Integrating Existentialism and Modern Structural Theory into Short-Term Psychodynamic Psychotherapy for OCD

Abstract

This article responds to two commentaries on my psychodynamic case study of "Serena," a Cuban-American woman with harm-related obsessive-compulsive disorder (OCD). In Part A, I respond to Lyon’s (2025) existential-psychodynamic reformulation, which posits Serena’s compulsions as defenses against death anxiety and fears of psychic disintegration. Lyon integrates Freud’s dual-drive theory, terror management theory, and attachment trauma to frame obsessive rituals as maladaptive efforts to manage existential dread rooted in early relational ruptures. I reflect on how existential interventions, such as explicitly naming death anxiety, addressing uncertainty, and leveraging termination in brief treatment, might have reduced shame around OCD symptoms and deepened Serena’s engagement. In Part B, I respond to Khademi and Steffen’s (2025) relational-developmental critique. They challenge the limitations of Leichsenring and Steinert’s (2017) manual-guided, short-term psychodynamic psychotherapy (STPP) approach, based on Luborsky’s (1984) Supportive-Expressive/Core Conflictual Relationship Theme (CCRT)_model. Instead Khademi and Steffen propose a shift toward Modern Structural Theory, identifying missed enactments and the need for greater therapist self-reflection. Their commentary reframes resistance and aggression not as treatment-interfering behaviors but as developmentally meaningful expressions of Serena’s emergent agency. I consider how supervision targeting my countertransference as it related to my bicultural identity could have prevented blind spots. In Part C, I synthesize the contributions, both of which call for greater emotional immediacy, cultural attunement, and recognition of the developmental origins of intrapsychic and interpersonal dynamics, while accounting for the limits of manualized therapy. Together, these perspectives offer valuable and nuanced directions for expanding the scope of short-term psychodynamic therapy with complex cases like Serena’s.