Finding Rest From Rituals

Susan (pseudonym) is a teacher in her mid-forties and lives in the San Francisco Bay Area with her husband and two children. She shares candidly about her lifelong mental health struggles, along with her persistent efforts to navigate her way to better health.

Keeping Secrets

Susan grew up in a less than stable environment: her mother has bipolar disorder, which was not well managed, and both of her parents abused drugs. For long stretches of time, Susan's mother would not be able to get out of bed, and Susan would want to "make it all better." For example, Susan recalls one episode where her mother had been complaining that the driveway was full of weeds and that she could not pick them due to her allergies. Hoping to solve her mother's problems, Susan spent hours picking the weeds. She was disappointed when her efforts did not yield the desired effect. In hindsight, Susan understands that her mother was severely depressed. She also remembers periods when her mother was manic, though the symptoms of this condition were difficult to distinguish from the effects of her mother's use of drugs. In one representative instance, Susan's mother threw plates against the wall and laughed hysterically, delighted with the sound. During this episode, her mother would beckon Susan to share in her amusement. Susan wound up scared and unsure of what was happening.

Susan's father maintained a quieter presence in her life, with a far more reserved personality than her mother. During her childhood, he regularly used cocaine around her. Neither his use nor the paraphernalia struck her as remarkable, and she remembers mimicking her father's behavior in front of her classmates, holding a little straw up to her nose. He was considerably upset when he heard about this, admonishing her that people were not supposed to know he used cocaine. Rather, his habit should be kept secret.

Susan's parents always wanted to be called by their first names, never "Mom" and "Dad." Susan posits that the practice might have been a way to protect themselves from emotional vulnerability. They did not say "I love you," and for a long time Susan thought it would be a sign of weakness to do so. At the time, she was too young to understand what she would later realize: her parents were preoccupied with their own personal challenges, not disapproving of Susan.

Susan's paternal grandparents lived nearby, and during her earlier years, Susan spent a significant amount of time living with them when her parents were unable to care for her. She remembers a lot of moving back and forth between the two homes, which was unsettling. While Susan enjoyed living with her grandparents, she also felt rejected by her parents. Additionally, living with her grandparents presented its own difficulties. Susan's family is Jewish and her grandparents were Polish survivors of the Holocaust. Having grown up in Warsaw and gone to Switzerland together to study architecture, they returned home to their families when the war began. Susan's grandfather was sent to a labor camp in Siberia while her grandmother was sent to a concentration camp. As would be expected, they experienced substantial trauma in the camps, and as was typical of their generation, they kept their experiences to themselves, secret. After settling in the United States, they also tried to keep their Jewish identity a secret. This necessarily became Susan's secret, too. The secrecy was confusing for Susan. She saw Jewish friends going to Hebrew school, having bat mitzvahs, and thought she also might like to participate. But her grandparents' worry about people knowing they were Jewish made the secret seem dangerous and slightly shameful.

Susan observed that her grandparents had substantial anxiety, especially her grandmother. Their traumatic past, with endangerment and uprooting, left them feeling vulnerable and worried something similar could happen again. Additionally, their consistent involvement with refugee organizations provided a constant reminder of their own experience of being forced into hiding for survival. Naturally, her grandparents were anxious about Susan and her brothers when caring for them, always wanting to know where they were. When Susan was six, the kids were staying with their parents for a time, and the parents' telephone line stopped working temporarily. After repeated unsuccessful attempts to reach the family by phone, Susan's grandparents went to her parents' house at 2:00 AM because they were sure something terrible had happened. In reality, everything was fine. Susan feels she absorbed this anxiety and became a very anxious child. She frequently engaged in magical thinking: "If I did the right thing, if I said the right thing, if I thought the right thoughts, if I did the right rituals, […] things would be okay." Susan recalls her earliest rituals from the age of five. The rituals primarily centered around numbers, such as repeating certain numbers aloud in a particular cadence. She might count or pick numbers she associated with specific colors to achieve a color palette she had in mind. Not wanting to be discovered, she would go to the bathroom to avoid being overheard. Susan began keeping her own secrets.

When Susan was ten, her grandfather suddenly died. Her grandparents had a close, loving relationship, and her grandmother relied heavily on her grandfather. Susan was living with her parents at that time, and her grandmother moved in with the family, sharing a room with Susan. Around this time, Susan started pulling her hair out, a practice that continued throughout her life. She thought no one else did this, but now knows there are others who do. There are specific areas on her scalp where pulling out her hair feels "really good" and "really satisfying," and therefore she pulls from these spots. Additional rituals have accompanied her hair pulling. She lines up the hairs, preferring the ones with the roots intact. After touching these hairs against her lip, she eats the roots. She comments that this is "disgusting, but it's something I do." Susan believes she started pulling out her hair to create space for herself as she shared a room with her bereaved grandmother and as her parents dealt with their own issues. Walking down the stairs at home one day, Susan's mother was behind her. Her mother asked, "Is that a bald spot?" Susan replied she must have pulled her ponytail too tight. Another time, her mother noticed Susan had a section of visibly shorter hair growing out from where she had pulled it. She told her mother that a friend's younger brother had cut it, which prompted her mother to talk to the boy's mother. Susan still feels remorse for causing him this trouble. She continued with her rituals, trying to regulate her anxiety and unstable surroundings, and trying to keep the practices a secret.

Susan developed additional behaviors as she grew older. As a pre-teen, she remembers rhythmically knocking and tapping on objects. She also sought frequent reassurances, asking the same questions again and again. In her mind, carrying out these tasks would stave off disaster, such as preventing harm to her family or potentially even another Holocaust. After experiencing the major Loma Prieta earthquake in 1989, Susan believed she was responsible for the event because she had not been doing anything to prevent it. Around this same time, her father's best friend died in a car accident. Subsequently, riding in cars involved a number of practices for Susan, who attempted to prevent crashes. She would use her numbers or tapping rituals, focus on certain thoughts, conjure certain images in her mind, or hold an armrest a specific way. These activities occupied her to such a degree that she found it difficult to talk while in the car. She also believed that listening to Steve Winwood's Higher Love in the car was required to prevent an accident. In anticipation of a car ride, Susan would start asking her father two or three hours before leaving if they could listen to the song in the car. Usually, he would agree and Susan would feel reassured for five or ten minutes. Then, she would frequently wonder if she might have imagined asking him, or if he had actually agreed, or if perhaps he had changed his mind since. She would ask him again, and he would say, "Yes, I told you we can." This might continue until sometimes, he would tell her they could only listen in the car if she stopped asking about it, which proved to be tremendously difficult for Susan. Battling internally with herself, she would think, "I can't ask. But I also have to check. I have to make sure." Occasionally, her father would say he would rather listen to the radio or rather have quiet due to a headache, and this caused her to panic. Although they never had a car accident when not listening to the song, Susan at that time believed that it was because she would compensate by doing something else to make up for it. For example, if she would usually massage the left armrest in the car, she could instead massage the right one, or both, or alternate between them. This enabled her to make sense of the situation when they were not listening to the right song, yet still avoided an accident.

Susan was a committed, straight-A student who enrolled in Advanced Placement classes. School provided a haven in which she could immerse herself. She believes her anxiety positively affected her education because she felt compelled to participate in many activities. "There was perfectionism involved." In addition to her advanced coursework, Susan played soccer, rowed with the crew team, and participated in the journalism club. While she enjoyed herself, she was mostly motivated by the sense that these activities were what she was supposed to do. During her summers, Susan worked in various capacities, including dishwashing, babysitting, and working at a sleepaway camp. Although money was generally not a large concern for her family, she was extremely worried about having enough. She worked to make as much money as possible, just in case.

Seeking Escape

Feeling responsible for looming calamity and keeping track of all the rituals needed to prevent them exhausted Susan. She found unexpected relief in alcohol. She remembers trying alcohol at six, seven, and eight, when she would have a few sips and then stop, put off by the taste. Her parents did not mind her trying alcohol, finding her forays into drinking alcohol "kind of cute." At ten, she drank enough to feel an effect and she liked it: "This feels kind of good, and my thoughts are slowing, and I am not feeling like I am holding on for dear life to keep everything running." At that age, Susan did not yet drink alcohol regularly at this point, primarily because her friends were not at that stage. But when Susan felt particularly anxious, she would drink for occasional relief. By thirteen, she was drinking by herself regularly. And when her peers started drinking in high school, she would drink more in social settings. Yet, even while going out drinking without a curfew, Susan did not cause trouble. It was important to her to not create problems for her parents.

As Susan neared the time for college, she wanted to escape and chose a small liberal arts college across the country in New York. She obtained a substantial academic scholarship for writing and eagerly anticipated what lay ahead. She imagined the change in surroundings would "fix everything." Instead, she "kind of hated it." Once Susan arrived, she felt unprepared. She experienced culture shock in an environment filled with students from wealthy, established East Coast families who employed live-in, uniformed staff. To the extent she had known wealthy kids before, there was less formality involved. Susan's anxiety level skyrocketed. Not knowing how to cope with her increased stress, Susan's ritual behaviors intensified. At the same time, she was trying to hide these behaviors from her roommate, which compounded her stress. She "felt like a total freak." In particular, her hair pulling got worse, all the while Susan acted like none of it was happening. Eventually, the problem was undeniable. Her roommate could not help but notice Susan's hairs scattered around the room despite Susan's efforts to clean it up. Susan became depressed. During this time, she drank more alcohol and started using drugs. Using substances indiscriminately, Susan would use "anything," including something called "cheap white powder" by "some guy" who was selling it. She still does not know exactly what that was. As with alcohol, Susan found that illicit sedatives offered relief from her relentless thoughts. Stimulants, meanwhile, gave direction to her otherwise unfocused anxiety and nervous energy.

The heavy drug use around that time caused some of Susan's memory to fade, but at some point, she began making comments that led her dorm resident advisor to think that she was suicidal. By policy, the advisor was then required to refer Susan to a mental health provider, and ensure that she went. Susan "hated" this mental health provider, finding her to be "very cold." Susan offers that she herself also may have been challenging as a client since her attitude was likely "totally obnoxious." During the first session, the provider asked about Susan's background. Susan remembers feeling frustrated and not understood. She felt that the provider was judgmental and did not care about her. Susan was supposed to see the provider weekly for several sessions in total. After four sessions, Susan started making excuses to miss appointments and never went back. Before she stopped seeing the provider, she was diagnosed with depression and anxiety and started taking antidepressants. Susan felt terrible about herself, having "all these weird secrets." However, she sensed this was not the entire problem, that there was something more.

For the next couple of months, Susan continued drinking heavily and using drugs such as hallucinogens, cocaine, and ketamine (although she did not like ketamine, it was readily available). Susan notes that ketamine is reputed to be helpful for depression if used in a supervised therapy setting. However, she was not benefitting from it, simply using what she could find. One night, while using alcohol and ketamine together, Susan became distraught. She apparently started talking about killing herself, although she does not recall doing so. Susan does not feel that she was actively suicidal. She did not want to die but remembers feeling desperate for an escape. Susan thinks she was saying she did not want to be alive, which was how she felt. But she also did not want to die. She just wanted "the noise to stop" and "did not know how to make that happen." She wanted someone to step in and do something.

Susan ended up in a psychiatric facility in New York for a week. It was an upsetting experience, and she does not remember much from her time there. She spoke with therapists and psychiatrists, whose primary goal was to keep her safe for as long as needed. While Susan was in the facility, her mother flew in from California. Susan was embarrassed and did not want to discuss with her mother what had happened. Susan felt something else was wrong, something more than depression. She was somewhat willing to talk about depression because she felt people understood that, and her mother did understand. But Susan did not know how to articulate her other troubling thoughts: "I have to wake up exactly at this time, otherwise, someone might die. Or I have to say these numbers in this order, otherwise there might be an earthquake." These thoughts and her ritual behaviors did not fit with the descriptions of depression and anxiety. She felt abnormal, like "a freak" and "a bad person," and did not know how to talk about it. Instead, she concluded there was something wrong with her, did not know what it was, and could not tell anyone. It felt shameful.

Returning Home

After leaving the psychiatric facility, Susan left school and returned home to Oakland. She had been away for eighteen months. She feels she probably should have left a few months sooner than she did, but leaving was difficult because people were proud of her attendance at that college and because of the high hopes she had for being there. Although Susan had enjoyed the academic and social aspects of college, the culture was different from the West Coast, and she missed being near her grandmothers and brothers. Susan thinks of herself as "kind of a mess" during her initial months back. She had some local friends she could spend time with, but she felt they were heading in different directions. Also, she lacked the structure of school. Left with a void to fill, Susan used more alcohol and drugs. She was living with her parents, which was difficult, though she recognizes that as a nineteen-year-old, she probably offered less-than-pleasant company. Susan describes herself at the time as opinionated and feeling superior. In retrospect, she sees she was deflecting her mental turmoil.

Susan's mother found Susan a new therapist, an associate of a therapist that Susan's mother had been seeing. In contrast to the mental health provider Susan had seen in college, this therapist seemed warm and motherly. However, Susan still did not feel the therapy was helpful. She would leave sessions feeling worse than when she arrived, though she does not fault the therapist. Susan was looking for some direction or guidance regarding decisions she had been making. Instead, she and the therapist only talked, which left Susan feeling an unwelcome sense of uncertainty. Susan could spend sessions repeatedly going over aspects of her life and past events, seeking reassurances. This led to further ruminating, which Susan was already prone to do on her own. In retrospect, Susan believes this attentive healthcare professional inadvertently sanctioned some of Susan's problematic thoughts and behaviors. Susan would also leave "a little bit more tightly wound," not feeling positive about herself or the session. Despite these negative effects, Susan continued the therapy because people in her life wanted her to do it and told her it was the right thing to do. She initially saw this therapist for a year and then stopped for a reason she does not remember. After a few months, Susan started seeing the therapist again, which lasted for another several months. She was also taking antidepressants at this time, which were of limited help because there was an issue other than depression that remained unaddressed. Susan was deeply embarrassed about the way her mind worked and still felt unable to articulate the problem.

Lacking direction and unsure about what to do, Susan started working in a primary care physician's office as a receptionist. Susan's mother had been prodding her to do something with her time, and the solo practitioner was a neighbor. In the small medical office, Susan worked with one other receptionist and a part-time file clerk. The other receptionist also used drugs and they quickly became good friends. At that point, Susan did not have experience with opiates, and the other receptionist suggested Susan try the opiate samples available at the office. The doctor remained oblivious as they covertly used samples of opiates and diet pills with amphetamine. In addition, part of their job duties entailed calling in the doctor's prescriptions to the pharmacy. Before long, they were regularly calling in illicit prescriptions for themselves, to obtain whatever drugs they liked. They avoided detection by paying cash. Thus, Susan's misuse of drugs expanded. While Susan's unhealthy use of alcohol remained constant, she valued these drugs more because they were more effective for "checking out." She used Valium and Norco and others, which worked better than alcohol and worked much better than cocaine.

In some ways, Susan felt her life had improved. She had a job, was earning money, and had made a close friend at work. Incidentally, Susan and her friend began spending time at a bar where Susan met a man named Sam (pseudonym). When they first met, she was twenty-one years old. He was thirty-six years old with two young children, and going through a divorce. They dated casually for a while, but they were in different places in their lives. Although they went their separate ways, they periodically kept in contact. All in all, Susan was feeling better to some degree. Nevertheless, she had not received the help that she needed.

During the first two years that Susan worked at the doctor's office, she felt extremely responsible for meeting the patients' needs. Over time, she found herself promising to complete tasks for patients within unrealistic timeframes and felt overwhelmed by the volume of work. Susan's boss wanted her to communicate when she was unable to complete the tasks that were asked of her ("completely fair," Susan says in retrospect), but at the time, Susan just felt misunderstood. These difficulties, combined with unsatisfactory pay, led Susan to leave that position to work in a law office for a while, which she enjoyed. While Susan worked at the law office, her friend from the doctor's office continued to call in prescriptions for them. However, access to drugs had become a priority for Susan, so she decided to return. Nevertheless, Susan's absence had given her some perspective, enabling her to realize she would not be able "to do everything for everyone immediately." She reigned in her promises to patients accordingly. Years later, tensions between Susan and the doctor resurfaced, partly due to the doctor's unwillingness to modernize the office with a computer. It was 2003 and the paper system in place created needless difficulties for everyone involved. Susan was also still unsatisfied with her pay, especially given her tendency to "hyper-focus" on money. She still valued her convenient access to illicit prescription drugs, but once regulations tightened around prescription writing, Susan's primary motivation for staying there evaporated. Susan moved on to be the front-office manager for another doctor.

While working, Susan also resumed her college studies. During her initial stint at the doctor's office, she had started attending college nearby. Susan continued to attend when she worked at the law office and graduated shortly after she had returned to her previous position in the first medical office.

Forming a New Family

Meanwhile, still in her early twenties, Susan began an intense relationship with a boyfriend. They had only seen each other twice when Susan received a phone call from the not-yet-boyfriend's roommate. The roommate said the future boyfriend was "melting down," saying he was going to kill himself, and asking for Susan to come see him. The roommate discouraged her from coming over, saying that he only called her because he had said that he would. Susan rushed there, eager to feel needed. This dramatic beginning turned into a tumultuous relationship in which her boyfriend "fairly quickly" became abusive. He would say "terrible things" to her. They both abused alcohol, with him drinking more than she did. He would become very drunk and start hitting her. More than once, he choked her, and she would stay home from work for a few days to hide the finger-mark bruising that resulted. Inevitably he would try to shift the blame to Susan, insisting she pushed him to that point. Although Susan recognizes this as a common tactic that abusers employ, she nonetheless sees a "grain of truth" in his claim because she actually did "push for a response." Susan felt shameful and believed there was "something deeply, deeply wrong" with her. She wanted to externalize this feeling by being hit. Theoretically, the idea was appealing, but the reality quickly turned frightening. She would think, "Wait, no, I don't want you to really hurt me."

"One, or more likely both, of us would have ended up dead if we had stayed together. It's pretty scary," Susan says. In her mind, the relationship served two purposes. Since she liked feeling needed, Susan wanted to care for him. She continues, "I also, if I'm being honest, kind of liked having someone who was more of a mess than I was, who was more dramatic, whose mental health was worse. It kind of made me feel like I had my [life] together, even though I didn't." Six years passed before Susan left the relationship. Throughout those years, she was occasionally spending time with Sam. Susan thinks she loved Sam for most of the time that she was with her boyfriend. But she felt that she "was really broken" and that Sam did not realize it. Still feeling she did not "know exactly what was wrong with her," she worried that Sam was too good for her and that she was undeserving. Over time, with Sam providing a supportive ear, she realized the extent to which being with her severely depressed boyfriend was negatively affecting her. Susan has always loved cooking and one night she came home with abundant groceries, excited to make dinner. Instead, she found her boyfriend too downcast to engage, even though they had discussed these plans in advance. In a flash of clarity, Susan decided this life was not what she wanted for herself. By now, she had developed friendships that extended beyond mutual substance use, and had aspects of her life she was enthusiastic about, including this dinner. She decided she had enough and was done with the relationship. After breaking up, Susan and her now ex-boyfriend stayed in their apartment for a couple of weeks until they could arrange to leave. They did not touch each other and were hardly speaking. Susan slept on the couch, and there was no further abuse.

Susan waited to tell Sam the news because she knew he would want to be with her, and she did not feel ready yet. After a day of packing up the apartment, Susan and her former boyfriend went to a bar because it was his birthday, and they saw Sam. Susan's ex-boyfriend was drunk, mentioned their breakup, and walked away. Sam told Susan to call him later, and they started dating. Their relationship was exclusive from the start, and within two months, Susan was pregnant despite being on birth control. Continuing to move quickly, Susan, now 28, and Sam got engaged and married while she was pregnant. Even though the pregnancy was not planned, Susan knew that she "really, really wanted this baby." Susan was able to abstain from drugs (including alcohol) for the duration of the pregnancy; although difficult, the demands of wedding planning and being pregnant helped preoccupy her.

Susan had previously thought of herself as "the fun girl at the bar who is down for whatever," but with the whirlwind progression of the relationship and added responsibilities of being pregnant, Susan felt that she could not be herself. She was still struggling with her thoughts and "doing all these weird things." Susan remembers picking fights with Sam "just to see… do you really love me? Do you really know me?" Still, Susan and Sam had a son and were in love with him and in love with each other. Wanting to grow their new family further, they had a daughter two years later. While it was "a really fun and exciting time," Susan quickly resumed the use of alcohol and, less so, other drugs when not pregnant. Adding to the stress of that period in life, Susan encountered various medical issues when pregnant with her daughter, including doctors at one point thinking that she had lymphoma. With all of these ongoing challenges, their relationship was stressed, and Susan and Sam decided to work on their relationship issues. Through their health insurance website, they found a marriage counselor whose office was close to where they lived, which was particularly important given the two young children. Finding time for counseling appointments was challenging. They would have to bring their kids along, who would play in the room next door; sometimes, the children would come over and interrupt the sessions. On the whole, Susan feels that the counseling somewhat helped her and Sam work through their issues. However, she observes that without receiving the help she needed for her own mental health issues, the marriage counseling had limited effect.

Getting Better

In her early thirties, Susan had been telling a friend that she worried about offending someone who overheard something Susan had said. Susan persistently asked her friend about what the other person may have overheard and what her friend thought about the situation. Even after Susan's friend reassured her that the situation was not that bad and that Susan had not said anything overly offensive, Susan kept talking about it despite trying to stop. This persistence prompted her friend to remark that Susan "can get really obsessive." The instance of hearing that word, and having someone else point it out, caught Susan's attention. She reflected and agreed she can be obsessive and she had these behaviors that seemed like compulsions. She soon started reading more about obsessive compulsive disorder (OCD). As she read, she thought, "A lot of this fits." Although she did not have certain symptoms discussed – such as repeatedly checking if the front door is locked or excessively washing her hands – many symptoms were familiar. However, Susan was not yet ready to deal with this.

When Susan's kids were in elementary school, Susan was offered a job at their school as a yard supervisor. There were 429 kids at the school, and in Susan's mind, she had to learn each of their names to keep them safe (she has always felt an outsized sense of responsibility for other people). Each night, Susan would spend hours racking her brain, writing lists of names from memory: "I would get close, 423, 424, and then I could not think of those other names." Susan would then be unable to sleep, worried that something terrible would happen to those unremembered kids. Still anxious the next day, Susan would consult the school roster and figure out which names she had missed. Those were the names she would start with the following night, but other names would invariably escape her memory. This continual cycle caused Susan much distress. Spending all night writing lists was time consuming, which reduced Susan's capacity to be the mother she wanted to be. Ultimately, this spurred Susan, at 36, to seek assistance with what she suspected was OCD.

At this time, Susan and her husband were still seeing their marriage counselor. Susan told the counselor she was wondSusang if she had OCD, and he recommended a local psychiatrist she could see. Before her first appointment with the psychiatrist, Susan expected she would have to conSam him that she had OCD and prepared to "lay out everything and make my case." With previous therapists, Susan had only gone as far as to say that she was extremely anxious and occasionally depressed. With this psychiatrist, Susan shared the "really scary, intrusive thoughts" and "disturbing, violent images" that haunted her mind. To her surprise, the psychiatrist immediately agreed that she had OCD. He suggested she try various medications, and Susan received her first prescription specifically intended to treat OCD. This was also the first treatment to provide Susan with a bit of relief, somewhat reducing the "white noise" in her head. However, their appointments were brief and clinical. Susan did not find the psychiatrist to be very insightful or helpful beyond the medications they tried and Susan still lacked the means to discuss, work though, and potentially prevent her compulsive behaviors. Although the potential benefit from treatment with this psychiatrist was limited, it was an initial step towards receiving more effective help.

As time went on, Susan continued to use alcohol unhealthily. She drank more and more. She would drink in the morning, before going to work at school with children. Eventually, Susan would drink in her car while she was at her workplace. She had already been waking up in an acute panic, anxious over memorizing the students' names at school. Now, without a drink in the morning, she would feel shaky. Susan recognized that she could not continue this way and that this was "undeniably a problem." But she did not know how to stop. After reading that people sometimes receive benzodiazepines in rehab facilities as treatment for alcohol use disorders, Susan "had this brilliant idea" to tell her psychiatrist that he simply needed to prescribe her benzodiazepines because she did not have time to go somewhere for rehab. He replied, "absolutely not," and told her he thought she did need to go somewhere. Instead, Susan requested pills from her younger brother who had addictions to various substances. He obtained Xanax and Valium for her.

Without a specific plan, Susan had a vague notion that she could potentially use some of these sedatives, relax at home, and her problems might disappear. In reality, she "took them all very quickly," while drinking, too. Consequently, she "lost a few days." It was July 2018 and Susan, as a school employee, had the summer off. She woke up one Monday afternoon and saw that Sam, her husband, was home. She asked why he was there. Sam told her he was worried and could not leave her alone, that she needed to go somewhere for help. When Susan learned that Sam had asked a neighbor who worked as a social worker for rehab recommendations, she "felt terribly betrayed" that he had told the neighbor and said so. Sam replied that he felt she was betraying their family. Moved by this, Susan agreed to go along with the arrangements he had made. Initially, she primarily agreed in order to satisfy Sam. But she also wanted to stop abusing alcohol. In addition to Susan's concerns about her behavior, she was also aware that her alcohol use was taking a physical toll. Susan had started drinking straight gin and had been frequently burping and vomiting, occasionally coughing up blood. An endoscopy revealed burns in her esophagus. In Susan's mind, she would go "dry out" and "maybe start drinking like a normal person. That was the goal."

When Susan arrived at the rehab facility, detoxing was arduous. She found the process physically more difficult for opiates, which she had also been using. However, the facility workers provided Susan with comfort and care. During her first couple of mornings, Susan would wake up panicked, feeling like the world was ending and feeling unable to breathe. She believed she needed pills and especially alcohol to help her cope. But by the third morning, Susan had improved. A nurse woke Susan to take her blood pressure. She remembers greeting the nurse with a smile, being in a good mood, and thinking, "This is different." She liked the difference and committed to giving rehab a genuine try. After completing rehab, Susan started attending AA meetings, which she continued to do for years. She has been sober since July 30, 2018.

Living With OCD

In Susan's view, her sobriety is another step in an ongoing, incremental progression towards better health. This step "was a big one." Nevertheless, Susan's mind "still spins" with intrusive thoughts. For example, she thinks extensively about spending and costs. She follows self-prescribed rules for grocery shopping, such as how to review the advertising circulars and in what sequence to visit specific stores. Also, concerns about expensive purchases linger in Susan's mind long after the expenditure, as do regrets over money she feels was wasted. For example, Susan and her husband tried a new soup at their favorite Chinese restaurant. The soup, with pork leg, preserved mustard, and bamboo shoots, sounded like a wonderful combination of ingredients she loved. Instead, the soup was disappointingly bland. She says, "I still think about that four years later, and I feel like I have to kind of repent for that. And, yeah, it was $14.88 and that still bothers me."

After four years of seeing the psychiatrist who diagnosed her OCD, and a couple of years after she went to rehab, Susan felt she had benefited as much as she could from the medications he had been prescribing. She was sober but still engaging in compulsive behaviors. Therefore, Susan decided she was done with taking medication prescribed for OCD and stopped seeing the psychiatrist. Since then, Susan has not detected a marked change without the medication, except perhaps a slightly increased anxiety level. However, her anxiety level was already high, regardless of the medication.

Upon realizing that she adores working with kids, Susan went back to school to become a teacher. She started teaching second grade. Because a large part of her OCD is the responsibility she feels for others, teaching a class of 25 children was challenging, and she was unsure how to manage that. Shortly before the pandemic, Susan found an OCD support group. The OCD support group that Susan found met every other week at Kaiser. This was the first time Susan had met other people with OCD, and "it was just amazing." She recalls crying through much of her first meeting. Partly, Susan was overwhelmed by other people's stories and her own sense of responsibility for them. But to a greater extent, Susan cried because she had "a sense of recognition and release." Even if the behaviors people described were different from hers, she understood the impulse. The group later started meeting on Zoom, and Susan continued to attend. In the group discussions, she started to hear about exposure and response prevention (ERP) therapy, specifically intended to treat OCD. Since traditional talk therapy has been of limited usefulness for Susan (she later learned that it is contraindicated for OCD), her curiosity was piqued. However, Susan felt intimidated by descriptions of the therapy, which involves teaching people with OCD how to tolerate levels of distress while resisting compulsive behaviors. She "was a little terrified. Or a lot terrified." Susan remained reluctant to try ERP until one of the symptoms of her OCD pushed her to seek additional help.

Part of Susan's OCD involves testing whether she deserves things. Periodically over the years, her concern that she may not deserve to have a car has led Susan to purposely leave her car keys in the car. She would then think, "What if it gets stolen? Because even if that means I don't deserve a car, I still kind of need a car." While she has always been aware these thoughts "don't really make sense," she did not "have much power to stop them" without help. Despite taking these risks with the keys, Susan's car was always fine until Thanksgiving Day 2022. On that morning, her husband woke her to ask where she had parked. Her car was no longer in front of the house, where she had left it with the keys inside. The car had been stolen, and Susan told her husband that she had left the keys in the car and why. Although the car was recovered and they had new keys made, the old keys were apparently not deactivated because the car was stolen again before long. Susan began to realize this was "a very dangerous compulsion and an expensive one." She also realized that even if other compulsions she had were not outwardly dangerous, they were harmful to her wellbeing and affecting her "in a very negative way." She wanted help and requested recommendations for ERP therapy from her OCD support group.

Exposure And Response Prevention Therapy

Several people in Susan's support group used an app called NOCD and most reported positive experiences. The app offers access to OCD therapists who use ERP therapy. She decided she could at least explore the option, though part of her remained reluctant. Susan feels "wedded to these compulsions." They are what she knows, "and it's scary to not do them." She thought her insurance might not cover the treatment and that the expense might provide a reason not to try the therapy. In fact, her insurance covers most of the cost, with a small co-pay for each session. Having run out of excuses, Susan took the plunge and signed up for the app. They conducted an extensive initial interview before matching Susan with a therapist. Susan was also able to request a therapist with particular characteristics. Due to the prominence of the Holocaust in many of her intrusive thoughts and compulsions, Susan requested a Jewish therapist if possible. She wanted a therapist who would be familiar with that context, as well as the religious holiday practices involved in some of Susan's behaviors. She received an excellent match and has been seeing this ERP therapist twice a week through the app.

Susan explains that ERP therapy differs from traditional talk therapy, although the therapy initially involved a fair amount of talking. They started by talking about her history and did several assessments to determine the particular characteristics of Susan's OCD. From there, they identified Susan's obsessions and associated compulsions. Susan would discuss a certain obsessive or intrusive thought and the behavior she would do as a result. Next, they assigned a number to indicate the level of distress Susan experienced from that thought and behavior. This way, they created a hierarchy of what was least to most upsetting for Susan. With that foundation in place, they began to talk less and focus more on completing exposure exercises.

Starting at the bottom of the hierarchy, the therapist deliberately created a situation to trigger one of Susan's less upsetting obsessions and had Susan resist the accompanying compulsive behavior. For example, with written communications such as texts and emails, Susan worries that she will make a typo, which upsets her and compels her to check the writing. Beyond worrying that the receiver of the communication will think less of her, she also finds the thought of a typo upsetting in and of itself, as if "something is not right with the world." Susan also worries about momentary lapses in judgment and, for instance, accidentally calling someone a "horribly offensive name" or quitting her job. With this in mind, one of the first exposure exercises Susan tried with her therapist was using the chat function in Zoom. Susan would intentionally write something with typos, then close the message and not check it. Or she would write something inflammatory and pretend to send it to her boss. She and her therapist would sit and wait, with the therapist checking in to see how Susan was feeling while she avoided checking what she had written. This exercise was "a fairly easy one" for Susan.

Many of Susan's more upsetting obsessions and compulsions concern the Holocaust. Susan worries that people have fabricated the Holocaust, that Jews "are actually terrible people," or that maybe she is a Holocaust denier or a Nazi. Here, the exercise she did with her therapist was much more difficult. She recorded herself on a loop saying, "the Holocaust didn't happen, my family members are liars, Jews are devious… we are hoarding wealth and destroying society." The plan is for Susan to sit and listen for as long as it takes to not feel acute anxiety when hearing these words, and for Susan to accept the uncertainty: maybe what she is listening to is true, maybe not. At the same time, she is supposed to refrain from pushing the thoughts away while also resisting the compulsive behaviors that might make her feel better.

Reducing Susan's level of anxiety by half is the goal of these exercises. "It's hard, it's really hard," Susan says. In addition to doing these types of exercise during her therapy appointments, Susan also works on them outside of her appointments. After just a few months of twice-per-week sessions, she has already found the process to be hugely beneficial.

Susan's mental health journey has been a long one, packed with many twists and turns. Having found effective assistance from her OCD support group and ERP therapy, Susan's life continues to improve. Susan now teaches a class with autistic children, who tend to have "fairly rigid thinking" and can be obsessive. Therefore, there are times when Susan feels she may understand these students in ways some of her colleagues may not.