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Thursday, September 13, 2012

Order-Cravers: Being O-C

OCD, OCPD, or just neat
Order Cravers.  Sounds like something out of Harry Potter. Unbeknownst to Harry, the Order-Cravers waited patiently for him to step out of his room.

Indeed, order-cravers can make you sick.  You want them to stop ranting about disorder, the shape of a room, the clutter.  And some of them really are sick.  But probably, most are not.

Those who are  impervious to hygiene, to dirt, in contrast to order-cravers, might suffer a severe mental illness.  Sick with depression, there's less energy to shower, and a dirty glass, a smudged coffee table, feels irrelevant.  Depression is like that, breeds apathy, zaps our energy.  The nemesis of an order-craver.

This is National Suicide Prevention Week.  (Tagline: You can make a difference.  Check out the link). So I have to stress that there's nothing pretty about mental illness, and nothing funny about it, certainly nothing funny about that Death-Eater-- depression-- that won't let up.  All that works is love, attention, time, and compliance with those impertinent doctors who make you exercise, eat right, smell the proverbial roses, take your medicine, and occasionally check into the hospital.  Day programs are great, and always, always, therapy is recommended.  These things make the difference between life and death.  As does lots of sleep.

And reading.  For those who can still open their eyes to read, reading is helpful.  (This is the best I can do to link over to a site that gave this blog a recent shout-out, an "award" on 25 Depression Information Sites without totally selling out.)

We elaborated on suicide prevention in 2009, that Fray song, How to Save a Life.  That might be worth a revisit.  But let's move along now, address order-craving, and how some people need so much order, but not everybody cares.  Should they?

Caring about physical space, the chaos that surrounds us, the never-ending mail, newspapers, dust, dirty dishes, dirty floors; wanting cleanliness and order, predictability, is the psychological equivalent of environmental hygiene. Unconvinced of the importance of picking up, some of us have other priorities, sleep among them.  Video games another.  And poor environmental hygiene.

We can take it when a three-year old throws a candy-wrapper out of a car window.  When we explain why he should not, he'll listen carefully, then vociferously disagree and toss something else out of the window.  It is normal to be oppositional at this age.  Funny.

Over the age of three, less so.

We assume that those who simply leave a mess for others were either indulged as children, or not introduced to the beauty of empty space.  Someone probably picked up, didn't insist upon better habits. (Parents can insist). Or nobody did anything at home in that family of origin, ever, not even the ones in charge.  Disorder becomes the norm.

This is discussed quite a bit in relationship and family therapies. It can become a goal of therapy, inspiring a partner to care about housework.  Young therapists will go over this same problem week after week in a couples therapy.

Label the problem:  One partner needs order, the other a rest from the insults.

It is the therapist's duty to elevate the discussion beyond wet towels on the floor.  The towels will be picked up when emotional needs, face-time, genuine eye-contact, replace them as a priority.  (Domestic abuse, child abuse excepted.  Abuse gets results, too, but not the ones we're looking for, see OCPD below).

Treat the lack of emotional intimacy, and suddenly attending to the chaos magically improves, assuming mental or physical illness doesn't incapacitate. And even then, laziness is forgiven with only a tad of lip service.  I wish I could get out of bed to help out around here.  But I also wish I had never met a pair of skis.  I'll help more as soon as I am able.

Those who don't notice the clutter and dirt, who don't care if a cup of milk has been sitting for days, or an entire carton of milk, for that matter, start to notice a bit more when they are noticed, addressed without insults and criticism.  Addressed intimately.

Order in the home can become a matter of power and control, which is why it tends to be such an emotional trigger.  An order-craver not only insults but threatens: "You're such a slob!  If you don't shape up, I'm out of here.  I can't live like this."  Interestingly,the less-than-ordered partner doesn't threaten divorce (it is nice to have a maid), and will even go so far as to suggest an hour after dinner, "Must you clean up now?  Come watch TV.  You are so O-C!"

The implication is that the neat freak is the one with the problem, the one who has a disorder. Obviously, O-C.

But we have to clarify, we really do.  Being an order-craver is not the same as having OCD, Obsessive Compulsive Disorder, not on its own, nor does it qualify a person as OCPD, having Obsessive Compulsive Personality Disorder.

Obsessive Compulsive Disorder (OCD) is defined by obsessions (intrusive thoughts), and compulsions, being compelled to do things, even illogically. It is not illogical to put things away.  Someone has to know where to find the scissors.

And Obsessive Compulsive Personality Disorder OCPD is defined by a need to control life to the max, no matter how it inconveniences others has nothing to do with clean dishes, either.  Hoarders have a corner on OCPD.  The idea of de-cluttering, getting rid of those precious piles of National Geographic magazines from the sixties, is not on the agenda of a person with OCPD.

A quick review.  Recognizing any disorder is relatively easy.  How to fix it,  generally less clear.

OCD, 300.3 (the anxiety disorder)

A) Either obsessions or compulsions:
           Obsessions include:
1) recurrent and persistent thoughts, impulses, or images that are intrusive and cause marked anxiety and distress
2) the thoughts, impulses, or images are not simply excessive worries about real-life problems
3) the person attempts to ignore, suppress, or neutralize them with some other thought or action
4) the person recognizes that they are a product of his or her own mind (not imposed from without as in thought insertion*)
          Compulsions include:
1) repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
2) the behaviors or mental acts are aimed at preventing or reducing the distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
B. At some point the individual recognizes that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time consuming (1 hour or more a day) or significantly interfere with normal routine, work, academics, social life or relationships.
D. If another Axis I disorder, the content of the obsessions or compulsions is not limited to that (i.e., preoccupation with drugs in the presence of substances, food for anorexics)
E. The disturbance is not due to the physiological effects of a substance or general medical condition.

versus 

OCPD, 301.4 (the personality disorder)

A pervasive (doesn't go away) pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by FOUR or more of the following: 
1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
2) shows perfectionism that interferes with task completion (unable to complete a project because his or her own overly strict standards are not met)
3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
4) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
5) is unable to discard worn-out or worthless objects even when they have no sentimental value 
6) is reluctant to delegate tasks or to work with others unless they submit toexactly his or her way of doing things
7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
8) shows rigidity and stubbornness


The ordering feature of OCD, the anxiety disorder in pink, above is ritualistic ordering, with no real purpose.  It isn't to straighten a room, not really.  The object is to create order in the brain, activity driven by intense anxiety.  People with OCD are the ones who straighten cans at the grocery store.  They count, for nothing, for the sake of counting.  They skip over cracks, can't help it.  They know what they do is irrational.

The ordering feature of OCPD, the personality disorder in orange above, refers to a need for control.  Saving, thumping about morality, working too hard and getting nowhere, an unusual adherence to rules as a response to having had history of acting out, unnecessary financial restraint-- it seems a penance.  Ebenezer Scrooge had OCPD.  It can seem very normal on the surface, but when there's no path to the kitchen, no room for a car in the garage, and refusal to spend money for a new pair of shoes more than once a decade, we call it sick.

Thus merely wanting a clean floor is not dysfunctional.  It is not a disorder, it isn't even O-C.

Yet it is lonely, being the only one at a sparkling, clean table.  So it is worthy of intervention.

STRATEGIES FOR COUPLES WITH ORDER-CRAVING ISSUES.  (These can be used in any type of relationship.)

(1) When couples have the problem, cranking up the emotional intimacy, talking rationally about feelings and needs, as opposed to clutter, is a good beginning.  The psychodynamics-- seeking out the roots, the history of a lackadaisical attitude toward environmental hygiene, can be surprisingly intimate.

Similarly, exploring why one needs things to sparkle is worth examining, too.  It could be as simple as finding that making things spotless is symbolic; it is how we wish others would see us.  The praise from others reinforces the behavior.  Most perfectionists suffer this need for praise, and their partners, their families, suffer them.  Not that we mind borrowing their keys when ours are lost.

(2) Quid pro quo agreements, you do this, and I'll do that, work when they work. The one who needs order agrees to  relinquish some of the control, to stop insulting and nagging.  The one who doesn't mind chaos picks up the pace, brings a dish to the sink, even washes dishes on a regular basis, throws out trash.

 (3) The give-in to it intervention, a paradox, is fun.  Rather than fight the need for order, or being critical of those who do not care, the order-craver accepts the role of the identified patient. He is told to freely criticize himself and everyone else.  Go ahead and criticize!  Say what is in your heart.  Feel free, express all of the criticism that you are thinking, do it all week.  Make that two weeks.  Let's see how that works for you.

Angered by an unwashed dish, "You left out a dish!"

The ostensibly errant, more relaxed partner should shout back.  "OMG!  You are so right!  I did!  Do you think I'm going to lose my afterlife for this?  Are the ants marching in as we speak?  Come, let's go see!"

(4) The diagnosis of the relationship, an over-adequate/under-adequate relationship, lends itself to the idea that the partner who is doing too much should stop working so hard. Give up on all that work, find your own corner and keep it clean.  Theoretically the under-functioning partner will get lonely, pick up the slack.  The problem, obviously, is that if that doesn't happen, it bodes poorly for relationship longevity.

(5) The middle ground.  Finding a middle ground is a real test for a true order-craver.  The room has to be picked up, the bed made, before this person will come to bed.  The therapist suggests that she try to go to bed anyway, knowing there is s still dust lurking somewhere.  The more relaxed partner meets her in the middle by making sure the bed is made.

The last intervention accomplishes so much more, in so many ways, than flowers or candy.

therapydoc


Sunday, September 02, 2012

Hope Springs-- Eternal

Meryl Streep as Kay in Hope Springs
Name of the film: 

Hope Springs

It is a feel good movie.  Already I'm getting new business. So I feel good.

For so many young couples in therapy, that word eternal has absolutely nothing to do with reality.  The phrase if from an essay on man by Alexander Pope.

They are right, of course, to be skeptical about the longevity of hope as it applies to human relationships, about eternal.  The newness that a young couple feels, the excitement, the arousal, the thinking that this could last, has to change over time as we vie for what we want, strive to meet our individual needs.

That's how we're made, most of us, self-protective. And we desensitize to a steady diet of almost anything; even our partners lose their glitter, just like a favorite brand of cereal.

Worse, if we stay together for many years, unless communication is direct, kind, well received, productive, intimate, it is likely to be received poorly.  When problems aren't resolved to the satisfaction of two, not one, an inventory grows, a list of grudges.  And the goodness, whatever the good used to be, is squashed by resentment, the bad.

We might be bad at math, but when it comes to our relationships, we're great at keeping score.

YES, THERE ARE SPOILERS

I'll keep the spoilers to a minimum. Does it spoil the movie to say that Steve Carelle, as Dr. Bernie Feld,  makes a cracker-jack couples therapist? Is he worth 4K to treat a couple for what we see as an hour a day for six days straight?

Suffice it to say that no therapist is worth 4K to spend 6-10 hours with you, and it is unlikely to be successful.  I get the couples who go through these magical workshops six to twelve months later, when it is obvious that the intensive week failed. In my humble opinion, you'll get the same with a well-trained couples counselor who might even be covered by your HMO, meaning is being paid $60-$90 dollars for a 45 minute session.  The couple pays $10-$50 of that out of pocket.  Swipe goes the Visa.

And of course, I have to complain that Steve, as Dr. Bernie Feld, does not provide nearly enough of the psychoeducation a couple needs in therapy, especially not about sex. Couples hang on to sex education, every word. Need a couple's undivided? Talk about sex.

Oh, let's do that for one moment. Sex is a natural, physical need, like breathing and, well, defecating. That it has been relegated to intimate relationships, committed relationships, is not a shame, rather a human cultural development (or you could say, if it is your cultural belief, a God thing). When it is good, and when it lasts in a relationship, it becomes a glue, a way of saying, You're My Number One.

That is comforting as our wrinkles begin to show, as the bellies go to flab.

What happened to Kay and Arnold?

Wonderful lessons in this movie, nothing you need to read about here. The movie will eventually be on HBO.  But Dr. Feld  wouldn't have turned anyone off had he addressed intimacy fears more directly.  He never brings in family of origin, or how affection matters in life, especially in marriage, how that begins with Mom and Dad, as do our unmet needs, our habits, our attitudes-- what we think is okay and is not okay when it comes to sex.  But we only have 90 minutes.

The main beef for those of us who study relationship therapies professionally, is that the therapist doesn't get out of the couple system quickly enough. He finally tells Kay to speak directly to Arnold on Day 4. He, the doctor, asks the questions and wants the answers directed to him.

A couples therapist wouldn't want to be in any of those conversations.
Therapist:  "Tell Arnold how you feel about your very best time having sex."

So much better than,

"Tell me about your very best sexual experience."

No wonder poor Arnold walks out on him.

therapydoc