Preparing Clients for Exposure Using Acceptance and Commitment Therapy: Creative Hopelessness through Finger Traps

Preparing Clients for Exposure Using Acceptance and Commitment Therapy: Creative Hopelessness through Finger Traps

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 Acceptance and Commitment Therapy (ACT), we use the term creative hopelessness to refer to the process of helping people experientially contact the costs of their avoidance behaviors. By “hopeless” we don’t mean that the client is hopeless. Instead, this term describes the new possibilities that can open up when we let go patterns of behavior that are not working (i.e., the behavior is hopeless). Developing this awareness can increase client willingness to engage in something as intense as exposure.

Below I discuss one exercise I find helpful in facilitating creative hopelessness in people with anxiety. There are plenty of other options. This is one of my favorites, and I use it quite frequently, especially as a rather gentle introduction to the idea that struggling with internal experiences may be counterproductive.

Introducing the Finger Trap

In order to do the exercise, it helps to have some actual finger traps. (Amazon has several cheaply priced options.) I keep some on hand in a small box of props and supplies within reaching distance of my seat.

Finger Traps

If you’re unfamiliar, fingers traps are woven bamboo tubes. You stick your index fingers into each end, and when you try to pull your fingers out, the tube contracts, trapping your fingers. When you push your fingers in, the tube expands and relaxes.

Using finger traps in session

If I hear any client talk suggesting struggle with anxiety, I may pull out a couple finger traps, handing one to the client and placing my own fingers in the other.

Case Vignette

T: These are finger traps—ever seen one before? [Slips fingers into trap]

C: Yeah, when I was a kid. [Also places fingers in trap]

T: Let’s play around with it a bit. [Spends a few moments, pulling against the trap until it tightens] OK, so what happens when you try to pull your fingers out? What do you notice?

 

C: It tightens up on me. I can’t get free.

 

T: Yeah, it tightens on you, it constricts around your fingers. Have you ever had that experience, with your anxiety or some other painful experience—you try to get away but it tightens up, becomes more painful?

 

C: Yeah, I think so, yeah. [Even if the client doesn’t link it to current problems, most people have had some experience of trying to get away from a painful emotions and feeling it intensify]

T: What happens when you press your fingers in? [Pushes fingers in]

C: It loosens a bit.

 

T: Yeah, it loosens up. You’re not out, you’re still in the trap, but you can wiggle your fingers. You still have some breathing room. What if you anxiety is like this? When you try to get away, it tightens up on you, becomes more painful. But when you lean into it, it doesn’t go away, but maybe you have a little bit of space. It’s a little counterintuitive. When we’re in pain, our tendency is to do this [pulls away] but that can make it much more painful. When we lean in, often there’s a little space there [pushes in].

Things to consider

Please note: although there is a way out of the actual physical finger traps, side-step this in your own presentation. If the client slips it off his fingers, you might comment on how it’s not so easy to slip out of anxious feelings. The emphasis is on the contrast between pulling away (e.g., experiential avoidance or struggle) and leaning in (e.g., willingness to experience feeling).

The exercise doesn’t have to take long: 5-10 minutes is often fine. Sometimes I’ll even introduce it at the end of the first session.

What I really like about this exercise is that I can give clients something tangible to take with them as a reminder. I’ll ask if they’re willing to take the finger trap home and place it where they might see it regularly (e.g., purse, desk, dresser, etc.).

To use a geeky behavior analytic term, the finger traps may serve as a form of stimulus control: a cue to remind clients of the metaphor and increase the likelihood they may notice in their own experience how struggling with anxiety intensifies pain.

Concluding words

Finger traps are a fun and brief way to introduce the idea that struggling with uncomfortable emotions may not be working. Most people get the idea pretty quickly even if they’re not aware of how pervasive the problem may be for them. It also helps orient clients to the idea that ACT may be a little different—that they’ll be noticing and doing rather than simply talking about what’s going on.

The icing on the cake: the client can take something home with them as a reminder of what you discussed. This little woven bamboo tube may serve as a cue to look more closely at their experience.

In my next post, I’ll discuss one other exercise for developing creative hopelessness: Tug-of-War with a Monster!

Exposure Therapy – Information and Resources

Exposure Therapy – Information and Resources

Exposure is arguably the most important component of anxiety-related treatment. Despite decades of study, however, researchers are still developing an understanding of how it works and refining the procedures to improve effectiveness. This is an exciting time for exposure! Newer research is questioning the role of habituation in successful exposure and increasingly emphasizing the importance of developing a willingness to experience fear and anxiety.

For the last few years, I’ve been working to immerse myself in exposure research. This has been a steep learning curve, as I didn’t receive much background in graduate school. At times I’ve felt overwhelmed by the more technical accounts. However, I’ve persevered, and although I still have a lot to learn, I feel my clinical work is better for it.

I’ve written these posts to develop my own understanding of exposure and in the hopes that other therapists would find them helpful, too. I’m extremely interested in the cutting edge work being done to create more flexible models and approaches for applying exposure-based interventions, particularly in the context of Acceptance and Commitment Therapy.

If you’d like to see me write about another topic related to exposure therapy or want to get some input about using exposure therapy in your practice, write me an email: bthompson@portlandpsychotherapyclinic.com

I’m collecting all my posts about exposure therapy on this page, so please check back as I update it.

Exposure therapy: What can we take away from newer research

This series of posts is meant to serve as an introduction to exposure therapy, examine some of the cutting edge research, and  look at shortcomings of some of the older models.

Research studies on exposure-based interventions

This series of posts summarizes some novel studies and applications of exposure-based interventions. Theory is less emphasized, if mentioned at all.

Understanding and using exposure in an Acceptance and Commitment Therapy context

This series of posts focuses on how exposure may be applied within ACT. This is still new territory, and some of these posts are my attempts to clarify and summarize my own ideas.

“What I Be”: A Defusion-Based Art Exhibit

“What I Be”: A Defusion-Based Art Exhibit

Words are amazing. Our minds attach a great deal of importance to words and verbal labels. Our ability to use language is an amazing tool, and yet, a fundamental assumption in Acceptance and Commitment Therapy (ACT) is that this ability may also be at the root of human suffering. According to ACT, words, and other forms of language, gain much of their power when we stop treating them as merely words, but instead as what they say they are. You’ve probably seen this in your clients (and in yourself too); words and labels, whether they be “broken” or “stupid” or “fat” or “unlovable”, can result in such shame that people will greatly restrict their lives and will turn away from doing what is meaningful and important in order to try to hide those labels from others and themselves. What if it didn’t have to be that way?

The concept of defusion in ACT is aimed at helping individuals see thoughts as thoughts, to see them for what they are and not for what they say they are. For those of you who have been to an ACT experiential workshop, you might be familiar with the defusion exercise where you write down a difficult thought you have about yourself on a name badge and then wear that name badge on your chest for the remainder of the day. In the abnormal psychology class that I teach, I have students do a similar exercise, but they wear other people’s labels. It can be a very powerful experience to encounter what others are hiding.

Steve Rosenfield has taken this concept to a whole new level through a photography exhibit entitled “What I Be”. In this project he has photographed people from all walks of life with their difficult thoughts or words about their histories written in bold black marker across their skin for all the world to see. The exhibit can be seen as a visual display of what we are often working with clients around the concept of defusion. And I’m very excited that this exhibit will be coming here to the Portland, OR / Vancouver, WA area. Yogi Roots in Vancouver, WA will be hosting an event with Steve Rosenfield on Thursday, November 29th from 7:30 pm – 9:00pm. There is also an opportunity to have a photo session with Steve for the “What I Be” project from Fri-Sun November 30th through December 5th. It might be potentially a very powerful experience for our clients (or ourselves) to be involved in this project. And if being a part of the photo shoot isn’t feasible, it might be an interesting homework assignment for clients to have them go to one of the following pages to view some of Rosenfield’s photographs:

“What I Be” photos 1

“What I Be” photos 2

ACT for Body Image Difficulties and Disordered Eating

ACT for Body Image Difficulties and Disordered Eating

I frequently struggle when trying to find referrals for therapists who work with individuals around issues of body image and disordered/dysregulated eating. The most common refrain I hear is “Oh, I don’t work with eating disorders.” Many of my colleagues even feel reluctant to work with individuals with subclinical levels of dysregulated eating or struggles with body image.

My sense is that there are probably many factors that contribute to clinicians’ reluctance to work with issues related to body image and weight. Many seem to feel like their training didn’t equip them to be effective in working with those difficulties. Some seem to buy into the stigma that clients who struggle with eating disorders and body image are “difficult”. But I also wonder if part of it could be because for many of us, it’s an issue that we have our own struggles with. Chances are, if you have a body, particularly if you are a woman in this culture and have a body, you have your own varying degree of dissatisfaction with it. And maybe because of that we feel like we aren’t the right ones to help someone else with those difficulties.  As clinicians, we know that we struggle with many of the same difficulties that our clients do; for example, many clinicians know first-hand the struggles of anxiety, depression, substance use, or trauma. But all these things can be hidden struggles. In contrast, our bodies are highly visible. Our bodies can be (and are) judged by ourselves and by our clients. Talking about issues related to food, body image, and weight often highlight that uncomfortable fact.

Many years ago, when I first started working with individuals around their body image difficulties, I felt an incredible hypocrisy. My body wasn’t (and still isn’t) shaped the way most people in American would say is the beauty ideal. Even so, I used to feel I needed to reflect back to my clients, even if only non-verbally, that I felt GREAT about my body, that I had conquered this whole body image thing and thus I could help them too by golly! Problem was that I didn’t and don’t always have universally positive thoughts and feelings about my body. No matter how hard I have tried, I too still have some of the same difficult thoughts and feelings about my body that my clients were coming to see me for; I too have a mind that was programed by this culture. So I was in a bit of a bind.

A different approach to body image struggles

But then I started studying  Acceptance and Commitment Therapy (ACT). From an ACT perspective, the problem isn’t that my clients or I had negative thoughts or feelings about our bodies. Rather than focusing on the importance of thinking or feeling more positively about our bodies, ACT suggests that what is most important is focusing on not letting those difficult thoughts or feelings stand in the way of doing what would be meaningful and important.  For some that will mean choosing to be physically intimate with your partner even if doing so will bring up self judgments about how you look naked. For others, it might mean exercising regularly so that you have the energy to be an active participant in your kids lives even though no matter how many times you go to that yoga class you might always have the same “YUCK!” thought that goes through your mind as you look into the mirrors at the front of the class.

ACT psychologist and assistant professor at University of Louisiana at Lafayette Emily Sandoz, Ph.D. is one of the country’s leading experts on in the area of body image and disordered eating. She is the author of several ACT books including Acceptance and Commitment Therapy for Eating Disorders, The Mindfulness and Acceptance Workbook for Bulimia, and the upcoming Mindfulness and Acceptance Workbook for Body Image. Dr. Sandoz’s recent interview in the Huffington Post offers a great synopsis on an ACT approach to dealing with body image concerns. In her interview, Dr. Sandoz highlights that in ACT we ask our clients the following questions:

“Would you be willing to have these terrible thoughts and feelings about your body if it meant you’re able to live the life you want to live? Would you be willing to feel distress about your body image if it meant you could be more present with your children? If it meant you could be more active in your community? If it meant you could pursue companionship? Would that be worth it to you?”

When I have a new client on my schedule and I see that eating dysregulation or body image are one of the presenting concerns, I still at times get a quick flash of anxiety. My own self judgments show up, as do fears about how I will be judged by that person I am about to meet. But then I practice what I encourage my clients to do; I thank my mind for that thought and then ask myself this question, “If I were free to choose, would I rather important trying to avoid having negative thoughts about my body or would I choose to important being fully present with this next person that is coming in to my office?”. Once I am centered on what is actually important to me,  I can get on to the valued work of connecting with peoples’ suffering, even when that suffering brings up discomfort for me.

Experiential Avoidance and Its Relevance to PTSD

Experiential Avoidance and Its Relevance to PTSD

This post is the first part of a series on using exposure in Acceptance and Commitment Therapy

 

Within the Acceptance and Commitment Therapy (ACT) literature, there’s a core concept called experiential avoidance. Experiential avoidance was arguably the lynchpin in ACT theory in the early days of ACT. The theory has been broadened since then.

Experiential avoidance is a basic umbrella terms for all sorts of avoidance behavior that people use to deal with all sorts of private experiences (e.g., thoughts, emotions, bodily sensations). Attempts to block out, reduce, or change these experiences are all forms of experiential avoidance. Behaviors associated with experiential avoidance include disputing thoughts, using substances (e.g., alcohol), and escaping or avoiding uncomfortable situations.

Everyone engages in some experiential avoidance on a daily basis.  Less problematic examples include putting on sweater when it’s cold, turning on a light switch when we enter a dark room, or mindlessly perusing the internet when we feel listless. Experiential avoidance becomes a problem when it is applied rigidly and inflexibly, and when it gets in the way of what’s important to us.

One of the clearest examples of experiential avoidance is how it functions in people with posttraumatic stress disorder (PTSD).

Experiential Avoidance and PTSD

As you might imagine, people with PTSD engage in a lot of experiential avoidance. In fact, avoidance behaviors are one of the core cluster (C) of symptoms for a PTSD diagnosis. There’s a large body of research suggesting that experiential avoidance plays a big role in maintaining PTSD symptoms over time.  For example, experiential avoidance predicts PTSD in adult survivors of childhood sexual abuse more than the severity of the abuse itself (Batten, Follette, & Aban, 2002; Rosenthal, Hall, Palm, Batten, & Follette, 2005).

Here are some possible reasons experiential avoidance may result in PTSD symptoms.

Reason 1: Avoidance leads to more of what the person wants avoid

Dostoevsky famously challenged his brother to not think of a white bear.

Can you do that? Can you not think of a white bear?

As you can imagine, trying not to think of something is really hard. Decades of research on thought suppression (e.g., Wenzlaff & Wegner, 2000) have shown that the very strategy of suppressing a thought tends to lead to more of the very thought the person is trying to avoid.

For people with PTSD, the result is that avoiding trauma-related internal experiences results in more of those very experiences over time.  For example, in survivors of motor vehicle accidents, those who attempted to avoid thinking about the accident showed greater PTSD symptom severity (Mayou, Ehlers, & Bryant, 2002; Steil & Ehlers, 2000).

Part of what maintains this tendency to avoid PTSD-related thoughts and feelings is probably a momentary sense of relief that comes from suppressing those thoughts and feelings. Unfortunately, this moment of relief becomes increasingly insignificant when compared against the long-term consequences of avoiding trauma reminders. As trauma reminders recur, avoiding them becomes a major focus on the person’s life. Other life goals and values get neglected and avoidance gains more and more influence of the person’s life.

Additionally, as people begin to avoid more and more experiences, even neutral stimuli can become reminders of the trauma. For example, a person may avoid a particular alley in which he was attacked. Over time, the person may avoid all alleys. Features of the alley, such as red brick, similar to what lined the alley, or even the experience of closed spaces, may become linked to the trauma if they are continually avoided. Only through maintaining contact with these stimuli can one learn or re-learn that these stimuli (e.g., bricks, enclosed spaces) do not need to be avoided.

Reason 2: Some avoidance behaviors increase the risk of further painful experiences

The potential for danger increases significantly when a person spends time abusing drugs and alcohol, having unprotected sex with people they hardly know, or engaging in daredevil activities. People with PTSD often do things like this to block out the trauma, putting them at risk for further harm (Chapman, Gratz, & Brown, 2006; Polusny & Follette, 1995). Actions such as substance use, overeating, and staying home from work can lead to painful consequences in the short-term and across time.

Please be clear: I don’t mean that people should be blamed for this pattern. The horrifying images involved in PTSD and painful feelings can easily overwhelm people’s ability to cope and people understandably turn to behaviors that bring relief. Unfortunately, strategies that decrease pain in the short term (such as those above) may actually lead to more suffering in the longer term.

Reason 3: People may lose out on helpful experiences

In addition to avoidance leading to harmful experiences, someone who chronically avoids may lose contact with experiences that are potentially helpful. The more time people spend avoiding events, memories, feelings, and thoughts, the smaller and narrower their lives become. This reduces contact with positive experiences over time, and it stymies valued and meaningful living. As behavioral activation research for depression has suggested (e.g., Kanter, Busch, & Rusch, 2009), it’s very important for people to be engaged in a variety of enjoyable and personally meaningful activities.

When avoidance becomes the norm, people lose contact with sources of positive reinforcement and reward. This might include relationships, exercise, hobbies, and other interests. Over time, someone’s life may become increasingly narrow (e.g., staying inside much of them time). In the absence of other enjoyable and meaningful experiences, someone’s range of activity may become so small, that all she has left is what is being avoided (e.g., trauma).

ACT and Experiential Avoidance

Nowadays, it’s more common to hear ACT therapists talk about “increasing psychological flexibility,” but in the not-so-distant past, the focus was on decreasing or undermining experiential avoidance. ACT theory and technology were specifically developed to target experiential avoidance.

ACT has a number of interventions and techniques that focus on helping people contact stimuli that are typically avoided: thoughts, emotions, bodily sensations, meaningful goals, and activities. ACT has been called an exposure-based treatment (e.g., Luoma, Hayes, & Walser, 2007); however, you could also consider exposure as one technique among many used by ACT therapist to reduce experiential avoidance and expand behavioral repertoires.

ACT is less procedural than other treatments, and, therefore, harder to manualize. Because ACT has so many methods for targeting experiential avoidance, though, ACT offers therapists an array of tools to use for conditions (e.g., PTSD) where exposure-based approaches remain the gold standard.

At this writing, there is little written guidance about how to use exposure in an ACT. People are talking about it, and giving workshops about using exposure in ACT, but it remains new territory.

This series of posts focuses on how therapists can use exposure in an ACT context to undermine experiential avoidance in people with PTSD.

I will mainly organize the posts according to ACT-specific processes. My hope is that the series will offer clinicians some practical guidance on using exposure-based interventions in an ACT-influenced way. Additionally, it is my aspiration that even non-ACT clinicians will find these posts helpful in expanding their understanding of clinically significant processes of change and range of potential clinical interventions.

UPCOMING TRAINING EVENTS

Case Conceptualization in Acceptance and Commitment Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 21, 2021 from 12-2pm

This workshop provides a chance to learn concrete methods for conceptualizing cases from the perspective of Acceptance and Commitment Therapy. Formulating a useful case conceptualization is a foundational clinical skill that is essential in delivering effective treatment, and one that can be often overlooked in the process of working with clients. Participants will learn several formats for doing formal case conceptualization outside of session as a means to further develop knowledge and skill with ACT theory, as well as to learn a means to enhance treatment planning. The importance of ongoing case conceptualization throughout a course of treatment will be emphasized, as well as common pitfalls in conceptualizing client problems. Participants will also have a chance to practice newly learned skills with a case in breakout groups. Read More.


Lunchtime Panel Discussion: Psilocybin Therapy and Mental Health Care in Oregon: What is Happening and Where do We Need to Go from Here?

Moderated by Brian Pilecki, Ph.D. with Ingmar Gorman, Ph.D, Kelly Sykes, Ph.D, Alan Davis, Ph.D, Aja Molinar, and Sam Chapman
May 28, 2021 from 12-1pm

Oregon Voters have recently approved a measure that will pave the way for the legal administration of psilocybin by state credentialed providers to begin in 2023. In this panel discussion, leading advocates, psychedelic therapy researchers, and psychedelic therapist training providers will elaborate on the implications during a moderated panel discussion and answer audience questions. Presenters will give an update on the status of the Oregon Psilocybin initiative, particularly as it relates to the training of facilitators, and will describe ways local therapists can get training in the practice of psilocybin-assisted therapy. Read More.


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.



Developing the ACT Concept of Defusion in Kids and Teens

Julianna Sapienza, Ph.D, LP
June 25, 2021 from 12-1:30pm

Cognitive restructuring is a concept that is useful for many patients, but many others really struggle with fighting or changing their negative thinking patterns. This 1.5 hour hands-on workshop is designed to introduce child and adolescent practitioners to defusion, an ACT concept that helps patients drop the struggle with their thoughts while also not buying into them. You will learn all about defusion, how to introduce the concept to child and teen clients, and how to use your creativity to make these skills effective for your clients. 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.

May 14th, 2021  Research on MDMA and Psychedelic-Assisted Therapy: An Overview of the Evidence for Clinicians with Jason Luoma, Ph.D.
June 11th, 2021 Becoming a Psychedelic-Informed Therapist: Toward Developing Your Own Practice with Nathan Gates, M.A., LCPC