J Contemp Psychother (2008) 38:87–96
DOI 10.1007/s10879-007-9072-y
ORIGINAL PAPER
A Flaw in the Fabric
Toward an Interpersonal Psychoanalytic Understanding of Obsessive–Compulsive
Disorder
John J. O’Connor
Published online: 7 March 2008
Ó Springer Science+Business Media, LLC 2008
Abstract There appears to be a broad impression that an
explicitly psychoanalytic framework of obsessive–com-
pulsive disorder (OCD) is outdated and obsolete. However,
interpersonal dynamics and experiences within the family
during childhood and their intrapersonal sequelae in par-
ticular, may have substantial bearing on the early stages of
the development of OCD. The author presents a set of
observations about obsessional thoughts based on case
material from research projects, psychometric assessments
and psychotherapy with these patients. Freud’s contribu-
tions to understanding the internal world of the patient are
discussed, suggesting a need to extend beyond the crucible
of emerging affects and their regulation and into the wider
stage in which the most profound struggle exists around
relating to the other. We place the individual’s experience
of others at the centre of our theories of the aetiology of
OCD. We need to expand our understanding of OCD,
particularly in how we locate the individual’s internal
struggles within the context of the social environment in,
and perhaps out of, which they have emerged.
Keywords Obsessive
Compulsive
Treatment
Introduction: A Portrayal of OCD
Obsessive–compulsive disorder (OCD) is one of the most
prevalent of all conditions met in child and adult psycho-
therapy and it has for long presented difficulties for those
who try to understand its origins and the most useful ways
of treating it. Rituals and ruminations are often highly
John J. O’Connor (&)
School of Psychology, University of Dublin, Trinity College,
Dublin, Ireland
e-mail: joconno8@tcd.ie
covert and an initial interview may reveal only the weakest
evidence of this. Later in our interactions, we find that the
true scale of the ruminations is actually far greater than
initially presented. The ruminations here remain hidden
behind apparently proportionate worries and concerns. The
pained process involved in OCD is well known to any
clinician working in this field. These patients are among
those who live with greatest mental anguish. They wash
their hands furiously. They check fixtures and fittings in
their homes and work places energetically to ensure that all
is in order. They play with numbers, arrange things in
particular ways, perform a range of bodily rituals, recite
prayers and other verbal material. Each is done repeatedly
and under the force of a great deal of anxiety and with a
vague hope that these actions, that are represented as
meaningless, will spare them and those around them
equally vague but terrifying possibilities (that others will
be damaged, injured, infected, killed, etc.). Such actions do
not offer any sustained reassurance and it is again neces-
sary to repeat these actions. For many, this can mean large
tracts of their days, for some almost without break, taken
up with rituals.
Shame and fear around the potency and destructiveness
of the ruminations and their contents seem to temper the
individual’s capacity to have these known. These features
continue to present substantial challenges for contemporary
psychotherapy as our work in this area often meets with
only partial changes at the level of symptom change—often
with the persistence of the ruminative component with a
reduction in the levels of particular kinds of rituals. While
psychotherapy often helps the person to accommodate to
their condition, and to decrease the level of certain kinds of
rituals, we are often left frustrated in our work with these
patients both by the enormous challenges they pose and by
the relatively small changes they achieve. It has to be
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acknowledged that, despite theoretical models and a vast
body of research literature, a comprehensive understanding
of the origins of obsessional thoughts remains as yet
undeveloped. We have not reached a point where, on the
basis of what has been gathered, we can develop an
assurance around what it is that brings a person to show the
associated symptoms and the relative influence of the
various kinds of factors that have been distinguished in the
literature. At the same time, of course, a kind of sense of
certainty has developed around the condition. New and
useful models only emerge and develop when we are
willing and able to question received understandings.
Much is at stake when it comes to our understanding of
the origins and development of OCD because this, in turn,
affects our approach to the kinds of psychotherapies we use
to treat these complex patients and, most importantly, the
nature of the shifts in the quality of a person’s experiences.
We cannot afford to systematically exclude reference to
possible sources of origin and of continuing influence of
factors that may have lost visibility at the level of clinical
observation. We might conceptualise in our aetiological
model the development of the features of OCD as being
like a precipitate that appears when a range of things come
together—perhaps a genetic predisposition, availability of
particular kinds of supports within the family, exposure to
experiences, presence of conflict in relationships, unac-
counted major losses and a way of responding to or
interpreting that is located in the energies of self, the sense
of self, the ego, etc. Within the two most widely discussed
psychological theories of aetiology of OCD, namely that of
Freud and that of the cognitive-behavioural school, we see
a narrowness in the construal of the place of the family.
While thinking has often centred on cognitive and
behavioural facets of the disorder and have approached
these aspects also in treatment, there are difficulties that
arise in therapeutic work with these patients that often
require a high level of sensitivity, flexibility and explora-
tion around the nature of the therapeutic engagement. This
is particularly necessary when we encounter a therapeutic
impasse, where the patient seems unable to benefit from
what is available, either refusing to proceed or feeling
incapable of doing anything that is suggested. It is in light
of such challenges and impasses that the present paper has
been framed.
Psychoanalytic Theories: A Historical Note
The questions of the origin and nature of any condition are
arguably closely related. In order to understand what is
taking place in OCD, we benefit greatly from considering
from where it has come. This was a logic that Freud clearly
recognised. It is useful to consider Freud’s rich work on
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obsessional neurosis as this really presents the first and
arguably the most comprehensive formulation around the
origins of OCD. Appearing relatively early in his psycho-
analytic works, his theory relates strongly to the drive
approach that emphasises the emergence of instinctual
forces within the person. Anxiety is aroused around these
instincts, experienced as threats to the integrity of the ego
and defences arise to manage these. In such defences, and
in the particular defences available to or chosen by the
individual, lies the origins of each neurotic condition.
Psychoanalytic theories have provided a rich way of
describing the obsessional patient and the dynamics of his
obsessionality, but they are now almost invisible within the
body of theory and practice as conveyed in mainstream
publications. Any search through the most widely read
compilations of perspectives and research in this field (e.g.,
Menzies and de Silva 2003; Jenike et al. 1998) reveals very
few psychoanalytic ideas. Psychoanalytic theories have lost
some of their vitality and have not been expressed with the
confidence with which they were originally developed.
Psychoanalytic thinkers have often surrendered claims to a
deeper, unconscious, basis for ruminations and rituals (e.g.,
Gabbard 2001). While such a concession is understandable,
a collapse in our regard for psychoanalytic theories of OCD
does not appear justified. Psychoanalytic theories still offer
something distinctive but that it is important that we revise
and amend them so that we can provide a fuller sense of the
relationship between the internal and external factors that
provide a basis for OCD.
Freud coined the term ‘obsessional neurosis’ to describe
a set of features, now more commonly described within
psychiatric nosologies as obsessive–compulsive disorder
(OCD: APA 1994). It is difficult to overestimate the place
of obsessional neurosis and Freud’s attempts to understand
it, describe it and account for it to his overall theory of the
unconscious and its expressions in mental life. He felt a
particular affinity to this work, partly recognising its
dynamics as something personally known as revealed in
some biographical work and autobiographical correspon-
dence. Freud’s ideas concerning obsessionality are
presented across thirty years of writing on the subject
(Freud 1896, 1907, 1908, 1909, 1913a, b, 1915, 1916–
1917, 1923, 1926). In his 1896 paper ‘The neuropsychoses
of defence’, in which he endeavoured to provide a psy-
chological theory of a number of disorders including
obsessional neurosis (approximating to OCD in current
parlance), Freud articulated his enduring theory of the
disorder for the first time. ‘‘In all the cases I have analysed
it was in the sexual life that a painful affect—of precisely
the same quality as that attaching to the obsession—had
originated.’’ While, early in his psychoanalytic writings,
Freud had considered the role of trauma (‘sexual seduction’
in many instances) as lying behind the development of
J Contemp Psychother (2008) 38:87–96
neurosis, he abandoned this in favour of an approach that
set the inner world of the child as the source of the neu-
rosis. This he did most famously in the case of hysteria, but
this is also the case around obsessional neurosis. His cen-
tral work on obsessionality is his 1909 paper ‘Notes on a
case of obsessional neurosis’, in which he presents the case
of the Rat Man as well as a detailed account of the origins
of the condition as a whole as he conceptualised it at that
time. As Esman (1989, 2001) notes, Freud’s views on OCD
developed little beyond his 1909 paper, and no great shifts
in psychoanalytic thinking, bar a retreat from theorising, is
evident. The case of the rat man has continued to arouse a
great deal of interest and discussion (e.g., Gans 1998;
Wertz 2003).
Freud’s enduring contribution to the understanding of
OCD lies around his recognition of the particular kind of
response to inner and outer threat that is involved here. The
very affects that have been denied acknowledgement,
expression, and sublimation perhaps ultimately, come to
dominate his experience. He has to work a great deal
psychologically in order to maintain these feared affects at
a distance. Feelings of hostility achieve a dominance and
the person’s attempts to deal with such thoughts through
their isolation and reversal. Freud’s approach contains most
of the central components required of a comprehensive
theory of OCD, addressing as it does the question of a
possible underlying predisposition to respond to anxiety
with a specific kind of regression or arrest in development
and the question of the nature and outcome of these
defences. However, Freud’s approach to obsessionality
neglects the interpersonal environment in which such an
internal process comes to be and the impact of this envi-
ronment on the process. Freud identified a specific
regression from the Oedipal to the anal sadistic way of
dealing with himself and his objects, something that we
might, quite liberally perhaps, translate as a way of
describing his retreat from the interpersonal into the
intrapsychic. He cannot completely evade the interpersonal
world but he can control his interactions with it (and fix it
in his mind) in such ways that mean that he is essentially
ridded of it. Any concept of retreat has to contain some
recognition of the subject who performs the retreat and that
something, be that real/imagined and internal/external, as
well as the middle ground. Freud suggested that, in general,
the central symptoms of OCD appear somewhere in middle
childhood—between approximately 6 and 8 years of age.
This has important implications for how we understand the
core developmental position of these patients.
Freud’s drive approach provides a rich portrayal of the
inner turmoils and allows us to construe the dynamic
interchange between ruminations and rituals. Such one-
person psychologies are partly accepted because they fit
with an individualism of the last number of decades.
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Freud recognised that these men and women are partic-
ularly locked within themselves and particularly anxious
about any ventures outward and into genuine relations
(that is, beyond the managed, false-self dominated rela-
tions to the other who is kept at a distance). It is as if they
have seized upon particular kinds of defences—including
reaction formation (turning a malign intent to a benign
one) and isolation of affect (splitting off one’s sense of
one’s own hate) most notably, and have not been able to
develop into the world. They live with a necessity to
protect others from the hostility they feel would surely
destroy them.
Most papers after Freud considered the kinds of ego
defences that operate within the obsessional patient. They
added relatively little new to the psychoanalytic theory and
this one-person defence-focused approach to the aetiology
of OCD still pervades in the slender literature of more
recent decades. In the 1960s, his daughter Anna, herself by
then one of the main figures of the psychoanalytic move-
ment, recognised that her father’s ideas had become lost for
a variety of reasons (Freud 1966). The main contributions
within psychoanalysis have been away from Freud’s ori-
ginal emphasis on the Oedipal basis for obsessional
thoughts and toward an ego-psychological approach that
appears to melt into the cognitive behavioural approaches
that have developed in recent decades. This apparent sur-
render of a psychoanalytic approach led to a shift in
thinking from a kind of interpersonal approach to obses-
sional thinking. Though thinking around the origins of
ruminations and rituals has now shifted radically toward
biological models, this shift in emphasis has not entirely
answered the question regarding the interpersonal diffi-
culties of people with OCD.
A Two Person Psychoanalytic Approach to OCD
While the drive approach certainly provided one important
set of possibilities around what takes place in OCD, there is
something clearly missing. All events outside the person
can be relegated to the position of ‘object’ and the impact
of any kind of engagement between the person and those
close to him could not enter this frame in any substantial
way. The great revolution that took place in psychoanalysis
toward the middle of the 20th century revolved around a
moving away from a singularly drive conception toward an
understanding of psychological life developing within
relations with others. While this has affected greatly the
psychoanalytic approach to psychotherapy, it has not yet
entered in any substantial extent into written works on
OCD. One way of expanding Freud’s ideas is for us to
consider that from which this young child was retreating
and to consider the ‘something out there’ that convinced
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him of the need for such a retreat. While Freud was
understandably drawn at points to the idea of some trau-
matic event, then later withdrawing from this, it might be
more useful to consider the important environmental con-
tribution as coming in the social environment’s capacity to
help the young child with the affects that emerge within
him. Particularly useful is the idea within object relations
theory that the person is fundamentally oriented toward
reaching out, finding, and maintaining a relationship with
the other. The concepts of projective identification and of
the container-contained relationship, developing in the
work of Bion (1967) provide conceptual routes into an
understanding of how the anxiety of one person may enter
into another and how, between the two, some possibility
for regulating anxiety arises.
Clinical experience suggests that many people with
OCD experience great uncertainty in their interpersonal
relationships (e.g., Barth 1990). As well as this, there is
evidence of another kind of division in thinking. The issue
of ambivalence appears again and again in accounts of
therapeutic processes with patients with OCD. Among
these are Bollas’ (1987) description of the scoffing and
rubbishing response of his patient, a man in his mid-
twenties, to his interpretations and, Furman’s (1985)
description of a 6-year-old girl’s initial rejection of her
therapeutic gestures. The hostility toward engagement
appears early in this work, however disguised or upfront it
is.
Passed through the lens of developing constructions of
psychological life, Freud description of the rat man allows
us to pursue questions that him himself did not ask and
could not answer within his central drive framework. In
particular, the case’s richness of detail allows us to con-
sider what the nature of the relationship between the rat
man and his family members, as well as between the
patient and Freud, does to our understanding of his
symptoms. We can view the case in light of a whole set of
relationship dynamics. For instance, the patient’s struggle
appears to be with finding a supportive father figure who
can help him to deal with his fears and to provide him with
a sense of security as a man. For his part, Freud was clearly
taken with this young man and sympathetic toward his
inner plight. Stepping in as a benign, yet firm, father figure,
he attempted to give sense to his patient’s troubling
thoughts. His success with the rat man may be partially
attributed to this extension beyond an interpretative
approach into a position of fatherly concern that meant
that, in a way, he could be more than simply a surgical
professional. This is seen in his development of mentor like
relationships with older men as an adolescent and even in
his seeking out of Freud himself as a therapist and the
responses he elicited in him. Freud’s own description of his
client carries hints of his own countertransference that,
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from the vantage point of a modern psychodynamic per-
spective, may point to the client’s interpersonal situation.
The then middle aged Freud writes of his interactions with
his client with a mixture of a parental protectiveness and a
demand for honesty in personal disclosure. Freud took up
the position of a father-like figure. At points in the narra-
tive of the analysis, Freud’s approach to his client takes on
quite an authoritarian quality, matched by a support for the
difficulties experienced by him. For instance, Freud lays
out clearly what he expected of his client within the
analysis—that he should say everything that comes into his
mind, without any censorship. While Freud pursued his
client’s complex ruminations and rituals as expressions
related to an underlying Oedipal struggle, it is also possible
to view in this case a more general struggle between the
client and his internal representations of his parents,
echoing in turn perhaps an earlier set of actual relationships
that were disturbed to a greater or lesser extent.
A number of quite straightforward observations have
brought me in the direction of my conviction that an
interpersonal disturbance underlies the intrapsychic fea-
tures of OCD. They are as follows: Firstly, and connected
in with the very core of the condition, we find that the
ruminations of people with OCD usually involve risks that
one will damage another in some specific manner or in a
number of less clear ways. Secondly, OCD usually has its
origins within a period during which the context of the
family is still central to the child’s psychological reality,
whether this be the periods of early or late childhood or the
early adolescent period. The child is still very much located
within the family in middle and late childhood and early
adolescence—the periods during which the earliest symp-
toms of OCD tend to appear. Thirdly, most patients with
OCD show a high level of protectiveness/defensiveness
around their families. When clinicians ask patients with
OCD about their families, we are often presented with
certain kinds of initially protective responses. We meet at
the forefront of their representation a kind of idealisation
that does not reflect the full balance of the person’s
thinking and experience (e.g., O’Connor et al. 2004).
When we ask further questions, we often encounter
something more sophisticated—details of highly complex,
often disturbed and ambivalent relations. This phenomenon
is in my experience quite characteristic of people with
OCD and I think it is one of the factors that has distracted
researchers and clinicians from pursuing questions around
the family experiences of people with the disorder.
Fourthly, we often observe or have reported changes in the
nature and intensity of ruminations and rituals relating to
changes in the person’s social circumstances. We may
observe an increase in the level and intensity of rituals at
times of conflict within the family and a decrease at times
of separation from family members. Finally, we recognise
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particular dynamics that take place in how people with
OCD relate to professionals as whole (something that
likely extends from their approach to people as a whole).
They are generally highly apologetic as if, in minor acts,
they have committed something grave.
It is important that we move outside the intrapsychic
perspective and observe the inner world as emerging from
an interaction between such a world and the external con-
text. It is here that the issue of the family as a part-source
and cradle of experience arises. The family is a sophisti-
cated entity, not simply a matter of parents and their
children, but also of more extended networks of figures who
play a central and guiding role in the person’s life. As well
as being a definite entity with clearly demarcated and sep-
arate members, the family is also an entity charged by our
imagination/fantasy. In looking at the issue of the role of the
family in the aetiology of OCD, we benefit from consider-
ing this from a number of angles and at a number of levels:
(1) Actual and direct influences by family members on the
development of features; (2) The influence of the experi-
ence, fantasies and interpretations that do not necessarily
reflect a reality but are decisively by the individual’s
internal world; (3) The influence of particular kinds of
person-to-person and person to persons experiences within
the family; and (4) The influence of the resources provided
by the family on the person’s capacity to moderate their
feelings. We might think of these various kind of issues as
related to realities, fantasies, interpretations and sense-
making. I think that it is often the last of these that is most
significant in the development of their conviction of their
culpability. At the centre of the difficulty of the person with
OCD is a feeling that they cannot access the other as a
source of comfort, particularly around distressing feelings.
Growing out of ideas appearing in the work of some of
the major post-Freudian object relations psychoanalytic
schools, there is a sense of psychological life (including
psychological distress) emanating from within two, three
and more person relationships. The influence here is not a
direct one but has to do with the quality of experience and
the contribution that family members make to the solution
of the inevitable internal turmoils during the various stages
of the process of separation and individuation. The family
helps the child to deal with those experiences that arise
within, that become attached to others and that cause dis-
tress. There is inherent in object relations theory (one of the
more widely discussed interpersonal approaches and that
brings together and views as connected, intrapsychic and
interpersonal processes) a sense that the child negotiates
his relationships with the world in such a way as to make
genuine contact with others and that his symptoms are what
happens as he both struggles to make and sustain contact,
on the one hand, and to deal with the problems arising with
this or anticipate in this, on the other.
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Family functioning and the experience of the family
play a decisive role in the emergence and sustenance of the
features of OCD. I believe in a model of aetiology that
locates the symptom within the relationship of the child
with significant figures in his life. Such an approach to
aetiology certainly does not blame parents. Rather, it aligns
the development of troubled ways of dealing with one’s
impulses in the realm of the interpersonal work in which it
emerges.
The family’s role within any such model is as the
dynamic environment in which the experience of oneself
and of the other, as well as of the relationship between self
and other, emerge. Thus, we find a way of registering both
the world of personal interpretation (the area in which
cognitive theories of OCD have been well-positioned) and
the world of the interchange and mutuality (that is descri-
bed within a range of relational approaches, including in
object relations theories). We might characterise OCD as
arising out of a difficulty at the level of the latter than leads
to the expression of features described in the former. We
can envisage a context in which something that the child
needs is not met within his environment. When there is an
overexposure to impinging events, without the presence of
supports or the capacity to access them, there is a tendency
to develop an emergency mechanism for protecting oneself
(e.g., O’ Connor 2007). When one feels oneself to be
responsible for damaging needed others (including parents
when they become ill, withdraw in depression, or even die),
the inclination arises also to develop ways to protect others
from oneself and from the toxins one feels one possesses
that may damage or destroy them. It is perhaps the latter
that we view most strongly in the case of persons with
OCD. This kind of approach, with a view of a failure at the
level of what we can conceptualise as ‘sense-making’ at its
centre, helps us to form an understanding of the process of
developing and maintaining rituals also. Ritualisation is a
form of one-person self-management of the internal world
that acts as an alternative to the sharing of self-manage-
ment and interpersonal management that is usually the
case. The person with OCD has great difficulties entrusting
contents of their inner worlds—their thoughts and feel-
ings—to others. This becomes a part of our therapeutic
engagement and something that we cannot ignore.
Two Cases
The cases of Barbara and Donal are, in my experience,
quite representative of people with OCD in so far as the
question of an interconnected between ruminations, rituals
and relationships is concerned. These are presented here as
a means of illustrating in broad tern the connections
between the interpersonal context of the origins of OCD, its
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contents and qualities and the character of the professional
consultation.
Barbara
Barbara is a 38-year-old woman, elegant in her presenta-
tion, who looks intensely around her, while also conveying
a kind of casualness. Barbara has highly (self) demanding
checking rituals, with obsessional thoughts that seem hard
to pinpoint but whose form becomes apparent over time.
She doubts that she has completed necessary tasks around
the house. She fears that she has left plugs in sockets, that
door haven’t been locked, that fires have been left on, etc.
Barbara described a childhood family environment, where
she assumed and was given a great deal of responsibility.
Her father, an alcoholic who safeguarded a large part of the
family finance for his daily visits to bars and drinking
clubs, seemed to her like a weak person, unable to hold
things together. She feels that she has somehow created
what seemed then like her father’s bizarre states of mind in
his drunkenness. She remembers how, as a young child, she
began to atone for what she felt she had done. She said that
she could remember trying to get everything in the house in
order, everything cleaned, everything repaired, every tear
in clothing damaged, so that she wouldn’t damage anyone
else. She remembered taking on a large part of the chores
in the ever-expanding household. With her mother, she
took on the household chores and the responsibilities in
taking care of a large family. Barbara described how she
essentially took his place in the order of the family. He
retired to the pub. With each arriving younger sibling,
Barbara felt a sense of an increased load on her life. She
had a feeling that it was her who had to keep it all together.
Hostile feelings toward her father have been kept at bay.
Barbara shows the classic pattern seen in many people with
OCD, where a devotion to the family and a continued
hostility to them exists side by side.
Barbara became her mother’s little helper from very
early in her childhood. When he becomes ill from an
alcohol-related condition, Barbara’s anger toward her
father comes to the surface in a strong way. She feels a
great rage toward him. She wishes him dead but then feels
great guilt. Even in the face of her father’s immanent death,
Barbara continues to ruminate over the daily chores and the
obligations of organising for meeting the needs of her
family—her mother and siblings, as well as her own chil-
dren. In fact, the intensity of her interest in these chores
seems to escalate as the gravity of his illness becomes
apparent and his death looms. Her ruminations and rituals
predominantly focus on her home and on ensuring that it is
always as close to perfect as is possible. Yet, her con-
sciousness shifts back to her own parents and siblings and
to ensuring their welfare also. She is drawn back to the
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demands of her parents and she satisfies them because, in
not doing so, she feels that she is actually damaging, even
destroying them. She must perform her organising activi-
ties around the house. There is no space for contemplating
any alternative. When I ask her about what it might be like
if she didn’t get round to these activities, she doesn’t
entertain the possibility. It simply could not be that this was
the case. When further I ask if she was physically unable to
perform these, she refuses to go beyond this point.
Barbara is highly suspicious of the therapeutic situation
and tries to maintain it at the level of a friendship at the
outset and through a large part of its course. Her tone is
often chatty and she is broadly dismissive of anything that
seems psychological in tone. It seemed that, in some way,
while she was the helper and the carer, she could not tol-
erate the existence of this outside of her. For much of the
time, she talks to me as if she is talking to a friend with
whom she is catching up. It is only over time, after about
2 years, that she begins to surrender this to some extent.
Over the course of therapy, Barbara begins to realign her
life and to deal with the struggle between satisfying her
own needs (felt as destructive and requiring atonement)
and satisfying those of others (felt as repairing damage but
also as emptying her out). Barbara begins to stand up to
those around her. She places limits on what she does and on
the ground she concedes to others. Her dreams of finding
some shape for her own ambition finds some realisation.
However, there is a great struggle for her in overcoming
her fear that her own self-development is a destructive
thing to those around her. Even when she comes to those
things she might secure for herself, she is initially inclined
to develop elaborate rituals around them. In order to
safeguard good experience for herself, she must initially
ward off the damage she might do to this. It was also
striking that Barbara was surprised when her children
achieve success in their lives because it directly defies her
thought that she has not destroyed them and made them
incapable of facing into the world. She runs into a difficulty
that also spurs a questioning of her felt destructiveness.
Donal
My three meetings with Donal are frantic ones. Donal
enters the consulting room with immediate apology. Sorry
to be taking up my time and delighted I have offered him
an appointment. Can I see him now? Am I sure that is
okay? If I need a few minutes to prepare or to finish
something else, that would be okay. Donal speaks without
much hesitation, merely enough to allow me to insert some
questions. He is a 65-year-old man who has struggled with
obsessional thoughts from an unknown point in his child-
hood and who has a long-standing diagnosis of OCD for
which he has received a variety of pharmacological
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treatments. He has also received, or been engaged in, a
number of ‘talking therapies’ that have been brief in nature
and apparently oriented toward reducing his reassurance-
seeking behaviours. It is not clear the extent to which these
have been successful, though it seems that they have had
the effect of softening the edges of his anxiety and of
assisting him in finding words to describe his states of
experience. His anxiety continues to lie at the centre of his
experience and his particular way of dealing with it,
through seeking reassurance from services, has resulted in
his being treated with some impatience and irritation by
staff. His child-like appeals have taken up a great deal of
the service’s time and inevitable attempts at reassuring him
have, in the usual pattern for these patients, only served to
heighten his sense that something serious is wrong. For
30 years, he has developed a pattern of contacting through
letters, phone calls, and recently by email, the services that
have been charged with his care. He has found in services
something similar to what he experienced with his
mother—an indifference that always seemed to tether on
the edge of rejection and abandonment.
At the centre of Donal’s description of his childhood is
his complicated relationship with his mother. Each sibling
seemed to receive her loving attention. She was not
available for him. He tried and tried to get her attention, but
all along he felt himself drifting further and further out of
view. His efforts did not cease with the early rejections and
he described a childhood of trying to get through to her. He
went so far as to claim that he had been attacked by an
intruder. This seems to catch her attention, but this quickly
diminished. When speaking with Donal, an impression
quickly arises that he is still addressing the question of why
his mother did not love him and that his seeking of reas-
surance is like a kind of continuing process that emerged
from early in his life when he sought this in a way that was
full of energy—then, when love was the most basic
requirement. Somehow, having not received a basic reas-
surance—which would involve having his anxieties
contained—he continued to need and seek this. This kind
of escalating process of seeking, of meeting rebuff, and of
further demanding seems like the basic vicious cycle
described by Karen Horney in her description of the origins
of neurosis in general (e.g., Horney 1937). Donal ventured
that she had perhaps bonded better with the other children,
his siblings, but this seemed like a rationalisation that
provided him with only passing reassurance. They did not
seem to have the same problem getting through to her. His
siblings hardly merit mention in his narrative. From his
account, it appears that within his world view, they were
mainly barriers on the way to his mother. They are hardly
differentiated in a world for him dominated by the need to
get beyond them, as others, to her. When he is near her,
she is preoccupied with something else and he experiences
93
her every action toward him as a rejection, while he hopes
that there is some love between the lines. This was com-
plicated further by the nature of his mother’s career. His
mother was a successful actress, who maintained her
career throughout his childhood and adolescence and into
a part of his adulthood. To Donal as a young boy, it
appeared that her attention was the more crucial, yet most
difficult thing to secure, and that everyone got more of her
than he did. It came as no surprise when taking a scissors
to one of her costumes. This is an event that seems to
capture the central concern for Donal. Around this arise
fears that his hostile attack on a mother experienced as
unloving will kill her or that it will lead her to take
revenge against him. His anger toward his mother was
(and still is) balanced, in a manner typical for many of
these patients, with a devotion. While he secretly accused
her of not having loved him, he gave over the larger part
of his adulthood to nursing her in her long-term illness
(something for which he himself felt some vague
responsibility). Having appealed throughout his childhood
for her attention and love, and feeling that this had been
denied him, he became, in his description, his mother’s
nurse over the 20 years when her health declined and as
she died. He described his various, often tortured, ways of
trying to get through to her and the constant sense of
rebuff at these efforts. In the over 20 years since her
death, his thinking seems to have never moved far from
her. Still in my meetings with him, there is a sense that he
is still inquiring about what was going on in her mind—
did she really love him?
At one point, Donal comments that he may be wrecking
my head, later saying that he hoped that his experiences
might be of value to someone else. This seemed to reflect a
process in which he would destroy and then try to repair or
reconstruct. Such a narrative of destruction and construc-
tion was repeated throughout our interaction in relation to
his thoughts on his mother, his wife and the mental health
system. Outside of this, Donal’s overall way of relating to
the world is highly constricted. He seeks reassurance from
those around him, reassurance that he has not damaged
them in a grievous manner. Initially on meeting a new
professional, he appears quite restrained and it is difficult
for his new conversant to detect his appeal for reassurance.
However, soon these appeals emerge. It seems that Donal
begins to attach his obsessions around his destructiveness
to the professional and then seeks reassurance that he has
not actually done what he fears. With this come his con-
cerns that he has damaged others and the need for
reassurance that this has not happened or that it wasn’t
possible. It seems that over the years, he has received such
reassurance over and over again. It is engrained in his way
of being in the world in an interminable cycle of appeal,
partial solution and repeated appeal.
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94
The Therapeutic Context: Revisiting the Two
We should be careful not to confuse the contemporary with
what has only recently blossomed. We need to recognise
that observations and ideas that have a long life can con-
tinue remain relevant. The work that is conducted by many
people using interpersonal and psychodynamic approaches
remains undocumented and unrepresented within the cur-
rently dominant paradigms and it is important that this
continues to be represented and its findings and observa-
tions disseminated. We should abandon what has
developed, but we should keep keeping our conceptions
open enough to allow new factors and forgotten ideas to be
considered in our conceptualisation of the condition. What
is required at a clinical level is a blending of what has been
gained over the span of thinking on the condition. Patients
require an environment that only gently challenges their
position but equally does not loose sight of the psycho-
logical reality in which they struggle. Patients require a less
robust attitude toward interpretation and a level of flexi-
bility in the treatment of boundaries and the parameters of
the therapeutic situation. They more than ordinarily require
a long period in an antechamber before developing a
capacity to enter into this work in a fuller way—that is,
before they can allow the therapist to really be the thera-
pist. This work requires all of the subtlety and sensitivity of
a long term psychoanalytic psychotherapy, while at the
surface of this work, it may appear more involved in the
present, convivial and even somewhat directive than
mainstream psychoanalytic approaches. We need a soft-
ening of the parameters in order to reflect or respond to the
individual’s difficulties in working within these.
The idea that we should approach the treatment of OCD
in a multi-modal manner is now widely encouraged,
including within psychoanalytic writings (e.g., Leib 2001),
as well as outside this (e.g., Rufer et al. 2005) and such an
approach seems to be necessitated by the complex nature of
the condition. We might debate whether some particular
part of such a multimodal approach might rest at its core or
whether components should really have an equal status. It
is arguable, with such a multi-modal approach, we also
have a responsibility to answer both the conscious demands
of our patient (often for us to help them strengthen their
defences or to find new more serviceable ones) and to help
our patient to encounter that very material he may prefer to
box away.
A high level of patience and sensitivity is required with
these patients. Freud may well have underestimated the
power of obsessional thinking, leading him to great dis-
appointment when relatively narrow kinds of insight-
oriented interventions, conducted within an archaeological
approach to the unconscious, proved unsuccessful in
bringing about change. Some hoped-for discovery of the
123
J Contemp Psychother (2008) 38:87–96
traumatic moment around which the symptoms may have
developed was not enough to bring about change. This led
Freud to express disappointment around the failure of his
method and to draw melancholic conclusions as he did in
‘Analysis terminable and interminable (Freud 1937)’.
Further, this expressed questioning of the value of his
method led many of his generation and of subsequent
generations to follow him into a withdrawal of psychoan-
alytic conceptualisation from this condition. Anna Freud
(1966), reflects the fact that little changed in the theory of
OCD, despite a loss of faith in its capacity to account
comprehensively for what takes place in the condition and,
more importantly, to provide an adequate treatment for it in
most instances.
It is not that OCD is caused by any particular set of
events as such or results from a single internal process. It is
rather that certain children at a particular point in time
respond in a particular defensive manner to internal and
external threats. Some children may respond by acting out
toward the external world; others may develop physical
illnesses (bringing the body onto the stage of their enact-
ment), while for those who develop ruminations and
rituals, the interpersonal crisis (or the crisis of one’s rela-
tionship with the other) is dealt with by protective
measures designed to safeguard the other.
If we begin to wonder whether the actual underlying
thought might have its source in the primitive commu-
nication between parent and child, we find ourselves
considering what may be a productive line of thinking. It
brings us to question whether the child ends up struggling
with an anxiety that belongs to the parent or perhaps,
more likely, that the child’s own anxiety is augmented by
the mirrored anxiety of the parent. Carrying the anxiety
of the two parties, he is overburdened and must find
a way out of this impossible situation and reverts to
the most straightforward of all ego defences. Within such
a broadened framework, an obsessive thought can be
construed not only as a thought that is banished intra-
psychically (that is, to the inner structure of the psyche
where it is isolated with only partial success, its force
tormenting the person) but one that is unacceptable within
the family—the unspeakable reality of a feeling that
seems altogether too explosive to be entertained. There
are then two great suppressing forces or two interlinked
agencies of suppression/repression. This helps also to take
the heat out of the scrutiny of the individual and to
develop a more balanced account of the individual within
the family. The problem of obsessionality is then a family
one rather than one that can be construed solely in terms
of the individual. This is not merely an attempt to shift
the sense of responsibility from the beleaguered patient
but a genuine recognition of the actual context of
obsessional thinking.
J Contemp Psychother (2008) 38:87–96
It is hard to stay ‘on task’ with these patients. While
there is good evidence of the effectiveness of various kinds
of interventions with people with OCD, we are still
encountered frequently by roadblocks that appear due to
the interpersonal reservations and retreats of these patients
(e.g., Shusta 1999). Efforts after giving meaning are
countered by shuffling attempts at breaking up sense.
Traditionally, this kind of complexity has been attributed to
co-morbid features of other disorders, including personality
disorders. But I believe that this actually misses the point
that, in fact, the central ruminations and rituals are directly
connected with the interpersonal disturbances rather than
reflecting two separate clinical entities. These patients
seem to require the kind of management that is afforded by
a cognitive approach, while, at the same time providing
some opportunity for exploring the broader aspects of the
person’s experience that links in with their development as
a whole. Most importantly, we need to find a way of
allowing the underlying anxiety and its various connections
to be recognised and articulated. We encounter the person
who worried intensely as a child and whose worries came
to be focused as some point in the shape of obsessional
thoughts. It might equally perhaps have taken the form of a
phobic relation to an object felt to be persecuting. Adept at
moving their anxiety from one kind of concern to another,
our apparent success in treating one target rumination or
ritual does not address the fundamental difficulty that
comes to find expression elsewhere. It is important to
consider a broad psychotherapeutic approach that reflects
the underlying complex nature of the disturbance that
originates in and continues to find expression in the inter-
personal struggle. While a psychoanalytic account might
provide the most comprehensive and incisive conceptuali-
sation of the origins of OCD (one that brings together
intrapsychic and interpersonal realities), a clinical psy-
choanalytic approach to psychotherapy with these patients
may yield little benefit in itself. This kind of decoupling of
theoretical model from associated therapy might help us to
draw on psychoanalytic ideas in a way that is creative and
might fit with the patient’s capacity to use what is on offer.
Our greatest challenge perhaps is in finding some means of
re-coupling this now decoupled theory–practice entity. For
obsessional patients, the relationship is experienced as
highly strained and it is often here that our efforts come to
a sudden end. Our obsessional patient is not ready to
‘relate’ as such in the form of relationship that we often set
up in psychotherapy and, instead, can only relate to us as
fictional figures (part-objects). Patients with OCD often
treat the therapeutic encounter as an impersonal one. They
experience the therapist as a functional figure, as an
instrument, in this way protecting him/her as a person. Not
accessing the therapist as a real and full person means that
he can be kept away from the toxicity of relating. We are
95
invited to become a part of the rituals and to ally ourselves
with the safekeeping cautious self. We are drawn into
reassuring our patient and of isolating the thought as
something alien, impersonal, nothing to do with the person.
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