-5; Blevins, Weathers, Davis, Witte, & Domino, 2015) was used to determine severity of PTSD symptoms, given that PTSD is a common comorbidity in the Veteran population. This reliable, valid 20-item questionnaire assesses for each Diagnostic & Statistical Manual, Fifth Edition criterion for PTSD (American Psychiatric Association, 2013). The recommended cutoff for probable PTSD is 33 (Bovin et al., 2015).

Other measures

Patients completed the Patient Health Questionnaire (PHQ; Kroenke & Spitzer, 2002) and the Generalized Anxiety Disorder-7 (GAD-7) scale (Spitzer, Kroenke, Williams, & Löwe, 2006) to assess severity of comorbid disorder symptoms. The PHQ-9 is a nine-item measure of depressive symptoms. Scores range from 0–27, with scores ≥ 10 suggesting the presence of clinically significant depression. The GAD-7 is a seven-item measure of generalized anxiety symptoms. Scores range from 0 to 21, with scores ≥ 10 suggesting the presence of generalized anxiety disorder.

Patient and therapist exit interviews

Following treatment completion, a research assistant contacted patients to complete a semistructured exit interview assessing acceptability of the treatment and video delivery, benefit for symptoms, and experiences with the video-delivery modality. Interviews were approximately 20 minutes by phone and were audio recorded. At the end of the pilot, all therapists participated in exit interviews regarding their experiences delivering ERP via video telehealth and any modifications made to ERP during treatment due to individual patient factors or the video modality. Interviews were 30–40 minutes by phone or in-person and were audio recorded.

Procedures

This study was approved by the relevant institutional review board and Department of Veterans Affairs (VA) research and development review board. Patients were recruited through mailings and clinician referral. After consenting via telephone or by mail, patients attended a 90-minute telephone baseline assessment consisting of a structured clinical interview and self-report instruments. After determining that patients met inclusion/exclusion criteria, we assigned all to a therapist to begin video-delivered ERP. Participants were allowed to receive concurrent medications for OCD, but not psychotherapy focused on OCD.

Treatment

ERP is a specialized cognitive-behavioral intervention typically conducted over 12–16 therapy sessions. ERP starts with psychoeducation about OCD and exposure principles and construction of a hierarchy of situations that are feared, avoided, or trigger ritualizing. Then, the therapist and client begin in-session exposures to hierarchy items, using response or ritual prevention techniques to allow the patient to habituate to the anxiety without reinforcing the ritual. Exposures can be in vivo, such as touching a contaminated item, or imaginal, such as imagining a feared consequence. In accordance with measurement-based care practices (Scott & Lewis, 2015), therapists administered the Y-BOCS biweekly to assess treatment response and guide treatment discontinuation. ERP was delivered in weekly 90-minute sessions. Treatment completion was defined as attending 8 ERP sessions, at which point therapists and participants reviewed progress and discussed whether additional sessions were needed. A maximum of 16 ERP sessions was allowed.

Video delivery

All treatment sessions were conducted via a specialized video telehealth program provided by the VA. This HIPAA-secure platform provides live-streaming video and audio connectivity, as well as a chat feature and the ability to incorporate a family member or partner with three-way video. Patients were given a brief introduction to the video telehealth platform by their therapist prior to starting treatment. Copies of reading materials, handouts, and self-monitoring forms were sent via mail to supplement the video sessions.

Therapists

Three licensed clinical psychologists with expertise in OCD served as therapists for this study, along with two advanced psychology trainees who were supervised by the first author. Only one of the therapists had prior experience delivering exposure-based mental health treatment via video telehealth.

Posttreatment assessment

Four to six months postbaseline, depending upon timing of treatment completion and number of sessions required, patients completed a 90-minute posttreatment assessment consisting of all self-report measures and a patient exit interview. After completing treatment for all study patients, therapists also participated in an exit interview.

Data analysis

Quantitative outcomes

Treatment completion rates and baseline and posttreatment scores on all measures were examined descriptively. Independent samples t-tests were conducted to examine whether dropouts differed from completers in terms of severity of baseline symptoms. In the completer sample, paired t-tests were conducted to examine pre-post changes in symptom severity; and Cohen’s d effect sizes were calculated for the pre-post change on each outcome measure. Individual pre-post change and posttreatment scores on the primary outcome were examined to see how many patients met criteria for clinically significant OCD symptom improvement (35% reduction in Y-BOCS score) and loss of OCD diagnosis (posttreatment Y-BOCS score ≤ 14), based upon Farris, McLean, Van Meter, Simpson, and Foa (2013).

Qualitative outcomes

Qualitative coding and analysis were completed by the first author and a master’s-level research assistant with substantial qualitative experience, using rapid qualitative analysis techniques (Curran et al., 2011). Rapid analysis is a systematic, rigorous process of data condensation conducted in a shorter timeframe than traditional qualitative coding techniques. Each coder independently coded the data and differences were resolved through consensus.

Results

Figure 1 shows the participant flow through the study. Outcome data are available only for treatment completers (n = 9), who engaged in an average of 9.8 sessions (range 8–16). Treatment dropouts did not differ significantly from completers on baseline OCD, PTSD, depression, or generalized anxiety symptoms. Therefore, subsequent analyses use data from the sample of nine completers.

Figure 1.

Figure 1.

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Participant flow through study.

As is typical of the VA facility the patients were recruited from, patients were primarily male (78%) and married (67%), with an average age of 47.2 years (SD = 15.2). Racial/ethnic identity was majority white (55%) and African American (44%). Nearly half had combat exposure (44%). Common comorbid disorders included PTSD (n = 5), major depression (n = 4), generalized anxiety disorder (n = 4), panic disorder or agoraphobia (n = 3), mild-to-moderate alcohol use disorder (n = 4), and cannabis use disorder (n = 2). Six (67%) were receiving VA disability payments for mental health conditions, although none was receiving payments for OCD specifically. Patients had a baseline self-report Y-BOCS score of 22.6 (SD = 5.4), in the “moderate OCD” range (see Table 1).

Table 1.

Baseline and post-treatment scores on outcome measures

  Baseline M
(SD)		 Post-treatment M (SD) t p Cohen’s d
Y-BOCS Total 22.6 (5.4) 12.2 (6.5) 7.79 < .001 2.60
OCI-R 45.7 (10.0) 23.2 (18.0) 3.68 .006 1.23
PCL-5 42.4 (17.1) 23.4 (19.5) 3.19 .013 1.06
PHQ-9 13.5 (5.7) 8.2 (8.3) 2.14 .065 0.71
GAD-7 11.5 (6.1) 7.1 (6.4) 1.78 .112 0.59
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Bolded items significant p < .05.

Quantitative outcomes

Treatment completers had significant reductions in OCD symptoms on both the Y-BOCS and the OCI-R and significant reductions in PTSD symptoms, with large effect sizes for all measures (see Table 1). There were no significant changes in depression or generalized anxiety symptoms. All patients had some reduction in Y-BOCS, ranging from 16% to 82%, with an average 46% reduction in Y-BOCS symptom severity (see Figure 2 for individual trajectories). Six of nine patients (67%) had clinically significant improvement (35% reduction in Y-BOCS score), and five of nine patients (56%) met the criterion for loss of OCD diagnosis (posttreatment Y-BOCS score of ≤ 14).

Figure 2.

Figure 2.

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Individual patient pre-post Yale-Brown obsessive-compulsive scale scores.

Lines represent individual patient scores at baseline and post-treatment (6 months poststudy enrollment).

Qualitative outcomes

Patient and therapist experiences with video telehealth-delivered ERP are presented separately below.

Patient perspectives on the benefits of video telehealth

Patients reported numerous benefits of engaging in ERP via video telehealth, including convenience, flexibility, and reduced travel burden of telehealth appointments. Patients appreciated the option of receiving ERP remotely. A 75-year-old white male Veteran stated, that telehealth “Is geared toward Veterans that otherwise might miss it due to time and distance.” Several participants also stated they felt more comfortable receiving care at home.

One patient, a 37-year-old African American transgender female Veteran, commented on the value of doing the exposures in her home environment.

Some of the things [exposures] I could do more at home, like walking barefoot vs. if I was at the office. [It was] more hands on. If I had not been at home, it would have been harder. Would have had to learn it then come here [home] and do it.

Patient perspectives on comparison to in-person treatment

Most patients found video telehealth to be very similar to in-person treatment. A 75-year-old white male Veteran commented,

Video session is really the way to go if you can’t be in the office. It’s an excellent way. I think at the outset anyone going through this program, it should be communicated to them that ‘It’s just like being in the office together except more convenient. It’s the same as face-to-face.’ Remind people that they won’t be short changed.

One patient, a 36-year-old Latino male Veteran, stated a preference for traditional in-person treatment: “I’m more of a hands-on, face-to-face person, so video and email is not really my thing.” He also reported a reluctance to discuss certain issues via video telehealth: “It’s harder to talk about certain issues that might be personal. Face-to-face makes it harder to avoid answering certain questions.”

Four patients reported technical difficulties with the video telehealth platform but noted that they were able to work through these issues with the assistance of the therapist. A 35-year old white male Veteran reported, “The app works better on a tablet. On the computer, audio would cut in and out. It worked perfect on the app using the tablet.”

Patient perspectives on the impact of the program on life

Following treatment, all patients reported an increased understanding of OCD, as well as improvement in OCD symptoms. A 59-year-old white male Veteran stated, “Most of the symptoms are in remission. I’m not as caught up in all the rituals. I was able to put things in perspective. I found out it’s more manageable than I could imagine.” A few patients also noted improvements in their ability to engage in the activities of daily life. A 62-year-old African American male Veteran reported, “I don’t let the symptoms get in the way of living life. Therapy has changed my way of thinking–think more positive and don’t give power to the negative.” A 50-year-old African American female Veteran stated, “I wake with purpose. It gave me back part of my life I completely forgot about.”

Therapist perspectives on the importance of video telehealth delivery of ERP

Therapists unanimously agreed that providing the option for video telehealth delivery of ERP was very important for the Veterans they treated in this study, primarily due to the limited availability of specialized therapists and the distance patients would have had to travel to receive ERP, as well as the anxiety associated with coming into the medical center. “All the Vets have said how great they feel video telehealth is for treatment. They know that they wouldn’t have the option for this treatment without video telehealth, due to distance or anxiety coming to the hospital.”

They also highlighted the convenience of accessing treatment through video telehealth:

I think for sure it helped that I was very available to see them. It didn’t take them as much effort to see me. They could schedule with me, click a link, and I was there. I think that ease and convenience of access were really important for rapport building–it was on their own terms with flexibility.

Therapist perspectives on the general impact of video telehealth on treatment

Therapists noted how being able to see the patients’ home environment via video telehealth enhanced ERP.

It was very helpful, especially for one of my patients regarding contamination. She thought her house was a mess, but it wasn’t. Even though you miss something compared to in-person care, you gain something with your knowledge of the environment. In-person—you can be guessing what’s in the environment. Seeing them in real time at home really helps as a therapist to know what to target in session.

They also noted the impact that observing the home environment can have on the therapeutic relationship.

Showing you their things can be helpful. Sharing part of their life with you can impact rapport. Seeing the personal space [of one patient] helped me have more empathy … It was a very tight living space with multiple family members. Easy to forget without seeing it.

An additional advantage of video telehealth was the ease of engaging family in ERP sessions. “Bringing in family was important. That’s always a goal but harder in-person. It helped to explain to mom why we’re doing what we’re doing.”

Therapist perspectives on the impact of video telehealth on exposure

Therapists highlighted several advantages of delivering ERP via video telehealth, including sharing screens to create and edit the exposure hierarchy and teaching patients how to do exposure in their home environments. They noted that certain exposures were well suited to video telehealth:

I think that with specific exposures it made it easier to do them on the spur of the moment. For example, with one patient–I pulled up some text online for the patient to read to work on accepting when things were incomplete–this would likely have been harder in-person.

Other types of exposures were more challenging to do over video telehealth, such as those in which patients had to identify contaminated objects that could be used during the session or those in which the therapist wished to model the exposure but was not sharing the same physical space. However, therapists noted that they were able to work around these challenges with advanced planning prior to the exposure session. Another limitation was the ability to review homework forms over video telehealth. “It was hard to see [homework], so I had to trust that they were doing it.”

Discussion

This pilot study evaluated the preliminary effectiveness, feasibility, and acceptability of ERP delivered via video telehealth for Veterans with OCD. Patients experienced significant reductions in OCD symptoms at posttreatment and improved ability to meaningfully engage in their daily lives. The very large effect sizes for OCD symptoms (ds = 1.23– 2.60) are comparable or better to those seen in randomized controlled trials of in-person ERP (d = 1.13; Rosa-Alcazar et al., 2008), suggesting that video-telehealth delivery has the potential to be as clinically effective as in-person ERP. These results add to the growing evidence that telehealth is generally comparable to in-person treatment for a wide variety of mental health conditions.

The significant improvement in PTSD symptoms is also encouraging since approximately half of Veterans with OCD have comorbid PTSD (Barrera et al., 2019). Psychotherapy trials for other disorders in Veterans often show attenuated effect sizes compared to civilian populations (Barrera et al., 2015; Hundt, Barrera, Robinson, & Cully, 2014), underscoring the impact of the large treatment effects for OCD and PTSD in the current study. These results add to the findings from case reports that ERP can be effective for patients with comorbid OCD and PTSD.

Both patients and therapists reported satisfaction with video-telehealth delivery and described numerous logistical and clinical benefits of conducting ERP via video. The primary benefit, unanimously noted by patients and therapists, is that video telehealth increases access to ERP for patients with OCD. Given the limited availability of OCD experts, video telehealth has the ability to connect the few ERP specialist therapists with geographically distant OCD patients and, thus, to increase access to high-quality OCD treatment while decreasing travel burden on patients. In addition, patients also noted that receiving ERP via video-telehealth in their homes was more comfortable than in-person treatment and allowed them to learn how to conduct exposures in their natural environment.

Video telehealth may be particularly clinically useful for ERP because in-home exposure exercises can focus on OCD triggers that patients encounter daily and, thus, generalize exposure learning to the patient’s life more effectively than in-office exposure exercises. Therapists in this study noted that seeing their patients’ home environments gave them a better understanding of their OCD triggers and compulsions, and the ability to conduct in-home exposures may enhance the effectiveness of ERP. Additional clinical benefits of providing ERP through video telehealth include the opportunity for the therapist to notice and address in-home safety behaviors or rituals the patient would otherwise not notice or report and increased ease of incorporating family members into treatment (Fletcher et al., in press) and to continue providing care during pandemics.

Limitations and future directions

Although study results are promising, findings should be interpreted in the context of limitations commonly associated with pilot open trials, including the absence of a control group and the lack of long-term follow-up assessments to assess maintenance of gains. Given the pragmatic nature of the study, psychotropic medication use was not restricted; current and recent substance abuse was not an exclusion criterion; and treatment and discontinuation of ERP was not standardized across participants but rather was informed by measurement-based care principles for each individual participant. Additionally, the small sample may have limited the ability to detect significant effects in anxiety and depressive symptoms. Future research should employ a randomized controlled design with follow-up assessments, examine the impact of comorbid PTSD, and evaluate patients’ preferences in receiving ERP delivered solely by video telehealth or a combination of both in-person and video telehealth delivery.

Conclusions

The results from this pilot study suggest that video telehealth-delivered ERP is feasible and acceptable to patients and therapists and demonstrates preliminary effectiveness in treating OCD and comorbid PTSD symptoms. Video telehealth is an effective delivery modality for increasing patients’ access to this specialized treatment for OCD. It can also be used to maintain continuity of care during natural disasters or pandemics for patients who typically receive ERP in-person.

Funding Statement

This research was supported by a South Central MIRECC Pilot grant awarded to the first and last author and an HSR&D Career Development Award (CDA 13-264) given to the last author and partially supported by the VA HSR&D Houston Center for Innovations in Quality, Effectiveness and Safety (CIN# 13-413), Michael E. DeBakey VA Medical Center, Houston, Tx. The views expressed reflect those of the authors and not necessarily the policy or position of the Department of Veterans Affairs, the US government, or Baylor College of Medicine. None of these bodies played a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication;South Central Mental Illness Research, Education and Clinical Center [Pilot Grant];U.S. Department of Veterans Affairs [CDA 13-264].

Data availability statement

No data available.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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