Ever since its introduction in the mid 1950’s, the psychodynamic theory of human behavior has been subject to critique and controversies. The pioneer of psychodynamic theory of human behavior was Sigmund Freud who proposed that the unconscious mind influenced human behavior. According to this theory, three elements constitute the human mind viz. the id, the ego and the superego and it is the interplay of these three elements which constitutes complex human behaviors (Wagner, n.d.).
The following paper discusses the article ‘Psychodynamic and Cognitive-Behavioral approaches of Obsessive Compulsive Disorder: Is it time to work through our ambivalence?’ by Stefan Kempke and Patrick Kuyten, published in the Bulletin of the Menninger Clinic (Fall 2007). This article discusses the traditional psychodynamic model of Obsessive Compulsive Disorders (OCD) and compares it to the Cognitive Behavioral model, highlighting the main similarities and differences between them. Furthermore, it discusses the significance of this convergence between these two models and how an integrated approach can be adopted in clinical practice and for future research. In my view, the development of an integrated model of OCD to explain the underlying psychopathology has important implications as OCD is a common psychiatric disorder and once a definitive model of psychopathology of OCD is developed, it can be used in focused treatment of the symptoms by resolution of the underlying pathology. Although the cognitive behavioral model and the psychodynamic model are separate entities, in my view, they have overlapping characteristics and therefore their commonalities can be converged and used to develop an integrated model for OCD which would have implications in the therapeutic approach towards this disorder and can be aimed to improve the existing treatment approaches.
OCD is an important clinical entity, characterized by obsessions and compulsions, with a lifetime prevalence ranging between 2% to 3% (Samuels & Nestadt, 1997 cited in Kempke, 2007 p. 291). Obsessions can be defined as recurrent, persistent thoughts, ideas and impulses which can lead to internal conflicts and cause significant emotional distress and anxiety (DSM; American Psychiatric Association, 1994 cited in Kempke, 2007 p. 291). Compulsions, on the other hand, are repetitive acts which are aimed to ease the distress caused by the obsessions (DSM; American Psychiatric Association, 1994 cited in Kempke, 2007 p. 291). Various etiological factors for this disorder have been proposed including genetic makeup of an individual, neurobiological abnormalities and psychosocial aberrancies as explained by the psychodynamic and cognitive behavioral models (Kempke, 2007 p. 292).
According to the psychodynamic theory, as proposed by Freud, OCD is a neurotic disorder which manifests itself as a consequence of a conflict between ones ego and superego, with contributions of id which gives rise to the emergence of sexual impulses (Fenichel, 1945 cited in Kempke, 2007 p. 293). It is this conflict and maladaptive repression of impulses which leads to a disequilibrium, which is not present in normal individuals, and hence OCD. It has also been postulated that individuals with OCD harbor ambivalent feelings of love and hate and employ the defense mechanism of reaction formation to deal with these conflicting feelings (Freud, 1926/1959 cited in Kempke, 2007 p. 293). Moreover, according to the more recent psychodynamic models of object-relations, individuals with OCD experience ambivalent representations of self and others and this subsequently leads to adaptation of anal character traits whereby there is overemphasis on intellectual process and avoidance of interpersonal relationships (Blatt & Shichman, 1983 cited in Kempke, 2007 p. 294).
On the other hand, the Cognitive Behavioral model postulates that the underlying etiology in OCD is the presence of intrusions and the negative connotations attached to them. These feelings lead to anxiety and in turn, compulsive behavior. The negative appraisals are thought to result from maladaptive cognitive-affective schemas which are created in early life and shaped by life events and experiences (Whittal, Rachman, & McLean, 2002 cited in Kempke, 2007 p. 295). Extensive research has proposed six main schemas involved in the pathology of OCD viz. overestimation of danger, which in turn leads to avoidance behavior, feelings of guilt due to an inflated sense of responsibility for negative outcomes, perfectionism and the strife to accomplish it, the inherent desire to control thoughts, images and impulses, the phenomenon of ‘Thought-Action Fusion’ (TAF) and Intolerance of Uncertainty (IU) (OCCWG, 1997 cited in Kempke, 2007).
In this article, after overviewing both the psychodynamic and cognitive behavioral models of OCD, Kempke and Luyten point out that as opposed to the cognitive behavioral model, the arena of psychodynamic approach to OCD is relatively underexplored and understudied. However, there exists a considerable overlap between both these models in terms of the key characteristics of OCD such as such as the strong need for control, perfectionism, responsibility, and overemphasis of thinking, and link it to reactions to intrusions. They also highlight the fact that some underlying important concepts of cognitive-behavioral are infact inspired by and thus derived on the basis of the psychodynamic model. The main difference between both these approaches, as suggested by Kempke and Luyten, is that while the cognitive behavioral approach focuses on micro-processes e.g. TAF and inflated responsibility, the psychodynamic approach is adopts a broader view and concentrates on macro-processes such as the role of ambivalence. Keeping these similarities in mind, led to the formulation of an integrated model of OCD which has been adapted by Guidano and Liotti and Bhar and colleagues (Guidano, 1987 & Bhar, 2007 cited in Kempke, 2007 p. 299 ).
The authors then discuss the clinical implications of these findings. Research has proven the efficacy of cognitive-behavioral treatments in reducing the symptoms OCD, whereby the therapist challenges patients’ irrational thoughts and underlying schemas, employing cognitive techniques and behavior experiments (Whittal & McLean, 1999 cited in Kempke, 2007 p. 301). In contrast, there is limited evidence for the efficacy of psychodynamic treatments for OCD (Fonagy, 2005 cited in Kempke, 2007 p. 301). Moreover, there is also a lack of existence of psychodynamic treatments specifically developed for OCD and as opposed to the cognitive behavioral model, the psychodynamic therapy focuses mainly on the interpersonal dimension of the therapeutic process (Blatt, 1997 & Cutler, 2004 cited in Kempke, 2007 p. 302). According to psychodynamic model, the therapeutic relationship is not only a prerequisite for therapy, but also therapeutic tool. Since integrated models of OCD, developed by Bhar and Guidano suggest the focus of treatment of OCD should be on the underlying self-ambivalence and therapeutic relationship has been shown to promote stabilization of self-ambivalence, it can be concluded that converging both the models can improve treatment standards for OCD.
With regard to future research in this arena, the authors suggest further research focused on the interaction and overlap between various cognitive-affective schemas associated with OCD, the relationship between attachment theory and ambivalent self-perceptions in OCD and integration of the psychodynamic and cognitive-behavioral models with other disciplines, such as the neuropsychological and neurobiological approaches. Moreover, comparative trials of psychodynamic and cognitive-behavioral treatments for OCD should be undertaken to assess the relationship of these treatments with outcomes relationships and to elucidate the role of specific components in treatment.
This article provides a fair review of both the psychodynamic and cognitive behavioral approaches of OCD. It adequately discusses the similarities and differences in both these approaches and the implications these have in clinical practice and for future research. There are however, certain limitations. Firstly, although the similarities between the two models have been discussed adequately, there is limited discussion on the differences between these two models. Secondly, the authors should also have focused on more on how these differences hinder the process of integration of both the models and suggested methods to overcome these hindrances.
In conclusion, this article sufficiently reviews the psychodynamic and cognitive behavioral models of OCD and the increasing convergence between them in terms of part played by mental representations or cognitive-affective schemas and the importance of feelings of ambivalence in the underlying psychopathology. Therefore, keeping in view the similarities between these two models, an integrated model for OCD can be proposed and can be employed for treatment purposes. Moreover, there exist gaps regarding research regarding the psychodynamic approach, and this model is relatively understudied. Hence, future research should focus on this arena and aim at overcoming these shortcomings.
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