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.


How to be Experiential in Acceptance and Commitment Therapy

Jason Luoma, Ph.D.
April 23, 2021 from 12-1pm

Acceptance and commitment therapy (ACT) is, at its core, an experiential treatment, but is frequently delivered in a non-experiential way. Experiential learning involves going beyond verbal discussion, insight, and explanations of experience. But how do we do this in ACT and how do we know when we are spending too much time engaged in non-experiential modes of learning? This workshop will outline a simple model you can use to identify when you are in less or more experiential modes during therapy and easy methods to switch to more experiential modes. You will then have a chance to practice it in breakout groups and get feedback. Read More.

Ethical & Legal Considerations in Psychedelic Integration Therapy

Jason Luoma, Ph.D. and Brian Pilecki, Ph.D.
May 7, 2021 from 12-2pm

This workshop is based on extensive research and writing we have conducted into the legal and ethical issues of working with psychedelics in the current regulatory climate, as well as clinical practice doing harm reduction and integration therapy with psychedelics. It is informed by consultation with multiple experts on harm reduction, as well as attorneys knowledgeable about criminal and civil matters relating to drug use and professional practice. We will share with you all we know so that you can be more informed in the decisions you are making in your practice and be better able to decide whether to jump into this kind of work if you are considering it. Read More.

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.

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.

April 9th, 2021 – Ketamine 101: An Introduction to Ketamine-Assisted Psychotherapy with Gregory Wells, Ph.D.
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