This study aimed to assess the effects of schema therapy on emotional self-awareness, vulnerability, and obsessive symptoms among OCD patients. None of the between-group differences regarding the pretest mean scores of emotional self-awareness, vulnerability, and obsessive symptoms were statistically significant. Therefore, significant between-group differences at posttest can be attributed to the effects of schema therapy.
Study findings indicated that schema therapy significantly improved emotional self-awareness through reducing the mean scores of the emotional inhibition and the emotional deprivation schemas and thereby, regulating emotions. These findings were in agreement with the findings reported by Dadomo et al., and Fassbinder et al., (18, 19). According to Young, these two schemas are related to the fulfillment of basic human needs such as the needs for being loved by others, worthiness, attention, intimacy, care, self-expression, and emotion expression without any fear over punishment (7).
High scores in these two subscales reflect the inability to identify and express basic needs, ask from others, and speak less frequently about self. Patients with these two schemas usually refer to therapists due to senses of loneliness and sadness and do not expect to be understood and supported by therapists. Schema therapists use techniques such as imagery to help patients recognize their emotional needs. Then, they use the two-chair, the schema re-writing, and the schema dialogue techniques to help patients get angry at individuals who had roles in the formation of their schemas, talk with them, and emphasize on their own rights as a child. Thereby, therapy relationship has the most significant role in schema therapy (6).
In the present study, the mean scores of the emotional deprivation and the emotional inhibition schemas reduced from 24.00 and 22.87 at pretest to respectively 19.73 and 18.27 at posttest. According to Dadomo et al., and Fassbinder et al., emotional regulation is a multidimensional concept, which includes awareness and acceptance of emotions, goal-oriented behavioral skills, and flexibility in using appropriate strategies for reducing the severity and the length of emotional response. Any problem in each of these dimensions plays a significant role in the development of mental disorders. Schema therapy holds that cognitive therapy cannot regulate emotions and hence, experiential techniques are used to help patients express and manage their emotions as healthy and mature humans (18, 19). In line with our findings, Halford et al., and Saffari et al., also reported the effectiveness of schema therapy in alleviating emotional inhibition, emotional deprivation, and symptoms among patients with social anxiety disorder (20, 21).
Saffarinia et al., noted that early maladaptive schemas are strongly correlated with patients’ cognitive biases and inaccurate assessments of environmental stimuli. This correlation can in turn result in avoidance or exaggerated behaviors. They attributed the effects of schema therapy to its focus on individual differences in planning and using cognitive and experiential techniques (21).
In addition, Halford et al., justified their findings by noting that therapeutic alliance is a significant factor behind therapeutic changes in that a positive therapeutic alliance with a therapist provides patients with a correcting emotional experience and hence, can significantly contribute to treatment. Positive therapeutic alliance creates a safe environment in which patients feel adequate safety to approach phobic affects and emotions (20).
Our findings also showed the effectiveness of schema therapy in significantly reducing the scores of the vulnerability and the failure schemas from 22.00 and 17.67 to respectively 16.87 and 14.8. These reductions are clinically significant. These two schemas are associated with incompetence and uncertainty in decision-making, extreme negligence or perfectionism, and exaggerated fear over an imminent catastrophe or violation of one’s own or others’ rights. Patients with these two schemas have unfulfilled safety, approval, and positive attention needs. In schema therapy, therapists use cognitive, skill-training, and reality-testing techniques to help patients obtain an accurate understanding of their own abilities and encounter phobic situations instead of exaggerated avoidance from them (6). Therefore, schema therapy can change patients’ thinking about catastrophizing and behavioral avoidance, which they use to prevent catastrophes and damages. The vulnerability and the failure schemas are strictly related to obsessive symptoms and therefore, we used techniques related to these schemas to increase the effects of exposure and response prevention therapy.
In line with our findings, Halford et al., Saffarinia et al., and Hamzeh et al., reported the positive effects of schema therapy on the vulnerability and the failure schemas among patients with depression, anxiety and social anxiety disorder. To justify their findings, they noted that through cognitive and behavioral techniques, such as role playing and also through subjective and realistic exposure to anxiety-provoking situations, schema therapy helps patients obtain a realistic estimate of a given danger, revise their estimate of the probability of catastrophe occurrence in social situations, and improve their capacity for effective coping with anxiety. Moreover, using behavioral techniques to change schema-driven pattern causes the formation of healthier coping styles and thus, facilitates distancing from maladaptive schemas (20-22).
The other finding of the present study was that schema therapy reduced the mean score of obsessive symptoms from 21.40 at pretest to 16.37 at posttest.
Theil et al., also made a study into the effects of exposure and response prevention as well as schema therapy and found that experiential techniques of schema therapy (such as the two-chair, schema dialogue, and imagery writing techniques) reduced patients’ resistance to receive treatments and alleviated obsessive symptoms among OCD patients. According to Thiel et al., exposure and response prevention is effective for patients who do not obtain high maladaptive schema scores. Thus, when schema scores are high, experiential techniques can facilitate the process of exposure (23).
In OCD patients, behavioral avoidance and repetitive rituals prevent the realistic processing of anxiety-provoking stimuli such as contamination and disorderliness. Cognitive techniques specifically assess and challenge deviations, which result in these behaviors. The therapist determines some tasks to expose patients to anxiety-provoking stimuli subjectively and then realistically, supports cognitive challenges, and hence, helps alleviate symptoms.
In fact, schema therapy helps patients become aware of their memories, cognitions, bodily sensations, emotions, coping strategies, and consciously manage their schemas (6).
4.1. Conclusion
Schema therapy alleviates obsessive symptoms through positively affecting maladaptive schemas such as emotional inhibition, emotional deprivation, vulnerability, and failure. These findings suggest that these schemas play significant roles in the development of obsessive symptoms. Conventional exposure of OCD patients to unpleasant stimuli is very anxiety provoking, while cognitive and experiential techniques of schema therapy help explore and modify the origins of these anxieties. Currently, schema therapy is not routinely used for OCD management; therefore, mental health specialists are recommended to use it as an effective treatment for OCD outpatients.
One limitation of the study was its small population and sample. Therefore, the generalizability of the findings should be done cautiously. Further studies are needed to produce more convincing evidence.
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