We all know what Obsessive-Compulsive Disorder (OCD) looks like: repetitive rituals, obsessive thoughts, and the people who are thinking or doing the compulsive thinking or behavior and know that they’re not being rational. Obsessive-Compulsive Personality Order (OCPD) is something else. People with OCPD are detail oriented, to the exclusion of the big picture. They are obsessed by control. They may get involved with organizational details, the minutiae of tasks, or tasks that have very little to do with what most needs to be completed in their jobs, their studies, their homes, and in their lives. Many OCPD folks are prone to angry outbursts when their environments, kids, or coworkers don’t go with the program. They may be very nice, but they’re not usually capable of intimacy.They are the nightmare managers from hell. They often don’t keep or rise very far in employment. though they work half again as many hours as any other employee. And nothing is ever right with anything. Expect depression, anxiety, and either massive pollyannish denial or massive criticism of everything, including you.

Avoidance of anxiety is their not-conscious organizing principal. Here’s how it works: If I need to get the big job done, and I feel anxiety when I think about the big job, I’ll bring my attention to this little task that’s not so scary and I’ll do it perfectly, for hours. Working on the little task makes me feel better. (Dan Goleman’s book Vital Lies, Simple Truths: the Psychology of Self-Deception descibes the biology of this phenomenom.) When I take my attention away from that which makes me anxious, the pharmacy in my brain gives me really good drugs. This is why procrastination and self-distraction are so popular. If I don’t work on the scary task, I’ll feel better, instantly. If I keep doing the intricately complex avoidance behavior, my brain keeps giving me good endorphins. If I’ve been self-medicating since childhood, by focusing on unimportant tasks, instead of anxious or checked-out or angry or controlling or absent mom and my own loneliness, I’m going to build a big neural net of reflexive avoidance/distraction behavior.

In my opinion, here’s the etiology: First, there’s a mom, who for some reason can’t connect well with her child. Non-connecting moms, be they passive or screaming, are frightening to kids. If a kid learns to distract him or herself by focussing on little tasks, she can dissociate/self-medicate away the terror of being all along and taking care of him or herself. What he or she doesn’t learn is the non-dissociative self-soothing techniques that arise from the attachment dance of connection, backing off a bit, and reconnection. So the child’s only self-regulation comes from distraction/dissociation.

How do you treat these people? Mostly, they don’t come to therapy, and you won’t get the chance. Good therapy is the opposite of avoidance, the pathology keeps them away. However, once in a while, someone gets "drug in" by their spouse, or employer, or even their own miserableness and the work begins.

They will try to control the session and keep you focused on the unimportant details. Don’t let it happen. Get more assertive than you usually are, or you and your client will unhappily spin your wheels for months. Since I start most clients off with Maureen Kitchur’s genogram-based intake with its predetermined list of "nosy, snoopy questions", (EMDR Solutions) I’m able to keep the initial sessions on task, and then share what I think much of the therapy will be. Then work on four things:

1. Staying on Task in the sessions: Make and keep a strong alliance. Show your compassion and your grit. When they change the subject to some small distress of the day, say "Oh that’s so upsetting when that happens! Let’s go back and get the underlying material, so this won’t have to be so distressing later on."

2. Work on Affect Tolerance and Self-Soothing: Tell them we’ll start with one-pound hand weights and work up to the big feeling. Teach them containerizing of emotions, mindfullness techniques, relaxation, and containing their own inner babies. (April Steele’s Imaginal Nurturing is wonderful for this, as are many kinds of ego-state work.)

3. Use EMDR or Brainspotting or whatever you have that works to target the early childhood relationship with the caregivers. "Imagine looking into your mother’s eyes when you were an infant. What do you notice in your body right now, as you imagine your mom?" Clear whatever comes up. Go through all the ages until there’s no distress.

4. Finally, target the avoided things. I adore Jim Knipe’s Level of Urge to Avoid in EMDR Solutions. Knipe would ask these clients, "How good on a scale of 1-10 would it feel to completely avoid that big project by focusing on sorting out your sock drawer?" "Where do you feel that feeling in your body?"  "Stay with it." While applying a bilateral stimulation. Often the "inappropriate positive affect" (the endorphins) go down by itself and the clients are left with the somewhat appropriate feeling of dread about what they’ve been avoiding. Then target the dread about the project, clear it, and have them imagine doing the damn thing, step by small step. And then imagine what having it finished would feel like. Aahhhhhh.   If the inappropriate affect doesn’t go down by itself, I often two-hand it. (Also in Solutions.)  "In one hand, hold how good it will feel to continue avoiding the project. In the other, hold the consequences for not doing it." Apply bilateral stimulation, and your clients are very likely to feel their discomfort and then be directable to clear it.

I won’t kid you. These people need a long therapy. They’ve been reinforcing avoidance in themselves since babyhood and you and they have a lot of neural networks to rewire. And it’s possible, with a good alliance and good attachment and affect work to create clients who can choose avoidance (vacations, breaks, movies, Spider Solitaire) and relationships and getting their real work done, over reflexive busy work, blowups, inadequacy, and loneliness.