Treatment of refractory obsessive-compulsive disorder: The St. Louis model

In this article, we describe a cognitive behavioral treatment approach to cases of obsessive-compulsive disorder (OCD) that have not responded to standard outpatient evidence-based treatment. The approach begins with an assessment of the reasons why patients have not responded to treatment, which can be grouped into two categories: (a) inadequacies in the level of OCD treatment the patient has received; and (b) The presence of treatment-interfering behaviors that have obstructed the patient's ability to participate adequately in treatment. Treatment is then assigned according to category. Patients in Category 1 receive a more intensive level of evidence-based OCD treatment. Patients in Category 2 receive readiness treatment, a cognitive behavioral treatment designed to help patients get ready for OCD treatment by modifying treatment-interfering behaviors. Case examples are provided to illustrate this treatment approach.