Agency and Mental States in Obsessive-Compulsive Disorder

Judit Szalai

Philosophy, Psychiatry, & Psychology, Volume 23, Number 1, March 2016,

pp. 47-59 (Article)

Published by Johns Hopkins University Press

DOI: https://doi.org/10.1353/ppp.2016.0001

For additional information about this article

https://muse.jhu.edu/article/629603

Access provided by University College Dublin (5 Nov 2018 16:13 GMT)

 Agency and Mental
States in Obsessive-
Compulsive Disorder
Abstract: The dominant philosophical conceptions
of obsessive-compulsive behavior present its subject as
having a deficiency, usually characterized as volitional,
due to which she lacks control and choice in acting.
Compulsions (mental or physical) tend to be treated in
isolation from the obsessive thoughts that give rise to
them. I offer a different picture of compulsive action,
one that is, I believe, more faithful to clinical reality.
The clue to (most) obsessive-compulsive behavior seems
to be the way obsessive thoughts, which are grounded
in an irrational cognitive style in matters of risk, dan-
ger, and responsibility, motivate compulsions through
bizarre means–end reasoning. I show that the patient
with obsessive-compulsive disorder (OCD) is not weak
and passive with regard to the compulsive act; rather,
the act is voluntary and regarded by the patient as an
instrument of control. I also defend the idea that OCD-
related cognitions are either beliefs or mental states with
relevantly similar functional roles.
Keywords: compulsion, belief, motivation, control,
obsession, choice, irrationality
I
n the current philosophical literature,
obsessive-compulsive disorder (OCD) tends
to appear as one of the main examples of be-
ing internally compelled to act in a certain way,
of lacking choice and control over one’s action.
Apart from some differences in the understand-
ing of the stipulated weakness and passivity on
the part of the agent, there has been remarkable
consensus regarding the phenomenological prop-
© 2016 by The Johns Hopkins University Press
Judit Szalai
erties of this condition and the basic character of
agency involved. A few quotations will suffice to
illustrate the view that the compulsive person is
in no position to control her compulsive motiva-
tions and acts:
OCD patients often indicate that they wish to be
rid of handwashing or footstep counting behavior, but
cannot stop. Pharmacological interventions, such as
Prozac, may enable the subject to have what we would
all regard as normal, free choice about whether or not
to wash his hands. (Churchland, 2002, p. 208)
We understand that a person suffering from obses-
sive–compulsive disorder, spending all day washing his
hands and checking dozens of times that he remembered
to lock the front door, cannot be thought of as having
free will. (Levy, 2003, p. 214.)
[A] loss of freedom—akin to the compulsions of the
obsessional. (Watson, 2003, p. 184)
Further, related claims are that the compulsive
agent does not act for reasons (so while her be-
havior can be explained, it cannot be justified) and
that the impulses on which she acts are unintel-
ligible (Bayne & Levy, 2006, p. 60; Tenenbaum,
2003, p. 152, fn. 15.). It is also thought that the
OCD patient is indifferent to incentivization aim-
ing to deter her from carrying out the action (Duff,
2005, p. 448; Huoranszki, 2011a, p. 131).
This paper is intended to show that, contrary
to the received philosophical understanding char-
acterized, although compulsive acts may seem to
be uncontrolled and lacking reasons, their agents
48  ■  PPP / Vol. 23, No. 1 / March 2016
typically perform them voluntarily, in a goal-
oriented and mostly controlled manner. What
constitutes the peculiarity of obsessive-compulsive
action, I submit, is an irrational, “magical” prob-
lem-solving strategy, based on biased cognitions,
rather than the inability to resist certain urges. In
support of my position, I draw extensively on psy-
chiatric research, as well as adduce considerations
drawn from the phenomenology of OCD, in favor
of regarding OCD-related behavior as voluntary
and manifesting agency (although in a peculiar,
somewhat constrained form).
I start with accounts of OCD we find in con-
temporary philosophy of mind and action. Then
I offer what I take to be a more plausible under-
standing of obsessive-compulsive agency and its
phenomenology, based on empirical research on
OCD. Finally, having given extended responses
to two possible concerns related to my account, I
contrast the characteristics of agency in OCD with
those in other pathological phenomena.
A caveat is in order here, though. I would not
find it appropriate to restrict the use of the word
‘compulsion’ to obsessive-compulsive behavior;
especially in everyday parlance, we use the term
‘compulsive’ more generally to phenomena involv-
ing acting on irresistible or allegedly irresistible
desires. My claim is that in as much as it is OCD
that philosophers have in mind—as they very often
do—when talking about and adducing examples
of pathological compulsion, it should be under-
stood in a specific way. I hope to make it manifest
that the everyday use of ‘compulsive’ cannot be
assimilated to the technical use of the term when
discussing pathological behavior such as compul-
sive handwashing and stove checking. Nor is OCD
relevantly similar to conditions that also tend to be
considered as involving “compulsion,” especially
substance-related and impulse control disorders.
I start by pointing out the distinction.
Pathological Compulsion
in Contemporary Theory
of Mind and Action: Other
Accounts
OCD and pathological compulsion are treated
as equivalent by some philosophical accounts (e.g.,
Huoranszki, 2011a, 2011b; Zaragosa, 2006); oth-
ers consider the former the case par excellence of
the latter. Before reviewing different theories, we
need to make a preliminary distinction, already
noted in the literature (Huoranszki, 2011b),
between the compulsion of the OCD patient and
certain behavioral excesses driven by desires that
are also often called “compulsive” (such as “com-
pulsive” eating, drinking, gambling, and lying).
Some of what we colloquially call “compulsive”
are recognized mental pathologies or symptoms
of such pathologies, but there is no single category
in which “compulsive eating,” “compulsive gam-
bling,” and “compulsive lying” would all belong.
Pathological gambling and pathological binge
eating have in the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5; American Psychiatric
Association [APA], 2013) acquired the status of
separate mental disorders; persistent deceitfulness
is a symptom of antisocial personality disorder
(APA, 2013, pp. 585, 350, 659). Although not
belonging in a single psychiatric category, such
phenomena—or most of them, except perhaps
pathological lying—have a feature in common that
distinguishes them from manifestations of OCD.
Persons who engage in these forms of behavior
are, at least initially, attracted to and enjoy the
action itself or some aspect of it.1 The compulsive
checker, in contrast, cannot be attracted to check-
ing the gas stove the way the drinker is attracted
to drinking. If we label certain forms of substance
use and gambling “compulsive,” a different kind
of “compulsion” from that of OCD is involved.
The majority of the available philosophical
accounts, although varying in their explanations
of the agent’s inability to refrain from acting on a
desire or avoid forming the intention to perform
the compulsive act, normally refer to a volitional
incapacity on the agent’s part (e.g., Holton, 1999;
Watson, 1977, 1999; Zaragosa, 2006).2 Watson
(1977) attempts to differentiate between compul-
sion and the weakness of will, which both seem
to involve a desire the agent is unable to resist.
Watson (1977, p. 332) suggests that the differ-
ence lies in the kind of irresistibility the respec-
tive desires exhibit: although persons are weak
willed in relation to desires a normal adult could
be expected to resist, “no degree of training and

discipline would have enabled him or her to resist”
a compulsive desire. This characterization, Watson
admits, makes the very existence of compulsive
desires doubtful.
Zaragosa’s (2006, p. 262) more recent account
uses the idea of “ego-depletion,” of temporarily
losing the capacity of self-control after its overly-
straining exertion. “A compulsive is subjected to
a nearly continuous stream of impulses to perform
a specified behavior, which eventually overworks
the will, producing a form of psychological stress.”
What explains OCD for Zaragosa is a failure of in-
hibitory mechanisms that would prevent the agent
from performing the compulsive act. As muscles
“give out” after extreme exertion, capacities of
self-control, of “suppressing or inhibiting desires
or behaviors” fail and resistance is abandoned.
An advantage of this account is doing justice to
the element of the tension release that accompa-
nies the execution of the action in OCD. It also
accommodates the patient’s feeling of the press-
ing need to perform it. Where my own account
significantly departs from Zaragosa’s is regarding
the role assigned to the OCD patient’s cognitions
and to agential effort. I argue that the patient does
not give in to an urge, but rather voluntarily initi-
ates, and retains a significant amount of control
over, her action.
Although concurring with the idea that com-
pulsives do not choose or control their behavior
and that compulsive acts are performed without
a reason, Huoranszki (2011b) understands the
compulsive’s failure as ultimately cognitive. The
pathologically compulsive agent cannot make a
choice for the reason that she does not believe
that she is able to perform (or not perform) cer-
tain kinds of action (even if, in fact, she is). This
understanding is supported by self-reports of OCD
patients who claim that they had to perform the
act and could not have done otherwise (Reed,
1977, passim).
Volitional deficiency accounts of OCD do not
substantially engage the causal role of beliefs in
this condition. I share Huoranszki’s view that
cognitive factors are just as important as volitional
ones: compulsion cannot be understood in isola-
tion from the beliefs that ground and maintain
them. To my mind, OCD-related beliefs are not
Szalai / Agency and Mental States  ■ 49
explanatory by themselves, though, but need
to be seen in the context of the patient’s other
cognitions.
Viewing OCD from the perspective of action, its
philosophical accounts tend to confine themselves
to the discussion of the compulsive act itself and,
to a lesser degree, those beliefs in the content of
which the act figures (such as the agent’s belief that
she is unable not to perform the act). I suggest that
the obsessions that in most cases trigger compul-
sions are an indispensable clue to the properties
of OCD behavior. Also crucial is the way the
obsessive-compulsive agent conceives of causal
relations in a particular thematic domain, that of
risk and danger. The irrationality of compulsive
behavior derives partly from the irrationality of
the obsessive thought itself and partly from a
bizarre, motivated means–end reasoning. In the
following, I offer an alternative account of the
cognitive background, typical mechanism, and
agency involved in OCD.
Obsessive Thought and
Compulsive Act: A Cognitive
Account of OCD
My cognitive account places the two sorts
of thought crucially involved in OCD in its fo-
cus: obsessive, intrusive thoughts and strategic
thoughts about ways of undoing the former and
preventing the events appearing in them. First,
what is the obsessive thought? The obsession is not
an urge to perform the compulsive act; the obses-
sion–compulsion pair cannot be assimilated to an
impulse and acting on it. Obsessive thoughts are
often highly image-like and are typically concerned
with terrifying potential occurrences, for example,
traffic accidents happening to the agent herself
or to a close person, serious illnesses through
contamination, or inappropriate (often sexual or
aggressive) behavior on the part of the agent (APA,
2013, p. 238.). For instance, many patients have
intrusive thoughts about harming a close person.
These thoughts disturb the patient’s mental life,
possibly to an incapacitating degree. The obsession
is “experienced as intrusive and unwanted” (APA,
2013, p. 237). Although the agent does not have a
sense of “making up” these intrusive images and
50  ■  PPP / Vol. 23, No. 1 / March 2016
they are experienced as coming unbidden, OCD
patients believe in the possibility and necessity of
controlling their obsessive thoughts.3
How is it possible to control such thoughts? The
OCD sufferer uses maladaptive strategic thinking
for this purpose, such as self-punishment and neu-
tralization, the mental “undoing” of the disturb-
ing thought. Compulsive actions serve a purpose
similar to the latter, so as their mental counterpart
is called “covert,” compulsive behavior is “overt”
neutralization (Veale, 2007, p. 241). “Neutraliza-
tion is defined here as any voluntary, effortful,
cognitive or behavioral act” (Freeston, Ladouceur,
Rhéaume, & Léger, 1998, p. 120). The goals of
neutralization can slightly differ: “removing the
thought, changing its meaning, preventing or un-
doing harm” (ibid, p. 121). The two are typically
connected for the OCD sufferer: she tries to keep
the obsession with the negative future event at bay
by performing a sequence of actions to prevent
the harm or negative event from happening. This
sequence of actions, for example, emitting certain
sounds or making certain gestures in a particular
order, can most appropriately be called a “ritual.”
Compulsions are explicitly identified as rituals by
the DSM: “Compulsions (or rituals) are repetitive
behaviors (e.g., washing, checking) or mental acts
(e.g., counting, repeating words silently)” (APA,
2013, p. 238). What seems to be involuntary be-
havior to the observer is actually an effort on the
agent’s part to control the future state of the world
and, through that, to ease the tension caused by
the obsessive cognitions.
Thus, compulsions are typically reactions to
obsessive thoughts. The agent tries to reduce dis-
tress by preventing the dreaded event presented in
the obsessive thought through the compulsive act.4
Now, there are occurrences we seem to be able to
do something about. This would be the point of
handwashing and checking: handwashing to make
sure we do not get contaminated, checking on the
gas stove to make sure we do not burn down the
house. But OCD handwashing and checking are
different from everyday handwashing and check-
ing in being ritual-like: they have to be repeated a
number of times and be done exactly “right” to be
effective. So the causal link is already tenuous in
these cases: washing hands yet again in 10 minutes
probably will not make a difference in contracting
or not contracting the disease. In the case of emit-
ting peculiar noises or looking in the corner many
times, the causal link becomes incomprehensible
to the observer, but it exists for the OCD patient;
she thinks that if she produces a certain sound
fifty times, she will not have a traffic accident, say.
This goal of the compulsive act is mostly con-
sciously pursued, not implicit or hidden, which
in itself suggests that the action is voluntary and
controlled by the agent. There are explicit state-
ments to this effect in the psychiatric literature. I
give a few examples.
The feature of compulsion that needs to be stressed
here is that a compulsion is actively brought about by
the patient: he is not happy about doing it, but it is es-
sentially his voluntary action … and not an automatic
behavior. (De Silva & Rachman, 2004, p. 9)
Although obsessions are felt as involuntary and are
strongly linked to anxiety and distress, ritualizing (both
overt and covert), is voluntary, controlled behavior.
(Arden and Linford, 2008, p. 186)
[C]ompulsions are voluntary, goal-directed, non-
rhythmic and under conscious control. (Anand &
Chandra, 2014, p. 345)
However, I do not intend to exclusively rely on
the literature here. I adduce three considerations
speaking for the purposeful, voluntary, and mostly
controlled character of compulsive acts: the agent’s
feeling responsible for the outcome and, through
that, the action itself; the effortful nature of com-
pulsive acting; and, most important, the agent’s
capacity to abstain from acting compulsively,
proved by clinical practice.
One of the well-established features of the
phenomenology of OCD is a heightened sense of
responsibility (Clark, 2004, pp. 94ff; Salkovskis,
Richards, & Forrester, 1995). The compulsive
agent, as we have seen, typically perceives herself
as facing a threat. The kinds of threat in point
are such that we normally do not consider to be
in our power to avert. Excepting special cases, we
cannot keep catastrophes from happening and can-
not help incurring great losses (regardless of how
we act, we may get harmed in a traffic accident,
our loved ones may fall seriously ill, and so on).
The obsessive-compulsive person, however, does
assume the existence of a causal link between her
actions and such anticipated occurrences. She feels

responsible for the potential bad outcome: if she
fails to check the lock again and again, her house
will be robbed; if she does not repeat washing
her hands, she gets seriously infected; she will be
fatally harmed in a traffic accident the next day
unless she repeats certain movements with her
right hand. Thus, the compulsive agent’s sense of
responsibility is inflated rather than reduced: her
imagined scope of responsibility vastly extends
that of the non-pathological agent.
That the compulsive person has a sense of
influencing such outcomes in the world provides
indirect evidence for her feeling responsible for the
compulsive act as well. If the act (in thought or in
physical action) were not in her power to initiate, if
she had no control over acting or failing to act, the
compulsive person could not blame herself if what
she fears becomes reality. The presence of guilt in
the case of not performing the act to protect one-
self or others also indicates the individual’s sense
of responsibility (cf. Shapiro & Stewart, 2011).
Unfortunately, arguments based on the phe-
nomenology of OCD are weakened by the fact
that OCD phenomenology is not a sufficiently
reliable indicator of actual agency (see below).
Therefore, we also need to look at the properties of
actual agency. The second and third arguments are
derived from the OCD sufferer’s manifest capacity
to initiate and terminate her action.
A well-documented characteristic of OCD is
a sense of not getting the action “just right,” for
example, not closing the door well enough or not
making precisely the right gesture. (From a vast
literature, I select a few items: Veale [2007, p. 440];
Salkovskis & Forrester [2002, pp. 53ff]; Coles,
Heimberg, Frost, & Steketee [2005, passim].)
This is often labelled a “perfectionistic” tendency
in OCD patients. They tend to feel that their ex-
ecution of the ritual falls short of the norm and
therefore will not achieve the intended effect. This
sense of imperfectness or incompleteness prompts
patients to repeat the action further, until they “get
it right,” which is perceived as requiring extra ef-
fort and “concentration.” The agent may find it
requiring persistent effort to perform the action
precisely in accordance with the difficult and tax-
ing rules she considers it necessary to observe for
the performance to be effective. The right number
Szalai / Agency and Mental States  ■ 51
of repetitions is determined along the way by the
agent herself, who repeats and stops executing the
ritual as she feels fit. Washers, for instance, use dif-
ferent and elevated evidence criteria for deciding
when to stop washing to achieve the right effect
(Wahl, Salkovskis, & Cotter, 2008).
Besides initiating and terminating her action,
the OCD patient can also desist from it altogether,
if provided the right incentives. According to the
standard philosophical picture, the compulsive
agent could not be deterred from the compulsive
act. The following is a case in point:
If an agent would resist an impulse when offered
suitable incentives to do so, he could resist it (even
when that incentive was not on offer): that is all that
“he could resist it” means. That is what distinguishes a
culpably weak-willed agent from one who is the victim
of a pathological compulsion. Although the weak-willed
person acts against what she sees to be the balance of
reasons, she has an intelligible reason for what she does
(she gives in to an intelligible temptation), and would be
persuaded to act differently if offered some even better
reason to do so: to stay in bed when I know I should
be going for a run might be weakness of will; to stay in
bed when I know the house is burning down is suicidal
or pathological. (Duff 2005, p. 448)
We have to augment this fictitious scenario with an
explanation of the behavior described. A person
with OCD will not find herself unable to get out
of bed owing to some force, including her own
desire, as a result of her condition. The only way
in which it could hinder her escape from the burn-
ing house is the unlikely possibility that she has a
ritual attached to the very activity of getting out
of bed or one that she performs while staying in
bed and is unwilling to break off or forgo, even in
extreme danger. Her reasons will be intelligible in
the light of her beliefs, even if we consider those
beliefs irrational. For instance, she might be con-
vinced that if she fails to perform her morning
ritual that she has adhered to for 5 years, she dies
on the spot—without ever getting the chance to
rise from her bed and escape. But if the content
of the obsession is less threatening than the actual
circumstance, she will get out of bed.
What is the evidence that the OCD patient can
be incentivized not to perform the compulsion?
This is most directly shown by the way in which
exposure and response prevention, the standard
52  ■  PPP / Vol. 23, No. 1 / March 2016
cognitive behavioral therapy treatment of OCD
(cf. O’Connor, Aardema, & Pélissier, 2005, p. xiv;
Veale, 2007, passim) is implemented. The point of
response prevention is to show that not perform-
ing the action does not lead to the feared event’s
occurrence. Physical prevention, for instance,
tying down the person, is not a recommended
practice anymore; rather, the patient is made to
voluntarily refrain from performing her rituals.5
Patients are simply instructed not to execute the
ritual (Foa, 2010, p. 201; Hiss, Foa, & Kozak,
1994, p. 803). When they are exposed to the theme
of their obsession, which would otherwise result
in the performance of the obsessive act, they can
and do abstain from performing it for therapeutic
purposes. The reasons why such therapy might
fail follow the same logic: a source of failure has
been that the patient refused to “risk” response
prevention, that is, she was afraid that without her
executing the appropriate rituals the event that is
the content of her obsession will occur (Salkovskis,
2007, p. 235). The possibility of voluntary refrain-
ing shows the voluntariness of the action itself.
On the basis of the above, the typical dynamic
of the obsessive-compulsive process is the follow-
ing. The content of the obsessive thought (which
may be grounded in a tendency to anxiety) is an
exaggerated threat. These recurrent representa-
tions are experienced as alien, not within the
agent’s control; they are also perceived as veridical:
the danger is considered real. The agent takes this
threat as a reason to act: she strives to eliminate
the threat and, through that, the overwhelming
thought itself. The agent is aware of acting for
these reasons: if asked why she performed the
compulsive act, she will reply something like:
“So that my mother does not die” or “Because
these thoughts drive me crazy, I have to get rid of
them.” The compulsive act itself is experienced
as the agent’s voluntary attempt to remedy her
(and others’) situation.6 The obsessive-compulsive
person feels responsible for performing or failing
to perform the act and doing it “in the right way.”
The act is irrational, in that whether the obsessive
thought is warranted to any degree, the threat
that constitutes its content is incapable of being
eliminated in the way the compulsive patient at-
tempts to do it,7 or—in the case of checking and
washing—the repetition of the behavior does not
increase the likelihood of the achievement of its
aim.
Agency characteristic of OCD is also con-
strained. Even though it manifests accepted
marks of agency—such as the act being caused
by, rather than just happening to the person and
being brought about for a reason8—it falls short
of full-blown agency on account of deficient action
guidance or control. Action guidance, the ability
and readiness to make “compensatory adjust-
ments” when necessary to achieve the purpose of
the action, is essential for agency.9 Now the OCD
patient is not guided by the customary clues of
reaching the goal of the action, but, as we have
seen, determines success by his idiosyncratic sense
of rightness. He fails to adjust his movements ac-
cording to the normal standards of goal reaching
and does not consider his action finished when
non-pathological agents would (e.g., closes and
reopens the door several times, to make absolutely
sure that it is closed properly). Further, owing to
her excessive attention to the details of her per-
formance and to “right” execution, the obsessive-
compulsive person tends to be a “low-level” agent
(Balconi, 2010, pp. 136ff.). This involves a form of
action monitoring and perception of agency that
does not focus on the overall action plan (while
not losing sight of the overall intention). In these
(related) respects, OCD agency can be said to be
constrained or even diminished.
Deliberation and Belief
in OCD: Replies to Two
Potential Objections
In this section, I address two potential objec-
tions. One is that if we consider OCD-related ac-
tions, or refraining from those actions, voluntary,
how are we to accommodate many patients’ sense
of “not being able to do otherwise?” My reply is
twofold. First, the phenomenology of OCD might
be misleading concerning the properties of the ac-
tual agency involved. Second, even in those cases
when we may be entitled to draw conclusions from
phenomenology to agency, there is a relatively un-
problematic way of making sense of the claim that
agents “cannot do otherwise” without interpreting
it as registering loss of control in a robust sense.

We have reason to believe that self-perception
is not a reliable guide to OCD patients’ agency
and control. More than one-third of patients are
unaware of the fact that their compulsive acts are
driven by obsessions (Kalra & Svedo, 2009, p.
737). Because so many patients fail to assess the
causal background of their action correctly, the
sense of “not being able to do otherwise” may
also be false. A sense of a lack of control may be
compatible with actual control. But even if we
stipulate that some of the remaining 60% to 70%
who have good insight into their condition would
also report not being able to do otherwise, we can
account for those cases.
We should work through the question: in what
sense is the claim that the OCD patient cannot do
otherwise to be understood? In the case of acting
compulsively, a different course of action is not
prevented by a physical impossibility, as in the case
of a person in a locked room who cannot open the
door and walk through it. Further possible senses
are 1) the agent “cannot do otherwise” due to lack
of some ability, and 2) because she perceives her
balance of reasons to be overwhelmingly in favor
of one course of action, which seems to preclude
choice. Those who claim that obsessive-compul-
sive agents lack control over their actions subscribe
to the first view: persons with OCD fail to have
or to retain a certain capacity, volitional or cogni-
tive, that normal agency requires, such as resisting
certain kinds of irrational impulses, or thinking
of themselves as competent agents. However, as
we have seen, obsessive-compulsive persons tend
to carry out compulsive acts in a manner that can
appropriately be labelled “voluntary” and do not
yield to some force they experience as beyond their
power to resist. They can decide to perform or not
to perform the act. Compulsives may be loath to
execute the ritual; they often express discontent,
even desperation with regard to their compulsion,
which may be rather time consuming, unreason-
able, and even ridiculous.10 In this sense, the act
is often “unwanted”; at the same time, the patient
often considers its execution necessary or inevi-
table, given that the alternative, in her perception,
is being exposed to, for example, extreme danger.
Thus, it is more in the latter—let’s call it “delib-
erative”—sense that we should understand the
claim that patients “must” execute their rituals.
Szalai / Agency and Mental States  ■ 53
The reason that the alleged threat gives the OCD
agent seems to be so strong that it overrides those
deriving from the inconvenience (or absurdity,
shamefulness, etc.) of the act. The stakes being
considered immensely high (such as the patient’s
own life or that of a close person), OCD patients
have to “make sure” that they have completed the
assigned task (emitting noises, making gestures,
etc.) and have done it “in the right way,” so that
it is effective. It is considered vitally important to
complete the assignment; the agent might fail to
do it, however, owing to physical obstacles, lack
of “concentration,” and so on, accompanied by
an acute sense of failure and impending catastro-
phe (not prevented by successfully performing
the action). The obsessive-compulsive agent thus
exercises a deliberative capacity and is capable of
making decisions concerning her acts, although
her decisions are likely to be based on mistaken
premises (presented by the obsessive thought) and
a faulty assessment of a means–end relationship
(how a particular type of danger can be averted).
The second objection is that the beliefs we are
attributing to OCD patients, that is, the obsessive
thoughts and the beliefs concerning the causal
significance of the compulsive act, are too bizarre,
and therefore the claim that obsessive-compulsive
agents actually hold them is implausible. (Who
would genuinely believe that making clicking
sounds with her tongue could prevent an accident
next day?) One consideration that may give us a
pause in this regard is that, according to the DSM,
OCD patients themselves may acknowledge their
obsessive thoughts to be “unreasonable.”11 This
can be interpreted in different ways, however.
Agents may only realize that their thoughts are
out of the ordinary and that they are incapable
of being supported by publicly available evidence.
This does not necessarily undermine the convic-
tion, however, because the agent may think, for
instance, that she has an “intuitive” grasp of its
truth, or possesses special evidence not available
to others.
The question we have to ask in dealing with
this objection is whether OCD-related thoughts
meet the plausible criteria of belief attribution. In
the following, I show that they may meet even the
stringent criteria of belief attribution that some
philosophers consider only applying to rational be-
54  ■  PPP / Vol. 23, No. 1 / March 2016
liefs. We would need powerful arguments against
considering those cognitions that live up to those
standards beliefs. (Further, if the instrumental
belief-candidate [e.g., “If I want to prevent the
accident from happening to me tomorrow, I have
to click my tongue 50 times”] passes the belief test,
the obsession it is a response to, which is included
in the content of the instrumental belief [“An ac-
cident will happen to me tomorrow”] also does.)
Obviously, not every criterion will apply in
every case of OCD; some cognitions may fall
short of having the status of belief. However, for
our purposes, namely, describing the mechanism
and character of compulsive acts, it does not
matter whether we accord belief status to the
cognitions involved, or label them something
else, for example, “quasi-beliefs.” These cogni-
tions are still action-guiding (APA, 2013: “The
behaviors or mental acts are aimed at preventing
or reducing anxiety or distress, or preventing some
dreaded event or situation” [p. 237]) and it has
been demonstrated that they fit into the net of the
patient’s more fundamental beliefs or cognitions
(see below). Thus, they fulfil the role attributed to
them by our account. (Because this account only
uses the functional roles of these cognitions, the
correctness or incorrectness of self-attributions of
beliefs can also be disregarded.)
One of the generally recognized marks of belief
is that it is not isolated from the subject’s other
beliefs but is embedded, at least to some degree,
in her belief system. Now OCD-related beliefs fit
in well with the OCD agent’s other beliefs. The
elements of the latter are well discussed in the
literature: over-assessment of risk and danger;
stronger than common belief in the significance of
thoughts; “thought–action fusion”; and belief in
the effect of rituals on the state of the world.12 An
OCD patient significantly overestimates the likeli-
hood that the dreaded event will occur; considers
it much likelier than it actually is that she will act
on an (aggressive, shameful, etc.) thought (and,
say, commit a murder or bare herself in public);
she quasi-superstitiously believes that there can be
influencing between seemingly causally unrelated
events (such as clicking tongues and accidents).
Recent research on OCD has even identified a pe-
culiar “reasoning style” in this condition, dubbed
“inverse inference”:
In inverse inference, instead of beginning with evi-
dence from the senses and then drawing conclusions,
people with OCD draw conclusions despite contradic-
tory evidence of the senses. So, in a sense, they work
backwards from what could be to what is, instead of
from what is to what could be. (O’Connor et al., 2005,
p. xi.)
The way OCD patients connect thoughts might
be peculiar but the connections and inferences are
nevertheless there.
Another widely accepted criterion of belief is re-
sponsiveness to evidence. It is true that motivated
beliefs in general tend to be more protected than
others. We are more reluctant to give up the belief
that we are good at x (driving, writing articles,
parenting) than the belief that we had good cof-
fee in the coffee shop today if—as it is likely—we
have emotional investment in the former and not
in the latter. The belief that a certain kind of danger
can be averted by a certain kind of ritual is also a
motivated belief: the high chance associated with
the particular danger by the agent and its marked
negative evaluation has a role in the formation
of the belief. Nevertheless, these states are also
responsive to evidence. Checkers, for instance,
were found to stop behaving compulsively after
their admission to a medical facility (Rachman
& Hodgson, 1980, p. 177). The explanation is
that they realized that there was no need for them
to check that the gas was not on in the hospital:
there are others who would have noticed if it was,
so there was no danger to avert. Thus, patients
adjusted their beliefs to evidence about the neces-
sity to check.
A third mark of belief is action guidance.
In contrast with, for instance, the patient with
Capgras delusion, who believes that his wife has
been replaced by another person or a robot and
nevertheless fails to report to the police that she
is missing (Bortolotti, 2010, p. 69), which might
raise doubts about the belief status of his cogni-
tion, the OCD agent tends to act on her belief. The
causal link between the obsessive thought and the
compulsive behavior is hardly questionable: the
agent does what she does because she believes that
something awful will happen otherwise.
These considerations suggest that OCD-related
cognitions are at least highly belief-like: they fulfil

the role of belief in guiding action; they have the
required connections to the agent’s other beliefs;
they can be responsive to evidence. Because, for
our purposes, it is not the labelling but the func-
tional links to the compulsive act that count, the
possibility of not granting belief status to OCD
cognitions does not constitute a serious challenge
to my account.
A final point concerning the question of the
attribution of bizarre beliefs. We habitually at-
tribute completely unwarranted and sometimes
bizarre beliefs to ordinary, non-pathological
agents. Students have private superstitions about
“lucky” objects (plush animals, etc.) they need to
have with them for their exams to be successful.
Some persons count their steps before important
negotiations. The apparent absence of a causal link
does not prevent us from attributing the relevant
beliefs to people. We should also keep in mind that
OCD-related convictions are often “metaphysi-
cal” in character, unfalsifiable by experience. The
therapeutic difficulty already mentioned, namely,
that patients are unwilling to “run the risk” of the
dreaded event happening by not executing the ritu-
al, also has to do with this “metaphysical” nature
of obsessive convictions. Given the character of the
OCD sufferer’s beliefs, she is hard to prove wrong.
Even if she can be persuaded to desist from the act
on certain occasions and is made to see that the
negative event failed to occur, she may find other
explanations for this fact, for example, that the
circumstances were ultimately not those in which
the event would happen, that this time she was
spared by some transcendent reality, and so on. (It
is characteristic of vows and ritualistic behavior to
operate with this kind of logic: if the rain-making
rituals did not work, it does not prove that they
do not make rain as a rule; perhaps the execution
was imperfect.) Obsessive beliefs are also typically
concerned with a singular potential life event, one
that the individual is unlikely to have undergone in
the past and come to have experience with, such
as contracting HIV or being fatally harmed in an
accident. Because we attribute bizarre beliefs to
healthy agents as well, we cannot deny them to
OCD patients merely on this count.
Szalai / Agency and Mental States  ■ 55
Agency and Control in OCD
and Related Phenomena
The OCD patient is motivated to carry out some
act that will remove the assumed threat rather than
being committed to a particular course of action
for its own sake. If there were a more convenient
way of eliminating the obsessive thought or the
danger presented in it, compulsives would prob-
ably opt for that. If a cure-all medicine were in-
vented against every possible infectious disease and
the compulsive handwasher could be persuaded of
its effectiveness, she would in all likelihood get rid
of her handwashing habit. Contrast this with the
conditions known as trichotillomania (hair pulling
disorder) and dermatillomania (skin picking dis-
order), also often labelled “compulsive.” Pulling
hair and picking at one’s skin are not intended as
means to achieve any particular effect. In these
conditions, the agent does feel an urge to act that
she cannot rationalize.13 These disorders may
be seen as anxiety reducing directly and in their
own special ways (e.g., Christenson & Mansueto
1999, p. 5.), just like whistling or fidgeting, which
are equally “pointless” activities. The obsessive-
compulsive patient, in contrast, reduces tension
only indirectly, by the sense that she did her part
to prevent a catastrophe. She would do what is
in her power, or promote a means that is in an-
other’s power, to eliminate the threat: the activity
is not a goal in itself, only an instrument that the
compulsive would readily dispense with. Thus, a
characteristic of obsessive-compulsive agency we
may observe in comparison with somewhat similar
mental pathologies is that the compulsive patient is
not committed to a particular act for its own sake,
but rather is interested in the results of her action.
Pathological conditions in which acts feel un-
intended by the patient, as if authored by another
agent, are the often mentioned “anarchic hand
syndrome” and the type of schizophrenic behav-
ior that is associated with delusions of external
control. A summary description of the former
condition is that patients “sometimes find one of
their hands performing complex, apparently goal-
directed movements they are unable to suppress
(except by using their ‘good’ hand)” (Eilan &
Roessler, 2004, p. 2). The anarchic hand may in-
56  ■  PPP / Vol. 23, No. 1 / March 2016
terfere with an action performed by the other hand
or do something wholly unintended by the agent
(i.e., collecting food from another person’s plate).
The patient’s perception of these actions is that she
does not initiate and cannot control them; they
feel “as if” they were someone else’s. Being goal
directed and well-executed, it is appropriate to
call these forms of behavior actions, despite being
unhinged from conscious agency and control (cf.
ibid.). The schizophrenic with control delusions
also lacks a sense of authorship of her acts. She
might feel compelled to carry out a certain act by,
for instance, voices she hallucinates. (According to
a study, about one-half of those with this condition
who experience command hallucinations comply
with the command [Junginger, 1990, p. 246].) In
both conditions, there is a dissociation between a
sense of ownership and a sense of authorship of
actions: although the agent acknowledges the act
to be her own (although, in the anarchic hand case,
this sense is diminished), she does not recognize
herself as the author of it, as the agent initiating
the action. Accordingly, she also lacks a sense of
responsibility for the act.
The sense of agency usually attributed to ob-
sessive-compulsive patients is similar: “We suspect
that as one begins to experience one’s movements
as caused by one’s mental states, one no longer
experiences them as one’s own actions. That is, one
no longer experiences the action as an instance of
first-person agency” (Bayne & Levy, 2006, p. 52).
The agent allegedly lacks the sense of the ability
not to carry out, or not to form the intention to
carry out, the act; some force (which, in contrast
with the schizophrenic’s case, is internal) has
gained control over her actions. We have seen,
however, that this is not the way the obsessive-
compulsive agent actually thinks of herself. She
interprets the situation (of imminent danger) as
one that calls for action on her part. She believes
that executing a particular ritual will be conducive
to averting the threat and thus understands herself
as having a very strong reason to do so. She initi-
ates her action, experiences herself as doing it,
and feels responsible if she fails to carry out the
ritual (while her agency is somewhat diminished
and peculiar, as above).
One possible exception to, or rather aftermath
of, the typical compulsive agency described has to
be mentioned. OCD-related action might become
highly habitualized and part of the execution au-
tomatic. This might also contribute to the sense
of “not being able to do otherwise” in some of
the self-reported cases. In such cases, the patient
may remain with a “bad habit,” analogous to fid-
dling with one’s beard or biting one’s fingernails,
unhinged from its original rationale. In these cases
we probably cannot talk of compulsive action any
longer, only of habitualized movements that have
lost their meaning and are likely to be retained for
a limited amount of time.
Conclusion
By a comparison with in some respects similar
mental pathologies, I have completed this sketch
of obsessive-compulsive agency and its phe-
nomenology, based on recent medical literature.
Understanding the cognitive and motivational
background of OCD has exposed the inadequa-
cies of the “weakness” understanding of OCD-
related behavior. The picture that emerged from
this discussion presents OCD as what we might
label “magical” or “superstitious” thinking turned
pathological, with the agent having an acute sense
of imminent danger, an inflated sense of her causal
influence on the state of the world, and making
a voluntary effort to exert that influence through
actions that exhibit control (although to a some-
what limited degree).
Acknowledgments
Versions of this paper were presented at the 21st
Annual Meeting of the European Society for Phi-
losophy and Psychology (University of Granada,
July 9–12, 2013) and the Theoretical Philosophy
Forum of Eötvös Loránd University (Budapest,
February 19, 2014). Special thanks to Eric Brown,
Katalin Farkas, Ferenc Huoranszki, László E. Sz-
abó, and Hong Yu Wong for discussion.
Notes
1. The DSM-5 formulation of the difference is
that “[c]ertain behaviors are sometimes described as
“compulsive,” including sexual behavior (in the case

of paraphilias), gambling (i.e., gambling disorder), and
substance use (e.g., alcohol use disorder). However,
these behaviors differ from the compulsions of OCD
in that the person usually derives pleasure from the
activity and may wish to resist it only because of its
deleterious consequences” (APA, 2013, pp. 241–242).
Concerning changes in the reward mechanism in later
phases of addiction, see Robinson and Berridge 2001.
2. If a disorder is considered volitional rather than
cognitive in nature, the agent’s behavior is not linked
to her will in the appropriate manner; that is, there is
impairment in forming intentions, in planning, or in the
implementation of action plans owing to some volitional
deficit. The latter can take different, pathological and
non-pathological forms, for example, the agent’s in-
ability to form the intention to act in the way he judges
best, his inability to execute the action according to the
intention formed (these can be cases of garden-variety
weakness of will), as well as avolition (a general lack
of motivation to act and form intentions) and an in-
capacity to resist certain urges. Volitional deficits are
central to a number of psychiatric conditions. These
are pathologies “in which the will is impaired or even
breaks down” (Prinz, Dennett, & Sebanz, 2006, p.
1), including schizophrenia, depressive disorder, and
substance abuse disorder. Those who take OCD to be
a disorder of volition see compulsion as the inability to
resist the urge to act in certain ways.
3. See, for example, Ladouceur et al. (2000, pp.
184ff), Amir, Cashman, and Foa (1997, passim), and
Tolin, Worhunsky, and Maltby (2006, p. 478).
4. This is standardly included in the description of
compulsion; random examples are Taylor (2002, p. 1)
and Waite and Williams (2009, p. 2).
5. “Clinical research and experience suggest that
EX/RP is only effective if patients can engage in the
necessary procedures of confronting their fears (i.e.,
exposures) and of voluntarily stopping their rituals”
(Simpson et al., 2010, p. 30).
6. We do not need to conceive of voluntariness in
an “all-or-nothing” manner. I have argued for the vol-
untariness of OCD agency on the grounds that, as is
observed in therapy, the patient can choose to abstain
from performing the act. The same is true of tic disorder,
which shows significant comorbidity with OCD, but has
been characterized in the literature as “semi-voluntary”
(for details, see, for example, The Tourette Syndrome
Classification Study Group, 1993; Verdellen, 2007). I
owe this point to an anonymous reviewer of PPP.
7. Gerben Meynen (2012, pp. 328–329) assesses
the degree to which control over the situation might be
achieved by the OCD patient: “[The compulsive hand-
washer] does not realize that to gain control of some
aspect of her life (not getting seriously ill by bacteria) she
has lost control of an important part of her life/behavior.
Szalai / Agency and Mental States  ■ 57
And she does not realize that, taken together, the entire
OCD behavior comes down to a net loss of control.
For the very behavior that should increase the control
of her life implies a significant loss of control over her
behavior and, therefore, her life. Yet, she does not have
this picture clearly in mind; she still considers her OCD
behavior as—although time consuming—‘enhancing
control.’ More precisely, she considers refraining from
it as losing control.” Control, Meynen argues, is linked
to OCD in the following ways in the literature: control
of thoughts and world (the negative event featured in
those thoughts); the patient’s increased desire for con-
trol; eliminating this desire for control through therapy.
The compulsive act is an effectless attempt to control
the feared situation or event which is the most central
issue of the three.
8. I do not claim that this criterion has to be met
by any form of behavior to count as an action; typical
OCD behavior, which I am describing in this paper,
does meet it, however.
9. This position is argued for, for example, by Frank-
furt (1978/1988) and Hunter (2011).
10. The OCD patient does not endorse the action as
such. In contrast, those who suffer from obsessive-com-
pulsive personality disorder (OCPD), another condition
that also involves a strong perceived need to perform
particular acts, do endorse those acts and regard them
positively. OCPD is characterized by rigid adherence to
principles and rules, preoccupation with orderliness and
doing things in the “right” way, as well as controlling
tendencies. OCPD actions are ego-syntonic: they are in
line with and reflect the patient’s values and preferences
(whereas the OCD patient does not identify with her
obsessions and compulsions in such a way). Given that
the OCPD patient values the relevant actions, carefully
plans their performance (from which he also tends to
derive satisfaction), and strives to overcome obstacles
in its way, the question of their voluntariness does not
seem to arise. At the same time, there is a similarity in
the sense of urgency and perceived need to act both types
of patient experience, as well as in the preoccupation
with “right” execution. (I thank an anonymous reviewer
of PPP for raising the issue of contrasts and similarities
between OCD and OCPD regarding agency.)
11. OCD patients do not seem to form a homoge-
neous group in this regard. The DSM-5 divides OCD
sufferers into three subgroups: patients with “good or
fair insight” into the unreasonable character of their be-
liefs, those with “poor insight,” and those with “absent
insight/delusional beliefs” (APA, 2013, p. 238). In the
DSM, the ratios are not specified; however, on the basis
of other literature, the majority seem to fall into the first
category, although there is also a significant proportion
(up to around 30%) with poor or no insight. (That is,
up to around 30% believe that the negative event will
58  ■  PPP / Vol. 23, No. 1 / March 2016

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