Michael P. Twohig

A Randomized Clinical Trial of Acceptance and Commitment Therapy Versus Progressive Relaxation Training for Obsessive-Compulsive Disorder

OBJECTIVE Effective treatments for obsessive-compulsive disorder (OCD) exist, but additional treatment options are needed. The effectiveness of 8 sessions of acceptance and commitment therapy (ACT) for adult OCD was compared with progressive relaxation training (PRT). METHOD Seventy-nine adults (61% female) diagnosed with OCD (mean age = 37 years; 89% Caucasian) participated in a randomized clinical trial of 8 sessions of ACT or PRT with no in-session exposure. The following assessments were completed at pretreatment, posttreatment, and 3-month follow-up by an assessor who was unaware of treatment conditions: Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Beck Depression Inventory-II, Quality of Life Scale, Acceptance and Action Questionnaire, Thought Action Fusion Scale, and Thought Control Questionnaire. Treatment Evaluation Inventory was completed at posttreatment. RESULTS ACT produced greater changes at posttreatment and follow-up over PRT on OCD severity (Y-BOCS: ACT pretreatment = 24.22, posttreatment = 12.76, follow-up = 11.79; PRT pretreatment = 25.4, posttreatment = 18.67, follow-up = 16.23) and produced greater change on depression among those reporting at least mild depression before treatment. Clinically significant change in OCD severity occurred more in the ACT condition than PRT (clinical response rates: ACT posttreatment = 46%-56%, follow-up = 46%-66%; PRT posttreatment = 13%-18%, follow-up = 16%-18%). Quality of life improved in both conditions but was marginally in favor of ACT at posttreatment. Treatment refusal (2.4% ACT, 7.8% PRT) and dropout (9.8% ACT, 13.2% PRT) were low in both conditions. CONCLUSIONS ACT is worth exploring as a treatment for OCD.

What Is Acceptance and Commitment Therapy

ACT is an example of a third wave behavior therapy that saves direct change strategies for overt behaviors and utilizes contextual and experiential methods such as mindfulness and acceptance to address cognitive process that hinder and limit overt behavioral change. The treatment is informed by RFT and is based on the philosophical position of functional contextualism. ACT seeks to undermine the literal grip of language (relational framing) that fosters experiential avoidance, cognitive fusion, and behavioral inflexibility, through the application of six core psychological techniques: acceptance, defusion, contact with the present moment, self-as as-context, values, and commitment to behavior change. Homework can play an integral role in the application of these techniques, by supporting the in-session therapy. Homework can be especially useful because it allows the client to utilize these principles in situations that cannot be created in the therapy sessions, such as public situation for someone who struggles with anxiety. As with most therapies, ACT has its own homework assignments, but therapists often create new techniques to serve the clients needs.

Acceptance and commitment therapy as a treatment for problematic internet pornography viewing.

Despite the prevalence of problematic Internet pornography viewing and the breadth of intervention approaches to potentially address it, no studies to address this problem have been reported to date. An emerging treatment approach, Acceptance and Commitment Therapy (ACT), holds promise as a treatment for Internet pornography viewing because of its focus on processes hypothesized to underlie this maladaptive behavior. In the first experiment on the treatment of problematic Internet pornography viewing, 6 adult males who reported that their Internet pornography viewing was affecting their quality of life were treated in eight 1.5-hour sessions of ACT for problematic pornography viewing. The effects of the intervention were assessed in a multiple-baseline-across-participants design with time viewing pornography as the dependent variable. Treatment resulted in an 85% reduction in viewing at posttreatment with results being maintained at 3-month follow-up (83% reduction). Increases were seen on measures of quality of life, and reductions were seen on measures of OCD and scrupulosity. Weekly measures of ACT-consistent processes showed reductions that corresponded with reductions in viewing. Large reductions were seen on a measure of psychological flexibility, and minor reductions were seen on measures of thought-action fusion and thought control. Overall, results suggest the promise of ACT as a treatment for problematic Internet pornography viewing and the value of future randomized trials of this approach.

A preliminary investigation of acceptance and commitment therapy and habit reversal as a treatment for trichotillomania

In this study, the combination of Acceptance and Commitment Therapy and Habit Reversal (ACT/HR) was evaluated as a treatment for trichotillomania with 6 adults. The effectiveness of ACT/HR was assessed within two separate multiple baseline designs. Self-monitoring data showed that treatment was successful in decreasing the numbers of hairs pulled to near-0 levels for 4 of the 6 participants, with results being maintained for 3 of the 4 participants at the 3-month follow-up. These findings were confirmed with ancillary measures. The treatment was found to be acceptable by all participants.

Habit Reversal as a Treatment for Chronic Skin Picking A Pilot Investigation

The purpose of this study was to compare the effectiveness of habit reversal (HR) to a wait-list control as a treatment for chronic skin picking in adults. Twenty-five adults with a chronic skin-picking problem were randomly assigned to a wait-list control or HR group. At pretreatment, posttreatment, and a 3-month follow-up, self-reported skin picking was assessed, and photographs were taken of the damaged areas and later rated by independent observers. Treatment acceptability data were collected at posttreatment only. Results showed that HR produced a greater decrease in skin picking at posttreatment and follow-up when compared to the wait-list control group. Data from the independent raters confirmed these findings. HR was also viewed as an acceptable intervention by the participants.

Response rates for CBT for anxiety disorders: Need for standardized criteria.

Full appreciation of the effectiveness of cognitive behavioral therapy (CBT) requires both effect size data and individual rates of positive response. Response rates are particularly helpful for clinicians when choosing among treatment options. However, systematic reviews on cross-study response rates have not been conducted, possibly due to the absence of a standardized metric for calculating response rates. We conducted a systematic review of the treatment outcome literature to determine overall response rates to CBT for anxiety disorders and whether current methods of defining treatment response influence overall response rates. Our database search (2000-2014) resulted in 87 studies that reported response rates and included at least one CBT condition. Results showed that overall treatment response rates across anxiety disorders averaged 49.5% at post-treatment and 53.6% at follow-up. Response rates varied significantly as a function of the properties used to define them. Measures that incorporated more than one criterion, the combination of a reliable change index with a clinical cutoff (a clinically significant change), and intent-to-treat samples yielded lower response rates at post-treatment. Blinded independent assessors yielded higher response rates than unblinded assessors. Based on previous empirical and theoretical work, we recommend that future studies use a clinically significant change index, in an intent-to-treat analysis (using a mixed-model approach), reflecting multiple modalities, and assessed by independent blinded assessors. Our results indicate that such measures are likely to reduce response rates, but may result in a less biased and more accurate representation of improvement and achievement of normative functioning.

Acceptance and Commitment Therapy for Anxiety and OCD Spectrum Disorders: An Empirical Review

A fair amount of research exists on acceptance and commitment therapy (ACT) as a model and a treatment for anxiety disorders and OCD spectrum disorders; this paper offers a quantitative account of this research. A meta-analysis is presented examining the relationship between psychological flexibility, measured by versions of the Acceptance and Action Questionnaire (AAQ and AAQ-II) and measures of anxiety. Meta-analytic results showed positive and significant relationships between the AAQ and general measures of anxiety as well as disorder specific measures. Additionally, all outcome data to date on ACT for anxiety and OCD spectrum disorders are reviewed, as are data on mediation and moderation within ACT. Preliminary meta-analytic results show that ACT is equally effective as manualized treatments such as cognitive behavioral therapy. Future directions and limitations of the research are discussed.

Body-Focused Repetitive Behavior Problems Prevalence in A Nonreferred Population and Differences in Perceived Somatic Activity

Body-focused repetitive behaviors (BFRBs) such as skin picking or scratching and nail biting can be physically and socially detrimental. Given the potential consequences associated with these behaviors, it is unfortunate this area has received relatively limited attention. The two purposes of the current study were (a) to determine the prevalence of BFRBs among typically developing persons and (b) to examine the contribution of reported somatic activity to the occurrence of BFRBs. Results indicated that 13.7% of the sample met criteria for at least one BFRB, of which the most common topographywas nail biting. Persons with aBFRBreported significantly more somatic activity than persons without a BFRB. Further analyses revealed consistent findings across three separate topographies in which persons with a BFRB for nail biting, mouth chewing, and/or skin picking reported significantly more somatic activity than did persons without a BFRB. Clinical implications and diagnostic considerations are discussed.

Viewing Internet Pornography: For Whom is it Problematic, How, and Why?

This study investigated the prevalence of problematic Internet pornography viewing, how it is problematic, and the psychological processes that underlie the problem in a sample of 84 college-age males using an anonymous online survey. It was found that approximately 20%–60% of the sample who view pornography find it to be problematic depending on the domain of interest. In this study, the amount of viewing did not predict the level of problems experienced. Mediational analyses suggest that the manner in which an individual interacts with urges to view pornography may be related to whether viewing is problematic or not.

The effects of cognitive defusion and thought distraction on emotional discomfort and believability of negative self-referential thoughts.

Previous research has shown that rapid vocal repetition of a one-word version of negative self-referential thought reduces the stimulus functions (e.g., emotional discomfort and believability) associated with that thought. The present study compares the effects of that defusion strategy with thought distraction and distraction-based experimental control tasks on a negative self-referential thought. Non-clinical undergraduates were randomly assigned to one of three protocols. The cognitive defusion condition reduced the emotional discomfort and believability of negative self-referential thoughts significantly greater than comparison conditions. Favorable results were also found for the defusion technique with participants with elevated depressive symptoms.