7 Vexing Questions & 7 Encouraging Answers for Therapists Who Treat Obsessive-Compulsive Personality

Originally published by: The Healthy Compulsive Project

I recently had a conversation with a colleague, Brittni Capps, who also works with people who struggle with rigidity, perfection and other obsessive-compulsive personality tendencies. She and I recognized some common, thorny and vexing issues that come up in psychotherapy for both therapists and clients. She formulated these as questions for clinicians, and I’ve done my best to answer them.

It’s a challenging condition to treat, and each of these clients has their own version of obsessive-compulsive personality (OCP). So, I can’t be too specific about what will come up and what to do about it. But even though I can’t tell you about the exact neighborhood you’re venturing into, I can give you some ideas about the overall territory there, and share some thoughts about how to deal with the difficult situations that can arise.

I’ve been a therapist for 33 years now, and the last ten largely with people with obsessive-compulsive personality. It’s been a wild ride and I wouldn’t have missed it for the world.

While this post about how to work with people who have obsessive-compulsive traits is addressed primarily to clinicians, I am imagining that those of you who are in psychotherapy will find this look “behind the curtain” interesting and helpful as well.

Please note that my comments are about obsessive-compulsive personality, not obsessive-compulsive disorder. For more on that important distinction, click here.

Change and Progress in the Obsessive-Compulsive Personality

Before I get into the specific questions themselves, let’s talk about change and progress in the obsessive-compulsive personality first.

It will save you much grief if you can see how their particular OCP tendencies affect the treatment process. For best results, use incursions of their traits into the treatment–because now you have the problem right there in the room with you. It’s Cozy.

For instance:

Teacher-Leader type compulsives will feel the urge to control the therapy, and, whether they tell you or not, they may be thinking how much better the process would be going and how much more progress they would be making if they were in control. And they could be right. Don’t be afraid to let them take some control. But talk about it. If you can bring it to light and explore it as it’s happening, you create a real-life experience that can be healing.

Doer-Workers will want behavioral assignments that allow them to DO and would happily skip over all the nasty chaos of feelings. “Just tell me what to DO so I can DO it!” Sorry, I can’t. Can we talk about what it feels like to sit with those messy emotions? Or even their absence? Homework is fine, especially when it grows out of the session organically. Avoiding emotions is not.

For Server-Friend types, the need to please the therapist, sweet as it is for the therapist, may become an obstacle to claiming their own power and authenticity. And their wanting to be liked could make them sensitive to suggestions about change. We used to call this transference but I realize that’s become passe, so I won’t mention it because I’d hate to offend anyone. But I’ll still suggest that you talk about how their wanting to please you affects their progress.

The Thinker-Planner type will feel perfectly comfortable flying around in circles high above the fray of feelings, trying to understand why they are this way. Understanding why can be good, like what purpose their obsessiveness has served. But it can’t be all. They may also be reluctant to take the risks of changing behavior. This may require more direction on your part as a clinician, and more focus on feeling and behavior. We need to facilitate experiences that go deeper into emotions and lead to active change, rather than just cogitating. If you can identify rumination and obsessing as it’s happening in the room, and explore what feeling they are trying to avoid, you can leave your office that day happy for having done great work.

And one final note. Urgency is characteristic of virtually all compulsives, even the obsessive ones. Since many therapists have obsessive-compulsive traits themselves, the pressure to produce progress may push their buttons. Just remember, you can’t do this by yourself. And you can’t cure everyone.

Now onto the questions.

1. How do you help clients distinguish between genuine self-improvement and what they fear is “letting themselves off the hook” or becoming complacent?

The simple answer is that genuine self-improvement moves them closer to that which is most important to them (e.g. peace of mind, fulfillment). Complacency leaves them stuck in defensive avoidance (e.g. security).

But since nothing is ever so simple, here’s the real answer.

The problem is that “letting themselves off the hook” or being complacent could actually signify progress.

A patient shows up to their session 60 seconds late and fear it means they’ve gotten lazy. I say, “No, it means you’re making great progress!” But I can’t say that if health, peace of mind and being less stressed and less depressed aren’t goals we’ve agreed on.

We need to agree early in the treatment process what their goals and values are, and therefore how we would define progress. Genuine self-improvement and complacency may feel like one and the same to the clients with obsessive-compulsive personality because they automatically pathologize their progress.

We may need to normalize what they’ve considered evil rather than allow them to continue to deny their needs and deny their shadow.

If you want to get to health you can’t get there by rushing around like the cartoon version of the Tasmanian devil. Progress, such as being able to slow down, may feel uncomfortable for a while.

Here are some ideas about how to help them get to where they want to go.

First, I would want to explore what it means to be “off the hook.” Do they think it would be preferable to be “on the hook,” I mean, like a fish? What is the hook that they want to hang on? Do they think that’s actually a good thing? The phrase originated from fishing and it’s a good image to make real and visceral how they’ve been living.

Depending on the patient, I might be so provocative as to say, “What’s wrong with being complacent?” Really! Who, or what part of them, tells them that that’s so bad?  Will their Complacency Police come after them if they are complacent? And what then?

What’s the feeling they don’t want to have? What are they afraid of?

Try to stay with the process of how they decide rather than whether it’s ok to be sixty seconds late. The danger is that you get caught in their struggle over judging what’s right and what’s wrong. As long as we’re talking about fish, teach them to fish rather than giving them a fish.

And beware the false bifurcation. Can one only either be “on the hook” or complacent? If you can, have them name and personify the cast of their characters that prolong the debate.

If they can’t do that, this might be a good time to introduce them to their Parent, Adult and Child as the three basic components of their personality. The Parent wants to keep you on the hook, and the Child, understandably, wants only to play after being “on the hook” for all those years. Ideally the Adult voice crafts a reasonable compromise which moves them closer to living their values.

But my experience is that the Adult is as novel to many clients as a Quaker is to a Mixed Martial Arts event. You may need to model an Adult approach, and to point out times when they do let the Adult take leadership.

And here’s a bonus suggestion for those of you who might be interested in a Jungian, mythological or prospective approach. Inanna was a Sumerian goddess who, after being divested of her divine garments, hung on a hook in the underworld. If you look for images of her online you’ll find only glamorous ones. We forget, or never knew, that this was a vital stage in her evolution toward humility and wholeness. If you can see the hook as a necessary but transitional and temporary stage, you’d make Joseph Campbell very happy—whether you want to or not. If the patient insists they need to hang on a hook, ask yourself, “What purpose might it serve in their psychological growth?”

2. What do you see as the deeper psychological meaning behind the fear of being ‘found out,’ even when clients are objectively making progress? It could mean that their true self would be seen, and they imagine that that would be a total disaster. What are they afraid others would see, and what’s so bad about that? And do they think the therapist has “found it out” yet?

If so, I’m still here.

I think we can all understand that it’s scary to reveal our true selves, even if we know it’s the best thing to do. It’s human to fear it. And it can be helpful to tell our clients this. Though I did once tell a client that what they felt was very human and they asked, “Is that a good thing?” This actually opened things up a lot.

We all have a Shadow side which we try to hide, and instead we try to promote our Persona, the mask that we want to present to the world so that we appear acceptable. What is the discrepancy between who they feel they really are, and how they want to appear to the world?

We often assume that others want us to be perfect, but I think most of the people we would actually want to spend time with really prefer authenticity. Being imperfect is what proves we’re human.

Perfectionists often make others uncomfortable. We sense that it’s only a matter of time before we come in for the same judgment that the perfectionist unleashes toward others and themselves.

And I also wouldn’t want to pass up the opportunity to wonder aloud if the deeper significance is that the client finds out about themself.

We need to acknowledge something about progress here. Even when patients have made observable behavioral progress, they might still feel like a 13-day old banana inside. Some obsessive-compulsive personality clients do change their behavior but still suffer mightily with the urge to overcorrect, overwork, overplease or overthink.

The old maxim that you change your behavior first and the feelings will follow is true to some extent. But the shift in feelings often takes much longer than we would like, and may never happen completely. We need to acknowledge this as clinicians. Implying that we can turn around an entire personality as quickly as you change your Fruit of the Loom bathrobe for a Versace version would be deceptive. Deep change takes time, and if we don’t accept and convey that, we are playing into the compulsive’s need for urgency and control, if not our own need to rescue as well.

But the good news is that we can learn not to be so fused with uncomfortable feelings so that they aren’t as disturbing. The feeling is still there, but, as you would a rattled rattlesnake, you keep it at a respectable distance.

3. How do you work with the inner narrative that says: ‘If I’m feeling better, I must be missing something, avoiding something, or deceiving myself’?

You could try investigating the content. What is it they imagine they’re missing or avoiding? I realize that it may be the unknown unknowns they are afraid of. I would ask this not because I think we can sort out what they might really be missing, but to pull back the curtain back on this Wizard of Laws who makes them feel they are missing something and look at the process.

The Parent-Dictator-Super-Ego mostly blows smoke and puts up mirrors in the obsessive-compulsive personality.

I want to encourage the cultivation of a voice, like the Adult voice I described before, that questions this other browbeating, parental voice, because it is so undiscriminating. It will always find an excuse to rip into us, so we really can’t trust it. We want the Adult voice to eventually be in the driver’s seat. This takes a lot of repetition, personifying the critical voice, and maybe even some gentle, judicious teasing.

“Ya know, I think you’re right. You do seem pretty dangerous to me. You should never let yourself feel good.”

And what if they were missing something? They may need to face the slings and arrows of their Parental voice rather than placate it, because living the old way was not sustainable and did not get them where they wanted to go.

I would want to ask “What’s it like being bossed around so much by an inner dictator who can’t even button his own fly?  And, you know, great baseball players strike out 65% of the time.” What’s most important to them? Their productivity and righteousness, or well-being, relationships or health?

How did they decide that they were so depraved? What purpose has it served for them to be on guard against their own transgressions all the time? We also need to be aware that these patients may be in denial of their feelings, and they are using work or planning to avoid them.

They are being driven by something other than well-being. Is that ok with them?

4. How do you approach obsessive-compulsive personality clients who present with high ego-syntonic rigidity and very little perceived distress? And similarly, what do you do when the client says, “But I feel better when I’m compulsive (or perfectionistic or productive)?”

“Well, that’s wonderful! You’ve found your own solution!“ OK. So maybe that‘s a little snarky. But my point is that if their precision, propriety and prudence weren’t causing them a problem they probably wouldn’t be here. If they like things as they are, that’s up to them. What are they coming to therapy for?

I’ll tell you. They’re coming either because someone in their life that they love is complaining about them, or some internal part of them is howling horribly to be let out like a cat that’s been locked in a tiny room for a month. That howling might take the form of rebellious behavior, anxiety or depression.

When they say “they” feel better, what part of them is doing the speaking? Are there other parts that have been silenced? Be on the lookout for these other parts.

To paraphrase Walt Whitman, “We are large. We contain multitudes.”

So, to answer the question, sometimes we need to serve as advocates for the marginalized parts, the parts that don’t have a voice. And I tell my patients as much. These parts may show up in dreams as pets or young children that desperately need attention. They may show up as compensatory indulgences they regret. They may show up as parts that are going on strike. Or they may show up depressed as hell.

You may also need to serve as a grief counselor.

If their partner wants them to change, then they may need to mourn the fact that they can’t keep going on as they have been and still stay in that relationship. They may need to acknowledge that they don’t come across as the good guy or gal they imagined they were.

Recognizing the excluded parts may take some mourning as well, because it will mean that they can’t work as much as they would like to. It may mean they have to slow down and take care of their body. Or it may mean they have to accept that, like any superhero, even they have limitations in what they can do.

Don’t let your caretaker complex convince you it’s your job to find an easier solution for them. And don’t take too much responsibility. They need to want change more than you.

But there is hope. What they give up in over-compensatory behavior they may gain back by re-engaging in what’s truly most important to them. Helping them make that pivot (to use the ACT term) is part of our work.

5. What do you do when the client says, “Maybe all that is true for other people, but that doesn’t apply to me.”?

Sounds like we have someone in the grips of an overactive Hero complex here, meaning a part of their psyche that brutally demands they accomplish superhuman tasks, as would Superman or Superwoman.

We need to start by exploring, “Why doesn’t it apply to you? Why is so much more demanded of you than of others?”

You may get some reasonable answers. Perhaps they were privileged or gifted and feel they owe it to the world to make a difference. Or perhaps they were decidedly unprivileged and feel they have to work harder to prove themselves to get what they want or need. This is a reality in some cases, depending on their goals, and sometimes we do need to take it into consideration.

But the kicker is that the brutal self-attacks insisting on heroism make it harder to achieve what they want or need to achieve.

They may know this intellectually but need your help to realize it emotionally so they can change it. To achieve change, think right brain. Think experiential. Think exposure. Think present moment. Think relationship. Think image. But don’t think too much.

There are often also deeper issues, shadow issues, involved when we believe we have to heroically deliver more than everybody else. Like pride. And identity. We like to imagine that our calling is more glorious than chopping wood and carrying water, more glamorous than doing well the mundane tasks of life that sustain the larger community. And we feel cheated when we don’t get to operate at that higher level.

Worse, we can then start to feel gratified by thinking of ourselves as righteous victims when heroism is withheld by the Universe.

If they seem to be stuck complaining about how unjust the world is, then we need to ask what they get out of focusing on that. It might not be pretty, but it probably has meaning. It might not be conscious yet, but it probably could become conscious.

But since pointing this out can hurt, we need to balance it by empathically asking: “What’s it like to live that way, under the constant threat of failing unrealistic expectations?” Encourage them to acknowledge and express the suffering this way of living has entailed.

If they persist in saying that what is expected of them is out of their control, then it’s time to ask what is within their control, and what do they hope to accomplish. Having a judgmental canon constantly pointed at you is alarming, and they may be hoping that Saint Therapy can perform a miracle.

Admittedly these are challenging questions, and they require a good relationship to ask them. But no one ever said turning around a personality disorder would be easy. If you can, get their permission to challenge them in the first session. And even thereafter, if you have a challenging question to ask, ask permission first.

6. What do you see as the most effective ways to help obsessive-compulsive personality clients reconnect with desire without triggering guilt or perceived irresponsibility?

Look who’s talking.

Name the guilt as a complex, personify it and objectify it as a part of them that had been helpful but has gotten out of control. And then help them have a discussion. Or a showdown.

How did the guilt complex gain so much power? What were the messages they got about desire from their family? Has it ever gotten them in trouble?

What do they imagine they can be responsible for? Their assumptions are usually unrealistic, and we do need to tell them that, but telling them works only in the easiest of cases.

It’s better if their own body tells them. One technique that you may want to learn in order to help them is Focusing. You can find the six steps of listening to the body at Focusing.org. Many obsessive-compulsive personality patients are so used to ignoring the body and just pushing through discomfort that their capacity to hear what it has to say has completely atrophied.

As therapists we can also respect the desire inherent in healthy compulsiveness rather than give them another message that what they want to do is bad. Help them to recognize desire whether through the relief the body feels when they can allow imperfection to exist, or from executing something brilliantly. It doesn’t matter. Cultivating desire is the goal. The signal from the gut to the brain has been choked off by years of trying to be perfect and they need help to open it again.

I will also ask them frequently to try to distinguish between what they feel they need to do and what they feel they want to do. This distinction is fundamental in helping OCP.

When we realize that much of our unhealthy compulsiveness arises out of a need to prove our worth, competence and decency, rather than because it’s actually The Right Thing To Do as we had thought, we can see that maybe desire isn’t so bad after all. It just got a bad rap.

Ask if they would consider a small experiment. Violate their vows never to leave dirty dishes in the sink, never throw away something someone might need ten years from now, or never fail to plan every minute of their vacation. And see what happens.

We may want to vanquish the guilt before we violate our vows so the guilt doesn’t overwhelm us. But sometimes we need to violate the vows first and realize that lightning will not strike. Uncomfortable? Yes. Disastrous? No.

This may take practice with little things first.

Like moving on to the next question before feeling you’ve answered the previous one perfectly.

Oh no. Do I have to?

Yes, dear. You can set a good example for your readers by accepting things that are incomplete or imperfect. Like that last question.

Oh, all right.

7. What misconceptions about OCPD treatment do you wish more clinicians understood and integrated into their work?

Putting aside for a moment awareness of the distinction between OCD and OCPD, and awareness of the different ways that obsessive-compulsive personality manifests, I wish that they understood that there is nothing fundamentally wrong with their patients’ compulsiveness.

I wish that clinicians would integrate the idea that compulsive traits can be adaptive, beneficial and fulfilling, rather than pathological.

Otherwise it’s like condemning water because you don’t like ice.

If no-one ever felt compelled to achieve, fix and produce, we’d still be suffering excruciating toothaches, eating far too many raspberries, and waiting endlessly for snail mail to arrive.

I’d also hope that therapists can see that it is possible to enlist obsessive-compulsive traits in the service of the therapeutic work. For instance, compulsives love to count. Have them count the number of minutes they can save to spend on more fulfilling endeavors if they spend less time cleaning.

As I point out in my book, The Healthy Compulsive: Healing Obsessive Compulsive Personality Disorder and Taking the Wheel of the Driven Personality, when the obsessive-compulsive personality has become disordered, it is only because the potentially adaptive energy, precision and meticulousness that comes with the personality has been hijacked for maladaptive purposes—like proving that they are OK rather than using those gifts to actualize their passions. They’ve lost track of what’s really most important to them.

Our role as clinicians is to help patients remember what they originally wanted to do with those gifts and find a fulfilling way to live them out. As the doctor in the following story did. Thank goodness.

Gillian Lynne

I’ll close with the story of Gillian Lynne, the famous British dancer and choreographer who choreographed Cats and Phantom of the Opera.  As a child Lynne was getting a very bad rep with all her teachers. They said she couldn’t sit still enough to learn and there must be Something Wrong With Her.

Her mother took her to a specialist for a diagnosis. After speaking with them for a while, the doctor asked the young girl if she would mind him stepping outside with her mother for just a moment. He turned the radio on to a music station and walked just outside the door with her mother. Through the window in the door they could see her dancing around with joy and abandon.

The doctor recognized something profoundly important, and told her mother, “Your daughter doesn’t have anything wrong with her. She’s a dancer. Take her to a dance school.”

What wild and wonderful things do our clients need us to recognize in the potential of their compulsiveness?

References available in original article on The Healthy Compulsive Project.