Wednesday, August 3, 2011
Obsessive Compulsive Disorder - Rituals in Control
Obsessive Compulsive Disorder commonly known as OCD can be one of the most debilitating problems one can face. The National Institute of Mental Health describes it this way: “People with OCD have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.” The thinking is very hard to control and it drives the behavior which can be treated with therapy as part of a difficult process. Medications may also help.
All of us have rituals. They help us get through the day, from morning coffee to evening prayers. Many of us check multiple times to make sure the stove is off or the door is locked. It is when these rituals take over and interfere with our lives, that there is cause for concern. We are unsure about the causes of OCD and the symptoms can ebb and flow. It’s often accompanied by other anxiety disorders and depression. The following story gives an extreme example, but not as uncommon as people would think.
He sat cross-legged on the floor, dressed only in his bright, white underwear. Tears ran down his face. Next to him on the floor was a bucket filled with water, a sponge and a scrub brush. Folded neatly in his lap was a pair of bright yellow rubber gloves. He shook his head from side to side in disbelief that I had entered his house. I had removed my shoes and put on surgical gloves that I got from a box I always kept in the car. “My God”, he said, “now I don’t know where to begin.”
His ex-wife had called to say she had not been able to reach him on the phone. “I’m concerned, not worried really,” She told me. “He could be standing next to the damn thing while it’s ringing, but if it isn’t cleaned properly or if he hasn’t performed the proper ritual, he won’t answer it. I’ve seen it happen a hundred times. Another thing that happens is he’ll sort of get stuck, like he is overwhelmed with what he needs to do and he’ll forget what he’s cleaned and he is immobilized. Maybe you could stop by and see if he’s ok.”
Elliot’s ex-wife was the person who introduced him to me two years earlier. He’d moved to Ithaca from Newark, New Jersey, after things fell apart for him. He’d been a mechanic for the New York City subway system for twenty six years when his obsessive compulsive disorder got the best of him. He’d taken early retirement and picked Ithaca because a high school friend lived here and he’d visited a number of times and liked it.
His ex-wife was also his best friend. They’d married young, both of them just 20. He’d been discharged from the army less than a week. She got pregnant on their honeymoon and again a year later while nursing her first daughter. He took the skills he learned in the service and was offered a position with the Transit Authority.
When her youngest daughter went to college, Amy told Elliot she wanted a divorce. She moved out of their house and into an apartment. She told me why when we first met. “He was driving me crazy. Not only the cleaning thing, but everything. It was classic! Checking the stove and checking the locks on the doors and windows and being afraid to go anywhere in the car because it might break down. I started to think I might lose my mind.” Elliot had not disagreed with this assessment when I met with them both. He also agreed that things got a whole lot worse when Amy was gone. He hadn’t realized what a moderating factor she’d been in his life until she left.
“A geographical cure!” the psychiatrist had said after seeing Elliot. “It rarely works.” Elliot had refused to take medication at that time. “It makes me feel drugged. I can’t get anything done.” Later, he’d agreed to have some medication in the house for those times when he felt completely overwhelmed. His effort to integrate himself into life in Ithaca was limited. The old friend got tired of him fairly soon and Elliot became as isolated here as he’d been in Jersey.
“Can you get up?” I asked, offering my hand. “My legs are pretty cramped. What day is it?” He asked as I pulled him up. When I told him, he determined he’d been on that spot on the floor for about eighteen hours. “I got to pee!” He announced and went down the hall to the bathroom. When he returned, I handed him a pair of pants and a tee shirt and we went outside to his front steps. He and I had been through this a couple of times before and we both knew the routine. Essentially, I had contaminated the entire apartment and when I left, he would start again from the doorknob inward. In the past, he’d allow me to visit and knock only if I had on rubber gloves and then we met on his steps.
He was tall and thin with graying hair in tufts on the front of his head. I started to explain, “I’m sorry, Amy called and was worried. When you didn’t answer the door I got a key from the landlord.” “No problem,” he said, “there were guys in to replace the stove two days ago. I told the landlord that the old stove was fine, but he insisted and finally got sort of pissed and sent his guys over. I started cleaning after that. And the new stove is really nice. When I got to the second bedroom upstairs I cleaned myself into a corner. The floor was wet all around me, so I thought; I’ll just let it dry and go downstairs. After it dried I didn’t really know where I’d cleaned so I stayed put. The phone rang about a dozen times. I knew it was Amy or one of the girls and they’d understand.”
I always found it interesting that when Elliot and I ended up on the steps together, how utterly normal he could be. It was like he was taking a break from his psychological problems. We’d chat and joke and make small talk as if his life had not been ruined by his condition. “What do you think about seeing Kevin again,” I asked, referring to the psychologist he’d worked with in the past. Kevin had used a form of classic exposure therapy with Elliot, having him make contact with various objects that others have touched. Elliot had once walked through the entire building touching doorknobs. He ended the session with both hands on the handles that opened the front doors of our building which hundreds of people touch each day. It appeared that Elliot was making progress, getting out, keeping appointments and attempting to make a life for himself when all of a sudden he stopped.
“I don’t think so,” Elliot said, referring to my question about treatment. “I like Kevin, but that stuff wasn’t really working for me.” I tried a different tack, “How about if he came over here and worked with you here? You could try some small things, like how to deal with the phone or people coming to the door. Also, you have to figure out a way for your caseworker to help you buy food. She can’t spend the whole day with you, she has other clients. Kevin might be able to help with that.” He replied, “I really appreciate what you’re trying to do and I know that exposure helps some people. It just didn’t seem to help me. It made me more anxious. Besides, now when I’m doing real bad I take the pills, they help a lot. I just didn’t have them with me this time. I’ll make sure I keep them close so this doesn’t happen again.” He held up his red, raw hands, palms up near his shoulders, blending surrender with goodbye. “Thanks for coming by.”
The U-Haul with Jersey plates was almost full. Amy and two young, attractive women were putting plastic bags of clothing on top of the furniture, before pulling the door down and locking it. Elliot sat in the front seat, his eyes closed, his head resting comfortably on a clean white towel covering the headrest. “It’s for the best.” Amy said to me, shaking my hand.
The stories are my remembrances. Each of them is based on a true event in my work for Tompkins County Mental Health in Ithaca New York. I have changed the names of every client, patient and co-worker except for Beau Saul, of the Ithaca Police Department, who I was fortunate enough to have as a partner. When confidentiality demanded it, I have changed details. The dialogue is my reconstruction of what was said at the time. I have felt honored to be let into the lives of so many individuals over the years. Their stories are a gift I have been given. Please enjoy them in the spirit with which they were written; to educate and inform.