Getting Better by Being Kind to Yourself: Compassion-Focused Therapy for OCD

Nicola Petrocchi, John Cabot University; Compassionate Mind Italia
Teresa Cosentino, Scuola di Psicoterapia Cognitiva S.r.l.
Valerio Pellegrini, Sapienza University of Rome
Giuseppe Femia, Scuola di Psicoterapia Cognitiva S.r.l
Antonella D’Innocenzo, Compassionate Mind Italia; Scuola di Psicoterapia Cognitiva S.r.l.
Francesco Mancini, Guglielmo Marconi University

Obsessive–compulsive disorder (OCD) is a debilitating mental health disorder that can easily become a treatment-resistant condition. Although effective therapies exist, only about half of the patients seem to benefit from them when we consider treatment refusal, dropout rates, and residual symptoms. Thus, providing effective augmentation to standard therapies could improve existing treatments. Group compassion-focused interventions have shown promise for reducing depression, anxiety, and avoidance related to various clinical problems, but this approach has never been evaluated for OCD individuals. However, cultivating compassion for self and others seems crucial for OCD patients, given the accumulating research suggesting that fear of guilt, along with isolation and self-criticism, can strongly contribute to the development and maintenance of OCD. The primary aim of this pilot study was to evaluate the acceptability, tolerability, and effectiveness of an 8-week group compassion-focused intervention for reducing OCD symptoms, depression, fear of guilt and self-criticism, and increasing common humanity and compassionate self-reassuring skills in treatment-resistant OCD patients. Using a multiple baseline experimental design, the intervention was evaluated in a sample of OCD patients (N = 8) who had completed at least 6 months of CBT treatment for OCD, but who continued to suffer from significant symptoms. Participants were randomized to different baseline assessment lengths; they then received 8 weekly, 120-min group sessions of compassion-focused therapy for OCD (CFT-OCD), and then were tested again at post-treatment and at 1 month follow up. Despite the adverse external circumstances (post-treatment and follow-up data collection were carried out, respectively, at the beginning and in the middle of the Italian lockdown due to the COVID-19 pandemic), by the end of treatment, all participants demonstrated reliable decreases in OCD symptoms, and these improvements were maintained at 4-week follow-up for seven of eight participants. The intervention was also associated with improvements in fear of guilt, self-criticism, and self-reassurance, but less consistent improvements in depression and common humanity. Participants reported high levels of acceptability of and satisfaction with the intervention. Results suggest that the intervention may be beneficial as either a stand-alone treatment or as an augmentation to other treatments.

compassion-focused therapy, obsessive–compulsive disorder, fear of guilt, self-reassuring, self-criticism, multiple baseline design, self-compassion, compassionate mind training

“Although effective treatments for OCD exist, such as cognitive–behavior therapy (CBT) that includes exposure and response prevention (ERP), only about half of patients seem to benefit from them when treatment refusal and dropout rates are taken into account. This constitutes a limit of the actual treatments of OCD, given that patients who attain only partial recovery are less likely to maintain their treatment improvements, and their quality of life is negatively impacted by residual symptoms.”

“there is increasing empirical evidence suggesting that OCD patients are characterized by heightened fear of guilt and that obsessive activity is aimed at preventing, reducing, or neutralizing the possibility of being guilty”

“Compassion-focused therapy proposes a model of affect regulation involving three cross-regulating evolved emotional systems: the threat and self-protection system, the drive and resource-seeking system, and the soothing system. Some emotional difficulties, such as high shame, self-criticism and, in the context of OCD, the fear and avoidance of some emotional experience such as guilt, can be conceptualized as stemming from a threat system that has been defensively hyperactivated by interpersonal traumas such as bullying or emotionally abusive dynamics in the family of origin. However, CFT conceptualizes another cause of emotional difficulties as an under-activated soothing system.”

“…the primary aim of this pilot study was to evaluate the acceptability, tolerability, and effectiveness of an 8-week group compassion-focused intervention for reducing OCD symptoms, depression, fear of guilt and self-criticism, and increasing common humanity and compassionate self-reassuring skills in treatment-resistant OCD patients. The intervention (CFT-OCD) was an adaptation of group CFT for OCD: it included an emphasis on developing greater understanding and acceptance of the “unchosen nature” of our evolved brain, of its “loops,” and cultivating present moment awareness and compassion to intrusive obsessive thoughts to help participants disengage from unhelpful automatic responses (compulsions).”

“all participants experienced a significant decrease in OCD symptoms as measured by the clinician-administered Y-BOCS, with large effect sizes. More specifically, during the two baseline assessments (T1 and T2), OCD symptoms remained stable or increased for 7/8 participants, irrespective of baseline duration.”

“At post-intervention assessment (T3), 100% of participants demonstrated marked, reliable reductions in OCD symptoms, relative to their scores at baseline. Gains were mostly preserved at follow-up (T4), where 6/8 participants showed reliable reductions at Y-BOCS, relative to T2.”

“All participants reported a reliable improvement on the compulsions dimension of the Y-BOCS after the treatment.”

“The beneficial effects of the treatment on the severity of OCD symptoms were confirmed by changes on the self-administered OCI-r, which was improved in 85% of the participants. The stable or worsening baselines, the decrease in OCD symptoms only after the intervention was introduced, and the magnitude of the changes indicate that the intervention effect is not likely due to repeated assessments, self-monitoring, the passage of time, chance fluctuations, regression to the mean, or spontaneous recovery.”

“Improvements at post-test were shown by all patients irrespective of the type of OCD they presented. This suggests that the CFT-OCD intervention, in line with its evolutionary transdiagnostic nature has hit a core element that is shared by different types of OCD presentations.”

“It is generally thought that ERP is necessary for practicing a new, more adaptive response to anxiety-provoking stimuli and for substantially improving the prognosis of OCD. However, although several studies have found large improvements in OCD symptoms after ERP, the outcomes are sub-optimal for the majority of patients (60% of treatment completers achieve recovery, and approximately 25% of patients are asymptomatic following treatment). Furthermore, 30% of patients with OCD refuse ERP or drop out from treatment prematurely, suggesting that ERP might be difficult to tolerate. The results of the present pilot study suggest that a relatively brief group compassion-focused intervention may be effective for reducing OCD symptoms, even without deliberately implementing ERP procedures.”

“In line with our expectation, the majority of participants experienced pre- to post-treatment decreases in self-reported symptoms of depression, but overall findings suggest small-to-medium beneficial effects of the compassion-focused intervention…These findings are consistent with previous studies investigating the benefits of CFT for depressive symptoms and suggest that the adapted CFT for OCD intervention may target both OCD symptoms and symptoms of depression.”

“Fear of guilt can be reduced not only by targeting it directly (asking patients not to prevent the guilt, but to expose themselves to it), but also by increasing patients’ capacity to develop a compassionate attitude toward themselves (and parts of themselves, including the fear of guilt) and others.”

“It is possible that compassion-focused practices have helped participants strengthen their capacity to build and access compassionate self-reassuring skills, dampening their chronically over-stimulated threat system and facilitating an improved physiological regulation of their overall arousal. As we know, chronically increased negative arousal modulates information processing, prompting a switch from a context-based and flexible cognitive system to a more rigid safety-focused cognitive processing, characteristic of OCD patients. Instead, the switch from an avoidance/safety focused motivation to an approach/care-focused motivation (i.e., compassion both for ourselves and others), cultivated in CFT treatments, might have promoted a felt sense of safeness, with resulting improved cognitive flexibility and ability to tolerate emotional disturbance.”

“Another possible mechanism of change is linked to the creation of a compassionate ‘inner secure base and safe haven’ that might have helped participants explore, face, and accept the “humanness” of making mistakes and, at times, experiencing guilt.”

“CFT practices seemed to promote an improved acceptance (not an avoidance) of threat (both internal, such as feelings of guilt, and external, such as people scolding or potentially rejecting). CFT practices also seemed to reduce (instead of increase) the typical excessive reassurance seeking that is unequivocally counter-productive in people suffering from anxiety disorders (OCD in particular), yielding short-term relief but a longer-term worsening of the original anxiety”

“Multiple baseline, a type of single-case experimental design that randomizes individuals to different lengths of baseline phase before starting treatment, was used as a time- and cost-effective method for evaluating effectiveness while controlling for the passage of time and repeated assessments. In particular, it helps to differentiate between a genuine treatment effect and natural recovery over time or other confounding factors.”

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