(PS7-C74) Whose Outcomes Are Most Impacted by Ritualizing During Exposure and Response Prevention?

The literature suggests that exposure and response prevention (ERP) is effective for obsessive-compulsive disorder (OCD; Reid et al., 2021), yet 20-52% of ERP recipients do not achieve remission (Ost, 2014; Springer et al., 2018) and some do not maintain gains (Grøtte et al., 2018). Clients ritualization during ERP may limit treatment response. Despite apparent consensus among emotional processing, inhibitory learning [IL], and acceptance theories favoring eliminating rituals (Craske et al., 2014; Foa & Kozak, 1986; Twohig et al., 2015), empirical findings remain mixed regarding safety behaviors (SBs) in exposure. Some suggest that permitting SBs facilitates ERP acceptability (Levy & Radomsky, 2014), and fading SBs may promote practice which is essential to exposure learning in IL (Blakey et al., 2019). There is evidence, however, that incorporating SBs detracted from treatment outcomes (Powers et al., 2004).

One explanation for mixed findings may be that ritualizing more negatively impacts certain individuals. Some with severe OCD report experiencing compulsions as automatic. Ritualizing during ERP may reinforce the perception of limited control and negatively impact treatment outcomes.

In the current study, we hypothesize that ritualizing more will negatively impact OCD symptom severity and quality of life at posttreatment, and this relationship will depend on baseline OCD severity. The current study differs from extant literature, focusing on ritualization in ERP for those with OCD in intensive, residential treatment (IRT).

The participants (N = 496) were, on average, young (M_age = 29.5, SD = 10.78), White (74.2%), Male (51.8%), experiencing moderate to severe OCD symptoms, and had functional impairment and little success in past treatment. Those who participated in research filled out surveys, including the Yale-Brown Obsessive-Compulsive Scale Self-Report (Baer, 1991) and Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Endicott et al., 1993). After ERP sessions, clinicians reported the percent of time during exposure tasks participants ritualized.

            To explore the hypothesis, we used linear regressions with averaged ritualization throughout treatment and baseline OCD severity as predictors and included their interaction term. Results indicated that baseline OCD severity significantly predicted posttreatment OCD severity (t = 4.24, p < .001), but the effect was not moderated by mean ritualization (p = .58). Posttreatment quality of life was, however, significantly associated with the interaction of mean ritualization throughout treatment and baseline OCD severity (t = -2.57, p = .01). For those with more severe baseline OCD, more ritualization was associated with worse quality of life at posttreatment. For patients with less severe baseline OCD, ritualization did not predict posttreatment quality of life as strongly.

            These results indicate that although ritualization may not specifically moderate the effect of baseline OCD severity on posttreatment symptoms, it may be more relevant for quality-of-life outcomes, such that less ritualization is related to well-being when baseline severity is high. Findings may inform clinician behaviors.