Conference with 20 international experts in Obsessive-Compulsive Disorder, with the scientific supervision of Prof. Francesco Mancini, chairperson Dr. Barbara Barcaccia, to better understand this disorder and the various therapeutic practices useful for its treatment.
The lifetime prevalence of OCD is estimated to be 2.5%, whereas punctual prevalence is around 1,5%. Nearly 120 million individuals are affected by obsessive-compulsive disorder worldwide. Despite being today a curable disorder, with cognitive-behavioural therapy being the treatment of choice, still some obsessive-compulsive patients are “treatment resistant”.
For all these reasons, it is very important to add new treatment strategies to the already well-established ones, and to disseminate information on the disorder and its treatment among clinical psychologists, psychotherapists, and psychiatrists.
Detailed illustrations of phenomenology, causes and processes of maintenance of obsessive-compulsive disorder. Top international scholars in this field will help us to understand how OCD works.
Complex clinical cases with their challenges during therapy: resistance to treatment, refusal to undergo Exposure/Response Prevention sessions, impasses in the therapeutic relationship, etc. Renowned international psychotherapists, with vast experience in research and treatment of OCD, will illustrate the case conceptualisation of a clinical complex patient and how did they manage his/her treatment.
Workshops on new strategies and techniques to enhance the treatment’s effectiveness.
MD, Neuropsychiatrist and Psychotherapist. Director of Postgraduate Schools APC -SPC. Associate Professor of Clinical Psychology at Unimarconi, Italy.
PhD, Psychotherapist and Neuropsychologist, Associate Professor of Psychology, Department of Psychology at Texas State University, USA.
PhD, Psychologist and Psychotherapist, APC – SPC trainer. She teaches Acceptance and Mindfulness in Psychotherapy at Sapienza Università di Roma, Italy.
PhD, Psychologist and Psychotherapist, Full Professor at the Department of Personality Psychology, University of València, Spain.
PhD, Psychologist and Psychotherapist, works at the Center for Child and Adolescent Psychiatry, University of Zurich, Switzerland.
PhD, Psychologist and Psychotherapist, Full Professor of Psychology and Director of the Doctoral School at Tel Aviv University, Israel.
Psychologist and Psychotherapist, Full Professor of Clinical Psychology at the Department of Psychology, University of Florence, Italy.
Phd, Psychologist and Psychotherapist, Associate Professor at the Baruch Ivcher School of Psychology, Herzliya, Israel.
PhD, Psychologist and Psychotherapist, Full Professor at the Department of Psychology, Hebrew University of Jerusalem, Israel.
CBT Psychologist and Psychotherapist, Forensic Psychologist, doctoral candidate in Human Sciences, trainer and supervisor in Schema Therapy, Italy.
PhD, Psychologist and Psychotherapist,
trainer and supervisor in Schema Therapy, Italy.
PhD, Psychologist and Psychotherapist, trainer and supervisor for the International Experiential Dynamic Therapy Association, Jerusalem, Israel.
Psychologist and Psychotherapist. President of AIDOC and IPSICO, Secretary of CBT-Italia, Italy.
Psychologist and Psychotherapist, carries out clinical and research activities at the clinical centre schools SPC, APC, AIPC and IGB in Rome, Italy.
PhD, Psychologist and Psychotherapist, he is Researcher at the University of Siena and Psychotherapist at Policlinico Santa Maria alle Scotte, Siena, Italy.
PhD, Psychologist and Psychotherapist, Full Professor in the Department of Psychology, University of Waterloo, Canada.
PhD, Psychologist and Psychotherapist, Associate Professor at the Department of Personality Psychology, University of València, Spain.
Angelo M. Saliani
Psychologist and Psychotherapist, trainer of SPC, AIPC, SICC, Professor at School of Specialization in Psychology of the Life Cycle, Sapienza, Rome, Italy.
Psychologist and Psychotherapist, trainer at APC and SPC, trainer and supervisor in Schema Therapy, Italy.
MD, Consultant Psychiatrist and Visiting Professor at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK.
Francesco Mancini and Barbara Barcaccia will briefly describe the program of the Summit.
Over three decades of cognitive neuroscience research in OCD has yielded hundreds of published studies examining cognitive functions and their associations with neurobiological processes and structures. This ever-growing body of research, utilizing increasingly more sophisticated technologies and methodologies, has increased our understanding of OCD. However, this work raises important questions concerning etiology and causality, ecological validity, and the association between cognitive neuroscience and psychopathological mechanisms of OCD. In this talk, I will review this body of research from a critical perspective while focusing on those questions, as well as issues related to the progression in the field, common pitfalls, systematic interpretational biases, and the potential ‘cost’ of directing the field’s focus and funding to neuroscience research and adhering to its paradigms. I will also critically review the state of the field and our knowledge of cognitive neuroscience of OCD and attempt to answer the question of whether the perpetual conclusion that ‘more research is needed’ is legitimate across several research themes in the cognitive neuroscience of OCD. Furthermore, I will review some oft-neglected aspects related to cognitive neuroscience of OCD that warrant further research, and that may enhance our understanding of the intersection between cognitive neuroscience and psychopathological mechanisms of OCD. Finally, I will examine a critically important, but seldom discussed question: Did this body of research directly benefit individuals with OCD? Did this investment of tens of millions of dollars and thousands of hours of labor-intensive efforts helped us attain the ultimate goal of improving the lives of people suffering from OCD?
6:20 – 6:30 pm Discussion
The standard CBT model of obsessive-compulsive disorder (OCD) emphasizes appraisal of obsessions as a causal factor in distress and the subsequent need to do compulsions. Cognitive behaviour therapy and exposure with response prevention targets appraisal of the obsession, which reduces distress and makes the compulsion obsolete.
However, a growing body of research suggests that a number of factors influence the persistence of compulsions besides distress over the obsession, including ironic effects of repetition on memory confidence, the way the proximal goal of the compulsion is framed, the distal goals of the compulsion, and the compulsion consistency with important values. This talk will review these factors and discuss treatment implications.
7:10 – 7:20 pm Discussion
I will present a complex case of OCD. After the ‘classic’ application of Exposure and Response prevention, combined with Cognitive elements, had reached a plateau, I added principles of Affect Phobia Therapy to improve the outcome.
I hope to show how Affect Phobia Therapy can enrich and improve CBT with populations suffering from OCD.
Fear of contamination within obsessive compulsive disorder (OCD) is traditionally conceptualized as a physical phenomenon. Research has also supported the notion of mental contamination (MC), in which people feel contaminated in the absence of contact with a physical pollutant.
The pioneering work on mental contamination involved sexual assault victims. Nevertheless, several factors (e.g. immoral behavior, imagined physical dirt, betrayal, appraisals associated with responsibility, violation, and immorality) were shown to trigger feelings of contamination and the urge to rinse or wash.
Rachman (2010) proposed that the treatment of mental contamination in OCD has to differ from standard OCD treatments, arguing that a more cognitive focus is needed to help patients deal with their sense of internal dirtiness. It is also well known that mental contamination is connected to previous traumatic experiences, such as victimization, humiliation, and betrayal; this suggests that therapy drawing on approaches used in the treatment of trauma–such as Imagery Rescripting or Eye Movement Desensitization and Reprocessing (EMDR)–combined with CBT techniques might lead to improved outcomes for OCD patients who experience mental contamination.
I present detailed phenomenological case of a young women with Obsessive Compulsive Disorder who was being evaluated and treated for severe mental contamination. This clinical case provide insight into various possible manifestations of contamination fear and extend our understanding of the phenomenon.
10:00 – 10:15 am Discussion
I shall present a couple of my most complex clinical cases in OCD.
I shall present the formulation and reflect upon the obstacles to helping our patients with standard interventions.
These include co-morbidity; severe avoidance behaviour; rigidity of beliefs; shame and social factors.
In this presentation I shall illustrate two complex clinical cases, which however are not such due to the normal difficulties of inadequate compliance (resistance, oppositivity, comorbidity …), but for other reasons: the two patients seem apparently highly collaborative, and with good intentions.
The first one seems to do everything I say, but, in actual fact, he does nothing but surreptitiously asking me for reassurance by text messages, while apparently following my indications; the second one, when the objective of the intervention seems to be defined and that the patient seems eager to identify, introduces me to new aspects and new areas that he wants to tackle, thus preventing us from actually starting therapy: by so doing, he avoids facing what he fears .
The motivations of these difficulties will be illustrated, as well as methods of dealing with them.
11:30 – 11:45 am Discussion
For centuries, there have been discussions about compulsive religious practices that go beyond the norm. In modern times, these excessive, distressing thoughts and behaviors related to moral or religious themes have been coined scrupulosity, and viewed as a subtype of OCD.
In the current talk, I will briefly review some historical mentions of intrusive thoughts from Christianity, Judaism, and Islam. I will then present current CBT formulations of scrupulosity, and discuss clinical issues that arise when treating religious, scrupulous patients. I will address issues including: how to assess scrupulosity, how to respectfully challenge and design exposures that might feel against the patient’s beliefs, whether to use religious writings to help convey the rationale of CBT, and if and when to include clergy in treatment.
12:45 – 1:00 pm Discussion
Prof. Francesco Mancini presents the 2 parallel workshops that will be held from 3.30 to 7.30 pm.
Each participant will be free to decide which of the two to follow ONLINE. Both will be recorded and each participant will be able to view them ONDEMAND within 24 hours and in the following 12 months.
Born to treat personality disorders, a growing body of empirical evidence has shown that Schema Therapy (ST) is effective for treating several other mental disorders, besides personality problems.
The aim of the current workshop is to provide a practical demonstration of the use of ST- experiential techniques, such as Imagery with Rescripting (IwR) and Chairwork in the treatment of Obsessive-Compulsive Disorder (OCD). Clinical observations show that in cases of reproach, parents of prospective OC patients withdraw their toward their child, ignore him/her, and are unwilling to forgive. Therefore, the meaning that is associated with early reproach experiences in OC patients is that guilt signals catastrophic consequences, i.e., the end of the attachment relation.
A recent study has shown that IwR, as stand-alone treatment, focussing on the early experiences of blaming reprimands fosters clinically meaningful changes in OCD symptomatology. Based on data showing the pivotal role played by the fear of guilt in both the genesis and maintenance of OCD, this workshop will illustrate strategies and techniques aimed at reducing its pervasiveness, promoting the acceptance of guilt. Experiential techniques can promote positive change in the obsessive patient, in particular by helping the clinician to work with patients who are highly self-critical and perfectionist, and in cases of patients who are resistant to standard CBT.
After the presentation of the theoretical framework and the model of OCD according to ST, it will be shown how to implement ST- experiential techniques specifically designed to target guilt. In particular, it will be illustrated how IwR can be used to address guilt memories, modifying the meaning that the patient had attributed to such experiences. It will be also shown how the Chair work can be useful for promoting functional ways of accepting blame and error, thus lowering self-criticism.
Practical exercises will allow participants to experience the potential power of these techniques in treating OCD.
Family members and, more generally, cohabitants of individuals with OCD, are always involved, to a greater or lesser extent, directly or indirectly, in the patient’s symptomatology. Scientific literature has shown that family members adopt two main attitudes towards their loved ones with OCD, ranging from extreme compliance, called “accommodation”, to its opposite, i.e. “antagonism”. Accommodation appears to be a negative prognostic factor and numerous studies show how it is associated to a worse response to treatments and to more frequent relapses. Equally negative effects are related to antagonism.
Clinical observation, however, suggests that the accommodation-antagonism continuum only partially captures the complex system of interpersonal reactions to the disorder. In other words, the family member does not limit himself/herself to pleasing or opposing his/her relative with OCD. Sometimes, before pleasing an obsessive request, the family member tries to evade it with a hasty reassurance or a “white” lie, or engages in gruelling dialectical disputes aimed at demonstrating that obsessive fears have no reason to exist, or devises and suggests ways around the obstacle posed by the symptom, or implores the relative exhorting him/her to change, or finally blames him/her. Each of these different reactions triggers a trap that contributes to fuel the disorder and to exacerbate the family climate. Furthermore, each of them takes part in a single huge interpersonal vicious spiral that typically culminates in the patient’s blaming and the strengthening of his/her most painful pathogenic beliefs. There are seven typical traps and each of them will be described in detail during the workshop.
Finally, many of the available CBT interventions for family members of OC patients mainly involve psychoeducational interventions and training in the Exposure/Response Prevention (E/RP) technique for the treatment of the symptomatology, but seem to neglect the psychological determinants of the disorder (hypertrophic sense of responsibility and deontological guilt) and the interpersonal dynamics that maintain them.
The workshop has two main objectives. First, to bring to the clinician’s attention the interpersonal factors that contribute to the maintenance and aggravation of the disorder, so that they are included in the case formulation. Second, with the help of various examples, exercises and clinical material provided by the trainer, to enable the attending clinicians to provide tangible help to both family members and patients engaged in the daily struggle against OCD.
Little is known regarding the adaptation of cognitive behavioural therapy (CBT) for religious obsessions, a subtype of OCD which often does not respond adequately to standard CBT. This talk will focus on a clinical case of a 55-year-old man who suffered from chronic, resistant to first-line medication religious obsessions associated with mental neutralisation rituals. Treatment was adapted combining metacognitive therapy with self-compassion elements. The effects were assessed on interpersonal guilt and narcissism, two clinical features potentially involved in the vulnerability/maintenance of religious obsessions, yet under-considered treatment outcomes. The four dimensions of interpersonal guilt were detected according to the Control-Mastery Theory (Silberschatz, 2015): survivor guilt (the irrational belief that the attainment of the good things in life is at the expense of those who have not obtained them), separation/disloyalty guilt (the belief that having different values, e.g., supporting different religious beliefs will be hurtful to loved ones), omnipotent responsibility guilt (an exaggerated sense of responsibility for other people’s well-being)and self-hate (the feeling of being inherently wrong, bad, inadequate, and not deserving of acceptance). Finally, the impact of treatment was studied on obsessive-compulsive symptoms in the context of grandiose-vulnerable narcissism vicious cycles, as conceptualized by Wink (1991).
The DID IT protocol is a brief (5-week), cognitive behavioural, transdiagnostic protocol based on a dual process view of psychopathology. This protocol uses Socratic questioning, motivational interviewing, and a novel ‘story and response prevention’ strategy to help clients decouple controllable from less controllable thinking processes and disengage from thinking processes maintaining psychopathology. In this presentation, I describe the implementation of this protocol with two cases of co-occurring relationship OCD (ROCD) and sexual orientation (SO-OCD) symptoms. In one case the client seemed to quickly benefit from therapy. In the other case less so. I will then discuss similarities and differences of the two cases in terms of demographic variables, history of their problem, current context and additional relevant processes identified during therapy and try to hypothesise to whom implementation of the DID IT protocol is better suited.
10:00 – 10:15 am Discussion
Information and communication technologies, including mobile apps and internet-based interventions, have been suggested to increase accessibility and availability of cognitive behavioral treatment (CBT). The mobile app GGOC was specifically designed to challenge maladaptive beliefs that underlie common OCD symptoms (e.g., contamination and repugnant thoughts). The effectiveness of GGOC was assessed in two studies, the first one a crossover randomized controlled trial with 97 non-clinical participants, and a single-case study, a 26-year-old woman who used GGOC for relapse prevention following CBT treatment. All participants were requested to complete Web-based assessments, with questionnaires relating to maladaptive beliefs (Obsessive beliefs questionnaire; OBQ-20), mood (depression subscale of the Depression, anxiety and stress scale, DASS-21) and OC symptoms (Obsessive-Compulsive Inventory, OCI-R; and Yale-Brown obsessive-compulsive scale, Y-BOCS, for patient only) and the Single-item self-esteem scale. Results: Non-clinical participants used the app for a mean of 14.07 (SD 1.41) days with 2.94 levels per day. The patient completed 47 levels over 15 days. Results showed that in non-clinical participants, app use was associated with medium-large effect size reductions in questionnaire measures. All effects remained significant during the 15 days of follow-up. Analyses focusing on the first two assessment occasions revealed significant treatment × repeated measures interactions on maladaptive beliefs (OBQ-20), several OC symptom measures (OCI-R), and self-esteem. In the single-case study, the OBQ-20 and OCI-R scores decreased from pre- to post-GGOC. The Y-BOCS decreased from 7 pre-GGOC to 2 post-GGOC. Conclusions: Both studies suggest the efficacy of GGOC as a mobile-delivered training exercise that is useful for reducing OCD-related beliefs and symptoms as well as a relapse prevention tool for individuals with OCD, and its contribution to maintaining gains after CBT.
11:10 – 11:25 am Discussion
The Seeking Proxies for Internal States (SPIS) model of OCD proposes that many OCD symptoms stem from diminished access to internal states, such as emotions, feelings, and motivations. As a results, people with OCD must rely on proxies, which are objective or easily discernible indices of the internal states. In this view, OCD rules and rituals serve as such proxies for various internal states, such as feelings of morality, cleanliness, or safety.
The distress caused by intrusive thoughts, according to the SPIS model, is magnified because other internal states, such as emotions and motivations, are not experienced clearly enough to balance the impact of these negative thoughts. In this presentation, I will explore potential implications of the SPSI model for therapy of clients with OCD. I will demonstrate how the SPIS model can help us formulate a complex case of a young man with OCD and what potential interventions can be derived from this formulation.
Obsessive-compulsive disorder (OCD) is characterized by the presence of unwanted or intrusive thoughts (obsessions) and behaviours or rituals (compulsions) that are performed to reduce distress or prevent a feared outcome. Aggressive obsessions are related to violence or harm towards oneself or others and include unwanted thoughts, images, or impulses. Up to 30-70% of youth with obsessive compulsive disorder experience aggressive obsessions.
Aggressive obsessions are often associated with a range of overt and covert compulsions like checking, reassurance seeking, thought neutralizing or praying.
This presentation will illustrate the case conceptualization, assessment, and treatment using cognitive behaviour therapy (CBT) with exposure and response prevention (ERP) of Dana, a 16-year-old female with aggressive obsessions.
12:40 – 1:00 pm Discussion
Some patients suffer from contamination OCD. The feeling of being contaminated implies in some individuals mainly the fear of harming one’s health and of being responsible for contaminating loved ones. In other individuals the feeling of being contaminated involves an intense disgust. In the case of disgust, the effectiveness of exposure therapy is relatively scarce. Indeed, disgust is activated more easily and is extinguished with much greater difficulty when compared to fear. In this presentation I will analyse the different facets of disgust, and, with the help of a clinical case, I will try to show how between OC patients and individuals without OCD there are no qualitative, but only quantitative differences.
These differences are plausibly attributable to the fact that for OC patients being contaminated with disgusting substances implies a greater self-debasement than for other people, making unacceptable even the mere possibility of contamination with disgusting substances. This implies a great investment in preventing and neutralising this possibility, consequently there is the exasperation of the heuristics with which the spread of disgusting contamination is processed. This results in increased sensitivity and increased propensity to disgust.
I will also present an intervention that aims at helping patients to counteract the heuristic of contamination, to accept the possibility and the feeling of being partially contaminated and to counteract the tendency to moral self-debasement
3:15 – 3:30 Discussion
Two parallel workshops that will be held from 3.30 to 7.30 pm.
Each participant will be free to decide which of the two to follow ONLINE. Both will be recorded and each participant will be able to view them ONDEMAND within 24 hours and in the following 12 months.
Starting from a description of clinical cases, I shall describe procedures aimed at a greater degree of acceptance of the experience of guilt than normally tolerated by obsessive-compulsive patients. The theoretical framework is the conceptualisation of obsessive-compulsive symptomatology as aimed at preventing the threat of guilt.
Specifically, the proposed procedures promote the abandonment of attempts at solutions, i.e., of all the overt and covert behaviours aimed at subjectively ensuring that the feared threat will not materialise and that one is morally right.
Unlike the interventions based on cognitive restructuring, acceptance interventions do not aim at reassuring the patient that the feared guilt is inexistent, or is less likely, less serious, less under the patient’s responsibility; rather, the objective of such interventions is to help the patient to acknowledge the inevitability of a certain “amount” of guilt and to abandon behaviours aimed at preventing the feared guilt scenario.
The proposed procedures and techniques have a specific target, i.e., the modification of a specific belief that maintain the investment towards a goal:
In line with the conceptualisation of OCD underlying this set of interventions, it will be highlighted how fostering acceptance offers greater therapeutic benefits than traditional restructuring interventions aimed at reassuring the patient that the feared scenario will not occur. Indeed, most clinical problems are conceptualisable in terms of threat, rather than damage; accepting higher degrees of risk is tantamount to reducing the risk of over-investment of a goal and, therefore, the vulnerability to automatic vicious circles fuelling the investment towards a goal even when it would be both possible and appropriate to give up.
Mindfulness refers to the capacity to pay attention to the present moment with awareness and without judging the experience that one is having, such as thoughts, emotions, impulses, sensations (Kabat-Zinn 1990). From this definition alone, it is easy to intuit how the practice of mindfulness could be particularly indicated in the treatment of Obsessive-Compulsive Disorder (OCD). Indeed, one particularly problematic aspect for the treatment of OCD is the overestimation of the importance of one’s mental contents. From a certain point of view, it could be affirmed that one of the main problems of this disorder is the difficulty of letting go of mental contents once they have appeared in one’s mind. These contents may be thoughts, but also mental images, which, once arisen, succeed in “hooking” the patient and lead him/her to enact rituals, hidden or manifest.
Developing mindful attitudes in the patient through the practice of mindfulness could be a valid instrument for helping people with OCD manage their internal experiences (thoughts, sensations, mental images) and learn how to respond to them in a functional way, rather than reacting automatically: Mindfulness is the opposite of acting mechanically on “automatic pilot,” and so, for OC patients it is an important ability, considering that it is precisely their reactivity to their obsessions and the subsequent enacting of compulsions that sets off the self-invalidating vicious circles of OCD.
Experiential Acceptance (EA), a core process in Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is the willingness to actively embrace “private events” (emotions, bodily sensations, thoughts, etc.) in the moment without attempting to change their frequency or form. EA is the opposite of experiential avoidance, the unwillingness to remain in contact with particular private events, such as anxiety and obsessions in OCD, leading to exhausting attempts at altering the form and frequency of these experiences.
The workshop will show, with practical exercises, how to incorporate these strategies into therapy: both Mindfulness and Experiential Acceptance offer a variety of strategies to help individuals with OCD to cope better with their symptoms, and that can be integrated into the treatment. Mindfulness and EA training can also prepare patients to exposure and increase their compliance to treatment, making them perceive E/RP as less upsetting than they do in other therapeutic contexts in which exposure with response prevention exercises are presented alone. Mindfulness and acceptance-based strategies can support patients in the work of accepting the discomfort and the negative emotions that accompany the presence of obsessions, and, finally, support them in not reacting with the enactment of compulsions, thereby promoting symptom alleviation.
The Summit will be held on Thursday, May 12, Friday, May 13, and Saturday, May 14, 2022, for a total of 27 hours of specialized training.