On Treating Obsessive Compulsive Personality Disorder

Given absurd federal regulations, we have to schedule courses and pick books nearly a year before teaching them. So it was last summer when I adopted Robert Feinstein, ed., Personality Disorders (Oxford University Press, 2021). We are finishing up the semester with that book, and recently focused on the chapter on Obsessive Compulsive Personality Disorder (OCPD), the epidemiology of which here and elsewhere often suggests it is perhaps the most widespread of all the personality disorders. 

In re-reading the chapter for class, I realized that a new case--which has been difficult to conceptualize coherently because psychological issues are intercalated with a rare and unpredictable multi-symptomatic cardiovascular condition about which medical science knows little to date--matched DSM-V criteria for OCPD.

Following this minor epiphany, I indulged my own OCD-ish tendencies by spending about 6 hours ransacking the databases to see what else I could find on OCPD that was useful. Herewith some results of that unsystematic survey.

In the first place, far and away the most helpful thing has been the chapter, "The Obsessive-Compulsive Patient" in The Psychiatric Interview in Clinical Practice by Roger A. Mackinnon, Robert Michels, and Peter J. Buckley. They have captured to an astonishing degree what I have seen, and highlighted two things I had seen but not thought clinically significant. They also give some very helpful recommendations on techniques, two of which I have already tried and found very fruitful. To read page after page of this chapter was to feel like pieces falling into place at long last, and a clarity which has frustratingly eluded us, "its hour come round at last," now emerging. To document all the insights of this article would take too long. Suffice it for me to say that if you can't read anything else noted here, read this!

After that chapter, I found my longstanding practice of returning to earlier writers never fails to pay dividends. Thus I read the late (d.2009) Georgetown psychiatrist Leon Salzman's article "Psychotherapy of the Obsessional," American Journal of Psychotherapy (1979). This then reminded me that I had, some time back, been given a copy of his 1968 book, The Obsessive Personality: Origins, Dynamics, and Therapy. I retrieved it and perused it. The whole thing seems to have held up very well, in my view, and is not only helpful and interesting but written in a remarkably accessible way. The last section of the book gives many similar technical recommendations as he did in the 1979 article linked above. 

E.g., he begins by noting the obsessional's "extraordinary capacity" to "evade, distract, obfuscate, and displace" in order to avoid confrontation and change. This is very much my experience to date. The author recommends ensuring a solid working alliance is in place before moving slowly and gently but firmly to confrontation of these maladaptive coping mechanisms, aware that the obsessional's perfectionism (about which see below) will make such confrontation slow-going, partial, and halting--but essential nonetheless.  

Psychodynamic clinicians, confronted with the relentlessly controlling and perfectionistic instincts of the obsessional, might be tempted, as I was early (too early!) in one treatment to encourage the patient to make great use of free association, but Salzman warns--and my mistakes again confirm!--that too heavy an insistence upon free association "might often aggravate the problem" by burying "the therapy under endless trivia." This is where some guidance may be necessary, and again some confrontation if the patient seems clearly to be free-associating in an obfuscating or evasive fashion. On this point Salzman bluntly advocates that "the therapist curtail techniques which defeat communication."

The broader metapsychological issue for the obsessive is the unwillingness or inability to deal with the universal human problems of ambiguity and ambivalence. These create a paralyzing anxiety in the obsessive, and the work of therapy will be centred here, helping the patient come to appreciate "the universality of anxiety" while stressing, and building up, the patient's inner capacity to handle this. Salzman says that in working on this issue it is best to stay in the moment and make use of "here-and-now" material. This is, in fact, a frequent technical recommendation he makes in this article and in his book: to draw on daily experiences, and the therapeutic relationship in the present, while gradually closing off the obsessive's recourse to past events.

In particular, the things that are frustrating about, and enraging in, treatment are especially to be focused upon: the therapist's mistakes (whether legitimate or perceived) as well as the patient's "feelings of distrust, dislike, or liking for the therapist" should be shared even though doing so is of course difficult. On this point Salzman says to watch out for the the obsessive's tendency to observe with exactitude, and externally comply with, the rituals and rules of therapy while seeking to defy them internally. This is the central bind of the obsessive--defiance vs. obedience or conformity, themes well covered in The Psychiatric Interview--and it will be particularly manifested in what he calls subtle, perhaps even petty, complaints about time, fees, office decor, the therapist's choice of dress, or similar matters. 

What these complaints mask is the patient's inability to make use (cf. Winnicott's understanding of use vs. exploitation) of the therapist in a deeper way at this point. Instead, the therapist will be confronted with the task of slowly but steadily wresting from the patient, one by one, his many defense mechanisms (cf. "Remembering, Repeating, and Working Through"), including the one that manifests as perfect outward compliance to the requirements of therapy. Some patients (a common theme in the literature, and also confirmed by my experience) will bring lists of things to each session they claim to want to remember to mention, or to prove how actively they are thinking about the session, or doing some apparent "homework" after the session. There is a strong consensus in the articles covered here that bringing such lists should be forbidden as soon as feasible. 

What you will rarely hear from the obsessive are warm, tender feelings or affectionate reactions. These are guarded against with characteristic fierceness, but as the therapy unfolds must gradually be encouraged and brought into view. One way I have found to "sneak" these in, as it were, is to invite the patient to share dreams. Many of them (and I have sometimes felt this in my own analysis) seem to have a curious distance on their dreams, as though they originated outside of their minds. So they will sometimes share warm, vulnerable, affectionate, moving dreams without being concerned or even very conscious of those dynamics. Such dreams can sometimes be processed in the moment or, as I have done, stored up in your memory for recall later at a more opportune moment when the alliance is stronger and the patient's capacity to experience warm emotions less heavily defended against. 

To do such things, Salzman says, you must help the patient "see how it will benefit him." They need to see, in other words, how becoming less angry and defiant, less controlling and more vulnerable, less cold and more warm, helps here and now. One way you can encourage such feelings to emerge more regularly (and here Salzman's advice shows up in other articles cited here) is to be more active and spontaneous in session as a clinician, changing parts of how sessions unfold to prevent them from becoming too ritualized and predictable, thereby reinforcing the obsessive's sense of control. You can also, he says, take some risks in sharing your own "doubts and uncertainties" as well as your own "weaknesses." Thus do not be afraid of "spontaneity, direct confrontation, and activity...to reduce distracting behavior."

From here we turn to Crayton Rowe, "Treatment of an Obsessive-Compulsive Personality Disorder: A Self Psychological Perspective," Psychoanalytic Social Work (2020). Rowe proposes, following Kohut, that "undifferentiated selfobjects" are the key to the development of various personality disorders, including OCPD. In particular detail, he highlights the threefold needs of such patients for:

        Mirroring:     To be recognized

        Idealizing:     To be aware of a new life, of new possibilities for living differently

        Twinship:      To experience companionship, in the therapist and beyond.

These (often insufficiently met developmental) needs are in competition with a developmental failure that left the patient often feeling "disappeared" early in life. This may lead some patients, he says, to come to therapy with notes, lists, and similar materials constantly written out in an effort to prove they exist. The use of such notes must gradually be discontinued while the therapy seeks to encourage a rediscovery of curiosity about the self and the patient's life. This goal will be constantly challenged by a patient "preoccupied with thoughts that are symbolic of disappearance." 

These dynamics are explored within the context of a case study about a patient in his 40s, an accountant, who had OCPD. Treatment was twice weekly for six years. Countertransference issues are briefly mentioned: these focus on a demand for instant results entirely engineered by the therapist, who thus feels enormous pressure to make the problems go away without any curious exploration of them. 

Two remaining useful articles include, first, Simone Cheli et al., "The Intertwined Path of Perfectionism and Self-Criticism in a Client with Obsessive-Compulsive Personality Disorder" in the Journal of Clinical Psychology (2020). This article and the one below are both Italian studies and both from a metacognitive perspective. 

I have been reading works in both mentalization and metacognitive therapy, much of which seems to have been pioneered here in Indiana at the IU School of Medicine down in Indianapolis. It has been useful for work with psychotic and borderline conditions, but also, in my experience, is useful in nearly every clinical case. Though some might cavil at this, and I would not stand by the comparison in every respect, it is, I think, quite justifiable to say that, broadly considered, metacognitive therapy is just the "American" word for what Fonagy in England has called "mentalization." 

These authors argue that perfectionism remains understudied in the literature. They describe a case treated for six months with metacognitive therapy. These authors usefully if briefly review some other treatments and the evidence for them, noting (as others I have read also do) that we do not have a lot of well-studied treatments for OCPD. The literature consists, based on my unsystematic survey, of a number of individual case studies, or very small comparison studies. From this highly limited evidence base, it seems that metacognitive, psychodynamic, and schema therapies show much promise, along with some CBT techniques. 

Similar countertransference issues show up here as noted above: the pressure the therapist feels to instantly produce a perfect solution to the patient's problems, solving them after a session or two. ("From a MIT point of view, what the therapist feels, perceives, and, generally speaking, experiences constitutes a core component of the intervention.") 

Much of the rest of this article consists of a single case-report of a young female patient (described as highly motivated and without comorbidities) whose progress was measured using a number of instruments, including the SCID-5-PD at the end of six months and again at a one-month follow-up. Two key parts of perfectionism were shown to be significantly reduced. In the end, she no longer met the criteria for an OCPD diagnosis, and her life was significantly improved across a number of measures after a six-month treatment that made regular use of guided imagery, rescripting, and behavioral techniques.

A 2011 article, Giancarlo Dimmagio et al., "Progressive Promoting Metacognition in a Case of Obsessive-Compulsive Personality Disorder Treated with Metacognitive Interpersonal Therapy," Psychology and Psychotherapy: Theory, Research, and Practice offers an awareness of the similarities between metacognitive and mentalizing stances, directly and frequently drawing on Fonagy's research. It begins by recognizing the failures of patients in this regard who suffer from personality disorders. Such failures include a lack of self-reflection, a lack of "understanding others' minds," and an inability to engage in "decentering," that is, an inability to remove the self from a dominating and obscuring place on center-stage so as to see more clearly what others might be thinking. 

Metacognitive techniques are tailored to the patient, and from the outset the authors caution that in highly intellectually defended and controlling obsessives, it is necessary to begin at a basic level of trying to help them recognize what emotions feel like in the body and to name them. Some are unaware of the meaning of even such seemingly simple gestures as facial blushing. 

From here they recommend that the therapist show the patient how many perceived problems are "internalized, i.e., a stable tendency to see others as critical and react by feeling ashamed and withdrawing" before trying to challenge this. Treatment is divided into two phases: "stage-setting and change-promoting." In the former, autobiographical incidents are invited as material to begin to reflect on, challenging old understandings and beginning to inculcate new ones based on the patient's developing capacity to think how others thought at the time. These authors are aware that at both phases of therapy ruptures to the alliance may occur, but their discussion and repair will prove especially salutary to OCPD patients, one of whom they spend much of the rest of the article focusing on. 

What worked with her is what will work, they recommend, with others: a patient process of promoting not just thinking differently about past patterns, but behavior change in the present, though change understood and promoted in a way that does not risk reactivating the perfectionistic tendencies that have hitherto been so problematic. In this the authors recommend that therapists will "not force them to use psychological knowledge they have no access to, but will gradually promote metacognitive growth." This is very similar to something Fonagy says: a non-mentalizing stance in the patient cannot be met with a mentalizing stance in the therapist. The latter must encourage the former to develop their own capacity to mentalize. 

This, they conclude, makes metacognitive and mentalization therapies as perhaps more time-consuming than other approaches. The treatment studied in this article ran for a year, which they take as a minimum to provoke new ways of mentalization and metacognition. 

Notes on Motivational Interviewing

Having here praised William R. Miller, whose book, co-authored with Theresa Moyers, was unexpectedly helpful, I realized I could now go back and read Miller's famous work on motivational interviewing. As so often seems to happen with me (a phenomenon first noted by Nina Coltart), current clinical work brings certain books back to mind and unconsciously nudges them up the priority list, on which reside, at any given moment, at least a dozen other works in various stages of being read, marked, and inwardly digested. So I found my copy of Motivational Interviewing and cracked it open again. 

Psychoanalytic snob that I have so often been, when I first heard that phrase years ago my eyes instinctively rolled so far back into my head they were able to watch old episodes of WKRP in Cincinnati. Herb Tarlek instantly came to mind--he who was always arrayed in a hideous jacket and had the oily demeanour of the salesman that he was. That is what I thought of "motivational interviewing": some smarmy technique devised by the more revolting apologists for "dollarland," Freud's acid nickname for America. 

But Adam Phillips taught me (this appears in many of his books, but perhaps most especially The Cure for Psychoanalysis) that ideological thinking is the antithesis of a psychoanalytic mind, and snobbery and defensiveness around it are both false to its promises and unnecessary to its survival (indeed, are fatal to its survival). 

My Canadian and Catholic instincts here further remind me that many differences are frequently exaggerated, and a careful work of "translation" will often reveal how similar things are. Though I have often thought the contemporary academy (especially in the humanities) is too enamoured of works of intellectual genealogy, they have their place, perhaps especially in the clinical sciences as we see just how much covert borrowing there is, especially by those (e.g., Aaron Beck, Marsha Linehan) who had analytic training but went to great pains to downplay or disown it in order to promote or tolerate the spread of myths of their own putative originality. 

Many concepts later "pioneered" (and trademarked and copyrighted) by others are demonstrably and indisputably analytic in origin. This is not noted smugly, but simply as a matter of honest intellectual history. Freud himself in several places notes how much he borrowed from others (Feuerbach, Schopenhauer), and I have myself noted his debts to monastic practices of late antiquity. There really is very little new underneath the sun. 

So if, in what follows--some selective, non-systematic notes on the second edition of Miller's Motivational Interviewing, bought years ago but left mostly unread--you find my taking particular pains to relate these to my analytic training, or to find psychoanalytic antecedents and analogues, you will understand why. (Others have done this with greater skill than I--Glen Gabbard for one, including in this article; see also Stanley Messer here; and perhaps most especially D. Westen's 1998 article--showing how often extremely similar techniques are to be found in differently labelled theories under different terms.) 

And the first note of significance comes at the start of the Acknowledgements page, where the authors note that "there is little that is truly original in motivational interviewing," referring to their debts to Carl Rogers in particular. 

It is an interesting exercise to return to this book after having read the more recent treatment of effective therapists. For much of that latter book is foreshadowed in Motivational Interviewing, as when they note already on p.6 that across different theories and types of treatment, common factors "frequently make a difference," and these factors are bound up with "certain characteristics of therapists." Therapists who consistently manifest empathy, avoid being high-handed, and do not infantilize their patients have better outcomes than those who view it as their mission to engage in "confrontation" and advice giving.  

I am also heartened that this book's second chapter is "Ambivalence: the Dilemma of Change." (Miller has a more recent book entirely on ambivalence.) Freud brought ambivalence to common awareness, though I sometimes fear it has largely disappeared from the clinical landscape, full as it often seems to be of much boosterish talk of techniques and tool boxes and work-sheets promising transformational change in 6 sessions or fewer (most of these barbaric self-promoters would write "less"). In any event, our authors note that ambivalence is universal and natural, and hectoring people who are ambivalent only serves to deepen the defenses and make change harder. 

Instead of that, you need to see what does motivate someone, for we are all motivated by something, and often several things. Discover what continues to motivate your patient even as they remain ambivalently attached to the thing they are trying to give up or alter. And while you're about it, do not--these authors strongly suggest--be a purist about this but a pragmatist: how much of the thing are they willing to give up? Go with that rather than pushing for total abstinence or complete change. (I am heartened to read this, because it seems to accord with something I've been calling "partial victories" with my patients who are inclined to totalized thinking.)

Developing Discrepancy: Our authors note that discrepancy is a good thing, and sometimes may actively need to be cultivated. Help the patient come to see the gap between where they claim to want to be, and where they are now. This then leads into what is called "change talk," which manifests itself in four ways:

1) Recognizing disadvantages of the status quo
2) Recognizing advantages of change
3) Hope for change
4) Intention to change.

This leads the authors to recognize the entire process of motivational interviewing is one led by the patient, and not an imposition on them--or a panacea either. It takes time and patience, and consists in the clinician giving space to talk through the ambivalence and bring patients to decide for themselves what they want to do. (That, of course, sounds very much like the kind of free and freeing environment that most of us try to create in psychodynamic treatment, which resists imposing our ideas upon, and thus infantilizing, the patient.) As they say a little later, the key here is "exploration more than exhortation" (p.34), and the exploration and decision-making sees the patient very much in the lead. 

All of this is premised upon something I have heard attributed to Rogers, and occasionally to Jung: "paradoxically, this kind of acceptance of people as they are seems to free them to change" (p.37). (So many people seem to come into my consulting room full of zeal for change which is motivated entirely by masses of self-loathing. They therefore find the idea of working from a place of self-acceptance utterly baffling.) Once people feel accepted as they are, and not forced prematurely into change by the therapist, then it is your next job with them to bring forward what they are already motivated by, and use that as a spring-board for action. Discovering a sense of self-motivation and self-efficacy will be key to everything that follows. 

At the outset of treatment the authors warn clinicians off the use of questions--closed are worse than open-ended, but both invite superficial and often defensive answers. (Other traps to avoid: labelling, instructing, playing the expert, taking sides, blaming, and going to fast--what a friend of mine calls a failure of pacing). 

At this stage, minimize the use of questions. Reflective listening and the use of statements are better. (In saying this, our authors remind me of Brodsky and Lichtenstein's useful article, "Don't Ask Questions.") Affirmation and elaboration are also useful techniques, particularly when the latter involves questions of values. Ambivalence can often be worked through if the desired change is in keeping with the patient's values.

Chapter 8: Responding to Resistance. I know that word has increasingly been avoided by some, but the authors note that no good alternatives have yet been found so they keep using it. Every time I hear it, I think of an example my first supervisor gave me. His besetting sin, he said, was getting too far out in front of the patient by moving too fast. He would look around and see how far behind him the patient was. Instead of chiding the patient for being a slow-poke, he realized he had gone too far too fast and had, he said, "humbly to walk back where they were and come along side them again." I think this example nicely illustrates Miller and Rolnick's ideas of resistance. Do not, they say, see this as something to blame the patient for: it is the fault of the clinician, just as my old supervisor recognized. 

So what do you do--how ought you to respond? You meet resistance with non-resistance. Shifting the focus (what I've heard called "lowering the anxiety temperature in the room" by changing the subject) is useful, along with exaggerated (but calm and sincere) reflection back are useful here. 

Ch.9: Enhancing Confidence: Not surprisingly, the authors recognize two traps at the outset to be avoided: one is to fall into the patient's totalized gloom-mongering and not have hope that things can change; the other is to be a mindless booster, offering cheap, soothing encouragement that is equally totalized and simplistic. You need to have and hold out hope for the patient, but it needs to be tempered and realistic hope. It also needs to be discerning enough that you know when to hope for change and when to gently bring the patient (as the Serenity Prayer reminds us) towards some reality-testing so they can see what is unlikely to change. 

Having found realistic hope, the process next moves on to actual planning of the change--lists of ideas, desires, hopes, obstacles, and strengths. At every stage this is led by the patient and your job as clinician is not to be the expert dispensing advice or telling them what and how to do something. This is repeated, along with many of the observations briefly noted above, throughout the first half of the book, which is easily twice as long as it needs to be. Overall, the summary of MI's "four general principles" occurs early in the book (p.36), thus:

1) Express empathy
2) Develop discrepancy
3) Roll with resistance
4) Support self-efficacy.

Part IV: Applications of Motivational Interviewing features nearly a dozen chapters by invited contributors focusing on specialized populations (groups, couples, adolescents, criminals et al) or issues. There are also chapters reviewing the evidence on the efficacy of MI and its application in medical and other contexts.