Question 1

1. What are the core processes to focus on?
2. How does ACT compare to ERP research wise?
3. Is there a specific type of client profile that benefits more from ACT that from ERP?

Patricia Zurita Ona · Accepted Answer

Great questions; here are my responses:
1. All processes within ACT - hexaflex - are interrelated so I think every ACT therapist will have different style. For me, when working with OCD and anxiety,  I focus a lot on acceptance + defusion (acceptance-based processes) and values & committed action (change processes)

2. There have been many studies showing the efficacy of act for anxiety and two large studies comparing head-to head ACT+ Exposure and ERP alone conducted; they both have shown similar results in post-data and follow up data. 
You can find some references here: 
for OCD and anxiety in general: https://www.utahact.com/dr-twohigs-publications.html
for OCD only: https://www.actbeyondocd.com/research-on-act-for-adults-with-ocd/

3. To my knowledge, research has not answered that question. Here is what I can say: 
A person that has been recently diagnosed with OCD or anxiety can benefit right away from ACT treatment
A person that didn't respond to traditional ERP could benefit from ACT.

Question 2

Is there a particular book that you recommend I can work through with clients - I see an OCD ACT workbook and one for teens...just wondering if you find this helpful between sessions.

Patricia Zurita Ona · Accepted Answer

I use the workbooks as a companion to my sessions; my clients read the workbook on their own and I answer any questions they may have. During sessions we practice values-based exposure exercises, create a weekly plan for exposures-on-the-fly and agree on chapters from the workbook they will read.

I also wrote a workbook for adults: https://www.amazon.com/Living-Beyond-Acceptance-Commitment-Therapy-dp-0367178478/dp/0367178478/ref=mt_other?_encoding=UTF8&me=&qid=1609565157

Question 3

When someone has somatic OCD and their compulsions are around breathing what do you use as an anchor during mindfulness?

Patricia Zurita Ona · Accepted Answer

After mapping the OCD episodes, after a person is clear of their values, and distinguishes the obsession from compulsions, I find it helpful to teach clients the skills of stepping back, acknowledging that obsessions and the urge that comes with them.

If they feel very overwhelmed with the obsessions and those urges, they can choose how to handle them by connecting with their body and connecting with their surroundings. Basically, If the emotion’s intensity increases, they can use their body to (1) ground themselves and (2) reconnect with the outside.

To ground themselves, a person can balance their body from one side to another, take slow deep breaths, or practice any other form of physical movement.

To reconnect with their surroundings, a person can use their senses to describe what’s happening outside of them, e.g., describe to themselves a smell and notice how it feels inhaling it; describe the shape of an object, describe a sound, and so on.

It's important to clarify to clients that connecting with their body and connecting with their surroundings won’t make the distressing emotion go away but it will help them to navigate through those overwhelming moments more effectively and without sinking.

And lastly, remind clients that they may have to repeat these steps multiple times in a giving moment.

Question 4

Question 5

I found that teenagers hide their irrational thoughts. I try to normalize them, but find it hard to gain their trust. Do you have any advice?

Patricia Zurita Ona · Accepted Answer

From an ACT point of view, in addition to appreciating a person's thoughts - including irrational ones, it's important to practice and teach functional thinking:

If I have to summarize how to develop functional thinking, I would say that involves micro-skills of

- separating workable from unworkable thoughts 
- recognizing workability as the stuff that works 
- distinguishing how a thought looks from how it works

So questions like, when having that particular "X thought" what do you do, how does it work, and does it take you far away or close to the stuff that matters to you?

Finally, just to clarify within ACT you won't find much written about looking at thoughts are irrational or not, since we're looking at thinking, all types of them, as natural activities of our mind.

Question 6

Question 7

Does this work as well with people who suffer from scrupulosity who have a difficult time trusting that the therapist isn't doing the work of the devil?

Patricia Zurita Ona · Accepted Answer

There are all types of content a person can be fused with when dealing with OCD, such as fears of causing harm to others by accident, fears of attracting bad thing happening to others, fears of passing bad energy to others. Thought-action fusion can take different forms: thought action fusion, event fusion, and object fusion: e.g. thinking about killing someone with my car by accident will make me do it;  thinking of a car accident means that it will be happen; I could pass this negative feeling into this object.

So, my approach is to teach functional thinking and practice functional thinking across treatment including the relationship to the therapist.

I would ask questions like: When this doubtful thought of your therapist shows up, what do you do with it? Is that helpful to you in the long run? Does it help you? what's the impact of it on your life? What happens to our work when we get hook on that thought?

My clients dealing with pedophile obsessions, scrupulous obsession, harm obsessions had had a harder time sharing these obsession because of shame and thought-action beliefs about them; so at the beginning of treatment we looked at the workability of those acting on those thoughts in our work

Question 8

Hi Dr. Z,

I am loving your ACT book for teens with OCD. I’m wondering how you present creative hopelessness to teens with OCD. It can be so powerful for clients to move away from the agenda of controlling feelings, but of course, OCD and adolescence can complicate this idea. Thank you!

Patricia Zurita Ona · Accepted Answer

Thank you for your consideration of the ACT workbook for teens and hope it's helpful in your work!

In regard to your question, I don't talk explicitly about creative hopelessness with the teens. I use the Choice Point as a way to map how a teen is responding to their obsessions, strategies that are doing (compulsions + avoidance) that keep them hook, consequences of those strategies in their life (school, friendships).

I use the choice point in every single exposure session, so I'm constantly helping teens to build the skill of noticing what happens when they get hooked on obsessions and the outcome of compulsions and avoidant behaviors in the short and long-term; so, as you can see 'creative hopelessness" happens throughout every single exposure session and not as a one-time thing.

hope that helps!

Question 9

Hi Dr. Z. I am a therapist in Nebraska where there are no other ACT-based therapists. My training has been through Steven Hayes/Russ Harris video trainings and books. I want to be a client of an ACT therapist to experience ACT from the perspective of my clients. Can you or one of your students help?

Patricia Zurita Ona · Accepted Answer

Hi thanks for reaching out. I would recommend check the  https://www.contextualscience.org website and see if you can connect with other ACT therapists. Also, there is a Facebook group ACT made simple where you can post to find other colleagues. 
hope that helps. Cheers, Dr. Z.

Question 10

What's the difference between CBT, ERP and ACT for Obessive Compulsive Disorder?

Patricia Zurita Ona · Accepted Answer

ACT, is a form of cognitive behavior therapy.

ACT by nature is an exposure treatment because it invites all of us to get in touch with those uncomfortable experiences - thoughts, feelings, sensations, urges - when doing what matters.

ACT also incorporates target exposures when needed; what's different is the way in which ACT delivers exposures (always in the services of values), what you track (psychological processes from the hexaflex) and what's the purpose (improvement of quality of life)

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