When I first saw Michael, I couldn’t help but notice just how depressed he looked. The red-haired strongly built seventeen year-old could hardly hold his head up. His parents said that he had been really down for several weeks, but no one knew why, and he wasn’t helping either. He couldn’t seem to come up with the energy to get to school, and preferred to stay in his room, alone. He had been a good student, enjoyed playing on his school’s lacrosse team, and was heavily involved in student government. At a time when he should have been thinking about choosing colleges to apply to, he seemed to have dropped out of life. Some possible clues were his parents’ report that he had suddenly thrown away his prized collection of bodybuilding magazines, and the fact that he seemed to be avoiding all contact with his guy friends. Another clue was that his father suffered from OCD, which was particularly interesting to me, as the disorder sometimes appears to run in some families. Finding out what was going one here would be my first, and probably most difficult task, since he was the only one who could help solve this mystery.
Michael and I sat across from each other, with him slumped forward in his chair, his head down, and his hands clasped together. I tried to engage him in some small talk to break the ice. All I got in return were some one-syllable answers. “Is there anything you want to tell me?” I asked. “Nope,” was the reply. His whole manner seemed to say that he was also really anxious. Maybe it was the way he chewed his lips and drummed his foot.
As we therapists sometimes do, I decided to take a chance and act on intuition – just take a shot in the dark based on what evidence I had. I knew it was risky, because if I was wrong, he might refuse to talk with me any further. I thought I had it right, though, based on the clues I had. “Michael,” I said suddenly, “Are you worried that you might be gay?” With that, he jumped back in his chair, his eyes wide. It was as if someone had given him a jolt of electricity. “What? How did you know that?” he gasped. “Nobody knows that. Nobody!” I went further. “Is that why you threw out your magazines?” I asked. He nodded at me. I had seen many cases like this over the past twenty-odd years, so I decided to pull out all the stops and really get things moving, now that I had his attention.
“Let me guess,” I said, leaning forward. “One day you were doing something you always do, and suddenly you started to pay attention to yourself in a different way. As you focused on yourself, the thought suddenly came into your head, “Maybe this means I’m gay. How do I really know I’m not?” I kept on, “Since then, you keep checking yourself, you know, like looking at guys or girls and trying to see who you’re attracted to. Maybe you watch the way you talk, or walk, or move your hands, to see if you do these things the way a gay or straight person would. How am I doing so far, Mike?” He stared at me and answered, “I feel creeped-out, like you’re reading my mind.”
I went on to explain that I definitely didn’t have ESP (as far as I knew), but that he was suffering from a very common form of Obsessive-Compulsive Disorder (also known by the abbreviation OCD); one that doesn’t get talked about very much, and certainly not a lot by people his age. Many people with obsessive sexual identity thoughts shared the particular symptoms I had outlined, so they weren’t very hard to guess at. I related to him that at one time, a few years ago, I actually found myself treating six different people at once for this type of OCD, and that we had even held a support group meeting just for this group. I added that these thoughts weren’t confined to heterosexual people, and that I had even treated a gay patient who was troubled by obsessive thoughts that he might be straight.
Michael went on to confirm that his doubtful thoughts of being gay came on suddenly one day when he was looking through one of his bodybuilding magazines. He remembered looking at one picture in particular and thinking, “I wonder if I find this guy attractive?” With that, he suddenly became very anxious and horrified that he could have such a thought. He also found that in the days following, he couldn’t get the thought out of his head. What made things worse, was that the other guys in school had a habit of teasing each other about being gay, a not unusual occurrence. Remarks that he used to shrug off now became very frightening. “What if they really can tell?” he remembered asking himself. He found himself avoiding his usual crowd. He threw away the bodybuilding magazines. He stopped going to school. Nothing helped. It seemed like the harder he worked to avoid thinking about whether or not he was gay, the more he would think about it. “But I’m not gay,” he emphasized, “I’m not attracted to guys, so why am I thinking this? I’ve never been attracted to guys!” He paused for a moment. “But the thoughts seem so real.”
I explained to Michael that these obsessive questions were not “real” questions, and the thoughts were not “real” thoughts. These things that seemed so real were the result of problems with his brain chemistry, and that there were no real answers to his doubts, so no matter how hard he checked himself and his behaviors and thoughts, he would not be able to erase the doubt. The OCD (once known as “The Doubting Disease”) would not let him. I told him that the thoughts were, after all, just thoughts, no matter how creepy they were, and that they really had no power to make him anxious. The truth was that he was actually making himself anxious. The proof of this was that even people who recovered from OCD would still report unpleasant thoughts, but also add that the thoughts no longer made them anxious. Why? Because with the help of therapy, they had faced the thoughts and built up a tolerance for them, to the point where they no longer produced a reaction. “The real problem is not the thoughts,” I said, “The problem is what your attempts to control your anxiety are doing to your life and your ability to live it.” Another thing I tried to emphasize to him was that it was not unusual for people to sometimes get doubtful thoughts about their sexuality, but that people without OCD were better able to decide how they really felt about these things, and could eventually put the thoughts aside. “Our goal,” I told him, “will be to learn to gradually face the thoughts and resist doing compulsions long enough for you to learn the truth about all this. You will have to face a lot of doubt and feel as if you are taking risks at times, but if you stick with it, you will gradually become desensitized to the thoughts, and they will no longer seem to have any power over you.” This was clearly a lot to think about, and Michael would need the next few sessions to really digest all this.
One of the really maddening qualities of OCD is that it can make a person doubt the most basic things about themselves – things no one would ever normally doubt. Even their sexual identity could be questioned. Sufferers will go to great lengths to overcome this doubt – even ruining their lives through their desperate actions. Doing compulsions, such as repeated questioning, avoiding things, looking for reassurance, and checking, can be rewarding in the short run, and this is what keeps the problem going. By staying away from the things that make them anxious, sufferers only keep themselves sensitive to these things. Also, this only helps for a little while, and before long, the doubt returns, as it always does. Fortunately, this process also works in reverse, or as a favorite saying of mine goes, “If you want to think about it less, think about it more.”
Michael had been attempting to control his anxiety chiefly by avoiding – throwing out his magazines, avoiding his friends, and not going to school. He also kept double-checking his own thoughts to see if he really believed them. He eventually revealed that he also would alternately look at other boys and then at girls, trying to decide whom he was more attracted to. He, himself, admitted that even when these things did work (and often they only raised more questions) the relief only lasted a short time.
After learning much more about Michael and his life, we began to prepare to do the behavioral therapy that would be the main part of our treatment. The specific type of therapy we would be doing is known as “Exposure and Response Prevention.” In this type of behavioral therapy, the person voluntarily and gradually exposes themselves to greater levels of the things that bother them, and at the same time, agrees to resist doing the compulsive activities that they have been using to make themselves less anxious. The purpose of all this is for them to learn that if they just stay with what makes them anxious long enough, they will come to see the truth of things – that these are only meaningless thoughts, and that the anxiety will gradually diminish even if they do nothing. The ultimate goal is for a person to be able to tell him or herself, “Okay, so I can think about these things, but I don’t have to do anything about them.”
As a first step in treatment, we identified all of Michael’s various obsessive thoughts concerning being gay, and then all the different compulsions he was using to try to control the anxiety that resulted from the thoughts. Next, we listed all the situations we could think of that would make him anxious. These included such things as being around his friends, having his friends joke about being gay, hugging another guy friend, going to a movie with just another guy, looking at pictures of attractive guys or girls, watching romantic scenes in movies, just hearing the word ‘gay’ or similar words, seeing gay characters on TV or in movies, looking at gay magazines, visiting gay websites, etc. We then tried to assign number values, from 0 to 100 to each of these situations, to help us to see what was worse than what. I told Michael that together, we would create a program especially for him, using the items on this list. We would start with challenging situations that he rated at about a 20, and work upward from there. I helped him pick several lower level items, and also recorded an audiotape for him to listen to several times per day. I explained that this was an Exposure Tape, designed to raise his anxiety to a moderate level, and to get him to “Think about it more.” He laughed a bit when I told him, “You can’t be bored and scared at the same time.” The tape was a two-minute recording of me, talking in a general way about how some people couldn’t be sure of their sexual preferences, and turning out to be different than they thought they were. He found this definitely caused some anxiety, but he believed he would be able to listen to it. He would keep listening to it until it became boring. Later tapes would actually tell him that he possibly was gay, and even later ones would tell him he definitely was. I planned for him to eventually record his own tapes, in which he would agree that he was gay, and would soon ‘come out’ and go public. I also stressed that it would become increasingly important for him to agree with his thoughts. This would probably be the single most important assignment we would do, and that we would be doing it all through the therapy. As I sent him on his way with his first list of assignments, I told him that he would see that it wouldn’t be as bad as he feared. I added that the worst day of the therapy was the day before you start.
Michael seemed truly surprised at the end of the first week when he came in and told me that the tape really had become boring, and that he was ready for a new one. He seemed somewhat less anxious overall, and proud that he had made it through the first round of homework. Week by week, he worked his way through the list. He gradually became more able to say things he feared to say, to look at pictures he disliked looking at, to listen to words he feared to hear, and to imagine things he really didn’t want to imagine. Some things were a struggle for him to stay with, as they represented his worst doubts. To his credit, he stuck with them, and refused to give up, even when he didn’t get instant results. He was developing trust in what he was doing. I could tell that he was improving when he was finally able to joke about his thoughts. At one session, he came wearing a pink shirt. “Do you know why I’m wearing this?” he said, raising his eyebrows. “Why?” I asked him. “Because I’m gay,” he answered, with a grin. “Didn’t you know?” I knew we were winning.
The day finally came when we had arrived at the end of Michael’s list. He was no longer avoiding anything, and the worst things on his list no longer seemed to have any effect on him. He could tolerate all of them, and didn’t feel the need to run away or avoid them. I showed the list to him to remind him of where he had started out. As he looked it over, he said, partly to himself, “I can’t believe these things made me nervous.” He added, “I really didn’t enjoy doing some of the things you had me do, but I’m glad I did them. I don’t have all that nasty stuff filling up my head.” I told him that the job was only half done. “What do you mean?” he asked, looking puzzled. “Now you have to stay this way,” I answered. “Consider yourself officially in recovery,” I announced. “But your work isn’t over. This means that you will have to do maintenance from this point on. When thoughts on the topic of being gay come up (and they will), you will have to continue to agree with them, and not go back to doing any of the things you used to do before – the ones that only made things worse. People who go back to those kinds of solutions wind up with a relapse. Like the therapy, doing maintenance will get easier as time goes on. It will become second nature.” I tried to leave him with the idea that this next phase would be just as important as the first one was. I stressed that OCD was a chronic problem, which means that even though you can recover, you are not “cured.” In a way, it’s kind of like having asthma or diabetes. “The people who relapse,” I told him, “are the ones who think they are cured.” “Don’t worry,” Michael replied, “I worked too hard to just give it up like that.” He was as good as his word. He went off to college not long after, and several e-mails he sent me indicated that he had learned his behavioral therapy well. Even the pressures of school couldn’t get him to go back. As of his last message, things were fine.
Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.
If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).