Journal of Contextual Behavioral Science 2 (2013) 6873

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Research Basic Empirical Research

Courage, self-compassion, and values

in Obsessive-Compulsive Disorder
Chad T. Wetterneck a,n, Eric B. Lee b, Angela H. Smith c, John M. Hart d
a

Rogers Memorial Hospital, 34700 Valley Road, Oconomowoc, WI 53066, USA

University of HoustonClear Lake, USA
c
University of Houston, USA
d
Menninger Clinic, USA
b

art ic l e i nf o

a b s t r a c t

Article history:
Received 12 October 2012
Received in revised form
31 August 2013
Accepted 23 September 2013

New interventions such as Acceptance and Commitment Therapy (ACT) have shown early promise in the
treatment of OCD, focusing on aspects of psychological exibility including valued living, mindfulness,
and committed action. However, research is needed to explore the relationship between the various
components of ACT and OCD. The present study sought to investigate the relationship between values
(i.e., self-compassion, courage, and the Valued Living Questionnaire [VLQ; the extent to which one has
values and is living out values in everyday life]) and OCD severity. Participants (N 115) who selfreported meeting criteria for OCD completed an online survey assessing levels of different values as well
as ratings of importance and consistent living within these values. Analyses yielded signicant
relationships between OCD severity and self-compassion, courage, and the VLQ. A multiple regression
analysis revealed the VLQ and courage to be signicant predictors of OCD severity. Interpretation of the
results and their implications is considered.
& 2013 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.

Keywords:
Obsessive-Compulsive Disorder
OCD
Values
Self-compassion
Courage

1. Introduction
Obsessive-Compulsive Disorder (OCD) is characterized by
obsessions and/or compulsions that cause marked distress, are
time consuming, and signicantly interfere with an individual's
normal routine, occupational functioning, or usual social activities
or relationships with others (American Psychiatric Association,
2000). Interventions such as cognitive behavioral therapy using
exposure and response prevention (ERP) and pharmacological
treatments have proven to effectively reduce obsessivecompulsive symptoms; yet 2060% of patients with OCD refuse, dropout,
or fail to benet from treatment (Abramowitz, 2006; Abramowitz,
Taylor, & McKay, 2005; Fisher & Wells, 2005; Pallanti & Quercioli,
2006). In light of this, further research is needed to improve the
treatment of OCD.
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, &
Wilson, 1999) is a relatively new form of therapy that has shown
promise as an effective treatment for OCD (Twohig et al., 2010).
One of the primary goals of ACT is to help individuals make
meaningful, values-based actions in spite of the presence of
negative affect. In ACT, the goal is to help the individual increase
psychological exibility and engage in values-guided behavior

Corresponding author. Tel.: 1 262 646 3158.

E-mail address: ocdspectrum@yahoo.com (C.T. Wetterneck).

rather than pursuing a primary goal of controlling one's private

events (i.e., escape or avoidance of negative affect). ACT principles
may enhance ERP as exposure from an ACT perspective is for
the purpose of increasing willingness to experience private events,
as they are, so the person can live a more valued life (an approach
that, ironically, often results in a decrease in negative content)
(p. 11; Twohig, Hayes, & Masuda, 2006). This shift from symptom
reduction to what is important to the client (i.e., values) may lead
to an increased willingness to exposures (Levitt, Brown, Orsillo, &
Barlow, 2004). Thus, values are of interest in OCD treatment and
may prove benecial to improving outcomes and decreasing
dropout rates.
Wilson and Dufrene (2008) dene values as freely chosen,
verbally constructed consequences of ongoing, dynamic, evolving
patterns of activity, which establish predominant reinforcers for
that activity that are intrinsic in engagement in the valued
behavioral pattern itself (p. 66). Dahl, Plumb, Stewart, and
Lundgren (2009) present a similar view adding that one chooses
values based behavioral patterns linked to a sense of meaning that
can guide behavior over long time periods (e.g., acting caring to a
spouse). In addition values are never achieved or completed;
rather they provide meaning and direction for behavior. If goals
are a destination, then values are a direction. Values are chosen
personally and can vary greatly from individual to individual with
domains of parenting and friendship important to one person,
while spirituality and recreation may be important to another.

2212-1447/$ - see front matter & 2013 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcbs.2013.09.002

C.T. Wetterneck et al. / Journal of Contextual Behavioral Science 2 (2013) 6873

The role that people's values play in the severity of their

anxiety is relatively unknown. A recent study provided evidence
that individuals with generalized anxiety disorder (GAD) describe
themselves as living more inconsistently from their values compared to non-anxious individuals (Michelson, Lee, Orsillo, &
Roemer, 2011). This nding suggests that how closely one is
guided by values may play an important role in the level of one's
anxiety (or that one's anxiety impacts the extent to which they live
according to their values). Values may also play an important role
in the treatment of anxiety disorders. Eifert and Forsyth (2005)
proposed that values might help those with anxiety reclaim their
lives and give them a reason to work to overcome their anxiety. In
a recent study of individuals with GAD, Hayes, Orsillo, and Roemer
(2010) found that values and acceptance increased in parallel over
16 sessions while worry decreased at a similar rate. By focusing on
values rather than anxiety symptom reduction, the energy exerted
in treatment is generated from what matters most to people.
This leads to the question of whether people with OCD engage
in certain values that may help them change the context in which
they experience anxiety. Eifert and Forsyth (2005) state that,
some clients nd it difcult to focus on what matters to them
because their mind tells them anxiety control is what matters
(p. 153). This difculty in focusing on values could result in their
underdevelopment. Pauley and McPherson (2010) give an example
of underdevelopment of self-compassion (i.e., a potential value for
self-care) in people with depression or anxiety. They state:
Although participants reected at length on the concept of
compassion, they did not mention self-compassion until
prompted to do so. This nding suggests that individuals with
psychological disorders either have not ever had a sense of selfcompassion or that this has been lost at some point during
their experience of either depression or anxiety (p. 139).
OCD sufferers may overlook values that could potentially play a
role in their recovery as obsessing and rituals are typically in the
service of reducing anxiety and not cultivating functional values.
By helping clients move toward values that are intrinsically,
positively reinforcing and that produce lasting rather than eeting
reinforcement, their quality of life may be positively affected. Due
to potential issues with pliance (e.g., demand characteristics of the
session, trying to please the therapist), the typical ACT approach,
including ACT for OCD, (Twohig, 2004, 2009) does not suggest the
therapist provide examples of values that may be functional when
living with OCD.
While there are many studies that have examined the relationship between OCD and quality of life (cf. Norberg, Calamari, Cohen,
& Riemann, 2008), there is no research that has examined the
relationship between OCD and values. Many current studies
investigating values use the Valued Living Questionnaire (VLQ;
Wilson, Sandoz, Kitchens, & Roberts, 2011) to identify clients'
values as well as discrepancies between values and their actual
lifestyle. The VLQ addresses many life domains (e.g., family,
education, spirituality) which may motivate behavior. However,
we propose that valuing certain personal characteristics also may
be important for individuals with OCD as they have the potential
to increase contextually motivated behavior. Specically, we
hypothesize that valuing the characteristic of self-compassion
may increase acceptance and contact with the present moment
and that valuing courage may lead to committed action in the face
of unwanted private events. We will outline these
relationships below.
Self-compassion is essentially compassion toward oneself.
A person acting in the service of self-compassion is able to turn
compassionate feelings inward with care, kindness, and the desire
to help oneself. According to Neff (2003a), self-compassion entails

69

three main components: (a) self-kindnessbeing kind and understanding toward oneself in instances of pain or failure rather than
being harshly self-critical, (b) common humanityperceiving
one's experiences as part of the larger human experience rather
than seeing them as separating and isolating, and (c) mindfulness
holding painful thoughts and feelings in balanced awareness
rather than over-identifying with them.
Acting with self-compassion has been shown to be related to
psychological health and exibility. In fact Raes (2010) hypothesized that self-compassion may counteract dysfunctional repetitive thinking (e.g., depressive ruminations and worrying) and
another study found self-compassion to be positively related to
happiness, optimism, and positive affect and negatively associated
with neuroticism (Neff, Rude, & Kirkpatrick, 2007). Selfcompassion has been shown to help buffer against anxiety and
is associated with increased psychological well-being (Neff et al.,
2007). There is also evidence that self-compassion is a better
predictor of symptom severity and quality of life than mindfulness
in people with anxiety and depression (Van Dam, Sheppard,
Forsyth, & Earleywine, 2011). Further, Thompson and Waltz
(2008) found a signicant negative correlation between selfcompassion and avoidance in students who had experienced a
traumatic event. Another recent study of individuals with OCD
found a signicant strong positive correlation (r .72) between
self-compassion and psychological exibility, indicating that individuals with high levels of self-compassion are less avoidant and
more psychologically exible (Wetterneck, Steinberg, Little,
Phillips, & Hart, 2012).
Self-compassion may be specically useful for symptom
dimensions of OCD that relate to one's moral character and shame
about one's thoughts. For example, many with OCD believe they
will be responsible for harm to others either indirectly (e.g.,
accidentally causing harm by being careless, contaminating an
object that others will encounter) or directly (e.g., molesting their
own child, stabbing a loved one). The capacity to observe these
experiences with self-kindness and from an observer perspective
may help one to better cope with these shaming thoughts, rather
than over-identifying and becoming fused with them. This proposed increase in psychological exibility would allow one to
focus effort on moving toward values rather than focusing on
symptom reduction, resulting in greater functioning. Based on
these ndings, we posit that self-compassion will be inversely
correlated with OCD severity.
Acting in the service of courage is another area that has
received limited research attention. Woodard and Pury (2007)
suggest that the lack of research on courage may be attributed to
difculties in establishing a clear and concise denition of the
construct. They provide the following denition of courage: the
voluntary willingness to act, with or without varying levels of fear,
in response to a threat to achieve an important, perhaps moral,
outcome or goal (p. 136). Similarly, Rate, Clarke, Lindsay, and
Sternberg (2007) conceptualize courage as: (a) a willful, intentional act, (b) executed after mindful deliberation, (c) involving
objective substantial risk to the actor, (d) primarily motivated to
bring about a noble good or worthy end, (e) despite the presence
of the emotion of fear. Further, Rate and colleagues' delineation
that courageous acts are performed despite the presence of fear
elucidates why courage may be an important construct for those
with elevated anxiety. Hannah, Sweeney, and Lester (2007) propose that courage is related to personality traits such as openness
to experience, hope, and resiliency. These traits have been shown
to negatively correlate with OCD symptoms (Hjemdal, Vogel,
Solem, Hagen, & Stiles, 2011; Lysaker, Whitney, & Davis, 2006;
Wetterneck et al., 2011).
As conceptualized, engaging in courageous behavior would be
of great potential benet to those participating in exposure-based

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C.T. Wetterneck et al. / Journal of Contextual Behavioral Science 2 (2013) 6873

therapies for several reasons. The aversive nature of ERP requires

an individual to willfully expose themselves to fears in an attempt
to reduce future suffering and/or live a more valued life. It seems
likely that individuals with higher levels of courage would more
successfully engage in exposure therapies, resulting in better
outcomes. Courage may also play an important role in moving
toward chosen values. Once an individual has successfully identied meaningful values he or she then faces the often arduous task
of behaving in a manner consistent with these values. Courage
may be the difference between simply identifying values and truly
living a life that is in accordance with them. Increased courage
may improve the likelihood of committed action in the face of
unwanted private events, perhaps functioning as an establishing
operation that leads to actions in the service of valued living. For
example, a woman with OCD fears of contamination who has
identied with the value of being a caring, loving mother to her
children would greatly benet from acting in a courageous manner
in order to behave in ways that are consistent with her value.
Actions such as working to provide for her children, taking her
children to social events, or providing them with physical affection
may be avoided due to the anxiety and discomfort that is
associated with them. In her case, acting courageously may help
orient her toward being more psychologically exible, increasing
the likelihood of making the bold moves and committed action
that may at times be required to live a values consistent life
despite these negative feelings. Thus, we predict courage to be
negatively correlated with OCD severity.
Valued behavior in the service of courage and self-compassion
may have the potential to transform the function of unpleasant
stimuli into something more tolerable. For example, a man with
intrusive violent thoughts may avoid situations that could be in
line with his values (e.g., social functions, family, and/or work). Yet,
if he could learn to pursue courage or self-compassion (i.e., act
courageously or treat oneself with compassion), it could change
the context in which he perceives and responds to his OCD
symptoms, therefore making it more likely to embrace rather than
avoid or merely tolerate his private events. His perspective may
change from only anticipating fear and anxiety in these situations
to viewing them as opportunities to act in courageous or selfcompassionate ways. This change in perspective would have the
effect of increasing his psychological exibility in these situations
allowing him to increase acceptance and committed action toward
a values driven life.
The current study aims to examine if people with OCD show
decits in the specic values of self-compassion and courage, and
the extent to which they are living in accordance with their overall
values. Further, it attempts to explore the relationship between
OCD severity and one's overall valued living as well as the personal
values of self-compassion and courage. We hypothesize that
valued living in general and specic values of self-compassion
and courage will be signicantly inversely related to OCD severity.
In addition, we aim to explore these constructs to better determine if they may be useful targets in treating OCD.

2. Method
2.1. Participants and procedure
Participants were recruited via advertisements on various OCD
related websites (i.e., the International Obsessive Compulsive
Disorder Foundation, Houston OCD Program, and Peace of Mind).
Participation was voluntary and no compensation was given.
Participants completed a number of screening questions designed
to indicate an OCD diagnosis based on DSM-IV-R criteria. They
were provided with denitions of obsessions and compulsions and

asked if they experience either symptom, if they believed the

obsessions and/or compulsions were unreasonable and caused
signicant distress, were time consuming (taking more than 1 h a
day), or greatly interfered with their normal routine, occupational
(or academic) functioning, or usual social activities or relationships. Each question contained a dichotomous yes/no answer.
Participants were excluded from the study if they did not meet
DSM-IV-R criteria for OCD (i.e., did not endorse obsession or
compulsions or answered no to any remaining screening question)
based on their responses to the screening questions (n 61) or if
they did not complete all of the measures (n 16). Of the original
192 participants, 115 are included in the present analyses. Of the
61 participants excluded for not meeting criteria, 21 completed the
Yale-Brown Obsessive Compulsive Scale: Self-Report (Y-BOCS-SR)
and Obsessive-Compulsive Inventory-Revised (OCI-R) with mean
scores of 12.10 (sd5.30) and 15.24 (sd8.41), respectively. These
scores were below the typical clinical cut offs for both OCD
measures, indicating that few of the excluded individuals reported
clinical levels of OCD severity. Participants were primarily female
(71.3%) with a mean age of 36.34 (sd 11.85; range 1869).
Participant ethnicity was 90.4% Caucasian/White, 3.5% Hispanic,
2.6% Indian, and 3.5% other.

2.2. Measures
2.2.1. Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al.,
2002)
An 18-item, self-report questionnaire designed to measure OCD
symptoms. Commonly, scores at or above 21 indicate the likely
presence of OCD. The OCI-R displays good psychometric properties
(Foa et al., 2002). Internal consistency in the current study was
excellent (Cronbach's .90).
2.2.2. Yale-Brown Obsessive Compulsive Scale: Self-Report (Y-BOCSSR; Steketee, Frost, & Bogert, 1996)
The Y-BOCS-SR is a 10-item, self-report scale designed to
measure the severity of OCD. The Y-BOCS-SR yields a total score
(range040) with 16 commonly used as the clinical cutoff. The
Y-BOCS-SR displays good psychometric properties (Steketee et al.,
1996). Internal consistency in the current study was excellent
(Cronbach's .91).
2.2.3. Courage measure (CM; Norton & Weiss, 2009)
The CM is a 12-item self-report scale designed to assess selfperceived courageousness. Questions are rated along a sevenpoint Likert scale. The average score found in the original validation study of non-clinical participants was 47.46 (Norton & Weiss,
2009). The CM has demonstrated acceptable psychometric properties (Norton & Weiss, 2009). Internal consistency in the current
study was excellent (Cronbach's .90).
2.2.4. Self-Compassion Scale (SCS; Neff, 2003b)
The SCS is a 26-item, self-report scale designed to measure how
one relates to oneself in times of distress. The SCS assesses
six subscales including self-kindness, self-judgment, common
humanity, isolation, mindfulness, and over-identication, although
only the total score was used in this study. SCS scores between
1 and 2.5 are classied as low levels of self-compassion and scores
between 2.5 and 3.5 are classied as moderate levels of selfcompassion. The SCS displays excellent psychometric properties
(Neff, 2003b; Neff, Kirkpatrick, & Rude, 2007). Internal consistency
in the current study for total scale was adequate (Cronbach's
.74).

C.T. Wetterneck et al. / Journal of Contextual Behavioral Science 2 (2013) 6873

Valued Living Questionnaire (VLQ; Wilson et al., 2011)

A two-part questionnaire designed to assess valued living. The
VLQ rates value domains on a Likert scale ranging from 1 (not at all
important/consistent) to 10 (extremely important/consistent),
with a 5.5 indicating average levels of importance or consistent
living. The rst portion assesses the importance of 10 domains of
living including: family, marriage/couples/intimate relations, parenting, friendship, work, education, recreation, spirituality, citizenship, and physical self-care. The second portion asks
participants to rate how consistently they have lived in accord
with these domains in the past week. Responses from both
portions are used to calculate a valued living composite score for
each participant, which the current study employs rather than
individual VLQ domains in an attempt to quantify the extent to
which one is living out values in everyday life. The composite
score is calculated by obtaining the product of the consistency and
importance ratings for each domain and then taking the mean of
these products. The VLQ displays acceptable psychometric properties (Wilson et al., 2011). Internal consistency in the current study
was good for both the importance and consistency subscales
(Cronbach's s: importance .83; consistency .89).
2.3. Data analysis
Data were analyzed using SPSS 20.0 software. The statistical
analysis consisted of exploratory Pearson's r correlations followed
by a multiple regression with the VLQ, courage, and selfcompassion predicting Y-BOCS-SR scores. The analysis was
exploratory in nature to determine which, if any, values may
account for OCD severity.

3. Results
Mean scores for each of the measures are presented in Table 1.
In regard to OCD severity, ndings from both the Y-BOCS-SR and
the OCI-R indicate that on average the participants had moderate,
clinical levels of OCD. The sample endorsed below average selfcompassion scores, based on Neff's (2003b) classication. For the
overall VLQ, participants rated their values as moderately important (M 6.16) and reported to moderately pursue their values in a
consistent manner (M 5.73). Although there are no designated
cutoffs for the courage measure, the mean scores also hold some
utility in better understanding the current participants' courage
levels, which were rated as slightly below average.
Results from Pearson's correlations are presented in Table 2.
The ndings indicated signicant inverse relationships between
the VLQ, courage, and self-compassion and OCD severity. These
signicant negative correlations between the different values and
the Y-BOCS-SR support our hypotheses of relationships between
low levels of values and high OCD severity.
A subsequent multiple regression was conducted predicting
OCD severity from the VLQ, courage, and self-compassion, which
were all signicantly associated with OCD severity in the prior
correlation analysis. Results indicated a statistically signicant
prediction model, F (3, 111) 16.29, p o.001, with an R2 of .31
Table 1
Mean scores for measures.

Y-BOCS-SR total
OCI-R total
SCS total
Courage total
VLQ composite

Mean

sd

20.98
28.15
2.26
43.97
37.30

7.37
14.71
.65
14.09
19.46

71

Table 2
Correlations between OCD severity and values measures.
1
1. Y-BOCS-SR total
2. SCS total
3. Courage total
4. VLQ composite
n

1
 .30n
 .45n
 .47n

1
.33n
.29n

1
.44n

p o .01.

Table 3
Multiple regression predicting YBOCS scores.

VLQ composite
Courage
Self-compassion

 .32
 .27
 .12

 3.59
 2.99
 1.35

o .001
o .01
n.s

and an Adjusted R2 of .29. Evaluation of the main effects indicated

that only the VLQ and courage were statistically signicant. Results
are presented in Table 3. The VLQ and courage were both
signicant predictors of OCD severity indicating that values in
both a global and a specic personal area are potentially important
areas to further explore.

4. Discussion
The present study examined the relationships between values
and OCD severity. Our ndings indicate that overall domains and
specic values were signicantly negatively related to OCD severity. These ndings provide evidence that values and valued living
may be an important area of study for OCD.
Courage was negatively correlated with OCD severity, and
positively correlated with both the VLQ and self-compassion value
measures. Individuals with higher levels of courage may naturally
be engaging behavior that reduces the likelihood of developing
OCD or that reduces the symptom severity of OCD. It is possible
that these individuals are less avoidant of fearful stimuli in their
environment and may be more resilient when confronted with
unwanted impulses or thoughts and therefore, better able to move
in value-focused directions. Further exploration of the construct of
courage is needed to better understand its effects, if any, on OCD
symptomology.
Although this study cannot speak directly to how values might
inuence treatment, a few speculations could be made to stimulate future research. Courage would seem to play a pivotal role in
the treatment of OCD given the perceived risk in challenging fears
via exposure work. Additionally, low levels of courage may factor
into delays in treatment seeking, which is often characteristic of
those with OCD (Belloch, Del Valle, Morillo, Carrio, & Cabedo,
2009). Levels of behavior in the service of courage may differ
between individuals with fears that vary in amount of threat to
self or others. For example, fears associated with feelings of shame
or guilt, such as pedophilic or violence toward loved ones, may
have more perceived risk for disclosure than more commonly
accepted fears, such as contamination. Simonds and Thorpe (2003)
demonstrated that people more heavily stigmatize certain obsessions over others. This stigmatization could require greater levels
of courage before individuals seek treatment for OCD. Therefore,
fostering courage development may enhance OCD treatment.
Additionally, the relationship between the VLQ and OCD
severity suggests that valued living as a broad construct relates
to OCD severity. These ndings suggest that developing and then

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C.T. Wetterneck et al. / Journal of Contextual Behavioral Science 2 (2013) 6873

living consistently within one's values may play an important role

for those with OCD. Perhaps those individuals who feel that they
have aspects of their lives that are important are more willing and
motivated to treat their OCD to better live in accordance with
these values. These individuals may be more likely to seek
treatment as well as more diligently follow treatment protocol.
There is also the possibility that those who live more valued lives
are simply less prone to developing as severe of OCD symptoms.
This could potentially be due to them seeking treatment earlier
than those living less value-driven lives. These ndings offer some
insight into the importance of valued living; however, further
research is needed in this area to better understand the important
role that identifying values and living according to those values
may play in OCD.
Finally, self-compassion was moderately negatively correlated
with OCD severity. Additionally, participants demonstrated below
average self-compassion scores, which replicates a previous nding (Wetterneck, Little, Hart, & Smith 2013). However, the regression analysis did not provide evidence that acting in a selfcompassionate manner signicantly contributed to OCD severity.
Although not directly related to OCD severity, self-compassion
may still hold some utility in other areas related to treatment. For
example, the ability to treat oneself with kindness may help
reduce rates of treatment drop-out due to self-compassion's
potential to temper the feelings of frustration and inadequacy
that can occur during exposure-based treatment. Previous
research has also found that it may be an important construct
for specic symptom dimensions such as harming thoughts and
unacceptable thoughts (e.g., sexual or violent thoughts;
Wetterneck et al., 2013). Further research on self-compassion
and its relation to OCD is needed.
Overall, it appears that OCD severity may be related to a
deciency in functional values, warranting further investigation
into the impact of increasing values and valued living in the
treatment of OCD. While the present study does provide some
insight into the importance of values and their relationship to OCD
severity, there is still much research to be done in regard to which
values, if any, play the largest role in the development, maintenance or recovery from OCD. We suggest that values such as
trust, patience, and hope could play roles in the successful
treatment of OCD. Bienvenu et al. (2004) found that low levels
of trust were associated with both social phobia and agoraphobia.
Further research is needed to better determine what role different
values may play in OCD severity. Finally, there is a need for
research that explores how the effort one focuses on OCD
symptoms may lead to decits in other important areas of one's
life. Because specic values have been shown to be related to OCD
severity, perhaps clients with OCD symptoms should be encouraged to prioritize specic values, that when practiced, may lead to
symptom reduction. This is somewhat contrary to ACT's approach
that values should be freely chosen. However, guidance may be
needed for individuals who may have lived the majority of their
lives without consideration for which values may be functional.
Trneke (2010) argues that knowing what one wants (i.e., identifying values) requires self-as-process development and the ability
to tact one's own private events as they occur. Further, certain
private events that appear threatening may lead to one deliberately avoiding focusing on those events. This can lead to difculties
in identifying what matters in one's life. Therefore, guidance may
be needed for individuals who may have lived the majority of their
lives without consideration for which values may be functional or
who have difculty tacting their own private events.
The present study has some notable limitations. Despite the
preceding case that values are a potentially important and underutilized aspect of OCD treatment, the current study is crosssectional in nature, therefore limiting the strength of the

conclusion. More studies similar to that of Hayes et al. (2010),

who measured values, acceptance and anxiety symptoms across
sessions could be useful in examining the relationships explored in
this paper in the context of OCD treatment. Moreover, due to the
cross-sectional nature of the current study, the directionality of
the relationship between values and OCD severity is unknown.
While the current study provides evidence that there is a positive
relationship between high levels of values and low levels of OCD
severity, the nature of this relationship has yet to be explored. It is
important to consider the possibility that simply having OCD could
result in behavior that is less likely to lead to developing values
such as self-compassion, courage, or the VLQ value domains and
that the process of treating OCD could naturally increase valuing in
these areas. Symptom severity could also inuence the types of
values identied and pursued; for example, obsessions about
dying from contamination could lead to a focus on or increase in
behaviors supporting a value of self-preservation or vigilance and
less on courage in challenging feared stimuli that interfere in other
valued areas of life. Also, due to the inherent qualities of online
data collection there is a possibility of a selection sampling bias.
All participants had access to the Internet and were recruited from
OCD related websites, indicating that they may have been seeking
information on OCD and/or treatment. Therefore, the generalizability of the ndings may be somewhat limited. Likewise, the
measures used to assess values may have limited generalizability
due to their norms being taken from college students or other
specic populations. Because of the online nature in which surveys
were taken, all participant data are self-report. We were unable to
diagnose participants with OCD; rather we assessed the participants for OCD symptoms by asking screening questions. Finally,
the generalizability of the ndings may be somewhat limited due
to the lack of ethnoracial diversity in the sample. Further research
is needed to determine the inuence of values on OCD severity
and vice versa.
Despite these limitations, the present study does provide
insight into values and their relationship to OCD severity. These
ndings provide some support to the idea that individuals with
OCD may not have a focus on or helpful levels of functional specic
values. Further research is needed to better understand what
values may contribute to reducing OCD severity, how increasing
value-oriented behavior may improve treatment outcomes and
quality of life, and how these values can be incorporated into the
lives of those with OCD.

Funding
The authors received no nancial support for the research,
authorship, and/or publication of this article.
References
Abramowitz, J. S., Taylor, S., & McKay, D. (2005). Potentials and limitations of
cognitive treatments for obsessive-compulsive disorder. Cognitive Behavior
Therapy, 34, 140147.
Abramowitz, J. S. (2006). The psychological treatment of obsessive-compulsive
disorder. The Canadian Journal of Psychiatry, 51, 407416.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental
disorders IV-TR (4th ed.). Washington, DC: Author.
Belloch, A., Del Valle, G., Morillo, C., Carrio, C., & Cabedo, E. (2009). To seek advice or
not to seek advice about the problem: The help-seeking dilemma for obsessivecompulsive disorder. Social Psychiatry and Psychiatric Epidemiology, 44,
257264.
Bienvenu, O. J., Samuels, J. F., Costa, P. T., Reti, I. M., Eaton, W. W., & Nestadt, G.
(2004). Anxiety and depressive disorders and the ve-factor model of personality: A higher- and lower-order personality trait investigation in a community
sample. Depression and Anxiety, 20, 9297.
Dahl, J. C., Plumb, J. C., Stewart, I., & Lundgren, T. (2009). The art & science of valuing
in psychotherapy. Oakland, CA: New Harbinger.

C.T. Wetterneck et al. / Journal of Contextual Behavioral Science 2 (2013) 6873

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance & commitment therapy for anxiety
disorders. Oakland, CA: New Harbinger.
Fisher, P. L., & Wells, A. (2005). How effective are cognitive and behavioral
treatments for obsessive-compulsive disorder? A clinical signicance analysis.
Behavior Research and Therapy, 43, 15431558.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., et al. (2002).
The ObsessiveCompulsive Inventory: Development and validation of a short
version. Psychological Assessment, 14, 485496.
Hannah, S. T., Sweeney, P. J., & Lester, P. B. (2007). Toward a courageous mindset:
The subjective act and experience of courage. The Journal of Positive Psychology,
2, 129135.
Hayes, S. A., Orsillo, S. M., & Roemer, L. (2010). Changes in proposed mechanisms of
action during an acceptance-based behavior therapy for generalized anxiety
disorder. Behaviour Research and Therapy, 48(3), 238245.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment
Therapy: An experiential approach to behavior change. New York: Guilford Press.
Hjemdal, O., Vogel, P. A., Solem, S., Hagen, K., & Stiles, T. C. (2011). The relationship
between resilience and levels of anxiety, depression, and obsessive-compulsive
symptoms in adolescents. Clinical Psychology and Psychotherapy, 18, 314321.
Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of
acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder.
Behavior Therapy, 35, 747766.
Lysaker, P. H., Whitney, K. A., & Davis, L. W. (2006). Obsessive-compulsive and
negative symptoms in schizophrenia: Associations with coping preference and
hope. Psychiatry Research, 141, 253259.
Michelson, S. E., Lee, J. K., Orsillo, S. M., & Roemer, L. (2011). The role of valuesconsistent behavior in generalized anxiety disorder. Depression and Anxiety, 28,
358366.
Neff, K. D. (2003a). Self-compassion: An alternative conceptualization of a healthy
attitude toward oneself. Self and Identity, 2, 85101.
Neff, K. D. (2003b). The development and validation of a scale to measure selfcompassion. Self and Identity, 2, 223250.
Neff, K. D., Rude, S. S., & Kirkpatrick, K. L. (2007). An examination of self-compassion
in relation to positive psychological functioning and personality traits. Journal
of Research in Personality, 41, 908916.
Neff, K., Kirkpatrick, K., & Rude, S. (2007). Self-compassion and adaptive psychological functioning. Journal of Research in Personality, 41, 139154.
Norberg, M. M., Calamari, J. E., Cohen, R. J., & Riemann, B. C. (2008). Quality of life in
obsessive-compulsive disorder: an evaluation of impairment and a preliminary
analysis of the ameliorating effects of treatment. Depression and Anxiety, 25,
248259.
Norton, P. J., & Weiss, B. J. (2009). The role of courage on behavioral approach in a
fear-eliciting situation: A proof-of-concept pilot study. Journal of Anxiety
Disorders, 23, 212217.
Pallanti, S., & Quercioli, L. (2006). Treatment refractory obsessive-compulsive
disorder: methodological issues, operational denitions, and therapeutic lines.
Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30, 400412.

73

Pauley, G., & McPherson, S. (2010). The experience and meaning of compassion and
self-compassion for individuals with depression or anxiety. Psychology and
Psychotherapy, 83, 129143.
Raes, F. (2010). Rumination and worry as mediators of the relationship between
self-compassion and depression and anxiety. Personality and Individual Differences, 48, 757761.
Rate, C. R., Clarke, J. A., Lindsay, D. R., & Sternberg, R. J. (2007). Implicit theories of
courage. The Journal of Positive Psychology, 2, 8098.
Simonds, L. M., & Thorpe, S. J. (2003). Attitudes toward obsessive-compulsive
disorders: An experimental investigation. Social Psychiatry and Psychiatric
Epidemiology, 38, 331336.
Steketee, G. S., Frost, R. O., & Bogert, K. (1996). The Yale-Brown ObsessiveCompulsive Scale: Interview versus self report. Behaviour Research and Therapy,
34, 675684.
Thompson, B. L., & Waltz, J. (2008). Self-compassion and PTSD symptom severity.
Journal of Traumatic Stress, 21(6), 556558.
Trneke, N. (2010). Learning RFT: An introduction to relational frame theory and its
clinical applications. Oakland, CA: New Harbinger Publications, Inc.
Twohig, M. P. (2004). ACT for OCD: Abbreviated treatment manual. Available from
http://contextualscience.org.
Twohig, M. P. (2009). The application of acceptance and commitment therapy to
obsessive-compulsive disorder. Cognitive and Behavioral Practice, 16(1), 1828.
Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increasing willingness to
experience obsessions: Acceptance and commitment therapy as a treatment
for obsessive-compulsive disorder. Behavior Therapy, 37, 313.
Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H.,
et al. (2010). A randomized clinical trial of acceptance and commitment therapy
versus progressive relaxation training for obsessive-compulsive disorder.
Journal of Consulting and Clinical Psychology, 78, 705716.
Van Dam, N. T., Sheppard, S. C., Forsyth, J. P., & Earleywine, M. (2011). Selfcompassion is a better predictor than mindfulness of symptom severity and
quality of life in mixed anxiety and depression. Journal of Anxiety Disorders, 25,
123130.
Wetterneck, C. T., Little, T. E., Chasson, G. S., Smith, A. H., Hart, J. M., Stanley, M. A.,
et al. (2011). Obsessive-compulsive personality traits: How are they related to
OCD severity? The Journal of Anxiety Disorders, 28, 10241031.
Wetterneck, C. T., Little, T. E., Hart, J. M., & Smith, A. H. (2013). Self-compassion and
emotion regulation in obsessive-compulsive disorder (under review).
Wetterneck, C. T., Steinberg, D. S., Little, T. E., Phillips, L., & Hart, J. M. (April, 2012).
Examining self-compassion and experiential avoidance in symptom dimensions of
OCD. Unpublished paper presented at the Anxiety and Depression Association
of America Conference. La Jolla, CA.
Wilson, K. G., & Dufrene, T. (2008). Mindfulness for two: An acceptance and
commitment therapy approach to mindfulness in psychotherapy. Oakland, CA:
New Harbinger Publications.
Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. (2011). The Valued Living
Questionnaire: Dening and measuring valued action within a behavioral
framework. The Psychological Record, 60, 249272.
Woodard, C. R., & Pury, C. L. S. (2007). The construct of courage: Categorization and
measurement. Consulting Psychology Journal: Practice and Research, 59, 135147.