ACT for OCD: How It Works, Examples, & Effectiveness

What Is Acceptance & Commitment Therapy?

Acceptance and commitment therapy (ACT) is a therapeutic approach developed by Steven C. Hayes in the 1980s when he was seeking relief from his own panic disorder. ACT is founded on the principle that being mindful of distressing thoughts can be more helpful than trying to change the thoughts themselves. The goal is to notice your thoughts and not take them on as a reflection of yourself, choose an intentional way to respond to the thought, and to move toward that choice that feels like it aligns with your values.

What Is OCD?

Obsessive compulsive disorder (OCD) is a mental health condition where a person experiences intrusive thoughts (obsessions), which a person tries to soothe by engaging in repetitive actions (compulsions). People struggling with OCD experience intense anxiety about their obsessions, which encourages them to engage with their compulsions repetitively. One of the most obvious symptoms of OCD is how much this disorder disrupts a person’s functionality – obsessions can distract a person for long periods of time, and compulsions often take hours to perform.

OCD is not an uncommon disorder – approximately 1.2% of US adults had OCD within the past year, and many people struggle with this for their entire lives.¹ Women are more likely to develop OCD,² and risk factors include having a family history of OCD, experiencing stressful or traumatic life events, and having other mental health conditions already present (such as depression or anxiety).³

OCD is typically characterized by a person having both obsessions and compulsions, but it is possible only to experience one or the other and still meet the diagnostic criteria for this disorder.

OCD is characterized by:

Obsessions

Obsessions are intrusive thoughts that cause a high level of distress and anxiety when they are experienced.

Types of obsessions can include:⁴

• Contamination Obsessions
• Responsibility Obsessions
• Perfectionism-based Obsessions
• Sexual Obsessions
• Violent Obsessions
• Religious Obsessions
• Identity Obsessions
• Relational Obsessions

Compulsions

Compulsions are behaviors that a person with OCD does in order to soothe and reassure themselves after they experience a distressing obsessive thought. Most people would rather not engage with their compulsions, but do so because they believe that they prevent something bad from happening.⁵

Types of compulsions can include:

• Washing and Cleaning
• Checking Behaviors
• Mental Compulsions
• Arranging Things
• Repeating
• Avoiding Situations that may trigger obsessions

How Does ACT Help With OCD?

ACT focuses primarily on helping a person change their beliefs and feelings toward their obsessions, which then impacts their engagement with compulsions. ACT directly challenges society’s view of categorizing obsessions as bad and works to allow the patient to have obsessions to come and go throughout their lives without needing to respond with compulsions to stay safe.

ACT can help OCD in the following ways:

• Creating a more positive relationship with the self
• Increasing a client’s awareness and flexibility with themselves
• Reduces shame and anxiety that a client is experiencing from obsessions

ACT for OCD Obsessions

The primary way that ACT targets OCD is by changing a person’s relationship with their obsessions. ACT teaches that a person is separate from their thoughts, and just because a person has a thought does not necessarily mean that they will engage with it. This means that when a person has an obsession, the client is taught to notice it and to make an intentional choice for the behavior they want to engage in that follows that thought.

ACT for OCD Compulsions

ACT works with compulsions by giving a client the psychological flexibility to view their compulsions as optional instead of mandatory for safety. When a person has an obsession, ACT focuses on helping them to hold the concept that there is an infinite number of behavioral responses that they could have – their past compulsions are just one of their options. The person is then encouraged to consider what behaviors align most with their values, and to take action toward doing behaviors that align with these.

Does ACT Effectively Treat OCD?

Research shows that ACT is an effective treatment for OCD spectrum disorders⁶ because of its ability to increase the client’s psychological flexibility and by disconnecting the compulsion from the obsession. However, it is important to note that ACT has been studied less intensely and frequently than ERP therapy, which is the primary approach currently used in the treatment of OCD.

ACT Vs. ERP

Exposure and response prevention therapy (ERP) focuses on increasing a client’s functionality by changing the obsessions a person experiences and by lessening their engagement with compulsions. This is primarily done by repeatedly exposing the client to not engaging with their compulsions in order to reduce the fear of what will happen if they do not perform their compulsions. ERP also works to reduce the obsessions experienced by changing them into more tolerable thoughts for the client.

ACT Vs. CBT

While ACT is technically a form of CBT, there are many differences between ACT and a classic CBT approach. Cognitive behavioral therapy (CBT) is often primarily based on challenging and reframing internal thoughts into something more realistic and tolerable, which then changes how the person responds to the thoughts. ACT focuses on allowing the thoughts and obsessions to be what they are, to accept and tolerate them, and to then intentionally choose how a person responds to those thoughts in a way that aligns with their values.

ACT Therapy Techniques Applied to OCD

ACT treatment for OCD focuses on separating a person’s thoughts from their beliefs about themselves as a person, bringing nonjudgemental and detached mindfulness to the thoughts they are experiencing, identifying values that a person wants to live their life by, and increasing a person’s regulation skills.

Here is how some ACT therapy techniques are applied to OCD:

Metaphors to Teach ACT Theory

Metaphors are a cornerstone of teaching clients about concepts and distancing themselves from thoughts within ACT therapy. By changing a person’s conceptualization of their thoughts and behaviors, they are able to approach and respond to them in a new way that is more aligned with who they want to be.

ACT metaphors that are used in OCD treatment include:

• Thoughts as Leaves in a Stream: A metaphor used to distance a person from the thoughts that come into their head, it can be helpful to consider your mind as a stream and the thoughts that come into it as leaves and sticks floating down a stream. You can observe the leaves floating down the stream without needing to jump in and pull all the debris out of the stream.
• Drivers Vs. Passengers: Another metaphor used to detach from your thoughts, thinking of the mind as a car driver and your thoughts/obsessions and feelings as passengers in a car – the passengers can tell you what to do and threaten you, but they are ultimately not the ones in control of driving the car.
• Beach Ball Underwater: A metaphor used to show the impact of avoidance, thinking of the emotions that a person is trying to avoid as a beach ball that they’re trying to hold underwater; trying to hold the beach ball underwater (bottling up emotions and thoughts) takes an incredible amount of energy and usually the ball comes to the surface at some point anyway.
• Quicksand: A metaphor that highlights the impact of trying to change thoughts and fears, it can be helpful to imagine distressing thoughts and engaging with compulsions as similar to finding yourself in quicksand – the more you struggle to change and control the situation with compulsions the worse the situation actually becomes.
• These metaphors are a very different thought process than you may be used to. You may benefit from trying these in a therapy session so that a therapist can help you work through any distress or resistance that you encounter.

Acceptance, Mindfulness, and Defusion Skills

Changing a person’s internal experience with their obsessions is the cornerstone of what makes ACT different from other therapeutic approaches for OCD. ACT works to reformulate a person’s beliefs about the thoughts that they have and works on how a person approaches these thoughts instead of trying to change the thoughts themselves.

Skills that are taught in OCD treatment include:

• Defusion skills: Clients are taught that thoughts do not determine a person’s worth or make a statement about them – they are just thoughts. Defusion teaches that what a person does in response to their thoughts can be a much bigger expression of who they are as a person.
• Mindfulness skills: Mindfulness skills in ACT include drawing awareness to the thoughts that a person is having, as well as their emotional and physical responses to these thoughts in the moment.
• Acceptance skills: After increasing mindfulness related to thoughts and reactions, the next step is to build nonjudgemental acceptance of these thoughts and reactions.

Identifying Values & Committing to Action

Identifying what kind of person your ideal self would be and living by the values connected to that are key pieces in responding differently to the urge to engage with compulsions. When a person can clearly identify their values and articulate the time that they deviated from them, they are able to commit to more intentional choices in the future. This can drastically reduce compulsions and increase a person’s sense of autonomy over their own life that they previously could not access with OCD.

What to Expect During ACT Treatment

Working with a therapist to treat OCD by using ACT will include typical-length sessions (about 50 minutes), and most people need at least a year of treatment to begin seeing relief from symptoms. Some people need several years of treatment and/or medication before they begin seeing relief, and how long treatment takes depends on individual factors – such as severity, subtypes of obsessions and compulsions, as well as the client’s environment outside of sessions.

ACT sessions will involve:

• Building rapport with your therapist: Having a trusting relationship with your provider is essential in order for them to be able to hold you accountable and highlight when you aren’t acting in accordance with your ideal self and values.
• Exploring your current mental state: This includes identifying the obsessions you’re having and any feelings and internal reactions that you’re having in response to these.
• Outlining your ideal self and your core values: Identifying these things act as your “North Star” that will help you to make intentional decisions about what behaviors you engage with after experiencing obsessions.
• Committing to specific actions: Once you have identified different ways that you can act in alignment with your ideal self and values, the next step is to talk with your therapist about what it would look like to commit to those and live a life that feels more aligned.

How to Find an ACT Therapist for OCD

If you feel that you or a loved one may be struggling with OCD and would benefit from treatment, beginning to work with a trained mental health professional is crucial. To begin the search for a qualified professional, beginning with an online therapist directory can be a good place to start. If you have limited financial resources, beginning with a professional on an online therapy platform can be a good place to start.

Alternative Treatment Options for OCD

While ACT can be a good fit for treatment for many people, there are several OCD treatment options to consider. There are several kinds of therapeutic approaches, and some people may benefit from also adding medication to help the effectiveness of therapy. Comprehensive treatment will consider the best therapeutic approach for an individual’s situation, whether adding medication could be beneficial, and focusing on supports outside of therapy that could aid in a client’s recovery.

Alternative treatment options for OCD include:

• Exposure response therapy (ERP): Exposure therapy for OCD is a therapeutic approach that focuses on facing obsessions and challenging them, as well as facing fears related to not participating in compulsions through gradually increasing exposure.
• Medications: There are several options for medications for OCD, which include medications that decrease a client’s stress responses in order to help engage in therapeutic treatment more effectively.
• Cognitive behavioral therapy (CBT): CBT for OCD also focuses on breaking the link between obsessions and compulsions, and classic CBT approaches also include challenging the obsessive thoughts and reframing it into something more realistic and helpful to the client.

In My Experience

In my experience, ACT can be extremely helpful for individuals who struggle with OCD. ACT can help a person to feel more empowered to take an active role in developing the life they want to live by making intentional choices that align with their ideal future and values. While OCD can feel debilitating and helpless, the outlook for a person who engages with and stays consistent with treatment is full of hope and promise. I tell my clients and truly believe that there is always the possibility of having a very different future than your current or past life once you begin therapy with a qualified provider that you trust.