The obsessive compulsive style (Shapiro, 1965)

In his chapter "obsessive compulsive style," David Shapiro (1965) describes the characteristics of obsessive compulsive (OC) people, beginning with the rigidity of thought which is clinically observed with compulsive characters. Shapiro depicts this characteristic as limited, very focused attention; an unwillingness to divert from an interest or a position or listen to other parties in conversation.

            Shapiro then depicts a second major characteristic as a mode of action. He refers to OC people as work prone, work invested, workaholics – not necessarily over-productive, but treating every life situation as a productive process that requires effort on their side – even enjoyment. Effort is described as mental effort of preoccupation about an issue, not necessarily making evident pragmatic efforts towards it. Shapiro connects this to a damaged sense of autonomy, attuned to a sense of should over a sense of will, with demanding impulses that threaten the cores of intent and control; then awareness becomes their struggle, and all human behavior becomes an issue to preoccupy with – an effort. Their struggle is to keep from madness.

            If a keyhole attention and a troubled soul aren’t enough, Shapiro adds a loss of the sense of reality to the mental dynamics of the obsessive compulsive people. The authentic position is replaced with a logical perspective. The logical perspective is maintained by the narrowing attention, and its maintenance is an effort. Spontaneous right and wrong are missing from their judgment and they mediate their experience with rational criticism instead.

            In view of DSM-IV-TR's criteria list for OCD and OCPD, I believe Shapiro is describing the dynamics of an obsessive compulsive personality disorder. His emphasis is on obsessions, and less on the very evident compulsions and rituals expected in an OCD by the manual. Furthermore, Shapiro's everyday register and empathic description of psyche dynamics may tell us that this phenomenon is on the clinical doorstep, not yet inside the madhouse.

It is said that Cameron Diaz suffers from OCD!

Jessica Alba too.

Classic CBT VS ACT

Classic CBT (cognitive behavioral therapy) aims to modify maladaptive cognitions by supplying more adaptive alternatives, while ACT (acceptance and commitment therapy) assumes the mind to be a meaningless chatterbox that should be habituated, not focused on, or manipulated.

For example, when a patient is afraid of flying, the classic CBT approach would be to teach him more realistic risk evaluation, which is minimal in this case, a manageable way to interpret his physical over-arousal, as expectation of danger – not actual danger, and behavioral exposure as means to learn that there is no real danger.

The ACT approach would not argue with the patient's risk assessment in flying and in his panic, claiming that these serve avoidance, and that the patient should just listen passively to the arguments in his mind like they were an open channel radio with other people talking, until the volume fades, and he can just go through the motions, just do what he should do, disregarding his anxious thoughts and feelings.

If we put aside the contradictory theoretical frameworks, we can find that a pragmatic similarity would be the behavioral "just do it," and the difference is whether to tackle specific maladaptive cognitions or circumvent them. A combined practice could be to direct the patient to exposure, tackling the grossly maladaptive cognitions that lead to avoidance, and circumventing debates where cognitive debating is a cause for avoidance. Alternatively we could use CBT when we can offer a more adaptive cognition and ACT when the cognition is sensible but nevertheless distressful. Another distinction can be to tackle the ego-ayntonic cognitions, which the patient tries to justify with arguments, while circumventing the ego-dystonic cognitions, which admits have no sense behind them.

In my view, psychotherapy's curative effect is replacing dogmatic responses with a soft dissonance that allows variability of response – not providing a more adaptive response but facilitating adaptivity itself. Classic CBT should not provide a right answer - "you know flying is 10X less dangerous than driving" - but provide the patient a grain of salt to his preconceptions - "did you ever question your conception that flying is dangerous?" - show him that another way is possible. In that way, ACT should not ask the patient to give up the meaning of his thoughts ("what were the numbers? You see? Meaningless, and you're stuck with them!") as much as it should alleviate intensity of the patient's internal debate regardless of the arguments - "where does all this thinking lead you?" – show that it can be harmful by itself. If the mutual goal of mental agility can be established, the therapist can vary his practices, being attuned to the patient's field of preoccupations, and estimating the patient's capacity to loosen up a variety of dogmatic mental structures. The combined practice can be focusing on specific cognitions as a start, and then generalizing the same principle to the entire internal discourse, giving the patient room for air. Unifying these practices under one goal could also allow us to measure their effects comparatively, and use them more appropriately.

Assimilation and accomodation in lay language:

I'm still reading this CPT book, and I have to translate the words assimilation and accommodation to lay language when I read. I wish I had a Dr Phil expression for them, so I will try to make them up. So imagine a Texan accent when I say this:

Over-accommodation: "If you fall off your horse, it don't matter if you get back on it, but don't take it out on your pickup truck..."

Assimilation: "With better boots you'd still be in this bullshit."

Accommodation: "You wasn't planning on the wind when you put your hat on this morning, but what else could you do?"

As country music hall-of-famer, Garth Brooks says, "if you want them to listen, you better take it down to three chords and the truth".