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ACT for OCD: Behavior Tracking and the Self-Monitoring Form

By Kate Morrison, Ph.D.

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

Highlights

  • Monitor behaviors in different ways throughout treatment.
  • See what makes the most sense and what’s the most relevant for clients.
  • Track the way they respond to their thoughts and their internal experiences.
  • Use a self-monitoring form.
  • Talk about what behaviors feel the most important and track them by duration or frequency.

 

Transcript

We’re now going to walk through an example of how to do behavior tracking with this specific example that we just walked through. So, we’re going to talk about the same 41-year-old woman who has fears that she has unintentionally lied to someone and that would mean that she is an immoral person.

So, let’s talk about some of the different options for behavior tracking. So I mentioned that there are some different ways that you can go about this, depending on what you want to focus on with this client. And I talk about those openly with the client to let them know it is their choice of how they want to proceed in tracking through treatment because this is based on what’s most important to them to get out of treatment. So, you might know the answer to this question based on your intake with them or based on information that you’ve gathered so far.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

There might be some really concrete things that they’re looking to get out of treatment. And if that’s the case, you definitely want those to be things that are being tracked through treatment because you want to make sure that you’re meeting the goals that they came to see you for. But I will give them other options just so they know what options are available.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

Well, the options you can give to anyone, but I’ll walk through the examples with this person. You can simply track the way that they are responding to their thoughts, and that you can do through a self-monitoring form that was created for the ACT plus exposure and response prevention study that was done. And in that manual, there is a form that walks them through those exact steps and you would have them complete this each week.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And the intention with this is to just see how are they responding to the thoughts, and the urges, and the obsessions. This isn’t to say how often they’re having compulsions. It’s just to get more of an understanding of the process. So because this is not being used to actually gather frequency or duration of rituals or obsessions, you don’t have to have them fill this out every single time they have an obsession or every single time they do a compulsion. The idea is just to get a general sample that represents how they responded to their obsessions that week.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

So, on the form, it asks them to complete this as soon as possible after they have had an obsession, just to make it as accurate as possible. And I say this to clients, “We, as humans, are pretty terrible about reporting our own behavior accurately and reporting our own experience accurately. And so we just try to do our best. And in order for it to be as accurate as possible, fill this form out as soon as you can after it’s happened.”

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

“So, keep this form. If you’re going to use paper, have it printed off and sitting somewhere where you’re going to see it if you feel comfortable with that. You can track things on your phone and then transfer it to paper later. Or you can send it to me later.” Find some way that it’s just going to be easy for them to actually have it with them at all times.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

So, they’d fill out the date and the time. But then the next column is just what was the experience? What were your feelings, your thoughts, your bodily sensations while it was happening? So, for this person, it might be something like, “I was at work and I told my coworker that I had a nice weekend. And after I got done with that conversation, I wondered, ‘Did I actually have a nice weekend?’ I think I may have been inaccurate in telling them I had a nice weekend. Like the weekend was okay, but it wasn’t nice.”

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compul1sive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

So, I encourage clients to not put everything I just said into that column. I would instead say something like, “I worry that I lied to my coworker about my weekend being nice.”

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And then their feelings, and their thoughts, and their bodily sensations would be added in there. So feelings might be anxiety or fear. Some thoughts might be, “I think I lied to them.” Bodily sensations might be tension in their chest.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

The second column is what did you do in response to your feelings, thoughts, or bodily sensations? And so for this person, this might be something like, “I felt really uncomfortable with it,” “I was angry that I was feeling that way,” or, “I just felt really frustrated and tired because I don’t want to be dealing with this again, I don’t want to think about this.” It could be that they responded with, “Uh-oh. I might have lied. I really need to go make sure and take care of that. I need to go talk with them.” So, those are more internal responses.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

This can also be external responses where they say things or they do something like, go and talk with that coworker and clarify like, “Hey! You know, earlier I mentioned I had a nice weekend, but, you know, I don’t know if it was that great. It was—it felt so-so.”

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And so you want to coach them on how they can do both internal and external responses here because both are important.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And then, the next column asks what was the result of that response on the obsession and your life? So what it’s asking here is, did that behavior work out for you? Did it work out as far as how it impacted your life? And did it work out as far as how it impacted this obsession?

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And so, for this example, the person might say something like, “That was really embarrassing to go talk with my coworker because their response was, ‘Um. Okay. Yeah, that’s fine.’” And they gave you this funny look because it was something that probably didn’t need to be clarified. So the impact that had on your life is maybe some distancing from relationships that you have in your life and being ostracized from your coworkers for some odd behavior that happened there.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

The result on what that did internally for them might have been that they were really beating themselves up. They were feeling really frustrated. They felt more anxious. And that would be the response on the obsession.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

So, what I just walked through with you would be very similar to what I would walk through with a client. You actually want to go through an example with them so they can see what goes in what column and allow them the opportunity to respond to that and ask questions.

So that’s if you’re going to have them do the self-monitoring of obsessions and rituals form. And I’ll tell them I want them to fill this out at least once a day. You can pick something really small or something really big, but at least once a day, I assume there’s going to be something that comes up in your mind that I want you to respond to and pay attention to how you respond to it.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And as they go through treatment, you might start to notice things like them saying, “I had this really strong urge and I chose to stay open to it. And I noticed and I said hello to it. And then, I continued on with my day and kept on with my workday and it was great because I got to maintain that relationship with my coworker.” So, you might start to see a shift in this as treatment goes on, but that’s something that you can use in your sessions to attend to and can give you information on what to talk about in that session.
 
References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

You can also have them track behaviors that are relevant to them, and we can look at behaviors both that they want to increase or decrease. And behaviors that they want to decrease are often compulsions or avoidance behaviors.

It’s hard to track not avoiding. I’d much rather we focus on increasing approach behaviors because that’s something that they can actually do. So, when we think about behaviors they’d like to increase—and we’ll talk about this much more later about tying this to what’s important to them and what their values are.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

So, one way I might talk about this with this client is to say, “Okay, one of your goals is to not do so much online researching about what a lie is. So let’s have you practice decreasing that. And we’re going to have you track how much time you spend on online researching. And I also want to know how you’re spending that time when you’re not online researching. So, if you’re not doing that online researching, how would you spend your time?”

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And she might say something like, “I don’t know. I’ve always wanted to pick up knitting.” “Cool, so maybe we could also have you track the things that you do to work toward knitting.”

Or they might say, “I really wanted to go have dinner with a friend.”

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

Okay, so if we’re cutting out this time that you’ve described as just being very wasteful and really frustrating for you that you spend your time doing that, if we’re taking that out of there, let’s put something else in there that feels meaningful to you.

And you can spend some time talking with them about what those would be.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

And these behaviors that you track can change over time. It doesn’t have to be set in stone. But this is for a couple of reasons. As I mentioned before, this is meant to track how they’re doing in treatment and to give you information of if you need to adjust treatment, but it also really places priority on certain behaviors.

And so we’re not just looking to stop compulsions. We’re also looking for them to live a meaningful life. And so if you’re going to track behaviors, I also really want to recommend putting ones in there that they also want to increase so you can celebrate when these things increase as well.

References

Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Bluett, E. J., Reuman, L., Blakey, S. M., & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1–9.

Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual]. University of Nevada.

So, some key points here are that you can monitor their behavior in different ways throughout treatment. And you’ll want to discuss that with the client to see what makes the most sense to them and what’s the most relevant for them.

Some of your options are to track the way in which they respond to their thoughts and their internal experiences. And you can use a self-monitoring form to have them actually walk through this from week to week.

They can also track behaviors that are relevant to them. And these are ones that can be increasing or decreasing, but you definitely want to talk with them about what behaviors feel the most important to them. And then, you can have them track those by duration or frequency of these particular behaviors.

And for this client, some examples of how that could be tracked would be the frequency that they’re checking, the amount of time or the duration that they’re doing online research, and having them track behaviors they want to increase, things like spending more quality time with loved ones or starting knitting, for example.

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