"How to Hide in Plain Sight": A Fictional Account of OCD

A synopsis, some OCD education, and an interview with author Emma Noyes

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Trigger warning: This article discusses what it is like to live with intrusive thoughts that are sexual or aggressive in nature.

Image from Penguin Random House

What if in an instant, you suddenly questioned everything you thought you knew about yourself?

That is what Obsessive-Compulsive Disorder does.

This summer, I read the novel How to Hide in Plain Sight by Emma Noyes, in which the main character has a common, but often misunderstood, form of Obsessive-Compulsive Disorder (OCD). Specifically, she suffers from intrusive sexual thoughts and images that cause intense fear, disgust, guilt and shame.

We aren’t talking about the healthy sexual thoughts and fantasies that most people enjoy from time to time. We also aren’t talking about deviant thoughts that create harmful urges and behaviors. No, these are thoughts that are intrusive, meaning they are NOT in alignment with a person’s values and actual desires, and occur spontaneously and outside of conscious control. Despite their provocative content, these types of thoughts are actually meaningless, like mental “spam” mail that says nothing about a person’s nature or intention. But for a person with OCD, the thoughts ignite a cycle of intense anxiety and compulsive actions to try to make the thoughts and feelings go away. Of course, the more an individual tries to avoid having the thoughts, the more frequent they become. Sufferers find themselves trapped in a cycle of obsessive thoughts and compulsions that erodes their trust in themselves.

Obsessive-Compulsive Disorder often manifests as intrusive thoughts about topics that are deemed “taboo”, like pedophilia, aggressive behavior, or suicide. Sometimes referred to as Harm OCD, these individuals are often consumed by fear about what these thoughts mean about them and/or whether they are at risk of acting on the thoughts. This is one of the most common ways that OCD is experienced, yet many people have never heard of it. Therefore, it takes sufferers years to get an accurate diagnosis and treatment.

OCD is always painful, but when individuals are experiencing obsessions around culturally taboo topics, they are often struggling with an additional layer of guilt, shame, and fear. They may be much less likely to share what they are experiencing with loved ones or seek professional help, for fear of being misunderstood and misdiagnosed. This is why I am so excited about How to Hide in Plain Sight and its realistic and compassionate representation of OCD. But it also left me curious about the author and her experience of creating and sharing a character with a mental health condition that is often misunderstood.

Synopsis

Eliot Beck is young and ambitious, living in New York City and working a job she loves as a copywriter. She works hard and is proud to say that she is supporting herself and making it on her own. In fact, being independent is what matters most to Eliot, because having anyone close is a risk that she is not willing to take. Three years ago, she cut off her family and her best childhood friend, left for New York and forged a life where she needed nobody.

Things are going well enough until Eliot returns home to her large, complicated, and rambunctious family for a wedding, after not seeing them for three years. She is shocked to find that her childhood best friend, Miguel, is in attendance. Everyone is curious about what Eliot has been up to and why she has been so elusive.

As the story progresses, we learn the truth. In childhood, Eliot and her family suffered a traumatic loss. Afterwards, Eliot struggled with grief and finding her place in the family. Soon after, she began to experience what she called “the Worries.”

Young Eliot was preoccupied and anxious about doing something bad, and began compulsively confessing about every possible, minor mistake. She was diagnosed with Obsessive-Compulsive Disorder (OCD) and began therapy. Everyone assumed that she was recovered. However, in adolescence, Eliot began experiencing “worries” about her sexuality. These fears were actually intrusive thoughts that made her question everything she knew about herself. “Am I attracted to women? My brother? Young children?” The fear and shame become so immense that she moves to NYC, cuts off her best friend, and has minimal contact with her family, all in order to protect them from finding out about the nature of her OCD. Eliot finds that if she isolates herself, and works 24/7, there is not much room for intrusive thoughts to take over. But of course, living this way comes at a cost. And it all falls apart when she returns home and faces the family and life that she ran away from.

“How to Hide in Plain Sight” is not just about OCD. It’s a love story, a coming-of-age story, and a story about the power of relationships to help us heal. But as a therapist, I appreciated the accurate and realistic portrayal of OCD in a fictional character. John Greene accomplished this in “Turtles All the Way Down” but that character demonstrated a more stereotypical presentation of OCD, with obsessions around germs and illness. I expect that for many readers of Noyes’ novel, this will be their first exposure to OCD obsessions that involve sex, sexuality, and fears of harming others.

The Many Faces of OCD

Let’s take a closer look at what makes Eliot’s character such an accurate portrayal of OCD.

Where are the compulsions?

The title How to Hide in Plain Sight alludes to the fact that Eliot’s OCD was not always apparent to the people around her, despite her managing a great deal of distress. Like a duck on a lake, she appeared to be floating along but was paddling furiously beneath the surface in order to stay afloat. Eliot has a form of OCD that is sometimes referred to as “Pure O”. The term “Pure O” has been used to describe OCD in which the compulsions are mainly mental compulsions, meaning that they are occurring internally to the person. When the term Pure O first came about, it reflected a belief that sometimes OCD presents without compulsions at all. However, this is a misunderstanding of the disorder (and many therapists now discourage the use of the term). Many compulsions are just difficult to identify.

Some common mental compulsions include:

• Mental review- reviewing a past event or interaction to feel more certain about its significance or accuracy, or repeatedly re-visiting issues that have already been “processed”

• Mental rehearsal- preparing and reviewing a mental script of how to behave, or imaging what you might feel or do in a situation

• Neutralizing- replacing a bad thought with a good thought, or otherwise doing something internally to erase or replace an unwanted thought or feeling

• Memory hoarding- intentionally trying to track and recall memories or information

• Prayer- compulsively praying to one’s self, in a repetitive and excessive manner and with the intention to minimize distress

• Scanning the body for symptoms or sensations- a “checking” behavior that occurs internally

• Mental repetition- repeating words, phrases, or numbers in a repetitive and ritualized way

• Rumination- repetitive thinking with the intention of “figuring it out”

In addition to mental compulsions, OCD sufferers are often engaging in avoidance and other subtle overt compulsive behaviors, which may not be as obvious as other rituals. These might include excessive internet research to find “certainty” or subtle ways of getting reassurance from others that their worries are not true.

You have thoughts about what?!

As the story progresses, we learn that Eliot suffers from unwanted, intrusive thoughts about sex and sexuality that cause her immense anxiety and disgust. She cannot control the thoughts, in fact, they intrude at the most inconvenient times and can be triggered by just about anything. As a result, she is plagued with fear and guilt about what the thoughts mean about her sexuality, morality, and goodness as a person.

Historically OCD has been associated with fears about germs, filth, and disorganization. In reality, these obsessions represent a minority of OCD cases. Oftentimes, OCD presents as a pattern of intrusive thoughts on one or more themes, which cause the individual intense anxiety, disgust, guilt, and/shame. The individual does not want to have these thoughts, and engages in compulsions in an attempt to figure out why they are thinking this way, to neutralize or otherwise eliminate the thoughts, or to avoid having the thoughts in the first place. This begins a mental tug-of-war in which the more a person tries to control their thoughts, the more they experience the unwanted thoughts. Research suggests that mental compulsions are most often associated with these sexual, aggressive, or harm-related intrusive thoughts.

Some common examples of taboo obsessions include:

• Unwanted sexual images or thoughts, that could include incest, pedophilia, or bestiality. These may occur as "what if” thoughts, suggestions, or simply as images. No matter how the thoughts present, they are always ego-dystonic, meaning they are inconsistent with a person’s values and desires.

• Violent or aggressive thoughts or images, like “what if I stab my husband while cooking” or “what if I push this stranger” at the bus stop. Usually associated with a fear of “going crazy” or “losing control.”

• Postpartum intrusive thoughts- thoughts about accidental or intentional harm coming to the baby, which may present as images, suggestions, or “what ifs”.

• Scrupulosity/Morality- Persistent questioning of whether the person has done something sinful, that may be associated with intrusive images or thoughts about blasphemous content.

• Suicide/self-harm- fear that a person could harm themselves, without any real desire to do so (which is distinct from actual suicidal ideation).

To illustrate how these thoughts are clearly OCD, let’s look at a common presentation:

Anna was bathing her young children and suddenly had a vivid image of her youngest slipping under the water. The thought was terrifying; as a loving and devoted mother, she was always on guard for anything that could potentially harm her children. But then, Anna began questioning why that distressing thought had come to her mind in the first place. “Why did I think that? Is that normal? Did I want to be thinking about that? Do I want something bad to happen to them?” Anna recalled stories she heard about other mothers that harmed their children on purpose. “Could I be like them?”

Although she had never behaved aggressively and never had urges to hurt anyone, Anna becomes completely preoccupied with worries about whether she could be the type of mother to harm her children. She dreads having another scary thought, and of course, the more she tries not to think about harm coming to her children, the more the thoughts come. She is often lost in her thoughts, analyzing her past behavior with her kids to detect any harmful behavior or urges. When caring for her kids during the day, she is monitoring herself closely for any feelings of frustration or aggressive urges. The more she worries, the more anxious and desperate she becomes, doubting her intentions behind seemingly benign behaviors. She starts avoiding doing certain activities with her kids, in order to avoid thoughts and the fear altogether. Sometimes she even contemplates whether she should take herself to the hospital or a police station, just in case she is a threat.

As a therapist that frequently treats individuals with OCD, I found How To Hide in Plain Sight did a powerful job of illustrating how OCD can progress and remain invisible to loved ones. If you do not have OCD, it may be challenging to understand how someone can become so confused about the meaning of their own thoughts. But the character of Eliot demonstrates how these thoughts manifest, creating fear and doubt that cripple an individual’s ability to trust themselves. We clearly see how Eliot’s thoughts are ego-dystonic (not aligned with her values, desires, and sense of self). We also see how Eliot structured a life that allowed her to avoid triggering situations and manage her thoughts and feelings, by isolating from loved ones, withdrawing socially, and overworking. On the outside, she may have looked like an ambitious young person who was devoted to climbing the career ladder. But we learn that this is really a lifestyle created to control and avoid emotional distress.

Emma Noyes Answers Some Questions

When I first learned about How To Hide in Plain Sight I was interested to see how the author would handle writing a character with taboo intrusive thoughts. Over the last several years, I have seen an increase in education about OCD on social media, including a push to decrease stigma about sexual and aggressive intrusive thoughts. Unfortunately, these conversations sometimes derail when the audience misunderstands, or is unwilling to believe, that OCD can present in this way. This is always unfortunate, because of the damage that this misunderstanding can have on sufferers who are already terrified of how others will perceive them.

Author Emma Noyes presents the character so convincingly, that it was no surprise to me to learn that Noyes suffered from OCD herself. I reached out to ask Emma a few questions about her experience of writing the character of Eliot.

Dr. Amber: In OCD treatment we often hear that the “content does not matter.” But for individuals with intrusive thoughts that involve sexual or aggressive content, there can understandably be additional distress over what other people will think of the person’s obsessions, and whether or not other people will understand that these thoughts are intrusive and unwanted. Did you have any trepidation about writing a character with “taboo” obsessions and/or did it come with any unique challenges as an author?

Emma: Absolutely. When I started writing this book, I didn't plan on publishing it. I didn't even really know that it was a book. I was just writing, recording the spirals of my mind, and eventually, those scribbles became a character, and that character had a story, and all of a sudden, I had created Eliot Beck. I went back and forth about whether or not I would actually try to publish it for a long time. It felt impossible to imagine that I could bare this part of my brain, a part I had kept secret for most of my life, to the rest of the world. But I'm so grateful I was brave enough to do it.

Dr. Amber: How have readers been responding to Eliot’s character and the presentation of OCD?

Emma: The response has been overwhelming. I can't tell you how many emails and DMs I've received from people telling me that they read HTHIPS, they related to it, and it has changed the way they view themselves and made them feel less alone. One night, I got a DM from a mom who told me that she recognized her 9-year-old daughter in Eliot, realized that her daughter probably has OCD, and was able to use that information to get her daughter in to see an OCD specialist. When I read her message, I burst into tears, because I was that 9-year-old girl. If someone had put me into the right form of treatment that early on, I would have been saved decades of suffering. I cannot put into words what it means to me that I might be able to do that for other children.

Dr. Amber: At the end of the book, Eliot has some breakthroughs and I think we are left with a sense of hopefulness. But it’s also clear that she still has a lot of healing to do. I am curious how you decided to end the story there?

Emma: I have now written two books with a main character who struggles with certain mental health issues (one on OCD, one on eating disorders, both of which I am diagnosed with) and I chose to end both of these books at sort of the same point - once they've finally asked for the help they so desperately needed, but before beginning the bulk of treatment. As I'm sure you know, entering treatment for any mental illness is a huge step forward, but it isn't the end. It's a whole new part of the journey, with its own nuanced struggles. If I wanted to write Eliot's journey in OCD treatment--and to do it right, without rushing it--I truly believe that I would have needed an entire second book.

Dr. Amber: What would you like readers to take away from this story?

Emma: You are not alone. You are not your thoughts. And despite what your brain is trying to tell you, you are not a bad person. You have a treatable mental illness, and you deserve to find someone who will love you not in spite of that fact but because of it.

I am so glad that Noyes pushed through her fear and published this book. I have no doubt that her story has already helped so many OCD sufferers to better understand, and have compassion for, their OCD experience. As a therapist, I have already begun recommending it to clients.

If you think you have OCD, please know that this is a treatable condition and you deserve relief. The International Obsessive-Compulsive Disorder Foundation is my go-to resource for education on the disorder. They also have a directory of therapists that specialize in the diagnosis and treatment of OCD.

More resources:

The OCD Stories Podcast- This podcast interviews individuals with every sort of OCD presentation. You will have the opportunity to hear sufferers describe their history with OCD, including how they accessed help and what treatment was like. The podcast also includes interviews with therapists and researchers who specialize in OCD.

Alegra Kastens on Instagram and Substack- Alegra is a licensed OCD therapist who also has lived experience with OCD. She works to increase education and compassion for OCD sufferers, especially those with intrusive sexual and aggressive thoughts.

Overcoming Harm OCD: Mindfulness and CBT Tools for Coping With Unwanted Violent Thoughts by Jon Herschfield, MFT

Harm OCD Vs. Being Dangerous by Marion Plessner Rodrigue, LMHC

I would love to hear your reactions in the comments!

• Have you ever heard of Harm OCD, “Pure O”, or mental compulsions?

• Do you think you will check out “How to Hide in Plain Sight” by Emma Noyes?

• Do you have other thoughts or questions about OCD that you would like me to write about in the future?

If you are interested in OCD, check out these that you may have missed:

From Both Sides of the Couch: An OCD Story

Exposure Therapy: The Only Way Out, Is Through

Disclaimer: This article is a reflection of my personal and professional experiences as a licensed clinical psychologist. It reflects my current and best understanding of these issues. It is intended to be educational and informative, but is not medical, clinical, or therapeutic advice. Following this newsletter does not establish a therapeutic relationship with me. Dr. Amber_Writes, and other written communication by Amber Groomes on Substack, is not a substitute for treatment, diagnosis, or consultation with a licensed mental health professional. I assume no liability for any action taken in reliance on my writing here at Dr. Amber_Writes. Any questions about your personal mental health treatment should be directed to your personal medical professional. You can find a therapist at Psychology Today.