The Integration of ACT and ERP Michael Twohig Utah State University Jonathan Abramowitz University of North Carolina at Chapel Hill

Plan for the session Jon: ERP Mike: ACT and exposure Jon: How he has used ACT Mike: ditto Time for case example and discussion

Learning Theory View of OCD Obsessional stimuli evoke fear, anxiety, or distress Compulsions produce an immediate reduction in obsessional anxiety Compulsions are negatively reinforced by the immediate reduction of anxiety they engender The performance of compulsions prevents the natural extinction of obsessional anxiety

Evidence for the Learning Model // BE - Before exposure to anxiety-evoking stimulus AE - After exposure AC - After compulsion Rachman, de Silva, & Roper, 1976

Behavioral Techniques for OCD are Derived from the Learning Model Procedures that evoke obsessional anxiety Exposure to obsessional cues (floors, driving) Procedures that eliminate the contingency between performing compulsions and anxiety reduction Response prevention (refrain from washing or checking rituals)

Cognitive Model of OCD Obsessions Intrusive unpleasant thoughts are universal A thought about stabbing my child at dinner “Obsessive beliefs” lead to misinterpretation of normal intrusions as anxiety-provoking “Only bad people have bad thoughts” “I am a bad person for thinking about this” Rachman, 1997; Salkovskis, 1999

Cognitive Model of OCD Compulsions Rituals and avoidance reduce obsessional fear Avoidance of child, keep knives locked up Asking for reassurances, checking, repetitive praying Avoidance and rituals prevent the correction of obsessive beliefs and misinterpretations Rachman, 1997; Salkovskis, 1999

“Obsessive” Beliefs 3 domains of beliefs found to underlie the misinterpretations of intrusions and development of OC symptoms Overestimates of threat and responsibility Importance of thoughts (need to control thoughts) Perfectionism and intolerance of uncertainty Obsessive Compulsive Cognitions Working Group (2001, 2003, 2005)

Relationship Between Obsessive Beliefs and OC Symptoms * *Grps 3 & 4 > grps 1 & 2 (p < .05). Abramowitz et al. (2006) Beh Res Ther

Cognitive Therapy for OCD is Derived from the Cognitive Model Psychoeducation Intrusive unpleasant thoughts are universal How do avoidance and rituals maintain obsessions Cognitive restructuring Identify and modify mistaken beliefs about intrusive thoughts Behavioral experiments Test out new beliefs about obsessional thoughts

CBT for OCD Includes: Situational Exposure: Prolonged confrontation with anxiety evoking stimuli (e.g., contact with contamination Imaginal Exposure: Prolonged imaginal confrontation with feared disasters (e.g., hitting a pedestrian while driving)

CBT for OCD Includes: Response Prevention: Resisting compulsive urges (e.g., leaving the kitchen without checking the stove) Cognitive procedures: Psychoeducation and discussions of mistaken cognitions

Typical CBT Program for OCD Education and treatment planning Exposure to fear cues Reduction of rituals (Response prevention) Cognitive restructuring to augment ERP Self-monitoring of rituals

Education and Planning Goal: Helps therapist to understand patient’s OCD symptoms and helps patients understand the nature and treatment of their symptoms Thorough assessment of individual obsessional triggers, cognitions, rituals, and avoidance Discussion of the model and rationale for CBT Self-monitoring of rituals Exposure hierarchy development

Cognitive Restructuring Goal: Teach patients how to think accurately about feared thoughts and other stimuli so they will only be as afraid as the facts warrant 1. Identify a specific dysfunctional belief that produces obsessional fear (e.g., thinking about harming someone is as bad as actually harming) 2. Examine the evidence for the accuracy of the cognition 3. Revise the belief based on the evidence 4. Reinforce the new cognition with behavioral evidence (exposure and RP)

Cognitive Restructuring Patients do not have to be 100% convinced in the senselessness of their beliefs for cognitive restructuring to be helpful Criterion for success: Patients doubt the accuracy of their assumptions about obsessional thoughts/stimuli enough to be willing to face their fears through exposure

Exposure and Response Prevention Goal: Experientially test the accuracy of anxious predictions, such as: Disastrous consequences will occur upon exposure without rituals Intrusive thoughts are intolerable and must be avoided Anxiety is unbearable and will last forever Uncertainty is intolerable Practice confronting obsessional thoughts and feared stimuli in a planned, gradual, systematic manner using a hierarchy Reduce the use of safety behaviors (response prevention) Emphasis on just experiencing anxiety and obsessive thoughts/doubts without resistance until habituation Anxiety is regularly recorded on a 0-100 scale and practices last until anxiety goes down (50%?)

Exposure and Response Prevention OCD symptoms are reduced when patients come to believe that (a) their obsessional thoughts are meaningless, (b) they can cope with anxiety, which is not dangerous, (c) they can cope with uncertainty, and (d) the act accordingly (i.e., approaching, not fighting, obs. fear) Simply talking about uncertainty, anxiety, and probabilities of harm is not as convincing as direct evidence from experience Patients need to directly confront their fears to truly master them ERP is the most powerful part of the intervention

Types of Exposure In vivo exposure - confronting feared stimuli in the environment Imaginal exposure - confronting feared mental stimuli such as thoughts, images, impulses, worries, and memories Like watching a scary movie 100 times over

Effects of Repeated and Prolonged Exposure

ACT and how it might be incorporated with ERP for OCD 6. Leads to broad research program 5. ACT involves targeting these constructs 4. Target hypothetical constructs: Psychological flexibility 3. Relational Frame Theory 2. Basic Science: Mostly behavior analysis 1. Philosophy of science: Functional contextualism

1. Philosophy of science: Functional contextualism Holistic and functional approach to analysis Pragmatic truth criterion

2. Basic Science: Mostly behavior analysis Extinction involves new leaning and not unlearning spontaneous recovery (passage of time) disinhibition (presentation of a novel stimulus) reinstatement (presentation of the US or reinforcer) renewal (a change in context) resurgence (new behavior introduced during extinction places on extinction) “optimizing learning …. based on increasing tolerance for fear and anxiety” (Arch & Craske, 2009)

3. Relational Frame Theory Most active lines of research in behavior analysis Stimuli have meaning and function This includes private stimuli Learned from experience and “verbally” The meaning and function are controlled by different contexts

4. Target hypothetical constructs: Psychological flexibility

5. ACT involves targeting these constructs Can be done within exposure exercises Procedure Contacting feared stimuli And/or engaging in valued activities While practicing ACT concepts Process of change Psychological flexibility Desired outcome Greater life functioning Change in internal experience not a concern

6. Leads to broad research program Active research at each of these levels But we will just focus on it as applied in this area

ACT alone for adult OCD YBOCS scores Twohig et al. (2010). Journal of Clinical and Consulting Psychology

% treatment responders

Refusal, drop-out, and acceptability

RCT of CBT vs ACT heterogeneous anxiety disorders Arch et al. (in press). JCCP available online

RCT of CBT vs ACT heterogeneous anxiety disorders Arch et al. (in press). JCCP available online

RCT of CBT vs ACT heterogeneous anxiety disorders Arch et al. (in press). JCCP available online

RCT of CBT vs ACT heterogeneous anxiety disorders Arch et al. (2012). BRAT

Moderation “CBT outperformed ACT among those at moderate levels of baseline anxiety sensitivity, and among those with no comorbid mood disorder.” “ACT outperformed CBT among those with comorbid mood disorders.” Wolitzky-Taylor etal. (2012) JCCP

How we use ACT and ERP

My Feelings about ACT I am an exposure therapist I like ACT! I think ACT overlaps about 75% with the goals and techniques of exposure-based CBT I think exposure therapists can incorporate ACT techniques to enhance ERP Adherence? Reduce dropout? Outcome?

Exposure and ACT: My Take on the Similarities and Differences What’s similar Importance of experiencing/confronting unwanted obsessional thoughts, anxiety, and doubt/uncertainty Importance giving up rituals and other forms of subjective resistance to obsessional thoughts/fear

Exposure and ACT: My Take on the Similarities and Differences What’s different How OCD is explained to the patient How outcome is measured: increasing willingness vs. reducing anxiety Use of metaphors to introduce conceptual issues and rationale for treatment Emphasis on values

How do I Incorporate ACT into my Work with OCD Patients How do I Incorporate ACT into my Work with OCD Patients? (“What have I learned from Mike?”) More explicit discussion of willingness to stay in contact with OCD internal experiences (thoughts, anxiety, uncertainty) Two scales metaphor Use of metaphors to explain the core problems in OCD and the rationale for ERP Man in the Hole Passengers on the Bus Bum at the Door etc.

Mike: ACT and exposure therapy ERP is a well-researched, effective, and theory-driven treatment ACT and ERP can be consistent But does not make it the same ERP is more than just bringing someone into contact with feared stimulus What is learned during this event is important We can influence that Focus on process of change

I think ACT adds a new how to help people contact feared stimuli Spend 4 sessions teaching psychological flexibility Psychological Flexibility

Things worth thinking about What is being taught What your and the client’s goals are How treatment success is defined

When might this be used Ethically ERP is the way to go Component studies and recent trials suggest ACT + ERP also makes sense Might look at Treatment failure Refusal Noncompliance Lack of motivation High obsession levels “Sticky thoughts”