Dual Diagnosis Treatment for the Obsessive-Compulsive Personality Disorder

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Richards (1993, p. 278) suggests that treatment failures for the dually diagnosed are often a result of neglecting to consider the function of the addiction, including the drug of choice, within the context of the psychopathology dominant in the individual. Dual diagnosis treatment must involve recognition of needs, behaviors and attitudes that foster addictive behavior. Specifically, new ways must be learned for dealing with OCPD drivenness and feelings of tension, fear, dread, and anger other than compulsivity. Peele (1985, p. 47) suggests that treatment focus be placed on the addicts' experience of the drug and alcohol use and how it fits into their psychological and environmental ecology, i.e., how the addictive behavior is used to cope with personal and social needs and changing situational demands. Peele believes that no substance or behavior is inherently addictive. Rather, people become addicted due to a combination of social, cultural, situational, personality, and developmental factors. Further, he suggests that unless the full range of addictive behaviors in a person's life is considered, e.g. substances used and compulsive behaviors delineated, the actual degree of addiction is not completely known (Peele, 1985, p. 103). Hoskins (1989, p. 13) proposes that addictions are formed in complexes in which each addiction reinforces the others. People usually agree to try recovery once they can no longer maintain three or more addictive options in their lives.

In assessing OCPD addiction, it is important to ascertain if the use of substances or the compulsive behaviors support compartmentalization by shoring up defenses (escape/avoidance or affect modulation) or provide an outlet for expressing unacceptable aspects of the self (facilitation). Individuals with OCPD tend to have muted expressions of addiction in contrast to other personality disordered individuals. They can remain functional addicts for long periods of time. With severe addiction, the extremes of the antisocial and dependent personalities are seen in individuals with obsessive-compulsive personality disorder, with aggressive grandiosity alternating with intense humiliation, shame, and guilt (Richards, 1993, pp. 256-257).

Interventions are rarely needed for addicted individuals with OCPD. Redirection from an authority figure, e.g. employer or physician, is often enough to prompt them to seek AOD treatment. Should they lapse or relapse, individuals with OCPD may be overwhelmed with guilt. With the intensity of their guilt, they are vulnerable to a complete loss of control and will need considerable support (Richards, 1993, p. 258).

In treatment, individuals with OCPD are good at following advice, accepting guidelines, and respond well to programmatic efforts that require note taking, records, measurements, and specific steps or sequences. Psychoeducation (for both personality issues and drugs) is important for these individuals to avoid stimulation of resistance (Richards, 1993, p. 257). They are likely to attend 12 Step Meetings when required to do so. However, service providers should be alert to the remarkable capacity these individuals have to evoke annoyance and rejection from others. They may need assistance to learn to utilize support groups well and to connect to a sponsor who will be both tolerant and patient.

Confrontation usual to substance abuse treatment may be needed to launch a successful assault on the formidable array of defenses used by individuals with OCPD. However, given the level of fear and shame underneath the defenses, the support behind the confrontation must be apparent and reliable. Abstinence can be a prerequisite for treatment. These people often have such a powerful defensive structure that firm limits are beneficial to the treatment process. They are also quite adept at following instructions and may well be able to utilize this aspect of their personality structure to facilitate recovery behaviors.

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Reviewed: 04/2006