* Published December 2022
In his book Individual Psychotherapy and the Science of Psychodynamics, Dr. David Malan offered a simple model for conceptualizing the emotional and relational dynamics underlying OCD.
This article presents my simplified version of Malan’s model, largely loyal to the original but filled in and slightly adjusted. I have found this model to be very helpful in identifying some of the emotional and relational factors contributing to people’s OCD symptoms. It is also helpful in understanding how these symptoms may be connected with past experiences, as well as other issues they struggle with in the present.
To understand Malan’s model of OCD, we first need to understand the psychodynamic/psychoanalytic model of psychopathology that his model is based on (1).
The Basics: Emotional Conflict and Repetition
Malan’s model is based on the idea that a psychological symptom is the result of an emotional conflict. An emotional conflict means that allowing oneself to feel what one would naturally feel would lead to a painful emotional consequence. (I’ll provide examples shortly.)
In order to resolve this conflict, the natural feeling is given expression in a way that somehow manages to avoid the painful emotional consequence. To accomplish this, the natural emotion is transformed or disguised in some way.
This is not as esoteric as it sounds. Passive aggression is an easy example. Let’s say a person feels angry at another person, but feeling angry at them evokes shame or a fear of retaliation. Passive aggression gives expression to their anger while avoiding those consequences.
In this model of psychopathology, psychological symptoms serve the same function as passive aggression in the example above: They give expression to a natural feeling in a way that manages to avoid a painful emotional consequence.
Put another way, psychological symptoms may result when natural feelings can’t be felt because they are too threatening for some reason. Or flipping this around, behind every psychological symptom is a healthy, natural feeling that isn’t being felt or acknowledged (Malan, p. 8-10).
Two important notes thus far:
- This approach sees feelings sort of like physical forces. They can’t just disappear; they have to go somewhere.
- All of the above happens unconsciously. Returning to the example of passive aggression, the person may not realize they are angry; may not realize that they are scared to be angry, or why; and doesn’t intentionally transform their anger into passive aggression. This all happens automatically, outside of their awareness.
To summarize what has been said so far, there are three parts to this model:
- The natural feeling (How would a person naturally feel in a given situation?)
- The painful emotional consequence (Why can’t they feel that way? What painful emotional consequence are they afraid of?)
- The symptom (What happens that manages to express the natural feeling while avoiding the painful emotional consequence?)
The other dimension of this model is repetition. Psychodynamic/psychoanalytic theory maintains that people tend to repeat the same emotional and relational patterns over and over again (Malan, p. 111). This indicates that whatever emotional conflict is driving a current symptom will be similar to emotional conflicts the person has experienced in the past, and also similar to emotional conflicts the person currently experiences in other areas of their life (Malan, p. 80).
While this might sound like a big assumption, it’s fairly intuitive. For example, let’s say that in childhood a person learns that expressing distress leads to shame, so they develop a way of dealing with their distress that avoids shame. It makes sense that they would bring both their expectation that expressing distress leads to shame, as well as their strategy for negotiating this conflict, into future relationships.
Turning to OCD
In order to apply this model to OCD, we first need to introduce the concepts of attachment and healthy aggression.
People have two sets of needs in relationships (K. Beard, personal communication, 2021): We need to be connected to other people, and we need to protect ourselves and get our individual needs met. Simply put, we need to preserve our relationships, and we also need to preserve our individual selves. We’ll use the terms attachment (Bowlby, 1980) and healthy aggression (2) to refer to these two sets of needs.
Since healthy aggression is not a construct we are used to thinking about, here are some examples of what might be included in this category:
- Feeling/expressing needs and wants
- Feeling/expressing anger when one’s needs and wants aren’t met
- Taking for oneself (satisfying one’s own needs and wants)
- Feeling/expressing personal boundaries
- Setting personal boundaries
- Feeling/expressing anger or disagreement
- One important example is anger at being controlled, which deserves special attention because it is central to many OCD cases.
- Feeling/expressing disappointment in another person; recognizing the bad in others; ambivalence
- Feeling/expressing the need to be autonomous
- Autonomy, separating from others
- Feeling/expressing sexual needs and wants (3)
Understandably, sometimes there are conflicts between healthy aggression and attachment. According to Malan, when feelings of healthy aggression cannot be felt or acknowledged because they pose a threat to attachment (4), these feelings may manifest as OCD symptoms (Malan, p. 95-110) (5). To illustrate this, here are some common examples of how certain symptoms may sometimes express certain types of healthy aggression:
- Many people with harm OCD, or rituals aimed at preventing harm, are unable or afraid to feel or acknowledge normal, healthy anger towards people they love.
- Many people with relationship OCD are unable or afraid to feel or acknowledge normal, healthy ambivalence towards a loved one. (This means that they are afraid to acknowledge that something about their partner is not ideal, which is always the case in a real relationship with a real person.)
- Many people with contamination OCD are unable or afraid to feel or acknowledge normal, healthy feelings about having their boundaries violated in some way.
Before going any further, I want to make the following abundantly clear: None of the above means that a person’s obsessions are true. For example, it does not mean that the person with OCD about killing their baby actually wants to kill their baby. Rather, it means that the symptom reflects a natural, healthy feeling that the person is unable or afraid to feel or acknowledge. For example, ruminating about whether one might kill their baby or might want to kill their baby might reflect anger towards the baby, which every parent feels, and is not only unconcerning but actually perfectly healthy (Winnicott, 1994).
Having explored the idea of healthy aggression, let’s turn to the idea of losing attachment. Here are examples of what loss of attachment can look like:
- Loss of care
- Loss of emotional attunement
- Loss of love (e.g., through splitting) (6)
While all of us are, on an existential level, terrified of being abandoned and alone, there is usually some factor in the histories of people with OCD that has made this fear more salient. Here are some examples of contextual factors that might magnify someone’s fear of losing attachment:
- Losing someone, whether due to death or abandonment
- Having a sick caregiver or a caregiver whom one perceives as fragile, overburdened, or otherwise unable to tolerate one’s needs, anger, autonomy, etc.
- Having a caregiver who threatens abandonment, or who one is afraid will leave
- Having an emotionally unpredictable caregiver
- Having a caregiver who splits (6) or whose love is sometimes withdrawn
- Having an invalidating caregiver or a caregiver who uses denial (such that expressing negative feelings leads to feeling emotionally disconnected, crazy, etc.)
- Having a caregiver who cannot tolerate having aggressive feelings directed towards them, such as a narcissistic caregiver who may respond to criticism or disappointment with devaluation, or any caregiver whose response to anger is retaliation
- Feeling chronically shamed, rejected, or excluded
I’ll pause here to say the following: While I believe that thinking about a person’s early relationships is crucial to understanding their personality and symptoms, as I write the above, I am also deeply concerned that my words might be used to blame or shame parents for their children’s OCD symptoms, and I feel the need to take a break to state that understanding how parents’ personalities and behavior may contribute to a person’s symptoms does not mean that the person’s OCD is their parents’ ‘fault.’
First of all, this is overly simplistic: There are so many factors, biological as well as environmental, that contribute to the development of a psychopathology; we can never point to one factor and say it “caused” someone’s OCD.
Moreover, to the extent that parents’ personalities and behavior are implicated in the development of their child’s OCD, we need to remember that parents, like everyone else, are doing their best, and are products of their own histories and circumstances. They are no more to blame for the issues they have as parents than someone with OCD is to blame for their symptoms. If a parent responds to anger with retaliation, maybe this is because that is how they were raised and the only way they know how to react; if a parent is made overwhelmingly anxious by their child’s autonomous strivings, this isn’t something they can simply switch off; if a parent feels hot shame when their child reflects their faults back to them … is unable to experience love and hate at the same time … unconsciously uses denial to cope with a scary world … these things aren’t their ‘fault.’
Nonetheless, the implication of this model is indeed that parents and families do play a role in the development of OCD symptoms, and can also play an important role in treating them. A full discussion of this is beyond the scope of this article (I’ll link that article here when it’s ready), but in the meantime, suffice to say that parents can play a role in treating their child’s OCD by:
- Addressing problematic sources of healthy aggression (if, for example, the healthy aggression is anger about something the parents are doing, such as being excessively intrusive or controlling)
- Helping to acknowledge and validate the child’s healthy aggression (e.g., “I think you’re angry because I was trying to force you to do that. I understand why that made you angry”)
- Addressing the threats to attachment associated with expressing healthy aggression (e.g., not shaming the child for getting angry at being controlled)
This also provides a way that parents of a child with OCD can work on the child’s OCD by working on themselves, even if the child is not interested in OCD treatment (since I do not believe in forcing someone to engage in ERP, and I believe that doing so can potentially make things worse).
Now back to the model.
Thinking About the Individual
I provided the examples above in order to bring this model to life, but examples can also distract from the individuality and nuance of each person’s experience. I encourage the reader to use the examples above as a jumping-off point for thinking about individual experience, rather than boxes to try and fit someone’s experience into. Consistent with this, instead of providing additional case examples, I’d like to provide some questions that can be helpful in exploring an individual’s experience of the dynamics discussed above.
Identifying the Sources of Emotional Conflict
One place to look for sources of emotional conflict is the past. Here are some questions that can help identify different forms of healthy aggression that a person could potentially have had trouble acknowledging in childhood:
- What about this person’s childhood might have been a source of anger?
- How might this person have felt controlled by others?
- How might this person have needed to control themselves or inhibit some form of healthy aggression?
- What kind of unmet needs might this person have had?
- Where are normal aggressive feelings conspicuously missing (e.g., if someone tells you that their childhood or parent was perfect)?
(Notably, we’re not saying that all of these things will have been an issue, but that these questions can help identify various different things that might have been an issue.)
Then of course the question is: Why? What were they afraid might happen? How were they afraid others would react? How could this have posed a threat to attachment?
Another place to look is the present, both in the therapeutic relationship and in the person’s other relationships:
- Does this person have trouble feeling or expressing healthy aggressive feelings?
- Does this person communicate aggression in an indirect way?
- Does this person feel controlled by others?
- Does this person overcontrol themselves or inhibit some form of healthy aggression?
- Does this person have trouble asking for their needs to be met?
- Where are normal aggressive feelings conspicuously missing? (E.g., does this person describe things that you would expect to make someone angry, but disavow those feelings?)
And again, the question is: Why? What are they afraid might happen? How are they afraid others might react? How would this pose a threat to attachment?
The Core Fear worksheet can be helpful with identifying these dynamics. Each column tells a story of how a person is afraid of arriving at their Core Fear, which as discussed here is often an individual’s particular version of loss of attachment. When you look at all of these stories together, it’s often possible to discern patterns and themes of specific types of healthy aggression that it is feared might lead to loss of attachment.
A final place to look for clues about the nature of underlying emotional dynamics is the symptoms themselves. As discussed above, symptoms aim to express a natural feeling while also avoiding a painful emotional consequence. Therefore they are often a symbolic or metaphorical expression of the natural feeling, and also often manage to get the natural feeling across somehow (Malan, p. 9). Both the symbolism and the effect of the symptom thus offer clues about what might be going on emotionally.
Words of Warning: Omniscience and Omnipotence
Having presented Malan’s model, I want to caution against its potential misuse.
First of all, I want to warn against anyone thinking that this model is everything one would need to know in order to understand a case. To the contrary, this model is just a starting point for thinking about the many emotional and relational factors involved in OCD symptoms. There is so much more to understanding any individual person and their symptoms, including many other psychodynamic/psychoanalytic mechanisms that may be at play.
I say this because people with OCD often hold onto the belief that we already know everything we need to know in order to solve our problems. This defensive ‘omniscience’ (a psychoanalytic term meaning believing that you know more than you actually know) may protect us from feeling helpless, but it can also prevent us from realizing that there is so much out there that we don’t already know. It would be typical of an obsessive-compulsive to read this article and imagine that they now have in their hands everything they need in order to cure their symptoms. Instead, let this article be a reminder of how much is out there that we don’t already know.
Next, I want to caution against turning self-analysis into compulsive rumination. While one might legitimately choose to spend some time reflecting on themselves in light of Malan’s ideas, this could easily become compulsive. This might reflect not only defensive ‘omniscience’ (“I know what the problem is”; “I know how to solve it”; “I can find all the answers within myself”), but also defensive ‘omnipotence’ (a psychoanalytic term meaning believing that you can control things that you really can’t). An omnipotent fantasy (which is another powerful way to think about OCD, but beyond the scope of this article) entails believing that one could solve a certain problem if only they did XYZ well enough. In this case, that fantasy might be that one could cure their OCD if only they figured out what type of healthy aggression they need to feel. Like omniscience, omnipotence protects us from feeling helpless when there is something that is out of our control (Gooch, 2001). But also like omniscience, it is a distortion of reality. You won’t cure your OCD through self-analysis. If you’re interested in understanding the unconscious emotional and relational dynamics contributing to your OCD, you will need to consider seeing someone with training in this area. We all need help, and as Margaret Little (1951) wrote, “to try to observe and interpret something unconscious in oneself is rather like trying to see the back of one’s own head.”
Integration with ERP
I am not recommending that we replace ERP with psychodynamic/psychoanalytic therapy. I am recommending that we enhance ERP by integrating everything that psychodynamic/psychoanalytic theory and therapy can contribute to our understanding and treatment of OCD.
Malan himself called for such an integrative approach:
“Now, even though the psychopathology in such (OCD) cases appears perfectly intelligible, accumulated practical experience suggests that often the symptom itself develops an autonomy, and no matter how extensively the pathology is interpreted and apparently worked through, the symptom remains untouched. It is apparently true, for instance, that there is no known authenticated case of an obsessional hand-washer being cured by psychoanalytic treatment. In my view, therefore, the treatment of choice immediately becomes behaviour therapy – or, even more, perhaps the treatment of the future will be a combination of behaviour therapy with dynamic psychotherapy … but this combination is not at present available.” (p. 218-219)
It makes me sad that Malan died in 2020, and that I just missed the chance to tell him that such an integrative approach is now available.
What follows are some specific examples of how a psychodynamic/psychoanalytic approach can fit into an ERP framework. However, psychodynamic/psychoanalytic treatment is an entirely different way of thinking about what someone’s problem is and how to treat it. Its role in an integrative approach isn’t limited to the ways in which it fits into ERP. With that being said, here are a few specific ways of using a psychodynamic/psychoanalytic approach to enhance and augment ERP:
- One way to integrate a psychodynamic/psychoanalytic conceptualization with ERP is to turn healthy aggression (any specific form the person is afraid of) into an exposure. This might entail saying no or setting boundaries; expressing needs or wishes; expressing anger, criticism, or disappointment; doing something autonomously; etc.
- It bears mentioning that from a dynamic/analytic perspective, what is essential to getting better isn’t expressing these feelings, but rather being able to acknowledge and validate them for oneself (K. Beard, personal communication, 2022).
- A psychodynamic/psychoanalytic approach can help us to understand the specific nature of a trigger more clearly, which can be helpful in sharpening exposures (as well as in anticipating and preparing for triggering situations).
- Not understanding why we are doing a certain compulsion, or what the compulsion is aimed at accomplishing, can make us feel out of control. Conversely, understanding why we are doing what we are doing can help restore our sense of agency and control over our behavior, which can in turn make it easier to stop.
- This article gives specific examples of how understanding the emotional process driving compulsive rumination can help a person make the decision to stop.
- Understanding that our fears emanate from past circumstances that are no longer present can facilitate the decision to let go of the symptoms, because we longer need them to protect ourselves.
- Finally, from a psychodynamic/psychoanalytic perspective, acknowledging the emotion that is driving a symptom may also directly attenuate the drive to do it. As just one example, if someone comes to understand that they worry about burning the house down when they can’t acknowledge their anger towards their family, acknowledging that anger might lessen the drive to check the stove. (This is an example of the independent therapeutic value of the approach, but I included it here because it would also facilitate response-prevention.)
Helping patients navigate internal experiences:
While ERP provides guidance about our behavior, it doesn’t provide much guidance about what to do with our emotional experiences (7). A psychodynamic/psychoanalytic approach can help. For example, let’s say someone with OCD is angry at a loved one, but feels anxious about it. According to a psychodynamic understanding, the goal would be for the OCD sufferer to allow themselves to feel angry, because that’s their natural feeling. In contrast, it would not be a goal for them to allow themselves to feel anxious, which is a symptom (8).
Conclusion and Further Reading
The psychodynamic/psychoanalytic approach sees people and their emotional issues as complex, and favors complex, multidimensional explanations over simple ones. Boiling OCD down to a conflict between healthy aggression and attachment is way too simple to capture everything this approach has to say about OCD in general, let alone about any individual person’s experience of OCD. I therefore hope that this article serves only as a jumping-off point for learning more about a psychodynamic/psychoanalytic approach to OCD. If you’re interested in learning more about this perspective, Malan’s book [LINK] is relatively accessible, and certainly a good starting point, and the following articles contain some of the work I am doing towards the goal of integrating this approach with CBT:
- Three Types of OCD Cases: Integrating Malan’s Model of OCD with the Core Fear Model
- Anatomical Models of Rumination
- Causal Justifications
Malan called for an OCD treatment that would integrate the best of what CBT and psychodynamic/psychoanalytic approaches have to offer. I hope this article is one step towards bringing his vision to fruition.
- ‘Psychodynamic’ or ‘psychoanalytic’ therapy focuses on a person’s emotional experiences in the context of their relationships. The two terms can be used interchangeably.
- “…aggression and self-assertion are a necessary and useful part of human interaction — and there are kinds of aggression that can be described as constructive, because they result in benefit not merely to the individual but to his whole environment as well.” (Malan, p. 96)
- Not all aspects of sexuality fit neatly into the category of “healthy aggression.” See Malan, pages 97 and 99 for some comments on the connection between these themes.
- “The almost universal fear on which these inhibitions are based is that the open expression of aggressive feelings will inevitably lead to disastrous consequences, such as ultimate rejection or the destruction of relationships.” (Malan, p. 96)
- This does not mean that inhibited healthy aggression always leads to OCD, nor does it mean that OCD is always a consequence of inhibited healthy aggression. According to Malan, inhibited healthy aggression may also lead to other types of symptoms (p. 95), and OCD symptoms can also result from other conflicts (p. 109). However, in my clinical experience, it is usually if not always possible to identify inhibited healthy aggression underlying OCD symptoms (at least when the former construct is defined as broadly as I’ve defined it here), and this is therefore a good working hypothesis when beginning to think about the emotional dynamics of a new case.
- Splitting means seeing other people as either good or bad. It entails, among other things, deficits in the ability to preserve a loving connection to someone while feeling angry with them. So if a parent splits, then when they get angry, their child may experience a terrifying loss of their parent’s love. This is often the experience of people with parents who have borderline personality structure, but can also be the experience of people with parents whom we might not identify as borderline, but who are nonetheless prone to such a dynamic. Notably, even people who are emotionally stable may still view others as either good guys or bad guys, and being in an environment where people are viewed this way can lead to all sorts of concerns for a child. For example, if one is the ‘good’ child, while a sibling is the ‘bad’ child, one may be afraid of losing that special status if they aren’t good enough; if one is the ‘bad’ child, while a sibling is the ‘good’ child, one may try desperately to be good enough to be loved; if one is neither here nor there, but witness to others being identified as ‘good’ or ‘bad,’ one may be concerned with trying to become ‘good’ and not become ‘bad.’ All of the above may entail the inhibition of healthy aggression.
- This may also be a reason that some people have gravitated towards ACT. However, I would argue that the guidance provided by ACT to accept all emotional experiences is at best clunky, because it doesn’t distinguish among natural feelings, symptomatic feelings, and feared emotional consequences. One could argue that all of these emotional experiences need to be ‘accepted’ in a broad sense. Nevertheless, a more nuanced approach can help the person resolve the emotional conflict and feel better, rather than just tolerate their suffering. Suggesting that someone should accept their anxiety also has the potential to undermine treatment in other ways, as discussed here.
- Their anxiety is evidence that they are ruminating, perhaps in an attempt to talk themselves out of being angry, as discussed here.
Bowlby, J. (1980). Attachment and loss. Basic Books.
Gooch, James A. (2001). Bion’s perspectives on psychoanalytic technique. Institute of Psychoanalysis. Retrieved from https://web.archive.org/web/20040204074203/http://www.psychoanalysis.org.uk/gooch2002.htm.
Little, M. (1951).Counter-transference and the patient’s response to it. International Journal of Psycho-Analysis, 32, 32–40.
Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. Butterworth.
Winnicott, D. W. (1994). Hate in the counter-transference. Journal of Psychotherapy Practice & Research, 3(4), 350–356.