A Comparison of Two Brief Interventions for Obsessional Thoughts: Exposure and Acceptance

Exposure and response prevention (ERP) is the most effective psychological treatment for unwanted, intrusive thoughts associated with obsessive-compulsive disorder (OCD). However, the procedures involved in ERP (i.e., exposure) are challenging, provoke high levels of anxiety, and may contribute to treatment refusal and dropout (Franklin & Foa, 1998). To address this problem, researchers have begun to evaluate alternative treatments for OCD, such as Acceptance and Commitment Therapy (ACT). Despite the value of both techniques, little is known about the differential impact of these strategies. This study examined the relative effects of a single session of ACT or exposure for obsessional thoughts. There were 56 under- graduate participants with obsessional thoughts randomly assigned to receive a brief interven- tion with the core components of exposure, ACT, or an expressive writing control condition. Obsessional symptoms and related process variables were assessed at baseline and at 1-week follow-up. There were no statistical differences in believability or acceptability of the 3 condi- tions. Significant reductions in obsessional severity, behavioral tests of distress and willingness to experience intrusive thoughts, and negative appraisals of intrusive thoughts occurred in all conditions, but no differences were found between these conditions. Furthermore, changes in dysfunctional beliefs, but not in willingness to experience intrusive thoughts, predicted changes in obsessional symptoms in both the ACT and exposure conditions.Keywords: OCD; exposure; ACT; obsessionsAlthough obsessive-compulsive disorder (OCD) affects 2%-3% of adults (Karno, Golding, Sorenson, & Burnam, 1988), research shows that 80%-90% of the population at large experiences unwanted, negative intrusive "obsession-like" thoughts (Rachman & de Silva, 1978). Although such "normal obsessions" are less frequent and intense relative to their clinical counterparts, they are similar in content and form to clinical obsessions. That is, they can be unwanted and/or unacceptable personally relevant images, impulses, or doubts (e.g., the thought of stabbing a loved one, the image of having sex with one's sibling). Furthermore, many individuals who do not have OCD report experiencing distress associated with such intrusive thoughts, and they attempt to resist these thoughts as do people with OCD (Ladouceur et al., 2000).The most espoused psychological model of obsessional problems, which is derived from Beck's (1976) cognitive model of emotion, posits that obsessions develop when unwanted intru- sive thoughts are catastrophically misinterpreted (Rachman, 1997) as overly important or threat- ening. This misinterpretation evokes anxiety and a preoccupation with the thought; for example, one might believe that an unwanted thought of harming a loved one is actually indicative of deep-seated violent tendencies or that merely having this thought makes the corresponding event more likely. Misinterpreting unwanted, intrusive thoughts in this way not only leads to distress and preoccupation but also provokes "safety behaviors" (i.e., rituals, reassurance-seeking, avoid- ance) that maintain the misinterpretations (Rachman, 1997).This model has implications for treatment, specifically that reducing obsessional problems requires correcting the misinterpretations about unwanted thoughts. One technique shown to produce such change is therapeutic exposure, which involves confronting feared stimuli until the associated anxiety/distress is reduced (Abramowitz, Deacon, & Whiteside, 2011). One par- ticular form of exposure-imaginai exposure (IE)-has been used to specifically address obses- sional problems. IE involves deliberately confronting anxiety-provoking intrusive thoughts (e.g., by writing and reading them over and over while resisting urges to perform safety behaviors) and not only teaches individuals that their distress will decrease in the presence of such thoughts but also teaches them to correct misinterpretations associated with these thoughts (Abramowitz et al. …