Sensorimotor OCD treatment using Acceptance and Commitment Therapy (ACT)
By George Maxwell
In this article, I’m going to take you through a 3rd wave behavioural treatment as it is applied to the OCD subtype, sensorimotor OCD. We’re going to be looking at Acceptance and Commitment Therapy (ACT) for sensorimotor OCD.
ACT is typically understood as a “radical behavioural” therapy, meaning that we can view everything that we do (both observably and in our heads) in the context of behavioural principles. The benefit to this is that we can then evaluate how certain behaviours (e.g., checking, rumination, neutralising) serve us in the direction of the type of life that we want, or hinder us. At risk of going too deep from the outset, this approach to understanding behavioural processes in terms of their function in ACT is founded in the philosophical position of functional contextualism. This philosophical position is used alongside another behavioural model of language development called, Relational Frame Theory (RFT). These foundations make ACT different in terms of how it is used, when compared to other therapeutic frameworks and treatments for mental health problems.
ACT is a transdiagnostic model, which means that it an be applied across diagnoses, problems and challenges. It does this by enhancing one valuable construct – Psychological Flexibility. Psychological flexibility is the idea of being free to move in the direction of the type of life that supports our values, without becoming “stuck” on unhelpful and workable thoughts, feelings and behaviours. Psychological flexibility seeks to improve our functioning by broadening our repertoire of responses to challenges in our lives and the world, so that we can direct our energies in the service of the life that we truly want.
Understanding how ACT can help Sensorimotor OCD
Sensorimotor OCD is a subtype of obsessive compulsive disorder (OCD) in which the sufferer becomes distressed by and pre-occupied with physical sensations and processes. As an example, they may become obsessed with breathing, blinking or swallowing. The distress associated with these processes is generated by negative thoughts related to the process. So, someone may have an intrusive thought about their blinking, which leads to a threat based emotion – typically anxiety – which then leads to increased attention on the physical sensation or process, and which is subsequently resolved by engaging in a compulsion like blinking “correctly.”
The use of these compulsions, and the relief that becomes associated with their use, leads to the compulsive behaviours getting maintained and used every time the intrusive thought around the sensorimotor sensation/process appears.
In traditional CBT with exposure and response prevention (ERP), we would seek to support the client to learn to tolerate the distress associated with the intrusion and sensation through prolonged repeated exposure, and we may also seek to enable reality testing around what it really does mean to have an intrusive thought. That is, is having a negative thought about a bad or scary thing the same as the bad or scary thing actually happening?
In ACT for sensorimotor OCD, we address the problem by developing psychological flexibility so that we use our values to guide our behaviour, rather than the internal elements of thoughts, emotions or sensations. We do this through the development of 6 processes:
- Present moment awareness: We use mindfulness skills to enable us to return to and maintain present attentional contact with the present moment. This means that we can attend to things in our lives as is, and maintain psychological flexibility.
- Defusion: Sometimes also called Cognitive Defusion, this process relates to recognising that the activity that our minds produce – our thoughts – are able to be observed and distanced from, rather than be taken literally and engaged in. We can defuse from all sorts of mental activity like worries, judgement, rumination, and memories and learn to “hold them lightly.”
- Acceptance: This is all about developing a preparedness, a willingness, to experience emotional and physical experience with openness and without struggle. By doing this we are freeing ourselves from internal struggles with with feelings that typically grab all of our attention and energy, and keep us stuck from the type of lives that we want.
- Self as context: This process is being able to recognise the part of our inner experience which is pure consciousness or awareness. This is a part of us that is able to hold and recognise all other aspects of experience.
- Values: In ACT terms, Values are viewed as a direction of navigation that we organise our behaviour around. If our behaviours are moving us away from our values, we are able to psychological flexibility and the techniques of ACT to use our values as our compass direction.
- Committed action: This is simply doing the behaviours necessary to move in the direction of the type of life that we truly want, while being open to inner experience and defused from unhelpful patterns of thinking.
Understanding Sensorimotor OCD from an ACT perspective could look like the following:
When we become aware of a physical sensation in our body, we fuse with negative thoughts, worries and ruminative processes which interpret that sensation as a threat or harmful in some way. This fusion leads us to feel anxiety, fear, frustration or disgust, and these emotional responses focus our attention on the sensation, just as it would if we interpreted an external threat like a predator or a bus coming towards us. We are not open to experiencing this emotion, and fuse with other thoughts around how much of a problem these emotions and sensations are for us, and about how we need to “fix” them.
Because we believe the thoughts that we need to fix our physical sensations and emotional states, we adopt certain behavioural strategies which we believe will reduce the likelihood of our negative thoughts coming true, and to get rid of the emotional distress that we are experiencing. The problem is that these efforts are not really going to be helpful or workable for us over the longer term. We are going to find ourselves dragged into an internal struggle with our thoughts, feelings and physical sensations because we believe (based on the thoughts that we are fused with), that the sensations are our problem, rather than our inflexible relationship to them.
When we focus on this internal struggle, which cannot be won using the strategies that we are using, we are no longer moving in the direction of the type of life that we really want and the problem becomes more of a focus for our attention. The focus on our sensations, our emotions and our ineffective use of compulsive behaviours as strategies to deal with them keeps us stuck and closely fused with the idea that we will have our sensorimotor OCD forever.
Defusion and Acceptance in Sensorimotor OCD
Let’s start by saying what acceptance is not. It isn’t a dismissive, hopeless, “just get over it” type of attitude. It is in fact much deeper and profound. It’s about allowing ourselves to get in direct conscious connection with whatever we perceive our problem to be. In the case of sensorimotor OCD, we would cultivate acceptance by getting in direct contact with the sensation or emotion, noticing but not being distracted by our thoughts, and exploring the feeling and all of its qualities as is. We would cultivate curiosity and openness into the feeling and explore qualities like intensity, location, boundaries, energy and depth. By practicing this we can reduce unhelpful reactive struggles with the sensation, and free ourselves up to move in the direction of our values.
In terms of defusion, despite never being born with language based thoughts, we grow to identify our thoughts, beliefs, and thinking processes as being “us”. So, whenever we have a negative thought about an aspect of our experience, we are likely to believe it and feel and behave in a way that is consistent with it. So, if we have a thought like, “I need to blink correctly or else someone else will die”, we will react to the thought as though it is true, rather than seeing it as just another thought.
In defusion we would teach you how to not overly identify with thoughts like this, to see then for what they really are and enhance your psychological flexibility to avoid stuckness.
Values and Committed action in Sensorimotor OCD
If we can’t trust our thoughts and our efforts to get rid of the physical sensations of sensorimotor OCD cause us more suffering than good, then we need to come up with a different strategy. To do this, we need to consider how we would be choosing to live our lives if our focus wasn’t on our OCD problem.
Values in ACT, which remember is a radical behavioural model of therapy, can be defined as:
““freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns of activity, which establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioural pattern itself” (Wilson, 2009).
Meaning that, when we establish our Values and engage in activities which are reflective of them, we are choosing to live our life on purpose in a valued and meaningful way.
Now compare living a life based on values to how life can look when we are battling with a sensation, thought or emotion. We may forego possibly life enhancing experiences because we are waiting until the problem goes, or because we are afraid of our OCD being triggered. Really, how much is our internal struggle causing us to deviate from our value based life?
Committed action is all about doing what we need to do to move in the direction of the Value based life. Engagement with an internal struggle can limit our behavioural repertoire of available responses. This means that when exposed to a potentially triggering situation for our OCD, we may avoid, or overtly or covertly use a compulsion. Committed Action requires us to build upon our psychological flexibility by broadening our behavioural repertoire beyond those of which our OCD limits us.
In practice, this could mean to go into a previously avoided social situation, maintain present moment awareness, defuse from thoughts, open up to the emotion and engage in behaviours that are workable in relation to our values.
This is just an overview of how we would approach sensorimotor OCD treatment using ACT. ACT is a very experiential therapy meaning that you learn through direct use of the techniques, rather than just reading about it. If you want to find our more about using ACT for sensorimotor OCD, or any other OCD subtype, then you can contact me, George Maxwell, at [email protected]