SUDS vs. Willingness: Values-Based ACT Exposure for OCD

Throughout the years, I’ve written a series of blogs posts on exposure therapy, including the use of exposure therapy in Acceptance and Commitment Therapy. In the absence of much guidance on using exposure in ACT, I co-authored a theoretical paper on its use in treating PTSD.

Recently I read an excellent paper outlining the use of ACT and exposure for OCD.

Exposure therapy for OCD from an acceptance and commitment therapy framework

The article is a collaboration of 2 major research labs: Utah State professor Michael Twohig, a pioneer in the use ACT for OCD, and Jonathan Abramowitz, a professor at the University of North Carolina – Chapel Hill, and an incredibly prolific researcher in the field of anxiety.

The article walks through how exposure in an ACT context is different from traditional exposure and includes an example case, Monica, to illustrate treatment.

The authors provide helpful examples of values-based exposure exercises that emphasize willingness (i.e., acceptance) towards uncomfortable thoughts and feelings over traditional reduction in discomfort (e.g., habituation). As I’ve written about previously, difficulty with acceptance may maintain and exacerbate OCD symptoms. The authors note an overlap between an ACT approach and newer inhibitory learning approaches to exposure.

As the article is very readable and straightforward, there’s not much for me to say about it. I thought I’d expand upon and share my experiences with a few of the authors suggestions about relinquishing the traditional use of SUDS scores (i.e., discomfort) in favor of tracking the ACT process willingness, and of some of the difficulties in creating values-based exposure exercises.

SUDS vs. Willingness

In place of a traditional SUDS scale, the authors recommend a Willingness Scale, defined as the degree to which clients are will to be open and accepting of inner experiences (i.e., thoughts, feelings, bodily sensations) during exposure in service of their values (i.e., qualities of living that are important to them).

As the authors note, when you ask a client for a Willingness score, you often receive an inverse SUDS score rather than willingness in a strict ACT sense. More simply, clients are typically more willing to accept lower distress and less willing to accept higher distress.

The authors describe how in these instances they help the client separate “one’s openness to the experience from the severity of the experience.” In my experience this can be tricky. Some clients take right away to the concept of willingness and it can be very powerful for them. Other clients I’ve worked with successfully complete treatment but (I suspect) may not quite understand willingness in the ACT sense.

I would also note that SUDS scores can be used as part of ACT for exposure. What would be inconsistent with an ACT approach would be to use SUDS to emphasize habituation to discomfort. I want to be clear that the article authors are not explicitly anti-SUDS—I only mention this because I have heard some people express the view that ACT-based exposure is incompatible with tracking SUDS. This is a misunderstanding.

For these reasons, I still ask about SUDS scores and Willingness scores when conducting exposure. For one, SUDS scores help me catch when Willingness score are simply an inverse of SUDS. Secondly, it provides a view into the client’s experience, as it’s often hard to gauge a client’s distress from the outside. Lastly, I see value in clients tracking distress—especially in people with OCD. Many people with OCD do not believe their obsessions 100%, but they fear their anxiety will spiral out of control if they don’t engage in their compulsions. SUDS scores can help clients observe if their actual experience matches what their minds tell them. Some notice distress doesn’t become overwhelming as predicted, or that it passes more quickly than expected.

Values-based exposure

I also want to comment on the authors’ discussion of values-based exposure. They have a really useful table (Table 2) in the article listing how exposure exercises were linked to values in the example case. Values can help motivate clients to engage in exposure and bring more meaning to the process. In my experience, though, it is not always easy to clearly link exposure exercises to values. This paper helps provide guidance.

Sometimes I’ve found it useful to start with a more basic exposure exercise that can be easily conducted in session even if it is less directly connected to values This can serve as an introduction and help orient clients to exposure work. When I was first experimenting with values-based exposure, I could spend entire sessions trying to identify one ERP exercise that a client really valued! Instead, I’ve found it simpler to come to session with some ideas and ask, “Would you be willing to start with X or Y?” to get started. As clients start to understand exposure work through experience, they can offer more precise guidance and feedback.

When asked about valued activity, additionally, some clients will tell you they are engaged in valued living but that dealing with obsessions is exhausting and interferes with connecting with joy. In these instances, the value may simply be learning to be more present with their experiences of activities in which they are already engaged.

Summary

This collaborative article `from two major OCD/anxiety research labs provides one of the best illustrations of using ACT and ERP for OCD that I’ve read. I highly recommend it to anyone interested in ACT and exposure, and even non-ACT people who are interested in advancing models for exposure. I’ve offered a few opinions based on my experience conducting exposure in an ACT context that I hope readers find helpful.

If you’d like to read the article and, like me, don’t have access to journals behind paywalls, you can download an uncorrected proof from the authors’ ResearchGate page. You’ll notice a few typos in the proof such as “fiend” instead of ”friend.” 🙂

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

Is Exposure Practice More Effective in the Morning?

Some studies have looked at enhancing exposure therapy by administering glucocorticoids, steroid hormones that increase levels of cortisol in the body. The exact mechanisms are not quite understood but studies have found that participants given glucocorticoids show better outcomes in exposure therapy for people with spider phobia (Soravia et al., 2014) and fear of heights (de Quervain et al., 2011). It is speculated that higher levels of cortisol enhance learning during exposure.

Rather than rely on drug administration, a new study researcher Dr. Alicia Meuret and colleagues studied a more naturalistic means to harness the exposure-enhancing effects of higher cortisol. People naturally have higher levels of cortisol in the mornings upon awakening.

In a blog post about the study, Dr. Meuret is quoted:

“The hormone cortisol is thought to facilitate fear extinction in certain therapeutic situations,” said Meuret, lead author on the research. “Drugs to enhance fear extinction are being investigated, but they can be difficult to administer and have yielded mixed results. The findings of our study promote taking advantage of two simple and naturally occurring agents – our own cortisol and time of day.”

Study

In this new study by Dr. Meuret and colleagues, 26 people with panic disorder were treated with 3 sessions of weekly exposure therapy followed by a fourth session 2 months later. Participants collected saliva samples at set points during the day which the researchers tested for cortisol levels.

Findings

Consistent with prior studies, the researchers found that higher cortisol levels were associated with a quicker response to treatment.

Moreover, participants who had morning sessions—when natural cortisol levels are higher—showed greater improvements at the end of treatment and 3 months later than participants who attended evening sessions, when cortisol levels are lower.

Some final thoughts

It’s important to keep these results in context. This was a pilot study showing a large effect in a small sample. Results in smaller samples are more prone to being influenced by outliers or other factors, and this study needs replication in order to be more confident about the findings. In particular, it’s possible that therapist expectancy may have had an effect here, as it doesn’t appear the therapists were blinded to the study hypotheses. Nevertheless, this is an intriguing and interesting study.

Limitations aside this study does suggest that—all things being equal—it might be advantageous to schedule exposure sessions earlier in the morning when cortisol levels are higher. The mechanism is not quite clear, but there is evidence that cortisol may enhance learning associated with exposure.

You can read the original blog post about the study on the Southern Methodist University website.

If you’d like to download a copy of the journal article, it is currently available on the authors’ ResearchGate page.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

An Interview with Michelle Craske, PhD, on “Maximizing Exposure Therapy for Anxiety Disorders”

An Interview with Michelle Craske, PhD, on “Maximizing Exposure Therapy for Anxiety Disorders”

In my ongoing series of posts about exposure therapy, I’ve written several times about the work of UCLA professor Michelle Craske, PhD. Dr. Craske has been on the cutting edge of exposure research, and her work has undermined the traditional notion posited in in the emotional processing theory that habituation to a feared stimulus is important in exposure work.

The Society for a Science of Clinical Psychology has posted an interview that Dr. Jacqueline Persons conducted with Dr. Craske on “Maximizing Exposure Therapy for Anxiety Disorders.” This approximately 47-minute interview is an excellent introduction to and distillation of Dr. Craske’s work. The webpage also includes a pdf of a 2014 paper Craske authored summarizing this model.

Dr. Craske’s model focuses on using exposure to cultivate inhibitory learning to create new learning that overrides the fear-based association called excitatory meaning. The idea is that through repeated exposure, new learning occurs that contradicts the unhelpful more fear-based associations that result in anxiety and avoidance behavior.

3 considerations in the inhibitory learning model for conducting exposure with a client

In her interview, Dr. Craske emphasized three important things to consider in using exposure:

  1. What does this person really need to learn (i.e., inhibitory learning) in order to be less afraid of the fear stimulus (i.e., excitatory meaning) that will lead to improvement?
  2. How can the exposure exercise be designed to maximally benefit that learning; that is, how can the exposure exercise “violate” what that person expects will happen (e.g., usually something bad) based on the excitatory learning?
  3. New learning will occur both during the exposure exercise and long afterward through a period of consolidation. Consequently, whether someone’s distress diminishes (i.e., habituation) during the actual exposure exercise is not as important as the actual learning that may occur during and following the exposure.

Role of cognitive restructuring

Dr. Craske also had some interesting things to say about the role of cognitive restructuring in exposure work.  In traditional CBT, exposure work may be preceded by cognitive restructuring. According to Dr. Craske, preceding exposure work with cognitive restructuring may actually undermine the exposure work by softening the violation of the person’s expectations—the expectations based on the excitatory meaning of the feared stimulus. Consequently, Dr. Craske stated her lab will do cognitive restructuring after the exposure work as a means to help consolidate the new learning (i.e., inhibitory learning).

Check out the tables on the linked research paper!

Dr. Craske’s work can be a bit dense to read. Even if you don’t intend to read it, I encourage you to download the 2014 paper that is linked to the interview. Following the Reference section are 6 tables that offer concrete examples for using inhibitory learning to conduct exposure with specific anxiety-related problems and deepening the impact of the exposure. The paper also includes clinical examples and can serve as a useful reference for the interview.

In conclusion

If you have any interest in exposure at all, I encourage you to listen to this interview with Michelle Craske on “Maximizing Exposure Therapy for Anxiety Disorders.” She speaks very clearly and elegantly about her work on inhibitory learning in manner that is very accessible.

The link also allows you to download a research paper summarizing this work. Download it. Even if you’re not up to reading a 30-page research article, it provides a nice reference and includes clinical examples and tables with suggested wording for setting up exposure exercises.

A special “thank you” to Dr. Jacqueline Person for conducting the interview, and to the Society for a Science of Clinical Psychology for posting it!

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

Shorter Imaginal Exposure Sessions as Effective as Longer Exposure for PTSD

Shorter Imaginal Exposure Sessions as Effective as Longer Exposure for PTSD

Prolonged exposure (PE) is an evidence-based cognitive behavioral treatment that uses imaginal and in vivo exposure in the treatment of PTSD. Imaginal exposure involves the client recounting a core traumatic event in great detail repeatedly in session, and then listening to an audio recording of the exposure daily between sessions. In additional to imaginal work, clients engage in in vivo (Latin for “in life”) exposure to trauma-related triggers. Exposure is done until the client habituates to the trauma-related similar, and/or until PTSD symptoms are largely resolved, according to the PE model.

For those unfamiliar with exposure therapy, you can read more about other blog posts I’ve written on exposure.

Standard PE sessions are too long for how most therapists now practice

The research supporting PE is impressive, and I’ve always been impressed with the relative simplicity of its protocol. However, one concern I’ve had about the treatment protocol is that sessions are 90 minutes long, which is nearly impossible to have covered by insurance nowadays. When medical billing codes were revised in 2013, the code for a 90 minute session was cut, and 60 minutes became the longest standard session for which a therapist could bill. This change made PE out-of-step with the practice limitations of many therapists in the US.

To their credit, PE researchers responded to this concern in a recent study (Nacasch et al., 2015). This study is an improvement of a similar study (van Minnen & Foa, 2006) from several years ago.

The study

In the most recent study, 39 veterans were randomly assigned to 10-15 sessions of PE at either 90-minute with 40 minutes of imaginal exposure each session, or 60 minutes with 20 minutes of imaginal exposure each session.

What did they find?

  • Participants in the 60-minute sessions improved just as much as those in 90-minute sessions. There was no difference in outcome between the 2 groups at treatment completion.
  • Although participants in the 90-minutes sessions exhibited greater habituation to trauma-related stimuli, this didn’t impact the overall outcome for either group. I interpreted this as further evidence that, contrast to the emotional processing theory underlying PE,  habituation is a poor marker of improvement in exposure. The authors defend between-session habituation to some degree but admit that it does not seem to be a necessary condition for improvement in PTSD.
  • Very interestingly, even though participants in the 90-minute session condition were receiving twice as much therapy, they did not improve any more rapidly than those in the 60-minute session condition. Both groups completed treatment in the same number of sessions. In this instance, more is not necessarily better.

Summary

This is an extremely important study in that it provides evidence that—for prolonged exposure, at least—not only do people show as much improvement in 60-minute sessions as 90-minute sessions, that 20 minutes of imaginal exposure is no less effective than 40 minutes per session.

Shorter sessions and shorter exposure times can reduce the burden (e.g., time; money) for clients, and it makes it more feasible to offer evidence-based treatments such as PE in settings where 90-minute sessions are not covered.

My hope is that the main researcher and PE core originator, Dr. Edna Foa, does a similar study with her OCD exposure protocol, too, which also relies on 90-120 minute sessions!

If you want to read the full article yourself, the published version is behind a pay wall. However, one of the authors made the “in press” version available here.

Brian Thompson Ph.D.

Author: Brian Thompson Ph.D.

Brian is a licensed psychologist and Director of the Portland Psychotherapy Anxiety Clinic. His specialties include generalized anxiety, OCD, hair pulling, and skin picking.

An Alternative to Exposure and Response Prevention for OCD

An Alternative to Exposure and Response Prevention for OCD

Numerous studies have now shown that Exposure and Response (or Ritual) Prevention (ERP) remains  our most effective treatment for obsessive-compulsive disorder (OCD).  In ERP, clients deliberately confront feared stimuli while learning to refrain from engaging in compulsions.

Even with the effectiveness of ERP, the search continues for how to get even better results, as not everyone benefits from ERP and some clients are resistant to it. Recent research on Acceptance and Commitment Therapy (ACT) suggests that other approaches—such as learning to observe obsessions without engaging or “buying into” the content of the obsessions—can supplement ERP. One of the core ideas of ACT is helping clients to mindfully observe obsessions with greater distance.

I recently came across a new paper that focuses on these newer approaches to OCD and thought it might be helpful for clinicians working with OCD. The authors provide a nice summary of recent research on the use of ACT, Dialectical Behavior Therapy, mindfulness-based approaches, and Metacognitive Therapy in the treatment of OCD.  They also provide some background on the roots of ERP in behaviorism and (later) cognitive therapy. The authors summarize what makes these approaches unique in the treatment of OCD:

In general we agree that most approaches to OCD address the function of inner experiences to some degree; in addition arguing that what makes the approaches covered here unique is the greater or complete shift toward addressing the function of inner experiences and a substantial reduction in categorizations of types or styles of inner experiences. (p. 34)

I would like to emphasize that none of these newer strategies are incompatible with ERP. I often find they are a useful complement to exposure work in my clinical work. My sense is that these strategies can help us expand our range of effective treatment interventions for OCD to help prepare clients for exposure work or as an alternative for those who are not willing to engage in ERP.

If you’d like to read the paper, you can currently download a pdf for free here. For a list of other blog posts I’ve written about exposure, click on this link.

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