Acceptance and Commitment Therapy (ACT) for OCD

Acceptance and commitment therapy, or ACT, is a form of treatment for obsessive compulsive disorder (OCD). The goal of ACT is to help you develop a neutral relationship with your obsessions, making it easier to step away from performing compulsions. By focusing on acceptance and your values, ACT aims to reduce shame and distress, helping you stay out of old patterns and become more mentally flexible overall.

To have a strong understanding of how ACT can help with OCD, and to explore your treatment options, we need to have a solid understanding of what OCD is. 

What is OCD?

OCD is a mental health condition that centers on intrusive, unwanted thoughts, images, urges, sensations, and feelings—known as obsessions—that cause a lot of anxiety or distress. These obsessions can take many forms, from doubts about your identity to fears of harm coming to loved ones and more. 

Some common examples of OCD obsessions include:

• Obsessive fears around contamination or exposure to germs
• Disturbing thoughts related to causing harm or aggression
• Persistent worries about responsibility and causing danger for yourself or others
• Intense focus on order, balance, or precision
• Distressing thoughts concerning inappropriate or taboo topics

To cope with the distress from these obsessions, people with OCD often engage in repetitive behaviors or mental rituals to ease distress or prevent something bad from happening. These behaviors are known as compulsions. While compulsions might offer temporary relief from the anxiety brought on by obsessions, they actually reinforce the belief that your obsessions are a real threat, making the cycle stronger over time.

Some common examples of OCD compulsions include: 

• Arranging or organizing items
• Engaging in checking routines
• Repeating specific words in your head
• Performing mental rituals
• Constant washing and sanitizing
• Avoiding triggers

This is where ACT comes in—it helps you shift your relationship to those thoughts and urges in a way that reduces the need for compulsions.

What is acceptance and commitment therapy (ACT)?

Acceptance and commitment therapy (ACT) is a form of psychotherapy developed by Steven C. Hayes in the 1980s that is used to treat OCD, anxiety disorders, depression and post traumatic stress disorder. Hayes created this method during his search for a way to manage his own panic disorder. The main idea behind ACT is that instead of trying to change your distressing thoughts, you learn to be mindful of them and accept them. 

The goal of ACT is to recognize anxiety-inducing thoughts without letting them define you, to have the power to choose how you want to respond intentionally, and to focus on actions that align with your personal values. It’s about accepting what you can’t control and moving forward in a way that feels true to your values. Dr. Marisa Mazza, founder of choicetherapy, is a strong advocate for ACT.  She believes that compared to some other treatment methods, ACT helps people live a fuller life while also improving symptomatology. 

Obsessions in OCD generally carry a negative connotation. ACT challenges this view and promotes a more neutral viewpoint: obsessions are just thoughts, and thoughts are neither good nor bad. By employing this mindset, ACT encourages you to see your obsessions as just passing thoughts, rather than something you need to act on. This shift helps you to resist the urge to respond with compulsions, allowing you to move forward without getting stuck in the cycle of reacting. 

ACT can help people with OCD create a more positive relationship with themselves, increase internal flexibility and awareness, and reduce the shame and anxiety that comes with performing compulsions.

How ACT helps with obsessions

One of the main goals of acceptance and commitment therapy is to shift how you relate to your obsessions. It emphasizes that you are separate from your thoughts, and just because you have a thought doesn’t mean you have to act on it. So, when an obsession pops up, ACT teaches you to notice it, acknowledge it, and then choose how you want to respond in a way that aligns with your values, rather than letting the thought dictate your behavior.

How ACT helps with compulsions

ACT helps you see compulsions as optional rather than something you must do to feel safe. When an obsession shows up, this treatment method reminds you that you have countless ways to respond—your usual compulsions are just one possibility. The goal is to encourage you to think about which actions align with your values and then take steps toward those, instead of feeling stuck in your old patterns and giving into compulsions. Most of the time, compulsions do not align with your values and principles, which causes a negative cycle.

How to understand ACT therapy

When engaging in ACT, one of the most important aspects is realizing your thoughts as just thoughts. ACT encourages you to approach these thoughts with a sense of nonjudgmental awareness. This means noticing them without getting caught up in them. The goal is to identify the values that matter most to you and build skills that help you regulate your emotions, so you can respond in ways that align with those values instead of compulsing.

In order to better understand ACT and the way it helps you to retrain your mind, therapists use metaphors throughout the treatment process. These metaphors teach you about different concepts within ACT therapy and how to create distance between yourself and your thoughts. By changing how you approach your thoughts and behaviors, you will be able to respond to them in a way that is more aligned with who you actually are.

Here are some of the common metaphors used by therapists during ACT:

• Passengers on a bus
  • Imagine your mind as the driver of a car or bus, and your thoughts, feelings, or obsessions as the passengers. The passengers might try to boss you around, but at the end of the day, they aren’t the ones steering. You are the driver, and you get to decide where the bus goes.
• Tug of war with a monster
  • Picture yourself in a tug-of-war with a huge, scary monster, and you’re pulling as hard as you can to avoid falling into a pit. No matter how hard you try, the monster pulls back even stronger. What if you just let go of the rope? Instead of trying to win an impossible battle, you can release the struggle with your obsessions by choosing not to engage.
• Two scales
  • Imagine a kid at the grocery store throwing a tantrum because they want candy. If the parent gives in, the kid learns that yelling works and will just do it louder next time. That’s how obsessions work: if you respond with a compulsion, the obsession gets stronger, knowing that it can push you into action. The trick is to ride out the discomfort and not give in, so eventually, the ‘tantrum’ (or obsession) quiets down on its own.
• Thoughts as leaves on a stream
  • Think of your mind as a stream, with thoughts flowing through it like leaves and sticks. You can watch the leaves float by without having to jump in and fish out every piece of debris. Let those thoughts drift past instead of getting caught up in trying to control or fix every single one.
• Beach ball underwater
  • Picture your emotions as a beach ball you’re trying to hold underwater. It takes a lot of energy to keep it down, and eventually, it’s going to pop back up anyway. The more you try to push it down, the more force it comes back with. Instead of using all your energy to keep it submerged, what if you just let it float? Allow your feelings to exist rather than constantly fighting to keep them hidden.
• Quicksand
  • Think of distressing thoughts and compulsions like being stuck in quicksand. The more you struggle and try to control the situation by reacting with compulsions, the deeper you sink. Instead of fighting, the key is to stay still and let yourself be, accepting the discomfort without reacting so you don’t get pulled in even further.

These metaphors give you a new way to look at your obsessions and compulsions. The goal is that by applying these metaphors to your own situations, you will be able to develop healthier strategies to understand the way your mind works and eventually deal with your OCD without compulsions.

What do acceptance and commitment mean?

Acceptance means allowing yourself to feel the full range of your emotions, thoughts, impulses and feelings without immediately trying to change or fight against them. It’s not about liking or agreeing with those thoughts. It’s about making space for them and recognizing that they’re part of your natural human experience.  “Am I willing to have the thought that something terrible is going to happen, and still do what is important to me?” asks Dr. Mazza. Thoughts are just thoughts, and just because a thought might seem ‘bad’ or ‘negative,’ that does not mean that you are either of those things. By accepting what you can’t control, you free up energy to focus on living in line with your values, rather than battling against your mind.

Commitment is about choosing actions that align with your values instead of performing compulsions, even if your thoughts and emotions try to pull you elsewhere. It’s about identifying what matters to you—like being present with loved ones, pursuing passions, or focusing on your health—and committing to those actions, regardless of the discomfort OCD might bring up. Commitment helps you build a life that feels meaningful and fulfilling, rather than letting OCD have control over you.

How is ACT different from ERP?

Exposure and response prevention therapy (ERP) is the first-line treatment for OCD due to the extensive clinical research showing its efficacy. ERP involves exposing you to your obsessions, fears, and intrusive thoughts during therapy and in daily life. The goal is that over time, you will learn to sit with the discomfort your obsessions bring instead of acting out on the compulsions that provide temporary relief. By engaging in the healthier responses ERP encourages, the strength of your obsessions will also become less powerful over time and your intrusive thoughts will be less intense. ERP focuses more on reducing obsessions overall, while ACT focuses on changing the way you experience them. 

In ACT, you view obsessions and anxiety as normal parts of your life. They are not inherently bad, and they do not define you. ACT aims to let these obsessions and anxieties come and go without creating an impact on your daily routine, believing that better functioning can be achieved without a big change in the frequencies of your obsessions. This is because ACT focuses on the difference between how you think and feel versus what you do based on it. The obsessions are not under your control, but what you do while experiencing them is, so the focus is on adopting healthier, values-based habits. 

ACT centers on building psychological flexibility and taking actions that align with your values. On the other hand, ERP focuses on lowering anxiety by repeatedly exposing you to your triggers and teaching you to get used to sitting with discomfort rather than turning to compulsive responses.

Some therapists choose to incorporate both ACT and ERP into their treatment methods together, taking key aspects of both and blending them.

Is ACT an effective treatment for OCD?

Yes! ACT is a relatively new approach to OCD treatment, so while ERP has more studies backing up its effectiveness, there is emerging research showing the efficacy of ACT. Research shows that ACT can be helpful for people with OCD because it focuses on increasing psychological flexibility. This means learning to see your thoughts and feelings as separate from your actions, so you don’t feel the need to react with compulsions every time you have an upsetting thought. ACT helps you notice those intrusive thoughts, accept that they don’t define you, and help you choose to act based on your values.

ACT is also a good option for people who have tried ERP and found it didn’t work very well for them. “When I was at the OCD Conference last year, I sat in on a session about ACT and OCD,” explains Dr. Mazza. She said McLean Hospital started an ACT group for people that were resistant to ERP and medications to the group. These individuals responded significantly better to ACT than the methods they had previously used. “It’s exciting… to provide another option to folks who aren’t responding to traditional ERP and medications,” she says.

It’s completely normal to have preferences about which treatment you want to try for your OCD. The good news is that there are options, and your therapist is there to guide you toward what works best for you. Your therapist can walk you through the differences between ACT and ERP, helping you figure out which approach might be the best fit for your situation—or if using a combination of both could be beneficial.

Bottom line

As we learn more about obsessive compulsive disorder and what works best to treat it, new and effective therapy methods continue to emerge. ACT therapy is a valuable option for treating OCD, offering an approach that focuses on acceptance, mindfulness, and aligning your actions with your values. 

OCD is a highly treatable condition—which treatment plan will work best for you depends on your own unique situation. Whether it’s ACT, ERP, or a combination of treatments, finding the right support can make a huge difference in managing OCD and improving your quality of life.