My writing should sell, or I’m a failure, but if I write for money, I will have no integrity.
I should do my best to stay thin, while bearing in mind that only trivial-minded women think about these things.
I should be a perfect and ever-attentive mother to my son, without being the kind of reactionary betrayer-of-the-sisterhood who allows her husband to support her.
I read them out to the therapist and realized, again for the first time, that they were entirely laughable. Now that did help: I saw, really saw, that my internal legislator was a ridiculous figure, who had never deserved the attention I’d been paying her. When she turns up these days, which she still does, I try not to engage with her too much. I suppose that, in principle, if I made enough of an effort, I could oust her altogether, and even stop my picking as well, but I’ve been living with these symptoms for decades now, and, to be perfectly honest, the thought of losing them almost terrifies me. What would I do without them? Who would I be then? And what could I blame when I failed?
This course of CBT had begun, as they always do, with the filling in of inventories. When I handed them back to the therapist, I shared my scepticism about them. No, she agreed, they weren’t perfect instruments, but you had to use something, and it might as well be those. And as for CBT, no that wasn’t magic either, but it was worth trying, because it might be some help at least. In a similar vein, when we discussed diagnoses, and my confusion about how many and which ones applied to me, she said that, as she saw it – as most clinicians saw it – patients were people who were suffering, who were having certain difficulties with their experience, and even though you had to give some label or other to these, to fill in some boxes, to provide some bureaucratic rationale for the treatment, all that mattered, in the end, was whether or not a person needed help, and whether or not you were able to give it to them.
This is just as well, because diagnostic categories are themselves subject to change, revision and obsolescence. I suffer from OCD; Samuel Johnson, living in another age and a different cultural context, suffered from the Hyps. It is entirely possible that in the next few decades, OCD may also become a defunct disease entity, either subsumed under a wider category, like impulse disorders, or broken up into smaller, more specific ones. Even as I write, the members of the American Psychiatric Association are revising their Diagnostic and Statistical Manual again, suggesting the inclusion of new disorders, proposing the dismissal of old ones, and arguing every point.
The compilation and revision of DSM is a Byzantine process, subject not only to the competing views and interests of the clinicians and researchers themselves, but also to those of other groups: the pharmaceutical companies who lobby for the inclusion of newly minted disorders which they claim their drugs can treat, and the American health insurance companies who would prefer to limit the number of diseases for which patients can legitimately claim funding for treatment. There are political pressures too, as ‘special interest’ groups, voluntary organizations and political activists argue for the inclusion or exclusion of this or that diagnosis. It was as a result of such campaigns that post-traumatic stress disorder came to be recognized as a psychiatric condition, and homosexuality ceased to be defined as such. As well as simply appearing or disappearing, a category may expand or contract, as the lists of criteria for each diagnosis are revised.
I have seen OCD described as an ‘imperializing’ diagnosis. Since the 1970s, estimations of its prevalence have risen from between 0.05 per cent and .005 per cent51 to around 2 per cent52of the population, a huge rise, suggesting that there are over a million sufferers in the UK alone. The older, more conservative estimates reflected the fact that, until fairly recently, only those too severely affected to hide their condition would have been diagnosed. This group were, and remain, difficult to treat. The difference between the two sets of numbers has been made up by people like me, who are mildly to moderately affected, and who have been found, in many cases, to be responsive to the pharmaceutical and therapeutic treatments which have appeared since the earlier estimates were made. It is not that we respond to treatment because we have the disease; it is that we have the disease, by definition, because we respond to treatment. If Prozac helps you with your shyness, then you have social anxiety disorder; if it alleviates your grief, you’ve been suffering from reactive depression. It’s very much that way round.
There are differences, important ones, between psychiatry as it’s practised in America and psychiatry as practised in the UK. If I were in the States, I would probably be on three drugs rather than just the one: my daily antidepressant, of course; a second drug, such as Xanax or Klonopin, which I could use when I needed to alleviate anxiety; then a third drug, perhaps to take the edge off some of the side effects from the other two. I would have a GP, a ‘family physician’, but I would also have a psychopharmacologist (do they even exist in the UK?) to visit, and we could experiment together. Maybe I would make an appointment after seeing a television advertisement for some exciting new product or other – ‘Why not ask your doctor about . . .?’
I was in America for ten days last summer, and I found these advertisements jaw-dropping. They made me desperately sad, too: they made me think of my brother, who had spent most of his adult life in the States, and who had been diagnosed two years earlier with adult attention deficit disorder,53 and prescribed, for a brief but catastrophic period, with amphetamines to treat it. As he came from the UK, with its socialized medicine, it had always been especially hard for him to negotiate the American medical system, with its competing practitioners and institutions, its insurance companies and its huge bills. After our father died, he was physically ill for over a year, and had to undergo expensive tests for every syndrome under the sun before being diagnosed, in the event retrospectively, with temporary thyroiditis. He also became very depressed – or grief-stricken, perhaps? – and tried several antidepressants before he found one that suited.
And he couldn’t afford to be ill. He had to finish his PhD. Then, when he did finish, and moved to the west coast to take up a post-doctoral position, he had to work, to keep producing, and keep publishing, in order to prove his worth. When the back pain which he had experienced since he was a teenager became much worse, the effects on his work, and his morale, were dreadful. The back pain was treated with the first of a number of cortisone injections. He and his wife moved to a town in the Midwest to take up a pair of tenure track positions; the pain kept recurring, and, after a struggle with his insurance company to persuade them to fund treatment with a surgeon he actually trusted, he had surgery on his back.
He still couldn’t afford to be ill, of course – he was on the tenure track; he had evaluations every year; he had to work; he had to recruit and manage the staff in his lab; he had to publish. His wife was in the same position. They had a baby daughter, and together stepped off the tenure track for a year, which, again, they couldn’t really afford to do – but had to. It was some time around her first birthday, if memory serves, that he was diagnosed with ADD.
After the brief but catastrophic period, he came off the amphetamines. He changed psychiatrists, and changed his therapist too. I couldn’t tell you which, if any, medications he was taking after that, because he never told me. Neither, for the same reason, could I tell you what he’d been given to understand was wrong with him. Maybe if I had been a more willing traveller, and had been prepared to take the time away from my home, and force myself on to the planes, to see him in person, we might have had a few proper conversations, and he might have told me then. He did suggest, over the phone, on more than one occasion that Chris and our son and I might like to come over and visit, to, you know, ‘just hang out?’ It always sounded like a casual suggestion, not as if he was desperate to see me, but just as if, you know, in that ascending American way that my brother used to finish his British-accented sentences, it would be nice? I thought it would be nice to see him too – I missed him – but the thought of travelling on all those tr
ains and planes and automobiles to the Midwest with a small child and then dealing with the jet lag on top of that, and then having to do the whole journey again in reverse made it seem quite impossible. I just hung on and hoped that he and his wife would decide to take their daughter on a visit to the UK, thus relieving me of the responsibility for travel. Stupid, selfish woman.
In spring and summer last year, I would often entertain fantasies of taking a plane or two by myself and arriving unannounced on his doorstep, so that we could have our proper talk and I could find out how he was, really. I hadn’t heard from him in a while, and our last conversation had been strained. There was something in the tone of his voice that suggested he’d rather not have to talk to me, or anyone else from his UK family, not even over the phone, that he wanted, and needed, some space to think away from us, but I felt, in my gut of guts, that I should go and see him face to face, or otherwise – otherwise what? I stayed in the UK, and worked on ‘Avoidance’, and described my Unbearable Feeling as if I had no particular reason for it. Then my uncle phoned to tell me that my brother had taken his own life. And so I had to make that trip, with my mother, in the end.
After some toing and froing, Bloodaxe accepted my second poetry collection in the summer of 2006. I was all poetried out again, and thought I might try and write a novel. I’d written a few short stories in the previous year, so it seemed like a reasonable ambition. All I needed was a decent idea, one for which I could sustain my enthusiasm for more than a couple of months. How about, I thought, a novel about a woman with OCD and her long-suffering husband? So I started to make notes, writing down lists of intrusive thoughts, memories of conversations, that kind of thing. Then I tried to change the central characters, to make those alterations that writers use to distance their fictional creations from the real-life people whose attributes they’ve ripped off to use as their starter ingredients. That’s when I got stuck, and it occurred to me that I hadn’t seen too many OCD memoirs. Depression, yes; anorexia, plenty; self-harm, getting there; OCD, not too much. It was inevitable that someone was going to write one at some point, so, I thought, it might as well be me.
And yet . . . I really wanted to write a novel. Novels were what proper writers wrote, and to write a memoir instead seemed, by contrast, like a failure of imagination, of creativity. It was a lesser form, I thought, and a narcissistic form at that; it was an act of unadulterated exhibitionism, in a way that even the most autobiographical poem, with its ritual clothing of rhythm and imagery, somehow manages not to be. I was concerned, too, about the morality of writing about all the people who had been involved in my life but happened not to be me, or to have chosen to have themselves depicted in someone else’s book.
I had lunch with a friend of mine, a novelist and self-proclaimed life-writing sceptic, and confessed that I was thinking of writing an OCD memoir, a piece of mad lit. She thought about this; it might be worth doing, she said, if it were done well enough. She could let me get away with it, she added, as long as I promised – promised – that I wouldn’t give it a redemptive ending. So I promised, and now here’s the ending, the real ending.
A couple of weeks after my brother died, I had a dream about him. I was at one of the innumerable dream versions of my mother’s house, when the phone rang. She picked it up, listened, and turned white. ‘It’s your brother,’ she said.
I told her to give the phone to me, took it into the downstairs toilet, and locked the door. Then we had one of our normal, bantering conversations, and laughed together, entirely as if nothing had happened. We kept this up for five minutes or so, and then there was a pause. I felt something change, in the dream atmosphere, and in me, and then I asked him, ‘So why did you do it?’
There was a silence.
‘Do what?’ he asked, as if he really didn’t know.
‘You know,’ I said. There was another silence and when he spoke again, he sounded as he had done in our last waking conversation: guarded, offhand, evasive.
‘I got distracted,’ he gabbled. ‘Things were distracting me. Look – I have to go now – ‘bye!’
Then he hung up, and I think that’s as much of an answer as I’m ever going to get.
51. Lennard J. Davis, Obsession: A History (University of Chicago Press, Chicago and London, 2008, p. 209)
52. Source: the Royal College of Psychiatry’s website
53. Although this diagnosis is almost unheard of the UK, it is far from uncommon in the States.
A note on permissions
The author and publisher wish to thank the following for permission to quote from copyright material:
The Padua Inventory reprinted by permission of Ezio Sanavio; Jacob’s Room by Virginia Woolf, reprinted by permission of The Society Authors as the literary representative of the Estate of Virginia Woolf; Pull Yourself Together!, reprinted by permission of the Mental Health Foundation; Sigmund Freud © The Institute of Psycho-Analysis and the Hogarth Press for permission to quote from Volumes 9,10 and 16 of The Standard Edition of the Complete Psychological Works of Sigmund Freud translated and edited by James Strachey, reprinted by permission of the Random House Group Ltd; ‘Developmental Precursors of Depression: the Child and the Social Environment’ by Elizabeth McCauley, Karen Paulidis and Kim Kendall and ‘Child Depression: Clinical Phenomenology and Classification’ by Israel Kelvin and Hartwin Sadowski in The Depressed Child and Adolescent, edited by Ian M. Goodyer, reprinted by permission of Cambridge University Press; Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well by Fred Penzel, reprinted by permission of Oxford University Press; ‘What She Said’, words and music by Johnny Marr and Steven Morrissey © 1985, lyrics reprinted by permission of Universal Music Publishing Limited (50%), and Warner Chappell Music Ltd (PRS) on behalf of Marr Songs Ltd (PRS) and Bona Relations Ltd (PRS) (50%), administered by Warner Chappell Music Ltd (PRS); The Second Sex by Simone de Beauvoir, translated by H. M. Parshley, first published by Jonathan Cape, 1949, reprinted by permission of the Random House Group Ltd, (new translation published by Jonathan Cape in 2009); Mind Over Mood by Dennis Greenberger and Christine A. Padesky, reprinted by permission of the Guilford Press; material reprinted from Behaviour Research and Therapy 40 773-791, Roz Shafran, Zafra Cooper and Christopher G. Fairburn ‘Clinical perfectionism: a Cognitive Behavioural Analysis’, © 2002 with permission from Elsevier; questions from 1991 Philosophy Tripos Part II Ethics paper reprinted by permission of the University of Cambridge; A Life of One’s Own by Joanna Field/Marion Milner, reprinted by permission of Paterson Marsh Ltd on behalf of the Estate of Marion Milner; The Suppressed Madness of Sane Men by Marion Milner, reprinted by permission of Cengage Learning Services Ltd; from The Language of Psychoanalysis by Jean Laplanche and JB Pontalis, published by Karnac, London, UK © Karnac, London UK; Contemporary Psychoanalysis: ‘Dialogic Analysis of the Obsessional’ Vol. 10, Issue 1 pp. 87–102; Wild Mild by Natalie Goldberg, published by Rider Publishing, reprinted by permission of the Random House Group Ltd; ‘Wake Up Boo!’ by Martin Carr © 1995 Warner/Chappell Music Ltd (PRS), all rights reserved; The Boy Who Couldn’t Stop Washing by Dr Judith Rapoport, © 1989 by Judith L Rapoport, M.D., used by permission of Dutton, a division of Penguin Group (USA) Inc; ‘Novocaine For The Soul’, words and music by Mark Everett and Mark Goldenberg Copyright © 1996 Sexy Grandpa Music, Faux Music and Bug Music-Songs Of Windswept Pacific, all rights for Sexy Grandpa Music controlled and administered by Almo Music Corp. All rights for Faux Music controlled and administered by UB Music-Songs Of Windswept Pacific, all rights reserved – used by permission; Prozac by Ronald R Fieve, reprinted by permission of HarperCollins Publishers Ltd © R Fieve 1994; ‘I Scare Myself’ by Dan Hicks © Oh Boy Music CO. (ASCAP) all rights on behalf of Oh Boy Music Co. (ASCAP) administered by WB Music Corp. (ASCAP) all rights reserved; Eve: Sex, Childbirth and Motherhood Through the Ages by Petrina Brown, published by Summersdale, by permission of the author; Journal of Clinical Psychiatry 67:8 1285–98, Lori E Ross and Linda Mc
Lean, ‘Anxiety Disorders During Pregnancy and the Postpartum Period: A Systematic Review’ © 2006, reprinted by permission of Physicians Postgraduate Press, Inc; from Obsession, Psychic Forces and Evil in the Causation of Disease by Arthur Guirdham, published by C W Daniel/Neville Spearman, reprinted by permission of The Random House Group Ltd; Overcoming Obsessive-Compulsive Disorder by David Veale and Rob Willson, reprinted by permission of Constable & Robinson Ltd.
Every effort has been made to trace or contact all copyright-holders. The publishers will be pleased to make good any omissions or rectify any mistakes brought to their attention at the earliest opportunity.
Acknowledgements
Thanks, first of all, to everyone at Atlantic, especially Angus McKinnon, Karen Duffy, Sarah Castleton and Caroline Knight; also to Louisa Joyner and my agent, Louise Greenberg. I would also like to thank David Veale for his time, and for answering my questions about OCD; Esther Binns, for answering questions about neuroscience; the health professionals whose contributions to my medical notes have been quoted in the text; Ruth Bell-Pellegrini, for help with permissions; Magdalene College, Cambridge; the Royal Literary Fund; Rowan Pelling, for encouraging me in the first place; my family and friends, for their willingness to be depicted; my husband, Chris, for this and everything else.
Woman Who Thought too Much, The Page 32