Not All Exposures Are Created Equally
Using Acceptance and Commitment Therapy-based ERPs for OCD
Posted March 4, 2018
Exposure and response prevention is a psychological intervention for Obsessive-Compulsive Disorder that involves exposing the patient directly to the feared stimuli which triggers obsessional thinking and resultant unwanted experiences (exposure) and resisting efforts to control or eliminate those unwanted experiences (response prevention). It has been used in treatment of OCD and related anxiety disorders, as well as PTSD, since the late 1980s and overwhelming empirical evidence indicates it is highly effective in reducing OCD symptoms (Craske, et al., 2014; Craske & Mystkowski, 2006; Abramowitz, Foa, & Franklin, 2003). ERP is one of the only psychological, in contrast with pharmacological, interventions which is considered to be the standard of care when treating a psychiatric illness.
The goal of ERP from an Acceptance and Commitment Therapy (ACT, a type of 3rd-wave Cognitive Behavior Therapy) perspective is a reduction in behavioral compulsions, not any reduction in internal experiences which have a negative valence. ACT, a scientifically-validated therapy which stemmed from research on Behavioral Theory and Relational Frame Theory, argues that symbolic language holds power because of the associations we naturally construct and tie to real-world events, places, and things. In and of itself, the idea that cognitions (thoughts) themselves, in any form, are not the problem but rather the behaviors stemming from thoughts, which are inflexible despite changing contexts. In fact, in OCD treatment and in the treatment of other severe anxiety-based or trauma-based disorders, it is often quite normalizing to express to clients that everyone has intrusive thoughts (including their therapists) which range in content and troubling nature; however, other "regular people" (read: there is no such thing as a "regular person") may not be pathologized for their thoughts because their actions are driven by choices that reflect their values and personal meaning. Behavioral choices which are values-driven are usually not the same actions one might pursue if driven exclusively by their thoughts or if fused with defending a certain view of oneself rather than engaging in what’s workable for the time, place, and context.
ERP from this lens emphasizes that emotions and thoughts may be whatever they are, and encourages clients to accept the full range of bodily sensations, emotions, and thoughts which may arise due to coming into contact with a feared stimuli. Though the mechanism by which ERP is successful has been contested in the literature (see past post on older habituation models versus newer inhibitory learning models), ERP has been shown to be as efficacious as medication and to have longer lasting benefits than pharmacological treatments and combined treatments in dozens of randomized controlled trials for anxiety based disorders such as OCD (Ponniah, Magiati, & Hollon, 2013; Simpson et al., 2008; Skoog & Skoog, 1999). Meta-analyses indicate that gains are maintained posttreatment and at follow up years later for clients who engaged in ERP for OCD, and similar studies indicate that ERP supported and supervised by the patient’s therapist is more helpful than patients’ self-directed ERPs (Roth & Fonagy, 2005). Exposures of about one hour have been shown in the literature to have the most benefit, while brief exposures of under 30 minutes have been shown to be of little benefit in long-term symptom reduction for OCD (Baer, 2012).
Similarly, there is a growing body of evidence suggesting that Acceptance and Commitment Therapy (ACT), an exposure-based approach at its core, is also well-suited for OCD and anxiety-based disorders due to its emphasis on reducing experiential avoidance through elements such as committed action, contact with present moment, and values (Arch, et al., 2016). Critically, acceptance in ACT is not an end in itself. Rather, acceptance is fostered as a method of increasing values-based action. This is a key distinction because clients may lose sight of why they are being encouraged to "accept" their symptoms to begin with. Who in their right mind would want to "accept" something that feels badly, right? If given a choice, most healthy, cognitive capable individuals would not intentionally move toward embracing a fear-eliciting situation. However, the point of acceptance in ERP is not simply to ride the wave of anxiety while pushing pause on life, waiting for symptoms or intrusive thoughts to diminish in the distance. Rather, it is more helpful to use acceptance as a means of increasing quality of life and aligned one's actions with longer-term values. Hayes, Strosahl, and Wilson (2012) state of the therapy, “At the level of process, ACT theory views exposure as organized, values-based contact with previously repertoire narrowing stimuli, for the purpose of producing greater psychological flexibility.” This emphasis on psychological flexibility is well-suited for OCD clients who may exhibit rigidity and rule-governed behaviors to their own detriment (even when these rule-bound behaviors, such as compulsions are not serving their values or overall life goals).
Abramowitz, J. S., Foa, E. B., & Franklin, M. E. (2003). Exposure and Ritual Prevention for Obsessive-Compulsive Disorder: Effects of Intensive Versus Twice-Weekly Sessions. Journal of Consulting & Clinical Psychology. 71, 394-398.
Arch, J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., Craske, M. G. (2016). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology. 80, 750-765.
Baer, L. (2012). Getting Control: Overcoming your Obsessions and Compulsions. London, England: Plume Books.
Craske, M. G., & Mystkowski, J. (2006). Exposure therapy and extinction: clinical studies. In M. G. Craske, D. Hermans, & D. Vansteenwegen, Fear and learning: Basic science to clinical application. Washington, DC: APA Books.
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B., (2014). Maximizing exposure therapy: an inhibitory learning approach. Behaviour Research and Therapy. 58, 10-23.
Ponniah, K., Magiati, I., & Hollon, S. D. (2013). An update on the efficacy of psychological therapies in the treatment of obsessive-compulsive disorder in adults. Journal of Obsessive-Compulsive and Related Disorders. 2, 207-218.
Roth, A., & Fonagy, P. (2005). What works for whom? : A critical review of psychotherapy research. 2nd Edition. Guilford: NY.
Simpson, H. B., Zuckoff, A., Page, J. R., Franklin, M. E., & Foa, E. B. (2008). Adding motivational interviewing to exposure and ritual prevention for obsessive compulsive disorder: An open pilot trial. Cognitive Behaviour Therapy, 37(1), 38-49.
Skoog G., Skoog I. (1999). A 40-year follow-up of patients with obsessive-compulsive disorder. Archives of General Psychiatry. 56(2), 121–127.