OCD and Compassion Focused Therapy
A starting point to get you thinking about integrating CFT with Therapy for OCD
I left my job as a general CBT therapist in an IAPT Service two years ago to jump into independent practice. I was advised to pick a niche to avoid burnout, focus my skills and make marketing easier.
I opted to specialise in OCD.
But my reason may surprise you.
For a little of my OCD backstory, keep on reading.
Or feel free to skip to the bottom for this month’s curation of resources
Working with OCD is hard
Although I loved the work, had good therapeutic rapport and great feedback from clients, people often came to the end of thier therapy a long way off being ‘in recovery’. OCD clients could make me feel deskilled and question the therapy I delivered. And I wasn’t the only one. My clients would share that this had been the 2nd or 3rd round of therapy. Drop-out rates and relapse rates are high for OCD across the board. But, this was the very reason for my decision. I wanted to be a better therapist for these people.
So, why choose something so challenging?
My OCD clients were some of the most wonderful, caring people I had the pleasure to work with. But they were also in pain and felt that people “just don’t get it”. Clients could not see past the fog of OCD telling them “you’re a bad person” to witness thier wonderfulness. As a private therapist, I would have the space and freedom to learn, grow and offer something that would be potentially life-changing.
The common thread within every client was the shame that ran deep into every part of the problem. From shame and self-disgust for having the intrusive thoughts to shame that they struggled to have a ‘normal life’. Having studied Compassion Focused Therapy (CFT), I was confident that there would be a way to treat OCD that could integrate a more flexible and compassionate approach than standard Cognitive Therapy for OCD or behavioural ERP.
Over the last two years, I’ve dedicated my CPD to focus on OCD, Trauma and CFT. I’ve had support from some wonderful people and have learnt a lot along the way. In future posts, I will delve a little more into how I adapt my OCD interventions and integrate CFT into my work.
Here are some excellent resources that I think are a great place to start.
The Curation Bit
When I started researching CFT for OCD, I discovered a wide range of wonderful resources about OCD and equally wonderful resources about CFT. But… there isn’t a huge amount of information on how to integrate CFT into treatment.
I’ve put together my best picks for you.
As always, I would love to hear from you if you have any recommendations, too.
Compassion in a T-shirt:
Dr Stan Steindl and Lisa Willimas
I love everything that Dr Stan produces and this episode doesn’t disappoint.
(Click here to read his Substack)
In this video Dr Stan interviews Lisa Williams who is an experienced CBT therapists at the South London and Maudsley NHS Foundation Trust. Lisa works in a specialist residential setting for people with OCD. The centre integrates CBT, ERP and CFT into their treatment of OCD. Lisa talked about how the organisation and staff team hold compassion at the heart of thier values and ethos. This is one of the best resources I’ve encountered about CFT for OCD. I wish I had found this years ago!
My hightlights:
Dr Stan and Lisa discuss how the standard CFT formulation can be used to explore the development of OCD from early experiences and also how OCD compulsions are an understandable strategy to cope.
They discuss emotional multiplicity within OCD and how intrapersonal self-relation to emotions is an important consideration in treatment.
Lisa and Stan discuss the three circle emotional system as general pscyho-education and for understanding OCD. This part includes an interesting reflection on how OCD can be understood as threat-based drive.
Lisa explained how flows of compassion are built intro the treatment programme; including active work with fears, blocks and resistance (FBRs) to compassion and how relating to others can be an important part of recovery.
Lisa gave a lovely summary of how she integrates compassion into her work. This includes the holistic nature of the programme, which allows “compassionate intention” to be part of day-to-day living. Lisa also outlines some of the set-pieces that you may be familiar with and how they are applied within ERP. In particular, the use of the Compassionate Self and Compassionate others to support ERP.
Kimberly Quinlan -
The Self-Compassion Workbook for OCD
Image taken from Kimberley’s website - Book available here
This next resource follows nicely from the interview with Dr Stan and Lisa. Kimberley’s book gives a clear overview of how to create a compassionate self to take to ERP.
I first came across Kim through her Instagram account, “Your Anxiety Toolkit” If you’re a social media user, I suggest you give her a look.
I attended some training with her, in which she taught the valuable lesson of how self-punishment and self-criticism can be viewed as compulsions maintaining the OCD cycle. This shift in how to view self-criticism has made a big impact on my clients. Clients can have FBRs around letting go of self-criticism due to the deep shame and fear that they somehow “deserve” this self-attack. However, the CFT lens can help us understand this as a threat-brain response, an attempt to keep us ‘safe’ from perceived danger - just like any other intrusion—compulsion response. When framed as an overlooked compulsion stemming from the threat brain’s misinterpreting the intrusions as having relevance, clients can soften up around it and use response prevention.
Within her book, Kim uses compassion practices to build a foundation before moving toward active ERP work. In doing so, clients can learn to shift out of a threat based mindset into a compassionate mindset of wisdom, strength, courage and commitment to "do what is helpful not harmful” - even if it’s tough going.
Kim appears to be mainly influenced by Neff and Germers’s Mindful Self-Compassion rather than Gilbert’s CFT. There are interventions I use which are not covered by Kim, such as the thee circles or using chairwork to differentiate the intrapersonal social mentality exchange. Nonetheless, this book has been a big influence on how I integrate CFT.
My highlights:
A self-help book designed for clients, meaning it is accessible and valuable to use with clients in session or between sessions to support your work.
Gives clear guidance on how to use compassionate practises to prepare for ERP and using a ‘compassionate self’ to strengthen ERP.
The book acknowledged fears, blocks and resistance to compassion and how OCD and shame can maintain these FBRs.
OCD Stories Podcast:
Dr Nicola Petrocchi - Compassion-Focused Therapy (CFT) for OCD (#296)
I could not make a post about OCD without mentioning The OCD Stories podcast. I’ve followed the podcast for years; it influenced my way of working before I quit my job, before I specialised, and at times when I had imposter syndrome and felt like I had no idea what I was doing! The podcast invites people with OCD to share their stories and also features interviews with therapists who share thier insight and wisdom on working with this client group.
Link to the podcast episode here
Dr Nicola Petrocchi’s paper “Compassion-Focused Group Therapy for Treatment-Resistant OCD: Initial Evaluation Using a Multiple Baseline Design” was the first bit of reading I came across when I started to explore CFT for OCD.
This study examined the effectiveness of CFT as a treatment for individuals who had previously had CBT but found it was unsuccessful. Eight people participated in an eight-week CFT group program. The results showed that most participants experienced significant reductions in OCD symptoms, which were sustained for at least a month after treatment.
The paper outlines the format for each group session, as follows:
Introducing Compassion
The three emotional systems
Mindfulness and self-awareness
Safeness vs. Safety
Compassionate Self and Flows of Compassion
Self-Criticism
Flows of Compassion to the self and emotional multiplicity
Cultivating Self-Compassion and Compassionate letter writing
With my own OCD clients, I don’t run through these concepts and practices in this sequence. However, I have used this as a framework for weaving in these concepts and practices with one-to-one clients.
In the future, I could see myself running a similar CFT group for OCD clients.
Maybe? Who knows!
My highlights (from the podcast):
Dr Nicola talks about the importance of recognising the evolutionary nature of motives and social mentalities and how CFT can be used to ‘train’ our minds to develop a compassionate social mentality. As the previous recommendations suggest, this mindset can then be applied to relating to the experience of OCD and treatment.
I like the way that Dr Nicola talks about CFT as an adjunct to other forms of treatment to “boost” effectiveness. It speaks to the fluid and flexible nature of CFT and how Compassion could be an additional mechanism of change within already established ways of working. It’s not necessarily a stand-alone ‘school’ of therapy.
Dr Nicola and Stuart discuss the future of integrating CFT with OCD treatment and what that may look like. This includes having a compassionate image alongside the ERP, the importance of the therapist also maintaining their own compassionate mentality towards the client as they undertake ERP, and ways to use self-self relating with flows of compassion to the OCD as a vulnerable scared part of the self.
Dr Nicola discussed the importance of “fear of guilt” within OCD. He explains the difference between pro-social and deontological guilt and how OCD sufferers tend to be more sensitive to the latter. It is explained how compassion can cultivate the courage required to “take risks” and drop compulsions and then tolerate the discomfort of guilt due to the increased capacity to self-soothe with compassion.
Dr Nicola and Stu discuss FBRs to compassion and therapy and how we can have a compassionate understanding towards the FBRs. As is often stated, “that is where the work is”.
Finally, Dr Nicola outlines the way that compassionate practises are used for working with self-criticism. Stu and Dr Nicola explore how self-criticism and OCD have a fear that sits behind it. The compassionate mind seeks to see and understand this fear and pain and offer compassion. Importantly they discuss that this is not a “one and done” process but is a way of being that takes time and practice.
The integrative Centre for OCD - Upcoming Training
The Integrative Centre for OCD (IC-OCD) was founded by the host of The OCD Stories podcast Stuart Ralph along with his friend and regular guest on the podcast Jonny Say.
I had the honour and privilege to work alongside the absolute legends of Stuart and Jonny in the early days of the Integrative Centre for OCD. The IC-OCD offers one-to-one therapy both in-person and online. Therapy is delivered by a team of specialist therapists who work in an integrative way, using CBT, Psychodynamic therapy, ACT, FAP, CFT and, of course ERP. They also run low-cost groups and an OCD camp.
When I was an associate at the centre, I received excellent training in ERP, ACT and Compassion for OCD. This was provided in-house both by Stu and Jonny and some of leading figures in the field. They have recently expanded their training offer for therapists interested in OCD.
If this article has inspired you to learn more about working with OCD or CFT for OCD, I would highly recommend taking a look at the upcoming training they have
On-demand training: OCD for non-specialists
In April - Compassion Skills for ERP and OCD Recovery
Take a look at Jonny’s Youtube channel for a taster of his skills video.
In May - FAP - Functional Analytical Psychotherapy for OCD
If you’re interested in FAP for OCD Stuart Ralph has a great episode on the OCD stories here.
What next?
I would love to hear from you if you would like to share resources or your experiences of CFT for OCD or CFT generally.
I’m considering writing some ‘intervention how to’ posts with examples of how I integrate ACT and CFT into my clinical work with OCD clients.
If you’re interested in this type of content, please leave a comment below.
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I love this, Kirsty--thank you for including so many great resources! It's wonderful that you chose to work with individuals struggling with OCD despite the challenges you faced initially. Very inspiring, thanks.