What is the Best Psychotherapy for OCPD (Compulsive Personality)?

If you’re trying to research the best psychotherapy for OCPD and compulsive traits, you probably won’t find much. There are very few studies which investigate treatment designed specifically for it. As a result there is a fair amount of misunderstanding out there that I’d like to try to rectify.

The Two Basic Types of Therapy

To simplify, we can divide therapy into two very broad categories: cognitive and behavioral therapies on the one hand, and dynamic and expressive therapies on the other.

• • Cognitive and Behavioral therapies (such as CBT) are more structured, and directed more by the therapist. They aim to relieve specific symptoms by challenging thought patterns and prescribing gradual behavioral change.

• • Dynamic and expressive therapies (such as psychodynamic and psychoanalytic therapies) are more free-flowing and self-directed. These aim to achieve broader and deeper changes in the personality by developing a greater awareness of unconscious influences. They also develop  insight into patterns of coping that developed as a result of early family and environmental issues.

One type of cognitive behavioral therapy designed for OCPD and related disorders is Radically Open Dialectical Behavioral Therapy (RO DBT). The intent of RO DBT is to help reduce overcontrol and to improve communication. There are a limited number of practitioners trained in RO DBT, and the process is highly structured–which some might find relieving, and others find uncomfortable.

Another type of therapy which may be helpful for OCPD is Schema Therapy. This approach includes both CBT and dynamic elements. While not designed specifically for OCPD, it may be effective for people with OCPD in part because at least one of its basic 11 schemas (also known as “Lifetraps”) apply directly: “It’s Never Quite Good Enough.”

The reality is that there is often overlap between how CBT and dynamic therapy are actually practiced, but most therapists tend to identify with one type more than the other.

Before I go on, a disclaimer. I make my living practicing dynamic psychotherapy. I can’t rule out bias on my part, but I’ll try to lay out the possibilities objectively and show the research behind what I say.

Are All Therapies Created Equal? The Research

There is some data which indicates that all legitimate forms of psychotherapy are equally effective. While clinicians and researchers argue about just how equal they really are, all bona fide forms do seem help more than no therapy at all.

Still, during their rotations most medical students get it pounded into their heads that cognitive and behavioral therapies are more effective, and the news spreads that these are the only treatments worth using. But to be accurate, there is just more evidence that they are effective—not evidence that they are more effective. These are very different claims, but they’ve been conflated.

Cognitive and behavioral therapies do have more research to support their efficacy for certain specific conditions. They tend to be shorter term, target specific symptoms, and are manualized—meaning the therapist follows a protocol laid out in a manual. These characteristics make cognitive and behavioral therapies easier and less expensive to research, which is one of the reasons there is more research showing that they’re effective.

Clearly many people benefit from these therapies.

Evidence, Dropouts and Fit

But more recent studies have not demonstrated the rates of success for cognitive therapy that earlier studies suggested. Nor have they demonstrated superiority over other types of therapy.

And, according to at least one study, on average 42% of the subjects in trials for cognitive and behavioral therapies drop out. So, a lot of people don’t feel comfortable enough with them to stick it out.

So, if cognitive therapy doesn’t feel like a good fit,  you’re not alone.  I’m not recommending you give up on your CBT therapist. In fact I’d suggest you tell your therapist if the therapy isn’t feeling right so that the two of you can work it out.

Barring that, other forms of therapy may feel like a better fit for you.

While there aren’t as many studies that support the efficacy of dynamic and expressive therapies, there is still plenty of research out there that does support them, as Jonathan Shedler at the University of Colorado Denver School of Medicine points out.

In fact in a study comparing the long-term effects of the two types of therapy for depression, “Psychoanalytic therapy shows significantly longer-lasting effects compared to cognitive-behaviour therapy three years after termination of treatment.”

(You can find a good, shortish description of the rationale behind psychoanalytic therapy here.)

Dynamic therapies are usually the treatment of choice for personality disorders. And there is good reason to believe that they might be the better treatments for obsessive-compulsive personality disorder in particular.

(Not everyone who is compulsive is disordered. There is a spectrum from healthy to unhealthy compulsivity, and most of us can benefit from therapy to make sure our tendencies don’t go awry.)

Best Psychotherapy for OCPD: Matching Therapy to Your Goals

Since both kinds of therapy are effective to some degree, these days researchers are trying to predict which therapies will work best for which people and which conditions.

For instance, if you want to remove the symptoms of OCD, bulimia, panic attacks, or a specific phobia, cognitive and behavioral therapies can be quite effective. (Note that treatments for compulsive personality (OCPD) and OCD are usually not the same, as they are really different, though sometimes overlapping conditions.)

But if your goals in therapy are broader, such as shaping deeper personality traits, dynamic therapies may be more helpful.

Here’s how Jonathan Shedler described the wider-ranging goals of dynamic therapy:

The goals of psychodynamic therapy include, but extend beyond, symptom remission. Successful treatment should not only relieve symptoms (i.e., get rid of something) but also foster the positive presence of psychological capacities and resources. Depending on the person and the circumstances, these might include the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a  realistically based sense of self-esteem, tolerate a wider range of affect, have more satisfying sexual experiences, understand self and others in more nuanced and sophisticated ways, and face life’s challenges with greater freedom and flexibility. Such ends are pursued through a process of self-reflection, self-exploration, and self-discovery that takes place in the context of a safe and deeply authentic relationship between therapist and patient.

An Additional Dimension

For me, one of the most important aspects of working with people who are compulsive is understanding the deeper motivations for compulsive behavior rather than pathologizing them. People who are compulsive have urges that they feel compelled to act on, and these urges aren’t all bad. Much of the creative and productive work done in the world is done by people who have compulsive personalities. Only when our urges get hijacked by shame and insecurities do they become unhealthy.

Finding the deeper well-springs of these urges is the core goal of Jungian analysis, a specific form of dynamic treatment that looks for the purpose and meaning behind symptoms. It is a growth-oriented therapy developed in the early 20th century by Swiss psychiatrist Carl Jung. It sees the unconscious as a source of wisdom and creativity, and spirituality in the broadest sense, rather than a storehouse for repressed memories. Jung suggested that we have a compulsive urge to realize our potential, or to individuate. Recognizing and utilizing this instinct can be a powerful motivation for change.

Part of what I find most attractive and helpful about Jungian analysis is its more positive attitude toward our symptoms. And I believe that it is particularly helpful for people who are obsessive-compulsive because it insists that we seek the meaning inherent in our challenges.  As I’ve written elsewhere, obsessive-compulsive disorder is a disorder of priorities–meaning has been lost.

Analyzing Therapy

Ultimately your choice will be based on what feels like a good fit for you personally and whether your goal is specific symptom remediation or broader personality growth. But whatever form of treatment you pursue, I hope that you’ll think of it as developing and harnessing your potential rather than remediation for bad behavior. That’s a good start.

To get a more detailed picture of what dynamic therapy is actually like in practice, check out my post about how psychotherapy works for the compulsive personality.  And you can get a sense of what the patient’s role in psychotherapy is by taking a look at my book, I’m Working On It In Therapy: How To Get The Most Out Of Psychotherapy.

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