BACKGROUND: THE DEVELOPMENT OF THE CONCENTRATED APPROACH
10 years ago, OCD patients in Norway did not have access to evidence based treatment, leading to prolonged, unnecessary suffering. Gerd Kvale had for a long time been working with concentrated treatment formats for anxiety disorders, and in 2009 when she was rewarded with two years of sabbatical after being a dean of the Faculty of Psychology, University of Bergen. She donated the two years to Haukeland University Hospital to establish an evidence based outpatient OCD-clinic working with concentrated treatments. Haukeland immediately added two years to the project.
Around the same time, Bjarne Hansen was heading the inpatient OCD clinic at St. Olav’s Hospital and launching the national OCD treatment implementation project. In collaboration with the Norwegian OCD foundation, he suggested that health authorities should establish 30 OCD treatment teams to ensure that evidence-based treatment was available for all OCD patients in Norway. After hearing about Bjarne’s work, Gerd invited him to join the Bergen clinic, and in 2011 they started this venture together. They were dedicated clinicians and researchers with the same goal: To improve treatment, carefully explore success rates, and optimize dissemination.
Currently, Gerd Kvale (with Bjarne Hansen as co-leader, and Thröstur Björgvinsson as a partner) is leading a national dissemination and research project in Norway: “Changing the specialist mental health care: The concentrated treatment format,” which is being financed by the national board of health authorities. This project will build upon OCD research and allows for the Bergen 4 Day Treatment (B4DT) to be tested and disseminated for a variety of disorders.
THE CONTENT OF THE B4DT: HARD AND LIFE-CHANGING
The B4DT is best described as an individual treatment delivered in a group setting; it is delivered simultaneously to 3-6 patients by the same number of therapists. The 1:1 ratio between therapists and patients ensures individually tailored, and therapist assisted, exposure training, while simultaneously taking advantage of the group setting. The therapists are working as a team, which means that a given patient typically work with more than one therapist. Prior to undergoing the treatment, the patients are thoroughly educated and prepared for what to expect, and have made the decision to dedicate four full days to working towards change. The program is setup in the following way:
- The first day is allocated to education and preparation.
- The two middle days are one prolonged treatment session interrupted by the natural occurrence of sleep. This ensures that the therapist has enough time to assist the patient in the OCD-demanding settings, and to help the patients become aware of all the micro-choices that they face when they are tempted to reduce the anxiety and discomfort by engaging in subtle avoidance strategies or mental/overt rituals. These micro-choices are seen as golden opportunities to make choices that are incompatible with having OCD. The exposure sessions are interspaced with group meetings, focused on patients progress and providing support.
- At the end of the third day, family and friends are invited to a lecture on how they can best support the patient.
- The fourth and last day is allocated to preparing the client for the coming three weeks; integrating the change into normal living.
Patients express high to very high treatment satisfaction after treatment, and typically describe it as hard and life-changing work.
When the B4DT was piloted, the reimbursement system in Norway was based on 45-minute sessions just like in the U.S. and the B4DT lost money for the treatment providers. As a consequence of the clinical success of the B4DT, the reimbursement system in Norway has changed; it now covers the concentrated format! We sincerely hope that the same will happen in the US.
The B4DT approach has received tremendous attention around the world. In October of 2018, Drs. Gerd Kvale and Bjarne Hansen were selected by Time Magazine as two of The Health Care 50: Fifty people transforming health care in 2018. They were the only honorees representing psychological treatment; truly a remarkable acknowledgement of recent advancement of OCD treatment. In addition, the B4DT was awarded the 2015 Innovation of the Year award by the Norwegian Psychological Science Association.
BERGEN 4-DAY TREATMENT: OUTCOMES
From the start, Gerd and Bjarne ensured independent outcome assessment, and the results show the following:
- more than 90% of the patients have reliably improved while 68% have remitted at 12-month follow-up (1).
- Furthermore, 69% are recovered at 4-year follow-up (2).
- Almost all patients who are offered the 4-day treatment accept it and enroll. There is almost no dropout (1-3), which clearly differs from typical psychological treatments for OCD, where approximately 15% of patients decline to enroll and 15% typically drop out of treatment (4).
- Importantly: Neither OCD severity, the number of co-morbid disorders, indications of personality disorders or presence of sleep disturbance predict treatment outcome (1-3).
- The B4DT is equally helpful for children and adolescents (5).
- At this time, approximately 1200 patients have received the B4DT.
In Norway, individuals with OCD are entitled to treatment by one of the 30 specialized OCD teams, and the B4DT is now part of that system. Only if a patient is suicidal, actively abusing drugs, experiencing psychosis, in the manic phase of bipolar disorder, or has an active eating disorder, is treatment postponed until these issues have been stabilized.
The development of the B4DT has created unique opportunities to upend mental health treatment delivery as we know it. In early 2017, the B4DT was implemented in Oslo (capital of Norway) where the Anxiety and OCD Clinic at University of Oslo had about 100 patients on their waiting list. Given the normal staffing practice of the clinic, it would have taken them 18 months to treat these patients. Thus, Gerd and Bjarne suggested that they treat the entire wait list by treating 45 patients during two 4-day interventions. A total of 90 patients with OCD were treated during two 4-day periods, thus effectively eliminating the wait list in a novel and creative way. At the three-month follow-up, 84% of patients had achieved clinically relevant change, and 68% were in remission (3). The B4DT has also been piloted in Iceland with comparable results (6). The question still remains: will this treatment work in the USA?
DISSEMINATION OF THE B4DT: BRINGING IT TO THE USA
Some people have expressed skepticism about this approach. Can this approach really work in 4 days? Maybe it works in Norway, but will it work here? Correctly, we cannot assume it will work in the U.S. without carefully evaluating it first. Thus, we are working on a thoughtful and rigorous dissemination in Houston beginning in June of 2019.
The dissemination plan, initially, involves two pilot studies (about 56 patients in each), one for adults and one for adolescents, with 3-month follow-ups. This work will be made available with generous support from:
- The Kavli Trust (https://kavlifondet.no) has provided five-year support to the Bergen group based at Helse Bergen, Haukeland University Hospital (https://helse-bergen.no) to ensure quality international dissemination of the B4DT.
- The Peace of Mind Foundation (https://peaceofmind.com) and Dr. Michael Jenike have pledged their support to sponsor the cost of the two pilot studies in the U.S. that will be conducted at the Houston OCD Program (https://houstonocdprogram.org). The team overseeing this dissemination are Drs. Kvale, Hansen and Björgvinsson in collaboration with McLean Hospital.
Dissemination of effective treatment is a major challenge in mental health care, and even though a clinic might offer evidence-based treatment, there is not a guarantee that patients who can access it will actually receive high-quality care. The Bergen group has developed a model for dissemination that eliminates any discrepancy between what is offered and what is delivered to patients; it ensures that the effectiveness of the B4DT is maintained. It assures that patients will receive competently delivered B4DT regardless of location and/or the composition of the team.
The core features of the model for dissemination are hands-on training and certification of therapist/group leaders, combined with an integrated quality- and outcome assessment that allows for benchmarking. It is now possible to establish “an expected outcome” where over 90% the patients reliably improve after the 4 days. If the treatment outcomes with a particular team fail to deliver optimal results, this elicits hands-on supervision and re-certification of the team and/or clinic. This integrated assessment is an essential part of the B4DT, and is an ongoing requirement for any clinic or team that wants to deliver the B4DT.
The Bergen site has also established a “control center” which is responsible for all logistics related to the assessment and integrated quality control. OCD-specific symptoms, as well as symptoms of anxiety and depression, are assessed both online and by trained assessors over the phone before, during, and post treatment.
The Bergen 4 Day Treatment is practical, evidence-based, focused and deliberate. It builds on four decades of empirical research and theories about the most effective approach to OCD treatment. The innovation and strength of the work is how it combines the most effective elements of proven treatment into one of the most profound, rapid, and robust treatment approaches that we have seen in recent years. Thus, this approach provides for a truly transformative treatment. It has the potential to be disruptive and to up-end how health care can be delivered in the U.S.
1. Hansen, B., Hagen, K., Öst, L-G., Solem, S., & Kvale G. (2018). The Bergen 4-day OCD treatment delivered in a group setting: 12-month follow-up. Frontiers in Psychology, 9, article 639.
2. Hansen, B., Kvale, G., Havnen, A., Hagen, K., & Öst, L-G. (2018). The Bergen 4-day treatment format: Four years follow up of concentrated ERP in a clinical mental health setting. Cognitive Behavioral Therapy, 8, 1-17.
3. Kvale, G., Hansen, B., Björgvinsson, T., Børtveit, T., Hagen, K., Haseth, S., Beate Kristensen, U., Launes, G., Ressler, K. J., Solem, S., Strand, A., van den Heuvel, O. A., & Öst, L. G. (in press). Successfully treating 90 patients with Obsessive Compulsive Disorder in eight days: The Bergen 4-day treatment. BMC Psychiatry, 18, 1-9.
4. Öst, L-G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993-2013. Clinical Psychology Review, 40, 156-169.
5. Riise, E. N., Kvale, G., Öst, L-G., Skjold, S. H., Hansen, H., & Hansen, B. (2016). Concentrated exposure and response prevention for adolescents with obsessive-compulsive disorder: An effectiveness study. Journal of Obsessive-Compulsive and Related Disorders, 11, 13-21.
6. Davíðsdóttir, S. D., Sigurjónsdóttir, Ó., Ludvigsdóttir, S. J., Hansen, B., Laukvik, I. L., Hagen, K., Björgvinsson, T., & Kvale, G. (under review). Implementation of the Bergen 4-day treatment for OCD in Iceland.