Journal of Obsessive-Compulsive and Related Disorders 30 (2021) 100650

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Journal of Obsessive-Compulsive and Related Disorders

journal homepage: www.elsevier.com/locate/jocrd

Metacognitive therapy versus exposure and response prevention for

obsessive-compulsive disorder – A pilot randomized trial
Julia Anna Glombiewski a, *, Jana Hansmeier b, Anke Haberkamp c, Winfried Rief c,
Cornelia Exner b
a
Institute of Psychology, University of Koblenz-Landau, Landau, Germany
b
Institute of Psychology, University of Leipzig, Germany
c
Institute of Psychology, University of Marburg, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: Cognitive behaviour therapy, especially exposure and response prevention (ERP) is the treatment of choice for
Obsessive-compulsive disorder obsessive-compulsive disorder (OCD). However, a substantial number of patients refuse this method or fail to
Metacognitive therapy benefit enough. Metacognitive therapy (MCT) claims to successfully treat OCD without prolonged exposures.
Exposure and response prevention
However, only case series and small, mostly uncontrolled trials have been published so far.
Pilot trial
The efficacy and feasibility of MCT for OCD compared to ERP were investigated in a pilot randomized trial.
Thirty-seven outpatients with OCD according to DSM-IV criteria were randomly allocated to individual, weekly
14-sessions of therapy with either MCT or ERP. Analyses focused on treatment efficacy at post-treatment and 3-
months follow-up, treatment fidelity and credibility.
Participants showed a significant reduction in OCD symptoms in both treatment conditions and with no dif­
ferences between MCT and ERP. Participants in the MCT condition required less face-to-face time with a therapist
than those in the ERP condition.
MCT and ERP were both effective with large effect sizes. There was no evidence that the two treatments lead to
statistically different outcomes. Larger controlled trials are justified.

1. Introduction
Exposure with response prevention (ERP) or treatments including
cognitive therapy and exposure or behavioural experiments (CBT) are
highly effective treatment options for obsessive-compulsive disorder
(OCD) (McKay et al., 2015). However, the majority of patients experi­
ence residual symptoms after treatment (Fisher & Wells, 2008).
Approximately 30% of patients refuse ERP (Olatunji, Cisler, & Deacon,
2010). A significant proportion of CBT therapists, in some studies up to
70%, never uses ERP or does not apply it optimally. In a German sample,
only a minority of therapists who claim to perform ERP allowed 2 h or
more for an exposure session or left their office for the exposure exer­
cises (Moritz at al., 2019). A recent study found that therapists generally
are informed about the effectiveness of ERP and know how it is per­
formed. However, patients’ lack of motivation, preference for exposure
as a self-help intervention, organizational difficulties, and fear of side
effects of ERP were named as the most frequent reasons not to include
ERP in OCD treatments. The authors of the study argue that when these
attitudes are paired with the typical ambivalence of individuals with
OCD, exposures will very likely be avoided (Moritz et al., 2019).
Metacognitive therapy (MCT) for OCD has been suggested as an
alternative to ERP and CBT (Fisher & Wells, 2008). Like CBT, MCT
utilizes verbal reattribution and behavioural experiments, but applies
these techniques to beliefs about rituals, thoughts and thought processes
instead of thoughts’ contents. The behavioural experiments are short
and can be performed at the therapists’ office. To date, a small number
of mostly uncontrolled pilot and single case studies have provided
support for the efficacy of MCT for OCD (Andouz, Dolatshahi, Moshtagh,
& ; Fisher & Wells, 2008; Rees & van Koesveld, 2008). In the largest
uncontrolled trial so far, which includes 25 patients with OCD, van der
Heiden et al. (van der Heiden, van Rossen, Dekker, Damstra, & Deen,
2016) could show that 80% of patients treated with MCT showed clin­
ically significant change at follow-up. In a controlled pilot study
including 21 participants MCT treatment was compared to either flu­
voxamine or combined treatment. After 10 weeks all seven patients in
MCT and five patients in the combined group met criteria for clinical

* Corresponding author. Department for Clinical Psychology and Psychotherapy, University of Koblenz-Landau Fortstr. 7, 76829, Landau, Germany.
E-mail address: glombiewski@uni-landau.de (J.A. Glombiewski).

https://doi.org/10.1016/j.jocrd.2021.100650
Received 19 November 2020; Received in revised form 14 April 2021; Accepted 15 April 2021
Available online 30 April 2021
2211-3649/© 2021 Elsevier Inc. All rights reserved.
J.A. Glombiewski et al. Journal of Obsessive-Compulsive and Related Disorders 30 (2021) 100650

significant improvement compared to only one in the fluvoxamine group
(Shareh, Gharraee, Atef-Vahid, & ). In a benchmarking study, MCT in
routine clinical service achieved response rates and effect sizes equaling
those of CBT (Papageorgiou & Wells, 2015).
To date, MCT has not directly been compared to the “gold standard”
ERP. Therefore, the main purpose of this study was to identify whether a
larger trial is feasible and justified by comparing MCT and ERP in a
controlled pilot study in an outpatient setting. Hence, the present pilot
trial aimed at proving the feasibility as well as informing the planning of
a larger controlled clinical trial. We were especially interested in the
following feasibility objectives: assessing recruitment and drop-out
rates, estimating treatment effects and their variance for MCT as
compared to ERP, assessing treatment fidelity for both conditions,
assessing participants’ treatment credibility and satisfaction and
assessing the number of sessions needed during treatment and after
follow-up (FU).
2. Methods
This pilot trial aims at answering the two following questions: What
are the effects of MCT compared to those of ERP and is MCT a feasible
treatment?
2.1. Participants
The sample consisted of 37 German speaking individuals. Inclusion
criteria were: a) primary diagnosis of OCD according to DSM-IV, b)
18–65 years of age. Exclusion criteria were as follows: a) lifetime
diagnosis of substance dependence, psychosis, neurological conditions,
b) mental retardation. Participants who were on medication agreed to
maintain the prescribed medication during study treatment. De­
mographic characteristics are provided in Table 1.
2.2. Procedures
This trial was registered with ClinicalTrials.gov (NCT01483339).
The study was approved by the Institutional Review Boards of both
universities, Leipzig and Marburg. Participants were recruited from
consecutive referrals to the universities’ outpatient clinics. Potential
participants were informed about the study and screened for eligibility
in a telephone and a face-to-face-interview. Those who met the criteria
and agreed to participate signed the informed consent form. Random
assignment was carried out by an independent researcher using
computer-generated random numbers and was stratified by a diagnosis
of comorbid depression because depression in people with OCD might
affect their ability to adhere to the treatment. After randomization,
subjects completed the baseline pre-treatment assessment and started
treatment according to either the MCT or ERP protocol with a study
therapist who had free capacities. Study recruitment and retention ac­
cording to the CONSORT statement is set out in Fig. 1. Post-treatment
assessment was obtained within one week after the last session. Dur­
ing the follow-up period, three short telephone booster sessions
following a fixed protocol took place. Follow-up assessment took place 3
months after post-treatment assessment.
2.3. Treatment conditions
The Wells-MCT protocol was slightly adjusted for this study (Wells,
2011). The ERP protocol was based on the manual by Kozak and Foa
(Kozak & Foa, 2001). The MCT protocol focused exclusively on modi­
fying metacognitive fusion beliefs, positive beliefs about rituals,
dysfunctional stop signals using verbal reattribution techniques,
behavioural experiments, and a special decentering technique called
detached mindfulness. In the first of four treatment phases, patient and
therapist developed an individual case formulation of the metacognitive
model of OCD by focusing on a situation with OCD symptoms. Through
the use of specific questions (e.g. What is the meaning of having this
thought?), the therapist can infer the patient-specific metacognitions
and their maintaining effect for OCD symptoms. Based on this idiosyn­
cratic case formulation, the patient is socialized with the metacognitive
model of OCD by means of verbal methods (e.g., What would happen if
you did not treat the thought as relevant?) and behavioural experiments
(e.g., suppressing the thought about a pink elephant for 1 min). At the
beginning, to familiarize the patient with an important MCT method in
OCD, detached mindfulness (DM) exercises are applied to neutral
thoughts and later to obsessive thoughts. The second treatment phase
aims to modify metacognitive fusion beliefs using verbal methods (e.g.
socratic questioning about mechanisms and evidence of patients’ beliefs,
like “How can some thoughts have the power to directly lead to actions
and others not?“) and behavioural experiments. One example of such an
experiment is the exposure and response commission, which asks pa­
tients to perform their rituals while keeping the obsessive thoughts in
mind (e.g. washing hands while thinking they are dirty). It allows them
to experience their thoughts as being unrelated to real events which
helps them to gain distance from those thoughts. Moreover, in MCT
patients are exposed to their obsessive thoughts and instructed to delay

Table 1
Demographic and clinical characteristics of participants.
Variablea MCT (n = 19) ERP (n = 18) Statistic P

Demographics
Age, y 30.2 ± 10.2 31.5 ± 11.4 t (35) = -0.333 0.741
Educationb, y 14.2 ± 2.1 14.6 ± 3.5 t (29) = -0.454 0.653
Gender, no. (%) female 11 (58) 13 (72) χ2 (1) = 0.833 0.362

Clinical characteristics
Duration of disorder, y 6.2 ± 4.6 7.7 ± 8.6 t (33) = 0.271 0.768
Age at onset, y 24.3 ± 8.9 23.4 ± 10.7 t (32) = -0.632 0.532
Previous treatment, no (%) 14 (74) 9 (50) χ2 (1) = 2.204 0.138
Current medication, no (%) 10 (53) 9 (50) χ2 (1) = 0.000 0.985
Any current co-morbidity disorder c, no. (%) 10 (53) 9 (50) χ2 (1) = 0.026 0.873
Current depression c, no (%) 8 (42) 6 (33) χ2 (1) = 0.302 0.582
Y-BOCS, Total, Pre 21.4 ± 8.2 24.5 ± 5.0 t (32) = -0.358 0.184
BDI-II, Total, Pre 19.9 ± 10.8 20.0 ± 10.4 t (30) = -0.039 0.969

Note: Y-BOCS: Yale-Brown Obsessive-Compulsive Scale, BDI-II: Beck Depression Inventory-II.

a
Table values are given as mean ± SD unless indicated otherwise.
b
Number of years spent in full-time education, MCT n = 17, ERP n = 14).
c
Co-morbid mental disorder according to SCID and DSM-IV criteria (apart from OCD).

2
J.A. Glombiewski et al.
Fig. 1. Flow of Participants
their rituals to a later time point (ritual postponement). Applying DM in
OCD-relevant situations should further enable patients to distance
themselves from their inner thoughts. In the third treatment phase,
metacognitive beliefs about rituals are modified by verbal methods
(advantage-disadvantage-list of performing rituals, reframing advan­
tages) and behavioural experiments (e.g. ritual postponement). The last
treatment phase aims to generate new response plans (e.g., applying
DM) for reacting in critical OCD-relevant situations by comparing them
with previously shown reactions (worrying about obsessive thoughts)
and changing the third type of OCD-specific metacognitions, i.e.
dysfunctional subjective when to stop ritual signals. A therapy blueprint
summarizes the treatment results (with e.g., case conceptualization(s),
the metacognitive beliefs and an overview of the results from chal­
lenging them) and aims to enable patients to maintain their treatment
success.
The ERP protocol focused on a behavioural treatment protocol to
reach habituation during therapist-guided and self-administered expo­
sure exercises with response prevention. The first out of three treatment
phases aims to prepare the exposure and response prevention by iden­
tification of individual fears and avoidance, psychoeducation to ERP (e.
g., habituation), and planning the individual treatment (e.g. hierarchy of
anxiety-provoking situations). After a plan of the specific exposures has
been specified, the exposure and response preventions were realized
during the second phase, both within sessions and between sessions.
Exposures could be adapted or psychoeducation could be repeated if
necessary (e.g., in case of motivational problems). Every treatment
session was allowed to take as long as necessary to reach a significant
level of habituation. Within the third treatment phase, only self-
administered exposures between sessions were implemented and
3
Journal of Obsessive-Compulsive and Related Disorders 30 (2021) 100650
treatment results were summarized within the session. As relapse pre­
vention, helpful interventions for critical situations as well as alternate
activities (e.g. hobbies) were discussed. Addressing dysfunctional
thought content was not part of the two protocols.
An overview of contents of both treatment protocols is presented in
Table 2. In both conditions, weekly individual sessions were offered. The
number of sessions for both protocols could vary between a minimum of
10 and a maximum of 14 sessions, depending on how much time was
needed to convey the content to the respective participant. The treat­
ment was defined as finished by the therapist and supervisor when all
previously defined goals were achieved and all contents were covered or
14 sessions were over. In ERP a session could last longer than 50 min,
depending on the individual exposure duration.
During the subsequent 3-month follow-up period, three telephone
booster sessions following a fixed protocol took place. Within these
sessions, participants were reminded of the specific techniques they had
learned during their therapy.
2.4. Therapists
The program was delivered by 11 doctoral-level clinical psycholo­
gists with advanced training in cognitive-behavioural therapy. All
therapists were trained in both manuals and received monthly group or
individual clinical supervision.
2.5. Measures
2.5.1. Diagnostic assessment
The German version (Wittchen, Wunderlich, Gruschwitz, & ) of the
J.A. Glombiewski et al.
Table 2
Overview of treatment contents for metacognitive therapy (MCT) and exposure and response prevention (ERP).
Phase MCT
Interventions
1 Individual case formulation of the metacognitive model of OCD,
socialization to the metacognitive model, providing treatment
overview, first introduction to detached mindfulness (DM); Modifying
metacognitive fusion beliefs by verbal methods (e.g. Socratic
questioning about evidence), behavioural experiments (e.g. exposure
with response commission, ritual postponement) and by applying DM in
OCD-situations
2 Continued challenging of metacognitive fusion beliefs via verbal
methods, behavioural experiments and by applying DM in OCD-
situations; modifying metacognitive beliefs about rituals by verbal
methods (advantage-disadvantage-list of performing rituals, reframing
advantages) and behavioural experiments (e.g. ritual postponement)
3 Continued work on fusion beliefs, rituals and stop signals, generation of
new plans for reacting in critical OCD-situations (by comparing old with
new plans, changing dysfunctional stopping criteria) and a therapy
blueprint (with e.g., case conceptualization(s), the metacognitive beliefs
and the overview of the results challenging them)
4 Three Booster Sessions
Structured Clinical Interview (SCID) was administered to assess for
DSM–IV–TR current and lifetime disorders. The SCID has demonstrated
good reliability for various disorders (Skre, Onstad, Torgersen, & Krin­
glen, 1991).
2.5.2. Outcome variables
2.5.2.1. Treatment adherence. The number of drop-outs and reasons for
attrition in each condition were assessed and displayed in the CONSORT
Flow Chart of Participants.
2.5.2.2. Primary Outcome Variable. The Yale-Brown Obsessive-
Compulsive Scale (Y-BOCS) (Storch et al., 2010) is a 10-item,
semi-structured interview. Y-BOCS interviews and ratings were con­
ducted by the treating clinicians. A sample of Y-BOCS videos at pretest
(n = 17), posttest (n = 12) and follow-up (n = 12) have been rated by a
second, independent rater who was blind to treatment condition and
time of measurement.
2.5.2.3. Secondary Outcome Variables. We assessed several secondary
outcomes for exploratory analyses (see also Clinical Trials registration
Masked Number) and will present a selection of them in the current
paper. We decided to include the Padua-Inventory Revised (Gonner,
Ecker, & Leonhart, 2010) to have a second measure of OCD symptoms.
MCT specifically addresses metacognitions; therefore, we included the
Meta-Cognitions Questionnaire (MCQ) (Cartwright-Hatton & Wells,
1997), a self-report scale assessing different dimensions of beliefs about
thinking. Since depression is the most frequent comorbidity in OCD, we
included the German version of the Beck Depression Inventory II (BDI-II)
(Kuhner, Burger, Keller, & Hautzinger, 2007).
2.5.2.4. Feasibility measures. In order to establish the feasibility of MCT
and ERP the following aspects were assessed:
Treatment Fidelity: For 25 participants (15 of the MCT condition and
10 of the ERP condition) 87 videos of sufficient quality were analyzed.
Due to occasional technical difficulties, it was not possible to film all
patients and all sessions. Additionally, some patients refused to be
filmed. Moreover, many ERP sessions could not be filmed because they
were very complex and took place at public places such as public toilets
or hospitals.
The fidelity evaluation was based on Leeuw and colleagues’ method
of assessing treatment delivery in clinical trials (MATD) (Leeuw, Goos­
sens, de Vet, & Vlaeyen, 2009). The treatment protocols were divided
into three distinct phases (Table 2). Within each phase possible
Journal of Obsessive-Compulsive and Related Disorders 30 (2021) 100650
ERP
Sessions Interventions Sessions
1–3 Preparation of exposures and response prevention by identification of 1–3
individual fears and avoidance, psychoeducation to ERP (e.g.,
habituation) and planning individual treatment (e.g. hierarchy of
anxiety-provoking situations)
4–9 Introducing exposure and response preventive methods, Implementing 4–9
both therapist-guided in-session exposure exercises and between-
sessions self-exposure (if necessary, adapting exposures, repeating
psychoeducation)
10–14 Fostering and reviewing self- exposure exercises; generation of a 10–14
treatment summary (e.g. summary of treatment results, promoting self-
contained exposures), relapse prevention (e.g., helpful interventions to
maintain treatment success, establishing alternative activities)
Three Booster Sessions
treatment elements of the MCT and ERP protocol were classified into
one of the following categories: (1) essential and unique; (2) essential
but not unique; (3) compatible but not essential and not unique; (4)
prohibited. Essential and unique elements are only allowed in one
treatment but not in the other.
Videos from three phases of the therapy protocols were examined by
two independent raters. Both had been made familiar with the two
treatment protocols but were unaware of the condition of each session.
The videos were paused every 10 min in order to classify the treatment
elements. Each possible element occurrence was rated as (1) “did occur”
or (0) “did not occur” for the whole session. Further, the raters indicated
for each of the 87 evaluated sessions whether they believed that this
session belonged to the MCT or the ERP condition. Agreement between
raters was assessed by calculating Cohen’s kappa.
2.5.2.5. Treatment credibility, satisfaction, and therapeutic alliance. The
Credibility/Expectancy Questionnaire (CEQ) (Devilly & Borkovec,
2000) was administered at the end of the first therapy session and at the
end of treatment.
2.5.2.6. Number of sessions and additional treatments needed. During the
treatment, the number of actually needed sessions (50 min duration)
was assessed. If needed, further cognitive behavioural treatment was
offered after the follow-up. The average total number of sessions needed
in each condition from session one to the end of any treatment was
assessed.
2.5.3. Statistical analyses
Data were analyzed using SPSS 22 and the R language and envi­
ronment for statistical computing. Analyses involving differences be­
tween groups at baseline were conducted with t-tests and Chi2 analyses.
We used Chi2 tests for drop-out analysis.
Pre-Post und Pre-FU effect sizes (d) including 95% confidence in­
tervals were computed according to Morris (Morris, 2008). A linear
mixed model using restricted maximum likelihood estimation was
computed to analyze the primary outcome. N = 19 participants from the
MCT condition and n = 18 participants from the ERP condition were
included following the “intent-to-treat” rationale. The fixed part of the
model included the intercept, an indicator variable for group, two in­
dicators for time (post-treatment and follow-up, with pre-treatment as
the reference), and two group × time interaction terms. A random
intercept for each participant accounted for repeated-measures. Signif­
icance tests for fixed model terms were derived from the comparison of
the full model including the respective term with a reduced model
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J.A. Glombiewski et al. Journal of Obsessive-Compulsive and Related Disorders 30 (2021) 100650

dropping the term. T-statistics for model parameters were computed Table 4
from approximate degrees of freedom (df) using the method of Kenward Comparison of the effects of MCT and ERP from pretreatment to posttreatment
and Roger (Kenward & Roger, 1997). and from pretreatment to follow-up via a linear mixed model.
Clinically significant change in the Y-BOCS scores was computed as b T df p
recommended by Fisher and Wells (Fisher & Wells, 2005). Only com­ Intercept 17.352 10.147 35 <.001***
pleters at follow-up (n = 11 from the ERP group and n = 14 from the Group − 2.035 − 0.869 34 .391
MCT group) were included in these analyses. Two criteria were defined: PrePost − 3.207 − 3.054 48 .003**
(A) the participant’s score decreased at least 10 points from pretest to PreFu − 3.911 − 3.611 49 <.001***
PrePost X Group 0.074 0.052 49 .958
posttest and follow-up, respectively; and (B) the Y-BOCS score amounted
PreFu X Group 0.993 0.685 49 .496
to 14 points or less at posttest and follow-up, respectively. Both criteria
had to be met for clinically significant change. We defined treatment
responder if they showed a reduction of 25% (and 35% respectively) in most definitions of “clinical significance” or “responders”, higher in ERP
Y-BOCS scores from pretest to posttest and follow-up. Chi2 analyses than in MCT (Table 5).
were performed to compare the rates of clinically improved participants
and treatment responder across the MCT and ERP conditions.
We computed treatment feasibility using t-tests and fisher’s test, 3.3. Feasibility of MCT
treatment credibility using a MANOVA, and t-tests and Chi2 analyses to
establish differences in the face-to-face time with a therapist for both MCT could be safely delivered following the manual. Videos for
treatments. adherence ratings were available for 87 sessions of 25 study partici­
pants, (23 videos of the starting phase of therapy, 45 of the main part,
3. Results and 19 of the final part of treatment), resulting in 174 evaluations by the
two independent raters. The mean protocol adherence scores, reflected
3.1. Drop-out analysis in the mean proportion of essential treatment elements over all rated
treatment sessions, was 82.6% for MCT and 80.7% for ERP, exceeding
Twenty-six per cent of the participants allocated to the MCT condi­ the minimum 70% criterion recommended by Leeuw and colleagues
(Leeuw et al., 2009). Treatment adherence did not differ significantly
tion and 39% of the participants allocated to the ERP condition did not
between treatments, t (108) = 0.693, p = .49. Treatment contamination
complete follow-up assessment for different reasons (Fig. 1). The num­
in terms of occurrences of prohibited elements was well below the rec­
ber of non-completers at follow-up did not differ between groups (X2 =
ommended upper limit of 10%: across all three phases 1.8% versus 4% of
0.13, df = 1, p = .56).
prohibited elements occurred in the MCT and ERP condition, respec­
tively. Treatment contamination did not differ significantly between
3.2. Effects of MCT compared to ERP treatments, t (39.879) = 1.165, p = .251. Treatment differentiation was
high: across both conditions and all three parts of the treatment process
The interrater reliability of the Y-BOCS ratings at pretest (r = 0.93, p 96.43% of sessions were correctly classified (MCT-sessions: 96.15%,
< .001), posttest (r = 0.93, p < .001) and follow up (r = 0.99, p < .001) ERP-sessions: 97.14%). Classification accuracy did not differ between
was very high. phases of therapy and conditions (fisher’s exact test, p = 1.0). Cohen’s
The effect sizes are displayed in Table 3. A linear mixed model kappa for all ratings across phases and conditions was substantial (0.78
revealed that both treatments led to significant changes from pre- (p < .01)) (Landis & Koch, 1977). Thus, ERP and MCT can be regarded
treatment to post-treatment and from pre-treatment to follow-up on as distinct treatments. For further details, please consult Tables 6–8
the primary outcome. The group × time interaction was not significant, MCT and ERP did not differ in terms of the credibility. A MANOVA
indicating that there was no difference between treatments (Table 4). with the CEQ credibility and expectancy scales as dependent variables
The rates of patients who showed clinically significant change and the and group (CBT vs. ERP) as a factor revealed no significant effect,
rate of responders varied between 28% and 86% with no statistically neither at pretest (F (1, 26) = 0.339, p = .716), nor at posttest (F(1, 26) =
significant differences between MCT and ERP (Table 5). E.g. in ERP, 0.493, p = .618).
50% were clinically improved at post-treatment and 54.5% at follow-up. In MCT, on average 13.1 (SD = 1.4) manualized weekly sessions
In MCT, 28.6% were clinically improved at both, post-treatment and were completed, in ERP also 13.1 (SD = 1.5). Since in ERP one session
follow-up. On a descriptive level, the total number of patients was, for could last more than 50 min, the average number of sessions á 50 min for

Table 3
Effect sizes (dRepeated measures) from pre-to post-treatment (pre-post) and pre-treatment to follow-up (FU) for completers (at FU) for all relevant outcome variables.
Outcome Pre Post FU ES [95% CI]

M SD M SD M SD Pre-Post Pre-FU

Exposure with Response Prevention (ERP)

Y-BOCS 23.82 5.81 12.55 7.81 12.55 8.02 1.75 [0.77, 2.73] 2.01 [0.99, 3.04]
Padua Inventory-Revised 45.00 16.19 22.77 9.45 22.91 9.28 1.01 [0.12, 1.89] 1.18 [0.23, 2.01]
Meta-Cognitions Questionnaire 157.00 29.31 130.64 28.51 129.63 24.01 2.01 [0.98, 3.04] 1.12 [0.23, 2.01]
Beck Depression Inventory II 19.68 9.34 11.00 9.00 9.91 11.09 0.93 [0.05, 1.81] 0.9 [0.02, 1.78]

Outcome Pre Post FU ES [95% CI]

M SD M SD M SD Pre-Post Pre-FU

Metacognitive Therapy (MCT)

Y-BOCS 23.14 6.54 13.36 6.59 13.57 8.25 1.88 [0.99, 2.76] 1.54 [0.69, 2.38]
Padua Inventory-Revised 36.07 12.83 23.45 15.23 21.36 12.05 1.27 [0.35, 2.19] 1.3 [0.38, 2.22]
Meta-Cognitions Questionnaire 152.5 26.83 114.18 24.92 117.09 27.15 2.15 [1.10, 3.20] 1.51 [0.57, 2.46]
Beck Depression Inventory II 20.46 11.44 9.73 8.84 8.73 10.14 0.86 [0.02, 1.69] 1.01 [0.17, 1.86]

Note: Y-BOCS: Yale-Brown Obsessive-Compulsive Scale.

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J.A. Glombiewski et al.
Table 5
N (%) of participants in each group showing clinically significant change from pre-post and from pre-follow up in Y-BOCS scores.
Pre - Post
ERP (n = 11) MCT (n = 14) Significance test
Clinical significance 6 (50.0%) 4 (28.6%) χ2 = 1.25, p = .42
Responder 25% 10 (83.3%) 12 (85.7%) χ2 = 0.28, p = 1
Responder 35% 8 (66.7%) 9 (64.3%) χ2 = 0.16, p = 1
ERP was in fact 22.9 (SD = 6.4) (performed during on average 13.1
meetings). The difference in the face-to-face time spent with a therapist
between those two treatments was significant (t (13.064) = 5.221, p <
.001.
After completing the study, nine of twelve (69.2%) patients in the
ERP group had further need for treatment either related to OCD or co­
morbid disorders of at least one session. In this case, they were usually
referred to new providers. They received a mean of 33.31 (SD = 10.08,
Min = 23, Max = 51) treatment sessions à 50 min in total. Six of 15
(46.7%) participants in the MCT group had further need for treatment
either related to OCD or comorbid disorders. They received a mean of
22.60 (SD = 11.31, Min = 15, Max = 45) further treatment sessions à 50
min in total. The difference between participants in the MCT group
needing further treatment versus participants in the ERP group needing
further treatment was significant (X2 = 6.42, df = 1, p = .011) with fewer
participants in the MCT group requiring any further treatment compared
to the ERP group. The number of sessions until the last assessment was
significantly lower in the MCT group (T = 2.26, df = 26, p = .014).
4. Discussion
This study was the first controlled pilot study comparing ERP and
MCT for OCD in an outpatient setting including 37 participants. MCT
and ERP were both effective. There was no evidence that the two
treatments lead to statistically different outcomes. MCT was a feasible
treatment option. Fidelity analyses revealed that MCT was distinct from
ERP and could be delivered by clinical psychologists in training. The
results also indicate that patients in the MCT group needed less face-to-
face time with a therapist than patients in the ERP group and that fewer
patients in the MCT group than in the ERP group had further need for
treatment after the end of the study.
Altogether, the present study could confirm the results from previous
single-case studies and uncontrolled pilot studies, showing that MCT
might be an excellent alternative to the established ERP. Unfortunately,
although being a very successful method, ERP for OCD evokes negative
expectations in some therapists (Moritz, 2019). These expectations
might result in lower effects of ERP for various reasons (e.g. not per­
forming ERP correctly, signalizing ambivalence to the patient). At the
same time, MCT is a “new” “third wave” method and does not include
much organization before and after treatment sessions. This might lead
to much more positive expectations on the therapists’ side and therefore
higher effects.
The results justify larger trials further investigating e.g. the non-
inferiority of MCT compared to ERP and further elaborating on
possible advantages of MCT such as being less time consuming then ERP.
Of course, it is possible, then if we have had restricted session length in
ERP, ERP could still be effective and not more time consuming then
MCT. Although preliminary, the result that fewer participates in the
MCT group felt the need for treatment for OCD and comorbidities after
the study completition should be highlighted. The reason for this may
lay within the MCT theory: the strategies learned during treatment, e.g.
detached mindfulness, are transdiagnostic, which means that patients
can use them for further OCD-related problems and also for comorbid
6
Journal of Obsessive-Compulsive and Related Disorders 30 (2021) 100650
Pre - Follow up
ERP (n = 11) MCT (n = 14) Significance test
6 (54.5%) 4 (28.6%) χ2 = 1.73, p = .24
8 (72.7%) 10 (71.4%) χ2 = 0.01, p = 1
7 (63.6%) 7 (50.0%) χ2 = 0.47, p = .69
disorders such as depression or anxiety. Exposures are, to some extent,
also a transdiagnostic tool, however less helpful e.g. for depression.
Additionally, it may be difficult for patients to transfer OCD-specific
exposure techniques to comorbid disorders without therapists’ help.
However, this finding is preliminary since the need for further treatment
was not based on strict criteria such as YBOCS scores and was deter­
mined individually by the therapist, supervisor and patients themselves.
Future studies should formulate clear hypotheses about the further need
for treatment for both OCD symptoms and comorbidities and use criteria
such as YBOCS cut-offs.
Further research should focus on long-term follow-up in order to find
out if MCT in comparison to ERP better addresses comorbidities due to e.
g. the trans-diagnostic approach.
One of the study’s advantages, besides the controlled design, is the
focus on treatment fidelity, since critics might argue that behavioural
exercises in MCT are “mini-exposures” making MCT similar to ERP. It is,
in fact, possible, that both treatments are effective due to successful
expectation violation because both treatments focus more or less
explicitly on changing expectations by utilizing behavioural tests or
exposures. However, we could show that the interventions in both
treatments differed. Therefore, even if the underlying mechanism might
be shared, clinicians and patients can choose between two distinguish­
able interventions.
Another advantage is that we followed all patients until the
completion of treatment in the naturalistic setting after the RCT study
and assed further treatment needs.
A major limitation is that we did not assess adverse events system­
atically. One of the major concerns of therapists who refuse to perform
ERP are potential side effects. Therefore, assessing adverse events sys­
tematically would have been necessary to gain first insights if MCT is a
safer treatment then ERP. We also did not define a cut-off for Y-BOCS
scores at the beginning of the treatment, resulting in surprisingly low Y-
BOCS scores in some participants; however, the average pre-post and
pre-follow-up effect sizes were still large for both treatments. A three
month follow-up is too short, but was chosen due to the ethical reasons
taking the pilot character of the study into concern. The sample size is
too small for more advanced statistical analyses and robust results.
Allegiance effects might have occurred since most of the supervisors
and first and senior author are experienced ERP therapists. However, all
supervisors were interested in MCT and the therapists were rather
unexperienced and therefore open-minded.
The present study has strong clinical implications, showing that MCT
can be a more economic, but equally effective alternative to ERP for
OCD patients and practitioners could choose between those two
methods depending on preferences on both sides. The study justifies a
larger trial with focus on non-inferiority of MCT compared to ERP,
mechanisms of changes, subgroup analyses, adverse events and possible
economic advantages of ERP.
Public health significance statement
Despite the efficacy of exposure and response prevention (ERP) for
obsessive-compulsive disorder (OCD) the application of ERP techniques
J.A. Glombiewski et al.
remains a challenge to patients and therapists. Metacognitive therapy
(MCT) relies on cognitive techniques and behavioural experiments
without prolonged exposure exercises. This controlled pilot study sug­
gests that MCT might offer an effective, feasible and less time-consuming
treatment alternative to ERP. A larger controlled trial is warranted.
Declaration of competing interest
The authors state that there are no conflicts of interest.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jocrd.2021.100650.
Author statement
Cornelia Exner, Julia Glombiewski: Conceptualization, Methodol­
ogy, Anke Haberkamp, Jana Hansmeier.: Data curation, Julia Glom­
biewski, Cornelia Exner, Jana Hansmeier, Anke Haberkamp: Data
Analysis. Julia Glombiewski: Writing- Original draft preparation,
Reviewing and Editing. Julia Glombiewski, Jana Hansmeier, Cornelia
Exner: Visualization. Cornelia Exner, Winfried Rief: Supervision.: Win­
fried Rief: Resources.
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