Essential Components in Crafting a Rationale for ACT-informed Exposure

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Exposure Therapy is one of the most effective treatments for anxiety disorders. Many models have been developed to understand how exposure works. Acceptance and commitment therapy (ACT), a third wave approach that focuses on contacting discomfort in order to take action towards what’s important to you, is one of the newer models that have been used with exposure.

Clients often have trepidation about exposure. We’re asking them to confront things they have been avoiding—often for an extended duration. Additionally, clients often fear that something terrible could happen as a result, or that they will become too overwhelmed with anxiety to cope. Because clients can be skittish about beginning exposure work, it’s important to get them on board with exposure therapy before moving forward.

Traditional exposure focuses on symptom reduction. Clients are told if they stay in the exposure long enough, they’ll experience a drop in anxiety. By contrast, exposure based on the ACT psychological flexibility model, the direct focus of exposure is increasing behavioral flexibility when in contact with stimuli that often narrow flexibility. As it does not promise symptoms reduction, an ACT-informed exposure rationale can be a harder sell for some clients than symptom reduction.

To what degree does what we say matter? In one study, a team of researchers versed in different exposure models came together to test this. The researchers looked at how people responded to different exposure rationales: a.) acceptance and commitment therapy (ACT); b.) traditional exposure based on the emotional processing theory (EPT); c.) inhibitory learning theory (ILT); d.) and a generic definition of exposure that was not rooted in any particular model of exposure.

What they found was that people found rationales rooted in theory—any theory, whether EPT, ITL, or ACT—were more credible than the generic rationale. The ACT rationale they used described exposure as a method for learning to “welcome” anxiety as “a meaningful part of your day-to-day experiences,” that 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.”

I’ll note here 2 components to an ACT-consistent rationale for exposure: a.) how one relates to anxiety during exposure; b.) an emphasis on meaningful living (e.g., values). As I note in my new book on ACT-informed exposure for anxiety disorders:

There’s no one way to craft an ACT rationale for exposure. The main points you may want to emphasize are remaining in contact with anxiety, and the client taking action towards 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,” “being present with,” and “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.”

There’s a variety of ways to craft a rationale for ACT-informed exposure. Be creative! The important thing to remember is to refrain from promising symptoms reduction. This may be difficult if you’re trained in traditional exposure. For this reason, I recommend writing out your rationale and practicing it in order to present an ACT-consistent rationale for exposure.

Author: Brian Thompson, PhD

If you liked this post, check out Dr. Thompson's upcoming workshop on ACT-Informed Exposure: A Practical Guide to Applying ACT-informed Exposure