Subscribe
Share
Share
Embed
For five years The Healthy Compulsive Project has been offering information, insight and inspiration for OCPD, obsessive-compulsive personality, perfectionism, micro-managers and Type A personality. Anyone who’s ever been known to overwork, overplan, overcontrol or overanalyze is welcome here, where the obsessive-compulsive personality is explored and harnessed to deliver what it was originally meant to deliver. Join psychotherapist, Jungian psychoanalyst and author Gary Trosclair as he delves into the pitfalls and potential of the driven personality with an informative, positive, and often playful approach to this sometimes-vexing character style.
Hello everyone. This is Gary Trosclair, psychotherapist, Jungian analyst and author of the Healthy Compulsive Project Book, blog and podcast. Today’s episode is about psychotherapy for obsessive-compulsive personality. There are two parts. The first part is about the different kinds of therapy for OCP, and the second part is about how therapy actually works, what goes on in the room, with plenty of short examples to demonstrate. In the original written blog there are lots of links to the research. So if you’re curious about the science behind what I’m saying, go to www.thehealthycompulsive.com where you can find out more. While Obsessive-compulsive personality disorder is probably the most frequently occurring personality disorder, there is very little research regarding treatment. But we do have related studies that point the way to what type of therapy might be most effective, and what you need to do on your end to make it more effective. In the end your choice of type of therapy is a matter of what feels best for you, and what your goals are.
This is Episode 35 of the healthy compulsive project podcast, Psychotherapy for the obsessive-compulsive personality.
Prt 1: What is the Best Psychotherapy for OCPD (Compulsive Personality)?
If you're trying to research the best psychotherapy for OCPD and compulsive traits, you probably won't find much. There are very few studies which investigate treatment designed specifically for it. As a result there is a fair amount of misunderstanding out there that I'd like to try to rectify.
The Two Basic Types of Therapy
To simplify, we can divide therapy into two very broad categories: cognitive and behavioral therapies on the one hand, and dynamic and expressive therapies on the other.
Cognitive and Behavioral therapies (such as CBT) are more structured, and directed more by the therapist. They aim to relieve specific symptoms by challenging thought patterns and prescribing gradual behavioral change.
Dynamic and expressive therapies (such as psychodynamic and psychoanalytic therapies) are more free-flowing and self-directed. These aim to achieve broader and deeper changes in the personality by developing a greater awareness of unconscious influences. They also develop insight into patterns of coping that developed as a result of early family and environmental issues.
One type of cognitive behavioral therapy designed for OCPD and related disorders is Radically Open Dialectical Behavioral Therapy (RO DBT). The intent of RO DBT is to help reduce overcontrol and to improve communication. There are a limited number of practitioners trained in RO DBT, and the process is highly structured--which some might find relieving, and others find uncomfortable.
Another type of therapy which may be helpful for OCPD is Schema Therapy. This approach includes both CBT and dynamic elements. While not designed specifically for OCPD, it may be effective for people with OCPD in part because at least one of its basic 11 schemas (also known as "Lifetraps") apply directly: "It's Never Quite Good Enough."
The reality is that there is often overlap between how CBT and dynamic therapy are actually practiced, but most therapists tend to identify with one type more than the other.
Before I go on, a disclaimer. I make my living practicing dynamic psychotherapy. I can’t rule out bias on my part, but I’ll try to lay out the possibilities objectively and show the research behind what I say.
Are All Therapies Created Equal? The Research
There is some data which indicates that all legitimate forms of psychotherapy are equally effective. While clinicians and researchers argue about just how equal they really are, all bona fide forms do seem help more than no therapy at all.
Still, during their rotations most medical students get it pounded into their heads that cognitive and behavioral therapies are more effective, and the news spreads that these are the only treatments worth using. But to be accurate, there is just more evidence that they are effective—not evidence that they are more effective. These are very different claims, but they've been conflated.
Cognitive and behavioral therapies do have more research to support their efficacy for certain specific conditions. They tend to be shorter term, target specific symptoms, and are manualized—meaning the therapist follows a protocol laid out in a manual. These characteristics make cognitive and behavioral therapies easier and less expensive to research, which is one of the reasons there is more research showing that they're effective.
Clearly many people benefit from these therapies.
Evidence, Dropouts and Fit
But more recent studies have not demonstrated the rates of success for cognitive therapy that earlier studies suggested. Nor have they demonstrated superiority over other types of therapy.
And, according to at least one study, on average 42% of the subjects in trials for cognitive and behavioral therapies drop out. So, a lot of people don't feel comfortable enough with them to stick it out.
So, if cognitive therapy doesn’t feel like a good fit, you're not alone. I’m not recommending you give up on your CBT therapist. In fact I’d suggest you tell your therapist if the therapy isn’t feeling right so that the two of you can work it out.
Barring that, other forms of therapy may feel like a better fit for you.
While there aren't as many studies that support the efficacy of dynamic and expressive therapies, there is still plenty of research out there that does support them, as Jonathan Shedler at the University of Colorado Denver School of Medicine points out.
In fact in a study comparing the long-term effects of the two types of therapy for depression, "Psychoanalytic therapy shows significantly longer-lasting effects compared to cognitive-behaviour therapy three years after termination of treatment."
(You can find a good, shortish description of the rationale behind psychoanalytic therapy here.)
Dynamic therapies are usually the treatment of choice for personality disorders. And there is good reason to believe that they might be the better treatments for obsessive-compulsive personality disorder in particular.
(Not everyone who is compulsive is disordered. There is a spectrum from healthy to unhealthy compulsivity, and most of us can benefit from therapy to make sure our tendencies don't go awry.)
Best Psychotherapy for OCPD: Matching Therapy to Your Goals
Since both kinds of therapy are effective to some degree, these days researchers are trying to predict which therapies will work best for which people and which conditions.
For instance, if you want to remove the symptoms of OCD, bulimia, panic attacks, or a specific phobia, cognitive and behavioral therapies can be quite effective. (Note that treatments for compulsive personality (OCPD) and OCD are usually not the same, as they are really different, though sometimes overlapping conditions.)
But if your goals in therapy are broader, such as shaping deeper personality traits, dynamic therapies may be more helpful.
Here's how Jonathan Shedler described the wider-ranging goals of dynamic therapy:
The goals of psychodynamic therapy include, but extend beyond, symptom remission. Successful treatment should not only relieve symptoms (i.e., get rid of something) but also foster the positive presence of psychological capacities and resources. Depending on the person and the circumstances, these might include the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a realistically based sense of self-esteem, tolerate a wider range of affect, have more satisfying sexual experiences, understand self and others in more nuanced and sophisticated ways, and face life’s challenges with greater freedom and flexibility. Such ends are pursued through a process of self-reflection, self-exploration, and self-discovery that takes place in the context of a safe and deeply authentic relationship between therapist and patient.
An Additional Dimension
For me, one of the most important aspects of working with people who are compulsive is understanding the deeper motivations for compulsive behavior rather than pathologizing them. People who are compulsive have urges that they feel compelled to act on, and these urges aren't all bad. Much of the creative and productive work done in the world is done by people who have compulsive personalities. Only when our urges get hijacked by shame and insecurities do they become unhealthy.
Finding the deeper well-springs of these urges is the core goal of Jungian analysis, a specific form of dynamic treatment that looks for the purpose and meaning behind symptoms. It is a growth-oriented therapy developed in the early 20th century by Swiss psychiatrist Carl Jung. It sees the unconscious as a source of wisdom and creativity, and spirituality in the broadest sense, rather than a storehouse for repressed memories. Jung suggested that we have a compulsive urge to realize our potential, or to individuate. Recognizing and utilizing this instinct can be a powerful motivation for change.
Part of what I find most attractive and helpful about Jungian analysis is its more positive attitude toward our symptoms. And I believe that it is particularly helpful for people who are obsessive-compulsive because it insists that we seek the meaning inherent in our challenges. As I've written elsewhere, obsessive-compulsive disorder is a disorder of priorities--meaning has been lost.
Analyzing Therapy
Ultimately your choice will be based on what feels like a good fit for you personally and whether your goal is specific symptom remediation or broader personality growth. But whatever form of treatment you pursue, I hope that you'll think of it as developing and harnessing your potential rather than remediation for bad behavior. That's a good start.
To get a more detailed picture of what dynamic therapy is actually like in practice, check out my post about how psychotherapy works for the compulsive personality. And you can get a sense of what the patient's role in psychotherapy is by taking a look at my book, I'm Working On It In Therapy: How To Get The Most Out Of Psychotherapy.
Part 2: Therapy for OCPD: How Treatment Actually Works
Let's imagine that you decide to go to therapy for OCPD (obsessive-compulsive personality disorder), to deal with your workaholic tendencies, need to control, and utter, uncontrollable frustration with people who are messy and don't follow the rules. What needs to happen for it to be helpful?
First I’ll speak about what a therapist can do to help that you can’t do for yourself. Then we’ll talk about what you’ll need to do on your end to make your time in therapy effective. Then I’ll give a short example demonstrating how the interaction between the two of you can help.
Your Therapist’s Role in Therapy for OCPD
Your therapist will help you to explore feelings you usually avoid. They will slow you down and ask you to experience those feelings long enough to see what you need to learn from them.
“Did you notice that you just said you were afraid no-one at work likes you, and then you rushed into what you need to do to get that project done? It seems you were avoiding feeling something. What was going on? What’s that fear about, and how do you usually cope with it? Getting stuff done?”
Your therapist will help you see patterns of thinking, feeling and behaving that you don’t notice because you can’t be objective about them.
“Have you noticed that everything you’ve said so far in this session is about planning the future? What’s going on inside right now--in this moment--as you speak with me?”
“I’ve noticed that every time you accomplish something you feel it’s not good enough and you rush into a new project to get away from that feeling.”
“I know that you care about your sister, but the way you talk to her about what she’s doing wrong probably doesn’t leave her feeling that you care.”
Your therapist will help you see patterns that you don’t notice because you simply haven’t had the training to recognize them.
“I suspect that the way you learned to connect with people when you were young affects how you use the passion and skills that you were naturally born with. If you don’t feel you have a secure connection with people, you might enlist your natural meticulousness to prove that you’re worthy of respect, but you do it in a way that actually pushes people away.”
Your therapist will model an attitude of patience and realistic acceptance, and help you find ways to break your patterns.
“Yes, it’s true that you made a mistake. Welcome to the human race. If you’re perfectionistic and tell yourself that you’re a loser just because you over-reacted, it’s not going to help anyone. Let’s try to understand what happened rather than get into blaming yourself or other people. Next time you're about to over-react PAUSE. See what you’re feeling and remember what’s really important to you. You might not be able to do this all the time at first, but with our discussions and practice you'll get better at it.”
Your therapist will challenge you to think about what’s most important to you.
“I know that you want things to be good at home. But what do you really want to happen as a result of criticizing your husband? Do you want to prove you’re right, or to have a family where people are safe, thrive and enjoy being together?”
“What did you want to happen by reaching partner at your firm? Now that you’re there, you’re still working like a newby junior associate. I think you’ve forgotten what your real goals in life are.”
Your Role in Therapy for OCPD
Try to allow yourself to feel a full range of emotions, including the layer of emotions beneath anger. You may not be used to this. Say what you feel, not what you think. Emotions serve as a lubricant for a brain that has gotten rusty and rigid.
“I just realized that I might seem really angry about what’s going on, but now that I’m sitting with it, I realize I’m actually really sad that there’s nothing I can do about it. I think I’ve been trying to get away from that feeling.”
Look for your own responsibility, what’s within your control.
“He really was being a jerk, but I didn’t have to respond the way I did. I think I was afraid of being blamed and I overreacted. I really like being right but I’m starting to wonder if it’s worth living that way.”
Figure out why you’ve come to use work or control as a strategy to cope with difficulties.
“I remember when my parents said they were getting divorced. I figured it was my fault. I had always been a little perfectionistic, but when that happened I got really controlling, in a bad way. They ended up staying together, but I’ve never stopped being that way.”
Use the everyday events of your life to identify your patterns such as judging, rushing, controlling, overworking. Connect the dots of the things you get caught in most often. Don’t waste time on behavior that's just a one-off.
“I was in line at the checkout and someone was fumbling with their credit card. I wanted to give them grief for taking so long. Then I realized that there was really no reason for me to be in a hurry. I recognized I always feel urgency whether there is a need to or not. I push myself and other people out of habit.”
Identify what’s at the root of your compulsive style. What’s really important to you that you want so badly to accomplish?
“I noticed how I work long hours so that we’ll have enough money for our daughter to get tutoring and go to a good college. And I get upset with her when she doesn’t get all A’s. But what I really want is to make a home were she feels loved and she feels she can pursue what's fulfilling to her. I’ve put the cart before the horse.”
All Together Now
This separation of therapist and client roles is somewhat misleading. A major determining factor in therapy is how well the two of you work together, how much real interaction there is between you. For people who are compulsive this offers an opportunity to learn about how they react to people and how they come across to people.
“I ran all the way here. I hate to be late. I thought you’d be angry at me for not taking this seriously.”
“Actually I’m not angry at you at all and the last thing I’d think about you is that you’re not taking this seriously. Do you imagine that with other people too? I suspect that what you imagine people think about you is very different from what they really do. Is it possible that you actually appear to be so serious and pre-occupied with getting everything right that people might see you as indifferent to them?”
What's harder to put into words about how therapy works is the experience that regular meetings with your therapist fosters. This is not just an intellectual exercise designed to make you behave more reasonably. A consistent and accepting exploration of your feelings cultivates not only awareness, but also increased comfort with who you are as you are, while still leaving room for growth.
Be patient and persist. You’ve been living compulsively for a long time. Don’t expect it to change immediately. If you’re consistent in your attendance, and you use you natural determination to work on yourself, your patterns will change sooner.