Psychodynamic therapy of obsessive‐compulsive disorder: principles of a manual‐guided approach

Obsessive-compulsive disorder (OCD) is a chronic disabling disorder characterized by recurrent obsessions and uncontrolled compulsions. Recent research suggests that OCD is more common than assumed before. Cognitive-behavioral therapy and selective serotonin reuptake inhibitors have been shown to be equally efficacious in OCD, but with rates between 50% and 60% for response and 25% or below for remission. Thus, further development of efficacious treatments is required. Despite the long clinical tradition of describing and treating OCD from a psychodynamic perspective, no evidence-based psychodynamic treatment exists. Recent research on anxiety disorders, however, suggests that manual-guided short-term psychodynamic therapy (STPP) may be a promising approach. Building on STPP for anxiety disorders, a model of STPP for OCD was developed which is based on Luborsky’s supportiveexpressive therapy. The treatment consists of twelve modules which include both the characteristic elements of supportiveexpressive therapy (i.e., focus on the core conflictual relationship theme, CCRT, and on the helping alliance) and additional disorder-specific treatment elements. In the following the treatment is briefly described. At the beginning of treatment, the CCRT associated with the symptoms of OCD is assessed. A CCRT encompasses three components: a wish (W, e.g. aggressive or sexual impulses), a response from others (RO, e.g. to be condemned), and a response of the self (RS, e.g. obsessions and/or compulsions). Focusing on the CCRT, the therapist relates the patient’s OCD symptoms (RS) to his or her wishes (or impulses and affects, W) and to the (expected) responses by others (RO). The CCRT is presented to the patient as his or her “OCD formula”. This formula allows patients to understand their pattern of anxiety and OCD reactions. It translates the patient’s symptoms into (internal and external) interpersonal relationships. Enhancing the patient’s cognitive and emotional understanding of his or her symptoms and of the underlying CCRT represents the expressive (interpretive) element of SE therapy. An expressive intervention addressing the CCRT for Shakespeare’s Lady Macbeth’s compulsive washing may be: “As we have seen your compulsive washing (RS) is related to your aggression, the murder of Duncan (W), and to your feelings of guilt (internalized RO). By your compulsive washing rituals, you are trying to make your deed undone and to get relief from your guilt feelings. . . By washing your hands again and again, you are replacing moral purity by physical cleanness”. During treatment, the CCRT and its components are worked through in present and past relationships, including the “here and now” relationship with the therapist. Consistent with available evidence, working through the CCRT can be expected to improve the patients’ understanding of their conflicts, to reduce their OCD symptoms and to help them in developing more adaptive behaviors (RS). Both within and between sessions, patients are asked to work on their OCD formula, that is to monitor their emotions including their bodily components and to identify the components of the CCRT that lead to anxiety and OCD. Doing so, patients may achieve a better understanding and awareness of their OCD symptoms and a sense of control (i.e., not being helpless towards OCD), the latter being of particular importance for OCD patients. Establishing a secure therapeutic alliance is regarded as the central ingredient of the supportive element of the intervention. Luborsky has formulated several principles for establishing a secure alliance, e.g. conveying a sense of understanding and acceptance or recognizing the patient’s growing ability to work on his or her problems in the same way the therapist does. In order to tailor the treatment specifically to OCD, we integrated disorder-specific treatment elements that proved to be clinically helpful in OCD into the manual-guided model of STPP. They encompass, for example: