Tag Archives: Jon Hershfield

Catching Up With Jon Hershfield

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I first hosted Jon Hershfield in a Tuesday Q&A in 2015 and he’s done so much since then it’s time to have him back! With four books under his belt, he puts authors like me to shame, so I don’t know why I’m continuing to promote him. But, really, he has a wealth of practical advice to offer and always does so with humor and compassion. We’re lucky to have him in the OCD community.

A lot has happened since we last chatted! You may be the most ambitious person I know: You just published your fourth book, Overcoming Harm OCDOne of the most common questions I hear about harm-related intrusive thoughts is “How will ERP work for me? It’s not like I can walk around with a sharp knife.” How would you answer that question as a therapist?

Well, you can literally walk around with a sharp knife. Normally we do this when we’re on our way to divide a sandwich. But the question has to do with concern about causing actual harm in the course of doing exposure to a fear of causing harm. In ERP we do a lot of scary things, but what we don’t do is actually hurt people. In OCD there’s been some problematic training of the brain to assign “danger” to uncertainty about harm thoughts. So if I see a knife and I have an intrusive thought of causing harm with it, my brain may believe we are in danger. ERP works by getting in the ring with that uncertainty, resisting compulsions and other safety behaviors, and retraining the brain to have a different association with the uncertainty. So actually, yeah, handling a sharp knife in the presence of unwanted thoughts and other triggers can be really good ERP. I think it’s easy to get confused here because one might think we don’t have people stab strangers as exposure simply because it’s wrong. It is wrong, but that’s not really why we don’t do it. We don’t do it because that would fail to actually teach the brain how to handle uncertainty. For exposures where handling a knife may be complicated (e.g., you can’t bring one on an airplane), we have imaginal exposure where we use writing as a strategy to trick the brain into thinking we could be in danger. In this state, we practice resisting compulsions and we create new learning about being uncertain. People with harm OCD are not the ticking time bombs they think they are, but no amount of me telling them this will actually touch the OCD. They have to experience the exposure without the compulsions to truly understand this.

We know that getting the right diagnosis and proper treatment can take years, and I’ve always wondered if it takes longer for folks with harm obsessions. When I was worried I’d hurt a child, I was afraid to tell anyone, even a therapist, because I thought they’d deem me a risk to society and call the police. In your experience, are individuals with harm obsessions less likely to seek help than those with, say, a germ phobia? Or is their fear that they’ll hurt somebody so strong they feel they must be stopped before it’s too late?

Both of these things are very common in unwanted violent obsessions. A person with harm OCD may avoid treatment because of the concern that the treatment provider will have them hospitalized or arrested, or that disclosure of these thoughts will bring shame and scorn to them and their families. In more severe cases, anxiety can be so high and insight so low that a belief develops in the mind of the person with OCD that they must be defective at the core. Essentially, they imagine that going to treatment will reveal this defect and the borrowed time they’re living with before hurting someone will come to a sudden end. We can largely blame external stigma about mental health issues, especially as it relates to intrusive thoughts, for inhibiting people from seeking help. But self-stigma is even more powerful and the belief that having these thoughts makes us immoral or bad keeps a lot of people from asking for help.

We know reassurance seeking is a compulsion, and giving reassurance only adds roadblocks to the recovery process, so what is the best way to help a loved one with these upsetting intrusive thoughts?

Loved ones can educate themselves about the disorder. Knowing your loved one without OCD understands that you have OCD is reassuring in the best possible way. If the sufferer and the family member (or partner, etc.) can work together with compassion and an educated understanding of the disorder, navigating reassurance becomes easier. Collaborating on non-reassuring, but compassionate, responses makes a huge difference. So rather than constantly telling a person with harm OCD that they’ll never hurt anyone, they can find appropriate ways of telling them that they understand OCD is really painful, that they are proud of and support the work that’s being done to overcome it, and that there are several shows on Netflix right now that demand more attention than the question on the table at the moment. Of course, none of this type of interaction is possible without empathy and kindness. Helping them access treatment when possible, supporting that treatment, and never confusing the symptoms with who the person really is are all instrumental.

Speaking of not giving in to compulsions, let’s talk about your book When a Family Member Has OCDIt must be hard for parents to resist the urge to act as a therapist themselves, and to instead support their child through the recovery process. What would you tell a parent who is at his wit’s end and just wants to make life easier for his child, even if that means doing the “wrong” thing?

In writing When a Family Member Has OCD, I really kept in mind two audiences: one is the family member who wants to better understand a loved one with OCD and the other is the OCD sufferer who wants to be understood. Families operate as systems. There is no such thing as a child with OCD that exists in a vacuum where the child just gets fixed by the therapist and life goes back to normal. A child with OCD does hard work with CBT/ERP to master the disorder. The parent of that child must also be willing to do exposure to their own fear that they aren’t doing enough to relieve their child’s suffering. It’s excruciating, but when parents sabotage the treatment by providing reassurance and accommodating rituals, they just set the stage for more pain for everyone later. Reassurance actually doesn’t make life easier for the child because it sends the message to the child’s brain that there was something dangerous to reassure about and that they could not have coped without your intervention. Confronting the discomfort over withholding reassurance means sitting with uncertainty about how much pain you and your child can withstand in the face of OCD. It’s not easy. But parents who overcome this fear get a better understanding of what it’s like for their child to overcome fear and when the child improves, the parent’s relationship to anxiety changes too, and the whole system improves.

You co-authored Everyday Mindfulness for OCD with Shala Nicely, an inspiring read about how to enhance ERP with mindfulness techniques. I’ll admit that I always thought sitting in silence with my horrific thoughts felt a little like torture—and many people can’t believe we’re supposed to accept those thoughts.

It’s an interesting way we often put it—“to sit in silence with horrific thoughts.” There are some inherent problems in framing it this way. First, it implies that in the absence of distraction, it’s just the self and the thoughts alone in space. But this isn’t true. In the absence of distraction, we see things as they really are, which includes input from all five senses and, yes, thoughts. So it’s really being in the company of six streams of information and treating them all as such. Sound, touch, thoughts, and so on are all just objects of attention being projected onto the screen of the mind, so if we learn how to pay attention, there’s a lot more to look at than just sitting with obsessions. This highlights the other problem, that word “horrific.” We get so used to categorizing thoughts like movie genres that we easily forget how thoughts are just words and pictures. They don’t really have positive or negative qualities unless we decide that they do. Yes, the thought of harming my children abhors me. But if I write “harming my children” in red marker on a piece of paper, the only thing that’s changed about the paper is that it has red ink on it. The same is true of us. When we think a thought, the thought is just words scribbled on the mind. It doesn’t change who we are.

Tell us how mindfulness can help, and explain why it’s a myth that meditation means completely clearing our minds of all thoughts.

Two problems occur in the way the OCD mind operates that can both be addressed with mindfulness, which simply means watching the mind objectively. First, the mind wanders from the present, as it should, no different than a puppy sniffing things on a walk around the block. But we often fail to notice that it’s wandered and then, in a way, we find the puppy pooping on the neighbor’s porch. In other words, we get lost in our obsessive thoughts because we have trouble paying attention to where the mind is in any given moment. Then, when we discover that we’ve been pulled away by an obsession, the disorder sets a precondition for returning to the present. We feel obliged to neutralize the obsession (i.e., get certainty that it isn’t true), to do a compulsion, and then we get permission to return to wherever we were before we got distracted. If, on the other hand, we had the capacity to notice early on when the mind has been pulled away by an obsession and could simply start over in that moment as if it never happened, without permission from the OCD, we’d be much more in command. Meditation is an exercise that targets these two strengths, of recognizing where the mind is in each moment, and starting over when we see the mind distracted. By definition, this requires the mind to not be clear, but to see it clearly. Have all the thoughts, but know that they are thoughts and don’t try to fix them.

What’s next for you?

It’s been brought to my attention that I’ve written four books in the past five years or so. I’m hoping that Overcoming Harm OCD helps more than just the kind, gentle, and creative people I’ve encountered in my clinical work, but harm OCD sufferers everywhere. I also hope it serves as an excuse for me to slow down before I find myself writing something about sexual obsessions. So what’s really “next” for me is just continuing to build my practice and doing the best I can to help empower the most people in their OCD recovery.

Review of When a Family Member Has OCD

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Since I have OCD myself, I’m not the target audience of When a Family Member Has OCD: Mindfulness & Cognitive Behavioral Skills to Help Families Affected by Obsessive-Compulsive Disorder (New Harbinger Publications, December 2015) by Jon Hershfield. Loved ones are. That said, I highly recommend this book for both family members and individuals with OCD.

Using anecdotes, charts, and bulleted lists, Hershfield does an incredible job breaking down this often infuriating and confusing disorder into terms family members and loved ones can understand. In fact, Part 1: Understanding OCD is devoted to explaining what OCD is. Hershfield illustrates for the non-OCD reader what having OCD feels like, with passages such as the following, in which he invites the reader to imagine her worst fear in detail:

Put yourself right at the edge of your fear coming true. How would you feel? How would you know that you felt that way? Consider what your body would tell you. Would your heart be pounding furiously? Would your skin feel clammy or right? How would your stomach feel in that moment? …

Consider now that what you may have felt for that moment is what your family member with OCD feels on a regular basis—anywhere from one hour a day (the OCD diagnostic minimum) to not just every waking moment but also in his dreams.

Wow. This is why this book is so important for loved ones to read — an essentially neutral third party is helping them put themselves in a sufferer’s shoes, without any of the history or baggage of the relationship. You’ll also find Mindfulness Tips peppered throughout the book, and each chapter of parts 1 and 2 ends with two sidebars, Consider This, which helps the reader see obsessions and compulsions through his loved one’s eyes, and Your Struggle, which pinpoints how OCD affects the reader as well as the sufferer.

Hershfield is an expert OCD therapist who gets what his patients go through, but he acknowledges — again and again — how difficult OCD is for the reader, the family member. And with this in mind, he offers concrete tips for not only helping people with OCD cope, but also their loved ones. What should you do, for example, when your spouse asks you to check to make sure the stove is off? Are you helping by taking over this compulsion, or are you hurting? (Spoiler: You’re not helping.) Hershfield feels compassion for everyone in the OCD cycle, and it shows.

While the book is organized in such a way that you can hop around and read a section here and a section there, Hershfield recommends that you read it from beginning to end — and I agree with this recommendation. You may come across a tip in Part 2 that will make more sense if you’ve read Part 1, and you don’t have to page back through trying to find an explanation you’d otherwise already have. And it’s a joy to read! I know I’m a little biased in that I have OCD and consider it an interesting topic, but Hershfield is so engaging you’ll be pulled in and will want to soak up all of his wisdom.

Tuesday Q&A: Jon Hershfield

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I think I first heard of Jon Hershfield on Twitter — we definitely had OCD in common, so I followed him and always loved what he had to say. And then I kept hearing about him and his first book, The Mindfulness Workbook for OCD, on OCD support pages on Facebook. People love that book! Then we ended up being situated near each other at a book signing at the OCD Conference in Los Angeles in 2014, but we didn’t have a chance to meet.H_Family_i

We went the entire conference without being formally introduced, and I thought I’d lost my chance to meet him. As my co-presenter/hotel-mate and I were walking away from the conference after it had ended, she saw Jon and his dad leaving a restaurant and shouted, “Hey, conference people! Hi, conference people!” She’s not as shy as I am, by a long shot.

So that’s when I finally met him, after the conference was over, and he was as delightful and sharp in person as he is on Twitter. Since he lived in LA, he was walking home to see his family–but he’s relocating to his first home, the East Coast, in June. His new practice, The OCD and Anxiety Center of Greater Baltimore, will be located in Hunt Valley, Maryland, and will open on June 22. He’s licensed in both Maryland and California, so he’ll continue to work with clients in California via teletherapy, as well as new in-person clients in Maryland, focusing on mindfulness-based cognitive behavioral therapy for OCD.

When you decided to go into psychotherapy, did you know you’d end up working so closely with patients with OCD? What is it about this disorder that inspires you to help people struggling with it?

I decided to go into psychotherapy specifically because of how much cognitive behavioral therapy (CBT) had helped me in my own journey living with OCD. When I was in the thick of it (both the worst part of my OCD and the hardest parts of treatment), I began contributing to online support groups. I spent a lot of time reading and responding to emails from other OCD sufferers and discovered that processing the stories of other people with OCD was really helping me better understand the way my own OCD mind works. It was with the support of my wife, my parents, and my therapist that I decided to depart from a career in entertainment and go to graduate school for a masters in clinical psychology. I knew that all I wanted to do was CBT for OCD and actually hit up Dr. Michael Jenike for the recommendation letter in my graduate school application. So perhaps I am biased towards working with OCD sufferers because of my personal connection to the disorder, but I also like to think that people with OCD have truly special minds capable of doing amazing things. They have access to a spectrum of thoughts and creativity that is both awe-inspiring and overwhelmingly painful at the same time. Suffering occurs as a result of not really understanding how that kind of mind works and so using ineffective strategies to try to change it. The idea that we can write our own instruction manuals to better operate this OCD mind is simply fascinating to me.

Have you ever worked with a patient with a very severe case of OCD? How did you work through it?

I’ve worked with several cases of what I would describe as severe OCD. In my time at the UCLA Child OCD Intensive Outpatient Program, we only saw kids in the significant-to-severe range, and part of the reason we were able to break through the severity barrier was by providing several hours of individual CBT several days/week and incorporating the use of group treatment, parent education, and psychiatric medication management. In a simple private practice, time and resources are more limited. You typically see the OCD sufferer for a little less than an hour once or twice a week. So making progress in a severe case involves a combination of wise time management in session and the use of collateral resources (e.g., working closely with the client’s psychiatrist, bringing the family or spouse in for psycho-education). Sometimes the inclusion of home sessions can make a big difference as well. Severe OCD is as treatable as moderate OCD, so long as it is the OCD that is presenting the primary problem. If depression, for example, is getting in the way of treating the OCD (e.g., by depriving the sufferer of motivation), then that may need to be addressed first. In the end, homework and medication compliance are probably the biggest predictors of whether a severe case will become a moderate or mild case. Of the clients I have seen progress from the darkest depths of OCD to the greatest health, the thing they seem to have had in common was the willingness to let go of the idea that you have to wait to get better before pursuing the things you value (relationships, work, creating art, etc). In those cases, my job was mostly just to discourage waiting and then the exposure and response prevention (ERP) came naturally from that decision.

I’ve met several people with OCD over the years, and we all think our own obsessions and compulsions are the worst. We think, “You’ll be fine — all you worry about is inadvertently bringing down civilization because you didn’t wash your hands thoroughly enough. But obsess about killing my own child.” How do you respond to patients who have this mindset, that they’re somehow the exception who can’t be treated?

I think the next DSM should include a criterion for diagnosing OCD that says the person must have a belief that his/her obsession is unique, worse than others, and less treatable. When patients tell me this, I try to remind them that it’s not useful information. If it’s true that this or that obsession is something no one has ever obsessed about and we have to be extra special creative in constructing the treatment, it has no effect on the reality that the OCD is treatable and it’s treatable with CBT/ERP. Overly manualized treatment won’t take you very far. You have to construct the CBT to fit the OCD. So we don’t have to prove anything about how bad the obsession is. We just have to see where the behavior (physical or mental) is keeping this obsession afloat, target it, and change it.Mindfulness

Your first book, The Mindfulness Workbook for OCD, has practically been a runaway success in the OCD world. People love it. What inspired you to write it?

People have been incorporating mindfulness with CBT for a long time. ERP is about putting yourself in the presence of unwanted thoughts and practicing allowing them to be there without pushing them away. This naturally lends itself to mindfulness. When I was approached by New Harbinger to submit a proposal for an OCD book, The Mindfulness Workbook for OCD just made sense. I’m extremely grateful for the opportunity and love that I was able to reach so many OCD sufferers in a format like this. I was used to writing blogs and, well, really long-winded emails, so a book was quite the learning curve!

When you’ve gotten feedback on the book, is there any one section or technique that seems to resonate with your readers? 

Honestly the part I hear about the most is the preface to Chapter 1 in which I attempt to describe the OCD experience overall, what it’s like from the inside. Many self-help books have examples like “Bob’s story” and so on, but I wanted to have something that every reader with OCD would get, so I put one example and called it “Your story.” This is where I was thinking most personally about the material and I think that must resonate with readers. People also seem grateful for the specific descriptions of mental rituals, which has been scarce in OCD literature so far. Overall I think the book’s strongest element is that it looks at mindfulness not as an alternative or a stand-alone tool, but as something that can be used to enhance OCD treatment in harmony with cognitive therapy and ERP.FamilyMember

The best way to help someone through OCD feels so counterintuitive: Don’t reassure the person, and don’t make it easier for her to follow through on her compulsions. That’s why I think your second book, When a Family Member Has OCD, is such an important title. What advice do you give family members and other loved ones who are struggling to understand their role in the recovery process?

Family members and other loved ones have to walk a very tricky line between supporting the person with OCD that they care about and also recognizing that this person needs to do their own work to get better. I hope to drive the point home that you can make hard choices to help your family member with compassion and without cruelty. In “When a Family Member Has OCD,” I highlight four potential steps that can be taken to approach this. (1) Identify the compulsions, not the person, as the problem. (2) Invite collaboration on addressing the problem. (3) Interrupt the OCD cycle with permission (this is where “don’t reassure” comes in). (4) Integrate healthy behaviors through modeling non-OCD responses and embracing uncertainty of your own.

I have what is (sometimes controversially) referred to as pure O because I never performed the obvious outward compulsions like excessive hand-washing or checking and rechecking. Do you have a different treatment method for folks with pure O?

No. The treatment for OCD is CBT, a collection of strategies that includes cognitive restructuring, behavioral modification (ERP), and mindfulness skill development. Mental behaviors, though they may appear automatic and elusive, are nonetheless behaviors, which makes them available for targeting and treating. OCD sufferers tend to notice thoughts that others may be more likely to overlook or find unimpressive. How they address this “noticing” can come in many different forms. But I think it’s important that people recognize something like hand-washing is a physical behavior a person engages in when her mental rituals have failed to produce the relief she’s seeking. As a clinician, I might be able to get her to stop compulsively washing, but if I don’t also address the compulsive mental attempts to feel clean, relapse is inevitable.

Speaking of pure O, what do you think of the name for this type of OCD? Do you, for lack of a better word, believe in pure O?

As a clinician, it’s a truism that there is no “pure O.” There’s nothing pure about it.  You have obsessions, you do compulsions (seen or unseen), it causes disorder in your life and so, you have OCD. That is all. Some people believed for a period of time that there were people with obsessions who were not doing any compulsions and they called them “pure obsessionals” and now we know they were mistaken. In fact, when you consider that the very nature of an obsessive thought is that it is assessed as intrusive and unwanted, that initial assessment is in some ways a compulsion right there, an attempt to disown and dismiss the thought. So if you’re treating OCD and you’re using the term “pure O” to describe a manifestation of OCD, reasonable educated clinicians will frown on this. And for good reason. If you call it something other than OCD, your patients will expect some other kind of treatment, and may not do what they need to do to get better.

All this being said, there is a large and beautiful community of OCD sufferers communicating internationally on the internet. These sufferers have used social media to form online support groups and these groups naturally form sub-sections. These subsections reduce the sense of isolation that sufferers feel because they know the people they are communicating with think like they do. For those who engage in a lot of physically noticeable rituals, like washing, cleaning, arranging, and checking, there is the sense that people get it. It’s on TV, and it looks like what people call OCD when they use the word on TV. For people who struggle with primarily mental rituals and intrusive thoughts about violence, sexuality, relationships, religion, morality, and hyperawareness–what gets called “pure O”–there is a sense of being different from the “washers and checkers,” so to speak. There is this feeling of being poorly understood, overlooked, and often misdiagnosed. While I’m the last person to promote tribalism, this sense of togetherness under some name that identifies the lack of physical rituals feels important to the “pure O” sufferer. When I was seeking support on the Internet, I knew right off the top that I didn’t want to be in a digital room of people concerned with things I wasn’t concerned with. I wanted to be in the company of people who feel like they can’t stop thinking about terrible things all the time, people like me. Somehow I knew to seek out a site called “pure_o_ocd” even though I knew the name couldn’t possibly be true.

So does “pure O” exist?  Well, it depends who’s using the term and what they think it means. If it means OCD with mental rituals and it helps you to have a name that makes you feel less alone, then it exists. If it is some therapist’s marketing ploy or a way to describe a manifestation of OCD thought of as “pure” from compulsions, then no. As for other names that would work better, I haven’t been able to think of any. One day, when stigma around mental illness is a thing of the past, perhaps there won’t be a form of OCD that feels marginalized by society and there won’t be any drive to have a special name for it.

If you could share just one piece of advice with someone who has OCD, what would it be?

Don’t rely on one piece of advice. If you can access and afford to see an OCD specialist, listen to what they have to say and do the work, all of it, even if the work makes very little sense in the beginning because it’s such the opposite of what you want to do sometimes. If you can’t access a therapist, read several books on OCD, utilize a workbook, educate yourself about the disorder and teach yourself the tools to master it as best you can. Join a support group, follow an OCD blog, go to an IOCDF conference, connect with other OCD sufferers. Take your own advice and pool it together with the advice of people who know about OCD. You’re not alone so don’t be alone.