I have completed a 14-hour course on Obsessive-Compulsive Disorder, which defines the malady as a matter of profound doubt. OCD, the creator of the course says, comes down to doubt that produces fear, which then, in turn, drives compulsive or ritual acts and stokes obsessional, often intrusive, thoughts. While I learned a lot and am already integrating insights into my clinical practice, I’m starting to have my own doubts about that founding premise.


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Before explaining, I want to address common misconceptions. OCD has become part of popular jargon. People will off-handedly describe themselves or someone else as “OCD” to connote a basic kind of perfectionism or finicky sense of order and neatness. Clinical OCD, by distinction, is a great blow to a person’s daily functioning. Obsession with neatness, cleanliness, symmetry, or aggression, for example, emerges out of deep fear. This fear spreads through whole personalities, including those of family members and others who are close to the person with OCD. There are certain terms that we work to get out of one’s daily vocabulary because of insensitivity, and I would argue that (casual use of) this term is one of them. Every joke about OCD casts a shadow on someone struggling to lead the semblance of an ordinary life.


Second, “compulsion” is a specific word that people often confuse with “impulsive.” In clinical language, however, they are different and require different therapeutic approaches. Impulsive behavior comes with a sense of risk that pushes into enjoyable or “ego syntonic” feelings. Imagine this scenario. You are in a meeting with colleagues and your phone is on the table. You see it light up with a notification. You know that checking the phone during the meeting can send the message that you aren’t paying attention or that you are disrespecting the speaker or the task at hand. The act of checking the phone is thus checked by a sense of propriety. But the desire to know who texted is so strong that you now find yourself in a battle against your impulse to pick up the phone and look at it. If you pick it up, you’ll feel a little rush, and that’s the pleasure of finding out - but this act of looking is also a need for instant gratification, which suggests a broader problem of phone dependency and dopamine seeking. In short: this episodes highlights thrill of risk, excitement through anticipation, desire for pleasing fulfillment, and generally ego-syntonic behavioral patterns as markers of impulsive action.


Compulsive action is basically the opposite. Compulsive actions seek to end risk and acquire certainty. Doing the action is not pleasurable; it is necessary. We call this “ego-dystonic.” Imagine this scenario. You have left the house in your car, and you’re about a mile from home. A thought occurs to you: did I leave the stove on? The thought pricks you and gains strength. You ruminate on it by chewing it with your thoughts. If you cannot find a sense of relief without going back to check, then you are compelled to go back. People with OCD feel this compulsion regularly, and it is accompanied by great discomfort. Worse, even after checking (or aligning, or washing, or yelling), the sense of fulfillment never comes. The doubt lingers. Without resolution, the compulsive act may take place over and over again. This can, and often does, lead to emotional and/or physical injury (sometimes likened to “self harm”).


Obsessions are easier to understand. These are thoughts that impinge on the thinker. They push in from without. They are often graphic, violent, and most frequently run counter to the thinker’s morality and preferences. These thoughts do not go away. They are the motor for compulsive behaviors. The latter seek to remedy the former. According to the clinical literature, all of this, collectively, can be attributed to doubt. A person doubts (about their capacity to fend off aggression, to keep their eyes averted from people’s body parts, to maintain cleanliness), and what follows is a ritual of ridding the self of doubt. If, for example, my steps always add up to even numbers, then I will be able to prevent a panic attack. Or if I touch the insides of my cheeks with my tongue in a very precise order, then I won’t tell that person that they are an asshole. In other words, I doubt my capacity to function normally or maintain health in the absence of these protocols I have created.


But here’s where I raise a question: are we dealing with doubt or with certainty? These are opposite beliefs…but not always. For example, I can doubt my ability to remain clean outside of my house, but I can also be certain that I will become contaminated outside of my house. Are these the same? Do we treat doubt and certainty the same way? The answer is no, but the nuances of that answer drudge up the gradual institutional shift away from psychoanalytic theories and toward behavioral adjustment. Investigating the difference between doubt and certainty in the context of OCD provides another opportunity to challenge that institutional shift and rethink what exactly we as therapists are dealing with when we meet a client suffering from clinical OCD.


Zwang

The original, Freudian term for this cluster of symptoms was Zwangsneurose (translated, misleadingly, as obsessional neurosis). Zwang is a great word and deserves analysis because of its rich tradition across different fields of literature, history, clinical work, and mythology. Unlike what the English translation of “obsessional” suggests, Zwang means compulsion; constraint. It appears in multiple German words where it consistently modifies the meaning of its partner word. For example, zwangsläufig (meaning “inevitable”) makes meaning by affixing Zwang to läufig, which is the suffixal adjective formed from the verb laufen, meaning “Running, moving, coursing, or tending toward a direction.”

In machine engineering, a Zwangslauf (“constrained motion”) describes a system where the movement of one component deterministically forces the exact, unalterable movement of another (such as gears, pistons, or cams). A mechanism functioning under these physical conditions was described as inevitably running according to a predefined course. By the late 19th and early 20th centuries, the term moved from mechanical engineering into logic, sociology, and political economy to describe events that follow inevitably from prior conditions—e.g., a process moving down a track where no alternative vector is physically or logically possible. Something that is zwangsläufig is inevitable because its trajectory (”running,” “course”) is entirely dictated by the structural constraints (Zwang) acting upon it.


Zwangsläufigkeit is the relentless, mechanical causality that binds the subject to a fixed track. It is the state of being fated, destined to find a certain outcome. Zwang produces the rigidity. If we follow that word back to classical philosophy, it tends to appear beside its opposite, which in English would be clinamen. Zwang is fixed reality, clinamen is the swerve, as Epicurus (using παρέγκλισις), and later Lucretius (translating the Greek into Latin as clinamen), hypothesized. Zwang is universal certainty. Clinamen is contingency. Zwang’s ontological and cosmological status even found personification in the Ancient Greek goddess Ἀνάγκη (Ananke) who expressed inevitability, compulsion, and necessity. She was in fact the Mother of the Fates. Whereas Zwangsläufigkeit constrains the flow of events to inevitable conclusions, Zwansneurose constrains thoughts to repeat obsessional patterns and behaviors to compulsive action.


Freud picks up this thread of Ananke in Civilization and Its Discontents (1930, Das Unbehagen in der Kultur (”The Uneasiness in Culture,” p.140). He writes,


We can only be satisfied, therefore, if we assert that the process of civilization is a modification which the vital process experiences under the influence of a task that is set it by Eros and instigated by Ananke [Ἀνάγκη] — by the exigencies of reality; and that this task is one of uniting separate individuals into a community bound together by libidinal ties.


That is to say, living in a society produces stress and discontent. How did this stressful social environment come to be the norm for human kind? Freud theorizes that it arose from the dynamic power of Eros acting within the constraints of reality. Human culture, not unlike a culture of bacteria, coalesces around the exigency of social bonds tied up artfully with Eros (which is more than erotic love). The key notion here is that there is no individuality without society and these social bonds, which means individuals are constrained within collective life. While that comes with certain benefits, like strength in numbers, it also means that individuals must cede pure autonomy and neuter the impulse to act only according to one’s desire. We are all constrained. As such, it makes sense that some people attempt to resist this civilization- and culture-sized constraint through specific obsessions and compulsions.


From Zwang to neurosis

Recasting OCD as a fitful adjustment to the constraints of social living means understanding “Zwang” not as an ontological certainty but, rather, as a human-made process of assimilation and acculturation. Once we challenge the idea of OCD as a pathological condition linked exclusively to misfirings in the basal ganglia, amygdala, and other regions of the brain, we can reframe the “disorder” as a fit caused by being ordered. Even if one believes that a goddess is producing a fated path, a person still has to deal with all the ways that the dictates of the profane world demand behaviors and compliance from each of us.

What, then, are the “compulsions” linked with OCD? What are the ritual behaviors that follow on the heels of intrusive thoughts that often feel alien to the thinker? Astrid Gessert brings a Lacanian perspective to these clinical questions and asserts that what the DSM calls clinical compulsions and related obsessions are better understood as an “idiom of distress” “that articulates a subject’s particular attempt at resolving fundamental questions of existence” (xvi). Each thought and ritual behavior works to impose an injunction: I must or I must not do these specific things. Why must I? Because I am certain of something that I do not want to be true. To deal with that, I will replace that certainty with another belief, a belief that I have the power to modulate certainty and contingency through my own actions. In a sense, I am certain that my individuality is linked inextricably with others (and that’s unsafe), so I will act as if I am an autonomous individual capable of producing and sustaining other certainties. To act as if is to acknowledge on some level that I must perform in order to belong. Such a recognition of the crucial role of performance in everyday life prepares the the shift away from doubt toward certainty. OCD is less about superficial doubts regarding banalities of everyday life, as in “Did I leave the stove on?” and more about radical certainty regarding the structural exigencies of the social fabric from which I cannot extricate myself.


Psychoanalysis seeks to help the obsessional person confront the truth they don’t want to be true. Theorists and practitioners of this persuasion hold that the fundamental truth is the same for most people. First, I am a body that is defenseless against the entropic forces of the universe. Second, my entire self is structured around a lack, an incompleteness, one that can never be made whole. This “lack” is the missing Other in me, the relational existence I lead that denies any truly autonomous action. Even though there is no wholeness, no completeness, I still desire it. Worse, I am driven to pursue it. Still worse, desire as such cannot be fulfilled because if it were then desire would end and I would cease to have purpose. Drives compel me to seek my desire but also have no intention of fulfilling it. And this is not only my predicament. Others have it, too. I may even find myself standing in as the object of the Other’s desire, which means I run the risk of becoming the end of that person’s existence should they obtain me. The whole situation is thoroughly vexing, maddening. The very worst part is, there is no escape from it.


The only possible way to avoid this play of the self and the Other is to produce a desire that can exist independent of the Other and the social field. This would be a pure desire. Again, there is a truth hiding here, the truth that the Other is indeed the locus of desire as such, and, because of that, the construct of a pure, unadulterated desire is imaginary. The imagination is able to project a version of desire and reality only as long as the self can sustain the compulsive actions and obsessional thoughts. This creates an impossible task and a thoroughly tiring existence. Gessert, writing about Luca Bosetti’s article in Obsessional Neuroses: Lacanian Perspectives, explains the obsessional’s plan:


He attempts to split the Other into an “Other of demand” and an “Other of desire”. By setting up the Other of demand who introduces rules and prohibitions, and who is endowed with rationality and consistency, the obsessional destroys the unpredictable and unfathomable Other of desire. While submitting to the set of rules and prohibitions of the Other of demand he can keep his desire alive as an impossible desire. (xx)


This would be an absolutely ingenious plan if it wasn’t all based on illusion. The illusion only exists because the obsessional person is certain that he is caught in an unfulfilling game of desire conditioned by social rules that predated his existence and over which he has very little power.


Treatment

The goal of treatment is to convince the obsessional person to stop bypassing the certainty of desire’s elusiveness and its imbrication with social living. Here again is Freud’s Eros and Ananke. Due to the fact that humans long ago elected to form social ties and build institutions to promote and sustain those ties, each subject must accept the objective power of such ties and institutions. Repressing Eros, whether we are talking about libidinal urges or evocative drives, only leads to more suffering. This does not mean that each person’s life is fated. Rather, it means that all search for purity and wholeness is based on illusion. Instead, we ought to seek moments when a minimal deviation—the swerve—becomes playable in the field of the social.


Instead of using purely behavioral methods and exposure therapy to exhaust the fear centers of the brain, what would happen if we started to treat OCD as a matter of performance? If each habituated and compulsive gesture is a performance rather than an absolute, fated necessity, the subject introduces a microscopic gap between the impulse and its execution. Awareness of the paradigm to Perform or Else in daily life could be a strong starting point. Each of our actions is compelled of us by structures that appear natural but are entirely fabricated. We feel the injunction to act according to pre-made roles and rules. We know we are being ordered. What we don’t know is that between the bodily cue that announces the social conditioning and the performed action that either represses, plays off, or accedes to the mandate exists a tiny crack through which something new might emerge.


What if doubt is a red herring? If the obsessional is certain that their individuality is compromised by the social fabric, yet creates a ritual to claim temporary agency, then they are using ritual to manufacture a temporary doubt about their own powerlessness. Doubt is not the foundation of OCD, it is the malady’s greatest invention. In Therapy Yet to Come, I argue for a repoliticization of therapy because of this tendency for therapeutic theory and practice to mistake symptoms and what Lacan calls synthomes. The latter is an act of production through which subjects learn to bear the weight of social existence and the status of the self as wanting. In clinical OCD, doubt is conjured negatively through repetition and constant adjustment. If we developed that negative image as one might develop a photographic negative and then printed it, we would see an image of desire.