Those struggling with anxiety, particularly Obsessive Compulsive Disorder (OCD), can understand the powerful message of this quote. The internal struggle of anxiety is that sufferers often hide or run from their lives, who they are as individuals, or hopes and dreams of who they might have been. People diagnosed with OCD, know this all too well.
The Diagnostic Statistical Manual V (DSM V) characterizes OCD as a condition in which individuals experience obsessions (i.e. intrusive thoughts, images, or impulses) which cause intense feelings of anxiety and emotional distress, and often disgust, guilt, and shame. These obsessions are often very disturbing to the individual and cause them to feel out of control. As a result, the individual often avoids objects or situations that they fear and/or engages in compulsions (i.e. repetitive behaviors, mental acts, or rituals) as a way to mitigate their anxiety and distress. For example, an individual may have an obsessive and intrusive thought that if they touch a door handle they will contract a serious disease, such as herpes or HIV, that may kill them. Even though the person may fully understand that one cannot catch herpes or HIV in this way or that touching a door handle will likely not result in death, individuals will continue to ruminate over these intense fears. Therefore, the individual will often avoid door handles at all costs. If they do touch a door handle, or simply just have a ruminating thought about touching a door handle, the individual may engage in a compulsion of washing their hands excessively and in a certain way, such as washing with an abrasive soap or detergent, under very hot water, for a lengthy amount of time until the anxiety decreases.
The resulting effects of OCD can be debilitating, as the cycle of obsessions and compulsions often significantly interfere with the individual’s daily life, particularly in acts of avoidance. Furthermore, the guilt and shame around obsessions and compulsions may be so severe that the individual will often isolate themselves from others and have difficulty maintaining healthy relationships. The OCD individual will often avoid social situations, work or school, performance relates activities, affection from loves ones, etc., leaving them with painful attempts of trying to disappear and remain unseen.
A common treatment for OCD is Cognitive Behavioral Therapy (CBT), which often includes Exposure Therapy, in which the therapist assists the individual in directly confronting their anxiety and fears head on by helping them to get closer to the objects or situations they fear, while at the same time assisting them in using coping skills and relaxation techniques to manage their anxiety without engaging in a compulsive behavior. Taking the example from above, when treating the individual who fears contracting a deadly disease from door handles, the therapist may ask them to touch a door handle and avoid washing their hands by using a deep breathing technique to watch their anxiety naturally decrease with time. This technique can be very helpful to the individual because they begin to learn that anxiety and fear will eventually subside, and the act of making contact with door handles is not going to kill them as they feared it would. If the individual repeats this exercise enough times, then they may begin to habituate, so that their reactions to the feared object or situation decreases and they weaken the association between their intrusive thoughts and compulsive behaviors.
While Exposure Therapy is an effective treatment to OCD, there is another therapy under the branch of CBT, called Acceptance and Commitment Therapy (ACT), that takes a slightly different stance using abstract thought, metaphors, and experiential exercises. ACT works by assisting individuals to increase Psychological Flexibility, or the balancing of emotions among various life domains, by using mindfulness to make contact with the present moment, holding thoughts and emotions lightly and with acceptance, and identifying values as the driving force for behaviors. Unlike the very active and direct approaches that CBT uses to change problematic behaviors, ACT maintains that it is acceptance of the problem that results in change. This paradoxical model asserts that there is nothing wrong with the individual or their problematic behaviors and that every individual possesses the ability to increase happiness and joy at any time they choose. Although one’s internal experiences (i.e. thoughts, feelings, emotions, impulses) may lead one to believe that there is something wrong with them or something about their situation that needs to change, ACT believes that the problem is actually the relationship the individual has with their internal experiences, which results in problematic symptoms and behaviors that get in the way of a vital and meaningful life.
To explain this more clearly, let’s look at the six core concepts of ACT, called the Hexaflex, that make up Psychological Flexibility:
Acceptance can also be called Willingness, and ACT Theory uses the two concepts interchangeably. Acceptance is simply the willingness to allow oneself to experience what they are experiencing, the good, the bad and the ugly, without trying to change it in any way. Acceptance and Willingness asks one to hold thoughts and emotions lightly and with compassion and curiosity.
2. Contact with the Present Moment:
Making Contact with the Present Moment is done through mindfulness and breathing activities to increase awareness and pay attention, non-judgmentally, by focusing on the here-and-now.
In Fusion, two things are joined together so that they become one. Defusion can be thought of as the opposite of fusion. In ACT, Defusion is an experiential technique used to create space between one and their internal experiences, which is accomplished by changing the way one relates to their thoughts, feelings, judgments, beliefs, impulses and memories by addressing their unhelpful functions in the individual’s life.
4. Self as Context:
Self as Context is otherwise known as the Observing Self and it works to change the individual’s perspective about themselves through the use of mindfulness. Self as Context is seeing one’s experience from a different point-of-view, one that is unchanged by time, space, roles, or contexts.
Values are used in ACT to assist individuals in identifying what really matters to them and how they can behave in service of a vital and meaningful life. In contrast to goals, which can be thought of as objective tasks that are to be completed, Values are chosen qualities or ways of behaving moment-to-moment and in every domain of one’s life.
6. Committed Action
Behavior change happens in ACT by assisting individuals in using their identified values as course of directions for Committed Actions that are useful to the client. In addition, ACT engages individuals in homework, called LIFE Exercises, that incorporates all six concepts of the Hexaflex to increase Committed Actions and overall Psychological Flexibility.
So, how can ACT be used to apply to the treatment of OCD?
Using the above example again, an ACT therapist may help the individual who fears contracting a deadly disease from door handles by first assisting them in increasing Acceptance of fear and anxiety by asking them to willingly experience the fearful thoughts or judgments, physical sensations (i.e. racing heart, difficult breathing, shaking, etc), impulses, and discomfort without trying to change it, avoid it, or control it in any way. The ACT therapist may guide the individual through mindfulness and breathing exercises to make Contact with the Present Moment, as well as help them to alter their point-of-view of their symptoms and behaviors by identifying the Observing Self (aka Self as Context), or the person who is noticing their symptoms and behaviors. For example, the ACT therapist may assist the individual in identifying the part of them that is experiencing fear about touching the door handle, as well as helping them identify the part of them that is watching or noticing they are experiencing fear. The ACT therapist may then lead the individual through Defusion exercises to help them create space around their internal experiences. For example, the ACT therapist will assist the individual in identifying a ruminating thought about touching door handle, such as “If I touch a door handle I will contract HIV and die.” Then the therapist will ask the individual to insert “I’m having the thought that” at the beginning of the individual’s original statement, “I’m having the thought that if I touch a door handle I will contract HIV and die.” The ACT therapist will ask them again to insert “I notice that” to the previous two identified statements, “I notice that I’m having the thought that if I touch a door handle I will contract HIV and die.” This is a very common Defusion technique to assist individuals in realizing that thoughts are just thoughts, not facts, and one can choose to engage in them fully as beliefs or simply notice them for what they are. Next, the ACT therapist is always engaging the individual in discussions about Values as a way of creating a vital and meaningful life. Think of Values as a compass that guides your direction. You can go North, South, East, or West at any moment, at any time, and you could move in any one of those directions forever and ever. In contrast goals are thought of as destinations, such as Paris, France. Once you get there, you can cross it off your list, ‘been there, done that.’ For example, the individual may say they have a goal to increase touching door handles. After some processing and discussion with the individual, the ACT therapist will assist them in identifying the Values associated with touching door handles, such as courage, safety, freedom, intimacy, or industry, etc. And rather than placing the focus of treatment on touching door handles, the ACT therapist may invite the individual to find ways to engage in their Values in their daily life as a course of direction to meeting their ultimate goal, which leads us to Committed Action. Values are used to help the individual determine Committed Actions that they would like to engage in as a way to increase behavior change. The ACT therapist assists the individual in aligning their behaviors to their identified Values, so that whether or not they are meeting their goals, the individual is creating a life they find meaningful.
It is important to note that the 6 Concepts of ACT that make up the Hexaflex, do not need to be used linearly. Rather, the ACT therapist may use them as needed, in any order they choose, and even conjointly as a way of meeting the client’s needs. Lastly, ACT is used to treat any and all disorders, Mood Disorder, Anxiety Disorders, Psychotic Disorders, etc. and is not limited to OCD. ACT is a valuable tool for anyone who desires to engage in the world in a meaningful and purposeful way that enables one to create a life worth living.