Bud Clayman: So talk about the therapist [in] cognitive behavioral therapy.
Jon Hershfield: Cognitive behavioral therapy is divided into the ‘C’ and the ‘B’ of CBT. The C is for cognitive, which refers to “thought” and one of the things we know about OCD is that while you can’t control the thoughts you have, you have some influence over how you respond to those thoughts and how you think about those thoughts.
This is kind of a nuance thing. There’s a difference between the having of a thought, meaning something pops up into your head and there it is – and thinking which is a behavioral act, analyzing, figuring out, addressing. So when you’re thinking, there are different ways of thinking about things and what we know is that people with OCD tend to have some distorted ways of thinking about things that push them into doing compulsions.
For example, if a thought pops into my head about hurting a loved one and –
Bud Clayman: Which is very frightening.
Jon Hershfield: – which is very frightening and then I’m processing that through a lens of, “If I have one violent thought, it means I’m a violent person.” Now, I’m not only thinking about how I might hurt a loved one but I’m also thinking about myself as a violent person. That’s very scary so I’m immediately going to feel discomfort, I’m immediately going to want to do a compulsion to convince myself that that person’s not going to get hurt.
However, if I noticed that I’m thinking in this very black and white of, “Oh, if I just think one violent thought, it makes me a violent person,” I can challenge that and say, “Well, wait a second. I don’t actually believe that. That’s a distorted belief. That’s me processing information. Yes, I have this violent thought and yes, it disturbs me. But the presence of a violent thought does not necessarily create my entire identity.”
Maybe I’ll take the risk this time and not do the compulsion and just say, “Well, okay, that’s the thought that went through my head. Let’s see how this goes.” So with the rest of cognitive therapy, there’s many different kinds of cognitive distortions which is what we call these, the errors in thought processing that you can learn to challenge.
I think most people treating OCD today recognize that there’s a role for that but it’s not nearly as significant as the role that the ‘B’ in CBT plays. The B, the behavioral therapy, that’s what we were talking about earlier, exposure with response prevention. So focusing on what is it that you’re doing in response to these obsessions – it’s actually sending the message to your brain that these thoughts are important, that these thoughts are dangerous. That these thoughts are producing an experience that you’re not capable of tolerating and how can we modify that behavior so that you can send a different message to your brain that these thoughts, unpleasant as they may be, are part of the normal way that the mind functions, that you could tolerate them, that you’re not going to let something like a thought get in the way of your values or of your objectives in life.
Bud Clayman: What is the treatment time [for OCD?] I’ve been told there isn’t a cure for OCD but it’s more managing the illness. Is that true?
Jon Hershfield: Yes. I like to say mastering the illness; managing sounds kind of like a downer. You know, the word ‘cure’ I think is problematic because obsessions being unwanted, intrusive thoughts are normal events. Everybody has unwanted, intrusive thoughts. We can’t control what goes on in our mind any more than we can control what happens to show up on the TV when we turn it on. It’s just what’s there. And compulsions are normal events. We all have little rituals that we engage in throughout the day that are part of the culture that we live in or just part of the way that we were raised and really serve no function at all but we’re just sort of used to doing them. So obsessions and compulsions themselves aren’t the problem. It’s the disorder, that’s the problem.
And so when you’re able to effectively treat the disorder and get it to a place where the obsessions and compulsions aren’t grossly interfering in your life, we can call that a cure because that’s pretty much as good as it’s going to get and that’s pretty good.
Bud Clayman: Somebody reading this interview, let’s say recognizes that, “Hey, I have OCD, but I don’t want to go through therapy. It’s going to take forever.” Is there a rough amount of time it takes or do you have to live with the uncertainty of that?
Jon Hershfield: I think you have to live with the uncertainty of that but I can give you a somewhat satisfactory answer. It’s the other problem with looking at it in terms of cure, I think[it’s] also understanding that besides the obsessions and compulsions and how they get in the way of your life, – there’s an OCD mind. There’s an OCD way of looking at the world and this has somewhat to do with your genetic makeup and literally just the way your brain is designed. And although you can influence these things through cognitive behavioral therapy, there’s a level of acceptance of, “You know what? This is just how I think. If I didn’t have OCD, I probably wouldn’t think this way but this is just how I think.”
And if you can learn to master that and actually appreciate that, that’s also another way of looking at a cure. I think people with OCD have a very wide open mind and there’s a window in your brain that sort of opens to a lot of stuff coming in that for other people, it exists, but it’s shrouded in a kind of darkness. They have to try to think about it whereas you don’t have to try to think about it. It just presents itself to you. This can work both ways. Yes, it means you have to deal with all the nasty stuff but it also means that a lot of really creative interesting ideas come your way with limited effort because of the way that your minds works; you have an OCD mind.
So even at your best, there’s a part of this disorder that you carry with you and that doesn’t have to be looked at as a curse. It should just be looked at as a thing that is.
Bud Clayman: It’s how you embrace it.
Jon Hershfield: Yeah. Now, in terms of how long does it take to get from being really sick and you know, being on top of it? I think it would depend on a lot of different factors. I think on average, CBT is not considered the longest of therapies. It’s usually measured in months. But when we say it’s measured in months, what we really mean is it would be anywhere from – well, let’s take sort of intensive residential treatment out of the equation for a second and just look at regular outpatient treatment. You’d probably see an OCD specialist once a week, maybe twice a week for a process of a few months. And then you would gradually start tapering those sessions down, every other week, once a month, and so on and so forth. Then it just becomes as needed, sometimes you can just go in every two months, every two weeks, whenever you feel that you need to get your screws tightened.
But how long does it take overall? It kind of depends on how you look at it. What is your goal here? It’s a journey that really shouldn’t ever end. When should we decide to stop improving the way that we look at our mind and improving the way that we deal with interesting thoughts?
Bud Clayman: That’s a good attitude. Do meds help?
Jon Hershfield: Meds help some of the people some of the time. I would say a lot of the people a lot of the time. It’s obviously a contentious issue for some but it’s undeniable that research shows that there’s some medications out there that clearly help reduce the intensity of obsessional thinking, reduce the intensity of anxiety and depression, and for many people, the way their brain chemistry is set up, it actually makes it very difficult to do the therapy that would get you better without medication because for that person without medication, their anxiety may be too high for them to ever really effectively do exposures because an exposure should take you from a somewhat neutral state to an anxious state.
If you’re already at a 10 on your anxiety scale, there’s not a lot of work to do. Or perhaps they’re too depressed to be motivated to think their life has enough worth and value to fight so hard to beat the disorder. I think without medication for people who need it, the treatment that works, the cognitive behavioral therapy isn’t really going to fly. There’s a lot of people who get better on medication. The medication is helping them but what’s really helping them is the medication is allowing them to make the choice, to stop doing compulsions in the face of their obsession and that’s what’s ultimately getting them better.
Bud Clayman: I was on Anafranil at one point I think for OCD.
Jon Hershfield: My understanding is that Anafranil is one of those medications that is considered to be very effective for OCD. It’s often not prescribed as a first-line medication only because many people have difficulty tolerating the side effects.
But there’s a class of medications that are typically prescribed as first-line medications for OCD called SSRIs and they effect the transmission of a neurotransmitter, a chemical in the brain called serotonin and the way that it affects how serotonin is transmitted throughout the brain seems to help with depression and OCD and with OCD, it’s typically prescribed in higher doses.
There are several other medications that are sometimes prescribed along with an SSRI that affect other areas of brain chemistry that can also be helpful for managing anxiety, managing the intensity of intrusive thoughts and things like that.
Editor’s Note: It’s important to make any medication decisions in consultation with a psychiatrist.
Bud Clayman: What would you say are some of the most popular misconceptions about OCD and its treatment?
Jon Hershfield: Let’s see – popular misconceptions – well, one is that – this one always kind of amused me is that people who have contamination OCD are clean. My experience is actually the opposite. People with severe Contamination OCD have trouble touching things that are dirty and if you want to get clean, you have to touch things that are dirty including your body, and bodily fluids, the floor. I’ve treated several people with severe contamination OCD and you go to their home, expecting it to have this kind of cartoon glimmer and it’s covered in garbage because they can’t pick it up.
Bud Clayman: That’s ironic.
Jon Hershfield: That’s ironic, yeah – and you know, a lot of OCD is ironic. I mean if you look at Harm OCD, why are you afraid of lashing out and hurting someone? Well, you don’t want to be a bad guy. If you hurt someone, you’re a bad guy and then maybe you go to jail, maybe you’d be rejected by society. Yet all of your rituals are keeping you from being social, they’re keeping you from leaving the house. They’re keeping you from relating in a healthy way to the news and television and stuff like that.
So ironically, a lot of what you’re afraid of happening as the result of acting on your intrusive thoughts is kind of already happening as a function of your doing compulsions.
Another common misconception about OCD and its treatment is that the treatment is cruel or dehumanizing or that it’s really about torturing people. There’ve been several things that have shown up in the media that are just plain silly where you’re taking somebody who’s afraid of something and you’re just throwing it in their face. People don’t learn to swim by being kicked in the back and thrown into the deep end of the pool and having the word ‘swim’ shouted at them.
People learn to swim by approaching a pool and not even going in the water for a long period of time until they’re ready to just dip their toe in and then gradually working their way up to being immersed in their discomfort. That’s really how CBT for OCD works. It’s about coming up with a plan with the sufferer to gradually confront the fear of theirs. By the time they’re dealing with the scariest of the scary thoughts, it’s really only a step up from what they’ve already pretty much conquered or pretty much decided they were capable of tolerating.
Bud Clayman: So they say baby steps is the way to go? Small steps.
Jon Hershfield: I’d say it really depends on the person because you know; a small step for you may not be a small step for another person. I think that the treatment needs to be aggressive and yet it needs to be at a pace that’s tolerable. When I’m working with someone, my objective is kind of, you know how I imagine what goes through the mind of my trainer at the gym which is he tells me to pick something up and I say, “I can’t pick that up.” And he says, “Well, give it a shot.” I say, “Oh, this is too heavy.” He says, “Okay, well try this one.” “Well, this is heavy but I think I can do it.” It’s the same sort of thing.
I’m kind of saying, “Well, here’s an exposure we can do. I think it will be really challenging. Do you think you’re up for it?” And if the client is telling me, “No, I’m just going to have a complete meltdown. I can’t do it.” I say, “Well, what do you think would be a step down from that? What do you think you’d be capable of doing?” and we collaborate on strategies, always keeping the goal in mind which is mastering the presence of these intrusive thoughts.
Bud Clayman: Please talk about mindfulness. I know that’s an important part now of OCD treatment. What is mindfulness and how can it help the OCD sufferer or anyone else in life?
Jon Hershfield: Mindfulness is actually a very simple concept and a very old concept. You know, you’re reading a lot about it now because people are finding that implementing it in a variety of different therapies for a variety of different disorders, helps in a very big way. But I think people have actually been doing it for a long time without calling it mindfulness.
At its source, it’s basically just a very simple concept of paying attention to the present moment and accepting the present moment exactly the way it is.
Bud Clayman: Which is hard for most people.
Jon Hershfield: Which is hard for most people, and especially hard for OCD sufferers because the present moment may involve the presence of a thought that you find abhorrent or an experience of anxiety that you find painful or perhaps you find it intolerable to be able to sit and observe and acknowledge, “Okay, this is what’s happening right now in this moment.” And the tendency is to think, “what if this lasts forever?” Well, that’s not mindfulness, that’s looking into the future. Or, “Oh, what if the thing I did before, what if I made this terrible mistake?” Well, that’s not mindfulness, that’s digging back into your mind and sort of investigating your imagination. Mindfulness is actually being right here and right here right now is, “I’m a person having a thought.” That in and of itself, is not particularly threatening.
Bud Clayman: Now, I know you have a book coming out on December 1st entitled, The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions using Mindful and Cognitive Behavioral Therapy. What was the genesis of this book? How did it come about and how would it be able to help the OCD sufferer or anyone else who might want to use it?
Jon Hershfield: I was working at a place called The OCD Center of Los Angeles under the supervision of co-author Tom Corboy, and I’d been writing blogs there about OCD and the experience that I was having treating people there and using cognitive behavioral therapy and mindfulness. Through that writing, I happened to be fortunate enough to come in contact with New Harbinger and they are well known for publishing many excellent self-help books including The OCD Workbook (by Bruce Hyman and Cherry Pedrick).
Bud Clayman: I’ve read some other books dealing with mindfulness but this seems like a new approach with specifically OCD. Is that true?
Jon Hershfield: Pretty much – I mean I think there’s a lot of books and various resources on OCD. I think there are a few books about OCD that have chapters devoted to mindfulness but I think in terms of a book that explicitly focuses on, “How do you apply mindfulness to cognitive therapy, behavioral therapy, the CBT, specifically for OCD overall,” I think this is the first book that’s really going to approach that subject exclusively.
Bud Clayman: Specifically the OCD sufferer, what will they be doing in the workbook? How will they use it?
Jon Hershfield: Well, the way we have it set up is it’s broken down essentially into three parts of addressing OCD, acceptance which is what we were talking about before which is mindfulness which is accepting what’s going on in the present moment, considering that doing compulsions would be the antithesis of acceptance. That would be trying to get rid of the thought. And the second part is assessment, that’s the cognitive therapy part. That’s taking a look at, “Well, hold on a second. If I can’t deal with this, let me just take a look at what’s objective reality here. Can I predict the future? Can I read people’s minds? No I can’t? Okay. Let’s go back to acceptance.”
Then action, which is referring to exposure and response prevention. How can I take action against my OCD and what the book offers is a series of strategies for each of those things. How can I accept this thought? If I’m having trouble accepting this thought, how can I assess whether or not I should do compulsions so I can go back to accepting the thought? If I’m having trouble assessing whether or not I need to do compulsions, how can I take action against this obsession and create a hierarchy of exposure that will allow me to overcome this? It’s broken down chapter by chapter for most of the major forms of OCD.
Bud Clayman: So this is a very active workbook that gets you involved doing active things.
Jon Hershfield: Yes. There is going to be a lot of things to write and consider and practice, absolutely.
Bud Clayman: Cool.
Jon Hershfield: It was very interesting for me writing a workbook because I’d only ever thought of it in terms of treatment in the room. I’d never really had the experience of saying, “Well, what about a person I’ve never met? How would I explain to them how to do what we’re doing in the room?” because CBT is very collaborative. So writing something in which I’m not able to collaborate directly with the client, I had to kind of think about what the reader’s experience would be here.
Bud Clayman: They can use this with their therapist, right?
Jon Hershfield: Yes. I mean technically it’s called a self-help workbook but I think certainly, it would be a great benefit to anybody who wanted to use it with their therapist. You might have questions and the questions might not immediately be answered there. The therapist may help to explain what’s going on.
THE SERIES: Check out Bud Clayman’s interview with Jon Hershfield from last week about Defining OCD and tune in next week for more!
The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions using Mindful and Cognitive Behavioral Therapy by Jon Hershfield MFT, Tom Corboy MFT, and James Claiborn PhD ABPP (Foreword) will be released on December 1, 2013.
Jon Hershfield, MFT is a psychotherapist in private practice in Los Angeles and the associate director of the UCLA Child OCD Intensive Outpatient Program.