Journal of Obsessive-Compulsive and Related Disorders 5 (2015) 1–7

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Journal of Obsessive-Compulsive and Related Disorders

journal homepage: www.elsevier.com/locate/jocrd

Stages of change and the treatment of OCD

Sadie Cole Monaghan a,b,c,n, Jordan E. Cattie a,d, Brittany M. Mathes a,
Leah I. Shorser-Gentile a, Jesse M. Crosby a,b, Jason A. Elias a,b
a
McLean Hospital, 115 Mill St., Belmont, MA 02478 USA
b
Harvard Medical School, USA
c
Harvard University Department of Psychology, 33 Kirkland St, Cambridge, MA 02138, USA
d
SDSU/UCSD Joint Doctoral Program in Clinical Psychology, 200 Dickinson St., San Diego 92103, USA

art ic l e i nf o a b s t r a c t

Article history: The Stages of Change model conceptualizes the process of behavioral change. The University of Rhode
Received 3 September 2013 Island Change Assessment (URICA) is a self-report measure divided into subscales that represent four of
Received in revised form the five different stages (Precontemplation, Contemplation, Action, and Maintenance). Research has shown
11 December 2014
that higher Precontemplation scores predict reduced treatment response in anxiety disorders. The purpose
Accepted 15 December 2014
Available online 23 December 2014
of this investigation was to examine the role of the stages of change in treatment outcomes with
individuals with OCD undergoing intensive residential treatment including exposure therapy and response
Keywords: prevention (EX/RP). We hypothesized that a patient's stage of change, initially and throughout treatment,
OCD would be associated with both treatment outcome and symptom severity. The URICA was administered to
Motivation
a sample of 424 patients admitted to a residential treatment program for OCD at admission and after 30
URICA
days of treatment. Y-BOCS was given at admission and discharge. Stage of change at admission did not
predict outcome. However, Precontemplation at discharge was associated with shorter length of stay.
Results and their implications will be presented along with a discussion of future directions.
& 2014 Elsevier Inc. All rights reserved.

1. Introduction of OCD include significantly reduced quality of life in addition to a high

The lifetime prevalence of anxiety disorders in the US is estimated
at 28.8%, indicating that nearly one-third of the population will suffer
from an anxiety disorder at some point in their lives. In the National
Comorbidity Survey Replication (NCS-R) sample (N¼1908 adults), the
lifetime prevalence of obsessive–compulsive disorder (OCD) as deter-
mined by the Diagnostic and Statistical Manual, 4th edition, Text
Revision (DSM-IV-TR; American Psychiatric Association, 2000), is 1.6%
(Kessler et al., 2005). OCD1 is characterized by the experience of
recurrent and unwanted thoughts, urges, or images (obsessions)
and/or repetitive behaviors or mental acts (compulsions) that the
person feels they must perform to reduce the anxiety associated
with obsessions, or in accordance with a rigid application of rules
(American Psychiatric Association, 2013). The functional consequences
n
correspondence to: Clinical & Research Post-Doctoral Fellow, North Belknap
G28, OCD Institute, McLean Hospital, 115 Mill Street Belmont, MA, 02478, USA
Tel.: þ 1 617 855 4437.
E-mail addresses: scmonaghan3@partners.org (S. Cole Monaghan),
jcattie@mclean.harvard.edu (J.E. Cattie), bmathes@partners.org (B.M. Mathes),
lshorser@skidmore.edu (L.I. Shorser-Gentile),
jcrosby@mclean.harvard.edu (J.M. Crosby), jelias@partners.org (J.A. Elias).
1 the response rate drops to 63% when people who refuse or dis-
Note: In DSM-5 (APA, 2013), OCD is no longer classified with the other anxiety
disorders and instead is contained within its own category of Obsessive–Compul-
sive and Related Disorders.
degree of role dysfunction. A meta-analysis of studies examining
quality of life in anxiety disorders (Olatunji, Cisler, & Tolin, 2007)
revealed that OCD patients fared significantly worse than controls in
overall work, physical health, mental health, and social functioning.
When we consider that approximately 50% of the OCD cases in the
NCS-R sample were classified as “severe”, it is apparent that OCD
represents a significant public health concern.
The standard of care for OCD is cognitive-behavioral therapy
(CBT) utilizing exposure and response prevention (EX/RP) (Meyer,
1966; see Abramowitz, Brigidi, & Roche, 2001 for a review). Repeated
investigations have demonstrated the effectiveness of EX/RP as an
intervention for OCD. An oft-cited finding is the superiority of EX/RP
or EX/RP with pharmacotherapy over pharmacotherapy alone in
producing long-term reduction of OCD symptoms (Foa et al. 2005;
Hembree, Riggs, Kozak, Franklin, & Foa, 2003), which rather drama-
tically demonstrates the utility of the therapy. In addition, a recent
meta-analysis and review (Olatunji, Davis, Powers, & Smits, 2013)
concluded that individuals undergoing CBT performed better than
those under control conditions on a number of relevant outcome
measures for both post-treatment and follow-up. However, although
treatment with EX/RP results in improvement in 80–90% of patients,
continue EX/RP are included (Stanley & Turner, 1995). Many factors
have been shown to impact treatment engagement and response to

http://dx.doi.org/10.1016/j.jocrd.2014.12.005
2211-3649/& 2014 Elsevier Inc. All rights reserved.
2 S. Cole Monaghan et al. / Journal of Obsessive-Compulsive and Related Disorders 5 (2015) 1–7
treatment in OCD, such as demographic variables, severity of symp-
toms, depression, general anxiety, assertiveness, treatment context,
and treatment expectancy and motivation, (Steketee & Shapiro, 1995).
For example, greater initial severity of complaints, in combination with
higher level of depression, longer problem duration, poorer motivation
for treatment, and dissatisfaction with the therapeutic relationship
predict poorer outcome for obsessive fear (Keijsers, Hoogduin, &
Schaap, 1994). However, treatment motivation and ‘readiness for
change' have been inconsistently measured across studies, leading to
equivocal findings and limited generalizability. The purpose of this
investigation was to examine the role of motivation or readiness to
change, operationalized using a robust and transdiagnostic instru-
ment, in understanding treatment response in OCD.
1.1. Motivation to change as a predictor of outcome in psychiatric
disorders
One construct that has garnered recent attention in predicting
treatment outcome in clinical populations is readiness for change,
operationalized along a continuum of motivation to change a
problem behavior. Prochaska and colleague (Prochaska &
DiClemente, 1983) developed a transtheoretical model based on
observations of differing treatment outcomes across a variety of
treatment programs, which posits that change processes (techni-
ques or therapies) are differentially effective depending on the
patient's readiness to implement new strategies and/or behaviors,
or ‘stage of change.’ The model conceptualizes five distinct stages
of change: 1) Precontemplation, in which the individual has no
intention to change in the foreseeable future and no insight into
the problem(s); 2) Contemplation, in which the individual becomes
aware that a problem exists and begins to think about change, but
has not yet made a commitment to take action; 3) Preparation,
when the individual intends to change imminently; 4) Action, in
which a person modifies their behavior, experiences, or environ-
ment in order to overcome a problem; and 5) Maintenance, in
which a person is actively engaged in relapse prevention and
consolidating gains attained during action. Norcross, Krebs, and
Prochaska (2011) suggest that the role of the therapist during
treatment should vary based on the stage to which the client has
progressed, such that as the person moves through the stages, the
role of the therapist shifts from nurturing (in Precontemplation) to
Socratic teacher (in Contemplation) followed by experienced
coach (in Preparation) and finally to consultant (in Action and
Maintenance). The authors argue that stage-matching therapy in
this way can be an effective method of providing guidance for
clients, and that doing so requires a valid and reliable measure of
readiness to change.
The stages of change model has been operationalized by the
University of Rhode Island Change Assessment scale (URICA;
McConnaughy, DiClemente, Prochaska, & Velicer, 1989), a factor-
analytically derived scale containing four subscales corresponding
to four of the five stages (Preparation was eliminated from the
factor analysis due to overlap with the Contemplation and Action
subscales). Higher scores on each subscale indicate the individual's
tendency toward that stage(s) of change. An overall “Readiness to
Change” score can also be derived from responses on the URICA.
Motivation for treatment, as measured by this scale, has been
associated with treatment outcome in a number of clinical popula-
tions, such as substance abuse (DiClemente, Schlundt, & Gemmell,
2004), health behaviors (e.g., exercise; Donovan, Jones, Holman, &
Corti, 1998), and smoking cessation (Carbonari, DiClemente, &
Sewell, 1999). Recently, research efforts have expanded the applica-
tion of the transtheoretical model to eating disorders (Dray & Wade,
2012), sexual violence prevention (Banyard, Eckstein, & Moynihan,
2010), and, of particular interest here, anxiety (Dozois, Westra,
Collins, Fung, & Garry 2004). As the authors point out, variable
response rates to even highly effective interventions (such as CBT
using EX/RP, above) suggest that more research into identifying
factors that may differentiate treatment responders and non-
responders – particularly at admission and continually throughout
treatment – is needed.
1.2. Stages of change in anxiety disorders
There is mounting evidence that this transtheoretical model
can be used to predict treatment outcome across a number of
anxiety-related diagnoses (reviewed briefly here). However, few
studies to date have focused on OCD specifically.
Beitman et al. (1994) examined stages of change and response
to medication in patients with panic disorder. One hundred and
three patients treated with a benzodiazepine were compared to
103 matching placebo controls at one and four weeks after
beginning the medication trial. All patients were administered
the Structured Clinical Interview for DSM (SCID; Spitzer & William,
1987) as well as several outcome measures. Patients who scored
higher on Precontemplation at baseline were significantly less
likely to improve over the course of treatment on the Clinical
Anxiety Scale (CAS; Snaith, Baugh., Clayden, Husain, & Sipple,
1982), Hamilton Anxiety Rating Scale (HAM-A; Hamilton, 1969),
and panic attack frequency. Patients who scored higher on Con-
templation, however, were significantly more likely to improve on
clinical measures. These results provide support for the idea that
the stage of change at baseline corresponds to clinical outcomes in
panic disorder.
In another study, Dozois et al. (2004) examined the psycho-
metric properties of the URICA in self-identified anxious under-
graduate students and in individuals presenting for treatment of
panic disorder. Across both study samples, the URICA demonstrated
good reliability and moderate convergent and divergent validity.
The authors report that the predictive validity of the measure was
good, especially as a predictor of treatment dropout. Thus, patients
who presented for panic disorder treatment but had lower Action
subscale scores were more likely to drop out of CBT therapy than
those with higher Action subscale scores. Furthermore, CBT respon-
ders scored higher on the Contemplation subscale than nonrespon-
ders. The authors offer cautious support for the utility of the URICA
as a predictive measure in anxiety treatment, which is consistent
with the report from Beitman et al. (1994).
Similar findings have been reported in posttraumatic stress dis-
order (PTSD). Research on treatment outcome in veterans admitting
for PTSD treatment revealed that stage of change at initial assessment
predicted symptom severity at follow-up (Rooney et al. 2007).
1.3. Motivation to change as a predictor of outcome in OCD
Despite the above reports across anxiety diagnoses, to date, few
studies have empirically examined motivation to change using the
URICA in OCD treatment using CBT with EX/RP, although treatment
motivation is widely hypothesized to influence the therapeutic
process. Pinto, Pinto, Neziroglu, and Yaryura-Tobias(2007) exam-
ined whether motivation to change predicted response to fluvox-
amine in OCD. In an open-label, 10-week trial of fluvoxamine, 32
outpatients diagnosed with OCD were assessed using the URICA
(McConnaughy et al., 1989) and the Yale–Brown Obsessive–Com-
pulsive Scale (Y-BOCS; Goodman et al. 1989). Mean pre-treatment
Y-BOCS scores reflected severe levels of OCD symptoms (M¼28.10,
SD¼5.27) and were significantly reduced at discharge (M¼18.00,
SD¼8.39). The analyses revealed no significant correlation between
overall Readiness to Change and symptom improvement as mea-
sured by the Y-BOCS; however, the authors did report a significant
negative association between Precontemplation and Y-BOCS change
from pre- to post-treatment. This is consistent with the relationship
 S. Cole Monaghan et al. / Journal of Obsessive-Compulsive and Related Disorders 5 (2015) 1–7
observed within a panic disorder sample, above (Beitman et al.,
1994) and suggests that higher Precontemplation scores at baseline
may predict poorer response to treatment in OCD. In another study,
Vogel, Hansen, Stiles and Götestam (2006) examined associations
between post-treatment Y-BOCS and helping alliance between
providers and patients, treatment motivation, and treatment expec-
tancy in individuals with OCD completing cognitive-behavioral
treatment as part of a randomized clinical trial. A positive treatment
alliance was predictive of posttreatment Y-BOCS, whereas treat-
ment motivation and treatment expectancy were not associated
with post-treatment OCD symptoms. Given these mixed results, it is
important to further elucidate the clinical predictors that may
influence treatment retention and outcome, particularly with
regard to treatment motivation.
1.4. Predicting treatment response in OCD using the URICA
Despite the success of empirically-supported treatment with
EX/RP for OCD, a relatively high proportion of patients completing
EX/RP do not experience relief from their symptoms, or may
experience improvement but then relapse. Based on the limited
data presented above, the current study investigates the relation-
ship between motivation to change throughout treatment and
clinical change in the context of intensive residential treatment
with EX/RP in patients with OCD. We hypothesized that 1) stages
of change would be related to symptom severity at admission,
such that greater symptom severity would correspond to higher
readiness to change, and 2) stages of change as measured by the
URICA would be associated with treatment outcome and overall
functioning, such that increased readiness to change at admission
would correspond to better treatment outcomes and overall
functioning at discharge. Because some components of depression
(e.g., hopelessness) may impact treatment engagement (Westra,
Dozois, & Boardman, 2002), a measure of depressive symptoms
will also be included in order to evaluate the potential role of
depression.
2. Method
2.1. Participants
The sample consisted of 424 patients (212 male, 212 female) in an intensive
residential treatment program for OCD with a mean age of 33.89 (SD ¼14.16). Of the
sample, 91.3% self-reported ethnicity as 84.2% White, 4.5% Asian, .9% Black or
African-American, .5% American Indian or Alaskan Native, .5% Native Hawaiian or
other Pacific Islander, and .7% Other. Patients were admitted to the program
between December 2008 and July 2013 with an average length of stay of 50.32
days (SD ¼26.38). Admission criteria included a primary diagnosis of OCD, along
with self- or family-reported functional impairment due to symptoms. The average
Y-BOCS total score at admission for the total sample was 26.00 (SD ¼6.77),
signifying severe OCD symptom severity. The diagnosis of OCD was established
by the clinical treatment team through a clinical interview and a review of the
patient history. Because data collection occurred in a naturalistic setting, proce-
dures were not in place to systematically assess for comorbid disorders. Prior to
analyses, data regarding participants' prior treatment (i.e., medication and psy-
chotherapy) were collected. Of the total sample, 40.3% self-reported having been
hospitalized and 69.3% reported having been in therapy due to a psychiatric illness.
Regarding prior outpatient treatment, 4.7% had received only medication, 14.8% had
received only psychotherapy, and 49.5% had received a combination of medication
and psychotherapy.
Due to the naturalistic nature of the study, some patients did not complete all
measures at all time points due to refusal or unexpected discharge; as such, only
patients with complete pre-post data were included in analyses. Participants who
had been admitted to the program more than once (N ¼16) were analyzed using
the data from their most recent admission. Patients who did not grant consent for
their data to be used for research purposes were not included in the analyses. This
study was approved by the hospital's institutional review board.
3
2.2. Treatment
All patients were admitted to intensive residential treatment (IRT) for OCD in a
suburban psychiatric hospital in the northeastern United States. IRT consisted of
individual, group, and milieu therapy within a hospital setting. All patients receive
individual CBT with a behavior therapist (BT; senior staff licensed psychologist or
clinical social worker) for 50 min 2–3 times weekly, in addition to weekly case
management with a social worker and psychopharmacology consultation with a
psychiatrist. Patients participate in daily exposure therapy consisting of two hours of
therapist-guided EX/RP and two hours of self-directed EX/RP. Patients adhere to
behavior plans designed by their BT to target obsessions and compulsions according
to a hierarchy established by the BT and the patient. The EX/RP work is the
centerpiece of the psychosocial therapy that occurs in IRT and the groups, and
milieu experiences are designed to support and compliment the work done in EX/RP.
2.3. Materials
2.3.1. The university of Rhode Island change assessment (URICA; McConnaughy
et al., 1989)
The URICA is a 32-item self-report questionnaire that measures participants'
motivation to change based on the five stages of change: Precontemplation,
Contemplation, Preparation, Action, and Maintenance. Psychometric studies (e.g.
DiClemente & Hughes, 1990) have determined that a four-factor solution is the
most parsimonious structure for the scale, including Precontemplation, Contem-
plation, Action, and Maintenance. Participants are asked to rate the extent to which
they agree or disagree with statements regarding their motivation to change (e.g.
“I think I might be ready for some self-improvement” and “I am really working hard
to change”). Participants use a Likert-type scale ranging from 1 (“strongly
disagree”) to 5 (“strongly agree”), and are evaluated based on the stage of change
in which they score the highest. The URICA has been shown to have good internal
consistency with clinical samples (α ¼.79; Dozois et al., 2004).
2.3.2. The Yale–Brown obsessive compulsive scale (Y-BOCS; Goodman et al. 1989)
The Y-BOCS is a 10-item self-report questionnaire that measures participants'
symptom severity. Participants are asked to answer questions regarding how their
obsessions and compulsions have impacted their lives in the past week (e.g., “How
much of your time is occupied by these obsessive thoughts?” and “How much of an
effort do you make to resist the compulsions?”). The Y-BOCS has been shown to
have good internal consistency in clinical samples (α ¼ .78; Steketee, Frost, &
Bogart, 1996). The Y-BOCS is available as clinician-administered or self-report; this
research utilizes the self-report form as part of ongoing clinical assessment.
2.3.3. The work and social adjustment scale (WSAS; Mundt, Marks, Shear, & Greist,
2002)
The WSAS is a 5-item self-report questionnaire that assesses participants'
functional impairment. Participants are asked to rate the extent to which various
aspects of their lives are impaired due to their OCD symptoms (e.g., ability to work
and social activities). Participants use a scale ranging from 0 (“not at all”) to 8 (“very
severe”). The WSAS has been shown to have good internal consistency in an OCD
sample (α ¼.79; Mundt et al., 2002).
2.3.4. The quick inventory of depressive symptomatology (QIDS; Rush et al., 2003)
The QIDS is a 16-item questionnaire designed to measure participants'
depressive symptoms, derived from the Inventory of Depressive Symptomatology.
Participants are asked to evaluate the extent to which they have experienced the
various diagnostic criterion for major depressive disorder in the past week (e.g.,
mood, appetite, sleep patterns, energy level, and concentration). The QIDS has been
shown to have good internal consistency in samples with clinically significant
depression (α ¼ .86; Rush et al., 2003). The QIDS is available in clinician-
administered or self-report formats; this research utilizes the self-report form as
part of ongoing clinical assessment
2.4. Design and procedure
Participants included patients diagnosed with OCD and admitted to IRT. All
participants completed a battery of self-report measures at admission and
discharge as well as at monthly time points while in treatment, including the
URICA, Y-BOCS, WSAS, QIDS, and a demographics form. Study data were collected
and managed using REDCap electronic data capture tools hosted by the Partners
HealthCare Research Computing, Enterprise Research Infrastructure & Services
(ERIS) group. REDCap (Research Electronic Data Capture) is a secure, web-based
application designed to support data capture for research studies. All patients
included in analyses completed a consent form that provided permission for their
data to be used for research purposes. These data were collected electronically on a
PC in the program laboratory. Each patient completed the battery while seated in
front of the computer in the presence of trained research assistants, who
introduced the protocol, explained the response formats for the various measures,
4 S. Cole Monaghan et al. / Journal of Obsessive-Compulsive and Related Disorders 5 (2015) 1–7

obtained informed consent from interested participants, and answered questions Table 2
as needed. Data collection was supervised by a licensed clinical psychologist. All Means and Standard Deviations of Y-BOCS, WSAS, and QIDS Throughout Treatment.
patients completed admission measures on the first two days of residential
treatment and discharge measures within two days of discharge from the program. Admission Month One Discharge Avg Change

2.5. Data analysis N M(SD) N M(SD) N M(SD) N M(SD)

Y-BOCS 324 26.0(6.8) 136 20.1(6.4) 235 16.5(6.2) 235 9.3(7.5)

SPSS (Statistical Package for Social Sciences) 20.0 software was used to WSAS 396 26.9(8.1) 191 23.8(9.3) 275 18.4(9.8) 266 8.5(9.3)
complete all statistical analyses. In order to test the hypotheses that 1) stages of QIDS 323 13.3(5.5) 134 10.9(5.1) 233 8.9(4.8) 233 4.3(5.2)
change as measured by the URICA would be significantly associated with measures
of treatment response and 2) stages of change would correlate with symptom Note. Y-BOCS: Yale–Brown Obsessive Compulsive Scale. WSAS: Work and Social
severity at admission, Pearson product-moment correlations between all relevant Adjustment Scale. QIDS: Quick Inventory of Depressive Symptomatology.
measures were computed. Treatment response was measured using the change in
Y-BOCS score from admission to discharge, defined as ΔYBOCS (calculated by
subtracting the discharge score from the admission score) where larger numbers
Table 3
correspond to greater improvement in Y-BOCS score. Change in functioning was
Regression analysis: factors affecting treatment outcome (ΔY-BOCS Score).
measured using the change in WSA score, defined as ΔWSA (calculated by
subtracting the discharge score from the admission score) where larger numbers
B SE(B) β
demonstrate improvement in functioning. The four subscale scores on the URICA
Step 1
were used as indices of each stage of change (Precontemplation, Contemplation,
Action, and Maintenance). Statistical significance was defined as p o .05 for all tests.
Age  .03 .04  .06
Because some patients discharged before completing Month One or Month Two
Length of stay .23 .02 .08
measures, the reader will note missing data in the results for these timepoints.
QIDS .12 .09 .09
Given the exploratory and naturalistic nature of the study, only patients who
Step 2
completed all relevant measures at each time point were included in the analyses.
Age  .05 .04  .10
Length of stay .02 .02 .07
QIDS .07 .10 .05
3. Results Precontemplation  .18 .15  .10
Contemplation .13 .24 .05
3.1. Stages of change and symptom severity Action  .04 .14  .02
Maintenance .25 .13 .14

The first aim of the study was to determine whether symptom Note. N ¼ 220. Adjusted R2 ¼ .01 for Step 1; ΔR2 ¼.03 for Step 2 (p's¼ .25 and .11).
severity was significantly related to stage of change rating at QIDS¼Quick Inventory of Depression Symptomatology. *p o .05.
admission, in order to determine whether motivation for treat-
ment may be associated with initial OCD symptom severity.
Consistent with this prediction, higher admission Y-BOCS scores Table 4
Regression analysis: factors affecting treatment outcome (ΔWSAS Score).
were significantly correlated with lower Precontemplation scores
(indicating less resistance to changing behavior), r (304) ¼  .14, B SE(B) β
p o.05 and higher Maintenance scores (indicating higher motiva- Step 1
tion to retain treatment gains to date), r (305) ¼ .12, p o.05, but not
Age  .07 .05  .11
with Contemplation (r ¼.03, p¼ .61) or Action (r ¼  .07, p ¼.22).
Length of stay .03 .03 .08
QIDS .24 .12 .14
3.2. Stages of change and treatment outcome
Step 2

The second aim of this study was to determine whether stages Age  .09 .05  .13
of change at admission would be significantly associated with Length of stay .02 .03 .05
change in two measures of treatment outcome (Y-BOCS & WSAS), QIDS .21 .13 .12
representing symptom severity and self-reported functioning. Precontemplation  .38 .20  .16
Contemplation  .16 .32  .05
Descriptive statistics for these measures are presented below in
Action .04 .19 .02
Tables 1 and 2 (URICA) and 2 (Y-BOCS & WSAS). Maintenance .15 .18 .07
Hierarchical linear regression using forced entry was employed
to test the hypotheses that readiness to change at admission Note. N ¼ 201. Adjusted R2 ¼ .02 for Step 1; ΔR2 ¼.02 for Step 2 (p's¼ .08 and .33).
would predict both a) treatment outcome (ΔY-BOCS) and b) QIDS¼Quick Inventory of Depression Symptomatology. *p o .05.

change in overall functioning (ΔWSAS). Results for both regression

analyses are reported in supplemental Tables 3 and 4, below. of outcome as measured by Y-BOCS change score. This result does
After controlling for age, length of stay, and depression symp- not support our hypothesis that stage of change would predict
tomatology, stages of change scores were not significant predictors improvement in OCD symptoms. We also evaluated stages of
change in relation to overall functioning. Stages of change scores
did not add significantly to the model after controlling for the
Table 1
Means and Standard Deviations of URICA subscales throughout treatment. other predictors. Neither regression model accounted for a sig-
nificant proportion of the variance in Y-BOCS outcome.
Admission Month One Discharge
3.3. Post-Hoc analysis: treatment motivation at discharge and length
URICA Subscales N M(SD) N M(SD) N M(SD)
of Ssay
Precontemplation 384 10.9(4.0) 186 10.8(3.6) 273 11.3(4.0)
Contemplation 390 31.1(3.0) 188 30.4(2.9) 276 29.7(3.3) For a variety of reasons, some patients in the residential program
Action 393 29.0(4.5) 191 31.1(3.3) 275 31.1(3.9) discharge prematurely. Following up on the regression analyses
Maintenance 390 26.8(4.4) 187 27.0(4.2) 272 26.9(3.8)
investigating the role of treatment motivation at admission, we aimed
Readiness to Change 375 10.9(1.6) 182 11.1(1.3) 269 10.9(1.5)
to evaluate whether level of motivation at discharge was signifi-
Note. URICA: University of Rhode Island Change Assessment. cantly associated with length of stay in the program. We observed
 S. Cole Monaghan et al. / Journal of Obsessive-Compulsive and Related Disorders 5 (2015) 1–7
that length of stay was significantly and negatively correlated with
Precontemplation scores at discharge, r (263)¼  .25, p o.001,
indicating that higher Precontemplation scores at this timepoint are
associated with shorter lengths of stay. Thus, more resistance to
change, evidenced by high Precontemplation, appears to correspond
with earlier discharge. Length of stay was not significantly correlated
with Contemplation, Action, or Maintenance scores at discharge.
Furthermore, Y-BOCS change scores were significantly and negatively
correlated with Precontemplation scores at one month, r (106)¼  .29,
p o.01, indicating that higher Precontemplation scores at one month
were associated with less change in Y-BOCS. Y-BOCS change scores
were not significantly correlated with Contemplation, Action, or
Maintenance scores at discharge.
4. Discussion
Motivation to change, as measured by the URICA, has been
demonstrated to be useful as a predictor of treatment outcome in
substance abuse, as well as GAD and panic disorder. It is also helpful
in predicting improvements in health behaviors, such as smoking
cessation and exercise. However, the relationship between motiva-
tion to change and OCD treatment outcome remains far from
definitively established. The data presented here indicate that,
contrary to our expectations and results observed in other anxiety
disorder populations, stage of change at admission to intensive
residential treatment does not appear to be a robust predictor of
treatment response. However, our data indicate that there is a
significant relationship between initial symptom severity and
motivation to change, and that motivation to change at later time
points may adversely affect treatment latency (resulting in pre-
mature discharge from intensive residential treatment). Relation-
ships between treatment motivation and outcome may be less
straightforward than initially hypothesized; instead, treatment
motivation may exhibit a fluctuating course, interacting with other
factors over time in ways that may ultimately affect treatment
adherence, latency, and outcome.
4.1. Stages of change and symptom severity
In line with our first hypothesis, symptom severity was signi-
ficantly related to stage of change rating at admission, specifically in
regards to the Precontemplation and Maintenance stages. Higher
scores on the Y-BOCS at admission were associated with lower
scores on the Precontemplation subscale. The negative correlation
between symptom severity and Precontemplation suggests that
individuals with higher symptom severity at admission do not tend
to experience low motivation and/or insight, both of which are
indicative of the Precontemplation stage. The positive correlation
between symptom severity and Maintenance, which might seem
counterintuitive, could suggest that individuals with higher symp-
tom severity at admission tend to enter treatment with a focus on
relapse prevention, because according to Prochaska and colleague
(Prochaska & DiClemente, 1983), the Maintenance stage is marked
by relapse prevention and an effort to continue building upon gains
made during treatment. It seems unusual that a patient experien-
cing high symptom severity and seeking residential treatment
would be in this stage of motivation; in fact, we expected the
opposite. This finding could suggest that those highly symptomatic
patients who have received treatment for their OCD prior to
enrolling in the residential program are therefore more oriented
toward building upon prior gains or motivation built through
psychoeducation regarding symptoms and the efficacy of residen-
tial treatment models. Patients who have previously received
psychoeducation and treatment may be more likely to be aware
of the problem and more motivated to change.
5
4.2. Stages of change and treatment outcome
The finding that stage of change at admission was not related to
Y-BOCS outcome was unexpected given findings in two previous
studies in anxiety samples (Pinto et al., 2007; Beitman et al., 1994).
However, at least one prior randomized clinical trial (Vogel et al.,
2006) observed similar null findings with regard to the relation-
ship between treatment motivation and expectations and post-
treatment outcome. Our results corroborate this observed lack of
main effects of treatment motivation. These mixed findings may
reflect that some investigations that observed significant effects of
baseline motivation (Pinto et al., 2007; Beitman et al., 1994) used
smaller samples and were focused on pharmacotherapy (with
fluvoxamine and adinazolam, respectively), as opposed to CBT, in
OCD. It is also possible that, after being educated regarding the
cognitive-behavioral treatment featured in both studies, patients
who actually entered treatment possessed treatment motivation
that – at least at admission – exceeded some meaningful thresh-
old; patients experiencing critically low levels of treatment moti-
vation may be less likely to apply for and subsequently enter these
types of treatments, and may therefore not be reflected in study
samples. Future studies might test this hypothesis by including
data on individuals who ultimately decide not to enroll in treat-
ment after pre-treatment assessment.
However, our follow-up analyses suggest possible refinements
in our interpretations of the role of treatment motivation over
time, which may be tested in future investigations across various
levels of care and symptomatic severity. Specifically, we observed
that despite the lack of associations between admission motiva-
tion to change and treatment outcome, experiencing higher levels
of Precontemplation later in intensive residential treatment is
associated with shorter length of stay. As the mean scores at
discharge reflect, most patients continue to experience clinically
significant – and sometimes severe – levels of OCD symptoms and
functional impairment at discharge. Therefore, earlier termination
with corresponding lack of motivation to change may lead to
premature or sudden discharge in the case of patients who are
unwilling to continue. This result indicates that motivation for
treatment later in treatment may influence treatment decisions to
suddenly or prematurely discharge from the program, which may
present inherent risks such as less developed and supportive
aftercare plans.
We also examined individuals with low treatment motivation at
admission and at one month. In an analysis of a subset of patients
who had complete cross-sectional data one month after admitting to
the program, we observed that, despite the fact that Precontempla-
tion at admission was not predictive of Y-BOCS outcome, individuals
who experience low motivation at one month post-admission tend
to achieve relatively lower treatment response over time. This
suggests that experiencing low motivation at admission may not
significantly impact treatment outcome, but experiencing ambiva-
lence or low motivation one month into treatment may be an
important determinant of treatment response. Because we exam-
ined these correlations at single timepoints, we cannot know
whether the low-motivation individuals at admission are the same
individuals who report low motivation at one month. However, low
motivation at one month appears to be predictive of worse outcome.
Although some patients remain in treatment at one month despite
reporting low motivation to change at that time, increased time in
treatment may not be helpful in reducing symptoms. One explana-
tion for this finding is that external motivators, such as pressure
from family or outpatient treaters, may keep patients from dischar-
ging early despite their low motivation to change. Low motivation is
likely to impact the progress that individuals can make in EX/RP due
to the treatment requiring significant effort on the part of the
patient to resist ritualizing and maximize opportunities to practice
6 S. Cole Monaghan et al. / Journal of Obsessive-Compulsive and Related Disorders 5 (2015) 1–7
in a self-directed context. Patients who do not possess internal
motivation to change may continue to ritualize despite outward
engagement in coached EX/RP, which would reduce the effective-
ness of the exposure. They also may not appropriately utilize the
time that is allocated to self-directed EX/RP, an important aspect of
treatment aimed to promote generalization of EX/RP skills that can
be utilized after discharge. Indeed, this finding (suggesting that
attendance in treatment is not necessarily sufficient) supports the
work that some investigators have directed toward increasing
factors that may impact treatment engagement, such as willingness
in ACT-based treatments for OCD (Twohig, Hayes, & Masuda, 2006).
4.3. Conclusions
Our first hypothesis, that symptom severity would be asso-
ciated with stage of change at admission, was supported. However,
our second prediction that admission stage of change would
predict Y-BOCS outcome and functioning was not supported by
our data; instead, it appears that treatment motivation may have
an individualized or fluctuating course over time that may interact
with various other factors to ultimately affect the patient's treat-
ment over time. Our study represents an expansion upon the
existing literature in several ways. When we consider the context
of the study alone, the implications of these findings may be of
multifaceted clinical importance. First, these data come from a
residential treatment setting in which the patients have, for the
most part, been placed on a wait-list for several months. It would
be expected that patients in this treatment would be highly
motivated, because the treatment is voluntary, and every patient
in this setting consented to treatment of their own accord. Thus,
we would expect that even if a person endorsed relatively low
motivation to change at admission, their presence in treatment
implies some desire to change. Therefore, this study illustrates that
even among these individuals who voluntarily commit to intensive
residential treatment, treatment motivation at later time points is
significantly associated with important clinical factors (i.e., treat-
ment latency, outcome).
The findings that low motivation one month into treatment is
associated with less improvement by discharge, and low motiva-
tion later in treatment is associated with earlier discontinuation of
treatment, both speak to a need for OCD therapists to be aware of
this vulnerability, with the goal of better tailoring their interven-
tions to assess and address changing levels of motivation over
time, rather than EX/RP “as usual.” This may involve beginning
EX/RP at a less challenging level (i.e., lower on the hierarchy) for
some patients, in order to better facilitate experience with
improvement early in treatment. In other words, patients who
express less motivation once treatment is underway may require
more incentive to “buy in” to exposure treatment. In addition, the
transtheoretical model emphasizes the evolving role of the thera-
pist during treatment based on the patient's stage of change; this
would be another relevant area for investigation. These remain
empirical questions, but we believe this may be a beneficial ave-
nue for our ongoing research.
Another potential solution for episodic low levels of motivation
would be to identify ways to increase motivation throughout
treatment when indicated; for example, by regularly assessing
patient's motivation and response to obstacles and including
adjunctive work focused on the patient's values, goals, and treat-
ment interference, or consultation with a therapist who specializes
in motivational interviewing (MI; see Miller, 2006). A recent paper
by Simpson and Zuckoff (2011) reviewed two studies in which MI
interventions were used with OCD patients. In one (Maltby &
Tolin, 2005), MI was used to reduce EX/RP refusal. Comparison of
the MI group to a wait-list control group revealed that 86% of the
MI group agreed to begin EX/RP, compared to 20% of the controls.
In a second study (Simpson, Zuckoff, Page, Franklin, & Foa, 2008),
MI was used to enhance EX/RP treatment for people who enter
EX/RP but drop out shortly thereafter, or adhere minimally to the
treatment. MI strategies were added to the initial EX/RP sessions
to evoke commitment to change; additionally, a 15 min MI module
was developed to address resistance later in treatment. During the
pilot trial, five of six patients completed EX/RP and experienced
significant symptom reduction (Simpson et al., 2008).
The results presented here would support the exploration of MI
strategies as an adjunct to standard EX/RP, particularly when
indicated by low motivation to change or engage in treatment.
This approach may also be useful for improving outcomes in
people who are admitted but who endorse low motivation at
various times throughout treatment. One way to address motiva-
tion would be to swiftly match individuals who indicate high
levels of Precontemplation on systematic assessment to a behavior
therapist within the facility who has MI training, with the goal of
facilitating the shift from Precontemplation toward Action. Thus,
one application of the data presented in this paper would be to
identify individuals with low motivation throughout treatment,
and administer the standard EX/RP approach with adjunctive MI,
as suggested by Simpson and Zuckoff (2011). MI is a relatively
simple intervention, and the additional training needed for staff
would likely be far outweighed by the potential benefit to patients.
This is especially true in the case of OCD, because the idea of
exposure can be so frightening for patients that they may refuse to
attempt it or adhere to the intensive regimen. We see these data as
providing support for the importance of assessing treatment
motivation throughout the course of demanding cognitive-
behavioral treatments for OCD, and further supporting the use of
interventions including MI in treatment of OCD when indicated,
consistent with Simpson and Zuckoff's work.
5. Conclusions: limitations & future directions
This study is limited by the fact that many of the data presented
are correlational, and cannot be presumed to indicate causation. In
addition, the lack of a control group introduces the possibility for
self-selection bias in the sample. We hope to address this in part
with the use of wait-list controls in future research. Furthermore,
many of the measures utilized in the study are self-report, which
may be subject to a patient's level of insight into symptoms.
Another concern is the heterogeneity of the treatment population.
The residential setting from which these data were collected
admits individuals with a variety of OC-spectrum disorders,
including a relatively high proportion of people with symptoms
of hoarding, trichotillomania, and a range of OCD subtypes (e.g.,
scrupulosity or contamination). These were not formally diag-
nosed, although assessment by trained clinicians indicated the
presence of these disorders as discussed in the methods. Regard-
less, grouping these individuals together in treatment outcome
research is not an optimal approach, and subtype analyses are an
important future direction for this research team. By the same
token, the sample was quite demographically homogeneous (84%
Caucasian), which may limit the generalizability of the results to
other cultural groups. In addition, as noted above, some patients
do not consent for their data to be used in research; such patients,
who may represent the lower end of the motivation curve, were
excluded from the study. Furthermore, patients were heteroge-
neous in terms of prior treatment and medication and ongoing
medication management strategies, “, and these factors might be
important in terms of both symptom severity and in potential to
benefit from CBT. Finally, one implication of this study was based
on the early discharge of some patients. Because of the naturalistic
setting, data are not available on the reason for discharge, and as
 S. Cole Monaghan et al. / Journal of Obsessive-Compulsive and Related Disorders 5 (2015) 1–7
such cannot account for the proportion of which early discharge
was due to other circumstances (e.g., insurance, family issues).
These data indicate that additional research into stages of
change and other indicators of motivation/willingness to engage
in OCD treatment would be a valuable addition to the literature.
Finding ways to address – and indeed, prevent – treatment failure is
without a doubt one of the more difficult and worthwhile pursuits
of treatment research. This is perhaps most crucial for empirically-
supported treatments like EX/RP, in which lack of improvement is
particularly concerning. We know that EX/RP, sometimes combined
with pharmacotherapy, is the most effective treatment for OCD.
However, we also know that some patients do not respond to the
intervention. Exploring the role of motivation in determining out-
come, and developing strategies to address low motivation or poor
insight, may provide additional avenues for intervention for people
suffering from severe OCD who are unwilling or unable to comply
with standard treatments.
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