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

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). OCD causes anxiety that leads to repetitive compulsions. One of the most obvious symptoms of OCD is how much this disorder disrupts a person’s functionality – obsessions and compulsions can take up hours of a person’s day.

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. However, 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 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?

Struggling with obsessive thoughts and repetitive behaviors can feel overwhelming. ACT for OCD offers a different way to manage symptoms by focusing on acceptance rather than control. ACT helps people change how they think about their obsessions, reducing compulsions.

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 thoughts don’t define you or dictate your actions and you learn to notice thoughts and choose your actions intentionally.

ACT for OCD Compulsions

ACT helps people see their compulsions as optional rather than necessary for safety. When a person has an obsession, ACT focuses on helping them to hold the concept that they could have an infinite number of behavioral responses – 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.

Is ACT for OCD Effective?

Research shows that ACT effectively treats OCD by increasing psychological flexibility and breaking the link between obsessions and compulsions.⁶ 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 an individual’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 to reduce the fear of what will happen if they do not perform their compulsions. ERP also reduces 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 it and the classic CBT approach. Cognitive behavioral therapy (CBT) is often primarily based on challenging and reframing internal thoughts into something more realistic and tolerable, changing how the person responds to them. ACT focuses on allowing thoughts and obsessions to be what they are, accepting and tolerating them, and then intentionally choosing 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 help clients understand concepts and distance themselves from thoughts. Changing how people view their thoughts helps them respond in ways that align with their values.

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 go into it as leaves and sticks floating down a stream. You can observe the leaves floating down the stream without jumping in and pulling 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 problem 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 you encounter.

Acceptance, Mindfulness, and Defusion Skills

ACT’s difference from other therapeutic approaches for OCD is its focus on changing a person’s internal experience with their obsessions. Rather than trying to change their thoughts, ACT helps people approach their thoughts differently. For instance, if someone fears germs, ACT might guide them to notice the thought without judgment and choose an action aligned with their values, like focusing on meaningful work rather than repeated handwashing.

Skills that are taught in OCD treatment include:

• Defusion skills: ACT teaches 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.
• Mindfulness skills: Mindfulness skills in ACT include noticing one’s thoughts and emotional and physical responses to them 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 people can identify their values and articulate the time that they deviated from them, they can 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. Treatment length varies based on severity, OCD type, and a person’s environment.

ACT sessions will involve:

• Building rapport with your therapist: Building trust with your therapist helps them guide and hold you accountable.
• Exploring your current mental state: This includes identifying your obsessions and any feelings and internal reactions you’re having in response to these.
• Outlining your ideal self and core values: Identifying these things will act as your “North Star,” helping you make intentional decisions about your behaviors after experiencing obsessions.
• Committing to specific actions: Once you have identified different ways to align 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 many people, there are several OCD treatment options to consider. There are several therapeutic approaches, and some people may benefit from adding medication to enhance therapy’s effectiveness. Comprehensive treatment will consider the best therapeutic approach for an individual’s situation, whether adding medication could be beneficial, and whether focusing on support outside of therapy 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 to help engage in 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 them into something more realistic and helpful to the client.