This blog was cross-posted here and on Dr. Szymanski’s blog on Psychology Today.
It is so rare to find a mental health condition portrayed accurately in the media. I get it… it’s entertainment. People are tuning into television shows to tune out and be entertained. But, when you invoke mental illness, could you at least get it right? So, when we saw that Lena Dunham, writer and star of the HBO show Girls, was tweeting about how the International OCD Foundation website had been a resource for her and that her character was depicted as having OCD in episode 8 of this season of the show, I scrambled to watch the episode (apparently half of our office already followed the show).
I needed to prepare myself, however. As someone who has treated individuals with OCD for a dozen years, it is hard to watch the cartoon-like depictions of individuals with OCD in television and film — whether they are portrayed as eccentric, sociopathic, or dismissively (just another hand washer). Having seen thousands of individuals with OCD, to know firsthand what this disorder does to them, to their lives, and to their families, is really quite heart breaking. So, when I began watching the scene between Hannah (played by Dunham) and her parents, I was pleasantly surprised. Caught engaging in compulsions, she at first denies her OCD symptoms have returned, or that she ever even had OCD. Shame, humiliation, embarrassment… I’ve heard and seen it all before. Here is the thing, if you are really trying to understand someone’s experience with OCD, you can’t just look at what they are doing, i.e., what compulsive behaviors they are engaging in (doing things in 8’s for Hannah). You need to understand why. Not the Freudian why (apologies to any psychoanalysts reading this, but OCD symptoms are not necessarily about underlying conflicts). The why with OCD is unrelenting anxiety. For this character, she has to complete tasks in multiples of 8 or…she will feel incredibly anxious. Not just “Oh I feel anxious today.” Paralyzing, all consuming, pervasive anxiety. When was the last time you felt something like that — a feeling incredibly intense, day after day, that wouldn’t go away.? The death of someone close? A break up? Getting fired from a job? Yet, in those cases, your feelings of anxiety likely felt justified. You were feeling depressed, anxious, or stressed for a reason. With OCD, individuals recognize that the intense anxiety they are feeling doesn’t exactly make sense. Lena’s character demonstrates this well in the episode. Her anger covers up — barely — a sense that she realizes this has gotten the better of her. That she doesn’t want to be doing these things. These aren’t quirks and being eccentric. These behaviors are done as desperate attempts to quell unending anxiety. And now she is being found out.
Here is what else caught my attention: the family dynamics. Individual therapy sessions perpetuate the idea that the person with the mental illness is the only one suffering. As Lena’s character reluctantly agrees to go back to therapy you hear the interchange between her and her parents. They are affected as well. They worry. They try to figure out what to do, how to help. Parents can come across as critical (“We don’t know why you have OCD. It’s not our fault,” her mom says), overly intrusive (“I hate it when you look so concerned about me,” Hannah remarks to her dad), and in some cases can accommodate the symptoms, which can make this worse. Hannah’s parents on the show actually do not demonstrate any accommodation, but is common. Essentially “accommodating” behaviors are ways of participating in the compulsive behaviors with your family member in an attempt to try to be of help to them, only to find yourself as intertwined as they are in the OCD symptoms and with no end in sight. For these parents, they understand the best way they can probably help is to get Hannah back into treatment. Which they do.
In the therapist’s waiting room, Hannah again struggles with what it is like to have a mental illness. The stigma associated with it. She has to see a therapist who successfully treated “an arsonist who strapped frogs to rockets and was deeply disturbed”. If I have a mental illness, what category do I belong to? The recent debate about gun control, for example, conflates mental illness with proneness to violence. If I do have a mental illness, what is the company I keep and what do people think about me and what I’m capable of doing?
A final note about the therapy. The therapist’s nonplussed response to a description of the characters’ symptoms was perfect: he calls it “classical presentation.” While it may not be a comfort to hear, it is an important distinction to make, since most people assume OCD is about hand-washing. In fact, hand washing is not the “classic” OCD presentation: intense anxiety, intrusive thoughts, and compulsive behaviors are the hallmark of the disorder. While many people with OCD have hand-washing and contamination concerns, to only focus on this group misses an even larger part of the OCD community. Counting, repeating, intrusive violent and sexual obsessions all fall within the realm of OCD.
I have just one small critique: at the end of the show, we see Hannah on the subway with her parents holding a pharmacy bag, inferring that she has now prescription to treat her OCD. While medication is one effective treatment for OCD, it is not the only treatment. I always like to hear when people acknowledge the importance of Exposure and Response Prevention therapy or ERP. ERP is an effective, but very difficult, treatment for individuals with OCD. It will be interesting to see how the story line develops on this point.
Maybe any show that depicts mental illness has to come from a first hand account in order to do it well. Lena did a service not only to herself by letting the world “see” what the struggle looks like, but to the entire OCD community at large by showing some of the pain, stigma, and struggle any person with mental health issues has to endure.