ERP or ACT/ERP: When to do what?
Timothy DiGiacomo, Psy.D., Clinical Director, Mountain Valley Treatment Center
Recent research (Twohig, M., and Abramowitz, J., 2017), has demonstrated that both Exposure Response Prevention (ERP) and Acceptance and Commitment Therapy (ACT) plus ERP with adults is effective for symptom reduction and maintenance of gains at one and three-month follow-ups post treatment.
Traditional ERP consists of habituation-based and inhibitory learning-based ERP models while ACT/ERP is based on relational-frame theory incorporating mindfulness, flexibility, values, acceptance and behavioral change. Despite the data from the aforementioned research, clinicians are still faced with the challenge of determining which clients may benefit from traditional ERP versus an ACT-based exposure approach.
I recently had the opportunity to present on this topic, along with Drs. Patricia “Dr. Z” Zurita-Ona, and Dustin Siegel, at the 2019 Conference for the Anxiety and Depression Association of America in Chicago. We described our methods for choosing which approach to take with clients and how our programs utilized both ERP and ACT/ERP. Despite the differing theoretical underpinnings and explanations for change, we all agreed that our focus remains on helping clients to achieve changes in their relationship with feared situations and overall improvements in functioning.
We discussed one client whose movement through therapeutic approaches involved beginning with traditional ERP, which initially led to good results and improved functioning, but then was complicated by ongoing intrusive obsessional thinking, significant difficulties accepting uncertainty, existential concerns, and symptoms of depression. Despite good adherence to facilitation of the traditional ERP model and working with a very competent therapist, traditional ERP was no longer appearing to be beneficial and the client was not making the changes that they desired.
At this point in treatment, the client began working with Mountain Valley Treatment Center. Not only was Mountain Valley a higher level of care, it was able to offer a different approach by incorporating elements of ACT into the exposure therapy. At Mountain Valley, we teach our residents about both traditional ERP as well as ACT with ERP.
As such, and with the assistance of staff, clients are able to move towards and utilize the approach that they find most appealing. This client found the inclusion of ACT to be both challenging and beneficial. Learning to engage in mindfulness; working towards identifying rigidity and fusion to thoughts; engaging in a process of learning to become more flexible and to practice defusion; to know that they were not their thoughts but to rather have distance between their thoughts; and being able to identify their values and then to take action that moved them towards a more values-based life was an eye-opening experience for this client.
This was also very different than being driven solely by OCD, anxiety, and overwhelming negative thinking. Inclusion of ACT for this client also led to more meaning and understanding for engagement in exposures and helped this client to be more ready and willing to engage in the difficult exposure work.
Mountain Valley found it useful to understand this client’s treatment history, and response to treatment, in deciding to incorporate ACT into the exposure work or to continue with a more traditional ERP model. Drs. Z and Siegel also echoed this sentiment as important in understanding which approach to utilize. In addition to accounting for past responses to treatment, we also discussed taking into account readiness to engage in ERP; the types of presenting problems; current willingness/readiness to potentially experience discomfort by engaging in exposures; the presence of comorbid disorders/problems; inconsistencies between exposures and a client’s values; client engagement in exposures as part of the compulsion; and client engagement in mental rituals.
It was exciting to be a part of this discussion and I found it encouraging to share and hear from other clinicians. If you’d like to keep the conversation going, or to learn more about Mountain Valley’s approach to treatment, please reach out and check out Mountain Valley.
To learn more about the excellent work being done by Drs. Z and Siegel:
Dr. Patricia Zurita-Ona: https://eastbaybehaviortherapycenter.com/
Dr. Dustin Siegel: https://anxietytreatmentcenter.com/
To learn more about ACT and ERP, check out the following sites:
Exposure Therapy: https://adaa.org/finding-help/treatment/therapy