The ACT Workbook for OCD Practice: Learning to Treat Yourself as a Friend

Practice: Learning to Treat Yourself as a Friend

This self-compassion exercise offers one way to explore being kind to yourself through a response that may come more naturally:
being kind to a friend. This time, the friend is you. Follow the steps and answer the questions in the space provided.
This exercise has been used with permission from the Mindful Self-Compassion Workbook (Neff and Germer 2018). The original
may be found at https://self-compassion.org.

1. First, close your eyes and think about the times when a close friend felt bad about himself or herself or was really struggling
in some way. How did you respond to your friend in this situation (especially when you were at your best)? Write down
what you did and what you typically do when friends are having a tough time. Note what you say and the tone in which
you usually talk to your friends.

2. Now close your eyes again and think about a time when you felt bad about yourself. How did you respond to yourself in
this situation? Write down what you did and usually do when you feel bad about yourself and what you say, and note the
tone in which you talk to yourself.

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Practice: Learning to Treat Yourself as a Friend

3. Do you notice a difference between how you respond to friends and how you respond to yourself in times of struggle? If so,
ask yourself why you respond differently. Write down the factors or fears that come into play and lead you to treat yourself
and others so differently.

4. Write down how things might change if you responded to yourself in the same way you typically react to a close friend in
moments of suffering.

Reflection: Write in your journal what you notice during and after this self-compassion practice.
The ACT Workbook for OCD Practice: Self-Compassion Break

Practice: Self-Compassion Break

This self-compassion exercise offers one way to explore being empathetic with yourself by reminding you of the three core aspects
of self-compassion: mindfulness, common humanity, and self-kindness. This practice can be done any time of day or night—and
especially when you need it the most.
This exercise has been used with permission from the Mindful Self-Compassion Workbook (Neff and Germer 2018). An audio
version may be found at https://self-compassion.org.
Think of a situation in your life that is difficult and causing you stress. Call the situation to mind and see if you can feel the
stress and emotional discomfort that comes along with this stress in your body.
Now, say to yourself:

This is a moment of suffering.

That’s mindfulness. Other options include:

• This hurts.

• Ouch.

• This is stress.

And now say to yourself:

Suffering is a part of life.

That’s common humanity. Other options include:

• Other people feel this way.

• I’m not alone.

• We all struggle in our lives.

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Practice: Self-Compassion Break

Now put your hands over your heart, feel the warmth of your hands and the gentle touch of your hands on your chest. Or adopt
the soothing touch you discovered that felt right for you.
Say to yourself:

May I be kind to myself.

That’s self-kindness. You can also ask explore what it is you actually need right now by first prompting with What do I need to
hear right now to express kindness to myself? Then you might come up with a phrase that speaks to you in your particular situation,
such as:

• May I give myself the compassion that I need.

• May I learn to accept myself as I am.

• May I forgive myself.

• May I be strong.

• May I be patient.

Reflection: Write what you noticed during and after this self-compassion practice.


The ACT Workbook for OCD Practice: Exploring Self-Compassion Through Writing

Practice: Exploring Self-Compassion Through Writing

This three-part exercise uses writing to help you explore the thoughts and ideas you have about yourself. It’s designed to help you
see where you might be overly harsh on yourself (judgmental) and where you can invite more compassion and kindness into your
self-image. You’ll need your journal, paper, and a pen or an electronic device that you can type on.
This exercise has been used with permission from the Mindful Self-Compassion Workbook (Neff and Germer 2018). The original
may be found at https://self-compassion.org.

Part 1: Which imperfections make you feel inadequate?

Everybody has something about themselves that they don’t like, something that causes them to feel ashamed, insecure, or not good
enough. It is the human condition to be imperfect, and feelings of failure and inadequacy are part of the experience of living a
human life. Try writing about how your OCD tends to make you feel inadequate or bad about yourself. What emotions come up for
you when you think about this aspect of yourself? Try just to feel your emotions precisely as they are—no more, no less—and then
write about them.

Part 2: Write a letter to yourself from the perspective of an unconditionally

loving imaginary friend.
Now think about an imaginary friend who is unconditionally loving, accepting, kind, and compassionate. Imagine that this friend
can see all your strengths and all your weaknesses, including your OCD. Reflect upon what this friend feels toward you and how
you are loved and accepted exactly as you are, with all your very human imperfections. This friend recognizes the limits of human
nature and is kind and forgiving toward you. With great wisdom, this friend understands your life history and the millions of things
that have happened in your life to create you as you are in this moment. Your particular inadequacy is connected to so many things
you didn’t necessarily choose—your genes, your family history, life circumstances—things that were outside of your control.
Write a letter to yourself from the perspective of this imaginary friend, focusing on the perceived inadequacy you tend to judge
yourself for. What would this friend say to you about your “flaw” from the perspective of infinite compassion? How would this friend
convey the deep compassion felt for you, especially for the pain you feel when you judge yourself so harshly? What would this friend
write to remind you that you are only human, that all people have both strengths and weaknesses? And if you think this friend
would suggest possible changes you should make, how would these suggestions embody feelings of unconditional understanding and
compassion? As you write to yourself from the perspective of this imaginary friend, try to infuse your letter with a strong sense of
acceptance, kindness, caring, and desire for your health and happiness.

Part 3: Feel the compassion as it soothes and comforts you

After writing the letter, put it down for a little while. Then come back and reread it, really letting the words sink in. Feel the com-
passion as it pours into you, soothing and comforting you like a cool breeze on a hot day. Love, connection, and acceptance are your
birthright. To claim them, you need only look within yourself.

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Exposure FAQs

Exposure FAQs

As you practice exposure, it is likely that many barriers and questions will arise. This is normal. I encourage you to keep up your
practice while trying to get your questions answered. Here are some answers to frequently asked questions that you may have:

How often do I need to be doing a formal practice?

Anywhere between four and seven days per week is commonly recommended to get the most benefit. Everyone is different, though,
and how often you schedule a formal practice will depend on a few different things, such as the severity of the OCD and how often
you are addressing it in the moment. The more severe the OCD, the more practice is recommended, but as your OCD gets quieter,
you will likely be able to cut back on the amount of time you spend doing a formal practice.
Since the goal of ERP in the model is learning, we know that the more days of consecutive practice you get, the more the learn-
ing will take hold. Some people get so caught up in doing exposures all day long, however, that the exposures get in the way of living
their lives. Thirty minutes a day of formal practice when you first start this process may be helpful, but be sure to spend the rest of
your day engaged in values-based behaviors and living your life. You can also ask yourself what a good enough practice would look
like. My mentor taught me this: in life, we don’t want to put too much energy into things or too little energy into things. Aim for a
good enough practice. Only you know what that looks like.

Is doing exposures in the moment as important as doing them formally?

Doing exposures in the moment is just as important as doing them formally, but I recommend starting out with formal exposures.
Thereafter, any time you run into the trigger in your day-to-day life, the expectation is you would do an exposure in the moment
that you’ve already practiced. Doing exposures in the moment can be hard to do, so I usually recommend doing them after you have
done formal exposures on that trigger.
It’s not uncommon for people to put off practicing. This is a form of avoidance. The sooner you acknowledge your fear and lean
into uncertainty and the feeling, the more present you will be in your life. In fact, when you practice embracing feelings and
thoughts in the moment, you may be able to cut down on your formal practice time later. For some people, addressing their fears in
the moment allows them to defuse from the thought, and then it is no longer bothersome. If this is the case, then you can discon-
tinue doing a formal practice on that particular trigger. For others, even after doing the exposure in the moment, the thought is still
nagging. In these instances, it’s good to do a formal practice as soon as possible afterward.

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Exposure FAQs

How can I motivate myself?

Doing this work is hard. Most people do not want to do it. The good news is you can be willing to do something even if you do not
want to. If you are feeling stuck, here are some questions you may want to ask yourself:

1. How will doing this practice help me live my life?

2. What value(s) is this exercise in line with?

3. Is this short-term discomfort worth the long-term gain?

4. What would my values say to do?

5. Am I willing to get back to living my life even if it is hard?

6. If I am not willing to do this exercise, what am I willing to do that will bring me closer to my values? Can I make this practice a
little easier in some way? How can I work my way up to this exercise?

If you are still unwilling to practicing having the feelings and thoughts, then perhaps you’re not at a point where you are ready
to make a change in your life. That’s okay too. Another option is to practice some of the self-compassion exercises that are in this
book. Perhaps practicing self-compassion will eventually get you closer to facing your fears.

What can I do if I am having trouble feeling the sensations in my body?

Connection to our bodies is different for everyone; some of us are more connected than others. The good news is that most people
can learn how to connect to their body with practice. Don’t give up on your exposure practice even if it is hard to locate the sensa-
tion. In addition to continued exposure practice, I would recommend daily body focused meditations; they are often called body
scans. You can find these on the insight timer app. You can also take a free online mindfulness-based stress reduction class (https://
palousemindfulness.com/) or search for a local class where you live (https://www.umassmed.edu/cfm/mindfulness-based-programs
/mbsr-courses/find-an-mbsr-program/).

What can I do if I am having trouble labeling the feeling?

Some of us have not learned how to label our feelings. Learning emotional language is the first step. Depending on who you ask,
there are anywhere between six and ten universal emotions, meaning all people experience them. A number of other emotions
branch off these six to ten emotions. For example: let’s take the feeling of sadness, which can branch off to depressed, hopeless, or
helpless. For more information about emotions, check out this article (https://www.psychologytoday.com/us/blog/hide-and-seek
/201601/what-are-basic-emotions). Google images has a ton of worksheets and visual guides that can also helpful. Mood tracking
apps such as the ones listed here (https://www.healthline.com/health/bipolar-disorder/top-iphone-android-apps-dbsa-wellness
-tracker) can also be helpful. I would recommend asking yourself once or twice a day “How do I feel right now?” and practice label-
ing the feeling, such as “I feel sad, mad, scared, bored, shame, helpless, excited.”

I don’t always realize when I am triggered or engaged in a compulsion.

How can I become more aware of when I am in my OCD cycle?
Awareness comes from slowing down. Most of us are used to multitasking and moving quickly through our day. The problem with
this is that we are often focused on what’s next rather than how we are feeling in the moment. Slowing down in our day to day allows
us to notice more, including how we feel.

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Exposure FAQs

Reflection: Here are some tips on how to slow down and increase awareness in your day-to-day life: Begin with asking yourself,
What could my day or life look like if I were to slow down? Get a real sense of what time you would wake up, how you would move
throughout your day, how you would travel, how you would work through tasks, how you would talk and connect with people, what
activities you would be focused on. Write your answers below.

Next, ask yourself, “How can I make the things I listed above happen? What will help me slow down?”

Some people make an effort to stop multitasking and instead focus on doing one thing at a time. One way to do this is by using
a calendar and task list to manage your tasks and time. The task list can help prioritize tasks and the calendar is where you can
schedule each task into a specific day and time. This can give you a nice visual of how you are spending your time and allow you to
see more clearly when you have multiple things planned for the same time. The goal is to use the calendar flexibly. You will not stick
to it 100 percent of the time. Even 60 percent of the time is great as long as it allows you to slow down, be more aware and present
in your life.
In addition to using a calendar and task list, some people choose to schedule alone time. Some examples are waking up earlier
to enjoy your cup of coffee or tea, scheduling in meal time to be aware of eating, taking breaks throughout the day to connect with
nature by going on walks or socializing with colleagues by going out to lunch. Meditating during alone time can also be helpful.
The ACT Workbook for OCD Exposure FAQs

Slowing down may also be about doing things like saying no to the people and things in your life that are not actually in line with
your values. This may free you up to be able to do some of the things that were mentioned above. Taking care of yourself is number
one. After taking care of yourself, you will be in an even better place to take care of others.

Do I have to do these exercises the rest of my life?

How long you choose to do a practice is up to you, but acceptance is lifelong. Perhaps it would be good to ask yourself whether or
not your practice helps you accept your experiences and be present in your life. If it does, you may want to consider it as a lifelong
practice.
Acceptance is a lifelong process for most of us, as choosing to be willing to be open to experiences is part of building a values-
based life. Sometimes we are more accepting of our experiences, and other times we are less accepting of our experiences. How you
choose to respond to your experiences is up to you, but know that doing formal exercise and exercises in the moment are two ways
to practice acceptance. Other ways can include meditation retreats, slowing down and being willing to acknowledge whatever
comes up, being in groups, talking with friends, crying, saying the serenity prayer, or doing a self-compassion exercise (such as the
Self-Compassion Break included in this online supplement) or using any other acceptance-based sayings, such as May I be accepting
of myself and my life as it is now. May I be accepting of all my vulnerabilities and strengths, including my OCD.

Why is my OCD still here, even after doing ERP?

Remember that the goal of these exercises is not to get rid of obsessions and doubt; it is to learn how to have them while living. Sure,
the OCD often improves through ERP, but if you get caught up in trying to get rid of the OCD, you will fail and likely feel depressed
and disappointed. OCD is lifelong. If you view pain as a normal part of life, then you may be less likely to focus on trying to avoid
it. Instead, you can use your time and energy to focus on living your life with pain.

How do I know if I’m doing the exposure right?

You may not ever know if you are doing your exposures 100 percent right. And doing them 100 percent right is not the point. You
see, there are different ways of doing exposures, and the model in this book is just a guide. Only you will know if you are being
honest with yourself about your deepest fear and leaning into the pain rather than running away from it.
Also notice if perfectionism is asking the question, Am I doing it right? Perfectionism may say you need to do exposures right or
perfectly. Try focusing instead on doing exposures in a good enough way. As long as you are doing things that are scary yet meaning-
ful, this is good enough. You will fail at times. We all do, and the beautiful thing about failing is all the rich learning that comes
from it. Rather than beating yourself up for failing, you can remind yourself that all human beings fail, and ask yourself, What did I
learn from this mistake?

How long will I feel anxious during my formal practice?

There is no easy answer, but one guarantee is that anxiety will always be a part of your life, because anxiety is a normal human
emotion. In fact, anxiety serves a very healthy purpose. It can help us in emergencies, and if we can learn to work with rather than
against our anxiety, it can help motivate us to move closer to things that are meaningful.
For example, Bob desperately wanted his anxiety to go away. Any time he had to speak at work, he fought his anxiety by pre-
tending it wasn’t there, and this often resulted in him losing his train of thought and his speech being scattered while he was speak-
ing. So, in practice, rather than trying to get rid of the anxiety, he began to view it as a messenger. You see, it was very important
to Bob to grow and learn within his career, and presenting in front of others was a part of this. His mind was trying to remind him
of this, but it was doing it in an unhelpful way. It was excessive and catastrophic. In practicing exposure exercises, he learned how
The ACT Workbook for OCD Exposure FAQs

to have the anxiety while being able to present and grow at work. Letting go of his agenda to control or get rid of the anxiety freed
him up to focus on how he wanted to be in the moment. As a result, he was able to be more focused and present in his meetings.
While his anxiety didn’t go away, he was able to show up how he wanted to show up, an important value for Bob.

How many sessions will ERP take to experience relief?

If your goal is relief, you will feel disappointed. Ask yourself what is your agenda relief or living? Living includes pain, which means
that doing ERP doesn’t mean we live pain free. It means we learn how to live with pain. In fact, most people experience more anxiety
when they start doing ERP and moving closer to the things that are important to them. The more accepting you are of your OCD
and other unwanted experiences, the less you are focused on getting rid of the OCD and seeking relief. Ask yourself “Am I willing
to have this in the service of living?” Dropping the relief agenda can free you up to spend more time and energy on what really
matters to you.

What if my anxiety never goes down?

Some people are scared to do ERP because they worry that their anxiety will never go down or that they won’t be able to handle it.
How about, let’s see if that happens?
The simple fact that you are reading this book means that what you have done thus far is not working. And if you keep doing
what you’re doing, you will get the same results. So are you willing to try something new, and then see what happens? This is often
the harder path because it includes taking a risk and not knowing the outcome, but taking this path also means the possibility of
learning you can do the harder thing, which is tolerating uncertainty and discomfort. Life will give you a ton of it.

If I am not supposed to be engaged in a compulsion, what am I supposed to be doing?

Learning how to connect with feelings and fears during practice is the answer. Here are some suggestions from chapter 9:

1. Ask yourself what you are most fearful of right now?

2. Say back to the OCD, I’m noticing the thought that…and state your fear.

3. Add, I don’t know if (repeat your fear) could/will happen.

4. Simply say back to the mind, Let’s see if (state you fear) happens.

5. Label the feeling in your body. I feel… (sad, scared, mad, ashamed…).

6. Notice the sensation the feeling has, what it looks like, and feel it as much as you are willing to.

How can doing exposures help with magical thinking?

Magical thinking is when you believe thoughts to be true and that they have power, for example, I can predict or influence the future
through my actions. Magical thinking often includes a sense of overresponsibility, such as it is up to you to prevent something bad
from happening. For example, Barbara believed she was psychic, she noticed certain coincidences that could influence how and
when her parents would die and world catastrophes would happen. When the coincidences occurred, she felt that she could control
the negative outcomes by avoiding people, places, products, words, numbers, and clothing. To target her magical thinking, one of
the things she practiced was doing things that were meaningful to her but that she would typically avoid and while saying her worst
fear and feeling the feeling. She practiced taking risks and leaning into not knowing if she were influencing her parents’ deaths or
The ACT Workbook for OCD Exposure FAQs

other catastrophes. An exposure example would be writing down the following Because I wrote the number 911 and listened to a song
by a dead artist, my parents will die and I may be making it worse by writing and saying this. Through practicing exposures, acceptance,
and self-compassion, over time, Barbara learned that she is capable of living her life without knowing whether or not she is influenc-
ing the outcome of things. She also learned that though feelings such as sadness and anxiety are difficult, she is capable of having
them and continuing to live. Lastly, she learned that the mind is not always truthful.

How do I know if I’m white knuckling it, or pushing through, exposures?

White knuckling it, or pushing through, exposures means that while you are doing the exposures, you are doing them quickly and
focused on getting them done rather than on connecting to the fear and feeling. It is recommended that you do these practices
slowly and thoughtfully. The point is to connect with the underlying fear and feelings, as this is how long-term learning will occur.
So notice as you are doing these exercises if you are connecting to the feelings and saying the underlying fear. If not, try doing a
different exercise in which you are willing to connect to the feelings and say the underlying fear.

What is the difference between self-reassurance and self-compassion?

Self-reassurance is a compulsion, which means its goal is to decrease anxiety in response to an obsession. Self-compassion is not
meant to decrease your emotional experience but to help you through it. For example, if your OCD says you are or may be a bad
person, an example of self-reassurance might be reminding yourself that you are a good person and thinking about all the good
things you have done. On the other hand, self-compassion would say, This is a moment of suffering. I don’t know if I am a bad person.
It’s okay to feel sad and anxious. Everyone feels sadness and anxious sometimes. May I be courageous and continue to live my live without
knowing. Or may I be kind to myself even if I don’t know whether or not I am bad. Notice if the language you use in your self-compassion
script is aimed at trying to prove the thought wrong or to control how you feel. If this is the case, see if you can change the language
so that it does not directly respond to the OCD but instead validates how you are feeling and describes how you want to show up in
moments of suffering.

Why does my OCD change?

Some people experience the same type of OCD throughout their life, but other people find that OCD can morph into different
kinds of OCD. For example, Cindy’s OCD has always focused on some type of harm, whereas Will’s OCD has shifted from perfec-
tionism to pedophilia to doubting his sexual orientation. Some people will also have more than one type of OCD at the same time.
For example, when Sally came to see me, she had obsessions about death, perfectionism, and emotional contamination. We don’t
exactly know why people have more than one type of OCD or why the type shifts. The stage of life you are in and current stressors
can sometime influence your OCD. For example, a new mother may be more likely to experience thoughts about harming her
newborn, while someone experiencing job stress may notice his obsessions are mainly focused on his job. What’s most important to
understand is that uncertainty is at the root of most OCD. The more you learn to lean into the uncertainty and discomfort, the
better off you’ll be, no matter what type of OCD you experience.
If your question is not listed here, you may want to ask an OCD professional or peers who have experience with doing ERP. The
International OCD foundation lists a number of online resources at https://iocdf.org/supportgroups/online-and-phone-ocd-support
-groups/#General.
A practice of embracing all feelings and thoughts while moving forward in your life is not easy. Your choice to do these exercises
speaks to your willingness to live more fully. All sorts of barriers and questions will come up in the process. Remember you are not
alone. Again, if your question was not answered here, please reach out for support. You’ll find that other people have had the same
question.
The ACT Workbook for OCD Values Map

Values Map

Adapted from the ACT matrix (Polk et al. 2016), the values map is a visual representation of your values, your values-based behav-
iors, your unwanted thoughts and feelings, and your unhelpful behaviors. This map can be used at any time to increase awareness,
but it can be particularly helpful when you are feeling stuck in life or unsure of what to do in situations. In such moments, the values
map can help redirect our focus from painful experiences such as OCD to what’s important to us.
Please answer the questions below using the information you filled out in previous chapters that pertains to your OCD. Also,
feel free to add any new information that may not be OCD-related but is a part of your experience.
The process of completing this map begins with the bottom-right quadrant. Here, you ask yourself who and what are most
important to you. Your top five values from Chapter 4 would go here. You can also add the people you value, like your family and
friends, and your pets: anyone and anything that gives your life meaning.
Then, in step 2, complete the bottom left quadrant by listing the unwanted, internal stuff that shows up when you are trying to
live your life and do the things that are important to you. List your obsessions from chapter 1, your other unhelpful thoughts from
chapter 5, and your core fear from Chapter 8, and add any other unhelpful thoughts, obsessions, feelings, and sensations you can
think of. After that, move to step 3, completing the top-left quadrant by noting all your unhelpful behaviors from chapter 6. You
can add any other behaviors you do to get rid of or neutralize your unwanted thoughts, feelings, and sensations (such as compulsions,
avoidance, worrying, ruminating, reviewing, overeating, binge watching TV, overexercise, and so on).

3) What physical and mental behaviors have

4) What behaviors could you be doing to move
you been doing to move away from (or to get
closer to your values (the who and what you
rid of) the unwanted internal stuff you wrote
wrote below)? List your values-based
below? List your unhelpful behaviors from
behaviors from chapter 4 and any other
chapter 6 along with any other behaviors you
behaviors you can think of.
can think of.

Noticing My
Experiences

2) What unwanted internal stuff gets in the

way when you are trying to get closer to your
values and living the life you want? List your
obsessions from chapter 1, your other 1) Who and what is important to you? List
unhelpful thoughts from chapter 5, and your values from chapter 4, and add any
your core fear from chapter 8, and add people or pets to your list.
any other unhelpful thoughts, obsessions,
feelings, sensations you can think of.

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Values Map

Once you’ve finished writing down all the away behaviors you can think of, ask yourself these questions:

1. In the short-term, do these behaviors push my painful thoughts, feelings, and sensations away or do they give me some
temporary relief?

2. In the long-term, do these behaviors keep my painful thoughts, feelings, and sensations away? Is this a permanent fix? Are
the experiences gone?

3. Do these behavior bring me closer to who and what is important to me in life? Is it in line with my values?

4. What patterns do you notice?

As a reminder, unhelpful behaviors provide short-term relief. However, in the long term, they do not make painful experiences
go away and often do not bring us closer to who and what is important.
Now, we all engage in unhelpful behaviors. We do them because they work in the short term; they give us a break from the pain.
The problem is that engaging in unhelpful behaviors most of the time gets us further and further away from who and what is impor-
tant to us. This is what creates additional pain and suffering.
Oftentimes you are faced with a decision: short-term pain for long-term gain, or short-term gain or relief for long-term pain. For
example, you can seek reassurance from friends and loved ones when you are feeling uncomfortable or unsure of something. In the
short-term, seeking reassurance may quiet the OCD thoughts and feelings, but in the long-term, it can lead to nagging other people
and not being present in your relationships. If, on the other hand, you choose not to seek out reassurance, but instead sit with uncer-
tainty and discomfort, it is harder in the short-term because it will feel uncomfortable, but in the long run, it may give you some
good practice on how to have these feelings and allow you to be more present in your relationships.
The aim of unhelpful behaviors is to avoid discomfort rather than live fully. The urge and desire to avoid pain is totally normal.
But what happens when our life agenda is about avoiding discomfort? Even the good stuff in life brings about pain.
The ACT Workbook for OCD Values Map

Take a moment to write down a satisfying situation in your life, something you are proud of or that you accomplished. (One
example may include a graduation or promotion, which usually includes stress and anxiety pertaining to the completion of work and
meeting deadlines. Another example could include having a child; this usually brings up physical and emotional pain.)

Now ask yourself: did this situation, or what led up to this situation, involve pain? What was the pain (anxiety, stress, physical
pain, sadness)? Was the pain worth the outcome?

If you act in ways that minimize your pain, you get a “safe” life. But a safe life often equals a smaller life, not doing as many
things or seeing as many people. And a smaller life usually equals some sort of pain, loneliness, boredom, or disappointment. So—all
of that work you did to get rid of that pain, and here is it again. Remember, life—big or small—includes pain.

What kind of a life do you want: a big life with pain or a small life with pain?


The ACT Workbook for OCD Values Map

Odds are you want a meaningful life, full of love, connection, and aspirations. All of the good stuff in life will include pain. You
will not be successful in getting rid of pain; it is an inevitable part of life. But you can certainly live a big, beautiful life that includes
pain.
Finally, we turn to step 4 of the values map—listing, in the top-right quadrant of the matrix, our values-based behaviors from
chapter 4. What could you do to move closer to who and what is important to you? On camera, what behaviors could you be doing?
When you’re considering this question, keep in mind that values-based behaviors are not necessarily what we are currently doing
but what we could be doing to move closer to our values and the life we want.
Taken together, the four quadrants of the values map give you a way to think about any action you might take in terms of
whether it’s toward your values or away from painful experience. The left side of the matrix is focused on getting rid of pain; the right
side is focused on living fully. Who knows if what you are doing is to avoid pain or if it’s to bring you closer to your values? Only you
do! Only you know if you are doing something to avoid pain or to bring you closer to what is important to you in life. For example,
take telling someone you love them. This would be a toward behavior if the intention is to bring you closer to them; perhaps the
values you’re acting on are openness, honesty, or vulnerability. Can you think of how telling someone you love then could be an
away behavior? Perhaps in moments of doubting your relationship or your partner, you might be telling them “I love you” with the
intention of figuring out if they love you too. It can be used as a form of reassurance. The mind is very sneaky! What’s more, some-
times you’ll do the same thing for different reasons at different times. Either way, only you know what is driving your behaviors.
Simply notice your toward behaviors each day. Notice when you are doing things that bring you closer to who and what is
important to you. You can do this by reviewing your matrix and/or writing your daily toward behaviors in your journal. This will
help refocus the mind. Most of us spend time dwelling on all the things we are not doing. This exercise asks you to review all the
wonderful things you are engaging in!
The ACT Workbook for OCD Tools Checklist

Tools Checklist

Tools The tools I would like to

keep using are: (✔)

OCD log

Calendar

Values Map

Skills The skills I would like to

keep using are: (✔)

Labeling unhelpful thoughts and behaviors

Noticing when I am trying to control my internal experiences

Practicing mindfulness

Practicing self-compassion

Identifying my core fear

Setting “good enough” goals when facing my fears

Setting up a formal acceptance practice

Practicing acceptance of uncertainty and discomfort in the moment

Reviewing my top five values and noticing what they would say when things get hard

Connecting with other people who have OCD

Practicing defusion: “I’m noticing the thought that…”

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Medications Continued…

Medications Continued…

Some individuals with mild OCD choose not to take medications and feel that the tools in this book are helpful enough. Those
with severe symptoms may be unable to participate in these exercises without the help of medications; one client told me, “Medications
take the edge off…I experience fewer thoughts and less anxiety but it is still present, and I continue to engage in avoidance and
compulsions.” Still others are somewhere in between: they find medications to be helpful but not necessary to live.
Also, fear can sometimes play a role in the decision to take medications, and this can make it hard to discern if taking medica-
tion is in line with your values. If fear is showing up around this issue, and you want to be curious about its role in your decision,
you could address it by asking yourself what you are most fearful of and lean into this fear using the exposure exercises in chapters
8 and 9. From there, you can check in with your values by asking yourself if taking medication is moving you toward what is impor-
tant to you in life or instead more of an escape from your experiences. You can refer to chapter 4, too, for more values exploration,
if you find you need it. The premise of ACT is to experience whatever shows up in the service of living, and only you know if medi-
cations will help you get there in the long run.

SSRIs
SSRIs are often casually referred to as “antidepressants,” but in practice, they’re used for a variety of non-depression conditions,
particularly anxiety disorders and OCD. There is still a lot of research and debate about the exact mechanism of how SSRIs work,
but the simplified version is that they increase serotonin in parts of the brain, which in turn affects other neurotransmitters and
ultimately results in lessening the activity in brain areas that are often overactive in OCD (Stahl, 1998). In short, SSRIs help
improve symptoms for about 50 to 70 percent of people with OCD (Bloch et al. 2010; Jenike 2004; Pallanti et al., 2002), which can
help make doing ERP a little easier. SSRIs are also favored over older classes of antidepressants because they have fewer side effects.
The most common ones include:

• Problems sleeping

• Fatigue

• Stomach upset

• Restlessness

• Sexual problems

• Sweating

It is important to remember that side effects usually start to resolve within a few weeks (Koran et al. 2007). Additionally, while
this is not true for all OCD patients, there is a percentage of patients who seem to do better with SSRIs at higher dosages than are
typically prescribed for a person suffering from depression alone (Bloch et al. 2010). For those with OCD, it is important to remem-
ber that obtaining the maximum benefit from SSRIs can take longer, sometimes eight to twelve weeks (Koran et al. 2007).
The SSRIs fluoxetine, paroxetine, fluvoxamine, sertraline, and citalopram have been approved for use in OCD. Here, however,
it is important to note there is no evidence that any one SSRI, even among SSRIs not approved specifically for OCD, is any better
than another. One medication may better fit with your body than another, so it’s important to be open to having to try more than
one or two medications before you find the best fit (Eddy et al. 2004).

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.
The ACT Workbook for OCD Medications Continued…

Beyond Medications
Medications alone are typically not enough. Although 50 percent of people with OCD experience some symptom improvement
when taking SSRIs, they often continue to experience some symptoms and impairments (Abramowitz et al. 2009). Also, the risk
for relapse once the medications are terminated is roughly between 24 and 89 percent (Abramowitz et al. 2009). When you add
exposure and response prevention, however, the results are greater symptom reduction and a decrease in the likelihood of long-term
relapse (12 percent compared to 24 to 89 percent) once medications are terminated (Simpson et al. 2004; Koran et al. 2007).
If you’re interested in medications for your OCD, you can start by researching medication options on IOCDF.org (but be sure
to put a time limit on it). You can also talk to a psychiatrist who specializes in OCD.
For more information about common SSRIs prescribed and dosages, check out this blog written by Dr. Michael Jenike, an OCD
expert and a psychiatry professor at Harvard Medical School: https://iocdf.org/about-ocd/ocd-treatment/meds/.
Meeting with a psychiatrist may give you more information about whether or not you would be a good candidate for medications
and what types of SSRIs would be best given your particular genetic makeup. You may be able to find a psychiatrist near you who
specializes in OCD by going to the International OCD Foundation’s Resource Directory (https://iocdf.org/ocd-finding-help/find
-help/). If there are no such psychiatrists in your area listed, you can reach out to an OCD therapist in the directory and ask them
for a referral.
The ACT Workbook for OCD References

References

Abramowitz J. S., S. Taylor, and D. McKay. 2009. “Obsessive-Compulsive Disorder.” Lancet 374 (9688): 491–9.

Bloch, M. H., J. McGuire, A. Landeros-Weisenberger, J. F. Leckman, and C. Pittenger. 2010. “Meta-Analysis of the Dose-Response
Relationship of SSRI in Obsessive-Compulsive Disorder.” Molecular Psychiatry 15 (8): 850–5. https://doi.org/10.1038/mp.2009.50.

Eddy, K. T., L. Dutra, R. Bradley, and D. Westen. 2004. “A Multidimensional Meta-Analysis of Psychotherapy and Pharmacother-
apy for Obsessive-Compulsive Disorder.” Clinical Psychology Review 24 (8): 1011-30.

Jenike, M. A. 2004. “Obsessive–Compulsive Disorder.” New England Journal of Medicine 350 (3): 259–65.

Koran, L. M., G. L. Hanna, E. Hollander, G. Nestadt, H. B. Simpson, and the American Psychiatric Association. 2007. “Practice
Guideline for the Treatment of Patients with Obsessive-Compulsive Disorder.” American Journal of Psychiatry 164 (7 Suppl),
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Neff, K. D., and C. K. Germer. 2018. The Mindful Self-Compassion Workbook: A Proven Way to Accept Yourself, Build Inner Strength,
and Thrive. New York: Guilford Press.

Pallanti, S., E. Hollander, C. Bienstock, L. Koran, J. Leckman, D. Marazziti, and J. Zohar. 2002. “Treatment Non-Response in OCD:
Methodological Issues and Operational Definitions.” International Journal of Neuropsychopharmacology 5 (2): 181–191.

Polk, K. L., B. Schoendorff, M. Webster, and F. O. Olaz. 2016. The Essential Guide to the ACT Matrix: A Step-by-Step Approach to
Using the ACT Matrix Model in Clinical Practice. Oakland: New Harbinger Publications.

Simpson, H. B., M. R. Liebowitz, E. B. Foa, M. J. Kozak, A. B. Schmidt, V. Rowan, et al. 2004. “Post-Treatment Effects of Exposure
Therapy and Clomipramine in Obsessive-Compulsive Disorder.” Depression and Anxiety 19 (4): 225–33.

Stahl, S. M. 1998. “Mechanism of Action of Serotonin Selective Reuptake Inhibitors. Serotonin Receptors and Pathways Mediate
Therapeutic Effects and Side Effects.” Journal of Affective Disorders 51(3): 215–35.

© 2020 Marisa T. Mazza / New Harbinger Publications.

Permission is granted to the reader to reproduce this form for personal use.