Abstract
The literature describing psychological interventions for co-occurring obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) is limited. Acceptance and Commitment Therapy (ACT) is a transdiagnostic intervention that targets functionally avoidant behavior underlying both OCD and PTSD. The current case report describes how an ACT-informed approach to treatment was implemented over 14 sessions to treat co-occurring OCD and PTSD in a 9-months postpartum adult woman. The patient was initially referred to psychotherapy by her psychiatrist and showed high motivation to engage in treatment. This case presentation outlines how the intervention targeted core ACT processes while also incorporating components from both exposure and response prevention (ERP) and cognitive processing therapy (CPT) to address the patient’s presenting concerns. Measurements of OCD and PTSD symptom severity, as well as of depressive and anxiety symptoms, over the course of treatment are included. Health-related comorbidities, psychiatric medications, and implications are discussed.
Keywords
1 Theoretical and Research Basis for Treatment
Both obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are characterized by inflexible avoidant responses to unpleasant internal experiences (e.g., obsessions, memories, urges, and emotions) that are often elicited by external cues (e.g., a public restroom and a loud noise). Exposure therapies, which aim to promote approach rather than avoidance behavior in the presence of feared stimuli; and to promote new learning, have strong empirical support for both disorders (Olatunji et al., 2013; Powers, et al., 2010). Specifically, exposure and response prevention (ERP) has been shown to be efficacious for OCD (Eddy et al., 2004), while Prolonged Exposure (PE) therapy and Cognitive Processing Therapy (CPT), both of which promote engagement with trauma memories, have support for the treatment of PTSD (Lancaster et al., 2016). ERP and PE are primarily focused on behavioral exposures and do not include principal cognitive components. CPT also promotes approach behavior through supporting patients to confront thoughts and memories that maintain trauma symptoms. Additionally, CPT helps individuals to identify impact statements and overgeneralized thinking patterns surrounding the trauma that may be affecting the patient’s behavioral flexibility (Lancaster et al., 2016).
Though the aforementioned cognitive-behavioral interventions have been thoroughly explored for OCD and PTSD individually, there is limited research exploring treatments targeting co-occurring OCD and PTSD, though previous work has demonstrated important associations between the two disorders. A recent meta-analysis indicated that trauma exposure is related to greater obsessive-compulsive spectrum symptom severity, especially in women, and that this association is likely driven primarily by compulsive (rather than obsessive) symptoms (Miller & Brock, 2017). Similarly, previous work has also shown that for individuals with OCD, having experienced one or more traumatic life events is associated with greater symptom severity (Cromer et al., 2007) and, importantly, that treatment-seeking patients with comorbid OCD and PTSD may respond less favorably to ERP than those with OCD but not PTSD (Gershuny et al., 2002). Given the functionally similar avoidant nature of OCD and PTSD-specific behaviors, Acceptance and Commitment Therapy (ACT; Hayes et al., 1999), a transdiagnostic acceptance-based behavioral therapy, may be particularly well-suited for the treatment of co-occurring OCD and PTSD.
Acceptance and commitment therapy targets experiential avoidance, or any attempt to control the form, frequency, or intensity of unpleasant internal experiences (e.g., thoughts, memories, and urges) when doing so interferes with valued living (Chawla & Ostafin, 2007; Hayes et al., 1996). An extensive literature now suggests that experiential avoidance may be implicated in a variety of forms of psychopathology (Chawla & Ostafin, 2007; Mellick et al., 2019; Spinhoven et al., 2014), and newer psychotherapy literature emphasizes the importance of identifying and targeting transdiagnostic processes of change (such as avoidance) rather than focusing solely on manualized treatments for individual diagnoses (Hayes and Hofmann, 2018; Hofmann et al., 2021). The inflexible behavioral responses characteristic of both OCD and PTSD can be conceptualized as experientially avoidant in nature. To undermine avoidance, ACT aims to promote psychological flexibility, or the ability to fully contact the present moment and to choose to engage in behavior that aligns with one’s values, even in the presence of unpleasant internal experiences (Doorley et al., 2020). In order to build psychological flexibility, ACT targets six core processes that apply across a variety of forms of psychopathology: 1) defusion—the ability to create space between oneself and one’s thoughts, 2) acceptance—the willingness to accept rather than avoid unpleasant internal experiences when doing so serves valued ends, 3) present moment awareness—the ability to flexibly contact the present moment and attend to the most relevant contextual stimuli, 4) self-as-context—the ability to take perspective on one’s own experience and self-stories, 5) values—identification of and connection with what one finds most important and meaningful in life, and 6) committed action—behavioral engagement in actions that are in line with chosen values (Hayes et al., 2012).
Importantly, ACT has shown preliminary support for the treatment of both OCD and PTSD, but the literature to-date is limited (for review, see Bluett et al., 2014). For example, a randomized-controlled trial (RCT) comparing ACT to Progressive Relaxation Training (PRT) for OCD showed that the 8-session ACT treatment led to greater changes in OCD symptom severity at posttreatment and 3-month follow-up (Twohig, et al., 2010, 2010a). Another study showed both ACT and ACT + selective serotonin reuptake inhibitors (SSRIs) to perform better than SSRIs alone in terms of reductions in OCD symptoms (Vakili et al., 2014). Similarly, an RCT comparing group ACT + selective serotonin reuptake inhibitors (SSRIs) to SSRIs alone for patients with OCD showed no significant differences in OCD symptoms at post-treatment, but showed significantly greater reductions in symptoms at 2-month follow-up for the ACT + SSRIs condition compared to SSRIs alone (Rohani et al., 2018). Finally, an RCT comparing gold-standard traditional ERP to a combined ERP + ACT intervention found no significant differences across outcomes (Twohig et al., 2018). Published case studies and conceptualizations provide additional support for the application of ACT for OCD (Twohig, 2009b; Twohig, M. P., Whittal, M. L et al., 2010). In terms of previous literature exploring ACT for PTSD, Orsillo and Batten (2005) and Thompson and colleagues (2013) describe how PTSD symptoms may be maintained through experiential avoidance and provide case examples illustrating how an ACT approach may be implemented in treating PTSD or to support traditional exposure-based treatment. Implementation of ACT for PTSD has been described (Twohig, 2009a; Walser & Westrup, 2007). A brief, single-session ACT intervention implementation pilot study demonstrated that adolescents with more reported trauma benefited most from ACT in terms of internalizing symptoms and avoidance (Kroska, et al., 2019). Previous work with veterans has explored the development of an ACT protocol for comorbid PTSD and substance use (Hermann et al., 2016) and of a multi-site RCT examining ACT as a transdiagnostic treatment for Veterans who served in recent wars in Iraq and Afghanistan (Lang et al., 2012). Additionally, recent pilot data showed support for the implementation of both group and individual ACT for Veterans diagnosed with PTSD (Wharton et al., 2019). Fiorillo and colleagues (2017) indicated preliminary support for the implementation of web-based ACT for women with psychological symptoms related to interpersonal victimization. Acceptance and commitment therapy has also been proposed as an intervention for moral injury (Nieuwsma et al., 2015). In summary, preliminary research and implementation work has indicated the potential utility of ACT for trauma-exposed individuals and PTSD.
OCD and PTSD in the Perinatal Period
There is existing evidence that the perinatal and postpartum periods are times of increased risk for OCD for women (Russell et al., 2013). One study by Zambaldi and colleagues (2009) found that 63.5% of postpartum women reported some obsessive-compulsive symptoms and approximately 9% met diagnostic criteria for OCD (2.3% of whom reported onset in the postpartum). Additionally, reviews have pointed to the unique relevance of obsessions surrounding aggression toward or harm to the infant in postpartum OCD (Abramowitz et al., 2003; Starcevic et al., 2020). Risk factors for perinatal or postpartum OCD may include both biological (e.g., hormonal changes) and psychological (e.g., interpreting intrusive thoughts as highly significant or dangerous) contributors (Brandes et al., 2004; Fairbrother & Abramowitz, 2007; Russell et al., 2013). Individual characteristics and experiences of the mother, such as a history of psychopathology or complications during pregnancy or birth, may be additional risk factors (Zambaldi et al., 2009).
Literature has also indicated the prevalence and importance of trauma-related symptoms during the postpartum period. A meta-analysis by Grekin and O’Hara (2014) indicated that 3.1% of postpartum women from community samples and 15.7% of women in at-risk samples met criteria for postpartum PTSD. Postpartum PTSD may result from traumatic events that occurred prior to the perinatal period (e.g., childhood abuse) or may be associated with birth trauma specifically (Grekin & O’Hara, 2014). One study examining postpartum women found that 45.5% of women reported a birth event they appraised as traumatic (Alcorn et al., 2010). Risk factors for postpartum PTSD may include current depression, history of psychopathology, labor experiences, and infant complications (Grekin & O’Hara, 2014). Additionally, recent work has highlighted the significance of fear of childbirth and both subjective perceptions of and objective characteristics of childbirth as important variables in predicting postpartum posttraumatic stress symptoms (Grekin et al., 2021).
Importantly, the co-occurrence of obsessive-compulsive and trauma symptoms during the perinatal period specifically has not been well-characterized. A recent meta-analysis examining anxiety disorders (including OCD and PTSD) during pregnancy and the postpartum estimated the probability of having various co-occurring disorders during this period (Fawcett et al., 2019). For someone with an OCD diagnosis, the study estimated a 7.2% probability of also having PTSD; for someone with a PTSD diagnosis, the study estimated an 11.4% probability of co-occurring OCD (Fawcett et al., 2019). As described above, a transdiagnostic approach such as ACT may be particularly appropriate for women experiencing a diverse combination of psychological symptoms, such as those associated with OCD and PTSD, during the perinatal period. To our knowledge, no intervention studies have specifically explored the implementation of ACT for co-occurring perinatal OCD and PTSD, but emerging literature has described the potential utility and feasibility of ACT during the perinatal period (Bonacquisti et al., 2017; Waters et al., 2020). Of additional note, a recent study implicated both experiential avoidance and a tendency to misappraise intrusive thoughts during pregnancy as predictors of postpartum OCD for first-time mothers (as well as first-time fathers), indicating the potential utility of a process-based approach like ACT (Ojalehto et al., 2021).
Building skills in the core transdiagnostic ACT processes may be a useful approach for addressing the experientially avoidant behaviors associated with both OCD and PTSD. Whereas a rigid manualized approach to treatment may require first targeting either PTSD or OCD symptoms in a modular way, a process-based approach to treatment allows for the idiographic targeting of processes that may be functioning similarly across diagnoses for a specific patient in their current context. For example, a therapist might help a patient to relate to intrusions and other unpleasant thoughts and emotions associated with OCD and PTSD through targeting the processes of acceptance and defusion. Additionally, intrusive thoughts and memories often capture significant attention. Thus, promoting the process of present moment awareness may help a patient to ground themselves in the moment. This in turn may allow for greater behavioral flexibility and a focus on important values, which transcend specific diagnosis. Importantly, ACT interventions can be applied flexibly as a therapist notices a process that may be particularly relevant to their conceptualization of the patient’s struggles broadly or in a particular moment during session.
Of additional importance, an ACT approach may facilitate engagement in aspects of other empirically supported treatments (e.g., ERP, PE, and CPT), especially if these treatments are also applied flexibly. For example, being able to experientially connect with the paradoxical increase in unwanted internal experiences following avoidance behavior may help to promote engagement in behavioral exposures. Identifying and connecting with values may also help to promote approach behavior. For an individual with OCD, being able to notice a thought such as “I must check that I locked the front door” as a thought rather than a command or literal truth (i.e., defusion) may allow her to more easily engage in exposure and response prevention surrounding this behavior. For a patient with PTSD, learning to defuse from the stuck point “it’s my fault” may help to facilitate more flexible responding and facilitate change in the impact statement used in CPT.
2 Case Introduction
The following case study describes the application of ACT with a postpartum mother who was experiencing comorbid OCD and PTSD symptoms. Cecilia “Cece” Bloom is a cisgender, Caucasian female in her early 30s. She is a full-time professional who lives with her husband and infant. To prevent disclosure of the client’s identity, the name of the patient has been changed to a pseudonym, which is not representative of her first or last name; non-pertinent details describing her life have been changed; and she consented to the publication of her case presentation and reviewed the manuscript in its entirety. She was 9-months postpartum when she was first seen in outpatient psychiatry and for psychotherapy following the increase in intrusive thoughts and associated symptoms following the birth of her daughter. Information for this study was collected via case notes, clinical records, audio recordings, patient self-report measures, therapist assessment, therapist-supervisor conceptualization, and therapist-supervisor reflections. Cece was diagnosed with and treated for Obsessive-Compulsive Disorder (OCD) and Posttraumatic Stress Disorder (PTSD). She reported a history of an eating disorder, and eating disorder symptoms were being treated by the prescribing psychiatrist throughout treatment. Per the client’s report, these symptoms improved, and they were therefore not a topic of discussion in psychotherapy. Evaluation and treatment occurred when Cece was 9-months postpartum and was experiencing significant occupational and psychosocial stress. Her partner was supportive throughout treatment, per Cece’s report. Cece expressed great pride in her career and accomplishments. She worked full-time for the year prior to and all throughout treatment in a high-stress position in an upper level administrative role for a large institution. Her job often precipitated significant distress due to frequent, significant conflict with a direct supervisor.
3 Presenting Complaints
Cece was referred to psychotherapy by her psychiatrist, who diagnosed her with OCD. The patient self-referred to psychiatry secondary to worsening symptoms of depression and anxiety following the birth of her child. She endorsed agoraphobia, irritability, sleep and appetite disturbances, low self-esteem, poor concentration, anxiety and worry, panic attacks, and compulsions. Her psychiatrist initiated the diagnosis of OCD and prescribed medications. Cece reported that her psychiatrist was the first medical provider to ever attend to OCD symptoms, which both shocked her and fit with her experiences. Cece appeared to have limited awareness of the frequency of her symptoms at the onset of treatment, although she quickly became increasingly aware that stress would intensify the occurrence of intrusive symptoms. Cece was taking birth control and sertraline at the time of the psychotherapy intake. She reported diagnoses of Polycystic Ovarian Syndrome (PCOS), Irritable Bowel Syndrome, and migraine headaches. She utilized fertility medications (letrozole) to achieve the most recent pregnancy, which was complicated by gestational diabetes and postpartum preeclampsia.
The psychiatric provider assessed thyroid function at intake and prescribed sertraline and lorazepam to target symptoms of depression and anxiety and Glucophage (PCOS). Sertraline was increased to 200 mg, which was poorly tolerated and later adjusted to 75 mg to balance efficacy and side effects. She noted that the daytime dose (0.25 mg) of lorazepam made her feel like a “zombie” but was helpful for sleep at bedtime (0.5 mg.), and eventually she took three doses (0.25 mg in AM, 0.25 mg around noon, 1 mg at bedtime) daily. She endorsed gastrointestinal side effects with Glucophage and changed to bupropion/naltrexone (Contrave) to target weight and binge eating. She tolerated the medication well, but due to cost, she was eventually prescribed Bupropion (500 mg) and Naltrexone (50 mg).
Throughout the course of therapy, Cece disclosed childhood traumatic experiences and related symptoms that necessitated a revised conceptualization of the case. Cece had spoken very little of her childhood traumatic experiences with family, friends, or medical providers. It was very important to her that she maintain her persona of a carefree, easy going, and independent woman. Sharing these childhood memories took significant trust and belief that disclosing them would help her seek peace. She was initially seeking support with what she believed to be postpartum anxiety confounded by psychosocial stressors at her work. Eventually, she attributed her compulsive counting to her first experience of ongoing childhood sexual abuse, after which she counted her prayers for forgiveness. She began therapy with the belief that if she treated the compulsions, then her anxiety and self-deprecating thoughts would reduce. Cece presented to the intake session motivated and convinced that behavioral health interventions were an appropriate course of treatment, which she noted were attributable to intrinsic motivation and strong encouragement from her psychiatrist.
4 History
Cece grew up in a rural area and was raised by middle-class, married biological parents with two siblings. Her family raised her as a practicing Catholic, although she identified that she was not religious or spiritual throughout treatment. Cece met her husband while in college and appeared to be in a healthy relationship. Cece had a history of an eating disorder from adolescence, which re-emerged with pregnancy and breastfeeding, though these symptoms were managed by the psychiatrist with medication and were reportedly not clinically significant areas of concern for the client when she presented to therapy. With the focus of treatment on Cece’s obsessive-compulsive and trauma-related symptoms, in combination with a limited number of sessions, there was minimal space to formally assess a possible relapse in binge-purge symptoms. Cece reported that her mother was conscious of cultural expectations of thinness, and Cece felt criticized for her weight and shape. Cece reported that she had a breast reduction before starting college due to back problems and hindered athletic ability. As her breasts grew while pregnant and breastfeeding, her shape and weight-related thoughts returned, triggering thoughts about her childhood traumas. There was concern for exacerbation of her symptoms, as is sometimes expected during the early stages of exposure-based therapy approaches, and regular contact with the psychiatrist was maintained in order to monitor these symptoms as related to medication management. She also reported a history of irregular periods since high school when they stopped as a result of an eating disorder.
Cece struggled with fertility, she took fertility medications, and she and her husband were on the verge of beginning in-vitro fertilization when they got pregnant prior to the scheduled procedure. The fertility process was described as “grueling,” therefore, she had fears around maintaining a healthy pregnancy. Initially, they wanted to wait to share the news with family to avoid sharing potential heartbreak, but they opted to tell family at 8 weeks. Just before they planned to share, she learned of her uncle’s death by suicide. This news was devastating for the entire family, including Cece. She felt she had to suppress her excitement about her pregnancy following his death and her grief about her uncle. She likely struggled with experiencing her true emotions and the emotions she thought she “should” have. Cece developed a superstitious outlook on life and subsequently connected getting pregnant with a contribution to her uncle’s death.
During the first three sessions in psychotherapy, Cece disclosed three experiences of childhood sexual abuse that she had not discussed at length with other providers or her social supports. The most traumatic experience initially identified was recurrent childhood abuse that lasted for multiple years by two related same-aged peers. As therapy progressed, however, the most traumatic event identified was sexualized stalking by a friend’s parent while in high school. Cece had refrained from sharing details of the trauma or revealing the trauma at all in many cases due to avoidance of intense shame.
5 Assessment
Cece completed various self-report assessment measures throughout treatment to provide quantitative progress in the primary areas of concern. The commonly used and well-validated Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001) and Generalized Anxiety Disorder (GAD-7) (Spitzer et al., 2006) measures were administered at intake and then periodically throughout therapy. The PHQ-9 is a 9-item measure that screens for depressive symptom severity by asking patients to report on how often they have been bothered by specific symptoms in the prior 2 weeks (not at all, several days, more than half the days, nearly every day) (Kroenke et al., 2001). Scores range from 0 to 27, with scores ranging from 0 to 4 indicating minimal depressive symptoms, 5–9 indicating mild symptoms, 10–14 indicating moderate symptoms, 15–19 moderately severe symptoms, and 20–27 indicating severe symptoms (Kroenke et al., 2001). The GAD-7 is a 7-item measure that screens for anxiety symptoms by asking patients to identify how often they have been bothered by specific symptoms in the prior 2 weeks (not at all, several days, more than half the days, nearly every day) (Spitzer et al., 2006). Scores range from 0–21, with scores in the 0–4 range indicating minimal anxiety symptoms, 5–9 indicating mild symptoms, 10–14 indicating moderate symptoms, and 15–21 indicating severe symptoms (Spitzer et al., 2006). The PHQ-9 and GAD-7 were administered during sessions 1, 5, 6,10, 11, 12, and (Figures 1 and 2). Providing these measures was standard practice in the location of the clinic where Cece was seen.
Symptoms of depression throughout the course of treatment.
Symptoms of anxiety throughout the course of treatment.
The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) severity scale (Goodman et al., 1989) measures severity of obsessions and compulsions and was first administered during session two. The Y-BOCS Symptom Checklist was not completed. The Y-BOCS is a 10-item measure designed to measure severity of obsessions and compulsions. Questions are administered by the interviewer as a semi-structured interview. Items are rated on a five-point Likert scale by time spent distracted by, interference, level of distress, resistance to, and degree of control over the obsession or compulsions, without influence by the type of obsessions, or compulsions present. Scores range from 0 to 40, with scores in the 8–15 range indicating mild severity, 16–23 indicating moderate severity, 24–31 indicating severe severity, and 32–40 indicating extreme severity. The Y-BOCS was administered during sessions 9, 12, 13, 14, and 15 (Figure 3). Although the patient provides their report of interference of symptoms, the final rating is based on the interviewer’s clinical judgment. Cece’s diagnosis of OCD was determined based on Cece’s self-report of symptoms meeting the DSM-5 criteria for diagnosis prior to the introduction of the Y-BOCS, which was administered as a measure of progress throughout treatment with regard to the impact Cece’s compulsions had on her daily life.
Symptom progression across sessions and symptom domains.
The Post-traumatic Stress Disorder Checklist (PCL-5) (Weathers et al., 2013) is a 20-item measure that assesses the severity of PTSD symptoms in the past week. It is commonly used to monitor symptom changes during treatment. Each item is rated on a scale from: “not at all,” “a little bit,” “moderately,” “quite a bit,” to “extremely.” Total symptom severity ranges from 0 to 80, obtained by summing the 20 items. Meeting diagnostic criteria for PTSD is determined based on the number of symptoms endorsed in the four categories. According to the developers, a 5–10 point change represents a reliable change, and a 10–20 point change represents a clinically significant change. A threshold for diagnosis of PTSD is regularly identified as scores above 33. A study investigating change indicated that reliable change on PCL-5 fell between 15 and 18 points, and clinically significant change was 28 points (Marx et al., 2022). Notably, this was among a sample of male Veterans. The PCL-5 was administered during sessions 2, 9, 12, 13, 14, and 15 (Figure 4).
Symptoms of posttraumatic stress disorder throughout the mid-to-late treatment course.
6 Case Conceptualization
For the majority of Cece’s adolescent and adult life she had participated in compulsive counting behaviors used to reduce anxiety, starting with counting her prayers before bed. It is likely these counting rituals and superstitious compulsions were negatively reinforced, as they removed the stress caused by her traumatic intrusive memories that evolved over time into obsessive thoughts. The avoidance helped her maintain emotional stability in the short-term, which led to a long-term pattern of rigid rule-following to maintain emotional stability. Psychological flexibility was a primary overarching long-term goal for Cece in order to break her learned rigid and ritualistic response to stress.
Cece had well-established values including family, career, and being a strong independent woman. Cece benefited from bringing her values to the forefront for motivation for change. Throughout treatment, reducing focus on symptom reduction and increasing focus on living a values-driven life helped maintain motivation to engage with the treatment plan. This therapist tracked symptoms (self-report and Y-BOCS) rather than therapeutic processes due to electronic medical record limitations and in order to systematically track changes in Cece’s daily experiences, although in session, the focus was on Cece’s time spent living a values-driven life.
Cece was fundamentally unaware of the time spent on her compulsive behaviors and of her present moment experience. Cece stated that she was unaware of the impact of her OCD symptoms until she began psychiatric treatment. However, Cece entered therapy with a repertoire of values-based behavior (committed action) and some indications that she was able to take perspective on her experiences (self-as-context). She had a self-established belief that her compulsive behaviors were the main contributor to her maladaptive and self-deprecating thoughts. She recognized prior to treatment that her compulsions were driving her obsessive thoughts, and she arrived ready to make behavioral changes. Her belief that changing her response to these thoughts could reduce her depression and improve self-worth set her up for success with treatment with motivation to participate in exposure and response prevention. She was also motivated to address the OCD symptoms due to the centrality of the obsessions on the well-being of her newborn.
Cece presented with multiple strengths in the ACT processes of committed action, values, and self-as-context. Although Cece was fused with her thoughts, often believing they were facts or acting on them, she was able to recognize that she was more than her thoughts (self-as-context). The patient’s strong rapport with her referring psychiatrist also likely contributed to the quick rapport built in therapy, due to the psychiatrist’s belief in and compelling referral to treatment. Motivation for treatment was largely centered on the desire to reduce the impact of obsessive thoughts and compulsive behaviors. It was not until later in the therapeutic relationship that the patient felt safe enough to disclose past traumatic experiences and related PTSD symptoms. The therapist had extensive training in evidence-based trauma treatments (PE and CPT), and it was beneficial to Cece to offer empirically supported treatment options to address her trauma-focused concerns that were directly connected to her symptoms of OCD. Concepts and strategies from CPT were adapted with flexibility to help defuse Cece’s self-blaming thoughts related to her childhood traumatic experiences.
Cece’s reported history of eating disorders caused concern for increased symptoms with exposure-based treatment for OCD. Through collaboration with Cece, her psychiatrist, and consultation with faculty, there was agreement that exposure-based treatment with close monitoring of potential urges to binge or purge by her psychiatrist was warranted and could be addressed safely. Due to Cece’s career goals, successful continuation with her employment, family responsibilities, and her confidence in being honest about her response to therapy, a full or partial-hospitalization program was not considered.
Treatment Plan and Goals
At the start of psychotherapy, Cece’s main concern was intrusive thoughts about inadvertent potential harm to her 9-month-old child if she did not act on her compulsions. ACT was offered as a transdiagnostic values-based intervention that could provide a consistent style and focus throughout the use of exposure-based treatment for OCD. The first treatment goal was to increase daily values-driven decisions to be demonstrated through the use of the ACT Matrix, which provided a shared language around “toward” (values-based) or “away” (avoidant) behaviors as related to Cece’s values. The second therapy goal was for Cece to reduce time spent on obsessions and compulsions through use of exposure and response prevention (ERP) strategies.
There are various starting points within ERP in conjunction with Cece’s avoidance hierarchy. Within the exposure therapy framework, a metaphor was used to convey the graduated and flooding exposures, with the goal of providing her information and a choice. The metaphor detailed a swimming pool, wherein one could wade into the pool gradually or jump into the deep end. The therapist noted that when jumping into the deep end, we may realize that the depth was 5 feet, or we remember how to tread water or swim, even if we are out of practice. Cece chose to start near the top of her fear hierarchy and “jump in the deep-er end” rather than start at the bottom for graduated exposure. Importantly, we did not remain near the top of the hierarchy throughout the entirety of therapy, but varied the intensity of the completed in-vivo exposures. This aligns well with inhibitory learning research, which proposes that variable exposures may be more effective than traditional progression up a hierarchy (Arch & Abramowitz, 2015; Craske et al., 2014).
Once the trauma and PTSD symptoms were acknowledged and accepted, options for addressing her trauma were presented. The therapist was previously trained in both Prolonged Exposure Therapy and Cognitive Processing Therapy (CPT), which were presented to the patient as potential evidence-based treatment options to directly address her symptoms of PTSD, the most distressing of which was her fusion with the belief that she was at fault for her traumatic childhood experiences. Cece chose CPT due to her value on emotion-based processes instead of an additional exposure-based intervention.
7 Course of Treatment and Assessment of Progress
The therapist who conducted the intervention was the first author (L.G.) during her pre-doctoral internship. Cece was ideally seen once every other week when the schedule allowed, with a shift to weekly during the final four sessions. Use of key ACT processes session-by-session are described in each session description.
Session One
The initial visit included a semi-structured assessment for diagnostic clarification and treatment planning. Cece’s diagnosis of OCD by her psychiatrist was confirmed along with a history of major depressive disorder (MDD) with anxious distress. Cece expressed primary concern with her obsessive thoughts and fears that her child would be harmed. Present moment awareness and values were targeted during the initial interview with rapport building throughout sessions.
Cece reportedly struggled with building rapport and trust with others and particularly her medical providers. Cece shared that quick rapport was built early in her first session as she felt surprised when the supervisor arrived, and she did not fully understand that the supervisor would be sitting in the room to listen for a portion of the session (a requirement for billing at the institution). When the therapist responded with acknowledgement and took responsibility for the miscommunication, Cece felt she was then able to trust the therapist and the proposed therapy process. This was presumably a critical point in the relationship development that likely contributed to the rapport vital for effective treatment.
Session Two
The ACT Matrix was completed in-session to increase awareness of obsessions and compulsions, internal experiences, and behaviors. The therapist also worked toward increasing committed action and noticing workability of avoidance. The therapist began discussing the rationale for exposure-based treatment for anxiety. All six ACT processes were addressed through the completion of the ACT Matrix to target psychological flexibility.
Assessment: Y-BOCS—Scored in the severe range (28). Home assignment: Committed action with a single “toward move”
Session Three
Cece discussed her values and noticed her experience (present moment) during behavioral pursuit of values (acceptance and values). Further awareness was developed through detailed descriptions of her compulsive behaviors, obsessions, and the associated emotions (acceptance and present moment).
Assessment: Identified obsessions (present moment). Clarified values. Home Assignment: Attempt a more challenging “toward move” (defusion, acceptance, and committed action)
Session Four
Cece described her first memories of her obsessions and compulsive behaviors. This exercise led to the identification of her first childhood sexual trauma. She recognized the role of her compulsions, described as “routines,” to avoid distress and to increase her internal sense of control (self-as-context, present moment awareness). The therapist used a snowball metaphor to identify the connection between her compulsions and an increase in her anxious thoughts (acceptance, defusion).
Home Assignment: Track awareness of obsessive thoughts and compulsive behaviors without making purposeful changes (present moment awareness, acceptance).
Session Five
The therapist provided continued rationale for exposure-based treatment. Cece identified that she wanted to begin at the top of her fear hierarchy (committed action and acceptance). Cece was vocal about her motivation for short-term treatment in the context of escalating stress with her boss at work (acceptance and values). A hierarchy was developed in collaboration with Cece.
Assessment: PHQ-9, GAD-7, and PCL-5 (scored above threshold for PTSD). Home Assignment: First exposure practice. Purposefully defy the urge to align all light switches before bedtime (near the top of her hierarchy).
Session Six
Started the session with a body-scan mindfulness practice (present moment and self-as-context). Cece ceased the practice early due to the intensity of discomfort with noticing her physiological internal experiences. Cece discovered the sense of failure in response to her inability to sit with her emotions, which elicited more emotions. Cece successfully implemented response prevention in between sessions of her identified compulsion by intentionally “poking the bear” of her internal experiences with astonishing results. Not only did she approach her feared obsessions, she also independently engaged in anxiety-provoking behaviors with the intention of confronting her obsessions directly (defusion, acceptance, present moment, and self-as-context). She reported improved sleep and fewer self-deprecating thoughts.
Home Assignment: Continue exposure to anxious thoughts and uncomfortable emotions (committed action, present moment awareness, and acceptance).
Session Seven
An in-session mindfulness exercise was completed via visualization of leaves on a stream (present moment awareness and self-as-context). Cece disengaged due to self-judgment that she did not see herself by the stream, but as a third-person observer. This distressed her greatly because she felt incapable of following the “rules” implied by the practice. We discussed the usefulness of the observer perspective (self-as-context). She connected with her emotions of shame and feelings of failure (acceptance and defusion). She used a metaphor of her own—feeling like she was drowning at the bottom of a pool—to describe these emotions. Cece’s ability to notice avoidance grew immensely as she recognized a concern that she was using music and alternative actions to avoid her internal experiences (self-as-context). We identified secondary emotions related to avoidance of primary emotions and discussed benefits of feeling distress and the role of avoidance behaviors (acceptance and defusion).
Home Assignment: Continue purposefully disrupting routines. Make time to allow yourself to feel uncomfortable emotions and notice thoughts.
Session Eight
Much of Cece’s processing and progress occurred in between sessions. Cece reported she took advantage of a long drive along with her baby sleeping to turn the music off, purposefully not count, and observe her emotions and thoughts (present moment awareness, acceptance, and committed action). She reported a sense of relief after sitting with her intense grief around the death of her uncle by suicide (acceptance). She stated, “I did what we talked about, and I feel tired but better” (committed action). Cece was able to face her superstitious thoughts around the influence of her pregnancy on her uncle’s suicide by accepting her emotions and being present without distractions of her routines and counter routines (present moment awareness and acceptance). She was able to recognize her thoughts and superstitious rules, noting that if some of these rules came to be, she could cope with them.
Home Assignment: Continue purposefully disrupting routines, and make space for sitting with thoughts and emotions daily.
Session Nine
With significant improvement, discussion focused on the next steps and her motivation to continue with treatment. The provider proposed a shift in treatment to focus on her childhood trauma to address years of avoidance and beliefs of self-blame (acceptance and defusion). The therapist described empirically supported options: prolonged exposure (PE) and cognitive process therapy (CPT). Cece and the therapist collaboratively agreed upon CPT due to its target on self-blaming thoughts (committed action). Cece briefly shared the impact of her childhood traumas and noticed the occurrence of new triggers since her child was born (values). She realized the link between her fears of her daughter being harmed with her experience as a child (acceptance). She stated, “I am seeing the benefits, it’s hard, but I think it’s good” (defusion).
Assessment: Y-BOCS Total Score:14 (mild); PCL-5 Total Score: 35. Home Assignment: Continue purposefully disrupting routines.
Session Ten
Cece reported concerns about the recurrence of rituals and connection with increased stress. The therapist addressed relapse prevention. The therapist planned to focus on abbreviated CPT with a focus on self-blame. The therapist started psychoeducation from session 1 of CPT (defusion, values, and committed action).
Assessment: PHQ-9; GAD-7. Home Assignment: Continue self-directed exposures to obsessions and purposeful disruption of routines. Consider journaling to increase mindfulness of thoughts and emotions.
Session Eleven
Cece reported feeling less anxious but more depressed in the context of escalating work stress. She heard that her superior was trying to “push her out” through the use of passive-aggressive behaviors. We focused the session on finishing CPT session-one of psychoeducation and treatment planning with Cece’s commitment to accelerate through the treatment to be able to complete it with this therapist (committed action and acceptance).
Assessment: PHQ-9: 10; and GAD-7: 7. Home Assignment: Complete CPT impact statement and continue to provide space for uncomfortable emotions daily (present moment). Be aware of potential increases in OCD symptoms while spending more time thinking and interacting with thoughts directly related to her traumatic experiences. Remember relapse prevention skills discussed (e.g., lapse vs. relapse).
Session Twelve
Cece read her impact statement, and with help from the therapist identified “assimilated stuck points” focused on self-blame, while acknowledging stuck points (present moment awareness). Socratic questioning was used, staying in line with the CPT approach to acknowledge beliefs and confront Cece’s perspective on the traumatic events (defusion, acceptance, self-as-context). One impactful question posed to Cece was “what would you say or do in response to your daughter disclosing a similar experience to you?” (self-as-context). Cece responded with indication she would respond very differently than her parents did (values).
Assessment: PCL-5 Total Score: 52; Y-BOCS Total Score: 11 (mild). Home Assignment: Complete Challenging Questions Worksheets and Patterns of Problematic Thinking Worksheets.
Session Thirteen
The therapist reviewed worksheets focused on the thoughts “It’s my fault all these things keep happening to me.” Cece acknowledged her continued struggle with a need to control uncontrollable events (acceptance). Most importantly, she shared that she had a pit in her stomach for the past 20 years (present moment awareness). Over the past week, she had had minimal intrusive thoughts about traumas. Discussed progress and continued plan for maintenance (committed action). Continuation of the abbreviated CPT course focused on stuck points on themes of self-blame, power/control, trust, self-esteem, and intimacy (defusion and values). The therapist discussed the difference between a stuck point and unsafe situations (present moment awareness). The therapist also discussed future hopes for identity development (values). Finally, the therapist engaged Cece in a values card sorting exercise and gave instructions to complete the exercise at home to recognize possible evolution of values (values). Cece shared that “the worksheets were difficult but helpful. . .they even helped with my anxiety about job interviews” (committed action and values).
Assessment: PCL-5 Total Score: 17; Y-BOCS Total Score: 8 (mild). Note that the PCL-5 Total Score dropped 35 points from the prior session. Home Assignment: Values card sorting exercise and Challenging Beliefs Worksheets around esteem.
Session Fourteen-Final Session
Continuing abbreviated CPT, Cece re-wrote her impact statement in-session (present moment awareness, acceptance). Cece read her new impact statement aloud and then listened to the therapist read her original impact statement. We discussed appropriateness to discontinue therapy with agreement that she was ready to discontinue therapy at that time. We reviewed how to continue self-directed use of skills, noticing urges to avoid, and continued pursuit of values (values, acceptance, committed action). She ended the session sharing, “[you] saved my life. Before this therapy I was a shell of a person.” Notably, Cece acquired a new job that was reportedly more congruent with her values (committed action). She discontinued therapy, and we discussed how to seek further behavioral therapy if needed. Assessment: PCL-5 Total Score: 17; Y-BOCS Total Score: 9 (mild); PHQ-9 Total Score: 10; GAD-7 Total Score: 4.
Cece arrived with many strengths and demonstrated amazing growth and change within just 14 sessions of behavioral therapy. Each session she was able to maintain progress, while increasing awareness of fused beliefs and etiology of her concerns. Moreover, Cece’s overall change in PCL-5 score was −35 points, and at the end of therapy, she no longer met criteria for PTSD according to the DSM-5 criteria.
Overview of ACT for OCD
The initial focus to address Cece’s OCD symptoms was to increase defusion from her anxiety to facilitate approach of the anxiety, a necessary component. She named her anxiety “Barbara” and would consistently refer to the anxiety by name. This intervention served to quickly defuse Cece from her thoughts. By the end of session two, she was laughing at her light switch compulsion, both in-session and with her husband at home. By session three, she identified her top three compulsions: 1) putting the light switches all in one direction before bed, 2) counting everything (e.g. stair steps or equal volume level), and 3) “Barbara” beating herself up when she has thoughts about her daughter getting hurt. Sessions then focused on examining the workability of avoidance behaviors and identifying the function of the compulsions as avoidance of uncomfortable thoughts and emotions. Cece was able to notice that when consumed by avoidance, she was unable to participate fully in values-based behaviors. Through sessions four and five, the focus continued to remain on acceptance and committed action in the presence of anxiety.
Overview of Cognitive Processing Therapy
The shift to CPT followed the identification of the role that Cece’s childhood traumas played in the development of her obsessions and compulsions. It was supposed that, without directly addressing the traumas, future lapses may be more likely. CPT starts with an impact statement that was useful in observing Cece’s conceptualized self, avoidance of internal experiences, and fusion. She was instructed to write why she thought her traumatic event had occurred, with the goal of finding stuck points to address in the next session. She was to consider the effects the trauma had on her beliefs about self, others, safety, trust, power/control, esteem, and intimacy. Her writing provided excellent points for intervention around identified self-as-content and self-criticism. She described herself as “naive, trusting, dirty, vulnerable, not good enough, embarrassed, stupid, insecure.” Her writing focused on her inadequacy (“not good enough”) and efforts to control her emotions. Only rarely did she mention that adults did not intervene on her behalf or suggest that others may have contributed to ongoing events. Her frequently stated strategy was to “just keep it in.” She wrote, “I can never actually be what I want to [be] because of my dark history.” Through Socratic questioning, the therapist labeled hindsight bias, encouraged notice of this bias, prompted perspective taking, and asked Cece to consider how she would teach her daughter the art of self-compassion (values).
The second impact statement in the final session and reading of her initial impact statement helped to show Cece the significant shift in perspective that occurred over four sessions. She was provided the same instructions as in the first prompt. Her responses were more organized, both on the page and in terms of actual syntax. She wrote that her traumatic events do not “make [her] a bad person or a victim.” She referred to the traumatic experiences as “innocent, not wrong, and natural.” She referred to the perpetrator of her teenage trauma as “a pathetic loser” and “rotten dude.” She noted that she is “better because of it happening as it increased [her] awareness of others.” She repeatedly stated the fault of others rather than blaming herself. She was readily able to take perspective when prompted.
8 Complicating Factors
With regard to medical management, Cece believed that her decision to remove her IUD, related to thoughts of future family planning, contributed to feelings of sadness and depression. Cece’s medications were adjusted throughout the course of therapy due to side effects. She shared additional changes in her medications following transition to a new psychiatrist following completion of this course of psychotherapy. She reported a major reduction in lorazepam in the morning and the addition of trazadone at night.
9 Access and Barriers to Care
Cece had employer-provided commercial insurance, which allowed her access to multiple options for her mental health care. Due to limited availability of the therapist, it was difficult at first to find open slots for Cece to be seen every other week. As treatment was wrapping up and when targeting the trauma, the therapist and Cece found time to ensure weekly sessions.
In the era of limited time for self-care due to the pressures of two income households and balancing work/family life, it is imperative to find therapeutic modalities that will be impactful, empathetic, efficient, and easily understandable. After Cece’s initial intake into therapy, the complexity and severity of her symptoms would have qualified her for a higher level of treatment. Nonetheless, even in the therapist’s infancy in developing the spirit of ACT, Cece was able to defuse from her anxiety and accept her past traumas in 14 sessions. The ACT process-based approach is particularly compelling given the ability to overlay these processes with exposure-based principles to enhance willingness and augment motivation to engage in difficult behaviors. It is standard practice, particularly for evidence-based treatment protocols, for treatment of each diagnosis to take 10–12 sessions. Most CBT treatment manuals, with the exclusion of Unified Protocol (Barlow et al., 2017), focus on a single DSM diagnosis.
There were many strengths—both patient- and provider-specific—that likely bolstered Cece’s motivation and participation in treatment. One strength was the established rapport and buy-in to behavioral therapy by the referring psychiatrist, thus increasing Cece’s motivation when she began therapy. The therapeutic relationship appeared healthy and strong from the perspective of the therapist. It would have been beneficial for Cece to have completed a therapy satisfaction survey for a more objective measure of her view of the therapeutic relationship. This case highlights the importance of collaboration among interprofessional teams for treatment buy-in. As the ACT processes were addressed, Cece was fully engaged and aware of the purpose of approaches taken within-session and for home assignments. More consistency with diverse measures would have allowed for a clearer picture of her presentation and progress.
10 Follow-Up
An eleven-month informal follow-up with Cece was conducted by phone to confirm her consent to publish the case study and examine symptom progression since therapy termination. She completed the Y-BOCS and the PCL-5, along with providing qualitative feedback on her experience and lasting effects from treatment. Cece scored a 3 on the Y-BOCS, indicating very mild symptoms. Her comments while completing the measure were even more telling of the lasting effects of treatment. Cece shared that it would be “naïve to say that she spends zero time on her obsessive thoughts. . .Now I have the tools to work through it, not suppress it.” When asked about how much her obsessive thoughts distress her, she stated, “before treatment I thought I shouldn’t feel that way at all, and now I acknowledge the thoughts, accept it, and move on.”
On the PCL-5 she had a Total Score of 18, below the threshold for diagnosis, but noting that this follow-up measure was completed during the COVID-19 pandemic and amidst new situational stressors. When asked about feeling very upset when reminded of the stressful experience she said: “It made me sad, of course, but it is a sad thing that happened. . .additionally, I just unwrapped it again when offering support for a friend whose child experienced something similar recently.” She shared that she can handle irritability better, and she advocates for herself by verbalizing her emotions appropriately. She noted that she still takes time before she can trust a new person. Finally, she continues to struggle with falling asleep, although she believes it is not due to racing thoughts, as it once was.
She shared her key three lessons learned from therapy: 1) “It is asinine to think that my actions control the universe. Checking light switches won’t change anything.” 2) She is no longer so “tightly wound up.” “What’s going to happen is going to happen, and sometimes crappy things happen, and it really sucks, but it’s here so now what are you going to do with it?” She described focusing more on what is in her control than what is not in her control. 3) She does not have to be ashamed of her traumas anymore. “Yes, I wish it did not happen, and that would be great, although I am pretty cool and pretty great. I wouldn’t be that way if those things did not happen to me.” As a final note, Cece wanted to share that she and her husband have been trying to get pregnant for the last 6–9 months, and they are going through fertility treatments again. Last time she felt like it was her fault they could not get pregnant because she was “dirty,” and she now blames it on her ovaries not working properly.
11 Treatment Implications of the Case
This case demonstrates a professional mother’s short journey from being a self-described “shell of a person” to a woman living a values-driven, fulfilling life. Gold-standard clinical intervention research-to-date has largely consisted of randomized-controlled trials that evaluate the efficacy of step-by-step protocols for the treatment of specific psychological disorders. Currently, evidence-based treatment recommendations have typically focused on the delivery of specific evidence-based protocols (EBPs) for individual diagnoses (e.g., ERP for OCD). Comorbidities are commonplace, however, and a strictly nomothetic approach to treatment does not always meet the needs of individual client presentations. Various approaches to the conceptualization of psychopathology such as the National Institute of Mental Health’s Research Domain Criteria (RDoC; Insel et al., 2010) and the Hierarchical Taxonomy of Psychopathology (HiTOP; Kotov et al., 2017) have aimed to create new structures to shape the field’s scientific examination and understanding of psychological suffering. Concurrently, recent work published following the completion of psychotherapy in the presented case has outlined a process-based approach to clinical intervention that emphasizes targeting relevant psychological processes with evidence-based procedures in order to meet the needs and goals of an individual client in their specific context (Hayes & Hofmann, 2018; Hofmann & Hayes, 2019; Ong et al., 2020). These processes are posited as the mechanisms of change that are targeted in psychotherapy. For example, in this particular case, experiential avoidance and psychological inflexibility were core processes that were targeted throughout the course of therapy.
Transdiagnostic interventions may be particularly important in the postpartum period given the potential aggravation of symptoms across diagnoses including OCD, the potential impact of psychological distress on maternal and child functioning, and the time-consuming nature of EBPs targeting individual disorders. Given Cece’s complex clinical presentation (co-occurring OCD and PTSD) and her current context (new mother, working full-time), an idiographic and process-based approach to treatment was implemented. As such, the therapist purposefully integrated evidence-based procedures from a variety of approaches (e.g., examining impact statements from CPT, exposure and response prevention from ERP, values and acceptance from ACT) to move Cece toward her treatment goals (which were tracked using both relevant symptom-based measures and more open-ended discussions). Each of these strategies were layered on top of a foundation of ACT-based skills in psychological flexibility, and each session connected the skills back to the client’s personally held values. This case study provides a useful framework for and illustration of how a focus on core processes can allow for integration of evidence-based principles in order to successfully treat the commonly co-occurring and functionally similar disorders of PTSD and OCD. Future clinical research will likely benefit from continuing to move toward a more fine-grained examination and understanding of how specific evidence-based procedures may be used to target processes of change that are relevant for individual patients at various points in treatment. Understanding mechanisms of change allows for the implementation of targeted interventions that are most closely aligned with a patient’s presentation, needs, and goals.
12 Recommendations to Clinicians and Students
This case study highlights multiple points of guidance for the implementation of transdiagnostic interventions. First, the case highlights the importance of functional assessment aimed at understanding processes (e.g., avoidance) that apply across diagnoses (e.g., OCD and PTSD). Additionally, the case demonstrates how the transdiagnostic processes targeted in ACT may be used to support approach behavior throughout exposure-based interventions. Finally, the case illustrates how evidence-based interventions may be intentionally modified, and symptoms can be tracked over time to provide briefer treatment that is both workable in a client’s life and still has lasting impact over time. Additionally, this case highlights the critical importance of communication and collaboration with psychiatric providers when treating complex cases with behavioral interventions.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
