How Do You Use Exposure in Acceptance and Commitment Therapy?

In June, Utah State professor Mike Twohig is coming to Portland to conduct a daylong workshop on using exposure in Acceptance and Commitment Therapy (ACT). [As a side note, I did my first ACT training with Mike literally one week before I moved from my doctoral program in Montana to complete my internship in Portland. Mike gave me a letter of introduction Jason Luoma, the director of Portland Psychotherapy, where I ended up doing post-doc and staying on.]

If you’ve read my other posts, you know I’m fascinated by  exposure therapy. Mike is a great person to talk about exposure, as he’s published some groundbreaking work in using ACT to treat OCD without the use of exposure and ritual prevention (ERP), the gold standard for OCD treatment. Instead, Mike has developed a protocol that helps clients develop awareness of obsessive thinking, practice acceptance of accompanying anxiety, and engage in activities that are important to them.

Why I Couldn’t Pay Attention to My Own Panel Discussion

At last year’s Association for Contextual Behavioral Science conference, I organized a panel discussion on using exposure in ACT. I put it together and chaired the panel because I wanted to develop my understanding of exposure (and I hoped other people might be interested, too). It was a great international line-up of experts: Jonas Ramnerö, Sonja Batten, Carmen Luciano, and Rikard Wicksell. Jonas Ramnerö, a professor in Stockholm Sweden, suggested the title: “Ask Not What Exposure Can Do for ACT—Ask What ACT Can Do for Exposure.”

Take a moment and reflect that a Swede suggested a great title which references a famous JFK line.

Now try to quote a famous Swedish politician.

I can’t either.

I organized this panel discussion because, although exposure has been around for several decades, and there’s an enormous amount of research showing it works, there’s little agreement about how it works.

However, as this was the first time organizing and chairing a panel, I felt bit nervous and self-conscious about my role; unfortunately, I spent most of the time during the panel stuck in my head and thinking about what I could have done better. To make matters worse, the air conditioning was broken in that particular room on an extremely hot Italian day. I stared out at the audience in front me, watching their sweating, lethargic faces project boredom and disinterest.

In a sense my exposure panel turned into an exposure session—for me.

It was also exciting to watching the lively debate unfold among the panelists, though. It even turned heated at times. The panelists were all rooted in the same model, but they had different opinions about the mechanisms of change when using exposure in ACT. It was fun to watch the participants light up with ideas as the sparks began to fly.

Enough about Me, Back to Exposure

Our understanding of exposure has gone through a number of shifts through the decades since it was first proposed as a treatment technique. We have had classical and operant models of exposure. We have cognitive-behavioral models of exposure that emphasize a behavioral understanding, and we have  cognitive-behavioral models that emphasize a cognitive understanding.

ACT and Exposure

If you’re familiar with ACT, you know that ACT rests upon a behavioral analytic tradition and includes a philosophy of science and an innovative understanding of human language, cognition, and emotion. A comprehensive understanding of exposure from an ACT perspective is a work in progress. People such as Mike, Jonas, Carmen, Sonja, and Rikard, among others, are at the vanguard of this development. An ACT understanding of exposure appears to be congruent with some of the more cutting edge research of people such as Michelle Craske, whose work I’ve written about here.

Based on the panel I organized and from my own reading, I’ve come to a few conclusions about what ACT offers in conducting exposure therapy:

1.     In ACT, exposure should be tied to some larger meaningful life direction (i.e.,

in ACT terms, “values” or “committed action”). Even if one doesn’t experience a reduction in distress, practicing exposure should allow someone to take steps towards an important direction or goal.

2.     ACT offers a variety of exposure-like exercises with which to help clients

contact experiences they typically avoid.

• Clients can be directed to contact unpleasant thinking without buying into the literal reality of specific thoughts (i.e., defusion).
• Clients can practice awareness of avoided bodily sensations or of emotions  while learning to tolerate and create space for these experiences (i.e., acceptance  or willingness).
• Clients can practice shifting their perspective in ways that allow them to observe the constant stream of their experiences (e.g., thoughts, sensations, feelings) without identifying with those experiences (i.e., observer self).

All of this leads to my third point:

3.     The ultimate goal in ACT is increasing psychological flexibility: the ability to be

psychologically present while engaging in meaningful activity. Rather than seeking to reduce arousal in response to aversive stimuli, an ACT approach focuses on expanding behavioral repertoires in the context of aversive stimuli. Exposure allows people to develop psychological flexibility by providing a chance to experience discomfort while taking meaningful action. For example, through exposure practice, a socially anxious person can learn to engage with people even when anxious, as opposed to fleeing or actively staying away from social situations.

If you’re new to exposure, I encourage you to learn more about it. If you’ve been using exposure for a long time, then you still may want to look at the current research, as our understanding of exposure is shifting. If you’re in Portland in June, I highly recommend you check out Mike’s training in ACT-based exposure therapy.