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.

ACT for Pornography Interview with Dr. Michael Twohig

We previously posted about recent data on a mindfulness-based therapy, Acceptance and Commitment Therapy, as a treatment for pornography addiction. For those who like interviews, I just recently discovered a podcast by Dr. Twohig where he talks about his research. Check it out.

MBCT for Individuals Whose Lives Have Been Affected by Cancer: A RCT

A recent issue of the well-respected Journal of Consulting and Clinical Psychology has an article on the use of Mindfulness-Based Cognitive Therapy (MBCT) for people with cancer. MBCT is an adaptation of Mindfulness-Based Stress Reduction (MBSR) and was developed to reduce depressive relapse. MBSR has already been used with good results in people with cancer across several studies (Carlson et al, 2003; Tacon et al., 2004), including one randomized controlled trial (RCT; Speca et al., 2000). Although it's not the first study employing a mindfulness-based treatment with an oncology population, this new study is the first controlled study of MBCT for people with cancer.

The authors of this study, a group of Australian researchers lead by Dr. Elizabeth Foley, call MBCT a “refinement” of MBSR twice in the article, which I found a strange choice of words. It could imply that MBCT may be better suited to addressing the needs of cancer patients; however, the authors don’t actually say this and the design of the study doesn’t allow for these conclusion to be drawn. Instead, the authors suggest that because depression and anxiety are common in cancer patients, and because MBSR has been shown to be helpful in people with cancer, using MBCT may also be beneficial.

The sample consisted of 115 patients across a range of cancer types. They were randomly assigned to either MBCT or a wait-list condition. The wait-list group received MBCT after the data was collected.

MBCT involves 8 weekly 2-hour sessions in groups of 8-12 people. MBCT was modified in several ways for these participants. Didactic information focused on common problems associated with cancer, including depression, anxiety, and pain. One change that particularly struck me was the body scan. The body scan involves mindfully moving your attention from your toes to the crown of your head. Apparently this was very difficult for many participants, for whom bringing awareness to the cancerous part of the body was very painful and difficult. Consequently, participants had the option of a “graded practice,” which might begin with awareness of the sensation of one’s clothing in the cancerous area. Sensitivity was paid to the physical difficulties of practice and to fatigue. Lastly, 32% of participants had people who cared for them also participate in MBCT per invitation by the researchers. Overall, I was really impressed by the sensitivity in adapting this treatment for cancer patients.

The results of the study indicated that, compared to the wait-list group, people who participated in MBCT showed improvements in anxiety, depression, and distress. These improvements were maintained at a 3-month follow-up. One thing I found impressive is that at 3 months, 62% reported regular meditation practice and 31% reported occasional practice. This means that over 90% found value in continued mindfulness practice.

Given that MBSR has already been used successfully with cancer patients in previous studies, I personally think comparing MBCT to MBSR (as opposed to a wait-list) would have been much more interesting. The authors note that the impact of treatment is comparable to the MBSR RCT by Speca et al. (2000). Consequently, I don’t think this study is particularly groundbreaking. That said, it’s always interesting to encounter a RCT for a mindfulness-based treatment, and the study adds to the growing literature in the use of mindfulness-based interventions for cancer patients.

Full citation for the MCBT study:

Foley, E., Baillie, A., Huxter, M., Price, M., & Sinclair, E. (2010). Mindfulness-Based Cognitive Therapy for individuals whose lives have been affected by cancer: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 78(1), 72-79.

Citations for studies of MBSR with cancer patients (links are included to free PDF's of articles ):

Carlson, L. E., Speca, M., Patel, K. D., & Goodey, E. (2003). Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine, 65, 571-581.

Speca, M., Carlson, L E., Goodey, E., & Angen, M. (2000). A randomized, wait-list controlled clinical trial: The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62, 613-622.

Tacón, A. M., Caldera, Y. M., & Ronaghan, C. (2004). Mindfulness-based stress reduction in women with breast cancer. Families, Systems, & Health, 22(2), 193-203.

Prickles and Goo

Today I'm offering something on the lighter side.

This video provides a cute illustration of some of the tensions that can build between those approaching mindfulness from an empirical standpoint and those who approach it more traditionally. That said, I think there's a little bit of prickles and a little bit of goo in all of us.

The narration is a clip of Alan Watts. Watts had a profound impact on the West in making Buddhism, particularly Zen, accessible to the English-speaking world. Watts published The Spirit of Zen in 1936 and continued to speak and publish until his death in 1973. The animation is by South Park creators Trey Parker and Matt Stone.