New Data: The Effectiveness of NOCD Member Advocates in Improving Therapy Outcomes 

Executive Summary:

• New peer-reviewed data validated by the journal Frontiers in Human Neuroscience, the third most-cited journal in the field of psychology, examined the outcomes of peer-support interventions in improving adherence to exposure and response prevention (ERP) therapy for OCD.
• An observational analysis was performed on the largest sample in OCD to date: a cohort of nearly 3,500 NOCD Therapy members identified as being at risk of potential non-adherence to treatment.
• Results demonstrated peer support’s effectiveness in improving adherence to ERP therapy for OCD, with members who engaged with a peer support intervention completing 30.4% more therapy hours on average and experiencing a notable improvement in OCD symptoms: a statistically significant average reduction of 2.41 points on the OCD symptom severity scale.
• These findings suggest opportunities to combine science, digital interventions, and strategic peer-to-peer communication and support in care across a range of conditions.

For the millions of people experiencing the debilitating effects of OCD, exposure and response prevention (ERP) therapy offers an evidence-based, highly effective method of treatment. ERP helps dissipate the distress caused by OCD over time, and can lead to a significant reduction in symptoms. However, the success of ERP therapy is dependent upon adherence, or consistent participation—and due to both the nature of the treatment and varying life circumstances that can arise while undergoing it, adherence can be challenging for some.

As part of our efforts to bring treatment to those struggling with OCD, the NOCD team, led by Dr. Jamie Feusner, Chief Medical Officer, developed a way to help improve adherence. Using machine learning, they identified members at risk of not adhering to treatment and connected them with peer support. The NOCD team then analyzed the results, which were published in Frontiers in Human Neuroscience, and demonstrated the powerful impact of this method in improving treatment adherence.

How ERP therapy treats OCD

OCD is prevalent, affecting 1 in 40 people in the US over the course of their lifetimes, and can have devastating impacts if left untreated. Thankfully, decades of clinical research have shown that OCD is highly treatable. One of the most, if not the most, effective treatments for OCD is ERP, a form of Cognitive Behavioral Therapy (CBT) that was developed specifically to treat the condition.

ERP has been proven to be highly effective in reducing OCD symptoms. Through gradual exposure to obsessions, accompanied by the development of response prevention skills, ERP disrupts the cycle of OCD, helping to reduce distress and prevent compulsive behaviors. It improves symptoms significantly in the majority of people treated, but these benefits can only be achieved with adherence.

The role of adherence in ERP

Similar to how adherence refers to consistent participation in ERP therapy, non-adherence refers to inconsistent participation, or not following through with the treatment. For people with OCD who are doing ERP, the rate of non-adherence is estimated to be about 31 to 65%. This presents a significant problem: although an effective treatment is available, if people aren’t following through with it, then it’s not delivering benefits for those individuals.

The term “non-adherence” might seem similar to dropping out, but non-adherence in ERP is less dichotomous. Because OCD can vary so greatly from person to person, treatment also varies in terms of how much time is needed, the amount of progress made, and the pace at which that progress is made. For example, while one person might experience an improvement in symptoms after seven sessions of treatment, another person might need to attend closer to fifteen or sixteen sessions to reach that same point. Because of this, non-adherence may be better measured in terms of therapy hours completed.

Barriers to adherence

As effective as ERP is, adherence can be difficult due to the nature of the treatment. ERP is intended to induce distress in order for people with OCD to learn to habituate and tolerate the emotions around their obsessions without engaging in compulsions. Because of this, OCD symptoms can be temporarily exacerbated by ERP in some cases, especially in the early stages of treatment.

Some individuals, upon learning this about the process of ERP therapy, may think too far ahead about exposures their therapist might want them to practice in the future. It’s important to note that ERP is carefully structured to begin with an individual’s least distressing fears. However, considering the prospect of facing their most distressing fears in the future, people may feel a great deal of anticipatory anxiety. This can prevent them from attending future ERP sessions, or even starting treatment in the first place.

Logistical barriers are another factor that can affect adherence. An individual may face financial challenges that make it difficult to continue ERP therapy. It may be that their particular health plan doesn’t cover the treatment and the expense of having to pay out of pocket is unmanageable. Changes in their financial situation could also result in other out-of-pocket costs that make treatment unaffordable. Or, sometimes, a person might not feel like they have the best fit with their therapist. Being busy with other commitments or responsibilities, such as childcare, work, or school, may also impact an individual’s ability to adhere to a treatment plan.

NOCD’s work to improve adherence

In order to address this issue of non-adherence, the NOCD team used machine learning to create a predictive model and trained and tested it in about 13,000 members to identify those who were likely at risk of becoming non-adherent. This model was used to predict new members’ risk of non-adherence from July 2022 to December 2022. In total, there were nearly 3,500 members in this group.

Using data on the number of therapy sessions members had completed, the model predicted the likelihood of them being adherent or non-adherent. Several additional factors were involved in this prediction, including demographic factors, psychometric factors, co-occurring conditions, and the severity of an individual’s OCD symptoms at the start of treatment. Behaviors around scheduling or canceling appointments and use of the NOCD app were also used.

After developing and training the algorithm used in this predictive model, the NOCD team used several different types of machine learning to test its accuracy before putting it into use. Once the model had identified an individual as being at risk of non-adherence, that member would be contacted by NOCD’s Member Advocate team. The goal of this method was to improve members’ adherence to treatment in an efficient, targeted way. The team then evaluated the effects of this targeted peer support from Member Advocates on adherence.

How Member Advocates support NOCD members

Because OCD can feel isolating, NOCD’s goal is to provide members with a community of people who relate and understand what they’re experiencing through the Member Advocate team. Member Advocates are dedicated to providing NOCD Therapy members with support in navigating their treatment journeys, whether they’re preparing for their first session or navigating a challenge further along in their recovery and could benefit from extra support. Every Member Advocate possesses a profound understanding of OCD and related conditions, as well as the NOCD Therapy process, with many of them drawing from personal experiences.

Communication with Member Advocates starts the moment a member schedules their first session, with a message in the NOCD app and via email. A Member Advocate will also check in before a member’s first session to make sure they feel they have everything they need to attend, as well as after their session to make sure that their therapist was a good fit, that they felt heard, and that they’re having a positive experience overall.

The Member Advocate helps promote recovery, engages with the member to help improve their quality of life, and provides a peer with whom they can speak at any time. This relationship creates an additional safe space for the member on top of the safe space they have with their therapist, which is more focused on the guidance of ERP. Member Advocates are there to address and resolve any concerns empathetically so members can continue therapy without disruption.

Peer support for at-risk members

There were two phases of messaging within the peer support interventions for members identified as being at risk of non-adherence. The first was the initial message inquiring about the member’s therapy experience at that specific point in their treatment.

Within this group, members received two different messages based on whether or not they had a future session scheduled with their therapist. For those who did have sessions scheduled, Member Advocates did a check-in to see if there was anything that a member needed at that time. For members who did not have sessions scheduled, outreach aimed to determine if there were any concerns or barriers preventing them from being able to continue treatment that their Member Advocate could provide assistance with.

When members replied, their Member Advocate could engage with them in a more personalized manner, depending on what they expressed. Within the responses from members who received the peer support intervention, several noteworthy trends emerged. The majority, about 42%, responded that there were no issues at this time. Almost 30% said they were having a positive experience with their therapist or therapy overall. In these cases, the goal became to build a relationship with that member, so that if something were to happen down the line, they would hopefully be more likely to come to their Member Advocate for support.

Responses from about 10% of members indicated they were dealing with operational barriers, such as scheduling, billing, or insurance. A smaller group of about 6.5% expressed general therapy-related concerns, including struggles with symptoms or their emotions around treatment. People in this group were at different stages in treatment, with some having started ERP and some not, depending on how sessions with their therapist were going. Among those who had not yet begun ERP, responses expressed nervousness around starting. Those who had started shared fears of ERP not working for them. 

Upon receiving these responses from members, Member Advocates could provide personalized assistance with each member’s concerns, enabling them to continue with therapy and keep getting better.

Results and key takeaways

Peer support from Member Advocates yielded impressive results, with at-risk members who engaged with a Member Advocate completing 30.4% more therapy hours, on average, and experiencing greater reductions in OCD severity. Members who were identified as at-risk but did not engage with a Member Advocate completed fewer therapy hours than those who did engage, indicating that engagement is an important factor in improving adherence.

A secondary outcome was improvement in OCD symptoms among members who received peer support. The NOCD team sensed that peer support could result in not only more therapy hours being completed, but also in a reduction in symptom severity. Findings showed a notable association between the two, with engagement being associated with a statistically significant average reduction of 2.41 points on the OCD symptom severity scale.

This demonstrates, in the largest sample in OCD to date, the effectiveness of peer support. Interventions using peer support can help reduce treatment non-adherence to ERP for OCD, resulting in better outcomes. These results also indicate the efficiency of identifying and targeting those at risk of non-adherence as a method of improving adherence. Based on these findings, there are opportunities to combine science, digital interventions, and strategic peer-to-peer communication and support in care across a range of conditions.

You can read more about this analysis and the full results in Frontiers in Human Neuroscience. 

Getting treatment and support for OCD

If you think you or someone you know may be struggling with OCD, NOCD can help. All NOCD therapists deeply understand OCD and are licensed and specialty-trained to treat OCD using ERP therapy. We work side-by-side with the OCD experts and researchers who designed some of the world’s top OCD treatment programs to provide the best care for our members and ensure they’re supported throughout their treatment journey.

That includes support between sessions, when it matters most. Our Member Advocates are here to provide you with support at every step of treatment, and serve as your go-to resource for any questions or concerns you may have. Their primary focus is ensuring that you have a seamless and positive experience, while knowing that they genuinely care about your journey.

NOCD Members Advocates are not Certified Peer Support Specialists. They are peers in the OCD community who are trained to deliver support to NOCD Therapy members, due to their profound understanding of OCD and related conditions—with many drawing from personal experiences—as well as their familiarity with the NOCD Therapy journey. 

Certified Peer Support Specialists are credentialed in their respective states to offer peer support, and are current on their credentials. They go through deep training to provide peer support, and many make an amazing impact. To find a list of Certified Peer Support Services for OCD, please contact Chrissie Hodges.

If you have any questions about starting ERP therapy with a NOCD Therapist and accessing between-session support, you can book a free 15-minute call with our team. On the call, they can assist you in getting started with a licensed therapist at NOCD who has specialty training in OCD and ERP, share more about our between-session support, or connect you to other resources that might be helpful.