The Importance of Acceptance in Dealing with Obsessive-Compulsive Disorder

People with OCD are often plagued with a wide variety of painful thoughts. These include horrible images, worries they might harm themselves or others, or beliefs that they are condemned altogether. It’s natural why people would struggle with these, why they would try to push them away and get rid of them.

However, there’s a wide literature of research demonstrating that efforts to get rid of painful thoughts make them more intense and more intrusive. And there’s newer research that finds that acceptance of painful thoughts and feelings may be the most effective way for defusing OCD.

The study

OCD expert Dr. Jonathan Abramowitz’s lab looked at the relationship of two ways of dealing with OCD. The study found an advantage for mindful acceptance over brute endurance of obsessions.

One way of relating to inner experiences, called distress tolerance, refers to enduring painful emotions. This is akin to “gritting your teeth” and powering your way through it.

The other way is called psychological flexibility, the opposite of what is called experiential avoidance. One major process in psychological flexibility involves experiential acceptance, being “open and willing” to experience uncomfortable thoughts and feelings.

What the researchers found was that willingness (i.e., choosing) to accept painful thoughts and feelings was associated with lower obsessions. They further suggest that this relationship may be especially true for people who struggle with mental rituals (e.g., Pure “O”).

Limitations

There are limitations to this study. It was correlational and involved college students. The study did not specifically look at the impact of treatment.

Summary

New research suggests that how people relate to OCD-related thoughts and emotions may be important in the maintenance of OCD symptoms. Specially, people who are more willing to experience discomfort without engaging in compulsions may do better than those who can resist compulsions but do so through gritting their teeth and enduring it.

For these reasons, newer acceptance-based treatments such as Acceptance and Commitment Therapy (act for short), which already has good research support in treating OCD, may have something unique to offer.

In working with OCD, I often start with ACT skills building to help people learn to mindfully accept unwanted thoughts and emotions before moving into ERP (exposure and response prevention). In my experience, the ACT work offers people—especially those with more mental rituals—additional tools for working with OCD symptoms, and helps prepare them to engage in the tough exposure work.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website, where I described how I use Acceptance and Commitment Therapy to help enhance exposure and response prevention

People with OCD Prefer Exposure to Alternative Treatments

Mad in America published a summary of a recent study that surveyed people with OCD about treatment preferences. I spent the last hour trying to track down a copy of the actual research article, which has not been officially published yet, but I was unable to locate a pdf and read it myself.

One of the authors is Dr. Helen Blair Simpson, whose brief information video about OCD is a good one.

The study

The researchers surveyed 216 people with OCD about their treatment preferences. Most people preferred Exposure and Response Prevention (ERP) as a 1st line treatment. The 2nd most popular treatment was serotonin reuptake inhibitors (i.e., antidepressants). Based on how the abstract was worded, there may be no statistically significant difference between preference for ERP (55%) and preference for antidepressants (45%).

Interestingly, people who preferred antidepressants were more likely to have higher income, private insurance, and a longer history of OCD treatment. According to the Mad in America article:

The researchers theorized that this may be due to this group having “received high-quality psychiatric care that afforded them the time and attention to discuss and resolve concerns about medication.” That is, people without these resources may have had poor experiences with medication management in which they felt pressured or their concerns were not heard. Psychotherapy may have provided an approach tailored to their individual concerns, making it more desirable.

People with OCD didn’t want antipsychotic drugs

People with OCD already taking antidepressant medication preferred ERP as an adjunct treatment over augmenting the antidepressant medication with an antipsychotic. In a prior post, I wrote about research that suggested that antipsychotics were not a useful adjunct treatment for OCD.

Acceptance and Commitment Therapy (ACT), an evidence-based treatment that we offer, was also well received among alternatives to ERP and medications. In a prior blog I used to write for, I wrote about a study on the use of ACT for OCD without deliberate exposure, and OCD researcher Dr. Michael Twohig has a page about ACT and OCD on the IOCDF website.

One theme that stood out to me reading about the study was how well-informed the sample of people with OCD is. Their preferences are remarkably consistent with current research about OCD treatment.

You can read the Mad in America article here, and an abstract of the research study here.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website, where I described how I use Acceptance and Commitment therapy to help enhance exposure and response prevention.

The Importance of Treating OCD Earlier: The Washington Post Article on Ethan’s Struggle from Childhood OCD through Adulthood

In people who develop obsessive-compulsive disorder, there are often signs in childhood. However, OCD in children can be hard to distinguish from childhood fears and age-appropriate magical thinking. For OCD Awareness Week, The Washington Post published an article by Sarah Maraniss-Vander Schaaf about the experiences of Ethan, a young man who developed OCD in childhood. It’s an effort to help people look past the stereotypes of people with OCD as being excessively clean and organized or washing their hands excessively. As the writer notes:

“…true OCD is often unspoken. It’s hard to recognize, as well, when growing up in a family where anxiety is normal, or in a school where behavior might be labeled school avoidance, or when no one else talks about the secret rituals that are too private to mention.”

The article traces the development of Ethan’s OCD from early childhood, though college, and the following decade of adulthood. It documents how OCD obsessions and rituals can escalate when left untreated and unchecked, and it provides a sober illustration of how the accommodation by the loved ones of someone with OCD’s obsessions/rituals—however well-meaning—can have disastrous consequences over time.

I’ve written in other posts about how some people with OCD have difficulty accessing appropriate treatments. Ethan was eventually accurately diagnosed and offered effective treatment, but it took several attempts before he was fully willing and able to engage treatment. He was even kicked out of OCD Institute at McLean Hospital, one of the leading residential treatment programs for people with OCD. Ethan didn’t recover from OCD until he was willing to commit to proper treatment—particularly exposure and response prevention. Ms. Maraniss-Vander Schaaf writes:

His improvement came when he accepted CBT and Exposure Response Prevention (ERP). He was taught to develop a new relationship with his thoughts. He learned to live with the uncertainties of life and not push away anxiety with obsessive-compulsive thoughts and actions.

Ethan’s story is inspiring as, even after 2 decades of struggling with severe OCD, he is currently enjoying a productive and independent life. As I work with adults, I don’t often have a full view of how OCD progresses across the lifespan in the clients I see. I found this article of Ethan’s personal journey into OCD illuminating in how it presents a narrative of someone’s struggles with OCD across more than 2 decades, and the way OCD symptoms can change, transform, and evolve over time.

You can read the full article here.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website.

If you want to learn about OCD, here’s post about a great introductory book, Tompkins’ OCD: A Guide for the Newly Diagnosed.

How Self-Compassion Helps with Anxiety

Anxiety can be a loud voice in your head telling you that something bad is going to happen.   Your heart rate starts to quicken, your thoughts speed up, and you feel a knot in your stomach. At times, you might feel disconnected from yourself or the world around you.

Moments in which you are experiencing anxiety can be quite uncomfortable. They can also be an opportunity to practice relating to yourself with self-compassion.

What is Self-Compassion?

Self-compassion has three parts:

  1. Self-kindness (instead of self-judgment)
    Self-kindness involves opening up to your experience in the present moment, whether feelings of joy or sadness, and acknowledging your experience with warmth and love.
  2. Common humanity (instead of isolation)
    Self-compassion includes an acknowledgement that suffering is a normal part of being a human being. Often we feel alone or isolated in our suffering, but it is actually what connects us to others.
  3. Mindfulness (instead of over-identifying)
    Mindfulness involves observing thoughts and feelings, rather than identifying asthoughts and feelings. There is a difference between noticing the content of your thinking (e.g., “I’m having the thought that something bad is going to happen”) and taking your thoughts at face value and buying into the content of your thinking (e.g., “Something badis going to happen”).

One important study found that more self-compassion is associated with less symptoms of anxiety and depression. This does not mean that people engaging in self-compassion do not feel anxious or sad sometimes. They certainly do, as do all of us. However, welcoming rather than criticizing experiences of anxiety allows us to let go of struggling with anxiety, helping us let go of harsh judgments of ourselves and our experiences.

One of the great things about self-compassion exercises is that they can be practiced at any time. You can feel incredibly sad, anxious, or frustrated with yourself, and begin to build a habit of self-compassion.

How Do I Practice Self-Compassion?

Dr. Kristin Neff is probably the world’s leading expert on self-compassion and one of the key exercises she teaches is something called the “Self-Compassion Break.”

The exercise is done when you are in the midst of a situation that is causing your suffering or you are feeling something like anxiety, frustration, sadness, or any other painful emotion. You can use this exercise during any moment where you are having a hard time. The basic instructions include three steps:

  1. Acknowledge the pain or discomfort that you are feeling. You might say, “This is a moment of suffering.”
  2. Acknowledge your connectedness to others. You could say, “Suffering is a part of life.”
  3. Put your hands over your heart and say, “May I be kind to myself.”

If you want to hear an audio version, you can listen to it here. For a more detailed description of the exercise, see here. Once you practice the exercise a few times, you’ll find you can do it quite quickly whenever you need it.


Relating to your anxiety with self-compassion can help you make space for it, allowing it to be, rather than getting caught in a prolonged game of “anxiety tug-of-war.” Through self-compassion–through learning to relate to yourself and your experiences with kindness and compassion–you can learn to let go of internal struggles and connect more fully with the world around you.

For more self-compassion meditations or exercises, you can visit Dr. Neff’s resources or resources compiled by Portland Psychotherapy.

Click here to learn more about Anxiety Treatment at Portland Psychotherapy

Self-Help for Anxiety in an International Sample

Since I saw him present on some preliminary results at a conference 6 years ago, I’ve been following with interest University of Albany – SUNY professor John Forsyth’s, PhD, research on his self-help book, The Mindfulness and Acceptance Workbook for Anxiety. (The Workbook was recently published in a 2nd edition but the research is on the 1st edition.)

The Workbook is based on Acceptance and Commitment Therapy (ACT) principles, and it is designed to treat a wide range of anxiety-related problems (it’s “transdiagnostic”).

Self-help books have great potential to help people who don’t have access to or don’t want to pursue psychotherapy. Unfortunately, self-help books are rarely based on well-researched treatments, let alone studied themselves as standalone treatment. Dr. Forsyth and his co-author Dr. Georg Eifert have been working very hard to make their book an exception.

The Most Recent Study

In the most recent published study, Dr. Forsyth’s lab gave out copies of the Workbook to a large (503 people!) international sample—mostly American, with people from the UK, Canada, Australia, New Zealand, and other countries. Participants either received a copy immediately, or they were assigned to a 12-week waiting period before receiving a copy. They completed questionnaires before receiving the book and 12-months later, with follow-up assessment at 6 and 9 months. All waitlist participants received a copy after 12-weeks and completed the same post-treatment and follow-up measures.

Contrary to research studies of self-help books that may include regular phone consultation or other forms of therapist/researcher contact, Dr. Forsyth’s lab deliberately chose to not offer guidance for participants using the Workbook in order to examine how useful it was in the way it would normally be used.

What They Found

The sample included people with generalized anxiety disorder, OCD, major depressive disorder, panic disorder, obsessive-compulsive disorder, social anxiety disorder, and posttraumatic stress disorder, among other conditions.

Participants in both conditions showed improvements in anxiety, depression, worry, quality of life, mindfulness, and self-compassion after using the book, and some continued to show improvement at the 6 and 9-month follow-ups. As a comparison sample, people on the waitlist did not show significant improvement until after receiving and working through the Workbook.

What was really interesting is that some of the improvements in scores on the measures were comparable to studies that involved individual ACT treatment delivered by therapists.

Summary

Dr. Forsyth’s recent publication offers further evidence that The Mindfulness and Acceptance Workbook for Anxiety is a helpful, cost effective treatment option for people struggling with a variety of anxiety-related problems. In my work as an anxiety specialist, I recommend this book more than any other because of the strong research support behind it—and because it offers a number of useful worksheets and recordings.

Here’s a link if you want to check out the 2nd edition of The Mindfulness and Acceptance Workbook for Anxiety.

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