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.