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 before1. Cognitive‐behavioral therapy and selective serotonin reuptake inhibitors have been shown to be equally efficacious in OCD2, but with rates between 50% and 60% for response and 25% or below for remission3. 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 approach4. Building on STPP for anxiety disorders, a model of STPP for OCD was developed which is based on Luborsky's supportive‐expressive therapy5. The treatment consists of twelve modules which include both the characteristic elements of supportive‐expressive 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)5. 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 therapy5. An expressive intervention addressing the CCRT for Shakespeare's Lady Macbeth's compulsive washing may be6: “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 evidence7, 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. Luborsky5 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 STPP8. They encompass, for example:
Differentiating between thinking and acting (e.g., “If you have sexual wishes towards these young women, this does not imply that you have actually committed adultery”).
Mitigating the rigid and hyper‐strict super‐ego (conscience) typically characteristic of OCD patients8 (e.g., by not condemning the patient for his or her sexual or aggressive impulses; by encouraging the patient to resist against the super-ego's strict demands7). The super‐ego can be regarded a part of the RO component of the CCRT.
Freud's original recommendation to induce OCD patients to face the feared situation and to use the aroused experiences to work on the underlying conflict9, in other words on the CCRT. The therapist may do so by saying, for example: “When you have these sexual (aggressive, etc.) thoughts towards young women, you get afraid that something terrible will happen to your wife. By carrying out your rituals you are trying to prevent this. We need to work on your expectation which entails not performing your rituals and tolerating the fear – and ultimately see what happens”.
Further modules include: a) informing the patient about the disorder and the treatment, b) addressing ambivalence and setting treatment goals, c) establishing an encouraging inner dialogue, d) addressing (potential) non‐response and resistance, and e) focusing on termination and relapse prevention.
We are planning to test the presented approach in a randomized controlled trial.
Falk Leichsenring, Christiane Steinert Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
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