Before we begin, please do not consider the following post an exhaustive treatment on how to treat Obsessive Compulsive Disorder. The intervention I discuss is only one strategy, and treating OCD can be quite long-term, begs different methods. It is never a simple behavioral therapy. I'm only suggesting that without a behavioral approach, the therapy is remiss.
Nor am I making fun of people who have the disorder or dismissing them as silly. That's the farthest thing in my mind. It's a very serious, painful disorder.
Many couples argue about the right and the wrong way to stack a dishwasher. There is, apparently, a right and a wrong way, depending upon the direction of the jets. You knew about the jets, right? So couples argue about this one quite a bit, and it's not an Obsessive-Compulsive Disorder thing, not even a control thing, so much as an
Are the dishes getting clean?thing.
So we could talk about that, for sure, but let's talk about me.
I’ve become one of those people who washes the dishes 100% before stacking them in the dishwasher. I never thought it would happen. There's no need to do this. This particular Whirlpool sounds like an airplane, but the dishes come out clean when the war is over.
So FD comes home and eats breakfast, wants to stack his plate of crusted bagel crumbs and butter in the dishwasher. He sees the clean dishes and asks me, “Are these clean? I just emptied this thing.” His tone is upset, confused.
“Yes, they’re clean. I’m using the rack to let them air dry.”
“Well, how am I supposed to know what’s clean and what isn’t?”
He has a point.
You're all thinking, I know you are, this is so obsessive-compulsive, washing before a wash. But the difference is that there is no second wash.
Another example of mythological OCD:
My mother, 84.5, lives independently but won’t cook for herself anymore. Or bake. She is a fabulous cook, a wonderful baker, and although I’ve tried to fill in, I’m too impatient for real baking; you know what I mean. She won’t cook because it’s too messy. Does she have Obsessive Compulsive Disorder?
She might, is the truth, but in this case, her behavior isn’t a function of her OCD; it’s a vestige of self-esteem. Why should she have to clean up for herself at her age? She's done enough of that, cleaning up for herself, for others. It's time to call it quits.
So we don’t have to treat Mom. But when should we treat compulsions? (Obsessions are the thoughts, compulsions the behavior). And when should we leave symptomatic behavior alone?
We might suggest that if a younger person refuses to cook for herself because a splat of omelet on the range causes her too much distress, then that might be something to treat, depending upon a host of other variables.
And how would we do that, treat it?
It’s not necessary to talk about toilet training as a child, although a therapist could make decent money off this approach. And it’s fun to talk about early childhood, for we do establish much of our irrational tendencies as children just coping with life stress. Life, if you're a kid, has inherent stressors, mainly having to do with weird rules and the behaviors of large people.
But far more elegant than talking about childhood is a behavioral approach. You start (I do) with something that’s upsetting to the patient, like a spill. A therapist like me might pour grape juice into a pitcher and leave it close to the edge of my desk for an entire visit to see how long it takes for the patient to say,
“Could you please move it? It’s going to fall.”Ridiculous, right? It’s not going to fall. It is a full pitcher. It isn't going anywhere. I move it an inch away from the edge.
“Good enough?”Of course not.
“Does this make sense?” I ask.Well yes, it does. We could have an earthquake. Anything could happen. We talk about the concept of stressing the mental set, making the brain grapple with the thought that it could fall, all kind of bad things can happen. But it won't. I won't let it. The thought is irrational and dysfunctional.
Dysfunctional because while under the influence of an obsessive thought, or a compulsive behavior, whatever else is going on in our lives, whatever else is important, is taking a second to something as small as a pitcher of grape juice. And we make other people miserable, waiting for us.
Sure, caution is a good thing, and most of us avoid precarious situations like spills, but when the caution is obligatory, rigid, symbolic for everything, somehow, then we have to tickle many sources, not only a difficult childhood. Pick a trigger, any cause for anxiety, then another, and play with it, talk about it, test it.
Try syrup, working with a spill phobe. No one with this set of compulsions (the cleaning set) is comfortable with spilled syrup.
Hold a spoonful of syrup over the floor, make like you’re going to spill it, but don’t. Get very close to spilling it, but definitely don't. This requires some coordination, but repeat the near accident over and over, each time measuring the length of time the patient is holding his or her breath. (Not literally, just look for any change in expression).
A little anxiety is what we’re shooting for, not too much, and a gradual magnification of the stimulus. This teaches the patient to manage his or her anxiety some other way, and hopefully you're familiar with relaxation techniques and have passed them on, or cognitive strategies, like the rational thinking we discussed above.
The technique of gradually increasing the stress of a feared stimulus is called desensitization. Gradual is key. No need to give anyone a heart attack with spilled grape juice of syrup. Not until you're sure that spilling won't cause a heart attack.
The therapy really can take years. There's always another trigger to desensitize the patient who has this disorder. Medication is helpful, and surely a couple's therapy is always in order, psycho-education for the spouse, and coaching, even shadowing.
So what about me and FD? With the dishwasher. We could dedicate one side of the dishwasher to clean dishes, another to dirty. But I feel this contaminates the clean ones that are minding their own business, just resting across from the dirty ones.
Maybe someone can think of a better idea. I’m not sure I want to quit washing the dishes 100%. It feels good, hot soapy water on skin (I never thought of it this way until a friend mentioned it to me). And it seems like something that should become a permanent bit of the home’s personality, saving counter space, like we're heading in a new direction.
And FD could actually look at a dish to see if the dish is clean. Would that be so bad?