More Avoidant Therapists Are Less Likely to use Exposure in OCD Treatment

More Avoidant Therapists Are Less Likely to use Exposure in OCD Treatment

In a previous post, I linked to a blog post about therapist reluctance to use exposure therapy. Exposure therapy is one of the most effective interventions for anxiety-related problems but, sadly, remains under-utilized by clinicians. It is an intervention that has been a major focus on my posts on this blog.

A recent study out of Drexel University looks at the role of experiential avoidance in therapist reluctance to use exposure therapy to treat OCD. Experiential avoidance (EA) refers to a tendency to avoid uncomfortable thoughts, feelings, and bodily sensations, and is a cornerstone in the model of psychopathology in Acceptance and Commitment Therapy.

Methods

The researchers recruited 172 clinicians who identified as cognitive behavioral therapists. Each participant completed self-report measures of EA, attitude towards evidence-based practice, thinking style, and treatment approaches. These therapists watched 2 of 4 possible video vignettes featuring actors portraying people with OCD based on scripts that were vetted by OCD experts. The therapists then rated how much time they would allot for different therapy techniques in treating the case example.

Findings

The researchers found that therapists who scored higher on experiential avoidance (EA) reported they would devote less time to using exposure for treating OCD clients in the vignettes they watched. This is striking as exposure is the gold standard treatment for OCD. Additionally, therapists who scored higher in EA showed a lower preference towards evidence-based practice. An interesting gender finding was that women exhibited a greater preference for evidence-based practice than men.

As the authors note, it’s impossible to derive a causal relationship between these variables. For example, they speculate that therapists who are more experienced in exposure may develop lower EA because of they themselves get used to doing exposure. In support of this view, the authors note that therapists who spent a larger portion of their time doing clinical work exhibited lower EA.

Overall, this study suggests that higher experiential avoidance may be a barrier to using exposure therapy and evidence-based practices.

Check out the article!

If you’re a member of the Association for Contextual Behavioral Science, you can download a copy of the article here if you log into your account.

Preparing Clients for Exposure Using Acceptance and Commitment Therapy: Training Clients in Present Moment Awareness and Affect

Preparing Clients for Exposure Using Acceptance and Commitment Therapy: Training Clients in Present Moment Awareness and Affect

These posts are a subset of my series on using exposure in Acceptance and Commitment Therapy. These particular posts are lighter on theory and instead focus on specific ACT metaphors and exercises therapists can us to help prepare clients for exposure.

 

Successful exposure therapy requires that individuals remain in contact with uncomfortable thoughts, feelings, and bodily sensations while confronting a feared experience.  However, the ability to identify and stay present with private experiences varies from person to person. Over my years as a therapist, I have discovered these are skills not everyone possesses. Consequently, I routinely introduce clients to basic exercises aimed at developing these core skills.

Why I steer clear of the word “mindfulness”

Some would call these mindfulness exercises. I generally don’t use the word “mindfulness,” unless the person already has a background in mindfulness.

As much of my early training in therapy emphasized mindfulness meditation, this was a big shift for me. I initially earned a master’s degree in Contemplative Psychotherapy at a university that strongly emphasized meditation (Naropa University) and studied mindfulness-based processes as a doctoral student. However, for a number of reasons that could fill a separate blog post, I don’t find the word mindfulness particularly useful anymore.

Noticing

Instead, I use the word “noticing.” It’s a neutral, almost bland word—and that’s what I like about it. My hope in using it is that it orients clients to the notion that we’re building very practical skills.

A favorite noticing exercise I use is the “Acceptance of Thoughts and Feelings” exercise from Eifert and Forsyth’s (2005) ACT for Anxiety book. I lead clients through the exercise in session and debrief afterward, assessing how they respond to the exercises. At the end of the session, I give them an audio CD I created of the exercise.

Within a 2-3 sessions, I will then introduce a second exercise from the same book, the “Acceptance of Anxiety Exercise.” This follows a similar script but asks the listener to deliberately imagine something that provokes fear or anxiety. I think this exercise provides a nice stepping stone into more structured exposure work.

You can listen to audio files of both exercises here. I’ve thought about writing my own versions—and I may yet—but I would definitely use these scripts as models. There’s a professional recording of the exercises in the self-help book Forsyth and Eifert’s (2007) The Mindfulness & Acceptance Workbook for Anxiety.

I’ll also note that I don’t generally use the word “acceptance,” as the concept can provoke strong reactions in people. In fact, I wrote about the difficulties of understanding acceptance in a blog post for our client-oriented blog, The Art and Science of Living Well

Some concluding thoughts

Between in-session exercises and out-of-session practice with the audio recordings, I can be more confident that a client has the skills to stay present during exposure. Being able to discriminate among uncomfortable thoughts, feelings, and emotions can help to enhance new learning. Through practice contacting a range of private experiences, clients develop some awareness that painful private experiences are not themselves dangerous. My hope is that these practices help to make exposure work more palatable and increase treatment engagement.

I‘d like to note that there are a number of ways to build up to engaging in exposure exercises. This is just one of them. There may be clients that are ready to jump right in. However, I like to begin with these exercises so that, when it’s time to begin exposure, I have a greater sense of the client’s abilities to contact and stay with painful thoughts, feelings and emotions.

Preparing Clients for Exposure Using Acceptance and Commitment Therapy: Creative Hopelessness through Tug-of-War

Preparing Clients for Exposure Using Acceptance and Commitment Therapy: Creative Hopelessness through Tug-of-War

These posts are a subset of my series on using exposure in Acceptance and Commitment Therapy. These particular posts are lighter on theory and instead focus on specific ACT metaphors and exercises therapists can use to help prepare clients for exposure.

 

In a previous post, I detailed how to use the fingers traps metaphor to help clients contact how avoidance of private experiences may result in greater suffering. For this post, I’d like to outline another exercise I use frequently with anxiety: Tug-of-War-with-a-Monster.

We’ll call it Tug-of-War for short. This particular metaphor has been floating around the ACT world for over 20 years, and there are a number of variations. What I present here is simply how I do it. Additionally, there are a number of ways this exercise can be adapted, so as you become comfortable with it, I encourage you to play around with the format.

For a more detailed description of this exercise, I urge you to pick up Eifert and Forysth’s ACT for Anxiety Disorders. I cannot recommend this book highly enough. I borrowed much of how I structure my work with anxiety from its session outlines.

The purpose of this exercise is to help clients experientially contact what is not working in their struggles with difficult thoughts and feelings.

Materials

It’s helpful to keep a four-to-five foot length of rope in your office if you plan to use this exercise. I purchased a piece of white, nylon rope at a hardware store. The helpful salesperson used a lighter to melt the cut ends. I created evenly spaced knots to improve grip. Prior to that, I used an old canvas bag that I would roll up. A towel works, too.

Introducing the exercise

In introducing the exercise, I’ll say something along the lines of, “I’d like to do an exercise to illustrate your struggle with anxiety. Would you be willing—we’re going to play tug-of-war!

I’ll admit: it’s a weird thing to do to ask your client to stand up and play tug-of-war with you. If you’ve never done this before and are reading this with skepticism, let me assure you that you may be surprised how willing people are to play. It’s memorable at the very least.

If the client is considerably stronger than you, and you sense his eyes lighting up with glee at prospect of exerting his full strength, you might preemptively offer caution, “It looks like you can probably beat me in this, but that’s not really the point here. What we’re getting at is looking more closely at your struggle.” Also, if you have any concerns at all about your client’s health, for example potential back or neck problems, it’s important to keep those in mind before you start the exercise.

Here are the key ingredients

For the most part, I try to adlib the exercise in response to the client’s responses. However, there are some core elements, and at its most prototypical, the exercise includes the following:

  • Once we have stood up, I usually say something along the lines of: “I’m the Anxiety Monster. I’m all the thoughts and feelings you don’t want to have. When I show up, we fight.
  • I might help the person get in contact with some important values and goals. I particularly look for ones that the client feels anxiety is a barrier to pursuing.
    • Specifically, I might ask the client what she would like to be doing if they weren’t struggling with anxiety. I’ll ask her to spend a few moments creating a mental image of this just behind me, the Anxiety Monster.
      • Sometimes people are in such pain, they can’t even imagine anything else. In these instances, I’ll let it go and stick to the struggle.
  • Pull the rope back and forth. Ask the person what they notice. Here are some key things to consider pointing out, if the client doesn’t relate them spontaneously:
    • With hands and feet locked in the struggle, they can’t do much else.
    • It’s really exhausting!
    • Are they moving any closer to what’s important to them? No!
    • Where is their attention focused? Usually on the struggle, not on their values.
  • After struggling with the rope for a bit, ask them what might they do instead?
    • Drop the rope” (e.g., struggle) is what you’re getting at, but be playful with everything they have to say.
      • For example, sometimes people notice how important the struggle is for them. That they don’t want to drop the rope. Explore this.
      • Sometimes clients say they want drop the rope but don’t actually drop the rope. They might notice that there is a difference between thinking about dropping the rope and the action of letting go of the struggle.
  • The client has dropped the rope. Now what?
    • What’s it like?” Explore the experience of having dropped the rope.
    • Dangle the rope in front of them and demand they pick it up. Insist they must “defeat” you first. This illustrates how persuasive anxious thinking can be, how struggling with difficult private experiences can be so automatic. If I know something about the client, I might say some of the things that they say to themselves while they get caught in their anxiety struggles.
    • Emphasize that you—the Anxiety Monster—are still there (e.g., “Have I gone away?” “No!”).
      • Instead, clients observe they can move towards what’s important even with the Anxiety Monster there.
  • People have a range of reactions to this exercise. Make room for them all.

Return to the metaphor throughout treatment as needed

Like my supply of finger cuffs, I keep my rope in a little box within easy reach of my chair. Throughout treatment, when it appears a client is struggling in session with difficult feelings, I may pull out the rope and toss the end them: “Is there a struggle going on. Are you playing tug-of-war here?” This helps them further discriminate these struggles and can bring a sense of playfulness to the room.

In sum

Playing tug-of-war with their therapist is an experience clients are unlikely to forget. It engages multiple senses: sight, tactile, imagination, etc.

It also serves as an informal assessment for you:

  • How did they respond to the exercise?
  • What was unique about their own struggle?
  • How did they respond when you asked them to imagine meaningful goals and direction?

Additionally, whether it’s worry, anxiety, obsessive thinking, or panic, people with anxiety-related difficulties can identify with the idea of struggle in ways that are not always so obvious with people who are depressed, for example. Tug-of-War-with-a-Monster was practically tailor-made for anxiety-related struggles.

Lastly, the idea of letting go of the struggle—of allowing anxiety to remain in the room while taking action towards what’s important—helps to lay the ground for eventual exposure work. It helps people understand experientially what they might find unpalatable if explained in words only. This exercise leaves a lasting impression, and you can refer back to it as appropriate.

Experiential Avoidance and Its Relevance to PTSD

Experiential Avoidance and Its Relevance to PTSD

This post is the first part of a series on using exposure in Acceptance and Commitment Therapy

 

Within the Acceptance and Commitment Therapy (ACT) literature, there’s a core concept called experiential avoidance. Experiential avoidance was arguably the lynchpin in ACT theory in the early days of ACT. The theory has been broadened since then.

Experiential avoidance is a basic umbrella terms for all sorts of avoidance behavior that people use to deal with all sorts of private experiences (e.g., thoughts, emotions, bodily sensations). Attempts to block out, reduce, or change these experiences are all forms of experiential avoidance. Behaviors associated with experiential avoidance include disputing thoughts, using substances (e.g., alcohol), and escaping or avoiding uncomfortable situations.

Everyone engages in some experiential avoidance on a daily basis.  Less problematic examples include putting on sweater when it’s cold, turning on a light switch when we enter a dark room, or mindlessly perusing the internet when we feel listless. Experiential avoidance becomes a problem when it is applied rigidly and inflexibly, and when it gets in the way of what’s important to us.

One of the clearest examples of experiential avoidance is how it functions in people with posttraumatic stress disorder (PTSD).

Experiential Avoidance and PTSD

As you might imagine, people with PTSD engage in a lot of experiential avoidance. In fact, avoidance behaviors are one of the core cluster (C) of symptoms for a PTSD diagnosis. There’s a large body of research suggesting that experiential avoidance plays a big role in maintaining PTSD symptoms over time.  For example, experiential avoidance predicts PTSD in adult survivors of childhood sexual abuse more than the severity of the abuse itself (Batten, Follette, & Aban, 2002; Rosenthal, Hall, Palm, Batten, & Follette, 2005).

Here are some possible reasons experiential avoidance may result in PTSD symptoms.

Reason 1: Avoidance leads to more of what the person wants avoid

Dostoevsky famously challenged his brother to not think of a white bear.

Can you do that? Can you not think of a white bear?

As you can imagine, trying not to think of something is really hard. Decades of research on thought suppression (e.g., Wenzlaff & Wegner, 2000) have shown that the very strategy of suppressing a thought tends to lead to more of the very thought the person is trying to avoid.

For people with PTSD, the result is that avoiding trauma-related internal experiences results in more of those very experiences over time.  For example, in survivors of motor vehicle accidents, those who attempted to avoid thinking about the accident showed greater PTSD symptom severity (Mayou, Ehlers, & Bryant, 2002; Steil & Ehlers, 2000).

Part of what maintains this tendency to avoid PTSD-related thoughts and feelings is probably a momentary sense of relief that comes from suppressing those thoughts and feelings. Unfortunately, this moment of relief becomes increasingly insignificant when compared against the long-term consequences of avoiding trauma reminders. As trauma reminders recur, avoiding them becomes a major focus on the person’s life. Other life goals and values get neglected and avoidance gains more and more influence of the person’s life.

Additionally, as people begin to avoid more and more experiences, even neutral stimuli can become reminders of the trauma. For example, a person may avoid a particular alley in which he was attacked. Over time, the person may avoid all alleys. Features of the alley, such as red brick, similar to what lined the alley, or even the experience of closed spaces, may become linked to the trauma if they are continually avoided. Only through maintaining contact with these stimuli can one learn or re-learn that these stimuli (e.g., bricks, enclosed spaces) do not need to be avoided.

Reason 2: Some avoidance behaviors increase the risk of further painful experiences

The potential for danger increases significantly when a person spends time abusing drugs and alcohol, having unprotected sex with people they hardly know, or engaging in daredevil activities. People with PTSD often do things like this to block out the trauma, putting them at risk for further harm (Chapman, Gratz, & Brown, 2006; Polusny & Follette, 1995). Actions such as substance use, overeating, and staying home from work can lead to painful consequences in the short-term and across time.

Please be clear: I don’t mean that people should be blamed for this pattern. The horrifying images involved in PTSD and painful feelings can easily overwhelm people’s ability to cope and people understandably turn to behaviors that bring relief. Unfortunately, strategies that decrease pain in the short term (such as those above) may actually lead to more suffering in the longer term.

Reason 3: People may lose out on helpful experiences

In addition to avoidance leading to harmful experiences, someone who chronically avoids may lose contact with experiences that are potentially helpful. The more time people spend avoiding events, memories, feelings, and thoughts, the smaller and narrower their lives become. This reduces contact with positive experiences over time, and it stymies valued and meaningful living. As behavioral activation research for depression has suggested (e.g., Kanter, Busch, & Rusch, 2009), it’s very important for people to be engaged in a variety of enjoyable and personally meaningful activities.

When avoidance becomes the norm, people lose contact with sources of positive reinforcement and reward. This might include relationships, exercise, hobbies, and other interests. Over time, someone’s life may become increasingly narrow (e.g., staying inside much of them time). In the absence of other enjoyable and meaningful experiences, someone’s range of activity may become so small, that all she has left is what is being avoided (e.g., trauma).

ACT and Experiential Avoidance

Nowadays, it’s more common to hear ACT therapists talk about “increasing psychological flexibility,” but in the not-so-distant past, the focus was on decreasing or undermining experiential avoidance. ACT theory and technology were specifically developed to target experiential avoidance.

ACT has a number of interventions and techniques that focus on helping people contact stimuli that are typically avoided: thoughts, emotions, bodily sensations, meaningful goals, and activities. ACT has been called an exposure-based treatment (e.g., Luoma, Hayes, & Walser, 2007); however, you could also consider exposure as one technique among many used by ACT therapist to reduce experiential avoidance and expand behavioral repertoires.

ACT is less procedural than other treatments, and, therefore, harder to manualize. Because ACT has so many methods for targeting experiential avoidance, though, ACT offers therapists an array of tools to use for conditions (e.g., PTSD) where exposure-based approaches remain the gold standard.

At this writing, there is little written guidance about how to use exposure in an ACT. People are talking about it, and giving workshops about using exposure in ACT, but it remains new territory.

This series of posts focuses on how therapists can use exposure in an ACT context to undermine experiential avoidance in people with PTSD.

I will mainly organize the posts according to ACT-specific processes. My hope is that the series will offer clinicians some practical guidance on using exposure-based interventions in an ACT-influenced way. Additionally, it is my aspiration that even non-ACT clinicians will find these posts helpful in expanding their understanding of clinically significant processes of change and range of potential clinical interventions.

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