by Gerd Kvale, PhD, Bjarne Hansen, PhD, and Thröstur Björgvinsson, PhD, ABPP
This article was initially published in the Winter 2018 edition of the OCD Newsletter.
Background: The Development of the Concentrated Approach
Ten years ago, OCD patients in Norway did not have access to evidence-based treatment, leading to prolonged, unnecessary suffering. As the dean of the Faculty of Psychology at University of Bergen, Norway, Gerd Kvale had long been working with concentrated treatment formats for anxiety disorders. In 2009, she was awarded two years of sabbatical, which she donated to Haukeland University Hospital to establish an evidence-based outpatient OCD clinic working with concentrated treatments. After she completed her sabbatical, Haukland decided to extend the project for two additional years.
Around the same time, Bjarne Hansen was heading the inpatient OCD clinic at St. Olav’s Hospital in Trondheim, Norway 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. In 2011, after hearing about Bjarne’s work, Gerd invited him to join the Bergen clinic. They were dedicated clinicians and researchers with the same goal: to improve treatment, carefully explore success rates, and optimize dissemination.
Currently, Gerd Kvale (together 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, but 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. 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 set up 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 patient become aware of all the micro-choices that they face when they are tempted to engage 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.
• 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 by integrating behavioral changes 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 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 1,200 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 change mental health treatment delivery as we know it. In early 2017, the B4DT was implemented in Oslo (the 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 all 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 United States?
Dissemination of the B4DT: Bringing it to the U.S.
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 initial dissemination plan 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 has provided five-year support to the Bergen group based at Helse Bergen, Haukeland University Hospital to ensure quality international dissemination of the B4DT.
• The Peace of Mind Foundation 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. 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 that has the potential to upend how health care is delivered in the U.S.
Gerd Kvale, Ph.D.
Dr. Kvale established, and is heading the OCD team at Haukeland University Hospital as well as the Bergen 4-day clinic. Kvale is Professor at the University of Bergen, Norway. Her main professional focus has been to develop and disseminate effective treatments for anxiety disorders and OCD, and she previously ensured the establishment of 35 specialized teams for treating dental fear, covering all Norway. She has published more than a 100 scholarly articles, where ones-session treatment for dental fear has been essential. At the moment, she is heading a number of national Norwegian research projects in clinical psychology. Kvale will be the director of The Bergen Center for Brain Plasticity.
Bjarne Hansen, Ph.D.
Dr. Hansen’s main dedication has been to ensure OCD patients access to evidence based treatment, and he initiated and headed the Norwegian National Project OCD-project in which 30 OCD teams covering all of Norway were established (2012-2016). He is Associate Professor at the University of Bergen, Norway, and working on the OCD team/ 4-day clinic at Haukeland University Hospital.
Thröstur Björgvinsson, Ph.D., ABPP
Dr. Björgvinsson the founder and director of the Houston OCD Program, a specialized residential OCD program in Houston, Texas, and the co-director of the OCD & Anxiety Program of Southern California. He is also an associate professor of psychology at the department of psychiatry, Harvard Medical School; the director of the Behavioral Health Partial Hospital Program at McLean Hospital, and co-director of psychology training at McLean Hospital / Harvard Medical School. He is very excited about bringing the B4DT to the USA.
You can visit the Houston OCD Program website to learn more about the Bergen 4-Day Treatment.
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.