Developmental Behavior Modification for the Treatment of Obsessive-Compulsive Disorder

Developmental Behavior Modification for the Treatment of Obsessive-Compulsive Disorder
[REPORTS]
Röper, Gisela1,2
1University of Munich, Germany.
2Correspondence concerning this article should be addressed to Gisela Röper, Abteilung für Klinische Psychologie, Institut für Psychologie, Leopoldstr. 13, D-80802 Munich, Germany (tel/fax +49 89 2180-5196. Electronic mail may be sent to roeper@mip.pacd.uni-muenchen.de).
Gisela Röper obtained her PhD in clinical psychology from the Institute of Psychiatry, University of London, UK. A Senior Lecturer at the Ludwig-Maximilians University in Munich, Germany, she is also Co-Director of the department's Outpatient Clinic. Her research interests include psychological theory and treatment of OCD and PTSD, as well as clinical developmental psychology and developmental psychopathology.
Behavioral methods for the treatment of obsessive-compulsive disorder (OCD), such as flooding and modeling plus response prevention, have been shown to be effective over the past 20 years or so (Opitz, 1980; Rachman & Hodgson, 1980; Reinecker & Zaudig, 1995; Röper, Rachman & Marks, 1975). However, those patients who do not benefit satisfactorily from treatment have challenged experienced therapists to search for ways to improve the available approaches or to find additional therapeutic strategies (Foa, Grayson, Steketee, Doppelt, Turner, & Latimer, 1983; Hand, 1988; Hiss, Foa, & Kozak, 1994; Salkovskis, 1991). Further, a growing number of OCD patients are being diagnosed as having an additional comorbid personality disorder. A wider framework may thus be called for.
This report describes the introduction of an adjunctive developmental element to behavioral treatment of OCD. Two developmental avenues are outlined: one is the biographical route, while the other involves considering the patient's current developmental position. Developmental therapeutic elements provide a wider scope of action, and add leverage during critical phases of the treatment process. It is to be expected that this adjunct will extend our understanding of the disorder.
Behavioral treatment methods remain the cornerstones of the developmental behavioral approach. The additional developmental elements are applied in separate treatment periods for a number of sessions at a time. While the behavioral treatment deals with the symptoms and consequent suffering, the developmental treatment components focus on the person and his or her development.
The developmental perspective applied here in the treatment of OCD has its roots in the field of “clinical developmental psychology and developmental psychopathology” (Cicchetti, 1989; Kegan, 1982, 1995; Noam, 1988; Sroufe & Rutter, 1984). The goals of this relatively new field, in which clinical and developmental psychologists combine both knowledge and research interests, were outlined by Cicchetti (1989):
“Developmental psychopathology is unique in its emphasis on the importance of recognizing the interplay between normal and abnormal psychology … a knowledge of normal development is considered to be critical to understanding abnormality and, similarly, examining deviant development is seen as a necessary enhancement of knowledge of normal functioning. In addition, a belief in the importance of employing a life-span perspective is central to this approach …
“Finally and perhaps most significantly, developmental psychopathologists are committed to bridging the dualisms that have separated scientific research from clinical application.” (p. 3).
More generally, it is suggested that behavior therapy should more explicitly derive both theoretical and practical guidance from the concepts of developmental psychology (Kegan, 1982; Kohlberg, 1969; Mahoney, 1985; Noam, 1986, 1991), such as attachment (Grossmann & Grossmann, 1990; Sroufe, 1988) and resilience (Masten, Best, & Garmezy, 1990; Spangler, 1995), as well as from the results of longitudinal studies (Rutter, 1989).
Two Developmental Avenues to Be Combined with Behavioral Treatment
The specific developmental perspective outlined here involves two avenues. The first is the biographical avenue, which involves taking a close look at the emotional learning history of the client, e.g., by scrutinizing the family atmosphere and philosophy concerning such factors as security, predictability, and adventurousness, both in attitude and in action. This also includes relationships with parents, siblings, and relevant others. Attention is paid to the typically multiple positive and negative ties, and their ongoing influence on the individual's development.
The second avenue focuses on the person's current stage of life, in relation to the challenges in life that all people of a particular age group have in common. The developmental task with which the person is struggling is considered both together with and independently of the current symptoms. The type of cognitive affective world view that the client operates from is given close attention, as well as small steps of change. Kegan (1982) refers to the ongoing process of meaning-making. This means considering the client's current developmental stage (Erikson, 1963; Kegan, 1982; Noam, 1988) and supporting further development.
Knowledge about the developmental typologies of meaning-making are used, but at the same time the individual's unique interpretation of reality is given full attention. The latter is based on constructivist theories (Noam, Chandler, & LaLonde 1995) in developmental therapy and on the notion of co-construction.
Biographical Work in Behavior Therapy
A great deal has been written about the inadequacy of learning theory models to account for the processes involved in OCD, particularly in its acquisition but also in its maintenance. The two-factor theory (Mowrer, 1950) has been found useful mostly to describe the long-term maintenance of the very painful and elaborate rituals that obsessive-compulsive patients perform, mostly against their better judgment. In clinical practice, the instrumental conditioning part of the theory was usually a centerpiece of the treatment rationale and was found to be helpful in motivating patients to refrain from their rituals, to endure the arising anxiety, and to learn to tolerate the feared situations without amending their rituals. This led eventually to them overcoming the urge to ritualize and, finally, the anxiety itself. The classical conditioning part of the two-factor theory was always considered far less convincing, since too many patients did not talk about any traumatic event preceding the outbreak of their symptoms. In those cases where a traumatic event was mentioned, it sometimes led to a distorted interpretation of the facts. As Beech and Vaughan (1978) pointed out:
“We would argue, however, that it is frequently the case that the relevant interrogation stops at a point indicated by the patient as marking the beginning of abnormality, and a false impression is gained of the historical pattern of disturbed behaviour” (p. 9).
This alludes to a longer thread, further back in time than the first occurrence of ritualistic behavior.
The concept of learning through modeling proposed by Bandura (1969) seemed a very promising addition at the time, and was soon included in the standard theory of OCD (Rachman, 1972). An analysis of 40 case histories from the Maudsley Hospital archives revealed a number of recurring themes in a patient's family of origin: thoroughness and orderliness, high expectations of the children, strict and narrow ethical values, or unquestioned obedience to church rules and social norms (Röper, 1975).
In their discussion of the factors involved in modeling, however, Rachman and Hodgson (1980) took a broader perspective:
“If instead of looking for evidence of direct transmission of obsessional-compulsive disorders, it is argued that obsessional traits are socially transmitted and, given additional contributing factors, may develop into a disorder, then the debate is left open” (p. 42).
It is clear that they did not believe in direct social transmission of parental instructions via observational learning. The authors made the point that more precise information is needed about the role of social learning or social transmission in the emergence of an obsessive-compulsive disorder. Despite the obvious interest in having a better understanding of how OCD arises, no moves towards including a fuller learning history were made at that time.
A clear step towards adhering more strongly to an individual's learning history was taken by Butollo and Höfling (1984) in their extended behavioral approach “experience-oriented learning” (ELT), which included elements of humanistic approaches such as gestalt therapy and body-work. They suggested experiential exposure to childhood memories: the facts, the emotional responses, and the old coping strategies (particularly when these were characterized by inflexibility and were performed automatically). The analysis was followed by planning and testing of new modes of handling old, biographically relevant themes.
Münzel and Tunner (1983) found in their clinical study on learning history and behavioral rehearsal that insight into the roots of a phobia led to increased involvement in the treatment, particularly when this insight was gained not only at a cognitive but also at an affective level. This treatment study included eight sessions of working with the learning history prior to exposure to feared situations.
Biographical Work in Developmental Behavior Therapy
Biographical work in the developmental behavioral approach presented here serves two major, and related purposes. When a plausible history of a symptom is uncovered and the notion of an inexplicable mental illness can be abandoned by the patient, his or her self-concept begins to be reconstructed. This will then, as a rule, increase the motivation for change.
In addition to their symptoms, OCD patients are usually heavily affected by a destructed and destructive self-concept. Since the contents of obsessional thoughts are experienced as noxious stimuli (Rachman, 1977), particularly when accompanied by feelings of guilt, these people are often convinced of their own intrinsically bad nature. Also, the experience of feeling forced to perform rituals despite knowing that they are irrational usually leads to low self-esteem and the conviction that personal will power is lacking.
Biographical work within the treatment package being presented here involves, for example, looking at various aspects of the family atmosphere, which may be the substrate for the later obsessive-compulsive problems. These aspects include specific characteristics of the relationships within the family as well as parental attitudes.
Further contributing factors that now appear to be involved in the acquisition of OCD include a lack of security provided by the environment, parental criticism, unresponsiveness to a child's curiosity and wish for exploration, as well as a specific style of handling anxiety. The relationship to the symptoms are pointed out whenever possible.
One woman who developed a fear of harming other people through contamination or neglect, was, as a child, in a permanent state of fear of arousing her mother's criticism. When she was sent to shop for food and, for example, came home with the wrong brand of margarine, she was accused of being unhelpful or inconsiderate and thus creating undue stress for her mother. Frequently, such failures on the part of one of the four children led to the mother not speaking to any of them for days. During one phase of biographical work this patient discovered that her earlier feelings of unworthiness in the eyes of her mother matched her current feelings of being contaminated and a danger to the health of everybody around her.
Of special interest is always the parent's style of handling the child's anxiety. In the context of his developmental model, Kegan (1982) talks about the importance of how the child's anxiety is met by the holding environment. He points out that cognitive-affective development is always accompanied by anxiety. Development may be supported or hindered, depending on how the parents deal with the anxieties that a child has during the course of normal development. Holding a child who is afraid, or concentrating on the anxiety and aiming to suppress it, imply two different messages: (1) anxiety is a fact of life, I am here with you to help bear it; (2) it is bad to be afraid; it is better to maintain the established order of things.
During biographical work with obsessive-compulsive clients it is frequently found that they came from a home environment which did not tolerate anxiety, or at least reacted to it badly: The parents frequently responded to the child's anxieties in a placatory manner or by immediately introducing security measures (sometimes rituals).
One patient reported that his father died when he was aged 7, and that family life changed at all levels, particularly the atmosphere in the home. While the mother was of a more brooding nature, the father had been the jolly one, popular both within and outside the family. The mother told her three children that a family without a father would easily be looked down upon, and so they must be particularly well behaved, clean, and modest. One day the client became involved in a fight with a group of boys. He confessed to his mother that he was afraid of them, and said he wanted to take up Jiu-Jitsu in order to be better prepared for any fights that might arise. His mother forbade both sons to get into with any fights in the village. This resulted in a permanent fear of the other boys, a sense of humiliation, and an inner conflict about his mother's mandate. Later, when the client was 14 years old, he wanted to take evening classes in addition to his apprenticeship. His mother successfully discouraged him, pointing to the public humiliation that would follow possible failure. A large proportion of this client's symptoms involved “magic” rituals which aimed to ward off future harm or embarrassment.
Fostering Development
The second developmental avenue concerns the patient's current developmental position. Considering the patient's developmental position implies supporting his or her search for new ways to relate to other people and new definitions of the self. This means focusing on a person whose life-project is inhibited by the incapacitating symptoms. A higher level of self-complexity opens up to the patient new possibilities for understanding his or her life-history and the function of the symptoms in relation to current circumstances and personal tasks.
The constructive-developmental position within clinical-developmental psychology looks at both the individual's unique interpretation of reality and also the consecutive phases of inner cognitive affective balance and phases of inner turmoil which are integral parts of personal change.
Inner processes and their stimulation through external events provide the momentum necessary to promote cognitive-affective development towards more complex forms of maturity. Such developmental transition periods are times in which a new perspective on the self and on relations with others and the world is constructed — transforming the old and creating a wider perspective.
Many workers in the field of clinical-developmental psychology propose that individuals who seek treatment are generally going through a developmental transition period. This means that a patient who seeks treatment is in a type of crisis through which many of his or her contemporaries (in terms of either chronological age or developmental maturity) also have to struggle. If this is the therapist's viewpoint and understanding of the patient's situation, it helps the latter to “dedramatize” part of their situation and experience him- or herself as a human being undergoing change, and not just as a patient with a severe psychological disorder.
This position is very much in keeping with descriptions of the typical onset of an obsessive-compulsive neurosis, which according to much of psychiatric and psychological literature occurs following major life changes, such as the first sexual experiences, the birth of a child, starting a new job, or taking up new responsibilities in general (Kolb, 1973; Rachman & Hodgson, 1980). Such major life events often lead to a longer period of cognitive-affective reconstruction in a person's life.
When the developmental work is concerned with a patient's current life circumstances, the therapist's attention is focused more on the patient's own definition of the self in relation to others than on the actual content of the story. In other words, it asks how the person currently constructs her or his world, what the inner friction is about, and what the specific quality of the course of development is. Expressing dissatisfaction with the self or with the self in relation to others is merely an example of the process of reconstruction. Also, when the patient probes for a new way of looking at or dealing with the world, this needs to be pointed out and brought into focus. The therapist's attitude is not that a person can be pulled to a new level of constructing the world, but rather that his or her development can be supported.
For instance, a young man was troubled by obsessional thoughts after the tragic death by drowning of the daughter of some friends. When he heard the terrible news he was immediately struck by the thought that he could have been responsible for her death. After years of ruminating over the event he could not regain his peace of mind, although he had not even been near the lake where the little girl had drowned. In addition, as time passed he became increasingly troubled by fears of harming other people, by running them over with his car or bicycle or when walking in crowded places. After some months into treatment, and when biographical work had revealed various roots to his guilt and responsibility, he began to talk about a number of social situations in the workplace or with friends and family. These stories all contained common themes: It became clear, for instance, that criticism by others close to him could induce an almost paralyzing feeling of guilt; and that he had a strong desire to take a stand in conflict situations, or to not keep quiet where in his judgment a comment was called for.
This patient reflected more and more on his concern about the reactions of others, questioned his need for approval, and strove to gain a sense of self-worth based on his own value-judgments. He began to see his daily journey to work on the underground train as a challenge to respond to situations in a way that were true to him-self. One day a drunkard attracted people's attention by swaying along the platform onto the track. When he tried to get back up, people nearby hesitated help this dishevelled and ragged-looking man. Without thinking about it, our client walked over and helped the man get back up on the platform. He also noticed that some people nodded to him with respect. When he told this story he commented that what he was most happy about was that the other people's recognition did not really count, but that he had felt proud of himself. After this event the client's descriptions of his part in social encounters clearly indicated a strong move towards greater autonomy. The obsessional thinking, which had responded well to habituation treatment (exposure and response prevention in imagination; Rachman & Hodgson, 1980), declined further, and his ruminations over the death of the little girl finally ceased.
Background knowledge of developmental models, including the various types of transition periods, provide the therapist with a solid basis from which to operate. This knowledge should include understanding of the different types of transition phases and their distinct challenges. Each type of transition phase (Kegan, 1982; Noam, 1986a, 1986b) benefits from a specific kind of support.
Biography and Affective-Cognitive Development Embedded in the Lifespan Perspective
The behavioral developmental approach regards the so-called lifespan perspective (as used in clinical developmental psychology) as a helpful concept for cognitive and behavioral therapy. In behavioral treatment of OCD finding and practicing alternative behavior when time is gained through giving up time-consuming rituals has always been part of the treatment package. Building up alternative behaviors becomes part of a bigger picture when functional analysis brings to light clear reasons why certain aspects of life were successfully avoided through the crippling symptoms. In addition to planning for new (or taking up old) activities, long term goals should be also be considered, if the client so wishes. Allowing some time for the discussion of life projects has often proved important in the later phases of therapy, and clients have reported in follow-up sessions that this gives them strength in moments of weakness after treatment has been terminated. New procedures derived from resource-oriented cognitive behavior therapy have proved particularly useful in this context (Meichenbaum, 1994).
How to Combine the Developmental and the Behavioral
The usual procedure is to begin with a phase of behavioral treatment, which aims to bring immediate alleviation of at least some of the incapacitating symptoms and broaden the patient's freedom of movement. This will promote the client's trust in the treatment and help in building up a therapeutic alliance. As long as behavioral therapy continues to bring progress, it should be continued. Success in the treatment of OCD is typically not steady and continuous; rather, fluctuation between phases of improvement interrupted by set-backs or periods of stagnation is usual. Moments of stagnation or complications in the treatment process be used as the starting point to enter a developmental avenue, by looking either at the learning history or at the developmental crisis or challenge at hand.
There are a number of common types of stagnation. First, the patient may experience a sense of exhaustion when confronting his or her fears. When avoidance behavior is replaced by exposure and response prevention, patients must tolerate a great deal of anxiety This often leads to a sense of exhaustion and a loss of determination, and may well be a sign of potential complications that need serious attention. When motivating the patient to continue the struggle with the help of behavioral exercises leads to frictions in the therapeutic relationship, a shift to developmental work is often the best next step.
A change in the quality of the therapeutic relationship may also necessitate a change in procedure. Conflicts in the therapeutic relationship always call for a period of developmental work. This may lead either to a phase of biographical work or to attending to the developmental motion when the therapeutic relationship has become a means to probe for new ways of interacting with others. A more dramatic point in treatment is when the old fears reoccur. This sometimes happens after an intense attack of anxiety flares up during one of the many fear-provoking situations in daily life.
Another type of complication is a shift of focus in the symptoms. More often than not, patients complain of a variety of obsessive-compulsive problem areas. Sometimes improvement in one area seems to be followed by deterioration in another. When the treatment process is not one of stepwise improvement in successive problem areas, but begins to feel like an (un)merrygo-round, a phase of developmental work can stop this unproductive cycle.
In addition, special challenges in the patient's circumstances may have to become the focus in the therapeutic work. Such challenges can be dealt with more effectively when the developmental transition that the patient may have to handle along with the particular challenge is also considered.
It is recommended that phases of behavioral work and phases of developmental work be kept relatively separate. However, during developmental treatment phases, it is important to watch out that progress at the level of behavioral symptoms continues. Brief discussions at the beginning or end of the session can encourage consolidation of the improvements achieved so far. Alternating phases of predominantly behavioral and predominantly developmental work has been found to be advantageous, as opposed to attending to both treatment components simultaneously. Concurrent work with both treatment components can become confusing both for the client and the therapist. Behavioral and cognitive behavioral work need the client's and therapist's full concentration for a significant period of time to result in noticeable changes. The same holds true for developmental work.
Developmental Behavior Therapy: Some Comments and Future Perspectives
The developmental avenue of biographical work is not new in behavior therapy. However, relatively few accounts of work with the learning history have been provided. Unfortunately, biographical work, if applied at all, is never described in detail, and so there is little possibility to compare procedures. Working with the cognitive-affective level of development is rather more novel, certainly in behavior therapy The crucial question here is whether cognitive-affective developmental maturation increases the chances of overcoming obsessive-compulsive disorders (or others disorders, such as phobias and depression), or whether it is a prerequisite. According to developmental-constructive models (Erikson, 1963; Kegan, 1982; Noam, 1986a, 1986b), each new level of development provides new means for dealing with one's life situation.
In an impressive treatment study involving 57 adolescent borderline patients, Noam (1991) found that progress in ego-development according to the Loevinger scales (1976) was associated with improvement in the symptoms. Some individual case histories (Röper, 1992, 1994) also support these results. More systematic research into the interplay between ego development and improvement in the symptoms of anxiety and affective disorder is urgently called for.
Developmental therapy should provide the opportunity for the patient to understand as much as he or she needs about the past, the present, and goals for the future. It is not the therapist's intellectual satisfaction at having understood the case fully that is important, but the client's need for change and insight.
In the case of severe OCD insight alone may not alleviate the symptoms, but it does often reinforce the motivation to carry on with the fight to overcome ritualistic thinking or behavior. Insight into the meaning of the symptoms, one of the cornerstones of psychoanalytic therapy, has with few exceptions been largely ignored in behavior therapy, and has even sometimes been explicitly referred to as unimportant. There are of course two opposing theoretical standpoints which may both (taken to their extremes) be incorrect. Insight into the development of an individual's symptoms can never provide a complete cure, and fortunately it does not seem to be necessary to overcome a neurotic disorder.
This type of behavioral developmental therapy focuses on development, and the symptoms are seen as a barrier to personal development. The goal of therapy is to allow the individual to pursue his or her life projects actively and responsibly, in communication with others.
The introduction of a clinical developmental perspective into behavior therapy opens up a number of interesting research questions:
1. Does a distinct developmental move take place in all cases when a patient overcomes severe symptoms?
2. Are these consecutive events, i. e., is one a prerequisite for the other, or do the two processes run in parallel?
3. Which therapeutic styles hinder or support development?
4. Is the efficacy of therapy enhanced when specific developmental transitions are accompanied by a specific type of therapeutic support?
5. Are different therapeutic settings (e.g., group or individual therapy) advisable for different developmental phases and the transitions between them?
These and other research questions mean that an exciting future lies in store for the merger of behavior therapy and clinical developmental psychology.
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