Using RfG to Engage Actively with OCD

Junheon Park, MD

In our hospital clinic, face-to-face psychiatric consultations are limited to 20 minutes, ruling out lengthier interventions. Rehearsals for Growth (RfG) has proven a valuable Approach in shifting habitual dysfunctional patterns in my patients.

Choi Jae-Young (CJY), a single, 26-year-old woman presenting with Obsessive-Compulsive Disorder (OCD) and depressive symptoms, has visited our clinic about every other week during the past two years. Medication has resulted in only partial remission of her symptoms. Except when working outside her home, CJY has almost no social contact, spending much of her free time minimizing contact with her parents, lying in bed alone due to fatigue. Her hobby is collecting small dolls.

Fifteen months ago, at the recommendation of another therapist, CJY got a job at a design company for a year. She worked at that position for 13 months, exceeding the 12 months planned at the start, despite a three-hour-long commute.  Following a two-month break she returned to work at a different job. The session described below was her first visit to the hospital after her re-employment that started the previous week.

CJY appeared with a dark face. She reported that the commuting distance was close and the atmosphere not bad, describing the company as designing retail products.  She complained that she could produce the required designs but it was too difficult to decide the price or the delivery date with the client.

CJY:“You know, when I’m asked to come up with a number, my head goes blank. Negotiating a price or a date is so hard.”
As she continued to complain about this difficulty I tried to cheer her up by reminding her of her year-long problematic experiences at her last company. At that, she expressed displeasure at my attempted encouragement and shifted to devaluing herself. Though her complaint about this difficulty seemed reasonable at first glance, she kept repeating it. Above all, the purpose of her complaint was quite vague; she neither accepted my encouragement nor expressed her will to quit. Overall, I found her communication full of redundancy, contradiction, and ambiguity. I was becoming bored with her monotonous, repeated melancholic down-beats.

However, my interest was attracted when I heard her say, “… And there is no one I want to get close to at the new company.” As she’s a client who has few interpersonal relationships, is that why she has been coming to our hospital so frequently for over two years?

On impulse, in an overconfident, exaggerated manner, I exclaimed, “Seeing that you’ve been coming here for over two years, you think I’m a decent person?”  (I know that CJY, a young female client, is not attracted to me).

I reflected on the status transactions and maneuvers occurring during this first half of the session. This client seeks help from a low-status position yet refuses it, while I try to help from a high-status position but fail to satisfy her. I see she is maneuvering to lower my status.

I next hit upon a strategy of pattern interruption: my exaggerating the high-status position projected by the client causes her awkwardness and results in her attempting to create an equal status relationship that allows our collaboration.

CJY: (laughing enough to make the room explode) “Do I think you’re fine? Nonsense! Doctor, are you crazy?”
(Unlike her former depressive affect, the client now responds cheerfully to my exaggerated behavior, accepting my offer of equal status).
Therapist: “Aren’t you laughing too much? How embarrassing!”
CJY: “Because you talk nonsense! (laughs)
Therapist: “Alright! Let us once again tell your story of the past two weeks. This time, I’ll put ‘fortunately’ or “unfortunately” in between your sentences.”
CJY readily accepts my offer to play the RfG exercise, Fortunately/Unfortunately:

• Fortunately, I found a job close to home.
• Unfortunately, I just spent all the money I had earned.
• Unfortunately, my family is in a financial situation that requires me to work.
• Fortunately, I can make money anyway.
• Fortunately, I can design.
• Unfortunately, at the company, I have to consult customers over the phone in addition to designing.
• Unfortunately, I’m too weak with numbers.
• Fortunately, now I can quit anytime with a three-month probationary period.
• Fortunately, I’m at home less time, so I don’t have to fight with my mother.
• Unfortunately, I have to work…

Therapist: “Now, at the end, which one would you like to end with, unfortunately or fortunately?”
CJY: “Unfortunately.”
Unfortunately, I have to go to work again on Monday.

The following dialog occurred in our Post-Enactment Processing (PEP):
Therapist: “How do you feel when you go to work on Monday?
CJY: “I should.”
Therapist: “Do you think you will have a lot of luck? Do you think there will be a lot of bad luck?”
CJY: I do it because I have to. Could be good luck or bad (The content is negative, but unlike at the beginning of the session CJY’s expression and attitude now are relaxed and smiling).
Therapist: “I guess so. I always hate to go to work!”
CJY: (laughs).

Commentary
Therapy is understood as a process in which the client’s self is transformed in the therapist-client relationship.
With 20 minute sessions, the use of psychodramatic techniques is not easy. When using psychodrama, it takes a lot of time to get immersed and get out of the immersion. Looking at the fact that most clinics in South Korea use psychodrama techniques, the degree of immersion is very weak, being largely limited to the level of role training.
By contrast, RfG enactments take four minutes at most. Due to the nature of these games, they do not result in immersion, but have the advantage of strong engagement. In addition, the features of simple rules and improvisation provides a very suitable environment for clients and therapists to try new things.
While the transmission of information provides energy to the therapeutic process, improving communication through RfG solidifies the basic conditions for successful treatment.