Early contributors to the psychoanalytic understanding of this character organization asserted that a constellation of character traits—parsimony, orderliness, and obstinacy—were signs of pathological regression. The castration anxiety connected with the oedipal phase of development led to a retreat to the relative safety of the anal period. These patients were regarded as having had early power struggles with their mothers around toilet training that led them to have difficulty expressing aggression and stubbornness leading to an insistence on getting their own way. Orderliness was regarded as a reaction formation against an underlying wish to engage in anal messiness. The self-critical nature was related to a punitive superego resulting from the internalization of power struggles with their mothers. Other defenses linked to OCPD in this classical conceptualization were intellectualization, isolation of affect, undoing, and displacement.

As the field of psychoanalysis has evolved away from ego psychology and more in the direction of British object relations thinking and American relational theory, the emphases have changed in terms of the conceptualization of the disorder. Vicissitudes of the anal phase of psychosexual development have been superseded by a focus on problems with spontaneity and control, interpersonal difficulties, management of anger and dependency, cognitive style, self-esteem, and the problems of balancing emotional intimacy with work productivity (Shapiro, 1965; Salzman, 1968, 1980, 1983; Gabbard, 1985, 2000; Gabbard and Menninger, 1988; Horowitz, 1988; Josephs, 1992; McCullough and Maltsberger, 2001). Self-doubt is also a marker of individuals who struggle with OCPD. Their childhood experiences often have made them feel that they were not sufficiently valued or loved by their parents or caretakers. Psychoanalytic exploration may reveal that this perception is often associated with excessively high expectations of parental demonstrativeness. Hence one cannot automatically jump to the conclusion that actual coldness in the parents was pathogenic. These children may in some cases require more reassurance and affection than the ordinary child to feel loved. Psychodynamic treatment of these patients also reveals strong unfulfilled dependent yearnings and a reservoir of rage directed at parents for not being more emotionally available (Gabbard, 2000). The defense mechanism of reaction formation, associated with isolation of affect, is often employed because both anger and dependency are consciously unacceptable to the person with OCPD. In a counterdependent effort to deny the existence of dependency, they may go to great lengths to demonstrate their ‘rugged individualism’ and staunch independence. They may similarly attempt to master their anger completely, and their conflict over anger may lead them to appear obsequious, ingratiating, and deferential to demonstrate that they are not harboring any feelings of rage or anger.

Work has the advantage of being at least potentially under the control of the worker, so people with OCPD are much more comfortable in the work place than in human relationships. Intimacy raises the possibility that they will be overwhelmed by powerful wishes to be taken care of. Those wishes entail a risk—namely, that they will be frustrated and lead the individual to feelings of hatred and resentment. Feelings in intimate relationships, then, are threatening because they have the potential to make someone with OCPD feel ‘out of control,’ which is one of the worst fears that these people harbor.

People in relationships with someone who has OCPD frequently feel that they are being controlled. This tendency to control others is related, in most cases, to a fundamental concern that sources of love or support in the immediate environment are prone to disappear at the drop of a hat. The child who grows up feeling unloved evolves into an adult who feels that any love from a partner is constantly imperiled. Because of the high levels of anger and the intense destructive wishes that lurk within, an obsessive-compulsive person may worry that this anger will drive people away. This fear is coupled with a general sense of self-doubt and low self-esteem such that many people with OCPD are convinced that if a friend or lover really knew them well, he or she would be filled with contempt and loathing.

In fact, the obsessive-compulsive style of relating to others often exasperates and irritates those who have to deal with it. Josephs (1992) stresses that subordinates may be treated differently than superiors. Power differential in the relationship shapes the style of relatedness. To subordinates, people with OCPD tend to come across as hypercritical, domineering, and controlling. To superiors, they are ingratiating and obsequious in a way that is perceived as a phony effort to curry favor. Hence, the approval and love they seek is undermined, so their fear of alienating others is a self-fulfilling prophecy. They tend to feel chronically unappreciated as they strive for an approbation they never receive.

The obsessive-compulsive's quest for perfection also leads to considerable misery. Psychoanalysis or psychoanalytic therapy often reveals a barely conscious or unconscious belief that if they could only reach a transcendent stage of flawlessness, they will finally receive the esteem and approval they missed as children. They seem to have the conviction that as children they simply did not try hard enough, so as adults they then feel a chronic sense of ‘not doing enough.’ The parent who was perceived as never satisfied becomes introjected as a harsh superego that expects more and more from the patient. Some persons with OCPD are workaholics because they are unconsciously driven by this conviction that love and approval could finally be attained if they could reach the top of their chosen profession. Here lies part of the tragedy in persons with OCPD. Even if they do achieve extraordinary accomplishments, they are rarely satisfied with any of them. They somehow feel that success is inherently disappointing. They are driven more by a wish to gain relief from a tormenting superego than by a genuine wish for pleasure. Hence they may feel that their achievement was essentially fraudulent and that they simply deceived those around them.

Josephs (1992) has found it useful to conceptualize the complex character structure of these patients as involving a public sense of self, a private sense of self, and an unconscious sense of self. Each has one dimension that applies more to superiors and another that is linked more to relationships with subordinates. The public sense of self in relationship to superiors, for example, is that of a conscientious and responsible worker who is predictable, considerate, serious, and always socially appropriate. The public sense of self in relation to subordinates is that of a constructive mentor or thoughtful critic who provides valuable feedback for those who wish to learn. Unfortunately, the subjectively experienced sense of a public self is not what is perceived by others. The reactions of others may give rise to a private sense of self that is conscious but largely hidden from others. Persons with OCPD frequently feel that they are unappreciated and consequently are dealing with a chronic sense of narcissistic wound. The lack of approval leads them to be even more tortured by self-doubt. They must shield this insecurity from those in superior positions because they dread humiliation from bosses and supervisors. They fear that if they expose this self-doubting side, they will be seen as weak and pathetic. Existing in association with this aspect of the private sense of self is a thoroughgoing conviction of moral superiority to those who occupy subordinate positions. Because OCPD patients are so intensely defended against their aggression and sadism, they do not want to appear contemptuous. Hence, they attempt to mask this aspect of the private sense of self to avoid appearing pompous, pretentious, or hypercritical. They may even feel proud of how considerate and self-contained they are toward those who are beholden to them.

The two dimensions of the unconscious sense of self involve a controlling sadist in relation to subordinates and an obsequious masochist in relation to superiors (Josephs, 1992). The mean-spirited and sadistic wish to hurt those who do not submit to their control is entirely unacceptable to OCPD patients and therefore must be repressed. To do otherwise would be to compromise their high moral standards. When it comes to authority figures, however, these same individuals fear humiliation in the context of being submissive and longing for love. Hence, they masochistically submit to their own excessively harsh moral standards and torture themselves for not living up to these expectations. This self-torture is a way of sparing them from what they fear most, namely, control, domination, and sadistic humiliation by others. The unconscious message they give to those to whom they are subordinate is, ‘You don't need to criticize me and attack me because I am already tormenting myself relentlessly.’

There is some evidence that broad personality characteristics—including those that may later become dysfunctional—involve a strong hereditary component (Kagan, 1989). Nevertheless, genetics do not account for all behavioral variability, as there is an ongoing interaction with the environment and learning experiences across the lifespan. From a cognitive-behavioral standpoint, OCPD behaviors and related beliefs are learned (and/or further strengthened) over time, primarily stemming from experiences with primary caregivers during the early developmental years, and later being reinforced by broader life experiences (e.g., peers, school) and societal values.

Regarding the latter factor, it is no surprise that OCPD is fairly common in Western culture, as our society tends to reward some of the characteristics of this personality style (Simon, 1990). For example, one of the messages that children receive during their years of schooling is that if they work hard and do things extremely well, they can achieve anything and become wealthy. Later, these same children grow up to witness the extreme competitive spirit that separates the ‘winners’ (‘the championship team,’ or the best product) from the ‘losers’ (all the others) and learn that they must take advantage of every ‘edge’ they have over other students if they wish to gain entry into elite secondary schools and colleges. In other words, working hard, being busy, being in control of the situation, and avoiding mistakes at all costs are viewed as part of the recipe for success. It becomes easy to see how these behaviors and attitudes can become magnified to the point where working hard becomes working obsessively, with little time for rest or reflection. Competing becomes a drive for perfection, and a reluctance to cooperate and get close to others. Trying to do things well becomes a paralyzing fear of making human mistakes, and an agonizing process in making decisions. Striving to be in control of oneself and one's life situation turns into needless self-restrictions, and excessive attempts to control other people. The full clinical problem of OCPD becomes reflected by the person's rigidity in thinking style and behavioral habits, punitive perfectionism, emotional constriction, ruminative indecisiveness and doubt, and other problematic manifestations of this personality spectrum.

In general, however, relatively little has been written about OCPD in the cognitive-behavioral literature. Much more theory and research has been invested in the Axis I OCD, which typically involves more discrete, circumscribed patterns of ritualized behavior intended to reduce excessive, acute anxiety. With regard to the broader personality style of OCPD, Shapiro (1965) observed that the disorder involved a rigid, intense, focused, ‘stimulus-bound’ quality of thought process—a style much more amendable to technical, highly detailed tasks than to ‘big picture’ endeavors such as navigating a social event, or engaging in the arts. Further, those with OCPD are extremely self-conscious about what they are thinking and doing, believing that they ‘should’ have control over the smallest details of their functioning, and overinvesting their identity in their tasks (‘I am what I do’). Shapiro also theorized that such individuals are also out of touch with their desires and wishes, and therefore experience marked subjective doubts about whether they are doing things properly, even as they steadfastly reject the well-meaning suggestions of others to ‘lighten up’ or do things a little differently. The result is a state of mind reflected by the apparently paradoxical thought, ‘I must do things this way; but what if it's not exactly right?’

Guidano and Liotti (1983) also have written about the cognitive and emotional styles of individuals with OCPD. One of the characteristics to which they point is the individual's belief that there is an absolutely correct solution for a given problem, and that it is best to postpone acting on the problem until this clear and certain path is ascertained. Such a stance may well lead one to suffer from (in colloquial terms) ‘paralysis by analysis.’ Guidano and Liotti hypothesize that individuals with OCPD grew up in households in which they were given very mixed, contradictory messages from parents. When this happens, children learn that doing the ‘right’ thing is very elusive, and the cost for being wrong can be very high indeed. The result is a demand for certainty, and an overconcern for the smallest of details.

In general, cognitive-behavioral theorists put less emphasis on uncovering a specific etiology for OCPD symptoms, and more on a descriptive evaluation of the faulty beliefs that comprise the disorder, as well as a conceptualization of the ways in which the disorder is maintained by the current interaction of patient's beliefs with his or her environment (see J. S. Beck, 1995). For example, a number of maladaptive beliefs have been identified that are emblematic of OCPD. Clinically generated by A. T. Beck et al. (1990), the diagnostic specificity of these beliefs has been supported by recent empirical investigation on the discriminant validity of the Personality Beliefs Questionnaire (PBQ: A. T. Beck et al., 2001). A brief sample of these beliefs is:

• ‘It is important to do a perfect job on everything.’

• ‘Any flaw or defect of performance may lead to a catastrophe.’

• ‘People should do things my way.’

• ‘Details are extremely important.’

Similarly, Young (1999) has developed a taxonomy of schemas hypothesized to be pertinent to chronic dysfunction such as personality disorders. It may be hypothesized that the schemas common to OCPD would be incompetence (overconcern that mistakes or flaws will indicate an overriding lack of capability), unrelenting standards (such that nothing less than the highest level of performance will be allowed in oneself or in others), and lack of individuation (in that they fear loss of identity and control if they change any aspect of how they customarily respond).

As mentioned above, some aspects of OCPD behavior are positively reinforced by a society that values hard work and competition. However, it seems that negative reinforcement may play an even more prominent role in the maintenance of the OCPD style. Much of the extreme behavior of individuals with OCPD is driven by anxiety—about making mistakes, missing something important, and not getting it ‘just right.’ By focusing on details, staying true to a familiar routine, avoiding risks, and maintaining ‘control,’ persons with OCPD find relief when their feared outcomes do not materialize. This relief—translated as the reduction of the aversive emotion of anxiety—negatively reinforces OCPD strategies. Unfortunately, relief becomes a dominant feeling in the person's life, obscuring other important emotions such as joy and rapture. Further, the patient's ultraconservative behavioral strategies do not permit the testing of new hypotheses, thus further maintaining the status quo. If the OCPD patients always do the same things, they will assume that what they are doing works best—there is nothing to which to compare it. However, for the OCPD individual who is dysphoric and seeking therapy, he or she will feel ‘stuck,’ sometimes making statements such as, ‘I know I should do things differently, but I just can't bring myself to do it.’ As for the important people in their lives, they often conclude that the person with OCPD ‘will never change.’

The following is a brief sample of a cognitive-behavioral conceptualization for a male, 45-year-old OCPD sufferer who is experiencing problems at work, marital difficulties, and a severe level of dysphoria that is sometimes accompanied by suicidal ideation. The therapist describes ‘Ace’ as a gentleman who demands perfection of himself and others, and whose emotions range from flat to dysphoric. Although his wife has complained for years that Ace is too critical and emotionally withholding, threatening to leave him on many occasions, Ace did not become depressed until he received a significant promotion at work that forced him to assume a new schedule and additional responsibilities. No longer able to do things the way he had done them for 20 years, and fearing that he was no longer capable of maintaining perfect standards, Ace lapsed into a severe depression. Ace's colleagues tried to give him some assistance, but he viewed them as patronizing and intrusive, and responded by isolating himself. He tried to compensate for his subjective sense of loss of control and competence at work by tightening the reins over his wife and kids at home, whereupon his wife informed Ace that she had contacted a divorce attorney. Ace agreed to see a therapist in order to appease his wife temporarily, but he viewed the act of consulting a therapist as an inherent failure, and his suicidal ideation worsened. Not surprisingly, his work performance suffered further, which only served to ‘confirm’ for Ace that he was losing control over himself and his life, and his self-reproach and hopelessness (as well as his irritability) became more pronounced. The treatment plan would focus on the suicidality first, and then the beliefs and behaviors that Ace used to punish himself and others when things would inevitably change or could not be done perfectly in life.

A general practice principle in treating patients with OCPD is that the intrapsychic defense mechanisms will be transformed into resistances as a psychotherapy process begins. If a patient characteristically intellectualizes, for example, as a way of fending off affect, that same pattern of intellectualization will occur when the therapist attempts to explore the patient's feelings. Patients may identify facts and gather data as a way of not dealing with feelings either directly toward the therapist or outside the therapeutic situation. Because lack of control and emotional spontaneity are among the most dreaded possibilities with someone with OCPD, patients with this disorder will often attempt to maintain firm control over what transpires in the session. A typical pattern of resistance to the free flow of associations and the exploration of feelings as they spontaneously occur is to structure the session by bringing in an outline of topics the patient wishes to cover.

A useful strategy to deal with this defensive style is for the therapist to make active efforts to help the patient identify feelings. When the patient provides a long factual account of events, it is helpful for the therapist to ask, ‘But what did you feel in reaction to those events?’ The therapist can also be active in making observations about feelings that slip through the defensive barrier. For example, the therapist might say to a patient, ‘I notice you teared up when you talked about your uncle's funeral. Could you tell me more about the feelings you had during the funeral service?’ The therapist can also point out reasons that rigid defenses are necessary. In other words, the fear of spontaneity, the dread of having angry feelings that would lead to feeling out of control, and the unacceptable nature of sexual feelings may all be major contributors to the need for the defensive posture with which the patient approaches therapy.

Another key practice principle is modification of the patient's harsh superego. The patient's punitive self-critical tendencies repeatedly get in the way of open and free exploration in the treatment process. Therapists must constantly look for ways to help patients accept their humanness. Reassuring the patient of his or her essential goodness is usually not effective. A nonjudgmental stance by the therapist is essential, and from this nonjudgmental perspective, the therapist can interpret conflicts around aggression, sexuality, and dependency. While OCPD patients will repeatedly attribute punitive attitudes toward the therapist, a consistent, nonjudgmental, accepting attitude over time will help patients begin to see that they are projecting their own self-critical nature on to the therapist. There is a cumulative effect of repeated interactions in which the therapist does not behave as the patient expects, leading to a gradual internalization of the therapist associated with a corresponding modification of the patient's superego (Gabbard, 2000). A clinical example will illustrate this process:

In this vignette the therapist modifies Mr A's punitive superego by stressing the transference distortion with which he regards his therapist. He points out the origins of the criticism in the patient and how that criticism is projected on to the therapist. By clarifying that he does not actually feel that way, he makes the patient take the projection back and consider why he reacted in the way he did. The ultimate effect is to help patients acknowledge their humanness—i.e., they learn to integrate feelings, failures, and foibles into a sense of who they are without feeling that they have lost any sense of self-respect or dignity.

The patient's superego may also be modified by interpreting defensive maneuvers designed to avoid unacceptable feelings. For example, a patient who is excessively deferential to the therapist may be using reaction formation to defend against hostile feelings. At an appropriate moment the therapist may wish to interpret this defense so the patient reflects on how it serves to control unacceptable feelings. The therapist might say, ‘I've noticed that when I tell you it's time to stop the session, you almost always thank me profusely for the help. I wonder if that pattern of thanking me conceals any hostility about my interrupting you and telling you it's time to go.’

The therapist also looks for opportunities to point out to OCPD patients how their defensive style interferes with pleasure outside of therapy. The tendency to overwork and to ignore intimate relationships can be an active focus of the treatment. Pointing out the patient's difficulty in prioritizing and delegating may be useful. In interpersonal relationships, the patient will describe interactions that reveal the discrepancy between how he views himself and how others view him. The therapist should systematically address the patient's behaviors, both in the transference and outside the transference, that produce certain reactions in others. For example, the therapist might say to a patient who is alienating others, ‘Do you suppose that your insistence that the other employees do things exactly as you do may irritate them?’ With a consistent focus of this nature, patients eventually learn that no matter how well defended they are, their controlling tendencies and hostility toward others seep out through their pores and result in problematic relationship.

In cognitive therapy, patients learn to assess their own thoughts and beliefs, and to make modifications based on the evidence of their life experiences, and on the basis of an objective evaluation about what would serve to improve the quality of their lives. Some OCPD patients are adept at recognizing the demanding and punitive nature of their thoughts, while others need the therapist to offer hypotheses for their consideration. Whatever the route to better understanding, it is important for patients to come to appreciate the impact that their subjective construal of themselves and their world play on their emotions and actions. A typical intervention, therefore, is to list and examine some of the typical beliefs that OCPD patients maintain, such as ‘I am a failure if I make a mistake,’ and ‘I must stay in complete control or else I will fall apart.’ Open-ended questioning—also known as ‘guided discovery’ and the Socratic method—are very useful in testing such rigid, problematic beliefs. Rather than simply telling OCPD patients that their beliefs are ‘maladaptive’ and instructing them on what they should believe instead, cognitive therapists ask patients questions such as, ‘How else could you maintain high standards, and yet not be so punitive toward yourself or others?’ or ‘Under what conditions could a person such as yourself show a lot of emotions—sadness, exuberance, grief, love, and so on—and yet still feel reasonably secure, safe, and even proud of yourself?’ These are important thought exercises that are intended to stretch the OCPD's conceptual comfort zone, while reducing the risk of incurring a power struggle in the therapeutic alliance.

As the patients begin to entertain new ways of thinking, therapists encourage them to test the new hypotheses in everyday life. Examples are numerous. One patient agreed that she might benefit from changing her daily routine, which led to a discussion about trying a new item on the lunch menu, driving the ‘scenic’ route to her mother's house on Sundays, and sometimes even calling her mother to cancel their weekly visit in favor of a recreational activity such as biking with a friend. Predictably, this patient had some misgivings, whereupon the therapist asked her to articulate her automatic thoughts. The patient stated that she might not like the new lunch item, and therefore would waste money, and that her mother might be upset with her if she took longer than usual to get to her house or postponed the visit altogether. When these sorts of thoughts are identified, the therapist's goal is not to convince the patient that she is wrong, and that being more flexible and spontaneous is right. Rather, the goal is to flesh out the patient's concerns and to evaluate them on their own merits, based on the patient's life experience. Additionally, however, the therapist tries to establish an openness to new ideas, and a willingness to explore new ways for the patient to choose to lead her life. Such new ways might very well include asserting herself with her demanding mother, learning to find diverse food choices that she might like, being less concerned about calculated gambles with small amounts of money (e.g., lunch at a cafeteria at work), and finding new activities (e.g., biking with a friend) in order to be healthier and to invest in more relationships. All of these ideas (and their implementation between sessions) will stir up more automatic thoughts and emotions, the likes of which become fodder for therapeutic discussion. The process becomes a positive feedback loop for change.

Another example is a gentleman who, after engaging in a Socratic dialog with his therapist, decided that he would try to invest more of himself in his relationships, and to write down his thoughts when he would experience time pressure to get back to his work. The therapist infused a good deal of humor into this patient's treatment, which in itself runs counter to OCPD in that it is often unexpected and off the beaten track, and involves a display of emotions. For example, when this patient said he would ‘Try to have sex with [his wife] this week,’ the therapist replied that the purpose was not so that the patient could strike the item ‘Make love to wife’ off his ‘to do’ list! The patient actually chuckled, and acknowledged that he might indeed be more concerned with getting the therapy assignment ‘right’ than in actually enjoying the time in bed with his spouse, assuming that she agreed to the activity! This led to a very fruitful discussion about the patient's concerns that ‘the emotions were dead from both sides’ in his marriage, a topic he had conspicuously avoided during 3 months of treatment. In the end, the patient scaled back his plans, and instead produced some ideas about how he would do more of ‘the little things’ for his wife, even if it took some time away from his work. This was viewed as a behavioral experiment that needed to be run for at least a month in order to really see what results were possible—not only in terms of the wife's responsivity, but with regard to the patient's feelings about himself as both a husband and a provider, and about his wife.

An important goal in treatment is for the OCPD patient to learn to be more tolerant of mistakes. Patients often misconstrue the intent of this goal, believing that the therapist is asking them to ‘lower their standards.’ Quite to the contrary, the therapist is trying to help patients to raise their standards in terms of risk-tolerance, willingness to do difficult tasks with uncertain outcomes, composure under duress, and benevolence toward the demonstration of human flaws in oneself and in others. The only variable the therapist is trying to attenuate is the degree of punishment that the patients heap on themselves as a result of their perceived miscues and shortcomings.

There is no need whatsoever to assign OCPD patients the task of doing things imperfectly on purpose. Imperfection occurs naturally in life, and its propensity for showing up at difficult moments can be used to therapeutic advantage, rather than be cursed as something terrible and devastating. The case example of Mr A is an illustration of the inevitability of imperfection. Along these lines, a useful cognitive therapy homework assignment might be for the patient to think of (and document) the things he would like to do, but usually avoids for fear of failing. Then, his task is to consider the pros and cons of trying each of these endeavors, bearing in mind his propensity for magnifying the consequences of not getting it ‘right,’ and underestimating the benefits of trying. Following that, the patient could then create a hierarchical list, from least threatening to most threatening, culminating in making attempts to engage in these activities, one at a time, in spite of the risk of making mistakes. As the patient proceeds through this list (which may take weeks and months to achieve), he can evaluate the process and outcome. Was it worth taking the risk? Did he learn something new and useful, even if his performance wasn't perfect? Is he better off now than he was before for having tried something new and difficult? Were the mistakes and imperfections calamitous? How did he handle the mistakes, and how is this a model for coping with mistakes in the future? As OCPD patients expand their repertoire of emotions, behaviors, and cognitions, they will experience uncertainty and missteps—experiences that can educate them further about how much is still possible in their lives, and what they're willing to go through to explore these possibilities.

Many OCPD patients are excessively indecisive as they wait for ‘certainty’ about the ‘right’ choice. This stance can lead to many missed opportunities in life that require ‘taking a chance’ and ‘going for it.’ The problematic belief underlying this problem is that there are always predetermined correct and incorrect decisions, and that it is the patient's responsibility to ascertain the difference before making the ‘irreversible’ choice. The following is an example of a reframe of this belief offered by a cognitive therapist for the OCPD patient's evaluation and feedback.

In order to encourage patients to have greater access to—and displays of—appropriate emotionality, therapists will need to go beyond the purely semantic and action-oriented techniques of therapy at times. Merely talking abstractly about profound emotional concepts such as love and grief can take one only so far. An intellectual understanding of the role of such emotions in an OCPD patient's life is the cinematic equivalent of watching a documentary about the life and death of a beloved person. Instead, we want to metaphorically watch tearjerker movies such as Terms of endearment with our OCPD patients. Somehow, we have to make our interventions more emotionally evocative. In order to do this, cognitive therapists make use of imagery exercises as well as other methods sometimes associated with experiential/gestalt therapies (e.g., Daldrup et al., 1988—focused-expressive psychotherapy).

For example, Newman (1991) describes the case of ‘Ms B,’ an emotionally constricted and overly controlled 30-year-old woman who wanted to be able to establish an intimate relationship with someone, but believed she was incapable of the necessary feelings. Discussing the issues was somewhat helpful, but Ms B still felt she could not access deeper feelings. Later in treatment, after describing the rationale for the proposed intervention in depth, the therapist walked Ms B through an evocative, combined relaxation-imagery induction, in which she was asked to remember and describe in detail (while her eyes were closed) the most significant romantic relationship she had experienced thus far in her life. As Ms B reflected on the ‘one who got away’ 10 years before, the therapist tried to escalate the emotionality of the intervention by asking Ms B to imagine the boyfriend's voice, telling her how much he loved her and wanted to be with her. Then, Ms B was instructed to speak aloud to the boyfriend as if he could hear her, but to speak to him with the mature emotions and insights she had gained over the past 10 years that she did not possess at the time of the actual relationship. Finally, the therapist asked Ms B to imagine a warm embrace with the boyfriend. ‘The therapist's intention was to help Ms B achieve an emotional state whereby her longing for love would be stronger than her fear of being rejected’ (Newman, 1991, p. 310). Finally, Ms B (who was now weepy) was asked to state her thoughts in the moment, which included, ‘This is what I want in my life… I don't want to be emotionally dead.’ The therapist responded by playing devil's advocate, asking Ms B the question, ‘Wouldn't it be [better] to go back into your nice, safe shell again?’ Ms B came up with many rational responses for the therapist's implied, maladaptive entreaty. Later, she was asked to write them down in her therapy journal. This intervention took place after a number of months of therapy, when a trusting therapeutic alliance had been well established.

Reflecting on ‘Ace,’ the patient referred to earlier who became suicidal in response to changes in his job responsibilities and his own ineffective compensatory strategies that alienated him further from his colleagues and his family, let us summarize the interventions that were required. First, Ace's suicidality took front and center stage, as the standards of good clinical practice would dictate. However, in addition to implementing the customary, practical safeguards in case management (see Bongar, 1991), the therapist focused on Ace's perfectionism as a problem area. As a man who was very responsive to ‘the facts’ of a situation, Ace was attentive when the therapist educated him about the data linking perfectionism to suicide risk (Hewitt et al., 1994; Blatt, 1995). Ace had always worn his perfectionism as a badge of honor. However, the therapist added, ‘Your analysis is incomplete… you have only looked at the potential benefits of perfectionism, but not the drawbacks, nor have you tried different variations of approaches to see if there is a safer, more effective way to have high standards without the punishment.’ The therapist's goal was to support Ace's goals related to accomplishment (thus counteracting his incompetency schema), while periodically monitoring the patient's reactions to the therapeutic relationship (e.g., did Ace feel that the therapist was trying to control him by suggesting therapeutic changes—a manifestation of the ‘lack of individuation’ schema?). Progress was evident when Ace was able to state that his perfectionism—as he practiced it—had many negative consequences. It made his family shy away from him, prevented him from ever being pleasantly surprised (because, by definition, he could never exceed his expectations), and always kept him anxious, because a single mistake could undo all the good work he had ever done. He generated two helpful flashcards as reminders to himself. They read:

When Ace's acute suicidality subsided (with the help of pharmacotherapy), he and his therapist focused on gradually modifying the beliefs and behavioral habits that had so typified his ‘unrelenting standards’ schema. For example, Ace dwelled on the idea that he was failing at his job. As a response, Ace was given the assignment of compiling his ‘collected works’ (he had been a technical writer for over 20 years) and to review them as evidence of his competency and productivity. Ace kept this formidable pile of publications and departmental handbooks on his desk as a reminder that he was more than capable of being successful, and that it was unnecessary to hold himself back from learning new skills. At home, Ace had to notice when he was about to make a critical comment to his wife or kids, to resist saying anything, and instead to write these thoughts in his ‘irritability journal.’ Then, he had to think ahead about the pros and cons of actually making such statements to his family, and to make distinctions between helpful and unhelpful feedback. Ace then practiced (via in-session role-playing) tactful, diplomatic ways of stating his views, in advance of actually trying them at home. Ace understood that it may not be possible to reverse his wife's tentative decision to seek a marital separation, but he was going to treat her and the kids more nicely regardless.

The therapist also taught Ace how to self-induce a state of relaxation through controlled breathing and imagery of pleasant environments. Additionally, Ace generated ideas for recreational and avocational pursuits, which he pledged not to try to do perfectly! Instead, the idea to was infuse a little bit of ‘down time’ into his life, yet still do things that interested him and helped him to grow. Throughout this entire process, the therapist monitored Ace's thoughts about the interventions and assignments, and engaged him in empathic, collaborative dialog whenever the patient would express doubts or concerns about any of the therapeutic methods and goals. Ace understood that ‘Old habits of thought and deed die hard’; thus, many repetitions of these new ways of responding in everyday life would be required.

One of the chief challenges therapists encounter when they treat OCPD patients is that the dutiful nature of the condition leads certain patients to try to become ‘perfect’ in the way they approach the therapy. They seek to produce in the therapy exactly what they think the therapist wants to hear. Their search for the therapist's approval may interfere with any authentic effort to understand themselves. McCullough and Maltsberger (2001) made the following observation: ‘The patient ritualizes the therapeutic encounter and is likely to fence the therapist in by never coming late, paying the fee immediately, and becoming superficially very ‘good’ in the service of boxing in the treatment’ (p. 2346). The therapist may have to address this style of relatedness forthrightly and even deliberately dislodge the patient from the usual rituals to try to help the patient think and speak spontaneously. For example, when a patient comes in prepared to cover several topics, the therapist might say, ‘Before you get into the topics in your outline, I'd like to talk to you about something you said last time.’ This type of intervention may discombobulate the patient but forces him or her to interact more authentically with the therapist.

A challenge related to the patient's efforts to be perfect is the patient's unconscious conviction that only perfection is acceptable. Therapists may need to work diligently to help such patients lower expectations of themselves and others. Patients can be helped to see that even though they may feel disappointed in themselves and others when they fall short of perfection, there is an associated relief and liberation from the fantastically high standards they have set. It may be helpful to explore with the patient whether there are any disastrous consequences for falling short of perfection and help them see that there rarely are such consequences.

Patients with OCPD may be intensely competitive with the therapist and not want to be in a position of being told things about themselves that they feel they already should know. The idea of the therapist making observations about them that were previously unknown may threaten their sense of being in control of their lives and their thoughts. The whole notion that they have an unconscious mind that may control them can be quite frightening. Patients with OCPD may discount the therapist's insights and comment that what the therapist has said is ‘nothing new.’ These patients may also attempt to revise what the therapist has said or pick apart the exact wording. A therapist said to a patient, ‘You said yesterday that your mother was an angry woman.’ The patient quickly corrected him: ‘No, no, what I said was that she was a hostile woman.’ This competitive interaction may lead to a countertransference posture in the therapist of attempting to prove that he or she is right. A kind of ‘one-upmanship’ may develop in the therapeutic dyad that becomes an enactment rather than a careful processing of what is going on between the two parties. Many people in the mental health professions have used obsessive-compulsive defenses in a highly adaptive way to achieve a great deal in their chosen profession. The therapists may overidentify with the patient and have a difficult time identifying the maladaptive aspects of the patient's defensive repertoire.

A major challenge involves countertransference boredom. Many therapists describe the monotonous droning of the patient with OCPD as sleep inducing. They may find their minds wandering, their eyelids getting heavy, and their eyes constantly checking the clock. The absence of affect and spontaneity may give the patient's speech a mechanical feel that does not engage the therapist. The optimal approach to this common countertransference experience is to take up the patient's style of talking before sleepiness sets in. There are numerous tactful ways to bring up the patient's way of relating. One is to point out that the patient does not seem to be very interested in what he or she is talking about. Another variation is to comment that the patient does not seem to expect the therapist to be very interested in the topic. Yet a third approach is to shift gears by asking the patient directly what he or she thinks is going on in the session between the two parties.

An overall challenge and a centerpiece of dynamic therapy or analysis of patients with OCPD is helping them see how they are hiding their private sense of self behind a public presentation that is not entirely convincing to others. Therapists must ‘unmask’ the patient and let the patient know that the therapist can discern the struggles underneath the surface presentation. At the same time, it is critical for therapists to empathize with the shame and guilt associated with the unacceptable aspects of the private sense of self and even the unconscious sense of self. When therapists can acknowledge the underlying self-loathing of the patient, many OCPD patients feel understood and can let down their guard a bit. It may take an extended period of time in therapy, but the major challenge is to help the patients accept themselves as they are without feeling they have to be inauthentic to be acceptable.

The tendency for obsessive-compulsive patients to think in all-or-none terms will likely cause them a sense of unrest with regard to ascertaining their prognosis, as well as understanding the process of therapy itself. Mental health assessment and treatment involve a certain degree of uncertainty and ambiguity. Persons who think in obsessive-compulsive terms will be very uncomfortable with this state of affairs, instead often insisting that therapists should give iron clad predictions about the time required for the patient to be ‘cured.’ When the therapists try to explain that this level of precision may not be possible at present, the OCPD patients may jump to the conclusion that their therapists are not knowledgeable enough, and/or that the entire field of psychotherapy is flawed beyond utility. The therapists’ explanation that the patients’ learning to tolerate uncertainty and ambiguity is part and parcel of the treatment may seem to them like so much double-talk.

In response, therapists may have their own dysfunctional thoughts and emotions, such as concluding prematurely that a bond cannot be formed with the patient, that the patient is so demanding as to render therapy hopelessly burdensome for the therapist, and that the therapist has only two choices: snap to attention and answer all patient's questions as if under cross-examination, or risk losing the patient in a failed attempt to engage. As one can see, the above is an example of the therapist's adopting the OCPD patient's rigid, all-or-none approach, rather than the patient modeling the therapist's openness to exploration with no guarantees. Cognitive-behavioral therapists who are aware of this potential pitfall can monitor their own thoughts so as not to abandon an approach that engages patients in collaborative empiricism and hypothesis testing. To go further, the therapists have to be aware that they may feel incompetent in the face of criticisms of OCPD patients who reject the clinician's perceived ‘fuzzy’ answers to their questions (e.g., ‘Exactly what percentage of my depression is biological, and what percentage is psychological?’). Therapists would do well to discuss this interpersonal process with their patients, and to explore parallels with other relationships in the patient's life, rather than simply trying to tell the patients what they want to hear to reduce the criticisms.

An interesting problem involves the OCPD patient who self-selects for cognitive therapy under the assumption that it is exclusively a ‘logical’ therapy about thinking, but not about emotions. They may have read some of the self-help books in the field (e.g., Burns, 1980) that contain lists of types of dysfunctional thinking, and that provide methods by which to change thought patterns, and concluded erroneously that the identification and addressing of issues surrounding emotions and relationships will not be necessary. They may be very interested to utilize Automatic Thought Records (J. S. Beck, 1995; Greenberger and Padesky, 1995), but become preoccupied with relatively trivial questions of whether a particular automatic thought is an example of overgeneralization versus all-or-none thinking, rather than focus on the emotions, interpersonal context, and life issues that are reflected by their thought process. When the cognitive therapist inquires about the patients’ feelings, wishes, hopes, and/or the quality of their personal relationships, the patients may feel as if they are not getting ‘true’ cognitive therapy and thus become dissatisfied.

Therapists can explain that the purpose of cognitive therapy is not to teach people to utilize logic at the expense of the full range of human experience. Rather, cognitive therapy chooses the patients’ thinking style as a particularly useful point of entry into the entirety of their psychological system, toward the goal of helping patients live their lives more productively, functionally, and adaptively. In the case of individuals with OCPD—who may demonstrate a problematic dearth of spontaneity, flexibility, and interpersonal warmth—focusing on emotions and interpersonal relationships in therapy may in fact be the most sensible and ‘logical’ thing they can do.

As one of the defining characteristics of OCPD is the individual's rigid adherence to a particular set of ideas and habits, therapists will sometimes find that their OCPD patients take umbrage at the implied suggestion that ‘therapists know best.’ In other words, even though the patients presumably are seeking therapy in order to obtain expert professional opinions and suggestions, they may be uncomfortable with the idea that the therapist is ‘right’ and they are ‘wrong’ about how they are navigating their lives. Of course, cognitive therapists strive to work collaboratively with their patients, to validate their experiences through the expression of accurate empathy and the formulation of a solid case conceptualization, and to eschew an ‘all or none’ approach to problem solving and decision making in therapy. Thus, in both cognitive and dynamic therapy, the therapeutic alliance is not about ‘Who is right and who is wrong?’ However, as OCPD patients often see things in black and white terms, they may believe they will be unduly relinquishing control over the course of their lives if they make the kind of changes their therapists are teaching and supporting.

Therapists need to be sensitive to this possibility, lest they themselves jump to conclusions and make negative generalizations such as, ‘This patient is markedly resistant to change,’ or ‘This patient always wants to engage in a power struggle with me, and to compete with me for control of the session.’ Rather than label the patient in this way, therapists can address the patient's concerns about somehow being diminished by the process of therapy, and can work with them to generate more palatable ways to reframe their interactions. For example, one patient was able to articulate that he felt his therapist was bossing him around, and didn't respect the patient's opinions. The therapist took this as a cue to be a little less directive, and to try to conceptualize the problem with occasional reflections and thoughtful questions such as ‘Do our differing views remind you of other interactions you have had in your life?’ The patient noted that the therapist might try to ‘take all the credit’ for the patient's positive changes, just as his older brother had ‘gotten all the glory’ for tutoring him in math, even though it was the patient's hard work that earned him the ‘A’ grade. The therapist responded in such a manner as to give evidence against the patient's feared outcome—by openly reflecting on all the patient's therapeutic accomplishments to date, and showing respect and admiration to the patient for his diligence and courage in being able to make such improvements. Following this, the patient was able to add, ‘You've been helpful too.’ Therapist and patient then shook hands, agreeing that their teamwork was formidable.

Cognitive therapists need to observe how their OCPD patients understand and utilize their homework and other ‘extra-session’ tasks. The overarching purpose of homework is to provide the patients with opportunities for practicing new psychological skills without the therapist's presence. This facilitates learning in that more repetitions can be achieved than are possible solely in the therapist's office, and the patients develop a sense of self-efficacy in doing the work on their own. Patients also fill out questionnaires that can give therapists useful assessment information without taking up time in the therapy hour per se. However, in keeping with the OCPD tendency to become excessively focused on the details at the expense of the bigger picture, some patients may miss the point of completing homework and mood inventories. For example, instead of using Automatic Thought Records to consider new ways to view their life situation and to solve problems, the patients get bogged down trying to determine into which precise category their dysfunctional thinking fits. Similarly, rather than using the Beck Depression Inventory (A. T. Beck et al., 1961) as a quick way to assess and reveal their current mood state, they spend inordinate amounts of time splitting hairs on the items, causing more distress, and delaying the start of the therapy session. Further, OCPD patients are sometimes reluctant to do a homework assignment if they believe there is a chance of making a mistake, or if a positive outcome cannot be guaranteed. Such problematic responses go against the spirit of collaborative empiricism, and diminish the utility of these homework and assessment procedures. Nevertheless, these problems are diagnostic in and of themselves.

An interesting problem occurs when the OCPD patients try to be perfect in their treatment, such that they demonstrate they are skilled and ‘good’ (and therefore worthy of the therapist's high regard?), that their problems are neat and easily managed, and so that the therapist will pronounce them well (which seems more important than actually feeling well). Such patients often endorse few if any symptoms on assessment questionnaires such as the Beck Depression Inventory (A. T. Beck et al., 1961) even though their life situations might suggest that more distress would be warranted and normative. They go to great lengths to be superficially agreeable, and to prepare homework that is either highly detailed, voluminous, and/or where everything has a simple, positive ending.

For example, Mr H, a high-powered businessman who met criteria both for OCPD and panic disorder (which greatly contradicted his sense of total control over his emotions), would repeatedly write clich's for rational responses on his Automatic Thought Records. Rather than actually generate new, original ways of thinking that might help him decatastrophize his occasional physiological spikes of arousal, or try to understand how these anxious moments were triggered, Mr H would simply write rational responses such as, ‘I will not fail because failure is not an option,’ and ‘Whatever doesn't kill me only serves to make me stronger.’ He had the most difficult time leaving the safety of these canned responses in favor of more personalized ones. In response, the therapist hypothesized that if Mr H believed he could not maintain actual control over his panic attacks, his next priority was to give the appearance of having such control. That Mr H might truly come to understand his feelings better, to talk to himself with more compassion, and to cope with his imperfections yet appreciate himself nonetheless was way down on his list of goals.