Edited - 4p79 Term Paper

1 Running head: EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD

The Efficacy of Freud’s Psychotherapeutic Approach for Obsessive Compulsive Disorder Brianna Wiederhold – 5866884 Baker – PSYC 4P79 December 4, 2018 Brock University

2 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD Introduction to Psychodynamic Therapy and Obsessive-Compulsive Disorder Psychodynamic therapy was popularized in the late 1800s by Dr. Sigmund Freud whose unique and breakthrough theories revolutionized psychology. To this day his theories hold great influence, and although they are often questioned, they still have great relevance in contemporary therapy. This paper will address the question if psychodynamic therapy is an effective therapeutic approach for Obsessive Compulsive Disorder (OCD) - what can improve the effectiveness of psychodynamic theory and in what ways can it be beneficial over other therapies? This paper will demonstrate the efficacy of Freud’s Psychoanalysis/Psychodynamic approaches for OCD and show the practical and clinical use of these techniques in the treatment of people with OCD. This paper will present case reports and studies that demonstrate the efficacy of therapeutic approaches for OCD. First, it will examine psychodynamic therapies efficacy in reducing OCD symptomology over and above other therapies. It will also examine its efficiency especially when integrated with the gold-standard approach of Cognitive Behaviour Therapy (CBT). Finally, research will show psychotherapeutic approaches effectiveness with treatment resistant cases. It will finish with a discussion of the implication of the results of the studies for the practice of psychotherapy and counselling. Obsessive-Compulsive Disorder OCD is characterized by obsessions, that are impulses and thoughts that are involuntary and repetitive, and compulsions that are also recurrent and unwanted, but are marked by egodystonic behaviour preformed in accordance to rules and stereotypes (Goldstein, 1985). Obsessions most commonly come in the form of preoccupation with religion, sexuality, death or illness, contamination, or catastrophe and the fear of responsibility for the harm to self and others, while common compulsions include cleaning and hoarding (Dembo, 2014). OCD has a lifetime prevalence up to 3% and is the fourth most common psychiatric disorder (Arzul & Cartwright,

3 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD 2016). It is most common in boys and has an average onset between 7.5 and 12.5 years old (Dembo, 2014). Children who develop early-onset OCD tend to be at a greater risk of developing comorbid conduct behaviour, tics, attention deficit hyperactivity disorder, and mood and anxiety disorders (Dembo, 2014). OCD’s etiology is multifaceted including an amalgamation of genetics, biology, both neurologically and chemically, personality, psychology, as well as environmental and social factors (Dembo, 2014). Psychodynamic Therapy The psychodynamic approach focuses on seven major features: affect and emotional expression, investigation into client’s avoidance of distressing thoughts and feelings, identification of frequent themes and pattern, focus on past experience and development, interpersonal relationships, the therapeutic alliance, and exploration of the clients wishes and fantasies (Shedler, 2009). Of these features, significant concepts and principles arise. In theoretical terms, avoidance is a defense mechanism seen in resistance, that is often towards treatment, and can also be seen in denial where the client avoids the existence of problems and reality (Shedler, 2009). Psychodynamic therapy also identifies other core concepts and defenses such as displacement, where the client transfers one intense emotion from the original recipient of the feelings to another. The exploration of past experiences often helps inform the therapist of current behaviours. The therapeutic alliance is an important relationship that provides the therapist insight unconscious fears and internal disturbances and struggles. Together, the use of these therapeutic techniques within clinical practice allows for the creation of personalized treatment regimes, revealing unconscious and conscious problems and magical thinking, addresses these problems, and aids in the treatment of complex psychiatric disorders such as OCD.

4 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD Literature Support: Efficacy of Psychotherapeutic Approach for OCD Symptomology Psychoanalytic approaches specifically for OCD are currently almost non-existent as little faith has been placed in the relevance of their treatment of this disorder, especially in the face of new technologies, such as pharmacological methods and therapeutic methods, such as CBT and exposure and response prevention (ERP) (Arzul & Cartwright, 2016). However, successful interventions of such therapies vary, especially over long periods of time. Arzul and Cartwright (2016) believe that psychoanalysis is better suited for the treatment of OCD as it’s theories better informs the therapist of the root cause of the client’s distress. For instance, a client’s investment in their obsessive and compulsive (OC) symptoms are rooted in conscious and unconscious meanings that is often largely interpersonal significance. Secondly, certain personality features undermine treatment and psychodynamic therapy can be used to counter noncompliant clients (Arzul & Cartwright, 2016). Although overlooked as a first-approach treatment for OCD, first first-line techniques like CBT do not always result in full remission (Dembo, 2014). A psychodynamically informed approach could benefit in areas where the ‘gold-standard’ approaches are lacking. Wells, Glickauf-Hughes and Buzzell (1990) identified the unique ways in which psychodynamic therapeutic style can benefit patients with OCD. In order to counter OC symptoms, psychodynamic therapy conceptualizes the clients’ interpersonal difficulties and unresolved issues and aids the client through their power struggle by bringing them insight into their behaviour, such as through childhood antecedents influence on their development. In the end this psychodynamic therapy gives the client the opportunity to reclaim their autonomy and control, of which patients with OCD usually feel as if they had lost. Psychodynamic therapy treatment goals and strategies include, modification of cognitive styles, changing magical thinking, addressing stressed superegos/perfectionism, increasing comfort surrounding emotional

5 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD needs and affective experience, resolving control issues, and modification of their current interpersonal styles (Wells, Glickauf-Hughes & Buzzell, 1990). Psychodynamic therapy is a multifaceted approach that delves into various psychological influences that affect the clients’ behaviours, feelings, and expression of interpersonal problems, in order to help the client through theories that link the appropriate intervention techniques for the disorder and generate alternative solutions to problems. Chlebowski and Gregory (2009) also sought to investigate the efficacy of the psychodynamic understanding of OCD. The current practices for the treatment of OCD is most commonly CBT and medication, (mainly serotonin-specific reuptakes inhibitors (SSRI) to restore chemical imbalances), or a combination of the two (Dembo, 2014). However, these methods are not onehundred percent effective as 40-60% of patients do not respond to SSRIs (Chlebowski & Gregory, 2009). Chlebowski and Gregory (2009) presented cases studies that exhibited successful psychodynamic therapy in the remission of patients with OCD. In one instance, the therapist helped the client recognize that her compulsions to harm her children was the displacement of her aggression towards her husband. This insight resulted in drastic reduction of OCD symptoms. In other instances, the therapist recognized the OC symptoms as co-occurring with borderline personality disorder and focused on the client’s emotion processing, resulting in significant improvement in OCD symptoms. In other cases, psychodynamic intervention demonstrated how psychodynamic therapy’s thoroughness in formulating extensive history and observations of the formation of the client’s OCD symptoms, fostered the creation of successful treatment plans (Chlebowski & Gregory, 2009). Psychodynamic therapy as illustrated, is an effective therapeutic intervention in cases of OCD that can benefit a client beyond what traditional medications and CBT alone.

6 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD Collectively these research articles demonstrate the efficacy of the psychotherapeutic approach. Psychodynamic therapy looks into the past experiences, current affect, and OC symptoms in order to draw conclusions as to why they behave the way they do, the reasons they are feeling distressed, and what anguishes them so that their OC actions alleviate these negative feelings. Psychodynamic therapeutic techniques address these problems in order to provide an overall reduction in OCD symptomology. Psychodynamic and CBT Integrative Approach to OCD Benns-Coppin (2008) recognized that our reliance on CBT as the choice treatment for OCD is concerning, since it can lead to the homogenization of treatment since it does not take into account the advantages of other therapeutic skills and theoretical views. A combination of treatments can be especially beneficial for complex pathologies such as OCD (Benns-Coppin, 2008). This section will demonstrate how integrating psychodynamic therapy and CBT can be most effective for unique cases of OCD. Case Study: Dembo (2014) Dembo (2014) outlined a case study that demonstrates that psychodynamic therapy in conjunction with CBT, narrative, existential, and metaphor therapy can enhance the treatment and clinical outcome of dynamic conflicts such as OCD. This specific treatment regime was created for a 12-year-old girl named Cassandra. Six months before her hospitalization, her OCD symptoms manifested in the form of hoarding, eventually developing a contamination obsession and a compulsion in which she avoided anything her grandmother touched. She further deteriorated as she created rituals that impeded her everyday life and relationships, and presented with suicidal ideation, anhedonia, weight loss, and insomnia (Dembo, 2014). The goal of the clinicians was to restore her to a medically stable state. Initially, she was hostile to medication, so CBT was the only treatment administered. CBT provided

7 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD psychoeducation as they developed her ‘ickiness hierarchy’, that was a description of the most to least distressing contaminated objects in her life, which then they gradually exposed her to (Dembo, 2014). Cassandra was then analyzed through a psychoanalysis lens that found that she exhibited a powerful superego of which Freud hypothesized as in combination with aggressive impulses manifested as OC symptoms (Dembo, 2014). This lens also helped identify her ‘lack of warmth’ as resistance, a common symptom of OCD, and her poor self-image as propagated by the psychoanalytic theory that perfectionism is defense against hostile impulses (Dembo, 2014). The psychodynamic component was introduced into therapy as it helped combat common OCD defense mechanisms, such as intellectualization, rationalization, denial, magical thinking, and isolation, that would have otherwise impeded CBT treatment (Dembo, 2014). During a two- month follow up to the combination treatment with psychodynamic, CBT, and other therapeutic techniques, Cassandra was described as a ‘normal’ girl that drastically contrasted her atypical presentation at the beginning of therapy (Dembo, 2014). This case study demonstrates how non-traditional treatments such as a combination of therapeutic approaches, including psychodynamic therapy, can enhance CBT to further the effectiveness of the treatment of OCD. Case Study: Garcia (2008) Garcia (2008) case study focused on, Bridgit, a 21-year-old presenting with OCD and comorbid depression. Her compulsions manifested as rituals of Catholic religious traditions, thus her unique situation required that the clinicians target the OCD symptoms but leave her religious beliefs intact (Garcia, 2008). Her treatment was administered for about three years with a total of 79 sessions. This treatment regime was split into two phases. The first, CBT was used to target her obsessions and compulsions through techniques such as cognitive restructuring, ERP, and building a strong therapeutic alliance. The second phase integrated psychotherapeutic themes into

8 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD CBT in order to address her interpersonal disparities and combat further difficulties such as her history of disturbed relationships with men and her scattered speech that interfered with her communication with the significant people in her life (Garcia, 2008). The purpose was to relieve her of her ritualistic symptoms by using CBT to alleviate the stress created by her sexual and moral issues (Garcia, 2008). However, CBT did not fully combat the root cause of all her distress. Psychodynamic therapy addressed issues not discovered by CBT, such as issues from her childhood, like her father’s death and how she connects his loss with the loss of her boyfriend when they broke up, and her identification as a ‘sufferer’ from years of her mother modeling self-sacrificing behaviour, in which she used her ‘atonement’ as a way to alleviate guilt (Garcia, 2008). Brigit showed immense progresses since the first session as she reported feeling more in control, had insight in her relational style, her ritualizing symptoms had been significantly reduced, and as per the Yale-Brown Obsessive-Compulsive Scale (YBOCS) and Beck Depression Inventory (BDI) her symptomology had reached nonclinical levels. This case study illustrated how CBT works to minimize compulsions and obsessions but may not delve deep enough in addressing to root causes of their OCD. Psychodynamic therapy psychodynamic better addresses OCD by approaching such matters in order to help prevent relapse. Collectively these studies demonstrate that restricting clients to a single therapy undermines the treatment of their mental health as incorporating psychodynamic therapy into current treatments such as CBT offers greater benefits than a single-mode treatment type. Psychodynamic therapy in combination with CBT has shown prolonged improvements in symptomology and appears to also provide an alternative approach to cases that may be resistant to CBT alone (Benns-Coppin, 2008).

9 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD Efficacy of Psychotherapeutic Approaches with Treatment Resistant Cases As mentioned previously, the golden-standard for OCD is either CBT, medication, or a combined approach. However, when OCD clients remain resistant to such approaches because of their unique and severe form of illness, psychotherapeutic approaches can step in to aid in their treatment. A benefit to this approach is the therapist’s ability to tailor the therapeutic technique more specifically according to the unique features of each case, building a creative approach that best counterattacks the defenses of the clients (Vyjayanthi, 2014). Gabbard (2008) believed that psychodynamic therapy is effective in helping clinicians understand the meaning behind the client’s symptoms and could assist in those resisting to treatment by encouraging compliance with pharmacotherapy and behavioural therapies. This section will focus on the efficacy of psychotherapeutic approaches for treatment resistant cases. Case Study: Vyjayanthi (2014) Mr.H, a 57-year-old man, was diagnosed with a recent onset of OCD (primarily obsession) that manifested in the form of fear of humiliation and preoccupation with the Indian Railways service, from which he retired, misrepresenting his records. He had a persistent need to go back and check the records but feared humiliation if he did. He refused medication, but had insight, aware that his fears and thoughts were irrational and sought help (Vyjayanthi, 2014). He underwent brief psychodynamic psychotherapy of only eight sessions that were aimed at combatting his obsession. The therapy primarily focused on building a therapeutic alliance and encouraging discussion to look into his unconscious thought processes. By the fifth session the therapist had brought forth his unconscious desire for one of his colleagues while he was married, the guilt of impropriety and anxiety had been displaced as his compulsions (Vyjayanthi, 2014). He felt fear of committing adultery but also feared that as he retired he would lose the connection with the woman. He was prone to magical thinking because

10 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD he had not acted upon his feelings but felt guilt as if he had, and he also exhibited reaction formation as he chose to voluntarily retire rather than face the humiliation had his feelings been revealed (Vyjayanthi, 2014). After the eighth session Mr.H was able to recognize his defense mechanisms as pointed out by the therapist, and the experience improved familial relations and resulted in him having less anxiety about his colleague. In the end, psychotherapy had resolved his compulsive symptoms but had also brought Mr.H more self-esteem and improved family dynamic (Vyjayanthi, 2014). His initial resistance to treatment was ebbed away in the face of psychotherapies therapeutic alliance (Vyjayanthi, 2014). Although Mr.H was initially noncomplaint to methods of treatment, his obsessions were gently alleviated though insight and identification of his defense mechanisms such as his unconscious feelings of guilt. This demonstrates psychodynamic therapy’s efficacy in its clinical and practical use when treating individuals that are resistant to other treatment methods. Case Study: Cohen, Delachoe, Flamment, & Mazet (2014) Cohen et al., (2014) case study investigated Jay, a 14-year-old with severe OCD, who had compulsions that consisted of washing rituals, repetition, magical numbers and counting steps, that was marked by avoidance of ‘dangerous’ rooms and people and made it so she could no longer attend school. She had previously resisted treatment in the form of CBT and as a result, was only administered a cornucopia of drugs including clomipramine, fluvoxamine, and sertraline that resulted in very little improvement on its own (Cohen et al., 2014). After four months of drug therapy she underwent a psychotherapeutic approach called individual psychodrama (ID). ID has the patient play out scenes with the therapist as an actor, where they have control as the director of the scenes in order to give the client ability to bring forth topics and highlight moments that evoke unconscious phenomenon such as enhanced emotional reactions (Cohen et al., 2014). A few months into the ID intervention she showed

11 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD improvement in her OC symptoms, and within the year was able to return to school. A two-year follow-up showed that Jay had continued her academic career into post-secondary education but was still taking medication to suppress OC symptoms (Cohen et al., 2014). In order to remedy this reliance on the medications after therapy is terminated, Gabbard (2008) proposed a psychoanalytically informed approach for OCD that works beyond traditional psychodynamic psychotherapy. This enhanced therapy is psychodynamic psychiatry, that includes both the psychodynamic theories such as unconscious meaning, transference, and countertransference, but also includes prescriptions such as SSRIs (Gabbard, 2008). Jay is an example of how psychotherapeutic approaches can work above and beyond pharmalogical approaches or CBT alone. IP in particular is an especially strong approach for youth with OCD as it is based on acting, therefore it is a more intriguing approach than the taxing and mentally grueling CBT (Cohen et al., 2014). Collectively these studies demonstrate psychodynamic therapy’s efficacy in treatment resistant cases over and above other forms of therapy as it inspired more compliance in clients and was able to effectively reduce OCD symptoms. Implications of the Results for the Practice of Counselling This research presented in this paper is important to the practice of psychotherapy and counselling as it outlines the relevance of psychodynamic therapy in contemporary psychology. Freud’s theories have often been disputed as old-fashioned, sexist, and/or irrelevant and overall misrepresented in modern society, thus there has been little recent evidence-based practice and empirical research on psychoanalytical and psychodynamic therapy. We now live in a time that is spearheaded by CBT and pharmaceuticals, that are effective within their own right, but researchers, therapists, and clinicians should consider integrating other therapies that hold similar

12 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD efficacy but have been pushed from conventional practices. Although Freud’s theories were developed a century ago, many of his observations still ring true today. Argument can be made against the efficacy of the psychodynamic approach for OCD. Psychodynamic therapy is not used as a first approach or as the sole treatment with therapy now and as a result there is very little empirical evidence beyond the 1900s for it. Researchers have not been conducting recent experiments focusing on this therapy in treatment of disorders such as OCD because it is no longer a common practice. Therefore, there is very few statistics derived from large populations and samples, that can give an overall impression of the therapy’s effectiveness. In order to gather research on psychodynamic therapy’s efficacy one must derive conclusions from case studies. Case studies are often extremely detailed and unique; therefore, it is hard to generalize the results of the interventions. Despite the lack of empirical-based evidence of psychodynamic therapy in contemporary psychological practices, psychodynamic therapy still has merit, as it still shows efficacy in treating OCD because of its personalized approach and psychotherapeutic techniques, skills, and theories that are sufficient in the reduction of symptomology. This essay argued that psychodynamic techniques are effective and could be used as a core feature of therapy within clinical practice. The collection of case studies presented illustrated various concepts, principals, and techniques of psychodynamic therapy. All of which were aiming to show the efficacy in reducing symptoms, in integrative therapy with CBT, and in treating treatment resistant clients. It also approached these topics in regard to OCD, a psychiatry disorder that is known to be particularly hard to treat because its complexity, unique expression within every case that illicit unpredictable responses from patients during treatment, and is marked by biological changes. Psychodynamic therapy is able to reduce OC symptoms by applying the theoretical lens to identify what ails them and perpetuates their behaviours, then

13 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD gives the client insight to help them overcome their irrational beliefs and help the clients change their maladaptive defense mechanisms. What may be of particular importance to the practice of psychotherapy is that the combination of psychodynamic approach with CBT, of which specifically attacks faulty beliefs and maladaptive behaviours, can help clinicians produce the desired outcome of reductions OCD symptomology that last for a longer period of time than CBT or pharmaceutical therapy alone.

14 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD References Arzul, J., & Cartwright, D. (2016). The reflective function in obsessive-compulsive disorder. Psycho-analytic Psychotherapy in South Africa, 24, 1-38. Retrieved from https://hdl.handle.net/10520/EJC188877 Benns-Coppin, L. (2008). Understanding, respecting and integrating difference therapeutic practice. Psychoanalytic Psychotherapy, 22(4), 262-284. doi: 10.1080/02668730802510975 Chlebowski, S., & Gregory, R. (2009). Is a psychodynamic perspective relevant to the clinical management of obsessive-compulsive disorder? American Journal of Psychotherapy, 63(3), 245-256. doi: 10.1176/appi.psychotherapy.2009.63.3.245 Cohen, D., Delaroche, P., Flament, M.F, & Mazet, P. (2014). Case report: Individual psychodrama for treatment resistant obsessive-compulsive disorder. Neuropsychiatrie de l’enfance et de l’adolescence, 62, 19-21. doi: http://dx.doi.org/10.1016/j.neurenf.2013.12.001 Dembo, J. S. (2014). “The ickiness factor:” case study of an unconventional psychotherapeutic approach to pediatric OCD. American Journal of Psychotherapy, 68, 57-79. Retrieved from https://proxy.library.brocku.ca/login?url=http://search.ebscohost.com/login.aspx?direct=tr ue&db=edsgao&AN=edsgcl.365072959&site=eds-live&scope=site Gabbard, G. (2008). Psychoanalytically informed approaches to treatment of obsessivecompulsive disorder. Psychoanalytical Inquiry, 2, 208-221. doi: https://doi.org/10.1080/07351692109348932 Garcia, H. (2008). Targeting catholic rituals as symptoms of obsessive compulsive disorder a

15 EFFICACY OF PSYCHODYNAMIC THERAPY FOR OCD cognitive-behavioral and psychodynamic, assimilative integrationist approach. Pragmatic Case Studies in Psychotherapy,4, 1-38. doi: http://dx.doi.org/10.14713/pcsp.v412.931 Goldstein, W. (1985). Obsessive-compulsive behavior, DSM-III, and a psychodynamic classification of psychopathology. American Journal of Psychotherapy, 39(3), 346-359. doi: https://doi.org/10.1176/appi.psychotherapy.1985.39.3.346 Shedler, J. (2009). The efficacy of psychodynamic psychotherapy. American Psychologist, 1-25. Retrieved from http://www.briancollinson.ca/wp-content/uploads/2010/06/ShedlerEfficacy-of-Psychodynamic-Psychotherapy-T-LAP-10-9-20091.pdf Vyjayanthi, S. (2014). Brief Dynamic Psychotherapy in a Case of Obsessive Compulsive Disorder. Indian Journal of Psychological Medicine, 36(3), 317–320. doi: 10.4103/02537176.135389 Wells, M. C., Glickauf-Hughes, C., & Buzzell, V. (1990). Treating obsessive-compulsive personalities in psychodynamic/interpersonal group therapy. Psychotherapy: Theory, Research, Practice, Training, 27(3), 366-379. doi: http://dx.doi.org/10.1037/00333204.27.3.366