Cognitive behavioral therapy practices in the treatment of obsessive-compulsive disorder in China

In 2014, a team of psychiatrists from Mainland China jointly published the “Guideline of Compulsive Disorders Diagnosis and Treatment” (1). Shortly thereafter, the “Guide to the Prevention and Treatment of Obsessive-Compulsive Disorder in China” was published. It recommends cognitive behavioral therapy (CBT) as the first line treatment for obsessive-compulsive disorder (OCD). Although therapists and psychiatrists have been trying to treat OCD with CBT ever since CBT was introduced in China in the 1980s, these position papers—which are consistent with recommendations in the United States and Europe (2)—drew greater attention to the need to promote access to this intervention.

Although CBT was introduced in China approximately 30 years ago, access remains a significant challenge. Indeed, fewer than 1,000 Chinese psychiatrists and psychologists have received systematic and standardized CBT training consistent with established protocols; even fewer have exposure to working with affected children. As a result, the vast majority of OCD patients in China do not have access to standardized CBT resulting in compounded impairment due to incomplete treatment.

Contributing to the problem of limited availability and update of CBT for OCD is that few peer-reviewed articles about CBT for OCD have been published in Chinese journals since 2000; nearly half of them were case studies and reviews, and very few data have been generated among children with OCD. While there are a few intervention studies using only CBT among individuals from China (3-5), most are combined with pharmacotherapy. However, these studies describe CBT in very general terms with limited specificity in terms of intervention details that challenges replicability. And, few translated treatment protocols have been introduced to allow for increased dissemination to front-line clinicians who work with individuals with OCD.

Since 2010, to address this issue exchanges and communication between Chinese mental health clinicians and foreign CBT specialists has been improving. CBT training is becoming more standardized within training programs in China and as postgraduate curricula, and, as a result, CBT is being applied more broadly. At China’s annual psychiatry conference this past year, experts in related fields again called for the promotion of CBT to treat OCD.

While this represents a significant step forward, the integrity with which the intervention is applied in China requires consideration. Huang, Li, Guo, Han (6) performed a Delphi survey of 28 Chinese CBT experts to evaluate the suitability of CBT techniques in the treatment of OCD in China, and to analyze the application of CBT techniques. The experts who participated in the study were selected because they met one of the following three criteria: (I) National CBT Conference Academic Committee member; (II) psychiatrist or therapist engaged in CBT clinical or academic work in a deputy senior role or higher; and/or (III) supervisor in CBT research. All the participating experts had received systematic CBT training and had experience treating patients with OCD. Regarding core CBT techniques, the results showed that the experts unanimously believed that “Socratic questioning” was operable, frequently used, and effective. However, patients were not believed to readily accept this method. The cognitive techniques that the experts thought were experienced as acceptable, effective, and operable were recognizing negative automatic thoughts, checking evidence, and developing alternative thoughts. The techniques that patients most readily accepted and demonstrated efficacy were data collection and evaluation about symptom nature, the establishment of a therapeutic alliance, and psychoeducation. The experts unanimously believed that “thought suppression” was neither frequently used nor effective. “Cost-benefit analysis” was effective, used frequently, and easily accepted by patients. Although patients easily accepted the “pie chart method,” it was infrequently used and not believed effective. As for behavioral techniques, the experts believed that relaxation techniques were easy for OCD patients to accept, and were frequently used, although demonstrated limited benefit for patients. Exposure and response prevention (ERP) treatment was not widely accepted by patients, but was highly frequently used, and showed efficacy with imaginal exposures demonstrating less benefit relative to in vivo exposures. Collectively, the current research supports CBT as an effective treatment for OCD in China. Cognitive treatment techniques were more widely used and accepted than behavioral techniques, especially ERP, although ERP has demonstrated superiority to cognitive therapy alone for OCD in Western samples (7).

Regarding the differences between China and foreign countries in the acceptance and application of ERP techniques, we must first consider the special characteristics of Chinese culture and the differences in patient acceptance level. While researching group therapy using CBT to treat patients with anxiety disorders, we discovered that Chinese patients are more inclined to regard therapy as a “classroom learning experience”. They need to obtain illness-related knowledge and grasp specific skills, such as relaxation techniques (8). On the other hand, Chinese CBT experts still require training in applying CBT, especially ERP techniques. For example, whether relaxation techniques are necessary and whether they undermine the effectiveness of exposure therapy are open questions for Chinese patients. Further, Chinese CBT professionals may underutilize the intensity of exposure required while conducting exposure treatment. Furthermore, our clinical experience suggests that many Chinese therapists have concerns about implementing ERP, which is similar to that found in the United States (9), or lack the training to implement it. These factors all affect the efficacy of ERP treatment and compliance with ERP techniques when it is attempted to be used. It may be the case that in some Chinese CBT trainings, cognitive approaches are primarily emphasized, with more limited attention to behavioral therapy.

Considering the above, efforts are needed to develop culturally sound cognitive-behavioral interventions for OCD—in both adults and children—and to evaluate the core elements in terms of efficacy and acceptability. Thereafter, randomized controlled trials are needed to evaluate efficacy of these interventions; in the case that findings are robust similar to data in Western countries (10-12), dissemination and training efforts are needed across China. Given the clinical demands of psychiatrists and therapists in China, considering alternative methods of treatment delivery are warranted such as using smart phone applications, computer-assisted approaches (13), and stepped care modalities.

Acknowledgements

Funding: The study was supported by SHSMU-ION Research Center for Brain Disorders; Shanghai Key Medicine Specialties Program (ZK2015A06); Hongkou District Key Medicine Specialties Program (2014-16).

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

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