Obsessive-compulsive disorder is an anxiety disorder in which individuals suffer from invasive and unwanted thoughts and behaviors that drive them to repetitive actions to ease anxiety (“ADAA”, 2010-2016). According to the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition, an individual diagnosed with OCD must present with obsessions, compulsions, or both in a time-consuming manner or cause impairment in some area of effective functioning (“Beyond OCD, 2016). Additionally, the DSM mandates the condition cannot be attributed to any other medical condition or physiological effects of substances such as drugs or alcohol (“Beyond OCD,” 2016).
Obsessions are recurrent intrusive and unwanted thoughts or impulses experienced by an individual that lead to distress or anxiety. The individual attempts to ignore the thoughts or subside the thoughts through the use of compulsory actions (“Beyond OCD” 2016). Compulsions are ritualistic or repetitive behaviors the individual indulges in according to specific rules to subside obsessive thoughts. The behaviors aim to reduce anxiety or distress, but disconnect from the reality of the obsession or occur in an excessive manner (“Beyond OCD”, 2016).
The symptoms of OCD include obsessions and compulsions that may or may not be recognizable by others. For instance, the compulsions are behaviors utilized to subside the obsessive thoughts. The obsessive thoughts are triggered by stimuli from a direct obsession or fear or the through certain sensory stimuli. Sensory stimulation of obsession may cause one to search for something that looks or feels right rather than diminishing a direct fear (“Beyond OCD,” 2016).
Effective treatment of OCD consists of Cognitive Behavior Therapy can reduce symptoms in conjunction with medication to treat underlying causes such as depression which often accompanies OCD (“Beyond OCD”, 2016). CBT utilizes exposure therapy to break the cycle of compulsions as the gradual introduction to the obsession occurs. For instance, one may present with excessive handwashing. The therapist may have the individual hold something and not wash their hands after. It is essential for the individual to continue exposures after therapy to maintain remission of symptoms (“Beyond OCD,” 2016).
The psychodynamic approach began with Freud and maintained human behavior is motivated by unconscious drives; the ego contains defense mechanisms used to deal with unresolved conflicts that contribute to behavior, and early experience impacts adulthood (Plante, 2011). Freud’s perspective anticipated that insight in combination with working through the unconscious motivators help improve psychological health and behavior, as well as analyzing the transferential relationship between therapist and patient improves mental health and behavior (Plante, 2011). Additionally, analyzing defensiveness and resistance to treatment allows insight into the behaviors being triggered (Plante, 2011). Techniques such as dream analysis and interpretation, free association, and transference analysis make it possible for the therapist to gain insight and understanding and work through unconscious impulses, wishes, drives, and conflicts the individual deals with on a daily basis (Plante, 2011).
OCD, initially termed by Sigmund Freud as “obsessional neurosis” fell under the umbrella of neurasthenia (Kempke & Luyten, 2007). Freud conceptualized the disorder as a conflict between the ego and superego, or aggressive and sexual impulses emerging from the id manifesting symptoms of obsessions as a punishment sent by the superego (Kempke & Luyten, 2007). According to Freud, an individual with OCD has actively repressed aggressive impulses which manifest through uncontrollable maladaptive behaviors, whereas an individual perceived as “normal” deals with the impulses in a more positive manner (Kempke & Luyten, 2007).
Treatment focuses on early childhood experiences, personality structure, and influences of the unconscious through analysis of past experience and dream relationships to the individual (Plante, 2011). The effectiveness of the psychodynamic theory holds the potential for a positive outcome. The theory dictates that past experience shapes individual behavior. A patient develops disorders such as OCD due to something in their past, learning, acknowledging, and dealing with the experiences that built the behaviors aids the patient in finding acceptance and leading the way to break the undesired cycle (Plante, 2011).
The cognitive-behavior approach focuses on thoughts and beliefs in conjunction with reinforcements to control undesirable behavior to control and manipulate behavior; however it draws more on behaviorism than cognitive psychology (Plante, 2011). Cognitive-behavior therapy derives from the research performed by psychologists such as Skinner, Watson, and Hull in regards to the principles of learning and conditioning (Plante, 2011). Both overt and covert behaviors acquired through learning and conditioning in the social environment (Plante, 2011). Primarily focused on current experience, Cognitive-behavior therapy applies emphasis on observable and measurable behavior, environmental influences on behavior, and empirical research on assessment, treatment, and intervention through the use of perspectives such as operant and classical conditioning, social learning, and attribution theories (Plante, 2011).
Classical conditioning, such as exposure can be used to overcome fears and anxieties (Plante, 2011). Gradually introducing the stimulus that causes the fear or anxiety allows an individual to overcome slowly the fear or anxiousness that arises when exposed to the stimulus (Plante, 2011). Thought-stopping techniques interrupt the negative thought patterns that lead to anxious behaviors and reinforce positivism, as in obsessive thoughts (Plante, 2011). Developing a behavior contract with a therapist may help patients stay focused, stick to the intervention plan and behavior rehearsal can prepare the patient for unexpected exposure and aid in breaking the cycle of as in compulsions (Plante, 2011).
The humanistic approach rejects the perspectives of behavior and psychodynamic theories and assumes a phenomenological approach that encompasses the individual’s perception of experience in the world (Plante, 2011). The underlying basis of the humanist perspective is that people are active, creative and strive for growth and love as they aim for the goal of self-actualization, or the greater love, peace, and acceptance from others and the self (Plante, 2011). To help individuals achieve the goal of self-actualization, humanists exhibit active listening, empathy, unconditional positive regard, and congruence with patients (Plante, 2011) allowing the patient to feel he or she is in control of their destiny and their thoughts and feelings are accepted no matter what they are.
Rogers developed the client-centered approach that emphasizes the importance of emotional honesty and a non-judgmental therapeutic environment (Plante, 2011). He emphasized people have an innate drive for growth. However that drive may be hindered by the social environment as pressure is placed on the individual to follow a path he or she is not truly passionate about resulting in a deficit of reaching self-actualization (Plante, 2011). Maslow developed the hierarchy of needs which is a ladder an individual must climb to reach their full potential and achieve peace and acceptance of themselves and within the world. He emphasized failing to complete all steps would result in the individual not fulfilling the peak experience of self-actualization (Plante, 2011). Perls Gestalt perspective assumes that problems occur due to the individual’s inability to be aware of their current self-status causing their focus to lay in the past rather than the present (Plante, 2011). Self-determination theory emphasizes the importance of the three fundamental psychological needs of competence, autonomy, and relatedness, which, when nurtured, lead one toward self-actualization allowing the client to feel respect from the therapist and in control of their services. The therapist goal is to see the world through the eyes of the client and not tell the patient what to do, but encourage positive choices in the direction of self-actualization (Plante, 2011).
The Humanist approach to dealing with OCD allows the patient to feel as if they are in full control of what is taking place as they experience empathy and respect from the treating therapist. The patient is encouraged to choose their destiny: to eliminate the obsession and compulsive behaviors caused by the obsession and not feel as if their disorder is being judged and scrutinized, rather accepted, but changeable.
Family Systems Approach
The family systems approach aims to reduce limitations from the other perspectives caused by intercommunication problems with the patient (Plante, 2011). This approach incorporates family members as well as others intimately related to the patient into therapy. Family systems therapist emphasize any change in a member’s behavior affects the family unit as a whole not just the individual experiencing the behavior change (Plante, 2011). Satir’s communication approach assumes family dysfunction attributed to ineffective communication. Promoting congruent communication encourages the member to speak only true feelings and break down any blocks in the communication line, to achieve understanding among all involved (Plante, 2011). Minuchin’s structural approach focuses on breaking patterns of enmeshment, differentiation, and disengagement by promoting a more balanced and functional family unit (Plante, 2011). The Milan approach focuses on the incorporating the therapist as a part of the family unit, not an outsider. Through the use of hypothesizing and positive, logical connotation positivity among the familial unit holds the potential to create solidarity among all members. Since the goal is to alter behavior, the assumption that resilience will be met is probable but repairable with certain techniques. Paradoxical techniques, or “reverse psychology” are effective when attempting to alter familial behaviors and faced with member resistance (Plante, 2011). Reframing holds promise in that it causes the family to see a negative behavior as a positive signal for something (Plante, 2011). For instance, an individual obsessed with hand washing can be perceived as an individual who is modeling the behavior of cleanliness and not spreading germs.
Effectiveness of Treatments
OCD is a disorder that cannot cure itself. It develops from some experience that leaves an impressive mark on the individual. All four perspectives, when incorporated together will hold the highest potential for breaking OCD cycles. Psychodynamic therapists force the individual to face past experiences and analyze them to get to the cause of the fear or anxiety that causes the compulsive behaviors and then guides the individual into acceptance enabling them to grow from the experience rather than dwell and become locked down. Cognitive behavior therapy utilizes conditioning techniques that produce reinforcement schedules that deter the compulsory negative behaviors and redirect the individual to more positive behavior. Additionally, exposure therapy has proven beneficial when attempting to break a fear and alter reactions to the fear. Humanistic therapy promotes a positive, accepting environment void of judgment that allows the individual to feel accepted rather than rejected adding promise to the acceptance of the modified behaviors. Family systems therapy incorporates all persons into therapy teaching the family and supportive individuals how to deal with the patient as well as how to be supportive and communicate effectively to achieve a more balanced and peaceful environment. Combining all four approaches would be beneficial to an individual living with OCD.