Friday, October 15, 2010

A RCT of Acceptance and Commitment Therapy vs. Progressive Relaxation Training for Obsessive-Compulsive Disorder

In a previous post about the use of Acceptance and Commitment Therapy (ACT) for problematic pornography viewing, I mentioned researcher Dr. Michael Twohig’s work with ACT for obsessive-compulsive disorder (Twohig, Hayes, &; Masuda, 2006; Twohig, 2009; Twohig &; Whittal, 2009). Well, it looks like Dr. Twohig is on a hot streak as Journal of Consulting and Clinical Psychology (JCCP) has just published another study by Dr. Twohig: the first randomized controlled trial (RCT) of ACT for OCD.

OCD is a condition characterized by frequent, unwanted thoughts (obsessions) and/or reliance on repetitive or ritualized behavior (compulsions) in order to get rid of obsessions and reduce anxiety. The gold standard of treatment is what’s called Exposure with Ritual Prevention (ERP; sometimes called Exposure and Response Prevention), which is often used in the context of cognitive behavioral treatment. ERP involves having people sit for extended periods of time with distressing stimuli related to obsessions without engaging in the compulsions they typically use to alleviate distress. For example, someone with a fear of germs who compulsively hand washes might be asked to smear dirt on his hands and spend a half hour sitting with dirty hands without washing them. For someone who spends hours a day compulsively washing his hands even when they are not observably dirty, this can be extremely stressful. Perhaps because of this, there is a high drop out rate for people using ERP—about 25% according to the article. Also, even though ERP is the most effective treatment for OCD, most clinicians are reluctant to use it. (Clinicians can be uncomfortable sitting with distress, too!)

Although exposure can be and often is incorporated into ACT treatment, Dr. Twohig specifically did not include ERP in his ACT protocol. This move is shrewd yet bold. Given the widespread research support for the use of ERP in OCD treatment, adding it to ACT would leave the study vulnerable to serious questions about whether ACT contributes anything new to OCD treatment.

It’s worth noting, however, that the study does not directly compare ACT to ERP. Instead ACT is compared to progressive relaxation training (PRT), in which people are systematically taught ways of relaxing, beginning with their muscles. PRT has some support in OCD treatment but is considered less effective than ERP. I’ll address the researchers' reasons for using PRT over ERP at the end of this blog.

Approximately 80 people were randomly assigned to receive either 8-weeks of ACT or 8-weeks of PRT delivered in 1-hour sessions. The protocol is striking in its brevity--eight 1-hour sessions is not a lot of time. Participants were assessed 1 week before treatment, 1 week, after treatment, and 3-months later.

Instead of ERP, ACT treatment focused on typical ACT processes. Participants learned to notice how attempts at controlling obsessions made them worse over time, respond to obsessions more flexibly, and make behavioral commitment to things that were important to them. The behavioral commitments may resemble in vivo or real-world exposure exercises often found in ERP treatments. However, emphasis was placed less on deliberate exposure as in traditional ERP. Instead, the emphasis was placed on moving towards something important and responding to any distress that showed up.

Results indicted greater improvement in OCD symptoms at the end of treatment and at follow-up for ACT participants compared to those assigned to PRT. Participants rated the acceptability of ACT very highly—more so than PRT. Additionally, dropout rates were lower for ACT than is common for ERP.

This study provides evidence that ACT is a useful treatment for OCD worth further study. ACT has several things going for it: 1.) ACT was well-tolerated by participants, which is extremely important given the high dropout rate associated with ERP; 2.) The ACT protocol was remarkably brief—eight 1-hour sessions—which is much shorter than average for ERP treatments; 3.) Although not directly compared, reductions in OCD were similar to those indicated in a review of ERP treatment for OCD.

The researchers caution that they believe the ACT protocol for OCD would benefit from more tinkering before it is compared to ERP. However, I expect we’ll see a direct comparison in the near future. ACT has the potential to be a treatment that is better tolerated but as effective as ERP, or it may be a treatment for people who cannot tolerate direct exposure as emphasized in ERP. Regardless, it’s off to a promising start.

For members of the Association for Contextual Behavioral Science, the article may be downloaded here. For full citation:

Twohig, M.P., Hayes, S.C., Plumb, J.C., Pruitt, L.D., Collins, A.B., et al. (2010). A Randomized Controlled Trial of Acceptance and Commitment Therapy vs. Progressive Relaxation Training for Obsessive-Compulsive Disorder. Journal of Consulting and Clinical Psychology, 78(5), 705-716.

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