ACT-Informed Exposure for Anxiety: Creating Effective, Innovative, and Values-Based Exposures Using Acceptance and Commitment Therapy [1 ed.] 1648480810, 9781648480812

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PSYCHOLOGY

exposure for anxiety disorders Exposure therapy is a well-researched intervention for helping clients confront anxiety-provoking stimuli in order to resist engaging in avoidance behaviors. Acceptance and commitment therapy (ACT) is an evidence-based treatment model and provides a theory for guiding the use of exposure therapy by encouraging clients to connect with their values, remain in contact with the present moment, and increase behavioral flexibility. This comprehensive book provides a process-based approach for utilizing ACT-informed exposure in session, and offers new ideas and tools to help your clients. ACT-Informed Exposure for Anxiety synthesizes the latest research, clinical experience, and theory into one powerfully effective professional resource. You’ll find an overview of exposure therapy and ACT, as well as cultural considerations to inform your work with clients of diverse backgrounds. Also included are strategies to help you create exposures tailored to clients’ specific needs, and guidelines for addressing common client and therapist barriers to treatment. Whether you’re new to ACT and exposure or experienced in other models of exposure and interested in incorporating ACT into

ACT-Informed Exposure for Anxiety

A process-based approach to

your practice, this is an essential addition to your professional library.

—Stefan G. Hofmann, PhD, Alexander von Humboldt Professor at the Philipps University of Marburg, and author of The Anxiety Skills Workbook

Context Press

An Imprint of New Harbinger Publications, Inc. www.newharbinger.com

Exposure for

Anxiety CREATING EFFECTIVE, INNOVATIVE & VALUES-BASED EXPOSURES USING

Thompson • Pilecki • Chan

“An intelligent and thoughtful integration, providing clear recommendations for improving treatment. I highly recommend this book.”

ACT-Informed

Context

Press

ACCEPTANCE & COMMITMENT THERAPY

Brian L. Thompson, PhD Brian C. Pilecki, PhD Joanne C. Chan, PsyD Foreword by Steven C. Hayes, PhD

“Exposure-based treatments are some of the most effective, but still poorly understood, clinical strategies for anxiety problems. This book is an important step forward by embracing a processbased perspective and linking it to acceptance and commitment therapy (ACT). It is an intelligent and thoughtful integration, providing clear recommendations for improving treatment. I highly recommend this book.” —Stefan G. Hofmann, PhD, Alexander von Humboldt Professor at the Philipps University of Marburg, and author of The Anxiety Skills Workbook and CBT for Social Anxiety “In this book, Thompson, Pilecki, and Chan articulate the core principles of ACT-informed exposure as clearly and accessibly as I have ever read. The content is comprehensive—even discussing cultural considerations—making the book an essential resource for any clinician doing exposures with their clients. Even if you’re already doing ACT-based exposures, you will still learn something new from the authors’ masterful dissection of this approach.” —Clarissa Ong, PhD, assistant professor at the University of Toledo, and coauthor of The Anxious Perfectionist “Pairing decades of strong efficacy data for exposure therapy with the strengths of ACT to build willingness and cognitive flexibility—this book is the perfect pairing of both! The book contains ‘how to’ pointers for developing therapists and real-world problem-solving for experienced therapists. It’s for the exposure therapist who wants to better help clients choose to engage and cultivate new learning. It’s for the ACT therapist who wants to better harness the power of exposure.” —Lori Zoellner, PhD, director of the Center for Anxiety and Traumatic Stress, and professor of psychology at the University of Washington; and coeditor of Facilitating Resilience and Recovery After Trauma “If you work with anxiety, obsessive-compulsive disorder (OCD), or trauma, you should read this book. ACT-informed exposures will enrich your practice and provide you with useful case conceptualizations and treatment moves.” —Michael Twohig, PhD, professor, and coauthor of The Anxious Perfectionist “Evidence-based treatment for anxiety emphasizes exposure. However, this treatment is a challenge for even the most seasoned clinician to carry out. ACT-Informed Exposure for Anxiety reframes exposure through a lens that is accessible to clinicians, and eases their own apprehensions about the method while also presenting a highly contemporary treatment method in a digestible way. It is sure to be an indispensable guide for therapists of all levels.” —Dean McKay, PhD, ABPP, professor of psychology at Fordham University; and past president of the Association for Behavioral and Cognitive Therapies, and the Society for a Science of Clinical Psychology

“Always a champion of emphasizing the work of exposure in ACT, I am delighted to highly recommend ACT-Informed Exposure for Anxiety. This book is ideal for therapists wishing to provide an effective and excellent intervention for their anxious clients. Authors Brian Thompson, Brian Pilecki, and Joanne Chan guide therapists in implementing exposure— tucked inside of willingness linked to values—in their process and the clients’ process in a straightforward and implementable way. A must for therapists.” —Robyn D. Walser, PhD, licensed clinical psychologist; author of The Heart of ACT; and coauthor of Learning ACT, The Mindful Couple, Acceptance and Commitment Therapy for Post-Traumatic Stress Disorder and Trauma-Related Problems, and The ACT Workbook for Anger

“ACT-Informed Exposure for Anxiety by Thompson, Pilecki, and Chan is an excellent, wellresearched, and comprehensive guide to process-based exposure. This is more than a handbook on integrating ACT with exposure and response prevention (ERP)—it demystifies how to conduct exposure founded in basic principles of fear acquisition and applied behavior analysis (ABA). Thank goodness these stellar clinicians and researchers put in the hard work to write this for us. It will be a go-to guide for all clinicians who treat anxiety disorders and OCD.” —Lisa Coyne, clinical psychologist, founding director of the New England Center for OCD and Anxiety, and assistant professor at Harvard Medical School/Mclean

“When we are willing to open up to our anxieties and fears, we gain the space and freedom needed to live our lives in line with what we care about. There is no shortcutting this process. Yet, inside ACT, we do this ‘exposure’ work in the service of helping our clients live well when faced with life’s inevitable obstacles, problems, and pain. In the process, your clients learn to cultivate a new relationship with their anxieties and fears, and hence regain control over their lives. This gentle and wise guide will show you how to do just that. A must-read for all mental health professionals interested in ACT, including those who wish to learn how to do processbased exposure work.” —John P. Forsyth, PhD, professor of psychology, and director of the Anxiety Disorders Research Program at the University at Albany, SUNY; clinical psychologist; ACT researcher, trainer, and clinical supervisor; and coauthor of The Mindfulness and Acceptance Workbook for Anxiety and Anxiety Happens

ACT-Informed

Exposure for

Anxiety CREATING EFFECTIVE, INNOVATIVE & VALUES-BASED EXPOSURES USING ACCEPTANCE & COMMITMENT THERAPY

Brian L. Thompson, PhD Brian C. Pilecki, PhD Joanne C. Chan, PsyD Context Press

An Imprint of New Harbinger Publications, Inc.

Publisher’s Note This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional should be sought. NEW HARBINGER PUBLICATIONS is a registered trademark of New Harbinger Publications, Inc. New Harbinger Publications is an employee-owned company. Copyright © 2023 by B  rian L. Thompson, Brian C. Pilecki, and Joanne C. Chan New Harbinger Publications, Inc. 5674 Shattuck Avenue Oakland, CA 94609 www.newharbinger.com All Rights Reserved Cover design by Amy Daniel; Acquired by Jennye Garibaldi; Edited by Jennifer Eastman; Indexed by James Minkin

Library of Congress Cataloging-in-Publication Data Names: Thompson, Brian L. (Brian Lantz), author. | Pilecki, Brian C., author. | Chan, Joanne C., author. Title: ACT-informed exposure for anxiety : creating effective, innovative, and values-based exposures using acceptance and commitment therapy /\ Brian L. Thompson, Brian C. Pilecki, Joanne C. Chan. Description: Oakland, CA : New Harbinger Publications, Inc., [2023] | Includes bibliographical references and index. Identifiers: LCCN 2022057389 | ISBN 9781648480812 (trade paperback) Subjects: MESH: Anxiety Disorders--therapy | Acceptance and Commitment Therapy--methods | Implosive Therapy--methods | BISAC: PSYCHOLOGY / Clinical Psychology | PSYCHOLOGY / Movements / Cognitive Behavioral Therapy (CBT) Classification: LCC RC489.C63 | NLM WM 172 | DDC 616.89/1425--dc23/eng/20230306 LC record available at https://lccn.loc.gov/2022057389

Table of Contents

Foreword: Why ACT Needs Exposure and Exposure Needs ACT Acknowledgments

v

ix

Background: History, Research, Current Trends Chapter 1: A Process-Based Approach to Exposure for Anxiety Disorders

3

Chapter 2: A Brief History and Overview of Exposure

9

Chapter 3: An Acceptance and Commitment Therapy Primer

23

Clinical Application: ACT-Informed Exposure in Practice Chapter 4: What the Therapist Needs to Know

41

Chapter 5: What the Client Needs to Know

59

Chapter 6: What to Do During and After Exposure

71

Chapter 7: Ending Treatment

93

Chapter 8: Create Your Own ACT-Informed Exposure Forms

109

Chapter 9: Case Examples of ACT-Informed Exposure 

121

Chapter 10: ACT Fails and Other Pitfalls and Barriers to ACT-Informed Exposure

139

Chapter 11: Cultural Considerations in ACT-Informed Exposure

155

References 167 Index 181

FOREWORD

Why ACT Needs Exposure and Exposure Needs ACT

Exposure is often spoken of as one of the crown jewels of evidence-based therapy. Here is a method that helps about half of the clients who try it and has a mountain of supportive evidence across a wide range of problem areas. In part as a result, nearly every introductory text in psychology includes exposure case examples, and often these examples are used to highlight explanations that have been repeated so often they have become almost truisms, such as the supposedly key role of reductions of arousal during exposure sessions. It is good to have a crown jewel, but we must be honest. The fact is that exposure is a method we still do not fully understand. Simple conditioning or habituation explanations cannot fully explain it. Traditional cognitive and emotional processing explanations falter as well. And, yes, spontaneous reductions of arousal during exposure sessions also fail. It now appears that what is most key is new learning, not eliminating the emotional echoes of the past. Being better able to observe and describe emotions may be important. Persistence is important. But the “jewel” is still, shall we say, unpolished. It is still a method or technique, not a well-understood process or set of processes. Acceptance and commitment therapy (ACT) was always cast as an exposure-based treatment simply because the processes it targets, such as emotional and cognitive openness, flexible attention to the now, and values-based behavioral commitments all readily bring people into contact with previously repertoire-narrowing experiences (Hayes et al., 1999, 2012). ACT naturally leads to “exposure” to previously avoided thoughts, feelings, memories, sensations, or situations. Unlike traditional exposure, ACT does not seek or promise elimination of emotional arousal—the point was more the creation of greater life freedom, the ability to live the kind of life you choose via greater psychological flexibility. As exposure-based ACT research began in earnest in the last decade and a half, it was found that it did indeed produce positive outcomes and did so generally via changes in psychological flexibility or related concepts. The flexibility-based view of exposure—namely that it is “organized presentation of previously repertoire-narrowing stimuli in a context designed to ensure repertoire expansion” (Hayes et al., 2012, p. 284)—has held up reasonably well. It fits broadly with what we are learning about exposure from many different

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modern laboratories. But in the last few years, we have also learned that the gains for ACT exposure were about the same as with the best existing exposure methods. That was undeniably a disappointment—but science is science, and we learn as much or more from our failures as our successes. Is that the end of the story? A fair answer is that we do not yet know. We do know that radically transdiagnostic methods are gaining ground and that ACT is rapidly assuming a role as a central method in modern evidence-based intervention worldwide. It is doing that not because it is spectacularly better in any one area but rather because its putative processes of change are robust, and they are incredibly broadly applicable. More than half of the known successful mediators of change for any psychosocial method in randomized trials focused on mental health outcomes are measures of psychological flexibility and its closely associated concepts (Hayes et al., 2022). Over a thousand randomized trials of ACT (bit.ly/ACTRCTs) show that the same model and same basic methods produce positive changes that usually meet or beat best of breed targeted alternatives across every kind of problem area or positive prosperity challenge you can name— from relationships to addiction, from panic to managing diabetes, from burnout to reducing the harmful impact of prejudice. And that is one major reason for this very book. If we know that ACT is important and exposure is important, is exposure important for ACT? The authors argue successfully that the answer is yes. This book shows that exposure in an ACT context can be thought of as simply another ACT experiential exercise that can help clients orient to the ACT model. Exposure offers an advantage over traditional ACT experiential exercises in its focus on repetition. Through repetition of specific exposure exercises conducted in a variety of contexts, clients have greater opportunity to experience ACT processes and practice psychological flexibility when in contact with previously repertoire-narrowing stimuli. In short, if clients don’t understand ACT concepts such as willingness, then exposure is a great way for them to contact ACT processes experientially. In other words, exposure is a way to do better ACT work! Exposure is a context; a platform. And unlike lots of alternative contexts for ACT work, it’s done where the rubber meets the road: it’s real, situational, behavioral, and repeatable. It is not just more talking. That is a hugely important idea and one that is as behaviorally sensible as an idea can be. But if exposure is helpful to ACT, is ACT helpful to exposure? I think there too the answer is yes. Here’s why. When you compare ACT exposure to say, traditional CBT exposure, the outcomes are similar…but not necessarily the moderators! For example, if you are working with multiproblem people, such as those who are diagnosable with an anxiety disorder and a mood

Why ACT Needs Exposure and Exposure Needs ACTvii

disorder, ACT-based exposure produces better gains than CBT-based exposure (WolitzkyTaylor et al., 2012). This means that you must consider client fit. It is not the only study finding different moderators for ACT-based exposure as compared to CBT-based exposure (e.g., see Craske, Niles, et al., 2014; Niles et al., 2017, among others). The deep message of findings like this is not that ACT-based exposure makes no difference as compared to CBT or other methods, but that it does make a difference, depending on the client. Now add to that the fact that we are currently examining mediation and moderation only through the filter of top-down normative statistics instead of using person-specific measurement and analysis—what is being called “idionomic” statistics (e.g., Hayes et al., 2022). In other words, we are using statistical methods to find treatment moderation and mediation that treat people as error terms, not individuals. And yet even through that darkened window, we see that ACT helps some people (but not all people) better than existing best of breed methods. Doesn’t that mean you need to learn ACT-based exposure if you work with populations that need exposure? I think it means precisely that. On both grounds, if you are a person interested in either exposure or ACT, you need this book. The authors do a wonderful job covering every detail of how to do ACT-based exposure. The voice is calm and reassuring; the writing is clear and helpful; the advice is detailed and evidence-based. It is simply the best book available on this topic. And with that, I will turn you, the reader, over to the authors’ capable hands with this simple message: this is an important book on an important area. I believe it will make a difference in the lives of those you serve. —Steven C. Hayes, PhD Foundation Professor of Psychology, University of Nevada, Reno Originator and codeveloper of acceptance and commitment therapy

Acknowledgments

First off, I’d like to thank my parents, who’ve been so supportive of me throughout my life and through my schooling, more schooling, and still more schooling. Second, on behalf of both my coauthors and me, I’d like to express our appreciation to Jason Luoma and Jenna LeJeune at Portland Psychotherapy for years of mentorship and for generously allowing us to carve time out of our clinical work and for providing a grant to support this book. To my wife, Elizabeth, and daughters, Alice and Josephine, who graciously tolerated my spending time in front the computer on weekends, when necessary. Lastly, I’d like to acknowledge the generosity of the ACT community. I’m almost reluctant to name names here, as I’m sure I’d leave someone out. Many my early ideas about ACT-informed exposure came from casual hallway conversations. Michal Twohig, John Forsyth, and Robyn Walser were particularly welcoming and generous with their time early on. And to my coauthors, who allowed me to take risks with this book and helped guide it. —Brian Thompson I’d like to express thanks to my parents and my aunt, who have always encouraged me to write a book and taught me to believe in myself. I’d also love to acknowledge the many mentors and supervisors that I’ve been lucky enough to work with. Dean McKay—your passion, integrity, and love of learning has influenced me in so many ways, and I am so grateful for all you’ve done for me. Paul Greene, Jamie Schumpf, Anna Edwards, Susan Evans, Dennis Tirch, Kristy Dalrymple, and Lisa Coyne—thanks for teaching me exposure and ACT and helping me find my own voice in this wonderful community of professionals. I’d also like to thank my coauthors for all your support over the last several years, as well as Jill Stoddard for your mentorship on the writing process. Finally, this project would not have been completed without the support, encouragement, and mentorship of Jenna LeJeune, Jason Luoma, and Kyong Yi at Portland Psychotherapy. —Brian Pilecki Thank you to my husband, Johan, for selflessly taking over childcare duties when I had to hole myself up in my office to work. I’m so incredibly touched by your act of love toward me

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this past year. To my daughter, Aster, you’ve been such a “big girl” when I’ve been unavailable to spend precious mommy-daughter time with you. Thank you both from the bottom of my heart. To my parents, thank you for always being my safety net. Your love and sacrifice have laid the foundation for who I am. To my coauthors, thank you for always making yourselves available to discuss book stuff in the midst of your busy work and personal lives. I’m grateful to have gone on this adventure with you! To my friend and colleague Cristina Schmalisch, thank you for sharing your wisdom and supporting me when I felt stuck. To Kyong Yi, thank you for being a rock for the three of us when we needed a touchstone. To Jenna LeJeune and Jason Luoma, thank you for providing such awesome examples of how to contribute to the professional community in important ways. To my former colleagues in the BIPOC diversity, equity, and inclusion group at Portland Psychotherapy, our honest, reflective conversations were a wellspring of inspiration as I wrote the culture chapter, and for that, I’m forever grateful. —Joanne Chan

BACKGROUND

History, Research, Current Trends

CHAPTER 1

A Process-Based Approach to Exposure for Anxiety Disorders

Exposure therapy involves the systematic confrontation of anxiety-provoking stimuli while refraining from avoidance behaviors (e.g., any behavior aimed at reducing fear or discomfort). It’s one of the major success stories in the treatment of anxiety disorders in adults (Hofmann & Smits, 2008; Norton & Price, 2007), as well as children and adolescents (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). Whenever I (Brian T) start to tell someone about my background in exposure therapy, I have to stop myself from saying, “My first exposure to exposure was…” Therefore, my first (ahem) experience with exposure was prolonged exposure (PE) for PTSD (Foa, Hembree, & Rothbaum, 2007). An exposure-based cognitive behavioral treatment for individuals with PTSD, PE consists of psychoeducation, a brief introduction to deep breathing, and then exposure, exposure, and more exposure. I’ve always admired the relative simplicity and elegance of the PE protocol. There are only a handful of worksheets in the protocol, and the focus of the treatment is almost entirely on exposure. There are a number of exposure-based interventions; PE is just one of them. Others include exposure with response or ritual prevention for obsessive-compulsive disorder (Foa, Yadin, & Lichner, 2012) and written exposure therapy for PTSD (Sloan & Marx, 2019). However, many treatment protocols I’ve picked up since learning PE have felt unnecessarily cluttered by comparison. Look at all these worksheets and handouts, I’d think, paging through a manual, Do we really need all of them? With PE, I never had these questions, because the approach is so streamlined. And although you’ll find some critiques of PE in this book, it remains my platonic ideal of a treatment protocol. In sum, PE ruined me for other treatment protocols. In the year after first learning and practicing PE, during a postdoc focused on acceptance and commitments therapy (ACT), I became interested in ACT approaches to exposure. ACT is a newer cognitive behavioral treatment with a strong research base. Even in the absence of deliberate exposure interventions, ACT has been described as an “exposurebased therapy” because it encourages people to remain in contact with difficult experiences they may otherwise avoid (e.g., Hayes, Strosahl, & Wilson, 2012).

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As I moved away from using a strict PE protocol, I naturally gravitated toward approaching ACT-informed exposure with the simplicity I’d valued in PE. At the time I was first reading about ACT approaches to exposure (circa 2009–2010), there wasn’t a lot published about it. I combed through Eifert and Forsyth’s (2005) exceptional ACT for Anxiety Disorders and a handful of published case examples and small studies (e.g., Batten & Hayes, 2005; Dalrymple & Herbert, 2007; Orsillo & Batten, 2005). I informally chatted with experienced ACT clinicians using exposure and combed the ACT listserv for morsels. Along the way, I started creating my own ACT-informed exposure worksheets, trying to put theory into practice. I would revise these forms based on what seemed to work or not work with clients. Adrift from a consistent connection with a scientific community, I was more like a crank trying to make contributions to quantum physics from his backyard garden shed than a behavioral scientist. Throughout it all, my goal was to distill ACT-informed exposure into its essence. How could I orient clients to the ACT model in as few sessions as possible? What metaphors and experiential exercises connected to the widest range of people I worked with? What did exposure offer that traditional ACT metaphors and experiential exercises did not? Gradually, published studies of larger, controlled trials of ACT-informed exposure trickled in. Initially there was some talk that ACT-informed exposure may offer advantages over traditional exposure in terms of more people getting better or fewer dropouts. As research indicated that ACT-informed exposure and traditional habituation-based exposure appeared to perform about equivalently on primary outcomes (Arch et al., 2012; Craske, Niles, et al., 2014; Twohig et al., 2018)—that is, about the same; no better, no worse—I grappled with why a therapist might use ACT-informed exposure over traditional exposure such as PE—especially therapists already comfortable with traditional exposure. Why learn a new model that appears no more effective than the old model? Traditional exposure promises symptom reduction, whereas the ACT model focuses on remaining in contact with discomfort to strengthen psychological flexibility in order to live a meaningful life. Why learn a model that feels more counterintuitive for clients compared to traditional exposure? Given that clients crave symptom reduction, why offer a treatment that denies them that? This book is the culmination of more than a decade of studying, reading, writing, and otherwise wrestling with ideas about ACT-informed exposure. It’s been shaped through thousands of hours of clinical work with clients who’ve let us know—implicitly and explicitly—what works and what doesn’t. As my coauthors and I began teaching trainees at our clinic and developing workshops on ACT-informed exposure, we further refined these ideas and how to present them to others. Our goal was to help answer the above questions and make ACT-informed exposure as practical as possible.

A Process-Based Approach to Exposure for Anxiety Disorders5

By “practical,” we don’t mean simple, though. We love ACT theory. We’ve tried to interweave the full complexity and texture of ACT theory into exposure to help readers creatively develop exposure exercises that address a wide range of client difficulties. As ACT is a process-based approach—more on that in the next section—we want to help therapists learn to flexibly use ACT across diagnostic categories and to think through exposures using the ACT psychological flexibility model. In some ways, this is the book I wish I’d had when I first started working with ACT-informed exposure over a decade ago.

From Protocols to Processes In the 1990s, a task force was created within the American Psychological Association for evaluating the evidence of psychological treatments (for more background, see APA Presidential Task Force on Evidence-Based Practice, 2006; Tolin, McKay, Forman, Klonskey, & Thombs, 2015). Their goal was the development of empirically supported treatments targeting specific diagnoses. This movement was wildly successful—especially with anxiety disorders. Therapists now have access to commercially available—and even free!—evidence-based treatment protocols written by experts in the field targeting specific anxiety disorder diagnoses. PE, mentioned earlier, is an exposure-based treatment protocol specifically for PTSD (Foa et al., 2007). The primary creator of PE, Edna Foa, PhD, has a separate treatment protocol for obsessive-compulsive disorder (e.g., Foa et al., 2012). For a period of time, protocols flourished as more and more manualized treatments became available. The victory lap for evidence-based treatments was short-lived, however. Almost immediately following the success of empirically supported treatments, some researchers questioned the focus on diagnosis-specific treatment protocols (Rosen & Davison, 2003). What about all the clients with comorbidities? Do we need to put them through multiple, individual protocols? If so, in what order should we do so? What about clients whose difficulties don’t cleanly fall within clear diagnostic categories? Another unfortunate side effect of the focus on protocols is the proliferation of approaches without regard to how these treatments work. Because protocols are typically tested as a package, they may have components that are not active in contributing to clinical outcomes (Tolin et al., 2015). For this reason, randomized controlled trials, considered the gold standard in clinical and medical research, have sometimes been derisively called “horse race studies.” These studies look at whether a treatment wins the race (i.e., is as effective or more effective than established treatments) but say nothing about the effectiveness of the individual components. A treatment may be shown to be effective in controlled trials even if we don’t know why it works or whether each intervention in a protocol adds to the whole. As an alternative to individual treatment protocols, critics have called for a focus on developing our understanding of evidence-based, transdiagnostic principles or processes of

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change (e.g., Hayes & Hofmann, 2021; Rosen & Davison, 2003). Instead of diagnosis-specific protocols, a process-based approach focuses on interventions that target evidencebased processes of change that help people across multiple domains. The idea is that clients will get more bang for their buck. Treatment might be briefer and more tailored to each individual than a protocol-driven approach would be. (As an aside, process-based approach is different than the notion of “common factors,” such as therapeutic alliance, that are found in every form of psychotherapy: e.g., Hofmann & Barlow, 2014; Wampold et al., 1997.) Something that drew me to ACT is its focus on process. Although ACT is not a “pure” process-based approach, it’s rooted in evidence-based processes of change based on the psychological flexibility model (Ong, Levin, & Twohig, 2020). Yes, there are plenty of controlled trials (“horse race studies”) on ACT—at this writing, over 850 and counting—but there’s also been an emphasis within the ACT community on understanding the mechanisms of change underlying ACT treatments. Research has found that components of the psychological flexibility model targeting core ACT processes of change can improve quality of life and symptoms in transdiagnostic samples of people seeking help (Levin, Hildebrandt, Lillis, & Hayes, 2012; Villatte et al., 2016). A large-scale study found that people with anxiety and a comorbid mood disorder improved more in ACT compared with traditional CBT for anxiety, which was more effective in people without a mood disorder (WolitzkyTaylor et al., 2012). Additionally, ACT processes are relevant in other non-ACT treatments for anxiety disorders such as traditional CBT (Arch, Wolitzky-Taylor, Eifert, & Craske, 2012) and cognitive therapy (Twohig, Whittal, Cox, & Gunter, 2010). Exposure, for example, appears to strengthen ACT processes whether delivered in an ACT context or not (B. L. Thompson, Twohig, & Luoma, 2021; Twohig et al., 2018). We also believe there are personal benefits for therapists learning ACT-informed exposure. For example, an ACT approach to exposure therapy may help to increase therapist flexibility (Luoma & Vilardaga, 2013). The ACT psychological flexibility model also offers an expanded vocabulary for talking about processes relevant to exposure for which there is not common language in other exposure models. For example, while the importance of emotional acceptance has been implicitly acknowledged in traditional approaches to exposure, newer acceptance-based treatments such as ACT make this process explicit, providing additional ways to talk with clients about how they relate to internal experiences (Moscovitch, Antony, & Swinson, 2009). In our focus on ACT-informed exposure, our goal is not to bury traditional exposure but to provide a bridge to ACT for clinicians experienced in older exposure models that focus on symptom reduction, allowing them to understand and integrate concepts such as acceptance and psychological flexibility in their exposure work with anxiety disorders.

A Process-Based Approach to Exposure for Anxiety Disorders7

Getting the Most Out of This Book Unlike PE, we have deliberately stopped short of providing an ACT-informed exposure treatment protocol. Readers who are completely new to exposure could benefit from learning a more straightforward exposure-based protocol first before jumping into this book. We have also tried to keep this book lean and focused on applications of ACT to exposure specifically. For example, the ACT literature is rich with many metaphors and experiential exercises to help people contact and practice psychological flexibility. In this book, we have deliberately limited focusing on specific ACT metaphors and experiential exercises so that these do not become calcified into a protocol. Instead, our focus is on exposure as an ACT experiential exercise. We see no difference between exposure and traditional ACT experiential exercises, as both allow clients to practice psychological flexibility. That doesn’t mean the use of ACT experiential exercises is not also valuable in ACT-informed exposure, as the authors of this book regularly draw from a variety of common ACT exercises in orienting clients to exposure work. There are plenty of other resources available that we recommend you use to supplement your work, such as general books on ACT metaphors and experiential exercises (e.g., Stoddard & Afari, 2014) and ones tailored for anxiety disorders (e.g., Eifert & Forsyth, 2005; Harris, 2021). As you embark on this process, we suggest you work through the exercises and begin creating your own ACT-informed exposure materials, customizing forms, worksheets, and treatment procedures that you can continue to revise and tweak over time. And we’ll guide you through the process of doing this in chapter 8. We want readers to think carefully about the materials they use and how clients respond to them. We are always changing and adapting our own ACT-informed exposure materials as we integrate new ideas and new research into our practices, and we encourage readers to do the same. Our hope is that you will come away from this book with a solid foundation on how psychological flexibility is strengthened through ACT-informed exposure and that this new understanding will enable you to address transdiagnostic clinical issues more effectively. With that, we’ll dive into chapter 2—in which we’ll walk through a brief history of the evolution of our understanding of how exposure works and why having a strong grasp of theory is helpful as a clinician. We will also begin to explore the unique insights ACT has to offer on why exposure works.

CHAPTER 2

A Brief History and Overview of Exposure

When I (Brian P) was a little boy, I stepped on a nest of bees while walking through the park on a cool fall afternoon. I had wandered off on my own, happily exploring the grassy fields and nearby pond. Prior to this, I had no real experience with stinging insects like bees or wasps. Suddenly out of nowhere, I felt an excruciating pain on my leg. I screamed. What was that? Then another sting and another scream. What is happening? I went into fullfledged panic mode. The stings kept coming, one after another—mysterious spikes of pain striking randomly all over my body. Luckily a friend’s parent came running over to help and began explaining what was happening: “You stepped on a nest of bees—insects that can sting you.” Crying and in shock, I was thankful that there was an adult who seemed to understand the situation. Physically, I was okay. I did, however, develop a phobia of bees and other stinging insects. In the summers that followed, going out in the backyard was a terrifying venture. I began scoping out all the places bees liked to visit—flowers, bushes, puddles of water, and so on. I avoided going outside in the summer. When I did go outside, I had difficulty enjoying myself, because I was on high alert. My parents did what any good parents might think to do—they coaxed me into going outside, reassuring me that I’d be okay, that I didn’t need to worry so much about being stung. Yes, it can happen, they offered, but it’s rare. The idea that we should face our fears is common sense. It’s found throughout our cultural messaging and is the theme of countless movies, books, and songs. My parents were on the right track; unfortunately, I remained terrified of being stung again, despite their best efforts. What was missing? Why wasn’t their encouragement enough to face my fears and overcome my phobia? This chapter is about the importance of theory and why the simple idea of “facing your fear” requires a lot more sophistication and nuance than it might seem. We will provide a rationale for the importance of theory when working with people who suffer from anxiety and will also provide a basic foundation in the history of exposure therapy, focusing on some of the main theories that have evolved to guide clinicians in helping people with anxiety problems.

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ACT-Informed Exposure for Anxiety

The Importance of Theory in Exposure Therapy Why is theory so important? To provide an in-depth response to this question, let’s consider the role of theory in exposure treatment. From a procedural perspective, exposure therapy, centered on basic ideas of helping people confront their fears, may appear to be unchanged over the decades since it was first discovered. A person with claustrophobia is encouraged to spend time in spaces that are difficult to exit, like an elevator. A person with social phobia is encouraged to make small talk with strangers. While this practice may seem simple and obvious (i.e., confront your fear), the nuances of exposure matter greatly. Where do you start? How do you know if it’s working? When are you done? Why does it work? Sometimes we receive phone calls from potential clients who tell us, “I’ve tried exposure—and it doesn’t work!” While not everyone benefits from exposure, these callers’ descriptions usually align with one of the following scenarios: • They tried exposure on their own once or twice and became overwhelmed. • They worked with a therapist who offered a vague, unstructured version of exposure that wasn’t grounded in theory. Perhaps the therapist used a “cookbook” approach or simply gave the client an exposure book and told to them to follow instructions without offering guidance. • They weren’t prepared for the potential of symptom relapse since they didn’t understand the theory behind how anxiety and exposure therapy works. Having a sound underlying theory is important in designing, implementing, and trouble-shooting a course of exposure treatment. Theory impacts moment-to-moment clinical decision-making and is the bedrock for successful treatment in many types of cognitivebehavioral therapy (Pilecki & McKay, 2013). Anxiety disorders are heterogenous (Stein et al., 2021; Lochner & Stein, 2003), with each individual client presenting with unique versions of anxiety. Theory is therefore critical when applying exposure therapy principles to the individual (Abramowitz, 2013; Abramowitz, Deacon, & Whiteside, 2019). While a cookbook approach based on a standardized treatment manual may be effective with many clients, without a grounding in theory, therapists may become stuck when clients are not progressing as expected or if there is high complexity to the problem. When unusual situations arise, as they often do, it’s helpful to have a model for guidance in making adaptations to the standard treatment course. The final reason we are highlighting the importance of theory comes from a more birds-eye view of the evidence base for exposure therapy. Overall, about 49.5 percent of clients with anxiety disorders show a response to exposure therapy (Loerinc et al., 2015). There are several reasons for this. First, not everyone responds to treatment, and some

A Brief History and Overview of Exposure11

clients experience only partial remission of their symptoms (Loerinc et al., 2015). Some proportion of these non-responders may be due to clinicians who lack the necessary skills and experience required to effectively deliver exposure. Second, some clients drop out of treatment (McGuire et al., 2015; Öst, Havnen, Hansen, & Kvale, 2015). Third, some clients experience a resurgence of symptoms after treatment has ended (Springer, Levy, & Tolin, 2018). Taken together, these findings suggest that while exposure is an effective treatment, there is much room for growth in how exposure is delivered, highlighting the need to help clinicians improve how they deliver exposure therapy through improving and refining their understanding of theory. What, then, is the current theory underlying exposure therapy? Newer students of exposure are often surprised to learn that there is no single unifying theory. Researchers have repeatedly developed and updated multiple theoretical models across the history of exposure as our understanding of learning, neuroscience, memory, and anxiety has advanced. The authors of this book have devoted a significant amount of time to understanding exposure in part because of our fascination with the constantly evolving science and theory in the ongoing improvement of anxiety treatment. Thankfully, when I was little, I was fortunate enough to meet with a child psychologist trained in exposure therapy and grounded in theory who helped me overcome my fear of bees and restore my ability to adventure out into the hot, buggy New Jersey summers. It took someone with the skill and training to translate the general idea of “facing your fear” encouraged by my parents into a systematic set of instructions and homework assignments that achieved the desired outcome.

Classical Conditioning The roots of exposure therapy span several decades to the beginning of behaviorism and early psychotherapy. While it’s beyond the scope of this chapter to present an exhaustive history of exposure therapy, it can be helpful to establish some key points of that history to better understand how exposure has evolved over time. It can also help with functionally understanding how fears are conditioned and reinforced in each client, which would provide the conceptual basis for a treatment plan. Much of what we know as exposure therapy is based on learning theory. One of the early pillars of learning theory is classical conditioning (a.k.a. respondent conditioning). Classical conditioning accounts for many of the ways that humans and other animals learn. If you’ve taken a Psych 101 class, you might know classical conditioning as “Pavlovian conditioning” due to its founder, Ivan Pavlov. In studying digestive processes in dogs, Pavlov observed that dogs would begin salivating when they perceived the presence of meat and

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that this occurred even in the response to the mere sight of the experimenter the dogs associated with bringing food (e.g., Kazdin, 1978). Through a series of studies, Pavlov found that if meat were paired with a neutral stimulus, such as a bell or tone, the dogs would begin salivating at the presence of the neutral stimulus even when no meat was present. These studies established several key concepts that are important in understanding exposure theory. First, the unconditioned stimulus (US) is any stimulus that leads to an unconditioned response (UR) of an organism. For example, the sight of meat (US) produces salivation (UR) in an animal. No learning is required so far. Next, during conditioning, a stimulus that was previously neutral or unrelated is paired with the US until it becomes the conditioned stimulus (CS). Pairing the unconditioned stimulus with the conditioned stimulus is called reinforcement, as it strengthens the relationship between the two stimuli. For example, the sound of a tone (CS) is paired with the sight of meat (US). After sufficient pairing, the relationship between the CS and US strengthens to the degree that the presence of the CS alone produces a conditioned response (CR) that is often similar to the UR. The relationship between the CS and CR reflects new learning. In Pavlov’s work, after pairing the presence of meat with a tone through several iterations, the animal would begin salivating in response to the CS. As another example of classical conditioning, we’ll return to our earlier example of my fear of bees (see figure 1). Before I stepped on a nest and got stung, bees were neutral stimuli and didn’t evoke a strong emotional reaction. However, pain (US) was hard-wired into my body to produce aversion and fear (UR) in response to pain. When I was stung, bees (a neutral stimulus) became paired with the sensation of pain (US), triggering fear. The UR of fear from pain became paired with bees (CS). I began to fear pain at the sight of bees. However, these associations didn’t begin and end with the sight of bees. In the days and weeks following this incident, I began associating bees, yellow jackets, and other similarlooking creatures (CS) with fear (CR) as potential sources of pain. This is an example of another learning theory concept called “generalization,” which refers to the ability of learning to spread from one stimulus to other similar stimuli (e.g., Ramnerö & Törneke, 2008). My bee phobia generalized further to insects without stingers, and I began to experience fear (CR) in the presence of even harmless insects such as flies, moths, and even butterflies. Moreover, the CR generalized in terms of location, spreading from the park where I was first stung to anyplace where these insects may congregate, such as flowers and bushes.

A Brief History and Overview of Exposure13

Before Conditioning Unconditioned Stimulus (pain)

Unconditioned Response (fear)

Neutral Stimulus (bees)

No Response

During Conditioning Unconditioned Stimulus (pain)

Neutral Stimulus (bees)

Unconditioned Response (fear)

After Conditioning Conditioned Stimulus (bees)

Conditioned Response (fear)

Although Pavlov’s work is associated with classical conditioning, he did not experiment with fear, as in the bee example above. Classical conditioning theory was put into practice toward understanding and treating fear by early behaviorists such as Mary Cover Jones and John B. Watson. To offer a simplified history: Watson took Pavlov’s work on conditioning and demonstrated how it could be applied to fear (e.g., Kazdin, 1978). In 1920, Watson trained an eleven-month-old infant called “Little Albert” to experience fear at the sight of a white rat by banging a metal rod to make a loud scary noise (US) in the presence of the white rat (CS). (This study would be unethical today.) After training, Little Albert began to experience fear (CR) at the sight of the white rat (CS). Through subsequent studies, Watson created CS fear associations toward a rabbit, a dog, a fur coat, cotton wool, and a Father Christmas mask (more examples of generalization). In sum, Watson demonstrated how to train fear responses through classical conditioning. Unfortunately, Little Albert left Watson’s experiment before Watson had the opportunity to extinguish the fear response. The task of demonstrating that fear could be extinguished was left to Mary Cover Jones three years later (Kazdin, 1978). Influenced by Watson’s work, Jones worked to help “Little Peter,” a thirty-four-month-old child who had developed a fear of several stimuli, including rabbits, rats, fur coats, cotton, and wool. As

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Peter demonstrated the greatest fear response in the presence of the rabbit, Jones experimented with several methods to untrain Peter’s fear of rabbits. The most effective of them involved direct conditioning. By pairing the rabbit with food that Peter liked, and then gradually bringing the rabbit closer to Peter while he was enjoying some delicious food, Jones was able to decondition the fear association. After Peter’s fear response diminished in the presence of the rabbit, Jones further found that Peter no longer experienced fear in the presence of the other similar objects such as a white rat and fur coat (i.e., generalization). Another behavioral principle is that of extinction learning. Extinction of the conditioned response is said to occur when the CS is repeatedly presented without the US. For example, when bees were present on many occasions and did not sting me, I learned that bees no longer signaled an impending presence of pain, as they once had. This may have led to a diminished fear response (CR) in the presence of bees (CS). Here, the association between bees and pain is said to be extinguished. The term “extinction,” however, may be a bit misleading. Although earlier theorists viewed extinction as a process of unlearning (e.g., Rescorla & Wagner, 1972), we now consider extinction learning as the development of new associations. The relationship between the CS and CR is not extinguished in the way a candle flame is extinguished. Associations that are made in the brain are not simply erased. For example, one may have learned that the sound of a tone signals food after repeatedly being presented food with the tone. When the food is no longer paired with the tone, one learns that, perhaps, the sound of the tone does not guarantee that food will be offered after all. However, one’s mouth may still salivate due to prior associations between the tone and food being presented. When one responds in a way that reflects prior learning, it may be a sign of spontaneous recovery (Rescorla, 2004). This is an important concept in exposure therapy in helping to understand why symptoms may relapse after successful treatment. By providing experiences that train extinction, we can help weaken the association between CS and the UR (anxiety or fear) in our clients. In other words, when my younger self put his face close to a bush to smell flowers and did not experience stinging pain, he learned standing near flowers was generally safe. This learning was strengthened the more he spent time outside without being stung. In the 1950s, Joseph Wolpe used principles of classical conditioning to inform a therapeutic technique to treat fear called systematic desensitization. Systematic desensitization differs from exposure therapy in that it relies on the induction of a physiological state incompatible with anxiety, such as relaxation (Wolpe, 1952, 1954). While his treatment was eventually abandoned in favor of modern exposure techniques, he did develop the concept of a fear hierarchy (developing a list of progressively challenging exercises) and assigning quantitative values to clients’ experiences of anxiety—commonly called the “subjective units of discomfort scale” (Wolpe 1969, 1990) These concepts will be described in more detail in later chapters.

A Brief History and Overview of Exposure15

In conclusion, classical conditioning theory is foundational to exposure theory. However, as important as classical conditioning is, it’s insufficient by itself to explain all the ways in which humans can learn new things. Why is that? We will answer this question as we explore the second pillar of learning: operant conditioning.

Operant Conditioning Classical conditioning involves a more passive form of learning, whereby an organism makes associations through the pairing of stimuli. By contrast, operant conditioning, first studied by Edward L. Thorndike (1898) and expanded upon by B. F. Skinner (1965, 1974), refers to the feedback process where we associate a behavior with particular consequences. In operant conditioning, there are two main categories of consequences that can occur after any given behavior (see table 2.1). 1. Similar to the notion in classical conditioning of reinforcement that involves strengthening an association between two stimuli, reinforcement in operant conditioning refers to the strengthening of a response based on its consequences. Reinforcers are usually pleasurable, attractive, or desirable things. The smile that we get when playing with a baby warms our heart and makes us more interested in playing games that are otherwise boring to adults. The refilling of my bank account every two weeks increases the likelihood I’ll wake up early and go to work each day. There are two types of reinforcement in operant conditioning: i. Positive reinforcement refers to the addition of a consequence that serves to increase the likelihood of a behavior occurring again in the future. Money or compliments for completing a task are examples of positive reinforcement. ii. Negative reinforcement refers to the removal of a consequence that serves to increase the likelihood of a behavior occurring again in the future. For example, the act of hitting the snooze button results in the temporary removal of the jarring, unpleasant alarm tone. In the context of operant conditioning, then, “positive” means the addition of something, and “negative” means the removal of something. The terms “positive” and “negative” are often misused by lay people. Note that the word “negative” in negative reinforcement does not mean something aversive. For example, many lay people say “negative reinforcement” when they mean punishment, which we discuss in the next section. 2. If “reinforcement” means we are more likely to engage in a behavior in the future, “punishment” means we are less likely to engage in a behavior in the future. As reinforcers increase the occurrence of behavior, punishment decreases behavior.

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Similar to reinforcement, the words “positive” and “negative,” in this context, refer to the addition or removal of a consequence, respectively. i. “Positive punishment” refers to the addition of a consequence that serves to decrease the likelihood of a behavior occurring again in the future. Receiving a ticket for speeding is one example of positive punishment. ii. “Negative punishment” refers to the removal of a consequence that serves to decrease the likelihood of a behavior occurring again in the future. To refer back to the example above, if you receive several speeding tickets, you may have your driver’s license suspended. Having your freedom to drive taken away would be a form of negative punishment.

Table 2.1. Positive

Negative

Result

Reinforcement

Addition of consequence

Removal of consequence

Increase in behavior

Punishment

Addition of consequence

Removal of consequence

Decrease in behavior

Outside of a lab setting, determining what is reinforcement or punishment, and whether it’s positive or negative, can become confusing—especially among humans, whose language ability can alter how these concepts are experienced. Public praise may be reinforcing for someone who enjoys the attention or punishing for someone who feels embarrassed at being singled out. As we’ll discuss in more detail in chapter 11, culture can influence how a stimulus, such as praise, can be experienced as reinforcing for a child from one culture and punishing for a child from another (Fong, Catagnus, Brodhead, Quigley, & Field, 2016). One person may increase the behavior that earned praise (positive reinforcement), and the second person may decrease the behavior that earned praise (positive punishment). Humans are complicated! Despite these fuzzy boundaries, awareness of the principles of operant conditioning is helpful in understanding how people develop problems with anxiety and how these problems are maintained and exacerbated over time.

How Avoidance Perpetuates Anxiety Let’s now talk about the role of avoidance and how it relates to anxiety. If you’re fearful of bees, what should you do? Common sense tells you that you should simply avoid all bees. No bees, no anxiety. Easy! Here the behavior of avoidance is reinforced via negative

A Brief History and Overview of Exposure17

reinforcement: I stay away from outdoor areas where bees are likely to reside, I feel less anxious. Admittedly, many people with a specific phobia can do a pretty good job of avoiding their feared stimuli by not going out into nature and remaining indoors as much as possible. This is one reason why people with specific phobias are less likely to seek treatment (Eaton, Bienvenu, & Miloyan, 2018)—they may be able to pull off avoidance of what they fear without giving up too much. However, there are major problems with this strategy. First, it is near impossible to completely avoid bees without avoiding the outside. Unless you live in Antarctica, you’ll encounter bees. Moreover, as my younger self learned, avoidance of one stimulus (e.g., bees) can generalize to other stimuli, such as non-stinging insects (e.g., flies) and places one predicts bees may be found (e.g., flowers and bushes). Avoiding bees can also have a human cost: giving up on activities that are part of what makes life worth living, like going on a camping trip, having a backyard BBQ with friends, or hiking through a forest. What’s more, these forms of avoidance can result in increasingly constrictive living than just having to avoid the outdoors. While it may be possible to mostly avoid bees by avoiding the outside, it is much harder to avoid other triggers of anxiety, such as unfamiliar people, driving, germs, or closed spaces, and still live a fulfilling life. As an operant, avoidance strengthens the conditioned relationship between the avoided stimuli and anxiety. For little Brian P, the more he avoided the backyard and stayed indoors (negative reinforcement, via the avoidance of bees), the more dangerous bees seemed to him. However, after being guided by his therapist to spend some quality time with a few of these marvelous, winged arthropods (positive reinforcement), the boy realized that they were actually kind of cool. Ultimately, he even began to develop a hobby around bug collecting, reading about bugs, and going on bug hunts. Subsequent models of exposure incorporated both classical and operant conditioning. The next session will describe several theories that have been used to explain exposure. While it’s beyond the scope of this chapter to explain each theory and its strengths and weaknesses, we hope this will give you a flavor of the depth of work in this area.

Integrating Classical and Operant Conditioning An early model that integrated classical and operant conditioning was Mowrer’s (1960) two-factor learning theory of fear acquisition and maintenance. According to the two-factor learning theory, fear associations are classically conditioned and then, through operant conditioning, avoidance behaviors are maintained through the reduction of anxiety (negative reinforcement). Although influential, one shortcoming of two-factor learning theory is that fears often develop in people without any particular incident that led to their formation via classical conditioning (Rachman, 1976).

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A second influential learning theory that incorporated both classical and operant conditioning, Lang’s bioinformational theory, focused on emotional memories or imagery associated with fear (Lang, 1977, 1979). The theory categorized emotional imagery according to three types of information: stimulus elements, behavioral responses, and meaning or interpretation of both of these (Lang, 1977, 1979). While this model was also influential in bringing attention to emotional imagery as salient fear-inducing stimuli, subsequent researchers considered it a major shortcoming that this model did not detail how the process of activating these fear structures was associated with therapeutic change in exposure therapy (Foa, Huppert, & Cahill, 2006). Again, this is not an exhaustive account of the strengths and weaknesses of this model, but rather just a glimpse into the complexity involved in understanding how exposure works in treating anxiety. Despite these shortcomings, researchers were able to build on Lang’s work in developing the theory that came to dominate exposure therapy, which focuses on what is called “emotional processing.”

Emotional Processing Theory and Habituation The concept of emotional processing has been tricky to define with specificity. Earlier theories fell short in clarifying how fear associations were acquired and treated through exposure therapy. Rachman (1980, p. 51) offered an early definition of emotional processing of fear as “a process whereby emotional disturbances are absorbed, and decline to the extent that other experiences and behaviour can proceed without disruption.” However, Rachman’s definition of emotional processing lacked depth in its theoretical explanation and was subject to circular reasoning. In Foa and Kozak’s (1986) influential account of emotional processing theory (EPT) and the mechanisms of change in exposure, they expand upon Rachman’s work and offer a more comprehensive and unifying theory of exposure. An emphasis in EPT is on habituation, or decreases in fear as a result of exposure, as a signal of new learning. In creating a comprehensive theory, EPT was to dominate exposure therapy for decades, up until the present. For many exposure therapists trained today, EPT is exposure therapy. According to EPT, improvement in fear response via exposure therapy involves (A) the weakening of old fear-based associations, as well as (B) the development of new informational structures. In other words, a combination of altering existing learning (e.g., changing an association between CS and fear-based CR) and learning something new (e.g., learning a new association between CS and non-fear-based CR). This theory informs necessary conditions for exposure to be effective. First, exposure exercises must sufficiently activate the underlying fear structure stored in memory, which is comprised of information about the fear stimulus, response to the stimulus (CR), and meaning derived from the experience (i.e., this part comes from Lang’s bioinformational theory). Second, new information must be integrated into the existing fear network to weaken it. For instance, take the absence of a

A Brief History and Overview of Exposure19

feared outcome or a decrease in physiological reactivity associated with a feared stimulus: these are incompatible with the idea that the stimulus in question is dangerous. For example, as my younger self spent more time smelling flowers, he learned that bees weren’t going to immediately attack him anytime he was near a bush or flowerbed! Change in meaning related to fear stimuli is one mechanism by which older fear structures are weakened and thereby new learning is strengthened. A key indicator that emotional processing is occurring successfully (i.e., something new has been learned) is the process of habituation. Habituation refers to a decrease in fear when in contact with the conditioned stimulus (Foa & Kozak, 1986). EPT emphasizes two forms of habituation in treatment. In-session habituation refers to habituation that occurs during an exposure exercise (e.g., distress begins high and then decreases), and betweensession habituation refers to habituation that occurs across exposure exercises (e.g., less distress at the beginning of the next exposure exercises compared to the preceding ones). Experiencing a reduction in fear when in contact with the CS may also disconfirm beliefs that maintain avoidance (e.g., I need to stay away from bees, because they are fraught with danger), because the belief is incompatible with the fear structure. According to EPT, repeated trials of confronting a feared stimulus will result in a decrease of a fear response through habituation. EPT has many strengths. First, there is a strong body of empirical evidence for EPT and decades of success using this theory to guide exposure treatment (Abramowitz, 2006). In other words, it works! Second, for decades, it has been the most comprehensive theoretical model for accounting for positive change in fear reduction associated with exposure therapy (Moscovitch et al., 2009). In other words, it has the broadest explanatory range in understanding all the ways in which fear improves with exposure therapy. However, many exposure researchers are moving away from EPT.

Our Current Understanding of Exposure While EPT has been the dominant theory in exposure therapy for several decades, and modifications to EPT have incorporated subsequent research findings (Foa & McNally, 1996; Foa, Huppert, & Cahill, 2006), newer research has not supported key elements of the theory despite attempts to update it. Several areas of research have emerged to challenge fundamental elements of EPT. The biggest blow to EPT is that habituation appears to be a poor predictor of learning. People appear to benefit from exposure whether they demonstrate habituation or not (e.g., Baker et al., 2010). This has been partially acknowledged in EPT-related research. For example, research on prolonged exposure for PTSD, which is based on EPT, has found that within-session habituation—decreases in anxiety during exposure—does not predict

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whether participants get better through exposure (Jaycox et al., 1998; van Minnen & Foa, 2006). Although some EPT researchers have maintained that between-session habituation (i.e., decreases in fear across exposure sessions) remains a useful prediction of treatment outcome (Jaycox, Foa, & Morral, 1998; van Minnen & Hagenaars, 2002), newer research has challenged even that assertion (see Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). Research on inhibitory learning theory (ITL), a newer account of exposure, has demonstrated that people show improvement from exposure therapy even if they don’t exhibit decreases in fear during and across exposures (Baker et al., 2010; Kircanski et al., 2012) Studies of ITL have demonstrated good outcomes while keeping fear levels elevated throughout exposure, which undermines one of the core tenants of EPT—the importance of activation and reduction of the fear response during exposure (Craske, Treanor, et al., 2014). As mentioned earlier, research on extinction learning suggests that older associations are not weakened or eliminated but that newer (non-threat) associations learned through exposure compete with the older threat-based associations (Rescorla, 2001; Bouton, 2002). In other words, there is no such thing as unlearning, as had been theorized in EPT and by prior exposure theories. Instead, newer exposure research, such as ITL, suggests that extinction promotes new learning which helps to inhibit the old, fear-based associations (Bouton, 2002; Craske, Treanor, et al., 2014). Another critique of EPT comes from challenging its core concept of fear structures. McNally (2007) argued that the notion of fear structures reflects a restatement of the problem it is meant to explain (e.g., people who respond fearfully to bodily sensations have fear structures that indicate those sensations are dangerous). Additionally, the concept of a fear network does not appear to distinguish people with anxiety disorders from people without them. In a study in which samples of people with panic disorder and people without an anxiety disorder were shown pairs of words associated with anxiety (e.g., “breathless— suffocate”), there was no difference in how the two samples responded to the threat associations (Schniering & Rapee, 1997), which does not support the notion that people with anxiety disorders have fear structures that represent excessive responses to fear-related stimuli. In sum, despite attempts by proponents of EPT to accommodate emerging research on exposure, some argue that EPT should be retired (e.g., Craske et al., 2008). EPT’s Achilles’ heel is its emphasis on habituation. While newer research suggests reduction in fear during exposure offers some indication of learning when distinguished from reductions in fear during engagement avoidance behaviors (Benito et al., 2018), it does not appear to warrant the emphasis EPT places on it. To accommodate new exposure research, any theory we rely on in conducting exposure must account for how people improve from exposure therapy even if they don’t exhibit decreases in fear during and across exposure (Baker et al., 2010; Kircanski et al., 2012).

A Brief History and Overview of Exposure21

Acceptance and commitment therapy (ACT), with its emphasis on strengthening psychological flexibility over symptom reduction, offers one model with which to understand newer research on exposure. As we noted in chapter 1, ACT-informed exposure has been studied against and performs as well as exposure therapy based on EPT (e.g., Arch, Eifert, et al., 2012; Twohig et al., 2018). The psychological flexibility model underlying ACT provides an expanded vocabulary for describing and understanding processes relevant in exposure therapy. In the subsequent chapters, we’ll provide a foundation in ACT theory, make a case for an ACT approach to exposure, and lead you through how to set up and guide clients through ACT-informed exposure.

Conclusion In summary, exposure therapy has a long history, spanning decades, from its roots in classical and operant conditioning. Exposure therapy based in emotional processing theory has dominated the field in recent decades (Foa & Kozak, 1986); however, recent research has challenged this theory—particularly its emphasis on habituation or fear reduction—and created the need for a model that better fits the subsequent data that some individuals benefit from exposure therapy even when they don’t show evidence of habituation. ACTinformed exposure, with its emphasis on helping clients learn to strengthen psychological flexibility, is one model that’s consistent with new research on exposure. Because of the importance of theory in exposure theory, we will focus our next chapter on giving you a solid grounding in ACT theory before we move into the practicalities of ACT-informed exposure.

CHAPTER 3

An Acceptance and Commitment Therapy Primer

Although the aim of this book is to make ACT-informed exposure practical and accessible no matter your experience with ACT, having some familiarity with some of the foundational theories supporting ACT is important in developing flexibility when using ACTinformed exposure. To place ACT in a historical context, ACT was developed by people who greatly respected Skinner’s brand of behaviorism but believed it was important to bring more clarity to the philosophical assumptions of the behavior analytic approach. Additionally, they felt that Skinner’s efforts in developing a behaviorist understanding of thinking and language fell short. Consequently, while both ACT and exposure are rooted in behaviorism with a shared language based in classical and operant conditioning (see chapter 2), ACT draws from a newer behavioral understanding of language and cognition called relational frame theory (RFT) and is grounded in a philosophy of science called functional contextualism (FC). While it’s possible to learn and practice ACT without knowing these more technical or philosophical aspects, we believe it’s useful to have some grounding in these topics to further clarify how ACT differs from traditional approaches to exposure therapy. We’ll note here that the main professional organization behind ACT is called the Association for Contextual Behavioral Science (ACBS). It’s not called the Association for ACT. ACT is simply one iteration of a treatment based on contextual behavioral science. Contextual behavioral science is a science of human behavior that includes FC, RFT, and evolutionary science with the goal of improving the human condition. Therefore, contextual behavioral science is broader than and transcends ACT. One additional goal in providing a grounding in FC and RFT is to help you look beyond ACT toward a contextual approach to exposure therapy—an approach that differs in function to traditional exposure therapy even if it appears to have some similarity in form. A contextual approach to exposure builds upon traditional behavioral theory as outlined in chapter 2 and offers, among other things, a set of philosophical assumptions, a guide for analyses of theorized processes, and an understanding of human health and functioning.

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ACT-Informed Exposure for Anxiety

In our experience, a deeper understanding of FC and RFT allows us to use ACTinformed exposure more flexibly with clients and to more effectively trouble-shoot problems. Much of the nomenclature found in ACT, concepts such as “willingness,” reflect what are called “middle-level terms,” which means they are not as precise or technical as more behavioral language, such as the language of classical and operant conditioning from the previous chapter and the terms we’ll be introducing in this chapter. Understanding the more technical aspects of ACT theory helps bring more precision and fluency to ACTinformed exposure. Our goal is to provide a foundation in ACT theory and, building on the prior chapter, to demonstrate what it has to offer our evolving understanding of exposure.

A Brief History of ACT Before diving into some of the more technical language of FC and RFT, let’s start with a brief history of ACT. In the early 2000s, a cresting wave of like-minded treatments created a sea change within CBT. Along with ACT, these treatments included dialectical behavior therapy (DBT; Linehan, 1993), functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991), and mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002). This confluence of evidence-based mindfulness and acceptance-based treatments came to be known as the “third wave” of cognitive behavioral therapy, first coined by Hayes (2004). In this context, the “first wave” is behaviorism (see chapter 2), and the “second wave” is cognitive therapy, spearheaded by innovators such as Beck (1979) and Ellis (1957). You’ll note that “CBT” is not considered a wave, as it’s more of an umbrella term that incorporates elements from the first two waves (e.g., Hayes, Villatte, Levin, & Hildebrandt, 2011). In CBT, some approaches emphasize the “B,” and some emphasize the “C,” making CBT more conceptually heterogeneous than the casual observer might assume. Although they developed relatively independently of one another, and not everyone agrees there’s been a third wave (e.g., David & Hofmann, 2013), there are few conceptual commonalities among these treatments. For one, third-wave approaches emphasize function rather than form in influencing human behavior. For example, third-wave treatments focus more on altering how people relate to their internal experiences (function) rather than changing what those internal experiences are (form). In cognitive therapy (second wave), cognitive therapists might teach clients to replace maladaptive thoughts with adaptive thoughts. Exposure based on emotional-processing theory (EPT) is second wave in its focus on altering fear structures (e.g., thoughts such as If I panic, I may pass out and die!) through “corrective information” (Foa & Kozak, 1986). That is, exposure based on EPT aims to replace maladaptive thoughts with more accurate thoughts. In contrast to the second-wave examples above, third-wave treatments are less focused on trying to change the content of thinking (i.e., the actual thoughts);

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instead, they focus on helping clients learn more flexible ways of responding to thoughts. In the third-wave treatment MBCT, for example, people engage in meditation and mindfulness practice as a method for recognizing unhelpful thoughts and feelings without trying to change these internal experiences (Segal et al., 2002). In these ways, third-wave approaches are more metacognitive in that they focus on awareness of the processes of thinking instead of changing the content of thinking. As third-wave treatments are more sensitive to context and function, they tend to emphasize the development of broad, flexible repertoires of adaptive behaviors over the targeting of narrowly defined problems based on the DSM. In other words, they are more a recipe for healthy living rather than a cure for a disease. This focus on health over disease represents a second commonality among third-wave treatments: a shift away from a more mechanistic view of human behavior aimed at reducing human experiences into discrete elements based on a disease model. The biomedical model, which attempts to reduce behavioral health diagnoses to biologically based disorders of the brain (e.g., Deacon, 2013), and on which the DSM is based, is one widely used example of a mechanistic approach. Third-wave approaches reject the notion that the human experience can be neatly dissected into mechanistic parts. Instead, they reflect a more contextual understanding of human experience that emphasizes broad processes of change that appear important in healthy functioning. As an example, Hayes and Hofmann (2021) compare mechanistic and third-wave approaches to anxiety. A therapist with a mechanistic perspective may view anxiety as a negative emotion due to the form, frequency, and intensity of the emotion. A third-wave therapist is interested in how anxiety functions in the contexts in which it occurs. Anxiety may function positively or negatively within different situations depending on its form, frequency, and intensity. With an emphasis on context, third-wave approaches have brought about a shift in philosophical assumptions related to the nature of assessment and treatment of behavioral health problems (see Hayes & Hofmann, 2017). The section on FC in this chapter will unpack this shift in philosophical assumptions in more detail, but we will say here that this philosophical shift resulted in a movement away from a disease model of mental illness that is oriented around diagnoses. Compared to second-wave approaches, where there was a focus on discrete treatment protocols targeting DSM diagnoses, third-wave approaches focus more on evidence-based procedures linked to evidence-based processes that enhance adaptive human functioning. In these ways, we might consider third-wave treatments such as ACT as more process-based treatments in their focus on broader transdiagnostic processes of change (e.g., Hayes & Hofmann, 2017, 2021). Having introduced how ACT and other third-wave treatments focus on changing the function of internal experiences without trying to change the content or form of them, in the next section, we provide an introduction to the philosophy of science that underlies ACT: functional contextualism.

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Functional Contextualism and Contextual Behavioral Science Anthropomorphized lab rats are a common subject in cartoon strips where they comment about stereotypical lab tasks such as completing mazes or the consequences of pulling levers. One funny take in some of these strips is that the lab rats believe they are influencing the behavior of the scientist, rather than vice versa. We’ve included our version here, which Joanne drew.

From a functional contextualist perspective (Hayes, 1993), whether the experimenter is influencing the behavior of the rat or the rat is influencing the behavior of the experimenter are equally valid perspectives. We’ll explain how and why after we’ve provided a brief introduction below to functional contextualism (FC), the philosophy of science in which ACT is grounded. As a philosophy of science, FC, whose goal is the prediction and influence of human behavior, serves as the foundation for ACT and contextual behavioral science. All science is based on philosophical assumptions, and FC holds its own set of assumptions that distinguish it from other approaches to science. If you’ve taken a research methods course, one

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philosophical assumption core to the scientific method is Karl Popper’s (1934) notion that scientific hypotheses should be falsifiable (i.e., that they can be proven false). If a hypothesis cannot be tested to see if it is false, it’s not a good hypothesis for scientific study. As a result, well-designed scientific studies are set up to test not that the researcher’s hypotheses are true, but that they are not false. A philosophy of science helps to guide how we frame scientific questions and how we may approach them. FC is an approach to contextualistic thinking originally fathered by William James’s pragmatism (Hayes, 1993). Contextualism is holistic in that it emphasizes the whole event, where every behavior is an act-in-context. “Context” here refers to stimuli, including both historical and current variables external to the behavior, that influence behavior (a.k.a. response). The functional part of functional contextualism adds a focus on the prediction and influence of behavior. In FC, depending on the goals of their analyses, clinicians and researchers may include thoughts, feelings, bodily sensations, external stimuli, learning history, and even evolution as part of how they define context. Context may be widened or narrowed based on what allows for prediction and influence of behavior. In other words, you may define the context in a number of ways depending on your goals of analysis. For these reasons, FC is pragmatic in that it’s defined by whether it achieved the goal of prediction and influence. Consequently, there is no objective truth in FC, because it’s all relative to one’s aims. To return to our comic panel in the beginning of this section, whether the researcher influences the behavior of the lab rats or the rats influence the behavior of the researchers depends on how the context is defined by the person interested in influencing behavior. Each framing is equally valid, depending on one’s analytic goals. If our goal is to predict and influence the behavior of the experimenter (e.g., cause him to nod in approval), then it makes pragmatic sense to focus on the action of the rat pulling on the lever. According to FC, the context we’re interested in can be big or small in how we define it: it may be a single moment in an individual’s life, or it may reflect the evolution of a civilization unfolding over hundreds of years. The term “shaping,” the emergence of more complex behaviors over time, is an example of how it can be impossible to isolate behaviors into discrete units. Before we learn to write, we must first learn the letters of the alphabet, then how to write the individual letters of the alphabet, then how to organize these letters into words, then how to organize these words into sentences, and so on. Each of these learning experiences gradually increases our ability to eventually write about complex ideas, but often, in retrospect, we cannot easily segment complex behaviors into discrete steps. As Skinner (1965) noted, operant conditioning (see chapter 2) “shapes behavior as a sculptor shapes a lump of clay” in that “we cannot find a point at which this [the behavior] suddenly appears” (p. 91). From a functional contextualist perspective, we cannot easily reduce learning into distinct steps, as the steps all overlap and inform each other, but we can determine where our analyses begin and end based on our goals.

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In understanding and defining FC, it may be useful to compare it against what it’s not. Earlier in the chapter, we used the word “mechanism” to describe attempts to reduce complex behaviors into discrete parts. Because the word “mechanistic” is used in lay language and is more easily misunderstood as a result, a more precise term for this philosophy of science is “elemental realism” (Hayes et al., 2012). Elemental realism is a common worldview and popular in psychology. As noted earlier, the biomedical model, which has dominated American healthcare, attempts to reduce human complexity into parts such as genes, neurotransmitters, or neuroanatomy (e.g., Deacon, 2013). Many therapists take an elemental realist approach when they challenge client thoughts and attempt to get clients to think in ways that correspond to some notion of “reality” (Hayes et al., 2012). Any therapist experienced in working with OCD knows this approach is rarely successful, as many people with OCD struggle with obsessions that they don’t necessarily believe are 100 percent accurate or likely to happen. FC is not mentalistic, either, in which mental constructs are considered causes of behavior (e.g., Hayes & Brownstein, 1986). Mentalism is common in our way of speaking. For example, clients often come to treatment looking for help in developing “self-esteem” or “confidence,” because they believe these mental constructs will allow them to pursue the lives they want. Regarding anxiety-related problems, from an FC perspective, fear does not cause behavior. One person may choose not to ride a particularly high roller coaster in part due to the presence of fear (e.g., That looks too scary!), whereas the presence of fear may influence another person’s decision to ride that particular coaster (e.g., Wow—that one looks exciting!). In neither instance, however, was fear the sole cause of behavior, as each individual’s learning history, biological makeup, and a variety of other variables were involved. Additionally, as most people (nearly 94 percent!) experience unwanted, intrusive thoughts, images, and urges, we cannot say that uncomfortable thoughts alone cause anxiety (e.g., Radomsky et al., 2014). Rather, it appears that how people interact with their thoughts and other variables have a greater impact on whether they develop an anxiety-related problem than the content of the thoughts themselves. This is the value of a contextual approach in moving beyond simplistic reductionism toward broader analyses so that we can more effectively predict and influence behavior. This aspect can be tricky for people new to ACT, who are used to thinking in terms of elemental realism and, particularly, mentalism. For example, people new to ACT sometimes misunderstand the notion of “values” by taking a mentalistic view of it. In ACT, “values” refer to qualities that are experienced through behavior—they are not “things” that one discovers. There are no “authentic values” or structures in the mind that we can point to and say, “There’s a value!” We’ll talk more about values in subsequent chapters. Some readers may be saying to themselves, Do I really need to understand an entire philosophy of science just to learn ACT? I haven’t had to do this for other evidence-based treatments. I just want to learn how to do ACT-informed exposure! We feel your pain. We don’t expect readers to be experts in FC by the end of this chapter.

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That said, here’s an example of how some familiarity with FC can be helpful for the ACT-informed exposure therapist in increasing therapist flexibility. When clients come to treatment with anxiety-related fears that seem particularly unlikely to come true, the urge to challenge the client or get caught up in a debate about the veracity of these fears can be seductive. Even though nearly all therapists learn that debating clients is rarely productive, it can be hard to resist taking the bait. Since FC doesn’t engage in debates about truth or falsity of ideas, the ACT therapist is in a better position to sidestep debates about the truth of client’s thoughts. Rather than disagreeing with a client about whether a particular thought is right or wrong, a functional contextualist therapist may ask, “When you live your life as if that thought were true, what happens?” This form of “ACT judo” allows the therapist to sidestep “truth” and focus on the consequences of a client’s particular pattern of behavior. As much as possible, the therapist tries to sidestep the evaluation of content and instead focus on the function of it: is it useful to the client or not in context? We will go into more detail about how to work through these strategies with clients in the next chapter. Another benefit of having some grounding in FC is that it provides a pragmatic framework for influencing client behavior. Clients often focus on trying to change the form of their experiences (e.g., thoughts, feelings, and bodily sensations). Unsuccessful on their own, they seek a therapist to teach them how to control their internal experiences (e.g., make painful thoughts and feelings go away). From an FC perspective, clinically relevant behaviors are defined by function rather than form, and it’s important to pay attention to the nuances of context. Within an FC approach, we use context to our advantage. Attempts at trying to directly alter internal experiences (a.k.a. painful emotions) are viewed as less fruitful (and often impossible) than attempts at changing the environment in which these experiences occur. If a client is depressed, what changes can they make to their lives to have a different experience? As the behavioral activation literature has taught us, because we have more control over external behaviors (e.g., taking a walk, visiting with friends) than we have over internal behaviors (e.g., uncomfortable thoughts and feelings), it’s generally more effective to try to effect change with what we can control or influence (Kanter et al., 2012). FC provides a framework for defining contexts in ways that help clinicians predict and influence client behavior and help alleviate human suffering.

Psychological Flexibility At the heart of the ACT model is a concept called “psychological flexibility.” Psychological flexibility refers to the ability to stay in contact with uncomfortable thoughts, feelings, and bodily sensations while taking action toward what’s meaningful and important (i.e., values). In other words, doing what is most important to us even if it’s uncomfortable. Psychological flexibility means we’re able to fully experience these moments of discomfort

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while still focusing on what’s important in the moment—whether that is washing the dishes or listening to our partner share about their difficult day at work. What may sound fairly simple is actually hard to pull off, given that we tend to engage in avoidance behaviors when we’re not fully present. In ACT, experiential avoidance (a.k.a. the opposite of psychological flexibility) is defined as attempts to avoid or suppress threatening thoughts, feelings, and bodily sensations in ways that inadvertently increase suffering (Hayes, Wilson, Gifford, Follette, & Strohsal, 1996). Experiential avoidance is how many of us naturally orient to our own experience because we are biologically disposed to avoid pain, and it’s encoded into how we think (Hayes & Gifford, 1997). Consider how you may casually brush away a fly that has landed on your arm without thinking about it. Avoidance of physical discomfort is generally adaptive. If you place your hand on a burning pan, it makes sense to move it away. Additionally, broad patterns of avoidance are evolutionarily adaptive, as it’s better to err on the side of perceiving danger where there was no danger than in not perceiving danger where there is danger. If you think you see a predator on the horizon, it’s more adaptive to assume you’re right and turn around than to assume you’re mistaken and risk being attacked. In sum, it’s better to experience false positives than false negatives. We might imagine that ancestors of ours who were less cautious were the ones who succumbed to danger (i.e., died horrifically), and in this way we can see how anxiety has been passed along the generations as an adaptive trait. The problem is, we naturally extend these avoidance strategies to internal experiences such as unwanted thoughts, emotions, and bodily sensations. Skinner (1965) called these inner experiences “private events,” as they are “private” in the sense that they’re not directly observable by others. Strategies aimed at avoiding uncomfortable private events often create more problems than they solve, even if we may not recognize it. For example, we may prioritize feeling less discomfort at the expense of pursuing a way of living that is meaningful to us. When we worry, ruminate, or try to suppress or avoid uncomfortable thoughts and emotions, it can backfire and make those uncomfortable experiences worse (Wenzlaff & Wegner, 2000)! This is the pickle of anxiety disorders: being trapped in this futile battle with anxiety that we think is winnable but that winds up getting us more and more stuck over time. Increasing psychological flexibility is helpful in getting out of this jam, as one increases awareness of the consequences of avoidance behaviors and reorients to pursuing what matters most. One method of increasing psychological flexibility in ACT-informed exposure is helping clients be more in contact with the contingencies of their behavior. Fundamental in operant conditioning (chapter 2), contingency is the relationship between a particular stimulus (i.e., discriminative stimulus) and its consequence. Many of our behaviors are shaped through contingencies or direct learning. If I do this, that happens. However, not all our behaviors are shaped through contact with contingencies (i.e., through direct experience). We call this “rule-governed behavior,” behavior that’s influenced by verbal rules rather than direct contingencies. It’s the opposite of contingency-shaped behavior. Rule-governed behavior is

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extremely useful in many situations, as life would be very painful and dangerous if we only learned through contingency-shaped behavior. Consider prehistoric people learning which berries were edible and which were poisonous. It saves time and lives if an elder can warn us, “Don’t eat that one! You’ll get sick and die!” The benefit of rule-governed behavior is that we don’t need direct experience of eating a poisonous berry to learn to avoid it. Suppose, though, that the elder is wrong, and the berries they pointed to are not poisonous, that the elder mistook an edible berry for a poisonous one. In that case, we might never know they were safe to eat because we were told they’re poisonous. We might even starve to death if all we can find to eat are those berries that we were once told were poisonous. The dark side of rule-governed behavior is that we may cling to verbal rules that don’t correspond to what actually happens or is likely to happen. The rules we learn may not always be accurate or they may work in one context and not another. Many of us grow up hearing messages that we should be able to control thoughts and feelings. Consequently, we may attempt to push away or suppress these experiences without thinking about it, rendering us less sensitive to whether what we’re doing is working or not. The issue of context in rule-governed behavior comes up a lot in working with people with abuse histories. Behaviors that were helpful in surviving abusive homes, such as being hypervigilant or not asking for what one wants, may be adaptive in those contexts and maladaptive outside of them. Someone learns to be constantly alert to the possibility of a threat and consider the wants of others at the expense of their own needs. When they continue these strategies throughout the rest of their life, at some point the person may find they are no longer helpful. In studies of people engaging in computer games, when one group of people are told the rules of the game, they perform better than people who must figure out the rules using trial and error. However, when the rules of the game change, the individuals who were never given the rules in the first place are better able to adapt to the changes than the people who were provided explicit rules about the game at the beginning. Instead, the people who were provided explicit, verbal instructions about the rules of the games are more likely to keep trying to apply these rules even when they no longer work (e.g., Hayes, Brownstein, Zettle, Rosenfarb, & Korn, 1986). This is another problem with rule-governed behavior: it can make us less sensitive to the consequences of our actions (i.e., contingencies). We keep trying what should work even though it repeatedly doesn’t. When people struggle with anxiety, they engage in all sorts of unhelpful rule-governed behavior. Many people attempt to avoid or suppress anxiety-related thoughts, even though avoidance often increases the intensity and frequency of these thoughts. People may even notice that avoidance makes things worse; because they are so wedded to their rules, however, they may interpret their worsening anxiety as signs they’re not trying hard enough or not following the rules correctly enough (i.e., they haven’t figured out the right ways to suppress anxiety). Avoidance or negative reinforcement (see chapter 2) can strengthen rule-governed behavior even when

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we’re aware of the harmful consequence of the behavior (Törneke, 2010). The awareness of the futility of their actions may even increase their frustration: many anxiety clients know what they’re doing doesn’t work—they just can’t stop, because the avoidance is so immediately reinforcing. Exposure is one method of undermining rule-governed behavior, because it puts people in contact with the direct consequences of their actions. In the subsequent clinical chapters, we will go into further detail about ACT’s psychological flexibility model, and how it may be broken down into six ACT processes.

Relational Frame Theory A major reason we struggle with thoughts, feelings, and bodily sensations is due to the role of language in human suffering. Relational frame theory (RFT) is a functional contextualist account of language and cognition that builds upon the behavioral tradition of Skinner and is rooted in evolution (Hayes, Barnes-Holmes, & Roche, 2001; Skinner, 1974; Törneke, 2010). RFT is based upon basic science and is an advancement of behavioral theory that underpins contextual behavioral science. If you thought functional contextualism was technical, RFT is about as technical as one can get in the ACT world! For the average clinician, an understanding of RFT is not necessary to becoming a skilled ACT therapist. However, many clinicians—including ourselves—have found that a basic understanding of RFT can help fine-tune one’s approach to ACT and ACT-informed exposure. What’s a “relational frame”? It’s an essential feature of language and cognition—relational frames refer to higher-order cognitive processes by which we create associations. As humans, we take these processes for granted, because they come so naturally. We easily create associations between verbal sounds and objects (a “pen” can be a writing utensil or a place to keep farm animals), visual stimuli and object (“P-E-N” spells pen), evaluations and objects (I prefer pens with black ink over blue ink). Relational framing allows us to learn with incredible speed and aptitude compared to other animals. On the flip side, our ability to engage in relational framing opens us up to limitless avenues of pain—in every single waking moment. We hear a song we haven’t listened to since high school, and it instantly triggers an embarrassing memory from that time. Maybe just reading the previous sentence brought up an embarrassing memory for you. Through the process of relational framing, we can always imagine someone smarter, faster, stronger, better looking, and healthier than ourselves. Thank you, relational framing! Even innocuous stimuli can cue painful memories, self-critical thoughts, and uncomfortable bodily sensations. Human suffering is often found where framing occurs. Have you ever seen a dog with three legs? Perhaps you’ve even owned a dog with three legs. As far as one can tell, dogs with three legs seem to be just as content as dogs with four

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legs. They wag their tails, hop around, and seek pets and scratches from their people. Here’s what dogs with three legs don’t seem to do: they don’t endlessly ruminate about how much better their lives would be if they still had that fourth leg; they don’t imagine their owners would prefer a dog with four legs; they don’t angle their bodies to obscure the missing leg from the view of others. Dogs with three legs don’t seem to demonstrate any outward angst about their appearance and abilities. They don’t wring their little paws about how much better their life would be with four legs. To return to anxiety disorders, relational framing allows people who’ve experienced trauma to re-experience functions of the trauma. This can occur due to associations with external reminders of the trauma as well as thoughts, images, and bodily sensations. The flipside of this is that because relational framing allows humans to contact painful experiences at any time, it also allows therapists to treat these experiences with exposure therapy. From a functionalist contextualist perspective, exposure is one method for evoking uncomfortable inner stimuli to create a context for altering the function of the stimuli in a manner consistent with third wave approaches. Although understanding RFT is not absolutely necessary for doing ACT-informed exposure, it may help ACT-informed therapists come up with outside-the-box ideas for exposure exercises. For example, many anxiety clients struggle with self-criticism. According to RFT, we may reduce suffering by altering or transforming the function of language via changing its context. For example, saying the thought I’m a loser aloud and in a silly voice is one context that can transform the function of those words. Heard in a silly voice, the words function differently and take on a new set of more humorous, absurd qualities. Singing a thought is another way to bring a lighter verbal context to thoughts. Writing self-critical thoughts down on notecards also changes the context in which the thoughts are experienced. A client might write down the most horrible thoughts on note cards in crayon, or they might decorate these thoughts with flowers, smiley faces, or anything that brings some levity. After repeated practice, when the client experiences a thought such as I’m a loser during daily life, they might remember the silly voice they sung it in or how they had drawn a flower sprouting out of the “l” and a smiley face in the “o” on a notecard. If a client is used to engaging in experiential avoidance in response to self-critical thinking, you might have the client record themselves reading a list of their most common self-critical thoughts. When listening to the recording, the client can practice being present with whatever emotions show up when they experience these thoughts to increase flexible responding. The client learns that when they allow themselves to fully experience emotions such as shame or guilt, the thoughts start to seem less compelling and may even quickly pass. In sum, an understanding of RFT provides a framework for understanding exposure and may help clinicians come up with novel ideas for exposure exercises. In a later section in this chapter, we’ll return to the topic of how FC and RFT informs ACT-informed exposure in ways that may be different from first and second wave approaches.

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Clarifying Processes of Change in Exposure Let’s return to ACT and the third wave of CBT. The idea of a third wave was initially controversial and not everyone agreed that a third wave represented anything novel (e.g., Hofmann & Asmundson, 2008). Even now, many therapists and researchers are perfectly happy with first- and second-wave treatments, which remain effective. Without an understanding of FC, the division between ACT and traditional CBT can be fuzzy and appear superficial. As there was initially some skepticism in cognitive-behavioral circles that ACT had anything new to offer CBT (e.g., Arch & Craske, 2008; Hofmann & Asmundson, 2008), and that ACT was little more than a repackaging of CBT, early studies of ACT for OCD deliberately left out exposure to demonstrate that ACT had a novel approach to OCD (Twohig at al., 2010). If exposure were included, critics could (rightly so) attribute any treatment outcomes to the effects of exposure. As more studies supported that ACT did offer something unique to CBT (e.g., Forman, Herbert, Moitra, Yeomans, & Gellar, 2007), ACT gained greater acceptance within cognitive behavioral circles. Researchers began comparing ACT-informed exposure against traditional exposure (based on emotional processing theory—see chapter 2), and results demonstrated that ACT generally performs as well as traditional exposure for anxiety disorders (e.g., Arch et al., 2012; Craske, Niles, et al., 2014; Twohig et al., 2018). Reviews of these studies have concluded that ACT with and without exposure is an effective treatment on par with CBT for many anxiety disorders and obsessive-compulsive and related disorders (Bluett, Homan, Morrison, Levin, & Twohig, 2014; Landy, Schneider, & Arch, 2015). Studies comparing ACT to CBT have also found that clients in ACT-informed exposure may experience additional improvements in symptom severity and psychological flexibility between the end of treatment and a follow-up several months later, whereas those in CBT simply maintained gains at follow-up (Arch, Eifert, et al., 2012; Craske, Niles, et al., 2014). Additionally, it’s been argued that the ACT notion of acceptance or willingness is an important predictor of change in exposure—more so than habituation (Reid et al., 2017). Proponents of traditional exposure began to acknowledge that ACT “greatly adds to our clinical understanding and to our arsenal of techniques” (Grayson, 2013, p. 208). CBT even absorbed concepts and interventions associated with ACT and third-wave approaches such as mindfulness, values, and acceptance (Hayes & Hofmann, 2017), as ACT processes are not completely unique to ACT treatment and appear useful in understanding processes of change in first- and second-wave approaches to anxiety (Arch, Wolitzky-Taylor et al., 2012; Reid et al., 2017; Twohig et al., 2018; WolitzkyTaylor, Arch, Rosenfield, & Craske, 2012). Because of its emphasis on increasing psychological flexibility, ACT-informed exposure may be more versatile in its application than traditional exposure. For example, Abramowitz and Jacoby (2014) argue that, because second-wave exposure is based on a fear-anxiety model, it’s not an appropriate intervention for problems that aren’t rooted in fear-anxiety

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such as body-focused repetitive behavior (e.g., hair pulling, skin picking). By contrast, ACTinformed exposure may be applied more broadly to issues where there is a narrowing of behavioral repertories (e.g., B. L. Thompson, in press). Overall, the influence of ACT and third-wave approaches on traditional CBT has expanded our understanding of how CBT works and has also reoriented CBT from a diagnosis-specific approach toward a more process-based approach (Hofmann & Hayes, 2019). Consequently, there is value in understanding ACT concepts even in the use of traditional exposure because ACT and other third-wave approaches elucidate processes of change that are relevant across third- and second-wave treatments.

An ACT Understanding of Exposure As noted in chapter 2, exposure as an intervention has been around for several decades and has survived many theoretical models explaining its mechanisms of change. For the past thirty years, the dominant model of exposure has been emotional processing theory (EPT; Foa & Kozak, 1986) based on the pioneering work of Dr. Edna Foa. The EPT model, with its emphasis on reductions in distress through habituation, has been so influential that for many exposure therapists EPT is synonymous with exposure. Instead of habituation, the emphasis in exposure within the ACT psychological flexibility model is on expanding behavioral repertoires when in contact with stimuli that typically narrow behavior. Because of the broad emphasis in ACT on remaining in contact with stimuli one usually tries to avoid, even ACT without deliberate exposure has been called an exposure-based treatment (Hayes et al., 2012). Both proponents of ACT and proponents of traditional models of exposure have suggested that acceptance is a form of exposure in that it is about changing one’s contextual relationship with discomfort to increase flexible responding (e.g., Grayson, 2013; Hayes et al., 2012). One subtle distinction is that for traditional exposure therapists, the goal of acceptance is symptom reduction. For ACT-informed exposure therapists, the goal of acceptance is psychological flexibility, from which symptom reduction may be a by-product or side effect. From an ACT and RFT perspective, it is imprecise to say that the goal of exposure is to increase psychological flexibility in the presence of an external trigger; instead, the goal is to increase psychological flexibility while in contact with private events that may occur in the presence of external stimuli (Dymond & Roche, 2009; Friman, Hayes, & Wilson, 1998). Any external stimuli are used to cue relevant private events. This may seem like we’re splitting hairs, but it’s a helpful distinction to make, as we want to emphasize that the goal of ACT-informed exposure is to work with thoughts, feelings, and bodily sensations. This view is not completely inconsistent with traditional exposure. For example, traditional exposure therapies make use of imaginal exposure to thoughts and feelings in the form of talking through traumatic memories or writing out scripts describing a feared scenario

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coming true. However, ACT places a particularly strong emphasis on targeting the function of these private events (Twohig & Smith, 2015). To reiterate in a way that ties everything together: the emphasis in ACT-informed exposure is altering the function of private events that may be contextually cued by external stimuli to increase behavioral repertoires in the presence of thoughts, feelings, and bodily sensations that typically narrow repertoires. What about the de-emphasis on symptom reduction in ACT? Don’t clients want their therapists to promise them symptom reduction? How the heck do ACT-informed exposure therapists get clients on board with treatment by promising them expansion of behavioral repertoires instead? Sometimes the de-emphasis on symptom reduction in ACT can create a poker-faced standoff between the ACT therapist and client. The ACT-informed therapist assures clients that they may benefit from an ACT approach while simultaneously discouraging the client’s desire for symptom reduction. What clients must learn is that a heavyhanded and rule-governed approach to feeling better is likely to result in more suffering through misguided attempts to suppress uncomfortable private events. This lesson isn’t completely new to traditional exposure therapists, who’ve long known that clients are unlikely to benefit from exposure when they try to “just get through it” without remaining open and present with their experience. What ACT offers is a framework for and array of metaphors and experiential exercises with which to train and orient clients to the psychological flexibility model. For therapists, we believe that ACT offers a process-based approach and expanded terminology that may also facilitate greater therapist flexibility in conducting exposure. In sum, with its reservoir of metaphors, experiential exercises, philosophy of science, and processes linked to behavior change, ACT offers an expanded tool kit to the exposure therapist and client alike.

Conclusion Functional contextualism, a philosophy of science foundational for ACT, offers a framework for the prediction and influence of behavior that is philosophically distinct from more mechanistic (elemental realism) and mentalistic approaches to understanding human behavior that pervade much of psychological thought. Although grounded in classical and operant conditioning, ACT also draws from relational frame theory, a post-Skinnerian understanding of language and cognition which takes a more contextual approach to suffering than theories rooted in classical and operant conditioning such as EPT. With its contextualist roots, ACT is part of a “third wave” of cognitive behavioral treatments that emphasize changing how we relate to thoughts, feelings, and bodily sensations rather than changing the internal experiences themselves. As a result, ACT-informed exposure differs from traditional exposure (based on EPT) because ACT does not emphasize habituation or

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reduction in discomfort; instead, ACT-informed exposure focuses on increasing psychological flexibility through the expansion of behavioral repertoires while remaining in contact with thoughts, feelings, and bodily sensations that tend to constrict flexible responding. The next chapter provides a foundation for understanding exposure from an ACT context. We’ll walk through how to gradually orient clients to the ACT model and prepare them for ACT-informed exposure.

CLINICAL APPLICATION

ACT-Informed Exposure in Practice

CHAPTER 4

What the Therapist Needs to Know

From an ACT perspective, exposure is “organized presentation of previously repertoirenarrowing stimuli in a context designed to ensure repertoire expansion” (Hayes et al., 2012, p. 284). Said more simply, in ACT-informed exposure, clients practice strengthening psychological flexibility while in contact with stimuli that tend to restrict flexible responding while learning to connect with what is important to them. In all fairness, if one were to poll traditional exposure therapists, it’s unlikely many would disagree with the ACT definition. In our experience in presenting on ACT to traditional exposure therapists, they see what they do reflected in ACT. They want their clients to engage in new behaviors and to do things they care about. Moscovitch and colleagues (2009) suggest that the main difference between traditional and acceptance-based exposure is the “relative emphasis on the process of managing internal experiences” (p. 473). While emotional acceptance is important in traditional exposure, its emphasis is less explicit than it is in third-wave approaches such as ACT. We present ACT-informed exposure with the aim of creating a bridge between ACT and traditional exposure therapists. We believe traditional CBT and ACT therapists are more alike than different in their aims. Both value evidence-based therapy and use research to guide treatment. We want to be clear that we do not believe traditional exposure therapists can simply call what they are doing ACT—“I’ve been doing ACT-informed exposure all along without realizing it!” As we note in chapter 1, we believe learning ACT, like any treatment model, requires discipline, and ACT’s grounding in a functional contextualist philosophy of science (as described in chapter 3) brings a distinctive flavor to ACT-informed exposure. It’s our aim to present ACT-informed exposure in ways that are accessible to traditional exposure therapists and to acknowledge common ground.

Clarifying Therapist Assumptions in ACT-Informed Exposure Before we focus on how to create an ACT context for exposure with clients, we want to explore the lenses through which an ACT therapist may view exposure. As ACT is a

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process-based model, there’s no uniform protocol with which to conduct ACT-informed exposure. Ours is just one way of conceptualizing ACT-informed exposure while remaining within the boundaries of the ACT model. Other ACT-informed exposure therapists may do things a little differently, and readers may develop their own innovations in using ACTinformed exposure while remaining consistent with the ACT model. We’ll start by clarifying the relationship between psychological flexibility and exposure. As we have mentioned in prior chapters, psychological flexibility involves the ability to remain present, while in contact with discomfort, in order to engage in deliberate action toward meaningful life directions. The importance of learning to be present with discomfort without trying to alter or change one’s experience of discomfort—and the de-emphasis on symptom reduction—can be difficult for clients to understand. They want to feel better, and they want to be reassured by their therapists that they will feel less anxious. By contrast, traditional exposure promises symptom reduction, which is a much easier sell. Additionally, ACT concepts such as acceptance or willingness and values are very nuanced, making them tricky for many clients—and many therapists, too, if we’re being honest—to grasp. Both require some experiential understanding. We’ve come across ACT treatment manuals that recommend delaying exposure until clients understand the ACT model and ACT concepts such as willingness. In our view, though, exposure in an ACT context is simply another ACT experiential exercise that can help orient clients to the ACT model. Exposure offers an advantage over traditional ACT experiential exercises in its focus on repetition. Through repetition of specific exposure exercises conducted in a variety of contexts, clients have greater opportunity to experience ACT processes and practice psychological flexibility when in contact with previously repertoire-narrowing stimuli. In short, if clients don’t understand ACT concepts such as willingness, then exposure is a great way for them to contact ACT processes experientially. In our experience, it’s common for clients to have an epiphany after several sessions of exposure work: “Now I get what you’ve been saying! You’ve been saying it all this time, but I just kept thinking my anxiety would go away. I get what you mean by willingness—if I let go of my desire to control anxiety and stay present with it, the consequences are not as catastrophic as my mind says they will be, and my anxiety doesn’t have to stop me from doing what I want to do.” Having defined our assumptions, we will focus the remainder of this chapter on understanding core ACT processes in exposure therapy.

Creative Hopelessness as Functional Analysis “Creative hopelessness” is an unfortunately named process in ACT that often frightens new therapists: “ ‘Creative?’—great, I’m on board!—um, ah, what’s this about ‘hope…less… ness?’ ” During trainings, we’ve witnessed mention of creative hopelessness evoke nervous

What the Therapist Needs to Know43

laughter among therapists. “Surely, I’m not going to make my clients hopeless!” they stutter, looking to the ACT trainers to reassure them. In practice, creative hopelessness is not necessarily as scary as it sounds, and it can be very powerful for clients. Creative hopelessness is a process by which clients come to more clearly perceive and acknowledge how control strategies (e.g., control of thoughts, feelings, bodily sensations) are not working for them. This, in turn, opens them up to trying something new (e.g., acceptance). Put more simply, it’s hard to start to feel better until we stop actively doing things that make us feel worse. Therapists trained in behavior therapy may notice that creative hopelessness involves a form of functional analysis. Functional analysis is about examining stimuli that may be associated with problematic client behavior and their function in order to identify the causes of the behavior you’re trying to change (see Ramnerö & Törneke, 2008, for an introduction). Through functional analysis, therapists explore with clients the antecedents, avoidance behaviors, and the consequences of their avoidance behaviors, as well as the function of their thoughts, feelings, and bodily sensations (i.e., private events). From an ACT perspective, rigid attempts to control anxiety create more problems than the anxiety itself. We discussed in chapter 2 how avoidance tends to make things worse. In the literature on thought suppression (e.g., Wenzlaff & Wegner, 2000), for example, researchers have demonstrated that suppressing uncomfortable private events tends to increase the frequency and intensity of what we’re trying to suppress. Trying not to think of particular thoughts actually makes them more likely to occur. Another problem is that when clients try to control anxiety, they lose contact with a variety of forms of social reinforcement—because that “control” often means withdrawing from activity. I can “control” social anxiety by staying home; however, I lose the reinforcement of human relationships. Often these control strategies are forms of rule-governed behavior in which clients have formulated rigid ideas about what they believe should work. A problem with rule-governed behavior is that it makes us less sensitive to contingencies. Because many people believe they “should” be able to control their anxiety, they may not perceive the consequences of their actions or simply conclude they’re just not trying hard enough to control their anxiety. Through creative hopelessness, clients learn to understand how their attempts to avoid, manipulate, or control uncomfortable inner private events are ineffective in the long term (and usually the short term too). This is the “hopelessness” part: what clients are doing to manage their anxiety is not working and may be making it worse. Their attempts to control anxiety backfire. Creative hopelessness in ACT tends to be more experiential than traditional functional analysis. Traditional functional analysis may be done verbally or through use of worksheets. By contrast, ACT therapists may use metaphors and experiential exercises to help clients connect experientially with how their attempts to avoid, alter, and distract from uncomfortable private events result in worsening anxiety.

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Although it can be intense, the message of creative hopelessness can be empowering to clients. Many clients believe they’ve not been trying hard enough to make their anxiety go away or that they’ve been using the wrong avoidance strategies. The message of creative hopelessness is that clients’ Herculean efforts to avoid their anxiety are all doomed to fail and that it’s not for lack of trying. While for some clients, the idea of letting go of attempts to suppress or alter inner experiences is terrifying, for others, it’s a relief, because it illuminates something that they had already intuited but needed some help articulating. Beginning the process of creative hopelessness may be as simple as asking a client, “What do you do when anxiety shows up?” Clients may describe a variety of avoidance behaviors. They may cancel plans, spend hours worrying, or engage in actions that waste time when they could be doing more important or meaningful things. The therapist may then ask clients to assess the impact of their strategies: “What happens after you do this? How effective are these strategies?” In our experience, clients with anxiety are generally able to see that what they’re doing isn’t working. When asked directly about the effectiveness of their strategies in managing anxiety, they may even laugh and say, “They’re not effective!” But even with these clients, a little creative hopelessness remains useful in helping them learn to observe in real time how their efforts backfire. It’s one thing for clients to understand abstractly that their efforts to avoid anxiety don’t work, but it’s even more helpful for clients to observe and contact their experience in the moment. For example, everyone reading this book probably has some experience with how procrastination is not helpful. However, we don’t always pay attention to the way our chests may tighten when we open a browser tab instead of the document we should be working on or the way our shoulders might relax when we finally begin typing up that report. Making direct contact with the costs of avoidance can be helpful in augmenting client motivation to make changes and engage in the arduous work of exposure treatment. For other clients, the process of recognizing their current helplessness in the face of their anxiety can be humbling. Many clients come to treatment hoping their therapist will teach them a more effective way to escape suffering through reasoning and coping strategies and to sidestep discomfort without having to feel it. And when they realize that these strategies don’t work, it may feel like a punch to the gut. Of course, because the long-term impacts of some avoidance strategies are not always clear, some clients may claim their strategies are helpful. They may insist that seeking reassurance from others or engaging in internet research is effective because occasionally they feel relief. They may even be correct. Raise your hand if you have ever looked up a medical symptom and learned it was likely nothing to worry about. Some strategies work occasionally. If a client is seeking treatment, however, it’s because their strategies to manage anxiety either are not working overall or have other unintended consequences (e.g., they’re incredibly time-consuming). It can be useful to probe these strategies in more detail. How long does the experience of relief last? Weeks, days, hours? Only a few seconds?

What the Therapist Needs to Know45

Some clients may dig in and defend their strategies, insisting that if they did not engage in these behaviors, they would become so overwhelmed by their anxiety they would not be able to cope. This can be a sign that creative hopelessness may be trickier for a particular client and that their psychological flexibility may be particularly low. When clients are wedded to their avoidance behaviors, the therapist may want to proceed through ACT and exposure more slowly. These clients may have difficulty understanding or may express resistance to core ACT concepts such as willingness, and they may have a lower capacity to observe and put words to their inner experiences. If a client is particularly low in psychological flexibility, creativeness hopelessness may just fall flat. These clients are often largely unaware of internal experiences such as thoughts, feelings, and bodily sensations, even when you ask directly about them. They may have difficulty observing when they feel anxiety or shame. Some of these clients can label their emotions vaguely but are completely out of touch with their bodies. We all vary in terms of our ability to put words to private events. Most people are “good enough” at it to engage in therapy, but when clients struggle with perceiving and labeling internal experiences, it’s often difficult for them to engage in creative hopelessness, because they are so out of touch with their actual experience (e.g., contingencies). For one client with whom one of us worked, when asked where in her body she felt anxiety, she would say, “My head.” When other areas of the body were suggested (e.g., tightness in chest? shoulders or neck? stomach?), she would angrily deny she felt anything in her body. It was because this client could not discriminate the tension in her body, she didn’t know how or where to look for signs of bodily discomfort. If she was asked to describe the signs she was anxious, she would become more frustrated: “I just know!” With these clients, training discrimination of thoughts, feelings, and bodily sensations may be crucial before moving into creative hopelessness. Ultimately, leading clients through at least one creative hopelessness metaphor early in treatment can give you a common language to describe avoidance throughout treatment. When you are aware the client is engaging in avoidance behavior, you might simply say, “It sounds like you’re pulling on the finger traps” (the finger traps exercise) [or “…you’re digging” (the child-in-the-hole exercise) or “…you’re pulling on the rope” (tug-of-war with the anxiety monster)] to remind them to pay attention when they’re struggling with their anxiety (see Eifert & Forsyth, 2005, for more on these exercises, although these “classic ACT” exercises may be found in numerous sources). That said, although an ACT therapist may often begin treatment with creative hopelessness, creative hopelessness may be interwoven throughout treatment to the degree clients have difficulty letting go of control strategies. We offer examples in chapter 9 illustrating the importance of returning to creative hopelessness when necessary. As we noted earlier about how exposure can help orient clients to the ACT model, exposure may also help clients contact the cost of experiential avoidance. Clients may be

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surprised at what happens when they remain in contact with experiences they usually try to avoid or suppress, and consequently, they may be more receptive to letting go of their efforts to control. Here are two important points to consider about creative hopelessness: • The effectiveness of creative hopelessness is contingent upon client capacity to observe and put their experience into words. If a client low in psychological flexibility cannot observe and discriminate how their efforts at avoiding anxiety backfire, you may need to focus on awareness training before engaging in creative hopelessness. • A client may understand intellectually that their avoidance behaviors are ineffective; however, being able to observe examples of when this happens in the moment is even more important. Even if a client tells you that they are aware of the unworkability of their actions, you should help to strengthen their ability to observe examples of this happening in the present moment. Tracking forms are one way to increase client awareness, and talking through a recent incident is another (e.g., “And then what happened, what thoughts were coming up for you? And what were you feeling in your body?”).

Discriminating ACT Hexaflex Processes in Client Behavior Through creative hopelessness, we can begin to assess psychological flexibility. Within the ACT literature, psychological flexibility has been described as a single, unitary process, and it has also been broken down into smaller sub-processes. The most common breakdown is the six processes of the ACT hexaflex: • Contact with the present moment • Willingness to stay in contact with discomfort (e.g., feelings, bodily sensations) • Defusion, or the ability to be aware of thoughts with some distance without necessarily believing in their literal reality • Self-as-context, or the ability to flexibly shift between perspectives rather than fusing with one or another self-concept • Values, or meaningful life directions in which we may choose to orient our behavior • Committed action, or taking action based on your values, rather than avoiding uncomfortable experiences like anxiety

What the Therapist Needs to Know47

Of course, there are many ways to cut the pie. For example, some writers have condensed the traditional six ACT hexaflex process into three (e.g., Harris, 2009; Strosahl, Robinson, & Gustavsson, 2012). We decided to stick with the traditional six processes, as we feel the distinctions between them are relevant in understanding and illuminating client experiences during exposure. Please note, however, that these are nontechnical, middlelevel terms that do not have the same precision as some of the behavioral terms we introduced in chapters 2 and 3. Also note that ACT processes are not mutually exclusive, as they overlap to varying degrees. When he was first learning ACT, one of us (Brian T) tried to create a table organizing common ACT experiential exercises and metaphors according to which core ACT hexaflex process each exercise targeted. He quickly became overwhelmed by the task. Not only did many exercises target more than one process, but he found inconsistencies in how specific exercises were categorized among the ACT books he consulted! What one source labelled a defusion exercise another categorized as a willingness exercise. Consequently, we want to be explicit here that the relationships among these processes are much messier than they might appear. Additionally, using the same exercises may impact different processes from client to client. For example, in repeatedly reading a triggering article, one client may focus on experiencing the tightness in their chest and butterflies in their stomach (e.g., willingness) while another may observe their thoughts (e.g., defusion, self-as-context). Thus, it’s important to emphasize that it’s not cut and dry when you target specific processes via experiential exercises. We offer examples of this in our case examples in chapter 9. The following sections will describe how exposure methods may impact ACT processes.

Exposure as Committed Action Committed action refers to engaging in behaviors linked to what is important to us. In ACT-informed exposure, exposure exercises are committed action. Additionally, you may identify other non-exposure forms of committed action in the service of treatment goals during ACT-informed exposure. If a client struggles with activities of daily living, for instance, they may commit to brushing their teeth twice daily or showering every other day between sessions. If they are unhappy in their job, they may commit to revising their resume, applying to new jobs, talking to people who have careers that interest them, or researching graduate programs. You may end sessions by offering clients the opportunity to identify committed actions with, “Is there anything you want to commit to doing between now and the next time we meet?” This allows clients an opportunity to make a public commitment toward behavior change, increasing the likelihood of follow-through.

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Exposure as Contact with the Present Moment People with anxiety spend a lot of time in their heads worrying, catastrophizing, planning, and judging. As a result, they’re often not in touch with their experience and can seem distant or aloof to people around them. In short, they’re not in contact with the present moment. Exposure is one means to address this shortcoming. Even in traditional exposure, therapists may ask clients to describe their experiences during and after exposure: “What are you thinking?” “What are you noticing in your body?” “What emotions are present?” “What is happening right now?” These questions help direct clients to focusing on their immediate experience. We know from research that simply labeling an emotion or experience during exposure improves outcomes (e.g., Niles, Craske, Lieberman, & Hur, 2015). Being present is crucial in ACT-informed exposure because we want clients to observe what really happens—not what they think is going to happen (e.g., contact contingencies and weaken rule-governed behavior). If they’re not present, they may miss what actually happens because they’re blinded by what they think will happen (e.g., rule-governed behavior). Interestingly, many clients are pleasantly surprised when they actually pay attention to their experience moment-to-moment. They’ve been so busy trying to avoid anxiety, they’ve never really sat with and observed it. They may not have noticed bodily tension. They may be unaware that much of the discomfort that preceded the exposure quickly dissipates or that their anxiety does not spiral out of control as they predicted. As much time as clients spend worrying, they tend to be poor predictors of their actual experience of anxiety. Being in contact with the present moment allows clients to fully grasp the futility of escaping anxiety, and consequently, this enhances their motivation to let go of urges to try to control their experience. Through repeated exposure exercises, clients may that find their momentto-moment experience of anxiety feels manageable when they stay present with it, as they are able to experience anxiety as uncomfortable sensations instead of the catastrophes their minds predict.

Activity Reflect on your own experience with this ACT process. Complete this exercise on a sheet of paper or in a notebook. If you have experience with exposure therapy, whether ACT-based or not, take a few moments to reflect on signs of contact with the present moment that have shown up in exposure exercises you’ve conducted. Consider comments clients have made during or debriefing exposure that would suggest they contacted this process.

What the Therapist Needs to Know49

Exposure as Willingness The only way to endure pain is to let it be painful. —Zen master Shunryu Suzuki Roshi Willingness involves remaining present with uncomfortable feelings and bodily sensations without trying to avoid or change them. In ACT, “acceptance” and “willingness” are synonymous. We’ve chosen to use “willingness” as sometimes people misconstrue the word “acceptance” as resignation, as a passive giving up. In ACT, willingness is a behavior, an active choice we may make in the present moment. We want to emphasize that willingness can only occur in the present. We cannot accept the future, we can only practice willingness with our moment-to-moment experiences. In our experience, willingness is a difficult concept for many clients to understand, and clients may not fully grasp willingness until they have worked through multiple exposure exercises. Because willingness is so important to exposure, we suggest that it’s the one core ACT process that may be useful to teach to clients explicitly. We’ve included additional information on willingness in the next chapter, chapter 5, as we feel it’s important to discuss the nuances of willingness with clients to clarify any potential misunderstandings. For those trained in traditional exposure, willingness offers a method for addressing covert forms of avoidance during exposure. These forms of avoidance include tensing the body and trying to “get through” exposure exercises (e.g., low present-moment awareness). Many clients are unaware of these behaviors or don’t discriminate them as important to enough to mention. Since we know these behaviors can interfere with learning from exposure, it’s important to monitor for signs of them. Willingness scores offer ACT therapists a way to detect when a client may be trying to avoid or control private events. For example, one of our clients feared stepping on discarded syringes whenever he left his downtown apartment. He engaged in a daily exposure exercise of walking from his home to his gym without compulsively looking down at the sidewalk for needles. After two weeks of practice, he remained as fused with his fears. Looking at the forms he completed, the therapist noticed the client consistently rated willingness during exposure a 5–6 on a scale of 0 to 10 (“not willing” to “completely willing”). These middling willingness ratings cued the therapist to the possibility that this client may have been engaging in some covert avoidance behavior. In talking through the exposure with the client, the therapist asked about the pace with which the client was walking and realized the client was walking too quickly through the exposure. The client acknowledged that he would jump on and off curbs as he engaged in a brisk walk toward his gym. We want to note that the client had been conscientiously practicing the exposure and had not been aware he’d been engaging in this behavior until the therapist brought it to his attention (a sign of low contact with the present moment). The therapist recommended that the client slow down. They practiced walking at a slower,

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deliberate pace in session. At the following session, the client reported that slowing his pace had allowed him to increase willingness. He was able to be more present during his walk to the gym while gently resisting urges to look for syringes on the ground. What’s more, during a subsequent exposure exercise, this client spontaneously applied what he’d learned, deliberately slowing down during a work procedure he’d been rushing through. He noticed his anxiety immediately felt more manageable when he was more present. Through the concept of willingness, exposure therapists possess a shared vocabulary through which to talk with their clients about more subtle forms of avoidance and to infer when it may be happening (e.g., low willingness ratings) even when clients are not conscious of their behavior. For these reasons, we recommend teaching clients about willingness. In chapter 9, we have a case example of how to use willingness ratings to adjust exposure exercises to where clients are.

Activity Reflect on your own experience with this ACT process. Respond to these prompts on a sheet of paper or in a notebook. •

If you have experience with exposure therapy, whether ACT-based or not, take a few moments to reflect on signs of willingness that have shown up in exposure exercises you’ve conducted. Consider comments clients have made during or debriefing exposure that would suggest they contacted with this process.

•

Take a few moments and write down forms of covert avoidance you’ve witnessed in clients practicing exposure. Reflect on how you might use the concept of willingness to address these avoidance behaviors.

Exposure as Cognitive Defusion Cognitive defusion refers to being aware of thoughts without believing in the literal reality of them (i.e., the opposite of cognitive fusion). When we observe ourselves experiencing self-critical thoughts (Loser!) without buying into what our minds are selling, we’re practicing defusion. The philosopher Michel de Montaigne nailed the experience of fusing with worry when he wrote, “My life has been full of terrible misfortunes, most of which never happened.” A classic defusion exercise involves repeating a word aloud for forty-five seconds until the word begins to lose meaning and dissolves into inchoate sounds. This exercise was first documented over a hundred years ago by the psychologist Edward Titchener (1916), though he did not call it “cognitive defusion.” A recent ACT study looked closely at what happens during this defusion exercise (Masuda et al., 2009). The researchers asked participants to

What the Therapist Needs to Know51

choose a negative self-referential statement such as “I am stupid.” Participants then distilled their statement into one word (e.g., “stupid”). They repeated the self-referential word aloud for different durations and rated how they experienced the thought. The emotional discomfort triggered by the thought tended to decrease within three to ten seconds. The believability of the thoughts took a little longer, about twenty to thirty seconds. The repetition of exposure provides many ways to practice defusion. Although more complex than the recitation of a single word, repeatedly reading triggering articles or passages of text, reading imaginal scripts aloud, or watching brief videos on YouTube provide opportunities for clients to experience defusion. It’s also true that defusion does not always require repetition. Sometimes simply saying thoughts aloud is enough for clients to experience defusion. In creating imaginal scripts, for instance, some clients find that the writing of the script is all that is necessary to defuse from fears (e.g., “I realized how unrealistic my fears were when I tried to write them down.”). One client even burst out laughing when she said aloud her fear that she would never find love again if her relationship with her current partner ended. Because defusion is often a simple matter of time and repetition, we recommend introducing clients to exposure through exercises that allow you to control more variables related to the exposure. For example, if you provide clients a passage of text to read that is triggering to them, you and your client have control over the content. The text itself does not change in the way, say driving conditions would during a driving exposure. If we read the same words repeatedly and consistently, we will typically experience some distance from what we read. As we become familiar with the text, we may start to notice other private events that occur during the reading. This works especially well with clients who endorse only partial buy-in or who are lower in psychological flexibility. Reading brief news articles or watching a thirty-second video clip over and over again increases the likelihood that clients will discriminate some change in their experience of the stimuli. Conversely, watching a two-hour movie or reading a twenty-page article may be too long and complex for clients to experience defusion. Through consistent repetition of a basic exposure exercise, clients are more likely to have the experience of Ah—now I get it!

Activity Reflect on your own experience with this ACT process. Respond to this prompt on a sheet of paper or in a notebook. •

If you have experience with exposure therapy, whether it is ACT-based or not, take a few moments to reflect on signs of cognitive defusion that have shown up in exposure exercises you have conducted. Consider comments clients have made during or debriefing exposure that would suggest they contacted with this process.

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Exposure as Self-as-Context Self-as-context (a.k.a. flexible perspective-taking) refers to an “I” from which we can observe all experiences. It builds upon cognitive defusion in that it describes a perspective from which one can defuse from the content of specific thoughts and observe the process of thinking. Conversely, one cannot experience fused thinking from self-as-context. It encompasses willingness in that we can observe and be present with uncomfortable feelings and bodily sensations. From a place of self-as-context, we can observe the flow of thoughts, emotions, and bodily sensations—an experience we may call “self-as-process.” We can also take the perspective of other people, imagining how they may think or feel. As many clients feel isolated in their pain and anxiety, this expansive perspective can help them feel connected to the greater human experience and to realize that everyone struggles, engendering compassion for themselves and others. This perspective has been compared to a way of experiencing that’s trained in meditative spiritual traditions (Hayes, 1984). One way of conveying this idea to clients is that they are “bigger than their anxiety”—that they can experience anxiety while remaining present and engaged in the world around them. In addition to the external world, we can observe the internal flow of our thoughts, feelings, and bodily sensations. From an ACT perspective, flexible perspective-taking is a form of verbal behavior that may be strengthened in the process of the weakening of verbal rules (e.g., “I can’t tolerate anxiety”) through awareness training (e.g., Hayes, 1984). The repetition of exposure provides an incredible opportunity for clients to experience self-as-context. Imagine watching a scene from a movie repeatedly. During our first viewing, we may be engrossed in the story of it, trying to figure out what’s going on. With repeated watching, we start to notice other things that are happening. We hear the swell of the score or ambient background noises. We may notice the transition of one edit to the next or become aware that a scene happens in one continuous take. We can marvel at the subtlety in the actors’ performances. Repetition frees us from the focus on the story because we already know what happens—now we can observe how it happens. The beauty of exposure is that repetition does the job for you. There’s no need to try to explain self-as-context to clients. You can train self-as-context through asking clients to describe what is happening during in-session exposure (e.g., “What do you notice in your body?”) and through debriefing. For example, when someone with health-related fears reads an article about cancer, they are typically reading for reassurance. Do I have those symptoms? Am I similar or different to the people described in the article? Based on the statistics, what is my risk? It’s as if their anxiety is reading the article. With repetition, clients expand their awareness. They describe thoughts and bodily sensations in response to triggering or reassuring passages. They start to notice nuances in the text they did not catch on initial readings. They may become aware of the font on the page or the way the paragraphs are organized. As they strengthen self-as-context, the article becomes “just an article” (i.e., it’s not a direct commentary on their relative risks for the content described in it).

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Self-as-context is contrasted with self-as-content, the conceptualized self from which we may hold rigid views of ourselves (e.g., I’m OCD; I’m mentally ill). In ACT, who we are depends on the context—there is no such thing as a “true self.” We’re constantly engaging in the process of “selfing” (e.g., I am a parent, a therapist, a spouse). One study found that, of all the ACT processes, self-as-content was most relevant to obsessive-compulsive symptoms, especially unacceptable thoughts and mental contamination (E. M. Thompson, Brierley, Destrée, Albertella, & Fontenelle, 2022). This may reflect a tendency of people with OCD to take their obsessions as a true reflection of who they are rather than as somewhat arbitrary products of their mind. Helping clients strengthen their ability to perceive their experiences from self-as-context, rather than the more rigid self-as-content, can be helpful in loosening client attachment to unhelpful stories they hold about themselves. After a client who believes I’m too much of an anxious person to go dancing does indeed go dancing, they realize that this identity is just an unhelpful series of words and thoughts that does not have to dictate their choices in life. This notion of multiple selves or “selfing” in ACT overlaps with other therapy traditions. For example, in many psychotherapies, the therapist may discuss parts or selves (e.g., the “anxious part,” the “hurt self”). In OCD treatment, it’s common for therapists to encourage clients to anthropomorphize their OCD and refer to it as something separate, such as “my OCD” (e.g., Yadin, Foa, & Lichner 2012). When working with children, the child might give their OCD a name (Wagner, 2003). This allows therapists to ask self-ascontext relevant questions, such as “What does your OCD want you to do? What do you want to do? Do you really want your OCD to call the shots for you?” This process helps clients develop distance from thoughts and feelings and can lead to an expansion in one’s sense of self. As clients practice remaining in contact with anxiety-provoking stimuli through exposure, they can practice stepping back from their experience of it: I am much bigger than my anxiety. My anxiety does not define me. Clients learn to both observe their experience of anxiety during exposure, as well as practice letting go of rigid identification with selves (e.g., My anxiety will overwhelm me.)

Activity Reflect on your own experience with this ACT process. Complete this exercise on a sheet of paper or in a notebook. •

If you have experience with exposure therapy, whether it is ACT-based or not, take a few moments to reflect on signs of self-as-context that have shown up in exposure exercises you have conducted. Consider comments clients have made during or debriefing exposure that would suggest they contacted with this process.

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Exposure as Values Values in ACT refers to meaningful life directions toward which we may orient our behavior. Values, as verbally constructed consequences, are also a form of rule following. They reflect what we care about, what moves us, what we’re passionate about. Values provide context for taking action toward doing difficult things and may be harnessed to augment motivation. Contact with values allows us to, say, drive a friend to the airport at five in the morning, when we’d rather be sleeping. There is evidence that values clarification increases client motivation to engage in exposure work (e.g., Hebert, Flynn, Wilson, & Kellum, 2021). LeJeune and Luoma (2019) outline four qualities in values: • Values are behaviors. They are actions—not abstract ideas. It is more accurate to say that we engage in valuing when we contact values. • Values are freely chosen. They reflect what’s actually important to us, not what we think should be important or what we imagine others want of us. • Values differ from goals in that we can always contact values (i.e., engage in valuing), and there is no end point in values (e.g., being a good parent). • Values are directions we move toward, not uncomfortable things we try to get away from. For example, “not being anxious” is not an ACT-consistent framing of a value. Anxious clients may come into therapy with a range of different struggles with values and valued living. Some may be very much in contact with what they value, whereas other clients have been spending so much time and energy trying to avoid anxiety that they’ve lost touch with what’s important to them. Clients are in contact with their values; however, anxiety is a barrier in taking action toward valued directions. This is the most common way values are incorporated into treatment. For example, with social anxiety, panic disorder, and agoraphobia, clients often avoid people. Values work might involve encouraging someone with social anxiety to make plans with an old friend or try joining a new group or club, as opposed to letting their anxiety dictate what they can and cannot do. Clients are in contact with their values, actively take actions toward values, but anxiety is interfering with their ability to be present and connect more fully with valued activities. These clients are often high achieving and disciplined. They tell you they are doing all the things they want to be doing in their lives but derive little fulfillment from them. For these clients, exposure is a way to clear the noise and clutter of anxiety to practice being

What the Therapist Needs to Know55

present during valued activities. Clients may want to practice approaching activities with personally chosen and meaningful qualities such as curiosity, playfulness, or open-heartedness. Clients are not in contact with their values and struggle to identify wanting anything other than alleviating their suffering. Clients who have difficulty identifying what they value often have been struggling with intense anxiety over a long period of time (e.g., years), having engaged in rigid patterns of avoidance, and have lost contact with what’s important to them. Their behaviors are under aversive control to such a degree that their primary concern is reduction in distress. They may experience even the idea of wanting something larger as intensely painful. From an ACT perspective, this is not a problem. Engagement in exposure may increase psychological flexibility to a degree that clients once again connect with what is important. For these reasons, values are not a prerequisite to engaging in ACTinformed exposure, as an increased focus on values may be aversive to these clients. Regardless of the degree to which your client can connect with values, values work may be integrated throughout treatment, even without using the word “values.” Much has been written about using values to create a context for exposure (e.g., Twohig, Abramowitz, et al., 2015), and what is written about typically focuses on working with the first type of clients described above, clients who know what they want to be doing but are not doing it. What has been less acknowledged is that exposure can indirectly facilitate contact with values and increase confidence in values-driven behavior. For example, one client who avoided freeway driving because of panic learned from repeated driving exposures that he could accomplish non-exposure goals if he put forth consistent time and effort. As a consequence of his exposure work, he began devoting long days toward improving his yard and looking more closely at needed home repairs he had neglected during the ten years he’d been withdrawn from the world as a result of anxiety. Another client who was making progress with exposure realized that she wanted to return to school to complete her bachelor’s degree. Before even consulting her therapist, she had registered for classes with a local college for the next term. In these ways, values may help orient clients toward exposure, and exposure may help clients contact values.

Activity Reflect on your own experience with this ACT process. Complete this exercise on a sheet of paper or in a notebook. •

If you have experience with exposure therapy, whether it is ACT-based or not, take a few moments to reflect on signs of values that have shown up in exposure exercises you’ve conducted. Consider comments clients have made during or debriefing exposure that would suggest they connected with values.

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Client Misunderstandings About ACT As therapists, all three of us authors love when treatment goes exactly as planned. We introduce ACT exercises and metaphors that clients totally connect with, and these clients say exactly what we want to hear—it feels great. We enjoy hearing ACT-consistent insights from clients such as: • “You’re right—trying to control my anxiety doesn’t work!” • “My anxiety-related thoughts aren’t helpful at all!” • “When I accept my thoughts and feelings, I stop struggling and feel free!” As clinicians with full-time practices, however, we have plenty of experience with clients who do not connect with ACT at all. Some clients see us because we identify as ACT therapists. Many more clients seek us out because we are evidence-based therapists who specialize in working with anxiety or because someone else referred them to us. They just want someone to help them feel better. In chapter 9, we provide case examples of the trial-and-error process of ACT-informed exposure, and in chapter 10, we’ll provide more in-depth case examples of clients who do not connect with ACT. For our purposes here, as you prepare clients for ACT-informed exposure, we want to acknowledge that:

ACT concepts such as willingness can be tricky for clients to understand. ACT protocols typically offer rationales, metaphors, and experiential exercises to orient clients toward the ACT model. This is very useful in preparing clients for ACT-informed exposure. For some clients, however, no matter how many exercises and metaphors you give them, they remain confused by ACT concepts. In all fairness, though, many new ACT therapists are confused by ACT concepts! ACT therapists debate the finer points of ACT processes on listservs and social media pages, attend multiple workshops about ACT, and read ACT books and articles. There are entire books for therapists devoted to cognitive defusion (Blackledge, 2015), and to values (LeJeune & Luoma, 2019) alone! If ACT therapists must spend countless hours learning about ACT processes, we can’t expect our clients will understand these processes after a handful of sessions. Here’s our view of how to proceed when clients have a shaky grasp of ACT: It’s sufficient for clients to “kind of” understand ACT. In our view, if clients are on board with the treatment plan, it’s not a problem if clients demonstrate a shaky understanding of ACT concepts. If you’ve tried multiple ACT exercises and discussed with clients the finer points of an ACT approach to treatment, and you still have a sneaking suspicion they do not quite understand ACT willingness or their understanding of values isn’t quite ACT

What the Therapist Needs to Know57

consistent, you might still proceed, trusting that over the course of their work with you, there’ll be more opportunities for them to refine their understanding of ACT processes as they experience them in action. So long as you, the therapist, have created a context for ACT-informed exposure, and you remain on message, many clients will strengthen their understanding of ACT through exposure. As we’ve emphasized, the repetition of exposure is one of its greatest strengths. With every exposure exercise and every debriefing, therapists have additional opportunities to help clients contact ACT processes and practice flexible responding. ACT, by nature, is an experiential treatment: create the context for intellectual understanding, focus on experience, and understanding will follow. We do want to be clear that we’re not giving therapists carte blanche to be sloppy in how they present ACT. We believe in the importance of a clear and ACT-consistent message. Our view is that if therapists remain consistent in their messaging and roll with clients’ imperfect understanding of ACT, many clients who may struggle with ACT concepts will deepen their understanding through exposure. They may finally understand willingness when they observe what happens when they openly engage in an exposure exercise, even if they did so with hesitation. They may have the experience of thoughts being “just thoughts” after a week of listening to a catastrophic imaginal script. With all their hard work and countless hours devoted to exposure, clients may even have a more experiential understanding ACT processes than many ACT therapists! Many clients connect with an ACT approach. Some even seek out readings, podcasts, and videos to learn more about ACT on their own. Yet we’ve also had clients who successfully graduate from treatment who (we suspect) still do not quite understand ACT, despite all our best efforts. This is okay too.

Conclusion In this chapter, you learned about ACT concepts that make up the psychological flexibility model: committed action, present-moment awareness, acceptance or willingness, defusion, self-as-context, and values. All of which are useful to understand, draw from, and strengthen during the course of exposure therapy. Ultimately, our focus in this chapter’s discussion of ACT theory and fundamentals is on the practical use of ACT to facilitate flexible exposure. We caution against allowing a rigid approach to ACT orthodoxy to hinder or delay exposure work. Given that treatment outcomes are comparable between ACT-informed and traditional exposure (e.g., Arch, Eifert, et al., 2012), we do not consider it a treatment failure if clients successfully complete exposure therapy and retain some non-ACT ideas (e.g., focus on symptom reduction). In the next chapter, we will focus more on creating an ACT context for exposure work with your clients, and in a subsequent chapter, we will also focus on common client misunderstanding about ACT.

CHAPTER 5

What the Client Needs to Know

Having laid down in the prior chapter foundational knowledge that’s important for therapists to consider, our focus in this chapter is on helping you create a context for ACTinformed exposure with clients. From the very first session, we can begin to acculturate clients to the ACT model in indirect ways. In the worksheets and forms we give to clients and through the language we use, we can help clients begin to understand their struggles through an ACT lens. For example, we might refer to clients’ process of thinking as “your mind,” rather than talking to them about what they thought: “What is your mind telling you right now?” “Sounds like your mind can be pretty hard on you.” “What happens when you listen to your mind in these situations?” If you’re new to ACT, these phrasings might sound a bit strange. Through how we speak with clients, however, we can begin training defusion and self-as-context in our language. Clients tend to intuitively grasp these phrasings and go along with it. In short, you can begin to introduce clients to the ACT model from your first session and without even uttering the words “acceptance and commitment therapy.” Let’s learn more about how.

Using Experiential Exercises to Orient Clients to the ACT Model The ACT model emphasizes the use of experiential exercises and metaphors to introduce clients to and help them contact ACT processes through methods that deepen understanding and learning. There’s even a book specifically dedicated to them, The Big Book of ACT Metaphors (Stoddard & Afari, 2014). As there’s no shortage of ACT books on exercises and metaphors—some readers may already have their favorites—we have chosen not to focus on specific ones here. We highly recommend Eifert and Forsyth’s Acceptance and Commitment Therapy for Anxiety Disorders (2005) as a great introduction to ACT metaphors, experiential exercises, and worksheets tailored for people with anxiety. Instead of providing a list of exercises, we’ll take a broader look at how ACT exercises can be used to prepare clients for exposure.

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Generally, when clients practice guided mindfulness exercises, they learn to observe and put words to their experience and to remain in contact with uncomfortable private events—all useful skills for exposure work. Other exercises may help clients to approach emotions or interoceptive sensations they typically avoid, which can help train willingness. In short, frontloading treatment with ACT metaphors and exercises helps to create a context for ACT-informed exposure. The use of experiential exercises and metaphors is also a form of ongoing assessment. How do clients respond to ACT concepts? Some clients may come to treatment with a set of assumptions that are ACT-consistent, such as an awareness that their avoidance of anxiety is causing problems, and even that their anxiety may never go away but that they can learn to coexist with it. These clients may quickly take to ACT concepts, connecting with the model and applying ACT in their daily lives between sessions with minimal therapist guidance. They may spontaneously reference metaphors throughout treatment or share experiences between sessions where they responded to uncomfortable private events with increased psychological flexibility. As we touched on in the previous chapter, however, not all clients take to ACT. Some may find the ACT model confusing or counterintuitive. Many clients come to treatment with the expectation that the therapist will teach them to control their anxiety. Many other clients hold views that are somewhere in-between these two poles: they intellectually understand ACT concepts while secretly hoping that they’ll learn to effectively escape anxiety. Therefore, the process of introducing ACT experiential exercises early in treatment allows the therapist to assess baseline knowledge and client psychological flexibility. How the client responds to ACT concepts may influence how you direct treatment. For example, highly avoidant clients who are skeptical of ACT ideas—or reject them outright—may benefit from starting with easier exposure exercises to build buy-in to the notion of developing psychological flexibility through exposure.

ACT Rationale for Exposure Historically, a traditional exposure therapy rationale emphasizes, among other things, symptom reduction (see chapter 2 for more detail). From an ACT perspective, an explicit focus on symptom reduction is ACT-inconsistent and may contribute to a “fear of fear.” This occurs when anxiety—an inner experience that, like all private events, is something we cannot control—becomes an enemy to be conquered through avoidance and suppression of uncomfortable experiences. Ultimately, ACT holds that it’s our attempts to control or avoid anxiety that cause anxiety to be a problem, rather than the anxiety itself. A deemphasis on symptom reduction is not unique to ACT, as there’s a movement in mainstream CBT away from the prior focus on habituation based on recent studies that have found that habituation is a poor predictor of learning (Craske, Treanor, et al., 2014). One

What the Client Needs to Know61

alternative model of exposure, inhibitory learning theory, shares some conceptual overlap with ACT (Arch & Abramowitz, 2015). In crafting an ACT-consistent rationale for exposure, it’s important to be clear about the message you want to impart to clients who are seeking treatment to reduce their suffering. If you’re used to explaining exposure in terms of symptom reduction, it’ll take some discipline to refrain from promising symptom relief, as we all want to reassure clients that they’ll feel better. For these reasons, it’s useful to develop an ACT-consistent rationale for ACT-informed exposure. Arch and colleagues (2015) conducted a study comparing the credibility of different exposure rationales: (A) ACT, (B) traditional habituation-based exposure, (C) inhibitory learning theory, and (D) a generic definition of exposure. They found that rationales rooted in theory (e.g., ACT; traditional exposure; inhibitory learning theory) had greater credibility compared to a generic definition. And none of the rationales rooted in theory were more credible than any of the others. Said another way, ACT was as credible as traditional exposure and vice versa. The ACT rationale the researchers created for the study described exposure as a method for learning to “welcome” anxiety as “a meaningful part of your day-to-day experiences.” Exposure was about “entering feared situations while openly allowing anxiety to occur and not fighting against it” and “treating your emotions in a more welcoming way.” There are two components to this rationale we want to highlight: (A) how one relates to anxiety, and (B) its emphasis on meaningful living (e.g., values). There’s no one way to craft an ACT rationale for exposure. The main points you may want to emphasize are (A) remaining in contact with anxiety, and (B) the client taking action toward what’s important to them. You’ll also want to avoid an emphasis on controlling anxiety or symptom reduction, which would be ACT-inconsistent. Other ways of describing emotional acceptance include “making space for” and “being present with” discomfort, as well as “allowing [discomfort] to be.” Synonyms for “values” include “things that are important to you,” “what you want to be doing with your life,” and “anything that is meaningful to you.”

Activity Complete this activity on a sheet of paper or in a notebook. •

Take a few moments here and write out words you might use in creating an ACT rationale for exposure. Resist any urges to consult ACT resources for the “right” wording—try to write what feels natural to you. You can revise later. We included a few prompts you may use. ƒ

Through exposure you will learn to…

ƒ

Learning to stay in contact with your anxiety will help you…

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The Willingness Switch In a research study of ACT-informed exposure for OCD conducted by one of us (Brian T), the therapist used a rationale based on an ACT metaphor, the Willingness Switch. There are variations of the Willingness Switch in other ACT sources (e.g., “Willingness Thermostat Metaphor” in Eifert & Forsyth, 2005). We have chosen to present this metaphor because it’s one way to set up an ACT-informed exposure and orient clients to an ACT process that we have found is useful to track in ACT-informed exposure. We have adapted the language for this book: Therapist: I have a metaphor I’d like to demonstrate for you. Imagine you have two switches in your mind. The first switch we’ll call your “anxiety switch.” [Draw vertical line with small horizontal lines at the top and bottom edges and label it “Anxiety.”] Let’s say it is on a scale from 0 to 10, with 0 being no anxiety and 10 being the most anxious you’ve ever felt. [Write 0 at the bottom of the line and 10 at the top, noting a midpoint between the two poles.] When you experience anxiety, how much control do you have over this switch? To what degree can you deliberately dial your anxiety down? Explore this with the client. Many clients will admit they don’t have much control over their anxiety. If a client believes they have control, explore this and the consequences of trying to manipulate the switch (e.g., anxiety intensifies; the client avoids activity). The main point to underscore is that clients cannot control their anxiety as much as they would like and that attempts to do so can make it worse or get in the way of doing activities that are important to them. Therapist: You’ve spent a lot of time trying to control your anxiety switch, but your efforts haven’t been very effective. If anything, it sounds as if your attempts to control may backfire for you. However, we also have another switch, one that we don’t tend to think about. We’ll call this the “willingness switch.” [Draw a vertical line with small horizontal lines at the top and bottom edges and label it “Willingness.”] By “willingness,” I mean choosing to be 100 percent open to any thoughts, feelings, or bodily sensations that show up. We’ll also place it on a scale of 0 to 10. [Write 0 at the bottom of the line and 10 at the top, noting a midpoint between the two poles.] In this instance, 0 refers to being unwilling or trying to make anxiety go away, and 10 means being fully present and allowing yourself to feel anxiety. You’ve

What the Client Needs to Know63

been practicing willingness indirectly in some of the exercises you’ve been doing. What is your experience with willingness so far? [Wait for client response.]

Anxiety

10

Willingness

 0

10

 0

When we experience anxiety, we can choose to be present with that discomfort. When you move your willingness switch, you choose to experience your anxiety rather than to struggle against it. It’s not a trick to make your anxiety go away, but it may keep it from getting worse, and it frees you to do things that are more important to you. Explore with the client. The major points to underline are that: 1. We cannot control our anxiety, but we can choose how we relate to our anxiety. 2. Willingness does not necessarily make anxiety dissipate, but it can keep it from escalating, freeing us to do other things. We offer this metaphor as an example of something that has worked for us in our practices, as the idea of acceptance in exposure can be a hard sell. It also orients clients to the task of learning to track and rate their willingness. The notion of willingness can be conveyed in subtle and nuanced ways. It’s important to choose wording that makes sense to you and the people with whom you work. Some ACT therapists avoid the word “acceptance,” as clients may misinterpret the idea of acceptance as resignation or giving up or being overwhelmed by anxiety. At times, some of us have regretted having “acceptance and commitment therapy” on our web pages, as clients see the word “acceptance” and are preemptively prepared to argue why it won’t work for them. Sometimes the word has become tainted for clients by prior experiences in therapy. We have heard more than once, “My last therapist told to me to ‘just accept it,’ ” the implication being that the client felt invalidated by their therapist, who did not teach them how to accept. You may also frame willingness practice as experiments. What does your mind predict will happen, and what actually happens? Let’s see what happens. Is the actual outcome as bad as your mind imagined? We encourage you to explore nuanced ways of describing the

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reasons for engaging in ACT-informed exposure using words that feel right to you and that your clients are likely to understand. With this in mind, we want to emphasize a few subtle points about willingness that may be helpful in talking with clients. • Willingness is really hard. Take a moment and reflect on all the ways you struggle with willingness in your own life. What do you do when you notice you’re struggling to accept an uncomfortable experience? What are some examples of difficult emotions you regularly find yourself avoiding? Do you struggle with uncomfortable feelings when you’re working with clients who struggle with willingness? Because willingness is difficult, we want to emphasize that it requires practice and practice and still more practice. In fact, exposure is one means to practice willingness. • Willingness takes a lot of work, and it’s never done. We can’t accept 100 percent of the time, as our default is to push away discomfort. When we’re distracted or caught up in thinking (e.g., worry, rumination), we’re often engaging in some form of avoidance. Ultimately, willingness is a choice. Every day we’re constantly controlling and manipulating our experiences (e.g., turning lights on and off; choosing our clothing based on the weather). We don’t have to allow the sun to be in our eyes when we can easily close the blinds. We may choose willingness when control backfires or prevents us from doing something important to us. It’s not a blanket panacea. Willingness is a process, not a destination. It’s never “done” or “complete.” • We can only practice willingness in the present moment. Sometimes a client will say, “You want me to just accept that my life will be ruined?” No, we’re not suggesting that at all. We can’t accept the future; we can only accept that we’re having thoughts about the future and anxiety related to our thoughts about the future. We may practice willingness with the knots in our stomach when we imagine a catastrophic outcome, but we cannot “accept” something catastrophic that has not yet happened. The technical definition of willingness in ACT refers to internal experiences (i.e., emotions, bodily sensations), not external events. When something tragic happens, there will be concrete steps with which to deal with it. Until then, we can only accept that we’re experiencing private events that evoke discomfort. • We can only accept specific private events. We would argue that you cannot practice willingness with “anxiety” because anxiety is too abstract a concept. Anxiety is some combination of thoughts, bodily sensations, and context. We can practice willingness with the bodily sensations that accompany anxiety (e.g., tightness in chest; sweating). This is the basis of interoceptive exposure practice.

What the Client Needs to Know65

Activity Look at the words you wrote out in the previous exercise for explaining ACT-informed exposure. Now write out your own ACT-informed exposure rationale. Underline the key words you want to use. Practice with clients. How do they react? How did you respond to their questions or concerns? Revise and rewrite your ACT-informed exposure rationale until it feels comfortable to you, and you feel confident in responding to client questions about it.

Choosing Exposure Exercises When I (Brian T) was exploring how to conduct ACT-informed exposure earlier in my career, little written material was available. Relatively new to ACT, I decided to aim for a “pure ACT” approach. All exposure exercises were to be cocreated in session with clients based on values. Each session, I would ask clients what sort of exposure felt most important to them “right now,” with the goal of identifying a doable exposure exercise linked to whatever the client was valuing in the present moment. My well-intentioned approach was a total fail. What would happen is that I’d spend the entire session unsuccessfully trying to identify a single exposure exercise with the client. I eventually gave up on this and realized it was much easier to come to sessions with some ideas for exposure exercises, generate other ideas with the client, and then link them to values. One reason for this is that, until clients have experience with exposure, it’s difficult for them to come up with their own ideas for exposure exercises—especially when their anxiety is telling them all the reasons not to do exposure. As clients practice and gain experience with exposure, they can provide more input into the development of exercises. Here are a few points to consider in coming up with ACT-informed exposure exercises. • It’s difficult for clients to create their own exposure exercises—at least in the beginning of treatment. It’s more practical for you to come to session prepared with ideas for exposure exercises to use as examples that may be applicable for clients. If you’re new to exposure therapy, Springer and Tolin’s (2020) The Big Book of Exposures has a collection of them. It takes some practice and experience to develop fluency in coming up with your own. • It’s easier to start with an exposure exercise and connect it with values than to start with a value and connect it with an exposure exercise. (Trust us: we’ve tried, and

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it’s a terribly inefficient way of doing things.) Suggest potential exposure exercises that are practical, doable, and relevant to clients’ difficulties and treatment goals. You can connect them with values later. • Although it may sound good in theory to connect all exposure exercises with values, in practice, it can be really tedious for you and the client. If every single time you and a client discuss an exposure exercise, you must ask, “What feels important to you about this?” the client may start rolling their eyes. Connecting exposure exercises with values may be more important during the first few exposures, as you create the context for exposure. Revisiting values can also be helpful if a client becomes discouraged or has difficulty completing homework. What we are cautioning against is making it a rigid requirement that is likely to create a barrier and reduce clinician flexibility. If an exposure exercise makes sense to a client, and they’re agreeable to it, it’s usually connected implicitly to something that is important to them.

What Do I Track During ACT-Informed Exposure? During exposure, it’s useful for clients to pay attention to their experience. Having clients provide ratings of their experiences allows the therapist and client to assess the impact of the exposure exercises. In traditional exposure therapy, clients rate their discomfort during exposure. A common name for this is the Subjective Units of Discomfort (or Distress) Scale (called “SUDS”—as in soapsuds—for short). In one randomized controlled trial comparing traditional exposure against ACT-informed exposure for OCD (Twohig et al., 2018), therapists in the ACT condition tracked “willingness” scores in place of traditional SUDS using the same forms with minimal changes. Using a 0–10 or 0–100 scale, with higher scores reflecting greater willingness, clients may rate how willing they are to experience discomfort. The Willingness Switch, described earlier in the chapter, offers some guidance for orienting clients to tracking willingness. Some of us have chosen to track both SUDS and willingness scores during exposure. The reason is that, in our experience, willingness can be a tricky concept for clients to understand. Some clients grasp willingness immediately and really connect to the concept. But many others express some confusion or uncertainty about it. Some clients understand it theoretically but require practice in understanding it experientially. Others can be overly perfectionistic in their willingness ratings (e.g., “I’m not sure I’m doing this right!”). This may lead them to underrate willingness for fear they don’t quite get it. For these reasons, we may include SUDS or distress-related scores because they’re easier for clients to grasp. As most clients have little difficulty rating their discomfort, distress-related scores may provide a more accurate window into client experience.

What the Client Needs to Know67

In our experience, willingness and traditional distress scores are complementary. Whereas distress scores provide a glimpse into what the client predicts will happen or into the moment-to-moment experience of anxiety, willingness ratings provide insight into client commitment to or difficulties during exposure. We offer examples of how to interpret willingness and distress scores in chapter 9. Higher willingness ratings often reflect greater client buy-in for exposure. Mid-range willingness scores may indicate forms of covert avoidance during exposure. Below is an example of how we track distress and willingness ratings during exposure. Rate your experiences every _5_ minutes. (Or circle N/A) • Time = Frequency of rating (e.g., five minutes, ten minutes, etc.) • SUDS = Subjective Units of Discomfort Scale (0–10) • Willing = Willingness to experience discomfort without struggle (0–10)

Table 5.1 Time begin

SUDS

Willing

8–9

8

5m

8

8

10m

8

9

15m

9

9

20m

7

9–10

Given our emphasis on how ACT is not about symptom reduction, you may ask, “How is tracking SUDS not a focus on symptom reduction? Isn’t this inconsistent with ACT?” This idea of tracking distress scores may be somewhat controversial among ACT therapists. In anticipation of any potential controversy, we’ll explain how tracking distress can be relevant to ACT processes. One function of rating distress is to encourage clients to pay attention to their momentto-moment experience. It’s not important that it goes down. Asking a client to rate their anxiety during exposure requires present-moment awareness. Clients may learn to observe a wide range of physical sensations, emotions, and thoughts in constant flux at each moment. Directing attention toward the moment-to-moment experience of anxiety also allows clients to practice acceptance or willingness, since one cannot practice willingness unless one is in contact with the present moment. In addition, distress scores can signal problems with exposure as it’s currently being conducted. Changes in SUDS may indicate something is happening during exposure, whether that’s new learning or client distraction or

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disengagement with the exposure (Benito et al., 2018). Scores that remain constant may indicate the presence of resistance or avoidance behavior, as it’s expected that there would be some variance in SUDS even if we’re not applying a conceptual model of habituation. Ultimately, it’s the act of tracking, and what clients’ ratings might reveal, that we encourage you to consider—over and above an emphasis on whether ratings go down. In our view, changes in fear, while imperfect, remain a practical indicator of shifts in client experience during exposure work. That said, we’re not saying you need to track distress-related scores. Some therapists prefer to use willingness scores alone or some other ACT-consistent rating system. Theoretically, ratings could be made for any of the core ACT hexaflex processes. For example, Eifert and Forsyth (2005) offer worksheets that track up to five items. We’ll note here that from a practical standpoint, it increases time and client attention to pay attention to and provide ratings for multiple scales. For that reason, consider carefully what you find is useful for you and your client. We emphasize it is important to ask clients to track something, as the process helps reorient clients toward their present-moment experience of their anxiety and observe what actually happens versus what their minds predict will happen. You might also change what clients track throughout treatment. One of the authors (Brian P) begins with tracking of traditional SUDS, switches to willingness scores, and then combines the two once the client has demonstrated sufficient understanding with each.

Activity Complete this on a sheet of paper or in a notebook. Take a few moments to consider what you want to track in treatment and why. Reflect on why this information may be useful to you and your clients.

How Do I Organize ACT-Informed Exposure Exercises? In traditional exposure therapy, exposure exercises are typically organized by SUDS scores in what is called an “exposure hierarchy,” which was first created by Wolpe (see chapter 2). Items with higher distress ratings are placed at the top and items with lower distress ratings are placed at the bottom, with the sequence of therapy moving from the bottom to the top of the list. The rationale for this approach is that it’s more palatable for clients to move from lesser to greater difficulty, and this may increase treatment retention.

What the Client Needs to Know69

Table 5.2 Example of exposure hierarchy by distress for harm obsessions

SUDS

Place scissors out in bedroom.

3

Place kitchen knife in bedroom.

8

Read article about serial killers.

8–9

Read article about suicide.

10

It’s not inconsistent with ACT to organize exposure exercises by difficulty, but an ACT approach offers other options. One alternative is to organize exercises by willingness ratings. Another is by values. Below is an example of a hierarchy arranged by willingness scores, where items with higher willingness ratings are placed at the top.

Table 5.3 Example of menu by willingness for pedophilia obsessions

Willing

Videoconferencing with niece

10

Spend time at playground while kids are out

8

Read article about pedophiles

6

Watch videos of children engaged in dance routines

5–6

One recent exposure study compared exposures conducted in a gradual (i.e., hierarchical) order against exposure conducted by a variable (i.e., randomly chosen) order in a sample of adults with obsessive thoughts but not diagnosed with OCD (Jacoby, Abramowitz, Blakey, & Reuman, 2019). This study provides evidence there may be some advantage in moving through exposure in a random fashion (e.g., low, then high, then moderate). If you try this approach, it may be prudent to make certain the more difficult exposures are not overwhelming for clients when assigned (i.e., that they can engage in the exposure with high willingness). We caution against choosing an exposure exercise that is so difficult that it will interfere with client ability to maintain willingness and may result in covert avoidance behavior. Some proponents of a randomized approach have suggested selecting a subset of exposure exercises that the client could engage in without being overwhelmed and then selecting them at random from within this subset to increase the likelihood the client will be able to practice willingness during the exercise. Regardless of how you choose to organize exposure exercises—some therapists do not organize them at all—there’s been a recent trend away from an “exposure hierarchy,” which implies a graduated approach. We prefer the term “exposure menu” because it conveys an

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attitude of flexibility with exposure. As with any menu, it is a list of options from which clients may choose. Throughout the course of treatment, the client may not do all of them. For example, some exposure exercises become obsolete for a client because of the completion of prior exercises (e.g., it now would not be difficult for them). As treatment progresses, clients may begin to contribute exposure ideas that are even better than exercises identified at the beginning of treatment. There are other reasons ACT-informed exposure may not proceed in a graduated fashion. For one, client ratings of exposure exercises—whether distress or willingness scales—may change over time spontaneously. However, with some exposure exercises, it may be more useful to continue with graduated difficulty (or willingness)—especially when someone is working through a particular type of exposure. For example, if a client conducting driving exposures is focused on a particular freeway stretch, it may make sense to maintain this focus (e.g., next exit; nighttime; traffic) than switch to different stimuli (e.g., bridges). With other clients, one may shift exposure themes from session to session. In our experience, clients are very capable of determining their next exposure exercise. Once a client understands the process with exposure, you might hand them the exposure menu and just ask, “What do you want to do next?” This can empower clients to be their own exposure therapist and learn to use these skills throughout their lives to prevent relapse. However you choose to arrange exposure exercises, we recommend some form of organization to help facilitate the choice of the next exercise. It’s much harder to choose the next exposure exercise when they’re penciled in an illegible scrawl on notebook paper (we know this from experience, too).

Conclusion This ends our chapter on preparing clients for exposure. Through judicious use of experiential exercises, developing your rationale, and letting clients know what you want them to pay attention to during exposure, you can begin to orient clients to the ACT model and prepare them for ACT-informed exposure. If a client still has a shaky grasp of ACT concepts as you approach beginning the first exposure exercises, we encourage you to continue to move into exposure work if the client is willing. With the emphasis on repetition and paying attention to moment-to-moment experiences, exposure work provides rich opportunities for clients to develop and refine their understanding of ACT principles. It’s not uncommon for clients to say, several sessions into exposure work, “I get it! I now understand why we’re doing this!” The next chapter focuses on what to do during exposure to help clients contact ACT processes and strengthen psychological flexibility.

CHAPTER 6

What to Do During and After Exposure Jefferson used to change his clothing in the garage after coming home from work, because he feared bringing contaminants into his house. Today he agreed to walk outside, touch the ground, and then enter his home without changing. We were working via telehealth. Jefferson positioned his laptop so I could see his living room well, and I heard a door open and then close. When he returned, I gently encouraged Jefferson to touch items around the room. At first, I saw that he was touching things deliberately and cautiously— making a mental list of each object. I recommended he haphazardly rub his hands and clothing on everything he could to the point that he could no longer keep track of everything. Jefferson turned up his “willingness switch” and complied. He ran his fingers across the spines of books in his bookshelf, items he could not decontaminate, and then continued around the room, touching things randomly. After he sat back down in front of his computer, he told me that his first thought when he began touching things quickly was I’m screwed! (Actually, the wording was a little stronger than that.) But then, when he realized he could not undo the exposure because he could not remember everything he touched, he experienced a sense of relief. He was surprised at this. Jefferson had predicted his anxiety would spiral out of control. Instead, when he saw that he could no longer control the contamination, he was able to accept it. The purpose of exposure made more sense to him in a way he had not quite grasped before. Clients new to exposure almost always have some trepidation. They fear being overwhelmed with anxiety, that they may do something they regret and cannot undo, or that they or someone they care about may be harmed as a result of what they do. In our experience, the nuances of exposure practice are difficult for clients to understand until they have firsthand experience of it. Reading about exposure and hearing examples can help clients get on board with the rationale; however, it usually requires some actual experience with it for clients to really “get it.” In order to help clients contact willingness, it depends in part on how they approach exposure. Some clients with high willingness will jump right in with both feet. But more commonly, clients will enter into their first exposure exercises with some caution. This means that your first exposure exercise for a client is critical, because it orients them to exposure in a way psychoeducation cannot. It’s recommended you introduce in-session exposure exercises whenever possible to allow you to guide and observe the process. This is especially important with the first exposures.

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This book was started during the COVID-19 pandemic, when nearly all therapists were practicing telehealth. One benefit of telehealth, especially when it comes to exposure, is that it allows convenient access to stimuli that otherwise aren’t accessible in the therapy room. For example, many exposure targets reside in clients’ homes. Video-conferencing apps allow therapists to travel with clients outside the home through their smart phone or other portable devices to coach them through exposures such as driving or walking in public. To date, research suggests that telehealth conducted through exposure is as effective as in-person exposure (e.g., Abramowitz, Blakey, Reuman, & Buchholz, 2018; Yuen et al., 2013).

Setting Up the Exposure In developing an exposure menu, the client and therapist work together to brainstorm a list of exercises consistent with the client’s values that evoke private events associated with narrowing of client behavior. When it’s time to put these ideas into practice, these rough sketches need to be developed into fully detailed plans. For each activity listed in the exposure menu, make certain you and the client are on the same page. What is the client exactly doing? For how long? In what location? With contamination exposures, for example, there are a variety of ways clients may use their hands after contaminating them. Do they hold their hands close to their body or far away? Are they permitted to wash their hands, and if so, when (e.g., one hour later; before eating)? Should they touch other items (e.g., chairs, books)? Should they touch themselves, and if so, where (e.g., face, mouth, tongue)? Whether an exposure is conducted in session or assigned as homework, the therapist and client should work through all necessary details so that both agree to what the client will do. If an exposure assignment is too vague, clients may be confused or frustrated. They may misinterpret the instructions in ways that undercut the effectiveness of the exposure. The process of coming up with specific steps and parameters for each exposure on the menu is also an opportunity to highlight committed action strategies—taking actions toward a meaningful life direction—such as demonstrating how we are more likely to follow through with challenges when the actions are concretely defined, scheduled, and realistic. For example, identifying when a client practices exposure (e.g., immediately after work, at around six) increases follow-through, because clients have a clearer idea of whether they’ve accomplished it at a certain point (e.g., It’s six-thirty, and I haven’t done my practice yet!). By contrast, leaving exposure procedures vague (e.g., sometime during the day) may allow clients to more easily delay until it’s too late (e.g., I don’t feel like doing it now. I’ll just do it later.). When exposures are initiated in session, you’re better able to figure out the details as you and the client go along. You might suggest ways in which clients may continue to challenge themselves, depending on how they respond to the exposure. In the example above,

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Jefferson initially didn’t consider that he might touch items he couldn’t decontaminate later. That seemed impossible! Jefferson began the exposure under the assumption that he’d be able to undo it if he felt too anxious. The therapist wasn’t aware of Jefferson’s implicit assumptions at the time. These details would be worked out at the end of session before assigning the exposure as home practice. If Jefferson hadn’t been willing to contaminate items he couldn’t decontaminate later, we would have needed to agree on an alternative procedure. For example, we might have specified a period of time Jefferson would wait before decontaminating. Fortunately, Jefferson was aware he was holding back and was willing to trust the suggestion that he contaminate his home with a seemingly reckless abandon. He both grasped the rationale for why I pushed him and was also surprised at the relief that greeted him when he followed through. When developing an exposure menu, it’s common that clients may underestimate what the therapist has in mind for the exposure. For example, a client predicts that touching a bathroom sink with their hands will be a “10” on their distress scale. When the therapist then asks that client to predict their distress or rate their willingness if they were then to rub their hands on their face, eyes, and tongue, they may be caught off guard (“What? I thought I was going to be able to wash my hands right away!”). For these reasons, it’s useful to identify potential misunderstandings before beginning the exposure and try to clarify them. Even though you may have agreed upon including a particular exercise from the client’s exposure menu, you and the client may have different ideas about its execution. So it’s best to talk through each one when it comes time to carry it out. That said, it’s not necessary to figure out all the details well in advance, since so much can change between the time you develop the exposure menu and the time you get to each individual exercise. Also, clients often increase their awareness and understanding of their avoidance behaviors with practice. Some exercises may become obsolete as clients strengthen their psychological flexibility. Ultimately, the exposure menu is a living document, subject to revisions and re-ratings, and it’s best to not assume that what was outlined several weeks ago will be as relevant later. In developing a plan for an exposure exercise, it’s also important to think through the exposures functionally: to consider what is likely to happen during the exposure, what private events your client may experience, and what they may be ready or not ready for. Could something unpredictable occur that might take them by surprise or unexpectedly increase the difficulty of the exposure? Is there something that might overwhelm them and cause them to discontinue the exposure or engage in avoidance behaviors? Deliberate avoidance behavior during exposure will undercut its effectiveness, like how Jefferson initially kept track of which items he touched so that he could undo them later. However, an exposure’s difficulty may be decreased to meet client willingness to experience discomfort while engaging in the exposure. If Jefferson had not been willing to run his fingers along his bookshelf, perhaps he would have been willing to touch all the chairs first and wait at least a day before deciding if he wanted to decontaminate them.

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How Long Should Exposure Exercises Be? In traditional exposure, such as prolonged exposure therapy for PTSD (PE), the length is prescribed: forty-five to sixty minutes, or until client’s distress decreases by 50 percent (Foa et al., 2007). When one of us (Brian T) began transitioning from traditional exposure to ACT-informed exposure, one of his first struggles was identifying the optimal length of time for exposure exercises if habituation was not the goal. Even as newer research indicated that decreases in distress are a poor predictor of treatment outcome (e.g., Craske, Treanor, et al., 2014), the concreteness of this approach was appealing. However, despite decades of focusing on a recommended amount of time for traditional practice, even hardcore PE researchers have since questioned the need for longer exposures. Studies have since found no difference in treatment outcomes in PE for PTSD between sixty and thirty minutes (van Minnen & Foa, 2006) or between forty minutes and twenty of imaginal exposure to trauma memories (Nacasch et al., 2015). It appears that imaginal exposures as brief as twenty minutes can be as effective as longer imaginal exposures. This shift is important for practical reasons as well: when billing codes in the US were revised in 2013, the ninety-minute session was phased out in favor of a sixty-minute session, making it more difficult to bill for the ninety- to 120-minute sessions recommended in traditional exposure protocols. Due in part to the reasons stated above, longer exposures can be more burdensome for clients and clinicians in terms of time and cost. From an ACT perspective, the question of “how long?” has many possible answers, depending on the aims of the exposure. As we have repeated throughout this book, it’s important to consider the functional relationship between the fear and the chosen exposure exercise. What does the client expect to happen, and in what amount of time? How long do they predict they can remain in the exposure? If an exposure exercise lends itself to varying the amount of time, you might approach this is by asking a client, “How long are you willing to engage in an exposure?” This question can be more complicated than it appears on the surface. For example, a client might respond “thirty seconds.” While thirty seconds may be a place to start, it also means the exposure may end before the client has an opportunity to practice psychological flexibility; that is, to practice new behaviors in response to uncomfortable stimuli. For example, if Jefferson had contaminated an item and then decontaminated it after thirty seconds, he wouldn’t have learned that he can be present with his anxiety for much longer than he had initially predicted and that he could accept contaminating in ways that he cannot later undo. Somewhat counterintuitively for clients, shorter exposures are not always easier, because they may end before the client has a chance to have an experience that is different from what their anxious mind predicts. Think about any experiences you’ve had with public speaking: you may feel most nervous when you first talking, but as you start getting into the material you’re presenting, you may gain flexibility. Sometimes it may even start to become fun! If all your public speaking experiences were limited to thirty seconds, you may never learn you can enjoy it.

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In ACT-informed exposure, it’s useful to engage in exposure long enough for clients to learn that they can be fully present with their discomfort without engaging in avoidance behaviors, which increases their confidence in their ability to do so again. Even simpler ACT defusion exercises, such as saying a word repeatedly, require a minimum number of repetitions to start to alter the function of how you experience the word. In driving exposures, if someone enters the highway and leaves at the next exit, there may not be enough time for them to engage in valuing while driving or to practice willingness with panic sensations. For someone who is afraid of impulsively killing themselves or someone else, they may need to leave a sharp knife out for the entire span of time between weekly sessions, until the knife transforms from a potential weapon back into a common kitchen item. If the client removed the knife from the drawer, set it on the countertop, and then quickly put it away again, this sequence would likely reinforce the fear (e.g., Good thing I put the knife away before anything horrible happened!). Sometimes an exposure exercise takes place over a longer time frame to directly target specific rule-governed behavior or acceptance of uncertainty. If a client predicts they will be struck dead within one hour of saying something blasphemous unless they repeat a prayer to neutralize their blasphemy, it may be useful to extend the exposure longer than one hour to truly test what happens when they do not pray and their ability to accept any discomfort. This is part of what is called “expectancy violation” in inhibitory learning theory—setting up exposures to challenge the client’s prediction in the most extreme manner that can be reasonably executed (Craske, Treanor, et al., 2014). If a client without diagnosed allergies fears that eating a new type of nut will cause an allergic reaction and that each nut consumed increases the risk, you might identify the specific number of nuts that their mind fears will most likely cause them to have an allergic reaction. For example, if the client believes eating five pecans is more likely to trigger an allergic reaction than one, the client would eat five. When there is a finite timeframe or threshold within a feared prediction, it’s useful to clarify this with the client and match the exposure accordingly. Contacting the actual contingencies of their actions can help to undermine rigid verbal rules that maintain avoidance behavior (e.g., “I will become so anxious that I will lose my mind”). In many instances, clients engage in avoidance behaviors not because they’re worried about the feared outcome but because they fear they will be unable to cope with their anxiety if it escalates. This nuance bears repeating, because it’s subtle, and many clients may not even be conscious of this distinction. For many clients, the feared outcome is not necessarily a specific catastrophe so much as the fear of being overwhelmed with anxiety. For these reasons, many exposures only need to be long enough for clients to realize they can be present with whatever distress they’re experiencing. Sometimes an exposure may be oriented around a value. For example, a client with social anxiety may choose to eat out at a hot new restaurant because they love food. A client who is afraid to drive outside of a limited area may agree to drive their kid to a park

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outside that limit because they value being a loving parent. In these examples, the valuesbased activity also has a natural beginning and end to it, so it’s less relevant to set an amount of time for the exposure. For some clients, engaging in values-based exposures at times during treatment may be helpful in enhancing motivation and demonstrating the benefits of the hard work required in exposure therapy. In sum, the length of exposures in ACT-informed exposure varies based on the functional relationship between the feared outcome and exposure procedure. How much time is needed for the client to practice a new behavior in response to their triggers? Consistent with recent PE research (Nacasch et al., 2015; van Minnen & Foa, 2006), twenty to thirty minutes is a useful rule of thumb, as it fits within a standard therapy session and is not too time-consuming for out-of-session practice. However, exposure may be longer or shorter, depending on the functional relationship between the core fear and procedure. We recommend not getting too bogged down with specifying time requirements. Be flexible! Encourage clients to challenge their fears while also demonstrating an openness to negotiate. That said, it’s important that the client does not end the exposure prematurely, as that would risk reinforcing the avoidance behavior. You might say, for example, “Whatever we agree to, I want you to be 100 percent committed to it. I would rather you agree to do a twenty-minute exposure and complete the twenty minutes than to try for forty minutes and end it after thirty. Otherwise, your anxiety is making the choice, not you.”

Therapist Behavior During Exposure If you interview a sample of exposure therapists, you will discover that we all vary in what we do with clients during in-session exposures. Some of us talk with them; others don’t. Some of us do the exposures with clients, if possible, while others stay in the observer role. Our goal is not to editorialize about what way is better or worse. Rather, we want to share with you how you may approach exposure therapy with the aim of enhancing core psychological flexibility processes in session.

Joining Clients in Exposure When practicing in-session exposure, it’s recommended that therapists model willingness to do exposure with clients (Jordan, Reid, Guzick, Simmons, & Sulkowski, 2017). Of course, some exposures lend themselves to therapist participation more than others for practical reasons. And in our experience, therapists also vary in their willingness to join clients in exposure.

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We should all be aware of our triggers, limits, and blind spots as therapists and be thoughtful about when we do and do not join clients in exposure—considering this question functionally. There are some in vivo exposures for which therapist participation is more sensible than others. For example, joining clients in contamination exposure conveys a sense of collaboration and teamwork, as does joining in the task of engaging in taboo behaviors. By contrast, a client afraid of driving over bridges due to fear of having a panic attack doesn’t need to witness their therapist demonstrate their own comfort with bridges. If we were to distinguish functionally between these two examples, what separates them is how widespread the client views the risk. For many clients with concerns about contamination, for example, anyone is at risk of getting sick, even if they recognize they may be overly cautious. For many driving-related fears, clients worry that they—but not necessarily others—could have a panic attack while driving and become overwhelmed or get into an accident. In short, it can help build rapport by joining clients in exposures when it’s practical to do so and when clients believe that you’re also at some degree of risk or discomfort. By contrast, it’s not necessarily helpful to do exposures with clients when they view the trigger as something unique to them; in fact, doing so may feed into client self-criticism that they are struggling with something “normal” people don’t. Within ACT-informed exposure, conducting exposure with clients allows the therapist to contact ACT processes within themselves. As you consider the degree to which you already join or intend to join clients in exposure, reflect on your reasons by asking yourself the following questions. What do you value about joining clients in exposure? Does it help you convey to clients that you’re in it together or that you care enough about them to expose yourself to risk? What thoughts come up during exposure and how do you relate to them (e.g., I don’t want to do this even though I technically could. What if I get sick?)? Is your willingness low? Would you be open to increasing your willingness in the service of joining a client in something uncomfortable? Note that therapist participation in exposure can implicitly provide reassurance to clients in ways that aren’t always unhelpful. However, as any therapist-authorized exposure carries with it a whiff of reassurance, this cannot be completely avoided. For this reason, clients may struggle more with out-of-session exposure practice, when the therapist isn’t there. When clients are new to exposure, and you suspect an exercise you’ve done in session may be more difficult for them when they’re alone, you might let them know, so it’s not a surprise. You might ask how much more difficult they think it will be to do something on their own. In some out-of-session exposures, it can be helpful for clients to practice first with someone they trust and then do them on their own. Thoughtful loved ones can be great exposure coaches. Regarding interoceptive exposure to bodily sensations, the writers of this book differ in their approach. One always does interoceptive exposure with the client (Brian T) and two

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only engage sometimes (Joanne; Brian P). One reason the first author engages in interoceptive exposure is to model willingness and to contact his own avoidance. When he finds himself holding back from performing the exercises with gusto, he tries to notice that and increase his own willingness. It also provides a window with which to help clients label bodily sensations. After hyperventilation practice, for example, you might offer, “I noticed my palms started to sweat after this second hyperventilation. Did you notice any new sensations?” Again, we encourage therapists to err toward doing exposure with clients, because it builds a sense of partnership, facilitates sharing of experiences, and can offer insights to what the client may be experiencing. However, it is important to know and respect your own limits in what types of exposure you may or may not be willing to engage in. In any event, whether you choose to do exposure with your clients or not, it’s useful, from an ACT perspective, to reflect on how you hope to practice your values in your work with clients. Let’s consider some questions about that now. Below, you’ll find some questions to help you consider the ways you might practice ACT principles in the task of conducting exposure with your clients. Complete them on a sheet of paper or in a notebook.

Activity: Making Exposure Committed Action ƒ

What do you value about joining clients in exposure?

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Consider exposure exercises you are not willing to do. What thoughts, feelings, and bodily sensations, do you consider barriers to specific types of exposure exercises?

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What ACT process do you contact when engaging in specific exposures? Consider the examples given below, then make your own notes. ƒ

Values (e.g., I value joining clients in exposure even if I experience discomfort because I want to convey a shared purpose and collaboration.)

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Willingness (e.g., I am willing to feel nauseous and dizzy to join my clients in interoceptive exposure to spinning.)

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Defusion (e.g., I can have the thought, What will others think of my browser history? and still look up provocative images and videos for my clients.)

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Self-as-context (e.g., My stomach feels nauseous, I’m starting to gag, and I’m having the thought, I think I might throw up, yet I’m still willing to hyperventilate with the client.)

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Contact with the present moment (e.g., I can be present with my discomfort and still guide my client through a difficult exposure.)

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What to Talk About with Clients During Exposure During a professional exposure workshop one of us attended, the presenter, a respected anxiety researcher, reflected that when he first trained in exposure, he would often sit and read a newspaper for an hour while the client engaged in the exposure. This is an example of traditional exposure, where the focus is on habituation. While this might be an extreme “old school” example, it was not uncommon for new therapists to be trained to have minimal engagement with clients during exposure, such as checking in only every five or ten minutes for a distress rating. One theoretical reason for minimal engagement during exposure is that talking could function as distraction and disrupt the process of habituation. As the goal in habituation models is for clients to get used to the feared stimulus over time, it was believed that engagement with the client might interfere with this process. In ACT-informed exposure, as one goal of exposure is to increase psychological flexibility in how clients relate to inner experiences, it’s important for clients to be aware of thoughts, feelings, and bodily experiences. Therefore, the therapist’s engaged presence can be helpful in encouraging clients’ attunement to internal experiences, especially if there’s a risk that anxiety may overwhelm their ability to observe private events. Without therapist guidance, clients may also be engaging in covert forms of avoidances such as distraction and may miss the opportunities to practice observing their moment-to-moment experiences. Assessing distress scores throughout exposure serves this function to some degree, as it requires that clients pay attention to their experience as they provide ratings. However, the use of a willingness rating in ACT-informed exposure is a more expansive way to further expand client awareness of inner experiences, as it asks clients to pay attention to both their engagement with exposure and how they’re relating to uncomfortable private events. Whatever ratings you choose to use in your practice, you’ll want to ask ACT-consistent questions during exposure to increase client awareness of and contact with private events. From an ACT perspective, one way to conceptualize communication during exposure is that it’s a means to change the context in which the client is experiencing anxiety. Altering the context can alter the function of stimuli, and it may allow clients to slow down and really notice internal experiences they may otherwise overlook. For example, labeling emotions may strengthen psychological flexibility processes such as contact with the present moment (bringing attention to what the client is feeling), self-as-context (observing and describing private events from an observer self), and defusion (labeling a thought or emotion creates distance from the experience). Clients may observe that the bodily sensations they fear aren’t as intolerable as they thought when they’re asked to describe them in precise detail. Or asking a client with emetophobia (i.e., fear of vomiting) what they notice when watching people’s facial expressions during videos of people vomiting may lead to an observation that surprise is one of the qualities that makes vomit so scary to a client. Judicious use of humor can help a client through a moment of great tension by conveyng a shared experience, increasing client engagement in exposure (Jordan et al., 2017)

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and potentially enhancing ACT processes. One therapist, while he and his client (who feared he was a pedophile) watched a clip of children dancing, noticed that he was really getting into the clip with each repetition, nodding his head to the beat of the music. To demonstrate that it’s not taboo to enjoy watching children dance, he shared, “You know— I’m really enjoying this! They [the dancers] look like they’re having a good time!” These sorts of self-disclosures also convey that exposure doesn’t need to be grimly serious. It’s okay to be playful. With humor, we do recommend the therapist exercise caution, as there is a risk it can be experienced as invalidating to clients. Fears that may appear lighthearted or silly from an outside perspective can still be experienced as terrifying by those who struggle with them. Clients may even feel frustrated by the intense anxiety associated with a fear they objectively know is impossible (e.g., forms of magical thinking)—and to use humor in such a situation can be especially invalidating. For these reasons, it is safer to share one’s personal experience during an exposure than to try to make a more objective comment that risks coming across as invalidating or judgmental (e.g., “You don’t really believe the socks you wear to bed will cause an earthquake the next day, do you?!”). Below are some ACT-consistent prompts you may use during exposure. Although we have loosely organized them by ACT hexaflex processes, we want to acknowledge there are not always clear boundaries between them.

Willingness or Acceptance • Can you make space for those uncomfortable sensations? • What would it be like to open up to this feeling and be fully present with it? • Breathe into that sensation, not trying to change it or make it go away, but letting it be there.

Cognitive Defusion • What is your mind telling you right now? • Would you be willing to say that thought out loud? What did you notice? • How helpful is that thought?

Present-Moment Awareness or Contact with the Present Moment • What’s coming up for you right now? • Where is your attention right now? • See if you can fully be right here in this moment.

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Self-as-Context or Flexible Perspective-Taking • What bodily sensations do you notice? Can you notice yourself noticing that? • Which part of you is showing up right now? • If your friend were watching you here today, what would they think?

Values • What is important to you about doing this exposure? • If you could accept this discomfort, what would you be able to pursue that you are not doing right now? • What does this feel like a step toward doing?

Therapist Disclosure During Exposure In modeling psychological flexibility, it may be useful for therapists to disclose their own experiences that occur during an exposure exercise. As we noted during the section about using humor, we recommend caution here. The therapist does not want to give the impression that they are a superbeing or to sound like an ACT caricature (e.g., “I am so willing right now!”; “I was connected to my values the whole time!”). The goal in sharing should always be for the client’s benefit, such as modeling how you, the therapist, also feel uncomfortable when you’re doing difficult things—which is a way to establish for clients how common to all humanity the experience of anxiety is. Clients typically idealize anxiety therapists as people who do not struggle with anxiety, when, in fact, many anxiety specialists choose an anxiety specialty due to their own personal experiences and difficulties with anxiety. At the next conference or training of anxiety specialists you attend, try noticing any of the following behaviors: awkward hugs, fidgeting, nervous laughter, averting eye gaze, and talking more quickly than usual. Odds are that you’ll see many of them! Sharing with clients that we also have intrusive thoughts, worry about trivial matters, and experience panic symptoms can be a powerful insight for them to adjust their expectations about how success comes from living with, not outside of, anxiety. In the end, you’ll want to consider the function of sharing your experience. For instance, if you want to demonstrate to a client that you, too, can be uncomfortable watching a violent video clip, you might share how grossed out you were: “I was surprised at how many times we watched that scene from The Exorcist before I stopped flinching! I then started to notice how the sound effects made what was actually onscreen seem so much worse!”

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Here, the therapist is also modeling how their experience of the stimuli changed over time and that they noticed new features of the experience the longer they stuck with it. This can be a helpful teaching point to encourage clients to pay close attention to stimuli during each repetition, as their experiences of stimuli may change. In interoceptive exposure, as noted earlier, the therapist may share their physical sensations to model for clients how they can label their own sensations and to demonstrate that therapists also experience discomfort (e.g., “I feel pretty nauseous right now!”). This can be helpful in many ways, such as teaching a client that everyone’s anxiety manifests differently or strengthening the alliance by demonstrating that the therapist is willing to experience discomfort as part of treatment for the client. Of course, it’s not always necessary to share, and any sharing you do should always be in service of the client. The general rule of thumb is to consider disclosing if you experience genuine discomfort or have a personal reaction that can model ACT processes to the client. In short, it is most helpful to share experiences in which you model being human, with all the fallibilities and imperfections this implies, or to highlight the experiences that help bring you, as the therapist, down to earth in your client’s eyes. We encourage therapists to be flexible and find their own voice and style in use of selfdisclosure during exposure. It’s okay to make mistakes—this is useful modeling as well. You may say things that backfire or have the opposite effect than you intended. In our experience, trainees we’ve supervised sometimes feel inhibited by a need to say the “right thing” or a fear of saying the “wrong thing.” Fused with these thoughts, they don’t say much at all. Did we mention anxiety therapists can also be perfectionistic? Whether you are new to exposure or have been practicing for years, we encourage you to experiment with different methods to expand your repertoire for talking during exposure. It can be easy to fall into the same, stale, boring patterns. Take a few minutes to think about the prompts in the following exercise—maybe even writing your answers out somewhere, if you feel it’d be useful.

Activity: Orienting Clients During Exposure •

What do I usually say during exposure?

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How can I try something new? What can I do to expand what I say to clients?

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If I were to be really bold during exposure, I might…

Talking That Increases Engagement Versus Talking That Distracts In therapy, asking clients to describe their experiences during exposure can increase engagement; it can also just as easily serve as a distraction. Probably all therapists who track

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distress scores have had the experience of clients attributing decreases in distress scores to being distracted. In a study by Benito et al. (2018), the researchers reviewed hundreds of video recordings of exposure sessions to help distinguish between changes in client experiences that occurred because of avoidance or distraction and changes that occurred through engaging the exposure. They found that changes related to exposure engagement predicted good outcomes, whereas changes from distraction and avoidance did not. Although we want to be mindful of clients using distraction to avoid exposure, from an ACT perspective, a little distraction can be a sign of psychological flexibility. Many clients would not predict that they’d be able to think about anything else during an exposure exercise. Think about when you were first learning to drive; you may remember that you struggled with any sort of distraction—even having music playing! Maybe this still comes up when you’re driving somewhere new (e.g., “Don’t talk, please. I’m looking for the cross street.”). As you became more experienced with driving, though, you became comfortable enough at the wheel that you could enjoy having the radio on or someone next to you to talk to as you drive. It might be helpful to think about varying your degree of interaction from exposure to exposure to see how your client reacts to your presence and conversation in the moment to assess their flexibility in responding. For example, you might notice signs of flexibility such as the client’s making lighthearted jokes or observations. You may also want to experiment with periods of silence so that clients can practice paying attention to their internal experiences and staying present with anxiety on their own as a way to bridge in-session exposure with out-of-session homework. Ultimately, being able to shift back and forth from focusing on internal experiences to casually chatting with the therapist during exposure helps train clients in psychological flexibility. Our concern is more with excessive or rigid forms of talking, such as when a client is clearly putting forth intense effort to distract or reassure themselves; those are the forms you’ll want to avoid.

Increasing Psychological Flexibility by Varying Intensity During Exposure When freed from an emphasis on habituation à la traditional exposure, there are many reasons therapists may want to increase the difficulty of the exposure during in-session practice. For one, variability in distress during exposure is related to better outcomes (Culver, Stoyanova, & Craske, 2012; Kircanski et al., 2012). This makes sense given that real world encounters with anxiety-provoking stimuli are likely to be less predictable than assigned exposure exercises, which are, by design, typically more controlled. Similarly, creating structure around exposure exercises is important, especially in the beginning of treatment—but the structure of exposure practice can become a hindrance if it doesn’t generalize

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to clients taking opportunities to challenge themselves spontaneously outside of session. Varying the difficulty of exposure in session is one way to give clients the texture of real experiences of anxiety-provoking stimuli in a way that can generalize to their lives out of session. Said another way, if a client’s experience with exposure is limited to structured, predictable exercises, they may struggle to spontaneously approach stimuli when opportunities unexpectedly come up in their daily lives, or they may relapse if they encounter an unexpected trigger. Additionally, varying the difficulty of exposure in session can help to gently challenge clients who may overestimate the difficulty of an exposure exercise or who initially agree to only a conservative exposure exercise. We should note that the therapist should be explicit that clients can freely choose to intensify exposure or not, and that it’s helpful for the client to spend some time in the stages between escalations to practice core psychological flexibility skills with each adjustment to the exposure task. In this way, clients benefit from learning they can often handle much more than they had predicted—or that they feel more engaged the more willing they are. Some warnings do apply. The therapist should never surprise the client by amplifying the exposure significantly beyond what was agreed upon. Therapists should also not force a client to do more than they are willing. Here, the metaphor of a coach may be useful. It’s a coach’s job to coax out the best performance of an athlete by helping them to repeatedly step outside their comfort zone. Pushing athletes too little or too much can easily be seen as ineffective in the mutually agreed upon goal of athletic performance. Similarly, as a therapist, you should pay close attention to your clients and flexibly adapt your responses during exposure to keep the goal of increasing the client’s psychological flexibility in mind.

After Exposure It’s important to leave time after an in-session exposure to debrief what happened and clarify out-of-session practice. This is an opportunity for clients to consolidate what they learned. As clients often have insights into their experiences the therapist may not predict, we recommend starting broadly: “What did you learn from the exposure today?” If the therapist is lucky, the client spontaneously describes what they learned in ACT-consistent language, shares how it was less difficult than predicted, and expresses enthusiasm for continued exposure work. And sometimes this exact thing happens. For example, a client might say something like, “It was hard to be with the discomfort, but it also felt empowering to stay with it, and my thoughts started to seem less believable!” But often, some additional questioning is helpful in shaping client consolidation of learning. For this reason, it can be useful to take notes during in-session practice, to talk through any changes in client experience during exposure, and to place client experiences in an ACT context. If a client states

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they simply felt anxious, you might note if they were less anxious than they predicted or they did not feel as overwhelmed as they had expected. We will discuss specifics in the section “Troubleshooting Exposure” later in this chapter. If there were fluctuations in exposure ratings, you might respond with: • “I noticed your willingness decreased during the exposure, that you were less willing as time went on. I’m curious what was going on for you there.” • “It looks like exposure became more intense after ten minutes, then felt less intense five minutes later, and then was more intense again toward the end. What was happening in your experience?” • “You really increased your willingness quickly during the exercise! I was wondering what was going on.” During the debrief, it’s helpful to reinforce effective client behaviors such as their willingness to stick it out or courage to engage in exposure therapy. Some clients are so focused on their own anxiety that they may perceive the exposure as a failure because of how they are feeling. Focusing too much on feelings can be a trap, as the goal of exposure is not to make anxiety go away. Instead, focusing on behaviors, such as the way they approached anxiety-provoking stimuli rather than avoiding them, can help enhance psychological flexibility and shape clients into moving toward scary things when it’s important to them. Sometimes it can be useful to highlight how well they responded while they were experiencing intense anxiety to illustrate how the experience of anxiety can be compatible with being a high functioning individual (e.g., “Here you were on the edge of panic, yet you still worked hard to remain polite with the shopkeeper—to be the kind and respectful person you want to be in those situations despite wanting to lash out with frustration!”). By using supportive language, tone of voice, and body language, therapists can do a lot to help create the context in which it feels good to do hard things, and they can increase the likelihood that these adaptive client behaviors generalize outside of the therapeutic encounter. Be sure to ask any questions you pose to your client from a place of genuine curiosity. Make a big deal out of a client’s first completed exposure. “You did it! That was amazing! Imagine how your life would be different if you could do more of that!” Following the debrief, it’s important to define the out-of-session practice you want your client to engage in. The same practice may be conducted out of session as it was in session, or there may be adjustments based on what you learned in session. It can also be helpful to identify when the client will practice (e.g., after work, by six) to increase likelihood of compliance. Some clients are conscientious enough to budget the time on their own; others may require more specific and structured instructions. We have included troubleshooting about out-of-session exposure exercises below.

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When Is a Client Ready to Move onto a New Exposure? In ACT-informed exposure, in the absence of habituation or focus on traditional distress scores, how do you know when a client is ready to move from one exercise to another? A functional approach is useful here. Are they able to consistently practice psychological flexibility when in the presence of stimuli that they had previously avoided or responded to in a restricted fashion? Does the client feel ready or willing to move on to a similar but more difficult exposure exercise? Are they getting bored with the exercise, or is it under-stimulating? In our experience, adult clients quickly become excellent at assessing when they’re “done” with a particular exposure exercise. They learn to recognize shifts in how they relate to anxiety-provoking stimuli and are ready for a new challenge. The therapist could ask, “Do you feel ready to move on, or would you like more practice?”

Troubleshooting Exposure Here are some common problems with ACT-informed exposure and suggestions for addressing them. Before we go into specific questions, we’ll present a case illustration of how the therapist may ideally set up each exposure to sidestep potential problems and maximize success.

•  Case Example: Samantha Samantha was a client in her twenties who struggled with concerns around contamination and health-related fears. Her exposure practice for the prior week had been to repeatedly read an article about young people with colon cancer for thirty minutes daily. She was usually friendly and engaging, but today she looked weary and tired. She said she had practiced exposure to reading the article on two days for twenty minutes each day and had not filled out her practice form—both signs of poor compliance. When I inquired what her experience with the exposure had been, she responded that she spent the week obsessing about skin cancer and wanting to contact a dermatologist. Although Samantha had chosen the article herself from several options, I’d been concerned the article was too difficult for her at this stage in treatment. Additionally, we’d only had ten minutes in our last session for in-session exposure to the task of repeatedly reading the article—allowing her only enough time to read it about three times—and she had remained fused with the content at the end of the session. In other

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words, she had not had an opportunity to strengthen psychological flexibility during the in-session exposure. In prior sessions, Samantha had done well exposing herself to contamination fears—touching items that had been lying on her hardwood floor and eventually walking barefoot on it. However, we were just beginning this new type of exposure of reading articles, and although Samantha had accepted the rationale that repeated reading of the article would help her gain some distance from and greater perspective on these fears, she remained skeptical that reading health-related articles would be helpful. Her skepticism was based in her learning history: whenever she read or heard about cancer, she would begin to obsess about it. In her experience, reading about cancer resulted in obsessing about cancer. So we tried to adjust the exposure task by choosing a less triggering article. The new article was about a rise in colon cancer, and it was drier, presenting a series of facts and statistics without any personalized stories of specific people as in the prior article. Per Samantha’s request, I explained the rationale for using the article for exposure. Check-in and homework review were kept brief to allow more time for exposure within the session. Samantha repeatedly read the article for forty minutes in session. By the end of the session, she had reported an increase in willingness (from 6 to 8 on a 0–10 scale) and a decrease in SUDS (from 6 to 3–4 on a 0–10 scale). She seemed more engaged and relaxed. When I asked what she learned through the exposure, she said she had noticed how initially, she had focused on researcher quotes that were more catastrophic and had paid less attention to the more nuanced passages. This time around, as Samantha was able to read the article with a slightly more defused perspective, she noticed more balance in the information presented. For instance, through repeatedly rereading the article, Samantha was able to notice that some doctors and researchers cited in the article believed increases in colon cancer among people her age remained statistically small and did not warrant earlier testing, which also carried risk. Maybe the risk wasn’t as bad as she had assumed. Samantha had also demonstrated contact with self-as-context in that she was able to observe the shifting ways she interacted with the article from greater to less fusion with content. She remained fearful of cancer but was able to acknowledge how her anxiety initially interfered with her ability to take in the full content of the article until she had read through it several times. In sum, Samantha had expressed an experiential understanding of the exposure exercise. In discussing this case example, I want to highlight two recommendations: 1. As much as possible, choose exposure exercises that are at a difficulty at which clients can truly practice psychological flexibility. One pitfall with a focus on purely

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values-based exposure is that clients may choose exercises that are important to them but may be too difficult. Think of psychological flexibility as a muscle that may initially be a little weak and becomes stronger with practice. Working with your client to determine accurate distress or willingness scores for different tasks may help you gauge an appropriate exercise at each point in treatment. Sometimes we may allow a client to choose an exposure we predict may be too difficult for them because it’s particularly important to them; however, we may then adjust it if they struggle with the out-of-session practice (e.g., if they are consistently overwhelmed or engage in avoidance behaviors). 2. Allow enough time in session for the client to understand experientially why the exercise may be useful for them. Said another way, allow enough time for the client to experience some increase in psychological flexibility during the exposure exercise. For example, Samantha fully expected to obsess about cancer after reading the articles. It did not occur to her that through repetition, she would be able to read the articles with greater nuance, clarity, and objectivity. This is especially important in the beginning of treatment, and it can remain important when beginning a new type of exposure (e.g., transitioning from imaginal to in vivo). Earlier in treatment, Samantha intuitively grasped how touching potentially contaminated objects allowed her to develop a new relationship with them. When we shifted to a different type of exposure—reading articles about health-related fears—her experiential understanding from her prior exposures did not translate to this newer exposure until she was able to spend more time reading and rereading a particular article and responding with increased psychological flexibility.

Common Problems in ACT-Informed Exposure As exposure therapists, flexibility is key to responding to complex issues that may arise and cause roadblocks in the process. In our discussion below, we’ll take you through the many different problems that therapists may face when doing exposure, as well as guidelines to consider as you try to work through them.

Client Refuses to Engage in Exposure Although it happens less frequently than might be expected, sometimes clients refuse to engage in exposure. There are many reasons for this. Here are some common solutions. • Return to your rationale. The more time you spend orienting clients toward the usefulness of exposure starting from the first session (see chapter 5), the less this is

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likely to happen unexpectedly. If a client is resistant to exposure, they will likely make this known early on. Sometimes reaffirming that there is no way around pain but through it and revisiting the consequences of their efforts to avoid discomfort (e.g., creative hopelessness) may augment motivation. • If a client refuses an initial exposure exercise, offer to adapt the procedure to something the client is willing to engage in or choose a different exposure. Offer to tweak the procedure in ways that allow the client to increase willingness. One important point: whatever you agree to, the client should be committed to following through with the exposure while resisting urges to engage in avoidance behaviors. Be mindful of signs the client may engage in exposure half-heartedly. Any deliberate engagement in avoidance behavior risks undermining the exposure. There may be ways to titrate the difficulties of the exposure, such as including the presence of a loved one, shortening the duration, or changing the time of day.

Ambivalence About Out-of-Session Practice Although there are some exposure-based treatments that do not require out-of-session practice, such as written exposure therapy for PTSD (Sloan & Marx, 2019), out-of-session practice is very important in exposure therapy (e.g., Abramowitz, Franklin, & Cahill, 2003). In our experience, anxiety clients tend to be on the conscientious side, yet homework compliance can still be a problem. Sometimes it’s easier when a client doesn’t practice at all, because you can more clearly address it. When practice falls somewhere in the middle (e.g., three out of seven days or five minutes instead of twenty), it can be more difficult to assess if practice is too inconsistent to allow the client to progress and to gauge client commitment. This is where a functional approach can be helpful: 50 percent compliance can be interpreted differently and can have varying impacts, depending on each client and where they are in treatment. For some clients, that might be a home run, given their life demands. For others, it may reflect an ambivalence about treatment. For a new client, low compliance initially may indicate the client’s acculturation process toward a more structured treatment such as ACT-informed exposure, and their compliance may improve as the client gains an understanding of the importance of out-of-session work and learns to budget time for it. In all instances, it can be useful to spend time with clients to identify when and where they will practice, explore the need for reminders (e.g., setting a reminder in their phone), and send the clear message that the meat and potatoes of this work is practice, practice, practice. Basking in their therapist’s beatific presence once a week is unlikely to result in behavior change. When you and the client agree on a particular out-of-session exposure assignment, be vigilant for signs of ambivalence. Unfortunately, in pop-culture depictions of therapy, all

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the profound work happens in session with the therapist. This would be comparable to a sports movie in which the protagonist never engages in formal practice and only plays competitive games. New clients may come to treatment simply not expecting that they will have to make time to complete work between sessions. Signs to look for include saying they will “try” to practice (really, the word “try” is a big red flag). In response, you might say, “I heard you say you’ll ‘try’ to do it. Whatever we agree to, I want you to walk out of here fully committed to it. We should choose something you can be confident you will follow through with.” Alternatively, clients may agree to an exposure that is quite ambitious. If you have the sense that the out-of-session practice they have chosen is too far of a leap forward from where they are, gently engage them about what you are observing and encourage them to reflect on what they can do with some degree of confidence.

Avoidance or Safety Behaviors During Exposure Sometimes clients are compliant with the act of engaging with the feared stimuli but continue to engage in avoidance behaviors during exposure. As we’ve noted, they may not even be aware of what they’re doing. For example, clients with contamination fears may lightly touch items with their fingertips rather than with their whole hand. This behavior reinforces their fear, because the client is still treating the items as potentially dangerous. Some clients engage in what are called “safety behaviors,” attempts to avoid, reduce, or detect a potential danger. Safety behaviors are not all bad. We wear seatbelts when we drive and helmets for certain activities, and we may lock our doors at night. The safety behaviors we focus on in exposure work are those that are excessive and interfere with psychological flexibility. Washing your hands once when using a public restroom is prudent, but being absolutely unable to leave a restroom without washing your hands or having to wash your hands multiple times—every time—can interfere with daily living; you might end up late to work because you didn’t feel confident you were clean, or your hands may be dry, cracked, and bleeding from the excessive washing, and so on. Although it’s been theorized that client engagement in safety behaviors always negatively impacts treatment, it’s not clear they’re invariably a hindrance to exposure work (Blakey et al., 2019; van den Hout, Engelhard, Toffolo, & van Uijen, 2011). As one recent review concluded that, overall, safety behaviors are more likely than not to interfere with exposure (Blakey & Abramowitz, 2016), it’s better to err on the side of helping clients engage in exposure without them, as reliance on them may limit psychological flexibility. A metaphor one of us uses with clients is rivulets feeding an anxiety river. The more rivulets that feed the anxiety river, the stronger it flows. Although we may not be able to block every single rivulet, we want to disrupt as many as we can to weaken the flow of the river as much as possible. Every avoidance behavior is a potential rivulet. Even if some appear small and inconsequential, they nonetheless reinforce anxiety and psychological

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inflexibility, and they should be disrupted as much as possible. Other examples of subtle avoidance behaviors in clients include: • Mental reassurance (I’m going to be okay) • Use of humor to deflect from feelings • Avoiding eye contact • Body tension • Covert deep breathing • Doing exposure quickly (i.e., getting it over with) Sometimes clients can’t let go of their control agenda, their focus on avoiding discomfort. The client may appear to be working hard: they understand the rationale, they’re willing to do difficult exposures, and they complete all their homework. After weeks of working through the exposure menu, the client remarks that they don’t feel any better and wonders what else they could be doing. Sometimes, client behavior looks ACT-consistent, but the client is functionally engaging in subtle forms of control or avoidance. Whenever they experience any anxiety, they fuse with the idea that they should be able to make it go away and that there’s something wrong with them if they can’t. Control agendas can be sneaky and subtle. But it’s important to note that this isn’t a problem per se; rather, it’s an opportunity for the client to gain a deeper understanding of how their behavior is keeping them stuck. If you suspect this is happening, assess for it, point it out, and continue to practice. In our experience, the repetition of well-designed exposure exercises is one of the best ways for clients to learn to let go of their focus on control. Regardless, it can be important to address in session. Slow down and direct a client’s attention back to their present-moment experience and focus on the process of what is happening rather than the content they are presenting with. Some prompts might include: • “Would you be willing to spend thirty seconds just being present with the anxiety symptoms that you are feeling right now?” • “Your mind is working hard to try to understand this experience. I wonder if we could take a moment to step back and just witness it—without words, labels, or descriptions?” • “Where in your body do you feel anxiety the strongest right now?”

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If their difficulty in being present reflects a genuine skills deficit for the client, it may be useful to suspend exposure work and focus on developing awareness of private events through simple experiential exercises, affect labeling, emotion charts, and mindfulness exercises.

Conclusions Err on the side of success with the initial exposure exercises to help orient clients to ACTinformed exposure and allow them to practice psychological flexibility. Also, always think functionally. Are we targeting what we want to be targeting? Is the client having a different experience with the stimuli? Last, be alert for signs of covert avoidance (e.g., low willingness) of which even the client may be unaware. Talk these through with the client as you explore potential barriers to strengthening psychological flexibility during exposure. In this chapter, we covered how to engage exposure with clients. In the next chapter, we’ll explore how we know when the client is done with exposure and ready to discontinue treatment or shift to another treatment focus. Should we use empirical measures, tracking forms, or verbal prompts? Also, how do we know when we are finished? Do we ask the client if they feel finished, trust our gut—or do we simply end when we run out of ideas for things to do?

CHAPTER 7

Ending Treatment

In ACT, engagement in valuing helps inform action toward larger life directions. There is no end goal in pursuing values. Similarly, there is no end to increasing psychological flexibility—we can always strive to improve. Given that, it can be hard at times to decide on an ending point for ACT. So the question for this chapter is: how do we know when a client’s done with ACT-informed exposure? The goal for ACT-informed exposure, ideally, is that clients develop sufficient psychological flexibility that they can continue to move toward meaningful life directions without the structure of regular therapy. Sometimes clients come to us expecting to be in treatment for months or years. Fortunately, anxiety-related issues tend to respond well to time-limited treatment. If treatment goes well, clients will inevitably graduate. Even clients who tell us they expect to be in treatment for a long time may find themselves ready to end sooner than they expect. Here we’ll identify signs that a client is ready to complete treatment and explore ACTinformed principles for making decisions about termination. For the purposes of this chapter, we’re going to assume you and the client engaged in what appeared to be a successful course of ACT-informed exposure—however that’s defined. While we can’t give you concrete criteria to determine when it’s time to end treatment, we can suggest some useful behavioral markers that often indicate when clients are ready to graduate therapy. Whether it’s you or the client who first brings up termination, it’s helpful to spend some time carefully considering whether the time is right, especially in cases where it’s not so clear-cut.

Clients Say, “I Think I’m Done” In our experience, clients are pretty good judges of when they’re ready to complete treatment. They’ve met their treatment goals—or at least the goals that are most important to them. They find their daily lives easier to navigate. They’re more engaged in values-based activities. They find they have the psychological flexibility to work through anxiety-related triggers. Maybe they’ve even made changes in their life they didn’t think were possible (e.g., new job, going to college). More importantly, they express confidence that they can handle any future ups and downs.

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Most of the time, clients ready to end treatment will be able to identify aspects of therapy that have been helpful in ways that inspire confidence in you as a therapist: Phew, they got it! Occasionally, some clients tell you they “feel better” but cannot tell you why. In the most crushing blow to the therapist’s ego, sometimes the client cannot even say with any confidence that treatment was helpful. Perhaps perceiving how transparently thinskinned and starving for praise we are, these clients will shruggingly offer that treatment may have been helpful. However, they cannot point to why. They can’t identify any skills they’ve learned. They don’t think their daily functioning has changed in any significant way. They simply find they’re less anxious than they were before they came to therapy. This may be due to several reasons. First, some clients are poor reporters of therapy progress and have trouble concretely naming the things they did that were helpful—that is, some clients simply don’t realize how mind-blowingly helpful their therapist was. In other cases, these spontaneous improvements may reflect what’s called regression to the mean: clients came to treatment during a particularly bad time, and after some time had passed, they gradually returned to baseline on their own. Additionally, clients sometimes feel better just by taking action and scheduling that first appointment. They may benefit from nonspecific components of treatment, such as talking about their problems, meeting with an empathic therapist, and setting aside time each week to focus on themselves. Some of these nonspecific benefits of treatment are what are called “common factors” of treatment and include therapist alliance and client expectations of treatment (Wampold, 2001). Although common factors may account for improvements in some anxiety clients, the impact of the common factors varies by disorder, and it’s likely some combination of common factors and specific techniques such as exposure that account for improvements in anxiety (Strauss, Huppert, Simpson, & Foa, 2018; Cuijpers, Reijnders, & Huibers, 2019).

Meaningful Living One of the first things to assess when you’re thinking about ending treatment is how clients are doing day to day. Are they engaged in meaningful activities? Does life feel manageable for them? How confident are they that they can handle what life throws at them? In ACT terms, are they demonstrating psychological flexibility in how they manage difficulties, and are they engaging in valued living? This greater focus on functioning may be a difference between traditional exposure and ACT-informed exposure. Decisions about ending treatment in traditional exposure may be more focused on symptoms and anxiety levels, whereas in ACT-informed exposure decisions may be more focused on functioning and valued living. Sometimes clients return to how they were living before anxiety became a problem. As rewarding as this is, what’s even more rewarding is when clients tell you they’re doing better

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than they ever have or even thought was possible. For many clients, anxiety has impacted their functioning for much of their lives. For years, they tried to work around or ignore it. They gave up on pursuing things that they wanted to do (e.g., college, relationships, challenging work). Life wasn’t great, but it wasn’t quite bad enough to seek help until it became painful enough that they came to see you. As a result, these clients never realized how impairing their anxiety was for them. For them, it was normal. They simply suffered through it until it started to get in the way of things that were important to them. After a successful course of ACT-informed exposure, these clients discover they’re functioning at a higher level than they’d ever imagined. They’re living more satisfying lives than they had prior to treatment and are more confident in their ability to handle problems in the future. This can be one added benefit of the focus on values in ACT-informed exposure. It can prime clients to look beyond symptom reduction toward the broader life directions they want to pursue. Maybe they’re still anxious about some things, but now they’re more out in the world doing the things that matter most to them.

Client Has Completed the Most Difficult Exposure Menu Items As the goal in ACT-informed exposure is increasing psychological flexibility, checking off and completing exercises on the exposure menu is one useful behavioral marker of progress. This doesn’t mean that clients must complete every single item on the original exposure menu, since completing the most challenging items may indicate that going through the entire menu is not necessary. If, after tackling the hardest items, a client indicates they could complete the remaining exposures with minimal difficulty, you may consider crossing off those items from the list. We offer the caveat, however, that it’s important that exposure work translates or generalizes to daily living.

Signs Ending Treatment May Be Premature If someone has completed all the exposure menu items but continues to engage in regular avoidance behaviors in their daily life, we might classify potential barriers in various ways.

Exposure Practice Has Not Generalized As noted in the prior chapters, the goal of exposure is to help clients practice and strengthen psychological flexibility in contexts that typically restrict or narrow their ability to flexibly respond. If the client has completed all the exposure menu items on their list and

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is still either regularly engaging in avoidance behavior in day-to-day life or is not doing the activities that are important to them, you may want to reassess their current functioning. In these instances, it’s possible that exposure work has not generalized to daily living. Steps to increase generalization of learning may include identifying additional formal exposure exercises to further strengthen psychological flexibility in situations where clients are still engaging in avoidance behavior and adding them to the exposure menu. At the end of treatment, however, it may also involve identifying broader ACT behavioral commitments in addition to or even in lieu of specific exposure exercises. If clients are not as engaged in valued actions as they would like, help them identify concrete actions they can take toward valued directions. For example, if a client is unhappy in their current job but has not taken steps to look for more meaningful work, some combination of exposure exercises and committed action strategies may be useful here. From an exposure perspective, perhaps the client may benefit from imaginal scripts targeting fears related to the job process. Keep in mind, though, that the client may not need additional exposure at all. It can be easy to get into “exposure tunnel vision,” where the therapist tries to solve all client problems with exposure. Instead, it may be more helpful to use committed action strategies to help the client develop a plan for applying for jobs. You may help this client set aside regular time each week (e.g., Saturday morning from nine to noon) and break down tasks into smaller behavioral commitments (e.g., check for new job postings, revise cover letter). Another method of generalizing learning is varying the contexts of the exposure exercises. Contexts may include different times of day, different locations, alone versus with a trusted other, and mood (e.g., anxious versus calm). If a client can eat at restaurants during less crowded times but avoids weekend dinner hours, consider targeting this context specifically. A client with driving-related fears may be able to drive anywhere they want during daylight hours in clear weather, but they may avoid driving after dark and when it’s raining or snowing. Continue brainstorming potential exposure exercises that would be challenging for them until they can engage in valued behavior anytime, anywhere, and under any circumstances.

Client Has Been Unwilling to Let Go of Specific Safety Behaviors Daniel, who struggled with panic while driving, completed all the driving exposures on his exposure menu and then some. He was able to drive on the highest bridge in his city—something he had never imagined he could do. In debriefing, though, we realized that, because he approached every exposure with his husband riding as a passenger—so that his husband could take the wheel if Daniel became overwhelmed—rather than completing the exposures alone, he remained unwilling to drive over unfamiliar bridges or

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on freeway routes by himself. In short, although Daniel had made great strides—more than he thought were possible—he was still limited by only being able to drive under certain conditions. We spent the next several sessions identifying new driving exposures for Daniel to willingly practice driving alone. Once the exposures were completed, Daniel expressed greater confidence in his ability to drive anywhere. In the example above, driving with his spouse was a safety behavior for Daniel. Once he was familiar with a route with a passenger, he was more confident in driving new routes alone. As we’ve noted, some safety behaviors may interfere with treatment, and some may not, depending on the feared predictions and client understanding of these behaviors (Sy, Dixon, Lickel, Nelson, & Deacon, 2011). For example, many of us feel safer driving when we have our cell phone with us, so that we can use a trusted maps app or contact someone in an emergency. For many of us, if we’ve forgotten our phone, this isn’t a problem, and we can continue with what we’re doing. However, if we can’t drive unless we have our cell phone with us—because we’re terrified that we could get lost or be unprepared for an emergency— then this safety behavior may be a problem that could interfere with flexible responding. Safety behaviors may even provide useful bridges—literally, in the case of Daniel!—to new and more challenging exposure exercises. Similarly, training wheels on a bicycle may allow children to develop their strength in pedaling, but it’s important to eventually take the training wheels off. If they’re not removed, training wheels will interfere with a child’s ability to learn to balance and trust that they can stay upright while riding. Similarly, behaviors that may facilitate treatment progress across exposure exercises can become barriers to completing treatment if they’re not eventually discarded (Blakey et al., 2019). With his husband riding along, Daniel was willing to engage in exposure to routes he would have refused to drive alone. From there, it was important that he learn to be willing to drive those and eventually new routes entirely on his own—without first approaching them with his spouse. Once he could do this, Daniel had more confidence that he could tackle any novel routes on his own in the future. Sometimes clients are unaware of their safety behaviors because they’re so subtle and habitual. Other clients may be so fused with their safety behaviors’ perceived importance that they aren’t able to imagine not engaging in them. These clients may assume every sensible person would do the same thing. Some clients are aware of their safety behaviors yet reluctant to spontaneously bring them up because they know their therapist is going to ask them to stop doing them. In these situations, clients should be reinforced for acknowledging their safety behaviors, even if they’ve deliberately delayed doing so. For example: Therapist: Thank you so much for mentioning that you always make certain you have your phone on you so that you could call someone in an emergency! I didn’t think to ask about this. Because there might be times you want to

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leave the house without your phone, we’re going to want to do some practice where you deliberately leave it behind. In sum, if a client has completed all items in their exposure menu, but improvements have not generalized to daily life, this might be a cue to reassess for the presence of safety behaviors or to target any safety behavior that may have initially appeared harmless. The presence or absence of safety behaviors may be the difference between a client who needs to continue treatment and a client who is ready to complete ACT-informed exposure.

Fusion with Rigid Ideas About Progress Clients often come to therapy with certain ideas about what success in treatment looks like. Many clients eventually appreciate the very real strides they make in treatment through their hard work, even if they’d initially imagined a rosier outcome. For other clients, being fused with ideas that are idealistic and unrealistic can interfere with taking steps toward the actual change that is possible. For example, a client may imagine that they will turn into a version of their sibling, who is a carefree and chill free spirit. They may imagine that “normal” people don’t experience intense anxiety. These occasions represent opportunities to explore client expectation (e.g., “What were you expecting to happen?”). In our experience, fusion with ideas about treatment progress is mainly an issue earlier in treatment. As clients develop greater psychological flexibility through working with ACT ideas, concepts, and experiential exercises (including exposure), these barriers start to melt away, and they generate new ways of responding to anxiety. For example, one client who completed a course of treatment of exposure for emetophobia (fear of vomiting) stated, “I never thought that my anxiety could still be there but not bother me so much!”

Habitual Engagement in Avoidance Behaviors Jake successfully completed a series of germ-related contamination exposures. However, he reported he was still washing his hands several times a day. He noted that the behavior was habit and that he would find himself in the bathroom washing his hands multiple times during the day without thinking about it. When he made the effort to limit handwashing to only specific scenarios, like before and after meals, he found it was easier than expected and within a few weeks, settled into this new pattern. Some avoidance behaviors become so well-practiced they’re almost second nature. In these cases, the avoidance behaviors may not function the way they used to—they may fail to provide any emotional relief—yet they’re still maintained because we’re creatures of habit. Clients may engage in avoidance behaviors mindlessly, without even being aware of

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what they’re doing. In these instances, they may need to make a conscious effort to be more vigilant toward when avoidance behaviors occur and make a deliberate effort to notice and accept the urge while choosing to refrain from the behavior. In doing so, clients may find they have little difficulty letting go of the urge when they make a concerted effort. We might call addressing small avoidance behaviors “pruning.” Even if they seem minor, addressing small avoidance behaviors can be the difference between a client feeling “kind of” ready and fully confident in their ability to end treatment. Here’s some sample text for how a therapist may communicate the importance of eliminating avoidance behaviors to clients: Therapist: In the beginning of treatment, I had no expectations that you would try to resist avoidance behaviors above and beyond the specific exposure exercises we agreed upon. In fact, it may have been too difficult for you to spontaneously stop these. Some of your triggers are unpredictable and unexpected, and you may have felt overwhelmed. However, now that you’ve done such a great job working through your exposure menu, and we’re getting close to being done with treatment, these behaviors are going to get in the way of you being able to be the person you want to be and do the things that are important to you. Moving forward, it’s vital that you be mindful of these behaviors—no matter how big or small. Notice them and choose to let them go without acting on them. Even the small ones can interfere with further progress. If you forget and miss one or two here and there, it’s not a huge deal, but each time you’re aware of an urge to engage in a safety behavior, it’s incredibly important to be mindful of staying present with your discomfort while not engaging in the safety behavior. Client:

You’re right. I kind of knew this was coming. I had hoped they would go away on their own, but I realize now I’m going to have to be really disciplined moving forward.

You might need to work with clients in creating a plan and being more disciplined in targeting these behaviors, such as completing a tracking form or setting a reminder on their phone. Sometimes clients may be less willing to let go of certain unhelpful behaviors. We’ll address more intransigent instances of avoidance behaviors in chapter 10.

Assessment of Change So far in this chapter we’ve focused on behavioral markers of change. However, assessment measures can provide additional data for making decisions on ending treatment. Formal

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assessment may even be required in some clinical settings. Assessment may include standardized interviewer-administered or self-report measures, samples of clinically relevant behavior, or idiographic measures created by the therapist. In our experience, many clients don’t like completing measures, because they can be tedious, especially if they’re administered too frequently. However, we’ve found that clients do appreciate having concrete evidence of how they’re progressing in treatment. Thus, when you explain to them that such measures can be helpful in gathering data to inform treatment and measure progress, it may be refreshing for clients who had negative experiences with prior therapists who did not use any form of progress monitoring to assess if they were benefitting from treatment.

Empirically Validated Measures As there are many empirically validated measures of anxiety-related symptoms and of ACT processes, it’s beyond the scope of this book to provide a thorough list of formal assessment measures. Additionally, given that new measures of ACT processes continue to be developed at a rapid pace, any attempt to provide a complete review of ACT-relevant measures would be obsolete by the time you’re reading this. For a continually updated list of ACT-relevant measures, we suggest you check out: https://contextualscience.org/actspecific _measures. If you’re going to be hand-scoring measures, we suggest you look for measures that are on the shorter side (e.g., fewer items) and are uncomplicated to score. For example, measures with multiple reverse-scored items are more complicated to hand-score than measures where you simply sum client ratings. Creating your own spreadsheets with built-in scoring formulas can save time. Using measures with clear cut-off scores and norms can be helpful in assessing treatment progress. Some measures identify ranges of scores by severity ratings—such as mild, moderate, severe, or extreme ranges—or they may offer a cut-off point between ratings of relevant behaviors that are clinically significant or not. By contrast, some measures widely used in research studies are not as easily interpretable at the level of the individual. For example, some measures don’t have clear cut-off scores; instead, these measures are used with large samples of people and require statistical analyses to interpret whether there are significant changes in treatment. For example, the Acceptance and Action Questionnaire (AAQ-II; Bond et al., 2011) is a widely used measure of psychological flexibility in ACT research. At the time of this writing, however, while there are means reported for various populations, there are no established markers of clinically significant change in the AAQ-II when administering to individual clients. We’ll note here that measures of symptom severity, while useful, may provide a limited window into psychological flexibility. For example, there’s evidence that there’s a weak

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relationship between anxiety symptom severity and functional impairment (McKnight, Monfort, Kashdan, Blalock, & Calton, 2016). Clients may report severe anxiety symptoms yet remain high functioning—or vice versa. Additionally, there may be delayed effects in improvements from ACT-informed exposure. There’s evidence that increases in psychological flexibility earlier in treatment predict symptom reduction later in treatment (Twohig, Vilardaga, et al., 2015), and that improvements in quality of life may take longer than improvement in symptoms (Craske, Niles, et al., 2014). In sum, we recommend choosing easily administered and scored measures that provide clinically relevant information through which to assess treatment progress. We also recommend flexible use of measures with your clients. While it may make sense to closely track one client’s progress with a particular set of measures, it might make less sense for another client. Getting into routines, such as always administering a similar set of measures after the first session, can be helpful in remembering available tools that offer great clinical utility.

Tracking Behavior Change As described in chapter 3, ACT is rooted in the behavior analytic tradition with a focus on predicting and influencing meaningful behavioral change. While the psychological field as a whole has relied on pen-and-paper self-report measures (such as those recommended in the prior section), where people are asked to report the frequency and severity of their thoughts, feelings, and behaviors, the behavioral tradition has historically been skeptical of these forms of assessment, since they rely on data that’s difficult to independently verify, due to not being observed directly by the therapist (e.g., Barlow, Nock, & Hersen, 2009). Similarly, when working with small children, the focus is often on behavior that is observable to others, such as parents and teachers. Consequently, the behavior analytic tradition has sometimes eschewed nomothetic measures (measures that are empirically validated with groups of people) that focus on internal experiences in favor of idiographic measures (measures that are chosen for and tailored to the individual) of observable behavior. In single-case experimental design studies (e.g., Barlow et al., 2009), a type of research study that may have as few as a single participant, researchers focus on sampling relevant behaviors related to their research questions. Usually in these instances, they track behavior quite frequently (e.g., daily, hourly, every minute) to assess changes more clearly. Data is graphed with the notion that, if behavioral change occurs, it should be apparent enough that it can be perceived visually on a graph. For example, in single-case design studies of ACT treatment for OCD, the researchers measure daily engagement in compulsions (B. L. Thompson et al., 2021; Twohig, Hayes, & Masuda, 2006). Assessment doesn’t need to be complex, as Twohig and colleagues simply gave participants a 3 x 5 index card to track compulsions.

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Below (table 7.1) is an example of a simple way of tracking clinically relevant behavioral change using idiographic measurement. A client with OCD was asked to write down the number of minutes she engaged in compulsions per day as part of a more comprehensive tracking form. She completed the form before bed each night. The therapist used standard Microsoft Excel software to graph daily ratings. For this client, the phase labeled “baseline” consisted of two sessions devoted to information-gathering (e.g., intake; assessment of obsessions and compulsions). At the third session (which signals the transition to the ACTinformed exposure phase), the client was oriented to the ACT model through metaphors and experiential exercises before moving into exposure work. Although there are occasional spikes in daily rituals, you can see a gradual decrease—particularly toward the end of the figure. This is an example of how therapists may target and track clinically significant client behavior.

Table 7.1

Rituals - Minutes

Date

Time

Trigger—thought; feeling; bodily sensation context

Baseline

300

Describe ritual (mental or physical)

# Min.

ACT-informed exposure

200 100 0 1

51

Days

101

Again, this kind of measurement is idiographic in that it is chosen and tailored to the individual. Use of SUDS and willingness scores, as mentioned in prior chapters, are other examples of idiographic assessments. In short, tracking concrete behaviors relevant to your

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client’s treatment goals can provide clinically relevant information that is every bit as valid—if not more valid—than common multi-item assessment measures, and the use of behavior tracking is consistent with the rich behavior analytic tradition upon which ACT was founded.

Reducing Frequency of Sessions As therapy progresses into middle and late stages, you may begin to reduce the frequency of sessions. For example, you may transition from meeting every week to meeting every other week—or once per month. This reduction may occur even before you decide to begin the process of terminating with a client, or it may occur after you and the client have started to discuss ending treatment. There are several benefits of this arrangement to consider: • First, reducing the amount of contact with clients is helpful in gauging how well they can maintain their treatment gains without the structure of weekly sessions. If you reduce frequency to every other week, and the client begins struggling to maintain their gains, it might mean they’re not yet ready to end treatment. You can also consider reducing the amount of formal exposure homework given in session or out of session to test how clients are able to engage in clinically relevant behaviors on their own between sessions. Are they engaging in spontaneous behavioral commitments in ways that indicate increased psychological flexibility? If so, they are more likely to be ready to graduate therapy. • Second, reducing session frequency communicates to clients your confidence in them. It’s empowering to let clients know that you believe they’re ready to see you less often and to practice the things you’ve worked on together on their own. This is especially important for clients who fear relapse if they discontinue treatment or may have become dependent on their therapist. Such clients may require more explicit efforts to transition toward independence. Some clients may want to linger and stay attached to therapy even if it feels to you as if you aren’t actively working on things together. ACT-informed therapists may differ in the degree to which they’re open to less-focused therapy. Some exposure therapists prefer time-limited therapy targeting specific, clearly defined treatment targets, and they are most engaged when their caseload is filled with these types of clients. Other therapists are more open to deviating from a structured approach and enjoy a combination of focused exposure work while helping other clients work on broader, more long-term treatment goals (e.g., valued actions). In ACT-informed exposure, you might conceptualize this as a shift from a focus on specific exposure exercises

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to broader committed actions toward valued directions (e.g., finding a more meaningful career). We’re not here to tell you how you should practice or that one style is better than another. However, we do recommend reflecting on what type of work you ideally like to engage in so that you have a clear idea of what you want when making decisions around terminating with clients.

Relapse Prevention Even when clients successfully complete ACT-informed exposure, there’s always the possibility of relapse. This is not necessarily the client’s fault. For example, stressful life events increase the possibility that anxiety-related problems will recur (Francis, Moitra, Dyck, & Keller, 2012). Consequently, it’s not unusual for clients to experience a resurgence of symptoms after a successful course of ACT-informed exposure. Maintenance of treatment gains for ACT-informed exposure are comparable to those for traditional exposure (Arch, Eifert, et al., 2012; Twohig et al., 2018). It’s important to prepare clients for the possibility of problems with anxiety returning after treatment ends. Some clients end treatment feeling empowered with skills for managing anxiety in the future. Other clients feel better but remain hypervigilant for any signs of recurrence, worried they won’t be able to maintain treatment gains. Relapse prevention may be particularly important for these latter clients, as they may panic at any sign of increased anxiety. One benefit of ACT-informed exposure—which emphasizes psychological flexibility over symptom reduction—is that clients may be better prepared for an eventual return of symptoms compared to those who completed exposure-based treatments focused on habituation (Arch & Craske, 2011). One distinction that can be useful to make with clients is between a “lapse” and “relapse.” A lapse is simply an increase in symptoms and perhaps a temporary return of avoidance behaviors and impairment. As an example, a client undergoing a lapse may start engaging in avoidance and safety behaviors for less than an hour or as long as a few weeks. It can be helpful to normalize for clients that a lapse is temporary. So long as clients remain committed to employing skills learned in therapy, such as not resorting to older patterns of avoidance, the lapse will likely pass. Compared to a lapse, a relapse is more severe and reflects greater lost ground, such as more frequent and prolonged engagement in unhelpful avoidance behaviors and impairment in daily functioning. During a relapse, it might be helpful for clients to return to treatment for what might be called “booster” sessions. Some clients interpret relapse as a sign of personal failure, that they’ve lost all treatment gains and are starting over. It can be helpful to emphasize that ACT-informed exposure involves new learning through expansion of behavioral repertories—and like anything we learn, skills can become rusty when we don’t use them. Sometimes clients are victims of their own success! When life goes too smoothly,

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we have fewer opportunities to practice strategies that are necessary during more difficult times. Returning to treatment is not necessarily a return to square one, but an opportunity to revisit what’s worked in the past and maybe to add a few new skills to one’s repertoire. If a client had already completed a successful course of ACT-informed exposure, we might assure them that they’ve “already done all the heavy lifting” (i.e., the hardest work), and that any future courses of treatment may be shorter than the first. And while clients would prefer to believe that a finite course of treatment would set them up for a problem-free life, it’s more realistic to expect there will be ups and downs. After all, the learning that occurs in ACT-informed exposure is often at odds with years or decades of unhelpful messages about emotional control or habits of avoidance. Each client’s process is unique to them, and helping to normalize the unexpected twists and turns that anxiety may take can potentially reduce any self-blame or disappointment. In sum, it’s important to prepare clients for the reality that they’ll have good and bad times following treatment. The balance is to both let them know you’re confident in their ability to handle resurgences in symptoms, while letting them know it could be helpful to return to treatment if they need some extra support down the line.

Termination Termination refers to the ending of therapy. While one can find many books, articles, and theories about the process of terminating, we want to mention a few benefits to having a thoughtful approach to ending treatment. First, it can be helpful to take time to review treatment gains. Even clients who’ve made a lot of progress may not be able to identify all the reasons why they’ve improved in treatment, and some clients may have trouble listing even a few. There’s an advantage in clients being able to name skills or principles they found useful in therapy: it helps them remember those principles in the future. For example, being able to name the skill “willingness” turns an abstract concept into a thing the client can tangibly recall. Once it’s a thing, it’s more likely to be remembered or used again in the future. However, we don’t believe clients need to understand the ACT hexaflex or be taught ACT middle-level terms. You may use the clients’ own words to describe important skills. We can assume that with time, clients will forget what they’ve done in therapy. They may even forget your name! Helping clients walk away with a concrete analysis of what they did in ACT-informed exposure can serve as a handy resource in case their anxiety returns in the future. Did you provide recordings of guided experiential exercises they could revisit in the future? Were there particular ACT metaphors with which they connected? Sometimes clients are scared to end treatment. As they may have lingering fears and may be reluctant to volunteer this information, it can be helpful to directly ask, “How are you feeling about ending therapy with me?” or “Do you have any concerns about this being our last session?” You might want to validate that ending involves a loss of support and that

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they’ll likely need to be more self-reliant. Other clients may need help accepting the uncertainty of not being able to predict how things will go. Just because a client is anxious during their last session doesn’t mean it isn’t a good time to terminate. Normalize that it’s understandable to be anxious or to feel sad. You might even consider self-disclosing how you feel, if you think it would be valuable for the client to hear. Many clients may not have had prior healthy experiences of saying goodbye to someone important in their life. Termination is an opportunity to model saying goodbye while accepting difficult emotions and to demonstrate the psychological flexibility you’ve worked so hard to strengthen throughout treatment.

Referring Sometimes termination happens for reasons that are not celebratory, such as a client’s not benefiting from treatment or because there are financial restraints, changes in insurance, moving away, or some other obstacle that prevents a client from completing treatment. In these cases, it’s best to be honest about what’s happening and direct in your recommendations, even if it’s hard to hear. Though it may be hard for us to admit, sometimes we’re not able to help a client. Perhaps it’s simply just not a good match between personalities or not all clients may take to ACT-informed exposure. In general, if therapy is not going well and a client does not appear to be benefitting from ACT-informed exposure, one should consider referring to another clinician (Natwick, 2017). If a client is not connecting with an ACT approach, you may consider referring to another therapist with a different approach (e.g., cognitive therapy). While some clients may be reluctant to start over with a new professional, if handled well, this can be an extremely beneficial decision for clients.

Conclusions Although there are many useful markers for assessing when a client is ready to complete ACT-informed exposure (e.g., assessment measures; behavioral markers; completion of exposure menu), perhaps the simplest way to assess client readiness to end therapy is to have a conversation about it, so that you can explore whether they also think they’re ready to graduate from ACT-informed exposure. Normalize the recurrence of anxiety, making a distinction between a lapse (e.g., temporary and short-term return of symptoms) and relapse (e.g., engagement in avoidance behaviors and decline in functioning) to help prepare clients for any future return of anxiety. Review treatment gains with each client to help them concretize what you’ve done in your therapy together.

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This ends our series of chapters on how to orient to, conduct, and end ACT-informed exposure. In the next chapter, we’ll walk you through how to create procedures, forms, and worksheets that are tailored for your own practice, and that will help guide you and keep you on track in implementing ACT-informed exposure.

CHAPTER 8

Create Your Own ACT-Informed Exposure Forms

If you’ve attended more than one ACT training, you know that there’s a variety of ways of doing ACT. One goal of this book is to help you adapt ACT-informed exposure using language that, while ACT-consistent, matches your own style and the context in which you work. We have deliberately stopped short of providing you with a treatment protocol or too many examples of forms because we want to encourage you to think more functionally about how you use forms. How will the specific forms and worksheets you use with your clients help them develop their skills or take steps toward their particular goals? With every form or worksheet that you develop, think about behavior and languaging that is consistent with how you practice and the clients with whom you work. And consider the reason for any decisions you make. Because behavior change is hard for therapists too, creating new forms for your practice is one way to shape how you develop your skills in facilitating ACTinformed exposure. This part cannot be overstated. Without forms and written procedures to guide you, it’s easy to fall into doing what’s familiar and comfortable. Consider your written materials as a way to keep both your client and you, the therapist, on target during treatment. Creating your own materials helps in: • keeping you on track (otherwise, it’s easy to fall into bad habits); • developing a structure that you may modify over time; and • maintaining clarity about the model that you are using. This chapter will focus on helping you develop two types of forms to support your ACTinformed exposure practice: • client self-monitoring forms; and • exposure forms.

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A few additional notes before we dive in. If you were trained in CBT and traditional exposure, you are probably comfortable giving clients a variety of worksheets and out-ofsession assignments. If you don’t have a CBT background, integrating the use of forms and worksheets into your practice may feel less familiar. If you’re completely new to CBT and exposure, you may even consider first practicing with a structured protocol—even one based on traditional exposure—to learn the basics, and then integrating the approach we outline here. Also, although this chapter emphasizes developing your own written materials, we also encourage you to continue to use any ACT-related forms or worksheets that you already find helpful. If you’re new to ACT, the website for the main organization of ACT, the Association for Contextual Behavioral Science, has places where members may download worksheets and other forms (https://contextualscience.org), and we’ll point you toward other ACT resources as well. With that said, let’s begin.

Behavior Tracking as Intervention Has anyone ever asked you what you did over the weekend, and you couldn’t remember— on a Monday! Have you ever thought you were doing more or less of something until you began paying attention and writing it down? Self-monitoring or tracking behaviors is common in cognitive behavioral approaches, and it lies at the heart of behavior change whether you’re changing a diet, losing weight, increasing exercise, or improving procrastination. The worksheets you provide your clients for homework are an essential tool for gathering information about clinically relevant behaviors. They provide clinically useful information for the therapist, and they strengthen client awareness of their habits and patterns. In fact, tracking behavior can be an important intervention in itself. Observation alone can influence behavior and the process of discussing observations can create a context for behavioral change (e.g., McFall, 1970; Ramnerö & Törneke, 2008). For example, if you were asked to make a hashmark for every snack chip you ate, you would probably find you ate far fewer than when you mindlessly reach into the bag and grab a fistful.

Tracking Strengthens Awareness Through tracking their behaviors, clients increase their awareness of them (Orji et al., 2018). They may discover aspects of behaviors such as antecedents or consequences of which they were unaware. For example, after a week of tracking the consequences of their

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efforts to control their anxiety, many clients notice that their control strategies are even less successful than they originally thought, helping to foster creative hopelessness! Clients are more likely to take responsibility for behavior change when they’re asked to pay attention to target behaviors. This helps to subtly orient clients to active treatment approaches such as ACT-informed exposure.

Tracking Provides Data to the Therapist The tracking that’s made possible by forms and written records also helps sharpen clients’ experience of therapeutic interventions and their ability to pay attention to, put words to, and process these experiences. Without writing things down, client self-report is more likely to be vague or general. Though clients may offer verbal descriptions of their behaviors, having them collect actual data or accounts shortly after the behaviors take place can be more revealing to both client and therapist. For instance, with a client who claims, “I’m always anxious,” tracking may indicate fluctuations in anxiety within or across days. Or a client who tracks mood daily over the course of a month might notice their mood dips every Thursday, suggesting something predictable about their environment that was previously unknown. Overall, information gathered through self-monitoring tends to be more context specific and more accurate (Orji et al., 2018). Key elements of self-monitoring forms for ACT-informed exposure may include the following: • A trigger (e.g., “I walked into the supermarket and found it was more crowded than I expected.”) • A sample of thoughts, feelings, and bodily sensations (e.g., “I thought, Oh no! People are going to stare at me! I felt my heart race.”) • Attempts to deal with discomfort (e.g., “I left the store and returned after eleven that night, when I was certain there would be fewer people.”) • Consequences of avoidance behavior (e.g., “I had to make an extra trip. It would be so much easier to go to the store on my way home from work. Because I went to the store so late, I was tired at work the next day.”) Here is an example of a self-monitoring form from a client, Shanice, seeking treatment for social anxiety disorder. (A blank version of this form that you can use in your own practice can be downloaded at http://www.newharbinger.com/50812.)

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Table 8.1 Date

Describe a situation that caused discomfort.

What did you do in response?

What happened? How effective was the response? Why or why not?

XX/XX/ XXXX

Messed up during a work presentation because I was so nervous.

I went into the bathroom and cried. I felt too scared to face my coworkers because of what they must think of me.

I left work early, despite having a lot of work to do. I spent the rest of the day worrying that my coworkers would judge me for that too.

XX/XX/ XXXX

I misjudged my timing and started dinner later than I should have. When my partner asked what time dinner would be ready, I snapped at her.

I felt so guilty that I spent the rest of the evening apologizing to her.

I think my partner started to become annoyed at my apologizing. I then began to worry that she thinks I’m weak and wants to leave me. I stayed up late and spent hours reading relationship forums to see if this has happened to anyone else.

In this form, Shanice was able to see more clearly how her anxiety interferes at work and at home. As clients become more aware of how their “solutions” to problems (i.e., avoidance) create more problems, they may be more willing to let go of efforts to control, suppress, or change their anxiety or more open to trying something new such as exposure. In these ways, self-monitoring helps enhance work with creative hopelessness.

Creating Exposure Forms This task involves developing forms that are versatile for different types of exposure and include key parts of the exposure process: what to guide your clients to track, how often, how to use your forms to ensure clients set up exposures comprehensively, what to track during exposure, what to track after exposure, and clarifying procedures for between-session practice.

What to Track In traditional exposure, as we discussed in chapter 5, the therapist and client typically track changes in client distress across exposure exercises using the subjective units of

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discomfort (or distress) scale (SUDS). This scale ranges from 0 (no anxiety) to 100 (extreme anxiety), although a 0–10 scale is also common. Abramowitz, Deacon, & Whiteside (2019) have a section on SUDS for more information. Tracking scores of “anxiety” or “distress” also works. In ACT-informed exposure, exposure is an opportunity to practice psychological flexibility; consequently, one could track any or all core ACT hexaflex processes during exposure. Eifert and Forsyth’s (2005) ACT-informed exposure forms include multiple items to assess during exposure: sensation intensity, anxiety, willingness, struggle, and avoidance. As we noted in chapter 5, perhaps the most common alternative to SUDS in the ACTinformed exposure literature is willingness scores. In a comparison of habituation-based exposure and ACT-informed exposure for OCD, researchers substituted willingness scores for traditional SUDS on a 0–100 scale (Twohig et al., 2018). Willingness (i.e., acceptance) is an experience distinct from that of symptoms because willingness involves how we relate to discomfort. We should acknowledge here that sometimes clients mistake willingness for an inverse of SUDS, or they may be more willing when SUDS are lower or less willing when SUDS are higher. However, the therapist should be clear that willingness and SUDS are distinct processes. Another study of ACT-informed exposure for OCD asked participants to rate and track their daily psychological flexibility with a focus on thoughts and emotions (B. L. Thompson et al., 2021). Interestingly, participants tended to provide almost identical ratings of flexible responding to thoughts and feelings such that these two separate items were combined for data analysis. In sum, you are not limited to a standard way of practice and can conceivably track anything you feel is clinically and functionally relevant to psychological flexibility in ACTinformed exposure.

What We Use The three authors of this book have experimented with different approaches to what we track. Two of the authors (Brian T; Joanne) initially abandoned traditional SUDS or distress scores in favor of willingness scores. However, each eventually reincorporated SUDS along with willingness scores. One argument in favor of retaining SUDS scores is that willingness can be a tricky concept for some clients to understand. As we noted, some clients mistake willingness for lack of distress. Other clients may be overly perfectionistic, underrating their willingness because they underestimate their commitment to exposure exercises or fear that they do not sufficiently grasp the concept of willingness. In our experience, the concept of willingness may not click for some clients until they’ve had more experience working with it across multiple sessions of ACT-informed exposure. By contrast, it’s easier to be on the same page with distress-related scores from the beginning of treatment.

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In some forms of exposure, it’s helpful to collect a different type of rating: similarity. To create a context to practice psychological flexibility, we want to be certain that the exposure exercise evokes repertoire-narrowing stimuli to create a context for practicing psychological flexibility; in other words, that it triggers similar private events with which clients struggle with out of session. If this is not the case, an exposure exercise may be uncomfortable for clients but fall short of evoking the specific context which they want to address. For example, interoceptive exposure exercises are generally uncomfortable for people—including therapists—but they may or may not contain the contextual cues with which clients struggle (e.g., panic symptoms). For these reasons, we may ask for similarity scores with clients (e.g., 0 = “not similar experience of panic”; 10 = “as if you were experiencing a panic attack”). If an exposure exercise is too dissimilar, it will not sufficiently create the contextual conditions for practice, and it may not feel meaningful to clients. Regardless of what you choose to track, ratings help orient clients to their experience and initiate conversations between you and your clients about what they observe during exposure. We caution that each rating you ask of clients increases the complexity of exposure and burden of homework, so we encourage you to think carefully about what is most important. Even asking clients to rate both SUDS and willingness can feel complicated at times—especially when a client struggles with understanding these concepts. For that reason, we recommend using the minimum number of ratings that provide clinically meaningful information, or to interchange them throughout treatment to fit with whatever you are currently working on.

When to Track and How Often? There are no standard guidelines about how often to ask for ratings during exposure, and each of the authors varies in their approaches depending on the client. You may ask for ratings every five to ten minutes, or you may simply ask for pre-, peak, and post-exposure ratings. Some exposures are more amenable to frequent assessment. For example, you probably don’t want a client to jot down frequent ratings while conducting a driving exposure. Alternatively, an exposure may last all day or multiple days (e.g., placing a kitchen knife on a nightstand and leaving it there until the client strengthens psychological flexibility in its presence). In creating your exposure practice forms, consider versatility: are you able to use your forms with a wide variety of exposures? You may want to have more than one type of form. For example, some of the authors use the same form for in vivo and imaginal exposures but a separate form for interoceptive exposure.

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Setting Up the Exposure As mentioned in chapter 6, setting up exposure exercises is important for every exposure therapist, regardless of theoretical orientation; and as precisely as possible, the exposures you have your clients do should evoke repertoire-narrowing stimuli. It can be helpful to transcribe the exposure exercise on the homework tracking sheet so that clients are less likely to forget: Example: Describe the exposure practice.

Each day around six in the evening, I will drive on Interstate 12 from exit 3 to exit 6. Drive at least 55 mph. May stay in same lane without changing.

Identifying the fear. It is also important to clarify the fear that the exposure is targeting. Sometimes there is a specific feared consequence, but some clients may have a vague fear that “something bad will happen” without being able to be more specific. Quite often, clients are more concerned that they will become overwhelmed with anxiety than of a specific catastrophic outcome. Whatever the nature of the fear, be sure there’s space on your form for you and the client to write it out in some detail. Note that in the example below, we include ACT languaging to foster defusion from the fear (e.g., “What does your mind tell you will happen…?”) Example: What is your fear about this practice? What does your mind tell you will happen as a result?

I will have a panic attack and crash my car.

Targeting other ACT processes. With the exposure procedure defined and the core fear(s) identified, you may include other questions on your forms to strengthen other core ACT processes. For example, it can be useful to connect exposure to values. Example: What is meaningful to you about this practice? What is it a step toward doing?

I want to be able to visit friends and take my daughter to parks without limiting myself to places that I can reach on side streets. I have turned down so many invitations because of my anxiety.

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During Exposure In addition to the ratings you have chosen, you may also ask clients to make qualitative observations of their experience during exposure. Thoughts, feelings, and bodily sensations. To continue to strengthen client awareness, it can be useful to ask clients to pay attention to private events. There are many benefits to this. Clients may observe discrepancies between their predictions and what actually happens during exposure. Putting words to experience helps to strengthen self-as-context and foster defusion. Example: Describe your thoughts, feelings, and bodily sensations during the exposure.

When entering the freeway, I immediately felt my anxiety spike. My heart began racing, and I felt tightness in my chest. I wanted to pull over. I thought, “I’m going to have an accident.” However, when I shifted my attention outward and noticed the passing trees, I was better able to be present with my anxiety.

After Exposure To consolidate learning, it’s useful to include debriefing questions on the forms you provide. These could be questions clients complete after each exposure exercise or just once at the end of the week. You may also ask them to reflect on what they observed during their regular practice. Again, this is an opportunity to target and strengthen ACT processes. Examples: What did I learn from this exposure?

I learned that, although I experienced panic, I was able to focus on driving and did not crash. I found it helpful to orient to the scenery around me rather than get caught up in my thoughts. When I paid attention to the trees, I didn’t feel so consumed by panic. What is important to me about this practice? How will this help me live the life I want?

I can actually imagine being able to eventually drive my daughter on the freeway to the beach. I don’t think I’m there yet, but it feels like a possibility for the first time in years. How did your experience with the practice change over time (if at all)?

Every time I drove, I had the thought, “I’m going to have an accident!” However, the thought started to feel quieter over time. It didn’t take so much of my attention. I could ignore it and refocus on my driving. I even had moments where I enjoyed driving again. I used to love to take road trips, and I was a pretty aggressive driver when I was younger. I started to connect with my enjoyment of driving again.

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Activity: Creating Your Own Exposure Form Now that you’ve had a chance to explore the elements of a useful tracking form for ACTinformed exposure, reflect on what components you would like to include in your exposure forms. Which ratings do you think are important (SUDS, willingness, similarity)? What questions do you want to ask? What feedback do you want to elicit? If you are uncertain where to start, begin by writing down ACT processes you may want to target on a sheet of paper and develop questions from there. Once you have a rough outline, create an electronic document based on your sketch. Here, you can begin the process of refining your form. And the great thing about creating an electronic document is that you can edit it over time—and it takes less time than you might predict! It’s okay if you’re not happy with your first draft. You may continue to refine over time forms that will work for you and your clients. We encourage you to think of this as a fun, creative process. This is a place to develop materials that bring out your best skills as a clinician.

Tips for Developing Your Own Forms As you develop your stable of ACT-informed exposure forms: • Try them yourself. The best way to understand ACT is through doing. Identify a fear with which you could practice exposure or imagine you are a client. Make notes about what it’s like to complete your forms. What questions come up? How does this provide perspective on what your clients will be doing? • Role play your ideas with colleagues. If you have a colleague or consultation group also interested in learning ACT-informed exposure, practice with role plays (clients) and real plays (bringing yourself into practice). Gather feedback from colleagues and incorporate changes to your materials. • Listen to client feedback. When giving clients forms to complete, it’s important to go over their data in session. If you don’t, clients may feel as if their efforts don’t matter (e.g., Lindgreen, Lomborg, & Clausen, 2018). Notice what clients connect with and what they find confusing. For example, one of us (Brian T) initially tried teaching willingness as a binary concept (e.g., a client is either willing or not willing). Although this is a valid view and is advocated by other ACT people, he found it was a hard sell to clients, so he eventually altered his exposure forms, placing willingness on an interval scale of 0 to 10.

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Do they complete the forms as you expect them to? Do clients understand the forms? When clients do not fill out forms in the way you intended—or leave sections entirely blank—there can be several reasons, including unclear instructions or prompts that do not fit the exercise. Explore their process of filling out the form. Ask about what might be confusing or seemingly irrelevant. • Assess if the information clients provide is clinically useful. One reason we have chosen not to provide a treatment protocol is that the therapist may use forms without regard to clinical utility, because they are trying to adhere to a protocol. Consider what you learn about clients from the forms. How is the information useful? To what degree does discussing the worksheets result in fruitful discussions? What is clinically useful may evolve during treatment. One of us (Joanne) begins treatment by assigning homework focused on client responses to triggers. As clients begin practicing new skills (e.g., through exposure), she modifies the form to include additional prompts for how to track the practice of these skills in exposure. • How versatile are your forms? Are there exposure exercises that do not fit well in your format? No form will be perfect for every client and every problem, but some are more versatile than others. There may never be a “one-size-fits-all” form—but it doesn’t hurt to see how close you can get. You may have a standard form, or you may tailor your forms to specific clients. One of us (Joanne) uses electronic versions of forms that can be easily modified and filled out by the client online or on paper. • Listen to clients about what they consider meaningful. If your form specifies that clients tally the number of times they perform a targeted behavior, and a client tells you it would be easier to tally time spent (e.g., minutes), consider adopting that change. While not all clients will offer specific suggestions—some may feel overwhelmed if you try to place this responsibility on them—some will appreciate your openness to modifying forms based on their feedback, enhancing the collaborative process. • Assess whether the language in your materials is ACT-consistent. For therapists trained in traditional exposure, perhaps the biggest shift is avoiding language that communicates a focus on symptom reduction (e.g., habituation). As language that emphasizes decreasing distress is reassuring to clients, it can be difficult to resist urges to reassure clients they will feel less anxious. One of us (Joanne) catches herself still using phrases such as “less anxiety” or “feel better” because that style of

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speech has been deeply practiced. Forms can help us all be more disciplined in our languaging of ACT-informed exposure. For more in-depth discussion on the topic of languaging, refer to chapter 5. • Consider how you may convey to clients the importance of completing the forms. Your ability to present a strong rationale for out-of-session assignments may influence compliance. If you find your clients don’t follow through with assignments, consider the larger context: Was the assignment clear to the client? Did the client indicate that they felt fully understood? Have you overloaded them with too much to do? When you’re familiar with a form, it’s easy to forget that the instructions may not be clear to clients. Also, in our experience, the more assignments you give to clients, the less likely they are to complete anything. For example, be cautious about assigning more than one exposure exercise at a time; you may quickly overwhelm your client this way.

Conclusions Make time to develop forms and assess their effectiveness on a consistent basis. If you’re used to practicing traditional exposure, your forms are one way for you to help shape your ACT-informed exposure practice and keep you on track. You may then revise your forms based on your experiences and client response. Be sure to consider the wording you want to use to integrate core elements of ACT-informed exposure into your forms. You may continually revise your forms from time to time. This is another reason we did not want to create a protocol. As authors we continue to tweak and improve our own forms over time. Now that you have learned about how tracking can support your exposure work and help to enhance psychological flexibility, let’s take some time to delve into some case examples to help illustrate many of the principles that you have learned in the book so far. While we have given many shorter examples so far, the next chapter is an opportunity to dive into more examples of how ACT-informed exposure is applied to typical clients with anxiety.

CHAPTER 9

Case Examples of ACT-Informed Exposure

We’ve spent much of this book orienting you to ACT theory and describing ways to implement ACT-informed exposure. So what does ACT-informed exposure actually look like? How different is it from traditional exposure in actual practice? While we’ve emphasized the importance of theory in ACT-informed exposure (chapter 3), we also believe it’s important to understand how a course of treatment might actually unfold. Although we’ve interwoven brief clinical vignettes throughout the book, here we’ll take a deeper dive into some clinical cases to illustrate what’s unique about ACT-informed exposure. As there are many areas where traditional exposure therapists might do things that overlap with ACT in form, if not in function, we’ve made efforts to select cases that demonstrate features of the ACT psychological flexibility model and case conceptualization that differ from a traditional exposure approach both in form and function.

Cases Illustrations We’ll note here that key client details have been changed to mask client identities. Even material presented as direct quotes was reworked. Below we include the ratings systems we use in some of the example cases of ACT-informed exposure. For more detail on setting up the subjective units of discomfort scale (SUDS) and willingness scores, please refer back to chapter 5.

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Table 9.1. Reference for client ratings in case illustrations Name

Description

Rating = 0

Rating = 10

Similarity

How similar were the thoughts, feelings, and bodily sensations triggered by the exposure to your experience of anxiety and panic?

Not similar

Matches experience of anxiety or like a panic attack

Willingness

How willing were you to experience discomfort without struggle?

Not willing

Completely willing

SUDS

subjective units of discomfort scale

No discomfort

Most discomfort

Maria—Improvising with the Willingness Scale Background Maria was a cisgender Black female in her late twenties who was struggling with panic attacks. She reported experiencing panic attacks upon arriving to work at a medical center before her shifts. Although Maria was still able to complete her work without issue, the panic attacks were increasing in intensity and frequency. And they were starting to occur earlier—sometimes during the drive to work. In addition to fear of having another panic attack, Maria reported panic attacks triggered fears of (A) having a heart attack, (B) passing out, and (C) being too overwhelmed to work.

Exposure Treatment began with an orientation to ACT-informed exposure using experiential exercises and metaphors to develop a common language for ACT processes and set the foundation for exposure work. Next, we agreed to create the context for practicing psychological flexibility during panic using interoceptive exposure to private events that Maria associated with panic. We created a list of common panic symptoms that Maria experienced and identified unhelpful thoughts that appeared to be cued by Maria’s panic. We tried various interoceptive exercises to match Maria’s experience of panic, with Maria rating them on a scale of 0 (not similar) to 10 (most similar) on how closely the symptoms matched her experience of panic. Maria also rated her ability to practice willingness during interoceptive practice on a scale of 0 (not willing) to 10 (completely willing). Typically, hyperventilation is practiced for sixty seconds with one breath approximately every two seconds. However, when Maria practiced hyperventilation for sixty seconds, she found she struggled with willingness. As the exposure approached the sixty-second mark, she would increasingly fuse with thoughts such as I can’t handle this! and tense up, struggling to be open and present. Even after a few practice trials, her willingness remained in the

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middle of the range, about 4–5. When a client engages in exposure exercises where they feel like they need to “just get through it,” they are less likely to be practicing psychological flexibility. Consequently, we experimented with reducing the length of the practice in order to increase her openness to experience discomfort. In our clinical experience, it can be more effective to adjust an exposure exercise to match client willingness than to try to get a client to increase their willingness to match the exposure. Like Goldilocks, we were looking for an exposure length that was “just right”—creating a context similar to Maria’s experience of panic but with an intensity at which she could practice flexible responding. We tried reducing the hyperventilation trial from sixty to thirty seconds. At thirty seconds, Maria was able to increase her willingness from a 4–5 to a 9. Now we’re getting somewhere! From thirty seconds, we experimented with increasing the length of the hyperventilation practice in five- to ten-second increments to find an optimal balance between evoking panic-related private events at an intensity that Maria could maintain willingness. At forty seconds, Maria observed physical sensations such as sweating palms, lightheadedness, and tingling in the extremities, as well as panic-related thoughts such as Am I having a heart attack? By contrast, at thirty seconds, hyperventilation triggered the physical sensations but not the panic-related thoughts. When we increased practice to forty-five seconds, Maria experienced both the physical sensations and the thoughts but struggled with willingness (6–7) and fused with thoughts such as I can’t handle this. As a result of our experimentation, we decided that forty-second trials of hyperventilation offered a nice balance of triggering contextual cues related to panic and private events that Maria associated with panic. See table 9.2 for a summary of Maria’s scores.

Table 9.2. Interoceptive exposure to hyperventilation Trial #

Similarity

Willingness

What Happened? (number of seconds, e.g., 60s, plus bodily sensations, thoughts, feelings, impressions)

(0–10)

(0–10)

1

8–9

4–5

60s. Sweating palms, lightheadedness, tingling.

2

8

8

30s. Sweating palms, lightheadedness, tingling.

3

7–8

8

40s. Sweating palms, lightheadedness, tingling, similar thoughts as panic attack (fear of heart attack).

4

8–9

6–7

45s. More intense. Sweating palms, lightheadedness, tingling “same” thoughts (heart attack) and I can’t handle this.

For home practice, Maria agreed to practice five consecutive trials of hyperventilation at forty seconds per trial each day. At the following session, Maria reported struggling more with willingness during out-of-session practice. This happens. Sometimes clients are more willing in the presence of the therapist but struggle with exposure on their own. Maria also

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reported she had experienced higher anxiety in general during the following week due to other stressors, which may have amplified the intensity of the exposure. After talking through options, we reduced the hyperventilation practice further from forty to twenty seconds. At twenty seconds, Maria expressed increased confidence she could practice on her own with greater willingness. Success! At the following session, Maria reported greater willingness and felt ready to increase the length of the hyperventilation practice. Whereas she had felt overwhelmed at forty-five seconds the prior session (see table 9.2), after a week of practicing at twenty seconds, Maria reported increased willingness during forty-five seconds of hyperventilation. We also tried fifty seconds, but her willingness dropped (see table 9.3). Forty-five seconds offered the best balance. As there’s evidence that adding contextual cues may help to deepen learning during exposure (e.g., Craske, Treanor, et al., 2014), we decided to add an additional layer of complexity to the interoceptive practice. Maria had reported she would often fuse with fears that she was going to pass out during panic attacks and would consequently sit down. To help Maria further expand her behavioral repertoire during exposure, Maria practiced standing up immediately after hyperventilating. By deliberately standing up while experiencing the thought I need to sit down. I’m going to pass out!, Maria was able to further defuse from these thoughts. Below in table 9.3 is a selection of Maria’s ratings.

Table 9.3. Interoceptive exposure to hyperventilation Trial #

Similarity

Willingness

What Happened? (number of seconds, e.g., 60s, plus bodily sensations, thoughts, feelings, impressions)

(0–10)

(0–10)

1

8–9

9–10

40s + standing up. Sweating palms, lightheadedness, tingling, thoughts such as I need to sit down. I’m going to pass out.

2

10

8–9

45s + standing up. Similar bodily sensations and thoughts comparable to 40s with increased intensity.

3

10

7–8

50s + standing up. Similar bodily sensations and thoughts to 45s, and increased intensity. Begins fusing with thought, Too intense.

Additionally in this session, we added a second interoceptive exercise in which Maria held her breath. Again, in experimenting with the length of the interoceptive exposure, we found that fifty seconds provided the optimal balance between triggering additional panicrelated cues, especially thoughts of passing out and not being able to get enough breath, at an intensity that Maria could maintain willingness (see table 9.4)

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Table 9.4. Interoceptive exposure to holding breath Trial #

Similarity

Willingness

What Happened? (number of seconds, e.g., 60s, plus bodily sensations, thoughts, feelings, impressions)

(0–10)

(0–10)

1

8

9–10

50s. Panic-related thoughts: Am I having a heart attack? I can’t breathe. I’m going to pass out.

2

7–8

7

60s. Similar panic-related thoughts with greater intensity.

We continued to increase the length and intensity of interoceptive exposure exercises as Maria strengthened her willingness and ability to defuse from panic-related thoughts. Additionally, Maria identified values-based goals she wanted to accomplish, such as participating in a professional certification program and joining a work committee. At termination, she reported fewer panic attacks, lower anxiety, and increased ability to respond to anxiety and panic with willingness.

Take-Home Points This case example illustrates how to experiment and adjust exposure exercises to maximize training of psychological flexibility. Here we also demonstrated how to use willingness scores to inform adjustments around exposure exercises. This is a departure from traditional exposure, where decisions are more typically based on just SUDS scores. However, we’ll note that the importance of willingness is consistent with traditional exposure. Whether one is conducting traditional exposure or ACT-informed exposure, if a client is unable to be present with and practice willingness during exposure, they may struggle to increase psychological flexibility in general, and the exposure may reinforce anxiety and avoidance (e.g., Benito et al., 2018; Jordan et al., 2017; Ong et al., 2022). Because you can adjust the duration so easily, interoceptive exposure exercises lend themselves particularly well to being fine-tuned in working with client willingness.

Lucy—How to Build a Better Context Background A senior in high school, Lucy was a white, cisgender female whose primary therapist encouraged her to seek exposure therapy when her anxiety began interfering with her ability to focus on school. Lucy reported she’d always had a close relationship with her father throughout childhood. But after she turned seventeen, Lucy began fusing with fears that she was losing her close bond with her father. The main themes of her fears were (A)

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she no longer felt as strong a connection with her father as a young adult as she had in childhood, and (B) she would not be able to cope with losing her father when he passed away. Lucy avoided songs, television shows, and movies that depicted father-daughter relationships, as they triggered anxiety symptoms and fusion with her fear of losing her connection with her father. Lucy compulsively spent time with her father, constantly checking if she still felt connected to him to try to reassure herself and reduce her anxiety.

Exposure We engaged in ACT-informed exposure through telehealth, a detail that will be important in this case example. After engaging in a functional analysis of Lucy’s triggers, we couldn’t identify any reliable way of triggering Lucy’s fears when she was physically present with her father. Lucy observed that when she was around her father, she sometimes felt anxious about their relationship, but sometimes didn’t, and she could not identify any stimuli that would predictably evoke these fears. Consequently, we identified other contexts that could reliably trigger Lucy’s anxiety and fusion about her relationship with her father. For example, we selected clips of songs and movies related to father-daughter relationships—ones that Lucy had enjoyed previously but now avoided. Lucy practiced looking at photos of her father and saying fear-inducing statements aloud, such as “I don’t feel any love for you” and “We’ll never feel the same connection we used to.” Lucy wrote imaginal scripts outlining feared consequences of losing connection with her father. However, Lucy struggled with writing detailed and elaborate scripts—they were often limited to three or four sentences. Brief imaginal scripts can be effective with some clients. With Lucy, though, I was concerned that the lack of detail in Lucy’s script meant they would not sufficiently create the context to practice psychological flexibility. Her difficulty with writing the scripts was not for lack of trying. Lucy was a very organized and conscientious client. She took notes during sessions and came to each appointment with detailed questions to ask. She even researched information about writing imaginal scripts on her own. I asked Lucy all sorts of questions to try to help her expand upon the content in her imaginal scripts; however, Lucy was unable to add more detail. Nonetheless, we moved forward with imaginal exposure. Lucy recorded herself reading the script aloud on her phone and listened to the recordings between sessions. She reported she was able to defuse from the content of her anxious thoughts (e.g., reporting that she “had perspective on and distance from fear”). Throughout all exposures, Lucy reported high willingness— usually a 10 on a 0–10 scale. After completing all the exposure exercises on the exposure menu, Lucy stated she had returned to baseline and felt ready to complete treatment. I had some concerns, however. Although ACT-informed exposure doesn’t have to be difficult just for the sake of being difficult, and some clients move through exercises and strengthen psychological flexibility quickly, I felt this course of ACT-informed exposure consistently fell short in creating the

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context that narrowed Lucy’s behavioral repertoires in daily life. That is, I was worried that the exposure exercises—especially the imaginal scripts—were not evocative enough, and that they did not generate the intense anxiety Lucy experienced when she was fused with fears about attachment to her father. For example, SUDS scores were rarely higher than 5–6 and dropped rapidly, often within two to four days of regular practice. Had we sufficiently created contexts for practicing psychological flexibility? How well would learning generalize when Lucy experienced similar private events again in the future? In sum, I was concerned that Lucy hadn’t developed sufficient psychological flexibility to respond effectively when the fears returned, and that she would resort to avoidance behaviors when triggered again. Despite my reservations, Lucy was happy with her treatment progress. Self-report measures also indicated minimal distress. I didn’t feel I was in place to make a strong case for continuing treatment.

Relapse Unfortunately, my intuition proved correct. Within three months after termination, Lucy began emailing me that she was again struggling with fears about her attachment to her father. Lucy had maintained some gains—she was able to make values-based decisions about spending time with her father, no longer seeking his company to try to reassure herself. However, I now realized she was and had been using coping skills compulsively. Lucy described how she repeated helpful phrases (e.g., “I’m not my thoughts”) she had learned during treatment to try to suppress uncomfortable thoughts. This was a theme in treatment: Lucy frequently misused any insights and ACT-related skills as forms of experiential avoidance. Initially, these phrases appeared to disrupt obsessions. In her heavyhanded use of them, however, they eventually stopped disrupting the private events Lucy was trying to avoid. On my end, I had taken Lucy’s interest in writing down core phrases as a sign of her engagement in treatment and was also a little flattered that a client found what I said so inspiring! My susceptibility to adulation initially blinded me to how Lucy was using my pearls of wisdom as avoidance behaviors. We’ll note here the importance of function over form: that ACT exercises and even exposure can function as avoidance. I also want to be clear that Lucy did not realize she was engaging in avoidance behaviors. In her mind, she was doing everything she could to get the most out of therapy. We agreed to another course of treatment. Despite feeling disappointed, discouraged, and depressed about this relapse, Lucy was eager to return to exposure. We started from scratch and engaged in a functional analysis of problem behaviors associated with anxiety. Based on the updated functional analysis, we agreed to revisit imaginal exposure. As Lucy had increased her ability to be present and observe internal experiences, she was able to notice that obsessing about whether she could feel her father’s love caused her to “numb out” (i.e., low willingness and low contact with the present moment). This time, I listened to my intuition and took a more active role in shaping her scripts. Initially Lucy expressed

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resistance to spending more time on the scripts. Extremely anxious and dysphoric, Lucy wanted to complete the exposure as quickly as possible to achieve relief. Here again is an example of how exposure itself can sometimes function as experiential avoidance (i.e., rushing through exposure exercises to get better)! I found I had to practice a willingness of my own! It would have been easier to go along with Lucy’s preference to write her own scripts and quickly move into exposure. However, I allowed myself to risk Lucy’s frustration as I slowed the process, patiently working with Lucy to bring more contextual cues into the imaginal scripts. Sharing my screen through our videoconferencing platform, Lucy and I could view the document with her script together. I would suggest a sentence or two of how I imagined Lucy might think or feel in the scenario and ask for her feedback. Although Lucy had struggled to generate detailed content on her own, she was able to quickly identify whether something I’d suggested resonated with her. When it didn’t, she also had an easier time coming up with alternative content (e.g., “I wasn’t feeling angry. I was frustrated.”). Below are examples of an initial script, and how we collaboratively expanded it: Lucy’s script: I feel anxious that Dad is getting older. I imagine how old I would be if he lives to ninety and passes away. I obsess about Dad passing away and can’t be present. I fear that when he dies, I’ll forget my experience of his love, because he won’t be around physically. Therapist’s expansion of Lucy’s script: I feel anxiety when I think about Dad getting older and eventually passing away. I notice more wrinkles on his skin, the sparse hair on his head, and how easily he gets tired. These remind me that he is growing older. I start obsessively calculating how many more years he might have to live, based on my grandparents’ ages. When we spend time together, I feel my chest tighten, my heart flutters, and I start to panic. I start to grieve that Dad won’t live forever. I think about how when he dies, I won’t be able to connect with him physically, and eventually, my love for him will fade. Because my memory of his love fades, I lose touch with my ability to feel safe. I feel empty for the rest of my life with a void I can never fill. My life has become meaningless since Dad died. It worked! As Lucy began reading the revised imaginal script aloud, she immediately experienced more intense physical sensations such as dizziness and queasiness in her stomach. Whereas she had rated SUDS for the shorter scripts ranging as 3–6, she rated the more detailed scripts as 8–10. These were signs that the expanded scripts were bringing more contextual cues to the exposure in ways that allowed her to further strengthen psychological flexibility. Lucy rose to the challenge and even expressed admiration for how much more evocative these were (e.g., “Wow! I find myself trembling!”). Her willingness remained high. I felt cautiously optimistic that we were getting somewhere.

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More so than during the prior course of exposure, Lucy found that in being present with her fears, they seemed less compelling (e.g., indicating increase in defusion and self-ascontext). With practice, Lucy learned that uncomfortable private events came and went if she allowed them to. After completing a series of scripts, Lucy felt ready to end treatment again. Being more cautious this time, we agreed to shift to monthly maintenance sessions to assess the stability of her treatment gains. After a few monthly maintenance sessions, at which Lucy had maintained her gains, Lucy made an interesting observation. I had asked her to explain to me in her own words what had been different about the second course of ACT-informed exposure compared to the first. My hypothesis was that the greater intensity allowed Lucy to further strengthen her ability to practice willingness with private events, and that through strengthening willingness, she was able to resist urges to engage in compulsive checking. Lucy’s response surprised me. Instead of confirming my hypothesis, she said, “It was the details in the newer stories that gave me more distance from my thoughts.” The use of the word “distance” was striking. In our ACT-informed exposure work, we repeatedly discussed willingness but never talked about “defusion” explicitly. However, from Lucy’s reflection, it appeared that defusion was the more relevant process in her treatment, and that expanding the scripts and including more details was crucial in strengthening defusion. It would be nice if this case example ended here. However, Lucy experienced a recurrence of anxiety a few months later. She returned to treatment a third time. As we were exploring her relapse, Lucy had a realization. She noted that, “I’m afraid my love for my father won’t stay the same.” I asked Lucy if she was trying to cling to the experience of love she had for her father as a child, perhaps having difficulty accepting that her affection for her father had evolved and matured in becoming an adult. Lucy turned quiet as she pondered this. It was one of those rare lightbulb moments in therapy. Not only was this true, she said, but because she was constantly checking her attachment to her father, she was comparing her current feelings to how they were when she was a child—or at least remembered them to be. To analyze this using an ACT lens, Lucy had been fusing with self-as-content. Lucy remembered the warm, loving feelings she’d had for her father as a child and found she didn’t experience affection for him in the same way. No longer an avatar of fatherly wisdom and warmth, her father had become a well-rounded human being with his own flaws and shortcomings. She now found herself occasionally annoyed with her father, and though this change in how a child sees their parent is developmentally normal, Lucy had difficulty accepting those frustrations. She remained attached to her idealized view from childhood. By acknowledging this struggle, Lucy was finally able to defuse from how she thought she should feel and use present-moment focus to connect with the emotions that she currently felt about him, even if that also included some periodic irritation. Lucy committed to journaling her feelings daily. During the following session, she reported feeling a “quietness”

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that was accompanied by greater acceptance of uncertainty and vulnerability in their relationship. Lucy felt comfortable terminating and did not return to treatment.

Take-Home Points We offer this case for a few reasons. For one, we want to underscore the importance of humility in ACT-informed exposure. The therapist had some blind spots of their own along the way. Although an eager, diligent, and conscientious client, Lucy often used the ACT exercises and metaphors she learned in therapy as ways to suppress and disrupt uncomfortable private events. These efforts worked until they didn’t, amplifying Lucy’s frustration. Additionally, during the first course of exposure, the therapist did not create exposure exercises that were evocative enough for Lucy as they didn’t sufficiently create the behaviornarrowing contexts with which she struggled. The therapist intuited that something was not working but had difficulty addressing it during the first course of ACT-informed exposure, especially as Lucy seemed eager to tackle the exposure exercises as quickly as possible. Second, the therapist’s working hypotheses about treatment was not confirmed by Lucy. The therapist had thought Lucy would benefit from strengthening willingness in order to respond more flexibly to anxiety and panic. Lucy’s feedback about what she learned from ACT-informed exposure, however, showed that she benefitted more from strengthening defusion. Of note, Lucy’s endorsement of defusion is consistent with one large-scale trial that found that cognitive defusion was a particularly important process of change across both ACT-informed exposure and traditional exposure for anxiety disorders (Arch, Wolitzky-Taylor et al, 2012). We chose this case example in part to dispel any illusions you might have about using exposure with laser-like precision to target specific processes. Clients may have different experiences with ACT-informed exposure than we predict. The good news is that a lot can happen during ACT-informed exposure, whether the therapist intends it or not! When you target one process, you’re likely to impact others, making exposure a great method for strengthening multiple ACT processes at once. So while there is sometimes value in targeting specific ACT processes, we want to emphasize that none of these six processes are completely distinct and that your intervention may not necessarily be impacting the process that you think it is. Last, this case provides an illustration for how exposure can be a useful tool to train psychological flexibility in individuals who are experiencing relational issues. The process of ACT-informed exposure helped Lucy develop greater awareness of these private events until she experienced her epiphany, and the exposure work allowed her to practice willingness with the sadness and vulnerability that came with this insight. During a brief email check-in months later, Lucy stated she had maintained her treatment gains and was more accepting of her evolving relationship with her father as she transitioned into adulthood.

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Deacon—Eyes Without a Face Background Deacon was a cisgender, Latinx male in his late twenties who came to treatment to address body dysmorphia. Deacon obsessed about his facial features, fusing with fears he looked prematurely old. He was constantly checking his appearance in the mirror and wore sunglasses to hide what he perceived as crow’s feet around his eyes. When eating out with friends, he made certain they sat in an area with low lighting. If his friends planned to go to a restaurant that he knew was too well lit, he sometimes backed out. These behaviors to manage distress associated with his appearance were clearly getting in the way of valued living.

Exposure To target concerns about his appearance, Deacon agreed to spend time looking at his face in the mirror each morning. Normally, Deacon focused on specific parts of his face such as his eyes and nose. In focusing on specific features, Deacon fused with critical evaluations of the features (e.g., “ugly,” “old”). To counteract this tendency, Deacon practiced mirror retraining (e.g., Wilhelm, Phillips, & Steketee, 2012) or directing his attention to view his face as a whole rather than hyper-focusing on the parts he didn’t like. He observed that, when he viewed his face holistically, he found his features pleasant to look at (i.e., “not too bad”). Deacon also practiced willingness with a feeling of “heaviness” in his chest that occurred when looking at his physical appearance in the mirror. As he practiced willingness with uncomfortable bodily sensations, he observed that he was less fused with thoughts about his appearance. After initially progressing in ACT-informed exposure, Deacon began experiencing increased panic and anxiety. I was surprised, as the exposure work had seemed to be going well. When Deacon allowed himself to experience this anxiety and panic, he became more aware of larger patterns of emotional suppression. He noticed how he often pushed away all uncomfortable emotions, especially shame and guilt. Deacon traced this pattern of habitual suppression to his childhood, as his parents were critical of any emotional expression. Thankfully, he also began to notice how his attempts at experiential avoidance toward emotions such as shame and guilt backfired by leading to longer-term increases in distress. Deacon had not initially been aware of these experiences of shame and self-criticism. Instead, when he felt anxiety and panic, he typically attributed it to an external cause and searched for some change he could make to resolve it. For example, Deacon noted a pattern of breaking up with someone or quitting a job in hopes that it would end his distress. He did these things almost blindly, hoping he would feel better after eliminating the perceived cause of his anxiety. Indeed, Deacon often did feel a little better after a breakup or quitting work, which reinforced these avoidance behaviors and helped maintain his belief that his

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anxiety was caused by external stimuli. However, he began to suspect these decisions were somewhat arbitrary and not based on values. He simply took action for the sake of taking action in an attempt to resolve his anxiety. These impulsive changes reinforced his avoidance because they gave him something else to focus on (e.g., the breakup, finding a new job). After Deacon was able to identify these patterns of experiential avoidance, we decided to focus on helping him strengthen psychological flexibility when in contact with intense emotional experiences associated with costly avoidance behaviors. He wrote out a list of self-critical phrases such as You’re evil and You’re a liar that reliably triggered the emotions he typically suppressed—especially shame. Using a recording app on his phone, Deacon repeatedly read the list of thoughts aloud and created a fifteen-minute recording of them, which he listened to between sessions. At the following session, Deacon reported that by listening to the recording, he was able to practice willingness with uncomfortable private events and defuse from the content of these thoughts. In being present with these private events without trying to resolve them, Deacon was able to connect with what was important to him (i.e., values). For example, he had been on the fence about ending his relationship with his boyfriend. Because breakups were part of this larger pattern of impulsively making radical changes in his life to resolve periods of intense anxiety, Deacon was unclear as to his true feelings about the relationship and, consequently, had delayed making a decision. In practicing exposure to previously avoided private events, Deacon was able to see more clearly that his desire to end the relationship with his boyfriend was rooted in feeling they were incompatible rather than simply an impulse to make his anxiety go away. Deacon ended the relationship “with more honesty” than in prior breakups, as he was able to communicate his feelings after practicing sitting with them and getting to know them in therapy. Across subsequent sessions, as Deacon practiced exposure with the recording, Deacon continued to increase contact with and clarify valued directions. He began to make plans to reduce his full-time work and grow his consulting business.

Take-Home Points In this case example, we want to illustrate how clients may become aware of other forms of avoidance during ACT-informed exposure. When Deacon started to experience greater anxiety and panic during exposure work, we could’ve continued to focus on his body dysmorphia in a dutiful commitment to seeing the original treatment plan through. However, the therapist’s application of functional analysis throughout treatment led to the discovery of a previously unseen variable (shame) and how this contributed to the client’s anxiety. In this instance, because Deacon’s emotional avoidance was broader than his dysmorphia, the therapist’s own flexibility and decision to shift focus wound up being the more

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effective choice. Additionally, Deacon was actively struggling with whether to end his relationship, and his pattern of avoidance appeared to interfere with his ability to make valuesbased decisions. By strengthening his ability to be present with uncomfortable thoughts and feelings, Deacon was able to clarify values-based actions. More importantly, this case illustrates the core definition of ACT-based exposure: creating behavior-narrowing contexts in order to practice expanding behavioral repertoires. Deacon became aware of how anxiety and panic appeared to be exacerbated by attempts to suppress shame and self-critical thinking. By creating a context where Deacon could practice psychological flexibility with these private events, Deacon strengthened contact with the present moment, willingness, defusion, and valuing. Through these periods of concentrated practice, Deacon was better able to respond more flexibly to these private events in his daily life and increasingly orient his behaviors around values rather than emotional avoidance, including breaking up with his partner and starting a consulting business. This is another example of a client clarifying values after engaging in exposure, rather than starting with a focus on values to motivate a client to engage in exposure.

Jamie—Revisiting Creative Hopelessness Background Jamie was a white, non-binary client in their early twenties who came to treatment to address health-related fears. Their primary fear was that unexplained physical symptoms (including dizziness, being easily fatigued, and mild throat soreness) were signs of serious— and possibly terminal—illness. In fusing with these fears, they had visited the emergency department four times in two months and had made appointments with their primary care physician about once per month. In addition, fears around having an unexpected allergic reaction led to avoidance of eating new foods and wearing cosmetics, as well as using newly purchased bed sheets and clothing.

Exposure Jamie initially progressed smoothly through a series of ACT-informed exposure exercises. We didn’t spend a lot of time on creative hopelessness in the beginning, as they seemed to buy into the value of exposure work and showed strong willingness to get started. Early exposures involved eating new foods believed to cause an allergic reaction (e.g., nuts), wearing new clothes without washing them first, and using new cosmetic products. Because they valued going out to eat with friends, exposures also involved visiting new restaurants and deliberately ordering new foods. As a defusion exercise, they repeatedly read articles about feared medical issues, such as cancer.

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After moving relatively smoothly through initial exposure work to fears of allergic reaction, we worked up to Jamie’s core fear: that their experiences of dizziness, throat soreness, and gastrointestinal issues were signs of cancer. They wrote an imaginal script in which these vague physical symptoms prompted numerous visits to their primary care physician who assured them nothing was wrong. In the script, the symptoms eventually worsen, and additional testing leads to a diagnosis of terminal cancer, with only a few months to live. What made this scenario so scary for Jamie was that in the face of death, they realize they felt they had not lived a valued life. Jamie had a history of excelling in school. In college, they’d taken pre-law courses, because their parents pushed them toward law school; upon graduating, however, they realized they didn’t really want to become a lawyer. While searching for a new career direction, they worked menial jobs that they didn’t find meaningful. Jamie also had never traveled overseas or lived beyond their hometown, due to their struggles with anxiety, and felt that they had missed out on having more excitement in their life. Jamie committed to listening to a recording of the imaginal script for twenty minutes daily but reported no progress upon returning to session the next week. Whereas they’d been conscientious about practice with prior exposures, they reported listening to the recording only a “couple of times” and had not completed their ACT-informed exposure tracking form. What could be going on? To assess avoidance behavior during exposure, I asked Jamie to practice in session by reading the script aloud. Jamie observed that in reading the script aloud, they were more present and engaged with the content. By contrast, when listening to the recording at home, they had experienced the recording “like a thought.” In other words, they functionally experienced little difference between listening to the imaginal exposure recording and engaging in health-related worrying and rumination. As a result, listening to the script led to fusion with its contents in a similar way that Jamie fused with worries about their health. Consequently, we adjusted the exposure by having Jamie read the imaginal script aloud instead, hoping this shift in context allowed them to engage in the exposure with less fusion and experiential avoidance. Problem solved! I thought. It was simply a procedural issue. The exposure hadn’t functioned to create the conditions to allow Jamie to practice psychological flexibility and needed some adjustment. Based on carefully observing how Jamie responded to the exposure in session, I was confident we were on the right track now. I was wrong. At the next session, Jamie again reported no change in how they experienced the script, which indicated to me that they were still fusing with its contents. What could be the problem now? I scratched my head and engaged in additional functional assessment. In discussing home practice, Jamie mentioned that they would “take breaks” (e.g., stop and look at their phone) during the exposure whenever they felt uncomfortable. Whereas before, it seemed like a simple, procedural problem, perhaps the issue was that Jamie was engaging

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in deliberate avoidance behaviors during the exposure. This surprised me. As mentioned earlier, Jamie appeared to have been on board with the rationale for ACT-informed exposure and had progressed smoothly through initial exposure work. It had seemed that we didn’t need to spend much time in creative hopelessness and demonstrating the costs of avoidance. But here it was becoming clearer that Jamie was engaging in experiential avoidance and potentially impeding progress. I began making an effort to functionally explore the consequence of Jamie’s avoidance behaviors with them to strengthen creative hopelessness. Anytime they mentioned something that sounded like experiential avoidance—such as pausing the exposure to look at their phone—I would inquire about the consequences of these actions. Often Jamie described these behaviors as a form of self-care or giving themselves “a break.” They found, however, that they were more often disappointed that they didn’t experience the relief they craved. For example, when they would take breaks during exposure to look at their phone, it would help reset them a little; however, they would also feel increased stress at putting off the exposure. After agreeing to not engage in distraction during homework practice, Jamie returned the following week and reported that they still remained fused with the content during exposure. This was the third session in a row in which I had thought we’d fixed the problem. I sighed inwardly. I began to assess for additional avoidance behaviors. After some backand-forth with Jamie, I reviewed the exposure practice form more closely and found another clue. Willingness scores were in the middle of the range (5–6). I wondered if there were additional avoidance behaviors occurring during the exposure that we hadn’t identified. I asked Jamie to read the script aloud in session slowly and more mindfully. Slowing down an exposure exercise is a great way to increase engagement with it, because when a client moves too quickly, it can be hard to be present and practice willingness. As they were reading the script more slowly, Jamie began tearing up. They realized they were able to fully contact feelings of fear and vulnerability for the first time. Contrary to their expectation that experiencing these emotions would be unpleasant, they felt relief in contacting these emotions during exposure. I also experienced relief, as it finally seemed we were getting somewhere. Third time’s the charm. At subsequent sessions, Jamie reported that in addition to making progress with the imaginal exposure exercise, they had become more aware of daily patterns of avoidance. They more clearly perceived their efforts to push away uncomfortable private events using thought suppression and distraction. “I thought I was taking care of myself,” Jamie commented, “that I deserved not to feel these things.” They would attempt to treat themselves to relaxing activities such as warm baths and going to the sauna. However, these attempts would backfire (e.g., more anxiety), and they would feel frustrated that they didn’t experience these activities as relaxing. This is a good example of form versus function. Jamie was expecting these activities to function as self-care. Instead, they functioned as experiential avoidance, as Jamie was trying to use them to suppress or relieve their anxiety. With this

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greater awareness, Jamie became more aware of how their efforts at self-care functioned as avoidance behaviors and contributed to increased anxiety and hopelessness. We agreed to suspend exposure the following week while Jamie focused on developing emotional awareness. Each evening they’d journal thoughts and feelings and note any ongoing stressors. At the following session, Jamie reported journaling a greater variety of emotions than they’d originally predicted and noted an experience of relief in allowing themselves to be present with a fuller emotional range. After returning to the imaginal exposure script, they observed that the script seemed “less of a true story” (e.g., increased defusion) and were able to finish exposure practice and complete treatment.

Take-Home Points We offer this case example for a few reasons. One is to illustrate the importance of troubleshooting ACT-informed exposure practice. When clients do not appear to be strengthening psychological flexibility through exposure practice, it’s important to engage in a functional analysis of possible barriers. We recommend doing this in session, so that you can directly observe the client’s behavior, develop a more informed conceptualization of barriers impeding exposure work, and consequently make adjustments to the way the client is engaging the exposure. For example, can the exposure exercise be adjusted to undermine avoidance? To overcome Jamie’s barriers, we both needed to fine-tune the exercise and take additional steps to increase Jamie’s awareness of avoidance behaviors and their costs. As Ong and colleagues (2022) found, the quality of exposure exercises, specifically the degree to which clients are able to practice openness to and willingness with discomfort, is particularly important in ACT-informed exposure—more so than quantity (doing more) and duration (longer). This case example also demonstrates how you may need to return to creative hopelessness throughout ACT-informed exposure. It’s not a “one and done” process. In ACT, creative hopelessness involves helping clients understand how avoidance behaviors backfire. In ACT treatment manuals, creative hopelessness is sometimes presented as something completed in the beginning of therapy. With Jamie, though, it was the reverse. Jamie needed little focus on creative hopelessness initially and was willing to engage in the early exposures. Although Jamie had completed twenty sessions of ACT-informed exposure and successfully worked through several exposure exercises to possible allergens, targeting their core fear of having an undiagnosed, terminal illness resulted in a greater narrowing of behavioral repertoires (e.g., taking breaks when they felt uncomfortable; rushing through it). Additionally, it became clearer that their “self-care” behaviors functioned as experiential avoidance. As we became more aware of Jamie’s pattern of avoidance through functional assessment, we engaged in more creative hopelessness work, carefully helping Jamie to understand how these behaviors contributed to worsening anxiety, panic, and frustration.

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Conclusions In sum, we’ve chosen case examples that involve therapists working through difficulties with ACT-informed exposure and using an understanding of ACT processes to illuminate barriers to exposure practice. We also hope that these case examples demonstrate some of what is unique about ACT-informed exposure. We want to emphasize the importance of function (versus form) in ACT-informed exposure—as it is in traditional exposure too. The therapists needed to be attuned to moments when exposure was not functioning as intended, so that adjustments could be made to the setup of the exposure. When exposure is not functioning to help clients practice psychological flexibility, it’s vital that the therapist revisit their treatment plan and engage in a functional assessment of the client’s engagement with exposure to identify barriers (e.g., covert avoidance behaviors; contextual issues). It can be particularly important to pay attention to client willingness during exposure, such as in the example of Maria, where interoceptive exposure exercises were titrated to match her willingness, or Jamie, where middling willingness scores signaled avoidance behaviors. Additionally, although many exposure exercises are only rough approximates of real-world triggers for clients, when they insufficiently evoke the private events with which the client struggles—as with Lucy’s initial imaginal exposure scripts, which were lacking in detail—the therapist may need to adjust exercises to capture contextual cues that allow for deeper practice in enhancing psychological flexibility. In all instances, the therapists did not rigidly adhere to the exposure menu. Instead, the therapist showed flexibility in making adaptations based on newly learned information and functional assessment. When Deacon became more aware of how pervasive feelings of shame and fusion with self-critical thinking contributed to patterns of avoidance, the therapist suspended the traditional body dysmorphia exposures and targeted these private events. By strengthening psychological flexibility while in contact with painful private events, Deacon was able to clarify valued directions and act with greater intention and deliberateness than he had in the past. We’ll note, however, that in none of these examples did the therapist completely abandon exposure. In each instance, the therapist worked collaboratively with the client to troubleshoot issues and tweak procedures. Even in the case of Jamie, when the therapist suspended formal exposure practice for a week, they agreed that Jamie would focus on behavioral commitments to help strengthen awareness of the impact of avoidance behaviors that would prepare them for returning to exposure. In sum, we want to stress the importance of ongoing functional assessment during ACT-informed exposure. In other words, good ACT-informed exposure relies on clinician psychological flexibility: paying close attention to what is happening and resisting our own tendencies to fuse with content, such as an initial treatment plan or how therapy “should”

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work. We also hope that these case examples normalize the touch-and-go nature of exposure work. It is rarely a neat and tidy linear path to growth. A client’s lack of progress in completing exposures also might contribute to experiential avoidance in therapists with their own anxiety, shame, or frustration. If a client struggles with a particular exercise after a week or two of consistent practice, step back and collaboratively explore barriers. To get a clearer picture of what might be going on, have the client perform the exposure in session, so that you can offer guidance and test out hypotheses for what’s not working. Carefully consider if the exposure has sufficient contextual cues to evoke relevant private events that narrow client flexibility. Don’t be afraid to experiment. As scary as it can be to admit therapist fallibility, be open with clients when you’re unsure if an intervention is having its intended effect. In our experience, clients are very accepting when the therapist doesn’t know the answer, so long as they feel they’re actively working together as a team. Assure them that with their help and feedback, you’ll continue adjusting until you can create the conditions to help them pursue the lives they want.

CHAPTER 10

ACT Fails and Other Pitfalls and Barriers to ACT-Informed Exposure

One of us (Brian P) used to work in the trauma program at an ACT-based partial hospital program for clients with acute needs. One of his clients, Cindy, came to the program with a long history of complex trauma and was struggling with anxiety and depression. Cindy was dedicated to the program, spending about six hours per day attending group and individual sessions where she learned about PTSD and received ACT-informed exposure treatment interventions for trauma. Cindy really pushed herself to engage with exposure and opened up for the first time in her life about the very painful experiences that she’d kept locked away from others. She was a model client in the program. However, over the course of her stay, Cindy seemed to stop responding to treatment, even though she was clearly working hard. She continued to have difficulty making changes that were important to her and reported feeling just as “stuck” as when she first entered the program. During weekends, which were unstructured, Cindy would feel lost within her recovery process and return to the program on Monday defeated and hopeless. Cindy’s account of feeling lost and stuck were hard to reconcile with how she threw herself into exposure practice, how she sang praises for the benefits of willingness among her peers, and how she appeared to be able to defuse from depressive thoughts while in the program. Why wasn’t she getting better? Her treatment team noticed this pattern and began to investigate. While Cindy could articulate ACT concepts and apply them during exposure-based sessions at the program, it became apparent that she would engage in many of the same pre-treatment avoidance behaviors upon returning home. Cindy was compartmentalizing her treatment. She thought that if she practiced willingness and opened up about her trauma in the program—in session—she wouldn’t have to work so hard at home, where it was much more difficult for her, in the absence of the support of her peers and treatment team. Once Cindy and her treatment team were able to identify this pattern of behavior, they engaged in a collaborative conversation about how the skills she had learned to use in the program also needed to be practiced at home to generalize her learning. Cindy was grateful to understand why she was stalling in treatment. By practicing more willingness at home,

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she was able to redirect her efforts away from avoidance and toward values-based actions. She began to spend less time isolating and binge-watching television, and instead, spent more time with her family and friends. Though she was initially terrified at taking steps toward independence, she eventually applied to a college program. These meaningful changes resulted in her returning to the treatment program each day reporting a greater sense of fulfillment, meaning, and purpose in her life. No longer feeling stuck, Cindy celebrated her graduation from the program after many weeks of hard work.

ACT-Informed Exposure Can Be Messy Many treatment manuals—especially ones on exposure—present treatment in a structured and orderly fashion. This is important in helping orient readers toward what to do and in what order. A downside of this is that it’s easy to get the impression that treatment is supposed to proceed in a straightforward manner; therapeutic concepts may seem simple enough in theory but are usually more complex to practice when using with actual clients. Although many therapist manuals offer clinician vignettes of client difficulties, they sometimes leave out the (often messier) nuances of how the therapist worked through complex issues. It’s also difficult to succinctly demonstrate interactions that may take several sessions to come to fruition. Sometimes ACT-informed exposure goes without a hitch. But, more often, there are twists and turns. It may take several sessions of trying out different metaphors, experiential exercises, and tweaking exposure exercises before clients grasp concepts such as willingness. To put it mildly, helping clients learn to practice psychological flexibility can sometimes be a real grind. It is our experience that while every client may pose unique challenges, there are commonly encountered difficulties when delivering ACT-informed exposure. In this chapter, we describe many of the more frequent ones, so that you’ll be more prepared if you encounter them yourself. We also offer some advice as to how to respond to these obstacles in ways that hopefully will deepen your understanding of how to use the ACT model in guiding exposure treatment.

Therapist Fails The first set of barriers that we’ll discuss has to do with ourselves as therapists. When practicing ACT-informed exposure, there are several common pitfalls that therapists are susceptible to. Don’t worry—if you find yourself doing these things, it doesn’t make you a bad therapist, it just means that you’re human. While it can be painful to face our mistakes or shortcomings in the therapy room, we first need to be aware of what they are, if we are going to grow into the best versions of ourselves.

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Therapist Experiential Avoidance “Sure, we can postpone our planned exposure to talk about your pet frog’s strange mole. Again.” As therapists, we are no different than our clients in our natural inclination to avoid things that are uncomfortable or painful. Exposure therapy can be distressing to the client and therapist alike! Therefore, perhaps the largest barrier that therapists face is avoidance. In fact, therapist avoidance predicts suboptimal delivery of exposure therapy in general (Farrell, Kemp, Blakey, Meyer, & Deacon, 2016; Scherr, Herbert, & Forman, 2015). It’s not always obvious when we’re avoiding things. Sometimes clients have something serious happen in their life (e.g., a breakup or an accident) that’s important to address. You wouldn’t say to a client, “I’m sorry your grandmother passed away unexpectedly yesterday. [Pause.] Anyhoo—are you ready to make farting noises in the public library today?” However, it becomes harder when there always seems to be something compelling to talk about each session until, suddenly, weeks have passed without doing any exposure work. In ACT-informed exposure, the goal of the therapist is to help clients learn to willingly remain in contact with previously avoided thoughts, feelings, and bodily sensations in order to practice new ways of responding. This requires willingness on the part of the therapist to experience their own discomfort. For example, on days when we may feel tired, stressed out, or just not in the mood, it may be tempting to have an easier session with a client. The clients fill the session talking about something interesting unrelated to exposure. They seem happy, so we’re happy! Additionally, therapists are not immune to fusing with thoughts such as, This client will drop out if I push them to do something uncomfortable. Therapist avoidance also plays out in other areas of treatment. For example, we may let it slide when a client comes to session not having completed their homework, rather than working to understand what happened and the potential problem-solving barriers. As therapists, we may fuse with fears that we’re nagging or shaming our clients if we address homework noncompliance. Or, perhaps more egregiously, we don’t ask the client to do the hardest exposure on the exposure menu, because it will be very emotionally demanding for the client (and therefore for us). Sometimes a therapist will hold back clients from doing more challenging exposures and, instead, needlessly break down what could be a single exposure exercise into several tiny steps. We should clarify that in previous chapters we have recommended modifying exposures based on willingness. If a client needs an exposure split into several steps, that’s different. What we mean here is not trusting clients’ judgment once they have gained some experience with exposure and slowing them down unnecessarily. In short, we should apply the ACT model to ourselves. None of us is perfect. When we catch ourselves engaging in experiential avoidance, we can let go of judgment and think, Oh, cool! I just caught myself doing that! Now I can be deliberate in making another choice right now. In fact, noticing our own avoidance helps us bolster compassion for our clients and be

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better able to take their perspective when they talk about their own avoidance behaviors. It can be easy to forget how hard exposure work is for clients when it involves doing things that don’t bother us (e.g., “Try to summon a demon by reciting a magical incantation.” “Don’t mind if I do!”). Here are some additional tips for managing our own avoidance: • Present-moment awareness: This may seem obvious, but it’s important to be mindful of our own avoidance habits. Bring a present-moment focus to your exposure sessions and try to catch any urges to avoid discomfort. • Values: Contacting your values as a therapist can be motivating when therapy becomes uncomfortable. Exposure, in and of itself, may begin to feel like an exercise in torture at times, but reminding yourself what exposure is in service of can be helpful in doing the hard work. • Connect with what’s working: It’s helpful to notice the times when we, as well as our clients, persist in values-driven behavior despite pain or discomfort. Paying attention to small treatment successes along the way can be helpful in strengthening our capacity to persist in doing difficult work as exposure therapists.

Activity: In What Ways Do You Avoid? Take out a piece of paper and reflect on your own practice. What are signs that you’re engaging in experiential avoidance? Common behaviors include not following up on missed homework or allowing clients too much time to talk about things that detract from exposure in session. Take a few minutes to jot down some of the things that you tend to do in your role as a therapist that can be labeled as avoidance. As we mentioned in an earlier chapter, there are many advantages to doing exposure alongside your clients. Are there types of exposure you could do with a client but then choose not to because of your own discomfort? Make a note of these situations and explore what might be coming up for you in these contexts.

Cartoon ACT, a.k.a. Therapist Inflexibility Another common barrier, especially for therapists new to ACT, is fusing with ACT concepts. Said another way, therapists new to ACT may be rigid in applying the ACT model. We’re using the term “Cartoon ACT” to describe a version of ACT therapy that is rigid, inflexible, and lacking in focus on underlying processes. It’s more akin to a cookie-cutter manualized treatment than to a functional approach that is sensitive to context.

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Overexplaining ACT “Still struggling with willingness? Let’s review the definition…” “That’s not a value!” ACT is an experiential treatment, and what’s more experiential than exposure? One sign we’re being rigid is when we find ourselves talking about ACT rather than doing ACT. It’s easy to get caught up in talking about ACT rather than helping clients contact ACT processes in session. Creating contexts in which a client can directly experience ACT processes is usually going to be more fruitful than just talking or thinking about it. By the way, this is a great way to think about exposure therapy! One of Brian T’s favorite sayings is: let the exposure do the work for you. If a client doesn’t seem to understand ACT processes, it just may take more repetition in practicing exposure until it really sinks in for them.

Dismissing Symptom Reduction “You felt less anxious after our exposure? Remember what I keep telling you—that’s not the goal…” In ACT-informed exposure, we’re careful not to emphasize habituation or symptom reduction. However, if treatment is going well, clients often feel better. Therefore, another example of rigidly applying ACT is to treat symptom reduction like a nuisance. Clients tend to like symptom reduction. We may fuse with thoughts such as This isn’t ACT consistent! They aren’t supposed to feel less anxious—they’re supposed to live a values-based life! It’s okay. We can allow clients this victory. Failing to celebrate a positive experience risks clients feeling invalidated, like they’ve done something wrong. Sometimes it can be helpful for clients to hear the message that sometimes you may feel better and sometimes you may not. From an ACT perspective, positive emotions or reductions in anxiety aren’t bad per se; it’s only the excessive seeking of positive emotion at the expense of valued action that is unworkable.

Trying to Find the Perfect ACT Value “It took us only forty-three minutes, but we finally crafted the perfect values-based exposure for you to do for homework!” “What do you value about this exposure exercise? How about this one? And that one?”

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“That’s not a value—that’s a goal. You’re going to give me an ACT-consistent value if it takes all day!” A third example of rigidity in ACT is related to values. Values in ACT are qualities in behavior that are meaningful, such as curiosity, patience, or compassion. Values are different from goals. For one, there’s no end to valuing, while goals are something that can completed. For example, if you value being a good friend, there’s no finite end point to that. Additionally, we can engage in valuing in any moment, whereas we cannot always accomplish goals. Many therapists new to ACT struggle with understanding values. Therefore, we should be forgiving and gracious when we ask clients for a value, and they give us something that’s not ACT-consistent. For example, when we ask clients what feels important to them about engaging in ACT-informed exposure, a common answer is “to feel less anxious.” This would not be a value, but a goal. As a goal, however, we might call it a “dead person goal,” which is defined as something a corpse would be more successful at than the client (e.g., Luoma et at., 2017). In ACT, “dead person goals” are less than ideal; instead, we want to help clients focus on active goals aimed at broadening behavior. Again, though, we don’t want to punish clients for not giving us a perfect, ACT-consistent response. We might help them reformulate the goal: “If you were feeling less anxious, what would you be doing with your life that you’re not doing now?” It can be helpful, and sometimes powerful, to link exposures with values in ACTinformed exposure. For example, a client with social anxiety may feel inspired to engage in exposures that reflect things that are really important to them (e.g., seeing friends or signing up for a dating app). On paper, it may sound easy to link a value to an exposure; in reality, however, this can be difficult to pull off, and it can unnecessarily eat up too much therapy time. It can be laborious to require that all exposure exercises must be linked to values, or to rigidly demand that clients offer you the perfect, ACT-consistent values. Link exposure exercises to values when you can, but don’t get hung up on it. Sometimes exposure can help client clarify values as they clear away the clutter of fusion and avoidance.

Imitating the Ideal ACT Therapist Another example of Cartoon ACT occurs when we fuse with rigid ideas about what an ACT therapist is or does. ACT is a model. Even among respected ACT trainers, everyone has their own style. Some ACT therapists are intense and emotive, and some are fun and playful. Perhaps we’ve attended an ACT workshop and were inspired by the trainer. Be careful about fusing with the notion that theirs is the “right way” to do ACT. Instead, learn how your style of ACT can be its best.

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You may also think that you need to read all of the ACT books, attend many workshops, and receive formal supervision in order to begin applying ACT to clients. We want to emphasize that the best way to learn ACT is through doing. You’ll definitely want to own and read this book, though. Maybe get two copies, just to be sure... Now that we’ve covered several common therapist fails, let’s shift to focusing on clients. We’ll discuss common areas that ACT-informed exposure can go wrong with clients so that you can be better prepared in the case that you run into similar situations.

Client ACT Fails As we’ve noted, ACT-informed exposure, like any treatment, doesn’t always go smoothly. In these next sections, we’ll outline common client difficulties that come with each of the core ACT processes. While our list is not exhaustive, we hope it will be helpful in normalizing clinical difficulties and offering guidance in responding to pitfalls in ACT-informed exposure.

Rationale Malfunction In a perfect world, clients would always be on board with the rationale behind ACTinformed exposure and quickly internalize ACT concepts such as willingness or values. However, that doesn’t always happen. Some clients really choke on the idea of “acceptance.” For example, a client may nod that they understand willingness but later tell you that they’re hopeful that exposure will finally get rid of anxiety once and for all. Or you may find that a client demonstrates a strong understanding of ACT in the beginning of therapy but struggles with willingness as you work toward more challenging exposures. First, this is normal and not necessarily cause for concern. Remember: let the exposure do the teaching. Through experiencing, clients may start to connect with ACT processes during exposure. Some clients just need to get into direct contact with ACT concepts before they get it.

Values Vortex “What do you mean by values? I thought this was anxiety treatment!” “I’d love to have greater meaning and purpose… Maybe we can tackle that after we get to the bottom of my fears.”

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Malcolm was married and had two young boys he totally adored. One of his sons had behavioral issues and could be quite a handful at times. Malcolm was extremely hard on himself for getting pulled into arguments with his son whenever his son acted out. At the root of his argumentativeness, which clearly was a problem and negatively impacting his son, was a deep-seated anxiety that he was not a good parent and that his son was headed for a life of problems. This anxiety reflected how much Malcolm cared about getting things right for his son in ways that his own father had failed to be a good parent to him. Pain and values are commonly thought of as two sides of the same coin in ACT. Often (but not always) what we are anxious about is also what we care about. We care about showing up for our loved ones, performing well at work, or being healthy. For clients who are wedded to getting rid of their anxiety, it can be helpful to point this out. One of us asked Malcolm if, in order to get rid of his anxiety and argumentativeness, he would have to stop caring about his kids. Of course, the answer was an emphatic no. Helping clients see when their anxiety is connected to values can be helpful in normalizing and increasing their willingness to have anxiety. That is an interesting aspect of values—when our pain is connected to meaning and purpose, it can change our perspective of the experience, and therefore make it more manageable. Many clients with anxiety have completely lost touch with what’s important to them. This can happen when clients struggle with severe anxiety for a long time. Their lives have become so small that they struggle to think of anything other than feeling better. From a contextual behavioral science (CBS) perspective, we would say that their behavior is under “aversive control,” meaning that they are oriented toward escaping discomfort. When we introduce values to clients like this, it can fall flat. It may even be painful to think of bigger life directions. Still other clients are so anxious and emotionally aroused that they are simply unable to have a conversation about any topic, let alone what they want their life to be about. As part of being a flexible ACT therapist, we recommend that when a client struggles with values (or any of the ACT processes) and you’ve made attempts to help them better understand them through metaphors and experiential exercises, consider letting go of it for the moment. This doesn’t mean that you give up on values forever. In fact, there may be opportunities to slip in values work later in treatment as clients increase psychological flexibility. Listen for values as clients talk about their goals or plans. In some cases, clients may spontaneously start engaging in values-related discussions. For example, a client who rejects values may tell you many sessions later that they are debating going to a sports game but aren’t sure if they are ready because treatment has only halfway helped their panic symptoms. This may be a moment when you help them to connect with what matters most to them and use values in a way that is more useful.

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Willingness Woes “My last therapist told me to just accept things. That didn’t work.” “I feel better when I push it away than when I try to make space for it.” “If I don’t try to block my anxiety out, it will destroy me.” It’s common for clients to struggle to varying degrees with the concept of willingness or acceptance. For one, willingness can be a tricky concept for clients to fully grasp. In fact, it’s a hard concept for therapists to fully grasp! One common client misunderstanding is mistaking willingness for resignation—that we are suggesting that they give up or that there is nothing to be done about their anxiety. Other clients may conflate willingness with liking something (e.g., I must convince myself that I enjoy the experience of anxiety). Because the word “acceptance” itself is loaded with cultural baggage, many ACT therapists prefer the term “willingness,” since it does a better job at describing acceptance as active and a choice. Second, not only is willingness tricky for clients to understand, but it can also be hard to implement fully and consistently. Clients may be saying “yes” to facing their feared stimuli with their words while still saying “no” with their behavior. In these instances, it can be counterproductive to push too hard in trying to convince them to be open to their anxiety. For these reasons, conceptualizing willingness as a continuum, rather than a binary, can be helpful. If willingness is on a spectrum, consider how you may shape clients to be progressively willing. It also may be unrealistic to expect someone to practice willingness within all contexts that induce anxiety. For clients, avoidance behaviors can be so habitual and automatic, they don’t even realize that they are doing it in the moment! Consider willingness like a muscle you’re strengthening, helping a client gradually take steps to bolster this through exposure. Some clients may pull you into a heady, philosophical conversation about willingness yet avoid practicing it. You may find yourself reciting Zen proverbs and debating the meaning of existence. Sometimes this feels nice. You, as a therapist, are having a stimulating backand-forth with your client and demonstrating your competence. There’s nothing wrong with philosophy—except that it can easily serve as a distraction from the pragmatic focus of exposure work. Again, we return to the point that intellectual understanding takes a backseat to experiential learning. You can spend hours and hours refining a client’s conceptual understanding of acceptance but guiding them to an experience of acceptance is worth more than its weight in gold. Finally, it can be helpful to understand what types of histories clients have around emotional control. A male client may have a tendency toward suppressing feelings such as sadness because he grew up hearing that real men don’t cry. Some clients grow up in environments where it’s not safe to express emotions. Beliefs or rules about emotions can come

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from families, teachers, culture, media—really anywhere. Ideas around emotional control may vary across cultures (see chapter 11). Understanding larger contexts and beliefs about emotional control can be helpful in developing more compassion for obstacles clients have in developing willingness.

Present-Moment Meltdowns “I tried mindfulness, and it didn’t work.” “I already know what the present moment is, and it sucks!” “When I pay attention to my anxiety, it just makes me more anxious.” One pitfall with encouraging clients to practice present-moment focus is that many clients can quickly become discouraged or disappointed when they have trouble keeping their attention on the present moment. For example, it is common for beginning meditators to give up and say things like, “Meditation isn’t for me, I couldn’t do it.” Clients prone to self-criticism may be hard on themselves, often feeling like a failure because they couldn’t keep their attention on their breath for a ten-minute meditation. Normalizing mind-wandering is key in helping clients develop realistic expectations about any attempt to be in the present moment—whether that be formal meditation or simply a general intention to be more grounded. For example, practicing present-moment awareness during routine activities like eating, driving, washing dishes, and walking may be more accessible to many people. You may also look for opportunities to enhance present-moment awareness in session. For example, slowing things down, taking pauses, and encouraging time to reflect on what is happening right now can all be present-moment interventions without necessarily having to explicitly call them that. Sometimes that can be helpful to really “sell” clients on mindfulness, such as helping them see the costs of being on autopilot. When we are connected to the present moment, we can usually perceive more choices. Therefore, a present-moment focus may be framed as a strategy for getting us closer to an intentionally chosen valuesbased life. Lastly, the present moment is filled with many hidden gems of reinforcement that we may miss when we’re caught up in the future or the past. A hot cup of coffee. A warm shower on a cold winter’s day. A slice of freshly baked cake. Are we really taking in and being nourished by all these amazing experiences that fill our lives? Many clients misuse present-moment strategies such as mindfulness to try to control anxiety. This is often what is meant by “it didn’t work.” Feeling calm or relaxed is not exactly what present-moment focus is all about. Unfortunately, there are also many therapists who misunderstand mindfulness, instead teaching it as a relaxation practice. While reduced anxiety may be a side effect of long-term mindfulness practice, mindfulness is really

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just about showing up to the present moment as it is. If our present moment contains anxiety, then that is our present moment. In the book Ambivalent Zen (1995, p. 60), the author Lawrence Shainberg related this encounter with his Zen teacher, Kyudo Roshi: As I’m leaving the zendo after evening sitting, Roshi asks if I’ve come to a decision about my girlfriend. It’s a question I’ve been dreading. “No. I can’t decide.” “Can’t decide? Ah, great decision, Larry-san! My teacher, he says, ‘If confused, do confused. Do not be confused by confusion.’ Understand? Be totally confused, Larry-san, then I guarantee: no problem at all!” In some ways, it is so simple and straightforward that many of us have trouble getting it. In ACT, present-moment focus is simply the full awareness of what is happening right now, which can include our thoughts, emotions, bodily sensations, and what is happening around us. Moreover, it can be helpful to frame this as a skill that can be practiced and improved over time, and it helps to normalize that our natural state is usually low in being present. It can also be helpful to set realistic expectations. Many clients believe that they should be present 100 percent of the time, which is totally unrealistic. Actually, just noticing when we aren’t present is mindfulness! If clients tell you that they weren’t able to be mindful, you can reinforce them for noticing that and frame the observation as a success.

Defusion Disasters “What do you mean that a thought is just a thought?” “I’m doing my best to only think happy thoughts.” “Why do you keep saying that my mind is talking to me?” In chapter 4, we described a common defusion exercise involving the repetition of a word until the sound loses its meaning, often used to demonstrate the arbitrariness of language. For many clients, it’s a fun little exercise that they almost always get. We say “almost always” because there are some clients who are so fused that they observe no change in how they experience the word no matter how long they repeat it. They may stare at you in a state of confusion or bewilderment—Why are you asking me to repeat this word again? As a therapist, this can be disconcerting. At the same time, a client’s stuckness provides incredibly valuable information about deficits in psychological flexibility. Some clients really struggle with taking perspective of their thoughts. They may be so strongly fused with thoughts that they can’t separate them from the observer who is able to perceive them. Thoughts such as I can’t go on airplanes or I need to bring my Ativan

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everywhere I go are experienced as literal truths, not transient mental events. Let’s look at signs that a client may be highly fused with their thoughts. First, a client may demonstrate narrowed attention and lack of awareness of other contextual features occurring at the same time as thoughts. For example, they may have trouble listening to you because they are so focused on thoughts. Blank stares and googly eyes are good indicators of this. Another sign of fusion is when clients repeat certain statements or phrases to you. For example, they say, “It’s too much for me!” or “I can’t seem to change no matter how hard I try.” For these clients, these statements are hard facts about their reality. Or you spend an entire session on various metaphors and experiential exercises only to be disappointed when your client naively proclaims, “Oh I get it, I just need to stop thinking all those anxious thoughts!” In other words, some clients interpret cognitive defusion interventions in a way other than you intend. Continuing with further explanations probably won’t clarify the concept. Finally, a major sign of fusion is when we get pulled into an argument over the truth of a client’s thoughts. This signals both client fusion and therapist fusion. Even for seasoned ACT therapists, some clients seem to have a knack for pulling us into debating their thoughts. This happened to one of us with a client with health illness anxiety during the beginning of the COVID pandemic in 2020. During one session, the therapist found himself arguing with the client about what the CDC had said were safe and reasonable precautions for avoiding COVID. Never get into a factual argument with someone whose compulsion is researching on the internet—you will lose every time! Whereas in traditional CBT, you might consider evidence for and against a thought to find the most rational, reality-based version that you can think of, in ACT, we’re not interested in the true-false debate. Instead, we’re interested in how a thought functions: what happens when a client buys into a thought as literal reality? Fusion can be hard to deal with in the moment when a client is highly fused. Instead, we recommend that you proceed with treatment and look for opportunities to target this process in later sessions. You might try informal prompting, such as saying, “I notice your mind always comes up with a catastrophe when I ask you to predict what will happen.” Or you might ask, “What is happening in this moment? Are there any thoughts present?” Gently probe client attachment to thoughts, seeing what you can do to help loosen client fusion.

Stuck in Our Stories “What is this ‘observer self’ thing you keep telling me about?” “I’m supposed to be the sky and not the weather?”

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“Why do you keep calling my anxiety a ‘story’?” Self-as-context can be tricky for many new ACT clinicians, as practically applying this process in clinical work may be less straightforward. You may remember from chapter 4 that “self-as-context” refers to the observing self that contains all of our experience. Sometimes ACT clinicians can get too caught up in “teaching” clients about self-as-context, with clients’ eyes glazing over like a freshly dipped donut. Some clients may be apt to pull you into a deep philosophical discussion about the fundamental nature of consciousness or the evolutionary purpose of anxiety. While at times such discussions can be fruitful, they can often serve as an unwanted detour. Here are some practical examples of common situations where clients can show weaknesses in self-as-context. First, some clients have difficulty with observing their own experience and labeling the differences between thoughts, feelings, and bodily sensations. For example, after asking a client where they feel anxiety in their body, you might hear, “I don’t feel anxiety in my body—I just feel anxious!” They have difficulty separating out thoughts and bodily sensations present in what they label as “anxious.” When we pay close attention, we will find that what we call “anxiety” is really a changing stream of experiences including sensations in our body (e.g., stomach turning, flushed face, tightness in throat, etc.), thoughts (e.g., This is terrible! I can’t handle this! When will this end? ), and sometimes blends of other emotions such as disgust, sadness, guilt, or anger. When this all gets lumped into one word— “anxiety”—clients are less able to make direct sensory contact with their experience and therefore have difficulty practicing psychological flexibility during exposure work. In addition to helping clients perceive more clearly the private events that show up during what they call “anxiety,” it can be helpful to use self-as-context interventions to expand clients’ sense of self so that they realize that they are bigger than these experiences and can inhabit a perspective in which they identify as the container in which anxiety is experienced. The opposite of self-as-context is self-as-content or getting stuck in a story about ourselves. Many sufferers of anxiety may fuse in their identification as being an anxious person. “That’s just who I am—I’m neurotic!” Friends and family may further reinforce this identity. “That Bob—he’s a real hand wringer!” As much as their anxiety brings them suffering, it can also bring a stable sense of self. One insight from relational frame theory is that identifying with self-stories such as “I’m an anxious person” can be reinforcing because it brings a sense of coherence to our experience (Törneke, 2010). Identifying with our story is not always a bad thing. For example, we can look at how unpleasant experiences shaped us for the better. However, rigid fusion with our stories can keep us stuck. “Because I’m an anxious person, I’ll never be able to...” There are the infamous “I can’t” statements, such as “I can’t go to parties” or “I can’t date.” In addition, fusion with stories may lead clients to fear that they won’t function well if not engaged in anxious behaviors. For example, many clients believe that their anxiety has served them well in some domains: “If I give up this anxiety, I won’t be as productive or

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driven.” Some clients genuinely believe that constant worrying about catastrophic outcomes is preparing them for the future. It may be hard for clients to see how fusion with a conceptualized self limits their ability to respond flexibility to situations, and that anxiety-related behaviors are less productive than clients believe. While you may have an urge to try to dispute such unhelpful stories, an ACT approach is more focused on changing a client’s relationship to such stories and to recognize them as just that—stories. An ACT therapist may ask, “So when you believe that about yourself, how much closer has that brought you to your goals?” Stories can be compelling, both to ourselves and to others. Some clients are so fused with their conceptualized self that we fuse with it too. If clients shoot down every suggestion we make—every tiny challenge to their stories—we may start to believe it. Look for cues that we might be fusing with our clients’ stories. Are you treating this client differently than you treat other clients, perhaps handling them with kid gloves (e.g., reluctant to encourage them to do exposure)? Are you feeling hopeless about the client (e.g., maybe they’re too stuck and can’t change)?

The “ACT Parrot” Throughout this book we’ve been mindful to remain respectful of the client’s experience. We’re going a little tongue-in-cheek with this section in calling it the “ACT parrot.” Joking aside, we think this is an important client presentation to be aware of, as we risk letting down the client if we fail to address it. The ACT parrot can speak eloquently about ACT processes such as willingness and values. Perhaps they seek out and read ACT books on their own, listen to ACT-themed podcasts, and regularly use mindfulness apps on their phone. They dutifully take notes during sessions and repeat back things you say for clarification. These clients say all the things that you, as an ACT-informed exposure therapist, want to hear: “I just need to accept my anxiety.” “I should just let my thoughts come and go without taking them seriously.” Whether implicitly or explicitly, they’re letting you know they agree with everything you’ve been telling them. This often feels great as a therapist! You may feel that this client is going to be a treatment success. However, as time passes, this client struggles to apply their knowledge outside of session. They fuse with unhelpful thinking and describe actions that indicate attempts to control their anxiety. They know all the concepts but have difficulty applying them. Why might this be? One of the authors (Brian P) worked with a client who was like this. He was extremely smart and really took to ACT. He even began constructing his own anxiety metaphors. For example, he likened his anxiety to quantum physics, whereby the observer in a scientific experiment can impact the results of a particle’s behavior simply by observing it. This client compared this to his own anxiety in that the more he directly focused on his own anxiety

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as a problem to be solved, the worse it got. He stated that by observing his anxiety in a larger context that included valued action, he was able to experience his anxiety in a less disruptive fashion. Brilliant! Except that this client continued to remain stuck in his life and unchanged from session to session. With these clients, you need to get experiential. As comfortable as it can feel, it’s not enough to keep talking about ACT. Exposure is one way to help these clients connect experientially with ACT processes. It may take some time, and trial and error. But keep trying. You can try interoceptive exercises, even for clients without a diagnosis of panic disorder. Have them write out imaginal scripts. Be experiential in session. Keep working with them until ACT starts to “click.” That is how this client eventually made progress—after the therapist caught on that too much time was spent reporting back on what the client did, more time was devoted toward practicing a variety of exposure exercises in session. This allowed for direct observation and feedback that helped the client to experientially practice being more psychologically flexible.

Conclusions Practicing ACT-informed exposure, like any other treatment, is rarely a straightforward, linear process. Becoming familiar with common pitfalls can be helpful in recognizing them when they first appear, so that you are more likely to respond in a flexible and effective manner. With exposure work, simply relying on the repetition of exposure exercises can often lead to successful resolution of emerging challenges. When that doesn’t work, case conceptualization informed by ACT processes can be helpful in recalibrating treatment when a client is struggling. Finally, remember to rely on experiential methods and pay attention to your own inner processes of psychological flexibility.

CHAPTER 11

Cultural Considerations in ACT-Informed Exposure To practice ethically requires awareness, sensitivity, and empathy for the patient as an individual, including his or her cultural values and beliefs. —Hoop et al., 2008

“Why do we have to keep going to diversity trainings at work year after year? We know what to do; we don’t need to go over it again and again.” This is something a white cisgender male friend said to me (Joanne, Chinese American cisgender female) many years ago. It sparked a heated but eye-opening discussion about the importance of talking about culture and diversity, especially in the workplace. After I provided a case for the importance of yearly trainings, my friend responded: “But I already know all that… What’s the point in repeating the same thing?” To his point, I can empathize with the frustration one might have when going to trainings year after year that don’t appear to offer anything new. However, as with any type of learning, how open we are to embracing new information can influence how much we gain from the experience. Whereas someone who embraces the learning process as ongoing and evolving may bring curiosity about what more they can learn at each training, someone who views learning about culture and diversity as finite (e.g., “one and done”) might approach trainings with skepticism, believing they already have all the knowledge and skills they need to be culturally sensitive. When we refer to “culture” throughout this chapter, we mean to refer to all the cultural identities outlined in Hays’s (2001) ADDRESSING framework: Age, Disability (developmental or acquired), Religion, Ethnicity, Socioeconomic status, Sexual orientation, Indigenous heritage, Nationality, and Gender. However, we want to acknowledge that our chapter does not address all aspects of culture, as we are limited by the available literature on cultural adaptations for ACT and exposure therapy, as well as our own clinical experiences. Unfortunately, research on empirically supported treatment such as ACT-informed exposure with diverse people is not as robust as it could be (e.g., Grau et al., 2022). Nonetheless, we hope our exploration of culture in this chapter offers a starting point for

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the importance of exploring cultural matters through the lens of an ACT-informed exposure therapist. Addressing cultural issues in ACT-informed exposure is not easy. Even therapists who value continued learning about culture may be reluctant to bring culture up in the therapy room. There is evidence that exposure therapists, many of whom have been trained in CBT, may be less proactive in introducing issues of culture compared to therapists from other treatment modalities. Maxie and colleagues (2006) found that CBT therapists were less likely to reference culture (36.8 percent) compared to therapists of other backgrounds such as psychodynamic (46.6 percent), humanistic (46.8 percent), and psychoanalytic (74.1 percent). Why are therapists reluctant to address culture with their clients? There are many reasons. Some therapists may avoid such discussions because they worry about potentially offending or upsetting clients. They may fuse with thoughts such as We are so different that I’ll never be able to help them or I don’t know enough about this client’s culture, so better to avoid the topic altogether. Some therapists may be open to talking about culture but wait for clients to bring it up first, perhaps believing this approach is more respectful to clients. However, clients may be uncomfortable initiating these conversations. For example, BIPOC clients with anxiety-related problems may be reluctant to bring up cultural issues for fear of reinforcing cultural stereotypes (e.g., Williams, Rouleau, La Torre, & Sharif, 2020), putting the onus on the therapist to initiate these discussions. Because ACT-informed exposure is a context-based treatment approach, talking about and integrating cultural issues into exposure work may better inform your interventions rather than applying the same general treatment approach with all clients. A psychologically flexible therapist is open to doing what works for their clients, such as talking about differences between them—even when it’s uncomfortable (Luoma, Hayes, & Walser, 2017). Conversely, low psychological flexibility is related to more prejudicial behaviors (Levin et al., 2016).

Microaggressions For those of us who have been brought up within a Western cultural context, it’s important to be aware that, over the course of our lives, we have formed attitudes and perspectives that are biased toward the white, majority culture. As a result, we may inadvertently do things that make some clients feel marginalized. These behaviors are called “microaggressions.” Microaggressions are “brief, everyday exchanges that send denigrating messages to certain individuals because of their group membership (people of color, women, or LGBTs)” (Sue, 2010, p. 24). They are normal human tendencies that we’re all susceptible to, but they can be harmful, and in a clinical setting, they can cause harm to the client and the

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therapeutic alliance. Being a psychologically flexible therapist means being aware of and addressing microaggressions if we inadvertently engage in them. Microaggressions include: • Any words or gestures that make someone feel like an outsider, less than, different, or not part of the in-group • Not bringing up issues of race and culture or acknowledging a client’s cultural background • Making assumptions about someone’s identity (e.g., gendering) or their needs (e.g., providing unwanted assistance to someone with a disability) based on appearance Even a culturally sensitive therapist may inadvertently engage in microaggressions in the midst of planning and implementing ACT-informed exposure. For example, a common exposure for social anxiety is paying for something in pennies. Clients from impoverished backgrounds, or who are unfairly stigmatized as being frugal, may experience greater shame or humiliation in being encouraged to engage in this exposure. Also, exposures that involve bringing attention to oneself in public may be riskier for BIPOC clients than for white clients because, relative to people who are BIPOC, there are implicit protections for white people in public. They belong to the majority culture and as such, they may be shielded from many of the social consequences for engaging in a “social faux pas” that their BIPOC counterparts would not be protected from. Consider also how one conducts an intake. For example, asking a client during intake, “Where are you from?” may be triggering for someone who is part of a marginalized group, as they may have been asked questions like this in the past due to the assumption that they must have been born in a different country because they do not look like other people from the majority population. In the process of writing this book, we even stumbled across a phrase common in exposure therapy that we had not before considered could be racially insensitive: “white knuckling” (e.g., Cook, Simiola, Hamblen, Bernardy, & Schnurr, 2017). In a literal sense, “white knuckling” refers to tensing up during an uncomfortable experience, gripping your hands so tightly that your knuckles turn white. When an exposure therapist uses the term, they usually mean the client is not being present with the exposure and instead engaging in covert avoidance. It can mean rushing through exposure, trying to “get it over with.” Brian T had included the term in an earlier draft of this book, but Brian P alerted us to the possibility of the racial implications of the metaphor, as not everyone’s knuckles turn white, depending on their skin color. To gather additional feedback from other clinicians, I (Joanne) posed the question about use of the term on a members-only social media page for anxiety specialists. Responses varied. Like us, the majority indicated that they commonly used the term “white knuckling” in exposure work and had not considered the racial implications of it. The general consensus was that if the term could potentially be perceived as insensitive and

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marginalizing, it would be best to retire it and use a synonym. We decided to err on the side of caution and excised the expression from our manuscript. We share our experience as an example of the fast-changing norms within our sociopolitical culture and how commonly used terms may be more culturally loaded than we realize. Given our potential blind spots, it’s important we bring openness, curiosity, and sensitivity to our clients’ cultural contexts so that we can bring greater sensitivity to treatment. Consultation with colleagues can also be valuable in helping you see your blind spots and expand your understanding of the common cultural norms and practices of clients with whom you’re working. We also recommend that if you become aware of a microaggression that you’ve made or a client brings it to your attention, that you adopt a non-defensive stance, take responsibility for the action, and do what is necessary to repair the relationship.

Cultural Adaptations to ACT-Informed Exposure Unfortunately, the literature on cultural adaptations for exposure-based treatments for anxiety disorders is sparse (Koydemir & Essau, 2018). It’s even rarer to find guidance on cultural adaptations for ACT-informed exposure specifically. However, what we do know is promising. Although culturally diverse clients may require more time to complete exposure therapy, there’s evidence that exposure is as effective with BIPOC clients as it is with white clients (Benuto & O’Donahue, 2015; Williams et al., 2015, 2020). While standard exposure treatments may work pretty well across diverse clients, there’s also evidence that cultural adaptations can enhance outcomes with exposure therapy compared to treatment that doesn’t incorporate culture in its interventions (Griner & Smith, 2006; Pan, Huey, & Hernandez, 2011). Additionally, ACT may be successfully adapted to different cultures for the treatment of anxiety disorders (Bahattab & AlHadi, 2021; Shabani et al., 2019). What does an ACT-informed therapist do in the absence of concrete guidance about cultural adaptations? Do we try treatment as usual and hope for the best, or do we experiment with making cultural adaptations that have not been empirically studied? We (the authors) don’t have clear answers to these questions. In the following sections, we explore these questions and offer examples of cultural adaptations taken from research and case studies.

Culture and Emotional Control In creative hopelessness, we explore with clients the workability of their control strategies (see chapter 4). Although much of the ACT literature is predicated on the notion that

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attempts at control or suppression of thoughts, feelings, and bodily sensations tend to backfire, there may be cultural variations in the degree to which control strategies are viewed as adaptive. Koydemir and Essau (2018) offer that, for collectivist cultures that are more oriented toward group harmony (e.g., some Asian, Middle Eastern, Latinx), the function of how emotions are expressed may be different than for clients from individualistic cultures where more value is placed on the self (e.g., Western European). For example, Krieg (2020), writing from a contextual behavioral perspective, argues that behaviors associated with social anxiety may be more adaptive in a Japanese context (i.e., helps to gather social support) compared to an European American context. In a study of European American and Asian American women that compared the impact of emotional suppression, Butler and colleagues (2007) found that for bicultural women with Asian values, emotional suppression resulted in less intense negative emotions compared to those with Western European values. Additionally, bicultural women with Asian values were perceived as less hostile compared to Western European women. Interestingly, these women exhibited greater flexibility in their use of emotional suppression compared to women with predominately Western European values, who used suppression more rigidly. In ACT terms, bicultural women with Asian values (e.g., Asian Americans) may manage their emotions with greater psychological flexibility. As a result, emotional suppression may have more deleterious consequences for those in some cultures (e.g., Western European) than in others (e.g., Asian). This study offers a useful reminder for ACT therapists to be sensitive to cultural differences when engaging in creative hopelessness and to approach the process with openness and humility. While there is literature on the detrimental effects of emotional suppression, it can be useful to suspend the belief that all emotional suppression is ineffective, as there may be instances where it may be adaptive or helpful. Moreover, it provides further support for the psychological flexibility model in that it isn’t the behavior itself that is problematic (e.g., emotional suppression), but rather the lack of flexibility and sensitivity to context with which one engages in the behavior. To return to our earlier discussion about cultural insensitivity and the risk of engaging in microaggressions, when assessing the workability of client behaviors in ACT-informed exposure, consider the language you use in assessing the workability of client strategies. To what degree does your language suggest cultural biases of your own? When inquiring about the workability of certain behaviors, the way we phrase our questions can reveal our assumptions that these behaviors are not effective. Try to be as neutral as possible and frame your explorations of creative hopelessness from a place of genuine curiosity (e.g., “When you do that, what happens?” versus “How effective is that?”) to protect against making biased assumptions about what works and doesn’t work for a client.

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Use of Metaphors and Experiential Exercises A quote attributed to the playwright George Bernard Shaw described America and England as “two nations separated by a common language.” We offer this quote as a segue into how ACT experiential exercises and metaphors from one culture may not translate in another—even if there’s a shared language. Words that appear to be similar on the surface may represent different corresponding ideas, and a metaphor that is commonly understood by one group of speakers may be unfamiliar to another if translated verbatim. For one, there may be ACT concepts that are not as easily understood by clients from all cultures. For example, Sobczak and West (2013) suggest the concept of acceptance or willingness may be harder to understand for clients from underserved backgrounds who are struggling daily with the necessities of living (e.g., transportation; housing). Consequently, we want to be sensitive to client context and try to adapt accordingly. Even if a client is able to understand what we’re saying, we may still want to make adaptations to bring more nuance to our work, as the use of imagery and language that aligns with a particular cultural group (e.g., the image of water for Buddhist individuals) may resonate much more than using standard, nonspecific imagery and language (Hinton, Pich, Hofmann, & Otto, 2013). Payne (in press) suggests use of the phrase “living life like it’s golden” when talking about values-based behavior to those who are part of the Black community, because she found that it resonated much better than the term values. ACT metaphors may have images or ideas that are completely unfamiliar to other cultures. A quicksand metaphor for acceptance (e.g., Luoma et al., 2017) may be confusing for clients unaware of this oddity of nature. The authors, for example, who’ve never actually seen quicksand, grew up with it as an omnipresent threat, due to it being a common trope on American television shows and movies in the 1980s! In adapting an ACT protocol developed in the US for Brazil, Laurito and colleagues (2022) changed an ACT creative hopelessness metaphor involving a jelly donut (“Don’t think of a jelly donut!”) to a common Brazilian dessert. If you’re finding that clients you work with have trouble with particular ACT metaphors or ideas, experiment! It’s one thing for a metaphor to fall flat with a client. A greater concern is that some ACT metaphors may come across as culturally insensitive with clients from other cultures. They may even be perceived as microaggressions. For example, a common ACT metaphor, “The Chessboard” metaphor involves using chess pieces to demonstrate a fight between negative thoughts and positive thoughts (e.g., Hayes et al., 2012). As Masuda (2014) notes, many chessboards have dark-colored pieces and light-colored pieces, and therapists may inadvertently reinforce negative stereotypes about skin color by using the dark-colored pieces to represent the negative thoughts. Another metaphor, “Joe the Bum” (Hayes et al., 2012), may reinforce negative stereotypes about individuals who are houseless. In working with Brazilians, Laurito and colleagues (2022) changed the metaphor from a “bum” to an “unwanted neighbor” to reduce stigma toward anyone struggling with housing.

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For some clients, religion and spirituality may be an important component of their care in ACT-informed exposure. In adapting ACT-informed exposure for clients of different religious backgrounds, it may be necessary to consider key terms and ideas to improve compatibility. Even terms such as “mindfulness” can be controversial in Western cultures. When I (Joanne) first entered graduate school to pursue my doctorate degree, a Christianidentified family friend warned me about how psychological approaches like mindfulness and meditation could steer me away from Christianity (which is what I had been practicing at the time) because it was “new age.” I recall feeling discomfort at this, because I respected this family friend. I am reminded of this exchange when I work with clients who are deeply spiritual or religious, wondering if they, too, have difficulty with aspects of ACT and, even more broadly, psychotherapy. To mitigate possible conflicts between ACT-informed exposure and your client’s religious or spiritual practice, we suggest consulting with a spiritual leader in your client’s community (or having your client do so for homework) to understand how ACT concepts and practices may or may not align with the client’s specific spiritual beliefs. Fortunately, there’s evidence that ACT can be integrated with clients’ spiritual and religious beliefs (Santiago & Gall, 2016). For example, it appears ACT psychological flexibility model is consistent with tenets of Islam (Bahattab & AlHadi, 2021; Langroudi & Skinta, 2019; Tanhan, 2019). If you find that common ACT metaphors don’t resonate with one of your clients, experiment with coming up with your own that are tailored to their perspective. Notice the words, phrases, and examples they use when they’re conveying a thought to you. Pay particularly close attention to language when clients express a strong emotion. You may even consider asking them to come up with a metaphor for an idea or concept: “Can we think of a way to describe your anxiety? When you talk about it as something frightening or as something hanging over you, it kind of sounds to me like an angry bear or a circling vulture—do any images or ideas come to mind for you when you think about your anxiety?” Inviting your client to make up their own metaphors may not only increase the likelihood that the metaphor or phrase is something they will understand, it may also be an opportunity for them to deepen their understanding of the concept you are teaching them.

Values Of all the ACT processes, values are most likely to be culturally influenced. In helping a client clarify and get in touch with values, ACT-informed exposure therapists typically focus on how to move the individual closer to the life they want—as opposed to the life that, for instance, clients imagine others want for them. In fact, the therapist may view a client’s focus on the desires of others as a sign of psychological inflexibility: that they have lived their life so focused on the opinions of others to the detriments of being able to observe, connect with, and put words to what they want for themselves.

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While this view may be productive when working with clients from individualistic cultures, such as Western European, it may miss the mark when working with clients from collectivistic cultures (e.g., Asian, more traditional Latinx cultures) which emphasize the interdependent nature of self-identity, maintaining relationships, and the needs of the group (Koydemir & Essau, 2018). For individuals from interdependent cultures, values may involve prioritizing family over what’s meaningful for them as an individual (LeJeune & Luoma, 2019). Consequently, in engaging in values clarification with a client from a collectivistic culture, instead of asking what’s important to them as an individual, you may want to be open to the idea that for some clients, what is important to the group is genuinely important to them. Considering the role of family with clients is an important adaptation in working with clients from many different backgrounds. For example, a Brazilian adaptation of an ACT protocol for OCD added an emphasis on family relationships traditionally valued in Latin cultures (Laurito et al., 2022). Consider seeking out information about what’s important within any cultural groups with which you work to get a sense of the kinds of values important in those communities. A little preparation may help facilitate the questions you ask and help you see any blind spots you might have.

Improving Access to Treatment For much of this chapter, we’ve focused on cultural adaptations of ACT-informed exposure in the service of strengthening cultural sensitivity. In addition to this, it’s important to consider general practical adaptations that may improve access to treatment for clients from underserved populations. For example, evidence suggests that clients from marginalized groups are much less likely to access treatment for OCD at specialty clinics compared to their majority-culture counterparts, even though both populations have similar rates of OCD and obsessive-compulsive symptom characteristics (Katz et al., 2020). Reasons for this disparity may include differences in cultural beliefs about therapy, financial and time constraints, stigma and shame, language barriers, and the mistrust of the healthcare system and behavioral health (Kolvenbach, Fernádez de la Cruz, Mataix-Cols, Patel, & Jassi, 2018; Shea & Yeh, 2008; Turner et al., 2016). While not every issue can be addressed in this chapter, we have offered some adaptations we think can be important in ACT-informed exposure.

Utilizing Supplemental Support to Ease Financial Costs The dominant model of exposure-based treatment is one session per week. Some anxiety clients may even benefit from meeting more often than that. However, even in the United States, where we live, weekly sessions may place treatment out of financial reach of

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many clients with middle-class incomes, let alone people from a lower socioeconomic status. In these situations, you may consider involving loved ones or other types of support (e.g., lower-cost clinicians-in-training, behavior-change coaches) to coach clients while engaging in exposure practice to replace some of your sessions. These “exposure coaches” may require an investment of time at first, but after they get going, you may only need to check in with them intermittently. I (Joanne) have found this particularly helpful in using ACT-informed exposure with clients who have hoarding and OCD behaviors, due to the significant amount of time that is needed to engage in skills practice in order to make progress in treatment.

Adaptations for Nonnative Language Speakers Sometimes we may find ourselves working with clients who don’t share our native language. Even if a nonnative-speaking client is fluent in the therapist’s language, allowing them to engage in ACT-informed exposure exercises in their native language may enhance outcomes, even if the therapist doesn’t understand the client’s native language (Murrell, Rogers, & Johnson, 2009; Szoke, Cummings, & Benuto, 2020). As the goal in ACTinformed exposure is to get into contact with painful private events, conducting exposure in a client’s native language may be particularly important in evoking contextual cues that allow for the practice of psychological flexibility. In this discussion, we’ve pulled from both the ACT and non-ACT exposure literature. When working with clients with PTSD, for example, it may be helpful for clients to engage in imaginal exposures to the traumatic events by talking through the trauma narrative aloud or writing about it repeatedly in their native language. Szoke and colleagues (2020) recount a case study of a Malaysian American female client who was traumatized by an abusive husband. An important detail within the context of her trauma experiences was that she and her husband communicated in her native language. The therapist noticed that the client had difficulty fully engaging in imaginal exposure in English, while the intensity of the exposure increased when the client switched to her native language. It appears that conducting exposure in the client’s native language facilitated access to contextual cues associated with narrowing behavioral repertoires. In addition to exposure work, ACT cognitive defusion exercises may also be more powerful when clients engage in them using their native language. Consider here that clients are more likely fusing with thoughts in their native language; consequently, defusion exercises using their nonnative language may lack the stimulus functions that contribute to fusion. Murrell and colleagues (2009) found that, even if the therapist does not understand the client’s language, they can attend to behavioral cues associated with client contact with discomfort (e.g., shallow breathing; clenched fists) and can still help clients practice psychological flexibility (e.g., draw their feelings; open up to discomfort with their posture).

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Activity: Bringing It All Together In the exercise below, we invite you to bring together any reflections and insights you have gathered throughout this chapter. Please write down your responses on a sheet of paper or in a notebook as you proceed through the steps. 1.

Take a moment to identify a client you have done either ACT or exposure therapy with who is different from you culturally. It can be someone you’re working with currently or someone you worked with in the past. Take a few moments to bring them to mind. Imagine they’re standing or seated in front of you.

2. Take a moment to notice what’s coming up for you as you imagine being in the same room as this client. Observe any thoughts, feelings, or bodily sensations. How do you feel toward them now, having worked through this chapter? How is what you feel now similar or different to what you felt then, when you last shared space physically? 3. Get in touch with your experience of working with this client. How connected did you feel? How was it to communicate with the client? How did you feel about your working relationship? 4. Whether you did ACT, exposure, or both, consider any modifications you made to treatment. What happened? Did you consult with anyone in their community or consult with a trusted colleague about this client? If you did ACT, did you make any cultural adaptations for common experiential exercises or metaphors? If so, what? If you did exposure, consider any adaptations you made. If you could go back in time, and the therapist you are here-and-now could consult with the therapist you were then-and-there, what (if anything) would you recommend doing differently? Consider these suggestions as part of your reflection: ƒ

Take more time to understand the client’s cultural norms, practices, and values.

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Take more time to discuss how you and the client can work together, given the cultural differences between you.

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Approach treatment with more openness and curiosity.

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Consult with individuals in client’s community or with colleagues.

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Consult the literature for any guidance related to the client’s cultural norms, practices, and values.

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Consult the literature for suggestions for cultural adaptations to experiential exercises, metaphors, exposure exercises that may improve fit with the client’s cultural context.

5. Now reflect on your own general process of understanding and approaching culture. ƒ

How do you approach cultural awareness, sensitivity, and competence?

ƒ

What—if any—discomfort do you observe in bringing up cultural issues in therapy? What emotions do you experience? What are some thoughts you may fuse with?

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ƒ

What’s your current involvement in culturally informed treatment? Are you part of a diversity, equity, and inclusion (DEI) group? Do you attend regular trainings on cultural issues or read literature on topics related to culture in order to further your knowledge?

6. Depending on your experience in working with the client and how effective you feel your process of understanding and approaching culture is, consider the following questions: ƒ

Is there an area of your practice that you would like to strengthen as you work toward strengthening cultural sensitivity?

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What’s one step you are willing to take toward changing how you practice?

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What might get in the way of following through with this step (e.g., thoughts, feelings, bodily sensations). How would you like to relate to any barriers—especially internal ones?

Conclusions As a treatment that emphasizes sensitivity to function and context, ACT-informed exposure is well positioned to being adapted in working with culturally different groups. However, as a treatment that was largely developed in a Western, individualistic culture, there may be cultural biases encoded in the approach. In values clarification, for example, ACT texts often focus on what the individual wants. Consequently, a focus on the needs of others may be viewed by a Western European ACT therapist as a sign that the client is not in contact with their values. For clients from collectivist cultures, a focus on others (e.g., family, community) may be what is most important to them, freely chosen. These caveats aside, while research on cultural adaptation of ACT and exposure is not as robust as it could be, findings suggest that ACT-informed exposure may be effective with clients from other cultures, often with minimal adjustments. We offer some suggestions and guidance about cultural adaptation that we’ve culled from the ACT and exposure literature. We want to emphasize here that educating yourself is no substitute for actually acknowledging and openly talking with your clients about cultural differences. Additionally, as every client is unique, no one approach to ACT-informed exposure will look the same across clients. As you continue to engage with the process of expanding your understanding of cultural context in your practice (your own and others), remember that this isn’t a finite process; it’s an ongoing journey that we’re all in different stages of. Although difficult, if you value being a culturally sensitive therapist, embrace any discomfort you experience as you take each step in your journey.

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Wagner, A. P. (2003). Cognitive-behavioral therapy for children and adolescents with obsessivecompulsive disorder. Brief Treatment & Crisis Intervention, 3, 291–306. Wampold, B. E. (2001). Contextualizing psychotherapy as a healing practice: Culture, history, and methods. Applied and Preventive Psychology, 10(2), 69–86. Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “all must have prizes.” Psychological Bulletin, 122(3), 203–215. Wenzlaff, R. M., & Wegner, D. M. (2000). Thought suppression. Annual Review of Psychology, 51(1), 59–91. Wilhelm, S., Phillips, K. A., & Steketee, G. (2012). Cognitive-behavioral therapy for body dysmorphic disorder: A treatment manual. New York: Guilford Press. Williams, M. T., Rouleau, T. M., La Torre, J. T., & Sharif, N. (2020). Cultural competency in the treatment of obsessive-compulsive disorder: Practitioner guidelines. The Cognitive Behaviour Therapist, 13, e48, 1–25. Williams, M. T., Sawyer, B., Leonard, R. C., Ellsworth, M., Simms, J., & Riemann, B. C. (2015). Minority participation in a major residential and intensive outpatient program for obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorder, 5, 67–75. Wolitzky-Taylor, K. B., Arch, J. J., Rosenfield, D., & Craske, M G. (2012). Moderators and non-specific predictors of treatment outcome for anxiety disorders: A comparison of cognitive behavioral therapy to acceptance and commitment therapy. Journal of Consulting and Clinical Psychology, 80(5), 786–799. Wolpe, J. (1952). Experimental neuroses as learned behavior. British Journal of Psychology, 43, 243–268. ———. (1954). Reciprocal inhibition as the main basis of psychotherapeutic effects. Archives of Neurology and Psychiatry, 72, 205–226. ———. (1969). The practice of behavior therapy. New York: Pergamon Press. ———. (1990). The practice of behavior therapy (4th ed.). New York: Pergamon Press. Yadin, E., Foa, E. B., & Lichner, T. K. (2012). Treating your OCD with exposure and response (ritual) prevention workbook. Oxford University Press. Yuen, E. K., Herbert, J. D., Forman, E. M., Goetter E. M., Juarascio, A. S., Rabin, S., et al. (2013). Acceptance based behavior therapy for social anxiety disorder through videoconferencing. Journal of Anxiety Disorders, 24(4), 398–397.

Brian L. Thompson, PhD, is a licensed psychologist; and director of the anxiety clinic at the Portland Psychotherapy in Portland, OR. He specializes in working with anxiety and obsessive-compulsive and related disorders, and has published research in these areas. Brian C. Pilecki, PhD, is a clinical psychologist at Portland Psychotherapy who specializes in the treatment of anxiety disorders, trauma, post-traumatic stress disorder (PTSD), and matters related to the use of psychedelics. Brian also has extensive experience in the areas of mindfulness and meditation, and incorporates them into his therapy with clients. He is an active researcher and has published on topics such as anxiety disorders, mindfulness, and psychedelic-assisted therapy. Joanne C. Chan, PsyD, is a licensed psychologist, and assistant professor of psychiatry at Oregon Health and Sciences University (OHSU) where she provides psychological support to medical and dental faculty, residents, and fellows. Joanne specializes in exposure therapy for anxiety and obsessive-compulsive and related disorders, and regularly provides training and education in her areas of expertise. Foreword writer Steven C. Hayes, PhD, is Nevada Foundation Professor in the department of psychology at the University of Nevada, Reno. He is originator and codeveloper of acceptance and commitment therapy (ACT), a powerful therapy method that is useful in a wide variety of areas.

Index

A about this book, 7 abuse clients, 31, 163 acceptance: exposure related to, 35, 80; willingness as, 49, 147 Acceptance and Action Questionnaire (AAQ-II), 100 acceptance and commitment therapy (ACT): behavioral basis for, 23; brief history of, 24–25; client misunderstandings about, 56–57; creative hopelessness in, 42–46; effectiveness of CBT vs., 6, 34; experiential avoidance in, 30; exposure in context of, v–vii, 3–5, 7, 21, 34, 35–36, 41–42; functional contextualism and, 26, 28–29; hexaflex processes in, 46–55; overexplaining, 143; process-based approach in, 6; psychological flexibility in, 29–32, 34, 35, 36, 46; relational frame theory and, 32, 33; symptom reduction and, 4, 35, 36 Acceptance and Commitment Therapy for Anxiety Disorders (Eifert & Forsyth), 59 ACT-informed exposure therapy: ACT processes and, 47–55; assessing the impact of, 66–68; barriers to, 95–99, 140–153; case examples of, 121–138; choosing exercises for, 65–66; clarifying therapist assumptions in, 41–46; common problems in, 88–92; cultural considerations in, 155–165; debriefing clients after, 84–85; developing a specific plan for, 72–73; ending treatment in, 93–106; forms created for, 109–119; improving access to, 162–163; length of exercises in, 74–76; messiness of treatment with, 140; metaphors and exercises for, 59–60, 160–161; moving on to new exposures in, 86; organizing exercises for, 68–70; psychological flexibility and, 34, 35, 42, 83–84; rationale for using, 60–61, 65; talking with clients during, 79–81, 82–83; therapist behavior during, 76–83; traditional exposure vs., 34–35, 36–37, 41; troubleshooting problems in, 86–88; values

related to, 54–55, 75–76, 144; varying intensity during, 83–84; Willingness Switch for, 62–64 ACT parrot, 152–153 ADDRESSING framework, 155 Ambivalent Zen (Shainberg), 149 American Psychological Association (APA), 5 anxiety: avoidance related to, 16–17, 30, 31–32; fear structures and, 20; observing the experience of, 151; panic attacks and, 122–125; relational framing and, 33; research on ACT vs. CBD for, 6; response to exposure therapy for, 10–11; river metaphor for, 90–91; values connected to, 146; willingness practice for, 62–64. See also fear assessment: in ACT-informed exposure, 66–68; of client behavior change, 99–103; empirically validated measures for, 100–101; exercises and metaphors for, 60 Association for Contextual Behavioral Science (ACBS), 23 avoidance: adaptive value of, 30; anxiety perpetuated by, 16–17, 30, 31–32; covert or subtle forms of, 49, 91; during exposure, 49, 90–91; habitually engaging in, 98–99; rule-governed behavior and, 31–32. See also experiential avoidance awareness: increasing through tracking, 110–111; present-moment, 67, 80, 142, 148–149

B barriers to treatment, 95–99, 140–153; clientrelated fails, 145–153; defusion struggles, 149–150; engagement in avoidance behaviors, 98–99; fusion with ideas about progress, 98; holding onto safety behaviors, 96–98; non-generalization of exposure work, 95–96; parroting ACT principles, 152–153; presentmoment meltdowns, 148–149; rationale malfunction, 145; stuckness in our stories, 150–152; therapist-related issues, 140–145;

182

values struggles, 145–146; willingness problems, 147–148 behavior change: assessment of, 99–101; committed action related to, 47; forms and worksheets for, 109, 110; tracking of, 101–103, 110, 111 behaviorism: ACT and exposure rooted in, 23; first wave of CBT as, 24 behaviors: avoidance, 90–92, 98–99; contingencyshaped, 30–31; rule-governed, 30–32; safety, 90–92, 96–98; tracking, 101–103, 110–112 between-session habituation, 19, 20 Big Book of ACT Metaphors, The (Stoddard & Afari), 59 Big Book of Exposures, The (Springer & Tolin), 65 bioinformational theory, 18 BIPOC clients, 156, 157, 158 body dysmorphia, 131–133

C Cartoon ACT, 142–145 case examples, 121–138; of body dysmorphia treatment, 131–133; of building a better context, 125–130; of failed practice behavior pattern, 139–140; of improvising with the willingness scale, 122–125; of revisiting creative hopelessness, 133–136; of troubleshooting exposures, 86–87 CBT. See cognitive behavioral therapy change. See behavior change Chessboard metaphor, 160 classical conditioning, 11–15; learning theory related to, 11–12; operant conditioning integrated with, 17–18 clients: common pitfalls of, 145–153; cultural issues with, 155–165; debriefing after exposure, 84–85; experiential exercises to orient, 59–60; exploring expectations with, 98; listening to feedback from, 117–118; misunderstandings about ACT, 56–57; moving onto new exposures with, 86; out-of-session practice issues with, 89–90; participating in exposures with, 76–78; refusal of exposure by, 88–89; self-monitoring forms for, 110–112; talking with during exposure, 79–81, 82–83; terminating treatment with, 93–106; therapist self-disclosure with, 81–82

ACT-Informed Exposure for Anxiety

coaching clients, 163 cognitive behavioral therapy (CBT): effectiveness of ACT vs., 6, 34; exposure in context of, vi–vii; third-wave of, 24–25, 34, 35 cognitive defusion: ACT exercise on, 51; client struggles with, 149–150; exposure as, 50–51, 78, 80; language considerations, 163 cognitive therapy, 24 collectivistic cultures, 159, 162, 165 committed action, 47, 78 common factors of treatment, 94 conceptualized self, 53, 152 conditioned response (CR), 12 conditioned stimulus (CS), 12 conditioning: classical, 11–15; operant, 15–17 contact with the present moment: ACT exercise on, 48; client problems with, 148–149; exposure as, 48, 78, 80; rating distress as, 67; therapist avoidance and, 142 contextual behavioral science (CBS), 23, 32, 146 contingency-shaped behavior, 30–31 control strategies, 43, 91 creative hopelessness, 42–46; case example on revisiting, 133–136; cultural issues related to, 158–159; important points about, 46 cultural considerations, 155–165; access to treatment, 162–163; ADDRESSING framework, 155; emotional control, 158–159; metaphor and exercise use, 160–161; microaggressions, 156–158; nonnativespeaking clients, 163; socioeconomic status, 162–163; therapist exercise on, 164–165; values, 161–162

D de Montaigne, Michel, 50 dead person goals, 144 debriefing after exposure, 84–85 defusion. See cognitive defusion dialectical behavior therapy (DBT), 24 disclosure by therapists, 81–82 distress scores, 66–68, 112–113

E elemental realism, 28 emotional control: culture and, 158–159; willingness and, 147–148 emotional processing theory (EPT), 18–20, 24, 35

Index183

emotional suppression, 159 ending treatment, 93–106; assessing change for, 99–103; client indications for, 93–95; potential barriers to, 95–99; reducing session frequency and, 103–104; referral process for, 106; relapse prevention and, 104–105; termination process and, 105–106 evidence-based treatments, 5 expectancy violation, 75 experiential avoidance, 30; ACT-informed exposure used as, 127, 128; self-care used as, 135, 136; therapist issues with, 141–142; tips for managing, 142 experiential exercises: ACT parrot and, 153; assessing the impact of, 66–68; choosing for ACT-informed exposure, 65–66; cultural considerations for using, 160–161; organizing for ACT-informed exposure, 68–70; orienting clients to ACT with, 59–60 exposure coaches, 163 exposure hierarchy, 14, 68–69 exposure menu, 69–70 exposure therapy: ACT context for, v–vii, 3–5, 7, 34, 35–36, 41–42; anxiety disorder treatment with, 3; classical conditioning and, 11–15; contextual approach to, 23; developing a specific plan for, 72–73; emotional processing theory and, 18–20, 24, 35; importance of theory in, 10–11; inhibitory learning theory and, 20; length of exercises in, 74–76; prolonged exposure as, 3, 5, 19, 74; rationale of using ACT in, 60–61; rule-governed behavior and, 32; telehealth for conducting, 72; therapist behavior during, 76–83. See also ACT-informed exposure therapy extinction learning, 14, 20

F family relationships, 162 fear: different responses to, 28; emotional processing of, 18–19; identification of, 115; learning theories of, 17–18; Wolpe’s hierarchy of, 14. See also anxiety fear network, 18, 20 fear structures, 18–19 feedback from clients, 117–118 financial issues, 162–163

flexible perspective-taking, 52–53, 81. See also self-as-context Foa, Edna, 5, 35 forms and worksheets, 109–119; ACT-informed exposure, 112–119; tips for developing, 117–119; tracking or self-monitoring, 110–112 functional analysis, 43, 136 functional analytic psychotherapy (FAP), 24 functional contextualism (FC), 23, 26–29, 36 fusion: with personal stories, 151–152; with thoughts, 98, 141, 149–150

G generalization, 12, 95–96 goals: dead person, 144; values vs., 54, 144

H habituation: emotional processing theory and, 18–20, 35; in-session and between-session, 19–20; traditional focus on, 79 Hayes, Steven C., vii hierarchy, exposure, 14, 68–69 horse race studies, 5, 6 humor, judicious use of, 79–80 hyperventilation practice, 122–124

I idiographic measures, 101–102 imaginal exposure: case examples of, 126–128, 134–136; exercise duration for, 74; scripts created for, 51, 126–128, 134; traditional use of, 35–36 individualistic cultures, 162, 165 inflexibility of therapist, 142–145 inhibitory learning theory (ILT), 20, 61 in-session habituation, 19–20 interdependent cultures, 162 interoceptive exposure: to bodily sensations, 77–78, 82; to breath holding, 124–125; to hyperventilation, 122–124

J James, William, 27 Joe the Bum metaphor, 160 Jones, Mary Cover, 13

184

L

ACT-Informed Exposure for Anxiety

meaningful living, 94–95 measures, assessment, 100–101 mechanistic philosophy, 28 mentalism, 28 metaphors: cultural considerations for using, 160–161; orienting clients using, 59–60 microaggressions, 156–158 mind, thinking referred to as, 59 mindfulness, 148–149; cultural issues with, 161; guided exercises on, 60 mindfulness-based cognitive therapy (MBCT), 24, 25 mirror retraining, 131

Pavlov, Ivan, 11–12, 13 philosophical discussions, 147, 151 Popper, Karl, 27 positive punishment, 16 positive reinforcement, 15, 16 post-traumatic stress disorder. See PTSD clients pragmatism, philosophy of, 27 present-moment awareness. See contact with the present moment private events, 30, 35–36, 116 problems in ACT-informed exposure, 88–92; ambivalence about out-of-session practice, 89–90; avoidance or safety behaviors, 90–92; refusal of exposure exercises, 88–89; troubleshooting process for, 86–88 process-based approach, 6 prolonged exposure (PE), 3, 5, 19, 74 protocols, traditional focus on, 5 psychological flexibility, 29–32; ACT processes and, 36, 46–47; exposure and, 34, 35, 42, 83–84 PTSD clients: language considerations for, 163; prolonged exposure for, 3, 5, 19, 74 punishment: positive vs. negative, 16; reinforcement vs., 15–16

N

R

negative punishment, 16 negative reinforcement, 15, 16 nonnative language speakers, 163

rating discomfort, 66–68, 112–113 rationale malfunction, 145 referral process, 106 refusal of exposure exercises, 88–89 reinforcement: classical conditioning and, 12; operant conditioning and, 15; punishment vs., 15–16 relapse prevention, 104–105 relational frame theory (RFT), 23, 32–33, 36 religious and spiritual beliefs, 161 research: on ACT vs. CBT for anxiety, 6; on ACT-informed exposure, v–vi, 4, 6 rigidly applying ACT, 142–145 river metaphor, 90–91 role plays, 117 rule-governed behavior, 30–32, 43

language considerations, 163 lapse vs. relapse, 104, 106 learning: consolidation of, 116; extinction, 14, 20 learning theory: classical conditioning and, 11–12; fear associations and, 17–18; inhibitory, 20, 61 Little Albert study, 13 Little Peter experiment, 13–14

M

O obsessive-compulsive disorder (OCD): ACT treatments for, 34, 53; exposure treatments for, 3, 5, 34; marginalized groups and, 162 obstacles to treatment. See barriers to treatment operant conditioning, 15–18; classical conditioning integrated with, 17–18; reinforcement and punishment in, 15–17 out-of-session practice: client ambivalence about, 89–90; defining after client debriefing, 85 overexplaining ACT, 143

P panic attacks, 122–125 parroting ACT principles, 152–153

S safety behaviors, 90–92, 96–98 self-as-content, 53, 151

Index185

self-as-context: ACT exercise on, 53; client weakness in, 151–152; exposure as, 52–53, 78, 81 self-as-process, 52 self-care activities, 135–136 self-criticism, 33, 77, 148 self-disclosure, 81–82 selfing process, 53 self-monitoring, 110–112 self-stories, 151–152 sessions: practice outside of, 85, 89–90; reducing frequency of, 103–104; telehealth, 72, 126 Shainberg, Lawrence, 149 shaping, 27 Shaw, George Bernard, 160 similarity rating, 114 Skinner, B. F., 15, 23, 27, 30 socioeconomic status, 162–163 spiritual and religious beliefs, 161 stories about self, 151–152 SUDS scores, 66–68, 112–113 Suzuki Roshi, Shunryu, 49 symptoms: ACT de-emphasis on, 36, 42, 60, 61; dismissing the reduction of, 143; measuring the severity of, 67, 100–101; traditional focus on reducing, 4, 35, 42, 60 systematic desensitization, 14

T talking during exposure, 79–81, 82–83 telehealth sessions, 72, 126 termination process, 105–106. See also ending treatment theory in exposure therapy, 10–11 therapists: behavior during exposure, 76–83; clarifying the assumptions of, 41–46; cultural considerations for, 155–165; experiential avoidance of, 141–142; exposure plan developed by, 72–73; imitating an ideal of, 144–145; inflexibility of, 142–145; postexposure debriefing by, 84–85; referring clients to other, 106; self-disclosure used by, 81–82 third-wave approaches, 24–25, 34, 35

Thorndike, Edward L., 15 thoughts: client struggles with, 149–150; mind reference for, 59; native language and, 163; observation of, 116; therapist fusion with, 141, 150 Titchener, Edward, 50 tracking: behavior change, 99–103, 110; client forms for, 110–112; data provided through, 111–112; increasing awareness through, 110–111; rating scales used for, 66–68, 112–113; times and frequency of, 114 trauma clients, 33, 139, 163. See also PTSD clients troubleshooting exposure, 86–88; case example of, 86–87; recommendations for, 87–88 two-factor learning theory, 17

U unconditioned response (UR), 12 unconditioned stimulus (US), 12

V values: ACT view of, 28, 54; anxiety connected to, 146; cultural issues related to, 161–162; exercises connected with, 55, 66; exposure related to, 54–55, 75–76, 78, 81, 144; four qualities of, 54; goals vs., 54, 144; therapist avoidance and, 142; trying to find perfect, 143–144

W Watson, John B., 13 willingness: ACT exercise on, 50; client problems with, 147–148; exposure as, 49–50, 78, 80; improvising with scale for, 122–125; major points about, 63, 64; metaphor for exploring, 62–63; organizing exercises by, 69; tracking distress and, 66–67, 113 Willingness Switch, 62–63, 66 Wolpe, Joseph, 14 worksheets. See forms and worksheets

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PSYCHOLOGY

exposure for anxiety disorders Exposure therapy is a well-researched intervention for helping clients confront anxiety-provoking stimuli in order to resist engaging in avoidance behaviors. Acceptance and commitment therapy (ACT) is an evidence-based treatment model and provides a theory for guiding the use of exposure therapy by encouraging clients to connect with their values, remain in contact with the present moment, and increase behavioral flexibility. This comprehensive book provides a process-based approach for utilizing ACT-informed exposure in session, and offers new ideas and tools to help your clients. ACT-Informed Exposure for Anxiety synthesizes the latest research, clinical experience, and theory into one powerfully effective professional resource. You’ll find an overview of exposure therapy and ACT, as well as cultural considerations to inform your work with clients of diverse backgrounds. Also included are strategies to help you create exposures tailored to clients’ specific needs, and guidelines for addressing common client and therapist barriers to treatment. Whether you’re new to ACT and exposure or experienced in other models of exposure and interested in incorporating ACT into

ACT-Informed Exposure for Anxiety

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Brian L. Thompson, PhD Brian C. Pilecki, PhD Joanne C. Chan, PsyD Foreword by Steven C. Hayes, PhD