ACT & OCD: Does It Really Work?
Kaitlyn honestly felt like her fiance, Jesse, was the love of her life. She was madly in love with him and believed he felt the same. However, lately Kaitlyn has been questioning her beliefs. She is starting to wonder if she truly loves him as much as he loves her. Every time she and Jesse are together she becomes quite nit-picky. Negative thoughts pop into her mind, which affect how she sees and responds to Jesse.
Thoughts like, “ I hate the way he chews his food. Why does he have to make such obnoxious sounds? It’s disgusting. If I marry him I’ll have to listen to that annoying noise for the rest of my life. Is it genetic? What if our children chew their food the same way? Omg! Maybe, I should call off the engagement? But, he’s just so handsome and kind, how could I do that to him?! He’s a great guy! But, what if I can’t take his chewing and we end up divorcing because of the way he chews his food? That would be devastating for me, him, and our kids.”
What is causing these negative and self-destructive thoughts? Anxiety. So, what does Kaitlyn do in response? First, she excessively frets over her feelings and relationship (obsessions). Then, she repeatedly asks friends and loved ones what they think about Jesse and their relationship (compulsions), so she can get the reassurance she desperately needs to feel “calm” and “good” about her upcoming wedding.
Once Kaitlyn gets that reassurance from the people she trusts most, she relaxes because her compulsions (repeatedly seeking reassurance from friends and loved ones) eases her anxiety and calms her nerves so she can once again be happy about the engagement.
Kaitlyn has become entangled in an OCD cycle – (1) Something makes her think about her fiance or relationship, (2) This initial thought begins to takeover her mind – she can’t think about anything else (obsession), (3) She begins to feel stressed, anxious, overwhelmed, and out of control because she can’t get this negative thought out of her mind (obsession), and (4) She is desperate for relief or reassurance so she asks friends and a loved ones to “remind” or reassure her that her fiance is a great guy and she’ll have a wonderful married life (compulsion).
The end result? Relief. But, it only lasts until the same or a new negative thought pops into her mind that causes her to question her beliefs, feelings, fiance and/or relationship. Then, the cycle begins again.
The truth is we have all had thoughts and feelings that have consumed our minds. When that occurred the only way most of us could get rid of those pesky thoughts and feelings was to do something (good or bad) to ease our minds – i.e. talking to friends about our problem(s), getting drunk or doing drugs, focusing on work or a hobby, binge-watching Netflix, drowning ourselves in our favorite foods, self-isolating, partying, adding cardio into our days, punching a pillow, asking questions, etc. These behaviors serve a purpose – to relieve us. To calm our hearts, minds, and even souls.
The truth is it is hard to control or navigate your feelings, when you’re struggling with OCD. However, ACT can help you look at your thoughts, feelings, and the situation in a clearer and more realistic way. The more you can look at everything from an “outside or different perspective,” the more equipped you’ll be to manage the stress and anxiety that is feeding your obsessions and compulsions.
What is ACT?
Acceptance and commitment therapy (ACT) is a form of cognitive-behavioral therapy (CBT) that helps you understand and accept that life is not always fair and that you may encounter issues and adversity at one time or another. Ironically, ACT is not new. In fact, it has been around for decades, however, it has only recently become a “go to” treatment for OCD.
ACT is heavily linked to mindfulness in its belief that you can achieve complete “oneness” and improved mental health by eliminating unhealthy, destructive, and negative thinking patterns and emotions from your life. Thus, ultimately, the goal of ACT is to identify any personality traits that may be influencing your behavior (actions), so you’ll feel less inclined to “avoid” or “hide” from stressful or overwhelming people and situations. This is especially prevalent when it comes to OCD.
For ACT to be successful, you must commit to making the necessary changes in your thought processes and behavior. Thus, this therapy approach encourages you to accept and embrace your thoughts and feelings, rather than avoiding or hiding from them. In fact, researchers have found that when ACT is paired with mindfulness exercises, OCD symptoms diminish.
If you opt for an ACT therapist, he or she will encourage you to confront and address your problems, because “hiding” from issues only makes resolving them even harder. Thus, the best way to deal with a problem is to tackle it head-on.
Studies indicate that ACT may be an effective treatment protocol for people struggling with a variety of mental health issues, such as depression, anxiety, substance abuse or addiction, and OCD. So, the key to therapy success lies with making a conscious effort to “direct” or “control” your behavior and embrace your fears or challenges. ACT aims to help individuals with mental health conditions accept and embrace reality, even when it’s difficult.
Who is ACT For and How Does it Work?
Therapists are constantly looking for treatments that can help individuals better manage their mental health issues, so it makes sense that they would turn to ACT for assistance. According to studies, ACT can effectively help people cope with workplace and personal stress, emotional or psychological distress, social anxiety, phobias, performance anxiety, and general anxiety disorder, depression, bipolar disorder, psychosis, eating disorders, and OCD. ACT can also be used to treat a variety of health conditions, such as diabetes, Lupus, substance abuse and addiction, high blood pressure, and aches and pains.
How does ACT work?
ACT teaches you how to reframe your thoughts, experiences, and feelings, so you do not automatically view stressful or challenging situations as “issues” or “problems.” ACT teaches you how to adapt to changes that impact your normal functioning or daily life. It helps you accept what is currently happening, while managing your thoughts and feelings, so they don’t cause you to behave “out of character.”
ACT also helps you change how you view or perceive certain situations and emotions, so they are no longer associated with “pain” or “discomfort” and simply seen as a “normal part of life.” ACT involves a variety of strategies, such as helping you align with your personal values, and making a commitment towards changing how you think, so you can reduce or eliminate harmful, dangerous, or destructive thoughts, emotions, and behaviors.
ACT therapists believe that trying to control negative emotions or stressful or upsetting experiences is not only ineffective, but also damaging. In other words, bottling up these feelings only leads to more emotional pain and distress. These therapists believe that there are reliable ways that you can change the way you think, feel, and behave, such as paying attention to your personal values or morals, being deliberately mindful of your reactions and behavior, and committing to change.
Thus, ACT works by helping you change your behavior, while simultaneously teaching you how to change your mood, feelings, and attitude by accepting and embracing both good and bad experiences.
What is the Goal of ACT?
The goal of ACT is to create a happy, healthy, fulfilling, and productive life, while accepting that stress and pain are natural parts of life. ACT teaches you how to be attentive and involved, while relying on your innermost values to guide your actions. ACT teaches you that the only way you can truly have an impactful life is through “mindful” or deliberate actions. ACT therapists believe that as we traverse through life, we are bound to encounter obstacles – i.e. unpleasant or upsetting thoughts, emotions, urges, sensations, images, and memories.
The best way to handle these “experiences” is through mindfulness meditation. ACT therapists use mindfulness meditation to help individuals cope with these personal experiences. This therapy approach relies on six core principles to expand or alter one’s thought processes. These six core principles are: values, committed or deliberate actions, acceptance, cognitive defusion or disconnection, self-awareness or being present in the moment, and self in context or deep sense of self.
Your personal values play an important role in ACT. During ACT, you learn how to identify what you value most (what matters most to you in life) and who you ultimately want to be. For instance, how you feel about lying, stealing, infidelity, etc.
- Committed or Deliberate Action
For ACT to be effective, you must be committed to the therapy process and take deliberate actions to do things that will add value and meaning to your life. For instance, volunteering a pet rescue or a homeless shelter, offering assistance to those, who are less fortunate, praying, documenting your experiences in a journal, taking care of a disabled loved one or friend, etc.
Acceptance is a keystone of ACT. Acceptance entails accepting and embracing all of your experiences – the good ones and the bad ones. For instance, accepting that you’re not always a burst of sunshine – you also have dark days or days where you feel “down” or depressed. Both versions are “you” and that’s okay. You’re not supposed to be happy every single day of the year. It’s natural to have both good days and bad ones. That’s just a part of life.
- Cognitive Defusion or Disconnection
What is cognitive defusion or disconnection? It involves separating yourself from, or looking at an experience, emotion, or event from the outside. In other words looking at the situation from a different angle or perspective. Thus, ACT therapists teach you how to become in-tune with your thoughts and emotions (looking at them as if you are an observer), without becoming fixated on them.
- Self-Awareness or Being Present in the Moment
ACT is most successful when you develop a strong self-awareness or are able to be present in the moment. When you focus on staying in the here-and-now, you become more aware of your experience because it is happening at that moment.
For instance, while hiking in the woods, you notice the varying heights of the trees, the green leaves, shadowy sky, and the dirt path beneath your feet. You are self-aware or present in the moment.
- Self-In-Context or Deep Sense of Self
The last core principle important to ACT is self-in-context or deep sense of self. This principle involves getting in touch with your inner self or the part of yourself that is observant and fully aware. Your inner self is completely separate from your thoughts, feelings, beliefs, and memories. For instance, this may entail where you are in your self-development and where you’d like to be or hope to be in the future.
For instance, a terrifying thought pops in your head while at work. You become afraid that something is going to happen to your spouse. In this situation, ACT would encourage you to acknowledge this thought, but not allow it to consume you, because you realize that there is little-to-no merit to the thought. ACT therapists teach individuals not to try to squash these thoughts because that does more harm than good. Rather, embrace them, but realize that the fear will most likely never manifest.
What is OCD?
Obsessive-compulsive disorder (OCD) involves intrusive thoughts, fears, and feelings (obsessions) that causes you to perform repetitive behaviors (compulsions) to ease your angst. OCD disrupts your daily functioning, triggering emotional distress. If you try to block out, prevent, or stop your obsessive thoughts, it only leads to more anxiety and compulsive behaviors.
In other words, trying to block these upsetting thoughts and behaviors only cause them to return with a vengeance. OCD makes you feel like the only way to ease your stress and calm your nerves is to engage in ritualistic behaviors. Thus, it is a never-ending cycle that repeats over and over again.
For example, Betty is deathly afraid of contracting coronavirus and because health experts say a person can become “contaminated” by the virus (germs) by touching people and objects. Because Betty has been inundated with COVID-19 warnings, she can’t get the idea of catching COVID-19 and becoming ill or dying from it out of her mind, so she obsesses over it.
To ease her anxiety and stress, she excessively washes her hands until they crack and bleed. Performing this act reduces her stress…until she sees another warning on the television. Then, the cycle begins again.
People with OCD often “hide” it from others because of the stigma associated with mental illness. The truth is there is nothing to feel ashamed about – it is an illness like any other illness. The good news is there are effective treatments that can ease your symptoms and help you manage your condition.
How is OCD Treated?
OCD is traditionally treated with psychotherapy, medications, or both. Although treatment may not cure every case of OCD, it can reduce your symptoms and help you better manage your condition. With treatment OCD lacks the ability to dictate how you live your life. Understand, however, that while some people can be effectively treated with outpatient services, such as psychotherapy and/or medications, others may require more intensive, ongoing treatments.
Cognitive-behavioral therapy (CBT) is the most common traditional psychotherapy used to treat OCD. Other forms of CBT, exposure and response prevention (ERP) and ACT, also help reduce the fears and anxiety by teaching people with OCD how to look at situations in a different way and by gradually exposing them to their fears or obsessions, such as bugs, dirtiness, or germs.
CBT teaches these individuals how to resist the urge or desire to perform ritualistic behaviors to alleviate their stress and anxiety. In other words, it focuses on helping people with OCD change their way of thinking and processing information, so they no longer feel the need to perform compulsive behaviors. So, even though CBT, ERP, and ACT take patience and practice, they can help you get a better grasp on your obsessions and compulsions, so you can have a better quality of life.
A variety of prescription medications can help you get a handle on your obsessions and compulsions. The first-line of treatment typically involves antidepressants, followed by or used in conjunction with benzodiazepines, beta blockers, and antipsychotic drugs.
Listed below are anti-anxiety meds used to treat OCD:
- Clomipramine (Anafranil)
- Fluoxetine (Prozac)
- Paroxetine (Paxil & Pexeva)
- Sertraline (Zoloft)
- Buspirone (BuSpar)
- Chlordiazepoxide (Librium)
- Diazepam (Valium)
- Lorazepam (Ativan)
- Oxazepam (Serax)
- Molindone (Moban)
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
- Propranolol (Inderal, Betachron E-R & InnoPran XL)
Why Use ACT for OCD?
ACT is used to treat OCD in the following ways:
- ACT therapists believe that behaviors are “moldable” or “adjustable” and all one has to do to make that happen is to manipulate his or her environment. So, instead of looking at a person’s behavior as simply neurological or biological, ACT suggests that behaviors can be changed through therapy. ACT also teaches people with OCD that they can change their thought processes (obsessions) and behaviors (compulsions) by altering things in their environment.
- ACT focuses on the way people internalize and respond to situations, events, or triggers. The goal of this treatment is to help individuals alter how they react to these events, instead of blaming their personality traits for their reactions and behavior. Thereby, ACT teaches people how to control their thoughts and responses to stressful or anxiety-provoking situations.
- ACT therapists believe in repeatedly testing the effectiveness of psychological interventions, so they can offer the best treatments to people struggling with OCD.
How Does ACT Help OCD?
First, understand that many psychotherapists still use CBT and ERP as first-line treatments. However, ACT is becoming more common for OCD, as more psychotherapists become familiar with its benefits. ACT is unlike traditional CBT and ERP in the fact that it focuses less on the “fading” or “removal” of personal experiences (i.e. obsessions), and more on changing how we view these experiences. In other words, ACT teaches people with OCD how to view their anxiety, obsessions and compulsions as a natural consequence of life. To ACT therapists, anxiety, obsessions and compulsions are not necessarily “unhealthy” or “bad” experiences, even if that is the societal norm. On the flip side, ACT encourages you to accept your obsessions and anxiety, while preventing it from interfering with your life.
Understand that it is common to try to “suppress” your anxiety, obsessions and compulsions because society views these emotions and behaviors as “destructive,” “unhealthy,” “dangerous,” “negative,” “threatening,” “stressful,” and “upsetting.” ACT therapists, on the other hand, teach people with OCD that these intrusive thoughts (obsessions) are simply “just thoughts,” their feelings are “just natural human emotions,” and their behaviors are really “just reactions to their thoughts and feelings.” Thus, ACT seeks to change how you look at situations, experiences, and your thoughts and behaviors.
Keep in mind that most of us are constantly thinking about something and with those thoughts comes a range of emotions. However, most of the time we do not attach to these “experiences.” Thereby, the ultimate goal of ACT is to teach people with OCD how to “experience” or “perceive” their anxiety and obsessive thoughts as simply “thoughts” and “feelings” that they can either react to or ignore.
The ritualistic behaviors, in turn, are reactions to your “thoughts” and “feelings.” Experiencing these things from this angle helps you become desentized to them, so they don’t have a significant impact on your life. So, ACT ultimately aims to help people with OCD feel comfortable enough to accept and embrace their thoughts, feelings, and sensations without becoming consumed by them.
What is the Ultimate Goal of ACT When Treating OCD?
The ultimate goal of ACT is to teach people how to acknowledge their urges, while still being in control of them. This approach is effective for OCD because you are not required to reduce or eliminate your obsessions to begin changing your behavior.
It is important to understand that the problem with OCD is not that it involves both obsessions and compulsions, rather the real issue is that the obsessions are always followed with compulsions. Thus, ACT teaches you how to be “adaptable enough” to exhibit a range of responses to your intrusive thoughts (obsessions). Thus, it is possible to work, spend time with your kids, loved ones, friends, and partner, prepare dinner, go out with friends, socialize, and enjoy life, while still obsessing over this or that. It does not have to be either/or.
How is that even possible?Although challenging, it is possible if you are able to look at your obsession in its truest form – simply thoughts floating around in your mind. That’s all. These thoughts are not dangerous and cannot physically hurt you. When you can see the intrusive thoughts as just thoughts or words in your mind, you can start enjoying life even if the obsession is still present.
ACT believes you have control of it, rather than it having control of you. The good news is if you practice mindfulness meditation and ACT techniques regularly, eventually you’ll be able to alter how you think about things and the thoughts and emotions will lose their power over you.
So, to sum it up, you can have an obsession AND still have a fulfilling life.
Note: Some people with OCD may find this approach odd or uncomfortable, especially if they are not keen on living with OCD. It is important to note that ACT may not be for everyone. It really just depends on your comfort level.
How Effective is ACT for OCD?
Is ACT effective for OCD? Yes!
In fact, ACT is effective for a wide-range of mental health conditions, including OCD. It is an uplifting and encouraging form of autonomy and independence. ACT use of mindfulness techniques makes it an extremely effective, reliable, and practical OCD therapy approach. This therapy approach is not only effective for OCD, but also beneficial for a variety of mental health needs like stress and depression.
ACT has been around for almost three decades, originating in the United States, and transcending into the Netherlands, England, Canada, Australia, and Sweden, Australia, and the Netherlands. Its spread stems from its effectiveness and usefulness. In fact, multiple studies suggest that ACT is more effective and beneficial for OCD than more traditional treatment programs like clinical case management.
What Do the Studies Say?
If you are like most people, you’ll want to know what studies say about a treatment before deciding if it is right for your condition. That’s totally normal and healthy. So, if you are wondering if ACT will work for your OCD, you are in luck because listed below are studies that can provide you with insight on how this treatment could or would work for you.
A 2010 study found that ACT was more effective than progressive muscle relaxation (PMR) in the treatment of all forms of OCD (i.e. hoarding, skin-picking, hair-pulling, repeated hand-washing and checking, excessive cleaning, etc.). Researchers also found that people with OCD may experience a noticeable decline in OCD after adding ACT to their prescribed treatment plans.
Similarly, others studies have found that ACT can reduce depression symptoms, and as a result, improve one’s quality of life. Researchers also found that ACT helps reduce OCD-related hospitalizations. Studies also indicate ACT “outperforms” other OCD treatments in life satisfaction, symptoms, and social functioning. It also has a positive effect on friends and loved ones, who care for people with OCD.
ACT’s effectiveness stems from its ability to embrace mindfulness, and help people with OCD connect to and accept reality through a cooperative relationship between reality and one’s deep-seated feelings, thus avoiding fixating on these emotions and experiences. Still, even though ACT has been used to treat mental health conditions like OCD for decades, research studies are limited on its effectiveness. Thus, more research is needed to determine its universal effectiveness for the treatment of OCD.
ACT for OCD has only been around for a few decades, so only a limited number of studies are available, as compared to more researched treatments like CBT and ERP. But, even though ERP research is more accessible, studies suggest that combining ACT and ERP may be highly beneficial for people, who are struggling with moderate-to-severe forms of OCD. ACT may also be a viable alternative treatment when ERP and traditional CBT have failed to successfully mitigate OCD symptoms.
Thus, researchers have concluded that ACT is useful for people, who have a hard time managing or controlling their obsessions, compulsions, and overall anxiety levels. This psychotherapy provides relief for these individuals after other treatments have failed. ACT also appears to be well-suited for people, who feel “tethered” to their obsessions – unable to break free from them on their own.
These individuals feel like they have little-to-no control over their OCD symptoms. So, yes, when it comes to using ACT for OCD, it works – at least for many people. Not only does it work, but it can help you have a productive life, despite the intrusive thoughts swinging around in your mind. Ultimately, ACT gives you back control over your life.
The good news is that more and more therapists are turning to ACT for OCD, which means you have more options to help treat your condition.
- Serani, D. (2011). An introduction to acceptance and commitment therapy. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/two-takes-depression/201102/introduction-acceptance-and-commitment-therapy
- Mayo Clinic. (2020). Cognitive behavioral therapy. Retrieved from https://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/about/pac-20384610
- Key, B. L., Rowa, K., Bieling, P., McCabe, R., & Pawluk, E. J. (2017). Mindfulness-based cognitive therapy as an augmentation treatment for obsessive-compulsive disorder. Clinical Psychology & Psychotherapy, 24(5), 1109–1120. Retrieved from https://doi.org/10.1002/cpp.2076
- Salazar, D. M., Ruiz, F. J., Ramírez, E. S., & Cardona-Betancourt, V. (2020). Acceptance and commitment therapy focused on repetitive negative thinking for child depression: A randomized multiple-baseline evaluation. Psychological Record, 70(3), 373–386. Retrieved from https://doi.org/10.1007/s40732-019-00362-5
- Sahebari, M., Asghari Ebrahimabad, M. J., Ahmadi Shoraketokanlo, A., Aghamohammadian Sharbaf, H., & Khodashahi, M. (2019). Efficacy of acceptance and commitment therapy in reducing disappointment, psychological distress, and psychasthenia among systemic lupus erythematosus (SLE) patients. Iranian Journal of Psychiatry, 14(2), 130–136. Retrieved from http://contemplative-studies.org/wp/index.php/2019/10/18/improve-the-psychological-well-being-of-lupus-patients-with-mindfulness/
- Butts, C. M. & Gutierrez, D. (2018). Using acceptance and commitment therapy to (re)conceptualize stress appraisal. Journal of Mental Health Counseling, 40(2), 95–112. Retrieved from https://doi.org/10.17744/mehc.40.2.01
- Gilmore, H. (2019). Brief summary of the 6 core processes of acceptance and commitment therapy (ACT). Psych Central. Retrieved from https://pro.psychcentral.com/child-therapist/2019/09/brief-summary-of-the-6-core-processes-of-acceptance-and-commitment-therapy-act/
- National Institute of Mental Health. (2020). Obsessive-compulsive disorder (OCD). Retrirved from https://www.nimh.nih.gov/health/topics/obsessive-compulsive-disorder-ocd/index.shtml
- Marsden, Z., Teahan, A., Lovell, K., Blore, D., & Delgadillo, J. (2018). Patients’ experiences of cognitive behavioural therapy and eye movement desensitisation and reprocessing as treatments for obsessive‐compulsive disorder. Counselling & Psychotherapy Research, 18(3), 251–261. Retrieved from https://doi.org/10.1002/capr.12159
- de Vries, Y. A., Roest, A. M., Burgerhof, J. G. M., & de Jonge, P. (2018). Initial severity and antidepressant efficacy for anxiety disorders, obsessive-compulsive disorder, and posttraumatic stress disorder: An individual patient data meta-analysis. Depression & Anxiety (1091-4269), 35(6), 515–522. Retrieved from https://doi.org/10.1002/da.2273
- Drugs.com. (2020). Medications used to treat OCD. Retrieved from https://www.drugs.com/condition/obsessive-compulsive-disorder.html
- Gans, S. (2020). Antidepressant and antipsychotic drugs used to treat OCD. Verywell Mind. Retrieved from https://www.verywellmind.com/medications-to-treat-ocd-2510644#:~:text=%20The%20following%20four%20SSRIs%20are%20approved%20by,3%20Paxil%20%28paroxetine%29%204%20Zoloft%20%28sertraline%29%20More%20
- American Psychological Association. (2020). What is cognitive behavioral therapy? Retrieved from https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
- International OCD Foundation. (2020). Exposure and response prevention (ERP). Retrieved from https://iocdf.org/about-ocd/ocd-treatment/erp/
- Psychology Today. (2020). Dialectical behavior therapy. Retrieved from https://www.psychologytoday.com/us/therapy-types/dialectical-behavior-therapy
- Stafford, B. J., & Pakenham, K. I. (2012). The effectiveness of an ACT informed intervention for managing stress and improving therapist qualities in clinical psychology Trainees. Journal of Clinical Psychology, 68(6), 592–513. Retrieved from https://doi.org/10.1002/jclp.21844
- Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., & Woidneck, M. R. (2010). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. J Consult Clin Psychology, 78(5), 705-16. Retrieved from https://doi.org/10.1037/a0020508
- Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behavioral Therapy, 37(1), 3-13. Retrieved from https://doi.org/10.1016/j.beth.2005.02.001
- Woods, D.W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behav Res Therapy, 44(5), 639-656. https://doi.org/10.1016/j.brat.2005.05.006
- Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., & Woidneck, M. R. (2010). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. J Consult Clin Psychology, 78(5), 705-716. https://doi.org/10.1037/a0020508
- Twohig, M.P. and Woods, D.W. (2004) A preliminary investigation of acceptance and commitment therapy and habit reversal as a treatment for trichotillomania. Behavior Therapy, 35, 803-820. Retrieved from https://www.scirp.org/(S(351jmbntvnsjt1aadkposzje))/reference/ReferencesPapers.aspx?ReferenceID=1217227
- Salyers, M. P., Stull, L. G., Rollins, A. L., McGrew, J. H., Hicks, L. J., Thomas, D., & Strieter, D. (2013). Measuring the recovery orientation of assertive community treatment. Journal of the American Psychiatric Nurses Association, 19(3), 117–128. Retrieved from https://doi.org/10.1177/1078390313489570
- Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behav Res Therapy, 44(1), 1-25. https://doi.org/10.1016/j.brat.2005.06.006
- Hayes, S., Wilson, K., Gifford, E., Follette, V., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology. 64, 1152-1168. https://doi.org/10.1037/0022-006X.64.6.1152
- Samaan, M., Treppner, K., Diefenbacher, A., Schade, C., Dambacher, C., & Fydrich, T. (2018). Effectiveness of acceptance and commitment therapy compared to CBT+: Preliminary results. The European Journal of Psychiatry, 32. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0213616317301398
- Grayson, J. (2013). ACT vs ERP for OCD: Is it war or marriage? The Behavior Therapist, 36, 12-17. Retrieved from https://www.researchgate.net/publication/280862832_ACT_vs_ERP_for_OCD_Is_It_War_or_Marriage