Diagnosis in Psychotherapy - Portrayed in a Movie

By Birgit Wolz

As Good As it Gets

Director: James L. Brooks
Producers: James L. Brooks, Bridget Johnson, John D. Schofield, and Kristi Zea
Screenwriters: Mark Andrus and James L. Brooks
Cast: Jack Nicholson, Helen Hunt, Greg Kinnear
MPAA Rating: R
Year of Release: 1997

Review

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".

Diagnosis

According to the DSM-IV-TR, people with OCD suffer from recurrent obsessions and/or compulsions.

Obsessions are defined as "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).    

Compulsions are 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 praying 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 or unreasonable (Criterion B). They experience their thoughts and actions as disagreeable to their own sense of self (ego-dystonic). These thoughts and behaviors take up a significant amount of time (more than one hour per day) and cause considerable distress. Because they displace useful and satisfying behavior, these thoughts and behaviors can be highly disruptive to a person's normal routine, occupational or academic functioning, or usual 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 successful author. 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).

         Melvin gradually overcomes his isolation of affect. He learns to recognize his feelings as well as the impact of his behavior on others.

Treatment Options

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.

Cognitive-Behavior Therapy:
Treatment failure with exposure and response prevention has been linked to client's beliefs that their obsessive ideas were - 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 their heads, at the expense of being centered and relaxed in their body. They are sensitized to their thoughts and impulses, but 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.

Interpersonal Psychotherapy:
Many clients who suffer from OCD have poor social skills, because they are wrapped up in their obsessions 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.

Therapies 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