BS16 1QY E-mail: email@example.com Antonietta DiCaccavo is a Chartered Counselling Psychologist and a senior lecturer on the Professional Doctorate in Counselling Psychology at the University of the West of England, Bristol.
Psychodynamic conceptualisation of obsessive thinking: An illustrative case study This paper suggests how a client presenting with obsessive thinking can be worked with effectively using a psychodynamic approach. This process is described as the exploration of issues of loss and separation in early childhood, using aspects of the relationship between client and counselling psychologist. The paper is of particular interest to counselling psychologists who encounter clients who have made little progress using cognitive-behavioural strategies and for those clients wishing to explore their difficulties in a longer term, more in-depth way. After first defining obsessive thinking, anonymised case study material is used to illustrate the application of psychodynamic theory in terms of conceptualisation and intervention.
Defining obsessive thinking
The central feature of obsessive thinking is compulsive and repetitive mental preoccupation with images, ideas or words that the individual finds highly disturbing. Typically the client experiences intrusive distressing thoughts that interfere with daily living and attempts to control these by further thoughts which seek to neutralise initial distressing ones (Cooper, 2000). For example, a person may think obsessively about a family member dying, "My husband is dead" and then try to neutralise this "My husband is not dead". In this example the obsessive thinking may be in the form of images of the dead husband and in turn the neutralising may take the form of having to imagine the husband alive and carrying out normal activities.
Relative to obsessive compulsive disorder, obsessive thinking has received little attention by academics or practitioners, perhaps reflecting the difficulties of accessing and controlling neutralising strategies that are covert (Roth and Fonagy, 2005). Nevertheless, it can be described as an important variant of the condition, differentiated by the absence of ritualised behaviour patterns (Rachman, 1983). It has been suggested that the content of obsessive thinking is commonly drawn from primitivised sexuality and aggression. The object of aggression is often a parent, spouse, or child (Freud, 1913; Rado, 1939; Rice, 2004). For example, a person might think 'My girlfriend has been strangled, "I am going to rape my stepdaughter", "My mum will die of cancer" and imagine the events taking place. Obviously, such thoughts and images arouse high levels of anxiety and disturbance and the person can spend hours ruminating back and forth between the obsessive thoughts and neutralising compulsions. Neutralising thoughts are often polar opposites, for example, "I love my stepdaughter and would never harm her" or take the form of magical words, phrases or images that must be focused on to negate the frightening content of the initial obsessive thinking.
Behaviour therapy, focussing on exposure and response prevention (ERP), in conjunction with the use of selective serotonin reuptake inhibitors, has emerged as the treatment of choice for OCD (Gabbard, 2001; Abramowitz, 1997; Kay, 1996). Cognitive methods have been used to help clients engage in ERP and as an alternative approach for those for whom it is not acceptable (Jones and Krochmalik, 2007; Salkovskis and Wahl, 2004). These models emphasise the roles of cognitions concerning ‘inflated responsibilty’, (Salkovskis, Wroe, Gledhill, Morrison, Forrester, Reynolds and Thorpe, 2000), and (mis)beliefs about the power and significance of thoughts, referred to as ‘thought-action fusion’, (Wells, 2000; Rachman, 1998). Behavioural and cognitive methods have also been used to treat obsessive thinking in the absence of overt compulsions. However, results from the small number of outcome studies that have been carried out with this group indicate more limited success in terms of symptom frequency and subjective reports of distress, (Roth and Fonagy, 2005).
In contrast to behavioural and cognitive approaches, examples of how OCD, (including obsessive thinking), have been successfully worked with using psychodynamic approaches are hard to come by. While acknowledging the overwhelming evidence of a biological basis for OCD (e.g. Baxter, et al., 1987; Swedo et al., 1989) and the success of cognitive-behavioural treatment interventions, some practitioners argue that understanding the conscious and unconscious meanings and functions of OCD symptoms to the client is relevant and can be understood and usefully worked with in a psychodynamic context (Gabbard, 2001; Merrett and Easton, 2008; Mollon, 2007). This approach is likely to be particularly relevant to clients who do not respond to cognitive-behavioural interventions, but are motivated to work within a relatively longer term relational framework.
A psychodynamic perspective on obsessive thinking
As one might expect, at the seat of a psychodynamic conceptualisation of obsessive thinking is an impoverished relationship with parental figures. In the absence of key relational processes, including emotional proximity (Holmes, 2003), attunement (Stern, 1985), mirroring and containment (Winnicott, 1967), it is suggested that the child experiences a void-like state. The anxiety that consequently arises in the child serves as a form of liveliness in a ‘dead’ inner world (Cooper, 2000). However, it arises out of a sense of abandonment and loss of good objects, and ultimately out of fear of annihilation (Klein, 1952). As a result, the child resorts to defensive strategies of splitting and idealisation (Klein, 1946). For example, in the absence of a psychologically present father, love and hate cannot be felt towards the mother because of fear of destroying and losing the sole good object. The consequent rage and hostility (Freud, 1909; Rado, 1969) is split off, and psychological effort is spent on attempts to keep the frustrating and persecutory object widely apart from the all loving and perfect one. Not surprisingly, this involves an over-evaluation of the intellect and an under-evaluation of emotional life (Wells, Glickauf-Highes and Buzzell, 1990).
In the obsessional structure, splitting takes the form of oscillation between alternative positive and negative perspectives towards the self and others (Cooper, 2000). Through the strategy of alternating opposing thoughts, the good object is never given up, or lost, but he or she is not retained either. Thus obsessive thinking can be seen as a way of 'fending off' the loss of a good object by controlling it within the mind. It is an attempt at magical control of losses (Mallinger, 1984) in order to obtain an illusory guarantee of security in a potentially dangerous, uncertain world (Horney, 1945; Salzman, 1980, 1985). However, the obsessive thinker’s solution becomes the problem as his/her self esteem and internal security are constructed around the spurious ability to control self and others (Wells, et. al., 1990). Ironically, the fact that the thought processes become compulsive means that the person ends up feeling that very sense of being out of control that he/she is defending against at a core level (Cooper, 2000).
Working with Adam
Relevant background and presentation
Context and referral
I worked with Adam for thirty-five weekly sessions in an out-patient adult mental health hospital setting in the NHS. He was referred by his psychiatrist who described his difficulties with ‘obsessional thinking’. Adam first sought help for anxiety and depression when he was 17. He received cognitive-behavioural intervention but found this of little benefit and was hospitalised for a short time. Adam was 23, white, lived alone and had never been in paid employment. For the past two years he had been in a relationship with a woman, ten years his senior with a 10 year old daughter from her previous relationship.
When he came to see me, Adam was experiencing anxiety and depression in relation to having negative thoughts about his girlfriend. He described his strategy whereby if he had a negative thought about her in relation to how she looked or acted (e.g. "She is ugly", "She is stupid"), he would have to make this thought ‘right’ by mentally fighting against it and thereby denying it (e.g. "She is beautiful", "She is wonderful"). He also described having these thoughts about his partner’s daughter (e.g. "She is a brat", "I hate her"). Adam talked of ‘no go’ areas of his mind and likened some of his thoughts as being ‘caged animals’ because the prospect of releasing them was so terrifying. These centred on his knowledge that his father had been sexually abused as a child and included three kinds of thinking. Firstly images of his father being abused, secondly of thoughts that his father might have wanted to have sex with him when he was a boy, and thirdly that he himself might become an abuser. Although helped to some extent by medication (serotonin selective re-uptake inhibitors), Adam described his mood as often very low. His motivation to seek further input at present seemed to be concerned with Adam’s fear of losing the relationship with his partner if he could not battle against his negative thoughts about her. My first impression of Adam was that he was very polite and eager to please. He presented as articulate and intelligent, keen to 'get the answers right'.
Relevant background history
At separate points in time, Adam’s mother and father were hospitalised for depression when he was a child. As he was growing up, he remembered feeling that his dad ‘hated’ him, and that his dad wished that Adam had not been born. In contrast, he described his mum as being wonderfully caring and supportive of him, protecting him from his dad. As an adult, he had been told by mum that his dad had been sexually abused as a child by a friend of his grandparents. Both mum and dad had been involved in extra-marital affairs, resulting in his dad fathering another woman’s child. Such issues were not openly discussed in the family and the child was not acknowledged by dad or the family. Despite these difficulties Adam retained regular contact with his parents and his older sister.
Psychodynamic conceptualisation of the Adam’s material
Having grown up with depressed parents, Adam's experience of key developmental processes such as attunement and containment appear to have been limited. In response to his feelings of distress, Adam describes his mum's need to deny problems and act like 'everything was fine', specifically in relation to his difficult feelings towards dad. In turn, Adam recalls that if he was upset, his dad would become angry with him. As a way of defending against hostile feelings that might threaten his relationship with mum, Adam seems to have split mum and dad into good and bad objects. He is unable to see them as differentiated for fear of the chaos and anxiety that threatens to ensue. This split appears to be encapsulated by his relationship with his girlfriend where he oscillates between negative and positive feelings towards her. As with his parents, Adam struggles against the notion that good and bad can co-exist in his girlfriend, for fear of losing her. Similarly, from a historical point of view he feels that if he accepts that mum had ‘bad’ as well as ‘good’ aspects, then he will lose his sole good object. Although the split works as a defence in the way that it leaves mum as a good object, uncontaminated by badness, Adam's splitting off of his dad as all bad is complicated by dad’s history of abuse. Thus, Adam feels that he simultaneously hates dad and cannot hate him given his abusive experience.
Psychodynamic intervention with Adam
One of the first goals for therapy was to develop a relationship of safety and trust within which Adam could make links between current and past relationships and to explore and express difficult feelings. I hoped to be sufficiently containing for Adam to embrace his experiential life rather than solely attempting to control it within the obsessive thinking. Specifically, my aim was for Adam to recognise his fear of the pain of loss, first of his mum (or idealised version of her) and more recently how this is repeated in his anxiety regarding the loss of his girlfriend. Moreover, I hoped that he would be able to mourn the imperfections of his girlfriend, and in the process of this, be able to grieve for the loss of his mum as a perfect object. With his fears consciously acknowledged, my aim was for Adam to devote psychological energy to his own emotional growth rather than defending against loss. With this new found freedom, I hoped that Adam would be able to pursue his interests and direct his life as an autonomous adult.
During the process of my work with Adam I was influenced by Malan’s triangles of ‘conflict’ and ‘person’ (1989), (see figure1). The triangle of conflict consists of ‘defence’, ‘anxiety’ and ‘hidden feeling’. It relates to the second triangle of person as the hidden feeling is directed towards one or more points of the triangle of person.
In the triangle of person there is a possible link between the current relationship and distant relationships, usually with parents, where feelings directed to a person in a current relationship are derived from those directed towards parents. There is the current relationship-therapist link where similar feelings are directed towards the therapist and the current relationship. Finally there is the therapist-parent link where transference feelings are derived from feelings about parents.
Each triangle stands on an apex, illustrating the aim of psychodynamic work to reach beneath an individual’s defence and anxiety to the hidden feeling. This feeling can then be traced back from present to its origins which are normally relationships with parents. For a detailed description of the triangles and their use, see Malan (1989).
Figure 1. (See separate sheet).
Using the triangle of conflict, I explored with Adam the bases of his distress. I felt that his obsessive thinking was a defence against his anxiety about losing a relationship and his hidden feeling was one of intolerable grief. By developing a trusting relationship with Adam he was able to loosen this defence and with containment, he allowed himself to feel and explore his anxiety. By relating his current difficulties to his early experience, he was able to enter into the process of grieving for the loss of early relationships to his parents, including phases of denial, anger and sadness.
This development was achieved through linking past to present via the triangle of person. Adam’s hidden feeling of loss was directed towards each category; to me as counselling psychologist in the here and now, to his girlfriend in the current relationship and historically to his parents. Examples of these dynamics and how they were used to deepen Adam’s insight into the nature of his difficulties are described below.
Beginning stage (sessions 1-6)
Early on in the therapy Adam focused on his current problematic thoughts about his partner and his fear that ultimately, he would lose her. He was concerned to monitor the time during sessions and announced to me when the session was at an end. On exploration of this Adam told me that he was concerned that he would feel rejected if I announced the time. So here there was a therapist-current relationship link, in that Adam showed fears of rejection from me in a similar way to fearing that his girlfriend would also reject him, exposing him to his hidden feeling of intolerable grief or loss.
Adam talked of his partner’s child’s experience of growing up with a mentally ill parent and I made the interpretation that he was talking about his own experience with his dad, hence a current situation-parental relationship link. This seemed to resonate with Adam and he started to talk about his early experience with dad for the first time. He became confused and lost his thread, telling me that he felt himself ‘switching off’. Here depersonalisation or ‘defensive fog’ seemed to be brought down by Adam to protect him from intense conflicting feelings. As a result he was fearful that I thought he did not want to continue therapy and would ask him to leave.
At this point I made a therapist-parental relationship interpretation which linked his fear of rejection from me with that of his dad. He talked of how he was rejected by dad and told me that after the sessions on the way home he had started to feel upset about dad. I felt that Adam was loosening his reign on his neutralising thoughts and starting to expose himself to his anxieties. Adam became increasingly agitated during sessions. He found it difficult to keep still in his chair and was not really able to talk much. At these times he described feeling overwhelmed with anxiety as he allowed himself to stay with very frightening thoughts. During this period I feel that he allowed himself to be emotionally ‘out of control’ with me and I felt that Adam was now starting to trust that I would not reject him even if he showed me his anxieties.
Middle stage (sessions 7-29)
These sessions were characterised by Adam’s resistance which we explored as a dilemma about whether to move forward or not, due to the anticipated pain of opening up feelings. I felt that he was at the point of entering into his most feared territory, the hidden feeling of grief and loss. At this point I was feeling anxious myself. I was afraid that Adam would give up therapy at this point and I was feeling in a dilemma myself about whether or not to try to encourage him to move forward. With supervision, I was able to explore my countertransference. I was able to see my anxious feelings as a reflection of Adam’s fears and use this as a way of gaining insight into his experience.
Adam became tearful and despairing in sessions, and seemed physically smaller to me. Initially he told me that he had been afraid of being upset in front of me in case I rejected him. He made the therapist-parental link himself, telling me how he was afraid of showing his feelings to his dad, for fear of upsetting him and consequently being rejected. As Adam became more aware of his feelings about his dad, he started to talk with his sister about their childhoods, something that he had never done before. As his sister validated his experiences I noticed Adam becoming angry during sessions. He became angry when we were being disturbed by building work outside the counselling room and was able to relate this to angry feelings towards his partner and dad for stifling his development.
At this point Adam was also able to explore his conflicting feelings towards his mum. He talked of how mum did not allow him to make his own decisions and expected him to do as she did, which involved putting others’ first and never upsetting anyone. We were able to make parental relationship-current relationship-therapist relationship links here. Adam told me that similarly he felt that he could not upset his girlfriend, even if it meant ignoring his own needs and feelings, he was afraid of upsetting dad and he had been afraid of upsetting me. Furthermore, Adam was able to make the link between these concerns about upsetting others and his fears of being rejected. These sessions culminated in Adam’s realisation that ‘mum is not perfect’, that she played some part in Adam’s disturbance. This was a very productive time in which Adam took risks in exploring his negative and positive feelings. He also began experimenting with being ‘natural’ with others, admitting to them that he felt depressed or angry instead of ‘putting on an act’.
Final stage (sessions 30-35)
The final six sessions were spent preparing for ending and realising the progress that Adam had made. Adam felt that he no longer needed to spend his time controlling his thoughts and began applying for part-time work which he managed to secure by the time we ended. When I initially raised the subject of termination he was defensive telling me that he would be fine. At the same time I felt that he was angry with me for letting him go. I gave Adam opportunity to explore this observation I had made. He talked about his fears of losing our ‘safe’ relationship and going back to where he was when he started.
At the same time he acknowledged that things were quite different; he was forging closer and more realistic relationship with his mum and dad and was finding support from his sister. He was feeling more secure in the relationship with his partner and ‘freed up’ from his obsessive and neutralising thoughts. I contained the fears that he expressed and by the end I felt that Adam was managing his anxieties while being able to look to the future. Having gone some way to engaging with and experiencing his loss of relationship with his parents in childhood, Adam no longer needed to use thought control to defend against the prospect of these terrifying feelings. Released from this threat, I felt that Adam was in a better position to form and maintain relationships, including those with his parents and partner, in a way that provides mutual support and nurturance rather than in a way that repeats historic and maladaptive processes.
In this paper, obsessive thinking is described from a psychodynamic point of view, as a displaced form of grieving in its preoccupation with the loss of good objects. Unlike normal grieving however, the person is unaware of their original losses and has become terrified of loss per se. Using an anonymised case study, the paper presents a way of working which seeks to engage clients with their losses and to facilitate and hold their experiences of threat and despair, rendering the defence of thought control as unnecessary. Obviously, a psychodynamic approach is not suitable for all clients presenting with obsessive thinking. Indeed, the example here describes a motivated client, with a reasonably coherent narrative of his early life, who was given the opportunity to engage in therapy for a relatively long period of time.
Nevertheless, given the 'relentless recommendation' of cognitive and behavioural approaches (Mollon, 2007), it is important to keep other ways of working in mind, especially those that strive to understand the particular psychological meaning of a condition as well as offering strategies of intervention. Practitioners working from cognitive-behavioural perspectives recognise the difficulties of engaging clients and keeping them in treatment programmes. Working with relational depth, clients are more likely to feel engaged and in control of their development than when their behaviours are being externally modified and their thinking directly challenged. Moreover, by working through core processes of separation and loss that lie behind their symptoms, clients are likely to make long term gains to their well being.
From a psychodynamic point of view, the quotation from Rice, given below, emphasizes the importance of acknowledging ‘painful distortions’ and an imperfect reality in order to be free from the ‘magical control’ of obsessive thinking.
…All of the phenomenon of this illness have an inherent meaning and unity of their own and are part of a total and purposeful drama. The child’s view of its frightening world is refracted through the prism of adult functioning and experience, thereby resulting in varying painful distortions. The play was written in childhood and since its premiere has been played to limited but selected audiences whose participation may be required. Unless, by appropriate therapy, we can divest it of its instinctual backing, the obsessive-compulsive’s ‘living theatre’ is guaranteed a very long and agonizing run. (Rice, 1974, pp. 70-71).
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Figure 1. Triangles of Conflict and Person (adapted from Malan, 1989).