Acceptance and Commitment Therapy

Exploring the Efficacy of ACT-Informed Exposure for Excoriation Disorder: A New Approach in Treatment  

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Excoriation Disorder (ExD), commonly known as skin picking disorder, presents significant challenges for those who suffer from it, often leading to severe distress and self-consciousness about their appearance. Traditional treatments, like Habit Reversal Training (HRT), have shown effectiveness in managing symptoms, but there is a growing interest in exploring how additional therapeutic approaches might enhance outcomes. A study by Brian L. Thompson, PhD, from Portland Psychotherapy, investigated the potential of using exposure therapy guided by acceptance and commitment therapy (ACT)  as an adjunct to HRT for treating ExD.  

The Study Design and Approach  

The study employed a nonconcurrent multiple baseline design, a method that allows for analysis of individual participants over time. Four participants with ExD were recruited and randomly assigned to two conditions: one group received HRT followed by exposure therapy, while the other group received exposure therapy first, followed by HRT. During the ACT-informed exposure therapy phase, participants were oriented to the ACT model. They then practiced deliberately triggering urges to pick while being open and present with these urges, and then flexibly expanding their awareness of other sense perceptions (e.g., touch, taste, sight, sound, smell). The goal was not symptom reduction, as in traditional exposure, but of flexible responding to urges while not engaging in picking behavior. This design was chosen to assess whether exposure therapy, when informed by ACT principles, could improve psychological flexibility and reduce the severity of skin-picking behavior beyond what HRT alone could achieve.  

Key Findings 

The results of this study highlight several important outcomes. Results provided further evidence that HRT is effective in reducing the frequency of skin picking across participants. These findings align with previous research and supports HRT as a first-line treatment for ExD. However, the addition of ACT-informed exposure therapy yielded mixed results. While some participants reported further reductions in skin picking during the exposure phase, these reductions were generally smaller compared to those observed during the HRT phase. For example, participants who underwent exposure therapy first experienced greater reductions in skin picking during the subsequent HRT phase than during the initial exposure phase.  

One of the study’s key aims was to determine if ACT-informed exposure could enhance psychological flexibility—a core process in ACT that involves accepting internal experiences while committing to actions that align with one’s values. Contrary to the researchers’ expectations, the exposure phase did not consistently lead to improvements in psychological flexibility across participants. This finding suggests that while exposure therapy might have some utility as a secondary treatment, it may not be as effective in fostering psychological flexibility as hypothesized, or psychological flexibility is less relevant as a process of change in people who struggle with skin picking. As the experimenter used broad measures of psychological flexibility, it is also possible the measures were too general and not specific enough to picking.  

Implications for Treatment  

Despite the mixed results, the study offers valuable insights into the treatment of ExD. All participants maintained their gains at a three-month follow-up, indicating that both HRT and ACT-informed exposure have lasting effects on symptom reduction. However, the study also raises questions about the specific role that exposure therapy should play in treating ExD. Given that HRT resulted in more robust improvements than exposure therapy, this research suggests that exposure therapy might be more effective when used as a secondary intervention.  

Participant feedback indicated that exposure was an acceptable treatment. Participants who began with exposure felt that exposure therapy helped them prepare for the strategies in HRT. Some participants even endorsed a preference for exposure. For example, one participant described exposure as “more helpful overall,” and another noted that “exposure has been what really accelerated” their progress. These subjective reports highlight the potential of ACT-informed exposure to complement HRT by increasing participants’ awareness and acceptance of their urges, which might help reduce relapse rates in the long term.  

Conclusion  

This study, represents a pioneering effort to integrate ACT-informed exposure therapy into the treatment of Excoriation Disorder. It is also the first published experimental study of the use of exposure in treating skin picking. While the findings do not support exposure therapy as a robust standalone treatment, they suggest it may be a useful adjunct to HRT to help people further manage picking behavior. With skin picking, any additional improvements in reducing picking may be meaningful.  

As the field of mental health continues to explore transdiagnostic approaches—therapies that can be applied across different disorders—the integration of ACT with traditional behavioral interventions like exposure therapy offers a promising avenue for future research. The protocol is relatively simple to implement, especially for therapists familiar with exposure therapy. This study underscores the importance of tailoring treatment to the individual, recognizing that while HRT remains the gold standard for ExD, there is room to enhance its efficacy through the thoughtful incorporation of exposure therapy.  

Moving forward, larger-scale studies are necessary to determine if combining HRT and exposure therapy is more effective than HRT alone. For clinicians and researchers alike, this study offers a steppingstone toward enhancing treatments for those suffering from Excoriation Disorder and other body focused repetitive behaviors.  

You can find an open access version of this article here.  

  

Addressing Shame in Body Dysmorphic Disorder: A Promising New Approach 

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Body Dysmorphic Disorder (BDD) is a severe mental health condition characterized by an obsessive focus on perceived flaws in one’s appearance, often leading to significant distress and impairment in daily functioning. While Cognitive Behavioral Therapy (CBT) has been the gold standard treatment for BDD, many individuals do not respond adequately to this approach. Recent research suggests that shame plays a critical role in the development and maintenance of BDD symptoms. Therefore, targeting shame directly may enhance treatment outcomes for those suffering from this debilitating disorder. 

In a pioneering study published in Behavior Modification, a team of researchers including Jason Luoma PhD, from Portland Psychotherapy, developed and tested an innovative therapeutic approach that combines Acceptance and Commitment Therapy (ACT) with compassion-focused approaches to address shame in individuals with BDD. This approach, called ACT with Compassion (ACTwC), is designed to reduce shame and self-criticism while increasing psychological flexibility and self-compassion. 

The Role of Shame in BDD 

Shame is a powerful emotion that involves seeing oneself as fundamentally flawed and unworthy. In BDD, this emotion is often tied to the perceived defects in one’s appearance, driving behaviors such as excessive mirror checking, comparing oneself to others, and social avoidance. These behaviors not only reinforce the negative self-view but also contribute to the persistence and severity of BDD symptoms. Research has consistently shown that higher levels of shame are associated with worse outcomes in BDD, including greater symptom severity, lower quality of life, and higher rates of depression. 

Despite the clear link between shame and BDD, traditional CBT does not specifically target shame, focusing instead on changing maladaptive thoughts and behaviors. The researchers recognized this gap and sought to create a treatment that would directly address the underlying shame fueling BDD symptoms. 

The ACT with Compassion Approach 

ACT with Compassion (ACTwC) integrates the principles of ACT, which encourages individuals to accept difficult emotions and commit to actions aligned with their values, with compassion-focused elements. The treatment protocol developed by the team involves 12 individual therapy sessions, each about 60 minutes long, delivered over weeks. 

The intervention includes psychoeducation about BDD and shame, mindfulness training, and experiential exercises designed to foster self-compassion and psychological flexibility. Patients are encouraged to confront and accept their feelings of shame rather than avoiding them, and to develop a kinder, more compassionate relationship with themselves. 

Promising Results from the Pilot Study 

The pilot study conducted by the researchers involved five participants diagnosed with BDD. The results were encouraging: four of the five participants showed significant reductions in BDD behaviors and self-criticism by the end of the treatment. Moreover, three participants reported decreases in body-related shame, and these improvements were maintained at a six-month follow-up. 

In addition to reductions in shame and self-criticism, participants experienced significant improvements in overall BDD symptoms, depressive symptoms, and quality of life. The treatment was well received, with participants rating it as highly credible and expressing satisfaction with the therapy. 

Implications for Future Treatment 

The findings from this study suggest that ACT with Compassion could be a promising new approach to treating BDD, particularly for individuals who struggle with intense shame and self-criticism. By directly targeting these underlying emotional drivers, this approach may offer a more effective treatment option for those who have not responded to traditional CBT. 

As with any new therapeutic approach, further research is needed to confirm these findings and to refine the treatment protocol. Larger, randomized controlled trials will be necessary to establish the efficacy of ACTwC compared to other treatments. However, the initial results are promising and suggest that this approach could help improve the lives of individuals suffering from BDD. 

You can find an open access version of this article here. 

The Newest Study Supported by Portland Psychotherapy: Helping People with the Stigma of Injection Drug Use and HIV in Russia

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Stigma is a pervasive problem that can negatively impact healthcare outcomes for those affected by it. Stigmatized groups, such as people living with HIV who inject drugs, can face many barriers to care that stem from societal attitudes toward their condition. HIV and substance use stigma, when combined, can lead to further avoidance of care and poor health outcomes.

The findings from the SCRIPT (Stigma Coping to Reduce HIV Risks and Improve substance use Prevention and Treatment) study were recently published. This study was conducted by Karsten Lunze, MD, of Boston University Medical School, in collaboration with Jason Luoma, the CEO of Portland Psychotherapy. This study aimed to test an intervention developed by Dr. Luoma to help people cope with intersectional HIV and substance use stigma. The research studied people with HIV who inject drugs, who often face significant barriers to accessing care due to both HIV and substance use stigma.

To develop the intervention, the research team modified an Acceptance and Commitment Therapy (ACT) approach to target people with HIV who inject drugs. ACT is a type of cognitive-behavioral therapy that focuses on accepting difficult emotions and thoughts rather than trying to eliminate them. By teaching people how to cope with stigma through acceptance-based approaches, the study aims to reduce the link between internalized attitudes, fears, and shame, and healthcare avoidance behaviors.

The SCRIPT study aimed to evaluate the intervention’s effects on HIV and substance use stigma, care engagement, and injection drug use frequency. The study will also assess the intervention’s implementation by looking at participant satisfaction, intervention fidelity, and uptake.

The study found that people who received the intervention were more likely to start HIV and substance use treatment than those who did not receive the intervention. The increase in care engagement may be due to the fact that the intervention helped people to cope with stigma and reduced their avoidance of healthcare settings. The intervention was not designed to directly reduce shame and fears related to stigma, but rather focused on helping people to cope with stigma and improve their behavior and care seeking.

The implications for practice are that acceptance-based approaches can be effective in reducing stigma and improving care engagement in people with HIV who inject drugs. Healthcare providers should be trained to recognize and address intersectional stigma in their patients and use interventions that incorporate acceptance-based approaches to reduce stigma’s negative impact.

Portland Psychotherapy’s involvement in this study exemplifies the organization’s commitment to using its resources to address societal problems. By supporting research that aims to improve healthcare outcomes for stigmatized populations, Portland Psychotherapy is helping to make a positive impact on the community.

New Acceptance and Commitment Therapy Resources for the Public

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At Portland Psychotherapy, for years we’ve been maintaining a list of the best ACT resources for the public that we know about. We have links to video, self help courses, meditation recordings, apps, and much more. I recently went out and searched the web for additional Acceptance and Commitment Therapy (ACT) resources to update our … Read more

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