What is Acceptance and Commitment Therapy,
What is its Effectiveness, and Should I Look Into It?

by Michael Twohig, Ph.D.

Michael P. Twohig, Ph.D. a licensed clinical psychologist in Utah and an assistant professor at Utah State University. He received his Ph.D. from the University of Nevada, Reno, and completed his clinical internship in the CBT track at the University of British Columbia. His research spans a variety of areas including the treatment of obsessive compulsive disorder and OC-spectrum disorders, substance use, mechanisms of action, and multicultural issues. He has published over 50 scholarly works including two books: An ACT-Enhanced Behavior Therapy approach to the Treatment of Trichotillomania (with Woods) and ACT Verbatim for Depression and Anxiety (with Hayes). His research is funded through multiple sources, including the NIMH.

What is Acceptance and Commitment Therapy for OCD?

Acceptance and Commitment Therapy (ACT, said as one word and not spelled out) is a form of Cognitive Behavioral Therapy (CBT) in the same way that Exposure and Ritual Prevention (ERP), Cognitive Therapy, and Dialectical Behavior Therapy are forms of CBT. All of these interventions share certain therapeutic or philosophical elements that put them under the CBT umbrella rather than other umbrellas (such as psychoanalysis or humanistic psychology, for example). Some of the defining elements of CBT interventions, including ACT, involve:

• Viewing behaviors as shapeable or changeable through environmental manipulations, rather than seeing behaviors as solely biological or neurological in nature, and thus responsive to psychotherapy;
• Focusing on the way the client interacts or responds to events (including thoughts and feelings) in his or her life rather than intrapsychic events, developmental milestones, or personality characteristics; and
• Testing the effectiveness of its interventions as well as the processes through which they work. There are some places, though, where ACT may be different than more commonly practiced forms of CBT. The most commonly used and supported forms of CBT for OCD are ERP and ERP with cognitive challenging (the term ERP will be used to cover both in this article). The ultimate goal of ERP is greater functioning of the client, and it appears that most ERP models focus on reducing obsessions and associated anxiety so that greater functioning can be achieved. Subjective Units of Discomfort (SUDS) scores are collected throughout therapy. Measures of OCD severity place equal emphasis on the frequency and severity of obsessions and compulsions. This focus is also evident in ERP where equal time is spent focusing on reducing obsessions and compulsions. ACT is purported to be different than ERP in that it focuses less on the reduction of inner experiences (such as obsessions) and more on altering the way they are experienced. ACT sees inner experiences, such as obsessions and anxiety, as part of our lives. Obsessions and anxiety are not inherently bad events, but they are treated that way by most of society. ACT focuses on finding a way to allow obsessions and anxiety to come and go without interfering with the way one lives his or her life. Thus, greater functioning can be achieved without a change in severity or frequency of obsessions or anxiety. This is a position that is shared with other forms of CBT, but possibly emphasized to a lesser extent.

Individuals diagnosed with OCD or therapists who work with these clients may have a “negative” reaction to the idea of living with obsessions and anxiety. If you experienced the same reaction when you read the last paragraph, just notice that reaction and answer these questions:

• Has attempting to control or regulate obsessions and anxiety worked over the long-term?
• Has this lessened the obsessions and anxiety in a meaningful way?
• Finally, has your life become more open and fulfilling as a result of these attempts to regulate obsessions and anxiety?

If you answered “yes” to all of these questions, then keep doing what you are doing. Follow your experience; it is more honest than your mind. If you answered “no” and what you are doing is not lessening these obsessions, your life feels more restricted, and you are getting further from where you want to be, then some of the concepts from ACT might be useful for you.

One of the central concepts of ACT is that there is a big difference between what one thinks or feels and what one does. ACT is based on the model that the things people think and feel, or the bodily sensations that one has, are not under that person’s control in any meaningful way. But, what a person does while thinking, feeling, or experiencing a sensation is under his or her control. To illustrate this, answer these two questions: 1) For $1,000, could you prevent yourself from having an obsession over the next 24 hours, and 2) For $1,000, could you stop yourself from engaging in your compulsion(s) over the next 24 hours? Most people would probably experience their obsession, but would find a way to avoid engaging in the compulsion(s). This exercise illustrates that while obsessions and compulsions often occur together, they are not technically tied to each other. We can experience obsessions and not engage in compulsions. Also, compulsions are much easier to control than obsessions. This is partially why ACT focuses on what one does and less so on what one thinks or feels.

People generally work to control obsessions and related anxiety because they are experienced as dangerous, threatening, uncomfortable, or some other “negative” evaluation. But there is another aspect to obsessions and anxiety that is overlooked—they are just thoughts in one’s head and are feelings that one experiences. Humans are constantly thinking and feeling, but most of the time we do not grab on to any of these events. ACT aims to teach us ways to experience obsessions and anxiety as just thoughts and feelings that we may or may not respond to. When obsessions and anxiety are experienced in this way, it is much easier to respond flexibly to these experiences.

The focus of ACT for OCD is to help clients get to a place where they can openly experience thoughts, feelings, or bodily sensations, not be overly impacted by them, and continue to move in directions in life that are meaningful. The benefit of this approach is that a reduction in obsessions and anxiety is not necessary to begin changing one’s actions. From the ACT point of view, the problem with OCD is not that obsessions and compulsions occur, but that every time an obsession occurs the compulsion follows. ACT aims to teach the flexibility to engage in an unlimited number of responses when the obsession is there. There is a way to keep working, play with the kids, eat dinner, talk with a friend, or engage in whatever the chosen activity is while experiencing the obsession. This involves experiencing obsessions for what they are (just words in one’s head, and words are not dangerous), making room for them as just another experience, and moving forward in directions that are meaningful while the obsessions are there. If this is practiced enough, eventually it becomes easy, and the precise thought or feeling that shows up does not interfere with one’s actions. There is a way to experience obsessions AND do what is important in life.

Is ACT for OCD Effective?

The effectiveness of ACT for OCD has recently been tested in a large trial funded through the National Institute of Mental Health (Twohig et al., 2010). In this study, eight one-hour sessions of ACT for OCD with no in-session ERP were compared to Progressive Muscle Relaxation (PMR) with assessments taken at pre-treatment, post-treatment, and at a three month follow-up. PMR was viewed as a control condition in this experiment, so most of this review will focus on the results for the ACT condition. In this study, 79 adults (41 in the ACT condition) diagnosed with OCD were treated. All types of OCD were included in this study (hoarding, primary obsessions, checking, cleaning, etc.) and there were very few exclusion criteria, thus hopefully representing a fairly realistic sample of participants. The treatment was found to be highly acceptable. Only 12% of the sample in the ACT condition refused or dropped out, which is quite low for OCD treatment trials. All participants in the ACT condition rated the treatment as a 4 or greater on a 5 point scale, with 5 being the most positive score. These findings are meaningful because low drop-out and high acceptability are difficult to achieve in the treatment of OCD. ACT was more effective than PMR in the treatment of OCD, with clinically significant change in OCD severity occurring more in the ACT condition than PMR using multiple criteria and including all participants, even those who dropped out (clinical response rates: ACT post=46-56% and ACT follow-up 46-66% vs. PMR post=13%-18% and PMR follow-up 16-18%). ACT also had a greater effect on depression and resulted in greater improvements in quality of life than PMR. These findings are in addition to previous smaller studies showing that ACT’s effectiveness for OCD (Twohig, Hayes, Mausda, 2006a), skin picking (Twohig, Hayes, Mausda, 2006a), and ACT plus habit reversal in the treatment of trichotillomania (hair pulling) (Twohig & Woods, 2004; Woods, Wetterneck, & Flessner, 2006).

Should I Look into ACT for OCD?

ACT for OCD is a newer treatment and the research is quite limited compared to the work that has been done on ERP and ERP with cognitive procedures (often referred to as CBT). ERP with or without cognitive procedures should be the first line of treatment someone seeks out. ACT procedures integrated into exposure therapy may be useful for people who are struggling with ERP. Finally, if exposure procedures are not useful, ACT may be considered as an alternative treatment. ACT is especially appropriate for people who have been unsuccessful at regulating or controlling obsessions and anxiety—especially after full trials of other treatments. It is also well-suited for people who are very tied into their obsessions and feel like they have very little control over their reactions to obsessions. There are a growing number of therapists who are trained in the use of ACT for OCD. If someone is interested in seeking out one of these therapists refer to the “Find an ACT Therapist” link at www.contextualpsychology.org.

References
Twohig, M. P., Hayes, S. C., & Masuda, A. (2006a). Increasing willingness to experience obsessions: Acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behavior Therapy, 37, 3-13.
Twohig, M. P., Hayes, S. C., & Masuda, A. (2006b). A preliminary investigation of acceptance and commitment therapy as a treatment for chronic skin picking. Behaviour Research and Therapy, 44, 1513-1522.
Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H. & Woidneck, M. R., (2010). A randomized clinical trial of acceptance and commitment therapy vs. progressive relaxation training for obsessive compulsive disorder. Under Review.
Twohig, M. P., & Woods, D. W. (2004). A preliminary investigation of acceptance and commitment therapy and habit reversal as a treatment of trichotillomania. Behavior Therapy, 35, 803-820.
Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy, 44, 639-656.