Diagnosis in Psychotherapy - Portrayed in a Movie
By Birgit Wolz
As Good As it Gets
James L. Brooks
James L. Brooks, Bridget Johnson, John D. Schofield, and Kristi Zea
Mark Andrus and James L. Brooks
Jack Nicholson, Helen Hunt, Greg Kinnear
MPAA Rating: R
Year of Release: 1997
Melvin Udall is a successful author who lives the life of a recluse.
He is a misogynistic, homophobic, anti-Semitic racist with an intense dislike of
people and dogs. All the neighbors in his Greenwich Village apartment building avoid him.
His psychotherapist diagnosed Melvin with OCD (obsessive-compulsive disorder)
because he avoids stepping on sidewalk cracks and touching other people, wears gloves
all the time, wipes off door handles, eats at the same restaurant every day, sits at
the same table, insists on the same waitress, Carol, and always orders the same meal.
Suddenly, Melvin's life takes a turn. His artist gay neighbor, Simon, is beaten up
by a group of robbers. Simon's art dealer, Frank, forces Melvin to care for Simon's dog during his
owner's recovery. Soon Melvin encounters another challenge, because his waitress is not at her job
one day when her son is sick. He expresses his frustration, and is finally thrown out of the restaurant,
followed by applause from the regulars. Melvin finds out where Carol lives and visits her. He offers to
pay a doctor to care for the sick son if she promises to wait on him again.
Gradually, Melvin discovers his love for Carol and the little dog in his care. After coming to terms with his
own failings, he starts to experience and demonstrate compassion. Of course, he does not change overnight, and there are
times when the
old Melvin Udall rears his ugly head, leading to many plot complications.
At one point, Carol and Melvin have a date at a fancy restaurant, only to discover that Melvin needs to
purchase a coat and tie to meet the dress code. Challenged by these demands on him, he insults Carol, saying that she is wearing
a housedress. She gets furious and demands a sincere compliment, or she will leave the restaurant. With anguish and many disclaimers,
Melvin finally states that because of his affection for her, he decided to take medication for his OCD. When Carol wants to know why that is
a compliment, he says that being with her makes him want to be a better man. When Carol responds very positively and affectionately, he tries to
take it back by saying that he "overshot the mark".
According to the DSM-IV-TR, people with OCD suffer from recurrent obsessions and/or compulsions.
"persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that
cause marked anxiety or distress" (Criterion A.1), which are difficult to dismiss, despite their disturbing
nature. These experiences are more intrusive than excessive worries about real-life problems, and they are
unlikely to be related to these kinds of problems. (Criterion A.2). Persons who suffer from OCD try to ignore,
suppress or neutralize their obsessions with some other thought or action (Criterion A.3) and recognize that
they are a product of their own mind (Criterion A.4).
Melvin Udall has repetitive
thoughts about germs and diseases (Criterion A.1 and 2). Even though the portrayal of OCD seems realistic in
most parts of this movie, it would be unlikely for clients to handle a dog when they have an obsession about
cleanliness as severe as this character. Melvin tries to neutralize his intrusive thoughts with compulsive
actions (Criterion A.3). He is aware that his obsessional thoughts are a product of his own mind since he
reflects on them in a conversation with Carol (Criterion A.4).
repetitive behaviors such as excessive or unreasonable cleaning, checking a stove or locks on doors, hand
washing, requesting assurances, or mental acts, such as repeating certain words silently, counting, or
excessively. (Criterion A.1) These behaviors either serve as coping mechanisms to reduce the discomfort
with the anxiety
or distress caused by the obsessive thoughts temporarily, or - unrelated to an obsession - they are
performed according to rules that must be applied rigidly. In the majority of cases these actions are
designed to prevent some dreaded event or situation. However, in other cases there is no obvious logical
connection between the two (both cases make up Criterion A.2)
Melvin Udall avoids stepping on
cracks in the sidewalk because that may bring bad luck. A causal connection also exists when he engages in
avoidance and ritualistic behaviors as a consequence of his obsessive thoughts about contamination
(Criterion A.1) The character avoids touching people to avoid germs. He brings his own utensils to his
diner, so he does not have to risk contamination from unclean silverware. He lays out his plastic-ware
in a ritualistic fashion (Criterion A.2), because this helps him feel less anxious since the world is now
more orderly and proper.
At some point during the course of
OCD, clients who suffer from this disorder recognize that their obsessions and/or compulsions are excessive
unreasonable (Criterion B). They experience their thoughts and actions as disagreeable to their own sense
self (ego-dystonic). These thoughts and behaviors take up a significant amount of time (more than one hour
day) and cause considerable distress. Because they displace useful and satisfying behavior, these thoughts
behaviors can be highly disruptive to a person's normal routine, occupational or academic functioning, or
social activities or relationship with others. (Criterion C).
Melvin knows that his compulsions
are unreasonable. He tells Carol that he sees a psychiatrist and started to take medicine in order to deal with
his problem (Criterion B). Even though obsessive intrusions can be distracting, and frequently result in
inefficient performance of cognitive tasks that require concentration, Melvin Udall is portrayed as a
Sometimes he complains that his neighbors distract him from his work, while his character's functioning
as an author seems to remain mostly intact. But whenever anything disrupts his well-established routine,
he becomes anxious and belligerent with people. (Criterion C).
his isolation of affect. He learns to recognize his feelings as well as the impact of his behavior
Exposure and Response Prevention:
This behavioral technique has been found successful in treating compulsions.
For example, if clients try to avoid germs in an excessive way, they are exposed to a surface that
they believe is contaminated, such as a doorknob, and asked not to wash their hands (response prevention).
Exposure techniques include systematic desensitization, paradoxical intervention, flooding, and satiation
either in vivo or in imagination.
Treatment failure with exposure and response prevention has been linked to client's beliefs that their obsessive ideas
at least to some degree - realistic. This approach aims for cognitive
restructuring by identifying and challenging the cognitive distortions.
Techniques that Teach Clients how to Work with Obsessions:
a) Postponing obsessing: 1. Paying attention to the obsessive thoughts, 2. Choosing a specific
time in the future when to return to them,
3. As the time arrives either starting to obsess or considering to postpone these thoughts to another
specific time. Whenever possible, choosing to postpone the obsessive thoughts.
b) Changing ways to obsess: 1. Mentally stepping back and acknowledging obsessions, 2. Noticing emotional
responses to obsessions (anxious, scared, ashamed), 3. Remembering that it is ok to have a momentary
obsession, 4. Affirming that the obsessive content is irrational, 5. Changing the emotional response to
the obsession by taking specific action (i.e. singing it, writing it down, or painting it).
c) Audio tape technique: Ask clients to speak obsessions and record obsessive thoughts on a loop tape and
to listens to the tape for 45 minutes every day until their distress has decreased significantly.
Relaxation and Body-focused Approaches:
Clients who suffer from OCD are frequently very intelligent and tend to spend a lot of time ruminating in
at the expense of being centered and relaxed in their body. They are sensitized to their thoughts and
are often out of touch with their bodies. Therefore, body-focused therapies are recommended.
Approaches that Help Clients to Access Underlying Feelings:
Psychodynamic theory explains obsessions in terms of suppressed feelings or impulses that
become so dissociated from the client's conscious mind that they take on a life of their own.
Any therapeutic approach that helps clients integrate and
gain conscious awareness of these feelings can lead to therapeutic success.
Many clients who suffer from OCD have poor social skills, because they are wrapped up in their
and compulsions, and therefore are oblivious to normal courtesies, to social context, and to
other's perception of them. Using interpersonal psychotherapy, the therapist first highlights the
ways in which the clients' current functioning, social relationships and expectations within these
relationships may have been causal in their problems and subsequently helps them explore problem
relationships and consider options available to resolve them.
for Post Traumatic Stress Disorder:
When an obsession has traumatic etiologies, they can be treated with methods that
are designed for PTSD.
Birgit Wolz wrote the following continuing education online courses;
Cinema Therapy - Using the Power of Movies In the Therapeutic Process, which guides the reader through the basic principles of Cinema Therapy.
Cinema Therapy with Children and Adolescents - This course teaches Cinema Therapy with young clients. It includes numerous movie suggestions, which are categorized according to age and issues. It serves therapists, teachers, and parents.
Positive Psychology and the Movies: Transformational Effects of Movies through Positive Cinema Therapy - This course teaches how to develop clinical interventions by using films effectively in combination with positive psychotherapy. It serves for mental health practitioners and anybody who is interested in personal growth and emotional healing.
Therapeutic Ethics in the Movies - What Films Can Teach Psychotherapists About Ethics and Boundaries in Therapy, which covers: confidentiality, self-disclosure, touch, dual relationships and out-of-office experiences (i.e., home visits, in-vivo exposures, attending a wedding, incidental encounters, etc.)
Boundaries and the Movies - Learning about Therapeutic Boundaries through the Movies, which covers informed consent, gifts, home office, clothing, language, humor and silence, proximity and distance between therapist and client, and, finally, sexual relations between therapist and client.
DSM: Diagnoses Seen in Movies - Using Movies to Understand Common DSM Diagnoses.
Psychodynamic Diagnostic Manual (PDM) - A New Approach to Diagnosis in Psychotherapy