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

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

3. 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

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

5. 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)

6. 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

7. 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

8. “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)

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

10. 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

11. 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)

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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 scale and practices last until anxiety goes down (50%?)

18. 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

19. 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

20. Effects of Repeated and Prolonged Exposure

21. 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

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

23. 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)

24. 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

25. 4. Target hypothetical constructs: Psychological flexibility

26. 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

27. 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

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

29. % treatment responders

30. Refusal, drop-out, and acceptability

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

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

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

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

35. 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

36. How we use ACT and ERP

37. 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?

38. 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

39. 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

40. 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.

41. 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

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

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

44. 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”