ACT and ERP for OCD

As I’ve mentioned many times before, ERP (Exposure Response Prevention) Therapy is the treatment of choice for OCD. However, a new acronym has recently made its way into the “OCD tool box.” Basically, ACT (Acceptance and Commitment Therapy) involves mindfulness and being able to accept your actions, as well as exploring your commitment to making changes. Think Serenity Prayer.

In a wonderful seminar at the 2012 IOCDF Conference, Dr. Jonathan Grayson discussed what is seen by many as competing therapies. He argued that the two therapies are really not at odds with one another, and that ACT is actually woven into ERP Therapy. Participating in an exposure involves acceptance. According to Dr. Grayson, the problem occurs when therapists use ACT without ERP.

ACT involves a top-down approach, where the sufferer works on changing his or her relationship with the whole world. While this therapy can certainly complement ERP Therapy, Dr. Grayson prefers starting with ERP Therapy, which is a bottom-up approach that specifically targets OCD. He used the analogy of an alcoholic working on his or her life’s problems while still drinking. It isn’t going to work. You’ve got to get the drinking under control and then you can move forward.

Surely, ACT can help those who suffer from OCD. For example, it can help with the acceptance of uncertainty, which is crucial in the treatment of the disorder. It can motivate sufferers who are engaging in ERP Therapy by helping them focus on their values, and what they want out of their lives. ACT has its place in the treatment of obsessive-compulsive disorder, and may even work as the main treatment for other mental health issues.

But OCD is unique, and the treatment for it is very specific. At this particular talk, and throughout the entire conference, this fact was stressed over and over: Exposure Response Prevention Therapy is the accepted treatment for OCD, and when done correctly, it works. While other therapies may have benefits as well, if you want to rid yourself of OCD’s grip, ERP Therapy is the way to go. And while it’s not easy, I don’t know of anyone who has ever regretted committing themselves fully to it. The payback is huge…..freedom from OCD.

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24 Responses to ACT and ERP for OCD

  1. 71º & Sunny says:

    You speak the truth, Janet! I do NOT ever regret undergoing CBT/ERP.

    ACT principles were (and continue) to be helpful to me – specifically the part of focusing on my values. My psychologist was quite bright, and she would help me to clarify what I really wanted out of life, and then to focus on that as the motivation for fighting the OCD. OCD was often an obstacle in achieving my life goals. Not so much anymore!!!

    Thanks for passing on great advice!

    • ocdtalk says:

      Thank you for sharing, Sunny! You are living proof that both therapies have their place in the treatment of OCD, and they both have definite benefits. Love your “Not so much anymore!!!”

  2. Good post, Janet. I’d really like to hear Dr. Grayson speak. I bet he was good.

  3. krystallynn says:

    Loved this post. It has recently come to my attention that OCD leaves me with so much anxiety when I do give in to my compulsions, that what do I have to lose doing an ERP? The relief of anxiety is so brief when I give in and check, it is never “just one more time”.
    Yes, doing ERP is uncomfortable, but if I am uncomfortable anyway why not take the chance on being uncomfortable with the ERP & doing myself some good? Your post today has re-affirmed that for me. Thank you.
    I can’t reason with my OCD because I already know my obsessions/compulsions are (what is the proper word?) false, lies . I can reason with the way I react to my thoughts and my (new) thinking, that I am going to be uncomfortable either way ,has helped me choose resisting a compulsion more and more these days. Not always, sometimes it is just too much.
    Maybe Dr. Grayson will write a book on ACT for those of us who do not have access to OCD therapy?

    • I enjoyed this entry and the discussion it provoked. It may have been mentioned here before but Jonathan Grayson did write a book on OCD treatment that includes what he would consider the ACT-like components of the treatment. I found it to be a great read as a therapist:

      Some of my colleagues and I recently had an article published that deals with some of the common pitfalls in ERP (referred to as “EX/RP” in the article) and how they can be addressed. It can be viewed here:

      • ocdtalk says:

        Thank you so much for commenting, Dr. Gillihan, and for those two great links. I have heard of Dr. Grayson’s book but haven’t read it and didn’t realize it included ACT components. I will definitely check it out. I appreciate the link to your article as well and look forward to reading it.

      • My pleasure! Dr. Grayson emphasizes learning to tolerate uncertainty as a key component of recovery from OCD. I think his approach–ERP generally, really–overlaps with ACT in that it’s about committing to choices that are consistent with what we value, rather than being driven by our fears, worries, OCD, and so forth. He also explicitly talks about acceptance in the context OCD. That said, I don’t think the book explicitly refers to ACT. I hope the article is useful. My guess is that the ideas will be very familiar. I’m open to any feedback you might have.

      • ocdtalk says:

        Thanks for the clarification. I hope to read the article in the next few days….

  4. ocdtalk says:

    I’ve always felt what you just stated, Krystal Lynn, that OCD sufferers have so much anxiety anyway, why not do the ERP? Of course, that’s easy for me to say as I don’t suffer from OCD. So I’m so glad you said it too!
    I know books have been written on ACT, but I’m not sure Dr. Grayson feels strongly enough about ACT for OCD to write a book about it. We’ll see!

  5. ocdsurvivor says:

    Loved this post, I too have never regretted undergoing CBT therapy!

  6. knowiterp says:

    Thanks for sharing a unique information on ERP Therapy I want more information on this topic will visit on your site again to read more please share some more information.

  7. ocdtalk says:

    Thanks for visiting my site. There is lots of information on Exposure Response Prevention Therapy out there. Check out some of the resources on my sidebar for more info!

  8. Emily says:

    My son and I have actually found tremendous benefits with the ACT approach without a heavy emphasis on ERP. I think it also depends on what kind of OCD one has. If it’s the so called pure O and the focus of it constantly changes, how do you even do the ERP in this case? ACT, on the other hand, allows you to not have to concentrate on the precise ERP steps which can in and of themselves turn into a compulsion and an obsession. I don’t know if others would agree with me but I also found that the approach we find most useful might have something to do with our personality type and the overall life philosophy. For example, my son is not at all a perfectionist and really believes in tolerance, acceptance of others, Buddism type beliefs etc. so the principles of ACT have suited him really well.

  9. Emily says:

    Sorry, also, forgot to mention the book we’ve used the most – it’s “The Mindfulness & Acceptance Workbook for Anxiety” by John Forsyth. I have read somewhere that the drop out rates in the ERP focused studies are much higher than in those concentrating on ACT.

    • ocdtalk says:

      Thanks for sharing your success with ACT, Emily. I’m happy you’ve found something that works for you. As you say, everyone is different, and you both obviously connected with ACT. I will say that my son also had mostly Pure O and did have success with ERP, so I don’t want those with Pure O to think that ERP can’t work for them. The bottom line is, if you’ve found a therapy that helps you battle OCD, that’s great! I’m glad you commented so that others who have not had success with ERP will be aware of this option.

  10. Janet: I was happy to come across your blog through your comment on the recent NY Times article, “Music of the Unquiet MInd”. Like you, I have a son (19) who has had pretty severe OCD for the past 3-4 years. We also live in the Boston area, and had him evaluated at the BU Center for Anxiety after junior year of high school. They referred us to a CBT psychologist that my son saw for a year. Although the therapist was a really nice guy and probably a good first therapy experience for my son–in terms of learning to talk to someone about his experience–CBT was not helpful for his OCD. We went through a crazily pressured senior year–the college search, etc. but it became clear that my son would need a gap year before going to college, so he could enroll in a program that really addressed his condition. (His decision–he didn’t want to go to college without being able to take full advantage of it). We enrolled him in McLean’s OCD Institute as a day patient (since we live in the area). Only then–through intensive ERP work, was my son able to start to really challenge and tackle his OCD effectively. As exotic and complicated as ERP was to us all at first, it is so clearly a vital part of OCD recovery. Unfortunately, after some weeks, insurance refused to continue to pay for this (very expensive) program because my son refused to take medication. He really wanted to tackle his OCD without meds. (Again–his decision).

    He became exposed to ACT in the latter stages of his time at McLean’s, right around when he also discovered insight meditation and mindfulness practice. Meditation, which mirrors many of the axioms of ACT, has been absolutely key to his continued recovery this past year.

    With the help of all this, he was able to do some more traditional gap year activities–travel to Central and South America–volunteering at an environmental project there…and was able to hold a job all summer upon his return.

    He also began an OCD support group that currently meets at the Friends Meeting House in Longfellow Park in Cambridge every Wednesday night at 7, for anyone reading this who is living in the Boston area.

    We have just returned from dropping him for freshman year at college. Not without trepidation, as he continues to deal with OCD and pretty acute social anxiety but meditation has helped him to accept his experience minute to minute, no matter how difficult.

    Like you, I have been heartbroken these past years watching my son suffer from this crippling disorder–although I am nothing short of inspired by his bravery and strength in tackling it. It takes such a huge toll. I continue to notice his sadness, the tension he carries so much of the time as a result of carrying this extra burden. It’s like he’s got to shoulder a 100 pound backpack all the time in addition to the regular load of living…

    But there is no question that the OCD journey has also been immeasurably rich, in terms of understanding mind, suffering, healing. I hope all the folks who are reading your blog seek the right combination of treatment, which from our experience, is multifold but definitely includes ERP and ACT as core components.

  11. ocdtalk says:

    Hi Dominique, I’m so glad you stopped by my blog and commented. Our sons stories do sound similar, and I wish your son all the best as he begins college. I blog for Connections (on Beyond OCD) and this month’s post (which should be up in a day or two) talks about some do’s and don’ts as those with OCD begin college, if you have any interest in reading it. You and your son have certainly been proactive and it sounds as if he has a lot of tools to help him. Please keep me posted as he begins this exciting part of his life!

    • Thanks, Janet. Please do send me the link to your blog re college students and I will pass it on to my son. I am sure it will be helpful–it makes such a difference to everyone to feel that a conversation about support and solutions is alive in the extended OCD community. I appreciate your efforts to deepen and broaden this conversation. The reason my son started an OCD support group was because there was really nothing available for young people in the Boston area–which is pretty shocking when you consider the area’s extensive mental health services. Combatting isolation and stigma and educating others about OCD is so key–I hope to go to the conference you attended next year.

  12. ocdtalk says:

    I think that’s amazing that your son started a support group, Dominique, and I’m guessing he is helping so many people, as well as (hopefully) himself. Yes, you would think something like that would already be available in Boston, but I’m not surprised. So many people have OCD and so many people are ashamed to admit it. So, yes, reducing stigma and keeping the conversation alive is so important. The blog link I mentioned is: and that post should be up in a day or so, I believe. The IOCDF Conference is pretty amazing… year it’s in Atlanta.

  13. First I wanna say thank you for this post, but for me.. I’m a 19 yrs old male suffering from Sensorimotor OCD about mainly blinkng/breathing & other pure O obsessions (anw I’ve already commented before on one post your wrote concerning sensorimotor issues describing my situation)… But for my case, I practiced ERP before.. It was useful no doubt, but I felt it had a paradoxical effect on my life because I was too concerned about my OCD and the ERP I practiced daily kept remnding me of my OCD, it kind putted my life on hold for a period of time till I improved a little bit… Whereas for ACT, the good thing is that you continue your life normally, and you Improve without thinking and practicing a lot, you just have to have a let go attitude.. Nowadays, I stopped ERP because I improved thank God, but I still do ACT when my obsessions occur during real life situations… So for me, I felt that ACT had a better impact on my life, in terms of my improvements , my peace of mind, and my productivity… That’s why, I think treatment efficiency depends from person to another… I would love to hear your opinion about that matter…
    Regards 🙂

    • Great to hear from you Ibrahim and I am so happy to hear you are doing well. I think it’s great that ACT has worked so well for you, and I’m not one to argue with success! While ERP is the accepted first line treatment for OCD, certainly different approaches and treatments might help different people, for different reasons. I wish you all the best and hope to hear from you again.

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