.png)
Blog book review written by Melissa Barsotti, LCSW, a therapist in private practice specializing in OCD.
As a trauma and OCD therapist, Jon Hershfield’s and Dr. Blaise Aguirre’s 2023 book on OCD and DBT and other CBT approaches is the book I have been waiting for. The Unwanted Thoughts & Intense Emotions Workbook is a guide for those living with OCD and related disorders, and practitioners alike. This book is actually fun to read and easy to understand. Thank you to the authors for breaking down concepts in such a relatable way.
I had the good fortune of meeting one of the authors, Jon Hershfield, at the 2023 OCD conference. Hershfield has written other books that I also love and recommend to my clients, including his 2018 book Overcoming Harm OCD. Needless to say, Hershfield is a very respected and known therapist, author, and specialist on OCD and related disorders.
Dr. Blaise is a renowned psychiatrist and professor at Harvard medical school and director of the successful DBT program for adolescents and young adults, 3 East Treatment Center at Mclean Hospital. Dr. Aguirre has also authored several books on the treatment of borderline personality disorder.
Although this book provides information for other mental health conditions that involve the experience of unwanted thoughts, this review will primarily focus on obsessive compulsive disorder. In a nutshell, OCD involves the experience of unwanted intrusive and ego-dystonic thoughts/urges/body sensations/images/sounds that cause distress. As a result of the distress, the human tendency is to make efforts to "get rid" of these unwanted experiences. Typically, there is a a false relief that is experienced through mental or physical compulsions. Compulsions are mental or physical behaviors aimed at alleviating distress caused by intrusive stimuli. This unfortunately turns into a repetitive cycle where the brain is continually reinforced that the intrusive thought is actually harmful or dangerous. The goal of treatment for OCD is to teach the brain that these intrusive stimuli are not in fact harmful or dangerous, and do not require any compulsions.
One of my favorite chapters in Hershfield and Aguirre's 2023 book is chapter 3, The Fundamentals of Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP). The C in CBT refers to our thoughts, also known as cognitions. Cognitive approaches help us in exploring and changing the way that we relate to our thoughts, in ways that are more helpful and healthier. B stands for behavioral, where behavioral approaches help us in observing how our behaviors impact our thoughts and feelings, and to explore and practice alternative behaviors that might be more helpful and healthier.
The authors review a list of cognitive distortions, which are patterns of thinking that are often irrational and cause us to make unhelpful conclusions about things. The authors highlight that cognitive distortions are “ways of thinking that have a negative impact on our ability to remain objective (Hershfield & Aguirre, 2023, p.26)." Of the eleven common cognitive distortions briefly reviewed in this chapter, there are two specific distortions I would like to highlight, as many readers may not be as familiar with them.
Selective Abstraction, per the authors is overfocusing on content that relates to your unwanted thoughts without taking in the bigger picture, and Thought-Action-Fusion, which the authors report as “believing that having thoughts about an act is the same thing as doing the act.” These two specific distortions are especially prevalent in OCD sufferers.
In Selective Abstraction, also referred to as “zeroing in/tunnel vision (Hershfield & Corboy, 2013)," the authors are telling us that we may have a hyperfocus on our specific fears, and miss the bigger picture. In Hershfield’s 2013 book on Mindfulness and OCD, he shares the example that we may notice more love songs following a breakup. In this example, there are probably just as many other songs focusing on different themes, but we are drawn to the love songs due to our current experience. So, if my OCD subtype is harm to myself or others, my brain might selectively highlight all of the dangers in the room. With harm intrusive thoughts, I may be hyperfocused on anything that might be used to cause harm with, such as broken glass, the steel fireplace poker, the baseball bat in the closet, the knives on the counter. This experience highlights the cognitive distortion of selective abstraction, AKA tunnel vision, where one would be missing the bigger picture which might be enjoying a visit with family and friends.
Continuing with the harm ocd subtype, the cognitive distortion of thought-action-fusion, also known as “magical or superstitious thinking (Hershfield & Corboy, 2013),” means that we believe we are murderers by simply experiencing an intrusive thought of bludgeoning our friend with a blunt object. We might also find ourselves avoiding sitting anywhere near “dangerous” objects for fear that sitting next to these objects might make it more likely that our intrusive thought of murdering our friend will come true.
These beliefs might sound comical to some, but for individuals with OCD and related disorders, living with these intrusive thoughts that are ego-dystonic is absolutely torturous.
In teaching us about cognitive distortions, the authors are clever in introducing the idea of a false vs a real project. The authors express that cognitive distortions “confuse us into thinking we have a project to solve that we actually cannot solve (Hershfield & Aguirre, 2013, p.28),” such as “changing the past, predicting the future, or obtaining certainty about something (Hershfield & Aguirre, 2013, p.28).” The authors express that this false project takes our attention away from the real project, which is “addressing the present moment, coping with our hard feelings, and accepting uncertainty (Hershfield & Aguirre, 2013, p.28).”
The authors provide us with an automatic thought record to help us keep track of the presence of our cognitive distortions, as well as to help us in increasing our awareness to the false projects and identifying the real projects. The thought record is shown below, with two additional columns I believe will also be helpful. You will also find a feeling wheel pdf to help in identifying specific feelings resulting from your intrusive thoughts.
The triggering intrusive thought examples on the thought record are truly disturbing, aren’t they? Living with these intrusive thoughts is a nightmare. Luckily, our authors are gifted in their ability to help us break down what a thought or a word actually are. In chapter one, our authors share that our thoughts are “objects of consciousness (Hershfield & Aguirre, 2023, p.4),” specifically, “a thought is an object in the sense that it’s something you can observe, and the place you are observing it is in your consciousness (Hershfield & Aguirre, 2023, p.4).” Our authors also highlight the fact that thoughts/ words may provoke emotions due to our conditioning, making us feel that it may be impossible to be objective about our thoughts.
In order to help us have a better understanding of our thoughts, the authors introduce the concept of thoughts being ego-dystonic and ego-syntonic. The ego referring to the self we know ourselves to be. Ego-dystonic thoughts are thoughts that are in conflict with how we identify as a person, and go against our specific values. Ego-dystonic thoughts in essence, do not make sense to us. Ego-syntonic thoughts are thoughts that do make sense to us and align with our worldview and values. Distressing thoughts, such as “I messed up,” may be ego-syntonic if they result after a behavior that you identify as “wrong,” such as committing adultery or cheating on an exam. Thinking "I messed up" makes sense due to the context. Ego-Dystonic thoughts do not make sense in any context and are not aligned with who we truly are.
In introducing Exposure and Response Prevention as an effective behavioral approach to OCD, our authors help us understand the way the brain works, specifically that “the brain itself, is an organ in your body, and has no opinion on the intrinsic meaning of your thoughts (Hershfield & Aguirre, 2023, p.28).” The authors share that “the brain learns how to relate to thoughts largely by our behavior.” For example, if you avoid something, you are teaching your brain that these specific things must be avoided. You have in essence programmed an alarm in your brain for the next encounters you have with whatever it is that you avoided (highways, big-rigs, sharp objects, nudity, etc). Our authors highlight that our brain “is designed to assume” that you know what you’re doing, not that you are guided by distorted thinking (Hershfield & Aguirre, 2023, p.28).” In other words, our brain assumes we have good reason to avoid our feared objects. Our authors beautifully highlight the nature of ERP with the following statement: “ERP exposes us to the conditions that make us want to do compulsions and then we show the brain that we can be in that space (with our fears), without engaging in those compulsions (Hershfield & Aguirre, 2023, p.31).”
What are compulsions? Our authors highlight that “anything can be a compulsion if it’s goal is to make you feel more certain (Hershfield & Aguirre, 2023, p.38)," and/or to provide immediate relief from your experienced distress as a result of experiencing an intrusive thought. To clarify, compulsions can be physical or mental acts utilized to provide relief from the anxiety resulting from intrusive unwanted thoughts.
Here are the 5 categories of compulsions outlined by our authors.
Chapter 4 and 5 introduce DBT, specifically DBT for OCD, which is what sets this book apart from other books on OCD.
Dialectical Behavioral Therapy (DBT) is a type of cognitive behavioral therapy, founded by Dr. Marsha Linehan. Dialectics/dialectical is a concept where two “seemingly polar opposites can coexist (Hershfield & Aguirre, 2023, p.47).” A common dialectical concept I often share with my clients is that it can be true that they have put in a lot of work to learning new tools and changing behavior, while it can also be true that in this present moment they may be having a panic attack. Having a panic attack, or any symptoms emerging again does not have to erase the fact that much healing, hard work, and growth has happened for a client.
DBT is centered around the practice of mindfulness, which is a core skill. Mindfulness is important because it requires the practice of stopping, noticing, observing what is happening in the present moment within and outside of someone, without judgment or criticism. The authors gently guide the reader in practicing the skill of mindfulness by highlighting the following steps:
Also in chapter 5, our authors highlight their understanding of what causes suffering, which they identify as psychological inflexibility. Psychological inflexibility means we are experiencing difficulty or resistance pivoting and adapting to whatever is in this moment because we want things to be a certain way. With OCD, psychological inflexibility is manifested by the following example:
Silvia is experiencing intrusive harm thoughts that are ego dystonic and internally responds and wrestles with “I shouldn’t be having these! This can’t be! What’s wrong with me?”
Luckily, DBT teaches us how to be psychologically flexible through accepting two opposing forces that occupy the same space. We may be experiencing unwanted ego dystonic intrusive harm thoughts AND we can tolerate them and let them pass without intervening. This is a great example of how DBT and ERP pair well together. With ERP, “we intentionally do things that are hard, and intentionally go in the opposite direction from avoidance (Hershfield & Aguirre, 2023, p. 74).” The opposite of avoidance is TOLERANCE. With ERP, we learn to tolerate being in a state of distress. We learn to tolerate what is unwanted (the intrusive thoughts).
Chapter 7 is a MUST-READ chapter for anyone experiencing OCD and considering utilizing exposure and response prevention. This chapter will also help therapists with questions they may have about how to go about utilizing ERP with their clients.
It is a myth that ERP has to be torturous. Yes, you are being exposed (via written exposure, verbal exposure, imaginal exposure, in-vivo, narrative exposure, etc) to your feared intrusive thoughts while resisting the false comfort of engaging in a mental or physical compulsion. This process will certainly be uncomfortable. Remember, discomfort is a part of life and we are already tolerating discomfort on a daily basis.
While resisting avoidance is necessary, and tolerating discomfort is part of the process, torture and white-knuckling this experience is absolutely not effective. The goal is to teach your brain that these intrusive thoughts are not harmful and that you can tolerate their existence and no intervention (compulsion) is required. If you find yourself becoming overwhelmed with ERP exposures, our authors encourage us to utilize DBT skills, specifically distress tolerance and emotional regulation. These skills can be used to “down-regulate without turning to a total avoidance or other compulsions.”
Below you will find a pdf that lists helpful exposure rules, which is adapted from: Hershfield, J. (2018). Overcoming harm OCD: mindfulness and CBT tools for coping with unwanted violent thoughts . New Harbinger Publications.
Have I convinced you of the importance of this book? There really are so many helpful nuggets of wisdom in this book, including chapters on letting go of control, how to practice acceptance, mindfulness, emotional avoidance, hypervigilance, perfectionism, shame, cultivating self-compassion, getting to know your core fears and accompanying compulsions. In Chapter 10, the authors help you create your own exposures and guide you in making sure exposures align with your values.
Thank you kindly for reading this review. Please know that I am not paid by these authors to write a review, and I only review books I personally utilize for myself and my clients.
Resources:
To learn more about OCD, you can visit my website here and here.
Complete Guide to OCD with author and therapist Kiberly Quinlan, LMFT
References:
Hershfield, J & Aguirre, B. (2023), The Unwanted Thoughts & Intense Emotions Workbook: CBT & DBT Skills to Break the Cycle of Intrusive Thoughts & Emotional Overwhelm. New Harbinger Publications, Inc.
Hershfield, J & Corboy, T. (2013). The Mindfulness Workbook for OCD, Second Edition:
A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Therapy. New Harbinger Publications, Inc.
Hershfield, J. (2018). Overcoming harm OCD: mindfulness and CBT tools for coping with unwanted violent thoughts . New Harbinger Publications, Inc.