ACT for OCD: Case Conceptualization and Therapy Structure


Independent practice, Kate Morrison LLC, Sandy, Utah

Key Points

  1. The hexaflex model, which includes acceptance, defusion, contact with the present moment, self-as-context, values clarification, and committed action, is at the core of case conceptualization in ACT.
  2. Clinicians can use the ACT advisor to assess the client’s position within each process of the hexaflex, and to guide treatment according to the client’s needs.
  3. Eight to 10 sessions are needed to cover the basics of this treatment for OCD. However, that timeframe might be extended, depending on the client and their needs and progres

Case Conceptualization and the ACT Advisor

Jazmin: How do you conceptualize a case before starting the treatment?

Dr. Morrison: During the intake appointment, you start gathering the information that will help you understand the type of treatment that might be beneficial for the person. Also, from the framework you’re working on, you will pick up on certain pieces. And so I primarily work from exposure-based therapies as well as acceptance and commitment therapy.

For this client, where it seems we’re going in the direction of ACT, I’m holding in my mind the ACT hexaflex. It refers to the six processes of ACT. I want to know which ones are high or low, which helps me understand where we want to start with Anne.

The concept that stood out from Anne’s initial assessment is that she cares deeply about her daughter, family, relationships, and her life. So she’s strong on the values clarification side. Some of the hypotheses I have are that she’s probably lower on the processes of acceptance, defusion, present moment, and committed action. Anne knows what’s important to her, yet she gets caught up in her thoughts and emotions, which doesn’t enable her to engage in what’s important. So those are the areas I start practicing with Anne first to get her to experience her internal experiences differently.

The ACT Advisor is a handy tool, especially if you’re new to ACT, so you don’t have to rely on just holding this information in your head. Writing it out after an appointment and saying where I think they’re at on each of these processes can be helpful to guide you in treatment later.

ACT for OCD: Sessions and Skills

Jazmin: In the protocol for OCD, it’s established that you need approximately eight sessions for a client to improve their quality of life. However, how many sessions do you recommend for Anne?

Dr. Morrison: I start by describing to clients that what we know from the ACT for OCD research is that we need about eight to ten sessions to cover the basics of the treatment, but that we might go further than that depending on the person. I don’t set it as a rigid expectations at the beginning of treatment with a client, as it depends on how they respond to the treatment. I would expect eight to ten sessions for Anne initially, but then there might be some processes she needs to practice more, based on your assessment as the therapist. So it could take longer. My average I see clients is probably about 20 sessions, including maintenance appointments, like seeing each other once a month.

Jazmin: The general rule is to have eight to ten sessions, depending on how each client reacts to the treatment. And during this treatment, which therapeutic skills do you think are essential for your clients?

Dr. Morrison: My therapeutic style is very much ACT-consistent. The skills that I go toward, especially at the beginning of treatment with any client, are a lot of warmth, validation, and joining with the person. I don’t make them feel crazy for what they’re doing or thinking but help them see that it is logical, based on the amount of distress they’re experiencing and how the mind works.

I try to join with my clients as much as possible and help them see that I’m here to guide them. That I will help them get their lives back from OCD to the ones they are looking to have. And so I go strong on validation, warmth, and understanding.

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