Demystifying ACT: A Practical Guide for Therapists

Learn how to apply ACT principles in your everyday practice.  Earn 5 CE/CME credits.

ACT for OCD: Assessing Treatment Progress

By Kate Morrison, Ph.D.

This video is part of our upcoming online course about ACT for OCD.

Highlights

  • Behavior tracking and self-report measures are used to assess treatment progress.
  • Assess the quantity of compulsions, valued living, and psychological flexibility.
  • The gold standard of OCD severity measures are the Y-BOCS or the CY-BOCS.

 

Transcript

Let’s talk now about how to measure progress in treatment. There are several options on how to do this.

To monitor treatment progress, you can use patient self-report measures. And these are important to integrate into your clinical practice. So these are the ones that I recommend starting from the beginning, but also, depending on the measure, you’re going to want to be using these throughout treatment to see if the treatment that you’re doing is effective and not to just be basing it off of your perception and your client’s perception. So you want to have some more objective ways to determine if they’re making progress.

References

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499.

One of the best ways to do this, within ACT and with OCD, is through behavior tracking. So at the beginning of treatment, you’re going to want to specify with your client what are the most important behaviors that you want to be tracking. Most likely, these are going to be falling into 2 categories.

References

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499.

The first category would be the frequency and the duration of problematic behaviors. And so the problematic behaviors in OCD are often compulsions or avoidance. But we’ll address avoidance in the other one.

References

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499.

So compulsions, we want to know how often they’re happening and at what duration. So you don’t want to just know that someone is washing their hands 20 times a day. You also want to know how long they’re washing their hands because as you start to reduce the frequency of handwashing, if there were 20 hand washes a day and they were washing for 5 minutes apiece, and then they’re like, “Great, I’m down to 5 washes a day,” but now they’re doing their handwashing for 30 minutes for those 5 hand washes, you’re not actually making progress there.

References

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499.

The other thing that you want to be attending to and tracking within the behavior tracking is increasing useful and healthy behaviors. And so these are things like, specifically for ACT, when someone is engaging in valued behaviors. So you also want to specify with them, “What does OCD get in the way of? What are the things that you want to be able to do at the end of treatment that you don’t feel like you’re able to do right now?”
 
References

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499.

And set that out for them at the beginning so you can be tracking this, again, to see if the treatment that you’re using is effective and if you’re getting to the end goal that they’re looking for in treatment.
 
References

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499.

The other way or the other thing that you’re going to want to assess is psychological flexibility. As we mentioned, this is the mechanism of change in ACT.

References

Ong, C. W., Blakey, S. M., Smith, B. M., Morrison, K. L., Bluett, E. J., Abramowitz, J. S., & Twohig, M. P. (2020). Moderators and processes of change in traditional exposure and response prevention (ERP) versus acceptance and commitment therapy-informed ERP for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 24, 100499.

And the most common way to measure this is through a self-report questionnaire and the most common one is the Acceptance and Action Questionnaire-II, so the second version of this. And there are also disorder- or symptom-specific versions of the AAQ and specifically there is one for OCD called the AAQ-OC. If you’re working with youth, you can have parents fill out the Parental AAQ and then for youth, there is the Avoidance and Fusion Questionnaire for Youth. All of these will be targeting psychological flexibility.

References

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. 

Cheron, D. M., Ehrenreich, J. T., & Pincus, D. B. (2009). Assessment of parental experiential avoidance in a clinical sample of children with anxiety disorders. Child Psychiatry and Human Development, 40, 383–403. 

Jacoby, R. J., Abramowitz, J. S., Buchholz, J., Reuman, L., & Blakey, S. M. (2018). Experiential avoidance in the context of obsessions: Development and validation of the Acceptance and Action Questionnaire for obsessions and compulsions. Journal of Obsessive-Compulsive and Related Disorders, 19, 34–43.

Now, the next measure I’m going to mention is not an ACT-specific measure, but I think it still can be useful and this is called the Interpretation of Intrusions Inventory-31. This is a measure that is commonly used within OCD, but not as much within ACT. However, this measure can be used at the intake to assist in deciding if ERP, exposure and response prevention, might be a better fit. And this is based on findings by Ong and colleagues recently, or in 2019, that I will discuss a little bit later in more detail in deciding how to go through treatment.

References

Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of the obsessive beliefs questionnaire and the interpretation of intrusions inventory: Part I. (2003). Behaviour Research and Therapy, 41(8), 863–878.

You’re also going to want to have a measure of OCD severity. The most common one is called the Yale-Brown Obsessive Compulsive Scale or the Y-BOCS. There is also a child or a youth version for this called the CY-BOCS. And these can be administered via self-report or therapist administered.

References

Cheron, D. M., Ehrenreich, J. T., & Pincus, D. B. (2009). Assessment of parental experiential avoidance in a clinical sample of children with anxiety disorders. Child Psychiatry and Human Development, 40, 383–403. 

Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. 

Jacoby, R. J., Abramowitz, J. S., Buchholz, J., Reuman, L., & Blakey, S. M. (2018). Experiential avoidance in the context of obsessions: Development and validation of the Acceptance and Action Questionnaire for obsessions and compulsions. Journal of Obsessive-Compulsive and Related Disorders, 19, 34–43. 

In my clinical practice, I do self-report and the reason for that is that, while the therapist-administered versions are really useful because you are there to walk them through what is an obsession and what might be just another worry and not particularly an obsession, it’s really time consuming. And so it’s great for research settings, but in a clinical practice, I am not able to fit that into my practice or I just don’t think it’s the best use of the client’s time and resources. So I have them fill out the self-report.
 
References

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. 

Cheron, D. M., Ehrenreich, J. T., & Pincus, D. B. (2009). Assessment of parental experiential avoidance in a clinical sample of children with anxiety disorders. Child Psychiatry and Human Development, 40, 383–403. 

Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102.

Now, this measure is not entirely consistent with the ACT framework. For example, one of the questions asks how often they’re having obsessions, where in ACT, I’m not really concerned about how often their obsessions are occurring. But I still recommend having this measure in there if you’re working with clients that have OCD.

References

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. 

Cheron, D. M., Ehrenreich, J. T., & Pincus, D. B. (2009). Assessment of parental experiential avoidance in a clinical sample of children with anxiety disorders. Child Psychiatry and Human Development, 40, 383–403. 

Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. 

The other reason it’s important is we do also see changes in the Y-BOCS when people have gone through treatment using ACT, and so you’re still going to see some changes there. You also might need to track outcomes as part of the clinic or the healthcare system requirements that your facility has. And clients are going to want to see progress. And so some of the symptoms on there are consistent with ACT, but just be aware that not all of them are.

References

Cheron, D. M., Ehrenreich, J. T., & Pincus, D. B. (2009). Assessment of parental experiential avoidance in a clinical sample of children with anxiety disorders. Child Psychiatry and Human Development, 40, 383–403. 

Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. 

Jacoby, R. J., Abramowitz, J. S., Buchholz, J., Reuman, L., & Blakey, S. M. (2018). Experiential avoidance in the context of obsessions: Development and validation of the Acceptance and Action Questionnaire for obsessions and compulsions. Journal of Obsessive-Compulsive and Related Disorders, 19, 34–43. 

And the reason for that is that this is the gold standard measure of OCD. And if you are going to be interacting with other professionals and needing to share any information about this client’s progress, they’re going to want to see the person’s Y-BOCS scores.

References

Cheron, D. M., Ehrenreich, J. T., & Pincus, D. B. (2009). Assessment of parental experiential avoidance in a clinical sample of children with anxiety disorders. Child Psychiatry and Human Development, 40, 383–403. 

Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. 

Jacoby, R. J., Abramowitz, J. S., Buchholz, J., Reuman, L., & Blakey, S. M. (2018). Experiential avoidance in the context of obsessions: Development and validation of the Acceptance and Action Questionnaire for obsessions and compulsions. Journal of Obsessive-Compulsive and Related Disorders, 19, 34–43. 

And then you’re also going to want to assess quality of life. So, you’re already going to be having them track behaviors that are important to them but you can also have self-report measures that assess quality of life. And the examples or the ones that I use are the Valued Living Questionnaire, the second version, and the Quality of Life Inventory.

References

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., Waltz, T., & Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688. 

Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood and adolescence: Development and evaluation of the Avoidance and Fusion Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. 

Let’s look back on the key points from how we assess progress. So, behavior tracking and self-report measures are used to assess progress in treatment. I recommend measures that assess the quantity of compulsions, valued living, and psychological flexibility.

And while the gold standard of OCD severity measure, the Y-BOCS or the CY-BOCS, is partially inconsistent with ACT framework, it still can be useful to use. And I still recommend including it within your practice.

More ACT for OCD presentations