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“I want y’all to walk to the sign that represents the kind of OCD you most identify with,” announces the moderator, a young woman named Angie Bello who sits cross-legged on the carpet and whose service doodle, Sully, has docked his submarine snout in her lap. Around the room, volunteers hoist placards that say things like violent harm ocd, sexuality ocd, and contamination ocd. They smile benignly, and for an instant all one hundred of us—people ranging from twenty to seventy, joined by nothing but a particular kind of madness—stand frozen, a forest of amygdalas flaring. Outside, San Francisco at dusk: Bob Ross clouds in haphazard sweepings of pink and feathered gray and, darkening beneath them, the city itself, garishly beautiful and troubled.
We are in an upstairs conference room at the Marriott Marquis, a fortress of cleanliness and order acceptable even to the most afflicted among us. This is the icebreaker on the first full day of the twenty-eighth Annual OCD Conference in July 2023, a global summit marshaling together hundreds with the illness and, alongside them, therapists who treat it and researchers who endeavor to grasp it. OCD, which swarms people with distressing thoughts and drives them to seek relief in life-consuming rituals, is an isolating and often secret condition; it is not, generally speaking, a thing one puts in a Hinge profile or drops over daiquiris. But this weekend, we are repeatedly reminded, is about “shattering the stigma.” It is also the first full-blown OCD Conference since COVID-19, and because that calamity hit many in this crowd with especial force—because, as one man will tell me, “everything we’d always feared was finally happening”—it feels historic.
I walk to contamination ocd, passing several goggle-eyed souls clustered tensely beneath violent harm. I’m late arriving: a sweet, spectacled computer programmer is describing his phobias of rabies and AIDS. “If I spot markings on anything in my apartment—groceries, furniture—my brain decides they’re bite marks, like by a bat, and even if I just bought it I have to toss it.” Everyone nods; encouraged, he goes on. “Sometimes I think about how recent all this is. Like, humans haven’t even known about germs for that long!”
Kellie, a slender woman of twenty-four, chimes in: “I sometimes feel like my various forms of OCD are at war. My contamination OCD forces me to shower, but then showering triggers my BDD.” Body dysmorphic disorder, sometimes thought to be a form of OCD, torments people with an illusion of physical defects. So, as a teen, Kellie became convinced something was wrong with her face—invisible to everyone else but to her as incontrovertible as the blueness of the sky. She would miss school, mesmerized by the bathroom mirror; believing she looked “subhuman” and plagued, too, by contamination dread, she took to drinking peroxide. At last, suicidal, Kellie checked into McLean Hospital in Massachusetts, undergoing exposure and response prevention therapy (ERP), the gold standard in OCD treatment, whereby patients incrementally confront the source of their fear and are barred from performing their rituals. Clinicians took photos of her, blew them up, and hung them from the walls of the kitchen for all to see while they ate, alongside signed declarations by other patients attesting to their intrusive thoughts (things like “I want to do a dog. Sincerely, James Lee”). It worked: she wrested control of her life, moved to San Francisco, and, belatedly, enrolled in college.
“How’s yours manifest?” someone asks. All are peering at me. “Breath stuff,” I say coolly. “Airborne contamination stuff through my mouth, my eyes. Identity stuff.” Since I was a boy, I have suffered from a kind of OCD driven, at bottom, by what I once described to a therapist as a “fear of self-loss.” There were people in my childhood orbit whose volatility gave life the feel of being perched on a tectonic rift. I grew afraid of becoming them—avoided looking at their pictures so I wouldn’t absorb their essence, held my breath when they walked by, frightened of inhaling their wake. In time the scope of my fear widened to encompass more and more people whom I deemed monstrous. I became a kind of anti-Proteus, hell-bent on safeguarding my self. By nine I’d devised a private religion, with strange mantras and rules so severe that Calvin would have dismissed them as fucked up. Having done something objectionable, I went off in secret to repeat “Scratch that from the record” over and over, and apologized to God.
“Time!” Bello’s voice rings out, astonishing the room. “You were all so vulnerable just now. Give yourselves a pat on the back for being vulnerable.” I look about me at wizened adults with, I imagine, paid-off mortgages, wills, and Roth IRAs, reluctantly tapping their deltoids. Preschool directives aside, the icebreaker triumphs: suffusing the room is an aura of defiance, of people lately emerged from a bomb shelter, dusting themselves off and looking gamely at a world that for two years confirmed their catastrophizing, where every rando, confronted with contagion, became an amateur Howard Hughes, a devotee of DoorDash and pumper of Purell.
Every kind of OCD sufferer is here: a new mother haunted by thoughts of killing her baby, who wonders through tears what to make of it all; a man who for years jumped on his bed hundreds of times before getting in, who’s incinerated months of his life alone in obscure rooms, spinning about suddenly in an effort to catch a lurker behind him; mild men like me, thoroughgoing Jekylls, racked by thoughts they’ll morph into Hydes, turn terrorist or Kia-jacker or #MeToo-able groper. We are all object lessons in the brain’s ungovernable will, its impishness, its refusal to be yoked to the ends to which we have put it.
When, at the close of the session, we reconvene in a single large circle, Bello asks us to take turns saying something we’re grateful for, which prompts a groundswell of confession and catharsis worthy of a revival meeting. “I’m grateful,” one man says, “for my diagnosis after forty years of suffering.” A young woman: “I’m grateful for the one weekend in the year when I don’t feel like a nutjob.” “I’m grateful,” I say, “for good health, and music, which has always been an escape from OCD.” This impresses no one particularly, and when the session ends we scatter and I shuffle downstairs to the atrium and cash bar, where hundreds have gathered for the welcome party.
We don’t know where it comes from, or even what it is. Classified as an anxiety disorder as far back as the DSM-III (1980), it was placed in a category all its own in the DSM-V (2013), to the intense annoyance of some specialists, I’ve learned. If we imagine the vast network of mental illnesses that have lately brought America to its knees as a crime syndicate—picture the evidence board at the police station, the pyramid of interconnected mug shots—depression is likely at the top, a Gotti-like kingpin colluding with those below, whose all-pervasive influence cost the United States $326 billion in 2018, roughly half what it spent on the military. See the whole sordid family, the gallery of rogues: PTSD, anxiety, eating disorders, panic; somewhere highup in the chart lies OCD, a capo perhaps, strongly comorbid with depression and conspiring with it to immiserate and kill. Afflicting at least three million U.S. adults, it’s the fifth most common mental disorder reported by Gen Z-ers. In a country that’s already seen a breathtaking 36.5 percent rise in suicide since the turn of the millennium—a country killing itself, quite literally and not merely through endless partisan hatred—it occupies a special place, making people up to ten times likelier to take their own lives.
Perhaps OCD has always been with us. Some have ventured that it is an atavistic relic from the prehistory of Homo sapiens, when it behooved hunter-gatherers to check their space compulsively for safety reasons, or when repeatedly washing or picking at one’s person made sense in an outdoor world rife with parasites. One of the most terrifying evolutionary theories of OCD is that the wild, often aggressive thoughts that can fuel it—which, I hasten to add, sufferers are in virtually no danger of acting on—are the genetic legacy of our berserk male ancestors: men given to sexual violence, depredation, and the killing of others’ babies to secure resources for their own, whose Darwinian success means that we carry traces of them deep in our brains. And the bad thoughts may serve a biological purpose: because mothers who have thoughts of infanticide are more likely to compulsively check on their infants, their hypervigilance may be what has ensured the continuance of their line.
The disorder has racked some of Western civilization’s most luminous minds. Martin Luther, who some historians suspect had OCD, was hijacked by thoughts of cursing Jesus and mental images of Satan’s ass, which moved him to take confession with such frequency that he alienated his fellow priests. When the artist William Hogarth met Samuel Johnson, another apparent sufferer, around 1750 at the house of Samuel Richardson, he found the lexicographer standing at a window “shaking his head and rolling himself about in a strange ridiculous manner” and, not knowing who he was, figured Johnson “an idiot” who’d been entrusted to Richardson’s care. Then Johnson opened his mouth, displaying “such a power of eloquence” that Hogarth sat astonished, concluding that he had been divinely inspired.
The driving force behind these antics is a tyrannizing uncertainty. So OCD is known as “the doubt disorder.” To be human is to have wild, bastard thoughts; to have OCD is perhaps to have more of them and, crucially, to invest them with power and importance—to be actually afraid that you will act on them and thus become a bad person. In this sense, most varieties of OCD amount to a fear of self-loss, a worry that the coils holding you in place will slacken and permit you to do something monstrous; thus such OCD sufferers fret less about being victims of mass shootings than about being the shooter. Overcome with anxiety, they reassert control through rituals that bear no causal connection to the underlying fear. So, troubled as a boy by the thought that I would morph into someone rage-prone, I doubled down on my virtue with a Houdiniesque holding of breath, engaging in the magical thinking—the freak, fantastical association—that defines OCD. Each time you perform the compulsion you further cement the conditioning that underlies it, until you find yourself mired in a Pavlovian feedback loop, powerless perhaps to recall the fear that first triggered it.
But to ask why certain people become ensnared in the first place is to plummet down a rabbit hole of controversy and even scandal. At least since Judith Rapoport’s 1989 bestseller The Boy Who Couldn’t Stop Washing, the disorder has been widely considered neurobiological—a hereditary scourge baked into the brain’s own chemistry and potentially linked, like depression, to low serotonin, or abnormalities in the brain’s basal ganglia and frontal lobes. These are explanations one still finds, albeit with qualifications, on the website of the International OCD Foundation (IOCDF), which hosts the conference; it has provided justification for untold SSRI prescriptions, and even challenged how we conceive of knowledge itself. What if doubt could be pinned to a particular neurotransmitter, and certainty—our whole faith in the data of our senses and stability of our selves—were nothing but a threshold level of serotonin?
In 2022, though, a bomb went off. Six scholars published a blockbuster article called “The Serotonin Theory of Depression,” a sweeping literature review that concluded there was “no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.” Although “80% or more of the general public” buys into the “chemical imbalance” hypothesis, it doesn’t hold water—and certain big stars in the OCD firmament, like Jonathan Abramowitz, a psychology professor at the University of North Carolina at Chapel Hill who attended the 2023 conference, maintain that the same holds for OCD. “There’s no relationship between serotonin and OCD,” he told me, and then went further: to this day, neuroscientists are unable to look at brain scans of people with any psychiatric ailment and identify them as people with OCD, schizophrenia, or bipolar disorder.
TikTok fairly trembled. The right-wing news outlet Daily Wire posted a viral video harking back to 2005, when a feral Tom Cruise attacked Matt Lauer on the Today show, insisting that “there is no such thing as a chemical imbalance.” Cruise’s beef was with Big Pharma, which, in tandem with psychiatry, had—so he argued—leveraged the chemical-imbalance hypothesis to gorge itself on proceeds from “very dangerous” drugs like SSRIs and Ritalin. The implication of the Daily Wire video was that we had soft-canceled Cruise for this in the days before cancellation, and now he’d gone and been vindicated.
Was Tom Cruise right? Never mind the fallacy in his argument—that simply because an illness isn’t caused by low serotonin doesn’t mean boosting one’s level of it won’t bring relief—or the fact that Cruise’s own proposed etiology of mental illness isn’t likely to land in The Lancet anytime soon. The firestorm sliced to the core of some of the most radioactive issues lately haunting American life: the provenance of mental anguish in a country wherein around one in four adults, and 42 percent of Gen Z-ers, suffer from a diagnosed mental-health condition; the trustworthiness of a pharmaceutical juggernaut that in peddling not just SSRIs but opioids has forfeited its credibility, thereby setting the stage for the anti-vax fiasco and Make America Healthy Again; the question of what insights we foreclose—about ourselves, about our world—when we attribute psychic pain solely or primarily to chemistry.
I followed the saga, entranced, thinking of my own OCD. Where had it come from? There wasn’t a time I could recall not having it; it was with me always, a continuous mental static muted only by sleep and, at times, a lostness in bodily exertion or music. SSRIs had never helped. But while it seemed plausible enough that it was etched into my genome in some way that science hadn’t yet learned to see, something else gripped me, a hypothesis pretty much every OCD authority rejected out of hand: that the zeitgeist was incubating this in people, that we had created a culture so profoundly conducive to it that everyone now lay at the lower frequencies of the OCD continuum.
What were we if not obsessive-compulsive, we who so often traced our origins to a people whose very name, the Puritans, epitomized the perfectionistic delusion underlying this illness? A people so committed to virtue that they’d risked life and limb traversing an ocean to do it their own way, finding refuge at last in the primordial safe space—the great Ball of Anxiety upon a Hill—from which we descend?
Now we’d created a machinery in tech that, abetted by COVID, brought mastery and order beyond the Puritans’ wildest imaginings. Here was control fit to send tremors up Winthrop’s thigh: reality filtered through feeds that weeded out what was noisome, bespoke news that flattered our priors, Ring cameras that screened out shitty people while we slouched indoors consuming it all. Here, starting in 2020, was a lifestyle that reinforced all my worst tendencies—every Zoomified interaction perfectly regimented and timed. When I ordered things online, they were delivered to my doorstep by someone I never had to meet, who sent me a photo as proof, just as I grew to expect. And when the lockdowns were over and it was time to go back, I recoiled, unready as so many were for handshakes and halitosis, chance meetings, the friction of the actual.
On my flight to San Francisco, I imagined the conference attendees as proxies for everyone else, their neuroses those of the wider world, only dilated, as if by a magnifying glass, so that in them—in us—something of the illness endemic to modern, overeducated, extremely online life might be made large and legible.
How can I conjure for you the hopping scene I found underway at the cash bar that first night?
It consisted of three groups. First there were, clustered about several tables and getting really loose, the off-duty therapists. These were not your parents’ hoary psychoanalysts but young clinician-influencers with Instagram followings the size of Toledo, who posted Stuart Smalley–ish stuff captioned “Reminding you you’re capable AF”; they crowded around a phone with a karaoke app open and chanted along to Speak Now (Taylor’s Version), which had dropped that day. One stood and, brandishing a White Claw, pointed rhythmically at the air and shouted, “She’s not a saint and she’s not whatcha think!” Another called out, “You look hot.”
Then there were the celebs. These were the hotshot authors, academics, and “advocates,” all unknown the moment they left the hotel, but who commanded a hushed solemnity within it. They floated aloofly at the edges, some with protective posses; now and then, common attendees fortified themselves with drink, muttered “fuck it,” marched right up to them, stood there gaga for a moment, then blurted something like, “The Slaying OCD Workbook saved my life.” The celeb would smile, embarrassed, offering a hand and a cool “Thank you so much.”
Among the celebs that weekend were Jonathan Grayson, a seventyish psychologist, who spoke in suavely cutting epigrams of his own invention, like “Research has shown that the only people who are certain are stupid or QAnon.” There was Kristina Orlova, a podcaster and anxiety specialist nicknamed the OCD Whisperer, and the filmmaker Ethan Smith, who gave the 2014 keynote address, a pink-cheeked cherub in the Rick Moranis genus—a poster child of the IOCDF, its Michael Jordan, who’d gone from a whimpering, bedridden thirtysomething to a fully functional adult following eighteen months of ERP.
Last there were the normies, who had OCD and made up the bulk of the room. They emanated an excitement that captivated the lapsed academic in me; I’d never been to a conference whose attendees actually looked stoked to be there. No tense, darting-eyed intellectuals armed with papers on Embracing Antinatalism in the Anthropocene, they had the determined optimism of people in the autumn of life, with youths squandered, resolved now to salvage what time they could. I saw that they were flirting: near me a man I’d met upstairs said something sly, and his interlocutor faux-swatted him across the pec, laughing. It dawned on me that the Annual OCD Conference was, in part, a mass singles event for people in varying stages of recovery who’d flown in seeking, if not a partner, then random play.
I walked up to the off-duty therapists singing Swift, meekly apologizing for crashing their party, and though they had known me some twelve seconds, they responded without missing a beat: “You are our party.” I asked about the debates roiling the field. “Whatever idiot did the most recent DSM and took OCD out of anxiety disorders, ignore that completely,” a Chicago-based therapist told me. “It’s the same anxiety disorder it always was.” Another therapist half stood, breaking in: “It’s the SAME SHIT.” They wanted me to understand that OCD was merely a specimen of anxiety whose “safety behavior”—the mollifying refuge—happened to be not shopping, Talenti, or Pornhub, but a life-liquidating ritual repeated hours a day.
What was the illness at the center of this event? The more I asked around, the more it eluded me. Among the celebs and therapists I discovered a consensus—that lingering one since at least the Nineties—that OCD was congenital, that the world merely furnished patients with incidental materials for it to “grab onto.” “We all agree there’s a genetic, biological component that says you’re going to get it,” Grayson told me, though he acknowledged, “I don’t believe the genes are identified.” Elizabeth McIngvale, director of the OCD Institute of Texas, concurred, telling me that OCD is “a neurobiological disorder, so our patients are born with it.” Likewise Ethan Smith, who maintained that he’d been “born with OCD”: his first word was “bug” or “fly,” which he believed portended the entomophobia that later overtook him.
Why did this so disturb me? Was it the total confidence and memetic regularity with which every expert here asserted the same origin story? Or the strange, deterministic push to essentialize something for which there existed no clear genetic marker—to establish, once and for all, that certain babies come tumbling from the womb already addled with something called obsessive-compulsive disorder?
None of this is to say that neuroimaging had made no inroads whatsoever: a 2018 study used fMRIs to suggest that the part of the brain that monitors for error is on overdrive in people with OCD, whereas those regions that typically halt compulsivity are, as it were, asleep at the wheel. But such findings are scant enough that a year before the conference, several high-profile academics published an article whose opening reads like a waving of the white flag for psychiatry itself. “It is sobering to acknowledge that functional neuroimaging,” they write,
plays no role in clinical psychiatric decision making, nor has it defined a neurobiological basis for any psychiatric condition or symptom dimension. Thus it remains difficult to refute a critique that psychiatry’s most fundamental characteristic is its ignorance, that it cannot successfully define the object of its attention, while its attempts to lay bare the etiology of its disorders have been a litany of failures.
Yet they are undeterred: the upshot is that psychiatry needs to “fail better,” that by viewing the brain as the “computational organ” that it is—seeing psychiatric symptoms as glitches in its “algorithmic processes,” harnessing “the exquisite power of computational modeling” to analyze these—we can at last identify the neural snags underpinning mental illness.
The article haunted me as I hovered about that night. The monomaniacal need to map the brain as though it were an Intel processor; the Ahab-like fixation on tracking down the biomarkers underpinning OCD and kindred afflictions; and behind it a hubristic hunger for certainty—all this gave the uneasy impression that the specialists around me, and the guild to which they belonged, had OCD. Christopher Pittenger, a Yale psychiatrist who loomed large that weekend, told me that researchers were now less focused on serotonin than on glutamate, another neurotransmitter, which, per a 2023 study, exists in “differential balance” with the amino acid GABA in people with OCD. Talking to him, I had the flickering sense that psychiatry was still arrested in the humoral understanding of mental illness that prevailed during the Renaissance and antiquity. If biomarkers like glutamate and serotonin had usurped bile and phlegm as the humors du jour, we remained mired all the same in the “chemical imbalance” logic that had made Tom Cruise go postal—and, more deeply, in the thought-universe of Hamlet.
Curiously, the celebs and therapists, when pressed, said things unassimilable to any neat biochemical model, suggesting that whatever weird spiritus mundi defined our moment was at least as culpable as chemistry. McIngvale told me she believed we had become victims of our own success as moderns—that the enormous, stupefying convenience of contemporary life, our pamperedness as a people and expectation of pleasure on demand, had left Americans with atrophied resilience, rendering us vulnerable to the escapist fixes of OCD.
Another clinician, Topeka-based Amanda Petrik-Gardner—author of An OCD Exposure Coloring Book, which invites sufferers to color pages bearing charged words (sex, sinner, murderer)—had flown to San Francisco to chair what would turn out to be a packed panel on “Cancel Culture OCD,” a new form of the illness whereby people fixate with terror on the prospect of their own cancellation.
Indeed, I would learn that I was surrounded by attendees living in mute dread of this fate—people who visited on themselves the strangulating self-control that is the essence of OCD but also, increasingly, just a barely conscious feature of being alive in a relentlessly surveilled present. From Rachel Schwartz, a research psychologist at Rogers Behavioral Health, I would learn of an OCD patient who recorded every moment of their waking life with their phone, then watched to see if they’d done anything objectionable. And I had again that creeping thought that had brought me here: OCD sufferers were merely amped-up versions of everyone now, or at least of the credentialed classes I knew so well. Was the pathological behavior of patients like Schwartz’s different in kind or simply in degree from that of my own journalistic peers, Twitter-cowed writers who, starting around 2015, self-monitored like cattle who’d internalized the limits of their electric fencing?
Evening advanced. I had a Tom Collins and threw myself into talk with the normies. An asymmetry emerged between the congealed understanding of OCD among the experts and the so-called lived experience of this larger group—people who struck me as the casualties of a pixelated world that had utterly reconstituted the brain. There was Melanie, a young woman of high octane who whirred all evening about the bar, flinging her head back momently and quaking with Pagliaccian laughter. A petsitter from L.A., she suffered from both OCD and digital hoarding: whipping out her iPhone, she told me she’d purchased terabytes of extra storage, then showed me hundreds of thousands of screenshots, plus vaults of video footage. Her hoarding, inextricable from her OCD, stemmed from an obsessional fear of forgetting. In 2020, she was humiliated as a control freak on Dr. Phil: having requested that an OCD expert accompany her on set, she learned that the staff had denied her request and she panicked. Dr. Phil confronted her on the air: “You wanted to produce the show,” he said, fixing her with an icy phallic stare. “You’re not going to control and manipulate me.”
There was Lael, a trans woman and tattoo artist from the Bay Area who struggled, like me, with “identity OCD,” and whose innermost fear was that she would wake to find herself turned into a straight white conservative male. In 2016, her fear crescendoed to a crisis: “I had intrusive thoughts of Donald Trump’s fucking hideous face.” Horrified, she compulsively summoned other images to replace it—a ritual so consuming, she had only minutes of any day to herself. She’d fallen prey to a disturbance widespread enough that in 2017 the Philadelphia Inquirer christened it Obsessive-Compulsive Trump Disorder. Relief came through a kind of ERP wherein a therapist gingerly presented her with pictures of Trump’s countenance, whose Medusa-like power dwindled by degrees.
Of course, Trump’s face was only the most ubiquitous image to be found on devices that were nothing if not obsession-minting machines, wedging likenesses into our brains by the tens of thousands. “I do think,” she said ruefully, “technology can’t help but lend itself to more mental disorders cropping up.”
Is there something ironic or even preposterous about classifying “compulsive checking” as a hallmark symptom of a disorder meriting its own chapter in the DSM when the average American checks their phone 205 times a day? What might it mean that obsession and compulsion are baked into the product design of the devices and apps we live on—that compulsion, particularly, forms the profit model of the tech companies that have rewired human consciousness since I graduated high school, and are based right here where this event was occurring?
All the next day, a Friday, people were buzzing about the big night out. This was the Road to Recovery Tour, an annual tradition and the weekend’s centerpiece, set for that evening at eight. Some two hundred attendees would plunge into San Francisco’s night scene as one, gallivanting through the Tenderloin and Union Square and, affirming the heck out of one another, perform a series of planned “exposures,” staring their aversions in the face and growing triumphantly inured.
I would join them. I confess the optics made me uneasy. That downtown San Francisco—holiest of holies for conservative media, muse of Breitbart and The Atlantic—was theater for exposure therapy seemed a gag out of The Babylon Bee. Still, I signed a waiver averring that, if anything happened to me, the IOCDF wouldn’t be responsible, and, handing it to someone without further thought, disappeared into the event again.
That day, in the depths of the Marriott Marquis, the therapeutic clergy I’d met the night before held forth on every kind of OCD treatment: ERP, SSRIs, transcranial magnetic stimulation, psychedelics, diet. At one standing-room-only session, a couple hundred sufferers sat, rapt as a multitude gathered in Galilee for an ancient wonder, while a speaker told of something called “fierce self-compassion.” Better was a panel on psychedelics in a packed auditorium where Christopher Pittenger, the Yale psychiatrist, explained that drugs like psilocybin might relieve “a tragically large percentage of people who aren’t helped by existing treatments”—that is, roughly 30 percent of those with OCD. It may be, he said, that psychedelics provide windows of cognitive flexibility during which OCD sufferers can learn to respond to the world in fresh, nonhabitual ways—and even attain a liberatory distance from their own minds, a glimpse of life without the illness.
Whatever their merits, the panels I attended felt insistently divorced from all contemporary context. Absent was any mention of smartphones, COVID, helicopter parenting, the wealth gap—they could have been playing out in 1994. Why this allergy to considering the particular societal kindling for madness? And why did I have such a bee in my bonnet over it? Maybe this: to insist on a congenital understanding of neurosis—to maintain that our naturally worrying brains would “grab onto” whatever was out there—was to deny the specificity of our world, the particular choices we were making about how to organize society and live. Perhaps it stood to reason that after centuries of stigmatizing people for mental illness, we would cleave to an innate model that exonerated them from blame. But in the process we did something unwittingly pernicious, deflecting onto the individual genome our collective failings.
Just before 7 pm I entered the auditorium, where the attendees had convened for the night out. Emanating a giddy, conspiratorial naughtiness suggestive of adult hooky, they sat gabbing and laughing, some dosing themselves with zinfandel. Onstage facing them stood Grayson, the mastermind of the night. This Grayson was a heady cocktail of signifiers garnished by an Indiana Jones–type hat he’d worn, I gathered, to all twenty-one Road to Recovery Tours to date. He had a Philly accent and a voice that, at heightened amplitudes, would strike me more than once that night as Trumpy. His energy was all Robin Williams in Dead Poets Society—that of a carpe-diem guru chanting paeans to risk, to the nobility we attain through failure alone.
“We are queens and kings,” he intoned, cradling the lectern, and all grew quiet. “Gloriously crowned, beautifully inept, marvelously imperfect. . . . We leave perfection to the few who seek what cannot be attained, who desire what cannot be given, who yearn for what cannot be achieved.” As he finished reading each page of this anonymous poem, he crumpled and threw it over his shoulder in theatrical disdain.
“Tonight,” he warned, “there is a possibility that various authorities might not like what we’re doing.” He had himself nearly been arrested once. We were to keep calm, do as directed, and above all, remember that we had at every moment the freedom to opt out.
The crowd stood up and with nervous laughter streamed toward the lobby, then galloped into the street with the glee of prisoners released. I watched them rush through the exit, so arrestingly childlike; one man called out, “I haven’t had sex in a really long time!” and then quickly added, “I shouldn’t have said that.” As the last few filed out, I saw a hotel employee standing open-mouthed by the door. Since no one else was left to explain, I walked up to him and, with an awkward stiffness I hated, said, “A bunch of people are going out on the town to conquer their phobias.” He nodded slowly.
Outside, in the wintry night air that is San Francisco’s in July, we hastened down Mission Street, shepherded by Grayson and a team of chaperones. I rambled beside a couple of women in their sixties who were comparing notes about contamination fears. “Do dogs set you off?” one asked. “Oh no,” said the other, “dogs are perfect. It’s my mom I can’t take.”
We were set loose in that nucleus of neighborhoods that, it gives me no pleasure to report, instantly confirmed the accounts of right-wing media. At intersections, people high or mad slalomed through traffic, gamboled in green-lit crossings and taunted Teslas, or waltzed in front of buses, cool as old men on constitutionals. On the sidewalks lay many of the homeless, an anonymous army bivouacked beneath blankets or balled up fetally, uncovered. No one seemed to notice. It was such a starkly symbolic tableau—the exodus from an antiseptic citadel of people who’d led lives of monastic avoidance, charging into close range of a population stricken with all they’d endeavored to block out: germs, sickness, BO, death itself, for these blanketed bodies a proximal thing.
Blocks away, the Cash App co-founder Bob Lee had been murdered months before, apparently by a peer in tech. I was myself nearly attacked on the Muni that week by a drug-addled man who rushed at me and crouched, karate-style, with his fist an inch from my face. I sat stunned, then grabbed his arm, standing up and shoving him backward, but he stood his ground and stared. “Stop!” I barked dumbly. He only grinned and called out, “He told me stop!” The conductor said nothing and the other passengers sat scrolling in a glazed-over indifference that reminded me, later, of the apathy of bystanders in the face of Lee’s stabbing. At last the man retreated to the back of the car, and I got off.
What did it mean? This city, home to an industry drawing us by compulsion into a disembodied parareality—an industry whose costliest venture to date, the metaverse, was a $36 billion effort to rivet headsets to all our faces—remained obstinately physical, a place where danger and distress came at you. San Francisco was, in all its woes, a counterpoint to the safetyist dream that we can insulate ourselves from threat, whether through VR or the redoubts of social media. If the internet was an OCD Eden—a riskless anesthetic escape—the city was its postlapsarian foil, alive with some possible truth I wanted to believe: that squalor might be redemptive, that the specter of bodily abjection in others might call us back to this world and the thousand natural shocks that flesh is heir to, and so build sympathy.
Just then we came to an overflowing dumpster behind a high-rise, where Grayson announced our first task: to scurry up to it, fondle some detritus, and, if we were so intrepid, lick our hands. He demonstrated, and there were audible gasps as, frenching his palm, he called out, “A little grainy.”
All lined up then, and I watched as a clutch of late-middle-aged women at the fore of the line jogged in place, gathering courage. “I’m gonna do it, Cheryl! I’m gonna do it!” one cried and, sallying toward the dumpster like a Price Is Right contestant, groped a biohazard bag while her friends whooped and cheered.
Near me a man named Brett muttered, “You have to stick your hand inside the bag with bodily fluids, or you haven’t truly done it.” Someone else laughed: “Don’t forget the needles!” There were grunting high fives as, one after another, all cleared the exposure. When my turn came, I trotted to the dumpster and did a scan—biohazard bag, Papa John’s box with petrified cheese—and, grazing the latter with my hand, dutifully licked.
On we went like wassailers in the night. A pair of moral exposures followed, meant to deliver the discomfort (or frisson?) of transgression. We broke into a parking garage, lining up and taking turns kicking a Chevy Silverado, then followed Grayson—who was blaring into a megaphone, “Who’s goin’ to jail tonight?”—out the exit. In the street, a mass of attendees stood on the curb, shaking their fists at traffic and shouting in unison, “Crash and burn! Crash and burn!”
We made our way to Yerba Buena Gardens for the exposure that was to prove the main event. Forming a line that snaked a quarter mile across the lawn, we learned what we were to do: they had found a homeless man named Bo, who would stand at the front of the line as we walked up to him one by one, giving him a quarter while shaking his hand, then embracing him. An uneasiness rippled through the crowd as the chaperones approached with satchels of quarters. In the new quiet I heard them processing: “How bad could it be, right?” A British voice: “Clearly I’m feeling a little bit uncomfortable.” Some forty yards away I noticed an encampment of homeless people huddled around a bonfire and eyeing us in silence. I saw where certain attendees had opted out—too queasy, apparently—while near me a junta of skeptics stood apart, stewing on the cringiness of the exercise. “What’s the word?” one guy said. “Problematic?” He added: “For me, the exposure is the condescension.”
Edging closer, I saw a tall blond chaperone standing beside Bo, directing things. One attendee approached, then froze before Bo in a stunned inertia as if he were a leper; the chaperone called out in daycare-ish tones, “Handshake, handshake! Can you do a handshake? There ya go.” Bo placed his hands on the frightened man’s shoulders, gazing into his eyes and talking to him sagely. For an instant the scene appeared like an inverted Gospel episode wherein the ailing pauper was Christ, tasked with healing an affluent, hale multitude. The man walked off and a woman succeeded him; Bo knelt before her like a courtier, accepting her coin and placing it in his hat. Behind me someone said, “This would’ve really bothered me as a kid. I couldn’t touch people who were really bad.”
It was nearly my turn. I stood fretting: Was this destitution tourism for a demographic grown so decadent that it had paid thousands to fly to a dysfunctional city for guided experiences of distress? And yet a good portion of the attendees were Bay Area residents who lived and worked in the midst of these outdoor people and should, theoretically, have had an intimate awareness of their plight. Their disgust suggested that whatever else lay behind the city’s unraveling—a housing crisis, chasmic inequality—it coexisted with something deeper: the revulsion of the haves for the have-nots.
My time had come, and to sit it out because the optics were questionable seemed its own sort of preciousness. I approached Bo, whose face, lit up through a kind of tenebrism by the nearby Target, was middle-aged, with questing green eyes, a lantern jaw, and a goatee. He wore multiple hoodies. I shook his hand, giving him the quarter and starting to hug him, and suddenly he drew me really tight and held me there, at last pulling back and scanning the longitude of me. “You’re fuckin’ awesome, dude,” he told me.
He had, by the end, collected a Vegas windfall of quarters that might have been enough to buy a sandwich here. “Thank you, everybody!” he called out. There was applause, then expectant silence. “If we could just fill the air with love, not hatred—” He broke off and started screaming to someone in the distance, then tore across the lawn, threw himself to the ground, and rolled about. The blond chaperone watched, then turned away, smiling. “I was looking back there feeling responsible, but then I thought, ‘It’s not my responsibility.’ ”
Bo came back, standing next to me while, in preparation for one of the evening’s last stunts, people with violent-harm OCD took knives from chaperones and formed a tunnel: they would hold out the knives while volunteers ran through, the sufferers leaning into the uncertainty that they might lose control and stab the runner. One of them, a young man, wandered over with his knife, smiled at Bo, and, with the wide-eyed innocence of Bobby Brady, said, “Do you know why we’re here? ’Cause we’re conquering OCD.” Bo pretended to seize up, looking at the knife and back at him: “Oh, shit! As long as you don’t ‘OCD’ me.” The young man grew instantly serious. “No, no!” he said, pointing at his own forehead. “I’m attacking this.” Bo laughed deliriously.
The volunteers ran through the knife tunnel, one actually shrieking “My eye!” in an unscripted prank that didn’t seem to go over well. Bo and I chatted all the while: he was from Santa Rosa, had family in the military, was extremely patriotic. He wondered where my wife was. When we finally left the gardens, he followed us as if morbidly curious, standing behind Grayson and making vulgar gestures while the latter addressed the group. He trailed us all through town, watching silently, bidding us adieu only at the entrance to the hotel, into which we vanished quite late.
The next morning, I set out walking. Cresting big parabolas that culminated, as they do here, in long corridors that stretched to the sea—the fretwork of bridge cables and the Bay beyond them, the Port of Oakland, everything coming into view with the shock of epiphany—I roamed on past hulking SUVs, apocalypse-ready and bearing eat the rich bumper stickers; something called Nancy Pelosi Drive; and the Haight, where Ben & Jerry’s peddled okay ice cream for $7.99 and lamppost decals proclaimed jesus is an assman.
Landing downtown, I took in the corporeal pungency of its streets—of Chinatown, where bins of pig snouts sat in store windows and crisp, glistening ducks were strung up above them, heads intact and eyes open, looking like molten midlife relics from Pompeii. The scent of porcine fat pervaded the air, and, to the south, a ubiquity of urine. Here were the bodies I’d seen in darkness the night before, people who’d slept on the terrible obduracy of concrete, waking now to a day that must have seemed Saharan in its blankness, in the raw calculus of survival it demanded.
I thought of how zealously, how Protestantly we had vacuumed our lives of this pungency—I who had spent my early life holding my breath when others passed me. I wondered whether this sickness would have afflicted me had I been born into a culture less pathologically enthralled by purity—one not so repulsed by its own humanity that it had spent much of the past century eliminating all olfactory evidence of it. We were the land of Procter & Gamble, the proud progenitors of the modern colonic, armpit Botox, and anticholinergic drugs to block your sweat glands; from our fertile imaginations had sprung yonic suppository melts scented kiwi, watermelon, and honey. If Pasteur had inaugurated modern hygiene with germ theory in the 1850s, Americans had responded with a perfectionistic fury whose end point was not only the scalding ablutions we underwent on waking, but a yearning that our genitals should smack of papaya.
“Your sin has been uncleanness, impudent uncleanness, repeated uncleanness, murderous uncleanness,” Cotton Mather excoriated his Boston peers in a 1693 sermon. How not to hear in his philippic the traces of an OCD inscribed in our cultural DNA, a sanctimony that launched the archetypal act of avoidance that forms our origin myth? Mather meant moral filth, of course, but for the holistic Puritans—obsessed with clean bedclothes and linens, afraid of the body’s unruly leakiness, full of cleaner-than-thou contempt for their Indigenous neighbors—spiritual and physical hygiene were one.
Was it even possible to think your way back to the everyday aromatics of the Old World they fled? Even the beleaguered place I now walked through seemed its paltry shadow. I thought of early modern London, bisected by a Thames that served as a sewer, rank enough that you could smell it twenty miles off; of its streets, a fetid chaos of animals, open fires, fishmongers, lamps burning rancid oil, and jostling multitudes gravid with the sweat that until recently formed an ambient halo around most everyone. Who bathed, even? Only the wealthy: the masses had given it up in the Middle Ages, fearful that bathwater transmitted the plague. Inevitably, one wonders what sex was like. Far more odorous, of course, but maybe richer for that: “I will return to Paris tomorrow evening,” Napoleon allegedly wrote Joséphine from a campaign. “Don’t wash.”
To sleep in shared beds at inns, unburden yourself alongside others in public latrines, be buried in a mass grave, touching others even posthumously—what room in such a lifeworld for the sharp delineation of ego, the paranoid holding of breath? I saw that we had enacted a twofold retreat from one another: first by concealing our physicality through hygiene run amok, then abdicating the corporeal altogether for a virtual realm promising perfection, cleanness, exquisite control. So Silicon Valley had fashioned for us a second Massachusetts Bay, a new frontier of avoidance whose effects lay all around me now, in the decay of the actual. Not ten feet away, a man moved his bowels beside a street near Union Square, while pedestrians passed him with the unconcern of people already elsewhere, émigrés to a pixelated country beyond the reach of others’ desperation.
“What we are seeing—and bringing on ourselves—resembles a neurological catastrophe on a gigantic scale,” Oliver Sacks wrote on his deathbed in 2015. He meant the smartphone era, the forfeiting of direct embodied experience in streets and on porches for the bloodless simulacrum that now claims our every conscious moment. To be imprisoned in that simulacrum was for Sacks to live a death in life without knowing it, hungering for an intimacy one has forgotten how to have. But it is also to relinquish the shared corporeal life that may be the ground, finally, for all fellow feeling, all mercy and class consciousness. “Art cold?” Shakespeare has Lear ask his shivering Fool, freshly aware thanks to his ordeal on the heath—a kind of exposure therapy—of the physical vulnerability of his subjects. The body is our moral anchor, rooting us in a world of suffering and senescence that is our only assured birthright. Forsaking it, we consign ourselves to depravity.
