Many of the problems that arise in treating OCPD stem from the character traits originally described by Freud: obstinacy, excessive orderliness, and parsimony. Because these watchful patients are highly self-protective and expect criticism, they do not readily accept therapeutic interventions, especially when they provoke anxiety. Even minor remarks by the psychotherapist will be subjected to close scrutiny, correction, revision, and dilution before they will be accepted. Interpretations may be so cut up, sifted through, and amended that they are rendered emotionally banal. “That is not quite right,” such patients will expectably reply to much of what the psychotherapist says. When these patients’ anxiety increases as they sense they are losing control of the session, rejection of interpretations ensues, and a wall of passive, subtly hostile resistance arises. When anxiety rises too high, the therapist may come under an obstinate, devaluative attack.
Patients with OCPD tend to drain their own remarks of emotional meaning. They often speak mechanically, in a monotone. They concentrate on myriad small details in order to keep control of the therapeutic exchange. The sessions tend to quickly become ritualized, with much repetition of affectively neutral material. Although these patients may wish for some degree of emotional closeness and engagement with the therapist, they are resistant to anything giving rise to discomfort, even of minor degrees. They do not want too much closeness and engagement; it has been said that they wrap themselves and the treatment enterprise with layers of emotional asbestos. The same memories are likely to be iterated in session after session, with the emotionally insulating addition of detail, correction, expansion, and revision, so that the therapist is left with the sense of trying to make his or her way through a thicket. Parsimonious in producing therapeutically valuable, emotionally colored material, these patients want to order and “clean up” what they say to such an extent that their communications are reduced to mouthfuls of thick, gray words.
When evidence of unconscious processes (such as slips of the tongue, lateness, or withholding the fee) is pointed out by the therapist, the patient is likely to dismiss such observations as insignificant. If superficially acknowledged as possibly meaningful, they are accepted as such only after being effectively neutralized by massive intellectualization that leads to emotional neutralization. Superficially compliant in accepting clarification and interpretations, OCPD patients are prone to remain secretly resistant to accepting clarifications and integrating them. Sometimes they so twist and distort what the therapist says that he or she appears ridiculous.
To avoid the anxiety that discussion of parapraxias arouses, such patients watch what they say very carefully and try to avoid anything that is truly spontaneous. If they report dreams, the dreams are likely to be obscure and baroque in detail. Sometimes the therapy session will be flooded with so much thick and detailed dream material that the therapist is left struggling to find anything that makes emotional sense.
The patient ritualizes the therapeutic encounter and is likely to fence the therapist in by never coming late, paying the fee immediately, and becoming superficially very “good” in the service of boxing in the treatment. OCPD patients have great difficulty in learning that occasional lateness, the odd spontaneous remark that seems nonsensical, or a short delay in paying the fee is a welcome detail that can deepen understanding.
Therapists must patiently point out the various aspects of character defense as they manifest themselves, especially the ritualization of the relationship in the service of controlling it and binding anxiety. Patients must be shown how their need to get each statement exactly right, to neutralize, to control, and to withhold represents an unconscious effort to overpower the therapist and to make him or her ineffectual. They must learn to increase their tolerance for anxiety within the context of reducing their fear of the therapist, who in time may be experienced more and more as an ally and less as an adversary.
The recognition that increased anxiety tolerance is desirable to enrich the treatment comes slowly to the patient as a therapeutic alliance builds. “Opening up” psychologically, surrendering the need to control, must come to be seen as desirable and not something to be feared and automatically avoided.
Psychodynamic psychotherapy for OCPD organizes itself around three basic considerations: 1) attention to the typical defenses, 2) softening and modification of morbid superego attitudes, and, ultimately, 3) identification and working through of underlying unconscious conflicts that generate the symptoms of which the patient complains.
Ego defenses The typical defenses of patients with OCPD are intellectualization, isolation of affect, undoing, reaction formation, displacement, and regression. As these devices come into play, they must be supportively pointed out and questioned so that patients have the opportunity to learn how they try to control anxiety at all costs and pay the heavy price of personal constriction. Defense analysis can be carried out successfully only if patients understand that there is something in it for them. They need to understand that if they must endure increased anxiety in treatment, there is a trade-off, and they have something to gain. They have to grasp not only that expansion of their self-awareness will be the reward but also that they can hope for a freer, less constricted life adaptation. Education is a part of the treatment; patients must be shown that their controlling, rigid style cripples personal relationships and hurts work performance.
Patients with OCPD are particularly inclined to all-or-nothing thinking and imagine that the direct expression of affect invites extreme overreaction in others (including the therapist). Furthermore, they tend to believe that to think something, or to feel an impulse to act in some way, is little different from acting on it. They are prone to “magical thinking” in this sense. An erotic thought or aggressive impulse is likely to be checked immediately as the possible occasion of punishment from without. It will certainly be punished from within: much that might be felt or thought is kept out of mind because of the patient’s conscientious strictures. Moralizing in this way is leveled against not only thoughts and feelings that rise to consciousness but also fantasies and impulses, which are kept out of mind by defensive operations.
For this reason, patients react fearfully to affectively colored material, hostile or erotic, that arises in the transference and automatically tend to wrap it up in intellectualization, isolation, or another defense. For example, a patient may protest that he or she feels no hostility toward the anxiety-provoking therapist, even when something obviously hostile occurs during the session. The patient will want to give a neutral explanation for it or possibly claim that the therapist has not quite understood its meaning correctly.
As the analytic clarification of the controlling defenses proceeds, anxiety will rise, and the patient’s harsh superego attitudes will be projected in the transference. Increased affect tolerance and expression will bring to light much of a hostile, controlling, and sadistic nature. This development, coupled with superego projection, makes the themes of punishing and counterpunishing (retaliation) emerge as leading concerns in the therapeutic endeavor.
Superego analysis As the patient becomes increasingly aware of his or her need to control the treatment (to torment, devaluate, and dirty the therapist and his or her efforts) and to resist the free flow of associations, the therapist will be experienced, at least in part, as a watchful, hostile person boiling with retaliatory counterimpulses of a comparable kind. With help, most OCPD patients can distance themselves from this negative, frightening view of the therapist and come to appreciate that this attitude (the negative transference) in itself forms a major resistance to the progress of the work.
The patient’s “observing ego” must be called into play as the transference is clarified and later interpreted. Reality testing of the true nature of the therapist’s attitude, with close attention to the minor as well as the major reality distortions that take place in support of the false-negative transference, enables the patient to understand the extent of his or her guilt and to grasp the unconscious need to be punished for what he or she experiences as the “badness” of the impulse life. More and more of it can then come forward into consciousness.
As the patient recognizes that hostile or erotic thoughts and impulses are not the same as acts and sees that the utterance of such material does not come under moral condemnation, anxiety can be reduced. In experiencing the therapist’s kindly, interested acceptance of the entire range of the patient’s primitive affect and fantasy, critical superego attitudes soften. Through identification, the patient has the opportunity to substitute a benevolent, analytic attitude for harsh, unrealistic self-judgment. Depression is likely to lift as a consequence, and masochistic, suffering-inviting behavior inside and outside the consulting room can be reduced. The result of this much-to-be-desired development will be a relaxation of defenses against hitherto warded-off fantasies and feelings, the enrichment of the therapeutic exchange, and the strengthening of the therapeutic alliance.
Self-expectations are modified in the course of this work. The patient no longer expects that the play of impulse and fantasy through his or her consciousness should be organized according to what one OCPD patient called “the principles of a Sunday school.” For the first time, the patient begins to take a nonjudgmental attitude to the flow of feelings and thoughts through the mind and experiences a reduction in the old constriction. The patient recognizes that he or she can pick and choose among the various possibilities for action when it is no longer felt that he or she dare not think and feel freely because everything that occurs must be assigned a moral value. The patient learns about, and has a chance to modify, the depth and reach of his or her superego (ego-ideal) demands for an impossibly clean, polite, and orderly mental life. Omnipotent expectations for perfection of performance and achievement are also modified in the course of this work. Relationships are likely to improve, greater productivity at work follows, and the door is opened to the achievement of realistic goals when the patient no longer quails and inhibits himself or herself before the old self-demands for impossible perfection.
Countertransference problems More mature ego defenses are highly adaptive in normal life as long as they remain flexible and are not overworked. Isolation and intellectualization are essential for psychotherapists; they must, from time to time, distance themselves from their own affective responses to patients if they are to carry out their work properly. Many psychotherapists are likely to rely heavily on the same defensive repertory typical of patients with OCPD. Furthermore, they are prone to overvalue order and correctness. It is essential that those attempting to treat these patients be aware of their own defensive organization and of their own superego attitudes, which tend to be strict. Otherwise, it becomes extremely difficult to clarify and soften the OCPD patient’s controlling character style.
The temptation can be great to join the patient in intellectualizing and isolating important fantasies and feelings, especially when their hostile or erotic nature bothers the therapist. Collusion in the patient’s defenses is a common problem, and it always impoverishes the treatment. The narcissistically vulnerable therapist may be drawn into angry struggles for control and is likely to respond in a retaliatory way when the patient attacks or devalues the treatment offered.
Buchanan (1977) described some of the countertransference difficulties in treating these patients. He mentioned boredom, avoidant daydreaming, impatience, a tendency to argue, devaluating the patient, and a depressive sense of therapeutic inadequacy. Unconscious sadism in the therapist can give rise to ill-timed interpretations and a failure to appreciate early, tentative signs of a patient’s positive feelings. Certainly, sadism and hostility in the therapist that go unrecognized will get in the way of helping the patient with morbid self-critical attitudes, a task that is essential to therapeutic success. For this reason, personal psychoanalysis for those clinicians offering this treatment is highly desirable as a means to develop the necessary patient, flexible, and benevolent therapeutic style.
Revision date: July 9, 2011
Last revised: by Jorge P. Ribeiro, MD