Shame, transference, and life issues after the reduction of obsessive symptoms: a case report of psychodynamic psychotherapy in a patient with taboo sexual obsessions

Sexually tabooed obsessions represent a clinically demanding form of obsessive-compulsive disorder, especially when they include incest-tinged content and pronounced shame. The psychotherapy course of a patient with long-term obsessive-compulsive symptomatology of various content is presented, among which the most disturbing were intrusive erotic and sexually coloured thoughts directed towards her father. The first symptoms appeared suddenly in adolescence, during her first romantic relationship. Since symptom onset, the patient has been involved in pharmacological treatment that changed several times, and before analytic group psychotherapy she also tried cognitive-behavioural treatment conducted by a psychologist in private practice, without significant improvement. During analytic group psychotherapy, a pattern of shame, discomfort and feelings of exposure in relation to the male group leader began to manifest. She discontinued the group treatment on her own initiative, contrary to the therapist’s opinion, while emotionally tense topics were opening up. After a break of approximately eight months, she began individual dynamic psychotherapy, in which the same transference pattern was re-actualised and gradually worked through. After approximately a year and a half of individual work, the obsessive thoughts began to decrease, and about two years after the start of treatment, the patient described an almost complete withdrawal of the previously dominant obsessive symptomatology. In parallel, there was a significant improvement in the relationship with her father and the development of closeness. After symptom withdrawal, the patient began to reinterpret the rapid entry into marriage as a possible attempt to distance herself from the family home and from the internal tension at that time, and raised the issue of divorce. The case emphasises the importance of a transference-relational understanding of symptoms, but also the significance of continuing psychotherapy after symptomatic improvement, when previously obscured life conflicts can be opened up.