ARTICLE IN PRESS

Journal of Behavior Therapy

and Experimental Psychiatry 37 (2006) 247–255
www.elsevier.com/locate/jbtep

Treatment motivation, treatment expectancy, and

helping alliance as predictors of outcome in
cognitive behavioral treatment of OCD
Patrick A. Vogela,, Bjarne Hansenb,
Tore C. Stilesa, K. Gunnar Götestamb
a
NTNU-Dragvoll, 7491 Trondheim, Norway
b
Department of Psychiatry and Behavioural Medicine, Postbox 3008, Lade, 7002 Trondheim, Norway
Received 16 July 2004; received in revised form 17 October 2005; accepted 20 December 2005

Abstract

Predictors of improvement in obsessive–compulsive symptoms (Y-BOCS) in a randomized clinical

trial with adult obsessive–compulsive disorder outpatients were examined. Results of multiple
regression analyses revealed that a positive helping alliance was significantly predictive of
posttreatment Y-BOCS. Treatment expectancy and high motivation to change were not significantly
related to posttreatment outcome. None of the predictors were significantly related to Y-BOCS levels
at 12-month follow-up, but positive alliance showed a trend to significance.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Cognitive behavior therapy; Obsessive–compulsive disorder; Adult; Outcome

1. Introduction

Therapy based on in vivo exposure and response prevention (ERP) is considered the
treatment of choice in obsessive–compulsive disorder (OCD) (Marks et al., 1988; Rachman
& Hodgson, 1980). This treatment approach is associated with a high level of discomfort
and seems to require a high degree of treatment motivation. This might be one factor
Corresponding author. Tel.: +47 73 55 04 25; fax: +47 73 59 76 94.
E-mail addresses: patrickv@svt.ntnu.no (P.A. Vogel), bjarne.hansen@medisin.ntnu.no (B. Hansen),
tore.stiles@svt.ntnu.no (T.C. Stiles), gotestam@medisin.ntnu.no (K.G. Götestam).

0005-7916/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbtep.2005.12.001
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248 P.A. Vogel et al. / J. Behav. Ther. & Exp. Psychiat. 37 (2006) 247–255

explaining the fact that 25–30% of the patients suitable for this treatment approach do not
want to enter, drop out early, or do not comply with it (Kozak, 1999; Salkovskis & Kirk,
1989). Among those who comply with treatment 20% or more do not respond (Foa et al.,
1983). Therefore, 50% or more of referred people with OCD are not helped by ERP.
Considerable effort has gone into identifying factors associated with premature
termination and poor response to ERP. OCD patients having overvalued ideation have
been found to have poorer outcomes for behavioral treatment (Turner, Steketee, & Foa,
1979). Consistent with these findings, another study (Basoglu, Lax, Kasvikis, & Marks,
1988; Lax, Basoglu, & Marks, 1992) found that bizarreness and rigidity of obsessional
beliefs were significant predictors of poorer treatment outcome. Recently, a measure of
overvalued ideation was found to predict an unfavorable response to behavioral treatment
for compulsions (Nezirolgu, Stevens, McKay, & Yaryura-Tobias, 2001).
Another variable that has been the subject of considerable research is the role of the
therapeutic alliance in producing positive psychotherapeutic outcomes. A vast bulk of
psychotherapy studies have demonstrated that a good therapeutic alliance predicts a
favorable outcome (Constantino, Castonguay, & Schut, 2002; Horvath, 1994; Roth &
Fonagy, 1996; Waddington, 2002) However, the effects of the therapeutic alliance has so
far not been examined with regards to OCD treatment. A third variable that has proven a
powerful predictor of psychotherapy outcome is patients’ expectancies of treatment
effectiveness (Kirsch, 1999; Sotsky et al., 1991; Weinberger & Eig, 1999). Although it has
been considered as one of the common factors of therapeutic effectiveness, it has not been
consistently found to predict outcome in OCD trials (Basoglu et al., 1988; Lax et al., 1992).
A fourth variable that also has not been systematically studied as a predictor of outcome
in OCD treatment is motivation to change. Since behavioral therapy for OCD is associated
with a high level of discomfort and requires active participation in and between treatment
sessions, it is reasonable to believe that a high level of motivation to change can enhance
treatment response and reduce the likelihood of premature termination of treatment.
In one study of cognitive behavioral treatment (CBT) of OCD, a measure of willingness
to participate and persevere in a demanding form of treatment that one has faith in was the
only variable that predicted clinically significant changes in obsessive symptoms at
posttreatment as well as at 6-month follow-up (de Haan et al., 1997).
Motivation to change has been defined as a dynamic state associated with the
probability of initiating and maintaining actions directed towards the attainment of new
behavioral goals (Miller & Rollnick, 1991). The Transtheoretical Stages of Change Model
(Prochaska & DiClemente, 1984) is one widely used conceptualization of the behavioral
change process. The five stages of change—precontemplation, contemplation, preparation,
action, and maintenance—are associated with different motivational levels, ranging from
having no intention to change (precontemplation) through stages producing significant
behavioral change and finally leading to intentions to sustain the new behavior
(maintenance).
The Transtheoretical Model is yet to be applied to and empirically evaluated for OCD,
but has been thoroughly investigated and successfully used to understand, and develop
interventions for smoking, drug and alcohol abuse, gambling, obesity, phobias, and
kleptomania (Prochaska et al., 1994). Moreover, the stages of change model has proven
useful in several studies of psychotherapy clients. Subscale scores representing the stages of
change (excluding preparation) have been derived from the University of Rhode Island
Change Assessment scale (URICA) (McConnaughy, Prochaska, & Velicer, 1983).
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Medieros and Prochaska (1992) found that transtheoretical stages and processes of change
could correctly classify 93% of clients into ‘‘premature’’ or ‘‘appropriate terminators’’.
Premature terminators in a study of psychotherapy outpatients (Brogan, Prochaska, &
Prochaska, 1999) scored highest on precontemplation and lowest on action and
maintenance. These results are consistent with, and even amplify, reports in prior
literature (McConnaughy et al., 1983; Prochaska, DiClemente, & Norcross, 1992).
However, the findings are not entirely consistent. In one study of mixed psycho-
therapy outpatients (Derisley & Reynolds, 2000), patients with high Contemplation
scores completed treatment. The authors speculate that the URICA may have better
predictive validity when there is a clearly identified behavioral problem that is being
treated.
It would be useful to be able to predict those OCD patients at risk for not responding
positively to treatment in order to develop strategies to ameliorate these problems. The aim
of this study was to evaluate the usefulness of the URICA as a predictor of treatment
outcome in OCD patients. Other predictors derived from the literature of predictors of
psychotherapy treatment outcome, not usually studied in OCD treatment research, such
as expectancy of a positive treatment outcome and quality of the therapeutic alliance,
were also examined in order to be able to understand the mechanisms involved in
producing clinical improvement (Joyce, Ogrodniczuk, Piper, & McCallum, 2003; Meyer
et al., 2002).

2. Method

2.1. Participants

Fifty-four patients were referred consecutively to a psychiatric outpatient clinic in a

major city of Norway from 1993 to 1998. Patients were included in the study if they met
the DSM-III-R criteria for OCD according to the Anxiety Disorders Interview Schedule-
Revised (ADIS-R) (Di Nardo & Barlow, 1988), and if OCD was considered the principal
diagnosis and overt compulsions were involved. Patients were excluded if they met criteria
for a lifetime history of psychotic disorder, alcohol or drug addiction, unstable acting-out
or suicidal behaviors, or chronic egosyntonic OCD. Consequently, patients were excluded
from the study for the following reasons: obsessions without compulsions (n ¼ 4), another
axis I diagnosis was considered primary (n ¼ 5), unstable acting-out or suicidal behavior
(n ¼ 2), psychosis (n ¼ 1), chronic (over 30 years) ego-syntonic OCD (n ¼ 1), and
subclinical OCD (n ¼ 2).
Thirty-nine patients met inclusion criteria and were offered treatment. Two patients (one
female and one male) refused the offer of treatment. Two others (both female) initially
accepted treatment and completed questionnaires and subsequently dropped out prior to
the start of treatment. Thus, the study consisted of data from 37 patients (27 females and
10 males) with a principal diagnosis of OCD. They had a mean age of 35.1 years
(SD ¼ 12.1).
Patients on stable doses of anti-obsessional medications were allowed in the study if they
agreed to maintain dosage levels unchanged during the study. Twelve patients (32%) were
taking such medications, anti-obsessional SSRIs (n ¼ 6), clomipramine (n ¼ 4), and other
tricyclic anti-depressive medications (n ¼ 2). Nine of them were being maintained on
clinically adequate dosages.
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All patients offered treatment completed a written informed consent form describing the
research conditions. A detailed research protocol for the study had been approved by the
Regional ethics committee for research with human subjects. ADIS-R interviews were
performed by the first author. All intake interviews and 12-month follow-up interviews
were videotaped. The inter-rater reliability of axis I diagnoses was assessed by using a
paired-rater design. Satisfactory levels of reliability were obtained as has been reported in
more detail elsewhere (Vogel, Stiles, & Götestam, 2004).

2.2. Treatments

Patients were randomly assigned to one of the two individual ERP treatments based on
adaptations of a treatment manual (Foa, 1991). Treatment was without charge. Those
terminating treatment were offered alternative treatment-as-usual that did not include
exposure therapy. The results of treatment for the two treatment conditions were in sum
generally equal with no significant differences in Yale-Brown Obsessive–Compulsive Scale
(Y-BOCS) ratings at any assessment period. Additionally, both treatments were nearly
structurally identical for 75% of session time, varying only as to whether additional
cognitive interventions aimed at altering beliefs underlying OCD or additional relaxation
exercises were employed during 30 min of each session. Thus, it was thought justifiable to
combine the data from the two active treatment conditions for the purposes of this study.
Two-hour sessions were held twice weekly for 6 weeks in both treatment groups (24 h
total). During a 12-month period of follow-up, all patients completing treatment met for
60-min supportive follow-up sessions (without further exposure therapy) at 3, 6, 9, and 12
month posttreatment. Some of these follow-ups were performed over telephone for four
patients that had moved from town. In order to improve the accuracy of the 12-month
assessments for the dropouts from the treatment study, all eight dropouts were approached
and four (50%) consented to be interviewed for a 12-month assessment. Since they had not
received full treatment, they received economic compensation for this ($30). The Y-BOCS
from this interview served as the basis for the 12-month assessment for these patients.
Other details of the treatment administered and the results of treatment are reported in
detail elsewhere (Vogel et al., 2004).

2.3. Measures

2.3.1. Obsessive– compulsive symptoms

The Y-BOCS (Goodman et al., 1989), including five obsession and five compulsion items
(0–4 point ratings), was conducted by the first author for all patients pretreatment and at
12-month follow-up. Only total scores from Y-BOCS were utilized. Therapists conducted
Y-BOCS interviews at mid-treatment, and at posttreatment. All Y-BOCS ratings were
audio- or videotaped. Difficult Y-BOC ratings were discussed with the first author. This
occurred with very few cases and involved only minor, if any, adjustments in the Y-BOCS
ratings.
Another clinical psychologist, blind to treatment condition and treatment outcome, re-
rated a random selection of 16 Y-BOCS pretreatment ratings and seven Y-BOCS 12-month
follow-up ratings. The inter-rater agreement with Kendall’s tau-b statistic for pretreatment
Y-BOCS total scores was .66 (po:001, two-tailed) and for Y-BOCS 12-month follow-up
ratings was .95 (po:001, two-tailed). Videotapes of three posttreatment Y-BOCS interviews
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conducted by the treating psychologist on his own patients were re-rated by the first author
and there was 100% agreement as to Y-BOCS total scores for these patients also at this
assessment point. Thus, in total, this suggests a satisfactory level of inter-rater agreement
for all three sets of ratings.

2.3.2. Motivation
The URICA (McConnaughy et al., 1983) was administered at pretreatment. It is a 32-
item self-report scale with eight items measuring an individual’s level of endorsement of
each stage of change with respect to the problem they are seeking treatment for. It yields
four highly reliable and statistically well-defined subscales: Precontemplation, Contempla-
tion, Action, and Maintenance. The URICA is scored using a five-point Likert format
(1 ¼ strong disagreement to 5 ¼ strong agreement).
Since the overall pattern of response on the URICA is considered to be of importance, a
method has been developed that combines the four subscales on the URICA into one
measure, the Readiness for Change Index (RCI) (McDonald & Warren, 2001). Here, mean
Precontemplation subscale scores are subtracted from the sum of the means of the three
other subscales to derive RCI (maximum ¼ 14, minimum ¼
2). This measure was chosen
to estimate patients’ degree of motivation at pretreatment.

2.3.3. Treatment expectation

A measure of treatment expectancy was developed based on the method used by
Borkovec and Nau (1972). In the first session of treatment, after patients were presented
with the habituation-based rationale for treatment, they were asked to indicate their
confidence that the treatment would help them with their problem on a scale from 0–100,
where 0 indicated minimum confidence, 50 moderate confidence, and 100 maximum
confidence.

2.3.4. Alliance
The Helping Alliance Questionnaire (HAQ) was used (Luborsky, 1984). This self-report
measure has been shown to be reliable and moderately related to outcome in several
studies (Horvath & Symonds, 1991). Treatment alliance was measured at the start of
session 6, half-way into the treatment. The patients were asked to evaluate 11 statements
with regard to his or her relation to the therapist by using a scale from +3 (absolutely true)
to –3 (absolutely wrong). It was explained that the therapist was not to be presented with
the statements before the end of therapy. The mean of responses to statements 6–10, which
particularly address the nature of the therapeutic bond, was the measure included in this
study. The item-total correlations of this subset of items varied from .60 to .89 and were all
significant at po:001, two-tailed. Cronbach’s alpha value was .85. These levels of internal
consistency were deemed satisfactory. All the statements were positively worded such that
larger positive values were indicative of higher levels of therapeutic alliance.

2.4. Statistics

This study applies a longitudinal design. Because the primary interest was in
determination of factors influencing engagement and improved responses to treatment,
intention to treat analyses were considered to be the analysis of primary importance. For
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the intention to treat analyses, the last available assessment was carried forward in cases of
dropout or missing data.
To assess the independent effects of the three hypothesized predictors of outcome,
multiple regression analyses were performed controlling for levels of obsessive–compulsive
symptoms at pretreatment.

3. Results

3.1. Demographic variables

There were no significant relationships between Y-BOCS scores, and gender, age, or civil
status variables (Vogel et al., 2004).

3.2. Multiple regression analyses

A multiple regression analysis was performed to predict Y-BOCS posttreatment values.

First pretreatment levels on Y-BOCS were entered in step one, followed by entering
expectancy, alliance, and motivation simultaneously in step two. In these analyses, alliance
significantly, and independent of expectancy and motivation, predicted Y-BOCS at
posttreatment (po:05, two-tailed). Treatment expectancy approached significance (po:06)
in a conservative two-tailed test of these hypotheses. Motivation was not significant and
the standardized b score was in the wrong direction. The correlations among the three
predictors ranged from .05 to .28, none of which were significant, suggesting that
collinearity was not a concern.
These steps were repeated using Y-BOCS 12-month follow-up as the dependent
measure. None of the predictors were significantly related to Y-BOCS at 12-month follow-
up, but alliance showed a trend of approaching significance (po:10, two-tailed). The
results of the multiple regression analyses are summarized in Table 1.

Table 1
Multiple regression analyses with predictors of Y-BOCS at posttreatment and 12-month follow-up

Step ba t Significance

Y-BOCS posttreatment
(1) Y-BOCS pretreatment .116 .582 .566
(2) Expectancy
.352
1.985 .060
Alliance
.437
2.384 .026
Motivation .179 .965 .345

Y-BOCS 12-month follow-up

(1) Y-BOCS pretreatment .254 1.312 .202
(2) Expectancy
.196
1.059 .301
Alliance
.358 1.871 .075
Motivation
.066
.338 .739
 po:05, two-tailed.
 po:10, two-tailed.
a
Standardized b values.
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4. Discussion

The quality of the therapeutic alliance, which is often found to be important in other
forms of psychotherapy, was also found important here in the treatment of OCD. This
aspect of exposure treatment for OCD has not often been emphasized. If these findings are
replicated, attending to enhancing the therapeutic alliance and perhaps also to patient
expectancies, may improve treatment outcomes for more OCD patients. Indeed, one study
of outpatient psychotherapy patients has recently found that having therapists attend to
patient motivation and alliance after the third session can double rates of improvement
(Lambert et al., 2003).
Motivation or readiness for change on URICA showed no relation to responses to
treatment on Y-BOCS. URICA has only proved predictive of the outcome of psychosocial
treatments in two other studies (Dozois, Westra, Collins, & Fung, 2004; McDonald &
Warren, 2001). Both these studies involved predominantly non-OCD patients and
employed larger samples.
An important weakness of the study was that alliance was obtained at mid-treatment
after some symptom reductions on Y-BOCS were already obtained. Unfortunately, it is
not possible to determine if the alliance scores were independent of the effects of the several
sessions of exposure that already had been performed or if other aspects of the treatment
may have contributed to making alliance predictive of improvements in obsessive–com-
pulsive symptoms at posttreatment. In future studies, it would be advisable to obtain
measures of alliance earlier in treatment and more often to shed more light on the role of
the development of the alliance in the treatment of OCD.
The small sample size of this study limits the generalizability of the findings. Secondly,
the large number of significance tests and the large number of factors employed in the
regression analyses may have exceeded the power obtainable from such a small sample.
The predictors studied here have been shown previously to be useful predictors in many
other studies of treatment outcome, which justified their inclusion on a priori theoretical
grounds. All these considerations taken together suggest that the findings are less
vulnerable to criticism as being due to multiple significance effects.
There are not often found significant predictors of treatment outcome in OCD. This
invites replication with a much larger sample where one perhaps could make effective use
of sophisticated mediator analyses to determine the inter-relationships of these constructs
(Holmbeck, 1997). The URICA measure itself needs more study. If employed with larger
samples of patients, it may be possible to perform item analyses to refine that measure and
make it more predictive of treatment outcome.

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