I Think It Moved
The understanding and treatment of the obsessional
doubt related to sexual orientation and relationship substantiation
by Steven J. Phillipson, Ph.D.
Center for Cognitive-Behavioral Psychotherapy
The television program is "Seinfeld." The setting is a professional office of a masseuse. One of the main characters, George Costanza, has agreed to receive the first professional massage of his life. Jerry Seinfeld has strongly recommended it saying that it will be extremely relaxing and beneficial. George is in the waiting room of this office. Expecting, and even hoping to be greeted by a young and attractive woman, he is surprised to find that his massage therapist is a large, well-built, attractive man in a white T-shirt and short pants. Although George is hesitant at first, he reluctantly agrees at Jerry’s urging to go through with the massage…
In the next scene we find George leaving the office greatly flustered with a tremendous sense of urgency. He meets with Jerry for a private conversation and with terror in his face, admits that during the massage he thinks "it" moved. Apparently, during the massage George found it relaxing yet stimulating. It seems some modicum of ambiguity was introduced as George might have experienced some initial signs of sexual arousal. As a result he became paralyzed with fear and doubt that his sexual orientation was now in question.
This comedic scenario reflects what, for some OCD sufferers, can be years of torment and agony. One of the more common forms of obsessional doubt involves the inability to clearly establish, with certainty, one’s sexual orientation and the resultant agonizing effort to derive a conclusive answer. Another very common obsessional doubt, which actually very often coincides with this intrusive thought (i.e., spike), is the endless effort to clearly establish whether or not the relationship is currently devoted to is authentic or substantial enough to warrant its continuation. Do I love him or her enough? Is he or she attractive enough? Am I spiritually connected with this partner of mine to a sufficient degree? And finally since I might be gay, shouldn't I break up with this person and seek out my genuine self. Without too much contemplation, it is not difficult to understand why these two spikes would coincide. If a person were involved in a deeply committed relationship, and all of a sudden their predominant anxiety featured the desperate need to be absolutely clear as to what their sexual orientation entailed, questions as to the extent of their genuine love for their partner would be natural.
Society's favorite spikes to enable
With the vast majority of OCD spike themes the unreasonable and irrational nature of the spike is generally obvious. Intrusive thoughts of a mother smothering her newborn infant are usually easily recognizable as a common form of OCD or even a common intrusive thought which many new parents experience. Civilians and professionals alike are perfectly capable of identifying the irrational nature of the fear of contracting AIDs from a door knob. The terror, anguish, and felt need for an immediate resolution the sufferer experiences, with the more traditional spike themes are similar, if not identical, to relationship and/or sexual orientation spikes. The major difference is that with these two spike themes one does not generally think of "OCD" as an initial consideration. As a result, most persons with these spike themes generally have a long and painful history of seeking and obtaining fruitless guidance from others in a effort to bring a reasonable resolution to these seemingly legitimate issues. The predominant distinguishing variable which can help determine the difference between a legitimate conflict (i.e., relationship or orientation confusion) and an OCD sufferer's torment, is the felt need and anxiety experienced by the sufferer to gain an immediate, definite, and conclusive resolution to the question.
Spikes pertaining to being gay or to not being in the correct relationship have a great deal in common. Many friends, family members, and mental health professionals are all too often willing to entertain the noble effort of helping someone come to a decision related to whether or not to remain in a relationship or to pursue a homosexual lifestyle. Unfortunately, there is ample opportunity for non-experts to provide a great deal of misguidance and misinformation for the OCD sufferer as to what makes someone gay or what variables make for a substantial relationship. In one case, a mother of a patient said to her daughter "If you have this many questions, this close to the wedding, then there must be a big problem." The weight of this feedback eventually led to the termination of a wonderful relationship. In another case, a gay spiker confessed in anguish to a school official that he was going through hell with the fear that he might be gay. His former high school coach sat him down and admitted that he had gone through the same torment in his own coming out process. Needless to say, this misguided, yet supportive information set back progress a couple of months. Suffice to say, these two themes are rampant in many of our day to day lives. Therefore, it is understandable that without properly identifying that the origins of these questions are OCD related, it is easy to believe that, in providing guidance for questions which have no definite answers, tremendous help in being offered. However, such "help and guidance" actually fuels the dilemma and distracts from the genuine issue at hand.
OCD sufferers who spike about washing their hands until they "feel" clean or turning off a light switch until it "feels" complete make a critical error in information processing. They allow their experience to guide their choice as to whether they have completed the task. This is a mistake since the prevailing conceptualization of OCD today is that the fear center of the brain (amygdala) is impaired and considered responsible for the OCD sufferer's acting in such an unreasonable way. The sufferer remains completely aware of the irrational nature of his or her concerns. Persons who do not experience OCD flip a switch once because they perceive and think that the light is off, or they shut the water off because they no longer think that dirt is on their hands. Non OCD sufferers rely on perceptual information to complete these tasks. OCD sufferers continue to perform a task, either behavioral or mental, until they no longer feel unsettled or threatened by its incompleteness. It is currently believed that since the part of the brain responsible for sending a signal of warning or danger is misfiring, the OCD sufferer is performing the escape or undoing response until they have calmed down their brain. In the non-clinical population, decisions to remain in a relationship or awareness of ones sexual orientation are in these instances based on experience. With these circumstances it is generally thought of as a given to rely on emotional variables to guide ones choices which pertain to being gay or staying with ones partner. The gay spiker and the relationship spiker are strongly aware that there is a reasonable basis on which to make these types of decisions based on experience. Therefore, they tend to be very reluctant to commit to a relationship or behave in a heterosexual manner without using emotional variables as a guide. Since the emotional portion of the brain is misfiring in OCD sufferers, it is essential that they abandon what would otherwise be a reasonable means of seeking guidance.
Maybe my pain is the natural outgrowth of having these real questions
Hey, isn't it natural that if you are considering breaking up with someone, that you would feel a great deal of pain and anguish?… Wouldn't anyone remaining in a relationship for all the wrong reasons feel this torment and guilt?… Isn't the coming out process, a tremendously stressful time for anyone?… Maybe I don't have OCD… Maybe I'm just here (i.e., therapy) as an excuse to avoid the horror of facing my true homosexual self. Just as we cannot ultimately prove that one cannot get AIDs from a door-knob, proof is also not available to those who ask these commonly sought after questions in therapy. These reasonable questions elude to what one would go through in the real world when faced with these actual issues. Ultimately, there is no way to prove with absolute conviction that we are not making a grave mistake in treating these questions as an anxiety disorder, when what one really needs is relationship counseling. Since obtaining an answer to these unsolvable questions is impossible, we are ultimately left with the opportunity to choose to pursue this treatment and accept the possibility that the real issues are being neglected.
Since these two spike themes have so much in common and tend to co-occur so readily, I felt that this article would provide a helpful guideline for the many persons who are challenged with either or both of these dilemmas.
The Gay Spike
The majority of sufferers with this form of OCD evidence a completely traditional and non-conflicted childhood and adolescence related to sexual mores and identity. A lifetime of unwavering clarity related to their sexual orientation becomes spontaneously interrupted by the panic-stricken need to fully ascertain that they are definitely straight. A complicating norm of early and mid adolescence is the tendency of children of both sexes to engage in natural same sex exploration. This common tendency may explain the rampant nature of this spike theme occurring at this vulnerable developmental stage in life. At some point in mid-adolescence to early adulthood, the onset of OCD is triggered, usually with panic attacks and the associated idea that one may be gay. Generally, what follows is a never-ending expansion of an internal cognitive search for some conclusion to firmly establish the sufferer's sexual orientation. Many sufferers take their endless search for an answer to the point of absolute desperation. In order to avoid being reminded that the painful question exists, persons will stop making eye contact with others of the same sex. In some rare cases persons have actually engaged in homosexual behavior to find a resolution to complete the search. These people think that if they find the encounter stimulating, then they are gay. On the other hand, if they are turned off by the encounter they feel they can rest assured they are straight. Unfortunately, even desperate acts such as this provide nothing but more questions. Typically, the obsessive doubter will examine, with profound scrutiny, their arousal levels while viewing members of the opposite or same sex. It is within this desperate effort that deeper levels of ambiguity are delivered as a payback for the OCD sufferer’s desperate search. The age-old adage, "the more we learn, the more questions we have" is certainly relevant here.
For the human sexual process to work effectively, the combined experience of both relaxation and arousal is a necessity. As it turns out, being anxious and aroused are mutually exclusive experiences. With this in mind, it becomes clear why any desperation related to an effort to become aroused has a paradoxical backlash effect of discomfort and non-sexual-responsiveness. "Gay spikers" often desperately attempt to use their ability to become sexually excited by persons of the opposite sex as a reassurance that they are completely straight. It is also sometimes the case that the more desperately one tries to not be aroused, the more one is likely to experience sensations in their groin, which could easily be mistaken for arousal. I often refer to this as a "groinal response", which is generally experienced equally by both male and female patients. The brain's desperate effort to search for any signal that might suggest the slightest hint of arousal furthers the likelihood that such an experience would be found. If a "gay spiker" were to see an attractive person of the same sex and check whether they are having a completely neutral sensation in their groin, there is a significant likelihood that they would feel a tingling and miss out on the opportunity to disqualify their homosexual inclination. This actual physical experience in their groin often validates in their own mind that they have definitive proof that this is not just a psychological condition but an actual manifestation of homosexuality. I am often confronted with the statement, "But Doc… if it were just an idea I'd be able to live with it… I actually feel something going on down there , so, I know it must be something more that just a question."
The desperation of the OC sufferer’s effort in getting an answer becomes inadvertently the greatest hindrance to having any sense of their own sexual awareness and genuine experiences. As a sex therapist, I am profoundly aware that within the human condition it is impossible to know with absolute certainty one’s own sexual identity. Many humans go through some period in their life where they question their sexual identity and sexual preferences. Although unsettling for most who go through this normal developmental process, it is nothing like the torture of the OC sufferer's desperate need to find an answer. Since this natural questioning process takes place during adolescence, and since the onset of OCD is also associated with adolescence, the common nature of this particular OCD theme is more understandable.
Within the obsessive-compulsive condition, the mere question of not being certain of one’s sexual identity becomes convincing proof that one’s sexual identity is in question. In other words, within the obsessive-compulsive’s mindset and cognitive framework, all persons on this planet have definite truths and absolute convictions about their sexual identity. Therefore, any possibility that one’s sexual identity is not firmly established, becomes a profound threat to reaching closure on this never-ending question.
It is very interesting that, for persons who have homosexual spikes, their general attitude toward homosexuality has nothing to do with the potential of this question to be threatening. Persons who are homophobic and terrified at the prospect of being gay, or persons who have a very raised consciousness about the acceptability of the homosexual lifestyle, are equally as likely to develop this form of OCD. Therefore, attempting to raise one’s consciousness of homosexuality as being an acceptable variant of a sexual lifestyle is not an effective treatment strategy. As is the case with all manifestations of OCD, the driving force for maintaining ritualizing involves: 1) the unsettling experience of merely "not knowing"; 2) the convincing sensation that one's life depends on the answer; and 3) the entrenched belief that getting the answer will solve the entire condition and bring about lasting relief. A case which exemplifies that this form of OC is about the desperate search, rather then the actual issue, came to me in early 1998. Apparently, a young man who had been completely accepting of his homosexuality for a number of years, developed the spike and terror that he might be straight. He had been agonizing that all the work he had done in coming to accept his sexual orientation was wasted. He felt that if he could only prove that being intimidated by women was not the justification for his homosexual preference, then he would be able to go on with his natural and more familiar lifestyle. Ultimately, he chose to accept that he might prefer women. With the acceptance of this possibility, he went on engaging in his own healthy and natural exclusively homosexual relationships.
Escape and Avoidance
The predominant rituals of people with this type of OCD involve a tremendous amount of avoidance of any stimuli that might provoke the question. Therefore, many persons stop looking at others of the same sex for fear that they might develop a reaction of interest or stimulation which might become further evidence of the seeming horror of being gay, or of not having the answer. There is also a tremendous amount of avoidance involved in dating or seeking out sexual contact from persons of the opposite sex for fear that the absence of an anticipated arousal response will become conclusive evidence that the threat might be real. Masturbation is also something that becomes threatening and, therefore, is often a discontinued natural practice. Internally, the rituals involve a never-ending, all consuming thought task to conclusively derive an answer at establishing one’s sexual identity. Being on a date, walking down the street, or engaging in masturbation are wonderful spike generators. If, while walking down the street, a male "gay spiker" were to notice "Boy, that guy is attractive," a predictable and equally automatic response that might follow would be, "Oh my god, why did I take notice of him…" If, someone were just about to kiss their boyfriend they might spike, "You're just going through the motions, you should be with what you really want, another woman…" Just prior to masturbatory climax, the face of a same sex friend pops into your mind. Terror and disqualifying efforts would generally frantically follow. These are very common scenarios for persons with this form of OCD.
Person's with this spike will typically do a tremendous amount of research or questioning of determinants toward what makes a person gay. There tends to be an inverse and paradoxical relationship between the amount of information one finds out about the determinants of homosexuality and the amount of doubt, ambiguity, and torture associated with ultimately not "knowing for sure." In plain English, this means that the more information the internet provides regarding "how to know if you are gay," the less convinced the "gay spiker" becomes of being straight. As more information is uncovered about the origins of homosexuality, the OC sufferer feels more distant then ever from deriving a conclusive answer. As a sex therapist, I could provide a detailed outline of what variables are explored in the psychological determination of whether a person is gay. This information would do nothing in the determination for the OC sufferer in closing the question. It is strongly recommended that little to no time be spent engaging in any discussion regarding the person's actual sexual orientation. If and when this discussion takes place, it is recommended that it be made very clear that this information gathering is not going to help the client to feel more at ease with their primary question.
Therapeutically speaking this is an extremely treatable form of OCD. However, most people dread the treatment because the therapeutic goal is the exact opposite of the person’s emotional agenda. Obviously, persons come in for treatment for this form of OCD desperately looking for the psychologist to give them the conclusive answer to their sexual orientation. For those mental health professionals who are not trained or sophisticated in the treatment of OCD, a tremendous amount of time and effort is wasted on endless attempts at reassuring the client that they are indeed not gay. On occasion, mental health professionals have even suggested giving a homosexual experience a try to help get the truth out. For those who are adept at identifying that these people are dealing not with a sexual orientation crisis, but with an anxiety disorder, the focus is not on deriving an answer about the person’s sexual orientation, but on helping a person accept the unanswerable nature of this question. As with treatment for all forms of being purely obsessional (i.e., "Pure-O"), giving one’s brain permission to be creative is a good start. Choices are encouraged which enable the "gay spiker" to allow for the constant reminder that they just do not have an answer to one of life's most important questions. For those clients who are successfully treated with behavioral techniques related to this question, the best therapeutic answer that comes at the end of treatment is the ultimate acceptance of the uncertainty related to the genuineness of their sexual orientation. "I may be gay" is then the best response to the question.
The concept of embracing a spike is paramount within this spike theme, as it is the case with all spike themes. Embracing a spike entails making an active choice to accept the uncertainty of the risk and tolerate the level of discomfort associated with the risk. A method of enhancing one's capacity to embrace challenges involves taking the opportunity to inquire within yourself whether all of your resources have been depleted. "Am I willing to persevere with the level of distress I am currently experiencing or have all of my resources been depleted?" If there is even a modicum of resilience left it is advised that a short interval be set aside to bear with the challenge and reassess one's resilience at a later time. During this interval, it is paramount to be willing to be reminded of the unresolved nature of the spike as often as your brain chooses to go there. The goal of embracing the spike is not to get rid of it but to manage it effectively.
Within the last weeks of treatment I frequently ask clients with this spike theme, "Are you gay?" I become affirmed in the client's clinical gains when they look at me with a smile and a wink and say, "I’m not sure," "I don’t know," or even "Let’s go to The Village and find out." One need not be sure of one’s sexual orientation in order to pursue members of the opposite sex. One need not be sure of one’s sexual orientation to ask a person out on a date. It is critical that, while following through on these potential interests, that one not search within themselves to derive an answer related to concluding that they are now sure what their sexual orientation. In other words, if at the end of treatment you find yourself having a "great time" on the fourth date, do not use this information to be convinced that this means you’re not gay and that this was OCD all along.
As is the case with all forms of treatment, with all forms of OCD, the clinical course initially involves the client establishing a hierarchy. In behavior therapy, a hierarchy is a stepwise list of items in ascending order which spell out challenging ideas. In this case, the items pertain to stimuli which provoke the potential reaction or questions about one’s sexual identity. A very common first step would be to have a person walk down the street and rate on a scale from one to ten the attractiveness of persons of the same sex… "After all, if I weren't gay, why would I be rating anyone of the same sex over a one…?" Mid-range exposures often entail watching movies such as Boys don't cry or But I'm a cheerleader At some point up the ladder the gay spiker might rate how cute the butt of another guy might be… And as a celebration of one's grand success, I recommend that the gay spiker go to web sites such as WWW.Gay.com and WWW.comingoutstories.com. Here, a multitude of stories are offered which match up with the confusion that the OCD sufferer was going through. And there are always the great photo layouts of your favorite gay porn star. Well, I'm sure you get the idea…
As in treatment of all forms of OCD, the disposition one possesses in engaging in these behavioral exercises can be as important as the exercises themselves. One of the primary dispositions that occurs regularly in the course of treating these forms of OCD entails the concept of embracing challenges, ambiguity, and emotional discomfort. I'd like to take this opportunity to define the word "embrace", since it is such a paramount part of treatment success. Embrace signifies making an active choice in deciding to tolerate both one's level of discomfort and accepting the cognitive threat which accompanies the spike. Ways of enhancing one's willingness to embrace challenges entails the honest questioning of oneself as to whether or not all of one's resources have been tapped or depleted. A question such as, "Am I completely at the end of my rope or do I have enough resilience at this moment to put up with the unsettled experience for at least ten more minutes?" In making the choice to manage the challenge for this designated time period, it is important that one be willing to be reminded during that time period regularly that the challenge is still present. Be very aware that one's goal here is not to be rid of the reminders of the questions or the reminders of the discomfort, but to make room for and manage these reminders.