1. The programme at a glance
Indication. The programme is intended for adults with obsessive-compulsive personality, treated as outpatients, when the disorder causes distress or impairment, for themselves or for those around them, and when they make a request, even one that concerns an associated symptom.
Reference model. Cognitive behavioural therapy for personality disorders, centred on the control cycle and on clinical perfectionism (section 4). It integrates behavioural experiments, here called experiments in imperfection: the patient deliberately does something in a "good enough" way and observes what happens (section 32). It also integrates problem-solving, work on emotions and elements borrowed from schema therapy, which links beliefs to the patient's history (session 14). The manual mentions, with attribution, radically open dialectical behaviour therapy, designed by Lynch for disorders of overcontrol (section 4), without reproducing its material.
Format. Treatment lasting about a year, some forty weekly 50-minute sessions. This manual describes sixteen key sessions, organised in five phases; each may take two or three (section 2). The tasks between sessions are short and deliberately imperfect. After the programme ends, three booster sessions, at one, three and six months, are added to this year of treatment (session 16).
Targeted mechanism. Make visible the cycle linking beliefs about error and control, anxiety, controlling behaviours and the absence of any experience of imperfection; experience "good enough"; decide and finish; delegate; welcome and express emotions; relax the rules imposed on those close to the patient; recover rest and pleasure; and replace rules with values.
| Phase |
Session |
Focus |
Session deliverable |
| I. Alliance |
1 |
Meeting without a power struggle |
Reason for coming stated, precision respected |
|
2 |
Goals framed as costs |
Goals written, framework set |
|
3 |
Assess |
Exhaustion, mood and risk assessed |
| II. Understand |
4 |
The control cycle |
Cycle drawn with a real situation |
|
5 |
What perfectionism protects and costs |
Balance written |
|
6 |
Rules and "musts" |
Rules listed, two examined |
| III. Change |
7 |
Good enough |
Two experiments in imperfection done |
|
8 |
Deciding and finishing |
A postponed task finished |
|
9 |
Delegating and letting others do it |
A task delegated without taking it back |
|
10 |
Mid-point review |
Measures repeated, plan revised |
| IV. Relationships |
11 |
Emotions |
An emotion noticed and expressed |
|
12 |
Flexibility in the couple and the family |
A compromise negotiated |
|
13 |
Free time and pleasure |
Moments without purpose planned and lived |
| V. Consolidate |
14 |
Beliefs and history |
Beliefs linked to history and revisited |
|
15 |
Values rather than rules |
Values written, self-compassion practised |
|
16 |
Review, relapse, next steps |
Plan written, measures repeated |
What distinguishes this programme from the other manuals on this site. Three things. A patient who often finds that their traits are virtues, and who is partly right. A treatment whose tasks must themselves be done imperfectly. And a session that can turn, without anyone noticing, into a debate about the best way to do therapy.
2. Before you begin
The four preliminary decisions
1. Is this obsessive-compulsive personality, obsessive-compulsive disorder (OCD), or both? The treatment is not the same. Section 7.
2. Is there exhaustion, depression or suicide risk? Section 9.
3. Is there an autism spectrum disorder that explains the rigidity? Section 7.
4. What does the patient recognise as a cost? It is the only possible starting point. Section 16.
What this programme does not treat
Obsessive-compulsive disorder, which calls for exposure and response prevention, possibly alongside this programme when the two disorders coexist: section 36.
Severe depression and burnout with complete cessation of activity, which are treated first.
Anorexia nervosa, even when perfectionism plays a major role in it.
Hoarding disorder, which has its own treatment.
How to use it
Read sections 3 to 14 first: they ground the choices made in the sessions. Read section 31 before the first session: power struggles and intellectualisation often begin in the first hour. The sessions described are key sessions; each may take two or three. Section 39 sets out what must not be dropped. The patient's folder contains seven worksheets: 1, "What it costs me" (sessions 2 and 5); 2, "My circle" (sessions 4 and 5); 3, "My rules" (sessions 6 and 12); 4, "Good enough" (sessions 7, 8, 9 and 15); 5, "What I feel, what I say" (sessions 11 and 12, section 33); 6, "For those close to you", which the patient hands over if they wish (session 12); 7, "My plan for what comes next" (sessions 13 to 16).
3. The clinical picture
What defines the disorder
The disorder is defined by a lasting, pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control, at the expense of flexibility, openness and efficiency, present since early adulthood and across a range of contexts.
The forms it takes
A preoccupation with details, rules, lists, organisation or schedules, to the point of losing sight of the purpose of the activity.
Perfectionism that prevents finishing: a project is never completed because it does not meet overly strict standards.
Excessive devotion to work and productivity, at the expense of leisure and friendships, when finances do not require it.
A scrupulous and inflexible conscience about ethics or values, beyond what culture or religion explains.
An inability to part with worn-out or useless objects, even without sentimental value.
A reluctance to delegate or to work with others unless they submit exactly to the patient's way of doing things.
Miserliness towards oneself and others, money being saved for future catastrophes.
Rigidity and stubbornness.
What patients describe
They rarely talk about perfectionism. They describe work that never ends, careless colleagues, a partner who does not tidy up, children who do not do what is expected, fatigue, constant tension, insomnia, a sense of never being able to rest, frequent and contained irritation. They also describe, when the alliance allows, a fear of error, a ready guilt, a difficulty feeling pleasure, and a loneliness in the midst of their obligations.
What you see in the consultation
You often see a patient who is punctual, precise, who corrects wording, brings notes, gives a great deal of detail, searches for the exact word, has trouble answering a question about what they feel, may challenge a method or a badly designed questionnaire, and cares about doing therapy properly. Their affect is contained, their warmth reserved, and irritation sometimes shows at imprecision.
Traits experienced as qualities
Obsessive traits are largely ego-syntonic: the patient regards them as rigour, seriousness, honesty, reliability. And often they are partly qualities, recognised and rewarded. The problem is not rigour; it is that it cannot relax when the situation calls for it.
Epidemiology
Obsessive-compulsive personality is, in several general population studies, one of the most common personality disorders. It is present in a substantial minority of patients with OCD, and common in anorexia nervosa. It is associated with depression, anxiety, occupational burnout and relationship difficulties, and it carries an often underestimated cost for those around the patient.
4. The control cycle
The model guiding this programme is cognitive and behavioural. It is presented to the patient without jargon.
The central piece
At the centre of the cycle are beliefs about error and control: a mistake is unacceptable, if it isn't perfect, it's a failure, if I don't control everything, everything will collapse, I am responsible for everything that could go wrong. They come with beliefs about others — other people are careless, you can't count on them —, about emotions — showing your emotions means losing control — and about worth — I am worth what I produce, and what I do correctly.
They form in a variety of histories: a demanding environment where mistakes were criticised or punished, value placed on performance and duty, emotions poorly tolerated, an anxious or conscientious temperament, sometimes family chaos that made order protective. You do not impose this link with their history on the patient.
The links
1. The situation. A task, a decision, something unexpected, a task entrusted to someone else, an expense, disorder, an emotion, a moment with nothing to do.
2. The thoughts. It isn't good enough, what if I got it wrong, he'll do it badly, I'm wasting my time.
3. The emotion. Anxiety, unease, irritation, guilt.
4. Controlling behaviours:
checking, redoing, correcting;
planning, listing, organising beyond what is useful;
putting off what cannot be done perfectly, or not deciding until certain;
doing it oneself rather than delegating, or taking back what was delegated;
imposing one's rules on others;
working more;
holding back one's emotions, keeping things, saving.
5. Immediate relief. The sense of control returns, anxiety falls. The behaviours are reinforced: because they bring relief, they come back in the next situation.
6. No experience of imperfection. The patient never discovers that "good enough" work would have been sufficient, that a mistake would have been repairable, that a colleague could have done it differently without catastrophe.
7. The consequences. Exhaustion, delays, conflicts, tense relationships, people around them controlled or driven away, no rest or pleasure, and sometimes real mistakes caused by fatigue.
8. The confirmation. Whatever the outcome, the patient draws a conclusion from it that strengthens the initial beliefs and closes the cycle: good thing I checked; or if only I had been more rigorous.
Clinical perfectionism
What characterises perfectionism that has become a problem is that self-worth depends on the pursuit of high standards, maintained despite their costs, and that reaching a goal does not reassure: the bar is raised or the success is judged insufficient. This mechanism, described by Shafran, Cooper and Fairburn (2002), is found in many disorders and at the heart of this one. When this clinical perfectionism occurs without the long-standing, rigid functioning extending to every area of life that defines the disorder, and in particular without control of those close to the patient or of emotions, the manual Perfectionism: a therapist's manual offers a shorter protocol, in ten sessions, focused on this process alone.
Overcontrol
Emotional constraint, rigidity, vigilance to threat and low openness to new experiences form a profile that some authors describe as overcontrol, which isolates socially because others perceive the person as distant and hard to get to know.
What the treatment does
It makes the cycle visible, it tests beliefs through experiments in imperfection, it reduces controlling behaviours, it works on deciding, delegating and relational flexibility, it opens space for emotions, rest and pleasure, and it replaces rigid rules with chosen values.
What the model explains to the patient
That their rigour has served them well. That checking and control really do bring relief, in the moment. That they prevent them from knowing whether that relief was necessary. And that we are going to check this, methodically, which should suit them.
5. Rigour, professional conscientiousness, OCD and the disorder
Why this section exists
Because rigour, a sense of duty and organisation are valued, sometimes indispensable in certain professions, and because the disorder's name fuels constant confusion with obsessive-compulsive disorder.
What needs to be distinguished
Professional conscientiousness: rigour, reliability, attention to detail, which adapt to the situation and leave room for life.
Marked obsessive traits, without major distress or impairment.
Obsessive-compulsive personality disorder: a rigidity that does not relax when the situation calls for it, with impairment for the patient or for those around them.
The confusion with OCD
Despite their names, these are two different disorders. OCD is characterised by obsessions — intrusive thoughts, images or urges, experienced as absurd or disturbing — and compulsions aimed at neutralising the anxiety they produce. The patient generally experiences them as foreign to themselves. Obsessive-compulsive personality does not necessarily involve obsessions or compulsions; it describes a way of being, experienced as the right one. The two can coexist. In French, the psychoanalytic term "obsessional neurosis" adds to the confusion.
Professional and cultural norms
Some professions require strict control: surgery, aviation, accounting, quality control. Some cultures and some religious traditions value order, thrift, sobriety and moral rigour. You assess rigidity outside what the profession and culture require, and its cost.
What you are aiming for
Chosen rigour: being able to be demanding when it is useful, and to relax when it is not. A patient who is rigorous at work, able to hand in a good-enough report, to let their partner tidy differently and to spend a Sunday without producing anything, has reached the goal.
The weight of the label
The word "obsessive" is often heard as "fussy" or "ill". You talk about very high standards, a need for control that costs a lot, and a difficulty letting go. If the patient asks for the name of the diagnosis, you answer honestly, and you explain the difference from OCD.