While much of Freudian theory has been extensively revised, the core components often remain, and that is true in the case of the psychodynamic approach to Obsessive-Compulsive disorder. The current Psychodynamic stance is very similar, but does not focus on the ‘psychosexual stages’ or the concepts of the id, ego and superego. Instead it suggests that the obsession can spring from the displacement and substitution of any repressed issue that causes great anxiety and threatens to invade conscious thoughts. This displacement will not be arbitrary, but rather will have some basic link to the original repressed thought or action. A popular example is that of a woman who suffered great anxiety and ‘burning sensations’ when confronted with what she considered ‘hot colours’ (such as red and orange). The anxiety and suffering would become debilitating unless she could look at a ‘neutral colour’ such as blue, green or white (Rachman and Hodgeson, 1980). When her case history was traced back, the Obsessive-Compulsive disorder was seen to develop at a time when the woman feared greatly for the health of her ailing mother, with her thoughts focussing on the fact that if her mother suffered a fever she could die. The Psychodynamic explanation suggests that it was this fear over her mothers health that was repressed, and transferred to a more suitable substitute (in this case her own health). In this case the obsession over hot colours was directly linked to fear of her mother getting the potentially fatal fever.
The Cognitive-Behavioural approach is significantly different to this, suggesting that the development of Obsessive-Compulsive disorder is an extreme reaction to the obsessive thoughts that all people suffer from time to time. It is said that any thought or action that produces anxiety leads to focussing or obsessing on the issue for a short period, but ‘normal’ people can usually dismiss this fairly quickly. The more upset an individual is made by an anxiety producing stimuli, the longer these intrusive and repetitive thoughts last (Horowitz, 1975). Moreover, the more depressed or stressed an individual is, the more susceptible they are to these obsessive thoughts (Seligman, 1975). The act of distraction or dismissal from such thoughts is both conscious and voluntary, and in extreme cases an individual can find themselves so anxious and depressed that they are unable to help themselves in this way. This inability to react in turn leads to greater levels of anxiety and depression, which results in the obsessive thought becoming entrenched. The compulsions seen are a way to temporarily alleviate these anxieties through the ritualistic execution of some superficial neutralisation. The anxiety relief that they cause only temporarily reduces the symptoms, however, and do not effect the cause, which means that not only is the disorder not cured, but moreover it becomes worse as the temporary relief of the compulsions is taken up more regularly. It can even be argued that the anxiety can be further accentuated by the fact that the relief is only temporary, yet the obsessions remain. This approach is often applicable to Obsessive-Compulsive disorder cases, such as one which involved a 38 year old mother who became obsessed with contamination by germs and led her to extensive cleaning rituals including confining her child to only one room of the house, which she scrubbed a number of times a day. In this case it could be said that the anxiety over the germs came at a time when she was particularly emotionally vulnerable (after the birth of her child) and the rituals were a natural response to the obsession. Moreover, the statistics that within Obsessive-Compulsive disorder sufferers, obsessive incidents triple at times of depression (Videbech, 1975). This approach, with its focus on the effects of anxiety, also puts a strong case forward for the perpetuation of the disorder, which the Psychodynamic approach fails to deal with.
In support of the Psychodynamic approach, the Cognitive –Behavioural view does not seem to give any convincing argument to the selection of obsession in the first place. In the case of the mother obsessed with germs, it can be claimed that the fear of contamination may have been socially conditioned to some extent, and so was merely an obvious choice. If we also take the case of the woman with the ‘hot colour’ obsession, the form taken here is much less compliant with the Cognitive-Behavioural view. As mentioned earlier, however, it is not necessary to therefore try and chose which one of these contrasting viewpoints is best, as they can be amalgamated to create one, much more comprehensive approach to understanding the disorder. For example, it could be said that the obsessions do indeed stem from unresolved internal conflicts. However, these conflicts are present to some extent in everyone and so it takes a combination of this and a period of emotional vulnerability such as depression to cause the issue to produce enough anxiety to be displaced onto a related but less threatening thought or item. Then the compulsions are created to deal with the anxiety in some symbolically related way, but their superficial nature will see the disorder perpetuated rather than cured. In this respect the strongest elements from both approaches can be seen to support each other. What has not been suggested by either approach, but seems congruent, is the possibility that the Obsessive-Compulsive disorder sufferer may not be able to distract themselves from the original conflict, and so displaces it onto a linked subject that can be more easily dismissed. Thus the creation of the compulsive routines (that often seem diametrically opposed to the obsession) may be an attempt to distract from the obsession by focussing on a different act.
Although it seems that there is some compromise to be reached between the two approaches regarding the understanding of Obsessive-Compulsive disorder, with both having their own relative merits, the treatments they prescribe are quite disparate. Both have been developed as ‘humane’ alternatives to the traditional (and largely unsuccessful) treatments, which included electro-convulsive therapy and psychosurgery.
The treatment of Obsessive-Compulsive disorder that is employed in the Psychoanalytic approach is a very simple derivative of basic cathartic therapy. It involves the therapist identifying the underlying conflicts that were displaced, and getting the patient to recognise it as the origin of their anxiety. Then it can be confronted and the Obsessive-Compulsive disorder should naturally disappear (as it is a defence mechanism that is no longer needed). There are a number of problems with this treatment, with the first being that it involves a thorough analysis of the defences, and an undoing of the repression, all of which can take years. The second problem is that, as the therapy is still in its relative infancy, there is no real statistics as yet that can be seen to confirm or refute its efficacy. In this respect it can be suggested that to some extent it questions the validity of the whole theory.
The Cognitive-Behavioural treatment of Obsessive-Compulsive disorder has, on the other hand, received the validation of a significantly high success rate, both immediately after treatment (with approximately 66% of patients loosing their symptoms) and in follow-ups of up to six years later (with over 90% of those patients who had improved maintaining their improvements)(Sue, Sue and Sue, 2000). The therapy involves a three stage system of modelling (showing them that their obsessive situation is actually safe), flooding (encouraging them to place themselves in that situation), and response prevention (not allowing them to carry out their compulsions). The success of these techniques is a strong indicator that the disorder is driven by or at least strongly connected to anxiety, as in particular flooding and response prevention have long been used as effective methods of dealing with anxiety disorders.
This apparent success should not, however be taken to show that the Cognitive-Behavioural approach is thus superior to the Psychoanalytic approach. The success of this therapy stems from a combination of ‘Pavlovian extinction’ (that the feared result is not directly linked to the obsessive subject that the patient is trying to avoid) in the flooding, and ‘Instrumental extinction’ (no negative effect results from not completing the compulsion) in the response prevention (Hollander and Stein, 1997). Therefore it is merely dealing with the symptoms through conditioning, rather than dealing with any underlying cause that may exist. If the concept of combining the two approaches (as in the discussion on understanding Obsessive-Compulsive disorder earlier) is to hold any merit, it would mean that this treatment alone is not enough, as it makes no attempt to deal with the unresolved unconscious issues that are responsible for the obsessions. This is supported by the fact that the effects of the Cognitive-Behavioural treatment are very specific; obsessive thoughts, compulsive rituals and anxiety are all largely removed, but the depression, social activity family harmony of the patient remain unaffected. This may be seen as suggestive that there is indeed an underlying problem which needs resolved for the sufferer to be totally cured. Perhaps then the most effective treatment would be the simultaneous use of both the Psychoanalytic and Cognitive-Behavioural methods, each of which is geared to deal with a specific aspect of the disorder.
While both the Cognitive-Behavioural and Psychodynamic/Psychoanalytic approaches to Obsessive-Compulsive disorder are in many ways quite disparate, the differing focuses that they hold means that they both contain a number of very salient points. Thus rather than having a preference for one over the other, it has been shown here that personal preference goes to a hybrid of the two. It seems that only in forming this amalgamation is it possible to fully understand and treat all the aspects of this disorder as it is understood at the moment. That is assuming, of course, that the problems prevalent in Obsessive-Compulsive disorder are not caused purely by some neurochemical dysfunction or other biomedical explanation.
References:
Dubovsky, S.L. & Butler, L.D. (1995) Abnormal Psychology: Casebook and Study Guide: London. W.W. Norton & Company.
Freud, S. (1909) Notes upon a case of obsessional Neurosis. In J. Strachey (Ed & Trans.) The Complete Psychological Works Vol. 10: New York. Norton (1976) cited in Rosenhan & Seligman (1995).
Hollander, E. & Stein, D.J. (1997) Obsessive-Compulsive Disorders: Diagnosis, Etiology and Treatment: New York. Marcel Dekker, Inc.
Horowitz, M. (1975) Intrusive and repetitive thoughts after experimental stress. Archives of General Psychiatry, 32, 1457-1463 cited in Rosenhan & Seligman (1995).
Rachman, S. & Hodgeson, R. (1980) Obsessions and Compulsions: New Jersey. Prentice Hall. Cited in Sue, Sue & Sue (2000)
Rosenhan, D.L. & Seligman, M.E.P. (1995) Abnormal Psychology: London. W.W. Norton &
Company.
Seligman, M.E.P. (1975) Helplessness: On Development, Depression and Death. San Francisco. Freeman. Cited in Rosenhan & Seligman (1995).
Sue, D., Sue, D.W. & Sue, S. (2000) Understanding Abnormal Behaviour: New York. Houghton Mifflin Company.
Videbech, T. (1975) A study of genetic factors, childhood bereavement, and premorbid personality traits in patients with anancastic endogenous depression. Acta Psychiatrica Scandinavica, 52. 178-222 cited in Sue, Sue and Sue, (2000).
