I’m honored to welcome back Patricia Zurita Ona—Dr. Z—to the Q&A! Dr. Z has written a workbook for adults with obsessive-compulsive disorder (OCD) called Living Beyond OCD Using Acceptance and Commitment Therapy: A Workbook for Adults and hosts a podcast called Playing It Safe, and we talk a lot about the concepts she explores in both projects—ACT, considering our values when we decide to face fears, approaching therapy with compassion, and more.
Tell me about your podcast. What’s it about? Who’s the audience? Why did you start it?
It’s another project from the heart. I was initially going to launch the podcast in 2022, but with COVID everything got put on hold, my book, my online class, I have this itch. I love creating things, so I decided to launch it in 2021. The podcast is called Playing It Safe. The purpose of it is sharing evidence-based and research-based skills for any person struggling with any type of fear-based struggles.
When we think about anxiety or fear-based struggles, very quickly we’re thinking about these disorders: social anxiety, OCD, panic attacks, and, yes, they are real and they exist, but also fear and anxiety are a common human experience and a day-to-day experience. Think about a mother who is afraid about her kid who is African American going to the streets and being shot. Think about the firefighter. Think about that surgeon who is performing heart surgery. Fear is a human experience and it’s embedded in our day-to-day life. Sometimes we feel it more than other times, and sometimes we handle it more effectively than other times. But, we all play it safe when dealing with fear. At times we play it safe by trying to do things right and perfect, by postponing, by avoiding, by overthinking, by anticipating that it’s going to be bad, terribly bad, by doubting ourselves. Sometimes those playing it safe actions work in our favor, sometimes against. The purpose is basically for any person experiencing fear in their day-to-day lives. It’s for the person who comes to therapy and they know they are struggling with social anxiety and panic attacks, but it’s also for the person walking in the streets, outside the coaching or therapy office. In a nutshell, I’m trying to normalize the day-to-day experiences of fear.
Do you think there are people who engage in these fear-based behaviors of avoidance and stuff who don’t realize that it’s fear? Maybe they don’t even really know they’re doing it, or maybe they would just never call it fear, they call it something else.
You know, the challenge with fear is that it doesn’t have good branding, we don’t talk much about fear; people will talk more about stress or anxiety, and I certainly have looked at gender-based differences in how we identify our struggles, but you’re right.
Anecdotally, I can tell you that there is a small group of people who acknowledge and notice when they are scared or afraid and we do have a large crowd who would say “I’m stressed, I’m upset.” People recognize when they are angry, depressed, but I don’t think we have been socialized to accept fear as part of our day-to-day life.
Your most recent book that came out was for teens, and now we’re moving on to adults. Do you want to talk about that decision? Are you trying to hit everyone who needs it, who needs ACT, who needs the workbook?
I’m a big proponent of the idea that one size of exposure doesn’t fit all. I think how people relate to obsessions, fears, panics, and worries is very different from person to person and it is important to acknowledge that there are different treatment options that are also research based. The research has been very consistent—for adults and teenagers—shown that ACT involves ERP and ACT is ERP already and is highly effective for OCD. What I wanted to do with the workbook is to show people that they can learn ACT skills in a way that is jargon-free and more accessible and perhaps relatable.
One variation that I encountered in my work with adults is that, at least in my experience, is very important to help people develop a new relationship with their thinking, with the mind, and with all the messages they have received about worries, fears, and anxieties before doing an exposure. Some people in the field may do a lot of mindfulness-based exercises in addition to ERP, and that’s one way of doing it. In my work what I have found is that especially in the case of OCD and chronic worry, there are some ruling thoughts or some sticky thoughts that people are holding onto with white knuckles, like “Because I think so it makes me so, if I have an obsession about being a pedophile it makes me a pedophile” or if I am thinking a lot about this thought it means it’s important and I have to respond to it. Or if that thought keeps showing up in my mind it’s because it’s showing something important about myself.
The challenge is that all those thoughts are not flexible. OCD literature has talked about thought-action fusion but what we have is a bunch of ruling thoughts that actually undermine exposure work, so even if a person can be ready to do exposure, the mind is still going to be going on and on, like are you sure you don’t want to do that compulsion you have to do it you are endangering someone if you don’t do that compulsion it is the same as causing harm to another person.
I’ve found that if we help people with these microskills to learn how the mind works, to notice that the mind has a life of its own, to notice that the mind will come up with all kinds of hypotheses, explanations before doing exposure work I think we have a larger chance of people responding in a more flexible and curious way to the process of facing their obsessions.
In the workbook there is a whole section on ruling thoughts. I have identified nine ruling thoughts: because I think so makes me so, if I think a lot about it it’s important, not doing my compulsion is the same as causing harm, and I teach clients microskills to tackle each of them. All of that is with the purpose of noticing that the mind has a life of its own, which I think is very, very important. In ACT, we already know that, we’re already stepping back and watching our own mind. But I know for my clients it feels like a foreign concept, and it’s very counterintuitive. So I have found that doing that when I’m teaching these skills for ruling thoughts, it’s really about creating a context of change. I have found that very helpful in the work. There’s a whole section on that. From that we move into the values-based exposure menus, which I think offers people an opportunity to really tackle what matters to them based on what is important. I don’t use hierarchies, I don’t keep track of anxiety because it’s easy to get hooked into this idea of exposure is about getting rid of anxiety, thinking more about how you’re holding onto the thought. Are you holding the thought like this? [Dr. Z is holding her hands in tight fists.] Are you holding an obsession like this? Are you watching it? Can you visualize it? How do you see it? How does it look? How does it sound? And I also talk about these W.I.S.E. M.O.V.E.S.
W.I.S.E. M.O.V.E.S. is an acronym for people to remember microskills about how they can face their fears. Here is the background: When I was delivering ACT exposures, many times my clients ask me “How do I do this? In the session I see it, I feel it, but how can I practice this in my life?” And as usual my clients are the best teachers I have ever had in my whole life. It’s their questions that always make me pause. And it’s because of those questions that I ask myself, okay, how can we make this more accessible for them so they know what to do and how to handle those moments of stuckness. W.I.S.E. M.O.V.E.S. stands for:
- Watching your mind
- Inviting your obsessions
- Staying with your experience—remember that you can make a choice, either to your values or away from your values.
- The M stands for making a choice.
- The O stands for observing what comes with making a choice—which is super important because if we’re doing exposures, and we are attached to the idea that if it’s going to work I will have less anxiety, I don’t have the obsession, it undermines the process. But if you make a choice and you’re willing to be curious and watch what happens when you touch something that may feel contaminated.
- The V stands for validating the effort you did. Exposure is hard work. It’s not easy. Many times I have seen my clients engaging in these very tough self-criticism judgments, so I think appreciating the effort is important.
- The E stands for engaging with life. Life is about living, life is not about dwelling in our head but what happens is that many times after an exposure, or when people get stuck, they actually keep dwelling and ruminating on it.
My invitation is for people to practice W.I.S.E. M.O.V.E.S. and remember that life is happening in front of them; whether you’re watching a movie or you’re listening to music, whether you’re talking to a friend, whether you’re playing with your puppy, there is life happening.
Personally, I think ACT offers a more compassionate way of looking at exposure but it’s also more validating of the fact that when doing exposures there are not always going to go great, and this also applies to compulsions.
I have heard from my clients that sometimes they say, “Dr. Z, I got stuck.” Those kinds of stuckness are part of the process and not signs that they are doing something wrong. To me it’s important, yeah, that happens. Sometimes we do a mental or physical compulsion, but what do we do next? Where will life take us from there? I think it’s a more flexible and softer approach I have tried to write about.
I know that I would appreciate a softer approach. I think some people want tough love, or they don’t want it to be touchy-feely at all, you know, they just want it to be like, “Do this,” but I feel like it would be so helpful to so many people when you do put the values around it, because then there’s a meaning to it, and I feel like that’s more motivating.
I think it’s a very different story to do an exposure because the therapist says so or because exposure is an evidence-based treatment versus saying yes to this awful feeling because it’s important to me to be the person I want to be. It’s very different.
In my opinion, behavior therapists, we are also a tough crowd; we may try sometimes to go quickly into the change phase—certainly in my training I have been one of those therapists. And, I also think that one of the powerful things that ACT has to offer to clients is that it teaches them—it teaches us, all of us—the skills to face life with all of the worries, obsessions, and fears we have. When you think about it, this approach of “just do it and be tough” puts a person on edge. They’re hyper-aroused.
Let’s think about this for a moment, who learns when feeling stressed or hyper-aroused? We know, you know by hundreds of studies, that we don’t learn much when we are very stressed or under high levels of hyper-arousal. And the new research on exposure has shown that that is not necessary for exposure to work. In fact, what we need is more variability of experiences, more variability of exposure exercises.
I think certainly facing an exposure comes with degrees of uncomfortable affect and stress because that’s the work, but it doesn’t mean that we have to quickly push the envelope. I am more invested in helping people to find their own rhythm, to face what matters, to be in charge of the process and be curious about it. And just to clarify, that doesn’t mean that we’re not going to do hard exposures.
I think my clients are incredibly courageous people and they are doing very, very tough exposures, but what is different is it doesn’t matter for how long they’re doing their exposures or how fast they’re practicing them; the emphasis is on them choosing how they are approaching their fears. They are always in charge, and they are the ones deciding how much they do it, how long they do it, how they do it.
Within ACT, there is so much engagement in this process, and you have less dropouts from treatment because a person is so much more engaged in their exposure process. Also, when we give people permission to have an imperfect exposure because that sometimes happens, we also normalize the message that there is no such thing as either/or when facing your fears; learning to live with fears and worries is a process.
Within ACT, we learn to accept and appreciate how hard the process of living with fears is and we learn to make choices—and as long as we are watching the choices we’re making and keep moving, things will work out fine. That has been a very powerful approach in the work I have been doing.
This has been a very rich experience for my clients. Some of them have been exposed to other approaches you mentioned, the “just do it” type of thing, and they noticed how hard it was to drop the compulsions or do exposures. When we switched gears all the way to ACT, one of my clients noticed that he wasn’t afraid as much and that he can actually choose so much more to disengage from compulsions and face obsessions. To me, those are sweet moments to capture. ACT offers something more flexible and compassionate approach and it can be very empowering for people.
It kind of makes me think of weight loss approaches people have sometimes, or getting in shape, where it’s like, “I want it to happen quickly now that I decided I want to make a change, I’m just going to go full bore into it” and then they stop doing it. I’ve done that myself, where I’m like, “I’m going to work out every day!” and then you end up hating working out, you’re sore, and you can’t see the point of it. If you have an easier approach into it or even thinking of your values around it, like “I want to work out to strengthen my heart because I want to be able to hike with my dogs” or something like that.
I think you’re making a really good point—we do have the data in other areas about what happens when people go quickly into the change side of behavioral approaches. Of course we’re advocating for a behavioral change. The challenge is that it makes a huge difference when we tell people let’s stand back, and watch what our mind is doing; watch how your mind has a life of its own, watch how your mind quickly wants to solve this.
All of us know when a person wants to do exposures and hammer exposures; we also know how in therapy that approach gets reinforced many times. Everyone can do that, it doesn’t mean it’s going to help our clients.
To me that’s an old-school belief. What happens if we teach people to learn to watch their mind, and that’s the beauty of mindfulness. For instance, in the case of OCD and chronic worry, the ruling thoughts need to be much more targeted. The umbrella of their particular ruling thoughts are driving very problematic behaviors; so I think, if we teach people to step back from their thinking that before any exposure work, which seems counterintuitive, it makes a huge difference in the long run.
Another thing that came to mind when you were talking is—and actually, I’ve thought about this a lot beyond this conversation—ERP and exposures for the sake of exposures. I wonder if they can be traumatizing for people if it isn’t connected to values at all or if it’s just really harsh. Even if you want to get better, if the idea of this exposure is so terrifying, maybe getting super graphic with a sexual obsession or something and you don’t really know why you’re doing it and it’s just upsetting. Is there evidence for that, that there is trauma sometimes, that people have negative effects from therapy? Even if the anxiety goes down, then there’s something else?
That’s a good question. Here’s what I can tell you: Years ago, I had a client with obsessions about a partner cheating on him and he read all the books, he’s googling, he’s searching on YouTube, very well-versed. My client read and heard that exposure would be imagining the partner having sex with another person. Who wants to do that in life? Why would I want that for myself? Why would I want that for my client? That was the main reason why that client, for maybe five, six years, didn’t enter into treatment.
We do know that in research settings an average of 20 to 35 percent of people don’t start treatment. I think this is the part that we have been missing many times—and it’s possible that there has been a shift, because exposure therapy and research in exposure has switched in the last few years. I haven’t seen that data though.
Practicing exposures is about approaching what is aversive, for example, fears that my partner cheated on me, but those fears are in relationship to the different behaviors that affect a person’s life. So, for example, in the case of my client—and I did exactly what I described in the workbook—we assessed how OCD shows up, we distinguished mental compulsions—those mental compulsions were primarily focused on replaying how my client’s partner talked to him, talked to another person— there were a lot of avoidant behaviors. We looked at the ruling thoughts my client was getting hooked on.
Then, based on the values-based exposure menu we developed, some of the exposures exercises were about my client and his partner hanging out with other people that are considered attractive and teasing my client’s partner with silly comments: look at this hot person; my goodness this person is so hot…look at their bodies…oh my goodness. Other exposures included watching movies with characters that were considered attractive to my client’s partner.
It’s a human experience to doubt whether a person loves us or not. In the example I’m sharing, we never did the exposure of my client imagining his partner having sex with another person. During treatment, my client decreased all these avoidant behaviors and now he’s fully in a beautiful relationship.
To answer your question, to my knowledge there is no data showing that we need to do extreme exposure exercises or always start the treatment there. There are some ACT folks who would do it, I have heard that. I don’t do that. If necessary, I will augment exposure exercises to extreme forms, always in collaboration with my clients. But, to me the beginning of exposure work is always a person’s life, I would always ask things like: how is this obsession affecting your day-to-day life? And let’s start there.
I have clients who certainly are very fused with their obsession like, what if I am emotionally abusing my children? And as a result, my client wouldn’t reprimand the kids when they’re misbehaving, was afraid that if she raised her voice, what if someone calls CPS?
In that case, because those obsessions were very, very sticky after many types of exposures, we augmented the exposure exercises and ended up doing something a bit different: we wrote flashcards: “I am hitting my kid” and we left the flashcards in the bathroom. That is a very tough exposure, but again, we didn’t start our exposure work there.
Sorry if I’m repeating myself here, but I don’t think there is this rule that you should go there right away or that you always have to have intense exposures. To me, it is more important to train my ears and my eyes to notice how sticky an obsession is, how much my clients are moving from holding an obsession as a truth or fact or how much they are just having it.
And if we have to intensify exposures, it’s always with clients’ permission, always. Now, when we think of trauma I think it’s helpful to clarify what PTSD is and how even when a person doesn’t have PTSD but have a history of trauma may still be affected by it. So, the criteria for PTSD is that a person re-experiences a traumatic event, is hyper-aroused and engages in avoidant behaviors, all related to a traumatic event. Now, even if a person doesn’t have the classic symptoms of PTSD, they also may have developed a belief system about themselves, others, and the world.
What I have heard from clients I work with is that first, intense exposures done without any preparation actually contribute to more hyper-arousal, so that will decrease a person’s capacity to face an obsession. And secondly, is that those intense exposures sometimes reinforce the belief that they cannot handle an exposure.
So, those beliefs are brutally hard in treatment. Think about it, it’s already hard to go to therapy, it’s already hard to tell a therapist when you’re having more shame-based obsessions, and then on top of that you have to do one of these awful things? That would reinforce the fear that they can get better and that there is something really wrong with them. I have heard more about those experiences as a reaction to these intense exposures.
I would think, especially if you’re still in a really bad place with your obsessions, the last thing you want to do is feel even worse. If you’re going into it thinking, things are going to be so much worse or I’m going to be more scared of stuff. I love that there’s a softer approach to it, and it doesn’t mean it’s any less effective.
Exactly. I think one of the frames I like to use in my work is clarifying that there is our comfort zone, there is our learning zone and there is my burning out zone. Yes, exposures are about getting out of our comfort zone, but we don’t have to reach a burning out zone. It’s not necessary.
I actually think it’s much more powerful for people when they have the freedom and if needed we can intensify things, but there are certain exposures I don’t do in day-to-day life. It’s always a great beginning. It’s the place to go. I know first hand that my clients didn’t start treatment because they were afraid what exposure would entail for them.
For instance, I had another client, a mother whose fear is of stabbing her children. That’s brutally painful when you really think you want to be a mom and imagine how awful it is to think you have the ability to harm your children. In a traditional model, exposure would be “Imagine you’re stabbing your children,” and I know for some people that has worked. We know that.
But I don’t think one-size exposure fits everyone. For some people that’s the barrier, it gets in the way of them getting help. So with that particular client for example, I never did any exposures about her imagining stabbing her children. We never wrote an imaginal exposure about it. We did more situational exposures about noticing when the obsession show up, how she’s going to name it—my client had a name like a murder movie—spending time with her children and participating in different activities: walking to the park, playing, cooking in the kitchen with them around. A lot of that work was also done on reducing accommodations my client’s partner was making. Again, the treatment was about connecting with the kids (my client’s values) and never did an imaginal exposure. That’s another case in which I didn’t have to push the envelope, it wasn’t necessary.
In the book, you have a section about what this book won’t do or won’t ask you to do, and I love that. One of the things was we won’t focus on your past. Can you say more about that, why you think that that’s important?
As a principle, I don’t think we can understand who we are today and our stories without understanding our history and our context. So, I think our behavior is always understood in the context of all experiences we have had in our lives.
In the book, Living Beyond OCD, I wanted to create a self-help program that will guide a person through how to use ACT and exposure skills, and gradually and progressively move into their lives. Many times I have heard from my clients how they spend two, three months and even years unpacking their stories. I am not saying it’s necessarily bad, I’m saying that the purpose of the book is to help people to get back into their lives.
In therapy, yes, we can’t understand that person’s context and history, but our histories don’t define us. Life is happening tomorrow and in the next couple of hours, not before. Also, in the case of OCD we know that a mental compulsion is going back into the past with what-if scenarios, and it’s easy to fall into that compulsion, so going back into the past is not necessarily helpful for a reader or any person dealing with OCD.
Right. That was a huge thing for me, and I imagine that a lot of other people with OCD too: Why is this happening to me, is there something from my childhood, is there something I did or that was done to me, and it can be a huge rabbit hole you go down. You’re right, it can be a compulsion, trying to remember, and are my memories correct, is it false memories? I definitely appreciate that it’s just like, here we are, in the present moment, we’re focusing on the present moment, and also, what comes next—not that we can control anything really, but what we have the most control over is how we respond to what’s happening now and the decisions we make. You can’t undo anything that’s happened in the past.
Yes, dwelling or opening possibilities for rabbit holes wouldn’t have been helpful.
Is there anything else you wanted to say about the book?
Thank you for asking that question. I would like to emphasize a couple of chapters in the book: There are chapters about what acceptance is and the difference with fake acceptance. There is a whole section on how create a values-based exposure menu. There is a whole section how to make a shift from reactive moves to W.I.S.E. M.O.V.E.S.; W.I.S.E. M.O.V.E.S. is an acronym I use to remind clients and readers of how they can use ACT skills and approach their exposure exercises. There is a whole section in the most common blocks that people experience when starting exposure work.
The book has 52 chapters and while that’s a large number, if you look at the book, you will see that each chapter is two to three pages so they’re actually easy to read. Chapter 5 and chapter 9 are a little bit on the long side but they cover the different types of OCD and the most common forms of mental compulsions respectively.
We know that OCD has a heterogeneous presentation, OCD can come in so many ways—people with OCD can have violent obsessions, somatic obsessions, harm obsessions, existential obsessions, metaphysical obsessions. So, in chapter 5, I put together a long table that captures many different types of OCD, with the purpose of having one single place people can go to and see, “Okay, which of the obsessions am I relating to?”
This chapter is a starting point to show that the brain will always latch on to anything. I really wanted to do something for any person who is learning about OCD or wants to learn about therapy can go to, so that’s a chapter that captures that. Chapter 9 has this super cool continuum of the different types of mental compulsions the brain can latch on to. From simple forms, like confessing, praying, repeating sentences, to more complex forms like figuring out my past, figuring out what I’m feeling, figure out the meaning of my experiences, playing with what-if scenarios, am I racist, did I say something racist, did I look, did I sound racist?
When we help people understand how they are responding to these obsessions and how mental compulsions work, it can be liberating.
That would be very helpful because it’s something people are always asking, what’s the difference between an obsession or intrusive thought and a mental compulsion because they’re both things that are in your brain. I’m sure seeing a list or chart like that would help clarify things for people.
Obsessions usually come with “What if?” “Did I?” “Could I?” “Would I?” and also obsessions can come in very plain statements and even commands. However, to distinguish obsessions from mental compulsions is helpful to keep in mind that, the first thought that’s the obsession, is in the house. The rest—did I do it, could I do more—that’s a mental compulsion.
The challenge we’re facing is OCD has a very heterogeneous presentation on the content of the obsessions and the form of compulsions. We can classify, “that’s compulsion, that’s avoidance,” but in a person’s day-to-day life, that is hard to catch! However, we can help our clients and the readers to map how OCD shows up in their life, and how they are responding to it. That can be extremely empowering.
In the book I also describe what’s fake acceptance. Every exposure treatment has some form of acceptance; what’s unique within ACT is that we have so many more tools and experiential exercises to practice that and the acceptance process goes beyond obsessions. It actually capitalizes our internal struggles, not just related to OCD.
On the chapter on fake acceptance, people can check whether they’re powering through an exposure, like “I have to do this” versus “I am saying yes to this yucky feeling as a choice” and how I can go to myself with many self-acceptance prompts, like “I will do my best to conquer this,” “I’m doing the best I can,” “I will do my best with this feeling coming and going.”
In this chapter I also describe how a person can use self-acceptance prompts; and just to clarify, I think sometimes people think that in ACT we’re all about minimizing coaching or self-talk. We’re not. There is a lot of self-talk and self-coaching within ACT, and it’s always in the service of what’s going to work and a person’s values. Think about it, many times we all have the need to have these natural verbal reminders. So again, I think that chapter clarifies the distinction between what’s acceptance and what’s fake acceptance.