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 one-

hundred 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 non-

complaint 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 obsessive-

compulsive 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/Shedler-

Efficacy-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: 10.4103/0253-

7176.135389

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/10.1037/0033-

3204.27.3.366