Brief dynamic psychotherapy in a case of obsessive compulsive disorder.

A 57 years old married, retired official of Indian Railway service presented with two months complaints of recurrent fears of circulation of a duplicate CD of one of his presentations in an international conference, recurrent thoughts that the years of winning medals during his tenure in Indian Railways service were misrepresented in the records as early years. He recognized these fears as irrational, intrusive causing irritability and extreme anxiety, as he felt an urge to go and check the records, and feared it would cause humiliation. A diagnosis of obsessive compulsive disorder predominantly obsessions were made. Patient refused medication and a keen interest to receive insight. Patient had strong ego functions, stable heterosexual partnership, was open to interpretations and therapeutic contract of ten sessions of David Malan's school of brief dynamic therapy was initiated. Unconscious therapeutic alliance dominated over resistance. Displacement, isolation of affect and undoing were the neurotic defenses interpreted by the therapist. Therapeutic focus was relief of obsessions occurred by 9(th) session and therapy was successfully terminated.

INTRODUCTION

Cognitive behavior therapy has become the most widely used form of psychotherapy to treat obsessive compulsive disorder; however, psychodynamic psychotherapy can also be used to treat this disorder. Since, the idiosyncratic nature of obsessional beliefs may benefit by a creative approach tailoring the interpretation of defenses unique to the individual case.

Brief dynamic psychotherapy is a psychotherapeutic technique that evolved with the early observations of Franz Alexander of a few patients who receive a crucial emotional insight in few sessions of dynamic therapy and obtain immediate relief from the problem that brought them to therapy.[1] It is a form of interpretative psychotherapy-interpretation of the defense and the link between patient's patterns of relation to current people and people in the past. Those patients with very little resistance and immediate response when defenses were interpreted are chosen to avoid the major resistance that led to the prolonged period needed in classic psychodynamic psychotherapy.[23]

All techniques of brief dynamic psychotherapy emphasize patient characteristics of motivation, responsiveness, circumscribed problem, single psychotherapeutic focus and healthy relations with both parents, recent onset of the problem and absence of deprivation.[4]

There are several schools of brief dynamic therapy; author has followed David Malan's brief dynamic psychotherapy that uses interpretation as a supreme therapeutic agent and also the capacity to be involved in the transference relationship.[4]

The mobilization of unconscious therapeutic alliance is employed to overcome the major (super-ego) resistance. Total numbers of sessions prescribed are 12. Patient characteristics are extremely important to choose this mode of therapy.

CASE REPORT

Patient is Mr. H, 57 years old married man with an adopted daughter, senior manager of a multinational company with past occupational history of being a senior official of Indian Railway Service had taken voluntary retirement a year ago with complaints of 2 months duration of recurrent fears of circulation of a duplicate CD of one of his presentations in an international conference, also recurrent thoughts that the years of winning medals during his tenure in Indian Railway Service were misrepresented in the records as early years. He recognized these fears as irrational, intrusive, causing irritability and extreme anxiety. He also tried to resist his urge to go to the administrative office of his previous employment and check the records. He was afraid he may give in to these urges that could cause public humiliation as he knew they were irrational fears and records would be in order. He was also unable to concentrate on his work and suffered from initiation phase insomnia.

Diagnosis + assessment for therapy + choice of therapy

Patient was diagnosed with obsessive compulsive disorder predominantly obsessions. Patient refused pharmacotherapy and demanded psychotherapy.

He said, “My mind is playing tricks on me, I want to know why?”

Patient had employed thought stopping, replacing automatic irrational thoughts with rational thoughts and distraction on his own and these were unsuccessful. He was aware of psychoanalysis and requested for a less time consuming form of the same treatment.

Patient had an easy temperament, was psychologically minded, responsive to interpretations, healthy and strong ego functions, stable heterosexual partnership of 25 years, no conflicts with both parents, no deprivation and was highly motivated to receive insight.

Hence, brief dynamic psychotherapy was chosen as a mode of therapy[567] and a therapeutic contract of ten sessions apart from the two initial sessions needed for diagnosis and choice of therapy was made by the author[4] (therapist).

Therapeutic focus was on the symptoms of obsessions.

Process of therapy

3rd session

Since the patient's symptoms were obsessive fears in the professional sphere, professional history was explored for both performance anxiety and social anxiety.

In the first exploratory session, patient recalled his steady climb in the bureaucracy, winning medals, accolades for his work. He was appreciated by his superiors and colleagues. He pursued his hobby as a mountaineer, climbing several peaks of Himalayas. He also was a connoisseur of music and literature.

He offered to show the therapist his collection, as both of them shared love of literature and he described his impressive collection of books and music. Therapist declined the offer. However a therapeutic alliance was established.

4th session

When asked about his responses to competition, rivalry or dominance in his work place in an attempt to uncover the primitive rage or anger, patient denied having experienced these, as he was always liked by his superiors and easily surpassed his contemporaries.

However, he paused and replied that though he did not feel resentment, he had found an equal in a junior woman colleague 1½ years prior to his retirement.

He said she was extremely efficient, focused, ambitious, shared most of his qualities. They had undertaken several projects together and he experienced a very stimulating companionship in their working partnership.

She had also shared his hobbies of literature and music. …He said “Yes, a lot like you” to the therapist. Here the therapist had to make explicit what patient had implied but was avoiding, that he liked the colleague. To focus on the actual experience of feelings and not on the technical snags in the projects they had undertaken together. He had established transference that enabled him to admit these feelings without being overwhelmed.

5th session (break-through)

Patient was probed for feelings of attraction toward the colleague. He did not wish to discuss it and spoke at length about intellectual compatibility. Pressure had to be built up by making him focus on the actual experience of feelings and confronting what he was avoiding. Finally, he accepted it (unlocking the unconscious and overcoming the major resistance).

Patient expressed anxiety he felt about the social impropriety in his feelings and intense guilt towards his wife and also his fear of trespassing the boundaries with the colleague.

Interpretation of his voluntary retirement as the avoidance behavior due to his anxiety was accepted by the patient, with an “Aha” sort of emotional insight.

6th session (interpretation)

Patient was gently pointed out the defenses “displacement” and “isolation of affect” that could be served by the duplicate CD. Patient said, “Duplicate? Yes, that was her!”

He was also more appreciative of the link between the underlying anxiety of losing the duplicate CD that seemed irrational, but could be due to the emotional link he felt with this woman and fear of losing that companionship and the inappropriate attraction becoming known to the public.

7th session (interpretation)

“Reaction formation” and “undoing” were the defenses interpreted for the symptom of the irrational fears that time of the receipt of his awards were dated earlier, to coincide with her tenure, to match her age (it was another social factor that upset the patient, as she was more than a decade younger to the patient).

These interpretations were accepted.

Patient re-experienced the ambivalence and guilt of feeling attracted as synonymous with adultery. Patient was explained that it amounted to “magical thinking” as he had not committed any act of adultery. With this his superego resistance was dispelled.

8th session (termination)

Patient reported that he was feeling free to love his family again. He said he was grateful for having experienced such terrific compatibility with a woman, though not his spouse.

“Perhaps I am young at heart and ahead of my times, my awards show that…?” He smiled as he said this.

He accepted the transference and it helped him to reframe his past experience in more positive terms “discovering me through your help was just as much interesting as working with her, thank you!”

He said he no longer experienced any obsessive fears. The mystery was solved.

In the 9th Session, patient terminated therapy, with a box of Swiss chocolates. He said, he had spoken to the woman colleague over the phone about some assignment and experienced no anxiety, just a mild discomfort. His relationship with his wife had improved, he was happy that his daughter was doing well in her studies. He was planning to take an expedition to a mountain. Patient was able to feel excited over his adventures like in the past.

He called the therapist over the phone to say he was maintaining the improvement 3 months later.

No further contact was made.

DISCUSSION

If a spectrum of psychoneurotic disturbances based on the degree of resistance could be drawn, this patient can be placed in the extreme left of the spectrum with least resistance and handling the resistance was tactical. The techniques used to build pressure before breakthrough were:[4]

Making explicit what the patient implied but was avoiding.

Directing the interview toward a specific area that patient did not wish to discuss.

Focus on the actual experience of feelings.

Asking the patient to be more specific, to give examples.

Confronting comments and pointing out some issues that are entirely true but that the patient did not want to look at.

In the 5th session there was the dominance of the unconscious therapeutic alliance over the resistance, hence the breakthrough.[8] Transference was also facilitated by the therapist characteristics, as the therapist was also 15 years younger to the patient and a woman professional, shared some of his hobbies such as music and literature. Patient had affective responses rather than cognitive responses to most queries, hence made it easy to work with.[9]

Working through involved interpretation of defenses:[3]

Displacement — Duplicate CD for the threatening emotional object (lady colleague).

Isolation of affect — Irrational anxiety over the circulation of duplicate CD.

Undoing — Predating the receipt of his awards to match her tenure in the service.

Reaction formation — Taking voluntary retirement in response to the public humiliation of his feelings becoming known to all.

Magical thinking — His feelings of attraction as synonymous with adultery.

There was not only resolution of symptoms, but also evidence of changes in the family dynamics. Patient related more intimately with the wife and was more actively involved in his daughter's studies. Hence the pathogenic organization of the unconscious was totally removed. There was more emotional flexibility, enhanced self-esteem.[10] There was a better emotional grasp of one's interpersonal world and one's sense of self within it. Dependence on the therapist was never an issue; he felt he had undertaken an exciting journey in to his own mind with the help of the therapist.[4] There was a restorative healing component in the therapeutic relationship.

CONCLUSIONS

Brief dynamic psychotherapy can be an effective mode of psychotherapy for selective patients with high ego functions, single psychotherapeutic focus, recent onset of problems and no major resistance in the form of murderous rage and guilt in relations to parents, siblings and other figures from the past.[7]

Transference relationship is a therapeutic agent and ability to establish it with a client can give much self-satisfaction to the therapist![9]

Dynamic therapy emphasizes the uniqueness of a client and humanizes therapy.

In this case, patient terminated therapy ahead of schedule, the question the therapist asks herself is did he act out the avoidance in the transference relationship? Since therapeutic focus was attained, it remains a speculation.