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.