The ACT for OCD Toolbox: A Guide for Therapists

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Behavioral Commitments in ACT for OCD

By Kate Morrison, Ph.D.

This presentation is an excerpt from the online courseThe ACT for OCD Toolbox: A Guide for Therapists“.

Highlights

  • Start behavioral commitments in session 3.
  • Behavioral commitments allow them to practice willingness and to align their behavior with their values.
  • Apply basic behavioral principles and strategies.
  • ERP practices are part of the behavioral commitments.
  • End session 3 with a clear plan for their behavioral commitments and willingness practice.

 

Transcript

Now, session 3 is where you will want to start planning for behavioral commitments, also just known as behavior goals.

These are to be completed between sessions. And you’ll want to do this each session, starting from session 3.

Behavioral commitments are done with a few intentions. One is to create opportunities to practice, specifically at this point, willingness, but also to practice other ACT processes that are introduced throughout treatment. Second would be to create patterns of behavior that align with their values.

References

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 ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual].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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

This is a place where you can use basic behavioral concepts that you may already know, such as setting goals that are attainable, letting the client choose their commitment—so don’t push any on them. And this is really something that can be focused when you’re discussing values as well as choosing the things that matter to them to change their behavior. You can encourage them to challenge themselves while helping them be realistic about what behaviors they can complete.

References

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 ACT for OCD: Abbreviated treatment manual [Unpublished treatment manual].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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

You can use baseline data from their tracking to know about where their behavior is at at this point. Then, if they’re trying to set a goal that is far beyond where their behavior currently is, then you may want to encourage them to adjust it to where they’re feeling very confident they can complete it but it’s still going to be challenging them.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

For example, if they never use a knife and set a goal to use a knife for 3 hours every day, it’s pretty unlikely to happen. It’s definitely possible—and you don’t want to discourage them if they are totally confident that they can do that—but you want to encourage them to set a goal where they have that 100% confidence they can complete it. You always want to set goals that are likely to happen rather than setting a goal that they can strive for but not meet in order to reduce any sort of shame or guilt that can come from not meeting those goals.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

You always want to be rewarding behavior as it occurs. And you want to make these goals as specific and measurable as possible. Instead of just saying, “Oh, I’m going to use a knife more this week,” you want to set a specific thing of “I will use a knife for 10 minutes 3 times this week,” because that’s when you can actually say, “Did you meet your goals or not?” And it makes it clearer for what their practice is actually going to be.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

You want to adjust the goal to match the level of practice that they are willing to do. So we’re not looking to have their willingness match the practice. Just adjust the goal that they have set so their willingness switch can be on during that whole practice. They say, “I can do this practice for 10 minutes and be willing during that entire 10 minutes.” But if they’re thinking 20 minutes would be a really hard time to stay willing and open to that distress, then adjust that goal. You don’t need them to be practicing something that feels unattainable to them at this point.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

And then, you can gradually increase the level of difficulty as the client successfully completes their goals. This is a thing that you will track through treatment with them and have them report back to you at each session to see how they’re doing with these. And if they’re not hitting the mark that they want to, then you can adjust the goals to match where they’re at and then slowly increase difficulty in order to get them to engage in behaviors that they are wanting to.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

You can focus on reinforcing desired behaviors, so tying it to their values, congratulating them on their progress rather than punishing unwanted behaviors. And this is just basic behavioral principles. It’s going to be much more likely that the behavior is going to occur if it has reinforcing qualities to it.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

Then identify any barriers to completing these goals. If they’re like, “You know, I just keep forgetting to do that,” or, “It’s really hard for me to remember the things that I need to get done,” or, “I just don’t know if I have enough time in the day,” you really want to just talk about how you can adjust their environment to make it more likely.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

So, setting alarms for their reminders. Putting a Post-it note on their mirror that they are going to see every morning or something next to their toothbrush. Really stacking the things that they want to be doing with other things that are already happening in their day and seeing where they can carve out time, if they can ask their partner to watch their kids for 30 minutes while they do this practice. Really setting them up for success so they can fit these practices in.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

As discussed in the ACT for OCD Manual done by Dr. Michael Twohig, one of the quotes in there about these practices that I found to be helpful is that these exercises provide very useful information for the following sessions. They’re likely to experience difficulties with the obsession between sessions, and this can be used as material for treatment the next week.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

You get to learn about how they’re interacting with their thoughts and their emotions, and what is difficult for them when they attempt to change these behaviors, and how they respond to that. It’s full of information. As they’re practicing these things, they’re going to run into the issues that they’ve been running into prior to treatment, but now they’re going to be able to talk about them in a different way and share them with you, so you know what things need to be/what processes need to be targeted in future appointments.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

As we will discuss in future videos, when ACT is added to exposure therapies, exposures and the associated response prevention are considered part of their behavioral commitments. And this can be added into treatment starting at session 3.

So, exposures are when you are having the person purposely face something that they fear or some sort of cue that is likely to bring up their obsession. And the response prevention piece is reducing compulsions associated with that practice.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

This can be where you can set goals around those particular practices, if they are allowed to do any sort of compulsions or if you have them not do any at all. And this can be part of the behavioral commitments that you set each session.

And repeated practice of these behaviors can result in larger patterns of effective action. And so, specifically to OCD and OC spectrum disorders, there are these particular behavior-change procedures. And these are going to be most likely in the form of behavioral commitments.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

Some examples of behavioral commitments, specifically for OCD, are if you were to set a goal of no more than 10 hand washes per day, or no more than 5 minutes to write and send an email to your boss, or to give your child a hug, or you can limit checking before leaving the house to 30 minutes.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

Or to ride public transportation, or to attend a church service, or to tell a friend a story without adding any qualifiers, like “sort of,” “kind of,” or “maybe”—specifically for someone who might have fears about being untruthful or lying.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

You really are just going to match these to the client and what they want to work on. And I really recommend having these match the things that are most important to them and that they are willing to do. So, if not washing their hands as many times a day is not that important to them, but being able to give their child a hug is extremely important, then maybe start there. Giving their child a hug might be a more difficult practice for them, but if their willingness is going to be higher because that is so important to them, let’s have them choose that.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

But really let them decide how they’re going to do this and what’s most important for them to tackle first because you want to follow where their motivation lies and where the importance of being in treatment lies for them.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

At the end of session 3, you are going to set a clear plan for their behavioral commitments as part of their home practice. And then, you also want to set a plan to practice willingness during these commitments based on the metaphors or the exercises they’ve chosen or that you did in session.

References

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

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.

Twohig, M. P., Morrison, K. L., & Bluett, E. J. (2014). Acceptance and commitment therapy for obsessive compulsive disorder and obsessive compulsive spectrum disorders: A review. Current Psychiatry Reviews, 10(4), 296–307.

Key points for this are that session 3 is where you start behavioral commitments. And behavioral commitments or goals are actions the client can take that will, one, allow them to practice willingness among other ACT concepts in the future and, two, align their behavior with their values.

Basic behavioral principles and strategies apply here. So, if you have a solid understanding of basic behavioral principles already, this is the place where you’re going to apply those strategies.

When adding ACT to exposure and response prevention, specifically the ERP practices, are part of the behavioral commitments. And that will be discussed more in future videos. And then, you end session 3 with a clear plan of action for their behavioral commitments and how they will practice willingness during these.

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