Demystifying ACT: A Practical Guide for Therapists

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Why ACT for OCD

By Kate Morrison, Ph.D.

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

Highlights

  • ACT is an empirically supported treatment for OCD based on RFT and rule-governed behavior.
  • ACT focuses on challenging problematic ways that we respond to internal experiences to increase behaviors aligned with one’s values.
  • Psychological flexibility is the name of the target of treatment in ACT.

 

Transcript

So now, we’re going to talk about acceptance and commitment therapy, also known as ACT.

It is an empirically based psychological intervention that has been showing quite a bit of promise in the treatment of OCD across the lifespan. So, it’s with adults, adolescents, and pediatric OCD. So instead of focusing on changing the internal experiences, specifically obsessions or anxiety, what ACT does is it focuses on the way that we interact with those internal experiences and how that impacts our behavior. So, we focus on changing the behavior with the intention of a person increasing their quality of life.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

ACT as a mindfulness and acceptance behavioral treatment. And in ACT, there are multiple processes. So, some of those are acceptance, values, and mindfulness. And these are used with the intention to foster willingness to experience difficult unwanted internal experiences.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

So these, for OCD, would be obsessions, urges, and the anxiety that comes along with that. And the goal is to see them as they are and to act in a way that’s consistent with their particular values.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

So, ACT draws heavily on the use of metaphors and this has specific intentions with the roots of ACT, being that we’re looking to connect the person’s internal experience with something that will represent that experience for them so they’re able to look at what they’re experiencing in a different way and to have less emotion and less rigid rules tied to their experience.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

And metaphors can actually, as some may say, surprisingly be a good fit for youth in that in adolescence, it’s a developmental period where it’s marked by values exploration and an increased capacity for abstract thinking, and find that these can be helpful, in particular, for youth. Although in doing treatment with youth, we try to make the concepts as concrete as possible as well for them to be able to understand it.

References

Armstrong, A. B., Morrison, K. L., & Twohig, M. P. (2013). A preliminary investigation of acceptance and commitment therapy for adolescent obsessive-compulsive disorder. Journal of Cognitive Psychotherapy, 27(2), 175–190.

ACT is based on a philosophical framework referred to as functional contextualism. And there is a basic behavioral science that underlies ACT. And this is called relational frame theory and rule-governed behavior. And relational frame theory is a basic behavioral account of language and cognition.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

Within this philosophy and these theories that guide ACT, the attention is placed on the context of a behavior and of the person and of the organism and the function of psychological events rather than the content or the form or the frequency of the psychological events.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

So, for example, attention is given to how one responds to their obsession and to the impact the obsession has on their behavior and their quality of life. So that would be the context rather than the legitimacy of their obsessions, which is the content. So, for example, if someone is having the thought if the person is gay and they’re questioning if they are heterosexual and they are wondering if that is the case, when working with that person using ACT, you would not explore that specific thought with them, more about the legitimacy of it.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

You would talk more about how having that thought how that impacts them, what emotional response do they have to it, how they respond internally when that thought comes up. And so, this shift in treatment of what we focus on in ACT is really important here.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

The main goal of ACT is to increase psychological flexibility. And this is the willingness to experience the present moment as it is, disentangled from internal experiences, in order to engage in value-driven actions that are unencumbered by these uncomfortable internal experiences.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

Responding rigidly to internal experiences is referred to as psychological inflexibility. And this can be problematic because it restricts behavior and it also restricts opportunity for rewards and reinforcement from the external environment, which, as you might imagine, would result in someone’s lower quality of life.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

Alternatively, the ability to flexibly attend to and interact to the things that we’re experiencing internally can allow our actions to be based on what’s important to us and can increase how flexible we are with our behavior. And so, within this model, psychological inflexibility is really the thing that we’re looking to adjust to create more flexibility. And it’s present in other forms of clinical issues, but we’re just going to be focusing on OCD today.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

So, for example, what happens with an OCD is when there is a particular fear—so, let’s say someone has a fear that they may stab their parents and so that belief that comes up into their mind is, “Oh no. I see a knife. I could stab my parents.”

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

A rigid response to that is that thought means that I will do this, that thought means I’m a bad person. That is terrifying. I need to get rid of that thought. I need to shove it down. I need to not be thinking that. That’s not okay. I need to not be around knives because if I have that thought when I’m next to this knife, I’m definitely going to follow through with that. And it brings up a lot of distress for them.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

And so, we’re looking to expand those because we want them to be able to interact with their parents, for them to be able to cook a meal with a knife.

And so, we’re having them expand their behavior and become more flexible there. But the flexibility also refers to how they’re responding to that thought and being able to have more options to how they can respond in that moment.

References

Bluett, E. J., Homan, K. J., Morrison, K. L., Levin, M. E., & Twohig, M. P. (2014). Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review. Journal of Anxiety Disorders, 28(6), 612–624. 

Now, let’s go over the key points of this particular video.

So, acceptance and commitment therapy, which is also referred to as ACT, is an empirically supported treatment for OCD and it is based on the basic behavioral science of language and cognition, in particular, RFT, or relational frame theory, and rule-governed behavior.

ACT focuses on challenging problematic ways that we respond to internal experiences in order to increase behaviors that are aligned with one’s values. So, the behaviors are guided by the person’s values and how they want to be living their life rather than the internal experiences they’re having, like obsessions.

Psychological flexibility is the name of the target of treatment in ACT and this is characterized by being present with the moment as it is, fully open to and disentangled from their internal experiences, and engaging in behavioral patterns that are consistent with a meaningful and value-driven life.

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