Indecent Exposure

Last year, an emergency room doctor asked me if I was having thoughts of “harming myself.” I had all the signs of a panic attack – pounding heart, sweating through my shirt, unreasonable sense of impending doom – but I didn’t understand what was happening. I said no, because I was not having thoughts of harming myself. The doctor wrote something on his clipboard, prescribed a Valium, and left.

I immediately started having thoughts of harming myself. I think.

A few painful weeks later, after a series of surreal conversations with my husband and various medical professionals, I had a name for what was happening to me: obsessive-compulsive disorder. That was surprising, because I thought OCD was something else entirely. (Isn’t it the hand-washing thing? Wasn’t there a Nicholas Cage movie? Or Leonardo DiCaprio as Howard Hughes repeating “come in with the milk” a disastrous number of times?)

I’ve since learned OCD is much stranger and much more philosophical than a mild germ phobia or a quirky tic. Dr. Jonathan Abramowitz, one of the country’s leading OCD researchers and a professor of psychology and neuroscience at the University of North Carolina at Chapel Hill, says the heart of OCD is an “intolerance of uncertainty.”

The National Institute of Mental Health estimates that 1.2 percent of Americans have experienced OCD, generally characterized by two main symptoms: unwanted intrusive thoughts and compulsive behaviors. The compulsions are meant to calm the fears brought on by the thoughts.

People with OCD aren’t delusional; that would be a different diagnosis. We’re more … philosophically troubled. We understand intellectually that we can’t really know whether Mr. Schrödinger's cat is alive or dead. The problem is we think we might die if we don’t find out.

Photograph by Antonio Guillem / Alamy Stock Photo.

A standard therapy for OCD, widely recognized by the international psychological community, is exposure and response prevention (ERP). The idea is to confront fear without trying to mitigate it. ERP isn’t supposed to make people with OCD feel “better,” although that’s usually a byproduct. It’s supposed to show us we are physically capable of looking at the box, conceding the cat might be alive or dead, and then going about our day, making a sandwich and picking our kids up from school without knowing for sure.

ERP is well supported by research, which suggests that up to 60 percent of OCD sufferers who engage in it will experience long-term improvement. It has also proved effective in treating general anxiety and post-traumatic stress disorder. But its animating principle – that the only way past anxiety is through it – violates a core tenet of late-modern American secular philosophy, in which discomfort and suffering are the worst things that can ever happen to a person and must be avoided at all costs.

Greg Lukianoff and Jonathan Haidt call this “safetyism.” Really, it’s just looking at the tradeoff between paranoia and the acceptance of vulnerability, and choosing paranoia. The paradox, of course, is that believing we’re fragile has made us fragile. This despite knowing all along that facing our fears makes us stronger – the data on exposure therapy is half a century old.

OCD is the wrong kind of weird to be chic. While some types of neurodivergence have become a badge of honor on social media, you don’t see TikTokers putting “I survived intrusive thoughts about murdering my family” in their bios. For that reason, most psychologists believe the number of people who suffer from OCD is much higher than reported.

Some people believe there’s such a thing as “pure” OCD, or the struggle with intrusive thoughts without any accompanying obsessions, but there’s some debate about that. However, there’s a lot of research that suggests everyone, even people without OCD, experiences intrusive thoughts, or thoughts and images that are “out of character.” I used to live in Arizona, where folklore tells of a phenomenon called “The Draw” – the sudden urge people get to hurl themselves into the Grand Canyon when they approach its edge. People without OCD shrug off these thoughts as mental noise. People with OCD believe they have terrible personal significance.

There are some common OCD “themes” which, on the surface, appear wildly unrelated. But the philosophical heart of each is that pesky fear of uncertainty; and you can be uncertain of just about anything. “Contamination” OCD is the nagging urge to get sure you’ve killed the germs. There’s a subtype called “scrupulosity” in which religious people obsessively worry they’re going to hell. There’s “responsibility for harm” OCD, where people are terrified they’ll cause a fire or a car accident or the death of all their loved ones if they don’t make sure they turned off the coffee maker, or if they don’t double-check that the bump in the road they felt on their way to work wasn’t a person. There’s “taboo” OCD, where sufferers are terrified they’ll involuntarily violate a significant social norm – that they’ll yell an obscenity in church or call a coworker a racial epithet.

These people deeply do not want to do these things. But they picture themselves doing them, and suspect that means they might. So they look for ways to mitigate the risk. In the absence of any logical strategies, they’ll invent some. They’ll wash their hands until they bleed, or stop driving altogether, or read their Bible for hours, miserable. These become compulsions.

Abramowitz says he once had a patient so obsessively terrified he had drowned someone in a lake and forgotten about it (“false memory” OCD) that he hired a team of divers to go look. (I know we’re not supposed to pity the rich, but can you imagine having OCD and the means to indulge every elaborately expensive compulsion?) Abramowitz doesn’t remember how the man responded when the divers didn’t find anything, but if I had to guess, I’d say poor old Daddy Warbucks convinced himself they couldn’t really have checked everywhere.

Whatever the logistics – and believe me, there’s a range – every OCD compulsion is after the same thing: certainty.

Some OCD “themes” intersect. The what-if-I-drowned-someone-in-a-lake fear might also be considered an example of “harm” OCD, which can involve the fear of harming others. It also includes the fear of harming yourself.

Just what exactly did that ER doctor mean when he asked me, “Do you have thoughts of harming yourself?” Now that he mentioned it, I am thinking about it, just as if he had said, “Are you thinking about an elephant?” and I wouldn’t have been able to help thinking about an elephant. Now I’m thinking about razors and belts and David Foster Wallace and my sleeping pills downstairs. Are thoughts the definitive proof of danger? Is the implication that if I can think these things – if I happen to think them – then I’d better tell someone? Because otherwise I’ll … what? Do it?

So I do tell someone: I go back to the ER. This is my compulsion. I go back again and again. I tell them what I’m picturing. They look at their clipboards. They say, “OK … but do you want to hurt yourself?” “No!” I scream. They send me home. I come back again. 

That’s “harm” OCD. 

An early description of what we now call OCD appears as far back as 1621, in Robert Burton’s tome The Anatomy of Melancholy. (An updated exploration of this subject came out in the mid-2010s called Every Sufjan Stevens Album.) Burton wrote of a pitiable old fellow who, anytime he was “in a silent auditory,” was paralyzed by the fear that he would “speak aloud and unaware, something indecent, unfit to be said.”

Still, there’s something characteristically modern about OCD. It’s hard to develop a debilitating fear of uncertainty without first believing certainty is possible. Most human beings throughout history did not have that luxury.

Philosopher Charles Taylor coined the term “immanent frame” in 2007 to describe the rose-colored glass through which late-modern secular cultures see the world. Through the immanent frame, the world looks fundamentally knowable on its own terms. Cultures that believe this are fairly convinced they’re better and smarter and more evolved than their ancestors, and that if there’s something about the world they don’t understand yet, their lack of enlightenment is a function of time, not metaphysics.

The very concept of an “intrusive thought” doesn’t fit that worldview, because to be “intruded upon” implies not being in total control. This is what makes people with OCD seem so pitifully modern: we don’t believe in “intrusive thoughts.” We believe we are in control! Which means those thoughts aren’t just thoughts. They’re us.

Dr. Abramowitz says the “themes” of people’s obsessions usually reflect what they value most. Moms with postpartum OCD obsessively worry they’ll hurt their newborns. Devout Christians worry they’ve displeased God. A mom with two kids and a job she loves and a charming old house and a kind, patient husband and truly nothing to complain about, really, obsessively fears she’ll kill herself.

The treatment for these crazy thoughts seems crazier by half.

I leave every therapy appointment with an “exposure” assignment, and this time it was to watch Shutter Island. It’s a 2010 Martin Scorsese movie starring Leonardo DiCaprio about a guy who thinks he’s a US Marshal looking for a patient who’s gone AWOL from a lunatic asylum. Except he’s not a US Marshal, he’s a delusional patient at that very asylum, which is very decrepit and right in the path of an incoming storm. DiCaprio’s character went crazy because he was traumatized by World War II and then traumatized further when he came home one day to discover his three children floating face-down in the lake behind his house and his wife sitting on the porch swing saying, “Darling, we should dress them up and take them on a picnic.” (The movie shows you all this. The lack of music compounds the dread.)

My assignment was to watch the movie by myself and to follow a few rules afterward: no talking about it to anyone (for catharsis!) and absolutely no Googling. No looking up whether Shutter Island was based on a true story. No researching the incidence rates of schizophrenia and post-traumatic stress-induced psychosis or paranoid delusions or, for that matter, filicide.

I watched the movie, cried a lot, panicked a little, and wanted so desperately to open Google that my fingers itched. I needed Google to show me the statistical unlikelihood that I am delusional, or that I am a patient in an asylum and don’t know it, or that I have psychosis and don’t know it, or that I am dangerous and don’t know it. Actually, Google, what are the signs of schizophrenia, and do I have any of them? Also, I’d like to see whether any mother has ever drowned her children in a lake, and if so, why did she do it, and did something happen to her that made her do it, and what was it, and what’s the likelihood that that thing will happen to me?

It’s difficult to articulate this experience, except to say I thought that if I didn’t find reassurance online I’d panic and go crazy, and my family would be in danger. I’m not being hyperbolic; this was my genuine fear. Before starting ERP, I had experienced this fear so earnestly that I went to the ER. Over and over. Even after I’d been diagnosed with OCD, I went back to the ER one more time to report “thoughts of harming myself.” Because, hold on … how can I be certain it’s OCD? What if it isn’t?

I experience this fear as if it were subconscious. Abramowitz doesn’t like that language. He says we don’t even know what consciousness is, so it’s definitely not fair to anatomize it. But what I mean is that while I could look myself in the mirror and say, “You are safe and everything is fine” – and believe it! – I may very well still dry-heave and sweat through my shirt. I could agree to bet my life savings (this is an official OCD therapy exercise) that I won’t kill myself; and while the realization that I’d take that bet is helpful, the physical panic might nevertheless show up, like a phantom limb. Or like a stroke patient whose corpus callosum shuts down and who has to watch one half of her body move without her permission. I don’t think the fear, I feel it; and there is simply no reasoning with it.

The only way to stop it is to humiliate it by proving it wrong. That’s what exposure and response prevention does. If I’m irrationally afraid that watching an upsetting movie about schizophrenia and filicide will make me schizophrenic and filicidal, then I need to watch the movie. I need to let the awful images and Leonardo DiCaprio’s stupid unplaceable accent terrify me (exposure) and then sit still in the terror (response prevention). And watch myself get through it.

Is there anything less America-in-2024 than a mental health professional telling a vulnerable, struggling patient to seek more pain? To scare herself on purpose and then avoid looking for relief? What about the conventional wisdom that seeing/hearing/thinking about things that make us afraid/sad/confused/angry/hungry/tired is dangerous and wrong and probably literal violence? I asked my therapist once if she ever felt like a sadist, considering her job includes designing ways to scare me. She laughed.

Exposure and response prevention was first explored as a potential therapy for OCD in the 1960s. Dr. Victor Meyer, a psychologist at Middlesex Hospital in London, was treating a woman who had been committed because she couldn’t stop obsessively cleaning. She was rational, and also miserable. So Dr. Meyer zagged when every other doctor (and the patient) wanted to zig: he made her get dirty. He exposed her to toxins and grime and turned off the water to her room so she couldn’t wash anything. She was more miserable at first. Then she was less so. Meyer later reported that while the ERP didn’t “cure” her OCD, she did recover the ability to function in day-to-day life. And no lobotomy (which had been on the table)!

There’s been a lot of trial and error and research on ERP since then. Abramowitz is still studying it. He says “good exposures” are clever, surprising, and unsettlingly bespoke. Recently I heard Dr. Steven Phillipson, the clinical director at the Center for Cognitive Behavioral Psychotherapy in New York, on a podcast talking about telling his OCD patients to go on “spike hunts,” by which he meant intentionally looking for things that threatened to trigger painful obsessions. He told a patient who obsessively worried he was homosexual and didn’t know it (and didn’t “want” to be) to deliberately make prolonged eye contact with every man he met over the course of two weeks.

My own therapist once had me spend a day walking around with a lethal number of sleeping pills in my left pocket. (I am very pleased to report that I never took them.) I had to use a razor-sharp knife to chop vegetables in the same room as my kids. (Everyone survived!) I had to write a short story about my own funeral.

These are not self-care strategies. I am decidedly not “finding my bliss.” But neither am I in the grip of untreated compulsions. One of OCD’s vicious cruelties is that people engage in a compulsion because they think it will make their lives better, but it actually makes them harder – logistically, practically, emotionally. It risks reinforcing our delusion of control by making our fears unfalsifiable. ERP is meant to falsify them – to a point.

Because the unfortunate truth is, not all fears are false. Sometimes, the worst will happen. But my strange experience with OCD and ERP has led me to believe the key to finding as much peace and fulfillment as possible is to accept the world as it actually is. Which is to say: full of uncertainty and not concerned at all with how you feel about it.

When university student groups, political opportunists, and academics say they know what we need and that it’s more safety, more avoidance, more vigilance, and more affirmation, they are ignoring the science. We need more fear, distress, discomfort, disappointment, and – God help us – boredom, because the world is going to give them to us at some point anyway and we need to watch ourselves get through them. We’ll be much better off with practiced resilience than learned fragility.

I’m convinced that, along with Robert Burton’s pitiable old fellow, the English writer and philosopher Frances Spufford has OCD. I’ll grant that I now spot the diagnosis everywhere – hammers seeing nails – but I think he must have it, because he once wrote this after listening to Mozart’s Clarinet Concerto:

I had heard it lots of times, but this time it felt to me like news. It said: everything you fear is true. And yet. And yet. Everything you fear you have done wrong, you have really done wrong. And yet. And yet. The world is wider than you fear it is, wider than the repeating rigmaroles in your mind, and it has this in it, as truly as it contains your unhappiness.

There’s a story in the Bible about Jesus entreating his disciples not to be anxious. “Consider the lilies,” he says. “They neither toil nor spin, yet I tell you, even Solomon in all his glory was not arrayed like one of these. But if God so clothes the grass of the field, which today is alive and tomorrow is thrown into the oven, will he not much more clothe you?” (Matt. 6:28–30).

As a Catholic kid I took this verse as an admonishment: Don’t you trust God? Now I see something else too. Just look at the lilies for a minute. Their life is short and so is yours, and maybe tomorrow something so distressing will happen to you that you will drown yourself in a lake. Also, maybe not. For now, these lilies are here, and aren’t they pleasant? You could choose to look at them and smile, even while you’re scared.