Tricky to Treat: Using Group Therapy to Address OCPD

While some studies posit that Obsessive Compulsive Personality Disorder (OCPD) is the most common personality disorder among adults in the United States, treatment studies of this disorder are rare. Why? Perhaps it is because OCPD can be especially tricky to treat. One of the most difficult challenges in treating clients with OCPD is that many aspects of perfectionism are actually highly adaptive.

Because individuals with OCPD tend to value their professional functioning, they sometimes view their desire to complete their work in a “perfect” way as a necessary component in their achievements. Therefore, those with OCPD are sometimes reluctant to begin or participate in treatment for fear that it could hinder their drive and success. However, a skilled clinician can work with OCPD sufferers to maintain the adaptive elements of their personality, while reducing the distressing components of the disorder. The moment an OCPD sufferer decides that they are willing to take the risks necessary to make these changes, wonderful progress can be made.

The brilliant clinician who guided my understanding of the nuances and rewards  of treating OCPD was Dr. Anthony Pinto, the Clinical Director at Northwell Health’s OCD Center and one of the world’s handful of psychologists who specialize in treatment and research of OCPD. Together, we developed one of the first group therapy treatments for OCPD. We found that the unique nature of OCPD makes it an excellent target for group therapy. Because interpersonal difficulties are a hallmark of OCPD, a group format is an excellent place to safely build interpersonal skills.

In addition, because treatment for OCPD is difficult to find, those with OCPD can feel alone and isolated in their struggles. Being part of a group of like-minded peers can provide invaluable support and validation as well as produce insight into one’s own maladaptive patterns. This set of circumstances paves the way for incredible moments. The end of our first session was filled with tears of joy and relief of group participants who had found in each other, for the first time, companions who shared their internal experiences.

The curriculum for this group was largely drawn from Egan’s Cognitive Behavioral Treatment for Perfectionism. First, we provided psychoeducation about the CBT model of perfectionism, explaining for example how thoughts, actions, and emotions all interact with each other. We then reviewed with the group the cognitive biases, or thinking errors, that are most prevalent in OCPD, such as all-or-nothing thinking, using “shoulds” or “musts”, discounting the positive, and the use of double standards.

We also employed the use of self monitoring. For example, we tasked participants to measure how many hours they spent procrastinating on various tasks. Furthermore, we encouraged participants to engage in behavioral experiments, such as not pre-washing dishes before using the dishwasher or setting an alarm every half hour to take a work break.

Throughout treatment, we guided clients in comparing the pros and cons of perfectionism in order to break down some of their rigid thought patterns. We actively worked on relapse prevention in forming an action plan, setting realistic and compassionate expectations, and dealing with setbacks. By discussing each topic in group, group members were able to share with one another their struggles and support each other’s goals.

However, while Cognitive Behavioral Treatment for Perfectionism is an extremely helpful component of treating patients with OCPD, it does not emphasize the rigidity and interpersonal difficulties that are hallmarks of the disorder. To address these issues we integrated a number of additional concepts to our group’s agenda. For example, a core component of OCPD is an anxious, busy mind. Thus, we decided that our group members would benefit greatly through learning mindfulness skills to establish a different relationship with these thoughts. We emphasized a focus on each member’s values throughout this experience in order to guide their decision making. For instance, identifying and reminding a patient about his value of spending time with his family helped motivate him to leave work on time or schedule in time to bond with his children. We also devoted a significant amount of group time to building interpersonal skills. Members were challenged to engage in activities such as sharing stories within a time limit or giving and receiving compliments without providing qualifiers explaining to what extent the compliment may or may not be true. The goal of this exercise was to build skills in conducting a conversation in a succinct and natural manner rather than rigidly striving for a conversation that has the “perfect” amount of information conveyed.

As with the interpersonal skill building exercises, we employed the use of in-session exposures to help patients build skills and tolerate distress. We had patients work on unfinished work in group and mindfully notice the thoughts and feelings that the mind produced before gently returning to the task at hand. This helped build members’ abilities to start and stop tasks without overly planning or procrastinating, tolerate thoughts of being unprepared or feelings of being unfinished, and pull themselves out of their work at a predetermined time. 

Finally, our group treatment provided participants with the opportunity to provide invaluable support and validation to one another. In general, being around others helped identify one’s own patterns, inspire one another, and provide a platform for troubleshooting.

Despite the hesitancy of the psychology community to invest in and treat an OCPD population, this group proved to be a wonderful success. Patients reported the skills learned and the camaraderie established to be useful elements that provided both cathartic relief from their suffering as well as concrete and measurable steps towards their recovery and maintenance.

This year I will be establishing new groups for OCPD based out of Dr. Steven Phillipson’s practice, The Center for Cognitive Behavioral Psychotherapy, which offers both in person and online treatment. If you are interested in participating in a group and beginning your journey towards improved mental health, please contact me at samccbp@gmail.com.