McLean Hospital 115 Mill Street Belmont, MA 02478
Over the past few years, clinicians and researchers at the Obsessive Compulsive Disorder Institute (OCDI) have become increasingly interested in acceptance and commitment therapy (ACT). ACT is tricky to understand—not because it is complicated, but because it does not fit with how humans typically think about their problems.
Imagine you are driving a bus with passengers on it towards places you want to go. The passengers represent the things you experience inside you (thoughts, feelings, urges, memories, etc.). Some are pleasant and helpful to you for driving where you want to go. Some are unpleasant and try to stop you from driving where you want to go. Some are neutral and hardly noticed. In ACT, we are trying to teach people to see the things they experience inside of them like passengers on a bus they are driving. This is tricky because it means the things they experience inside of them are no longer treated as good/bad, right/wrong, true/false. Instead, all inner experiences are simply seen as potentially helpful or unhelpful in driving the bus toward the desired destination.
In order to teach people how to drive the bus with their passengers on it, ACT focuses on six psychological processes that seem to be at the core of human struggles and well-being. They are as follows: Defusion: seeing the passengers for what they are (just passengers) instead of what they say they are (harmful, in control of the bus); Acceptance: being open and welcoming to the passengers; Present Moment Awareness: flexibly shifting focus towards what is most useful for driving the bus where you want to go; Self-as-Context: seeing yourself as the bus that contains the passengers instead of seeing yourself as the passengers; Values: choosing directions to drive in that are important to you; Committed Action: flexibly driving the bus towards where you want to go.
Recent treatment and research efforts at the OCDI have focused on learning how to identify and influence these six psychological processes in order to move people toward greater psychological flexibility. There are many clients who work very hard in treatment at the OCDI, but have difficulty making progress or relapse after having made progress because their psychological flexibility remains low. An example of this might be a client who leaves the OCDI having eliminated all rituals and avoidance behaviors and greatly improved their functioning while desperately hoping their unwanted passengers do not return to their bus. We are beginning to suspect that in order for progress to be sustained, clients must fundamentally change how they relate to the passengers on their bus so that they are able to drive flexibly regardless of what the passengers are doing.
The OCDI has developed a reputation for helping people struggling with treatment-resistant OCD. It is an exciting time at the OCDI as we integrate ACT treatment and research into our program in an effort to learn how to help those who are not improving enough with traditional treatments alone.
Nate Gruner, LICSW, is a behavior therapist at the OCD Institute.