A focused review of Capel & Twohig’s case study
Why this paper matters
While outcome studies have established that acceptance and commitment therapy (ACT) performs comparably to traditional CBT and ERP for obsessive–compulsive disorder (OCD), fewer papers show how ACT-informed exposure is actually implemented in clinical work.
This case study by Capel and Twohig provides a detailed, session-by-session illustration of values-based exposure within ACT for OCD, making it particularly useful for clinicians who want to translate theory into practice.
Rather than arguing for ACT over ERP, the paper demonstrates how exposure can be functionally re-oriented when the therapeutic target is psychological flexibility rather than symptom reduction.
The clinical context
The client (“Lana”, pseudonym) was a woman in her 30s with long-standing OCD, primarily characterised by contamination fears centred on the safety of her children and family. Her difficulties had escalated to the point of being largely housebound, socially withdrawn, and highly reliant on avoidance and accommodation.
Her compulsions and avoidance were understandable attempts to reduce distress and prevent feared outcomes, yet they came at a significant cost to valued roles; particularly parenting, connection, and community involvement.
From an ACT formulation, the central difficulty was psychological inflexibility: internal experiences (obsessions, anxiety, uncertainty) had come to dominate behaviour, pulling her away from values-consistent action.
Why ACT + exposure was chosen
The authors situate their intervention within the broader evidence base showing that:
- ACT alone and ACT combined with exposure produce outcomes comparable to ERP
- Psychological flexibility is consistently associated with reductions in OCD severity
- Exposure provides a structured context for practising flexibility skills in vivo
In this case, values-based exposure was particularly important because the client was unwilling to engage in traditional habituation-focused or imaginal exposure exercises, and because many feared stimuli were closely tied to moral and relational values.
ACT processes as the foundation for exposure
Before introducing exposure work, therapy focused on building core ACT skills:
- Acceptance of unwanted internal experiences rather than control attempts
- Cognitive defusion, helping obsessions be experienced as thoughts rather than facts
- Present-moment awareness, shifting attention from threat monitoring to lived experience
- Self-as-context, reducing identification with OCD content
- Values clarification, especially around parenting and relationships
These processes were not taught abstractly but through metaphors and experiential exercises, creating a shared language that could later be used during exposure practice.
What “values-based exposure” meant in this case
In contrast to traditional ERP, exposures were not selected based on anticipated distress or arranged into a fear hierarchy. There was no emphasis on habituation, SUDS ratings, or anxiety reduction.
Instead, exposures were designed around one guiding question:
How does this action help you be the person you want to be?
Examples of values-based exposures included:
- Attending therapy sessions in person
- Visiting family members
- Going to public places with her children
- Re-engaging socially
Each exposure was explicitly linked to identified values (e.g. being a present parent, maintaining relationships), and the aim was to practice willingness and flexibility while obsessions and anxiety were present.
Success was defined by engagement in valued action, not by reductions in distress.
How exposure was conducted in sessions
Before each exposure, the client selected ACT skills or metaphors to use (e.g. noticing thoughts as a “storyteller”, observing sensations without struggle). During exposures, the therapist regularly checked in on:
- What internal experiences were present
- Whether the client was responding with openness or control
- How the activity connected to values
Importantly, the therapist did not attempt to reassure, challenge beliefs, or encourage anxiety reduction. The therapeutic stance remained consistent: make space, notice, and keep moving toward what matters.
Between-session exposures were framed as extensions of in-session practice, reinforcing generalisation into daily life.
Outcomes reported
Across standardised measures, the client showed clinically significant improvements:
- Y-BOCS scores reduced from severe to moderate
- Psychological flexibility (AAQ-II) improved significantly
- Anxiety and depressive symptoms reduce
However, the authors emphasise behavioural and functional change as central outcomes:
- Increased engagement in family and social life
- Reduced accommodation and avoidance
- Greater presence and quality of life
The client continued to experience distress at times, but reported feeling better equipped to live meaningfully with it.
Clinical implications
The paper underscores several practice-relevant points:
- Exposure does not require habituation or distress reduction to be effective
- Values-based exposure may increase engagement, particularly when traditional ERP is resisted
- Psychological flexibility provides a coherent process target across ACT and exposure
- Exposures linked to values may avoid ethical or moral conflicts in certain OCD presentations
The authors are careful to note limitations, including the use of a single case and the client’s readiness for change, but argue convincingly for the clinical utility of this approach.
This case study offers a concrete demonstration of how ACT-informed, values-based exposure can be implemented with adults with OCD. Rather than replacing ERP, it reframes exposure as practice in living well with uncertainty, grounded in what matters most to the client.
For clinicians seeking practical guidance on integrating ACT processes into exposure work, this paper provides a clear, clinically rich example.
Reference
Capel, L. K., & Twohig, M. P. (2025). ACT for OCD: An Example of ACT and Values-Based Exposures. Journal of clinical psychology, 81(2), 93–101. https://doi.org/10.1002/jclp.23759
Link to the paper here.