An Initial Investigation into the Processes of Change in ACT, CT, and ERP for OCD.

The development of empirically based treatments for obsessive compulsive disorder (OCD) has gone through many phases and has been informed by several practices. Initial applications of behavioral treatments for anxiety disorders were directly linked to laboratory research on conditioning (e.g., Jones 1924; Wolpe, 1958). Meyer (1966) refined these procedures for the treatment of OCD into what we now know as exposure and ritual prevention (ERP). Behavioral processes such as respondent conditioning and operant avoidance (e.g., Mower, 1960) were proposed as the processes through which the effects were produced in ERP (Eyseneck & Rachman, 1965; Rachman & Hodgson, 1980). ERP has been well-researched and its effectiveness demonstrated (Abramowitz, Franklin, & Foa, 2002), and remains a first line intervention for adult and childhood OCD. However, secondary to the difficulties associated with ERP including high drop-out and treatment refusal rates, and partial treatment response, cognitive approaches to OCD have increased in popularity (e.g., Rachman, 1997, 1998; Salkovskis, 1985; Wilhelm & Steketee, 2006). Original cognitive conceptualizations of anxiety disorders focused on the role of inaccurate cognitions as proposed by Beck (1976) and Ellis (Ellis, 1962). Carr (1974) and McFall and Wollersheim (1979) put forward initial cognitive conceptualizations of OCD. Since that time, cognitive conceptualizations of OCD evolved (Rachman, 1997, 1998; Salkovskis, 1985) to incorporate the detrimental effects of thought control (Clark, Ball, & Pape, 1991; Tolin, Abramowitz, Przeworski, & Foa, 2002), thought action fusion (Shafran, Thordarson, & Rachman, 1996), and inflated responsibility (Salkovskis et al., 2000), as well as other concepts (e.g., Wilhelm & Steketee, 2006). Nevertheless, cognitive theorists postulated that belief change at least partially mediates changes in behavior (e.g., Rachman, 1997, 1998; Salkovskis, 1985). At the same time that CT was developing, a separate line of research grew out of behavior analysis that focused on language and cognition as explicated in relational frame theory (Hayes, Barnes-Holmes, & Roche, 2001). Based on this line of research and a functional contextual approach to science, another version of "CBT," acceptance and commitment therapy (ACT) (Hayes, Strosahl, & Wilson, 1999), developed. ACT generally focuses on the function of cognitions and other inner experiences to decrease their impact on overt behavior without targeting the content of these inner experiences. Overt behavior is addressed through values work (e.g., future directed motivational enhancement) and commitments to behavior change. The data on ACT as a treatment for OCD is limited to a time-series design and one randomized clinical trial comparing ACT to Progressive Muscle Relaxation (Twohig, Hayes, & Masuda, 2006, Twohig et al., 2010). The addition of ACT and other third generation therapies has led to a noticeable amount of theoretical discussion on the similarities and differences of these treatments. Special issues on this topic have occurred in Clinical Psychology Review (Longmore & Worrell, 2007; Hofmann, 2008a; Worrell & Longmore, 2008), the Behavior Therapist (DiGuiseppe, 2008; Hayes, 2008a; Leahy, 2008; Moran, 2008; O'Brien, 2008; Salzinger, 2008) one review dealing with the treatment of anxiety disorders in Clinical Psychology Science and Practice (Arche & Craske, 2008; Hoffman, 2008b; Hayes, 2008b; Heimberg & Ritter, 2008) and one issue on OCD specifically Cognitive and Behavioral Practice (Chosak, Marques, Fama, Renaud, & Wilhelm, 2009, Himle & Franklin, 2009; Tolin, 2009; Twohig, 2009; Twohig & Whittal, 2009); these are in addition to individual reviews and replies that exist (DiGiuseppe, 2006; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hoffman & Asmundson, 2008; Levin & Hayes, 2009; Ost, 2008; Powers, Zum Vorde Sive Vording, & Emmelkamp, 2009). …