Exposure Exercise Brainstorming Worksheet

Exposure Exercise Brainstorming Worksheet

Although it always seems easy enough when I read treatment manuals on exposure-based therapies, I’ve found in practice that it can be time consuming in session to come up with ideas for exposure-based exercises. Perhaps in part because exposure involves confronting uncomfortable experiences, even really motivated clients can have difficulty  coming up with suggestions on the spot. Moreover, most exposure manuals budget for 60-120 minute sessions, whereas a practicing therapist more frequently must make do with the 45-minutes permitted by insurance companies.

Recently, a light bulb went off: Why not simply ask clients to come up with ideas for exposure exercises outside of session? Worst case scenario is that they don’t do it, and we’re back to where we started. At the very least, the assignment primes clients to think about possible exposure exercises between sessions.

For this reason, I revised a fear hierarchy worksheet I had come up with for an online exposure training I completed last year.

Because I work from an Acceptance and Commitment Therapy (ACT) perspective, I call the worksheet: Valued Living Plan. It’s written in ACT language but could be used with other approaches.

In session, I describe exposure to clients, talk about the purpose and what makes a good exposure exercise, and give them the worksheet to complete between sessions. I’m still experimenting with it but am hoping it saves valuable in-session time for other things, such as in-session in vivo or imaginal exposure.

If it interests you, download a copy, and try it out. I’d love to hear your feedback!

A woman and her voices: The case for a functional contextual view of psychosis.

A woman and her voices: The case for a functional contextual view of psychosis.

“Insanity – a perfectly rational adjustment to an insane world.”

– R. D. Laing, Scottish psychiatrist

When I teach “Abnormal Psychology,” one of the first things I do is tell the students that we will no longer be referring to the class as “Abnormal” psychology but rather, “The Psychology of Human Suffering.” Much of the course focuses on helping students see how those who suffer in ways that happen to be associated with a diagnostic label are not fundamentally different from those who suffer in ways that are yet to be pathologized.  A main message is that mental health is not an “us” versus “them” problem. Rather, we all struggle and suffer. Some forms of suffering we happen to label with names that are written in a book called the DSM and others we label with names that aren’t in that particular book. Usually toward the end of the semester, students are generally on-board with this alternative to the traditional medical model view of mental illness.

But then comes the final chapter of the course: Schizophrenia and psychosis. The reaction is predictable and goes something like this: “OK, I can get that people who experience what we call ‘Depression’ or ‘Panic Disorder’ or even ‘PTSD’ aren’t fundamentally different than me, but psychosis?!? Those people are really crazy! Right?” Of all the psychiatric diagnoses we put on people, the one that we still cling to as being fundamentally “crazy” or as being a “brain disease” is psychosis, usually defined as people hearing or seeing things that others don’t hear or see. It’s a very common presumption, even probably among we mental health professionals. Even look at the phrase we frequently use to describe the phenomenon; we describe people who have these experiences as “SMI patients” (i.e. “serious mental illness”). This presumption of pathology is so tenacious that it’s been difficult for me to help my students question it in the same way they have come to question some of the other presumptions they have.

So I was delighted a few weeks ago when I came across this inspiring and refreshing TED talk through my Upworthy feed this week. In it, Eleanor Longden, international speaker, doctoral candidate in Psychology, and voice hearer, describes her experience hearing voices and how unhelpful she found the pathologizing approach taken by the mainstream establishment. She talks of how the psychiatric and psychological establishment was solely focused on trying to figure out what was “wrong” with her, and then, following their assumption of pathology, try to “fix” her (i.e. make her voices stop or at least make her stop acknowledging that she hears voices) by doing whatever means necessary. The result was that they were largely unsuccessful and even made it worse.

I found Ms. Longden’s story both inspiring and very consistent with some of the assumptions of Acceptance and Commitment Therapy (ACT) and contextual behavioral science in general . Contexual behavioral scientists, which would include ACT therapists, would not view hearing voices as inherently problematic. Rather, from perspective contextual scientific perspective, the experience of hearing voices needs to be examined in the same way we would explore any other behavior –contextually. While hearing voices is not inherently pathological or even problematic, they ways that people react to voice hearing often makes things worse.  The focus is less on the voices themselves as problematic, but instead how the voices are responded to and function in a person’s life.

Research seems to support this contextual non-pathologizing view of psychosis. To date there are at least 8 empirical studies, including 3 randomized controlled trials, demonstrating the effectiveness of ACT for people who experience psychosis. In ACT, the focus is not on decreasing a particular symptom, such as the hearing of voices, but rather on increasing flexible, adaptive functioning across a wide variety of contexts, including contexts in which the person may be hearing voices. And the data suggest that this approach tends to increase quality of life, and decrease a whole host of problematic outcomes, including rehospitalization, by some pretty astonishing rates.

If you are interested in learning more about ACT for psychosis, the protocol is available for free on the Association for Contextual Behavioral Science (ACBS) website. You do need to be a member of ACBS to get access to the protocol, but ACBS has “values based” dues which start at $10 per year. Those dues also get you access to the Journal for Contextual Behavioral Science as well as all the incredible wealth of resources and information available on the ACBS website.

Does Ms. Longden have a unique experience that falls outside the normal range of the bell curve? Probably. Does her experience of hearing voices result in suffering for her? At times. But does treating her experience as some disease, some pathology that must be stamped out at all costs help her live a fuller and richer life? Unfortunately not.  ACT and Contextual Behavioral Science offer an alternative that holds incredible promise for helping us all live meaningful, productive lives as Ms. Longden is doing.

New Study: ACT for Chronic Headache Pain

New Study: ACT for Chronic Headache Pain

The Study
In a study recently published in the journal Headache, preliminary evidence was found to support to use of ACT for chronic headache pain.  The study aimed to examine the efficacy of group-based ACT treatment for reducing the experience of pain, disability, and affective distress due to recurrent episodes of headache pain.  The study sample consisted of outpatient Iranian women.
ACT has been validated through numerous studies to date for chronic pain and has been given the highest grade of evidenced-based backing by APA division 12, ‘strong research support’.  While division 12 includes headache pain within the general category if chronic pain, there has been a gap in the literature to date regarding the efficacy of ACT specifically with severe and chronic headache pain.
The results of the study indicated that the addition of 8 weeks of ACT group treatment (in addition to treatment-as-usual) produced significant reductions in disability and affective distress due to pain.  However there were not significant reductions in sensory experience of pain.
What Does This Mean
These findings are consistent with similar studies in that ACT treatment does not tend to reduce pain intensity itself, but rather reduces pain-related disability and affective distress related to how the person copes with the pain. ACT aims to help the person change their relationship with pain, so that they can hold it more gently and spend less time in pain-related rumination. This aspect of ACT is similar to other mindfulness-based interventions, such as Mindfulness-Based Stress Reduction. In addition to changing one’s relation to pain, another major focus of  ACT is increasing engagement with valued life domains such as work, play, exercise, and flexibly moving on with life even as pain occurs. This aspect is relatively less emphasized in most other mindfulness-based therapies and is a unique contribution of ACT
The Takeaway
The evidence supporting the use of ACT for chronic pain is strong. This study further elaborates the kinds of chronic pain problems that ACT can be applied to, suggesting that ACT might work well in the area of chronic headache pain.

For further information and news on evidenced-based treatment for headache pain, please see the author’s website – Headaches101.com.

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.


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.


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.


ACT Precision Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Help You be Focused and Strategic in Your Interventions

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
June 18, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop focuses on helping you use ACT theory & in-session clinical markers to make more precise and strategic interventions. The main goal of this workshop is to help you become more adept at identifying in-session client behaviors that are indicators for particular ACT processes that are likely to be most relevant. The workshop uses a process we call ACT Circuit Training, which involves intensive analysis of a video of an ACT session and intentional practice in conceptualizing client behavior and generating possible ACT responses, followed by discussion and feedback. Read More.

ACT Agility Training: In-Session Case Conceptualization in Acceptance and Commitment Therapy to Increase Flexible Responding

Jason Luoma, Ph.D. and Jenna LeJeune, Ph.D
July 16, 2021 from 12-2pm

This workshop provides a chance to learn and practice in-session, in-the-moment case conceptualization of cases from the perspective of Acceptance and Commitment Therapy. This workshop is intended to help therapists be more flexible and nimble in their use of ACT processes, strengthening their ability to fluidly shift as needed between processes within sessions. Therapist learning ACT often develop tunnel vision, focusing too much on particular processes or responding rigidly when more flexibility is needed. Read More.

Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC
September 10th, 2021 – Cultural Considerations in Outreach to and Assessment of Minoritized/Marginalized Individuals in Psychedelic-Assisted Psychotherapy with Terence Ching, Ph.D.