When you talk to Patricia Zurita Ona—Dr.Z. to her patients—her passion for acceptance and commitment therapy (ACT) comes through loud and clear. She has embraced this form of cognitive-behavioral therapy (CBT) as a way for individuals with obsessive-compulsive disorder (OCD) to face their fears by focusing on what they value in life.
Dr. Z. is the director of the East Bay Behavior Therapy Center, is on the board of directors for the OCD SF Bay Area, and is a medical director for Made of Millions. She has written several books about ACT, with the latest called The ACT Workbook for Teens with OCD: Unhook Yourself and Live Life to the Full. As busy as she is, she still found time to share her insight with us. Thank you, Dr. Z.!
How long have you been a therapist? What led to your interest in treating OCD?
Do you want the Latino version or the American version, because I can go into storytelling mode!
I love stories!
Oh, it’s a beautiful thing. Here’s the middle ground version. My undergrad is in school psychology, so when I was in Bolivia I was working as a school psychologist for maybe six years for children, teens, and families primarily in a school setting. And then when I came to the States, I completed my doctoral degree in clinical psychology and started working primarily with adults. As a licensed clinician I have been practicing for the last twelve years; if I include all the years of training, maybe 18 years—don’t count my age!
When I think about my affinity and passion for working with OCD and other fear-based struggles like social anxiety, chronic worry, and specific phobias, there are two tiers to my response. One is my own experience, how I have to deal with my own anxiety. There is one particular memory that usually pops in my mind: When I was maybe in my early twenties I was driving back from a camping trip in Bolivia—I had this amazing, amazing camping trip, it was beautiful—and I saw this humongous truck. In a fraction of a second my mind had an image of myself dying in an accident—I saw myself covered in blood. I started to hyperventilate and hold the wheel of the car with both of my hands really, really hard. That was the first full-blown panic attack I had. I pulled over for like two hours to try to calm myself down. It had been maybe four seconds when the truck was driving by me, but for me it felt longer than that. This image of dying in a car accident has popped up in my life on and off, not only when I’m driving, but when I’m walking, exercising, reading, or even when I’m chatting with you. The image pops up, as do many other fears, too.
My passion for anxiety and OCD has come from my own experience in terms of my own fears, because of this image, because of how I was raised, because of how my fears about being an immigrant in this country with a different language morph in different ways—I have developed so much appreciation for the internal struggle.
Secondly, I think that fear is an emotion that can easily narrow a person’s life. My passion comes from that learning, from things I’ve experienced in my own life, fears I had to face, and how I really know inside out how fear-based responses can be paralyzing and keep us stuck. I think we have been socialized with messages about powering through things, getting things done, and conquering our feelings at all costs, but I don’t think that’s consistent with the human experience. When I’m working with clients it’s super important for me to create this frame of getting better at relating to these yucky experiences, and that what is actually key is not to get rid of the fears but to actually make room for them, as they pop up, obsessions being one of them.
You specialize in CBT, including exposure and response prevention (ERP) and ACT. What makes CBT so effective?
That’s a beautiful question, one of my favorite ones! Thank you for asking that. I grew up in Bolivia where there’s a lot of mysticism, so I grew up in a family who are superstitious by nature. If you spill sugar it means happiness is coming your way, so you have to get a little bit in your pocket, and if you find that your hands are itchy it may mean money so you have to line your pockets, and if you spill salt, watch out, because that’s something bad coming out.
However, my sister and I developed science-based minds, and the program I went to for undergrad was strongly driven by CBT and cognitive psychology, so I had been fully trained in CBT, searching for evidence for and evidence against our thoughts, and doing all types of logs challenging all types of thinking. But while I was trained in a cognitive model, at the core of my work, action has been always my currency—so within CBT I always emphasized the big “B” and it just got bigger and bigger as I keep moving in that career. When I discovered ACT, maybe 14 years ago, it was really this 180-degree shift I had to do because it’s a very different way of doing therapy, practicing behavioral science, and a unique way of relating to your internal experiences. ACT has transformed a lot of what we knew of what works with current science, and I think it brings the roots of behaviorism in a way that is so much friendlier, so much more compassionate, and deconstructing rigid ideas about behavioral science.
My clinical work is focused on bringing to the core all behavioral principles. In my opinion, when we look at a phenomenon, whether it’s a social phenomenon, interpersonal phenomenon, or private phenomenon, behavioral science invites us to see beyond what we see with our eyes; we truly unpack a situation, a struggle, a fear. There is so much beauty that comes from that process. And as a clinician in general, I do my best to build a bridge between what the researchers are doing and how I work with my clients. To me, it’s something that I breathe and I live. It speaks to the way I look at the world, reality, and a person’s behavior. This is extremely important given that at some point, let’s say 20 years ago, with OCD in particular, so much has been written that has been so pathologizing and so disrespectful of people. In fact, there was one paper that made Sigmund Freud famous, a long time ago, the “rat me” when he’s describing a client suffering with obsessions about harmful things happening to others. This is why it is more important than ever to bring science-based therapy to any setting we’re working in. CBT has been always an empirically supported treatment, and ACT is another form of CBT.
What makes ACT different from ERP, and how does it work with ERP?
We know that exposure treatments work, we know that exposure is the front-line treatment for OCD and all anxiety problems, and we also know that we do have many times cases in which people don’t relate to it—not because they cannot do it but because it’s too scary for them to approach their fears, whether that’s a situation, a fear of contamination, or images. So what ACT adds a lot to the treatment of ERP is that we can anchor every single thing we do in the service of our values. So, for example, let’s imagine that I have fears about driving over the bridge in San Francisco. I can go to see a therapist and the therapist tells me the treatment is exposure and you have to get used to driving over the bridge multiple times so the anxiety gets more manageable over time. In an ACT frame we say if you drive over the bridge in what way does that behavior help you be the person you want to be in life? What’s that about? And I may say things like, “Well, I have my mother in a hospital in San Francisco and if I drive over that bridge I will be able to see her.” So driving over the bridge will help me to be the caring daughter I want to be. Right? And that’s just an example of how there’s a huge difference between approaching an exposure as the big thing and just to manage anxiety or approach an exposure and facing what I’m afraid of in the service of my values. Doing it because it matters to me, doing it because it helps me be the person I want to be with the people I love. So I think the motivation, the willingness to approach our fears, the intention we put into it, are very unique within the ACT model.
Within the traditional models of exposure we approach things to manage anxiety either to habituate or to tolerate the feeling. However, there is not much intervention about helping a person augment the capacity and willingness to choose how they approach it. The ACT model is based on exposure as the means to develop more flexibility to dance with fear with touches of willingness, curiosity, and choice. So exposure’s one of those things we do, again, but it’s not everything. ACT can help in motivation, providing a person the courage to approach fear in a more global way, in a more holistic way, to face life as it comes with fearful moments.
At a micro-level, exposures in ACT look different than traditional exposures. For example, if you’re afraid of contamination, when you’re doing an ACT exposure it’s not enough to simply touch the keyboard of a public computer or to hold a pen. What we’re doing is a lot of prompting about how a person is relating to the internal experience that comes when touching that particular item. We’ll ask questions like how does it feel, what do you notice in your body, what is that feeling telling you to do? Okay, is the obsession kicking in? Okay, what do we do with your obsession? So within ACT you are prompting a person and helping them build a capacity to notice, be present and even curious of an internal struggle. And the reason why it is important is because ACT as a whole model is exposure but we still do this targeted exposure, recognizing that anytime we avoid any type of uncomfortable experience the worse it gets. The more we help people sit with, approach, and lean toward what they are avoiding, the more skillful they are going to be to respond flexibly to all types of situations that show up in their way even after treatment.
You’ve said the point of therapy isn’t to make anxiety go away. Would you say that at least in the past the goal of ERP is “Okay, we have our levels of anxiety up here, and let’s get it down to this level”? Do you think that’s not the goal of ACT?
In the traditional model—I mentioned that I was trained as a traditional behaviorist—we were telling clients that the goal is to not have anxiety. Then the inhibitory learning model came in 2013 by Michelle Craske and her colleagues at UCLA, and we started telling clients, well, it’s not about not being anxious, it’s about having different experiences and learning to relate to it in a different way, they need to have more variability, they need to label their affect and they can mix different types of exposures or ways of doing exposures. Within ACT, we capitalize on the current advances of exposure therapy based on the inhibitory learning model; if I have to summarize, the message would be “Getting better at feeling the yuckiest stuff that comes when you’re doing what matters.” Doing exposures just because the therapist tells me to or because I’m avoiding every single thing and as a dictator I have to approach them, that’s not ACT-consistent, and it’s not consistent with life.
I love that.
It’s quite unique. Even as a therapist I can tell you that—and I feel very fortunate—I have trained as a behaviorist, but I think that the sense of vitality and the ability to build flexibility in the room came from learning, practicing, and teaching ACT over and over. I didn’t have that that frame in the traditional model. So for me as a clinician and a person, ACT has given me so much more of that lens.
Can you explain why you decided to focus on teenagers for your ACT workbook?
Overall, when I look back at different projects I participated in, everything I have done in my career has been thinking about the people I work with. I pay very close attention to the feedback they have, the input they have, moments when I’ve realized how much we were struggling with something, aha moments we may have had in our sessions, and also the moments of “stuckness.” All of the books I have written are coming from that frame of direct experiences I’ve had with my clients as a full-time therapist.
When I decided to focus on this workbook it was really because of the first session I had with a teenager. I was working with his family—a very sweet family—and at the first intake session he very loudly and clearly told me he hated therapy. And in that conversation he said something very clear, very insightful: “I know this is OCD and I know I want to work on it, but I hate that my parents and the therapist tell me what to do.” To me that was this huge moment; I realized that up to this point, we were doing a great job with exposure treatments, and yet we needed to do better to engage teens in exposure work. And that’s why, basically for two years I tried different ways, different acronyms, different graphics, different physicalizing activities, kept getting input from my clients, until I landed into the choice point. I was very invested in capitalizing on that capacity we all have, the capacity to choose how to respond to the world outside of me and how to respond to the world inside of me. And how teenagers, given where they are developmentally speaking, they are developing and exercising that capacity, right? They don’t like to be told what to do, what to think, or what to wear. So I think a treatment that capitalizes on that will give us much better outcomes. We need to do better for the kids.
Also, academically speaking, while we have great success with teenagers and families, we also have a large percentage of dropouts from treatment, or relapses. I think it’s time we start looking at that as a whole. I am more interested in maintenance of treatment gains. After three months, six months, how are we doing? How are our clients doing? In that sense, the data on exposure—while again it’s extremely solid treatment, we know it works—we also have a percentage of people who either relapse or don’t respond well to treatment and they drop out early. With teenagers that’s something to think about. The more options we have to introduce exposure work, and the more we make the treatment accessible, the more adherence we have in treatment, and that’s a great thing.Can you give an explanation of the choice point?
I tried different graphics, a square, boxes, the boring form of having lines and questions, right? But the kids said, “No, that’s too traditional, Dr. Z., no this, no that.” I have sweet memories from me trying different stuff and getting input from them. Teens are as real as they can be. The choice point is basically a graphic: the bottom has this equation you’re approaching, for example, if you are afraid of contracting germs maybe you are outside with your friend and there is a person walking a dog. And you’re in the coffee shop hanging out with your friend and you see the dog and you’re thinking about petting the dog. On top there is a thought bubble where you write down the obsession that comes for you: Fears about getting sick, fears about getting the coronavirus. And then on the left side you write down all the things you do that keep you hooked on the obsession. So that would be all the avoidance, reassurance seeking, mental compulsions, physical compulsions. On the right side you have all the “unhooking” skills, which are ACT processes to actually learn to live with that obsession, that fear, and move forward in life. In my exposure sessions with clients, we use the choice point for every single exposure. What is super cool is I also introduce the choice point with different yoga postures, or physical exercises where we stand on one leg or stretch another arm and leg, just to show many times that at some point our body will find a natural balance so we can stay steady.
While the choice point is a graphic, it’s also a way to learn and remember that we have a capacity to choose. So, the graphic isn’t to torture people, but to build more learning. So much learning in terms of, “I can step back and I can remember that I can do things that keep me hooked and take me away from what I want to do in life, or I can do other skills, an exposure that will help me move forward toward the things I care about.” I use that with every single exposure session with the hope that at the end of treatment the client will be walking on the street and they have a thought about, “Was that me? Did I hit this person? Why did I do that?” and remember to step back and visualize a choice they have: Do I keep doing this, do I continue getting hooked, or what’s the skill I can practice to get unhooked and move along with my day?
What is the purpose of the workbook, for teens to use it on their own, or with their therapist?
The book is really written for a teen to grab and do the exercises. The chapters are very short, two to three pages, and they have super cool illustrations by Louise Gardner, who loves blending her art with ACT. However, what is interesting is because it’s a full workbook there’s no stats or academic stuff, so I’ve been getting emails from therapists telling me they are basically doing two or three chapters in session with the clients. They’ll ask me, “What do you think of this order?” So I’m hoping in the next couple of months to put an outline for therapists on how to use the workbook, but right now it can be bought. It’s written for the teens so they can do it on their own, but also can be a great guideline for the sessions. Every chapter has one micro-skill. Every chapter is building this capacity to approach versus to avoid, so I think it’s workable in both senses. It’s also very helpful for the parents to be familiar with. I have in the book a letter for the parents that basically invites them to be patient and to be caring, to not push the envelope with their kids, but also not to rescue them.
If you could share just one piece of advice with someone with OCD, what would it be?
First, I want to say it’s very courageous to be walking in the world when your brain is overreactive and throwing obsession after obsession, so tons of respect to everyone who has an overactive brain. The biggest thing is that while that’s hard, any person can start exactly where they are. They can learn to tame OCD, they can learn to have all the yuckiest stuff that comes when the brain goes into “blah blah blah blah blah,” and they can do what is important. No matter where people are in treatment and in life, they can have an amazing and fulfilling and meaningful and rich life. We cannot lose hope.