Saturday, August 27, 2011

Major Approaches to Clinical Psychology: Obsessive-Compulsive Disorder

Slide 2:  A variety of approaches exist for the treatment of obsessive-compulsive disorder (OCD). Four major approaches include psychodynamic, cognitive-behavioral, humanistic, and family systems. Each approach perceives obsessive compulsive disorder as an intrusive condition characterized by unwanted repetitive and anxiety-producing thoughts accompanied by the compulsive act of rituals the individual believes will protect them from the anxiety (Hansell & Damour, 2008). The obsessions are thoughts or impulses over which the individual has no control except to apply the ritual for relief, and the compulsions make the individual feel driven to do something - usually the ritualistic practice for the purpose of relieving the anxiety (Hansell & Damour, 2008).

OCD has a well-established biological component similar to other anxiety disorders. According to the National Institutes of Health (2010) anxiety produces affective physical reactions in people, and the biological perspective views the activation or stimulation of the nervous system and its excesses or deficiencies. There may also be associated genetic predispositions, neuro-chemical, and hormonal malfunctions (Schimelpfening, 2009). Emotion components include underlying concerns or experiences that have not been openly addressed. From a psychodynamic perspective, there may be pain and sadness resulting from early childhood parental relations. Most psychologists consider underlying conditions as a prelude to OCD (Hansell & Damour, 2008).

The cognitive-behavioral components of OCD include cognitive distortions of oneself and one's environment. Anxiety is often the result of maladaptive thought processes and dysfunctional thought patterns. Misinterpreted situations, and the underestimation of emotional ability may contribute to the disorder. As mentioned previously, behavioral components include the obsessive thoughts or impulses which precedes the application of ritualistic practice (Hansell & Damour, 2008). Each approach has distinct perceptions of OCD and equally distinct methods of management.

Freud believed obsessive-compulsive symptoms are based on defense mechanisms that he called isolation of affect and undoing. These mechanisms help the affected individual manage anxiety-provoking impulses and thoughts. Using the isolation of affect, individuals treat unwanted thoughts as unconnected to their feelings and experience and more as intruding annoyances. Isolating relates to how individuals treat their obsessive thoughts. Undoing is the use of ritual as a magical treatment to rid oneself of the disturbing thought. The undoing relates to the compulsion side of OCD.

Freud also theorized the symptoms of OCD were caused by misunderstood punishment and rigid toilet training that led to internalized conflicts. Other psychodynamic theorists considered OCD the result of the cultural demand for cleanliness and neatness, as well as parental style and punishment tactics during childhood. According to Fraum (2011), "the fundamental issues that drive these symptoms include fear of rejection or abandonment, as well as interpersonal issues regarding intimacy, sex, control, power or other problems in their relationship" (para. 11). Freud published a case study on a patient he called Rat-man. He claimed he successfully treated the man for obsessive thoughts and compulsive behaviors which Freud thought began from sexual and punitive issues in his childhood (Wertz, 2003).

The goal of the psychodynamic interventions is to help clients understand the roots of their symptoms, gain greater self-acceptance, develop better solutions to emotional conflicts, and decrease needs for problematic defense mechanisms (Hansell & Damour, 2008). In the case of OCD by relieving individuals’ stress, they will cease to need to use the defense mechanism.
According to Abend (1996), psychodynamic therapy focuses on pathological anxiety that arises from unconscious emotional conflicts, so therapists in this discipline tend to use basic psychodynamic techniques to address most anxiety disorders (Abend, 1996). Through an established bond between the patient and the therapist, the patient is encouraged to speak freely to uncover the roots of the anxiety, and to recall dreams. Guided imagery and movement is also used in the psychodynamic approach. The therapist helps the client identify and understand problems as a reaction to present and past issues.

Since the psychodynamic approach seeks to uncover unconscious directives, the therapist must be capable of interpreting the patient's thoughts, feelings, and dreams and assisting the patient to identify the unconscious motives to help the patient resolve the conflicting emotions. A significant part of psychodynamic therapy is the ongoing bond built between the patient and the therapist and the trust within the relationship will allow the patient to thoroughly investigate the issues.

Uncovering the roots of anxiety is effective in any anxiety disorder and psychodynamic therapy has been successfully used in the development of treatment goals, as well as, especially in group treatment (Wells, Glickauf-Hughes, & Buzzell, 1990). The patients modify their character by “evolving autonomous functions and partly through evolving relationships with other individuals” (Wells, Glickauf-Hughes, & Buzzell, 1990, p. 375). According to Bram and Björgvinsson ( 2004), in severe cases of OCD cognitive behavioral therapy was more successful than psychodynamic therapy alone and relieved more symptoms of the OCD. Bram and Björgvinsson ( 2004) claim that training psychodynamic clinicians to accommodate cognitive-behavioral techniques will help successfully treat patients with OCD.

According to cognitive behavioral theory, in obsessive compulsive disorder, an association is made between a compulsive ritual that seems to reduce anxiety caused by a disturbing thought or impulse (Hansell & Damour, 2009). In effect, the reduction in anxiety negatively reinforces the ritual. Traditionally, cognitive-behavioral theory claims behavior is a product of one's environment and is either positively or negatively reinforced, or positively or negatively punished. Individuals learn to adjust behavior according to the response received from the environment.

In a cognitive behavioral intervention, the goal would be to change the way the individual responds to the stimulus in effect, changing the ritualistic response to the disturbing thoughts. For example, a client may be asked to allow themselves to think about the disturbing thoughts without engaging in the usual ritualistic behavior. According to Hansell and Damour (2009), the goal of cognitive-behavioral therapy would be to interrupt the ritualistic behavior to allow the client to experience the dissipation of the anxiety even without the application of the ritual. When the process of obsessive thoughts followed by ritualistic behavior is interrupted, the behavior ceases to negatively reinforce the anxiety, so the pattern is broken.

Cognitive therapists teach strategies and perspectives for responding to the challenges that life has to offer so that individuals can gain a greater sense of self-efficacy (i.e. developing faith in their abilities to achieve specified goals). Equally as important as knowledge, training, experience, and credentials on the part of the cognitive therapist are warmth, understanding, and compassion (Phillipson, n.d., para. 3).
Cognitive interventions for anxiety disorders are generally goal-oriented and highly structured; cognitive therapists take an active, directive stance toward the client and his or her problems (Beck, Emery, & Greenberg, 2005). The therapist will help the client identify the automatic responses to the disturbing thoughts, and the negativity associated with the thoughts. They might discuss the logic (or lack thereof) of the disturbing thoughts and identify the distortions involved in such thinking. Ultimately, the client will be taught how to challenge his or her typical thought processes.

Because the cognitive- behavioral perspective is based on the idea that people learn from reinforcement from the environment, the strategies in therapeutic application emphasize altering the pattern of reinforcement. If a response causes disordered patterns, a change in response is necessary (Phillipson, n.d.). The behaviorist approach claims all learning takes place by the organisms adaptability to change according to its environment, and changing that response alters the established pattern.

Research (Clark et al., 2003) finds cognitive-behavioral therapy effective in treating anxiety disorders. According to Phillipson (n.d.), cognitive behavioral treatment for obsessive-compulsive disorder provides the client with effective tools with which to continually manage anxiety and challenge internalized thinking. Rather than depending on a therapist for longer periods, the client can immediately learn to use the cognitive-behavioral tools. The behavioral tools are ultimately important in the client's ability to continue the management of the disturbing thoughts, and finally decrease the endless ritualizing. Nathan and Gorman (2002) found the interventions were as effective used alone as in combination with other behavioral techniques such as relaxation training.

The humanistic approach uses philosophy, existentialism, and the belief that humans are motivated toward fulfilling certain growth potential. Humanism is committed to a paradigm that emphasizes the human ability "to be consciously reflective and have the ability to experience self-determination and freedom" (Plante, 2011, p. 58). This perspective was strongly influenced by philosophy and an existential approach to psychotherapy, which became popular after World War I. Humanism embraced the human characteristic need to understand life's meaning. Thus, the individual is not considered a passive being who requires the intervention of an expert, but rather an active cognitively aware being. This notion reflects the fundamental underlying principle of humanism that states traditional schools of therapy see the approach as a treatment for illness, rather than seeing patients as active and responsible and participatory in creating and maintaining their mental and emotional states. The patient can chose to alter their mental state under appropriate conditions (Dombeck, 2006). Unlike Freud's psychoanalytic view, humanism views people as essentially good, rather than dysfunctional and bad by nature.

The goal of humanistic therapy for OCD is to create an appropriate environment by which the patient will be able to develop, mature, and evolve, and as a result continue the process in healthy development (Dombeck, 2006). I the humanistic view, psychological dysfunction is caused by an interruption in development because of social and emotional immaturity. By enabling natural development, the patient regains his or her natural ability to proceed in a healthier direction. By maintaining natural development, individuals continue along their personal life pathway, and meeting their psychological needs.

Because the humanistic approach sees the patient as an active participant, and an active cognitively aware party who has the inherent power to determine the course of life and mental disturbances, the patient is the center of the therapy. Several techniques include Rogerian humanistic therapy best known for its gentle engineering of the patients own determination of how they feel about certain topics. Alternatively, Gestalt therapists might use a more direct approach enabling patients to allow the emotional experience within the body rather than in a more limited cerebral experience (Dombeck, 2006).

One well-known Gestalt technique is known as the empty chair technique which is a visualization technique wherein the patient is directed to imagine a person in the empty chair that sits in the therapists office. By entering into a discussion with the imagined person, conflicts are more easily resolved. The goal is to allow the patient to work with the fears and emotions surrounding the issue, ultimately rendering the situation less scary whereby the patient no longer needs to avoid the other person or situation (Dombeck, 2006).

According to Whelton (2004), depth of experience in psychotherapy is positively related to outcome. In humanistic therapy, this depth is a normal expectation and one goal of its application. This indicates feelings and emotions are being processed and new more appropriate meanings are formed as well as finding solutions to problems that create fear and avoidance, and other issues that derail the natural human proclivity to evolve. There is, however, no empirical research clarifying the effective role of humanistic therapy in relieving the intrusive symptoms of obsessive -compulsive disorder.

According to Plante (2011), "prior to the 1950s most psychological treatment focused on the identified patient defined as the person regarded within the family as manifesting problematic symptoms, behaviors, or attitudes" (p. 60). Family members did not participate directly in the identified member's therapy. Neither were they considered an integral part of the recovery nor were they considered part of the problem. Later in the 1970s the family system approach became popular in clinical applications (Plante, 2011).

Family systems approaches differ from psychodynamic, behavioral, and humanistic approaches as they use the integration of the family in recognizing and treating disordered emotions and behavior. Rather than working with the individual having the specific problem, the whole family is involved in the therapy. Psychological insight provided a new platform for therapy that supported the family as an interrelated system, not a group composed of members with random, unrelated experiences. Rather than viewing the identified individual as affected by motivations exclusive of the family, this new systems saw the identified individual as a product of the family unit and "dysfunction resided in the family as an interrelated system" (Plante, 2011, p. 60).

The goal of family systems therapy is to treat the whole family and reduce the dysfunction affecting all the members, but more severely expressed by the identified family member. The issues of the identified individual are acknowledged and addressed, although within the scope of the family. As well as developing the identified individual, the system also develops each family member as autonomous and independent while re-establishing family solidarity (Plante, 2011). The system seeks a balance between the function of the group and the independent individual performance.
In family systems the therapist guides the family in assessing their needs and defining goals. Improving communication within the group is accomplished by several techniques including reframing or changing perceptions within the group, and paradoxical intention, which defines symptoms, especially those of OCD to alleviate resistance to the therapy. Joining or developing a rapport with the family allows the therapist to become more familiar with the mechanisms by which the OCD became symptomatic. Through establishing rapport with the family unit, the therapist can identify any anxiety producing relationships or psychological enmeshment between members (Plante, 2011). Furthermore, the therapist assists in the recognition of disengagement of one or more members whereby the individuals remove themselves from the family unit as a coping mechanism, in this case the symptoms of disturbed thoughts and ritualistic coping behavior. Alleviating the symptoms of OCD in one family member includes understanding the anxiety and psychological pressure the individual experiences. Identifying such issues will help to establishing new ways of relating within the family, disabling the individual's need for obsessive-compulsive behaviors.

The communication approach seeks to re-establish healthy communication within the family thereby eliminating unreasonable expectations, inappropriate rules, and inaccurate assumptions between the individuals, which may be causing the OCD symptoms. The structural approach aims to disengage dysfunctional family patterns and balance relationships, while the Milan approach establishes the therapist as an integral member of the family, providing a neutral position and garnering respect for the unit. The guidelines of all the specific techniques and strategies embrace the general assumption that the family unit contains the dysfunction causing the OCD, and issues are not exclusive to the identified individual (Plante, 2011).

Unlike the other three approaches addressed herein, family systems therapy addresses inadequacies in the family unit. Although addressing these relational issues, there is little evidence that family systems therapy is efficient as an exclusive therapy for treating OCD. Carr (2000) believes family therapy is an effective treatment "either alone or as part of a multimodal or multisystemic treatment program for child abuse and neglect, conduct problems, emotional problems, and psychosomatic problems" (p. 48) although severe symptoms of OCD requires adjunct therapy.
The major theoretical approaches are philosophies about human behavior that provide psychologists with a thematic conceptual understanding of mental health, illness, and disorder. The approaches also provide a consistent parameter by which to assess and treat the patient and a dependable plan of action in a variety of situations and patient needs. Whereas the psychodynamic perspective emphasizes the unconscious directives that influence the individual's ability to maintain normal functioning, the foundation of the cognitive-behavioral approach focuses on contemporary, measurable and observable behavior. It uses classical and operant conditioning as explanations for many types of behavior.

The humanistic approach emphasizes the natural human ability to evolve and develop and perceives people as "active, thinking, creative, and growth oriented" (Plante, 2011, p. 133) and crave self-actualization. The family systems approach views the unhealth of the individual as a consequence of dysfunction in the family, and only by creating health and solidarity within the family can the individual be freed from symptoms of mental illness.

Psychologist have become more integrating with their perspective preference and less rigid to one particular theoretical approach. Each approach has advantages for specific challenges, and some perspectives lend themselves to particular research whereas others do not. The integration of various theoretical perspectives in clinical psychology allows the therapist to afford the broadest potential for successful change within the individual. "Furthermore, as more research and clinical experience help to uncover the mysteries of human behavior, approaches need to be adapted and shaped in order to best accommodate these new discoveries and knowledge" (Plante, 2011, p. 132). The human psyche is a rich and complex maze of diverse needs and challenges, served most appropriately by an equally elaborate and divergent palette of treatments and interventions.

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