1. Similarities between CBT and ACT
Incorporating ACT in Traditional Group CBT for OCD
Challenges and Possibilities
Ruth Aharoni (Msc.), Kirsten Stengaard Møller (Msc.), Elsebeth Steno Hansen (MD. Phd.)
Psychiatric Center Copenhagen, The Anxiety and OCD unit.
   Abstract
In our clinical practice we have applied ACT in traditional CBT Group Therapy for OCD outpatients in Psychiatric Center Copenhagen. Quantitative data of treatment effect is presented. Based on our findings, we have conducted a further hermeneutic, narrative discussion of our experiences with incorporating ACT into traditional CBT. We discuss the similarities and differences between ACT and CBT concepts as creating possibilities as well as difficulties in incorporating ACT in CBT. In this discussion we focus on the use of ACT techniques when working with rumination and worry. We elaborate on aspects of ACT which are related to preventing rumination and worry.
Background
This is a retrospective naturalistic study based on our work with 10 groups, each consisting of 6-8 patients. Patients participating in therapy in our clinic are psychiatric outpatients with OCD symptoms ranging from medium to severe OCD (YBOCS >16). The sample included 27 women and 17 men. Participants were not controlled for co-morbidities, medication, sex, or dropout rates, since this study is naturalistic and hermeneutic in nature. Since data was gathered post-hoc and not systematically we have only data for 66.6% of the patients participating in therapy.
Method
We compared Y-BOCS scores before and after treatment. The same manual has been used for all groups. Therapy was based on traditional CBT for OCD and included an assessment session, an individual session with a case formulation, 14 group sessions of 2.5 hours and an individual follow up session.
Combining ACT and CBT:
In order to combine two apparently different therapies we structured our CBT/ACT manual, with elements from both therapies that we found essential so that therapy was grounded i CBT treatment. We incorporated ACT techniques that we found relevant, efficient and in line with existing tradition.
1. Therapy started with traditional CBT, in which the patients got to know their personal history by working with the cognitive model, Assumptions and Core Beliefs with Old and New system (Salkowskis et al., 1998; Mooney & Padesky, 2000; Fennell, 2009)
2. Metacognition/ACT: with the personal historical information in mind, we went on to work with Theory A and theory B (Salkowskis & Bass, 1997). From here we started viewing cognitions overall as ruminations and worries, without restructuring them any further. In this process we used the concept of defusion to explain the differences between being hijacked by ones emotions and being able to observe them and oneself, and in this way seeing oneself as context (Hayes, 2005; Harris, 2007).
3. During exposure we had focus on both CBT and ACT aspects: New system and new assumptions and core beliefs (CBT), being present in the moment and using mindfulness (ACT), Accepting all thoughts, emotions and body sensations (ACT), with the exposure done in line with the patients values and goals (found in the individual session prior to group) (ACT and CBT) (Greenberger & Padesky, 1995; Salkowskis et al., 1998; Hayes, 2005; Kabat-Zinn, 1994).
Results
μ1=24
μ2=15
Our results are compatible to Y-BOCS reduction in the general litteraature:
CBT for severe OCD (Rodrigues et al., 2011: Belotto-Silva, 2012: Hougaard, 2011)
Mindfulnes for OCD (Hale et al., 2012)
Significance between Y-BOCS scores (n=44) before and after treatment using dependent t test for paired samples:
66% had a reduction of more than 25% in Y-BOCS score
56% had an end Y-BOCS <16
μdif
σdif t p
8.65 6
9.45
<0.001
Discussion
What are the challenges?
During our work we often wondered if ACT and CBT are two essentially different forms of therapy, or if the difference is merely linguistic. We believe that the slightly different view of human nature that is represented in the two therapy forms dictates a different therapeutic focus for treatment: While CBT focuses on relief from unpleasant symptoms, ACT stresses accepting whatever unpleasant thoughts, feelings or body-sensations one might have in order to be able to live a vital life. As therapists we often had dilemmas about which point of view to adopt in a given situation, and which intervention was needed in a given situation. We experienced that while an ACT intervention was often focused on accept and allowing emotional pain, a CBT intervention was often focused on coping and on perusing emotional relief. In general, we experience that ACT stresses living in the moment, even when the moment is unpleasant, while CBT tries to strengthen the patients coping strategies, so that the moment becomes less unpleasant.
Another challenge we experienced was that when working with ACT, the focus are mostly on processes and metacognitions whereas when working with CBT the focus are often on content and the relationship between thoughts, feelings, behaviour and bodily experiences. With rumination, the dilemma was often whether to spend time on cognitive restructuring, assessing probabilities of worries and exploring coping strategies, or to spend time on distracting away from the process of rumination, and engaging the patients in meaningful actions, which were relevant to their life goals and values and helped them be more present at the moment rather than engaged in their thoughts.
Effectiveness of ACT in relation to rumination and worry
Traditional restructuring of worries can be an endless negotiation and we found that it was more effective to use a metacognitve approach by elevating awareness to the process of rumination and letting go of it. Letting go of worries and shifting attention away from them was done by choosing to act according to ones goals and values in a mindful way, and by being mindful of ones actions at the present moment while accepting and allowing emotional pain. We experienced that being more mindful of ones goals and of the present moment, helped our patients achieve greater peace of mind and greater focus under exposure. This helped them to experience themselves as “normal” and capable of living a vital life in their everyday. Finally, accepting emotional pain and acting despite it, took the ‘wind out of the sails’ of rumination – especially when rumination was used as a coping strategy to relief emotional pain.
Similarities between CBT and ACT
CBT
ACT
Goals
Values
Systematically working with values was more motivating for our patients
Theory A vs. Theory B
Defusion, self as context
Distraction techniques, attention regulation techniques, relaxation
Mindfulness
Meaningful existential context
Response prevention
Accept and willingness
Elevated patients commitment to change
Conclusion
Easier to implement ACT strategies in traditional CBT than predicted
Semantic differences between the two approaches were important and beneficial to the patients
Focus on the present moment and personal values created a more meaningful existential context for the CBT techniques
Metacognitive aspects were more time efficient than cognitive restructuring of worries
Time spent on response prevention and exposure was the same
Satisfying reduction in Y-BOCS scores and treatment effect. Compatible with other studies