Changes in psychological flexibility during acceptance and commitment therapy for obsessive compulsive disorder

Twohig, Michael P.; Vilardaga, Jennifer C. Plumb; Levin, Michael E.; Hayes, Steven C.

doi:10.1016/j.jcbs.2015.07.001

Cited by 72Mindfulness and Compassion InterventionsObsessive-Compulsive Spectrum DisordersAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Changes in psychological flexibility during acceptance and commitment therapy for obsessive compulsive disorder

Twohig, Michael P., Vilardaga, Jennifer C. Plumb, Levin, Michael E., Hayes, Steven C.·2015·Journal of Contextual Behavioral Science

DOI 10.1016/j.jcbs.2015.07.001

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Broader ACT research shows that defusion, acceptance, self-as-context, and committed action reduce cognitive fusion and experiential avoidance while enhancing psychological flexibility across clinical populations.
“Broader ACT research shows that defusion, acceptance, self-as-context, and committed action reduce cognitive fusion and experiential avoidance while enhancing psychological flexibility across clinical populations (87, 88).”
From The therapeutic role of self-transcendence in moral injury recovery: theory, mechanisms, and clinical implications (2026) · cites this paper as [88]
Psychological flexibility mediates reduction in OCD severity in response to an ACT intervention for OCD.
“Twohig et al . (2015) also demonstrated a mediatory role for psychological flexibility in obsessive compulsive disorder (OCD) severity in response to an ACT intervention for OCD.”
From Acceptance and commitment therapy as an approach for working with climate distress (2024) · cites this paper as Twohig et al., 2015
ACT can improve the PF of patients with OCD, which in turn predicts the reduction of OCSs.
“Studies have consistently found that ACT can improve the PF of patients with OCD, which in turn predicts the reduction of obsessive-compulsive symptoms (OCSs) [45-47].”
From Effectiveness of an Internet-Based Self-Help Acceptance and Commitment Therapy Program on Medical Students’ Mental Well-Being: Follow-Up Randomized Controlled Trial (2024) · cites this paper as [47]

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“This approach, focused on fostering psychological flexibility (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013), has been supported in component studies (Levin, Hildebrandt, Lillis, & Hayes, 2012) and a similar number of process studies (e.g., Hayes et al., 2013).”
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“Treatment based on this conceptualization has support in a number of studies for OCD and related disorders such as compulsive pornography use, skin picking, trichotillomania, and OCD (Arch et al., 2012; Bluett et al., 2014; Twohig et al., 2014).”
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“In addition, but only lightly covered in this paper, ACT and ACT plus behavior therapy have been found to be useful for OC-related disorders including trichotillomania, excoriation disorder, body dysmorphic disorder.17 Analyses of processes of change supported psychological flexibility as a mediator of long-term outco…”
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“ACT is a mindfulness-based therapy that has an increasing evidence base for effectively treating a number of psychological disorders (A-Tjak et al., 2015; Twohig et al., 2015).”
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“[30,39,51], it was shown that ACT affected aimed outcomes and change processes.”
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“…areas or populations such as smoking (Avoidance and Inflexibility Scale; Gifford et al., 2004), parenting (Parental AAQ; Green, Field, Fargo & Twohig, 2015), weight (AAQ for Weight-Related Difficulties; Lillis & Hayes, 2009), work settings (WorkRelated AAQ; Bond et al., 2012), and stigma…”
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“…reappraisal, and extinction at preassessment and beginning of each session Extinction was found to be the most central mechanism of change in all the therapies, while the highest changes were seen in psychological flexibility Twohig et al. (2015)[28] RCT comparing ACT (n=41) and PRT (n=38).”
Background
Comparison between obsessive compulsive disorder and panic disorder on metacognitive beliefs, emotional schemas, and cognitive flexibility
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“…the mediating role of hypothesized processes of change, including psychological flexibility, valued action, and aspects of mindfulness, on various outcomes (e.g., symptom severity, functioning, quality of life; Cederberg et al., 2016; Hayes et al., 2010; Pots et al., 2016; Twohig et al., 2015).”
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“Further analysis of data from this RCT found that post treatment psychological flexibility levels mediated decreases in OCD severity from pre-treatment to three month follow up [28].”
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Acceptance and commitment therapy as an approach for working with climate distress
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“Twohig et al .”
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“Our results contradict the results of Twohig et al. (2015a, 2015b) who found that the level of psychological inflexibility at the time of discharge mediated the change in OCD symptoms between the values at admission and follow-up.”
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Mediating role of psychological flexibility in the effect of obsessive-compulsive symptoms on sleep quality among nurses during the COVID-19 pandemic
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“Previous studies have reported that obsessive-compulsive symptoms are associated with a lack of psychological flexibility (Blu - ett et al., 2014; Twohig et al., 2015).”
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“Studies have consistently found that ACT can improve the PF of patients with OCD, which in turn predicts the reduction of obsessive-compulsive symptoms (OCSs) [45-47].”
Psychometric properties of the Persian version of the acceptance and Action Questionnaire for obsessions and compulsions (AAQ-OC)
Soltani, E., Ghanizadeh, A., Dastgheib, S. A., Wong, Q. J. J., & Jaafari, N. (2020) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2020.100582 · Cited by 7 · see citing works
Effectiveness of ACT-based intervention in compliance with the model for sustainable mental health: A cluster randomized control trial in a group of older adults
Chojak, A. (2023) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2023.03.007 · Cited by 7 · see citing works
Facets of experiential avoidance differentially predict engagement in a contamination-based behavioral approach task
Conley, S. L., Lee, S. R., Martyn, H. F., & Wu, K. D. (2019) · Journal of Obsessive-Compulsive and Related Disorders · doi:10.1016/j.jocrd.2019.100453 · Cited by 7 · see citing works
The Experience of Being Emotionally Maltreated and Self-regulatory Strategies in Obsessive-compulsive Disorder: Pathways to Depressive Symptoms
Ardakan, A. M., Khosravani, V., Kamali, Z., & Dabiri, S. (2024) · Journal of Rational-Emotive & Cognitive-Behavior Therapy · doi:10.1007/s10942-024-00552-3 · Cited by 7 · see citing works
“Acceptance and commitment therapy has been identified as a valuable intervention for modifying EA (Twohig et al., 2015 ).”
The “how” of exposures: Examining the relationship between exposure parameters and outcomes in obsessive-compulsive disorder
Ong, C. W., Petersen, J. M., Terry, C. L., Krafft, J., Barney, J. L., Abramowitz, J. S., & Twohig, M. P. (2022) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2022.03.009 · Cited by 6 · see citing works
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Psychotherapeutische Verfahren
Voderholzer, U., Rubart, A., Kathmann, N., Staniloiu, A., Kordon, A., & Zurowski, B. (2024) · Springer eBooks · doi:10.1007/978-3-662-67878-7_4 · Cited by 7 · see citing works
Acute and post-dosing effects of single-dose psilocybin for obsessive-compulsive disorder in a randomized, double-blind, placebo-controlled trial: an interpretative phenomenological analysis
Ching, T. H. W., Stahnke, B., Shnayder, S., Agin-Liebes, G., Adams, T. G., Amoroso, L., Baiz, O., Belser, A., Bohner, C., Burke, M., et al. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1726818 · Cited by 6 · see citing works
Scoping Review of Acceptance and Commitment Therapy for Obsessive–Compulsive Disorder in Iran
Twohig, M. P., Seydavi, M., Capel, L. K., Levin, M. E., & Akbari, M. (2024) · Journal of Cognitive Psychotherapy · doi:10.1891/jcp-2023-0009 · Cited by 7 · see citing works
Self-citation
Effects of an acceptance and commitment-based psychoeducation program on prospective psychological counselors’ some personal and professional qualifications
Değerli, F. İ., & Odacı, H. (2023) · Current Psychology · doi:10.1007/s12144-023-04274-0 · Cited by 7 · see citing works
“Various studies show that ACT has been actively used in many areas, such as obsessive-compulsive disorder (Dehlin et al., 2013; Twohig et al., 2015), anxiety disorders (Dalrymple & Herbert, 2007; Kelson et al., 2019; Landy et al., 2015), depression (Forman et al., 2007; Twohig & Levin, 2017),…”
A network analysis of mechanisms of change during exposures over the course of intensive OCD treatment
Ong, C. W., Sheehan, K. G., Xu, J., Falkenstein, M. J., & Kuckertz, J. M. (2024) · Journal of Affective Disorders · doi:10.1016/j.jad.2024.03.089 · Cited by 4 · see citing works
A randomized controlled trial of self-help acceptance and commitment therapy and cognitive behavioral therapy for perfectionism
Bowers, E. M., Levin, M. E., Ong, C. W., & Twohig, M. P. (2025) · Behaviour Research and Therapy · doi:10.1016/j.brat.2025.104806 · Cited by 5 · see citing works
Self-citation
Evaluating the core processes of a hybrid trauma-informed acceptance and commitment therapy intervention for college students
Schachter, J., Ajayi, A. A., & Delgado, J. E. (2024) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2024.100852 · Cited by 3 · see citing works
Obsesif-Kompulsif Bozuklukta Üçüncü Kuşak Terapilerin Etkililiği: Bir Gözden Geçirme
DANACI, G. O. (2021) · Psikiyatride Guncel Yaklasimlar - Current Approaches in Psychiatry · doi:10.18863/pgy.779029 · Cited by 4 · see citing works
La influencia de la evitación experiencial y la fusión cognitiva en personas con diagnóstico de trastorno de pánico y agorafobia y TOC
Mellado-Pastor, S., Del-Río-Sánchez, C., & Morales, J. P. (2023) · APUNTES DE PSICOLOGÍA · doi:10.55414/ap.v41i2.1548 · Cited by 3 · see citing works
Development of the Psychological Flexibility in Romantic Relationships Scale (PFRRS): A Validity and Reliability Study
ŞAHİN, S. B., & Hamarta, E. (2024) · Research on Education and Psychology · doi:10.54535/rep.1557924 · Cited by 3 · see citing works
The Effectiveness of Acceptance and Commitment Group Therapy on Psychological Capital in Cardiovascular Patients in Babol
Kebria, M. F., Hassanzadeh, R., Mirzaeian, B., & Khoshli, A. K. (2018) · DOAJ (DOAJ: Directory of Open Access Journals) · Cited by 3 · see citing works
Preliminary evidence of the effectiveness of acceptance and commitment therapy for death anxiety in Iranian clients diagnosed with obsessive-compulsive disorder
Davazdahemami, M. H., Bayrami, A., Petersen, J. M., Twohig, M. P., Bakhtiyari, M., Noori, M., & Kheradmand, A. (2020) · Bulletin of the Menninger Clinic · doi:10.1521/bumc.2020.84.suppa.1 · Cited by 12 · see citing works
Self-citation
Integrating ACT with ERP for OCD treatment: A randomized controlled trial examining symptom reduction and psychological flexibility mechanisms
Soumee, Z. N., Rasouli, A., Lee, E. B., & Mousavi, S. E. (2025) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2025.100924 · Cited by 2 · see citing works
The three circle model of compassion focused therapy: An experimental paradigm to assess dynamic psychophysiological changes of emotion regulation systems.
Moloney-Gibb, D., Sherwell, C. S., Lynn, S., & Kirby, J. N. (2026) · Behaviour Research and Therapy · doi:10.1016/j.brat.2026.105028 · Cited by 2 · see citing works
Obsesif Kompulsif Bozuklukta; Klasik Bilişsel Davranışçı Terapi ve Yeni Nesil Kabul ve Kararlılık Terapisi, Karşılaştırmalı Müdahale Yaklaşımları
Akdag, A. (2023) · Türkiye Bütüncül Psikoterapi Dergisi · doi:10.56955/bpd.1370907 · Cited by 2 · see citing works
Relación entre la inteligencia espiritual y la flexibilidad psicológica en el marco de la terapia de aceptación y compromiso
Samperio, G. (2023) · MLS Psychology Research · doi:10.33000/mlspr.v6i1.1287 · Cited by 4 · see citing works
“…(Twohig y Levin, 2017); en el tratamiento del trastorno obsesivo compulsivo (Philip y Cherian, 2021; Shabani et al., 2019; Thompson et al., 2021; Twohig et al., 2015; Twohig et al., 2018); en los trastornos psicóticos (Yıldız, 2020a); para el tratamiento psicológico de pacientes con cáncer…”
Background
The effectiveness of acceptance and commitment therapy on cognitive flexibility, rumination, and distress tolerance in persons with Migraine headache
Larimi, N. B., Zebardast, A., & Rezaei, S. (2021) · Shenakht Journal of Psychology and Psychiatry · doi:10.32598/shenakht.8.2.74 · Cited by 2 · see citing works
Comparison of the effectiveness of acceptance and commitment therapy (ACT) with metacognitive therapy (MCT) in objective cognitive information processing style of obsessive–compulsive patients (OCD)
Saeidi, L., Afsharinia, K., Kakabraee, K., & Arefi, M. (2023) · Journal of Education and Health Promotion · doi:10.4103/jehp.jehp_40_23 · Cited by 2 · see citing works
Acceptance and Action Questionnaire: Substance Abuse
Joos, L., Krägeloh, C. U., Medvedev, O. N., & Henning, M. A. (2025) · Springer eBooks · doi:10.1007/978-3-030-89738-3_65-1 · Cited by 1 · see citing works
COVID-19 anxiety's influence on obsessive compulsive symptoms among African American young adults
Willis, H. A., Williams, M. L., & Ayala, Y. (2026) · Journal of Affective Disorders · doi:10.1016/j.jad.2026.121596 · Cited by 1 · see citing works
The therapeutic role of self-transcendence in moral injury recovery: theory, mechanisms, and clinical implications
Fleming, W. H. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2026.1701564
The Treatment of Obsessive-Compulsive Disorder
Collins, L. M., Bragdon, L. B., & Coles, M. E. (2018) · Evidence‐Based Psychotherapy · doi:10.1002/9781119462996.ch6 · Cited by 1 · see citing works
The comparison of the effectiveness of Acceptance and Commitment Therapy and Clomipramine in treating patients with obsessive compulsive disorders in men and women in the city of Shiraz
Derakhtkar, A., Tabriz, F. N., Mordadi, H., & Khani, A. S. (2020) · Women Intercsiplinary Researches · doi:10.52547/.2.1.23
The Effectiveness of Acceptance and Commitment Education with an Attitude of Islamic Concepts on Impulsive Decision Making and Cognitive Flexibility of Women Drug Users
soltanAbadi, A. M., Mottaghi, S., & Ardakani, E. K. (2022) · فصلنامه علمی و پژوهشی اعتیادپژوهی · doi:10.52547/etiadpajohi.16.63.309
" فعالية العلاج بالقبول والالتزام في تعديل استراتيجيات ضبط الفكر وخفض اضطراب الوسواس القهري لدى طلاب الدراسات العليا"
محـمد, ف. ا. م. (2023) · المجلة التربوية لکلية التربية بسوهاج · doi:10.21608/edusohag.2023.282990
Wirkfaktoren der kognitiven Verhaltenstherapie von Zwangsstörungen
Schubert, C. (2022) · doi:10.20378/irb-57543
The contribution of cognitive behavioral therapy to the treatment of obsessive-compulsive disorder
Popa, C. O., & Rus, A. V. (2016) · Romanian Journal of Psychiatry & Psychotherapy · doi:10.37897/rjpp.2016.4.2
“Cognitive diffusion techniques serve to help the patient understand that obsessions and anxiety are directly connected more with his subjective experiences than the events of real life and that ultimately a thought is nothing more than a thought, in other words there is a big difference between thought and action (55).”
Background
Mindfulness as Stabilization in Mental Healthcare
Mukund, B., & Dehuri, B. K. (2023) · Advances in psychology, mental health, and behavioral studies (APMHBS) book series · doi:10.4018/978-1-7998-8228-2.ch003
Una interpretación contextual y conductual de la responsabilidad moral
Miranda-Rodríguez, R. A. (2023) · Revista Mexicana de Análisis de la Conducta · doi:10.5514/rmac.v49.i2.87776
Acceptance and Commitment Therapy for the Treatment of Obsessive-Compulsive Dis-order: A Systematic Review
陈, 旭. (2024) · Advances in Psychology · doi:10.12677/ap.2024.142100
Effectiveness of Positive Cognitive Behavioral Therapy on Psychological Flexibility and Meaning in Life Among Single Women
Dlfard, S. S., Toosi, M. R. S., & Jafari, F. (2024) · doi:10.61838/kman.aftj.5.2.17
Remediating cognitive inflexibility in obsessive compulsive disorder and anorexia nervosa neither moderates nor mediates treatment effects: an exploratory study
van Passel, B., Danner, U. N., Dingemans, A. E., Broekman, T. G., Sternheim, L. C., Becker, E. S., Elburg, A. A. V., van Furth, E. F., Hendriks, G., & Cath, D. C. (2025) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2024.1456890 · Cited by 1 · see citing works
Implementation of Acceptance and Commitment Therapy in Obsessive Compulsive Disorder
Sarıtaş, M., & Ata, E. E. (2025) · Psikiyatride Guncel Yaklasimlar - Current Approaches in Psychiatry · doi:10.18863/pgy.1573153
“Additionally, in a separate part of the study by Twohig et al. (2010), Twohig et al. (2015) reported that changes in psychological flexibility mediated changes in OCD symptoms.”
A Comparison of the Efficacy of Acceptance and Commitment Therapy and Positive Psychotherapy on Body Image and Emotion Regulation Difficulties in Women with Body Dysmorphic Disorder: A Randomized Controlled Experimental Design with Three Groups
Ahmadi, S., Khalatbari, A., & Arab, S. (2025) · Middle East Journal of Rehabilitation and Health Studies · doi:10.5812/mejrh-166808
“In fact, this therapy assists patients in letting go of the cognitive control strategies they used to engage in, not defusing with their problematic thoughts, and managing their unpleasant emotions (38, 39).”
Emotion dysregulation in autistic adults : an ecological, self-report, and physiological approach
Costache, M. E. (2024) · theses.fr (ABES) · doi:10.70675/575e0a4az1174z4c91z976cz320b40c5304a
Spezielle Aspekte psychologischer Interventionen bei der Zwangsstörung
(2024) · Elsevier eBooks · doi:10.1016/b978-3-437-22541-3.00011-7

Psychological Flexibility as Shared Process of Change in Acceptance and Commitment Therapy and Exposure and Response Prevention for Obsessive-Compulsive Disorder: A Single Case Design Study
Thompson, B. L., Twohig, M. P., & Luoma, J. B. (2020) · Behavior Therapy · doi:10.1016/j.beth.2020.04.011 · Cited by 37 · see citing works
Self-citation
Needed: More master's and doctoral degrees
(1997) · Home Care Provider · doi:10.1016/s1084-628x(97)90060-5
An initial investigation into the processes of change in ACT, CT, and ERP for OCD.
Twohig, M. P., Whittal, M. L., Cox, J. M., & Gunter, R. W. (2010) · International Journal of Behavioral Consultation and Therapy · doi:10.1037/h0100898 · Cited by 35 · see citing works
Self-citation
Investigating an Acceptance and Commitment Therapy-Based Exposure Therapy Intervention in Treatment-Refractory OCD and Related Disorders: Changes in Psychological Flexibility, Treatment Engagement, and Treatment Perceptions.
Gruner, N. G., Cullen, J. M., Crosby, J. M., DeCross, S. N., Mathes, B., Garner, L., Gironda, C., Hu, Y., Krompinger, J. W., Elias, J. A., et al. (2024) · Journal of Cognitive Psychotherapy · doi:10.1891/jcp-2022-0033
Self-citation
A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder
Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., & Woidneck, M. R. (2010) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0020508 · Cited by 434 · see citing works
Self-citation

Authors: Twohig, M. P., Vilardaga, J. C. P., Levin, M. E., & Hayes, S. C.
Affiliations: Utah State University (US)
University of Nevada, Reno (US)
Corresponding author: Twohig, Michael P.
ORCID: Twohig, Michael P.
Levin, Michael E.
Hayes, Steven C.
Venue: Journal of Contextual Behavioral Science
Publisher: Elsevier BV
Published: 2015-07
Volume: 4
Issue: 3
Pages: 196-202
ISSN: 2212-1447 (ISSN-L)
DOI: 10.1016/j.jcbs.2015.07.001
OpenAlex: W745035260
Cited by: 72
References: 41
Citations by year: 2026: 3 · 2025: 7 · 2024: 13 · 2023: 14 · 2022: 8 · 2021: 5 · 2020: 7 · 2019: 7 · 2018: 2 · 2017: 5 · 2016: 1
FWCI: 3.31
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: Journal of Contextual Behavioral Science (publishedVersion)
Digital Commons - USU (Utah State University) (submittedVersion)
Topics: Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords: acceptance and commitment therapy, obsessive-compulsive disorder, psychological flexibility, treatment process, progressive muscle relaxation, mediation, treatment outcome prediction

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