P s y c h o t h e r a p y of t h e O b s e s s i o n a l * L E O N

S A L Z M A N ,

M.D.f

| Bethesda,

Md.

Obsessional defenses require a confronting, active therapist in order to break through the intellectualized, ritualized, and highly distracting productions of the patients. The tendency to obfuscate through details and rigid adherence to the instructions demands a loose, flexible, and direct interaction from a therapist who is not too obsessional and willing to forego his own perfectionistic expectations from therapy. ROOTS

OF

OBSESSION

I n p s y c h o t h e r a p y a n i n d i v i d u a l ' s b e h a v i o r is e x a m i n e d i n o r d e r t o i l l u m i n a t e those c h a r a c t e r o l o g i c a l t r a i t s w h i c h i m p a i r his i n t e r p e r s o n a l relationships a n d i n t e r f e r e w i t h p r o d u c t i v e a n d satisfying activity. Such d i s t o r t e d b e h a v i o r is l a b e l e d n e u r o t i c o r m a l a d a p t i v e a n d i t is t h e beh a v i o r a l scientist's task t o u n d e r s t a n d its s o u r c e i n o r d e r t o c h a n g e i t . P s y c h o t h e r a p y m u s t t h e r e f o r e be based o n a n u m b e r o f p r e m i s e s t h a t a r e m u t u a l l y a c c e p t e d by p a t i e n t a n d t h e r a p i s t , n a m e l y : 1. B e h a v i o r is d e r i v e d f r o m m e n t a l processes w h i c h can be t r a c e d to m o t i v a t i o n a l o r a d a p t a t i o n a l sources. S o m e o f these sources, h o w e v e r , a r e o u t s i d e o f one's i m m e d i a t e awareness; 2. D i s t o r t e d , m a l a d a p t i v e b e h a v i o r is caused b y a n x i e t y w h i c h transforms goal-directed activity i n t o actions—called defenses— designed to relieve o r eliminate anxiety. 3. W h e n a n u n d e r s t a n d i n g o f these s o u r c e s — c a l l e d i n s i g h t — i s a t t a i n e d , a c t i v i t y can be d i r e c t e d t o w a r d a l t e r i n g o r a b a n d o n i n g t h e beh a v i o r w i t h n o t a b l e changes i n t h e c h a r a c t e r o l o g i c a l s t r u c t u r e o f t h e i n dividual. W h a t e v e r t h e r a p e u t i c system is a p p l i e d t h e basic p r e m i s e s u n d e r l y i n g its t h e o r i e s w o u l d essentially a g r e e w i t h t h e t h r e e I have d e t a i l e d . T h e r e f o r e the type o f therapy, the techniques, a n d explanatory i n t e r p r e t a t i o n s as a d v o c a t e d b y t h e w i d e r a n g e o f t h e r a p e u t i c a p p r o a c h e s depend on the particular theoretical model o f h u m a n development a n d the variety o f d i s t o r t i n g influences that p r o d u c e defensive alterations i n * P r e s e n t e d at t h e F o u r t e e n t h N a t i o n a l S c i e n t i f i c M e e t i n g o f T h e A s s o c i a t i o n f o r the A d v a n c e m e n t o f P s y c h o t h e r a p y , A t l a n t a , G e o r g i a , M a y 6, 1 9 7 8 . tClinical Professor of Psychiatry, School of Medicine, Georgetown University. address: 6 6 2 5 B r a e b u r n P a r k w a y , B e t h e s d a , M d . 2 0 0 3 4 . A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol.

32

X X X I I I ,

No.

1, J a n u a r y

1979.

Mailing

33

P S Y C H O T H E R A P Y OF T H E O B S E S S I O N A L

behavior.

A l l r e q u i r e v e r b a l i n t e r a c t i o n a n d s o m e i n t e l l e c t u a l capacity

b u t f o c u s o n t h e e m o t i o n a l e l e m e n t s i n b e h a v i o r as w e l l as o n t h e r e l a tionship between therapist a n d patient.

W h e t h e r i m p l i e d or explicit, all

i n v o l v e issues o f t r a n s f e r e n c e , c o u n t e r t r a n s f e r e n c e , i n t e r p r e t a t i o n , a n d exhortation t o w a r d change. A r a t i o n a l p s y c h o t h e r a p y m u s t also i n c l u d e a n u n d e r s t a n d i n g o f t h e p a t i e n t ' s pervasive t e n d e n c y

t o resist c h a n g e i n o r d e r t o p r e s e r v e t h e

r e l a t i v e s t a b i l i t y o f t h e d e f e n s i v e s t r u c t u r e w h i c h r e d u c e s a n x i e t y , as w e l l as a k n o w l e d g e o f t h e r a p e u t i c t e c h n i q u e s w h i c h a i d t h e process o f i l l u m i nation, insight, a n d behavior alterations.

B o t h the knowledge o f the

n e u r o t i c s t r u c t u r e a n d t h e awareness o f t h e o v e r p o w e r i n g n e e d o f t h e obsessive i n d i v i d u a l t o m a i n t a i n i t i n t a c t is c r u c i a l i n t h e t r e a t m e n t o f t h e obsessional states.

E v e r y tactic, i n t e r p r e t a t i o n , a n d c l i n i c a l i n t e r v e n t i o n

m u s t t a k e i n t o a c c o u n t t h e e x t r a o r d i n a r y c a p a c i t y o f t h e obsessional t o evade, distract, obfuscate, a n d displace i n o r d e r to avoid c o n f r o n t a t i o n and change.

T a c t i c s w h i c h r e i n f o r c e those defenses m u s t be a v o i d e d b y

t h e t h e r a p i s t w h o , m o r e o f t e n t h a n n o t , has m a n y obsessional c h a r a c teristics h i m s e l f . Obsessional defenses I n t h e p s y c h o t h e r a p y o f t h e obsessional p a t i e n t t h i s issue is especially r e l e v a n t since t h e essence o f t h e obsessional defenses is a n t i t h e t i c a l t o t h e essential r e q u i r e m e n t s o f t h e t h e r a p e u t i c process a n d m i l i t a t e a g a i n s t t h e e x p o s u r e o f t h e p a t i e n t ' s deficits a n d deficiencies.

T h e obsessional

o f t e n views t h e r a p y as a c h a l l e n g e t o his o m n i s c i e n c e a n d o m n i p o t e n c e a n d steadfastly rejects a n y n e w awareness w h i c h w o u l d r e q u i r e h i m t o a d m i t any shortcomings to h i m s e l f a n d others.

H e feels he m u s t k n o w i t

a l l , a n d t h e r e f o r e f r e q u e n t l y rejects a n o b s e r v a t i o n as i n v a l i d o n l y t o p r e s e n t i t l a t e r as his o w n d i s c o v e r y .

T h e therapist's early tolerance o f

t h i s tactic m u s t give w a y t o a l a t e r c o n f r o n t a t i o n a f t e r a p o s i t i v e r e l a t i o n s h i p has b e e n e s t a b l i s h e d .

T h i s m a y be l o n g i n d e v e l o p i n g , since p r o -

c r a s t i n a t i o n , d o u b t i n g , a n d a v o i d a n c e o f c o m m i t m e n t a r e essential elements

i n t h e obsessional d e f e n s i v e process.

T h i s process n o t

only

p r e v e n t s i n v o l v e m e n t a n d t r u s t , b u t p e r m i t s t h e obsessional t o h a v e a n i l l u s o r y f e e l i n g o f b e i n g safe a n d i n c o n t r o l .

N e e d i n g t o be f r e e o f u n -

c e r t a i n t y , t h e obsessional fights a n y a t t e m p t at c h a n g e .

T h u s the strug-

gle t o achieve e n o u g h t r u s t f o r e v e n a m i n i m a l c o m m i t m e n t m a y o c c u p y a large p a r t o f the therapeutic p r o g r a m .

T h e obsessional's c o o p e r a t i o n

m a y n e v e r b y t r u l y f o r t h c o m i n g r e g a r d l e s s o f his ostensibly c o o p e r a t i v e behavior.

T h e obsessional r e m a i n s a f f e c t i v e l y t o t a l l y u n e n g a g e d u n t i l

w e l l i n t o t h e r a p y a n d s p e n d s endless t i m e i n d i s t r a c t i n g a v o i d a n c e s a n d c o n t e n t i o u s d i s a g r e e m e n t s , t h o u g h he is i n t e l l e c t u a l l y a n d c o g n i t i v e l y ca-

34

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

p a b l e o f c l e a r e r analysis.

T h i s is i n c o n t r a s t t o t h e t r e a t m e n t o f t h e

hysteric, whose v o l u b i l i t y , labile e m o t i o n a l i t y , a n d histrionic readiness facilitate the b e g i n n i n g o f therapeutic w o r k .

T h e rapidity and decep-

t i v e q u a l i t y o f s u c h a facile c o m m i t m e n t a r e t h e m s e l v e s subject t o l a t e r examination and interpretation.

2

F r o m t h e o u t s e t t h e t h e r a p y o f t h e obsessional is h a m p e r e d b y t h e v e r y essence o f his n e u r o t i c s t r u c t u r e .

The

3

p e r f e c t i o n , w h i c h c o l o r s his c o m m u n i c a t i o n ,

obsessional's n e e d

for

poses a g r a v e p r o b l e m i n

the t r e a t m e n t situation, i n w h i c h verbal p r o d u c t i o n s are an i n t e g r a l p a r t o f t h e process.

Since t h e obsessional w a n t s t o be precise a n d clear h e i n -

t r o d u c e s m o r e a n d m o r e q u a l i f i c a t i o n s i n his p r e s e n t a t i o n t o be c e r t a i n t h e m a t t e r is p r e s e n t e d i n its f u l l e s t f o r m .

T h i s adds confusion to the

process a n d , i n s t e a d o f c l a r i f y i n g , t e n d s o n l y t o o b f u s c a t e t h e issues. T h e t h e r a p i s t m u s t u n d e r s t a n d t h a t t h e p a t i e n t is n o t d e l i b e r a t e l y t r y i n g t o c o n f u s e t h e t h e r a p i s t , b u t t h a t he is t r y i n g t o be m o r e precise a n d a v o i d m a k i n g e r r o r s ; h e is not t r y i n g t o sabotage t h e t r e a t m e n t .

The

t e n d e n c y t o m o v e o f f o n t a n g e n t s keeps t h e p a t i e n t f r o m g e t t i n g t o t h e p o i n t o f his c o m m u n i c a t i o n a n d m a k e s i t d i f f i c u l t t o p i n d o w n a n issue a n d tease o u t t h e r e l e v a n t i t e m s . o f t e n aggravate the p r o b l e m .

T h e f r e e - a s s o c i a t i o n process m i g h t

A r i g i d r e q u i r e m e n t t o f r e e l y associate o r

t o say e v e r y t h i n g t h a t c o m e s t o m i n d c o u l d b u r y t h e t h e r a p y u n d e r e n d less t r i v i a . Therapist's Task T h e t h e r a p i s t m u s t be a w a r e o f t h e obsessional's use o f i r r e l e v a n c i e s b y w h i c h he avoids c o m i n g t o g r i p s w i t h t h e basic p r o b l e m a n d h e m u s t be r e a d y t o i n t e r r u p t t h e r e c i t a t i o n o f details a n d f o c u s o n t h e r e l e v a n t , w h e n e v e r i t is a p p a r e n t t o h i m . t h a t is, t o d e t e r m i n e

T h i s i n t r o d u c e s t h e m o s t d i f f i c u l t issue,

w h a t is r e l e v a n t a n d w h a t is i r r e l e v a n t i n t h e

c l a r i f i c a t i o n o f a n obsessional p r o b l e m .

T h e n o t i o n t h a t " e v e r y t h i n g is

r e l e v a n t " i n a d e t e r m i n i s t i c v i e w o f t h e m i n d o f t e n leads t o i n t e r m i n a b l e inquiries which reinforce certain communications illuminating

details.

t h e obsessional p a t t e r n , w h i l e

discouraging

may i m p e r i l the u n f o l d i n g o f significant a n d Clinical

judgment

based

on

the

growing

k n o w l e d g e o f w h a t experiences a n d patterns o f behavior are related to t h e d e v e l o p m e n t a n d m a i n t e n a n c e o f a n obsessional n e u r o s i s p e r m i t s us t o m a k e s u c h decisions w i t h r e a s o n a b l e e x p e c t a t i o n o f success. A c t i v i t y o n t h e p a r t o f t h e t h e r a p i s t is essential f r o m t h e b e g i n n i n g o f therapy to the end.

Even a meager u n d e r s t a n d i n g o f the dynamics

of

t h e obsessional state r e q u i r e s t h a t t h e t h e r a p i s t c u r t a i l t e c h n i q u e s w h i c h defeat c o m m u n i c a t i o n — a l t h o u g h

t h e t h e r a p i s t ' s activities m u s t n e v e r be

so i n t e n s e as t o o v e r w h e l m t h e p a t i e n t o r m a k e h i m f e e l t h a t t h e t h e r a p y

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P S Y C H O T H E R A P Y OF T H E O B S E S S I O N A L

is b e i n g r u n b y t h e t h e r a p i s t e x c l u s i v e l y .

I t means the therapist must

m a i n t a i n t h e p a t i e n t ' s a n x i e t y at a level t h a t w i l l f a c i l i t a t e l e a r n i n g a n d u l t i m a t e l y resolve t h e obsessional p a t t e r n s . O n e o f t h e i n s o l u b l e c o m p l i c a t i o n s o f t h e r a p y is t h e p a t i e n t ' s p r o d u c t i o n s a n d associations, w h i c h are o p e n t o a v a r i e t y o f i n t e r p r e t a t i o n s . O n e m u s t d e c i d e a m o n g t h e a b u n d a n c e o f issues w h i c h s h o u l d be d e a l t w i t h at o n c e a n d w h i c h can be l e f t f o r a l a t e r d a t e .

W h a t is selected d e -

p e n d s o n m a n y f a c t o r s s u c h as t h e t h e r a p i s t ' s t h e o r e t i c a l o r i e n t a t i o n , o r the n a t u r e o f the m a i n theme c u r r e n t l y b e i n g e x p l o r e d , o r the possibility of

a

potentially e n l i g h t e n i n g recollection

being

contradictions or substantiation o f earlier material.

introduced,

or

the

O f a l l t h e possible

d e t e r m i n a n t s I w o u l d suggest t h a t t h e m o s t c o g e n t issue is t h e t h e r a p i s t ' s t r e a t m e n t p l a n a n d t h e d i r e c t i o n he is c u r r e n t l y p u r s u i n g . T h e goals o f t r e a t m e n t r e q u i r e : 1. D i s c o v e r y a n d e l u c i d a t i o n o f t h e basis f o r excessive f e e l i n g s o f i n s e c u r i t y w h i c h r e q u i r e absolutes t o g u a r a n t e e one's e x i s t e n c e b e f o r e a n y a c t i o n is a t t e m p t e d .

E x a m i n a t i o n o f each s y m p t o m

a n d obsessional

tactic t o s h o w h o w i t ties i n t o t h e o v e r r i d i n g n e e d t o c o n t r o l .

Explora-

t i o n o f rituals, phobias, personality traits i n terms o f t h e i r role i n g i v i n g the patient the illusory feeling o f absolute c o n t r o l . 2. R e p e a t e d i n t e r p r e t a t i o n a n d e n c o u r a g e m e n t t o a c t i o n as

proof

t h a t s u c h g u a r a n t e e s are n o t o n l y u n n e c e s s a r y b u t i n t e r f e r e w i t h l i v i n g . T h i s involves m o t i v a t i n g the i n d i v i d u a l to a t t e m p t novel a n d u n f a m i l i a r p a t t e r n s o f b e h a v i o r by a n active assistance i n s t i m u l a t i n g n e w tures.

adven-

I t can h e l p o v e r c o m e c o n d i t i o n e d avoidance reactions to u n e x -

p l o r e d areas o f f u n c t i o n i n g o r f a c i l i t a t e c o u n t e r p h o b i c a c t i v i t y . 3. T h e

recognition

that the foregoing

is possible o n l y w h e n

p a t i e n t c a n accept s o m e a n x i e t y as p a r t o f his l i v i n g .

He must

the ac-

k n o w l e d g e t h e u n i v e r s a l i t y o f a n x i e t y as a p a r t i c i p a n t i n a l l h u m a n endeavors.

T h i s m e a n s a b a n d o n i n g a t t e m p t s at p e r f e c t i o n a n d accept-

i n g l i m i t e d goals u t i l i z i n g t h e m o s t c r e a t i v e r e s o u r c e s t h e i n d i v i d u a l has. H e m u s t l e a r n t o accept his h u m a n l i m i t a t i o n s . 4. Use o f a n t i a n x i e t y d r u g s t o c o n t r o l excessive a n x i e t y t h a t m a y acc o m p a n y t h e p a t i e n t ' s a t t e m p t t o b r i n g a b o u t c h a n g e s i n his l i f e .

The

t h e r a p i s t m u s t m a i n t a i n t h e a n x i e t y at a l e v e l w h i c h w i l l f a c i l i t a t e l e a r n ing rather than impede it. 5. F o c u s i n g o n f e e l i n g s r a t h e r t h a n c o g n i t i v e e x c h a n g e s f a c i l i t a t e d by a c o n f r o n t i n g h e r e - a n d - n o w a p p r o a c h to the role o f the patient's defenses.

I n e f f e c t t h e p a t i e n t m u s t a l l o w h i m s e l f t o e x p e r i e n c e a n d ac-

c e p t f a i l u r e , s o m e loss o f false p r i d e a n d p r e s t i g e a n d possible h u m i l i a t i o n b e f o r e he w i l l r e l i n q u i s h his e x t e n s i v e d e f e n s i v e system d e s i g n e d t o prevent such an eventuality.

36

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

Recent Events I t t h e r e f o r e f o l l o w s t h a t m u c h o f t h e t h e r a p e u t i c process c o m e s f r o m t h e e x a m i n a t i o n o f events t h a t c a n be e x p l o r e d i n t h e i m m e d i a c y o f t h e t h e r a p e u t i c h o u r s , especially i n t h e t r a n s f e r e n c e r e l a t i o n s h i p .

While

t h i s is t r u e i n a n y p s y c h o t h e r a p e u t i c s i t u a t i o n w h a t e v e r t h e d i s o r d e r o r p e r s o n a l i t y style, i t is c r u c i a l i n t h e t r e a t m e n t o f t h e obsessional, w h o s e r e c o l l e c t i o n s are p e r v a d e d w i t h d o u b t s t h a t l i m i t c o n v i c t i o n a b o u t t h e i n terpretations that grow out o f earlier reconstructions.

The

endless

b i c k e r i n g a n d u n c e r t a i n t y a b o u t past events m a k e i t i m p e r a t i v e t h a t t h e p a t i e n t see

his d i s t o r t i o n s o r o t h e r d e f e n s i v e a c t i v i t y u n d e r c i r c u m -

stances w h e r e d o u b t s c a n n o t be i n t r o d u c e d o r u s e d t o d e f e a t i n s i g h t . T h i s means

t h a t t h e m o s t e f f e c t i v e t e c h n i q u e is t h e e x a m i n a t i o n o f

r e c e n t events, t h e h e r e a n d n o w , w h i c h allows f o r t h e least d i s t o r t i o n s . E v e n u n d e r these c i r c u m s t a n c e s t h e r e a r e m a n y c o m p l i c a t i o n s . difficult to avoid getting involved i n a

flypaper-relationship

I t is

or a tug-of-

w a r w i t h t h e p a t i e n t , w h o reacts t o w h a t h e e x p e r i e n c e s as c o n t r o l a n d a t tempts to p u t d o w n the therapist a n d m i n i m i z e the value o f the exploration. T h e analysis o f t h e c u r r e n t s i t u a t i o n is m o s t s u i t e d t o d e v e l o p i n g i n s i g h t i n t o t h e p a t i e n t ' s f u n c t i o n i n g since i t is t h e c u r r e n t s i t u a t i o n t h a t has t h e greatest c l a r i t y a n d c o n v i c t i o n a n d is also least o p e n t o evasion and doubting.

I n a d d i t i o n , t h e n e e d t o e x p l o r e t h e e m o t i o n s is a i d e d b y

t h i s tactic since i t is m o r e d i f f i c u l t t o pass o f f t h e h o s t i l e a n d u n f r i e n d l y b e h a v i o r o f t h e p r e s e n t a n d i m m e d i a t e past t h a n o f t h e d i s t a n t past. T h e p a t i e n t c a n r e a d i l y discuss t h e f r u s t r a t i o n s , d i s a p p o i n t m e n t s , a n d d e s p a i r s o f p r e v i o u s years.

T h o s e are b e h i n d h i m a n d are o p e n

explanations and justifications o f many kinds.

to

T h e present hostilities

a n d f r u s t r a t i o n s , especially as t h e y i n v o l v e o n g o i n g r e l a t i o n s h i p s , a r e much

more

difficult

to

acknowledge.

They

represent failures or

deficiencies a n d e x p o s e t o o m u c h o f t h e p a t i e n t ' s f e e l i n g .

I n contrast,

past f e e l i n g s c a n be d e s c r i b e d a n d e x p e r i e n c e d c a l m l y a n d i n t e l l e c t u a l l y , so t h a t t h e v a l u e o f t h e i r assessment i n t h e t h e r a p e u t i c process is s h a r p l y reduced.

S h a r i n g his f e e l i n g s o f d i s t r u s t , d i s l i k e o r l i k i n g f o r t h e

t h e r a p i s t is d i f f i c u l t e v e n t h o u g h h e a t t e n d s t o t h e f o r m a l r e q u i r e m e n t s o f the therapeutic contact. more

actively e n c o u r a g e d

A n g e r is m o r e easily e x p r e s s e d because i t is and

presumed

to

be

therapeutic.

The

obsessional is o f t e n v i s u a l i z e d as h a v i n g s t o r e d u p h o s t i l i t i e s , a n d t h e c r i t i c a l e l e m e n t i n t h e r e s o l u t i o n o f t h e d i s o r d e r is t h e e x p r e s s i o n o f these aggressive f e e l i n g s . T h e o v e r r i d i n g tendency t o w a r d control blankets b o t h tender a n d h o s t i l e f e e l i n g s a n d c o n s e q u e n t l y t h e obsessional a p p e a r s t o be c a l m a n d controlled. invariably

H o w e v e r , his h o s t i l e f e e l i n g s are m o r e a v a i l a b l e t o h i m a n d expressed

i n subtle, b u t unmistakable, m i n i m a l

ways

by

37

P S Y C H O T H E R A P Y OF T H E OBSESSIONAL

detracting, derogating, sniping, petty oversights, a n d the like.

Direct

e x p r e s s i o n s a r e a v o i d e d b u t t h e p r e s e n c e o f h o s t i l i t y is a p p a r e n t t o t h e patient a n d others.

I t is t h e t e n d e r i m p u l s e s a n d a f f e c t i o n a t e

reactions

t h a t a r e securely b o u n d d o w n a n d r a r e l y e x p o s e d , e v e n i n t h e s u b t l e t y o f parapraxic behavior.

T h e s e n e e d t o be severely m a n a g e d since t h e y a r e

v i e w e d as t h r e a t e n i n g a n d d a n g e r o u s .

T h e obsessional m u s t l e a r n t o

i d e n t i f y these f e e l i n g s a n d be e n c o u r a g e d t o e x p r e s s t h e m . o v e r these t e n d e r f e e l i n g s defense.

Expression

Control

c o n s t i t u t e s t h e essence o f t h e obsessional

o f his f e e l i n g s m a y i n i t i a t e r e t a l i a t o r y b e h a v i o r

f r o m o t h e r s a n d i t is t h i s fact t h a t stirs u p t h e obsessional's w r a t h a n d hostile rejoinders. Grandiosity To

d e a l w i t h his f e e l i n g s o f powerlessness a n d his a s s u m p t i o n

omnipotence, belittling therapist.

and

of

t h e obsessional d e v e l o p s a t t i t u d e s t h a t a r e e x p r e s s e d as condescending

toward

others

as w e l l as t o w a r d

the

T h i s issue l a r g e l y a c c o u n t s f o r t h e f a i l u r e o f t h e p a t i e n t t o be-

come involved i n a relationship w i t h the therapist. d i s t a n t b u t p r o p e r i n f u l f i l l i n g his r o l e .

T h e patient remains

Secretly he feels s u p e r i o r a n d

c o n t e m p t u o u s o f t h e t h e r a p i s t a n d sure h e is " o n " t o a l l t h a t is g o i n g o n . H e c a t a l o g u e s a l l t h e t h e r a p i s t ' s deficiencies, s t o r i n g t h e m u p f o r use at a proper time.

I n t h i s w a y h e m a i n t a i n s a secret a m m u n i t i o n d u m p a n d

an advantage over the therapist.

T h e therapist t h e r e f o r e cannot take

f o r g r a n t e d t h a t t h e p a t i e n t , e v e n t h o u g h h e a p p e a r s t o be p u r s u i n g t h e t h e r a p e u t i c process is, i n f a c t , d o i n g so. "right" thing.

H e m a y s i m p l y be d o i n g t h e

I t is a l o n g t i m e b e f o r e s u c h p a t i e n t s c a n e x p e r i e n c e a n d

e x p r e s s t h e i r d o u b t s a n d c o n c e r n s a b o u t t h e process.

T h e i r omniscient

n e e d s d o n o t p e r m i t t h e r e c o g n i t i o n o f deficiencies a n d t h e r e f o r e t h e y resist i n t e r p r e t a t i o n s w h i c h r e q u i r e t h e m t o a d m i t a n y i g n o r a n c e , especially a b o u t t h e i r i n t e r p e r s o n a l r e l a t i o n s h i p s . In

order

couraged

f o r t h e p a t i e n t t o accept n e w i n s i g h t s h e m u s t be

t o see

how

it will benefit

en-

h i m , instead o f visualizing the

disasters t h a t w i l l c o n f r o n t h i m w h e n h e feels helpless a n d n o t i n t o t a l control o f everything.

T h i s p r o b l e m b e c o m e s acute w h e n t h e p a t i e n t is

c a l l e d u p o n t o t r y o u t f r e s h i n s i g h t s i n his l i v i n g a n d his n e e d s f o r certainty a n d guarantees deter h i m f r o m a t t e m p t i n g new a n d u n t r i e d pathways or solutions.

T h e patient will r e p o r t difficulties and failures

i n his a t t e m p t s at c h a n g e a n d t h i s t e n d e n c y m u s t be c l a r i f i e d t o a v o i d b e coming

entrenched

i n his n e u r o t i c , c i r c u m s c r i b e d

e x p e r i e n c e d as safe because i t is f a m i l i a r .

e x i s t e n c e w h i c h is

4

T h e process o f t h e r a p y i n v o l v e s a t e d i o u s e x a m i n a t i o n a n d e x p o s u r e o f a p a t i e n t ' s p a t t e r n s o f b e h a v i o r w h i c h he c o m p u l s i v e l y m a i n t a i n s a n d r e l u c t a n t l y alters.

T h e t h e r a p i s t ' s task is t o r e v i e w a n d s t r e n g t h e n t h e

38

A M E R I C A N J O U R N A L OF P S Y C H O T H E R A P Y

p a t i e n t ' s awareness o f these p a t t e r n s a n d assist h i m i n o v e r c o m i n g doubts.

his

B e f o r e a n y m o v e s can be m a d e t o c h a n g e one's b e h a v i o r , t h e

i n d i v i d u a l m u s t have a s t r o n g c o n v i c t i o n about the n e e d to change a n d a trust i n the understanding derived f r o m collaboration with the therapist. T h i s is especially naciously

t r u e f o r t h e obsessional, w h o c l i n g s r i g i d l y a n d t e -

t o his b e h a v i o r a l p a t t e r n s a n d t o his r a t i o n a l i z a t i o n s .

s t r e n g t h o f his defenses d e m a n d s s t r i c t , r i g i d , c o m p u l s i v e

The

adherence

since t h e d a n g e r s w h i c h w o u l d u n f o l d unless he does so w o u l d be severe and dramatic.

T h e obsessional's p e r s i s t e n t i n t e l l e c t u a l d e f i a n c e

and

resistance t o s e e i n g his b e h a v i o r i n a l t e r n a t i v e ways a r e i n t e n s e a n d s t u b born.

H i s views a n d a t t i t u d e s a r e f i r m l y e m b e d d e d a n d d e f e n d e d b y

b a r r i c a d e s t h a t m u s t be s l o w l y e r o d e d , piece b y piece a n d i n c h b y i n c h . T h i s requires patience a n d tolerance a n d the ability to sustain a c o n t i n u a l i n t e r e s t i n t h e face o f b o r i n g , r e p e t i t i v e b e h a v i o r w h i c h seems t o c o n t i n u e i n spite o f c l a r i f i c a t i o n a n d a g r e e m e n t negative quality. which

a b o u t its d e s t r u c t i v e ,

I n f a c t , t h i s is t h e n a t u r e o f t h e c o m p u l s i v e

is r e p e a t e d

with

no

alteration or

symptom,

d e v i a t i o n i n spite o f

the

k n o w l e d g e o f its lack o f v a l i d i t y a n d its d e s t r u c t i v e p o t e n t i a l . Consequently,

a l a r g e p a r t o f t h e t h e r a p e u t i c process is c o n c e r n e d

w i t h a r e v i e w a n d r e - e x a m i n a t i o n o f issues t h a t a r e d e a l t w i t h o v e r a n d over again.

T h e t h e r a p e u t i c s k i l l lies i n t h e t h e r a p i s t ' s a b i l i t y t o see t h e

same issues i n a n e w l i g h t , a d d i n g a n a d d i t i o n a l piece o f i n s i g h t a n d r e v i v i n g an a d d i t i o n a l recollection to strengthen the patient's conviction a b o u t t h e u n d e r s t a n d i n g so t h a t i t b e c o m e s s u c h a n i n t r i n s i c p a r t o f h i m s e l f that he

finally

sees i t as i f h e d i s c o v e r e d i t a l l a l o n e .

Familiar

n e u r o t i c t e n d e n c i e s m u s t be e x p l o r e d f r o m t h e f r e s h p e r s p e c t i v e o f d i f f e r e n t events w h i c h i n c l u d e n e w pieces o f d a t a a n d a d d i t i o n a l i n s i g h t s . T h i s also relieves t h e m o n o t o n o u s r e f r a i n o f t h e p a t i e n t , w h o says: " W e went t h r o u g h that already," a n d the deadly dullness for the therapist, w h o m u s t b e c o m e r e c o n c i l e d t o t h e awareness t h a t a s i n g l e c l a r i f i c a t i o n is r a r e l y f o l l o w e d by a c h a n g e i n b e h a v i o r a n d t h a t t h e r e f o r e , he m u s t r e p e a t t h e same f o r m u l a w i t h a n e w a n g l e .

W o r k i n g t h r o u g h m u s t be

seen as a necessary i n g r e d i e n t i n t h e process o f c h a n g e i n p r o v i d i n g c o n v i c t i o n a n d t r u s t t o r i s k a n e w a p p r o a c h t h a t p r e v i o u s l y was c o n s i d e r e d d a n g e r o u s by

the

patient.

T h i s is c r u c i a l t o t h e r e s o l u t i o n o f

an

obsessional d i s o r d e r . Conclusions N o t e v e r y obsessional p a t i e n t p r e s e n t s a l l o r t h e same d e g r e e o f t h e obsessional c h a r a c t e r i s t i c s .

S o m e obsessionals d e a l w i t h t h e n e e d t o be

i n m a j o r c o n t r o l by b r i n g i n g i n lists o r a g e n d a s t o t h e session; o t h e r s w i l l h a v e severe r i t u a l s o r p h o b i a s t h a t o c c u p y t h e f o r e f r o n t o f t h e c o m m u n i -

P S Y C H O T H E R A P Y OF T H E O B S E S S I O N A L

39

c a t i o n process; m a n y a r e h a m p e r e d b y t h e i r g r a n d i o s i t y a n d for

most

people;

still

others

are

overwhelmed

by

contempt

their need

for

g u a r a n t e e s a n d c e r t a i n t i e s t h a t p r e v e n t t h e m f r o m t a k i n g a n y risks o r acc e p t i n g any new i n t e r p r e t a t i o n s .

T h e p a r t i c u l a r elements w h i c h are

most p r o m i n e n t i n the patient being treated determine the general p r i n ciples t h a t n e e d t o be a p p l i e d i n each i n s t a n c e .

W h e r e intellectual dis-

cussions seem t o be p r e - e m i n e n t t h e t h e r a p i s t m u s t p e r m i t h i m s e l f t o be somewhat spontaneous i n expressing

s o m e o f his o w n f e e l i n g s

and

p e r h a p s t h e r e b y e n c o u r a g i n g t h e p a t i e n t t o d o t h e same b y a l l o w i n g a n d fostering the c o m m u n i c a t i o n taneous behavior

o f his d o u b t s a n d u n c e r t a i n t i e s .

Spon-

is so d i f f i c u l t f o r t h e obsessional t h a t t h e t h e r a p i s t

s h o u l d encourage this by g e t t i n g m o r e i n v o l v e d w i t h the patient, t a k i n g s o m e risks i n e x p o s i n g s o m e o f his o w n weaknesses, t h u s a l l o w i n g t h e p a t i e n t t o r e c o g n i z e t h a t h u m a n f a l l i b i l i t y is n o t a cause f o r t o t a l r e j e c tion by others.

I n t h i s c o n n e c t i o n i t is i m p o r t a n t f o r t h e t h e r a p i s t t o be

a w a r e o f h o w he is b e i n g c o n t r o l l e d o r m a n i p u l a t e d by t h e obsessional's tactics.

T h e inevitability o f b e i n g d r a w n i n a n d b e i n g unable to

find

one's w a y a f t e r b e i n g c a u g h t i n t h e sticky w e b o f obsessional c o m m u n i c a t i o n n e e d n o t be

viewed

as lack o f t e c h n i c a l s k i l l b u t s i m p l y as a n

e x a m p l e o f t h e e n o r m o u s d i f f i c u l t i e s i n d e a l i n g w i t h obsessional behavior.

Reviewing

illuminating.

the

entrapments

faced

by

therapists

R u l e s c a n o n l y be d r a w n i n a g e n e r a l w a y .

can

be

E a c h occasion

i n t h e d e v e l o p m e n t o f t h e i n t e r a c t i o n w i t h t h e t h e r a p i s t needs t o be seen i n t h e l i g h t o f t h e obsessional m e c h a n i s m s a n d t h e t h e r a p i s t ' s t e n d e n c i e s t o be f a l l i b l e .

T h i s allows t h e process o f t h e r a p y t o be o n e w h i c h is n o t

autocratically d e t e r m i n e d

b y t h e e x p e r t a n d his helpless p a t i e n t , b u t

r a t h e r b y t w o p e o p l e a t t e m p t i n g t o e x p l o r e a n issue t o g e t h e r i n w h i c h o n e has skills t h e o t h e r does n o t . SUMMARY O b s e s s i o n a l b e h a v i o r is a d e f e n s i v e e f f o r t t o d i s p l a c e t h e f o c u s o f those t h o u g h t s , desires o r i n t e n t i o n s w h i c h t h e i n d i v i d u a l feels w i l l t h r e a t e n his s e c u r i t y .

H e experiences extreme anxiety about losing con-

t r o l a n d t h e r e f o r e a t t e m p t s t o f o r e s t a l l t h i s loss t h r o u g h m a n y tactics: i n tellectualization; perfectionistic

a n d s u p e r m a n e f f o r t s at a b s o l u t e c o n -

t r o l ; a v o i d a n c e o f f e e l i n g s w h i c h c a n n o t be c o m p l e t e l y c o n t r o l l e d ; p r o c r a s t i n a t i o n a n d indecisiveness w h i c h a v o i d c l o s u r e ; l e a v i n g t h e p e r s o n subject t o e r r o r a n d c r i t i c i s m ; a n d obsessional o r c o m p u l s i v e r i t u a l s w h i c h are r i g i d m a n e u v e r s to give one the i l l u s i o n o f c o n t r o l . T h e therapist must avoid a r i g i d , ritualized therapeutic plan that aggravates

t h e process.

Spontaneity, direct c o n f r o n t a t i o n , a n d activity

f r o m the therapist to reduce distracting behavior

m u s t be c a l l e d i n t o

40

AMERICAN JOURNAL

play.

The

"here

and

now"

must

be

OF

PSYCHOTHERAPY

emphasized

and

issues

that

s t r e n g t h e n the patient's capacity to procrastinate a n d d o u b t m u s t avoided.

be

C o m m i t m e n t s h o u l d be e n c o u r a g e d a n d t h e e n s u i n g a n x i e t i e s

s h o u l d be e x p l o r e d i n o r d e r t o i l l u m i n a t e t h e obsessional's d e m a n d f o r certainty

and

absoluteness.

Ultimately

the

patient

must

face,

k n o w l e d g e , a n d i n t e g r a t e his h u m a n f a i l i n g s a n d i n c a p a c i t i e s

ac-

through

t h e e x p e r i e n c e o f b e i n g h u m a n w i t h its s e e m i n g l y cataclysmic consequences. REFERENCES 1.

Nemiah,J.

Obsessive-Compulsive Psychoneurotic Disorder.

of Psychiatry, 2.

Horowitz, M.

3.

Salzman, L .

4.

In Comprehensive

F r i e d m a n , A . et a l , E d s . W i l l i a m & W i l k i n s , N e w Y o r k , Stress Response

Syndrome.

The Obsessive Personality.

Jason Aronson, New York, Jason Aronson, New York,

Psychotherapy: G o l d or Alloy.

Contemp.

Psyhcoanal.

Textbook

1974.

1977.

1968.

V o l . 10, N o v . 4,

1974.