Dr. Karen Singh

Dr. Karen Singh is Aza Holmes’s clinician and a steady presence in her struggle with obsessive-compulsive disorder and anxiety. She offers concrete ways to interrupt compulsive behavior, but also treats Aza’s metaphors and descriptions of pain as attempts to communicate an experience that ordinary language cannot easily contain. Their work does not produce a sudden cure: it becomes most consequential when Aza’s symptoms, medication difficulties, and physical trauma converge in a medical emergency.

Identity and Clinical Setting

Aza sees Dr. Karen Singh at Indiana University North Hospital in Carmel. The office is windowless and sparsely decorated; its bare walls hold only a small picture of a fisherman with a net, an image Aza later studies while trying to talk. Dr. Singh has no diplomas displayed. The plain room gives their conversations little visual distraction, although Aza finds the clinician’s sustained eye contact difficult to meet and sometimes looks at the picture instead.

The appointments are part of continuing care rather than a single intervention. Dr. Singh asks how Aza is doing, follows up on medication and intrusive thoughts, and considers how changes in Aza’s life affect her anxiety. Her manner combines familiar clinical prompts with direct explanations. Aza occasionally finds those prompts frustrating, but continues to bring her fears, metaphors, and resistance into the sessions.

Treatment and the Intrusive Thought Cycle

Dr. Singh has taught Aza a breathing exercise: breathe in through the nose and out through the mouth, slowly enough to make a candle flicker without extinguishing it. During a cafeteria episode, Aza tries the exercise while changing the Band-Aid on her callused finger. Dr. Singh’s advice also includes not using her phone to search the same health questions repeatedly. Aza remembers the instruction, but still retrieves her phone and rereads information about the human microbiota. The episode makes the gap between knowing a coping strategy and being able to follow it visible: the thought spiral continues to tighten even as Aza attempts the prescribed breathing.

Dr. Singh also proposes exposure response therapy, which Aza had tried before. The exercise is specific to her contamination fears: she is to touch a dirty surface with the callused finger and then refrain from cleaning it or covering it with a Band-Aid. Aza recalls that the treatment had helped for a time, but remembers most vividly how frightened it made her. When Dr. Singh asks whether she is willing to try again, Aza shakes her head no. The refusal is not presented as lack of understanding; it reflects how difficult it is for her to tolerate the anxiety the exercise deliberately evokes.

Medication is another continuing point of difficulty. When Dr. Singh asks whether Aza takes Lexapro, Aza admits that she does not take it every day because taking it frightens her. Later, despite being prescribed medication, she is still not taking it consistently. Aza finds the idea that medication can change the self unsettling: treatment seems to ask her to rely on a substance that alters the very self she is trying to understand. Dr. Singh emphasizes that medication only works if taken consistently, while Aza struggles to accept that account of her experience.

Metaphor, Pain, and Selfhood

Dr. Singh notices how often Aza approaches her experience through metaphor, describing consciousness as a bus, a prison cell, a spiral, a whirlpool, or a loop. Rather than treating these images as literal explanations, she uses them to discuss how Aza experiences a mind that feels difficult to direct and sometimes alien to its owner. When Aza describes feeling contaminated by the microorganisms in her body, she explains that she cannot locate a pure inner self distinct from them. Dr. Singh responds, “That’s not uncommon,” and returns to the recurring question of how Aza understands her own experience.

Dr. Singh also argues that physical and psychic pain are hard to convey directly because language reaches them through metaphor. She shares a passage by Virginia Woolf about the difficulty of finding words for a shiver or headache, and observes that people may struggle to know what they cannot name. Broad labels such as “crazy” or “chronic pain,” she says, can minimize suffering even as they mark it as something set apart. She asks Aza to frame her mental health with a word other than “crazy,” making the language used for illness part of their therapeutic work rather than a neutral description.

In a later session, Dr. Singh connects Aza’s anxiety with the demands of a new relationship. Aza explains that she had stopped kissing Davis because she was preoccupied with microbial exchange, while Dr. Singh distinguishes the form the worry takes from the broader anxiety beneath it. When Aza questions how she can be herself if medication changes her, the disagreement reveals a persistent tension in their work: Dr. Singh emphasizes treatment and consistency, while Aza experiences those requirements through fears about contamination, control, and identity.

Dr. Singh’s clearest response to that tension is her distinction between thoughts and the person who has them. She tells Aza, “Thoughts are only thoughts. They are not you.” When Aza counters with the idea that thinking establishes existence, Dr. Singh invokes Descartes’s formulation through doubt: Aza’s capacity to doubt does not make her less real. The reassurance does not erase the thoughts, but it offers Aza a way to resist treating each intrusive thought as a definition of her identity.

Crisis and Change in Treatment

After Aza drinks hand sanitizer while hospitalized with a lacerated liver, the medical staff initially suspect she did so because she was desperate for alcohol. They contact Dr. Singh, who comes to Aza’s bedside. She identifies two issues: Aza has not been taking her medication as prescribed, and the accident has caused serious trauma. Aza says she had taken it almost every day and felt it was making her worse, then recognizes that this account was not accurate. Dr. Singh rejects the idea that drinking sanitizer marks progress and stresses that ingestion is dangerous because of both the alcohol and the chemicals it contains.

The exchange is direct, but Dr. Singh does not reduce the crisis to medication nonadherence alone. She also names the accident as a serious trauma that would challenge anyone and proposes changing to a medication Aza can tolerate and take. Aza objects that none of the medications work. Dr. Singh’s answer is not a promise of immediate relief: she identifies time, treatment, and taking medication as what can help. When Aza describes feeling trapped in a tightening spiral, Dr. Singh meets the fear with a firm assurance that Aza will survive.

Aza remains in the hospital for eight days, and her recovery does not become a triumphant turning point. In the months that follow, she gets better without ever quite getting well. That distinction accords with the treatment Dr. Singh describes: survival and improvement are possible without a clean end to illness. The narrative does not establish that every later change results from Dr. Singh’s care, but her counsel supplies a language for understanding recovery as ongoing rather than as a battle conclusively won.

Narrative Role and Significance

Dr. Singh’s role is to listen to Aza’s account while also challenging the conclusions that fear draws from it. She does not simply endorse Aza’s metaphors: she recognizes them as ways of approaching pain, then offers distinctions—between a thought and a self, between the content of a worry and the anxiety expressing itself, and between feeling worse and evidence that a medication is causing harm. Her clinical explanations cannot make Aza’s experience transparent or immediately manageable, and Aza sometimes resists them. That friction keeps treatment grounded in the uneven reality of living with symptoms.

The book’s larger interest in the limits of language is especially clear in these sessions. Dr. Singh acknowledges that pain cannot be represented as easily as an object, while still working through words, images, questions, and practical instructions. Her advice about breathing and repeated searching addresses what Aza can do in a particular moment; her discussions of metaphor and selfhood address what those moments mean to Aza. Together, these parts of her practice make her more than a voice of reassurance: she represents care as repeated attention to a mind whose distress cannot be talked away, but whose thoughts need not be mistaken for the whole person.