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Self-exposure: therapy and a pandemic

Thesis as cure

 

On 31 December 2019, I wrote in my diary that 2020 would be a Year of Exposure. I had no plans to make this public. For as long as I could remember I had felt it necessary to control ‘the narrative’, which in practice meant that I resisted telling essential facts about myself to anyone other than those people who, within the stark ecosystem of my mind, fell into the categories of ‘necessary’ or ‘safe’. Behind a shame-faced semblance of functionality, I hid a version of myself that was shaped by the irrational contortions of fear that had been with me since childhood, and the failed rituals that I desperately used to exorcise myself of my terror. After years of denial, this fearing self emerged only in moments of out-of-control feeling, and within the medical settings that were designed to bring feeling back under control. Eventually, this self found the fate of a diagnostic determination. To shrinks, in their language of shrinkage, I was suffering with a Specific Phobia of Vomiting and health-related OCD.

 

After a number of aborted therapeutic interventions, in mid-2019, through a collision of events – nothing so spectacular or drastic as hitting rock-bottom, but some luck, lots of desperation and enough willingness – I began a course of treatment. The recommended treatment for phobias and OCD is Exposure Therapy, which methodically places the patient into situations they have habitually avoided, with the aim of helping them overcome their fear.

 

By the end of the year, I had found some small yet significant success. Filled with the endorphins of progressive change, I set myself on the senseless quest of self-experiment – a commitment not just to the standardised series of sessions provided by medical guidelines, but to a Year of Exposure. I made a lengthy list of things I would do; it ranged from small acts of disclosure about my phobia, to what I termed ‘vomit simulations’ – where I would spit chewed acidic concoctions into the depths of the toilet bowl – to taking a flight for the first time in three years. In my imagination, I saw myself formally joining a fugitive coalition of self-experimenters – those who for reasons of need, not curiosity, were forced to find treatments for their bodies and their minds. I was going to undergo a radically bastardised field project of Exposure Therapy.

 

*

 

Phobias are hard to understand, for the not-phobic and phobic alike. Persistent and outsized fears are primarily the realm of children and the irrational, neither of whom are privileged subjects in a world governed by the values of knowledge production and controlled emotional affect. The fabled ‘origin story’ tends to be the primary framework through which phobias are understood. A traumatic event provides the germ of a beginning, through which undigested affects supposedly attach to a meaningless object that ultimately becomes the focus of displaced feeling. This version of events offers the easy clarity of a narrative line between past pain and present folly.

 

But for many people who suffer with phobias, tracing the origins of their fear is a difficult task. Figuring out why vomiting became such a visceral threat to me is beset by impenetrable blanks, like trying to determine the archaeology of a cognitive void. My ‘story’ lacks the basic facts: I don’t know when the magnitude of my fear moved into the zone of ‘phobic’. I vaguely remember one year – between the ages of five or six – becoming hyper-conscious of my body, of the threat of invasion, of the repulsion of my body’s mechanisms. I found out from my mother that a child in nursery school once vomited on me, but this memory is nowhere in my consciousness. I mistrust this recall for the ways in which it so neatly reduces the present to merely an outcome of repressed memory.

 

That I have no sufficient origin story has been something of a point of frustrated speculation. Perhaps Freud would have told me I was stuck in the oral stage, fixated on controlling my feeding. At times I blame my parents for the provenance of my namesake, Cassandra, a Trojan woman who literally was killed for what came out of her mouth (speech, not food). Another explanation arrived via a psychic who told me that in a past life I was a French man who was hung during the Revolution for a blasphemous act (an interpretation replete with potential puns on the notion of a psychological ‘hang-up’). A concern for all things gullet-related seems the logical price of reincarnation from a body whose throat was the locus of death. The explanations that I could generate – with or without the aid of a therapist – are as various as they are insufficient, none getting to the core instability that has, in the past, made me say something as ridiculous as ‘I would rather die than vomit’.

 

Phobias that have to do with the body’s functioning – unlike dogs or heights or needles, all of which may be avoided – are insidious because they affect every aspect of how people exist, in relation both to themselves and others. It started with the fear of being sick, but it quickly become all-encompassing. I feared the smell of sickness, I feared places that people might be sick, I feared long car journeys, I feared eating food from restaurants, I feared germs, I feared dirty hands, I feared brushing my tongue too much, I feared rollercoasters, I feared flying, I feared eating too much, I feared eating too little, I feared raw chicken, I feared confined spaces, I feared emotions, I feared too vigorous exercise, I feared laughing uncontrollably, I feared illness, I feared my stomach, I feared pain, I feared the word vomit. Most of all I feared my body’s loss of control, the thing it could be when it failed. I feared and feared and feared until my neural pathways were so well-hewn that I could enter a state of unbidden panic in seconds.

 

Exposure Therapy emerged out of Behaviour Therapy, a framework that was established in the 1950s and built on the findings of Ivan Pavlov. Working in the late nineteenth century, Pavlov’s research showed that, through repetition, an animal could learn to develop specific trained responses to stimuli, otherwise known as conditioning. During observation, Pavlov noticed that a dog’s saliva could be stimulated at the mere sounding of a metronome, through training the dog to associate a ‘food reward’ with the sound. A key aspect of Pavlov’s findings – one that is often forgotten – is that the conditioned response (e.g. the metronome-induced saliva) could also be unlearnt. After several occasions of the metronome ringing with no food present, the dog’s salivary response gradually decreased until eventually it disappeared. In Pavlovian terms, the response was ‘extinguished’. This process of learning/forgetting became known as ‘extinction learning’, which remains central to the formulation of Exposure Therapy.

 

In the mid-twentieth century, following increased scientific capabilities within physical medicine, the psychiatric profession sought to establish a ‘medicalised’ model of mental health treatment, one that would resist the theoretical formulations of personality and notions of unconscious drives made popular by psychoanalysis. From this emerged Behaviour Therapy, of which Exposure Therapy was just one sub-type; it criticised Freud’s methodologies as ‘unscientific’, looking instead to create replicable psychological interventions grounded in empirical research.

 

The type of treatment I pursued through the NHS – for a complex of reasons including therapist specialism, logistical practicality, and clinical provisions – was an adaptation of Systematic Desensitisation, first developed by the psychiatrist Joseph Wolpe. As Michael Specter put it in an article for the New Yorker, ‘Pavlov’s lab was essentially a physiology factory, and the dogs were his machines’. For Wolpe, he created his own feeling factory: in the 1950s he began inducing artificial fears – often called ‘experimental neuroses’ – in laboratory cats by way of administering electrical shocks. Wolpe became obsessed with finding fear’s ‘cure’. With the aid of his terrified cats, he attempted to undo the terror he had created and, ultimately, all terrors beyond his creation. Just as Pavlov had shown in the case of his drooling dog, Wolpe believed that if all neurotic responses are learnt then, by implication, they could be unlearnt. Wolpe’s search for a human curative led him to develop the technique of ‘Systematic Desensitisation’. Founded on a belief in the simultaneous incompatibility of certain affects, it attempted to weaken the conditioned response of fear by replacing anxiety with its supposed opposite, relaxation. He figured that, through attaching ‘pleasant’ feelings to visualisations of fear-invoking situations, the patient could eventually ‘extinguish’ their phobia. A person who was phobic of driving, for example, would imagine themselves at the wheel of the car while simultaneously practicing breathing exercises and techniques of progressive muscle relaxation, until a state of perceived ‘calm’ was reached.

 

Sitting in the sparse room in a psychiatric hospital in North London – a place whose architecture resembled the set for a Hollywood asylum thriller – I positioned myself on the generic wooden chair offered to me by the therapist. Abandoned were the historical preamble of psychodynamic therapies, or the elaborate stagecraft of psychoanalysis. The therapist simply asked my reasons for seeking treatment and said that she had received my case notes from the therapist who had interviewed me two years earlier. Exposure Therapy is regimented, she explained; cradling her clipboard awkwardly, she began by asking me to list some of the fears I suffered from. The questions corresponded to a sheet that was held on the plastic board, a repetitive table that required the patient to list the activity alongside how anxious they would feel if made to give up the behaviour, or the behaviour of avoidance. The scores I gave derived from a scale that Wolpe himself had designed and named SUDS (Subjective Units of Distress Scale). This index attempted to convert personal levels of disturbance into a comparative unit against which fears could be correspondingly measured. From the list I produced, a few activities and their ‘fear rating’, scored out of one hundred: eating in a restaurant – 55, exercising – 75, going into hospital settings – 82, refraining from using anti-nausea medication – 95.  This table, known as the hierarchy of fears, lay at the core of Wolpe’s methodology. It created an ordered schema, ranging from the least to the most fear-provoking of situations. This list is supposed to provide a blueprint for the therapy, an affective roadmap of graded exposures. Each step functioned like a level in an increasingly anxious videogame, where passage to the next stage was only permitted if an adequate state of relaxation could be reached. At the end of the session the therapist handed me my own personal photocopy of my hierarchy.

 

I folded the sheet in half and put it in my bag. At home, I didn’t know what to do with it, so I took it out of my bag and put it in a drawer. The list had a gnawing effect. The hierarchy wasn’t impactful in its specificity but for what it revealed in totality, the invasiveness of the phobia made clear through the volume of items on this list. Reading through this inventory, a lifetime’s worth of anxieties, I realised how much of what constituted my ‘self’ was structured around fear and my avoidance of it. It was like looking at the scaffolding of a building that I had always mistaken for the building itself: who I thought I was was merely the buttressing of amnesia that holds the present together, an outcome not of any foundational stability of ‘I’, but rather the instability of feeling as it moved through my body. This uncomfortable ‘hierarchy’, with its privileging of terror, made plain that I was constituted less by what I perceived as my ‘self’, and more by something else – that elseness being the absence-presence of fear, a burning hole filled with things that I was too afraid to experience. Who was I without it?

 

The sessions of Exposure Therapy themselves were mechanical, a repetitive cycle of Fear-Exposure-Relaxation that involved various props and near-compulsive ‘checking in’ on the part of the therapist. How do you feel? What about now? I answered in numbers between one and one hundred.

 

Treatment of this kind was like contorting my mind into painful flexions in the hope of achieving new growth. In Bodies of Work (1997), Kathy Acker describes bodybuilding as a ‘working around failure’: a method of breakdown that entails ‘com[ing] face to face with chaos, with my own failure or a form of death’. The perilous yet mundane limit-experience of growth through decay is the body’s natural analogue to what Exposure Therapy attempts to achieve. The muscles flex, the brain extends: there is an attempt to find the apex of failure, a targeted, repetitive shock, not in order to hurt oneself but to find a recuperative breakdown. Like a bodybuilder, I wanted to see new shape to my edges, to recoup the proverbial gains.

 

Aside from the numbers I rattled off, we spoke little; the therapist knew practically nothing about me, yet each week we sat in a room and poked at the primordial panic, her hand holding the clipboard, and mine attempting not to grip the chair as we jabbed at the abject together. Session three included looking at CGI portraits of people vomiting – their graphic, pixelated spew reminding me of all the occasions of onscreen puke I had encountered before I could look away. In session six, I visualised the time that I saw someone be sick in the Boots pharmacy on Tottenham Court Road, the session devolving as I described the abstracted pool in the clean space of the shop. Session nine provided a return to a childhood, in which the therapist played Lionel Richie and Diana Ross’s duet ‘My Endless Love’ on her iPhone, a song whose syncopated rhythms and breathy refrains made me shudder in remembrance of a particular night of childhood illness. The ballad was featured on a CD-ROM of love songs that had acted as my sleep aid for years: through the magical thinking of phobic experience, its sounds had become indelibly attached to that evening’s nausea.

 

Week after week, I crossed items off my list of riddle-like terrors, but each time I felt like a disingenuous child plagiarising their homework. I recognised that the status of my ‘extinguished’ fears was tenuous at best. The intensity of feeling might have decreased, but for how long? In moments of circumspection, relaxation felt as flimsy as the sheet of paper that attempted to describe the load-bearing structure of my phobia, and still I had not managed to broach the upper echelons of the hierarchy. In the realm of fears beyond ‘50’, so much more life was contained. Experience provided me with the intuition that terror doesn’t fade so easily. This intuition, it turns out, was supported in clinical literature, which describes the sudden reacquisition of extinguished fear as the process of ‘spontaneous recovery’. In the strange reversals of language that characterise Exposure Therapy, spontaneous recovery marks the sudden re-entry of an extinguished fear, often timed with the cessation of treatment. I wondered which of my list of extinctions would make their ghostly return. Which absence was merely a temporary excision, like the superficial removal of stubborn weeds? How deep did their roots go?

 

Antithesis as poison

 

On 31 December 2019, the World Health Organisation alerted countries to an emerging number of cases of an unknown respiratory illness affecting the region of Wuhan, China. On 11 March 2020, after much discussion of ‘thresholds’ of spread, WHO made a declaration that shifted the world into the official state of being that is ‘pandemic’.

 

Only a few months into my purported Year of Exposure, the sense of exposure as a condition of being without protection could not be expunged. In a world that is attempting to stave off an invisible pathogen, suddenly everything has become ‘exposure’. Everything contains the potential for contagion; strangers, loved ones, oneself, the outside, surfaces, touch, air. In a nightmare of real contamination, my personal reference points for what I considered my sanity, health and ways of being have imploded in the quiet of isolation.

 

My Exposure Therapy sessions ended abruptly on 24 February, a few weeks before their official end date. There were no formalities and no goodbyes. Nor was I provided with any blueprint that could map my therapeutic experiences onto a world that was increasingly being shaped by the chaos of novel risk. Ever since the onset of the virus, for want of a better method, and without the support of a therapist, I have tried to make sense of what is taking place by writing it down. In purging words, I caution myself to be careful what I write. A common feature of the phobic is magical thinking: the belief that one’s thoughts or actions have a hidden causal relationship to events. This is something I have suffered since childhood but, in the acuity of a new global stressor, each sentence writhes with the necromantic potential to breathe life into fear.

 

Each day brings with it a visceral encounter with the ‘new’ of the news; the day’s reporting folding itself into the waves of a present-continuous panic. It is hard to believe there will be a normal to go back to – that ambivalent zone of being that produced the conditions for this present chaos. Days, no longer meaningfully designated, are filled with numbers. Rates of hospitalisations, rates of dying, rates of healthcare staff without protective gear, rates of new transmissions – attempts to quantify the uncertain. I watch as the on-screen map of the world is reshaped into a real-time cartography of disease, saturations of infected territories. These technologies of quantification remake the landscape through the aerial surveillance of sick bodies; a sense of place is parsed through geotagged updates of ‘Confirmed cases in your area’.

 

Plague infects every facet of the social corpus. For anyone with a case history of phobic fear, hypochondria, OCD, or body obsession, you would expect a new infectious disease to be an obvious flash point for anxiety. As someone who has lived under the label of ‘pathological’ for much of their life, I could not think about the health of my body without also thinking of the health of my mind. For all the ways that COVID-19 has changed the world, one of the most palpable is that it has abruptly reinstated a sense of the body as a carrier of openings. Strategies of mitigation – dousing ourselves in hand sanitiser, the wearing of masks and gloves, inventive air filtration systems, the avoidance of all human touch – have all failed to mass-produce a perfect state of hermetic enclosure.

 

Faced with bodily vulnerability, more often than not, people respond with fear. Not only are people living through an unfamiliar disease, but also the trauma of simultaneous worldwide crises. While information – useful, reliable – drip-feeds through networks, the noisy onslaught of opinion and lies flows unabated. Affect is reproduced through bodies in much the same way as a virus; it moves between us and through us, mutating and transforming from carrier to carrier. Fear, especially, is contagious, the more so when rendered through the loudspeaker of the media.

 

During the early stages of the pandemic, this affective commons threw my internal navigation into disarray. At first, I responded with cold frankness. I remember joking to the therapist in early January, ‘Welcome to the world of body horror’. It is immensely strange, as a person who suffers with paranoia, to find that one’s catastrophising is suddenly real. I asked the therapist if other people had come to her with fear around COVID-19, looking for indications of what my cohort of the ‘mentally ill’ were feeling about mass corporeal terror. She demurred in the evasive way of therapists, but I found answers elsewhere. The YouTube algorithm’s answer came a few weeks later: I opened a video titled ‘COVID 19’, which showed a bearded, middle-aged white man in a bright red polo neck, sitting in front of a bright red wall. With the colour of alarm in the background, the talking head provided a psychoanalytic perspective on COVID-19. He explained a phenomenon he had noticed in his clients: ‘My hysterical patients feel better because everyone is hysterical, my paranoid patients feel better because everyone is paranoid, and my obsessive patients feel better because everyone is obsessive.’ Was my coldness a version of feeling better? Vindicated paranoia is the type of proof that sours into a depth of confusion: being right is no comfort in a world that aligns to one’s terrified pathologies.

 

Unlike the world maps that circulate news of the illness’s progressive spread, it is impossible to map the exact moment when the virus became a cause of global fear; harder still to discern who, or how many people, are experiencing this affect-at-scale. Reading the news felt like ‘research’ at a time when little information was available, and so I did it constantly. In January, I began to notice a pattern emerge in the British press: journalists shoving microphones in front of scared hoarders, gaping at their irrationality, whilst also phishing for answers extreme enough to befit an article titled ‘Confessions of a Coronavirus Prepper’. Outside the coverage of actual events, including the region-wide quarantine of Wuhan, these articles attempted to ‘report on’ the magnitude of emotional irrationality, often picturing a Prepper-confessor in front of their hoarded stash of hand-sanitiser and a vast array of tinned foods, neatly stacked like ingots of gold. Those willing to admit their fear were presented as freakish, the voice of the extreme outlier. Why did admitting to trepidation have to be a sideshow? I wondered, where were the fearful who were stuck in a quandary of ‘Is this happening or not?’, ‘Am I crazy or not?’ I knew that they were merely silent, going about their lives as they had done before.

 

In facing mass illness, the ‘healthy’ are becoming initiated into the rites and rituals of the sick person’s state of constant bodily vigilance. The binaries between health and illness have become exquisitely porous. Exposure Therapy, my own personal lodestar, was also coming under scrutiny.

 

If Exposure Therapy is contingent on the assessment of ‘healthy’ risk, then what is one to do when the very categorisations of ‘health’ are themselves disintegrating? How do I reconcile the lessons of Exposure Therapy with a world that is ostensibly in retreat? What does it mean to attempt to build a life, beyond neuroses, while the threat of COVID-19 remains present?

 

I was saturated with the belief that this treatment offered the alchemy of a cure. The power to relieve fear in the fearful is a kind of capture, indenturing them to the institution of psychological intervention. I had drunk the Kool-Aid, taken the Red pill, become a believer. In other contexts, this might be called brainwashing. But the consensual reorganising of the mind by way of belief is the appeal of therapy. In the new world of a pandemic, the institutions that created the conditions of treatment were closed indefinitely. Their closing made me feel bereft not for the loss of the institution, but for the disappearance of a fantasy, a neverland of ‘healthy’ thoughts around hygiene and ‘moderate’ bodily behaviours that I was missing.

 

In The Cultural Politics of Emotions (2004), Sara Ahmed refutes the idea of emotions as endogenous ‘psychological states’, arguing instead that they are ‘social and cultural practices’, controlled and meditated by the societies we live in. As with emotion, so too with behaviours of compulsion. What this newly emergent reality resembled was a public commanded to take up the compulsive behaviours that I had just barely managed to put down. Hand-washing suddenly became an act of saving the nation. As people stormed supermarket aisles for antibacterial soap, the very thing that had made me ‘sick’ had become the picture of health. And instead of feeling well, I felt nauseated with grief.

 

Synthesis as sacrifice

 

As someone who self-describes as pathologically anxious, living before this pandemic in a state of frequent and extreme fear, I watched the progressive shift in affect as it escalated in the United Kingdom and elsewhere, seeing people take up behaviours and patterns of feeling that I have long held as personal indicators of a disease of my mind, my own ritualistic mitigations against exaggerated expectations of danger. The previously ‘pathological’ has been recast as the sensible and responsible. I have seen people’s fears externalised in the space around me in a way that collapses any conceptions I previously had of mental ‘health’ or illness.

 

The men who formulated Exposure Therapy – with their neuroticism scales and designations of ‘excessive’ fear – sought to find a way to ease the present suffering of the anxious individual through conditioning a ‘normalised’ response. Through a programme of ‘modifying’ behaviour in order to manage affect, they practised a kind of psychology that believed that which was conditioned into a person could be iteratively removed out of them. What was a failure of the individual could supposedly be removed without a trace.

 

In deciding to undergo a Year of Exposure, perhaps I had bought into Exposure Therapy’s illusory promises of progressive control, in which perceived ‘normal’ affect can be achieved by adhering to ordered forms, systematic procedures, emotional hierarchies and a logical sequence of events. In short, something that closely resembles disciplinary models of neoliberal self-improvement. Exposure Therapy is a treatment designed for those who have been ordained as ‘sick’ by the ruthless managerial class that controls our existing society.

 

If it has demonstrated anything, living with a phobia and OCD has taught me to be deeply suspicious of my fears. I don’t know what it’s like to be a person who believes their fears to be well-founded. This is something for which I have come to feel bizarrely grateful. In addressing the demands of the afraid, there is a need to recognise the extent to which fear doesn’t usually end simply in the uptick in anxious bodily sensation. There is an existential threat that comes from the self-proclaimed ‘well’, who believe themselves to be of ‘sane’ mind, and thus switch out their feelings of fear with deadlier mutations: anger, blame and hatred. Fear is also a kind of virus, one capable of causing death. I feel a palpitating danger when I think about the people who believe their fears to be unilaterally justified, and how it is often those very people who occupy positions of power and implement governance.

 

Considering my experience of Exposure Therapy now, I wonder about its multiple redundancies. In the context of society-wide disease, I am not quite able to square the logic of ‘feel the fear and do it anyway’ with the real awareness that the observance of cautious behaviours, like handwashing, has become a matter of life or death. Even more alarming is the ethical vexation of creating a psychology of conditioned ‘normality’, one that believes in the possibility of the human mind as a tabula rasa. The fallacy of this is made uncomfortably obvious when the very ‘normality’ that it relies upon becomes obsolete.

 

At the end of March, facing worldwide contagion, my scales of phobic risk assessment were no longer applicable. Therapy – at least the kind that I experienced – doesn’t prepare you for a pandemic; it was no vaccine against fear. In the hierarchy of fears I had compiled with my therapist, nowhere did I list a global infectious disease. We didn’t practice for a scenario of exposure to an epidemic. We didn’t talk about mandated hand-washing policies.

 

*

 

After lockdown was declared in the UK, I spent days inside, afraid to step beyond the threshold of the house. I didn’t shower. I spent the time in which I wasn’t attempting to seem like a functional employee through the surveillance portal of Zoom calls watching Mad Men, feeling on the verge of hysterical laughter at Don Draper’s ignorance of the pandemic future. He doesn’t know what’s coming, I kept thinking, every scene lit by the distortions of a misplaced dramatic irony.

 

On a day in April, for reasons I cannot entirely explain, I forced myself to go outside. I walked out into the street and watched the sky. It was the same sky, the same dopamine-inducing blue. The birds were the same birds, their songs sounding more varied in the silence of empty roads. And in the encounter with constants that had nothing to do with being human, or living through a global pandemic, something shifted. I realised I was no longer standing in the same world that I had lived in two months ago. The world in which I had gone to therapy on a set time and date in a building in North London, planning to overcome my fears and live a life outside of the obsessive vulnerability I had been taught to detest – all of that was gone. With the sun dipping below the houses, I knew my Year of Exposure had come to an end. I was already changed, and so was everybody else.

 

None of what happens will be OK, even if, in the ‘end’, there will be survival, a vaccine, the end of capitalism, the rise of mutual aid, reparations for those marginalised and oppressed, the reversal of climate change – though I hold no delusion that those are the only possible scenarios. Instead they are versions of ‘what if’ that proliferate on an unknowable horizon. But there is something on the other side of this. And when I finally managed to step outside, I decided that I would put my hope in being able to get through this rupture, not in the pretence of special knowledge or the alleviation of fear, but for the inexplicable reason that I felt I knew what surrender – to fear, to uncertainty, to shame, to grief – could look like.


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ABOUT THE CONTRIBUTOR

is an artist and writer. Most recently, she completed the audio documentary, Touchdown, aired on BBC Sounds. She was the 2019 recipient of the Michael O'Pray Art Writing prize, and her texts have been published on Art Monthly, The Architectural Review, and others. She has shown works at ICA, IMT Gallery, SPACE studios, and Auto Italia.

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