Acceptance and Commitment Therapy (ACT) for OCD

OCD & Co.

Nov 23

Written By Turning Point Psychological Services

Photo by: ESB Professional / shutterstock.com

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

Viktor E. Frankl

What is Acceptance and Commitment Therapy (ACT)?

ACT is a type of behavioral therapy that is becoming increasingly popular in the treatment of OCD, and there is a good reason for it. It is so easy to get entangled in endless obsessions and compulsions and to lose sight of what really matters to you. With ACT, you don’t have to delay living the life you want to live until your OCD gets better. ACT provides the compass that allows you to start taking steps toward being the person you want to be right away.

Life isn’t easy. It is full of emotional and physical pain, disappointments, rejections, failures, and losses. And as if these painful experiences were not enough, our minds tend to constantly ruminate about the past, worry about the future, beat us up for our mistakes, warn us about all kinds of real and imaginary dangers, and discourage us from taking healthy risks.

Our minds throw all kinds of unwanted, intrusive thoughts at us and at times, these thoughts become very sticky. They pull us away from the present moment and into our heads.

According to ACT, our difficult thoughts and feelings are not inherently problematic. But when we let our mind’s constant warnings and admonishments hook us, we often neglect doing what’s important and instead, go for quick fixes to get rid of discomfort and pain. This may help in the short-term but leads to moving away from what truly matters to us in the long run.

When we take what our minds tell us too seriously, we tend to take one of the following destructive approaches:

1. We become consumed by our thoughts or emotions and engage with them by ruminating, arguing with them, or wasting time trying to figure out why we are having these thoughts or feelings and what they mean.

2. We try to get rid of our thoughts or emotions by implementing all kinds of thought-stopping techniques, using mind-numbing substances or food, distracting ourselves, or avoiding triggering situations or people.

If the above strategies are our main ways of reacting to difficult thoughts, then we live most of our lives vacillating between autopilot and avoidance modes and miss out on what matters most – the present.

Unfortunately, all this accomplishes is signaling to our minds that these thoughts and emotions are “important” and “significant,” and our minds then “helpfully” generate more of them.

This is especially true if you have OCD. The more you try to get rid of unwanted inner experiences (thoughts, images, emotions, physical sensations, urges, or memories), the more they persist. You then increase your efforts to control the unwanted thoughts and feelings. But control is the problem, not the solution, and the more you engage in the struggle, the more you get sucked into the quicksand of your internal experiences.

To help you get out of this endless struggle, ACT promotes developing psychological flexibility, whose core processes can be summarized as:

1. Being present in the moment.

2. Opening up to whichever thoughts and feelings come up without trying to fight them.

3. Doing what matters to you and taking steps toward being the kind of person you would like to be.

“The more you try to get rid of unwanted inner experiences..., the more they persist. You then increase your efforts to control [them]. But control is the problem, not the solution, and the more you engage in the struggle, the more you get sucked into the quicksand of your internal experiences. ”

With psychological flexibility, you lean into your discomfort with self-compassion and curiosity. You stop running away. This opens up a road toward the freedom to choose what kind of person you want to be in the moment.

When OCD has a grip on you, you react in a psychologically rigid way, which means that you have a very narrow range of responses to your obsessions – that is, you respond with either compulsions or avoidance. Responding flexibly, on the other hand, involves doing whatever you choose to do while making room for the obsession without engaging with it. When you respond to your thoughts and feelings flexibly, you notice them, allow them to be there, and continue taking steps towards whatever matters to you without resorting to compulsions.

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ACT emphasizes that we don’t have control over our internal experiences, including obsessions (which are basically just garden-variety thoughts even though you have learned to perceive them as scary or disturbing). We do, however, have control over our actions. Therefore, the most workable approach is to let the obsessions come and go at their own time instead of wasting time and energy doing compulsions.

ACT teaches us a very different way of being in the world. Instead of white-knuckling through life, it helps us move toward what is meaningful to us. It is a very empowering approach that allows us to do what matters without being consumed by whichever feelings and thoughts may show up.

Instead of spending our days in between avoidance and autopilot modes and trying to mindlessly chase endless tasks and goals (many of them meaningless to us), ACT helps us move strategically toward what is really important with intention and purpose.

To summarize, ACT will help you:

- Learn to make room for your emotions and thoughts.

- Choose what truly matters to you.

- Take steps toward being the person you want to be and living the life you want to live while being strongly rooted in the present moment.

“And what if my compulsions stand in my way to this?” you may ask. Great question as your OCD will certainly attempt to sabotage your progress. Thankfully, ACT is a very practical, action-oriented therapy approach (that’s why it’s so aptly abbreviated as “act”). It will provide numerous practical skills to help you handle your obsessions and compulsions.

ACT vs ERP

You probably heard that the most effective treatment for OCD is ERP. So how does ACT fit into the treatment and how is it different from ERP?

ERP (Exposure with Response Prevention) is a specialised CBT approach that teaches people with OCD to face scary stimuli (external or internal) while refraining from performing compulsions.

ACT is, by itself, an exposure therapy. As stated above, its main foundation is the ability to experience difficult thoughts and feelings without doing anything to get rid of them or letting them consume us, and instead, to flexibly choose to take value-driven actions toward our goals.

One of the most important components of ACT is the willingness to experience uncomfortable internal experience and moving in the direction of our values.

So, in this way, ACT and ERP have a lot of similarity as both promote exposure.

One of the differences between ACT and ERP is that ACT approaches exposure as a way of taking steps toward the life that is full of purpose. So instead of just “tolerating” the scary thought or object and waiting for the distress to subside, an ACT therapist will encourage you to identify your values, establish value-driven goals, and take steps toward those goals regardless of what thoughts or feelings are showing up.

That is, ACT is an exposure therapy, but provides a much more fulfilling way to do exposure. You are taking steps to being the best version of yourself instead of just learning to endure your anxiety. You discover that you may feel anxious and still do the things that are important to you. Instead of doing the hard stuff for the sake of “getting rid of OCD,” you work toward something bigger, something that is deeply important to you. This makes your therapy work so much more meaningful and increases motivation to work hard toward recovery.

While many ERP therapists track anxiety levels while doing exposure (they use SUDS – Subjective Units of Distress as a measurement), ACT therapists do not view anxiety levels as important and don’t track them. After all, anxiety, like every other emotion, comes and goes in its own time and we don’t have control over it. If anything, tracking your anxiety just brings more of your attention to it and makes you feel it’s important, sending your mind and body a message to produce more of it. Instead, ACT therapists may track things like willingness to experience whichever feelings show up and doing what is important. They may also track how effectively you were able to unhook from your intrusive thoughts, or how you are progressing toward your value-guided goals. This allows you to drop the struggle, to get out of the tug of war with OCD and to focus on what matters.

In addition to never trying to encourage you to get rid of anxiety, an ACT therapist may actually encourage you to see your anxiety as helpful. We experience strongest emotions about the things we care about. And an ACT therapist will urge you to look which yearnings –-things that matter the most to you -- may be underneath your anxiety. These insights will help you channel your anxiety or other emotions in the right direction.

Exposure exercises in ERP are often driven by a certain topic and by the severity of anxiety (low to high). In ACT, however, the exposures are driven by what stands in your way of being the person you want to be and living the life you want to live. ACT helps people to be more motivated and engaged when practicing exposure.

Can OCD be treated with ACT only - without ERP?

First of all, who is asking this question – you or your OCD?

Usually, behind this question is the desperate attempt to avoid facing your fears in ERP. Also, behind it is the assumption that your fears are different, special, unusual, impossible-to-control, realistic, shameful -- and that for you ERP won’t work. So, you are on a mission to find a treatment that is less scary. You may be secretly hoping for a treatment that will allow you to get away with continuing doing compulsions. You may have already tried all kinds of alternative therapies, anxiety-reduction techniques, self-help books, positive thinking, or trying to find that one charmed compulsion that would get rid of the obsessions once and for all.

This quest to find a magic way to get rid of difficult emotions is the essence of OCD and the only way to get over OCD is to accept that it’s impossible to get rid of your emotions forever, no matter how much you compulse.

There is a lot of overlap between ACT and ERP. ACT without ERP, when done by a therapist with an in-depth understanding of OCD treatment, is very effective in the treatment of OCD.

It is important to note, however, that it is crucial that the ACT therapist is indeed an expert in the treatment of OCD and has substantial knowledge about cognitive and behavioral principles in general, as well as the patterns that are specific for OCD. Usually, such therapist will have a very good knowledge of and experience with ERP. Such therapist, naturally, will use ACT as a way to practice exposures. When a therapist does not have a solid understanding of OCD’s sneaky ways, he or she may erroneously view rumination (a compulsion) as an involuntary thinking process, thus, confusing an compulsion with an obsession and creating wrong interventions. Or, such a therapist may miss numerous subtle mental compulsions that are so typical for most OCD types.

When ACT is combined with ERP, the treatment is the most effective as it incorporates building a strong ACT-driven foundation and motivation for the treatment with focused ERP techniques. After learning ACT principals, people usually have a better understanding of how ERP works and what its purpose is (and no, its purpose is NOT to get rid of anxiety or obsessions. Its purpose is to learn to make space for your anxiety and instead of letting it push you around, do what matters to you without relying on compulsions to alleviate your distress. It’s not about learning to “tolerate” anxiety either. It’s about radically changing your relationship with anxiety, distress, fear, disgust, and other emotions and thoughts, as well as about willingness to do what’s important to you regardless of your emotions).

In fact, if a therapist has a great understanding of OCD, then whether he or she provides an ERP treatment or ACT treatment, these treatments will be equally effective and will actually look very similar. In both approaches, the goal is to create and strengthen new learning pathways that compete with the previously learned pathways of fear.

So the answer is: Yes, you can treat OCD with ACT if your therapist is an OCD specialist (as opposed to being a “generalist”).

And the second part of the answer is: You will still need to face your fears, anxiety, uncertainty, “not right” feeling, discomfort, disgust, or whichever painful emotions currently compel you to do you compulsions. You will need to face the uncertainty of whether the thing you fear the most may happen. And incorporating specific ERP exercises into the treatment will make the treatment faster and more successful.

ACT vs CBT

CBT (Cognitive Behavioural Therapy) consists of the cognitive and behaviour parts of the treatment. While the behavioural part of CBT is very similar to both ERP and ACT, there are significant differences in the cognitive part.

Both ACT and CBT address changing your thinking.

CBT does it through strategies such as challenging negative automatic thoughts, addressing cognitive distortions, and changing “unhelpful” thoughts to more “rational” ones.

ACT therapists, on the other hand, would rarely encourage you to dispute your thoughts in any way. They will work on changing your relationship with your thoughts by learning to observe them, effectively unhook from them, and increase your flexibility of responses to the thoughts. In ACT, the content of a thought is not that important. What is important is how helpful would it be for you if you would allow that thought to guide your actions.

This distinction is especially crucial in the treatment of OCD. In OCD, the content of the thoughts is never the real problem. It’s the engagement with the thoughts, taking them seriously, being afraid of the thoughts – in other words, the process of being hooked by the thoughts is the driving force behind OCD. So, disputing the thoughts is just another compulsion.

ACT, therefore, is the therapy that allows you to step out of your struggle and break free from being a prisoner of your thoughts, rather than engaging in endless debates with them.

Have you tried Acceptance and Commitment Therapy for OCD? Are you considering trying it? Please share your thoughts and experience in the comments below.

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Anna Prudovski is a Psychologist and the Clinical Director of Turning Point Psychological Services. She has a special interest in treating anxiety disorders and OCD, as well as working with parents.

Anna lives with her husband and children in Vaughan, Ontario. When she is not treating patients, supervising clinicians, teaching CBT, and attending professional workshops, Anna enjoys practicing yoga, going on hikes with her family, traveling, studying Ayurveda, and spending time with friends. Her favorite pastime is reading.

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