How Do You Use Exposure in Acceptance and Commitment Therapy?

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.

Using ACT to target internalized homophobia and self-stigma

Using ACT to target internalized homophobia and self-stigma

Many of our clients struggle with shame and stigma. Despite its prevalence in the therapy room, there are few clinical interventions that specifically target self stigma,  defined here as “negative thoughts and feelings (e.g., shame, negative self-evaluative thoughts, fear) that emerge from identification with a stigmatized group” (p. 48, Luoma, O’Hair, Kohlenberg, Hayes, & Fletcher, 2010). This is an issue that we at Portland Psychotherapy are exploring, both in our clinical work and in the research we are conducting. We currently have several research projects underway, looking at various aspects of stigma and shame, how they impact functioning, and ways to target stigma and shame inside and outside the therapy office.

For these reasons, I was very interested in a recent article in Cognitive and Behavioral Practice by Yadavaia & Hayestitled “Acceptance and Commitment Therapy for Self-Stigma Around Sexual Orientation: A Multiple Baseline Evaluation.”  In the article, the authors report on the effectiveness of a brief (6-10 session) ACT intervention for self stigma in those who experience same sex attraction– sometimes referred to as internalized homophobia. While the ACT intervention in the study was individualized to each participant, similar to standard clinical practice, all 6 of the basic ACT processes were covered and expert ratings of treatment integrity were high.

The study found that participants evidenced positive changes on a variety of factors including self stigma/internalized homophobia, depression, anxiety, quality of life, perceived social support, and overall psychological flexibility. What I found to be most significant was that while participants reported a decrease in the believability of same-sex thoughts, the frequency of those thoughts did not change. This finding is consistent with previous studies using ACT to target other psychological difficulties (e.g. Bach & Hayes, 2002) and appears to support an ACT-consistent mechanism of change. In ACT, it is the workability of a thought in terms of valued action, rather than the form of the thought that is targeted. As such, we would expect, and this study did indeed find, that the frequency or even the form, of particular thoughts would not necessarily change significantly, but rather that change is found in the function that thought serves. It other words, after the intervention, participants continued to still have the same same-sex thoughts, but they were much less troubled by the thought.

Previous studies have supported the use ACT to target other forms of self-stigma, including those who struggle with substance use problems (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008) and obesity (Lillis, Hayes, & Bunting, 2009). Although power was limited because of the small sample size  (n=5), the pattern of findings in this study were consistent with previous findings and suggests that ACT may be an effective intervention for individuals who struggle with self-stigma related to sexual attraction and sexual orientation.

Contextual Behavioral Exposure: An Acceptance and Commitment Therapy Approach to Exposure

Contextual Behavioral Exposure: An Acceptance and Commitment Therapy Approach to Exposure

For the past year, I’ve been interested in how to use exposure in the context of Acceptance and Commitment Therapy.

Even after a year, I feel I’m only ever so slowly developing my understanding.

At Portland Psychotherapy, we have a weekly lab meeting where we discuss ongoing research projects and brainstorm new ones. Every so often, one of us gives a presentation to about something we’ve been working or reflecting on. Not long ago, I presented some guidelines for using exposure from both an ACT perspective and, more broadly, a contextual behavioral science perspective. The presentation was an attempt to offer practical suggestions for guiding exposure treatment in ACT. At the encouragement of our clinic director, I created a screencast of it.

Some Caveats About the Screencast


My presentation is a work in progress. It presumes a basic familiarity with ACT and exposure. I shied away from getting bogged down in research citations and focused on suggestions and decision points. I don’t consider it definitive or even fully fleshed out; rather, it’s a snapshot of my thoughts at the moment, a work in process.

Please keep these things in mind if you decide to watch it. It’s more of a sketch than a finished work. Hopefully, you may find something of value in it.

There are two parts:

Contextual Behavioral Exposure, Part 1

Contextual Behavioral Exposure, Part 2

Watch both of them via this playlist.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.

Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.

Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.

Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.

Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 11, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.

The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. 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.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD

May 13th, 2022Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div, M.S.