Book Review: ACT workbook for teens with OCD by Dr Zurita Ona

This is a fairly in depth book review as far as reviews sometimes go. However, although this book is aimed at teens, the principles are no different, and so I’ve tried to link it to my own experiences where relevant. Thus it is a review combined with more general discussion around the key points. The main purpose of the book is to synchronise Exposure Response Prevention (ERP) with Acceptance and Commitment Therapy (ACT). Both approaches I have found useful for helping with OCD, but very few books seem to explicitly combine both approaches into one, so I was excited to read this. Let’s get started….

Introduction

The book starts off with personalised letters to various stakeholders in the process of OCD recovery, which I thought was a nice touch. Such an approach sets the tone of the book, which is inclusive and participatory in nature. This is always a good sign in my opinion as the therapeutic relationship is key for OCD. OCD treatment, ERP in particular, is tough, and OCD can be loaded with guilt and shame; thus establishing authentic trust is important. Dr Ona comes across as genuine and caring in this first section.

Section 1: The Beginning

This section focuses on describing what OCD is in simple and easily understood terms. It gives a good overview of the different types of OCD with some useful diagrams explaining the process that occurs.

There is even a crossword puzzle about OCD. And yes, I did it!

The Basics of Treatment

Clear and concise explanations of what ERP and ACT are. In simple terms ERP is facing what you fear and resisting compulsions. ACT is figuring out your values and focusing on activities or behaviours related and grounded in these, rather than compulsions.

Most books will not mention ACT explicitly and will be more Cognitive Behavioral Therapy (CBT) focused. This book does have CBT techniques also intertwined. Although ACT is technically a branch of CBT, or perhaps an innovative derivative of CBT, the main difference between the two is that CBT focuses on reappriasing the thoughts, whereas ACT focuses on acceptance, without judging or challenging the content. That is my understanding anyway. From my personal experience the combination of ERP and ACT has been the best approach to OCD recovery.

There is also an OCD word search, and yes, I also did this. Bit easy to be honest Dr Ona 😉.

Why Do I Have to Deal with OCD?

This is a question we all ask. Why me? Whether from a medical or biological perspective, or even a spiritual or philosophical perspective. OCD is painful and can be life destroying. Understanding the why is important, even if the answer can never be comprehensive or fully known.

This section covers the basics including; brain chemistry, genetic predisposition, and how the brain responds to fear and in turn programmes certain responses.

There is also an interesting discussion about fear. Sometimes our views about fear, what it means and importantly how to manage it can often become distorted based on previous experiences or core beliefs. There are activities here to help explore this.

Section 2: The Choice Point meets OCD

Firstly, the book goes into a bit more depth about how OCD works. It starts with the trigger, which brings up the obsession, which then leads to compulsions or avoidance. In the short term this solves the problem, however over the longer term, the consequences are that you are no longer able to focus on what is important to you. This is why ACT and grounding responses in values can be so powerful. Overcoming OCD requires passion and dedication, and what better way to do this by motivating yourself with what you love (such as family and hobbies). The reader is then invited to reflect on their OCD and the impacts this has on them personally with an activity.

Dr Ona rightly points out that the compulsions are the problem, the only thing I would also add to this is that over time the brain can wire these fear based responses and thus the biological side of OCD can make it harder to recover the longer it goes on. Not only that but compulsions can become worse as the brain demands more and more certainty.

The Choice Point

The “Choice Point” helps clients distinguish between value-based and non-value-based decisions when the obsessions strike.

I have never personally used this concept explicitly in the form shown in this book, but I love it. In simple terms the Choice Point asks us to look at an activity (that triggers us), and then look at how the obsession comes up. Each time this happens we come to a junction a.k.a the Choice Point. Will we decide to go left, to compulsions and avoidance and therefore away from what we care about, or will we go right, and head towards what we value? Again, the reason why this is so powerful is because love overcomes fear, and focusing on what you value will help you push through. For example, if I have a lapse and have to pick myself back up I focus on the value I place on being a father to my children. So even if I have obsessive thoughts and feel like hiding upstairs, I will go and play with my boys. It’s not easy, but it makes a massive difference.

Section 3: Meeting the “Annoying Obsessions”

Unwanted Annoying Thoughts

Thoughts are normal: the weird and the wonderful, the scary and the disturbing, and it’s important to remember this because sometimes OCD sufferers forget that the content of their thoughts are actually no different to the general population. The only difference is that ours can get stuck and become clinical obsessions.

The focus of this chapter looks at the different types of obsessive thoughts and importantly lays the foundation for OCD recovery: we shouldn’t look into whether or not the thoughts are “real” (I wrote about this here), rather we need to learn to catch them and let them be. This would be the A of ACT in action. A good way of doing this can be to use the Choice Point as discussed above.

Unsolicited Bizarre Images and uninvited urges

This can be underestimated in other OCD books as the emphasis is mostly on thoughts, but actually, intrusive images can be a serious problem for many with OCD. Sometimes these images can be extremely taboo involving sexual or violent content, including about people they love. It can be very difficult for some to open up about this (understandably) and therefore it’s great Dr Ona brings this up.

Similarly to OCD images, OCD urges can also be an understated problem. Urges can include such things as swearing in church, abusing people, being racist, jumping off a bridge, and many other acts that the person finds distressing and goes against their values (also known as ego-dystonic).

The Choice Point can be used when these images or urges strike, just the same as with thoughts. There are more activities in this section helping sufferers to hone in on their particular obsessions and look at how to approach them.

Finally, another fun game, and this time it’s a word scramble! We sometimes do word scrambles in our weekly family quiz so I’m well practised.

Section 4: Are You Hooked?

Compulsions

Although still concise, this section is truly excellent. Dr Ona breaks down compulsions and gives an accurate and comprehensive overview of the different types, not just overt compulsions, but also those covert and hidden compulsions within the mind (often the hardest to recognise and therefore remove). I also like the way that Dr Ona highlights that compulsions can seem like “normal” behaviours that others do and therefore be ignored. In sum, it’s important to remember that anything used immediately to reduce anxiety from the obsession is compulsive.

Once we have highlighted the compulsions we can use the Choice Point to show that when we engage with these we are actually going away from our values.

Avoidance

Surely if we can avoid triggers then we have nothing to worry about right? Wrong. Whilst avoidance can start innocently, it can quickly escalate. For example, when I had religious OCD I started out by avoiding going to church, this then morphed into avoiding watching or reading anything I thought might have a religious theme, I would even avoid walking near a church. Therefore, from experience I know how important avoiding avoidance is. Things can escalate quicker than you think.

Again, the activity helps to highlight avoidance techniques and how we can use the Choice Point to focus on our values. So, for example, for me the activity could have been walking to town. I value my free time and thus walking the long way to avoid the church would be moving me away from my values as I waste unnecessary time. As you look into it you’d be surprised how much OCD can take you away from your true self.

Accommodations from others

These are requests we make to others to either stop doing something or modify a particular behaviour in order to reduce our OCD anxiety. For example, if I worry about blood contamination and ask my wife to change my son’s nappy instead of me, she would be making an accommodation of my OCD.

It is important to highlight areas where we ask others to accommodate our OCD because these actually make the disorder worse over the long run. We must also ask ourselves how these affect our ability to live by our values. For example, I value caring for my child, changing his nappy is something I am proud to do, but if I allow OCD to dictate my interactions with him then it takes away from the life I want to live. None of this is easy, but its crucial, families, relationships and lives can be destroyed by uncontrolled OCD. When you are in the midst of a serious obsession the scary part is sometimes you don’t notice the destruction around you.

The Costs of Getting Hooked

This is a really important section because acknowledging the costs of having OCD in our lives can be a painful experience. Those of us with OCD can spend hours upon hours trying to solve unsolvable problems. Dr Ona points out the inconvenient truth that this is simply a battle we cannot win. Even if we manage to avoid one trigger, or move on from another obsession, our overworking brains sending an inordinate amount of danger signals will eventually just land on new content.

Compulsions are never the answer and in the long run always take us away from our values and spending time doing the things we love. As Dr Ona points out, we need to learn to live flexibly with these distressing and fear inducing thoughts.

The activity in this section is simple but brilliant; it encourages us to analyse what compulsions (i.e. avoidance or using logic to refute thoughts) achieve in the short term. We then break down individual compulsions and the time they take to perform. After this we look at the impact of OCD in various areas of our life including; friendships, school, home, and hobbies. Following this we are asked to reflect on how compulsions have affected our lives over the long term.

This is brilliant because most of us with OCD forget about the long term damage and only focus on short term relief. OCD compulsions are papering over the cracks personified, yet it is so easy for us to be tricked into putting our head in the sand and thinking “this time will be different” – it won’t.

Ultimately this all comes down to intolerance of certain thoughts and feelings and the behavioural reaction to them. Dr Ona briefly explains why thought suppression is counter-productive and no matter what short term solutions we find to counteract obsessions, it always makes it worse in the long run.

Section 5: Choosing to Live Your Life

Now that we have a better understanding about OCD and how we feed into its vicious cycle, we need to decide how to move forward with our lives and actually focus on what is important to us.

OCD can be all consuming, stripping us of time and energy to the point where little else matters. In this section we explore what we would like to actually do if OCD wasn’t there. I really like the fact that Dr Ona points out that values are personal, and don’t have to be what society dictates they should be. Some of the examples she mentions include things like “being silly” and “being real”. These might sound like simple values to live by, but for those with OCD this can be extremely difficult. OCD hates you to think you are being yourself.

For instance, when I am in the presence of obsessions “being silly” feels impossible because my brain tells me that if I have fun or enjoy myself the obsessions are more likely to be real. As Dr Ona points out, values are just words, the important part of all this is to put them into action every day.

In order to encourage readers to think creatively about this there is an activity to think of someone they are a fan of and the qualities they admire of this person. Another activity asks the reader to write what they would like people to say about them at different birthday milestones from 20th to 50th (thanks Dr Ona for making me feel old). Finally, readers are encouraged to write what kind of person they would like to be as a student, relative, friend and community member.

Overall then, the reader should now have a good sense of what their values are which will be crucial moving forwards when using ACT and the choice point.

Doing the Stuff You Care About!

We all feel scared, lost, tired and confused and different times of our lives. Values can act as a compass to point you back in the right direction. Dr Ona talks about a time where she was lost in the Amazon rainforest and they didn’t know which path to take to find their way back to camp. This is a good analogy for how OCD can feel, but I would also add in a severe phobia of trees, animals and insects to the mix to get even closer to the indescribable horror of being trapped within an obsession.

However, values in these situations are not enough on their own, we must also assign activities to live out those values. So now we need to take the values we have chosen in the previous section and start to match them with actions. So for example, when I had an obsession about HIV before I even knew I had OCD, I would attend a children’s HIV support group every other Friday (as part of the charity I worked for) to play with the children. Without even knowing it I was using ACT to overcome my OCD. I remember saying to myself that I love working with children so much that I don’t care about the obsession because my values are more important. (Not that it was even possible to transmit the virus this way, I wrote about that in more detail here). When it comes to activities that bring forth obsessions we must use the choice point and decide which path to follow.

The “Fightometer”

Dr Ona asks us to perform a task where we write something horrible happening to someone close to us. This reminds me of the Jon Grayson experiment (here) that I posted some time back. It’s a useful activity you can give to family and friends to give them a sense of how OCD can feel (it doesn’t come close, but it’s the best experiment I’ve certainly come across).

The thoughts, feelings, emotions and often pure terror that comes along with distressing thoughts is compounded when we fight against them. The Fightometer is all the efforts you put into pushing away or avoid the discomfort. This is one of the truly awful components of OCD. You can be the strongest-willed person in the world and this can actually work against you. On another early post (here) I wrote about the Mr Robot chess game where Elliot was playing his father (hallucinating) which meant that he was actually playing against himself. This is what is happening here; you are playing yourself and you cannot win.

Once you get going with the Fightometer it can be very difficult to turn down, especially as compulsions build and you get stuck in a very painful and stubborn cycle of OCD.

Dr Ona offers 5 steps to counteract this process, and I cannot emphasis enough how important these are to those of us with OCD:

  1. Check when the Fightometer is on (usually when there is a strong sense of urgency)
  2. Check and describe what or how you are feeling
  3. Check what you feel like doing right now (probably compulsions)
  4. Try to relax your body
  5. Choose in that moment what is important to you

The discomfort is likely to remain for some time after this, but over the short-medium term it will eventually dissipate. I have been here more times than I can count, it feels like there is no escape. Radical acceptance is important at this stage, surrendering to the anxiety and allowing it to be there is crucial and the only way out.

Section 6: Getting Unhooked

Great section this, with multiple practical tools we can use to “unhook” ourselves from the grips of obsession; honestly, I have read so many books over the years about OCD and some of these ideas I have never heard before (in a good way). I won’t go into them all here apart from a couple (but they are all useful – not enough OCD books have these type of creative suggestions). The Mindfulness Workbook for OCD by Shala Nicely and Jon Herschfield has some ERP “games” which I would also highly recommend.

Teasing the Obsessions

Comedy is a great weapon against OCD. I don’t mean making jokes about how it feels, but just purely laughing at some of the content can be helpful to diffuse the anxiety. I have often laughed at myself in the mirror because I’ve realised how bizarre certain obsessions are. Dr Ona also recommends using a different accent, talking like one of your favourite TV characters or even using a voice changer app. I haven’t tried these particular methods, but I do love an impression so I might just start!

Messing Around with Compulsions

Again this isn’t a technique I have tried, and because my compulsions are largely mental this could be difficult to apply in certain contexts. However, there are probably ways to break down most mental compulsions into stages or groups in order to apply this technique. For example, if I get a HIV blood contamination obsession I might look at the survival of HIV outside the body first, then look at transmission probabilities, and then look at prognosis with modern medicine (just in case I’m the first person in history to contract HIV from the environment). At this point this all can occur internally because I know the facts, statistics and sources by heart. So for instance I could reverse the order just to disrupt the sequence, which in theory could help unhook me from the compulsion. For more overt compulsions such as cleaning rituals or checking in a certain order, I can imagine this technique being a lot more effective. I have known people to have a compulsion song that they sing as they go around the house to check, in this case that person could mix up the lyrics or do a random freestyle rap of checking.

As a caveat, from experience, what I would add here is that we always have to be careful with OCD that the very tools we use to confront it doesn’t become compulsive in itself. For example, whilst saying obsessions out loud can be helpful, if you find yourself doing it for reassurance it will become counter-productive (I spoke about this here, see no.2 and 6 in particular). Even teasing the obsessions might become compulsive if you’re not careful. In other words just be mindful.

Section 7: Exposure skills

As most of you will know, Exposure Response Prevention is damn hard. It’s the Navy Seals training of OCD therapy. It’s painful, but it works (if done correctly and consistently). What Dr Ona’s main intention here is to couple ERP with with ACT and tie in the concepts together – she does this really well. ERP and ACT as a combination is one that I personally have, and continue, to use with a lot of success. In fact ACT is the main maintenance technique I use. Well that and having a nap 🙂.

With ERP you expose yourself to fears based on a hierarchy, increasingly challenging yourself as you go along whilst at the same time preventing the response (compulsions). Following this clients are encouraged to refocus or sit with the anxiety until it lowers (then repeat). With ACT the action after the exposure is always focused on what you value. This can make all the difference believe me.

Think of it this way. If you are in the military and are sent on a mission but you don’t know why you are there, what the purpose is, or what exactly your fighting for; how determined are you going to be when fighting the enemy? On the other hand, if you know exactly why you are there, what the purpose is, and what you are fighting for, your spirits are likely to be high and your determination and strength increased. It’s the same with ERP. I have personally found that without rooting my exposures in values (such as family, helping others, philosophy of religion, studies, fitness – all the things OCD takes away from me) then I am more likely to give up the fight.

Value-guided exposures consistently remind you of why you are putting yourself through such pain with ERP. Values are not always enough to push you forward, but for me they are a vital component and make success and adherence to treatment more likely. But this us why, sometimes, the obsessions can be so overwhelming that we need something different to pick us back up again (which is why the “unhooking” strategies are so important).

The book has useful tables to use to devise, rank and plan value based exposures and gives examples on how this can be done. I would always recommend a person do ERP (at least initially) with an accredited therapist because OCD is not to be underestimated and oftentimes we have to “borrow someone else’s brain” as I sometimes say. However, for many, treatment is unavailable and/or unaffordable, so self-directed therapy is the only way. This book is very careful in breaking down the process step by step and links all the previous sections together to form a toolkit for approaching values based exposures.

The part I love most about this section (I was already sold on combining ACT and ERP before reading the book anyway) is the reflection part. Reflection is such an under-utilised tool with OCD, especially because we can tend to be extremely harsh on ourselves and have ridiculously high standards. So this “reflection form” as given in the book helps us to look at the exposure, how it affected the “frightometer”, how it linked to values (whether it got you closer or not), and then a reflection on any compulsions. So even if you slipped up with a couple of minor compulsions (which can happen), the next time you do the exposure you can plan an unhooking technique to counteract it the next time. Mistakes happen, it’s how you react to them.

This section also discusses imaginal exposures, which are sometimes a point of contention amongst experts from what I’ve read, with some arguing them to be much less effective than in vivo exposures (those done in the physical world). Personally I think in vivo exposures are better when possible, but imaginal exposures can also be useful as a supplementary approach. Dr Ona also discusses bodily sensation exposures, which is an interesting technique I haven’t ever needed to use myself. Basically, when obsessions come a lot of people focus on bodily sensations as evidence of the obsession meaning something. If it is possible to simulate these responses and sit with the anxiety, then that could be helpful. For example, if you have an obsession about choking, you could gargle some water which would trigger a fear response. I’m quite unfamiliar with triggering bodily sensations as an exposure in all honesty, but I can definitely see where it could be useful. I know people who have obsessions about their sexuality will often look for bodily responses as a compulsion and therapists will work on triggering this and sitting with the doubt.

I think most would agree there is no one size fits all model here and people will respond differently to different approaches, it also depends on the nature and content of the obsession – that’s my understanding at least. Skilled therapists will adjust accordingly to meet the needs of the individual client, but it can often take a lot of trial and error (with or without a therapist). I learn every single day!

Section 8: Moving Forward with Your Life

We don’t choose when intrusive or obsessional thoughts come. Sure, they can be triggered by certain people, places or states of mind (stress, tiredness, hunger); however, they can equally come out of nowhere. I sometimes struggle when I am happy because OCD will see happiness as a danger and then send me a few random “what if” thoughts to remind me that life is dangerous. Thus, to counteract this, the book encourages us to log “on-the-go” value guided exposures. I think this is an important tool for life with OCD in my opinion. For most, even after treatment, OCD will be in the background and lapses can occur. The vast majority of experts would deem this to be a chronic disorder, even when “recovered”. Staying well with OCD takes a lot of effort and you cannot take it for granted. So, being ready to tackle obsessional thoughts if and when they arrive is crucial for preventing yourself relapsing, or at least limiting the distress the OCD can cause.

Another important part of OCD recovery is recognising how far you have come in your journey and how much closer you are to living according to the values you choose. The path can be hard and long for many, but celebrating victories (big or small) is good for keeping you motivated. The book encourages us to reflect on this and record how far we have come periodically.

Having “allies” is another aspect that Dr Ona encourages the reader to consider. Having loved ones or supportive others can be hugely beneficial when the relationship is appropriate (from an OCD standpoint). It is important that allies do not become part of your compulsions (this can happen very easily) and it is vital that you do not put pressure on others or make them responsible for your recovery.

The final recommendations in the book are to treat yourself with kindness and compassion (something a lot of us struggle with); encouragement to get out of your mind and into your life, and; the most important underlying philosophical implication of the book YOU HAVE A CHOICE!

Concluding remarks

Overall I would give this book 5 stars (out of 5). It’s detailed, but as concise as possible. There is a lot to take in, especially for young people, and it would probably take a few reads if most of these concepts are new to someone. OCD is complex, and recovery rarely simple – thus inevitably some level of depth is always required to avoid an oversimplified or superficial analysis.

The book successfully combines ERP and ACT, which for me has been the best method. The book is consistent and I didn’t find myself disagreeing with any of the core arguments. Some of the concepts are repeated in almost every section, but I understand why this had to be done. OCD is relentless, and you need to be relentless in recovery. Focusing on the key strategies such as the Choice Point is vital, especially when disorientated by the obsessions. Dr Ona is a good drill sergeant in drumming home the important concepts.

I would have liked to see a bit more detail about reassurance seeking, but that would probably take another book in itself; in fact Martin Seif and Sally Winston did write a whole book about it called Needing To Know For Sure, which I highly recommend. I think a section on medication might have been useful, but obviously this can be a tricky area with teens.

Some OCD books are overly clinical and devoid of emotion, but Dr Ona writes with compassion, and you feel her genuine warmth and empathy as you read the pages.

I seriously wish I had this book when I was younger, looking back I cannot believe how many years I suffered, how many tears I shed, how many times I was prevented from doing what I wanted in life, all because of OCD (which I didn’t even know about when I was a teen). Even many years after I was diagnosed with OCD it would be a while before I started to use ACT.

The book is marketed towards teens but I can honestly say I have learnt more from this book than many of those directed primarily towards adults. ACT can sometimes be shunned or ignored by some more traditional experts, but I wouldn’t be where I am today without ACT. This is hopefully one of many OCD specific ERP/ACT books to come.

I invite Dr Ona to now write another version geared towards adults, but this time, I want a harder crossword puzzle!

2 thoughts on “Book Review: ACT workbook for teens with OCD by Dr Zurita Ona”

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