Journal Pre-proof

Acceptance and Commitment Therapy in the Treatment of Obsessive-Compulsive

Disorder: a Systematic Review

Joel Philip, M.D (Psych), MRCPsych, Vinu Cherian, M.D (Community Medicine), DNB
(Community Medicine)
PII: S2211-3649(20)30124-X
DOI: https://doi.org/10.1016/j.jocrd.2020.100603
Reference: JOCRD 100603

To appear in: Journal of Obsessive-Compulsive and Related Disorders

Received Date: 9 August 2020

Revised Date: 10 October 2020
Accepted Date: 23 October 2020

Please cite this article as: Philip J. & Cherian V., Acceptance and Commitment Therapy in the Treatment
of Obsessive-Compulsive Disorder: a Systematic Review, Journal of Obsessive-Compulsive and
Related Disorders, https://doi.org/10.1016/j.jocrd.2020.100603.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
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© 2020 Elsevier Inc. All rights reserved.

 Title Page

1. Title: “Acceptance and Commitment Therapy in the Treatment of Obsessive-

Compulsive Disorder: a Systematic Review of an Emerging Therapeutic Modality”

2. Authors:

1. Dr. Joel Philip M.D (Psych), MRCPsych

Consultant Psychiatrist

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Neurocenter Kochi

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2. Dr. Vinu Cherian M.D (Community Medicine), DNB (Community Medicine)
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Assistant Professor
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Department of Community Medicine

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Sree Narayana Institute of Medical Sciences

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Chalakka, Kochi
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3. Details of corresponding author: Dr. Joel Philip

Tel: +91. 8129434650

E-mail: joelphilipmd@gmail.com

Mailing address: Villa 11, Skyline Ebony Woods, Shine Road,

Vyttila, Kochi-682019,

Kerala, India.
4. Word counts:

Abstract: 279

Main text: 5088

5. Number of tables: 2

Number of figures: 1

6. Declarations of interest: None

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Funding: No external grants were availed

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 Acceptance and Commitment Therapy in the Treatment of Obsessive-Compulsive

Disorder: a Systematic Review

Abstract

Background:

Acceptance and Commitment Therapy (ACT) is the most prominent among the ‘third wave’

psychotherapies. This is the first systematic review that evaluates the current body of

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evidence for the efficacy of ACT as a therapeutic modality in OCD.

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Method:

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A comprehensive literature search was conducted on the PubMed and Medline databases.
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The publications thus obtained were screened by title, abstract, and main text. Articles

meeting the defined inclusion and exclusion criteria were assessed, and the results presented
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under the relevant sub-headings, to depict the various study designs employed in the included
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studies.
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Results:
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Out of 690 articles that were evaluated, 16 articles were finally included in the review. ACT

was found to produce a significant decrease in OCD symptoms, with the gains largely being

maintained at follow-up. Although ACT was more effective than control conditions like wait-

list and placebo, it did not outperform the established frontline psychological treatments for

OCD, i.e., traditional CBT and ERP. However, when combined with pharmacological

management, ACT was comparable to a combination of CBT and pharmacotherapy in

treating OCD.

Conclusion:

There is potential evidence to support the utility of ACT as a therapeutic intervention in OCD

when used in combination with pharmacotherapy.

Keywords:

Acceptance and commitment therapy, obsessive-compulsive disorder, third-wave

psychotherapy

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 Acceptance and Commitment Therapy in the Treatment of Obsessive-Compulsive

Disorder: a Systematic Review

1. Introduction

Obsessive-compulsive disorder (OCD) is the cause of significant psychiatric

morbidity across age groups. It has a global presence and is estimated to have a lifetime

prevalence of 1-3% (Regier, Narrow, & Rae, 1990). Currently, as the world is coming to

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terms with an ongoing pandemic, there has been a general uptick in symptom severity among

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diagnosed cases of OCD (Davide et al., 2020). The classical features of OCD are recurrent,
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intrusive thoughts and impulses (obsessions), and repetitive, intentional behaviors
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(compulsions) that are undertaken to reduce the associated anxiety (American Psychiatric
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Association (APA), 2013). Most people who suffer from OCD recognize the unreasonable
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nature and repetitive quality of their thoughts and behaviors. Despite this, they are often

unable to resist them, which, in turn, has a significant impact on their quality of life (Lack et
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al., 2009).
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Psychological interventions have a strong evidence base for symptom reduction in

OCD (Hofman & Smits, 2008; Norton & Price, 2007; Tolin, 2010; Abramowitz, 2006).

Several randomized controlled trials (RCTs) have documented the efficacy of cognitive

behavior therapy (CBT), especially exposure and response prevention (ERP), in reducing the

distress associated with the disorder. However, in recent years, several newer psychological

techniques have been introduced, which have been broadly classified under the umbrella of

‘third-wave behavior therapies’. Acceptance and Commitment Therapy (ACT) falls within

this domain and has garnered considerable interest among mental health professionals for the

management of OCD (Hayes, 2004).

 Traditional cognitive therapies, as propounded by Beck, targeted cognitive change as

the primary focus of treatment. These therapies were ‘antecedent-focused’, i.e., they targeted

a stage in the response-generation process before the emotion has been activated; for

instance, the content of the distressing thought (Hofmann & Asmundson, 2008). Later studies

challenged this objective, showing that providing ‘cognitive interventions’ had no additional

benefit for patients with depression (Dobson & Khatri, 2000). This, in turn, paved the way for

the second and third waves of psychotherapy (Zettle, 2005). Many of these newer therapies

were response-focused, i.e., they attempted to alter the ways in which the emotions that

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follow a thought are experienced. This so-called ‘third-wave’, in which ACT is categorized,

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abandoned attempts to change the form or frequency of unwanted thoughts and emotions.
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Instead, its focus was on mindfulness and being fully present to experience the context in
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which these thoughts occur (Hofmann & Asmundson, 2008).
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ACT is founded on the philosophical concept of ‘functional contextualism’ in which,

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broadly speaking, maladaptive behavior is evaluated against the backdrop of the context in
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which it occurs. The client is encouraged to be open to all emotions and experiences, even if
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they are distressing. Instead of avoiding such ‘negative’ experiences, these are imbibed

simply as a part of the person’s history. Patients are guided towards identifying those values

in life that are most important to them, with therapy being directed at helping the client

ultimately lead such a ‘value-based life’ (Biglan & Hayes, 2016; Parker & Pepper, 1942).

Functional contextualism is, in turn, derived from a broader psychological framework

known as ‘relational frame theory’. Relational frames refer to patterns of thinking and

relating events to one another, which humans use to make sense of the world around us. This

theory proposes that there are three fundamental properties of learning, which in combination

forms a relational frame. If a person learns that ‘A’ is related to ‘B’ in a certain context, then

he infers that ‘B’ is related to ‘A’ in some way in the same context; this is called ‘bi-
directionality’. ‘Combinatorial entailment’ states that if ‘A’ is related to ‘B’, and ‘B’ is

related to ‘C’, then ‘A’ must be related to ‘C’ in the same context. Finally, the above-

mentioned patterns of learning are utilized in the ‘transformation of stimulus function’. For

instance, if it is stated that A, B, and C are related in such a way that A is more than B, which

in turn is more than C, then there is a relation stated between them. However, if a specific

value is placed on one of them, say, it is stated that C is valuable, then A and B also derive a

certain value owing to the relation with C, despite nothing specifically being mentioned about

A or B (Twohig & Levin, 2017; Hayes, Barnes-Holmes & Roche, 2001).

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The above-mentioned principles, although seemingly abstract at first glance, have

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clinical utility in the real world. Emotions associated with a certain event can be replicated

when experiencing separate events that originally had no relation with the first, owing to
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cognitive mechanisms that have unknowingly related the events. Hence, attempting to avoid
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distressing stimuli is often counter-productive; because the more one tries to avoid such a
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thought or stimulus, the more frequently it appears in one’s consciousness, in turn provoking
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unsettling emotions. This ‘experiential avoidance’, or attempts to avoid distressing stimuli, is

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often practiced by patients, but is largely a futile venture and only propagates the problem

(Hayes et al., 2004). ACT stresses on overcoming ‘experiential avoidance’, and simply

accepting thoughts and emotions for what they are. In this manner, ACT adopts a line of

reasoning that is in contrast to the principles of CBT (Hayes, Luoma, Bond, Masuda & Lillis,

2006).

Ultimately, ACT aspires to increase the client’s ‘psychological flexibility’ (Twohig,

Whittal, Cox & Gunter, 2010). Psychological flexibility can be understood as the capacity to

be in contact with the present moment, fully aware of one's thoughts, emotions, and

sensations, and accepting all of them, including the distressing ones. The intent is to prevent

short-term negative thoughts and emotions from interfering with living a life that is consistent
with one’s chosen values. A central premise of ACT in the treatment of OCD is to improve

the client's psychological flexibility so that obsessional thoughts and compulsive urges no

longer hinder the person from living a more full and vital life. This is accomplished by

utilizing six primary principles; de-fusion, acceptance, maintaining contact with the present

moment, the observing self, identifying what constitutes a value-based life, and taking

committed action to live such a life. Studies have shown that changes in psychological

flexibility, mindfulness, and valued living accompany clinical improvement in persons with

OCD who are provided structured ACT sessions, and the extent of changes in these

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psychological constructs are not replicated in those provided CBT as an intervention (Twohig

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et al., 2010; Twohig, Vilardaga, Levin & Hayes, 2015).
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Therefore, the primary emphasis of ACT when utilized as a treatment strategy in
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OCD is not to challenge or restructure cognitive biases, or to reduce the frequency or severity
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of obsessions and compulsions, but rather to help patients to learn to change their relationship
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to obsessive thoughts so that they are not fighting these experiences. Clients are encouraged
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to identify those values in life that are important to them, and strive to live such an envisaged,
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productive life, while continuing to experience the obsessions. The obsessions are reframed

as just "thoughts that come and go", and simply part of the amalgamation of experiences that

comprise life. This, in a nutshell, forms the theoretical basis for the use of ACT in OCD.

Although systematic reviews and meta-analyses have been previously undertaken to

study the efficacy of ACT, the majority of these reviews compiled studies associated with the

use of ACT across multiple psychiatric disorders. Only one review thus far has focused on

the efficacy of ACT in anxiety disorders (Swain, Hancock, Hainsworth & Bowman, 2013).

Moreover, an in-depth search of the available literature yielded only one narrative review,

published six years ago, that studied the use of ACT, specifically in OCD (Twohig, Morrison

& Bluett, 2014).

 Accordingly, the present article is the first comprehensive systematic review focused

on the use of ACT specifically in OCD. Newer psychological interventions, especially ACT,

are now being employed to a greater extent by mental health clinicians. The primary intention

of this review was therefore to assimilate the available evidence relevant to the empirical

basis for the use of ACT in OCD. The data comparing ACT to well-established psychological

treatments such as CBT and ERP were also examined.

A strength of this review is that it has taken into account all the available literature

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published on the topic, irrespective of study design, after subjecting it to a rigorous quality

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assessment. The pertinent findings have been presented in ascending order of methodological

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rigor, beginning with individual case reports and progressing to RCTs. Hence, we have

attempted to create a narrative within the text, wherein the reader can trace the arc of the
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progress made over the years in this research domain. This would facilitate a better
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understanding of how ACT came to be utilized in the treatment of OCD, and the available
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evidence for the same.

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2. Methods
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The review methodology was discussed and a consensus was reached by all the

authors prior to initiating the review process.

2.1. Search strategy

A comprehensive literature search was conducted on the PubMed and Medline

databases to extract articles pertaining to the use of ACT in OCD. The search was done

independently and in duplicate by two authors. The search identified articles that were

published up to 15 June 2020. The search terms that were utilized were “Acceptance and

Commitment Therapy”, “ACT”, “Obsessive-Compulsive Disorder”, “OCD”, “Third-wave

psychotherapies” etc. (refer Appendix)

2.11. Search of grey literature

The above-mentioned search terms were employed in varying permutations to search

for additional literature on Google scholar. The first 100 results were evaluated for any

relevant material. This was done in an attempt to reduce publication bias.

2.12. Citation tracking

The bibliographies of the included articles were searched for any other articles that

may have been overlooked in the primary search of the electronic databases.

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2.2. Expert Consultation

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The departmental heads of the Psychiatry and Psychology units of a local teaching
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hospital provided input on several aspects of the review.
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2.3. Eligibility criteria

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2.31. Inclusion criteria

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Studies were considered eligible for inclusion in the review if the main intent was to
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treat OCD and the primary outcome measure was a reduction of obsessive-compulsive (OC)

symptoms or the associated anxiety. Only articles published in English language, peer-

reviewed journals were selected. The studies had to necessarily incorporate a clear

explanation of methodology, data analysis, and interpretation of results. Moreover, they had

to employ a minimum of two of the six core principles, i.e., mindfulness, acceptance, self-as-

context, cognitive de-fusion, value-based living, and committed action. This was done as

there are several published works on related psychological processes, like mindfulness; yet

these studies do not cover the entire scope of ACT, and therefore, are not an accurate

representation of the ACT technique. It also served to facilitate sufficient breadth of the
review, while ensuring that the included studies detailed more than a single technique

described within the ACT model.

2.32. Exclusion criteria

Studies dealing solely with mindfulness-based interventions were excluded from the

review, as such interventions utilize measures that are beyond the scope of ACT to bring

about cognitive change. Studies dealing with anxiety disorders in general, with neither further

sub-classification into specific types, nor a specific focus on OCD, were also excluded.

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2.4. Data extraction and synthesis

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A spreadsheet was created to enter the data derived from each article in a systematic
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manner for obtaining a ‘bird’s eye view’ of the literature. The information entered included
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the names of the authors, year and country of study, type of study, nature of study sample,
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number of participants, psychological interventions that were employed, number of sessions

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and treatment duration, assessment scales that were utilized, findings, and conclusions of the
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study. The outcome measures of interest were a reduction in self-reported or investigator-

rated OC symptoms, and whether these improvements were maintained at follow-up sessions.
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This process was done in duplicate by two authors and the results were combined.

2.5. Quality Assessment

Independent critical appraisals of the included articles were carried out separately by

two authors. The CARE checklist was used to ascertain that the case studies included in the

review were reported while adhering to recommended standards. This is a 14-item checklist

that facilitates the systematic reporting of information from case reports and corroborates the

completeness, accuracy, and transparency of published case reports (Gagnier et al., 2013).

For cross-sectional studies, the risk of bias was assessed using the checklist published by the

United States National Heart, Lung, and Blood Institute for the same (National Heart Lung
and Blood Institute, 2020). The Cochrane Collaboration Tool was used to evaluate the RCTs

for the reliability of their findings (Higgins et al., 2011).

2.6. Reporting

The review is reported in accordance with guidelines from the Preferred Reporting

Items for Systematic reviews and Meta-Analyses (PRISMA) protocol (Moher, 2009).

For the purpose of this review, the available literature on the utility and effectiveness

of ACT in OCD has been categorized on the basis of the methodology and study design

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employed. Accordingly, the results have been reported under the following sub-headings.:

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1. Case studies: In a case study, no comparison is made with an untreated group or with
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a group that is receiving some other treatment. Although such a study is easier to
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conduct, an obvious limitation is that, in the absence of a comparator, it becomes
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difficult to derive a causal inference regarding the treatment and its subsequent
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outcome. Therefore, case studies rank lowest on the scale of the strength of
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supporting evidence for an intervention.

2. Case series and open trials: These are aggregations of several similar cases. Their
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limitations are similar in many ways to those of a case study.

3. Randomized controlled trials: RCTs are considered the gold standard of study designs

because they control for non-specific factors that might influence outcome, such as

regression to the mean, the natural course of problems such as OCD, use of additional

treatments, and placebo effects. Despite this, RCTs may not inform clinicians about

which subset of patients benefit from a prescribed treatment in real-world conditions

(Celentano, Szklo & Gordis, 2019).

As the present review involved studies on the efficacy of a particular psychological

intervention (i.e., ACT) for a particular problem (i.e., OCD), and comparisons to established
treatments such as ERP, a majority of the articles utilized psychometric scales to establish

reductions in OCD symptomatology. The most commonly applied instrument was the Yale-

Brown Obsessive-Compulsive Scale (Y-BOCS). The Y-BOCS is a standardized rating scale,

with both clinician-administered and self-report versions available, that includes five items

pertaining to obsessions and five pertaining to compulsions. Items are rated on a five-point

Likert scale from 0 (no symptoms) to 4 (severe symptoms), and a total score is calculated by

summing items one to ten to achieve a score from 0 to 40. The Y-BOCS' reliability, validity,

and sensitivity to change are well established in Goodman et al.'s original report (Goodman

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et. al, 1989). Previous studies have selected a 35% decrease in Y-BOCS scores from baseline

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as indicative of clinically significant improvement (Goodman & Price, 1992).
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3. Results
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Six hundred and ninety articles were obtained following the initial search, which were

then screened by titles, abstracts, and main text, in order to select the most relevant articles.
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Sixteen articles, comprising several design types, such as case reports, case series, and RCTs
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were finally included in this review. The flow chart detailing the methodology of screening
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and the selection of articles is elaborated in Figure 1. Table 1 summarises the findings of the

articles included in this review. The studies excluded from this review and the reasons for the

same are elucidated in Table 2 (supplemental table). The results of the quality appraisal of the

included studies have been provided as an addendum in this paper.

 Articles identified through Additional articles identified
database searching through other sources

n= 690 n= 4

Total records found Duplicates removed

n= 694 n=172

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Titles screened Excluded after title

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n= 522 screening
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Abstracts screened Excluded after abstract
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screening
n= 158
n=134
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Full-text articles assessed for

eligibility
Excluded after full-text
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n= 24 screening

n=8

Final articles included

n= 16

Figure 1: Flowchart of screening and inclusion/exclusion of studies

3.1. Case studies

Vakili and Gharai reported a case of the successful treatment of a middle-aged male

with OCD using ACT. The patient’s symptoms had not subsided despite receiving several

adequate trials of different selective serotonin reuptake inhibitors (SSRI). Following eight

sessions of ACT, the authors reported that there were substantial reductions in the levels of

OCD, depression, and anxiety, as recorded by appropriate rating scales. The symptoms of

OCD decreased by more than 50% over the treatment period of eight weeks, as quantified

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using the Y-BOCS scale. These gains were noted to be maintained even subsequently on

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follow-up at three and six months (Vakili & Gharraee, 2014).

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Lee et al. outlined the treatment of a fictional case of scrupulosity-related OCD,
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which was conceptualized as an amalgamation of similar cases that they had treated in the
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past. The patient was described as a male in his mid-thirties, who presented with

blasphemous thoughts causing immense anxiety, which he sought to reduce by engaging in

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excessive spiritual and religious acts. Twenty sessions of ACT were provided, which led to
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significant relief. The authors suggested that a typical response would be a reduction of 50%
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in the Y-BOCS score, from the initial pre-treatment level. They also expected that there

would be an increase in psychological flexibility following the intervention, as measured by

the Acceptance and Action Questionnaire (AAQ-II). The authors expressed the opinion that

ACT may be a useful therapeutic technique, and called for greater adaptability of the therapy

for use in patients with OCD (Lee, Ong, An & Twohig, 2018).

Brown et al. published a case report focused on the use of ACT in treating OCD in a

person with an intellectual deficit. Although a significant reduction in obsessive ruminations

was reported, this could not be quantified using a scale, owing to the co-existing intellectual

deficit. They argued that in comparison to CBT, ACT is a more suitable treatment technique
because it does not require significant evaluation and testing of one’s thoughts and core

beliefs. ACT was thus portrayed as a useful psychological intervention in patients with

limited language and verbal reasoning skills (Brown & Hooper, 2009).

3.2 Case series

Twohig et al. tested the efficacy of ACT on four adults with OCD, who were recruited

on a university campus. The compulsions that were reported included checking, hoarding,

and cleaning. Each person received eight, weekly, one-hour sessions of ACT. The symptoms

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of OCD, as measured using the Obsessive-Compulsive Inventory (OCI), showed a 68%

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improvement from pre-treatment to post-treatment, which further improved to 81% from pre-
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treatment to follow-up. ACT was found to produce clinically significant reductions in
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compulsions post-treatment for all subjects, with gains maintained when evaluated at a three-
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month follow-up consult. The acceptability of the intervention was also high (Twohig, Hayes

& Masuda, 2006). It is, however, important to note that hoarding is no longer considered as a
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symptom of OCD.
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Dehlin et al. carried out a study where five adults with scrupulosity-based OCD were
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treated with eight sessions of ACT. ACT for OCD was implemented in weekly sessions of

one to 1.5 hours duration. Participants reported a 74% reduction in compulsions and a 79%

reduction in avoided valued behaviors, with these improvements being maintained at a three-

month follow-up. The post-intervention behavioral changes were assessed by self-monitoring

of specific behaviors after appropriate training, which has been found to provide a fair degree

of accuracy in previous studies (Jackson, 1999; Korotitsch and Nelson-gray, 1999). They

concluded that these results showed the promise of ACT as an intervention technique,

especially in scrupulosity- based OCD; as there were relevant gains despite the fewer number

of sessions provided (Dehlin, Morrison & Twohig, 2013).

 A study by Izadi et al. on five patients with obsessive thoughts examined the

effectiveness of ACT as a therapeutic intervention and concluded that it holds promise as a

tool in the armamentarium of the mental health specialist. ACT was provided in ten weekly

sessions of one hour duration. All five participants had clinically significant decreases in the

severity of OCD symptoms, as measured using the Y-BOCS scale, with these results being

maintained at a one-month follow-up (Izadi, Asgari, Neshatdust & Abedi, 2012). Similar

results were obtained with short-term intervention in relatively small samples of children and

adolescents with OCD (Barney, Field, Morrison & Twohig, 2016; Armstrong, Morrison &

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Twohig, 2013). However, all of these studies had the limitation of small sample sizes.

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Fabricant et al. carried out an RCT to compare the effectiveness of ACT and CBT in
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OCD. The obsessions subscale of the Obsessive-Compulsive Inventory-Revised (OCI-R)

scale was used in this study as a measure of symptom severity. Participants received a single
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session of the randomly allocated intervention lasting 45 minutes, and they followed up one
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week later to complete a battery of self-reported measures assessing obsessional symptoms. It

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was found that there were significant reductions in obsessional symptoms in all three study

groups (two intervention groups that received ACT and CBT, and the control group);

however, no differences were found between these conditions (Fabricant, Abramowitz,

Dehlin & Twohig, 2013).

Twohig et al. carried out an RCT to test whether any additional gains could be

attained by integrating ACT with traditional ERP. Participants were randomized to receive

either ERP or ACT in conjunction with ERP, which was delivered in 16, individual, twice-

weekly sessions. The primary outcome measure was a decrease in OCD severity, which was

assessed using the Y-BOCS and Dimensional Obsessive-Compulsive Scale (DOCS). A score

of 16 on the Y-BOCS was set as the cut-off for determining clinically significant change
using the Jacobson methodology (Jacobson & Truax,1991). Assessments occurred prior to

the first treatment session (pre-treatment), one week after the final session (post-treatment),

and six months after post-treatment (follow-up). It was noted that participants in both

conditions showed substantial pre-to post-treatment decreases in clinician-rated and self-

reported OCD symptoms as well as in depressive symptoms, with these improvements being

maintained at follow-up. Although ACT and ERP were both found to be effective

interventions, no differences were found in the outcomes, processes of change, acceptability,

or exposure engagement on adding ACT to an existing ERP regimen (Twohig et al., 2018).

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Twohig et al. also conducted a trial to compare the efficacy of ACT in the treatment

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of OCD to progressive relaxation training (PRT), which was chosen as the control
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intervention due to its successful use as a credible control condition in prior studies (Fals-
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Stewart, Marcks, & Schafer, 1993). Participants attended 11 total sessions: an intake session,
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eight one-hour weekly treatment sessions, a post assessment session, and a three-month
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follow-up assessment session. Objective evaluations were carried out at pre-treatment, post-

treatment, and three-month follow-up using validated scales. ACT was found to produce
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greater changes at post-treatment and follow-up over PRT on OCD severity scales. The
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primary outcome, i.e., OCD severity, was measured using the Y-BOCS scale. Improvement

in Quality of Life (QOL), measured using the Quality of Life Scale (QOLS), was also

marginally in favor of ACT. ACT was observed to have higher acceptability than PRT among

study subjects. The drop-out rate observed for ACT in this study was only about 10% when

compared to that of traditional ERP, for which previous studies have reported a high drop-out

rate of 25% (Franklin, Abramowitz, Foa, Kozak & Levitt, 2000). Hence, the authors

concluded that the role of ACT in ameliorating symptoms of OCD was worth a second look

(Twohig et al., 2010).

 Vakili and colleagues carried out an RCT comparing psychological and

pharmacological interventions in varying permutations for the treatment of OCD. The stated

purpose of the trial was to compare the effectiveness of ACT, SSRI, and the combination of

ACT and SSRI in the treatment of adults with OCD. Thirty-two patients who were diagnosed

with OCD were randomly assigned to one of the three treatment groups. Participants

receiving only the psychological intervention were provided eight sessions of ACT, patients

in the drug group received an SSRI for ten weeks, while those in the combination group

received both ACT and an SSRI for ten weeks. The study protocol did not call for any

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follow-up asssessments. The severity of OCD symptoms was measured using the Y-BOCS

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scale. The study revealed that ACT and combined treatment resulted in significantly greater
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improvements in OCD symptoms and experiential avoidance, and a higher rate of recovery
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and complete remission of OC symptoms, relative to SSRI use alone (Vakili, Gharaee &
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Habibi, 2015). A similar RCT carried out in Iran that recruited 25 patients with OCD in each
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arm of the trial (n=75), had also reported identical findings. (Baghooli, Dolatshahi,

Mohammadkhani, Moshtagh & Nazri, 2014).

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The efficacy of ACT delivered in a group format was tested by comparing the
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effectiveness of ACT in conjunction with treatment with SSRI, CBT in conjunction with

SSRI, and SSRI treatment alone in 69 adolescents with OCD. In this study, the Children’s

Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) was utilized as a measure of the

severity of OCD, as it included adolescents (Shabani et al., 2019). The intervention

conditions received one hour of ACT + SSRI or CBT + SSRI group therapy on a weekly

basis. The ACT + SSRI condition consisted of a ten-session protocol while the CBT + SSRI

condition consisted of a 12-session protocol. All participants were assessed at pre-treatment,

post-treatment, and three months following post-treatment. Results revealed that ACT was as

effective as CBT in treating adolescent OCD when combined with SSRI. Few quasi-
experimental studies have also documented that ACT is as effective as traditional CBT in

reducing the severity of OC symptoms (Esfahani, Bagher Kjbaf & Reja Abedi, 2015;

Ghazanfari, Amiri & Abadi, 2015).

4. Discussion

4.1. Main findings

Preliminary evidence for the use of ACT in OCD was derived primarily from case

reports and case series. These studies had obvious limitations with regard to the small sample

sizes and anecdotal nature of the reports, yet the positive results that were documented were

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important in flagging ACT as a possible intervention in OCD. A plethora of OCD symptoms

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were evaluated, including checking, hoarding, contamination, blasphemous thoughts, etc.
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Reductions in symptom severity were captured by both self-report questionnaires and
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objective quantitative scales. These works paved the way for RCTs, often carried out by the
lP

same investigators who had reported improvements in individual cases.

na

The efficacy of ACT in producing OCD symptom reduction, when compared to a

wait-list control group, has been shown in several RCTs carried out in multiple countries
ur

across the globe. One RCT of good methodological rigor noted that both ACT and ERP were
Jo

associated with significant reductions in obsessional symptoms, and the results did not seem

to indicate substantial differences between ACT and imagined exposure (IE) in efficacy

(Fabricant et al., 2013). However, there is a paucity of head-to-head RCTs that compare the

efficacy of ACT versus ERP in OCD. Another study observed that ACT does not

significantly augment primary outcomes when added to an existing intervention of ERP

(Twohig et al., 2018). Hence, there is a need for further studies before the efficacy of ACT as

a stand-alone treatment for OCD can be recommended over existing interventions such as

ERP.
 Our review also revealed that ACT, when used alone or in conjunction with

pharmacological interventions like SSRIs, produces greater relief from obsessional symptoms

when compared to SSRI use alone. This has been found to hold true even when ACT is

provided in a group format. This harbors good news for mental health service providers, as

such group formats would allow for more patients to be treated by a trained therapist in a

single session, thereby facilitating the implementation of ACT in a cost-effective manner

without sacificing effectiveness.

4.2. Clinical implications

of
This review has a number of clinical implications. First, it provides evidence that

ro
supports the use of ACT in treating OCD, thereby offering up ACT as a useful tool for
-p
clinicians to treat a disorder that impacts the quality of life of millions of people worldwide.
re
Second, it reveals that ACT may have a slightly more profound effect on improving the
lP

quality of life of patients when compared to the traditional CBT approaches. Third, it
na

suggests that ACT could be effectively administered in group formats for the treatment of

OCD . Finally, it provides support for the psychological constructs that are considered to be
ur

the foundation of ACT.

Jo

4.3. Limitations

This review, and the literature we reviewed, also have several limitations. First, some

of the articles that are reviewed are preliminary and anecdotal studies. These, however, were

included to gain an understanding of the nature of the continuing research in ACT, which is a

relatively new and evolving psychological technique. Second, some of the studies had

relatively small sample sizes, and hence may not be generalizable to a larger population.

Third, the comparators used in the RCTs were mostly waitlist or control conditions. There

was a paucity of head-to-head RCTs comparing the efficacy of ACT to front-line treatments

such as ERP. This raises questions about the relative efficacy of ACT to existing OCD
treatments. Fourth, the possibility of publication bias and allegiance effect could not be ruled

out, as several of the studies were carried out by the same teams of researchers affiliated with

the same institutions. Finally, observations of whether ACT produces sustained improvement

in OCD symptoms and permanent behavioral change was limited to a three-month follow-up

visit. While previous studies have established that the treatment gains for patients with an

anxiety or depressive disorder are better maintained at follow-up when they receive CT as

opposed to ACT, similar research pertaining to the long-term outcomes of the use of ACT in

OCD is lacking (Forman et al., 2012).

of
ro
4.4. Future directions

-p
Although the future of ACT as a psychological intervention in OCD holds
re
promise, there is a dearth of methodologically sound RCTs pertaining to this in the
lP

currently available body of evidence. There is a need for further head-to-head studies
na

that compare ACT with traditional CBT for OCD in particular, with sufficient sample

sizes wherein the results may be generalized to larger populations. Follow-up studies are
ur

also the need-of-the-hour to demonstrate the role of ACT in effecting sustained change
Jo

in OCD symptomatology. Finally, there is room for further research in order to

determine the role of age, gender, race, ethnicity, etc. in predicting the response to ACT

in OCD, and the utility of these (and other) variables in selecting the most appropriate

psychological intervention for the patient.

Appendix
Search terms:

1. acceptance and commitment therapy; 2. ACT; 3. accept; 4. defusion; 5. values;

6.anxiety; 7. anxious; 8. anxiety disorder; 9. obsession; 10. Obsessive-compulsive; 11.

Obsessive-compulsive disorder 12. OCD;

Declaration of Conflicting Interests

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public,

commercial, or not-for-profit sectors.

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Table 1: List of studies included in the review
Study/ Design Sample size and Duration Psychologic Outcome

Country characteristics al Measures

Brown and Case study One patient Ten ACT AAQ Post-ACT scores were lower on every question on

Hooper 18 years old sessions AAQ, indicating less avoidance of cognitions,

(2009) Female emotions, and motives.

f
oo
United (Patient had moderate to
Episodes of rumination were observed by the primary

pr
Kingdom severe ID)
caregiver to be shorter.

e-
Pr
Gains were maintained at the four-month follow-up.

al
rn
Vakili and Case study One patient Eight ACT Y-BOCS Reductions were seen in symptoms of OCD,

Gharraee 39 years old u sessions depression, and anxiety.

Jo
BDI-II
(2014) Male Scores on Y-BOCS and BAI reduced by 15 points,
One, three,
Iran BAI i.e., 50% from the baseline.
and six-
Score on BDI-II reduced by 13 points, i.e., 50% from
month
baseline.
follow-up
Gains were maintained at one-month, three-month,

and six-month follow-ups.

AAQ-Acceptance and Action Questionnaire, ACT- Acceptance and Commitment Therapy, BAI- Beck Anxiety Inventory, BDI-II-
Beck Depression Inventory II, ID- Intellectual Deficit, Y-BOCS- Yale-Brown Obsessive Compulsive Scale
 Lee et al. Case study One patient 20 ACT SCID-5 Not elaborated as the report dealt with a fictional

(2018) Mid 30s sessions ‘reference’ client.

AAQ-II
USA Male

PIOS

Y-BOCS

f
oo
QOLS

pr
e-
Twohig, Case series Four subjects Eight ACT OCI ACT produced clinically significant reductions in

Pr
Hayes, and sessions BDI–II compulsions.

al
rn
Masuda AAQ
OCI improved 68% from pre- to post-treatment and
(2006)
u TEI-SF
Jo
improved further to 81% from pre-treatment to
United
follow-up.
States of

America Results were maintained at the three-month follow-

up.

AAQ-Acceptance and Action Questionnaire, ACT- Acceptance and Commitment Therapy, BDI-II- Beck Depression Inventory II, PIOS- Penn
Inventory of Scrupulosity, QOLS- Quality of Life Scale, SCID 5- Structured Clinical Interview for DSM-5, OCI- Obsessive-Compulsive
Inventory, TEI-SF- Treatment Evaluation Inventory–Short Form,Y-BOCS- Yale-Brown Obsessive Compulsive Scale
Izadi et al. Case series Five patients Ten weekly Y-BOCS Significant decreases were seen in all measures in the

(2012) ACT post-test in all patients.

(Three males and two BDI-II
Iran sessions of
females) Scores of all subjects dropped below the previously
one-hour BAI
established cut-off score of 18 on the Y-BOCS scale.
duration
Results were maintained at the one-month follow-up.

f
oo
pr
e-
Pr
al
u rn
Jo

ACT- Acceptance and Commitment Therapy, BAI- Beck Anxiety Inventory, BDI-II- Beck Depression Inventory II, OCD- Obsessive-
Compulsive Disorder, Y-BOCS- Yale-Brown Obsessive Compulsive Scale
Armstrong, Case Three adolescents 8-10 CY-BOCS 40% mean reduction in self-reported compulsions

Morrison, series sessions of from pre to post-treatment.

12-13 years old
and Twohig ACT
Results were maintained at the three-month
(2013)
follow-up.
United

States of

America

f
oo
pr
Eight Y-BOCS Average daily compulsions reduced as follows:
Dehlin et al. Case

e-
sessions of pretreatment = 25.0, post-treatment = 5.6, and
Five adults with PIOS

Pr
(2013) series
ACT follow-up = 4.3.
scrupulosity-based

al
United
BDI–II

rn
States of OCD Average daily avoided valued activities reduced

u QOLS
Jo
America as follows: pretreatment = 6.0, post-treatment =

0.7, and follow-up = 0.5.

SCSORF

AAQ-II

AAQ-II- Acceptance and Action Questionnaire–II, ACT- Acceptance and Commitment Therapy, BDI-II- Beck
Depression Inventory II, CY-BOCS- Children's Yale-Brown Obsessive Compulsive Scale, OCD- Obsessive-
Compulsive Disorder, PIOS- Penn Inventory of Scrupulosity, QOLS- Quality of Life Scale, SCSORF- Santa Clara
Strength of Religious Faith Questionnaire, Y-BOCS- Yale-Brown Obsessive Compulsive Scale
Barney et al. Case series Three children Nine weekly CY-BOCS Clinically significant reductions in OCD symptoms were

(2016) ACT sessions seen across participants.

10-11 years old AFQ-Y
United lasting 50-
The average CY-BOCS reduction across participants was
States of minutes PAAQ
69%.
America
NIMH-GOCS

CGI

f
oo
AAQ- Acceptance and Action Questionnaire, ACT- Acceptance and Commitment Therapy, AFQ-Y- Avoidance and Fusion Questionnaire for
Youth, CGI- Clinical Global Impressions Scale, CY-BOCS- Children's Yale-Brown Obsessive Compulsive Scale, NIMH-GOCS- National

pr
Institute of Mental Health Global Obsessive Compulsive Scale, OCD- Obsessive-Compulsive Disorder, PAAQ- Parental Acceptance and Action

e-
Questionnaire

Pr
al
u rn
Jo
Twohig et al RCT Comparison of the efficacy Eight weekly Y-BOCS ACT produced greater changes at post-treatment and
(2010) of ACT versus PRT sessions of
BDI-II follow-up compared to PRT on OCD severity scales.
United (control) in the treatment of ACT or PRT
States of OCD of one hour QOLS Y-BOCS: ACT pretreatment = 24.22, post-treatment =
America duration
AAQ 12.76, follow-up = 11.79; PRT pretreatment = 25.4, post-

treatment = 18.67, follow-up = 16.23.

TAF
Clinically significant change in OCD severity occurred

f
TCQ

oo
more in the ACT condition than PRT (clinical response

pr
TEI-SF
rates: ACT post-treatment = 46%-56%, follow-up = 46%-

e-
66%; PRT post-treatment = 13%-18%, follow-up = 16%-

Pr
18%).

al
rn
Improvement in QOL was marginally in favor of ACT.

u
Jo
ACT had higher acceptability than PRT among study

subjects. The dropout rate for ACT (10%) was less than

that of traditional ERP (25%).

AAQ- Acceptance and Action Questionnaire, ACT- Acceptance and Commitment Therapy, BDI-II- Beck Depression Inventory II, OCD-
Obsessive-Compulsive Disorder, PRT- QOLS- Quality of Life Scale, RCT- Randomized Controlled Trial, TAF- Thought–Action Fusion scale,
TCQ- Thought Control Questionnaire, TEI-SF- Treatment Evaluation Inventory–Short Form,Y-BOCS- Yale-Brown Obsessive Compulsive
Scale.
 Fabricant RCT 56 undergraduate Single BAT Significant reductions in obsessional severity,

et. al participants with session of behavioral tests of distress and willingness to

PRR
(2013) obsessional thoughts ACT or experience intrusive thoughts, and negative appraisals

United randomly assigned to exposure TEI-SF of intrusive thoughts occurred in all conditions.

States of receive a brief

III No differences were found between these conditions.

f
America intervention of exposure,

oo
OCI-R Changes in dysfunctional beliefs, but not in the
ACT, or an expressive

pr
willingness to experience intrusive thoughts,

e-
writing control condition

Pr
predicted changes in obsessional symptoms in both

al
the ACT and exposure conditions.

u rn
Baghooli et RCT 75 patients diagnosed Not Not Patients treated with ACT and combined treatment
Jo
al. (2014) with OCD randomly elaborated elaborated experienced a greater improvement in obsessive-

Iran assigned to one of the compulsive symptoms at post-treatment compared to

three treatment those treated with medication alone, and this was

conditions: ACT, statistically significant.

tricyclic antidepressants,

and combined treatment

ACT- Acceptance and Commitment Therapy, BAT- Behavioral Approach Test, III- Interpretation of Intrusions Inventory, OCD-
Obsessive-Compulsive Disorder, OCI-R- Obsessive-Compulsive Inventory-Revised, PRR- Personal Reactions to the Rationales
questionnaire, RCT- Randomized Controlled Trial, TEI-SF- Treatment Evaluation Inventory–Short Form
 Twohig et RCT 41 adults with OCD 8 one-hour Y-BOCS Treatment effects in ACT were gradual with

al (2015) who were treated with weekly significantly better outcomes occurring in the final
AAQ
USA ACT compared with 38 sessions of two sessions.

individuals who ACT/PRT TAF

received PRT
TCQ

f
oo
Esfahani et RCT n = 60 adults; ACT vs. Ten sessions Y-BOCS ACT was more effective than TPT and NT in the

pr
e-
al. (2015) TPT vs. NT of ACT, six treatment of OCD. The differences between the

Pr
Iran sessions of total mean score of severity of obsessive symptoms

al
TPT, eight between pre- and post-test and between pre-test

rn
sessions of and follow-up were highest in the ACT group and
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Jo
NT (1 hour this was found to be significant (p value<0.001).

weekly

sessions)

AAQ- Acceptance and Action Questionnaire, ACT- Acceptance and Commitment Therapy, NT- Narrative Therapy, OCD- Obsessive-
Compulsive Disorder, PRT- Progressive Relaxation Training, RCT- Randomized Controlled Trial, TAF- Thought–Action Fusion scale, TCQ-
Thought Control Questionnaire.Y-BOCS- Yale-Brown Obsessive Compulsive Scale
Vakili et al. RCT 27 outpatients with OCD Study Y-BOCS Patients treated with ACT and combined treatment

(2015) randomly assigned to one duration of AAQ experienced greater improvement in obsessive-

Iran of the three treatment ten weeks SCID compulsive symptoms and EA at post-treatment

conditions: ACT, SSRIs, with eight compared to those treated with SSRIs alone, and this was

and combined treatment sessions of statistically significant.

15 males, 12 females ACT Patients achieving clinically significant change (Y-BOCS

f
oo
Mean age = 26.96 ± 6.83 total score reduction of eight or more from pre- to post-

pr
years treatment and a final score<14) at post-treatment was

e-
44.4% for ACT, 40% for ACT+SSRI, and 12.5% for

Pr
SSRI alone.

al
rn
Unlike SSRI alone, ACT and combined treatment led to

u greater improvement in obsessive-compulsive symptoms.

Jo
There were no significant differences between the ACT

and combined treatment on obsessive-compulsive

symptoms and EA.

AAQ- Acceptance and Action Questionnaire, ACT- Acceptance and Commitment Therapy, EA- Experiential Avoidance, OCD- Obsessive-
Compulsive Disorder, RCT- Randomized Controlled Trial, SCID- Structured Clinical Interview for DSM 5, SSRI- Selective Serotonin Re-
uptake Inhibitor, Y-BOCS- Yale-Brown Obsessive Compulsive Scale
 Twohig et RCT Multi-site RCT with a 16 Y-BOCS ACT + ERP and ERP were both highly effective

al. (2018) two-armed parallel individual treatments for OCD.

DOCS
United design. twice-
68% of subjects in the ERP condition and 70% in the
States of weekly BDI-II
58 adults diagnosed with ACT+ERP condition attained clinically significant

f
America sessions of

oo
OCD. TCEQ change, defined by a reduction below a Y-BOCS
either ERP

pr
cut-off score of 16, as determined by the Jacobson
PEAS

e-
or ACT +
methodology.

Pr
ERP TEI-SF

al
No differences were found in outcomes, processes of

rn
AAQ-II
change, acceptability, or exposure engagement.
u
Jo
OBQ

AAQ-II- Acceptance and Action Questionnaire-II, ACT- Acceptance and Commitment Therapy, BDI-II- Beck Depression Inventory II, DOCS-
Dimensional Obsessive-Compulsive Scale, ERP- Exposure and Response Prevention, OBQ- Obsessive Beliefs Questionnaire, OCD- Obsessive-
Compulsive Disorder, PEAS- Patient Exposure and Response Prevention Adherence Scale, RCT- Randomized Controlled Trial, TCEQ-
Treatment Credibility and Expectancy Questionnaire, TEI-SF- Treatment Evaluation Inventory–Short Form, Y-BOCS- Yale-Brown Obsessive
Compulsive Scale.
Shabani et al. RCT 69 adolescents with OCD 10-12 CY-BOCS ACT + SSRI was as effective as CBT + SSRI in

(2019) on a stable SSRI dose sessions of treating adolescent OCD.

CDI
Iran randomly assigned to ACT/CBT
Participants in the CBT+SSRI condition reported, on
either group ACT+SSRI, AFQ-Y
average, large, statistically significant reductions in
group CBT +SSRI, or
VLQ CY-BOCS score from pre- to post-treatment (33.3%),
continued SSRI
and large, statistically significant reductions from post-

f
CAMM

oo
treatment.
treatment to follow-up (17.7%).

pr
e-
Similarly, participants in the ACT+SSRI condition

Pr
reported, on average, large, statistically significant

al
reductions in CY-BOCS score from pre- to post-

u rn
treatment (29.4%), and large, statistically significant
Jo
reductions from post-treatment to follow-up (21.8%).

Participants in the continued SSRI condition reported,

on average, only small, statistically non-significant

reductions in CY-BOCS scores.

ACT- Acceptance and Commitment Therapy, AFQ-Y- Avoidance and Fusion Questionnaire for Youth, CAMM- Child and Adolescent Mindfulness Measure,
CDI- Children's Depression Inventory, CY-BOCS- Children's Yale-Brown Obsessive Compulsive Scale, VLQ- Valued Living Questionnaire
 Highlights

1. This is the first systematic review focusing on the use of ACT specifically in

OCD

2. ACT facilitates changes in psychological processes that are distinct from CBT

3. ACT brings about clinical improvement in OCD

4. There is evidence to support the use of ACT as a therapeutic intervention in

OCD

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 Author Disclosure Document

Statement 1: Role of Funding Sources

No funding source was involved in the preparation of this manuscript

Statement 2: Contributors

Both authors contributed equally to the conceptualization, literature search, drafting

and editing of the manuscript. Both authors approved the final manuscript.

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Statement 3: Conflict of Interest
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Both authors declare that they have no conflicts of interest.
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Statement 4: Acknowledgements
na

The authors wish to thank Dr. Gitanjali Natarajan for her valued inputs on the

research material.
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