Question 1

How and how well does ACT work for people with OCD?

Patricia Zurita Ona · Accepted Answer

Multiple studies have shown the effectiveness of ACT + ERP for OCD; so ACT + ERP does work as equally as ERP alone; it just happens the "why's" and "how's" of doing exposures is quite different.

Here is a summary of the research: https://www.actbeyondocd.com/research-on-act-for-adults-with-ocd/

Question 2

How does ACT conceptualise the symptoms experienced with OCD?

Patricia Zurita Ona · Accepted Answer

From an ACT point of view you can conceptualize OCD as:

- Fusion with obsessions, weird thoughts, intrusive thoughts
- Fusion with rule-governed behaviorsRule: I have to do my compulsion. 
(Rule: I have to talk back to my obsessions or arguing with your stuck thoughts
Rule: I need to know (uncertainty).
- Avoidance of emotions - fear, anxiety, off feelings - associated with obsessions
- Unworkable behaviors: compulsions - mental and physical - and avoidant behaviors
- Short-term of unworkable behaviors: reduction of anxiety, fear, and related emotions
- Long-term of unworkable behaviors: disconnection from values-based living

Question 3

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 4

Does ACT target compulsions?

Patricia Zurita Ona · Accepted Answer

Great question! Absolutely yes!

When working with teens I use the choice point as a way to help them to remember a skill they already have, but may have forgotten to use: their ability to choose how to live their life,
how to handle those defiant OCD episodes, and how to deal with all types of fearful and uncomfortable situations that will come along their way.

With adults I talk about the shift from reactive moves (compulsions + avoidance) to WISE MOVES.

I think in general, whether that's working with children, teens, and adults dealing with compulsions it's important to help them to notice that when experiencing obsessions, worries, fears, and anxieties they can learn and choose how to respond to do uncomfortable experiences.

As they learn about their values, the natural qualities of their mind, how the OCD episodes look like and their impact in their life, the impact of their compulsions in their life, they also learn how to handle those overwhelming moments when dealing with urges to do a compulsion.

They practice in general to notice the urge to do a compulsion, check how they want to show up in those moments of struggle, check what matters to them, and choose their actions. It's like they're answering the question of: how do I want to show up to this moment of hurt?

Here is a list of the most common forms of mental compulsions a person engages when dealing with OCD: https://www.actbeyondocd.com/types-of-mental-compulsions/

Question 5

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)

Question 6

How does ACT aim to help alter the way in which a person experiences obsessions?

Patricia Zurita Ona · Accepted Answer

The frontline treatment for  OCD, anxiety, and related conditions is exposure.
ACT by nature is an exposure treatment and within this framework, we still practice targeted exposures for stimuli that narrow a person's life.

Within ACT you still help a person to get in contact with aversive stimuli in the context of their values while practicing ACT skills/processes (Contextualizing learning)

You guide clients to learn to flexibly respond to public and private experiences

The focus of ACT when dealing with OCD is on behavioral flexibility - not on anxiety reduction - 
So instead of using Subjects Units of Distress Scale (SUDS) you want to track psychological flexibility, such as the degree of acceptance or avoidance; the degree of fusion or defusion; the degree of presence/engagement; the degree of control over actions; the degree of connection with values.

Question 7

What is meant by "commitment" in ACT for OCD?

Patricia Zurita Ona · Accepted Answer

ACT starts by helping you figure out the stuff you care about (values) as a starting
point and then "commit" (commitment) to take steps towards living those values while learning to have all the uncomfortable private experiences that show up your way as you take those steps (acceptance)

For example, let's say that your personal value is “being caring with animals”. From there, you learn skills to handle the obsessions that pop up in your mind, face fearful situations when it matters to you, and take specific actions without shrinking your life by doing compulsions or avoidance behaviors. 
All with the intention of helping you do the things you care about and live life to the full.

Question 8

How can a person with OCD live a fulfilling life without changing the severity and frequency of obsessions or anxiety?

Patricia Zurita Ona · Accepted Answer

Great question!
No treatment or therapy can make obsession go away for every; obsessions, intrusive thoughts, and unwanted thoughts are a normal phenomenon that happens to all of us. It just happens that some people have more biological vulnerabilities  - overreactive brain, genetics -

Now, what happens with ACT is that, when people learn to flexible respond to the obsession that show up their way,  decrease their compulsions, increase their values-based activities, then as a by product some people experience their obsessions as more manageable.

I also would like to clarify that because OCD is can have a very heterogenous presentation ( different types/forms of obsessions and compulsions), some people will require both pharmacological treatment + therapy as the combo to get unstuck from OCD and live a fulfilling life.

Question 9

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 10

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 11

How do you best utilize the ACT hexaflex and/or are there useful metaphors you prefer, from you experience, when working with Obsessive thoughts related to suicidal ideation? Thanks!

Patricia Zurita Ona · Accepted Answer

I don't use the word hexaflex in my work with clients; I use the hexaflex to formulate and conceptualize cases but not during treatment. I usually mention skills such as acceptance, unhooking, taking values-based steps or stepping back.

I think my go-to metaphors/experiential exercises are:

Referring to the mind as a content-generating, pattern-making and meaning-making machine that is constantly coming up with content, creating patterns of thinking, and generating meaning about everything and anything we do.

referring to delusion as ways of unhooking from unworkable thoughts

Practicing basic yoga postures to find our balance as a metaphor to find our choice point in every single thing we do, especially when dealing with fears, worries, anxieties and obsessions.

Using the choice point to map every single values-based exposure exercise

Referring to the shift from reactive moves onto WISE MOVES when approaching exposure exercises

Besides the above experiential exercises/metaphors I practice regular defusion exercises: singing obsessions, writing them down, watching them in action, physicalizing them, and so on.  But all of that is after I have created a context of change at the beginning of treatment and on the front end.  By context of change I mean, being clear with my clients why we're doing exposures, their values, the impact of OCD episodes in their lives, the unworkability of compulsions and avoidance, the different ruling-thoughts they're hooked on, and so on.

Question 12

How to help a client who is in a relationship and has persistent thoughts of finding other people more attractive than the current partner and these thoughts lead to questioning the current relationship.

Patricia Zurita Ona · Accepted Answer

You're describing relationship OCD. Here are my suggestions:

I would suggest to help the client to distinguish the obsession from the compulsion.

What's the obsession and what's the core fear: What's the worst thing that could happen if this person finds another person more attractive? What would happen if this person doesn't question this current relationship?

Separating the obsession from the compulsion is important to teach ACT skills and facilitate exposure exercises that focus on that core fear.

Here are a couple of resources to look at:

About the different types of OCD: https://www.actbeyondocd.com/types-of-ocd/

About mental compulsions: https://www.actbeyondocd.com/types-of-mental-compulsions/

A book to read: Living beyond OCD

Question 13

I understand ACT aims to help find a way to allow obsessions to come and go; however, how might ACT help when obsessive thoughts are stuck and seem to be there all the time?

Patricia Zurita Ona · Accepted Answer

Great question; many times when people hear about ACT, acceptance skills and the idea of letting obsession coming and going, they related to this skills as another tool, skills that have to solve the obsessions problem.

In my clinical work I have found that there is a significant difference in treatment when clients have have experiential exercises, conversations around their values, ruling-thoughts about anxiety, obsessions and basically creating a frame of change before doing any exposure work or practicing acceptance skills. Otherwise it's easy to use acceptance, delusion or any other act process as a technique, control strategy and as a solution to the obsession - problem.

So, I think it's fundamental to discuss with clients up front the reasons for exposure work, ways in which obsessions are driving problematic behavior, costs of all of the problem-solving strategies they're doing (compulsions and avoidance) before introducing any process/skill .

Question 14

How many weeks of treatment are typically required when using ACT for obsessive-compulsive disorder?

Patricia Zurita Ona · Accepted Answer

There is not specific number of sessions required in particular; most research has been conducted in 16-sessions. In there I usually ask my clients to commit to 20-sessions to start.

Question 15

What techniques in Acceptance and Commitment Therapy assist with reducing the self-judgment that surrounds an OCD episode?

Patricia Zurita Ona · Accepted Answer

Given that the content of some obsessions can be related to issues of morality/immorality, aggression, sexuality, some people may experience more intense feelings of shame in regard to those obsessions than others. So there are a couple of considerations:

- Normalize that obsessions are unwanted thoughts that a person "HAS" versus thoughts that define the character of a person.
- Identify the non-good enough stories a person is struggling with because of OCD and that are related to shame (e.g. I'm broken, I'm unlovable, etc); then look at the workability of them
- Normalize the protective functions of the mind as a content-generating and pattern-making machine or old protector we have; not as a device that has the truth of who we are.
- Facilitate acceptance-based exercises towards the feelings/sensations/ related to shame
- Identify shame-related behaviors and look at the workability of them: do they enrich a person's life or they keep a person stuck?

Question 16

At what point during Acceptance and Commitment Therapy for obsessive-compulsive disorder would you expect to see a change in psychological flexibility, and do you use a specific measure for this?

Patricia Zurita Ona · Accepted Answer

That's a great question; it really depends of each client, levels of avoidance, degrees of fusion they have with obsessions. I think, when doing traditional exposures, clients may related quickly to the mechanics of exposures; when teaching ACT + ERP skills it may take a different pace because clients are deconstructing problem-solving skills but once they get them, it's incredible to witness the shifts they make for a long run. I think a key advantage of blending ACT + ERP is that clients learn to relate to their minds in a different way, and face fears as they come in their life - outside of treatment. I usually use the Y-BOCS, AAQ, and AAQ-OCD  (acceptance and action questionnaire for OCD; you can look at it here www.actbeyondocd.com)

Question 17

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 18

What is the reason to use ACT in anxiety instead of CBT?

Patricia Zurita Ona · Accepted Answer

CBT - in particular exposure-based interventions have shown to be as effective as ACT for anxiety, OCD, and related conditions.  While both treatments work, more than thinking of them "in opposition of each other" I would invite you to consider "what works for whom."  Some clients may respond positively to traditional CBT treatments, exposure work based on the habituation model; but one-size doesn't fit all, and ACT can be an alternative.

At the same time, ACT emphasizes a more values-based and process-based approach to exposure interventions that it can also be a starting point for treatment from the beginning for some clients.

In my clinical experience delivering ACT services, I noticed that my clients develop a flexible response to their fears, worries, anxieties, and obsessions that go beyond treatment; they also are much more engaged in treatment because every exposure, session, intervention is always within the context of their values.

Question 19

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 20

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 21

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 22

Can Obessive Compulsive Disorder be cured without going to a therapist?

Patricia Zurita Ona · Accepted Answer

A person struggling with OCD can benefit from self-direct programs and workbooks; there are currently some studies looking at the effectiveness of ACT self-directed programs. In some cases certainly, professional help is necessary.

Question 23

Can you treat Obessive Compulsive Disorder with no medication?

Patricia Zurita Ona · Accepted Answer

In some cases, considering the impact of OCD, we can start the treatment without medication; if after 6-8 weeks, there is no shift it will be helpful to consider medication. In other cases, clients experience such a high level of arousal - physiological vulnerability - that it will important to start the treatment simultaneously with pharmacological treatment.

Question 24

How do people get Obsessive Compulsive Disorder?

Patricia Zurita Ona · Accepted Answer

There are three possibilities:
(1) having brain chemistry imbalances and genetic predisposition
(2) observing others
(3) having OCD-related associations.

(1) HAVING BRAIN CHEMISTRY IMBALANCES AND GENETIC PREDISPOSITION TO ANXIETY
There are different held views of brain chemistry imbalances and genetics when looking at the causes of OCD: (1) there is a long-held view that OCD is caused by deficiencies in serotonin and dopamine, which are chemical messengers in the brain; (2) a second view posits that OCD is genetically transmitted; and (3) a final view suggests that a person suffering with OCD has a different brain structure. However, despite the popularity of all these explanations, scientists and researchers have not fully supported any of them up to this point, but at least now you’re familiar with them.

Some families are more “predisposed” to having anxiety, but that doesn’t necessarily mean that if your grandmother was anxious, you will develop OCD. It just means that in some families there is genetic susceptibility to develop anxiety.

(2) WATCHING OTHERS STRUGGLING WITH OCD
It’s conceivable that people show OCD behaviors after observing others displaying some compulsions or avoidance behaviors. While this is possible, this hypothesis does not explain the extent to which some people struggle with OCD while others are able to manage their obsessions, suggesting that observing or living with others struggling with OCD may not be the sole cause of it.

(3) MAKING CONNECTIONS BETWEEN AN OBSESSION AND FEAR-BASED RESPONSES
It’s also possible that in a given moment a person's brain came up with an awful intrusive image that came along with tons of fear, dread, and panic; and the brain quickly made a connection between that “unwanted obsession” and fear-based reactions.

Question 25

What does it feel like to have Obessive Compulsive Disorder?

Patricia Zurita Ona · Accepted Answer

I can speak about the direct experience of a person experiencing OCD; however, the way I describe it is that dealing with obsessions is similar to having your fingers inside an electrical outlet for hours; your body is in shock, you cannot let it go of the obsession and it's hard to do the next thing.

Question 26

Does general anxiety disorder have to have a trigger?

Patricia Zurita Ona · Accepted Answer

Most anxiety disorders have a trigger; in the case of generalized anxiety disorder,  chronic worry, the tricky part is that the triggers are internal. A person can be walking and there is a what-if thought about money, finances, work, and so on. It just happens that it happens so quickly and it's such an automatic process to experience a worry-thought and then going into rumination.

ACT for OCD, Panic, Anxiety, Fears and Worries

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