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ACT for OCD: Deciding on a Course of Treatment

By Kate Morrison, Ph.D.

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

Highlights

  • ERP is recommended as the first course of behavioral treatment for OCD.
  • For clients who don’t respond to ERP, ACT is an empirically based option for OCD treatment.

 

Transcript

When you have a client come into your office that is presenting with symptoms of OCD, you’re initially going to need to decide on the best course of treatment for them.

And while we’re talking about ACT today, I wanted to talk a little bit about exposure and response prevention. And the reason for that is that exposure and response prevention is the gold standard treatment for OCD and this is with and without medication, typically SSRIs.

So, if you are working with someone that has not had a quality course of ERP, I recommend starting them with that because it just has much more data behind it than ACT does currently.

References

American Psychiatric Association. (2006). American psychiatric association practice guidelines for the treatment of psychiatric disorders: Compendium 2006.

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.

As I mentioned before, the III-31 questionnaire can be helpful in deciding a course of treatment.
In a study where ERP alone was compared to ACT plus ERP, what Ong and colleagues found is that those that had III scores that fell in the low range responded better to ERP. When their scores were in the moderate to high range, they responded the same to both treatments. So, this is one piece of data, but it might be a useful piece of information and is the reason I recommend giving the III at intake so it can help you make the decision of what might be a better treatment course for the individual.

References

American Psychiatric Association. (2006). American psychiatric association practice guidelines for the treatment of psychiatric disorders: Compendium 2006.

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.

There are certain situations when to consider ACT for OCD.

First, it’s just good to know that there is a growing body of evidence that suggests ACT is useful and effective at treating OCD—and this is with and without explicit exposures. In the study I just mentioned, when ACT was combined with ERP compared to ERP alone, there was an equal effect of the treatments.

When ACT is done alone, it’s also found to be effective. It has been studied in comparison to active treatments as well. So ACT certainly has evidence. It just doesn’t have as much as ERP does at this point.

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., 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 versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.

So, when to consider ACT is when someone has had a quality course of ERP and they had insufficient results. It happens. ERP doesn’t work for everyone and so this is a great option for those individuals.
 
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., 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 versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.

Clients may also be unwilling to do exposures as they are presented in ERP. Exposures are, understandably, a terrifying thing to do, to be asking someone to do the thing that they fear the most. And so some clients may not be interested in that.

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., 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 versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.

ACT can be a nice way to truly get to a similar goal because you’re going to ask them to do things that are difficult, but how it’s presented initially might be less terrifying for them. In clients that have a tendency toward acceptance and mindfulness principles already and use these principles in other areas of their life, ACT might be a better fit for them than how treatment is presented in ERP.

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., 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 versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.

ACT has a briefer course of treatment. So ACT alone is about eight to ten 45- to 60-minute sessions that occur weekly. An ERP can be about 16 sessions and that’s once or twice a week for 90-minute sessions. Just another option to consider is that ACT can be done in a shorter period of time 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., 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 versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.

But ultimately, you’re going to want to have a collaborative and open discussion with your clients about the evidence base for these treatments and assist them in deciding what fits best for them.

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., 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 versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.

Looking at the key points on how to decide treatment, know that exposure and response prevention, or ERP, is recommended as the first course of behavioral treatment for OCD. And this is with and without medication, usually SSRIs. But for those that don’t respond to ERP or choose not to do ERP, ACT is an empirically based option for OCD treatment.

More ACT for OCD presentations