How Clean is “Clean?”
By Fred Penzel, Ph.D.
Recently, a couple came to see me at my practice. They were both in their early 40s, professionals, nicely dressed. The husband began our session by saying: "Doctor, have you ever seen anyone scrub a ceiling, or polish a towel bar? I can't live like this any more. She's driving me and the children crazy with her cleaning. There are rules for everything. She controls all our lives. I don't feel free to live in my own house any more. It's like living in a museum."
He went on to relate how every day of the week his wife had a compulsive and meticulous cleaning routine that lasted about six hours, beginning on weekdays with her return from work and ending about midnight. Sometimes it even ended later. On weekends, it would also take up almost half of each day. It was always done in the same order. He also complained that he and the children were forced to remove their shoes and coats in the garage before they could enter the house, and then were supposed to go directly into the laundry room, where they would change their clothes for a new, clean set laid out for them. This was so they would not bring dirt or dust in from outside. Only then could they move about the rest of the house.
They were not allowed to eat in the kitchen because it would dirty the floor with crumbs. Instead. they had to eat on snack trays in one corner of their family room, and the floor had to be vacuumed immediately afterwards. If the children (ages 6 and 10) wanted to eat or drink anything at any other time. they had to ask their mother and she would get it for them. No one else was allowed to use the refrigerator. No one else was allowed to do laundry or load the dishwasher. Although their home had three full bathrooms, they were all made to share just one. The doors to the other two remained closed to everyone. No one was allowed to go to bed without first showering. The living room was off-limits because lint or dirt might get on the carpet or the furniture, or the couch cushions might get disarranged. The children were only allowed to have their friends in the family room, and could not go with them to other parts of the house. They were not particularly encouraged to invite them over anyway. If anyone violated any of these rules, an angry reaction would erupt. "It's strange," said the husband, "but outside our house, there are no rules, and she's really relaxed when we go to other places. She doesn't even care if the car needs a wash."
A need for symmetry was also part of the problem. In the clothes closets, all the hangers had to be the same distance apart. All boxes, cans, and containers in the pantry and refrigerator had to be lined up in size order with the labels facing forward. The same applied to the medicine cabinet. Every new thing that came into the house such as toys, clothes, groceries, etc., had to be washed, wiped, or cleaned in some way, and then put in its new and special place. She had someone come in to clean her home every week, but she would follow the cleaning person and clean everything again herself.
When the wife finally spoke, it was to explain: "I don't know why I do it, exactly. It's not that I'm afraid of germs or contamination. I just don't feel right unless everything is perfectly clean and in order. It makes me angry and anxious if things get messed up, and I can't concentrate on anything else until it's fixed. I feel like my house is the one thing I have control over." She did admit, however, that she was gradually becoming more exhausted, was upset that her husband and children were growing increasingly angry with her, and believed that life was passing her by as she spent all her time cleaning. She said: "I began doing this about 15 years ago when my husband and I moved into our first home. It began very gradually in small ways, and just seems to have increased over the years. I guess it became a lot more noticeable in the last five years. It seems to have a life of its own. I'd like to stop, but I've been doing this for so many years, that I just can't imagine myself acting differently. I don't know how I would stand the anxiety it would cause me."
This represents a very accurate picture of what life is like for someone suffering from this type of compulsive perfectionism. In this case, the focus of the symptoms was this sufferer's home. While we live in a society that values cleanliness and neatness, there is a line that is crossed when the individual moves into a dysfunctional zone. At one point, my new patient asked, "Is having a clean house really so bad?" "It is,"I answered, "when the price includes ruining your marriage and your relationship with your children, as well as having it take over your entire existence." I pointed out to her the paradox she had created: By trying to control everything within her home, she was losing control of her life.
Her husband had gradually become more exasperated with her as time went by. He found himself unwillingly participating in all sorts of compulsive behaviors, and had come to feel that she was somehow doing this to him on purpose to make his life miserable. He had already considered divorcing her, but decided to give behavioral treatment a try as a last resort. It took some time to convince him that this was most likely a genetic problem to begin with, and that his wife had had no choice about having her disorder. She was not to be blamed, and his getting angry with her would just add to her stress, only causing her to have more symptoms.
In the course of therapy, I explained to her that she would need to help retrain herself to clean normally, and to gradually give up the excessive control of her home and family. She might not like some of the things she would have to do, but she would have to accept that there could be no other way to correct the situation. She would also need to accept that she had lost the struggle to make her home "perfect" and, at the same time realize she could have a decent life. She would have to accept the short-term discomfort of letting go in order to achieve a long-term recovery. She asked me if medication would be necessary, and I explained that I would recommend it only if she felt her anxiety was so high that she could not follow treatment. If she did need it, it would not mean that she was too weak or "crazy," just that the problem had been allowed to grow to a level where something extra was needed. I further explained that because OCD was partly a biological disorder, medication was a helpful tool that could reduce her obsessions about perfection, alleviate her cleaning compulsions, and improve her mood; by itself could not change her beliefs about perfection or eliminate all the behaviors that had now become habitual.
Behavioral therapy was explained to her, specifically the type known as "Exposure and Response Prevention." The basic principle is to confront the obsessive thoughts while resisting the use of compulsions to relieve the anxiety in order to buildup a tolerance for the discomfort. We would create a list of everything she was controlling in her home, and then rate, from one to 100, how nervous she would feel if each particular item was disarranged or unclean and left that way. She would have to gradually work her way through this list, starting with items rated at about 20 to 30. By staying with the anxiety and not cleaning or straightening up to relieve it, she would gradually build up her tolerance to these unpleasant thoughts and feelings, and would not feel as pressed to act on them. She would, in a way be conducting "experiments" to see if anything awful would happen if things weren't so neat or perfect. One of her beliefs was that if others saw she was being messy, they would think she was a slob who could not control her life, and they would reject her. She also believed that she would come to think badly of herself and then give up all cleaning in a sort of "all-or-nothing" way. I suggested that we would test these beliefs to see if they were true, but that she might have to prepare to be proven wrong.
We proceeded with the therapy process. Each week, she would clean fewer things or do them less perfectly. At the same time, she let her children and husband live more freely in their home. Other techniques we employed included the following: listening daily to a series of audio tapes that gradually exposed her to the thought that she was rapidly becoming a filthy slob whom no one could respect; wearing a T-shirt around the house with the word "SLOB" in bold letters on it; and posting signs around the house with such slogans as, "This place is a dump," or "A slob lives here." Later on, we began to bring in cognitive therapy to teach her to challenge her beliefs about the value of trying to be perfect. Most importantly, we examined the illogical idea that she could be rated in her entirety as a human being based upon how neat and clean her home was. After a while, she was instructed to begin inviting friends and family to her home, and was told to not clean after they left. She was shocked when people still commented about how nice her home was, rather than condemning her. She correctly began to question her own ability to judge just how clean "clean" was.
After about six months of weekly sessions, her home had begun to look a lot more like everyone else's. She, of course, had her lapses where she would forget herself and start cleaning things, but as time went on, she seemed to gradually catch herself a bit more quickly each time. It also took more and more disorder to get her anxiety going. I would constantly remind her that she would never "perfect" her symptoms. That is, she would never be able to make her home perfect and live a life like everyone else. Through persistence and determination, she began to accept this, and her world gradually returned to normal.
This particular story has a happy ending. Not all do. In this case, my patient realized in time that it was becoming too risky to continue as she had been, and that she stood to lose much of what was important to her. Also, at the point where she had gone for help, her husband was still in a supportive frame of mind, and had not given up on her or their marriage. She was also able to get through the process without medication -- something that not everyone is able to do.
We finally moved on to maintenance, where she was given a set of guidelines and schedules for housekeeping which, if she stuck to them, would enable her to stay out of trouble. I ran into her recently and she excitedly told me how she had allowed her younger child to have a birthday party for friends in the house. "You should have seen all the crumbs!" she laughed. Some of the children had even spilled their drinks, but she was able to matter-of-factly clean up the mess a few hours later. Her son was worried about what she would say, but she told him that it was all right and that it was more important to have fun.