It’s 9:22 a.m. A frail adolescent boy sits crossed-legged on his bed. His polo shirt, once soft and bright red, is ripped and stained grey, draping over his limbs. His hair hangs over his eyes, clumped with sweat, shielding his hollowed, acne-ridden cheeks.
The open doorway is just a few feet away from his bed. If he stretched his arm far enough, he could touch that empty space between him and the outside world.
There are twenty-two scars on his left arm, some deeper than others. There are fourteen specks of dirt on the wooden floor. His jeans are frayed and mouldy from the urine. Before he can reach the bathroom, he must pull off the blankets. He must tap the blanket over and over and move it back and forth, four-hundred and ninety-six times. His fingers must not touch each other. Tap. Tap. Tap. Repeat.
Sometimes, if it feels just right after two-hundred and sixteen times, he stops. Usually, his fingers touch, or he fears they did, and he has to start over.
Did they touch? No, they couldn’t have. I didn’t feel it—But did you see it? I mean—then can you really be sure? What if they did touch, and you just missed it? What if? What if?
It’s an ongoing battle against vivid, often violent, images in his head. A car crash. A knife slash. A fall down the stairs. All gnawing at his mind. He knows—just somehow knows—that if he doesn’t start over, these things will happen.
It’s 11:43 p.m. when he finishes the blanket rituals. He now stands on the floor, each toe stretched to avoid touching each other or any of the fourteen specks of dirt around him. If one speck gets moved from its place, he must begin again.
Outside his room, a few feet down the hallway and past the two holes in the wall, the bathroom door is ajar. His right pant leg, ripped open at his calf, is held together by a small, metallic safety pin. No one knows this but him, but he must protect this safety pin. If I don’t, my family will die.
These are the troubling thoughts of Steven Miller, a 16-year-old from Toronto who, in the sweltering summer of 2012, nearly killed himself. For the past five years, Steven has wrestled with his mind. It’s been a tug of war of thoughts, emotions, and behaviours. And, so far, the illness has won.
Steven has obsessive-compulsive disorder. OCD. A chronic and debilitating neuropsychiatric condition that afflicts about two per cent of people worldwide. Like Steven, people with OCD endure “serious impairments” in their daily life. They lose their abilities to work, get dressed, maintain bodily hygiene, attend school, meet up with friends, or in some cases, hug their parents.
OCD has two components. Obsessions are any recurrent, unwanted—or intrusive—thoughts or images that arise from fear and cause distress. There is an infinite number of obsessions, which vary specifically between each individual’s fears. However, the majority fall within four subtypes: contamination, checking, symmetry, and ruminations.
Compulsions are all the repetitive, irrational, and avoidant behaviours—or “rituals”—a person performs to ease the distress caused by their fears. People with OCD have a lower perceived sense of control and an elevated desire for control compared to neurotypical people and even those with anxiety disorders. And so, rituals, however irrational, feign control amid a world marred by uncertainty.
While the novel coronavirus spreads across the globe—and anxiety, depression, and suicidal ideation rise worldwide—people everywhere are seeing their lives upended. The pandemic is particularly challenging for some OCD sufferers, who now face the seemingly rational fear of contamination, illness, and death.
But those who’ve battled OCD their whole life, and who’ve undergone treatment, may be the most equipped and mentally prepared to weather the pandemic. People like Steven, and their stories, can impart valuable lessons for others during these uncertain times. His story is about one hellish year in 2012 and the journey to break through his unrelenting mind, reclaim his identity, and re-discover happiness.
While his friends return to school in Toronto, recounting the fun experiences they had over the summer, Steven sits on a well-worn green leather sofa, miles away. He’s in a residential treatment centre in the American Midwest, legs jittering, eyes to the carpet floor, as a team of psychiatrists, behavioural specialists, nurses, and therapists sit opposite him, telling him he’ll get better.
“Getting better” seems like an abstract idea. He can comprehend the words in his mind, flip them over and massage them how he wishes. He can also imagine it: a healthy adolescent guy with clean clothes that fit him, a short haircut, hanging out with his friends, and smiling. He can picture this guy; see his face. But it isn’t him.
Steven seldom smiles anymore. He hasn’t played hockey in over nine months, something he’d do almost every week. This September afternoon, in this cramped office room, seated beside his parents, is the first time he hears the word “ERP.”
Exposure-response prevention, or ERP, is a specific type of cognitive-behavioural therapy in which a person challenges his or her irrational obsessions and compulsions. As acronyms fly around freely in therapeutic circles, it’s easy to get confused. Part of the appeal of ERP is just how basic, yet effective, it can be.
The therapy follows a two-step process. First, a person must consciously expose oneself to their obsessions—the internal or external things they find distressing. Second, they must willingly refrain from any ritualistic behaviour meant to dampen the ensuing distress.
Time is the key in all of this. Our bodies cannot sustain elevated stress forever, so the scary feelings naturally dissipate over time. ERP trains people to ignore their obsessions and compulsions through habituation and confirmation that their rituals are irrational and meaningless.
While effective, ERP isn’t a one-size-fits-all treatment. Instead, it’s tailored to each person and their harmful thought patterns and idiosyncratic behaviours. This is because OCD is specific to the person—not everyone will feel compelled to scrub their hands over and over at the sight of someone yawning, nor feel the need to check the oven every twenty minutes to ensure their house won’t burn down.
To tailor ERP to each individual, clinicians use “fear hierarchies.” Fear hierarchies work by taking all of someone’s obsessions and compulsions and ranking them by how much distress they cause. Hierarchies are like ladders. It’s easy for most people to raise one foot and reach that first rung. But it’s a lot harder to step up to the 10th rung if you haven’t reached the ninth one already, let alone taken your foot off the ground.
Trivial to the average person, two things top Steven’s ladder: changing his underwear and getting rid of the safety pin that holds his ripped pant leg together. Taking a shower ranks somewhere in the middle.
As Steven will soon learn, the road to recovery isn’t linear—it’s circuitous, winding, dipping to dead ends, and rising to momentary relief.
A loud thump sounds against Steven’s bedroom door.
“You have to get up now. The unit is waiting to get breakfast,” says his therapist.
She doesn’t know that, on the other side of the door, Steven has been trying to get dressed for the past four hours. He’s gotten through his shirt ritual. He’s brushed his teeth. Now, he’s working on putting on his socks, taking them off, and putting them back on again until it feels “just right.”
It was done right, why do you keep doing it over? You know it wasn’t right, don’t even pretend—then what if I go without socks? I can’t do it wrong if I don’t wear socks. Yes but you have to wear socks, if you don’t the blood will drain from your dad’s—
“I can’t fucking do this anymore,” Stephen punches the metal frame at the bottom of his bed. He keeps punching and punching until he realizes where he is, what he’s doing, and the blood trickling down his wrist.
Above him, the yellow light has gone stale, like he’s been trapped in some Skinner box for his OCD to probe and pick him apart. The sky outside his window has slowly dimmed, desaturating into purple, and then black.
Steven opens his bedroom door.
The night counsellor leads him off the residential unit. The two descend the crimson-carpeted steps and through the narrow hallway. They pass the communal garbage bins, then turn the corner until they’re in front of the cafeteria door. With her lanyard, the counsellor taps the keypad to open it. Steven peers inside. Emptiness. Tables packed in fours; chairs tucked in under dry, spotless tabletops.
The kitchen staff has packed up, and the buffet centrepiece is empty. All that’s left is a wicker basket of granola bars and brown-spotted bananas. The counsellor holds the door open for Steven. Acid sears his stomach. He takes two steps forward until he’s on the threshold, then remembers everything. He takes two steps back. Steps forward. Steps back. Forward… back…
It takes Steven one-thousand and forty-two tries before he enters the cafeteria.
One of the primary goals of ERP is to build resilience. Resilience is the ability to adapt in the face of adversity, threats, and stress. For people with OCD, this means inhibiting their compulsions in response to intrusive thoughts.
When OCD sufferers engage in ERP, exposing themselves to that which threatens them, they’re inevitably elevating their stress levels in the short term. After repeated exposures and the therapeutic effects of elapsed time, they can better adapt to and overcome their intrusive thoughts in the future. The obsessions don’t go away completely, but their impact lessens over time, and people strengthen their ability to overcome such stress and foster resilience.
Overcoming OCD is an arduous, lengthy, and continuous process. To build resilience, clinicians encourage people to recall their experiences and reflect on past moments of success. Whether they have OCD or not, people often focus too much on what goals they still need to accomplish and forget to acknowledge how far they’ve already come.
Today, the pandemic rages on across the globe. The world appears gloomy, the winter months are in full force, and schools and companies are ramping up demands. These all easily contribute to anxiety and depression, as people cannot accomplish what they normally would.
As the calendar flips from September to October, the leaves slowly turn yellow and red and orange on the cedars and birches in the American Midwest.
In the residential centre, Steven sits at his desk, combing through his sketchbook. Most pages are blank; some have black-and-white sketches of hockey players; others feature inspirational quotes. You get better before you feel better. This one, his therapist told him, the morning he broke down in front of her.
Steven closes his sketchbook and slides open the desk drawer. The safety pin rests in the back right corner—it’s usual spot. He picks it up, gently, two inches above the drawer and places it back down. He does this again. Once more. Exactly three dozen more times.
On October 20, 2012, Steven trudges on in the narrow old-carpeted halls of the residential treatment centre, a towel tucked under his arm, a bottle of shampoo in one hand, and an empty black garbage bag in the other. He thinks about the last time he showered. New Year’s Eve, 2011. Two-hundred and ninety-four days ago.
I can’t do this. What if I get stuck? What if it’s never right?
Steven locks the door to the sky-blue bathroom. Unlocks it. Locks it again. And then taps it one-hundred and twenty-eight times—and exhales.
There’s a rusty mirror that he must align without his fingers touching the wall behind it. But before he reaches for the mirror, he catches a face in it. Peach fuzz lines his upper lip, an unrecognizable stubble on his chin.
The next part happens quickly.
Don’t think about it, don’t think about it, don’t think about it. But what if? No, you can’t get stuck now.
He rips the sweater over his head, removes the shirt underneath, and drops his jeans, placing them all within one tile on the floor. He’s naked, safe for a pair of underwear and a black garbage bag wrapped around his waist. Steven reaches behind the shower curtains, carefully avoiding the grimy wall above the tub. He turns the lever to the middle and steps under the falling water.
Back in his room, Steven plods to his desk, clutching the wet garbage bag at the waist. He slides open the desk drawer. He pauses. A disorienting buzz grates in his mind, pricking underneath his scalp. He collapses on the carpeted floor, clenching his fists until they tremble. Hot tears sting his eyes. The day that he feared had come. The safety pin was gone.
Because of the consuming nature of OCD, sufferers lose chances to engage in joyful and fulfilling activities. Over time, being away from these activities produces hopelessness. People forget about their interests and stop trying to seek them out, which can spiral into depression and stunt ERP treatment. OCD seeps through the cracks of the brain and erodes one’s identity, or sense of self.
In social psychology, the self is subjective knowledge about one’s own beliefs, personality traits, abilities, values, and agency. People with OCD often have a reduced sense of self, which leads many sufferers to become “emotionally numb” and “lost,” disconnected from the self, the people, and the world around them.
Realizing one’s loss of self is difficult for people with OCD as many conflate illness with their identity. Since the illness sounds the same as their conscious voice, sufferers often struggle to separate their rational self from the irrational symptoms.
To help disentangle these voices, clinicians encourage people to strengthen their sense of self. Research shows that the most effective ways to do this include setting goals and re-engaging with one’s interests. By fulfilling one’s sense of self, through interests or elsewhere, people not only minimize anxiety and depression but become happier and more resilient.
No Thanksgiving celebration. Leaves, shrivelled and colourless, cling to the frozen earth. Newly fallen leaves flutter in the breeze while soft-falling snow blankets the cornfields and the flat plains of the Midwest and the parking lot outside Steven’s foggy bedroom window.
All the geese have gone south, leaving the forest outside his room quaint, save for the sounds of a few woodpeckers rattling at the trees, and a few light taps of snow on the windowpane. Soon, Christmas will be here. Steven can’t help but think that he’ll experience it just like Thanksgiving: alone.
Steven changes his shirt every day and his pants every three days. He showers once a week, and no longer performs his blanket rituals nor tiptoes over specks of dirt on the floor.
Outside his bedroom door, his therapist holds a big cardboard box against her stomach. She knocks gently. Steven doesn’t know it yet, but December 5, 2012 is a special day.
Inside the box is a pair of Steven’s hockey skates. His cheeks tingle. He hasn’t seen or touched or smelt his skates since the hazy winter of last year when he stopped going to games, and friends started wondering why.
Ten minutes later, Steven and his therapist are in a green sedan, driving through the cedar-rich forest, along the winding road that dips and rises between the residential centre and nearby houses. Kids in toques and puffy winter coats chase after one another in the snow, their backpacks swinging behind them. Eventually, the sedan veers left and continues onto the flat country road.
Up ahead, nestled beside a gas station and a donut shop, is a small wooden arena. It looks just like the arenas Steven would see during his hockey road trips with his friends. How they’d stay up late in the hotel, sneaking out at midnight to walk around the town. The laughing and ribbing the boys would give each other.
Inside the arena, the Zamboni tours the rink. A deep, comforting hum envelopes Steven. The sharp smell of fresh ice and the velvety aroma of warm coffee swirl around him. Frissons tickle his arms.
At one end, beneath the scoreboard, the American and Canadian flags hang still. Silence. Nothing but him and two-hundred feet of glistening ice.
Steven lines up at the blue line and skates as fast as he can, the wind ripping through his short hair and billowing out his black sweater. He can’t help himself.
His mind is still now, easing like mist on a hot spring. He smiles.
If the pandemic has given people anything, it’s a heavy dose of uncertainty. Every single person faces uncertainty each day to varying degrees. But take these uncertainties, magnify them, add a host of new ones, and it’s enough to make even the most resilient of people stumble.
Steven Miller’s story, and the recovery of other OCD sufferers, leaves us with valuable lessons—why we should engage with our interests and embrace uncertainty as a way to overcome the obstacles, tragedies, or intrusive thoughts that life whirls our direction.
Steven walks alongside his therapist through the narrow halls of the residential centre. They descend the rickety steps to the basement. He holds a thin white envelope in his right hand.
Along the way, they chat about the college hockey game from last night. His therapist brings up the next steps in his treatment and what needs to be done before he can head back home.
Steven hops down the last step and turns the corner to face the communal garbage bins. He opens the flap of the envelope and digs inside, pulling out a tiny, rusted safety pin. He eyes it, just for a moment, and throws it into the trash. Then, Steven walks further down the bright hallway until he reaches the cafeteria’s threshold.
He peeks inside, breathes in, and steps through the open doorway.