Showing posts with label criticism. Show all posts
Showing posts with label criticism. Show all posts

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


Monday, June 21, 2010

The Power of Confusion

Patient complains that I'm not educating anymore, that all the good stuff is in the archives, 2006. He doesn't say it in a critical way, he says it in a just saying way. He says it so nice, I hear it..

So back to work.  Do I have to remind you that I make up people? The patient below doesn't exist, so if you think it's you, it's not.

The Story:

A woman who has been passive all her life determines to make a change. No more Mrs. Nice Guy. She wants to level the playing field when her husband's family criticizes her.  She wants to err on the side of aggression, and wants me to teach her how to criticize, to insult back.

I'm thinking: No.  Let's not.  It would work, would make her one of them.  But it's not who she is; she's better than that.  Why regress?

The joke is that her spouse has married her because she is really, really nice. She never hurts anyone's feelings. Before she opens her mouth she thinks, "Is this going to hurt someone's feelings? Am I going to be disrespecting this person?"

I know, unbelievable. But there really people like this. If you find some of these, don't let them go. Hang on for dear life.

Anyway, he marries her because she's so nice, and he's very happy. But she discovers that his family is very difficult, very different from hers, very quick to criticize. She has married the white sheep, a nonjudgmental, easy-going person, but they judge people, especially her and how she looks, expect her to be perfect, at least to look perfect, to be like them.  And they carp on her when she's not.

Perfect, in this family, means every hair in place, dressed to the nines, make-up. Some people dress up to go to the grocery store, others wear sweats. Our friend falls somewhere in the middle. She asks me,
Should I have to put on heels to visit a sister-in-law in the middle of the day?  Is this normal?
I'm thinking: No.

But maybe, yes. Maybe she should.   Maybe if she does this, dresses up like them, looks like they want her to look, they'll feel more of a connection to her. The subtext, the unconscious text, is that when we conform, when we follow the herd, the other sheep assume we admire them, that we're not judging them, irony of ironies, so their unconscious anxiety is mollified. That's why like attracts like. So fake it 'til you make it, baby.  Join the club.

Those of you with self-esteem are thinking: NoLet's not and say we did.  (This is a sarcastic remark, passed down to me by my older brother, very useful, although in general I frown when it comes to sarcasm).

And you are correct. No matter how hard we try, we'll come up short with a person who wants us to come up short. Sometimes I think the world is binary. There are only two kinds of people* -- those who communicate in a sensitive fashion, and those who don't.

Many would say we learn more from those who are not esteeming, who are insensitive. We hear a negative message and think, "Wow, I really am a zjihlub!  (Yiddish, two syllables, je, as in the French je, and lub, rhymes with tub  Means slob). I should change!"

Except most of us are just hurt when someone insults us, so we don't change. We get angry and resistant and depressed, immature. We're regressed when it comes to criticism. We feel like we did when we were little and our parents shamed us for things like playing with our food.  It is an art delivering a message that fosters emotional growth, personality change, and still doesn't hurt feelings in the process. It is why parenting is so hard.

But back to our story; better would be to assert:   When the sister-in-law frowns, turn on the baffle, that confused look.  Act as if you seriously don't get it but want to understand.  If you use the following script, first emphasize that you don't want to be interrupted.

The long version, for the short, skip the first paragraph:
I notice you always make a point of making nasty remarks when I'm not wearing nice clothes. In your family, seems to me, people can take it, the nasty remarks, it just bounces off of you, and you seem to enjoy jumping on one another, or on anyone who isn't dressed up.  You'll even laugh about total strangers if they don't meet your approval.

But you need to know that  when you say something negative about how I look, it hurts my feelings. I wasn't raised to be judgmental. So I take it as this huge put-down, a comment about how I look. Could you try not to do this? Just don't comment about how I look and I won't go home feeling badly.

And why do you do it, anyway? Why is it so important for everyone in this family to have to look fabulous all the time?  I don't know how you all pull it off, always gorgeous.   I don't understand why it's so important.  Seriously, what's the deal?  Where's this come from? How do I get to be like you?  How did you all get so fashion conscious?
This should stimulate dialogue that you can steer to the topic of criticism in the family.  It can be a really decent, intimate dialogue. Often about child abuse.  Don't back down if they shrug and say, "Don't know."  Someone knows.  Someone's got some psychological saichel.  (Rhymes with Rachel, but a soft-gutteral ch, means smarts).  After the dialogue you predict the future.
"Okay, so when I come over here in pajamas, you are not going to say anything, right? But I'll try not to come over in pajamas if it's a disrespect to you.  I'll wear sweats."
Then you label the process. When it happens again, the criticism, you say,
"See? You're doing it again. I thought the new deal we have it that it's okay that I be the zjilub, and you be the gorgeous one.
Works every time.

therapydoc

*Binary thinking is shallow, black-white thinking, and virtually nothing is black and white. That's what the bell curve is all about, normality, the normal curve. To be exceptional, extraordinary, abnormal, one's score on a certain trait must be in the tails, must be rare. But you can be anywhere, totally normal, and still not know what's flying when it comes to relationships.

Tuesday, August 26, 2008

History and Strategy

You might find this question and answer interesting.

A reader writes in response to the shame post, The Bistro and the Date (below). First he answers those all important questions* then asks
How can I keep my boundaries tight when my family tries to sabotage what I think should be a moratorium (a.k.a. cut-off ) for the sake of my mental health?
The reader worked for years to distance himself from his verbally abusive father, a man who denies his emotionally violent parenting to this day.

If I were the reader's therapist, I would explain that it is shame that is buried under those layers of denial, that his father and he may not be all that different. The difference is subtle but important. His father's shame is so tragic, so toxic, that it is no longer conscious, he has successfully defended with that most primitive of defenses, denial, unconscious denial, the worst kind. He has to believe himself a good dad. Anything else would destroy him. He hasn't psychic permission, he hasn't given himself permission, to be imperfect.

An identified patient like our reader will sometimes try to cut off communication with people in the family who were "dysfunctional" "toxic" "violent." He may try to hang onto one limb, to save a relationships with a sibling, the seemingly healthiest member of the family.

But this last branch, his only connection, will eventually become angry and resentful, may even threaten to cut him off unless he reconnects when parents become elderly and physically unwell. Siblings needs one another when that happens, when there's family work to share.

We're addressing cut-offs here, obviously. The reason people cut-off their families is not that they don't need them or feel responsible and connected to them, but their families became sources of pain. Families do abuse and shame, betray members. Mis-steps such as these (including addicted siblings who visit and steal the silverware) make us wary. We put up boundaries.

It's the permeability of the boundary that concerns me. Boundaries need to breathe.

Parents who emotionally abuse with words, who shame their children, who fertilize a child's self-doubt, sense of inadequacy, and unworthiness have to be sealed off for a little while. The fence needs some sturdy nails. Not electricity. No, I won't block the metaphor, let's keep it going.

See, you need a fence, because children who grow up with verbal abuse believe it and when it's a steady stream of negativity will join the dissension, believe the words, find someone else who will abuse them, or do the dirty work themselves, continue the lashing, cut, try suicide. Maybe succeed.

This is why therapists will advise conflicted patients to stay away from the source, to protect themselves from further emotionally violent communications with family. Heal.

But we're all human. We will want to cling to the healthiest member of the family, perhaps the one who saw the abuse, who may have also been a victim. And ultimately cut-offs fail. The family guilt and invasiveness is stronger than the average soul can stand. Therapists often get cases like these when they're sinking, shored up by a quick but ineffective hospital stay.

Sometimes during that stay the family has been involved. A family therapist like me will keep that going if I can, at discharge, will contact family members (with the patient's permission and release of information). I work to convince the family to let me take over for awhile, to give the patient less of themselves, not more. But don't worry. We'll be in touch.

And I stay in touch.

It takes time, but if a family therapist can work with the healthiest branches, things can change, really change for the best. Branches only need be a little green to grow. People change late in life, given the chance, given the relabel, the opportunity to be a hero.

But what do we do when it's too late for that, when the cut-off is fragile and not working, and Dad is sick in the hospital and our Identified Patient hasn't the strength to deal?

Not at all uncommon. The sibling, the one care-taking Dad, wielding the chain-saw (help me or you're no longer my brother/sister), is clearly of the tougher child variety. But even the tougher children wear down when they have to care-take sick parents. They look tough. But it's just for show.

Family therapists push for direct communication. First the identified patient has to be straight with his or her sibling(s), the care-taker(s), either by writing (under a therapist's direction and editorial skill) or calling (in the therapist's presence) to communicate something along these lines:
I'm going to call Dad or write to him and tell him what's going on with me. I'm sorry you're stuck with this, but for the time being I probably won't be visiting. I'm not quite healthy enough yet, but I'm working on it. Here's what I'm going to tell our father:
And here is what the identified patient would tell his or her father, either by telephone or in a letter, not face to face, something along these lines
I'm sorry that I'm too sick to reconnect with you right now, that I'm no good to you. Some children, the ones with big issues, get a little funky when parents get sick, and that's what I am right now, laid a little low, too depressed and withdrawn to get out of my shell to help out with you, visit with you.

I know you don't believe in mental illness, but you and I are different like that. You probably see this as a weakness and an excuse. So be it. It's real enough to me to make visiting impossible right now. I just can't do it. I hope that you don't hate me for it. I imagine you do.

One day I'm sure I'll regret this decision, not seeing you, not helping you. It doesn't seem fair to do this to you, especially now. But I don't see life as fair. A parent raises his kids, gives them his all, and just when he needs them, they're gone.

I have bad memories of us, and they haunt me (this is called chipping denial, you're not accusing him of anything). I have to work through things, mostly negative thoughts about myself, nobody else. You did the best you could. You tried to parent the best you could.

I feel like a bad person, a failure, for not meeting your expectations.

I'm in therapy, working on my own set of expectations, and how I'm going to live with myself when you're gone.

Maybe I'll get it together soon. Who knows? I don't expect you to forgive me for this or to really understand me. But despite your take on mental illness, I think everyone gets depressed sometimes. Maybe even you.
And then the identified patient stops talking or signs off (he doesn't have to write "Love" that's up to him) and hopes his father begins to talk about his own feelings, his own depression, his own childhood abuse, knowing he probably won't.

But he might. They sometimes do.

This is a strategic intervention, full of lies. The identified patient is not remorseful, probably doesn't even believe his father did the best that he could. The identified patient may never regret not talking to his father, cutting him off.

With good therapy, he will live with himself just fine once his father has passed on. He probably won't care. Some celebrate. It is survival we're talking about here. And you can't always sleep with a person you perceive as the enemy. You can't always go home just because they're ringing the dinner bell.

The therapy, surely, is about changing that perception, the one that identifies the parent as the enemy. If that's possible.

To do that, you need history. You need the extent to which the parent suffered abuse during childhood. If the identified patient doesn't know the history or denies transgenerational abuse, I make finding out a therapeutic objective. It's there.

He was criticized, abused, shamed. Not loved. Abandoned. The child who cuts him off finishes the job. It's the unkindest cut.

In family therapy you want to get to a point with an abusive parent that you can admit you're not so tough. You don't know how he survived his childhood. How did he do it?

Families can toughen us up or wear us down. The resilience variable is having a healthy adult around who counters the abuse, one who puts a hand on the abused child's shoulder and says, "You're a good kid, a wonderful kid. You'll grow up. You'll get out. Talk to me any time. Tell me everything."

We can get into calling authorities about child abuse another day. In a word, Yes. Call.


therapydoc

*Those questions include:
Did (your father/mother/guardian) call (you) lazy?
Retarded?
A loser?
A fool?
Stupid?
With gusto? With sarcasm? With hate? Disgust?
Were there tirades directed at making people feel badly about themselves?

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