A Theoretical Integration of Schema Therapy and Cognitive Therapy in OCD Treatment: Conceptualization and Rationale (Part II)

Abstract

Cognitive Behavioral Therapy has been identified as the first choice treatment for Obsessive Compulsive Disorder (OCD). Although a significant proportion of patients benefit from Cognitive Behavioral Therapy, another still fails to respond to CBT. To improve outcomes, new targets of intervention have been broadened, but no clear and comprehensive conceptualizations of the disorder have been suggested. In the last few years, in the context of Schema Therapy (ST), several specific models have been proposed for the treatment of Axis I diagnostic categories (according to the classification of DSM IV), in addition to the more well-known conceptualizations related to Personality Disorders. Concerning OCD, several studies have investigated the effectiveness of ST in the treatment of OCD, but only few have tried to elaborate a conceptualization of the disorder in terms of modes. This lack of knowledge and shared conceptualization might lead to difficulties in planning and evaluating effective interventions. The aim of this work is to present a conceptualization of the Obsessive Compulsive Disorder that results from the integration between the Cognitive Therapy framework, as proposed by Mancini and collaborators, and the framing in terms of modes, in line with ST, starting from the research data available. In particular, the rationale of the intervention will be proposed, aimed at accepting the risk of committing mistakes or of coming into contact with disgusting substances. This general aim will then be articulated in sub-aims, which may direct it, in a more specific way, on the basis of the different modes that characterize the experience of obsessive patients.

Cognitive–Behavioral Treatment of Obsessive–Compulsive Disorder: The Results of a Naturalistic Outcomes Study

“…In fact, several studies suggest that in obsessive patients, there are often memories of early experiences characterized by the fear of parental reprimand, by hyper-responsibility, or by an education very attentive to morality. These are experiences, therefore, that plausibly sensitized the future patient to the fear of guilt [ 69 , 70 , 71 , 72 ].…”

“…With imaging rescripting [ 73 , 74 ], it is possible to intervene effectively in the memories of these experiences, helping the patient to re-elaborate them in a less dramatic and more functional way. This phase’s purpose is to make sensitizing experiences less relevant from an emotional point of view [ 70 , 71 , 72 ]. Relapses are always possible, but they can have a very different outcome if the patient experiences them without being frightened by them or dramatizing them and while having clear indications on how to manage them and when to contact the psychotherapist [ 75 ].…”

Group schema therapy for patients with severe anxiety disorders

“…When patients with anxiety disorders are schema‐activated and feel vulnerable, avoidant or over‐controlling coping modes are often triggered (Tenore et al, 2018). Therefore, these coping styles increase anxiety and are given particular attention in the program.…”

Explanatory Psychological Models of Obsessive Functioning: Systematic Review of Mancini’s Cognitive Model and Theoretical Review of Young’s Maladaptive Cognitive Schemas Model

“…There are several types of modes describing a person's intrapsychic dynamic: Child modes (parts that express needs and emotions (e.g. the vulnerable, alone, abused, neglected, sad, furious, impulsive child, etc), Parent modes (parts that represent introjected parental voices -the critical, punitive, demanding parent), the specific Coping modes (submissive-unassertive mode, Avoidance modecharacterised by isolation, dissociation, behavioural avoidance, Attack/Overcompensator mode -violent, critical, judging) (Rădulescu et al, 2020;Tenore et al, 2018). Whereas a schema reflects a unidimensional theme, a mode reflects numerous schemas and coping styles active at a certain point.…”

“…Hence, the vulnerable child mode, angry child mode, punitive parent, exigent parent, as well as overcompensation schemas (perfectionist/overcontrol, grandiosity) and avoidance mode manifested as the detached protector, and the self-calming modes were associated with OCD and obsessive personality (Arntz, 2012;Basile et al, 2017b;Gross, 2012;van Wijk-Herbrink et al, 2108). Several recent studies tried to integrate the two models of cognitive theories (Tenore et al, 2018). Their purpose was to elaborate therapeutical interventions targeting not only the reduction of specific symptomatology but also the dysfunctional cognitive schemas as causes for symptomatology.…”