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.”