ACT-Informed: Anxiety Exposure

PSYCHOLOGY
A process-based approach to
ACT-Informed
ACT-Informed Exposure for Anxiety

exposure for anxiety disorders
Exposure therapy is a well-researched intervention for helping
Exposure
clients confront anxiety-provoking stimuli in order to resist engaging
in avoidance behaviors. Acceptance and commitment therapy
(ACT) is an evidence-based treatment model and provides a theory
for guiding the use of exposure therapy by encouraging clients to
connect with their values, remain in contact with the present moment,
and increase behavioral flexibility. This comprehensive book provides
for
a process-based approach for utilizing ACT-informed exposure in
session, and offers new ideas and tools to help your clients.
Anxiety
ACT-Informed Exposure for Anxiety synthesizes the latest research,
clinical experience, and theory into one powerfully effective
professional resource. You’ll find an overview of exposure therapy
and ACT, as well as cultural considerations to inform your work
with clients of diverse backgrounds. Also included are strategies to
help you create exposures tailored to clients’ specific needs, and
guidelines for addressing common client and therapist barriers to
treatment. Whether you’re new to ACT and exposure or experienced CREATING EFFECTIVE, INNOVATIVE
in other models of exposure and interested in incorporating ACT into
your practice, this is an essential addition to your professional library.
& VALUES-BASED EXPOSURES USING
Thompson • Pilecki • Chan

“An intelligent and thoughtful integration, ACCEPTANCE & COMMITMENT THERAPY
providing clear recommendations for improving
treatment. I highly recommend this book.”
—Stefan G. Hofmann, PhD, Alexander von Humboldt Professor at the
Philipps University of Marburg, and author of The Anxiety Skills Workbook
Brian L. Thompson, PhD

Brian C. Pilecki, PhD
Context Press
An Imprint of New Harbinger Publications, Inc.
Joanne C. Chan, PsyD
www.newharbinger.com
Foreword by Steven C. Hayes, PhD
Context
Press
“Exposure-based treatments are some of the most effective, but still poorly understood, clinical
strategies for anxiety problems. This book is an important step forward by embracing a process-
based perspective and linking it to acceptance and commitment therapy (ACT). It is an intel-
ligent and thoughtful integration, providing clear recommendations for improving treatment. I
highly recommend this book.”
—Stefan G. Hofmann, PhD, Alexander von Humboldt Professor at the Philipps
University of Marburg, and author of The Anxiety Skills Workbook and CBT for
Social Anxiety
“In this book, Thompson, Pilecki, and Chan articulate the core principles of ACT-informed
exposure as clearly and accessibly as I have ever read. The content is comprehensive—even
discussing cultural considerations—making the book an essential resource for any clinician
doing exposures with their clients. Even if you’re already doing ACT-based exposures, you will
still learn something new from the authors’ masterful dissection of this approach.”
—Clarissa Ong, PhD, assistant professor at the University of Toledo, and coauthor
of The Anxious Perfectionist
“Pairing decades of strong efficacy data for exposure therapy with the strengths of ACT to build
willingness and cognitive flexibility—this book is the perfect pairing of both! The book con-
tains ‘how to’ pointers for developing therapists and real-world problem-solving for experienced
therapists. It’s for the exposure therapist who wants to better help clients choose to engage and
cultivate new learning. It’s for the ACT therapist who wants to better harness the power of
exposure.”
—Lori Zoellner, PhD, director of the Center for Anxiety and Traumatic Stress,
and professor of psychology at the University of Washington; and coeditor of
Facilitating Resilience and Recovery After Trauma
“If you work with anxiety, obsessive-compulsive disorder (OCD), or trauma, you should read
this book. ACT-informed exposures will enrich your practice and provide you with useful case
conceptualizations and treatment moves.”
—Michael Twohig, PhD, professor, and coauthor of The Anxious Perfectionist
“Evidence-based treatment for anxiety emphasizes exposure. However, this treatment is a chal-
lenge for even the most seasoned clinician to carry out. ACT-Informed Exposure for Anxiety
reframes exposure through a lens that is accessible to clinicians, and eases their own apprehen-
sions about the method while also presenting a highly contemporary treatment method in a
digestible way. It is sure to be an indispensable guide for therapists of all levels.”
—Dean McKay, PhD, ABPP, professor of psychology at Fordham University; and
past president of the Association for Behavioral and Cognitive Therapies, and the
Society for a Science of Clinical Psychology
“Always a champion of emphasizing the work of exposure in ACT, I am delighted to highly
recommend ACT-Informed Exposure for Anxiety. This book is ideal for therapists wishing to
provide an effective and excellent intervention for their anxious clients. Authors Brian
Thompson, Brian Pilecki, and Joanne Chan guide therapists in implementing exposure—
tucked inside of willingness linked to values—in their process and the clients’ process in a
straightforward and implementable way. A must for therapists.”
—Robyn D. Walser, PhD, licensed clinical psychologist; author of The Heart of ACT;
and coauthor of Learning ACT, The Mindful Couple, Acceptance and Commitment
Therapy for Post-Traumatic Stress Disorder and Trauma-Related Problems, and
The ACT Workbook for Anger
“ACT-Informed Exposure for Anxiety by Thompson, Pilecki, and Chan is an excellent, well-
researched, and comprehensive guide to process-based exposure. This is more than a handbook
on integrating ACT with exposure and response prevention (ERP)—it demystifies how to
conduct exposure founded in basic principles of fear acquisition and applied behavior analysis
(ABA). Thank goodness these stellar clinicians and researchers put in the hard work to write
this for us. It will be a go-to guide for all clinicians who treat anxiety disorders and OCD.”
—Lisa Coyne, clinical psychologist, founding director of the New England Center
for OCD and Anxiety, and assistant professor at Harvard Medical School/Mclean
“When we are willing to open up to our anxieties and fears, we gain the space and freedom
needed to live our lives in line with what we care about. There is no shortcutting this process.
Yet, inside ACT, we do this ‘exposure’ work in the service of helping our clients live well when
faced with life’s inevitable obstacles, problems, and pain. In the process, your clients learn to
cultivate a new relationship with their anxieties and fears, and hence regain control over their
lives. This gentle and wise guide will show you how to do just that. A must-read for all mental
health professionals interested in ACT, including those who wish to learn how to do process-
based exposure work.”
—John P. Forsyth, PhD, professor of psychology, and director of the Anxiety
Disorders Research Program at the University at Albany, SUNY; clinical
psychologist; ACT researcher, trainer, and clinical supervisor; and coauthor of
The Mindfulness and Acceptance Workbook for Anxiety and Anxiety Happens
ACT-Informed
Exposure
for
Anxiety
CREATING EFFECTIVE, INNOVATIVE
ACCEPTANCE & COMMITMENT THERAPY

Context Press
Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject
matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychologi-
cal, financial, legal, or other professional services. If expert assistance or counseling is needed, the services
of a competent professional should be sought.
NEW HARBINGER PUBLICATIONS is a registered trademark

of New Harbinger Publications, Inc.
New Harbinger Publications is an employee-owned company.
Copyright © 2023 by B
rian L. Thompson, Brian C. Pilecki, and Joanne C. Chan
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
All Rights Reserved
Cover design by Amy Daniel; Acquired by Jennye Garibaldi;

Edited by Jennifer Eastman; Indexed by James Minkin
Library of Congress Cataloging-in-Publication Data

Names: Thompson, Brian L. (Brian Lantz), author. | Pilecki, Brian C., author. | Chan, Joanne C.,
author.
Title: ACT-informed exposure for anxiety : creating effective, innovative, and values-based
exposures using acceptance and commitment therapy /\ Brian L. Thompson, Brian C. Pilecki,
Joanne C. Chan.
Description: Oakland, CA : New Harbinger Publications, Inc., [2023] | Includes bibliographical
references and index.
Identifiers: LCCN 2022057389 | ISBN 9781648480812 (trade paperback)
Subjects: MESH: Anxiety Disorders--therapy | Acceptance and Commitment Therapy--methods
| Implosive Therapy--methods | BISAC: PSYCHOLOGY / Clinical Psychology |
PSYCHOLOGY / Movements / Cognitive Behavioral Therapy (CBT)
Classification: LCC RC489.C63 | NLM WM 172 | DDC 616.89/1425--dc23/eng/20230306
LC record available at https://lccn.loc.gov/2022057389
Table of Contents
Foreword: Why ACT Needs Exposure and Exposure Needs ACT v
Acknowledgments ix
Background: History, Research, Current Trends
Chapter 1: A Process-Based Approach to Exposure for Anxiety Disorders 3
Chapter 2: A Brief History and Overview of Exposure 9
Chapter 3: An Acceptance and Commitment Therapy Primer 23
Clinical Application: ACT-Informed Exposure in Practice
Chapter 4: What the Therapist Needs to Know 41
Chapter 5: What the Client Needs to Know 59
Chapter 6: What to Do During and After Exposure 71
Chapter 7: Ending Treatment 93
Chapter 8: Create Your Own ACT-Informed Exposure Forms 109
Chapter 9: Case Examples of ACT-Informed Exposure 121
Chapter 10: ACT Fails and Other Pitfalls and Barriers to ACT-Informed Exposure 139
Chapter 11: Cultural Considerations in ACT-Informed Exposure 155
References 167
Index 181
FOREWORD
Why ACT Needs Exposure and

Exposure Needs ACT
Exposure is often spoken of as one of the crown jewels of evidence-based therapy. Here is a
method that helps about half of the clients who try it and has a mountain of supportive
evidence across a wide range of problem areas. In part as a result, nearly every introductory
text in psychology includes exposure case examples, and often these examples are used to
highlight explanations that have been repeated so often they have become almost truisms,
such as the supposedly key role of reductions of arousal during exposure sessions.
It is good to have a crown jewel, but we must be honest. The fact is that exposure is a
method we still do not fully understand. Simple conditioning or habituation explanations
cannot fully explain it. Traditional cognitive and emotional processing explanations falter
as well. And, yes, spontaneous reductions of arousal during exposure sessions also fail.
It now appears that what is most key is new learning, not eliminating the emotional
echoes of the past. Being better able to observe and describe emotions may be important.
Persistence is important. But the “jewel” is still, shall we say, unpolished. It is still a method
or technique, not a well-understood process or set of processes.
Acceptance and commitment therapy (ACT) was always cast as an exposure-based
treatment simply because the processes it targets, such as emotional and cognitive open-
ness, flexible attention to the now, and values-based behavioral commitments all readily
bring people into contact with previously repertoire-narrowing experiences (Hayes et al.,
1999, 2012). ACT naturally leads to “exposure” to previously avoided thoughts, feelings,
memories, sensations, or situations. Unlike traditional exposure, ACT does not seek or
promise elimination of emotional arousal—the point was more the creation of greater life
freedom, the ability to live the kind of life you choose via greater psychological flexibility.
As exposure-based ACT research began in earnest in the last decade and a half, it was
found that it did indeed produce positive outcomes and did so generally via changes in
psychological flexibility or related concepts. The flexibility-based view of exposure—namely
that it is “organized presentation of previously repertoire-narrowing stimuli in a context
designed to ensure repertoire expansion” (Hayes et al., 2012, p. 284)—has held up reason-
ably well. It fits broadly with what we are learning about exposure from many different
vi ACT-Informed Exposure for Anxiety
modern laboratories. But in the last few years, we have also learned that the gains for ACT
exposure were about the same as with the best existing exposure methods.
That was undeniably a disappointment—but science is science, and we learn as much
or more from our failures as our successes.
Is that the end of the story? A fair answer is that we do not yet know.
We do know that radically transdiagnostic methods are gaining ground and that ACT
is rapidly assuming a role as a central method in modern evidence-based intervention
worldwide. It is doing that not because it is spectacularly better in any one area but rather
because its putative processes of change are robust, and they are incredibly broadly appli-
cable. More than half of the known successful mediators of change for any psychosocial
method in randomized trials focused on mental health outcomes are measures of psycho-
logical flexibility and its closely associated concepts (Hayes et al., 2022). Over a thousand
randomized trials of ACT (bit.ly/ACTRCTs) show that the same model and same basic
methods produce positive changes that usually meet or beat best of breed targeted alterna-
tives across every kind of problem area or positive prosperity challenge you can name—
from relationships to addiction, from panic to managing diabetes, from burnout to reducing
the harmful impact of prejudice. And that is one major reason for this very book. If we
know that ACT is important and exposure is important, is exposure important for ACT?
The authors argue successfully that the answer is yes. This book shows that exposure
in an ACT context can be thought of as
simply another ACT experiential exercise that can help clients orient to the ACT
model. Exposure offers an advantage over traditional ACT experiential exercises in
its focus on repetition. Through repetition of specific exposure exercises conducted
in a variety of contexts, clients have greater opportunity to experience ACT pro-
cesses and practice psychological flexibility when in contact with previously reper-
toire-narrowing stimuli.
In short, if clients don’t understand ACT concepts such as willingness, then
exposure is a great way for them to contact ACT processes experientially.
In other words, exposure is a way to do better ACT work! Exposure is a context; a

platform. And unlike lots of alternative contexts for ACT work, it’s done where the rubber
meets the road: it’s real, situational, behavioral, and repeatable. It is not just more talking.
That is a hugely important idea and one that is as behaviorally sensible as an idea can be.
But if exposure is helpful to ACT, is ACT helpful to exposure? I think there too the
answer is yes. Here’s why.
When you compare ACT exposure to say, traditional CBT exposure, the outcomes are
similar…but not necessarily the moderators! For example, if you are working with multi-
problem people, such as those who are diagnosable with an anxiety disorder and a mood
Why ACT Needs Exposure and Exposure Needs ACTvii
disorder, ACT-based exposure produces better gains than CBT-based exposure (Wolitzky-
Taylor et al., 2012). This means that you must consider client fit. It is not the only study
finding different moderators for ACT-based exposure as compared to CBT-based exposure
(e.g., see Craske, Niles, et al., 2014; Niles et al., 2017, among others). The deep message of
findings like this is not that ACT-based exposure makes no difference as compared to CBT
or other methods, but that it does make a difference, depending on the client.
Now add to that the fact that we are currently examining mediation and moderation
only through the filter of top-down normative statistics instead of using person-specific
measurement and analysis—what is being called “idionomic” statistics (e.g., Hayes et al.,
2022). In other words, we are using statistical methods to find treatment moderation and
mediation that treat people as error terms, not individuals. And yet even through that
darkened window, we see that ACT helps some people (but not all people) better than
existing best of breed methods. Doesn’t that mean you need to learn ACT-based exposure
if you work with populations that need exposure? I think it means precisely that.
On both grounds, if you are a person interested in either exposure or ACT, you need
this book. The authors do a wonderful job covering every detail of how to do ACT-based
exposure. The voice is calm and reassuring; the writing is clear and helpful; the advice is
detailed and evidence-based. It is simply the best book available on this topic.
And with that, I will turn you, the reader, over to the authors’ capable hands with this
simple message: this is an important book on an important area. I believe it will make a
difference in the lives of those you serve.
—Steven C. Hayes, PhD

Foundation Professor of Psychology,
University of Nevada, Reno
Originator and codeveloper of
acceptance and commitment therapy
Acknowledgments
First off, I’d like to thank my parents, who’ve been so supportive of me throughout my life
and through my schooling, more schooling, and still more schooling. Second, on behalf of
both my coauthors and me, I’d like to express our appreciation to Jason Luoma and Jenna
LeJeune at Portland Psychotherapy for years of mentorship and for generously allowing us to
carve time out of our clinical work and for providing a grant to support this book. To my
wife, Elizabeth, and daughters, Alice and Josephine, who graciously tolerated my spending
time in front the computer on weekends, when necessary. Lastly, I’d like to acknowledge
the generosity of the ACT community. I’m almost reluctant to name names here, as I’m sure
I’d leave someone out. Many my early ideas about ACT-informed exposure came from
casual hallway conversations. Michal Twohig, John Forsyth, and Robyn Walser were par-
ticularly welcoming and generous with their time early on. And to my coauthors, who
allowed me to take risks with this book and helped guide it.
—Brian Thompson
I’d like to express thanks to my parents and my aunt, who have always encouraged me to
write a book and taught me to believe in myself. I’d also love to acknowledge the many
mentors and supervisors that I’ve been lucky enough to work with. Dean McKay—your
passion, integrity, and love of learning has influenced me in so many ways, and I am so
grateful for all you’ve done for me. Paul Greene, Jamie Schumpf, Anna Edwards, Susan
Evans, Dennis Tirch, Kristy Dalrymple, and Lisa Coyne—thanks for teaching me exposure
and ACT and helping me find my own voice in this wonderful community of professionals.
I’d also like to thank my coauthors for all your support over the last several years, as well as
Jill Stoddard for your mentorship on the writing process. Finally, this project would not have
been completed without the support, encouragement, and mentorship of Jenna LeJeune,
Jason Luoma, and Kyong Yi at Portland Psychotherapy.
—Brian Pilecki
Thank you to my husband, Johan, for selflessly taking over childcare duties when I had to
hole myself up in my office to work. I’m so incredibly touched by your act of love toward me
x ACT-Informed Exposure for Anxiety
this past year. To my daughter, Aster, you’ve been such a “big girl” when I’ve been unavail-
able to spend precious mommy-daughter time with you. Thank you both from the bottom of
my heart. To my parents, thank you for always being my safety net. Your love and sacrifice
have laid the foundation for who I am. To my coauthors, thank you for always making your-
selves available to discuss book stuff in the midst of your busy work and personal lives. I’m
grateful to have gone on this adventure with you! To my friend and colleague Cristina
Schmalisch, thank you for sharing your wisdom and supporting me when I felt stuck. To
Kyong Yi, thank you for being a rock for the three of us when we needed a touchstone. To
Jenna LeJeune and Jason Luoma, thank you for providing such awesome examples of how
to contribute to the professional community in important ways. To my former colleagues in
the BIPOC diversity, equity, and inclusion group at Portland Psychotherapy, our honest,
reflective conversations were a wellspring of inspiration as I wrote the culture chapter, and
for that, I’m forever grateful.
—Joanne Chan
BACKGROUND
History, Research,
Current Trends
CHAPTER 1
A Process-Based Approach to Exposure

for Anxiety Disorders
Exposure therapy involves the systematic confrontation of anxiety-provoking stimuli while

refraining from avoidance behaviors (e.g., any behavior aimed at reducing fear or discom-
fort). It’s one of the major success stories in the treatment of anxiety disorders in adults
(Hofmann & Smits, 2008; Norton & Price, 2007), as well as children and adolescents
(Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016).
Whenever I (Brian T) start to tell someone about my background in exposure therapy,
I have to stop myself from saying, “My first exposure to exposure was…” Therefore, my first
(ahem) experience with exposure was prolonged exposure (PE) for PTSD (Foa, Hembree,
& Rothbaum, 2007). An exposure-based cognitive behavioral treatment for individuals
with PTSD, PE consists of psychoeducation, a brief introduction to deep breathing, and
then exposure, exposure, and more exposure. I’ve always admired the relative simplicity and
elegance of the PE protocol. There are only a handful of worksheets in the protocol, and the
focus of the treatment is almost entirely on exposure. There are a number of exposure-based
interventions; PE is just one of them. Others include exposure with response or ritual pre-
vention for obsessive-compulsive disorder (Foa, Yadin, & Lichner, 2012) and written expo-
sure therapy for PTSD (Sloan & Marx, 2019). However, many treatment protocols I’ve
picked up since learning PE have felt unnecessarily cluttered by comparison. Look at all
these worksheets and handouts, I’d think, paging through a manual, Do we really need all of
them? With PE, I never had these questions, because the approach is so streamlined. And
although you’ll find some critiques of PE in this book, it remains my platonic ideal of a treat-
ment protocol.
In sum, PE ruined me for other treatment protocols.
In the year after first learning and practicing PE, during a postdoc focused on accep-
tance and commitments therapy (ACT), I became interested in ACT approaches to expo-
sure. ACT is a newer cognitive behavioral treatment with a strong research base. Even in
the absence of deliberate exposure interventions, ACT has been described as an “exposure-
based therapy” because it encourages people to remain in contact with difficult experiences
they may otherwise avoid (e.g., Hayes, Strosahl, & Wilson, 2012).
4 ACT-Informed Exposure for Anxiety
As I moved away from using a strict PE protocol, I naturally gravitated toward approach-
ing ACT-informed exposure with the simplicity I’d valued in PE. At the time I was first
reading about ACT approaches to exposure (circa 2009–2010), there wasn’t a lot published
about it. I combed through Eifert and Forsyth’s (2005) exceptional ACT for Anxiety
Disorders and a handful of published case examples and small studies (e.g., Batten & Hayes,
2005; Dalrymple & Herbert, 2007; Orsillo & Batten, 2005). I informally chatted with expe-
rienced ACT clinicians using exposure and combed the ACT listserv for morsels. Along
the way, I started creating my own ACT-informed exposure worksheets, trying to put theory
into practice. I would revise these forms based on what seemed to work or not work with
clients.
Adrift from a consistent connection with a scientific community, I was more like a
crank trying to make contributions to quantum physics from his backyard garden shed than
a behavioral scientist.
Throughout it all, my goal was to distill ACT-informed exposure into its essence. How
could I orient clients to the ACT model in as few sessions as possible? What metaphors and
experiential exercises connected to the widest range of people I worked with? What did
exposure offer that traditional ACT metaphors and experiential exercises did not?
Gradually, published studies of larger, controlled trials of ACT-informed exposure
trickled in. Initially there was some talk that ACT-informed exposure may offer advantages
over traditional exposure in terms of more people getting better or fewer dropouts. As
research indicated that ACT-informed exposure and traditional habituation-based expo-
sure appeared to perform about equivalently on primary outcomes (Arch et al., 2012;
Craske, Niles, et al., 2014; Twohig et al., 2018)—that is, about the same; no better, no
worse—I grappled with why a therapist might use ACT-informed exposure over traditional
exposure such as PE—especially therapists already comfortable with traditional exposure.
Why learn a new model that appears no more effective than the old model? Traditional
exposure promises symptom reduction, whereas the ACT model focuses on remaining in
contact with discomfort to strengthen psychological flexibility in order to live a meaningful
life. Why learn a model that feels more counterintuitive for clients compared to traditional
exposure? Given that clients crave symptom reduction, why offer a treatment that denies
them that?
This book is the culmination of more than a decade of studying, reading, writing, and
otherwise wrestling with ideas about ACT-informed exposure. It’s been shaped through
thousands of hours of clinical work with clients who’ve let us know—implicitly and explic-
itly—what works and what doesn’t. As my coauthors and I began teaching trainees at our
clinic and developing workshops on ACT-informed exposure, we further refined these ideas
and how to present them to others. Our goal was to help answer the above questions and
make ACT-informed exposure as practical as possible.
A Process-Based Approach to Exposure for Anxiety Disorders5
By “practical,” we don’t mean simple, though. We love ACT theory. We’ve tried to
interweave the full complexity and texture of ACT theory into exposure to help readers
creatively develop exposure exercises that address a wide range of client difficulties. As
ACT is a process-based approach—more on that in the next section—we want to help
therapists learn to flexibly use ACT across diagnostic categories and to think through
exposures using the ACT psychological flexibility model. In some ways, this is the book I
wish I’d had when I first started working with ACT-informed exposure over a decade ago.
From Protocols to Processes

In the 1990s, a task force was created within the American Psychological Association for
evaluating the evidence of psychological treatments (for more background, see APA
Presidential Task Force on Evidence-Based Practice, 2006; Tolin, McKay, Forman, Klonskey,
& Thombs, 2015). Their goal was the development of empirically supported treatments
targeting specific diagnoses. This movement was wildly successful—especially with anxiety
disorders. Therapists now have access to commercially available—and even free!—evi-
dence-based treatment protocols written by experts in the field targeting specific anxiety
disorder diagnoses. PE, mentioned earlier, is an exposure-based treatment protocol specifi-
cally for PTSD (Foa et al., 2007). The primary creator of PE, Edna Foa, PhD, has a separate
treatment protocol for obsessive-compulsive disorder (e.g., Foa et al., 2012). For a period of
time, protocols flourished as more and more manualized treatments became available.
The victory lap for evidence-based treatments was short-lived, however. Almost imme-
diately following the success of empirically supported treatments, some researchers ques-
tioned the focus on diagnosis-specific treatment protocols (Rosen & Davison, 2003). What
about all the clients with comorbidities? Do we need to put them through multiple, indi-
vidual protocols? If so, in what order should we do so? What about clients whose difficulties
don’t cleanly fall within clear diagnostic categories?
Another unfortunate side effect of the focus on protocols is the proliferation of
approaches without regard to how these treatments work. Because protocols are typically
tested as a package, they may have components that are not active in contributing to clini-
cal outcomes (Tolin et al., 2015). For this reason, randomized controlled trials, considered
the gold standard in clinical and medical research, have sometimes been derisively called
“horse race studies.” These studies look at whether a treatment wins the race (i.e., is as
effective or more effective than established treatments) but say nothing about the effective-
ness of the individual components. A treatment may be shown to be effective in controlled
trials even if we don’t know why it works or whether each intervention in a protocol adds to
the whole.
As an alternative to individual treatment protocols, critics have called for a focus on
developing our understanding of evidence-based, transdiagnostic principles or processes of
change (e.g., Hayes & Hofmann, 2021; Rosen & Davison, 2003). Instead of diagnosis-spe-
cific protocols, a process-based approach focuses on interventions that target evidence-
based processes of change that help people across multiple domains. The idea is that clients
will get more bang for their buck. Treatment might be briefer and more tailored to each
individual than a protocol-driven approach would be. (As an aside, process-based approach
is different than the notion of “common factors,” such as therapeutic alliance, that are
found in every form of psychotherapy: e.g., Hofmann & Barlow, 2014; Wampold et al.,
1997.)
Something that drew me to ACT is its focus on process. Although ACT is not a “pure”
process-based approach, it’s rooted in evidence-based processes of change based on the
psychological flexibility model (Ong, Levin, & Twohig, 2020). Yes, there are plenty of con-
trolled trials (“horse race studies”) on ACT—at this writing, over 850 and counting—but
there’s also been an emphasis within the ACT community on understanding the mecha-
nisms of change underlying ACT treatments. Research has found that components of the
psychological flexibility model targeting core ACT processes of change can improve quality
of life and symptoms in transdiagnostic samples of people seeking help (Levin, Hildebrandt,
Lillis, & Hayes, 2012; Villatte et al., 2016). A large-scale study found that people with
anxiety and a comorbid mood disorder improved more in ACT compared with traditional
CBT for anxiety, which was more effective in people without a mood disorder (Wolitzky-
Taylor et al., 2012).
Additionally, ACT processes are relevant in other non-ACT treatments for anxiety
disorders such as traditional CBT (Arch, Wolitzky-Taylor, Eifert, & Craske, 2012) and cog-
nitive therapy (Twohig, Whittal, Cox, & Gunter, 2010). Exposure, for example, appears to
strengthen ACT processes whether delivered in an ACT context or not (B. L. Thompson,
Twohig, & Luoma, 2021; Twohig et al., 2018).
We also believe there are personal benefits for therapists learning ACT-informed expo-
sure. For example, an ACT approach to exposure therapy may help to increase therapist
flexibility (Luoma & Vilardaga, 2013). The ACT psychological flexibility model also offers
an expanded vocabulary for talking about processes relevant to exposure for which there is
not common language in other exposure models. For example, while the importance of
emotional acceptance has been implicitly acknowledged in traditional approaches to expo-
sure, newer acceptance-based treatments such as ACT make this process explicit, providing
additional ways to talk with clients about how they relate to internal experiences
(Moscovitch, Antony, & Swinson, 2009). In our focus on ACT-informed exposure, our goal
is not to bury traditional exposure but to provide a bridge to ACT for clinicians experienced
in older exposure models that focus on symptom reduction, allowing them to understand
and integrate concepts such as acceptance and psychological flexibility in their exposure
work with anxiety disorders.
A Process-Based Approach to Exposure for Anxiety Disorders7
Getting the Most Out of This Book

Unlike PE, we have deliberately stopped short of providing an ACT-informed exposure
treatment protocol. Readers who are completely new to exposure could benefit from learn-
ing a more straightforward exposure-based protocol first before jumping into this book. We
have also tried to keep this book lean and focused on applications of ACT to exposure
specifically. For example, the ACT literature is rich with many metaphors and experiential
exercises to help people contact and practice psychological flexibility. In this book, we have
deliberately limited focusing on specific ACT metaphors and experiential exercises so that
these do not become calcified into a protocol. Instead, our focus is on exposure as an ACT
experiential exercise. We see no difference between exposure and traditional ACT experien-
tial exercises, as both allow clients to practice psychological flexibility. That doesn’t mean
the use of ACT experiential exercises is not also valuable in ACT-informed exposure, as the
authors of this book regularly draw from a variety of common ACT exercises in orienting
clients to exposure work. There are plenty of other resources available that we recommend
you use to supplement your work, such as general books on ACT metaphors and experien-
tial exercises (e.g., Stoddard & Afari, 2014) and ones tailored for anxiety disorders (e.g.,
Eifert & Forsyth, 2005; Harris, 2021).
As you embark on this process, we suggest you work through the exercises and begin
creating your own ACT-informed exposure materials, customizing forms, worksheets, and
treatment procedures that you can continue to revise and tweak over time. And we’ll guide
you through the process of doing this in chapter 8. We want readers to think carefully about
the materials they use and how clients respond to them. We are always changing and adapt-
ing our own ACT-informed exposure materials as we integrate new ideas and new research
into our practices, and we encourage readers to do the same. Our hope is that you will come
away from this book with a solid foundation on how psychological flexibility is strengthened
through ACT-informed exposure and that this new understanding will enable you to
address transdiagnostic clinical issues more effectively.
With that, we’ll dive into chapter 2—in which we’ll walk through a brief history of the
evolution of our understanding of how exposure works and why having a strong grasp of
theory is helpful as a clinician. We will also begin to explore the unique insights ACT has
to offer on why exposure works.
CHAPTER 2
A Brief History and Overview

of Exposure
When I (Brian P) was a little boy, I stepped on a nest of bees while walking through the
park on a cool fall afternoon. I had wandered off on my own, happily exploring the grassy
fields and nearby pond. Prior to this, I had no real experience with stinging insects like bees
or wasps. Suddenly out of nowhere, I felt an excruciating pain on my leg. I screamed. What
was that? Then another sting and another scream. What is happening? I went into full-
fledged panic mode. The stings kept coming, one after another—mysterious spikes of pain
striking randomly all over my body. Luckily a friend’s parent came running over to help and
began explaining what was happening: “You stepped on a nest of bees—insects that can
sting you.” Crying and in shock, I was thankful that there was an adult who seemed to
understand the situation.
Physically, I was okay. I did, however, develop a phobia of bees and other stinging
insects. In the summers that followed, going out in the backyard was a terrifying venture. I
began scoping out all the places bees liked to visit—flowers, bushes, puddles of water, and
so on. I avoided going outside in the summer. When I did go outside, I had difficulty enjoy-
ing myself, because I was on high alert. My parents did what any good parents might think
to do—they coaxed me into going outside, reassuring me that I’d be okay, that I didn’t need
to worry so much about being stung. Yes, it can happen, they offered, but it’s rare.
The idea that we should face our fears is common sense. It’s found throughout our cul-
tural messaging and is the theme of countless movies, books, and songs. My parents were
on the right track; unfortunately, I remained terrified of being stung again, despite their
best efforts. What was missing? Why wasn’t their encouragement enough to face my fears
and overcome my phobia? This chapter is about the importance of theory and why the
simple idea of “facing your fear” requires a lot more sophistication and nuance than it might
seem. We will provide a rationale for the importance of theory when working with people
who suffer from anxiety and will also provide a basic foundation in the history of exposure
therapy, focusing on some of the main theories that have evolved to guide clinicians in
helping people with anxiety problems.
The Importance of Theory in Exposure Therapy

Why is theory so important? To provide an in-depth response to this question, let’s consider
the role of theory in exposure treatment. From a procedural perspective, exposure therapy,
centered on basic ideas of helping people confront their fears, may appear to be unchanged
over the decades since it was first discovered. A person with claustrophobia is encouraged
to spend time in spaces that are difficult to exit, like an elevator. A person with social
phobia is encouraged to make small talk with strangers. While this practice may seem
simple and obvious (i.e., confront your fear), the nuances of exposure matter greatly. Where
do you start? How do you know if it’s working? When are you done? Why does it work?
Sometimes we receive phone calls from potential clients who tell us, “I’ve tried expo-
sure—and it doesn’t work!” While not everyone benefits from exposure, these callers’
descriptions usually align with one of the following scenarios:
• They tried exposure on their own once or twice and became overwhelmed.
• They worked with a therapist who offered a vague, unstructured version of expo-
sure that wasn’t grounded in theory. Perhaps the therapist used a “cookbook”
approach or simply gave the client an exposure book and told to them to follow
instructions without offering guidance.
• They weren’t prepared for the potential of symptom relapse since they didn’t under-
stand the theory behind how anxiety and exposure therapy works.
Having a sound underlying theory is important in designing, implementing, and trou-

ble-shooting a course of exposure treatment. Theory impacts moment-to-moment clinical
decision-making and is the bedrock for successful treatment in many types of cognitive-
behavioral therapy (Pilecki & McKay, 2013). Anxiety disorders are heterogenous (Stein et
al., 2021; Lochner & Stein, 2003), with each individual client presenting with unique ver-
sions of anxiety. Theory is therefore critical when applying exposure therapy principles to
the individual (Abramowitz, 2013; Abramowitz, Deacon, & Whiteside, 2019). While a
cookbook approach based on a standardized treatment manual may be effective with many
clients, without a grounding in theory, therapists may become stuck when clients are not
progressing as expected or if there is high complexity to the problem. When unusual situa-
tions arise, as they often do, it’s helpful to have a model for guidance in making adaptations
to the standard treatment course.
The final reason we are highlighting the importance of theory comes from a more
birds-eye view of the evidence base for exposure therapy. Overall, about 49.5 percent of
clients with anxiety disorders show a response to exposure therapy (Loerinc et al., 2015).
There are several reasons for this. First, not everyone responds to treatment, and some
A Brief History and Overview of Exposure11
clients experience only partial remission of their symptoms (Loerinc et al., 2015). Some
proportion of these non-responders may be due to clinicians who lack the necessary skills
and experience required to effectively deliver exposure. Second, some clients drop out of
treatment (McGuire et al., 2015; Öst, Havnen, Hansen, & Kvale, 2015). Third, some clients
experience a resurgence of symptoms after treatment has ended (Springer, Levy, & Tolin,
2018). Taken together, these findings suggest that while exposure is an effective treatment,
there is much room for growth in how exposure is delivered, highlighting the need to help
clinicians improve how they deliver exposure therapy through improving and refining their
understanding of theory.
What, then, is the current theory underlying exposure therapy? Newer students of
exposure are often surprised to learn that there is no single unifying theory. Researchers
have repeatedly developed and updated multiple theoretical models across the history of
exposure as our understanding of learning, neuroscience, memory, and anxiety has
advanced. The authors of this book have devoted a significant amount of time to under-
standing exposure in part because of our fascination with the constantly evolving science
and theory in the ongoing improvement of anxiety treatment.
Thankfully, when I was little, I was fortunate enough to meet with a child psychologist
trained in exposure therapy and grounded in theory who helped me overcome my fear of
bees and restore my ability to adventure out into the hot, buggy New Jersey summers. It
took someone with the skill and training to translate the general idea of “facing your fear”
encouraged by my parents into a systematic set of instructions and homework assignments
that achieved the desired outcome.
Classical Conditioning
The roots of exposure therapy span several decades to the beginning of behaviorism and
early psychotherapy. While it’s beyond the scope of this chapter to present an exhaustive
history of exposure therapy, it can be helpful to establish some key points of that history to
better understand how exposure has evolved over time. It can also help with functionally
understanding how fears are conditioned and reinforced in each client, which would provide
the conceptual basis for a treatment plan.
Much of what we know as exposure therapy is based on learning theory. One of the
early pillars of learning theory is classical conditioning (a.k.a. respondent conditioning).
Classical conditioning accounts for many of the ways that humans and other animals learn.
If you’ve taken a Psych 101 class, you might know classical conditioning as “Pavlovian con-
ditioning” due to its founder, Ivan Pavlov. In studying digestive processes in dogs, Pavlov
observed that dogs would begin salivating when they perceived the presence of meat and
that this occurred even in the response to the mere sight of the experimenter the dogs
associated with bringing food (e.g., Kazdin, 1978). Through a series of studies, Pavlov found
that if meat were paired with a neutral stimulus, such as a bell or tone, the dogs would begin
salivating at the presence of the neutral stimulus even when no meat was present.
These studies established several key concepts that are important in understanding
exposure theory. First, the unconditioned stimulus (US) is any stimulus that leads to an
unconditioned response (UR) of an organism. For example, the sight of meat (US) pro-
duces salivation (UR) in an animal. No learning is required so far. Next, during condition-
ing, a stimulus that was previously neutral or unrelated is paired with the US until it
becomes the conditioned stimulus (CS). Pairing the unconditioned stimulus with the con-
ditioned stimulus is called reinforcement, as it strengthens the relationship between the two
stimuli. For example, the sound of a tone (CS) is paired with the sight of meat (US). After
sufficient pairing, the relationship between the CS and US strengthens to the degree that
the presence of the CS alone produces a conditioned response (CR) that is often similar to
the UR. The relationship between the CS and CR reflects new learning. In Pavlov’s work,
after pairing the presence of meat with a tone through several iterations, the animal would
begin salivating in response to the CS.
As another example of classical conditioning, we’ll return to our earlier example of my
fear of bees (see figure 1). Before I stepped on a nest and got stung, bees were neutral stimuli
and didn’t evoke a strong emotional reaction. However, pain (US) was hard-wired into my
body to produce aversion and fear (UR) in response to pain. When I was stung, bees (a
neutral stimulus) became paired with the sensation of pain (US), triggering fear. The UR of
fear from pain became paired with bees (CS). I began to fear pain at the sight of bees.
However, these associations didn’t begin and end with the sight of bees. In the days and
weeks following this incident, I began associating bees, yellow jackets, and other similar-
looking creatures (CS) with fear (CR) as potential sources of pain. This is an example of
another learning theory concept called “generalization,” which refers to the ability of learn-
ing to spread from one stimulus to other similar stimuli (e.g., Ramnerö & Törneke, 2008).
My bee phobia generalized further to insects without stingers, and I began to experience
fear (CR) in the presence of even harmless insects such as flies, moths, and even butterflies.
Moreover, the CR generalized in terms of location, spreading from the park where I was first
stung to anyplace where these insects may congregate, such as flowers and bushes.
Before Conditioning
Unconditioned Stimulus Unconditioned Response
(pain) (fear)
Neutral Stimulus (bees) No Response
During Conditioning
Unconditioned Neutral Stimulus Unconditioned

Stimulus (pain) (bees) Response (fear)
After Conditioning
Conditioned Stimulus Conditioned Response
(bees) (fear)
Although Pavlov’s work is associated with classical conditioning, he did not experiment
with fear, as in the bee example above. Classical conditioning theory was put into practice
toward understanding and treating fear by early behaviorists such as Mary Cover Jones and
John B. Watson. To offer a simplified history: Watson took Pavlov’s work on conditioning
and demonstrated how it could be applied to fear (e.g., Kazdin, 1978). In 1920, Watson
trained an eleven-month-old infant called “Little Albert” to experience fear at the sight of
a white rat by banging a metal rod to make a loud scary noise (US) in the presence of the
white rat (CS). (This study would be unethical today.) After training, Little Albert began
to experience fear (CR) at the sight of the white rat (CS). Through subsequent studies,
Watson created CS fear associations toward a rabbit, a dog, a fur coat, cotton wool, and a
Father Christmas mask (more examples of generalization). In sum, Watson demonstrated
how to train fear responses through classical conditioning.
Unfortunately, Little Albert left Watson’s experiment before Watson had the opportu-
nity to extinguish the fear response. The task of demonstrating that fear could be extin-
guished was left to Mary Cover Jones three years later (Kazdin, 1978). Influenced by
Watson’s work, Jones worked to help “Little Peter,” a thirty-four-month-old child who had
developed a fear of several stimuli, including rabbits, rats, fur coats, cotton, and wool. As
Peter demonstrated the greatest fear response in the presence of the rabbit, Jones experi-
mented with several methods to untrain Peter’s fear of rabbits. The most effective of them
involved direct conditioning. By pairing the rabbit with food that Peter liked, and then
gradually bringing the rabbit closer to Peter while he was enjoying some delicious food,
Jones was able to decondition the fear association. After Peter’s fear response diminished in
the presence of the rabbit, Jones further found that Peter no longer experienced fear in the
presence of the other similar objects such as a white rat and fur coat (i.e., generalization).
Another behavioral principle is that of extinction learning. Extinction of the condi-
tioned response is said to occur when the CS is repeatedly presented without the US. For
example, when bees were present on many occasions and did not sting me, I learned that
bees no longer signaled an impending presence of pain, as they once had. This may have
led to a diminished fear response (CR) in the presence of bees (CS). Here, the association
between bees and pain is said to be extinguished.
The term “extinction,” however, may be a bit misleading. Although earlier theorists
viewed extinction as a process of unlearning (e.g., Rescorla & Wagner, 1972), we now con-
sider extinction learning as the development of new associations. The relationship between
the CS and CR is not extinguished in the way a candle flame is extinguished. Associations
that are made in the brain are not simply erased. For example, one may have learned that
the sound of a tone signals food after repeatedly being presented food with the tone. When
the food is no longer paired with the tone, one learns that, perhaps, the sound of the tone
does not guarantee that food will be offered after all. However, one’s mouth may still sali-
vate due to prior associations between the tone and food being presented. When one
responds in a way that reflects prior learning, it may be a sign of spontaneous recovery
(Rescorla, 2004). This is an important concept in exposure therapy in helping to under-
stand why symptoms may relapse after successful treatment. By providing experiences that
train extinction, we can help weaken the association between CS and the UR (anxiety or
fear) in our clients. In other words, when my younger self put his face close to a bush to smell
flowers and did not experience stinging pain, he learned standing near flowers was gener-
ally safe. This learning was strengthened the more he spent time outside without being
stung.
In the 1950s, Joseph Wolpe used principles of classical conditioning to inform a thera-
peutic technique to treat fear called systematic desensitization. Systematic desensitization
differs from exposure therapy in that it relies on the induction of a physiological state
incompatible with anxiety, such as relaxation (Wolpe, 1952, 1954). While his treatment
was eventually abandoned in favor of modern exposure techniques, he did develop the
concept of a fear hierarchy (developing a list of progressively challenging exercises) and
assigning quantitative values to clients’ experiences of anxiety—commonly called the “sub-
jective units of discomfort scale” (Wolpe 1969, 1990) These concepts will be described in
more detail in later chapters.
In conclusion, classical conditioning theory is foundational to exposure theory.

However, as important as classical conditioning is, it’s insufficient by itself to explain all the
ways in which humans can learn new things. Why is that? We will answer this question as
we explore the second pillar of learning: operant conditioning.
Operant Conditioning
Classical conditioning involves a more passive form of learning, whereby an organism makes
associations through the pairing of stimuli. By contrast, operant conditioning, first studied
by Edward L. Thorndike (1898) and expanded upon by B. F. Skinner (1965, 1974), refers to
the feedback process where we associate a behavior with particular consequences. In
operant conditioning, there are two main categories of consequences that can occur after
any given behavior (see table 2.1).
1. Similar to the notion in classical conditioning of reinforcement that involves
strengthening an association between two stimuli, reinforcement in operant condi-
tioning refers to the strengthening of a response based on its consequences.
Reinforcers are usually pleasurable, attractive, or desirable things. The smile that
we get when playing with a baby warms our heart and makes us more interested in
playing games that are otherwise boring to adults. The refilling of my bank account
every two weeks increases the likelihood I’ll wake up early and go to work each day.
There are two types of reinforcement in operant conditioning:
i. Positive reinforcement refers to the addition of a consequence that serves to
increase the likelihood of a behavior occurring again in the future. Money or
compliments for completing a task are examples of positive reinforcement.
ii. Negative reinforcement refers to the removal of a consequence that serves to
increase the likelihood of a behavior occurring again in the future. For example,
the act of hitting the snooze button results in the temporary removal of the
jarring, unpleasant alarm tone.
In the context of operant conditioning, then, “positive” means the addition of
something, and “negative” means the removal of something. The terms “positive”
and “negative” are often misused by lay people. Note that the word “negative” in
negative reinforcement does not mean something aversive. For example, many lay
people say “negative reinforcement” when they mean punishment, which we discuss
in the next section.
2. If “reinforcement” means we are more likely to engage in a behavior in the future,
“punishment” means we are less likely to engage in a behavior in the future. As
reinforcers increase the occurrence of behavior, punishment decreases behavior.
Similar to reinforcement, the words “positive” and “negative,” in this context, refer
to the addition or removal of a consequence, respectively.
i. “Positive punishment” refers to the addition of a consequence that serves to
decrease the likelihood of a behavior occurring again in the future. Receiving
a ticket for speeding is one example of positive punishment.
ii. “Negative punishment” refers to the removal of a consequence that serves to
decrease the likelihood of a behavior occurring again in the future. To refer
back to the example above, if you receive several speeding tickets, you may
have your driver’s license suspended. Having your freedom to drive taken away
would be a form of negative punishment.
Table 2.1.
Positive Negative Result
Addition of Removal of
Reinforcement consequence consequence Increase in behavior
Addition of Removal of
Punishment consequence consequence Decrease in behavior
Outside of a lab setting, determining what is reinforcement or punishment, and whether

it’s positive or negative, can become confusing—especially among humans, whose language
ability can alter how these concepts are experienced. Public praise may be reinforcing for
someone who enjoys the attention or punishing for someone who feels embarrassed at being
singled out. As we’ll discuss in more detail in chapter 11, culture can influence how a stimu-
lus, such as praise, can be experienced as reinforcing for a child from one culture and pun-
ishing for a child from another (Fong, Catagnus, Brodhead, Quigley, & Field, 2016). One
person may increase the behavior that earned praise (positive reinforcement), and the
second person may decrease the behavior that earned praise (positive punishment). Humans
are complicated!
Despite these fuzzy boundaries, awareness of the principles of operant conditioning is
helpful in understanding how people develop problems with anxiety and how these prob-
lems are maintained and exacerbated over time.
How Avoidance Perpetuates Anxiety

Let’s now talk about the role of avoidance and how it relates to anxiety. If you’re fearful
of bees, what should you do? Common sense tells you that you should simply avoid all bees.
No bees, no anxiety. Easy! Here the behavior of avoidance is reinforced via negative
reinforcement: I stay away from outdoor areas where bees are likely to reside, I feel less
anxious. Admittedly, many people with a specific phobia can do a pretty good job of avoid-
ing their feared stimuli by not going out into nature and remaining indoors as much as
possible. This is one reason why people with specific phobias are less likely to seek treat-
ment (Eaton, Bienvenu, & Miloyan, 2018)—they may be able to pull off avoidance of what
they fear without giving up too much. However, there are major problems with this
strategy.
First, it is near impossible to completely avoid bees without avoiding the outside. Unless
you live in Antarctica, you’ll encounter bees. Moreover, as my younger self learned, avoid-
ance of one stimulus (e.g., bees) can generalize to other stimuli, such as non-stinging insects
(e.g., flies) and places one predicts bees may be found (e.g., flowers and bushes). Avoiding
bees can also have a human cost: giving up on activities that are part of what makes life
worth living, like going on a camping trip, having a backyard BBQ with friends, or hiking
through a forest. What’s more, these forms of avoidance can result in increasingly constric-
tive living than just having to avoid the outdoors. While it may be possible to mostly avoid
bees by avoiding the outside, it is much harder to avoid other triggers of anxiety, such as
unfamiliar people, driving, germs, or closed spaces, and still live a fulfilling life.
As an operant, avoidance strengthens the conditioned relationship between the avoided
stimuli and anxiety. For little Brian P, the more he avoided the backyard and stayed indoors
(negative reinforcement, via the avoidance of bees), the more dangerous bees seemed to
him. However, after being guided by his therapist to spend some quality time with a few of
these marvelous, winged arthropods (positive reinforcement), the boy realized that they
were actually kind of cool. Ultimately, he even began to develop a hobby around bug col-
lecting, reading about bugs, and going on bug hunts.
Subsequent models of exposure incorporated both classical and operant conditioning.
The next session will describe several theories that have been used to explain exposure.
While it’s beyond the scope of this chapter to explain each theory and its strengths and
weaknesses, we hope this will give you a flavor of the depth of work in this area.
Integrating Classical and Operant Conditioning

An early model that integrated classical and operant conditioning was Mowrer’s (1960)
two-factor learning theory of fear acquisition and maintenance. According to the two-fac-
tor learning theory, fear associations are classically conditioned and then, through operant
conditioning, avoidance behaviors are maintained through the reduction of anxiety (nega-
tive reinforcement). Although influential, one shortcoming of two-factor learning theory is
that fears often develop in people without any particular incident that led to their formation
via classical conditioning (Rachman, 1976).
A second influential learning theory that incorporated both classical and operant con-
ditioning, Lang’s bioinformational theory, focused on emotional memories or imagery asso-
ciated with fear (Lang, 1977, 1979). The theory categorized emotional imagery according to
three types of information: stimulus elements, behavioral responses, and meaning or inter-
pretation of both of these (Lang, 1977, 1979). While this model was also influential in
bringing attention to emotional imagery as salient fear-inducing stimuli, subsequent
researchers considered it a major shortcoming that this model did not detail how the process
of activating these fear structures was associated with therapeutic change in exposure
therapy (Foa, Huppert, & Cahill, 2006). Again, this is not an exhaustive account of the
strengths and weaknesses of this model, but rather just a glimpse into the complexity
involved in understanding how exposure works in treating anxiety. Despite these shortcom-
ings, researchers were able to build on Lang’s work in developing the theory that came to
dominate exposure therapy, which focuses on what is called “emotional processing.”
Emotional Processing Theory and Habituation

The concept of emotional processing has been tricky to define with specificity. Earlier theo-
ries fell short in clarifying how fear associations were acquired and treated through expo-
sure therapy. Rachman (1980, p. 51) offered an early definition of emotional processing of
fear as “a process whereby emotional disturbances are absorbed, and decline to the extent
that other experiences and behaviour can proceed without disruption.” However, Rachman’s
definition of emotional processing lacked depth in its theoretical explanation and was
subject to circular reasoning. In Foa and Kozak’s (1986) influential account of emotional
processing theory (EPT) and the mechanisms of change in exposure, they expand upon
Rachman’s work and offer a more comprehensive and unifying theory of exposure. An
emphasis in EPT is on habituation, or decreases in fear as a result of exposure, as a signal of
new learning.
In creating a comprehensive theory, EPT was to dominate exposure therapy for decades,
up until the present. For many exposure therapists trained today, EPT is exposure therapy.
According to EPT, improvement in fear response via exposure therapy involves (A) the
weakening of old fear-based associations, as well as (B) the development of new informa-
tional structures. In other words, a combination of altering existing learning (e.g., changing
an association between CS and fear-based CR) and learning something new (e.g., learning
a new association between CS and non-fear-based CR). This theory informs necessary con-
ditions for exposure to be effective. First, exposure exercises must sufficiently activate the
underlying fear structure stored in memory, which is comprised of information about the
fear stimulus, response to the stimulus (CR), and meaning derived from the experience (i.e.,
this part comes from Lang’s bioinformational theory). Second, new information must be
integrated into the existing fear network to weaken it. For instance, take the absence of a
feared outcome or a decrease in physiological reactivity associated with a feared stimulus:

these are incompatible with the idea that the stimulus in question is dangerous. For example,
as my younger self spent more time smelling flowers, he learned that bees weren’t going to
immediately attack him anytime he was near a bush or flowerbed! Change in meaning
related to fear stimuli is one mechanism by which older fear structures are weakened and
thereby new learning is strengthened.
A key indicator that emotional processing is occurring successfully (i.e., something new
has been learned) is the process of habituation. Habituation refers to a decrease in fear
when in contact with the conditioned stimulus (Foa & Kozak, 1986). EPT emphasizes two
forms of habituation in treatment. In-session habituation refers to habituation that occurs
during an exposure exercise (e.g., distress begins high and then decreases), and between-
session habituation refers to habituation that occurs across exposure exercises (e.g., less
distress at the beginning of the next exposure exercises compared to the preceding ones).
Experiencing a reduction in fear when in contact with the CS may also disconfirm
beliefs that maintain avoidance (e.g., I need to stay away from bees, because they are fraught
with danger), because the belief is incompatible with the fear structure. According to EPT,
repeated trials of confronting a feared stimulus will result in a decrease of a fear response
through habituation.
EPT has many strengths. First, there is a strong body of empirical evidence for EPT and
decades of success using this theory to guide exposure treatment (Abramowitz, 2006). In
other words, it works! Second, for decades, it has been the most comprehensive theoretical
model for accounting for positive change in fear reduction associated with exposure therapy
(Moscovitch et al., 2009). In other words, it has the broadest explanatory range in under-
standing all the ways in which fear improves with exposure therapy. However, many expo-
sure researchers are moving away from EPT.
Our Current Understanding of Exposure

While EPT has been the dominant theory in exposure therapy for several decades, and
modifications to EPT have incorporated subsequent research findings (Foa & McNally,
1996; Foa, Huppert, & Cahill, 2006), newer research has not supported key elements of the
theory despite attempts to update it. Several areas of research have emerged to challenge
fundamental elements of EPT.
The biggest blow to EPT is that habituation appears to be a poor predictor of learning.
People appear to benefit from exposure whether they demonstrate habituation or not (e.g.,
Baker et al., 2010). This has been partially acknowledged in EPT-related research. For
example, research on prolonged exposure for PTSD, which is based on EPT, has found that
within-session habituation—decreases in anxiety during exposure—does not predict
whether participants get better through exposure (Jaycox et al., 1998; van Minnen & Foa,
2006). Although some EPT researchers have maintained that between-session habituation
(i.e., decreases in fear across exposure sessions) remains a useful prediction of treatment
outcome (Jaycox, Foa, & Morral, 1998; van Minnen & Hagenaars, 2002), newer research
has challenged even that assertion (see Craske, Treanor, Conway, Zbozinek, & Vervliet,
2014). Research on inhibitory learning theory (ITL), a newer account of exposure, has dem-
onstrated that people show improvement from exposure therapy even if they don’t exhibit
decreases in fear during and across exposures (Baker et al., 2010; Kircanski et al., 2012)
Studies of ITL have demonstrated good outcomes while keeping fear levels elevated
throughout exposure, which undermines one of the core tenants of EPT—the importance
of activation and reduction of the fear response during exposure (Craske, Treanor, et al.,
2014).
As mentioned earlier, research on extinction learning suggests that older associations
are not weakened or eliminated but that newer (non-threat) associations learned through
exposure compete with the older threat-based associations (Rescorla, 2001; Bouton, 2002).
In other words, there is no such thing as unlearning, as had been theorized in EPT and by
prior exposure theories. Instead, newer exposure research, such as ITL, suggests that extinc-
tion promotes new learning which helps to inhibit the old, fear-based associations (Bouton,
2002; Craske, Treanor, et al., 2014).
Another critique of EPT comes from challenging its core concept of fear structures.
McNally (2007) argued that the notion of fear structures reflects a restatement of the
problem it is meant to explain (e.g., people who respond fearfully to bodily sensations have
fear structures that indicate those sensations are dangerous). Additionally, the concept of a
fear network does not appear to distinguish people with anxiety disorders from people
without them. In a study in which samples of people with panic disorder and people without
an anxiety disorder were shown pairs of words associated with anxiety (e.g., “breathless—
suffocate”), there was no difference in how the two samples responded to the threat associa-
tions (Schniering & Rapee, 1997), which does not support the notion that people with
anxiety disorders have fear structures that represent excessive responses to fear-related
stimuli.
In sum, despite attempts by proponents of EPT to accommodate emerging research on
exposure, some argue that EPT should be retired (e.g., Craske et al., 2008). EPT’s Achilles’
heel is its emphasis on habituation. While newer research suggests reduction in fear during
exposure offers some indication of learning when distinguished from reductions in fear
during engagement avoidance behaviors (Benito et al., 2018), it does not appear to warrant
the emphasis EPT places on it. To accommodate new exposure research, any theory we rely
on in conducting exposure must account for how people improve from exposure therapy
even if they don’t exhibit decreases in fear during and across exposure (Baker et al., 2010;
Kircanski et al., 2012).
Acceptance and commitment therapy (ACT), with its emphasis on strengthening psy-
chological flexibility over symptom reduction, offers one model with which to understand
newer research on exposure. As we noted in chapter 1, ACT-informed exposure has been
studied against and performs as well as exposure therapy based on EPT (e.g., Arch, Eifert,
et al., 2012; Twohig et al., 2018). The psychological flexibility model underlying ACT pro-
vides an expanded vocabulary for describing and understanding processes relevant in expo-
sure therapy. In the subsequent chapters, we’ll provide a foundation in ACT theory, make
a case for an ACT approach to exposure, and lead you through how to set up and guide
clients through ACT-informed exposure.
Conclusion
In summary, exposure therapy has a long history, spanning decades, from its roots in clas-
sical and operant conditioning. Exposure therapy based in emotional processing theory has
dominated the field in recent decades (Foa & Kozak, 1986); however, recent research has
challenged this theory—particularly its emphasis on habituation or fear reduction—and
created the need for a model that better fits the subsequent data that some individuals
benefit from exposure therapy even when they don’t show evidence of habituation. ACT-
informed exposure, with its emphasis on helping clients learn to strengthen psychological
flexibility, is one model that’s consistent with new research on exposure. Because of the
importance of theory in exposure theory, we will focus our next chapter on giving you a
solid grounding in ACT theory before we move into the practicalities of ACT-informed
exposure.
CHAPTER 3
An Acceptance and Commitment

Therapy Primer
Although the aim of this book is to make ACT-informed exposure practical and accessible
no matter your experience with ACT, having some familiarity with some of the founda-
tional theories supporting ACT is important in developing flexibility when using ACT-
informed exposure. To place ACT in a historical context, ACT was developed by people
who greatly respected Skinner’s brand of behaviorism but believed it was important to bring
more clarity to the philosophical assumptions of the behavior analytic approach.
Additionally, they felt that Skinner’s efforts in developing a behaviorist understanding of
thinking and language fell short. Consequently, while both ACT and exposure are rooted
in behaviorism with a shared language based in classical and operant conditioning (see
chapter 2), ACT draws from a newer behavioral understanding of language and cognition
called relational frame theory (RFT) and is grounded in a philosophy of science called
functional contextualism (FC). While it’s possible to learn and practice ACT without
knowing these more technical or philosophical aspects, we believe it’s useful to have some
grounding in these topics to further clarify how ACT differs from traditional approaches to
exposure therapy.
We’ll note here that the main professional organization behind ACT is called the
Association for Contextual Behavioral Science (ACBS). It’s not called the Association for
ACT. ACT is simply one iteration of a treatment based on contextual behavioral science.
Contextual behavioral science is a science of human behavior that includes FC, RFT, and
evolutionary science with the goal of improving the human condition. Therefore, contex-
tual behavioral science is broader than and transcends ACT. One additional goal in provid-
ing a grounding in FC and RFT is to help you look beyond ACT toward a contextual
approach to exposure therapy—an approach that differs in function to traditional exposure
therapy even if it appears to have some similarity in form. A contextual approach to expo-
sure builds upon traditional behavioral theory as outlined in chapter 2 and offers, among
other things, a set of philosophical assumptions, a guide for analyses of theorized processes,
and an understanding of human health and functioning.
In our experience, a deeper understanding of FC and RFT allows us to use ACT-

informed exposure more flexibly with clients and to more effectively trouble-shoot prob-
lems. Much of the nomenclature found in ACT, concepts such as “willingness,” reflect what
are called “middle-level terms,” which means they are not as precise or technical as more
behavioral language, such as the language of classical and operant conditioning from the
previous chapter and the terms we’ll be introducing in this chapter. Understanding the
more technical aspects of ACT theory helps bring more precision and fluency to ACT-
informed exposure. Our goal is to provide a foundation in ACT theory and, building on the
prior chapter, to demonstrate what it has to offer our evolving understanding of exposure.
A Brief History of ACT

Before diving into some of the more technical language of FC and RFT, let’s start with a
brief history of ACT. In the early 2000s, a cresting wave of like-minded treatments created
a sea change within CBT. Along with ACT, these treatments included dialectical behavior
therapy (DBT; Linehan, 1993), functional analytic psychotherapy (FAP; Kohlenberg &
Tsai, 1991), and mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale,
2002). This confluence of evidence-based mindfulness and acceptance-based treatments
came to be known as the “third wave” of cognitive behavioral therapy, first coined by Hayes
(2004). In this context, the “first wave” is behaviorism (see chapter 2), and the “second
wave” is cognitive therapy, spearheaded by innovators such as Beck (1979) and Ellis (1957).
You’ll note that “CBT” is not considered a wave, as it’s more of an umbrella term that incor-
porates elements from the first two waves (e.g., Hayes, Villatte, Levin, & Hildebrandt,
2011). In CBT, some approaches emphasize the “B,” and some emphasize the “C,” making
CBT more conceptually heterogeneous than the casual observer might assume. Although
they developed relatively independently of one another, and not everyone agrees there’s
been a third wave (e.g., David & Hofmann, 2013), there are few conceptual commonalities
among these treatments.
For one, third-wave approaches emphasize function rather than form in influencing
human behavior. For example, third-wave treatments focus more on altering how people
relate to their internal experiences (function) rather than changing what those internal
experiences are (form). In cognitive therapy (second wave), cognitive therapists might teach
clients to replace maladaptive thoughts with adaptive thoughts. Exposure based on emo-
tional-processing theory (EPT) is second wave in its focus on altering fear structures (e.g.,
thoughts such as If I panic, I may pass out and die!) through “corrective information” (Foa &
Kozak, 1986). That is, exposure based on EPT aims to replace maladaptive thoughts with
more accurate thoughts. In contrast to the second-wave examples above, third-wave treat-
ments are less focused on trying to change the content of thinking (i.e., the actual thoughts);
An Acceptance and Commitment Therapy Primer25
instead, they focus on helping clients learn more flexible ways of responding to thoughts. In
the third-wave treatment MBCT, for example, people engage in meditation and mindful-
ness practice as a method for recognizing unhelpful thoughts and feelings without trying to
change these internal experiences (Segal et al., 2002). In these ways, third-wave approaches
are more metacognitive in that they focus on awareness of the processes of thinking instead
of changing the content of thinking. As third-wave treatments are more sensitive to context
and function, they tend to emphasize the development of broad, flexible repertoires of adap-
tive behaviors over the targeting of narrowly defined problems based on the DSM. In other
words, they are more a recipe for healthy living rather than a cure for a disease.
This focus on health over disease represents a second commonality among third-wave
treatments: a shift away from a more mechanistic view of human behavior aimed at reduc-
ing human experiences into discrete elements based on a disease model. The biomedical
model, which attempts to reduce behavioral health diagnoses to biologically based disorders
of the brain (e.g., Deacon, 2013), and on which the DSM is based, is one widely used
example of a mechanistic approach. Third-wave approaches reject the notion that the
human experience can be neatly dissected into mechanistic parts. Instead, they reflect a
more contextual understanding of human experience that emphasizes broad processes of
change that appear important in healthy functioning. As an example, Hayes and Hofmann
(2021) compare mechanistic and third-wave approaches to anxiety. A therapist with a
mechanistic perspective may view anxiety as a negative emotion due to the form, frequency,
and intensity of the emotion. A third-wave therapist is interested in how anxiety functions
in the contexts in which it occurs. Anxiety may function positively or negatively within
different situations depending on its form, frequency, and intensity.
With an emphasis on context, third-wave approaches have brought about a shift in
philosophical assumptions related to the nature of assessment and treatment of behavioral
health problems (see Hayes & Hofmann, 2017). The section on FC in this chapter will
unpack this shift in philosophical assumptions in more detail, but we will say here that this
philosophical shift resulted in a movement away from a disease model of mental illness that
is oriented around diagnoses. Compared to second-wave approaches, where there was a
focus on discrete treatment protocols targeting DSM diagnoses, third-wave approaches
focus more on evidence-based procedures linked to evidence-based processes that enhance
adaptive human functioning. In these ways, we might consider third-wave treatments such
as ACT as more process-based treatments in their focus on broader transdiagnostic pro-
cesses of change (e.g., Hayes & Hofmann, 2017, 2021).
Having introduced how ACT and other third-wave treatments focus on changing the
function of internal experiences without trying to change the content or form of them, in
the next section, we provide an introduction to the philosophy of science that underlies
ACT: functional contextualism.
Functional Contextualism and Contextual

Behavioral Science
Anthropomorphized lab rats are a common subject in cartoon strips where they
comment about stereotypical lab tasks such as completing mazes or the consequences of
pulling levers. One funny take in some of these strips is that the lab rats believe they are
influencing the behavior of the scientist, rather than vice versa. We’ve included our version
here, which Joanne drew.
From a functional contextualist perspective (Hayes, 1993), whether the experimenter is

influencing the behavior of the rat or the rat is influencing the behavior of the experi-
menter are equally valid perspectives. We’ll explain how and why after we’ve provided a
brief introduction below to functional contextualism (FC), the philosophy of science in
which ACT is grounded.
As a philosophy of science, FC, whose goal is the prediction and influence of human
behavior, serves as the foundation for ACT and contextual behavioral science. All science
is based on philosophical assumptions, and FC holds its own set of assumptions that distin-
guish it from other approaches to science. If you’ve taken a research methods course, one
philosophical assumption core to the scientific method is Karl Popper’s (1934) notion that
scientific hypotheses should be falsifiable (i.e., that they can be proven false). If a hypothesis
cannot be tested to see if it is false, it’s not a good hypothesis for scientific study. As a result,
well-designed scientific studies are set up to test not that the researcher’s hypotheses are
true, but that they are not false. A philosophy of science helps to guide how we frame sci-
entific questions and how we may approach them.
FC is an approach to contextualistic thinking originally fathered by William James’s
pragmatism (Hayes, 1993). Contextualism is holistic in that it emphasizes the whole event,
where every behavior is an act-in-context. “Context” here refers to stimuli, including both
historical and current variables external to the behavior, that influence behavior (a.k.a.
response). The functional part of functional contextualism adds a focus on the prediction
and influence of behavior. In FC, depending on the goals of their analyses, clinicians and
researchers may include thoughts, feelings, bodily sensations, external stimuli, learning
history, and even evolution as part of how they define context. Context may be widened or
narrowed based on what allows for prediction and influence of behavior. In other words,
you may define the context in a number of ways depending on your goals of analysis. For
these reasons, FC is pragmatic in that it’s defined by whether it achieved the goal of predic-
tion and influence. Consequently, there is no objective truth in FC, because it’s all relative
to one’s aims. To return to our comic panel in the beginning of this section, whether the
researcher influences the behavior of the lab rats or the rats influence the behavior of the
researchers depends on how the context is defined by the person interested in influencing
behavior. Each framing is equally valid, depending on one’s analytic goals. If our goal is to
predict and influence the behavior of the experimenter (e.g., cause him to nod in approval),
then it makes pragmatic sense to focus on the action of the rat pulling on the lever.
According to FC, the context we’re interested in can be big or small in how we define it: it
may be a single moment in an individual’s life, or it may reflect the evolution of a civiliza-
tion unfolding over hundreds of years.
The term “shaping,” the emergence of more complex behaviors over time, is an example
of how it can be impossible to isolate behaviors into discrete units. Before we learn to write,
we must first learn the letters of the alphabet, then how to write the individual letters of the
alphabet, then how to organize these letters into words, then how to organize these words
into sentences, and so on. Each of these learning experiences gradually increases our ability
to eventually write about complex ideas, but often, in retrospect, we cannot easily segment
complex behaviors into discrete steps. As Skinner (1965) noted, operant conditioning (see
chapter 2) “shapes behavior as a sculptor shapes a lump of clay” in that “we cannot find a
point at which this [the behavior] suddenly appears” (p. 91). From a functional contextual-
ist perspective, we cannot easily reduce learning into distinct steps, as the steps all overlap
and inform each other, but we can determine where our analyses begin and end based on
our goals.
In understanding and defining FC, it may be useful to compare it against what it’s not.
Earlier in the chapter, we used the word “mechanism” to describe attempts to reduce
complex behaviors into discrete parts. Because the word “mechanistic” is used in lay lan-
guage and is more easily misunderstood as a result, a more precise term for this philosophy
of science is “elemental realism” (Hayes et al., 2012). Elemental realism is a common world-
view and popular in psychology. As noted earlier, the biomedical model, which has domi-
nated American healthcare, attempts to reduce human complexity into parts such as genes,
neurotransmitters, or neuroanatomy (e.g., Deacon, 2013). Many therapists take an elemen-
tal realist approach when they challenge client thoughts and attempt to get clients to think
in ways that correspond to some notion of “reality” (Hayes et al., 2012). Any therapist
experienced in working with OCD knows this approach is rarely successful, as many people
with OCD struggle with obsessions that they don’t necessarily believe are 100 percent accu-
rate or likely to happen.
FC is not mentalistic, either, in which mental constructs are considered causes of
behavior (e.g., Hayes & Brownstein, 1986). Mentalism is common in our way of speaking.
For example, clients often come to treatment looking for help in developing “self-esteem” or
“confidence,” because they believe these mental constructs will allow them to pursue the
lives they want. Regarding anxiety-related problems, from an FC perspective, fear does not
cause behavior. One person may choose not to ride a particularly high roller coaster in part
due to the presence of fear (e.g., That looks too scary!), whereas the presence of fear may
influence another person’s decision to ride that particular coaster (e.g., Wow—that one looks
exciting!). In neither instance, however, was fear the sole cause of behavior, as each indi-
vidual’s learning history, biological makeup, and a variety of other variables were involved.
Additionally, as most people (nearly 94 percent!) experience unwanted, intrusive thoughts,
images, and urges, we cannot say that uncomfortable thoughts alone cause anxiety (e.g.,
Radomsky et al., 2014). Rather, it appears that how people interact with their thoughts and
other variables have a greater impact on whether they develop an anxiety-related problem
than the content of the thoughts themselves. This is the value of a contextual approach in
moving beyond simplistic reductionism toward broader analyses so that we can more effec-
tively predict and influence behavior.
This aspect can be tricky for people new to ACT, who are used to thinking in terms of
elemental realism and, particularly, mentalism. For example, people new to ACT sometimes
misunderstand the notion of “values” by taking a mentalistic view of it. In ACT, “values”
refer to qualities that are experienced through behavior—they are not “things” that one
discovers. There are no “authentic values” or structures in the mind that we can point to
and say, “There’s a value!” We’ll talk more about values in subsequent chapters.
Some readers may be saying to themselves, Do I really need to understand an entire phi-
losophy of science just to learn ACT? I haven’t had to do this for other evidence-based treatments.
I just want to learn how to do ACT-informed exposure! We feel your pain. We don’t expect
readers to be experts in FC by the end of this chapter.
That said, here’s an example of how some familiarity with FC can be helpful for the
ACT-informed exposure therapist in increasing therapist flexibility. When clients come to
treatment with anxiety-related fears that seem particularly unlikely to come true, the urge
to challenge the client or get caught up in a debate about the veracity of these fears can be
seductive. Even though nearly all therapists learn that debating clients is rarely productive,
it can be hard to resist taking the bait. Since FC doesn’t engage in debates about truth or
falsity of ideas, the ACT therapist is in a better position to sidestep debates about the truth
of client’s thoughts. Rather than disagreeing with a client about whether a particular
thought is right or wrong, a functional contextualist therapist may ask, “When you live your
life as if that thought were true, what happens?” This form of “ACT judo” allows the thera-
pist to sidestep “truth” and focus on the consequences of a client’s particular pattern of
behavior. As much as possible, the therapist tries to sidestep the evaluation of content and
instead focus on the function of it: is it useful to the client or not in context? We will go into
more detail about how to work through these strategies with clients in the next chapter.
Another benefit of having some grounding in FC is that it provides a pragmatic frame-
work for influencing client behavior. Clients often focus on trying to change the form of
their experiences (e.g., thoughts, feelings, and bodily sensations). Unsuccessful on their
own, they seek a therapist to teach them how to control their internal experiences (e.g.,
make painful thoughts and feelings go away). From an FC perspective, clinically relevant
behaviors are defined by function rather than form, and it’s important to pay attention to
the nuances of context. Within an FC approach, we use context to our advantage. Attempts
at trying to directly alter internal experiences (a.k.a. painful emotions) are viewed as less
fruitful (and often impossible) than attempts at changing the environment in which these
experiences occur. If a client is depressed, what changes can they make to their lives to have
a different experience? As the behavioral activation literature has taught us, because we
have more control over external behaviors (e.g., taking a walk, visiting with friends) than
we have over internal behaviors (e.g., uncomfortable thoughts and feelings), it’s generally
more effective to try to effect change with what we can control or influence (Kanter et al.,
2012). FC provides a framework for defining contexts in ways that help clinicians predict
and influence client behavior and help alleviate human suffering.
Psychological Flexibility
At the heart of the ACT model is a concept called “psychological flexibility.”
Psychological flexibility refers to the ability to stay in contact with uncomfortable thoughts,
feelings, and bodily sensations while taking action toward what’s meaningful and important
(i.e., values). In other words, doing what is most important to us even if it’s uncomfortable.
Psychological flexibility means we’re able to fully experience these moments of discomfort
while still focusing on what’s important in the moment—whether that is washing the dishes
or listening to our partner share about their difficult day at work.
What may sound fairly simple is actually hard to pull off, given that we tend to engage
in avoidance behaviors when we’re not fully present. In ACT, experiential avoidance (a.k.a.
the opposite of psychological flexibility) is defined as attempts to avoid or suppress threat-
ening thoughts, feelings, and bodily sensations in ways that inadvertently increase suffering
(Hayes, Wilson, Gifford, Follette, & Strohsal, 1996). Experiential avoidance is how many of
us naturally orient to our own experience because we are biologically disposed to avoid
pain, and it’s encoded into how we think (Hayes & Gifford, 1997). Consider how you may
casually brush away a fly that has landed on your arm without thinking about it. Avoidance
of physical discomfort is generally adaptive. If you place your hand on a burning pan, it
makes sense to move it away. Additionally, broad patterns of avoidance are evolutionarily
adaptive, as it’s better to err on the side of perceiving danger where there was no danger
than in not perceiving danger where there is danger. If you think you see a predator on the
horizon, it’s more adaptive to assume you’re right and turn around than to assume you’re
mistaken and risk being attacked. In sum, it’s better to experience false positives than false
negatives. We might imagine that ancestors of ours who were less cautious were the ones
who succumbed to danger (i.e., died horrifically), and in this way we can see how anxiety
has been passed along the generations as an adaptive trait. The problem is, we naturally
extend these avoidance strategies to internal experiences such as unwanted thoughts, emo-
tions, and bodily sensations. Skinner (1965) called these inner experiences “private events,”
as they are “private” in the sense that they’re not directly observable by others.
Strategies aimed at avoiding uncomfortable private events often create more problems
than they solve, even if we may not recognize it. For example, we may prioritize feeling less
discomfort at the expense of pursuing a way of living that is meaningful to us. When we
worry, ruminate, or try to suppress or avoid uncomfortable thoughts and emotions, it can
backfire and make those uncomfortable experiences worse (Wenzlaff & Wegner, 2000)!
This is the pickle of anxiety disorders: being trapped in this futile battle with anxiety that
we think is winnable but that winds up getting us more and more stuck over time. Increasing
psychological flexibility is helpful in getting out of this jam, as one increases awareness of
the consequences of avoidance behaviors and reorients to pursuing what matters most.
One method of increasing psychological flexibility in ACT-informed exposure is helping
clients be more in contact with the contingencies of their behavior. Fundamental in operant
conditioning (chapter 2), contingency is the relationship between a particular stimulus (i.e.,
discriminative stimulus) and its consequence. Many of our behaviors are shaped through
contingencies or direct learning. If I do this, that happens. However, not all our behaviors
are shaped through contact with contingencies (i.e., through direct experience). We call
this “rule-governed behavior,” behavior that’s influenced by verbal rules rather than direct
contingencies. It’s the opposite of contingency-shaped behavior. Rule-governed behavior is
extremely useful in many situations, as life would be very painful and dangerous if we only
learned through contingency-shaped behavior. Consider prehistoric people learning which
berries were edible and which were poisonous. It saves time and lives if an elder can warn
us, “Don’t eat that one! You’ll get sick and die!” The benefit of rule-governed behavior is
that we don’t need direct experience of eating a poisonous berry to learn to avoid it. Suppose,
though, that the elder is wrong, and the berries they pointed to are not poisonous, that the
elder mistook an edible berry for a poisonous one. In that case, we might never know they
were safe to eat because we were told they’re poisonous. We might even starve to death if
all we can find to eat are those berries that we were once told were poisonous. The dark side
of rule-governed behavior is that we may cling to verbal rules that don’t correspond to what
actually happens or is likely to happen. The rules we learn may not always be accurate or
they may work in one context and not another. Many of us grow up hearing messages that
we should be able to control thoughts and feelings. Consequently, we may attempt to push
away or suppress these experiences without thinking about it, rendering us less sensitive to
whether what we’re doing is working or not.
The issue of context in rule-governed behavior comes up a lot in working with people
with abuse histories. Behaviors that were helpful in surviving abusive homes, such as being
hypervigilant or not asking for what one wants, may be adaptive in those contexts and
maladaptive outside of them. Someone learns to be constantly alert to the possibility of a
threat and consider the wants of others at the expense of their own needs. When they con-
tinue these strategies throughout the rest of their life, at some point the person may find
they are no longer helpful.
In studies of people engaging in computer games, when one group of people are told the
rules of the game, they perform better than people who must figure out the rules using trial
and error. However, when the rules of the game change, the individuals who were never
given the rules in the first place are better able to adapt to the changes than the people who
were provided explicit rules about the game at the beginning. Instead, the people who were
provided explicit, verbal instructions about the rules of the games are more likely to keep
trying to apply these rules even when they no longer work (e.g., Hayes, Brownstein, Zettle,
Rosenfarb, & Korn, 1986). This is another problem with rule-governed behavior: it can
make us less sensitive to the consequences of our actions (i.e., contingencies). We keep
trying what should work even though it repeatedly doesn’t. When people struggle with
anxiety, they engage in all sorts of unhelpful rule-governed behavior. Many people attempt
to avoid or suppress anxiety-related thoughts, even though avoidance often increases the
intensity and frequency of these thoughts. People may even notice that avoidance makes
things worse; because they are so wedded to their rules, however, they may interpret their
worsening anxiety as signs they’re not trying hard enough or not following the rules cor-
rectly enough (i.e., they haven’t figured out the right ways to suppress anxiety). Avoidance
or negative reinforcement (see chapter 2) can strengthen rule-governed behavior even when
we’re aware of the harmful consequence of the behavior (Törneke, 2010). The awareness of
the futility of their actions may even increase their frustration: many anxiety clients know
what they’re doing doesn’t work—they just can’t stop, because the avoidance is so immedi-
ately reinforcing. Exposure is one method of undermining rule-governed behavior, because
it puts people in contact with the direct consequences of their actions.
In the subsequent clinical chapters, we will go into further detail about ACT’s psycho-
logical flexibility model, and how it may be broken down into six ACT processes.
Relational Frame Theory

A major reason we struggle with thoughts, feelings, and bodily sensations is due to the
role of language in human suffering. Relational frame theory (RFT) is a functional contex-
tualist account of language and cognition that builds upon the behavioral tradition of
Skinner and is rooted in evolution (Hayes, Barnes-Holmes, & Roche, 2001; Skinner, 1974;
Törneke, 2010). RFT is based upon basic science and is an advancement of behavioral
theory that underpins contextual behavioral science.
If you thought functional contextualism was technical, RFT is about as technical as
one can get in the ACT world! For the average clinician, an understanding of RFT is not
necessary to becoming a skilled ACT therapist. However, many clinicians—including our-
selves—have found that a basic understanding of RFT can help fine-tune one’s approach to
ACT and ACT-informed exposure.
What’s a “relational frame”? It’s an essential feature of language and cognition—rela-
tional frames refer to higher-order cognitive processes by which we create associations. As
humans, we take these processes for granted, because they come so naturally. We easily
create associations between verbal sounds and objects (a “pen” can be a writing utensil or a
place to keep farm animals), visual stimuli and object (“P-E-N” spells pen), evaluations and
objects (I prefer pens with black ink over blue ink).
Relational framing allows us to learn with incredible speed and aptitude compared to
other animals. On the flip side, our ability to engage in relational framing opens us up to
limitless avenues of pain—in every single waking moment. We hear a song we haven’t lis-
tened to since high school, and it instantly triggers an embarrassing memory from that
time. Maybe just reading the previous sentence brought up an embarrassing memory for
you. Through the process of relational framing, we can always imagine someone smarter,
faster, stronger, better looking, and healthier than ourselves. Thank you, relational framing!
Even innocuous stimuli can cue painful memories, self-critical thoughts, and uncomfort-
able bodily sensations. Human suffering is often found where framing occurs.
Have you ever seen a dog with three legs? Perhaps you’ve even owned a dog with three
legs. As far as one can tell, dogs with three legs seem to be just as content as dogs with four
legs. They wag their tails, hop around, and seek pets and scratches from their people. Here’s
what dogs with three legs don’t seem to do: they don’t endlessly ruminate about how much
better their lives would be if they still had that fourth leg; they don’t imagine their owners
would prefer a dog with four legs; they don’t angle their bodies to obscure the missing leg
from the view of others. Dogs with three legs don’t seem to demonstrate any outward angst
about their appearance and abilities. They don’t wring their little paws about how much
better their life would be with four legs.
To return to anxiety disorders, relational framing allows people who’ve experienced
trauma to re-experience functions of the trauma. This can occur due to associations with
external reminders of the trauma as well as thoughts, images, and bodily sensations. The
flipside of this is that because relational framing allows humans to contact painful experi-
ences at any time, it also allows therapists to treat these experiences with exposure therapy.
From a functionalist contextualist perspective, exposure is one method for evoking uncom-
fortable inner stimuli to create a context for altering the function of the stimuli in a manner
consistent with third wave approaches.
Although understanding RFT is not absolutely necessary for doing ACT-informed
exposure, it may help ACT-informed therapists come up with outside-the-box ideas for
exposure exercises. For example, many anxiety clients struggle with self-criticism. According
to RFT, we may reduce suffering by altering or transforming the function of language via
changing its context. For example, saying the thought I’m a loser aloud and in a silly voice
is one context that can transform the function of those words. Heard in a silly voice, the
words function differently and take on a new set of more humorous, absurd qualities. Singing
a thought is another way to bring a lighter verbal context to thoughts. Writing self-critical
thoughts down on notecards also changes the context in which the thoughts are experi-
enced. A client might write down the most horrible thoughts on note cards in crayon, or
they might decorate these thoughts with flowers, smiley faces, or anything that brings some
levity. After repeated practice, when the client experiences a thought such as I’m a loser
during daily life, they might remember the silly voice they sung it in or how they had drawn
a flower sprouting out of the “l” and a smiley face in the “o” on a notecard. If a client is used
to engaging in experiential avoidance in response to self-critical thinking, you might have
the client record themselves reading a list of their most common self-critical thoughts.
When listening to the recording, the client can practice being present with whatever emo-
tions show up when they experience these thoughts to increase flexible responding. The
client learns that when they allow themselves to fully experience emotions such as shame
or guilt, the thoughts start to seem less compelling and may even quickly pass.
In sum, an understanding of RFT provides a framework for understanding exposure
and may help clinicians come up with novel ideas for exposure exercises. In a later section
in this chapter, we’ll return to the topic of how FC and RFT informs ACT-informed expo-
sure in ways that may be different from first and second wave approaches.
Clarifying Processes of Change in Exposure

Let’s return to ACT and the third wave of CBT. The idea of a third wave was initially con-
troversial and not everyone agreed that a third wave represented anything novel (e.g.,
Hofmann & Asmundson, 2008). Even now, many therapists and researchers are perfectly
happy with first- and second-wave treatments, which remain effective. Without an under-
standing of FC, the division between ACT and traditional CBT can be fuzzy and appear
superficial.
As there was initially some skepticism in cognitive-behavioral circles that ACT had
anything new to offer CBT (e.g., Arch & Craske, 2008; Hofmann & Asmundson, 2008),
and that ACT was little more than a repackaging of CBT, early studies of ACT for OCD
deliberately left out exposure to demonstrate that ACT had a novel approach to OCD
(Twohig at al., 2010). If exposure were included, critics could (rightly so) attribute any treat-
ment outcomes to the effects of exposure. As more studies supported that ACT did offer
something unique to CBT (e.g., Forman, Herbert, Moitra, Yeomans, & Gellar, 2007), ACT
gained greater acceptance within cognitive behavioral circles. Researchers began compar-
ing ACT-informed exposure against traditional exposure (based on emotional processing
theory—see chapter 2), and results demonstrated that ACT generally performs as well as
traditional exposure for anxiety disorders (e.g., Arch et al., 2012; Craske, Niles, et al., 2014;
Twohig et al., 2018). Reviews of these studies have concluded that ACT with and without
exposure is an effective treatment on par with CBT for many anxiety disorders and obses-
sive-compulsive and related disorders (Bluett, Homan, Morrison, Levin, & Twohig, 2014;
Landy, Schneider, & Arch, 2015). Studies comparing ACT to CBT have also found that
clients in ACT-informed exposure may experience additional improvements in symptom
severity and psychological flexibility between the end of treatment and a follow-up several
months later, whereas those in CBT simply maintained gains at follow-up (Arch, Eifert, et
al., 2012; Craske, Niles, et al., 2014). Additionally, it’s been argued that the ACT notion of
acceptance or willingness is an important predictor of change in exposure—more so than
habituation (Reid et al., 2017). Proponents of traditional exposure began to acknowledge
that ACT “greatly adds to our clinical understanding and to our arsenal of techniques”
(Grayson, 2013, p. 208). CBT even absorbed concepts and interventions associated with
ACT and third-wave approaches such as mindfulness, values, and acceptance (Hayes &
Hofmann, 2017), as ACT processes are not completely unique to ACT treatment and
appear useful in understanding processes of change in first- and second-wave approaches to
anxiety (Arch, Wolitzky-Taylor et al., 2012; Reid et al., 2017; Twohig et al., 2018; Wolitzky-
Taylor, Arch, Rosenfield, & Craske, 2012).
Because of its emphasis on increasing psychological flexibility, ACT-informed exposure
may be more versatile in its application than traditional exposure. For example, Abramowitz
and Jacoby (2014) argue that, because second-wave exposure is based on a fear-anxiety
model, it’s not an appropriate intervention for problems that aren’t rooted in fear-anxiety
such as body-focused repetitive behavior (e.g., hair pulling, skin picking). By contrast, ACT-
informed exposure may be applied more broadly to issues where there is a narrowing of
behavioral repertories (e.g., B. L. Thompson, in press).
Overall, the influence of ACT and third-wave approaches on traditional CBT has
expanded our understanding of how CBT works and has also reoriented CBT from a diag-
nosis-specific approach toward a more process-based approach (Hofmann & Hayes, 2019).
Consequently, there is value in understanding ACT concepts even in the use of traditional
exposure because ACT and other third-wave approaches elucidate processes of change that
are relevant across third- and second-wave treatments.
An ACT Understanding of Exposure

As noted in chapter 2, exposure as an intervention has been around for several decades
and has survived many theoretical models explaining its mechanisms of change. For the
past thirty years, the dominant model of exposure has been emotional processing theory
(EPT; Foa & Kozak, 1986) based on the pioneering work of Dr. Edna Foa. The EPT model,
with its emphasis on reductions in distress through habituation, has been so influential that
for many exposure therapists EPT is synonymous with exposure.
Instead of habituation, the emphasis in exposure within the ACT psychological flexi-
bility model is on expanding behavioral repertoires when in contact with stimuli that typi-
cally narrow behavior. Because of the broad emphasis in ACT on remaining in contact with
stimuli one usually tries to avoid, even ACT without deliberate exposure has been called an
exposure-based treatment (Hayes et al., 2012). Both proponents of ACT and proponents of
traditional models of exposure have suggested that acceptance is a form of exposure in that
it is about changing one’s contextual relationship with discomfort to increase flexible
responding (e.g., Grayson, 2013; Hayes et al., 2012). One subtle distinction is that for tradi-
tional exposure therapists, the goal of acceptance is symptom reduction. For ACT-informed
exposure therapists, the goal of acceptance is psychological flexibility, from which symptom
reduction may be a by-product or side effect.
From an ACT and RFT perspective, it is imprecise to say that the goal of exposure is
to increase psychological flexibility in the presence of an external trigger; instead, the goal
is to increase psychological flexibility while in contact with private events that may occur
in the presence of external stimuli (Dymond & Roche, 2009; Friman, Hayes, & Wilson,
1998). Any external stimuli are used to cue relevant private events. This may seem like
we’re splitting hairs, but it’s a helpful distinction to make, as we want to emphasize that the
goal of ACT-informed exposure is to work with thoughts, feelings, and bodily sensations.
This view is not completely inconsistent with traditional exposure. For example, traditional
exposure therapies make use of imaginal exposure to thoughts and feelings in the form of
talking through traumatic memories or writing out scripts describing a feared scenario
coming true. However, ACT places a particularly strong emphasis on targeting the function
of these private events (Twohig & Smith, 2015). To reiterate in a way that ties everything
together: the emphasis in ACT-informed exposure is altering the function of private events
that may be contextually cued by external stimuli to increase behavioral repertoires in the
presence of thoughts, feelings, and bodily sensations that typically narrow repertoires.
What about the de-emphasis on symptom reduction in ACT? Don’t clients want their
therapists to promise them symptom reduction? How the heck do ACT-informed exposure
therapists get clients on board with treatment by promising them expansion of behavioral
repertoires instead? Sometimes the de-emphasis on symptom reduction in ACT can create
a poker-faced standoff between the ACT therapist and client. The ACT-informed therapist
assures clients that they may benefit from an ACT approach while simultaneously discour-
aging the client’s desire for symptom reduction. What clients must learn is that a heavy-
handed and rule-governed approach to feeling better is likely to result in more suffering
through misguided attempts to suppress uncomfortable private events. This lesson isn’t
completely new to traditional exposure therapists, who’ve long known that clients are
unlikely to benefit from exposure when they try to “just get through it” without remaining
open and present with their experience. What ACT offers is a framework for and array of
metaphors and experiential exercises with which to train and orient clients to the psycho-
logical flexibility model. For therapists, we believe that ACT offers a process-based approach
and expanded terminology that may also facilitate greater therapist flexibility in conducting
exposure. In sum, with its reservoir of metaphors, experiential exercises, philosophy of
science, and processes linked to behavior change, ACT offers an expanded tool kit to the
exposure therapist and client alike.
Conclusion
Functional contextualism, a philosophy of science foundational for ACT, offers a frame-
work for the prediction and influence of behavior that is philosophically distinct from more
mechanistic (elemental realism) and mentalistic approaches to understanding human
behavior that pervade much of psychological thought. Although grounded in classical and
operant conditioning, ACT also draws from relational frame theory, a post-Skinnerian
understanding of language and cognition which takes a more contextual approach to suf-
fering than theories rooted in classical and operant conditioning such as EPT. With its
contextualist roots, ACT is part of a “third wave” of cognitive behavioral treatments that
emphasize changing how we relate to thoughts, feelings, and bodily sensations rather than
changing the internal experiences themselves. As a result, ACT-informed exposure differs
from traditional exposure (based on EPT) because ACT does not emphasize habituation or
reduction in discomfort; instead, ACT-informed exposure focuses on increasing psychologi-

cal flexibility through the expansion of behavioral repertoires while remaining in contact
with thoughts, feelings, and bodily sensations that tend to constrict flexible responding.
The next chapter provides a foundation for understanding exposure from an ACT
context. We’ll walk through how to gradually orient clients to the ACT model and prepare
them for ACT-informed exposure.
CLINICAL APPLICATION
ACT-Informed
Exposure in Practice
CHAPTER 4
What the Therapist Needs to Know
From an ACT perspective, exposure is “organized presentation of previously repertoire-

narrowing stimuli in a context designed to ensure repertoire expansion” (Hayes et al., 2012,
p. 284). Said more simply, in ACT-informed exposure, clients practice strengthening psy-
chological flexibility while in contact with stimuli that tend to restrict flexible responding
while learning to connect with what is important to them.
In all fairness, if one were to poll traditional exposure therapists, it’s unlikely many
would disagree with the ACT definition. In our experience in presenting on ACT to tradi-
tional exposure therapists, they see what they do reflected in ACT. They want their clients
to engage in new behaviors and to do things they care about. Moscovitch and colleagues
(2009) suggest that the main difference between traditional and acceptance-based expo-
sure is the “relative emphasis on the process of managing internal experiences” (p. 473).
While emotional acceptance is important in traditional exposure, its emphasis is less
explicit than it is in third-wave approaches such as ACT.
We present ACT-informed exposure with the aim of creating a bridge between ACT
and traditional exposure therapists. We believe traditional CBT and ACT therapists are
more alike than different in their aims. Both value evidence-based therapy and use research
to guide treatment. We want to be clear that we do not believe traditional exposure thera-
pists can simply call what they are doing ACT—“I’ve been doing ACT-informed exposure
all along without realizing it!” As we note in chapter 1, we believe learning ACT, like any
treatment model, requires discipline, and ACT’s grounding in a functional contextualist
philosophy of science (as described in chapter 3) brings a distinctive flavor to ACT-informed
exposure. It’s our aim to present ACT-informed exposure in ways that are accessible to
traditional exposure therapists and to acknowledge common ground.
Clarifying Therapist Assumptions in

ACT-Informed Exposure
Before we focus on how to create an ACT context for exposure with clients, we want to
explore the lenses through which an ACT therapist may view exposure. As ACT is a
process-based model, there’s no uniform protocol with which to conduct ACT-informed

exposure. Ours is just one way of conceptualizing ACT-informed exposure while remaining
within the boundaries of the ACT model. Other ACT-informed exposure therapists may do
things a little differently, and readers may develop their own innovations in using ACT-
informed exposure while remaining consistent with the ACT model.
We’ll start by clarifying the relationship between psychological flexibility and exposure.
As we have mentioned in prior chapters, psychological flexibility involves the ability to
remain present, while in contact with discomfort, in order to engage in deliberate action
toward meaningful life directions. The importance of learning to be present with discom-
fort without trying to alter or change one’s experience of discomfort—and the de-emphasis
on symptom reduction—can be difficult for clients to understand. They want to feel better,
and they want to be reassured by their therapists that they will feel less anxious. By con-
trast, traditional exposure promises symptom reduction, which is a much easier sell.
Additionally, ACT concepts such as acceptance or willingness and values are very nuanced,
making them tricky for many clients—and many therapists, too, if we’re being honest—to
grasp. Both require some experiential understanding.
We’ve come across ACT treatment manuals that recommend delaying exposure until
clients understand the ACT model and ACT concepts such as willingness. In our view,
though, exposure in an ACT context is simply another ACT experiential exercise that can
help orient clients to the ACT model. Exposure offers an advantage over traditional ACT
experiential exercises in its focus on repetition. Through repetition of specific exposure
exercises conducted in a variety of contexts, clients have greater opportunity to experience
ACT processes and practice psychological flexibility when in contact with previously reper-
toire-narrowing stimuli.
In short, if clients don’t understand ACT concepts such as willingness, then exposure is
a great way for them to contact ACT processes experientially. In our experience, it’s common
for clients to have an epiphany after several sessions of exposure work: “Now I get what
you’ve been saying! You’ve been saying it all this time, but I just kept thinking my anxiety
would go away. I get what you mean by willingness—if I let go of my desire to control
anxiety and stay present with it, the consequences are not as catastrophic as my mind says
they will be, and my anxiety doesn’t have to stop me from doing what I want to do.”
Having defined our assumptions, we will focus the remainder of this chapter on under-
standing core ACT processes in exposure therapy.
Creative Hopelessness as Functional Analysis

“Creative hopelessness” is an unfortunately named process in ACT that often frightens
new therapists: “ ‘Creative?’—great, I’m on board!—um, ah, what’s this about ‘hope…less…
ness?’ ” During trainings, we’ve witnessed mention of creative hopelessness evoke nervous
What the Therapist Needs to Know43
laughter among therapists. “Surely, I’m not going to make my clients hopeless!” they stutter,
looking to the ACT trainers to reassure them. In practice, creative hopelessness is not nec-
essarily as scary as it sounds, and it can be very powerful for clients.
Creative hopelessness is a process by which clients come to more clearly perceive and
acknowledge how control strategies (e.g., control of thoughts, feelings, bodily sensations)
are not working for them. This, in turn, opens them up to trying something new (e.g.,
acceptance). Put more simply, it’s hard to start to feel better until we stop actively doing
things that make us feel worse.
Therapists trained in behavior therapy may notice that creative hopelessness involves a
form of functional analysis. Functional analysis is about examining stimuli that may be
associated with problematic client behavior and their function in order to identify the
causes of the behavior you’re trying to change (see Ramnerö & Törneke, 2008, for an intro-
duction). Through functional analysis, therapists explore with clients the antecedents,
avoidance behaviors, and the consequences of their avoidance behaviors, as well as the
function of their thoughts, feelings, and bodily sensations (i.e., private events).
From an ACT perspective, rigid attempts to control anxiety create more problems than
the anxiety itself. We discussed in chapter 2 how avoidance tends to make things worse. In
the literature on thought suppression (e.g., Wenzlaff & Wegner, 2000), for example,
researchers have demonstrated that suppressing uncomfortable private events tends to
increase the frequency and intensity of what we’re trying to suppress. Trying not to think of
particular thoughts actually makes them more likely to occur. Another problem is that
when clients try to control anxiety, they lose contact with a variety of forms of social rein-
forcement—because that “control” often means withdrawing from activity. I can “control”
social anxiety by staying home; however, I lose the reinforcement of human relationships.
Often these control strategies are forms of rule-governed behavior in which clients have
formulated rigid ideas about what they believe should work. A problem with rule-governed
behavior is that it makes us less sensitive to contingencies. Because many people believe
they “should” be able to control their anxiety, they may not perceive the consequences of
their actions or simply conclude they’re just not trying hard enough to control their anxiety.
Through creative hopelessness, clients learn to understand how their attempts to avoid,
manipulate, or control uncomfortable inner private events are ineffective in the long term
(and usually the short term too). This is the “hopelessness” part: what clients are doing to
manage their anxiety is not working and may be making it worse. Their attempts to control
anxiety backfire.
Creative hopelessness in ACT tends to be more experiential than traditional functional
analysis. Traditional functional analysis may be done verbally or through use of worksheets.
By contrast, ACT therapists may use metaphors and experiential exercises to help clients
connect experientially with how their attempts to avoid, alter, and distract from uncomfort-
able private events result in worsening anxiety.
Although it can be intense, the message of creative hopelessness can be empowering to

clients. Many clients believe they’ve not been trying hard enough to make their anxiety go
away or that they’ve been using the wrong avoidance strategies. The message of creative
hopelessness is that clients’ Herculean efforts to avoid their anxiety are all doomed to fail
and that it’s not for lack of trying. While for some clients, the idea of letting go of attempts
to suppress or alter inner experiences is terrifying, for others, it’s a relief, because it illumi-
nates something that they had already intuited but needed some help articulating.
Beginning the process of creative hopelessness may be as simple as asking a client,
“What do you do when anxiety shows up?” Clients may describe a variety of avoidance
behaviors. They may cancel plans, spend hours worrying, or engage in actions that waste
time when they could be doing more important or meaningful things.
The therapist may then ask clients to assess the impact of their strategies: “What
happens after you do this? How effective are these strategies?” In our experience, clients
with anxiety are generally able to see that what they’re doing isn’t working. When asked
directly about the effectiveness of their strategies in managing anxiety, they may even laugh
and say, “They’re not effective!” But even with these clients, a little creative hopelessness
remains useful in helping them learn to observe in real time how their efforts backfire. It’s
one thing for clients to understand abstractly that their efforts to avoid anxiety don’t work,
but it’s even more helpful for clients to observe and contact their experience in the moment.
For example, everyone reading this book probably has some experience with how procras-
tination is not helpful. However, we don’t always pay attention to the way our chests may
tighten when we open a browser tab instead of the document we should be working on or
the way our shoulders might relax when we finally begin typing up that report. Making
direct contact with the costs of avoidance can be helpful in augmenting client motivation
to make changes and engage in the arduous work of exposure treatment. For other clients,
the process of recognizing their current helplessness in the face of their anxiety can be
humbling. Many clients come to treatment hoping their therapist will teach them a more
effective way to escape suffering through reasoning and coping strategies and to sidestep
discomfort without having to feel it. And when they realize that these strategies don’t work,
it may feel like a punch to the gut.
Of course, because the long-term impacts of some avoidance strategies are not always
clear, some clients may claim their strategies are helpful. They may insist that seeking reas-
surance from others or engaging in internet research is effective because occasionally they
feel relief. They may even be correct. Raise your hand if you have ever looked up a medical
symptom and learned it was likely nothing to worry about. Some strategies work occasion-
ally. If a client is seeking treatment, however, it’s because their strategies to manage anxiety
either are not working overall or have other unintended consequences (e.g., they’re incred-
ibly time-consuming). It can be useful to probe these strategies in more detail. How long
does the experience of relief last? Weeks, days, hours? Only a few seconds?
Some clients may dig in and defend their strategies, insisting that if they did not engage
in these behaviors, they would become so overwhelmed by their anxiety they would not be
able to cope. This can be a sign that creative hopelessness may be trickier for a particular
client and that their psychological flexibility may be particularly low. When clients are
wedded to their avoidance behaviors, the therapist may want to proceed through ACT and
exposure more slowly. These clients may have difficulty understanding or may express resis-
tance to core ACT concepts such as willingness, and they may have a lower capacity to
observe and put words to their inner experiences.
If a client is particularly low in psychological flexibility, creativeness hopelessness may
just fall flat. These clients are often largely unaware of internal experiences such as thoughts,
feelings, and bodily sensations, even when you ask directly about them. They may have dif-
ficulty observing when they feel anxiety or shame. Some of these clients can label their
emotions vaguely but are completely out of touch with their bodies.
We all vary in terms of our ability to put words to private events. Most people are “good
enough” at it to engage in therapy, but when clients struggle with perceiving and labeling
internal experiences, it’s often difficult for them to engage in creative hopelessness, because
they are so out of touch with their actual experience (e.g., contingencies). For one client
with whom one of us worked, when asked where in her body she felt anxiety, she would say,
“My head.” When other areas of the body were suggested (e.g., tightness in chest? shoulders
or neck? stomach?), she would angrily deny she felt anything in her body. It was because this
client could not discriminate the tension in her body, she didn’t know how or where to look
for signs of bodily discomfort. If she was asked to describe the signs she was anxious, she
would become more frustrated: “I just know!” With these clients, training discrimination of
thoughts, feelings, and bodily sensations may be crucial before moving into creative
hopelessness.
Ultimately, leading clients through at least one creative hopelessness metaphor early in
treatment can give you a common language to describe avoidance throughout treatment.
When you are aware the client is engaging in avoidance behavior, you might simply say, “It
sounds like you’re pulling on the finger traps” (the finger traps exercise) [or “…you’re
digging” (the child-in-the-hole exercise) or “…you’re pulling on the rope” (tug-of-war with
the anxiety monster)] to remind them to pay attention when they’re struggling with their
anxiety (see Eifert & Forsyth, 2005, for more on these exercises, although these “classic
ACT” exercises may be found in numerous sources). That said, although an ACT therapist
may often begin treatment with creative hopelessness, creative hopelessness may be inter-
woven throughout treatment to the degree clients have difficulty letting go of control strat-
egies. We offer examples in chapter 9 illustrating the importance of returning to creative
hopelessness when necessary.
As we noted earlier about how exposure can help orient clients to the ACT model,
exposure may also help clients contact the cost of experiential avoidance. Clients may be
surprised at what happens when they remain in contact with experiences they usually try
to avoid or suppress, and consequently, they may be more receptive to letting go of their
efforts to control.
Here are two important points to consider about creative hopelessness:
• The effectiveness of creative hopelessness is contingent upon client capacity to observe

and put their experience into words. If a client low in psychological flexibility cannot
observe and discriminate how their efforts at avoiding anxiety backfire, you may
need to focus on awareness training before engaging in creative hopelessness.
• A client may understand intellectually that their avoidance behaviors are ineffective;
however, being able to observe examples of when this happens in the moment is even
more important. Even if a client tells you that they are aware of the unworkability of
their actions, you should help to strengthen their ability to observe examples of this
happening in the present moment. Tracking forms are one way to increase client
awareness, and talking through a recent incident is another (e.g., “And then what
happened, what thoughts were coming up for you? And what were you feeling in
your body?”).
Discriminating ACT Hexaflex Processes in

Client Behavior
Through creative hopelessness, we can begin to assess psychological flexibility. Within the
ACT literature, psychological flexibility has been described as a single, unitary process, and
it has also been broken down into smaller sub-processes. The most common breakdown is
the six processes of the ACT hexaflex:
• Contact with the present moment
• Willingness to stay in contact with discomfort (e.g., feelings, bodily sensations)
• Defusion, or the ability to be aware of thoughts with some distance without neces-
sarily believing in their literal reality
• Self-as-context, or the ability to flexibly shift between perspectives rather than

fusing with one or another self-concept
• Values, or meaningful life directions in which we may choose to orient our

behavior
• Committed action, or taking action based on your values, rather than avoiding
uncomfortable experiences like anxiety
Of course, there are many ways to cut the pie. For example, some writers have con-
densed the traditional six ACT hexaflex process into three (e.g., Harris, 2009; Strosahl,
Robinson, & Gustavsson, 2012). We decided to stick with the traditional six processes, as
we feel the distinctions between them are relevant in understanding and illuminating client
experiences during exposure. Please note, however, that these are nontechnical, middle-
level terms that do not have the same precision as some of the behavioral terms we intro-
duced in chapters 2 and 3.
Also note that ACT processes are not mutually exclusive, as they overlap to varying
degrees. When he was first learning ACT, one of us (Brian T) tried to create a table orga-
nizing common ACT experiential exercises and metaphors according to which core ACT
hexaflex process each exercise targeted. He quickly became overwhelmed by the task. Not
only did many exercises target more than one process, but he found inconsistencies in how
specific exercises were categorized among the ACT books he consulted! What one source
labelled a defusion exercise another categorized as a willingness exercise. Consequently, we
want to be explicit here that the relationships among these processes are much messier than
they might appear. Additionally, using the same exercises may impact different processes
from client to client. For example, in repeatedly reading a triggering article, one client may
focus on experiencing the tightness in their chest and butterflies in their stomach (e.g.,
willingness) while another may observe their thoughts (e.g., defusion, self-as-context).
Thus, it’s important to emphasize that it’s not cut and dry when you target specific processes
via experiential exercises. We offer examples of this in our case examples in chapter 9. The
following sections will describe how exposure methods may impact ACT processes.
Exposure as Committed Action

Committed action refers to engaging in behaviors linked to what is important to us. In
ACT-informed exposure, exposure exercises are committed action. Additionally, you may
identify other non-exposure forms of committed action in the service of treatment goals
during ACT-informed exposure. If a client struggles with activities of daily living, for
instance, they may commit to brushing their teeth twice daily or showering every other day
between sessions. If they are unhappy in their job, they may commit to revising their resume,
applying to new jobs, talking to people who have careers that interest them, or researching
graduate programs. You may end sessions by offering clients the opportunity to identify
committed actions with, “Is there anything you want to commit to doing between now and
the next time we meet?” This allows clients an opportunity to make a public commitment
toward behavior change, increasing the likelihood of follow-through.
Exposure as Contact with the Present Moment

People with anxiety spend a lot of time in their heads worrying, catastrophizing, plan-
ning, and judging. As a result, they’re often not in touch with their experience and can
seem distant or aloof to people around them. In short, they’re not in contact with the
present moment. Exposure is one means to address this shortcoming. Even in traditional
exposure, therapists may ask clients to describe their experiences during and after exposure:
“What are you thinking?” “What are you noticing in your body?” “What emotions are
present?” “What is happening right now?” These questions help direct clients to focusing on
their immediate experience. We know from research that simply labeling an emotion or
experience during exposure improves outcomes (e.g., Niles, Craske, Lieberman, & Hur,
2015). Being present is crucial in ACT-informed exposure because we want clients to
observe what really happens—not what they think is going to happen (e.g., contact contin-
gencies and weaken rule-governed behavior). If they’re not present, they may miss what
actually happens because they’re blinded by what they think will happen (e.g., rule-gov-
erned behavior).
Interestingly, many clients are pleasantly surprised when they actually pay attention to
their experience moment-to-moment. They’ve been so busy trying to avoid anxiety, they’ve
never really sat with and observed it. They may not have noticed bodily tension. They may
be unaware that much of the discomfort that preceded the exposure quickly dissipates or
that their anxiety does not spiral out of control as they predicted. As much time as clients
spend worrying, they tend to be poor predictors of their actual experience of anxiety. Being
in contact with the present moment allows clients to fully grasp the futility of escaping
anxiety, and consequently, this enhances their motivation to let go of urges to try to control
their experience. Through repeated exposure exercises, clients may that find their moment-
to-moment experience of anxiety feels manageable when they stay present with it, as they
are able to experience anxiety as uncomfortable sensations instead of the catastrophes their
minds predict.
Activity
Reflect on your own experience with this ACT process. Complete this exercise on a sheet
of paper or in a notebook.
If you have experience with exposure therapy, whether ACT-based or not, take a few
moments to reflect on signs of contact with the present moment that have shown up in
exposure exercises you’ve conducted. Consider comments clients have made during or
debriefing exposure that would suggest they contacted this process.
Exposure as Willingness
The only way to endure pain is to let it be painful.
—Zen master Shunryu Suzuki Roshi
Willingness involves remaining present with uncomfortable feelings and bodily sensa-
tions without trying to avoid or change them. In ACT, “acceptance” and “willingness” are
synonymous. We’ve chosen to use “willingness” as sometimes people misconstrue the word
“acceptance” as resignation, as a passive giving up. In ACT, willingness is a behavior, an
active choice we may make in the present moment. We want to emphasize that willingness
can only occur in the present. We cannot accept the future, we can only practice willing-
ness with our moment-to-moment experiences.
In our experience, willingness is a difficult concept for many clients to understand, and
clients may not fully grasp willingness until they have worked through multiple exposure
exercises. Because willingness is so important to exposure, we suggest that it’s the one core
ACT process that may be useful to teach to clients explicitly. We’ve included additional
information on willingness in the next chapter, chapter 5, as we feel it’s important to discuss
the nuances of willingness with clients to clarify any potential misunderstandings.
For those trained in traditional exposure, willingness offers a method for address-
ing covert forms of avoidance during exposure. These forms of avoidance include tensing
the body and trying to “get through” exposure exercises (e.g., low present-moment aware-
ness). Many clients are unaware of these behaviors or don’t discriminate them as important
to enough to mention. Since we know these behaviors can interfere with learning from
exposure, it’s important to monitor for signs of them. Willingness scores offer ACT thera-
pists a way to detect when a client may be trying to avoid or control private events.
For example, one of our clients feared stepping on discarded syringes whenever he left
his downtown apartment. He engaged in a daily exposure exercise of walking from his home
to his gym without compulsively looking down at the sidewalk for needles. After two weeks
of practice, he remained as fused with his fears. Looking at the forms he completed, the
therapist noticed the client consistently rated willingness during exposure a 5–6 on a scale
of 0 to 10 (“not willing” to “completely willing”). These middling willingness ratings cued
the therapist to the possibility that this client may have been engaging in some covert avoid-
ance behavior. In talking through the exposure with the client, the therapist asked about
the pace with which the client was walking and realized the client was walking too quickly
through the exposure. The client acknowledged that he would jump on and off curbs as he
engaged in a brisk walk toward his gym. We want to note that the client had been conscien-
tiously practicing the exposure and had not been aware he’d been engaging in this behavior
until the therapist brought it to his attention (a sign of low contact with the present moment).
The therapist recommended that the client slow down. They practiced walking at a slower,
deliberate pace in session. At the following session, the client reported that slowing his pace
had allowed him to increase willingness. He was able to be more present during his walk to
the gym while gently resisting urges to look for syringes on the ground. What’s more, during
a subsequent exposure exercise, this client spontaneously applied what he’d learned, delib-
erately slowing down during a work procedure he’d been rushing through. He noticed his
anxiety immediately felt more manageable when he was more present.
Through the concept of willingness, exposure therapists possess a shared vocabulary
through which to talk with their clients about more subtle forms of avoidance and to infer
when it may be happening (e.g., low willingness ratings) even when clients are not con-
scious of their behavior. For these reasons, we recommend teaching clients about willing-
ness. In chapter 9, we have a case example of how to use willingness ratings to adjust
exposure exercises to where clients are.
Activity
Reflect on your own experience with this ACT process. Respond to these prompts on a
sheet of paper or in a notebook.
• If you have experience with exposure therapy, whether ACT-based or not,

take a few moments to reflect on signs of willingness that have shown up in
exposure exercises you’ve conducted. Consider comments clients have
made during or debriefing exposure that would suggest they contacted
with this process.
• Take a few moments and write down forms of covert avoidance you’ve wit-
nessed in clients practicing exposure. Reflect on how you might use the
concept of willingness to address these avoidance behaviors.
Exposure as Cognitive Defusion

Cognitive defusion refers to being aware of thoughts without believing in the literal
reality of them (i.e., the opposite of cognitive fusion). When we observe ourselves experi-
encing self-critical thoughts (Loser!) without buying into what our minds are selling, we’re
practicing defusion. The philosopher Michel de Montaigne nailed the experience of fusing
with worry when he wrote, “My life has been full of terrible misfortunes, most of which
never happened.”
A classic defusion exercise involves repeating a word aloud for forty-five seconds until
the word begins to lose meaning and dissolves into inchoate sounds. This exercise was first
documented over a hundred years ago by the psychologist Edward Titchener (1916), though
he did not call it “cognitive defusion.” A recent ACT study looked closely at what happens
during this defusion exercise (Masuda et al., 2009). The researchers asked participants to
choose a negative self-referential statement such as “I am stupid.” Participants then distilled

their statement into one word (e.g., “stupid”). They repeated the self-referential word aloud
for different durations and rated how they experienced the thought. The emotional discom-
fort triggered by the thought tended to decrease within three to ten seconds. The believ-
ability of the thoughts took a little longer, about twenty to thirty seconds.
The repetition of exposure provides many ways to practice defusion. Although more
complex than the recitation of a single word, repeatedly reading triggering articles or pas-
sages of text, reading imaginal scripts aloud, or watching brief videos on YouTube provide
opportunities for clients to experience defusion. It’s also true that defusion does not always
require repetition. Sometimes simply saying thoughts aloud is enough for clients to experi-
ence defusion. In creating imaginal scripts, for instance, some clients find that the writing
of the script is all that is necessary to defuse from fears (e.g., “I realized how unrealistic my
fears were when I tried to write them down.”). One client even burst out laughing when she
said aloud her fear that she would never find love again if her relationship with her current
partner ended.
Because defusion is often a simple matter of time and repetition, we recommend intro-
ducing clients to exposure through exercises that allow you to control more variables related
to the exposure. For example, if you provide clients a passage of text to read that is trigger-
ing to them, you and your client have control over the content. The text itself does not
change in the way, say driving conditions would during a driving exposure. If we read the
same words repeatedly and consistently, we will typically experience some distance from
what we read. As we become familiar with the text, we may start to notice other private
events that occur during the reading. This works especially well with clients who endorse
only partial buy-in or who are lower in psychological flexibility. Reading brief news articles
or watching a thirty-second video clip over and over again increases the likelihood that
clients will discriminate some change in their experience of the stimuli. Conversely, watch-
ing a two-hour movie or reading a twenty-page article may be too long and complex for
clients to experience defusion. Through consistent repetition of a basic exposure exercise,
clients are more likely to have the experience of Ah—now I get it!
Activity
Reflect on your own experience with this ACT process. Respond to this prompt on a
• If you have experience with exposure therapy, whether it is ACT-based or

not, take a few moments to reflect on signs of cognitive defusion that have
shown up in exposure exercises you have conducted. Consider comments
clients have made during or debriefing exposure that would suggest they
contacted with this process.
Exposure as Self-as-Context
Self-as-context (a.k.a. flexible perspective-taking) refers to an “I” from which we can
observe all experiences. It builds upon cognitive defusion in that it describes a perspective
from which one can defuse from the content of specific thoughts and observe the process
of thinking. Conversely, one cannot experience fused thinking from self-as-context. It
encompasses willingness in that we can observe and be present with uncomfortable feelings
and bodily sensations. From a place of self-as-context, we can observe the flow of thoughts,
emotions, and bodily sensations—an experience we may call “self-as-process.” We can also
take the perspective of other people, imagining how they may think or feel. As many clients
feel isolated in their pain and anxiety, this expansive perspective can help them feel con-
nected to the greater human experience and to realize that everyone struggles, engendering
compassion for themselves and others. This perspective has been compared to a way of
experiencing that’s trained in meditative spiritual traditions (Hayes, 1984). One way of
conveying this idea to clients is that they are “bigger than their anxiety”—that they can
experience anxiety while remaining present and engaged in the world around them.
In addition to the external world, we can observe the internal flow of our thoughts,
feelings, and bodily sensations. From an ACT perspective, flexible perspective-taking is a
form of verbal behavior that may be strengthened in the process of the weakening of verbal
rules (e.g., “I can’t tolerate anxiety”) through awareness training (e.g., Hayes, 1984).
The repetition of exposure provides an incredible opportunity for clients to experience
self-as-context. Imagine watching a scene from a movie repeatedly. During our first viewing,
we may be engrossed in the story of it, trying to figure out what’s going on. With repeated
watching, we start to notice other things that are happening. We hear the swell of the score
or ambient background noises. We may notice the transition of one edit to the next or
become aware that a scene happens in one continuous take. We can marvel at the subtlety
in the actors’ performances. Repetition frees us from the focus on the story because we already
know what happens—now we can observe how it happens. The beauty of exposure is that
repetition does the job for you. There’s no need to try to explain self-as-context to clients. You
can train self-as-context through asking clients to describe what is happening during in-ses-
sion exposure (e.g., “What do you notice in your body?”) and through debriefing.
For example, when someone with health-related fears reads an article about cancer,
they are typically reading for reassurance. Do I have those symptoms? Am I similar or dif-
ferent to the people described in the article? Based on the statistics, what is my risk? It’s as
if their anxiety is reading the article. With repetition, clients expand their awareness. They
describe thoughts and bodily sensations in response to triggering or reassuring passages.
They start to notice nuances in the text they did not catch on initial readings. They may
become aware of the font on the page or the way the paragraphs are organized. As they
strengthen self-as-context, the article becomes “just an article” (i.e., it’s not a direct com-
mentary on their relative risks for the content described in it).
Self-as-context is contrasted with self-as-content, the conceptualized self from which

we may hold rigid views of ourselves (e.g., I’m OCD; I’m mentally ill). In ACT, who we are
depends on the context—there is no such thing as a “true self.” We’re constantly engaging
in the process of “selfing” (e.g., I am a parent, a therapist, a spouse). One study found that,
of all the ACT processes, self-as-content was most relevant to obsessive-compulsive symp-
toms, especially unacceptable thoughts and mental contamination (E. M. Thompson,
Brierley, Destrée, Albertella, & Fontenelle, 2022). This may reflect a tendency of people
with OCD to take their obsessions as a true reflection of who they are rather than as some-
what arbitrary products of their mind. Helping clients strengthen their ability to perceive
their experiences from self-as-context, rather than the more rigid self-as-content, can be
helpful in loosening client attachment to unhelpful stories they hold about themselves.
After a client who believes I’m too much of an anxious person to go dancing does indeed go
dancing, they realize that this identity is just an unhelpful series of words and thoughts that
does not have to dictate their choices in life.
This notion of multiple selves or “selfing” in ACT overlaps with other therapy tradi-
tions. For example, in many psychotherapies, the therapist may discuss parts or selves (e.g.,
the “anxious part,” the “hurt self”). In OCD treatment, it’s common for therapists to
encourage clients to anthropomorphize their OCD and refer to it as something separate,
such as “my OCD” (e.g., Yadin, Foa, & Lichner 2012). When working with children, the
child might give their OCD a name (Wagner, 2003). This allows therapists to ask self-as-
context relevant questions, such as “What does your OCD want you to do? What do you
want to do? Do you really want your OCD to call the shots for you?” This process helps
clients develop distance from thoughts and feelings and can lead to an expansion in one’s
sense of self.
As clients practice remaining in contact with anxiety-provoking stimuli through expo-
sure, they can practice stepping back from their experience of it: I am much bigger than my
anxiety. My anxiety does not define me. Clients learn to both observe their experience of
anxiety during exposure, as well as practice letting go of rigid identification with selves (e.g.,
My anxiety will overwhelm me.)
Activity

not, take a few moments to reflect on signs of self-as-context that have
shown up in exposure exercises you have conducted. Consider comments
clients have made during or debriefing exposure that would suggest they
contacted with this process.
Exposure as Values
Values in ACT refers to meaningful life directions toward which we may orient our
behavior. Values, as verbally constructed consequences, are also a form of rule following.
They reflect what we care about, what moves us, what we’re passionate about. Values
provide context for taking action toward doing difficult things and may be harnessed to
augment motivation. Contact with values allows us to, say, drive a friend to the airport at
five in the morning, when we’d rather be sleeping. There is evidence that values clarifica-
tion increases client motivation to engage in exposure work (e.g., Hebert, Flynn, Wilson, &
Kellum, 2021).
LeJeune and Luoma (2019) outline four qualities in values:
• Values are behaviors. They are actions—not abstract ideas. It is more accurate to
say that we engage in valuing when we contact values.
• Values are freely chosen. They reflect what’s actually important to us, not what we
think should be important or what we imagine others want of us.
• Values differ from goals in that we can always contact values (i.e., engage in
valuing), and there is no end point in values (e.g., being a good parent).
• Values are directions we move toward, not uncomfortable things we try to get away
from. For example, “not being anxious” is not an ACT-consistent framing of a
value.
Anxious clients may come into therapy with a range of different struggles with values
and valued living. Some may be very much in contact with what they value, whereas other
clients have been spending so much time and energy trying to avoid anxiety that they’ve
lost touch with what’s important to them.
Clients are in contact with their values; however, anxiety is a barrier in taking action
toward valued directions. This is the most common way values are incorporated into
treatment. For example, with social anxiety, panic disorder, and agoraphobia, clients often
avoid people. Values work might involve encouraging someone with social anxiety to make
plans with an old friend or try joining a new group or club, as opposed to letting their
anxiety dictate what they can and cannot do.
Clients are in contact with their values, actively take actions toward values, but anxiety
is interfering with their ability to be present and connect more fully with valued activi-
ties. These clients are often high achieving and disciplined. They tell you they are doing all
the things they want to be doing in their lives but derive little fulfillment from them. For
these clients, exposure is a way to clear the noise and clutter of anxiety to practice being
present during valued activities. Clients may want to practice approaching activities with
personally chosen and meaningful qualities such as curiosity, playfulness, or
open-heartedness.
Clients are not in contact with their values and struggle to identify wanting anything
other than alleviating their suffering. Clients who have difficulty identifying what they
value often have been struggling with intense anxiety over a long period of time (e.g., years),
having engaged in rigid patterns of avoidance, and have lost contact with what’s important
to them. Their behaviors are under aversive control to such a degree that their primary
concern is reduction in distress. They may experience even the idea of wanting something
larger as intensely painful. From an ACT perspective, this is not a problem. Engagement in
exposure may increase psychological flexibility to a degree that clients once again connect
with what is important. For these reasons, values are not a prerequisite to engaging in ACT-
informed exposure, as an increased focus on values may be aversive to these clients.
Regardless of the degree to which your client can connect with values, values work may be
integrated throughout treatment, even without using the word “values.”
Much has been written about using values to create a context for exposure (e.g., Twohig,
Abramowitz, et al., 2015), and what is written about typically focuses on working with the
first type of clients described above, clients who know what they want to be doing but are
not doing it. What has been less acknowledged is that exposure can indirectly facilitate
contact with values and increase confidence in values-driven behavior. For example, one
client who avoided freeway driving because of panic learned from repeated driving expo-
sures that he could accomplish non-exposure goals if he put forth consistent time and
effort. As a consequence of his exposure work, he began devoting long days toward improv-
ing his yard and looking more closely at needed home repairs he had neglected during the
ten years he’d been withdrawn from the world as a result of anxiety. Another client who was
making progress with exposure realized that she wanted to return to school to complete her
bachelor’s degree. Before even consulting her therapist, she had registered for classes with a
local college for the next term. In these ways, values may help orient clients toward expo-
sure, and exposure may help clients contact values.
Activity

not, take a few moments to reflect on signs of values that have shown up in
exposure exercises you’ve conducted. Consider comments clients have
made during or debriefing exposure that would suggest they connected
with values.
Client Misunderstandings About ACT

As therapists, all three of us authors love when treatment goes exactly as planned. We
introduce ACT exercises and metaphors that clients totally connect with, and these clients
say exactly what we want to hear—it feels great. We enjoy hearing ACT-consistent insights
from clients such as:
• “You’re right—trying to control my anxiety doesn’t work!”
• “My anxiety-related thoughts aren’t helpful at all!”
• “When I accept my thoughts and feelings, I stop struggling and feel free!”
As clinicians with full-time practices, however, we have plenty of experience with

clients who do not connect with ACT at all. Some clients see us because we identify as
ACT therapists. Many more clients seek us out because we are evidence-based therapists
who specialize in working with anxiety or because someone else referred them to us. They
just want someone to help them feel better.
In chapter 9, we provide case examples of the trial-and-error process of ACT-informed
exposure, and in chapter 10, we’ll provide more in-depth case examples of clients who do
not connect with ACT. For our purposes here, as you prepare clients for ACT-informed
exposure, we want to acknowledge that:
ACT concepts such as willingness can be tricky for clients

to understand.
ACT protocols typically offer rationales, metaphors, and experiential exercises to orient
clients toward the ACT model. This is very useful in preparing clients for ACT-informed
exposure. For some clients, however, no matter how many exercises and metaphors you give
them, they remain confused by ACT concepts.
In all fairness, though, many new ACT therapists are confused by ACT concepts! ACT
therapists debate the finer points of ACT processes on listservs and social media pages,
attend multiple workshops about ACT, and read ACT books and articles. There are entire
books for therapists devoted to cognitive defusion (Blackledge, 2015), and to values (LeJeune
& Luoma, 2019) alone! If ACT therapists must spend countless hours learning about ACT
processes, we can’t expect our clients will understand these processes after a handful of ses-
sions. Here’s our view of how to proceed when clients have a shaky grasp of ACT:
It’s sufficient for clients to “kind of” understand ACT. In our view, if clients are on board
with the treatment plan, it’s not a problem if clients demonstrate a shaky understanding of
ACT concepts. If you’ve tried multiple ACT exercises and discussed with clients the finer
points of an ACT approach to treatment, and you still have a sneaking suspicion they do
not quite understand ACT willingness or their understanding of values isn’t quite ACT
consistent, you might still proceed, trusting that over the course of their work with you,
there’ll be more opportunities for them to refine their understanding of ACT processes as
they experience them in action. So long as you, the therapist, have created a context for
ACT-informed exposure, and you remain on message, many clients will strengthen their
understanding of ACT through exposure. As we’ve emphasized, the repetition of exposure
is one of its greatest strengths. With every exposure exercise and every debriefing, therapists
have additional opportunities to help clients contact ACT processes and practice flexible
responding. ACT, by nature, is an experiential treatment: create the context for intellectual
understanding, focus on experience, and understanding will follow.
We do want to be clear that we’re not giving therapists carte blanche to be sloppy in
how they present ACT. We believe in the importance of a clear and ACT-consistent
message. Our view is that if therapists remain consistent in their messaging and roll with
clients’ imperfect understanding of ACT, many clients who may struggle with ACT con-
cepts will deepen their understanding through exposure. They may finally understand will-
ingness when they observe what happens when they openly engage in an exposure exercise,
even if they did so with hesitation. They may have the experience of thoughts being “just
thoughts” after a week of listening to a catastrophic imaginal script. With all their hard
work and countless hours devoted to exposure, clients may even have a more experiential
understanding ACT processes than many ACT therapists!
Many clients connect with an ACT approach. Some even seek out readings, podcasts,
and videos to learn more about ACT on their own. Yet we’ve also had clients who success-
fully graduate from treatment who (we suspect) still do not quite understand ACT, despite
all our best efforts. This is okay too.
Conclusion
In this chapter, you learned about ACT concepts that make up the psychological flexibility
model: committed action, present-moment awareness, acceptance or willingness, defusion,
self-as-context, and values. All of which are useful to understand, draw from, and strengthen
during the course of exposure therapy. Ultimately, our focus in this chapter’s discussion of
ACT theory and fundamentals is on the practical use of ACT to facilitate flexible exposure.
We caution against allowing a rigid approach to ACT orthodoxy to hinder or delay expo-
sure work. Given that treatment outcomes are comparable between ACT-informed and
traditional exposure (e.g., Arch, Eifert, et al., 2012), we do not consider it a treatment failure
if clients successfully complete exposure therapy and retain some non-ACT ideas (e.g.,
focus on symptom reduction).
In the next chapter, we will focus more on creating an ACT context for exposure work
with your clients, and in a subsequent chapter, we will also focus on common client misun-
derstanding about ACT.
CHAPTER 5
What the Client Needs to Know
Having laid down in the prior chapter foundational knowledge that’s important for thera-
pists to consider, our focus in this chapter is on helping you create a context for ACT-
informed exposure with clients. From the very first session, we can begin to acculturate
clients to the ACT model in indirect ways. In the worksheets and forms we give to clients
and through the language we use, we can help clients begin to understand their struggles
through an ACT lens. For example, we might refer to clients’ process of thinking as “your
mind,” rather than talking to them about what they thought: “What is your mind telling
you right now?” “Sounds like your mind can be pretty hard on you.” “What happens when
you listen to your mind in these situations?” If you’re new to ACT, these phrasings might
sound a bit strange. Through how we speak with clients, however, we can begin training
defusion and self-as-context in our language. Clients tend to intuitively grasp these phras-
ings and go along with it. In short, you can begin to introduce clients to the ACT model
from your first session and without even uttering the words “acceptance and commitment
therapy.” Let’s learn more about how.
Using Experiential Exercises to Orient Clients to

the ACT Model
The ACT model emphasizes the use of experiential exercises and metaphors to introduce
clients to and help them contact ACT processes through methods that deepen understand-
ing and learning. There’s even a book specifically dedicated to them, The Big Book of ACT
Metaphors (Stoddard & Afari, 2014). As there’s no shortage of ACT books on exercises and
metaphors—some readers may already have their favorites—we have chosen not to focus
on specific ones here. We highly recommend Eifert and Forsyth’s Acceptance and Commitment
Therapy for Anxiety Disorders (2005) as a great introduction to ACT metaphors, experien-
tial exercises, and worksheets tailored for people with anxiety. Instead of providing a list of
exercises, we’ll take a broader look at how ACT exercises can be used to prepare clients for
exposure.
Generally, when clients practice guided mindfulness exercises, they learn to observe
and put words to their experience and to remain in contact with uncomfortable private
events—all useful skills for exposure work. Other exercises may help clients to approach
emotions or interoceptive sensations they typically avoid, which can help train willingness.
In short, frontloading treatment with ACT metaphors and exercises helps to create a
context for ACT-informed exposure.
The use of experiential exercises and metaphors is also a form of ongoing assessment.
How do clients respond to ACT concepts? Some clients may come to treatment with a set
of assumptions that are ACT-consistent, such as an awareness that their avoidance of
anxiety is causing problems, and even that their anxiety may never go away but that they
can learn to coexist with it. These clients may quickly take to ACT concepts, connecting
with the model and applying ACT in their daily lives between sessions with minimal thera-
pist guidance. They may spontaneously reference metaphors throughout treatment or share
experiences between sessions where they responded to uncomfortable private events with
increased psychological flexibility.
As we touched on in the previous chapter, however, not all clients take to ACT. Some
may find the ACT model confusing or counterintuitive. Many clients come to treatment
with the expectation that the therapist will teach them to control their anxiety.
Many other clients hold views that are somewhere in-between these two poles: they
intellectually understand ACT concepts while secretly hoping that they’ll learn to effec-
tively escape anxiety. Therefore, the process of introducing ACT experiential exercises
early in treatment allows the therapist to assess baseline knowledge and client psychological
flexibility. How the client responds to ACT concepts may influence how you direct treat-
ment. For example, highly avoidant clients who are skeptical of ACT ideas—or reject them
outright—may benefit from starting with easier exposure exercises to build buy-in to the
notion of developing psychological flexibility through exposure.
ACT Rationale for Exposure

Historically, a traditional exposure therapy rationale emphasizes, among other things,
symptom reduction (see chapter 2 for more detail). From an ACT perspective, an explicit
focus on symptom reduction is ACT-inconsistent and may contribute to a “fear of fear.”
This occurs when anxiety—an inner experience that, like all private events, is something
we cannot control—becomes an enemy to be conquered through avoidance and suppres-
sion of uncomfortable experiences. Ultimately, ACT holds that it’s our attempts to control
or avoid anxiety that cause anxiety to be a problem, rather than the anxiety itself. A de-
emphasis on symptom reduction is not unique to ACT, as there’s a movement in main-
stream CBT away from the prior focus on habituation based on recent studies that have
found that habituation is a poor predictor of learning (Craske, Treanor, et al., 2014). One
What the Client Needs to Know61
alternative model of exposure, inhibitory learning theory, shares some conceptual overlap
with ACT (Arch & Abramowitz, 2015).
In crafting an ACT-consistent rationale for exposure, it’s important to be clear about
the message you want to impart to clients who are seeking treatment to reduce their suffer-
ing. If you’re used to explaining exposure in terms of symptom reduction, it’ll take some
discipline to refrain from promising symptom relief, as we all want to reassure clients that
they’ll feel better. For these reasons, it’s useful to develop an ACT-consistent rationale for
ACT-informed exposure.
Arch and colleagues (2015) conducted a study comparing the credibility of different
exposure rationales: (A) ACT, (B) traditional habituation-based exposure, (C) inhibitory
learning theory, and (D) a generic definition of exposure. They found that rationales rooted
in theory (e.g., ACT; traditional exposure; inhibitory learning theory) had greater credibil-
ity compared to a generic definition. And none of the rationales rooted in theory were more
credible than any of the others. Said another way, ACT was as credible as traditional expo-
sure and vice versa.
The ACT rationale the researchers created for the study described exposure as a
method for learning to “welcome” anxiety as “a meaningful part of your day-to-day experi-
ences.” Exposure was about “entering feared situations while openly allowing anxiety to
occur and not fighting against it” and “treating your emotions in a more welcoming way.”
There are two components to this rationale we want to highlight: (A) how one relates to
anxiety, and (B) its emphasis on meaningful living (e.g., values).
There’s no one way to craft an ACT rationale for exposure. The main points you may
want to emphasize are (A) remaining in contact with anxiety, and (B) the client taking
action toward what’s important to them. You’ll also want to avoid an emphasis on control-
ling anxiety or symptom reduction, which would be ACT-inconsistent. Other ways of
describing emotional acceptance include “making space for” and “being present with” dis-
comfort, as well as “allowing [discomfort] to be.” Synonyms for “values” include “things that
are important to you,” “what you want to be doing with your life,” and “anything that is
meaningful to you.”
Activity
Complete this activity on a sheet of paper or in a notebook.
• Take a few moments here and write out words you might use in creating an
ACT rationale for exposure. Resist any urges to consult ACT resources for
the “right” wording—try to write what feels natural to you. You can revise
later. We included a few prompts you may use.
Through exposure you will learn to…
Learning to stay in contact with your anxiety will help you…
The Willingness Switch

In a research study of ACT-informed exposure for OCD conducted by one of us (Brian T),
the therapist used a rationale based on an ACT metaphor, the Willingness Switch. There
are variations of the Willingness Switch in other ACT sources (e.g., “Willingness Thermostat
Metaphor” in Eifert & Forsyth, 2005). We have chosen to present this metaphor because it’s
one way to set up an ACT-informed exposure and orient clients to an ACT process that we
have found is useful to track in ACT-informed exposure. We have adapted the language for
this book:
Therapist: I have a metaphor I’d like to demonstrate for you. Imagine you have two
switches in your mind. The first switch we’ll call your “anxiety switch.”
[Draw vertical line with small horizontal lines at the top and bottom
edges and label it “Anxiety.”] Let’s say it is on a scale from 0 to 10,
with 0 being no anxiety and 10 being the most anxious you’ve ever felt.
[Write 0 at the bottom of the line and 10 at the top, noting a midpoint
between the two poles.] When you experience anxiety, how much control
do you have over this switch? To what degree can you deliberately dial
your anxiety down?
Explore this with the client. Many clients will admit they don’t have much control over
their anxiety. If a client believes they have control, explore this and the consequences of
trying to manipulate the switch (e.g., anxiety intensifies; the client avoids activity). The
main point to underscore is that clients cannot control their anxiety as much as they would
like and that attempts to do so can make it worse or get in the way of doing activities that
are important to them.
Therapist: You’ve spent a lot of time trying to control your anxiety switch, but your
efforts haven’t been very effective. If anything, it sounds as if your
attempts to control may backfire for you.
However, we also have another switch, one that we don’t tend to
think about. We’ll call this the “willingness switch.” [Draw a vertical
line with small horizontal lines at the top and bottom edges and label
it “Willingness.”] By “willingness,” I mean choosing to be 100 percent
open to any thoughts, feelings, or bodily sensations that show up. We’ll
also place it on a scale of 0 to 10. [Write 0 at the bottom of the line and
10 at the top, noting a midpoint between the two poles.] In this instance,
0 refers to being unwilling or trying to make anxiety go away, and 10
means being fully present and allowing yourself to feel anxiety. You’ve
been practicing willingness indirectly in some of the exercises you’ve been

doing. What is your experience with willingness so far? [Wait for client
response.]
Anxiety Willingness
10 10
0 0
When we experience anxiety, we can choose to be present with that

discomfort. When you move your willingness switch, you choose to
experience your anxiety rather than to struggle against it. It’s not a trick to
make your anxiety go away, but it may keep it from getting worse, and it
frees you to do things that are more important to you.
Explore with the client. The major points to underline are that:
1. We cannot control our anxiety, but we can choose how we relate to our anxiety.
2. Willingness does not necessarily make anxiety dissipate, but it can keep it from
escalating, freeing us to do other things.
We offer this metaphor as an example of something that has worked for us in our prac-
tices, as the idea of acceptance in exposure can be a hard sell. It also orients clients to the
task of learning to track and rate their willingness.
The notion of willingness can be conveyed in subtle and nuanced ways. It’s important
to choose wording that makes sense to you and the people with whom you work. Some
ACT therapists avoid the word “acceptance,” as clients may misinterpret the idea of accep-
tance as resignation or giving up or being overwhelmed by anxiety. At times, some of us
have regretted having “acceptance and commitment therapy” on our web pages, as clients
see the word “acceptance” and are preemptively prepared to argue why it won’t work for
them. Sometimes the word has become tainted for clients by prior experiences in therapy.
We have heard more than once, “My last therapist told to me to ‘just accept it,’ ” the impli-
cation being that the client felt invalidated by their therapist, who did not teach them how
to accept.
You may also frame willingness practice as experiments. What does your mind predict
will happen, and what actually happens? Let’s see what happens. Is the actual outcome as
bad as your mind imagined? We encourage you to explore nuanced ways of describing the
reasons for engaging in ACT-informed exposure using words that feel right to you and that
your clients are likely to understand.
With this in mind, we want to emphasize a few subtle points about willingness that may
be helpful in talking with clients.
• Willingness is really hard. Take a moment and reflect on all the ways you struggle
with willingness in your own life. What do you do when you notice you’re strug-
gling to accept an uncomfortable experience? What are some examples of difficult
emotions you regularly find yourself avoiding? Do you struggle with uncomfortable
feelings when you’re working with clients who struggle with willingness? Because
willingness is difficult, we want to emphasize that it requires practice and practice
and still more practice. In fact, exposure is one means to practice willingness.
• Willingness takes a lot of work, and it’s never done. We can’t accept 100 percent of
the time, as our default is to push away discomfort. When we’re distracted or caught
up in thinking (e.g., worry, rumination), we’re often engaging in some form of
avoidance. Ultimately, willingness is a choice. Every day we’re constantly control-
ling and manipulating our experiences (e.g., turning lights on and off; choosing our
clothing based on the weather). We don’t have to allow the sun to be in our eyes
when we can easily close the blinds. We may choose willingness when control
backfires or prevents us from doing something important to us. It’s not a blanket
panacea. Willingness is a process, not a destination. It’s never “done” or
“complete.”
• We can only practice willingness in the present moment. Sometimes a client will
say, “You want me to just accept that my life will be ruined?” No, we’re not suggest-
ing that at all. We can’t accept the future; we can only accept that we’re having
thoughts about the future and anxiety related to our thoughts about the future. We
may practice willingness with the knots in our stomach when we imagine a cata-
strophic outcome, but we cannot “accept” something catastrophic that has not yet
happened. The technical definition of willingness in ACT refers to internal experi-
ences (i.e., emotions, bodily sensations), not external events. When something
tragic happens, there will be concrete steps with which to deal with it. Until then,
we can only accept that we’re experiencing private events that evoke discomfort.
• We can only accept specific private events. We would argue that you cannot prac-
tice willingness with “anxiety” because anxiety is too abstract a concept. Anxiety
is some combination of thoughts, bodily sensations, and context. We can practice
willingness with the bodily sensations that accompany anxiety (e.g., tightness in
chest; sweating). This is the basis of interoceptive exposure practice.
Activity
Look at the words you wrote out in the previous exercise for explaining ACT-informed
exposure.
Now write out your own ACT-informed exposure rationale. Underline the key words you
want to use. Practice with clients. How do they react? How did you respond to their
questions or concerns? Revise and rewrite your ACT-informed exposure rationale until
it feels comfortable to you, and you feel confident in responding to client questions
about it.
Choosing Exposure Exercises

When I (Brian T) was exploring how to conduct ACT-informed exposure earlier in my
career, little written material was available. Relatively new to ACT, I decided to aim for a
“pure ACT” approach. All exposure exercises were to be cocreated in session with clients
based on values. Each session, I would ask clients what sort of exposure felt most important
to them “right now,” with the goal of identifying a doable exposure exercise linked to what-
ever the client was valuing in the present moment.
My well-intentioned approach was a total fail.
What would happen is that I’d spend the entire session unsuccessfully trying to identify
a single exposure exercise with the client. I eventually gave up on this and realized it was
much easier to come to sessions with some ideas for exposure exercises, generate other ideas
with the client, and then link them to values. One reason for this is that, until clients have
experience with exposure, it’s difficult for them to come up with their own ideas for expo-
sure exercises—especially when their anxiety is telling them all the reasons not to do expo-
sure. As clients practice and gain experience with exposure, they can provide more input
into the development of exercises.
Here are a few points to consider in coming up with ACT-informed exposure
exercises.
• It’s difficult for clients to create their own exposure exercises—at least in the begin-
ning of treatment. It’s more practical for you to come to session prepared with ideas
for exposure exercises to use as examples that may be applicable for clients. If you’re
new to exposure therapy, Springer and Tolin’s (2020) The Big Book of Exposures has
a collection of them. It takes some practice and experience to develop fluency in
coming up with your own.
• It’s easier to start with an exposure exercise and connect it with values than to start
with a value and connect it with an exposure exercise. (Trust us: we’ve tried, and
it’s a terribly inefficient way of doing things.) Suggest potential exposure exercises
that are practical, doable, and relevant to clients’ difficulties and treatment goals.
You can connect them with values later.
• Although it may sound good in theory to connect all exposure exercises with
values, in practice, it can be really tedious for you and the client. If every single
time you and a client discuss an exposure exercise, you must ask, “What feels
important to you about this?” the client may start rolling their eyes. Connecting
exposure exercises with values may be more important during the first few expo-
sures, as you create the context for exposure. Revisiting values can also be helpful
if a client becomes discouraged or has difficulty completing homework. What we
are cautioning against is making it a rigid requirement that is likely to create a
barrier and reduce clinician flexibility. If an exposure exercise makes sense to a
client, and they’re agreeable to it, it’s usually connected implicitly to something
that is important to them.
What Do I Track During ACT-Informed Exposure?

During exposure, it’s useful for clients to pay attention to their experience. Having
clients provide ratings of their experiences allows the therapist and client to assess the
impact of the exposure exercises. In traditional exposure therapy, clients rate their discom-
fort during exposure. A common name for this is the Subjective Units of Discomfort (or
Distress) Scale (called “SUDS”—as in soapsuds—for short). In one randomized controlled
trial comparing traditional exposure against ACT-informed exposure for OCD (Twohig et
al., 2018), therapists in the ACT condition tracked “willingness” scores in place of tradi-
tional SUDS using the same forms with minimal changes. Using a 0–10 or 0–100 scale,
with higher scores reflecting greater willingness, clients may rate how willing they are to
experience discomfort. The Willingness Switch, described earlier in the chapter, offers
some guidance for orienting clients to tracking willingness.
Some of us have chosen to track both SUDS and willingness scores during exposure.
The reason is that, in our experience, willingness can be a tricky concept for clients to
understand. Some clients grasp willingness immediately and really connect to the concept.
But many others express some confusion or uncertainty about it. Some clients understand
it theoretically but require practice in understanding it experientially. Others can be overly
perfectionistic in their willingness ratings (e.g., “I’m not sure I’m doing this right!”). This
may lead them to underrate willingness for fear they don’t quite get it. For these reasons, we
may include SUDS or distress-related scores because they’re easier for clients to grasp. As
most clients have little difficulty rating their discomfort, distress-related scores may provide
a more accurate window into client experience.
In our experience, willingness and traditional distress scores are complementary.

Whereas distress scores provide a glimpse into what the client predicts will happen or into
the moment-to-moment experience of anxiety, willingness ratings provide insight into
client commitment to or difficulties during exposure. We offer examples of how to interpret
willingness and distress scores in chapter 9. Higher willingness ratings often reflect greater
client buy-in for exposure. Mid-range willingness scores may indicate forms of covert avoid-
ance during exposure. Below is an example of how we track distress and willingness ratings
during exposure.
Rate your experiences every _5_ minutes. (Or circle N/A)
• Time = Frequency of rating (e.g., five minutes, ten minutes, etc.)
• SUDS = Subjective Units of Discomfort Scale (0–10)
• Willing = Willingness to experience discomfort without struggle (0–10)
Table 5.1
Time SUDS Willing
begin 8–9 8
5m 8 8
10m 8 9
15m 9 9
20m 7 9–10
Given our emphasis on how ACT is not about symptom reduction, you may ask, “How
is tracking SUDS not a focus on symptom reduction? Isn’t this inconsistent with ACT?”
This idea of tracking distress scores may be somewhat controversial among ACT therapists.
In anticipation of any potential controversy, we’ll explain how tracking distress can be rel-
evant to ACT processes.
One function of rating distress is to encourage clients to pay attention to their moment-
to-moment experience. It’s not important that it goes down. Asking a client to rate their
anxiety during exposure requires present-moment awareness. Clients may learn to observe
a wide range of physical sensations, emotions, and thoughts in constant flux at each
moment. Directing attention toward the moment-to-moment experience of anxiety also
allows clients to practice acceptance or willingness, since one cannot practice willingness
unless one is in contact with the present moment. In addition, distress scores can signal
problems with exposure as it’s currently being conducted. Changes in SUDS may indicate
something is happening during exposure, whether that’s new learning or client distraction or
disengagement with the exposure (Benito et al., 2018). Scores that remain constant may
indicate the presence of resistance or avoidance behavior, as it’s expected that there would
be some variance in SUDS even if we’re not applying a conceptual model of habituation.
Ultimately, it’s the act of tracking, and what clients’ ratings might reveal, that we encourage
you to consider—over and above an emphasis on whether ratings go down. In our view,
changes in fear, while imperfect, remain a practical indicator of shifts in client experience
during exposure work. That said, we’re not saying you need to track distress-related scores.
Some therapists prefer to use willingness scores alone or some other ACT-consistent rating
system.
Theoretically, ratings could be made for any of the core ACT hexaflex processes. For
example, Eifert and Forsyth (2005) offer worksheets that track up to five items. We’ll note
here that from a practical standpoint, it increases time and client attention to pay attention
to and provide ratings for multiple scales. For that reason, consider carefully what you find
is useful for you and your client. We emphasize it is important to ask clients to track some-
thing, as the process helps reorient clients toward their present-moment experience of their
anxiety and observe what actually happens versus what their minds predict will happen.
You might also change what clients track throughout treatment. One of the authors (Brian
P) begins with tracking of traditional SUDS, switches to willingness scores, and then com-
bines the two once the client has demonstrated sufficient understanding with each.
Activity
Complete this on a sheet of paper or in a notebook.
Take a few moments to consider what you want to track in treatment and why. Reflect
on why this information may be useful to you and your clients.
How Do I Organize ACT-Informed Exposure Exercises?

In traditional exposure therapy, exposure exercises are typically organized by SUDS
scores in what is called an “exposure hierarchy,” which was first created by Wolpe (see
chapter 2). Items with higher distress ratings are placed at the top and items with lower
distress ratings are placed at the bottom, with the sequence of therapy moving from the
bottom to the top of the list. The rationale for this approach is that it’s more palatable for
clients to move from lesser to greater difficulty, and this may increase treatment retention.
Table 5.2
Example of exposure hierarchy by distress for harm obsessions SUDS
Place scissors out in bedroom. 3
Place kitchen knife in bedroom. 8
Read article about serial killers. 8–9
Read article about suicide. 10
It’s not inconsistent with ACT to organize exposure exercises by difficulty, but an ACT
approach offers other options. One alternative is to organize exercises by willingness ratings.
Another is by values. Below is an example of a hierarchy arranged by willingness scores,
where items with higher willingness ratings are placed at the top.
Table 5.3
Example of menu by willingness for pedophilia obsessions Willing
Videoconferencing with niece 10
Spend time at playground while kids are out 8
Read article about pedophiles 6
Watch videos of children engaged in dance routines 5–6
One recent exposure study compared exposures conducted in a gradual (i.e., hierarchi-
cal) order against exposure conducted by a variable (i.e., randomly chosen) order in a
sample of adults with obsessive thoughts but not diagnosed with OCD (Jacoby, Abramowitz,
Blakey, & Reuman, 2019). This study provides evidence there may be some advantage in
moving through exposure in a random fashion (e.g., low, then high, then moderate). If you
try this approach, it may be prudent to make certain the more difficult exposures are not
overwhelming for clients when assigned (i.e., that they can engage in the exposure with
high willingness). We caution against choosing an exposure exercise that is so difficult that
it will interfere with client ability to maintain willingness and may result in covert avoid-
ance behavior. Some proponents of a randomized approach have suggested selecting a
subset of exposure exercises that the client could engage in without being overwhelmed and
then selecting them at random from within this subset to increase the likelihood the client
will be able to practice willingness during the exercise.
Regardless of how you choose to organize exposure exercises—some therapists do not
organize them at all—there’s been a recent trend away from an “exposure hierarchy,” which
implies a graduated approach. We prefer the term “exposure menu” because it conveys an
attitude of flexibility with exposure. As with any menu, it is a list of options from which
clients may choose. Throughout the course of treatment, the client may not do all of them.
For example, some exposure exercises become obsolete for a client because of the comple-
tion of prior exercises (e.g., it now would not be difficult for them). As treatment progresses,
clients may begin to contribute exposure ideas that are even better than exercises identified
at the beginning of treatment.
There are other reasons ACT-informed exposure may not proceed in a graduated
fashion. For one, client ratings of exposure exercises—whether distress or willingness
scales—may change over time spontaneously. However, with some exposure exercises, it
may be more useful to continue with graduated difficulty (or willingness)—especially when
someone is working through a particular type of exposure. For example, if a client conduct-
ing driving exposures is focused on a particular freeway stretch, it may make sense to main-
tain this focus (e.g., next exit; nighttime; traffic) than switch to different stimuli (e.g.,
bridges). With other clients, one may shift exposure themes from session to session.
In our experience, clients are very capable of determining their next exposure exercise.
Once a client understands the process with exposure, you might hand them the exposure
menu and just ask, “What do you want to do next?” This can empower clients to be their
own exposure therapist and learn to use these skills throughout their lives to prevent
relapse. However you choose to arrange exposure exercises, we recommend some form of
organization to help facilitate the choice of the next exercise. It’s much harder to choose the
next exposure exercise when they’re penciled in an illegible scrawl on notebook paper (we
know this from experience, too).
Conclusion
This ends our chapter on preparing clients for exposure. Through judicious use of experien-
tial exercises, developing your rationale, and letting clients know what you want them to
pay attention to during exposure, you can begin to orient clients to the ACT model and
prepare them for ACT-informed exposure. If a client still has a shaky grasp of ACT con-
cepts as you approach beginning the first exposure exercises, we encourage you to continue
to move into exposure work if the client is willing. With the emphasis on repetition and
paying attention to moment-to-moment experiences, exposure work provides rich opportu-
nities for clients to develop and refine their understanding of ACT principles. It’s not
uncommon for clients to say, several sessions into exposure work, “I get it! I now understand
why we’re doing this!”
The next chapter focuses on what to do during exposure to help clients contact ACT
processes and strengthen psychological flexibility.
CHAPTER 6
What to Do During and After Exposure
Jefferson used to change his clothing in the garage after coming home from work, because
he feared bringing contaminants into his house. Today he agreed to walk outside, touch
the ground, and then enter his home without changing. We were working via telehealth.
Jefferson positioned his laptop so I could see his living room well, and I heard a door open
and then close. When he returned, I gently encouraged Jefferson to touch items around
the room. At first, I saw that he was touching things deliberately and cautiously—
making a mental list of each object. I recommended he haphazardly rub his hands and
clothing on everything he could to the point that he could no longer keep track of
everything. Jefferson turned up his “willingness switch” and complied. He ran his fingers
across the spines of books in his bookshelf, items he could not decontaminate, and then
continued around the room, touching things randomly. After he sat back down in front
of his computer, he told me that his first thought when he began touching things quickly
was I’m screwed! (Actually, the wording was a little stronger than that.) But then, when
he realized he could not undo the exposure because he could not remember everything he
touched, he experienced a sense of relief. He was surprised at this. Jefferson had
predicted his anxiety would spiral out of control. Instead, when he saw that he could no
longer control the contamination, he was able to accept it. The purpose of exposure made
more sense to him in a way he had not quite grasped before.
Clients new to exposure almost always have some trepidation. They fear being overwhelmed
with anxiety, that they may do something they regret and cannot undo, or that they or
someone they care about may be harmed as a result of what they do. In our experience, the
nuances of exposure practice are difficult for clients to understand until they have firsthand
experience of it. Reading about exposure and hearing examples can help clients get on
board with the rationale; however, it usually requires some actual experience with it for
clients to really “get it.” In order to help clients contact willingness, it depends in part on
how they approach exposure. Some clients with high willingness will jump right in with
both feet. But more commonly, clients will enter into their first exposure exercises with
some caution. This means that your first exposure exercise for a client is critical, because it
orients them to exposure in a way psychoeducation cannot. It’s recommended you intro-
duce in-session exposure exercises whenever possible to allow you to guide and observe the
process. This is especially important with the first exposures.
This book was started during the COVID-19 pandemic, when nearly all therapists were
practicing telehealth. One benefit of telehealth, especially when it comes to exposure, is
that it allows convenient access to stimuli that otherwise aren’t accessible in the therapy
room. For example, many exposure targets reside in clients’ homes. Video-conferencing
apps allow therapists to travel with clients outside the home through their smart phone or
other portable devices to coach them through exposures such as driving or walking in
public. To date, research suggests that telehealth conducted through exposure is as effective
as in-person exposure (e.g., Abramowitz, Blakey, Reuman, & Buchholz, 2018; Yuen et al.,
2013).
Setting Up the Exposure

In developing an exposure menu, the client and therapist work together to brainstorm a list
of exercises consistent with the client’s values that evoke private events associated with nar-
rowing of client behavior. When it’s time to put these ideas into practice, these rough
sketches need to be developed into fully detailed plans. For each activity listed in the expo-
sure menu, make certain you and the client are on the same page. What is the client exactly
doing? For how long? In what location? With contamination exposures, for example, there
are a variety of ways clients may use their hands after contaminating them. Do they hold
their hands close to their body or far away? Are they permitted to wash their hands, and if
so, when (e.g., one hour later; before eating)? Should they touch other items (e.g., chairs,
books)? Should they touch themselves, and if so, where (e.g., face, mouth, tongue)?
Whether an exposure is conducted in session or assigned as homework, the therapist
and client should work through all necessary details so that both agree to what the client
will do. If an exposure assignment is too vague, clients may be confused or frustrated. They
may misinterpret the instructions in ways that undercut the effectiveness of the exposure.
The process of coming up with specific steps and parameters for each exposure on the
menu is also an opportunity to highlight committed action strategies—taking actions
toward a meaningful life direction—such as demonstrating how we are more likely to follow
through with challenges when the actions are concretely defined, scheduled, and realistic.
For example, identifying when a client practices exposure (e.g., immediately after work, at
around six) increases follow-through, because clients have a clearer idea of whether they’ve
accomplished it at a certain point (e.g., It’s six-thirty, and I haven’t done my practice yet!). By
contrast, leaving exposure procedures vague (e.g., sometime during the day) may allow
clients to more easily delay until it’s too late (e.g., I don’t feel like doing it now. I’ll just do it
later.).
When exposures are initiated in session, you’re better able to figure out the details as
you and the client go along. You might suggest ways in which clients may continue to chal-
lenge themselves, depending on how they respond to the exposure. In the example above,
What to Do During and After Exposure73
Jefferson initially didn’t consider that he might touch items he couldn’t decontaminate later.
That seemed impossible! Jefferson began the exposure under the assumption that he’d be
able to undo it if he felt too anxious. The therapist wasn’t aware of Jefferson’s implicit
assumptions at the time. These details would be worked out at the end of session before
assigning the exposure as home practice. If Jefferson hadn’t been willing to contaminate
items he couldn’t decontaminate later, we would have needed to agree on an alternative
procedure. For example, we might have specified a period of time Jefferson would wait
before decontaminating. Fortunately, Jefferson was aware he was holding back and was
willing to trust the suggestion that he contaminate his home with a seemingly reckless
abandon. He both grasped the rationale for why I pushed him and was also surprised at the
relief that greeted him when he followed through.
When developing an exposure menu, it’s common that clients may underestimate what
the therapist has in mind for the exposure. For example, a client predicts that touching a
bathroom sink with their hands will be a “10” on their distress scale. When the therapist
then asks that client to predict their distress or rate their willingness if they were then to rub
their hands on their face, eyes, and tongue, they may be caught off guard (“What? I thought
I was going to be able to wash my hands right away!”). For these reasons, it’s useful to iden-
tify potential misunderstandings before beginning the exposure and try to clarify them.
Even though you may have agreed upon including a particular exercise from the client’s
exposure menu, you and the client may have different ideas about its execution. So it’s best
to talk through each one when it comes time to carry it out. That said, it’s not necessary to
figure out all the details well in advance, since so much can change between the time you
develop the exposure menu and the time you get to each individual exercise. Also, clients
often increase their awareness and understanding of their avoidance behaviors with prac-
tice. Some exercises may become obsolete as clients strengthen their psychological flexibil-
ity. Ultimately, the exposure menu is a living document, subject to revisions and re-ratings,
and it’s best to not assume that what was outlined several weeks ago will be as relevant later.
In developing a plan for an exposure exercise, it’s also important to think through the
exposures functionally: to consider what is likely to happen during the exposure, what
private events your client may experience, and what they may be ready or not ready for.
Could something unpredictable occur that might take them by surprise or unexpectedly
increase the difficulty of the exposure? Is there something that might overwhelm them and
cause them to discontinue the exposure or engage in avoidance behaviors? Deliberate
avoidance behavior during exposure will undercut its effectiveness, like how Jefferson ini-
tially kept track of which items he touched so that he could undo them later. However, an
exposure’s difficulty may be decreased to meet client willingness to experience discomfort
while engaging in the exposure. If Jefferson had not been willing to run his fingers along his
bookshelf, perhaps he would have been willing to touch all the chairs first and wait at least
a day before deciding if he wanted to decontaminate them.
How Long Should Exposure Exercises Be?

In traditional exposure, such as prolonged exposure therapy for PTSD (PE), the length
is prescribed: forty-five to sixty minutes, or until client’s distress decreases by 50 percent
(Foa et al., 2007). When one of us (Brian T) began transitioning from traditional exposure
to ACT-informed exposure, one of his first struggles was identifying the optimal length of
time for exposure exercises if habituation was not the goal. Even as newer research indi-
cated that decreases in distress are a poor predictor of treatment outcome (e.g., Craske,
Treanor, et al., 2014), the concreteness of this approach was appealing.
However, despite decades of focusing on a recommended amount of time for traditional
practice, even hardcore PE researchers have since questioned the need for longer exposures.
Studies have since found no difference in treatment outcomes in PE for PTSD between
sixty and thirty minutes (van Minnen & Foa, 2006) or between forty minutes and twenty
of imaginal exposure to trauma memories (Nacasch et al., 2015). It appears that imaginal
exposures as brief as twenty minutes can be as effective as longer imaginal exposures. This
shift is important for practical reasons as well: when billing codes in the US were revised in
2013, the ninety-minute session was phased out in favor of a sixty-minute session, making
it more difficult to bill for the ninety- to 120-minute sessions recommended in traditional
exposure protocols. Due in part to the reasons stated above, longer exposures can be more
burdensome for clients and clinicians in terms of time and cost.
From an ACT perspective, the question of “how long?” has many possible answers,
depending on the aims of the exposure. As we have repeated throughout this book, it’s
important to consider the functional relationship between the fear and the chosen exposure
exercise. What does the client expect to happen, and in what amount of time? How long do
they predict they can remain in the exposure? If an exposure exercise lends itself to varying
the amount of time, you might approach this is by asking a client, “How long are you willing
to engage in an exposure?” This question can be more complicated than it appears on the
surface. For example, a client might respond “thirty seconds.” While thirty seconds may be
a place to start, it also means the exposure may end before the client has an opportunity to
practice psychological flexibility; that is, to practice new behaviors in response to uncom-
fortable stimuli. For example, if Jefferson had contaminated an item and then decontami-
nated it after thirty seconds, he wouldn’t have learned that he can be present with his
anxiety for much longer than he had initially predicted and that he could accept contami-
nating in ways that he cannot later undo. Somewhat counterintuitively for clients, shorter
exposures are not always easier, because they may end before the client has a chance to have
an experience that is different from what their anxious mind predicts. Think about any
experiences you’ve had with public speaking: you may feel most nervous when you first
talking, but as you start getting into the material you’re presenting, you may gain flexibility.
Sometimes it may even start to become fun! If all your public speaking experiences were
limited to thirty seconds, you may never learn you can enjoy it.
In ACT-informed exposure, it’s useful to engage in exposure long enough for clients to
learn that they can be fully present with their discomfort without engaging in avoidance
behaviors, which increases their confidence in their ability to do so again. Even simpler
ACT defusion exercises, such as saying a word repeatedly, require a minimum number of
repetitions to start to alter the function of how you experience the word. In driving expo-
sures, if someone enters the highway and leaves at the next exit, there may not be enough
time for them to engage in valuing while driving or to practice willingness with panic sensa-
tions. For someone who is afraid of impulsively killing themselves or someone else, they may
need to leave a sharp knife out for the entire span of time between weekly sessions, until the
knife transforms from a potential weapon back into a common kitchen item. If the client
removed the knife from the drawer, set it on the countertop, and then quickly put it away
again, this sequence would likely reinforce the fear (e.g., Good thing I put the knife away
before anything horrible happened!).
Sometimes an exposure exercise takes place over a longer time frame to directly target
specific rule-governed behavior or acceptance of uncertainty. If a client predicts they will be
struck dead within one hour of saying something blasphemous unless they repeat a prayer
to neutralize their blasphemy, it may be useful to extend the exposure longer than one hour
to truly test what happens when they do not pray and their ability to accept any discomfort.
This is part of what is called “expectancy violation” in inhibitory learning theory—setting
up exposures to challenge the client’s prediction in the most extreme manner that can be
reasonably executed (Craske, Treanor, et al., 2014). If a client without diagnosed allergies
fears that eating a new type of nut will cause an allergic reaction and that each nut con-
sumed increases the risk, you might identify the specific number of nuts that their mind
fears will most likely cause them to have an allergic reaction. For example, if the client
believes eating five pecans is more likely to trigger an allergic reaction than one, the client
would eat five. When there is a finite timeframe or threshold within a feared prediction, it’s
useful to clarify this with the client and match the exposure accordingly. Contacting the
actual contingencies of their actions can help to undermine rigid verbal rules that maintain
avoidance behavior (e.g., “I will become so anxious that I will lose my mind”).
In many instances, clients engage in avoidance behaviors not because they’re worried
about the feared outcome but because they fear they will be unable to cope with their
anxiety if it escalates. This nuance bears repeating, because it’s subtle, and many clients
may not even be conscious of this distinction. For many clients, the feared outcome is not
necessarily a specific catastrophe so much as the fear of being overwhelmed with anxiety.
For these reasons, many exposures only need to be long enough for clients to realize they
can be present with whatever distress they’re experiencing.
Sometimes an exposure may be oriented around a value. For example, a client with
social anxiety may choose to eat out at a hot new restaurant because they love food. A
client who is afraid to drive outside of a limited area may agree to drive their kid to a park
outside that limit because they value being a loving parent. In these examples, the values-
based activity also has a natural beginning and end to it, so it’s less relevant to set an
amount of time for the exposure. For some clients, engaging in values-based exposures at
times during treatment may be helpful in enhancing motivation and demonstrating the
benefits of the hard work required in exposure therapy. In sum, the length of exposures in
ACT-informed exposure varies based on the functional relationship between the feared
outcome and exposure procedure. How much time is needed for the client to practice a new
behavior in response to their triggers? Consistent with recent PE research (Nacasch et al.,
2015; van Minnen & Foa, 2006), twenty to thirty minutes is a useful rule of thumb, as it fits
within a standard therapy session and is not too time-consuming for out-of-session practice.
However, exposure may be longer or shorter, depending on the functional relationship
between the core fear and procedure. We recommend not getting too bogged down with
specifying time requirements. Be flexible! Encourage clients to challenge their fears while
also demonstrating an openness to negotiate. That said, it’s important that the client does
not end the exposure prematurely, as that would risk reinforcing the avoidance behavior.
You might say, for example, “Whatever we agree to, I want you to be 100 percent committed
to it. I would rather you agree to do a twenty-minute exposure and complete the twenty
minutes than to try for forty minutes and end it after thirty. Otherwise, your anxiety is
making the choice, not you.”
Therapist Behavior During Exposure

If you interview a sample of exposure therapists, you will discover that we all vary in what
we do with clients during in-session exposures. Some of us talk with them; others don’t.
Some of us do the exposures with clients, if possible, while others stay in the observer role.
Our goal is not to editorialize about what way is better or worse. Rather, we want to share
with you how you may approach exposure therapy with the aim of enhancing core psycho-
logical flexibility processes in session.
Joining Clients in Exposure

When practicing in-session exposure, it’s recommended that therapists model willing-
ness to do exposure with clients (Jordan, Reid, Guzick, Simmons, & Sulkowski, 2017). Of
course, some exposures lend themselves to therapist participation more than others for
practical reasons. And in our experience, therapists also vary in their willingness to join
clients in exposure.
We should all be aware of our triggers, limits, and blind spots as therapists and be
thoughtful about when we do and do not join clients in exposure—considering this ques-
tion functionally. There are some in vivo exposures for which therapist participation is
more sensible than others. For example, joining clients in contamination exposure conveys
a sense of collaboration and teamwork, as does joining in the task of engaging in taboo
behaviors. By contrast, a client afraid of driving over bridges due to fear of having a panic
attack doesn’t need to witness their therapist demonstrate their own comfort with bridges.
If we were to distinguish functionally between these two examples, what separates them is
how widespread the client views the risk. For many clients with concerns about contamina-
tion, for example, anyone is at risk of getting sick, even if they recognize they may be overly
cautious. For many driving-related fears, clients worry that they—but not necessarily
others—could have a panic attack while driving and become overwhelmed or get into an
accident. In short, it can help build rapport by joining clients in exposures when it’s practi-
cal to do so and when clients believe that you’re also at some degree of risk or discomfort.
By contrast, it’s not necessarily helpful to do exposures with clients when they view the
trigger as something unique to them; in fact, doing so may feed into client self-criticism that
they are struggling with something “normal” people don’t.
Within ACT-informed exposure, conducting exposure with clients allows the therapist
to contact ACT processes within themselves. As you consider the degree to which you
already join or intend to join clients in exposure, reflect on your reasons by asking yourself
the following questions. What do you value about joining clients in exposure? Does it help
you convey to clients that you’re in it together or that you care enough about them to expose
yourself to risk? What thoughts come up during exposure and how do you relate to them
(e.g., I don’t want to do this even though I technically could. What if I get sick?)? Is your willing-
ness low? Would you be open to increasing your willingness in the service of joining a client
in something uncomfortable?
Note that therapist participation in exposure can implicitly provide reassurance to
clients in ways that aren’t always unhelpful. However, as any therapist-authorized exposure
carries with it a whiff of reassurance, this cannot be completely avoided. For this reason,
clients may struggle more with out-of-session exposure practice, when the therapist isn’t
there. When clients are new to exposure, and you suspect an exercise you’ve done in session
may be more difficult for them when they’re alone, you might let them know, so it’s not a
surprise. You might ask how much more difficult they think it will be to do something on
their own. In some out-of-session exposures, it can be helpful for clients to practice first with
someone they trust and then do them on their own. Thoughtful loved ones can be great
exposure coaches.
Regarding interoceptive exposure to bodily sensations, the writers of this book differ in
their approach. One always does interoceptive exposure with the client (Brian T) and two
only engage sometimes (Joanne; Brian P). One reason the first author engages in interocep-
tive exposure is to model willingness and to contact his own avoidance. When he finds
himself holding back from performing the exercises with gusto, he tries to notice that and
increase his own willingness. It also provides a window with which to help clients label
bodily sensations. After hyperventilation practice, for example, you might offer, “I noticed
my palms started to sweat after this second hyperventilation. Did you notice any new sensa-
tions?” Again, we encourage therapists to err toward doing exposure with clients, because
it builds a sense of partnership, facilitates sharing of experiences, and can offer insights to
what the client may be experiencing. However, it is important to know and respect your
own limits in what types of exposure you may or may not be willing to engage in.
In any event, whether you choose to do exposure with your clients or not, it’s useful,
from an ACT perspective, to reflect on how you hope to practice your values in your work
with clients. Let’s consider some questions about that now.
Below, you’ll find some questions to help you consider the ways you might practice
ACT principles in the task of conducting exposure with your clients. Complete them on a
Activity: Making Exposure Committed Action

What do you value about joining clients in exposure?
Consider exposure exercises you are not willing to do. What thoughts,
feelings, and bodily sensations, do you consider barriers to specific
types of exposure exercises?
What ACT process do you contact when engaging in specific expo-

sures? Consider the examples given below, then make your own notes.
Values (e.g., I value joining clients in exposure even if I experience

discomfort because I want to convey a shared purpose and
collaboration.)
Willingness (e.g., I am willing to feel nauseous and dizzy to join my

clients in interoceptive exposure to spinning.)
Defusion (e.g., I can have the thought, What will others think of my
browser history? and still look up provocative images and videos for
my clients.)
Self-as-context (e.g., My stomach feels nauseous, I’m starting to

gag, and I’m having the thought, I think I might throw up, yet I’m still
willing to hyperventilate with the client.)
Contact with the present moment (e.g., I can be present with my

discomfort and still guide my client through a difficult exposure.)
What to Talk About with Clients During Exposure

During a professional exposure workshop one of us attended, the presenter, a respected
anxiety researcher, reflected that when he first trained in exposure, he would often sit and
read a newspaper for an hour while the client engaged in the exposure. This is an example
of traditional exposure, where the focus is on habituation. While this might be an extreme
“old school” example, it was not uncommon for new therapists to be trained to have minimal
engagement with clients during exposure, such as checking in only every five or ten minutes
for a distress rating. One theoretical reason for minimal engagement during exposure is that
talking could function as distraction and disrupt the process of habituation. As the goal in
habituation models is for clients to get used to the feared stimulus over time, it was believed
that engagement with the client might interfere with this process.
In ACT-informed exposure, as one goal of exposure is to increase psychological flexibil-
ity in how clients relate to inner experiences, it’s important for clients to be aware of
thoughts, feelings, and bodily experiences. Therefore, the therapist’s engaged presence can
be helpful in encouraging clients’ attunement to internal experiences, especially if there’s a
risk that anxiety may overwhelm their ability to observe private events. Without therapist
guidance, clients may also be engaging in covert forms of avoidances such as distraction and
may miss the opportunities to practice observing their moment-to-moment experiences.
Assessing distress scores throughout exposure serves this function to some degree, as it
requires that clients pay attention to their experience as they provide ratings. However, the
use of a willingness rating in ACT-informed exposure is a more expansive way to further
expand client awareness of inner experiences, as it asks clients to pay attention to both their
engagement with exposure and how they’re relating to uncomfortable private events.
Whatever ratings you choose to use in your practice, you’ll want to ask ACT-consistent
questions during exposure to increase client awareness of and contact with private events.
From an ACT perspective, one way to conceptualize communication during exposure
is that it’s a means to change the context in which the client is experiencing anxiety.
Altering the context can alter the function of stimuli, and it may allow clients to slow down
and really notice internal experiences they may otherwise overlook. For example, labeling
emotions may strengthen psychological flexibility processes such as contact with the present
moment (bringing attention to what the client is feeling), self-as-context (observing and
describing private events from an observer self), and defusion (labeling a thought or emotion
creates distance from the experience). Clients may observe that the bodily sensations they
fear aren’t as intolerable as they thought when they’re asked to describe them in precise
detail. Or asking a client with emetophobia (i.e., fear of vomiting) what they notice when
watching people’s facial expressions during videos of people vomiting may lead to an obser-
vation that surprise is one of the qualities that makes vomit so scary to a client.
Judicious use of humor can help a client through a moment of great tension by con-
veyng a shared experience, increasing client engagement in exposure (Jordan et al., 2017)
and potentially enhancing ACT processes. One therapist, while he and his client (who
feared he was a pedophile) watched a clip of children dancing, noticed that he was really
getting into the clip with each repetition, nodding his head to the beat of the music. To
demonstrate that it’s not taboo to enjoy watching children dance, he shared, “You know—
I’m really enjoying this! They [the dancers] look like they’re having a good time!” These
sorts of self-disclosures also convey that exposure doesn’t need to be grimly serious. It’s okay
to be playful. With humor, we do recommend the therapist exercise caution, as there is a
risk it can be experienced as invalidating to clients. Fears that may appear lighthearted or
silly from an outside perspective can still be experienced as terrifying by those who struggle
with them. Clients may even feel frustrated by the intense anxiety associated with a fear
they objectively know is impossible (e.g., forms of magical thinking)—and to use humor in
such a situation can be especially invalidating. For these reasons, it is safer to share one’s
personal experience during an exposure than to try to make a more objective comment that
risks coming across as invalidating or judgmental (e.g., “You don’t really believe the socks
you wear to bed will cause an earthquake the next day, do you?!”).
Below are some ACT-consistent prompts you may use during exposure. Although we
have loosely organized them by ACT hexaflex processes, we want to acknowledge there are
not always clear boundaries between them.
Willingness or Acceptance
• Can you make space for those uncomfortable sensations?
• What would it be like to open up to this feeling and be fully present with it?
• Breathe into that sensation, not trying to change it or make it go away, but letting
it be there.
Cognitive Defusion
• What is your mind telling you right now?
• Would you be willing to say that thought out loud? What did you notice?
• How helpful is that thought?
Present-Moment Awareness or Contact with the Present Moment
• What’s coming up for you right now?
• Where is your attention right now?
• See if you can fully be right here in this moment.

Self-as-Context or Flexible Perspective-Taking
• What bodily sensations do you notice? Can you notice yourself noticing that?
• Which part of you is showing up right now?
• If your friend were watching you here today, what would they think?
Values
• What is important to you about doing this exposure?
• If you could accept this discomfort, what would you be able to pursue that you are
not doing right now?
• What does this feel like a step toward doing?
Therapist Disclosure During Exposure

In modeling psychological flexibility, it may be useful for therapists to disclose their
own experiences that occur during an exposure exercise. As we noted during the section
about using humor, we recommend caution here. The therapist does not want to give the
impression that they are a superbeing or to sound like an ACT caricature (e.g., “I am so
willing right now!”; “I was connected to my values the whole time!”). The goal in sharing
should always be for the client’s benefit, such as modeling how you, the therapist, also feel
uncomfortable when you’re doing difficult things—which is a way to establish for clients
how common to all humanity the experience of anxiety is. Clients typically idealize anxiety
therapists as people who do not struggle with anxiety, when, in fact, many anxiety special-
ists choose an anxiety specialty due to their own personal experiences and difficulties with
anxiety. At the next conference or training of anxiety specialists you attend, try noticing
any of the following behaviors: awkward hugs, fidgeting, nervous laughter, averting eye gaze,
and talking more quickly than usual. Odds are that you’ll see many of them! Sharing with
clients that we also have intrusive thoughts, worry about trivial matters, and experience
panic symptoms can be a powerful insight for them to adjust their expectations about how
success comes from living with, not outside of, anxiety.
In the end, you’ll want to consider the function of sharing your experience. For instance,
if you want to demonstrate to a client that you, too, can be uncomfortable watching a
violent video clip, you might share how grossed out you were: “I was surprised at how many
times we watched that scene from The Exorcist before I stopped flinching! I then started to
notice how the sound effects made what was actually onscreen seem so much worse!”
Here, the therapist is also modeling how their experience of the stimuli changed over
time and that they noticed new features of the experience the longer they stuck with it.
This can be a helpful teaching point to encourage clients to pay close attention to stimuli
during each repetition, as their experiences of stimuli may change.
In interoceptive exposure, as noted earlier, the therapist may share their physical sensa-
tions to model for clients how they can label their own sensations and to demonstrate that
therapists also experience discomfort (e.g., “I feel pretty nauseous right now!”). This can be
helpful in many ways, such as teaching a client that everyone’s anxiety manifests differently
or strengthening the alliance by demonstrating that the therapist is willing to experience
discomfort as part of treatment for the client.
Of course, it’s not always necessary to share, and any sharing you do should always be
in service of the client. The general rule of thumb is to consider disclosing if you experience
genuine discomfort or have a personal reaction that can model ACT processes to the client.
In short, it is most helpful to share experiences in which you model being human, with all
the fallibilities and imperfections this implies, or to highlight the experiences that help
bring you, as the therapist, down to earth in your client’s eyes.
We encourage therapists to be flexible and find their own voice and style in use of self-
disclosure during exposure. It’s okay to make mistakes—this is useful modeling as well. You
may say things that backfire or have the opposite effect than you intended. In our experi-
ence, trainees we’ve supervised sometimes feel inhibited by a need to say the “right thing”
or a fear of saying the “wrong thing.” Fused with these thoughts, they don’t say much at all.
Did we mention anxiety therapists can also be perfectionistic? Whether you are new to
exposure or have been practicing for years, we encourage you to experiment with different
methods to expand your repertoire for talking during exposure. It can be easy to fall into
the same, stale, boring patterns.
Take a few minutes to think about the prompts in the following exercise—maybe even
writing your answers out somewhere, if you feel it’d be useful.
Activity: Orienting Clients During Exposure

• What do I usually say during exposure?
• How can I try something new? What can I do to expand what I say to clients?
• If I were to be really bold during exposure, I might…
Talking That Increases Engagement Versus Talking That Distracts

In therapy, asking clients to describe their experiences during exposure can increase
engagement; it can also just as easily serve as a distraction. Probably all therapists who track
distress scores have had the experience of clients attributing decreases in distress scores to
being distracted. In a study by Benito et al. (2018), the researchers reviewed hundreds of
video recordings of exposure sessions to help distinguish between changes in client experi-
ences that occurred because of avoidance or distraction and changes that occurred through
engaging the exposure. They found that changes related to exposure engagement predicted
good outcomes, whereas changes from distraction and avoidance did not. Although we
want to be mindful of clients using distraction to avoid exposure, from an ACT perspective,
a little distraction can be a sign of psychological flexibility. Many clients would not predict
that they’d be able to think about anything else during an exposure exercise. Think about
when you were first learning to drive; you may remember that you struggled with any sort
of distraction—even having music playing! Maybe this still comes up when you’re driving
somewhere new (e.g., “Don’t talk, please. I’m looking for the cross street.”). As you became
more experienced with driving, though, you became comfortable enough at the wheel that
you could enjoy having the radio on or someone next to you to talk to as you drive. It might
be helpful to think about varying your degree of interaction from exposure to exposure to
see how your client reacts to your presence and conversation in the moment to assess their
flexibility in responding. For example, you might notice signs of flexibility such as the cli-
ent’s making lighthearted jokes or observations. You may also want to experiment with
periods of silence so that clients can practice paying attention to their internal experiences
and staying present with anxiety on their own as a way to bridge in-session exposure with
out-of-session homework.
Ultimately, being able to shift back and forth from focusing on internal experiences to
casually chatting with the therapist during exposure helps train clients in psychological
flexibility. Our concern is more with excessive or rigid forms of talking, such as when a
client is clearly putting forth intense effort to distract or reassure themselves; those are the
forms you’ll want to avoid.
Increasing Psychological Flexibility by Varying

Intensity During Exposure
When freed from an emphasis on habituation à la traditional exposure, there are many
reasons therapists may want to increase the difficulty of the exposure during in-session
practice. For one, variability in distress during exposure is related to better outcomes
(Culver, Stoyanova, & Craske, 2012; Kircanski et al., 2012). This makes sense given that
real world encounters with anxiety-provoking stimuli are likely to be less predictable than
assigned exposure exercises, which are, by design, typically more controlled. Similarly, cre-
ating structure around exposure exercises is important, especially in the beginning of treat-
ment—but the structure of exposure practice can become a hindrance if it doesn’t generalize
to clients taking opportunities to challenge themselves spontaneously outside of session.

Varying the difficulty of exposure in session is one way to give clients the texture of real
experiences of anxiety-provoking stimuli in a way that can generalize to their lives out of
session. Said another way, if a client’s experience with exposure is limited to structured,
predictable exercises, they may struggle to spontaneously approach stimuli when opportuni-
ties unexpectedly come up in their daily lives, or they may relapse if they encounter an
unexpected trigger.
Additionally, varying the difficulty of exposure in session can help to gently challenge
clients who may overestimate the difficulty of an exposure exercise or who initially agree to
only a conservative exposure exercise. We should note that the therapist should be explicit
that clients can freely choose to intensify exposure or not, and that it’s helpful for the client
to spend some time in the stages between escalations to practice core psychological flexibil-
ity skills with each adjustment to the exposure task. In this way, clients benefit from learn-
ing they can often handle much more than they had predicted—or that they feel more
engaged the more willing they are.
Some warnings do apply. The therapist should never surprise the client by amplifying
the exposure significantly beyond what was agreed upon. Therapists should also not force a
client to do more than they are willing. Here, the metaphor of a coach may be useful. It’s a
coach’s job to coax out the best performance of an athlete by helping them to repeatedly
step outside their comfort zone. Pushing athletes too little or too much can easily be seen
as ineffective in the mutually agreed upon goal of athletic performance. Similarly, as a
therapist, you should pay close attention to your clients and flexibly adapt your responses
during exposure to keep the goal of increasing the client’s psychological flexibility in mind.
After Exposure
It’s important to leave time after an in-session exposure to debrief what happened and
clarify out-of-session practice. This is an opportunity for clients to consolidate what they
learned. As clients often have insights into their experiences the therapist may not predict,
we recommend starting broadly: “What did you learn from the exposure today?” If the
therapist is lucky, the client spontaneously describes what they learned in ACT-consistent
language, shares how it was less difficult than predicted, and expresses enthusiasm for con-
tinued exposure work. And sometimes this exact thing happens. For example, a client
might say something like, “It was hard to be with the discomfort, but it also felt empowering
to stay with it, and my thoughts started to seem less believable!” But often, some additional
questioning is helpful in shaping client consolidation of learning. For this reason, it can be
useful to take notes during in-session practice, to talk through any changes in client experi-
ence during exposure, and to place client experiences in an ACT context. If a client states
they simply felt anxious, you might note if they were less anxious than they predicted or
they did not feel as overwhelmed as they had expected. We will discuss specifics in the
section “Troubleshooting Exposure” later in this chapter.
If there were fluctuations in exposure ratings, you might respond with:
• “I noticed your willingness decreased during the exposure, that you were less
willing as time went on. I’m curious what was going on for you there.”
• “It looks like exposure became more intense after ten minutes, then felt less intense
five minutes later, and then was more intense again toward the end. What was hap-
pening in your experience?”
• “You really increased your willingness quickly during the exercise! I was wondering
what was going on.”
During the debrief, it’s helpful to reinforce effective client behaviors such as their will-
ingness to stick it out or courage to engage in exposure therapy. Some clients are so focused
on their own anxiety that they may perceive the exposure as a failure because of how they
are feeling. Focusing too much on feelings can be a trap, as the goal of exposure is not to
make anxiety go away. Instead, focusing on behaviors, such as the way they approached
anxiety-provoking stimuli rather than avoiding them, can help enhance psychological flex-
ibility and shape clients into moving toward scary things when it’s important to them.
Sometimes it can be useful to highlight how well they responded while they were experienc-
ing intense anxiety to illustrate how the experience of anxiety can be compatible with
being a high functioning individual (e.g., “Here you were on the edge of panic, yet you still
worked hard to remain polite with the shopkeeper—to be the kind and respectful person
you want to be in those situations despite wanting to lash out with frustration!”). By using
supportive language, tone of voice, and body language, therapists can do a lot to help create
the context in which it feels good to do hard things, and they can increase the likelihood
that these adaptive client behaviors generalize outside of the therapeutic encounter. Be sure
to ask any questions you pose to your client from a place of genuine curiosity. Make a big
deal out of a client’s first completed exposure. “You did it! That was amazing! Imagine how
your life would be different if you could do more of that!”
Following the debrief, it’s important to define the out-of-session practice you want your
client to engage in. The same practice may be conducted out of session as it was in session,
or there may be adjustments based on what you learned in session. It can also be helpful to
identify when the client will practice (e.g., after work, by six) to increase likelihood of com-
pliance. Some clients are conscientious enough to budget the time on their own; others may
require more specific and structured instructions. We have included troubleshooting about
out-of-session exposure exercises below.
When Is a Client Ready to Move onto a

New Exposure?
In ACT-informed exposure, in the absence of habituation or focus on traditional distress
scores, how do you know when a client is ready to move from one exercise to another? A
functional approach is useful here. Are they able to consistently practice psychological
flexibility when in the presence of stimuli that they had previously avoided or responded
to in a restricted fashion? Does the client feel ready or willing to move on to a similar but
more difficult exposure exercise? Are they getting bored with the exercise, or is it
under-stimulating?
In our experience, adult clients quickly become excellent at assessing when they’re
“done” with a particular exposure exercise. They learn to recognize shifts in how they relate
to anxiety-provoking stimuli and are ready for a new challenge. The therapist could ask,
“Do you feel ready to move on, or would you like more practice?”
Troubleshooting Exposure
Here are some common problems with ACT-informed exposure and suggestions for address-
ing them. Before we go into specific questions, we’ll present a case illustration of how the
therapist may ideally set up each exposure to sidestep potential problems and maximize
success.
• Case Example: Samantha

Samantha was a client in her twenties who struggled with concerns around
contamination and health-related fears. Her exposure practice for the prior week had
been to repeatedly read an article about young people with colon cancer for thirty
minutes daily. She was usually friendly and engaging, but today she looked weary and
tired. She said she had practiced exposure to reading the article on two days for twenty
minutes each day and had not filled out her practice form—both signs of poor
compliance. When I inquired what her experience with the exposure had been, she
responded that she spent the week obsessing about skin cancer and wanting to contact
a dermatologist.
Although Samantha had chosen the article herself from several options, I’d been
concerned the article was too difficult for her at this stage in treatment. Additionally,
we’d only had ten minutes in our last session for in-session exposure to the task of
repeatedly reading the article—allowing her only enough time to read it about three
times—and she had remained fused with the content at the end of the session. In other
words, she had not had an opportunity to strengthen psychological flexibility during the
in-session exposure.
In prior sessions, Samantha had done well exposing herself to contamination
fears—touching items that had been lying on her hardwood floor and eventually walking
barefoot on it. However, we were just beginning this new type of exposure of reading
articles, and although Samantha had accepted the rationale that repeated reading of the
article would help her gain some distance from and greater perspective on these fears, she
remained skeptical that reading health-related articles would be helpful. Her skepticism
was based in her learning history: whenever she read or heard about cancer, she would
begin to obsess about it. In her experience, reading about cancer resulted in obsessing
about cancer.
So we tried to adjust the exposure task by choosing a less triggering article. The new
article was about a rise in colon cancer, and it was drier, presenting a series of facts and
statistics without any personalized stories of specific people as in the prior article. Per
Samantha’s request, I explained the rationale for using the article for exposure.
Check-in and homework review were kept brief to allow more time for exposure within
the session. Samantha repeatedly read the article for forty minutes in session. By the
end of the session, she had reported an increase in willingness (from 6 to 8 on a 0–10
scale) and a decrease in SUDS (from 6 to 3–4 on a 0–10 scale). She seemed more
engaged and relaxed.
When I asked what she learned through the exposure, she said she had noticed how
initially, she had focused on researcher quotes that were more catastrophic and had paid
less attention to the more nuanced passages. This time around, as Samantha was able to
read the article with a slightly more defused perspective, she noticed more balance in the
information presented. For instance, through repeatedly rereading the article, Samantha
was able to notice that some doctors and researchers cited in the article believed
increases in colon cancer among people her age remained statistically small and did not
warrant earlier testing, which also carried risk. Maybe the risk wasn’t as bad as she had
assumed. Samantha had also demonstrated contact with self-as-context in that she was
able to observe the shifting ways she interacted with the article from greater to less fusion
with content. She remained fearful of cancer but was able to acknowledge how her
anxiety initially interfered with her ability to take in the full content of the article until
she had read through it several times. In sum, Samantha had expressed an experiential
understanding of the exposure exercise.
In discussing this case example, I want to highlight two recommendations:

1. As much as possible, choose exposure exercises that are at a difficulty at which
clients can truly practice psychological flexibility. One pitfall with a focus on purely
values-based exposure is that clients may choose exercises that are important to
them but may be too difficult. Think of psychological flexibility as a muscle that
may initially be a little weak and becomes stronger with practice. Working with
your client to determine accurate distress or willingness scores for different tasks
may help you gauge an appropriate exercise at each point in treatment. Sometimes
we may allow a client to choose an exposure we predict may be too difficult for
them because it’s particularly important to them; however, we may then adjust it if
they struggle with the out-of-session practice (e.g., if they are consistently over-
whelmed or engage in avoidance behaviors).
2. Allow enough time in session for the client to understand experientially why the
exercise may be useful for them. Said another way, allow enough time for the client
to experience some increase in psychological flexibility during the exposure exer-
cise. For example, Samantha fully expected to obsess about cancer after reading
the articles. It did not occur to her that through repetition, she would be able to
read the articles with greater nuance, clarity, and objectivity. This is especially
important in the beginning of treatment, and it can remain important when begin-
ning a new type of exposure (e.g., transitioning from imaginal to in vivo). Earlier in
treatment, Samantha intuitively grasped how touching potentially contaminated
objects allowed her to develop a new relationship with them. When we shifted to a
different type of exposure—reading articles about health-related fears—her expe-
riential understanding from her prior exposures did not translate to this newer
exposure until she was able to spend more time reading and rereading a particular
article and responding with increased psychological flexibility.
Common Problems in ACT-Informed Exposure

As exposure therapists, flexibility is key to responding to complex issues that may arise
and cause roadblocks in the process. In our discussion below, we’ll take you through the
many different problems that therapists may face when doing exposure, as well as guidelines
to consider as you try to work through them.
Client Refuses to Engage in Exposure

Although it happens less frequently than might be expected, sometimes clients refuse
to engage in exposure. There are many reasons for this. Here are some common solutions.
• Return to your rationale. The more time you spend orienting clients toward the
usefulness of exposure starting from the first session (see chapter 5), the less this is
likely to happen unexpectedly. If a client is resistant to exposure, they will likely

make this known early on. Sometimes reaffirming that there is no way around pain
but through it and revisiting the consequences of their efforts to avoid discomfort
(e.g., creative hopelessness) may augment motivation.
• If a client refuses an initial exposure exercise, offer to adapt the procedure to some-
thing the client is willing to engage in or choose a different exposure. Offer to
tweak the procedure in ways that allow the client to increase willingness. One
important point: whatever you agree to, the client should be committed to follow-
ing through with the exposure while resisting urges to engage in avoidance behav-
iors. Be mindful of signs the client may engage in exposure half-heartedly. Any
deliberate engagement in avoidance behavior risks undermining the exposure.
There may be ways to titrate the difficulties of the exposure, such as including the
presence of a loved one, shortening the duration, or changing the time of day.
Ambivalence About Out-of-Session Practice

Although there are some exposure-based treatments that do not require out-of-session
practice, such as written exposure therapy for PTSD (Sloan & Marx, 2019), out-of-session
practice is very important in exposure therapy (e.g., Abramowitz, Franklin, & Cahill, 2003).
In our experience, anxiety clients tend to be on the conscientious side, yet homework com-
pliance can still be a problem. Sometimes it’s easier when a client doesn’t practice at all,
because you can more clearly address it. When practice falls somewhere in the middle (e.g.,
three out of seven days or five minutes instead of twenty), it can be more difficult to assess
if practice is too inconsistent to allow the client to progress and to gauge client commit-
ment. This is where a functional approach can be helpful: 50 percent compliance can be
interpreted differently and can have varying impacts, depending on each client and where
they are in treatment. For some clients, that might be a home run, given their life demands.
For others, it may reflect an ambivalence about treatment. For a new client, low compliance
initially may indicate the client’s acculturation process toward a more structured treatment
such as ACT-informed exposure, and their compliance may improve as the client gains an
understanding of the importance of out-of-session work and learns to budget time for it. In
all instances, it can be useful to spend time with clients to identify when and where they
will practice, explore the need for reminders (e.g., setting a reminder in their phone), and
send the clear message that the meat and potatoes of this work is practice, practice, prac-
tice. Basking in their therapist’s beatific presence once a week is unlikely to result in behav-
ior change.
When you and the client agree on a particular out-of-session exposure assignment, be
vigilant for signs of ambivalence. Unfortunately, in pop-culture depictions of therapy, all
the profound work happens in session with the therapist. This would be comparable to a
sports movie in which the protagonist never engages in formal practice and only plays com-
petitive games. New clients may come to treatment simply not expecting that they will have
to make time to complete work between sessions. Signs to look for include saying they will
“try” to practice (really, the word “try” is a big red flag). In response, you might say, “I heard
you say you’ll ‘try’ to do it. Whatever we agree to, I want you to walk out of here fully com-
mitted to it. We should choose something you can be confident you will follow through
with.” Alternatively, clients may agree to an exposure that is quite ambitious. If you have
the sense that the out-of-session practice they have chosen is too far of a leap forward from
where they are, gently engage them about what you are observing and encourage them to
reflect on what they can do with some degree of confidence.
Avoidance or Safety Behaviors During Exposure

Sometimes clients are compliant with the act of engaging with the feared stimuli but
continue to engage in avoidance behaviors during exposure. As we’ve noted, they may not
even be aware of what they’re doing. For example, clients with contamination fears may
lightly touch items with their fingertips rather than with their whole hand. This behavior
reinforces their fear, because the client is still treating the items as potentially dangerous.
Some clients engage in what are called “safety behaviors,” attempts to avoid, reduce, or
detect a potential danger. Safety behaviors are not all bad. We wear seatbelts when we drive
and helmets for certain activities, and we may lock our doors at night. The safety behaviors
we focus on in exposure work are those that are excessive and interfere with psychological
flexibility. Washing your hands once when using a public restroom is prudent, but being
absolutely unable to leave a restroom without washing your hands or having to wash your
hands multiple times—every time—can interfere with daily living; you might end up late
to work because you didn’t feel confident you were clean, or your hands may be dry, cracked,
and bleeding from the excessive washing, and so on.
Although it’s been theorized that client engagement in safety behaviors always nega-
tively impacts treatment, it’s not clear they’re invariably a hindrance to exposure work
(Blakey et al., 2019; van den Hout, Engelhard, Toffolo, & van Uijen, 2011). As one recent
review concluded that, overall, safety behaviors are more likely than not to interfere with
exposure (Blakey & Abramowitz, 2016), it’s better to err on the side of helping clients
engage in exposure without them, as reliance on them may limit psychological flexibility.
A metaphor one of us uses with clients is rivulets feeding an anxiety river. The more
rivulets that feed the anxiety river, the stronger it flows. Although we may not be able to
block every single rivulet, we want to disrupt as many as we can to weaken the flow of the
river as much as possible. Every avoidance behavior is a potential rivulet. Even if some
appear small and inconsequential, they nonetheless reinforce anxiety and psychological
inflexibility, and they should be disrupted as much as possible. Other examples of subtle
avoidance behaviors in clients include:
• Mental reassurance (I’m going to be okay)
• Use of humor to deflect from feelings
• Avoiding eye contact
• Body tension
• Covert deep breathing
• Doing exposure quickly (i.e., getting it over with)
Sometimes clients can’t let go of their control agenda, their focus on avoiding discom-
fort. The client may appear to be working hard: they understand the rationale, they’re
willing to do difficult exposures, and they complete all their homework. After weeks of
working through the exposure menu, the client remarks that they don’t feel any better and
wonders what else they could be doing. Sometimes, client behavior looks ACT-consistent,
but the client is functionally engaging in subtle forms of control or avoidance. Whenever
they experience any anxiety, they fuse with the idea that they should be able to make it go
away and that there’s something wrong with them if they can’t. Control agendas can be
sneaky and subtle. But it’s important to note that this isn’t a problem per se; rather, it’s an
opportunity for the client to gain a deeper understanding of how their behavior is keeping
them stuck. If you suspect this is happening, assess for it, point it out, and continue to prac-
tice. In our experience, the repetition of well-designed exposure exercises is one of the best
ways for clients to learn to let go of their focus on control. Regardless, it can be important
to address in session. Slow down and direct a client’s attention back to their present-moment
experience and focus on the process of what is happening rather than the content they are
presenting with. Some prompts might include:
• “Would you be willing to spend thirty seconds just being present with the anxiety
symptoms that you are feeling right now?”
• “Your mind is working hard to try to understand this experience. I wonder if we

could take a moment to step back and just witness it—without words, labels, or
descriptions?”
• “Where in your body do you feel anxiety the strongest right now?”
If their difficulty in being present reflects a genuine skills deficit for the client, it may be
useful to suspend exposure work and focus on developing awareness of private events
through simple experiential exercises, affect labeling, emotion charts, and mindfulness
exercises.
Conclusions
Err on the side of success with the initial exposure exercises to help orient clients to ACT-
informed exposure and allow them to practice psychological flexibility. Also, always think
functionally. Are we targeting what we want to be targeting? Is the client having a different
experience with the stimuli? Last, be alert for signs of covert avoidance (e.g., low willing-
ness) of which even the client may be unaware. Talk these through with the client as you
explore potential barriers to strengthening psychological flexibility during exposure.
In this chapter, we covered how to engage exposure with clients. In the next chapter,
we’ll explore how we know when the client is done with exposure and ready to discontinue
treatment or shift to another treatment focus. Should we use empirical measures, tracking
forms, or verbal prompts? Also, how do we know when we are finished? Do we ask the client
if they feel finished, trust our gut—or do we simply end when we run out of ideas for things
to do?
CHAPTER 7
Ending Treatment
In ACT, engagement in valuing helps inform action toward larger life directions. There is
no end goal in pursuing values. Similarly, there is no end to increasing psychological flexi-
bility—we can always strive to improve. Given that, it can be hard at times to decide on an
ending point for ACT. So the question for this chapter is: how do we know when a client’s
done with ACT-informed exposure?
The goal for ACT-informed exposure, ideally, is that clients develop sufficient psycho-
logical flexibility that they can continue to move toward meaningful life directions without
the structure of regular therapy. Sometimes clients come to us expecting to be in treatment
for months or years. Fortunately, anxiety-related issues tend to respond well to time-limited
treatment. If treatment goes well, clients will inevitably graduate. Even clients who tell us
they expect to be in treatment for a long time may find themselves ready to end sooner than
they expect.
Here we’ll identify signs that a client is ready to complete treatment and explore ACT-
informed principles for making decisions about termination. For the purposes of this
chapter, we’re going to assume you and the client engaged in what appeared to be a success-
ful course of ACT-informed exposure—however that’s defined. While we can’t give you
concrete criteria to determine when it’s time to end treatment, we can suggest some useful
behavioral markers that often indicate when clients are ready to graduate therapy. Whether
it’s you or the client who first brings up termination, it’s helpful to spend some time carefully
considering whether the time is right, especially in cases where it’s not so clear-cut.
Clients Say, “I Think I’m Done”

In our experience, clients are pretty good judges of when they’re ready to complete treat-
ment. They’ve met their treatment goals—or at least the goals that are most important to
them. They find their daily lives easier to navigate. They’re more engaged in values-based
activities. They find they have the psychological flexibility to work through anxiety-related
triggers. Maybe they’ve even made changes in their life they didn’t think were possible (e.g.,
new job, going to college). More importantly, they express confidence that they can handle
any future ups and downs.
Most of the time, clients ready to end treatment will be able to identify aspects of
therapy that have been helpful in ways that inspire confidence in you as a therapist: Phew,
they got it! Occasionally, some clients tell you they “feel better” but cannot tell you why. In
the most crushing blow to the therapist’s ego, sometimes the client cannot even say with
any confidence that treatment was helpful. Perhaps perceiving how transparently thin-
skinned and starving for praise we are, these clients will shruggingly offer that treatment
may have been helpful. However, they cannot point to why. They can’t identify any skills
they’ve learned. They don’t think their daily functioning has changed in any significant
way. They simply find they’re less anxious than they were before they came to therapy. This
may be due to several reasons. First, some clients are poor reporters of therapy progress and
have trouble concretely naming the things they did that were helpful—that is, some clients
simply don’t realize how mind-blowingly helpful their therapist was. In other cases, these
spontaneous improvements may reflect what’s called regression to the mean: clients came
to treatment during a particularly bad time, and after some time had passed, they gradually
returned to baseline on their own.
Additionally, clients sometimes feel better just by taking action and scheduling that
first appointment. They may benefit from nonspecific components of treatment, such as
talking about their problems, meeting with an empathic therapist, and setting aside time
each week to focus on themselves. Some of these nonspecific benefits of treatment are what
are called “common factors” of treatment and include therapist alliance and client expecta-
tions of treatment (Wampold, 2001). Although common factors may account for improve-
ments in some anxiety clients, the impact of the common factors varies by disorder, and it’s
likely some combination of common factors and specific techniques such as exposure that
account for improvements in anxiety (Strauss, Huppert, Simpson, & Foa, 2018; Cuijpers,
Reijnders, & Huibers, 2019).
Meaningful Living
One of the first things to assess when you’re thinking about ending treatment is how
clients are doing day to day. Are they engaged in meaningful activities? Does life feel man-
ageable for them? How confident are they that they can handle what life throws at them?
In ACT terms, are they demonstrating psychological flexibility in how they manage diffi-
culties, and are they engaging in valued living? This greater focus on functioning may be a
difference between traditional exposure and ACT-informed exposure. Decisions about
ending treatment in traditional exposure may be more focused on symptoms and anxiety
levels, whereas in ACT-informed exposure decisions may be more focused on functioning
and valued living.
Sometimes clients return to how they were living before anxiety became a problem. As
rewarding as this is, what’s even more rewarding is when clients tell you they’re doing better
Ending Treatment95
than they ever have or even thought was possible. For many clients, anxiety has impacted
their functioning for much of their lives. For years, they tried to work around or ignore it.
They gave up on pursuing things that they wanted to do (e.g., college, relationships, chal-
lenging work). Life wasn’t great, but it wasn’t quite bad enough to seek help until it became
painful enough that they came to see you. As a result, these clients never realized how
impairing their anxiety was for them. For them, it was normal. They simply suffered through
it until it started to get in the way of things that were important to them. After a successful
course of ACT-informed exposure, these clients discover they’re functioning at a higher
level than they’d ever imagined. They’re living more satisfying lives than they had prior to
treatment and are more confident in their ability to handle problems in the future. This can
be one added benefit of the focus on values in ACT-informed exposure. It can prime clients
to look beyond symptom reduction toward the broader life directions they want to pursue.
Maybe they’re still anxious about some things, but now they’re more out in the world doing
the things that matter most to them.
Client Has Completed the Most Difficult Exposure

Menu Items
As the goal in ACT-informed exposure is increasing psychological flexibility, checking
off and completing exercises on the exposure menu is one useful behavioral marker of prog-
ress. This doesn’t mean that clients must complete every single item on the original expo-
sure menu, since completing the most challenging items may indicate that going through
the entire menu is not necessary. If, after tackling the hardest items, a client indicates they
could complete the remaining exposures with minimal difficulty, you may consider crossing
off those items from the list. We offer the caveat, however, that it’s important that exposure
work translates or generalizes to daily living.
Signs Ending Treatment May Be Premature

If someone has completed all the exposure menu items but continues to engage in regular
avoidance behaviors in their daily life, we might classify potential barriers in various ways.
Exposure Practice Has Not Generalized

As noted in the prior chapters, the goal of exposure is to help clients practice and
strengthen psychological flexibility in contexts that typically restrict or narrow their ability
to flexibly respond. If the client has completed all the exposure menu items on their list and
is still either regularly engaging in avoidance behavior in day-to-day life or is not doing the
activities that are important to them, you may want to reassess their current functioning. In
these instances, it’s possible that exposure work has not generalized to daily living. Steps to
increase generalization of learning may include identifying additional formal exposure exer-
cises to further strengthen psychological flexibility in situations where clients are still
engaging in avoidance behavior and adding them to the exposure menu. At the end of
treatment, however, it may also involve identifying broader ACT behavioral commitments
in addition to or even in lieu of specific exposure exercises. If clients are not as engaged in
valued actions as they would like, help them identify concrete actions they can take toward
valued directions. For example, if a client is unhappy in their current job but has not taken
steps to look for more meaningful work, some combination of exposure exercises and com-
mitted action strategies may be useful here. From an exposure perspective, perhaps the
client may benefit from imaginal scripts targeting fears related to the job process. Keep in
mind, though, that the client may not need additional exposure at all. It can be easy to get
into “exposure tunnel vision,” where the therapist tries to solve all client problems with
exposure. Instead, it may be more helpful to use committed action strategies to help the
client develop a plan for applying for jobs. You may help this client set aside regular time
each week (e.g., Saturday morning from nine to noon) and break down tasks into smaller
behavioral commitments (e.g., check for new job postings, revise cover letter).
Another method of generalizing learning is varying the contexts of the exposure exer-
cises. Contexts may include different times of day, different locations, alone versus with a
trusted other, and mood (e.g., anxious versus calm). If a client can eat at restaurants during
less crowded times but avoids weekend dinner hours, consider targeting this context specifi-
cally. A client with driving-related fears may be able to drive anywhere they want during
daylight hours in clear weather, but they may avoid driving after dark and when it’s raining
or snowing. Continue brainstorming potential exposure exercises that would be challenging
for them until they can engage in valued behavior anytime, anywhere, and under any
circumstances.
Client Has Been Unwilling to Let Go of Specific

Safety Behaviors
Daniel, who struggled with panic while driving, completed all the driving exposures on
his exposure menu and then some. He was able to drive on the highest bridge in his
city—something he had never imagined he could do. In debriefing, though, we realized
that, because he approached every exposure with his husband riding as a passenger—so
that his husband could take the wheel if Daniel became overwhelmed—rather than
completing the exposures alone, he remained unwilling to drive over unfamiliar bridges or
Ending Treatment97
on freeway routes by himself. In short, although Daniel had made great strides—more
than he thought were possible—he was still limited by only being able to drive under
certain conditions. We spent the next several sessions identifying new driving exposures
for Daniel to willingly practice driving alone. Once the exposures were completed, Daniel
expressed greater confidence in his ability to drive anywhere.
In the example above, driving with his spouse was a safety behavior for Daniel.
Once he was familiar with a route with a passenger, he was more confident in driving
new routes alone.
As we’ve noted, some safety behaviors may interfere with treatment, and some may not,
depending on the feared predictions and client understanding of these behaviors (Sy, Dixon,
Lickel, Nelson, & Deacon, 2011). For example, many of us feel safer driving when we have
our cell phone with us, so that we can use a trusted maps app or contact someone in an
emergency. For many of us, if we’ve forgotten our phone, this isn’t a problem, and we can
continue with what we’re doing. However, if we can’t drive unless we have our cell phone
with us—because we’re terrified that we could get lost or be unprepared for an emergency—
then this safety behavior may be a problem that could interfere with flexible responding.
Safety behaviors may even provide useful bridges—literally, in the case of Daniel!—to
new and more challenging exposure exercises. Similarly, training wheels on a bicycle may
allow children to develop their strength in pedaling, but it’s important to eventually take
the training wheels off. If they’re not removed, training wheels will interfere with a child’s
ability to learn to balance and trust that they can stay upright while riding. Similarly,
behaviors that may facilitate treatment progress across exposure exercises can become bar-
riers to completing treatment if they’re not eventually discarded (Blakey et al., 2019). With
his husband riding along, Daniel was willing to engage in exposure to routes he would have
refused to drive alone. From there, it was important that he learn to be willing to drive
those and eventually new routes entirely on his own—without first approaching them with
his spouse. Once he could do this, Daniel had more confidence that he could tackle any
novel routes on his own in the future.
Sometimes clients are unaware of their safety behaviors because they’re so subtle and
habitual. Other clients may be so fused with their safety behaviors’ perceived importance
that they aren’t able to imagine not engaging in them. These clients may assume every
sensible person would do the same thing. Some clients are aware of their safety behaviors
yet reluctant to spontaneously bring them up because they know their therapist is going to
ask them to stop doing them. In these situations, clients should be reinforced for acknowl-
edging their safety behaviors, even if they’ve deliberately delayed doing so. For example:
Therapist: Thank you so much for mentioning that you always make certain you
have your phone on you so that you could call someone in an emergency!
I didn’t think to ask about this. Because there might be times you want to
leave the house without your phone, we’re going to want to do some
practice where you deliberately leave it behind.
In sum, if a client has completed all items in their exposure menu, but improvements
have not generalized to daily life, this might be a cue to reassess for the presence of safety
behaviors or to target any safety behavior that may have initially appeared harmless. The
presence or absence of safety behaviors may be the difference between a client who needs
to continue treatment and a client who is ready to complete ACT-informed exposure.
Fusion with Rigid Ideas About Progress

Clients often come to therapy with certain ideas about what success in treatment looks
like. Many clients eventually appreciate the very real strides they make in treatment through
their hard work, even if they’d initially imagined a rosier outcome. For other clients, being
fused with ideas that are idealistic and unrealistic can interfere with taking steps toward the
actual change that is possible. For example, a client may imagine that they will turn into a
version of their sibling, who is a carefree and chill free spirit. They may imagine that
“normal” people don’t experience intense anxiety. These occasions represent opportunities
to explore client expectation (e.g., “What were you expecting to happen?”). In our experi-
ence, fusion with ideas about treatment progress is mainly an issue earlier in treatment. As
clients develop greater psychological flexibility through working with ACT ideas, concepts,
and experiential exercises (including exposure), these barriers start to melt away, and they
generate new ways of responding to anxiety. For example, one client who completed a
course of treatment of exposure for emetophobia (fear of vomiting) stated, “I never thought
that my anxiety could still be there but not bother me so much!”
Habitual Engagement in Avoidance Behaviors

Jake successfully completed a series of germ-related contamination exposures. However,
he reported he was still washing his hands several times a day. He noted that the
behavior was habit and that he would find himself in the bathroom washing his hands
multiple times during the day without thinking about it. When he made the effort to limit
handwashing to only specific scenarios, like before and after meals, he found it was
easier than expected and within a few weeks, settled into this new pattern.
Some avoidance behaviors become so well-practiced they’re almost second nature. In

these cases, the avoidance behaviors may not function the way they used to—they may fail
to provide any emotional relief—yet they’re still maintained because we’re creatures of
habit. Clients may engage in avoidance behaviors mindlessly, without even being aware of
Ending Treatment99
what they’re doing. In these instances, they may need to make a conscious effort to be more
vigilant toward when avoidance behaviors occur and make a deliberate effort to notice and
accept the urge while choosing to refrain from the behavior. In doing so, clients may find
they have little difficulty letting go of the urge when they make a concerted effort. We
might call addressing small avoidance behaviors “pruning.” Even if they seem minor,
addressing small avoidance behaviors can be the difference between a client feeling “kind
of” ready and fully confident in their ability to end treatment.
Here’s some sample text for how a therapist may communicate the importance of elimi-
nating avoidance behaviors to clients:
Therapist: In the beginning of treatment, I had no expectations that you would try
to resist avoidance behaviors above and beyond the specific exposure
exercises we agreed upon. In fact, it may have been too difficult for you to
spontaneously stop these. Some of your triggers are unpredictable and
unexpected, and you may have felt overwhelmed. However, now that
you’ve done such a great job working through your exposure menu, and
we’re getting close to being done with treatment, these behaviors are
going to get in the way of you being able to be the person you want to be
and do the things that are important to you. Moving forward, it’s vital
that you be mindful of these behaviors—no matter how big or small.
Notice them and choose to let them go without acting on them. Even the
small ones can interfere with further progress. If you forget and miss one
or two here and there, it’s not a huge deal, but each time you’re aware of
an urge to engage in a safety behavior, it’s incredibly important to be
mindful of staying present with your discomfort while not engaging in the
safety behavior.
Client: You’re right. I kind of knew this was coming. I had hoped they would go
away on their own, but I realize now I’m going to have to be really
disciplined moving forward.
You might need to work with clients in creating a plan and being more disciplined in
targeting these behaviors, such as completing a tracking form or setting a reminder on their
phone. Sometimes clients may be less willing to let go of certain unhelpful behaviors. We’ll
address more intransigent instances of avoidance behaviors in chapter 10.
Assessment of Change
So far in this chapter we’ve focused on behavioral markers of change. However, assessment
measures can provide additional data for making decisions on ending treatment. Formal
assessment may even be required in some clinical settings. Assessment may include stan-
dardized interviewer-administered or self-report measures, samples of clinically relevant
behavior, or idiographic measures created by the therapist.
In our experience, many clients don’t like completing measures, because they can be
tedious, especially if they’re administered too frequently. However, we’ve found that clients
do appreciate having concrete evidence of how they’re progressing in treatment. Thus,
when you explain to them that such measures can be helpful in gathering data to inform
treatment and measure progress, it may be refreshing for clients who had negative experi-
ences with prior therapists who did not use any form of progress monitoring to assess if they
were benefitting from treatment.
Empirically Validated Measures

As there are many empirically validated measures of anxiety-related symptoms and of
ACT processes, it’s beyond the scope of this book to provide a thorough list of formal
assessment measures. Additionally, given that new measures of ACT processes continue to
be developed at a rapid pace, any attempt to provide a complete review of ACT-relevant
measures would be obsolete by the time you’re reading this. For a continually updated list of
ACT-relevant measures, we suggest you check out: https://contextualscience.org/actspecific
_measures.
If you’re going to be hand-scoring measures, we suggest you look for measures that are
on the shorter side (e.g., fewer items) and are uncomplicated to score. For example, mea-
sures with multiple reverse-scored items are more complicated to hand-score than measures
where you simply sum client ratings. Creating your own spreadsheets with built-in scoring
formulas can save time.
Using measures with clear cut-off scores and norms can be helpful in assessing treat-
ment progress. Some measures identify ranges of scores by severity ratings—such as mild,
moderate, severe, or extreme ranges—or they may offer a cut-off point between ratings of
relevant behaviors that are clinically significant or not. By contrast, some measures widely
used in research studies are not as easily interpretable at the level of the individual. For
example, some measures don’t have clear cut-off scores; instead, these measures are used
with large samples of people and require statistical analyses to interpret whether there are
significant changes in treatment. For example, the Acceptance and Action Questionnaire
(AAQ-II; Bond et al., 2011) is a widely used measure of psychological flexibility in ACT
research. At the time of this writing, however, while there are means reported for various
populations, there are no established markers of clinically significant change in the AAQ-II
when administering to individual clients.
We’ll note here that measures of symptom severity, while useful, may provide a limited
window into psychological flexibility. For example, there’s evidence that there’s a weak
Ending Treatment101
relationship between anxiety symptom severity and functional impairment (McKnight,

Monfort, Kashdan, Blalock, & Calton, 2016). Clients may report severe anxiety symptoms
yet remain high functioning—or vice versa. Additionally, there may be delayed effects in
improvements from ACT-informed exposure. There’s evidence that increases in psychologi-
cal flexibility earlier in treatment predict symptom reduction later in treatment (Twohig,
Vilardaga, et al., 2015), and that improvements in quality of life may take longer than
improvement in symptoms (Craske, Niles, et al., 2014).
In sum, we recommend choosing easily administered and scored measures that provide
clinically relevant information through which to assess treatment progress. We also recom-
mend flexible use of measures with your clients. While it may make sense to closely track
one client’s progress with a particular set of measures, it might make less sense for another
client. Getting into routines, such as always administering a similar set of measures after the
first session, can be helpful in remembering available tools that offer great clinical utility.
Tracking Behavior Change

As described in chapter 3, ACT is rooted in the behavior analytic tradition with a focus
on predicting and influencing meaningful behavioral change. While the psychological field
as a whole has relied on pen-and-paper self-report measures (such as those recommended in
the prior section), where people are asked to report the frequency and severity of their
thoughts, feelings, and behaviors, the behavioral tradition has historically been skeptical of
these forms of assessment, since they rely on data that’s difficult to independently verify,
due to not being observed directly by the therapist (e.g., Barlow, Nock, & Hersen, 2009).
Similarly, when working with small children, the focus is often on behavior that is observ-
able to others, such as parents and teachers. Consequently, the behavior analytic tradition
has sometimes eschewed nomothetic measures (measures that are empirically validated
with groups of people) that focus on internal experiences in favor of idiographic measures
(measures that are chosen for and tailored to the individual) of observable behavior.
In single-case experimental design studies (e.g., Barlow et al., 2009), a type of research
study that may have as few as a single participant, researchers focus on sampling relevant
behaviors related to their research questions. Usually in these instances, they track behavior
quite frequently (e.g., daily, hourly, every minute) to assess changes more clearly. Data is
graphed with the notion that, if behavioral change occurs, it should be apparent enough
that it can be perceived visually on a graph. For example, in single-case design studies of
ACT treatment for OCD, the researchers measure daily engagement in compulsions (B. L.
Thompson et al., 2021; Twohig, Hayes, & Masuda, 2006). Assessment doesn’t need to be
complex, as Twohig and colleagues simply gave participants a 3 x 5 index card to track
compulsions.
Below (table 7.1) is an example of a simple way of tracking clinically relevant behavioral
change using idiographic measurement. A client with OCD was asked to write down the
number of minutes she engaged in compulsions per day as part of a more comprehensive
tracking form. She completed the form before bed each night. The therapist used standard
Microsoft Excel software to graph daily ratings. For this client, the phase labeled “baseline”
consisted of two sessions devoted to information-gathering (e.g., intake; assessment of
obsessions and compulsions). At the third session (which signals the transition to the ACT-
informed exposure phase), the client was oriented to the ACT model through metaphors
and experiential exercises before moving into exposure work. Although there are occa-
sional spikes in daily rituals, you can see a gradual decrease—particularly toward the end of
the figure. This is an example of how therapists may target and track clinically significant
client behavior.
Table 7.1
Date Time Trigger—thought; feeling; Describe ritual (mental or # Min.
bodily sensation context physical)
300
Baseline ACT-informed exposure
Rituals - Minutes
200
100
0
1 51 101
Days
Again, this kind of measurement is idiographic in that it is chosen and tailored to the
individual. Use of SUDS and willingness scores, as mentioned in prior chapters, are other
examples of idiographic assessments. In short, tracking concrete behaviors relevant to your
Ending Treatment103
client’s treatment goals can provide clinically relevant information that is every bit as
valid—if not more valid—than common multi-item assessment measures, and the use of
behavior tracking is consistent with the rich behavior analytic tradition upon which ACT
was founded.
Reducing Frequency of Sessions

As therapy progresses into middle and late stages, you may begin to reduce the fre-
quency of sessions. For example, you may transition from meeting every week to meeting
every other week—or once per month. This reduction may occur even before you decide to
begin the process of terminating with a client, or it may occur after you and the client have
started to discuss ending treatment. There are several benefits of this arrangement to
consider:
• First, reducing the amount of contact with clients is helpful in gauging how well
they can maintain their treatment gains without the structure of weekly sessions. If
you reduce frequency to every other week, and the client begins struggling to main-
tain their gains, it might mean they’re not yet ready to end treatment. You can also
consider reducing the amount of formal exposure homework given in session or out
of session to test how clients are able to engage in clinically relevant behaviors on
their own between sessions. Are they engaging in spontaneous behavioral commit-
ments in ways that indicate increased psychological flexibility? If so, they are more
likely to be ready to graduate therapy.
• Second, reducing session frequency communicates to clients your confidence in

them. It’s empowering to let clients know that you believe they’re ready to see you
less often and to practice the things you’ve worked on together on their own. This
is especially important for clients who fear relapse if they discontinue treatment or
may have become dependent on their therapist. Such clients may require more
explicit efforts to transition toward independence. Some clients may want to linger
and stay attached to therapy even if it feels to you as if you aren’t actively working
on things together.
ACT-informed therapists may differ in the degree to which they’re open to less-focused
therapy. Some exposure therapists prefer time-limited therapy targeting specific, clearly
defined treatment targets, and they are most engaged when their caseload is filled with
these types of clients. Other therapists are more open to deviating from a structured
approach and enjoy a combination of focused exposure work while helping other clients
work on broader, more long-term treatment goals (e.g., valued actions). In ACT-informed
exposure, you might conceptualize this as a shift from a focus on specific exposure exercises
to broader committed actions toward valued directions (e.g., finding a more meaningful
career). We’re not here to tell you how you should practice or that one style is better than
another. However, we do recommend reflecting on what type of work you ideally like to
engage in so that you have a clear idea of what you want when making decisions around
terminating with clients.
Relapse Prevention
Even when clients successfully complete ACT-informed exposure, there’s always the possi-
bility of relapse. This is not necessarily the client’s fault. For example, stressful life events
increase the possibility that anxiety-related problems will recur (Francis, Moitra, Dyck, &
Keller, 2012). Consequently, it’s not unusual for clients to experience a resurgence of symp-
toms after a successful course of ACT-informed exposure. Maintenance of treatment gains
for ACT-informed exposure are comparable to those for traditional exposure (Arch, Eifert,
et al., 2012; Twohig et al., 2018).
It’s important to prepare clients for the possibility of problems with anxiety returning
after treatment ends. Some clients end treatment feeling empowered with skills for manag-
ing anxiety in the future. Other clients feel better but remain hypervigilant for any signs of
recurrence, worried they won’t be able to maintain treatment gains. Relapse prevention may
be particularly important for these latter clients, as they may panic at any sign of increased
anxiety. One benefit of ACT-informed exposure—which emphasizes psychological flexibil-
ity over symptom reduction—is that clients may be better prepared for an eventual return
of symptoms compared to those who completed exposure-based treatments focused on
habituation (Arch & Craske, 2011).
One distinction that can be useful to make with clients is between a “lapse” and
“relapse.” A lapse is simply an increase in symptoms and perhaps a temporary return of
avoidance behaviors and impairment. As an example, a client undergoing a lapse may start
engaging in avoidance and safety behaviors for less than an hour or as long as a few weeks.
It can be helpful to normalize for clients that a lapse is temporary. So long as clients remain
committed to employing skills learned in therapy, such as not resorting to older patterns of
avoidance, the lapse will likely pass.
Compared to a lapse, a relapse is more severe and reflects greater lost ground, such as
more frequent and prolonged engagement in unhelpful avoidance behaviors and impair-
ment in daily functioning. During a relapse, it might be helpful for clients to return to treat-
ment for what might be called “booster” sessions. Some clients interpret relapse as a sign of
personal failure, that they’ve lost all treatment gains and are starting over. It can be helpful
to emphasize that ACT-informed exposure involves new learning through expansion of
behavioral repertories—and like anything we learn, skills can become rusty when we don’t
use them. Sometimes clients are victims of their own success! When life goes too smoothly,
Ending Treatment105
we have fewer opportunities to practice strategies that are necessary during more difficult
times. Returning to treatment is not necessarily a return to square one, but an opportunity
to revisit what’s worked in the past and maybe to add a few new skills to one’s repertoire. If
a client had already completed a successful course of ACT-informed exposure, we might
assure them that they’ve “already done all the heavy lifting” (i.e., the hardest work), and
that any future courses of treatment may be shorter than the first. And while clients would
prefer to believe that a finite course of treatment would set them up for a problem-free life,
it’s more realistic to expect there will be ups and downs. After all, the learning that occurs
in ACT-informed exposure is often at odds with years or decades of unhelpful messages
about emotional control or habits of avoidance. Each client’s process is unique to them, and
helping to normalize the unexpected twists and turns that anxiety may take can potentially
reduce any self-blame or disappointment.
In sum, it’s important to prepare clients for the reality that they’ll have good and bad
times following treatment. The balance is to both let them know you’re confident in their
ability to handle resurgences in symptoms, while letting them know it could be helpful to
return to treatment if they need some extra support down the line.
Termination
Termination refers to the ending of therapy. While one can find many books, articles, and
theories about the process of terminating, we want to mention a few benefits to having a
thoughtful approach to ending treatment. First, it can be helpful to take time to review
treatment gains. Even clients who’ve made a lot of progress may not be able to identify all
the reasons why they’ve improved in treatment, and some clients may have trouble listing
even a few. There’s an advantage in clients being able to name skills or principles they found
useful in therapy: it helps them remember those principles in the future. For example, being
able to name the skill “willingness” turns an abstract concept into a thing the client can
tangibly recall. Once it’s a thing, it’s more likely to be remembered or used again in the
future. However, we don’t believe clients need to understand the ACT hexaflex or be taught
ACT middle-level terms. You may use the clients’ own words to describe important skills.
We can assume that with time, clients will forget what they’ve done in therapy. They
may even forget your name! Helping clients walk away with a concrete analysis of what they
did in ACT-informed exposure can serve as a handy resource in case their anxiety returns
in the future. Did you provide recordings of guided experiential exercises they could revisit
in the future? Were there particular ACT metaphors with which they connected?
Sometimes clients are scared to end treatment. As they may have lingering fears and
may be reluctant to volunteer this information, it can be helpful to directly ask, “How are
you feeling about ending therapy with me?” or “Do you have any concerns about this being
our last session?” You might want to validate that ending involves a loss of support and that
they’ll likely need to be more self-reliant. Other clients may need help accepting the uncer-
tainty of not being able to predict how things will go. Just because a client is anxious during
their last session doesn’t mean it isn’t a good time to terminate. Normalize that it’s under-
standable to be anxious or to feel sad. You might even consider self-disclosing how you feel,
if you think it would be valuable for the client to hear. Many clients may not have had prior
healthy experiences of saying goodbye to someone important in their life. Termination is an
opportunity to model saying goodbye while accepting difficult emotions and to demon-
strate the psychological flexibility you’ve worked so hard to strengthen throughout
treatment.
Referring
Sometimes termination happens for reasons that are not celebratory, such as a client’s
not benefiting from treatment or because there are financial restraints, changes in insur-
ance, moving away, or some other obstacle that prevents a client from completing treat-
ment. In these cases, it’s best to be honest about what’s happening and direct in your
recommendations, even if it’s hard to hear.
Though it may be hard for us to admit, sometimes we’re not able to help a client.
Perhaps it’s simply just not a good match between personalities or not all clients may take
to ACT-informed exposure. In general, if therapy is not going well and a client does not
appear to be benefitting from ACT-informed exposure, one should consider referring to
another clinician (Natwick, 2017). If a client is not connecting with an ACT approach, you
may consider referring to another therapist with a different approach (e.g., cognitive
therapy). While some clients may be reluctant to start over with a new professional, if
handled well, this can be an extremely beneficial decision for clients.
Conclusions
Although there are many useful markers for assessing when a client is ready to complete
ACT-informed exposure (e.g., assessment measures; behavioral markers; completion of
exposure menu), perhaps the simplest way to assess client readiness to end therapy is to
have a conversation about it, so that you can explore whether they also think they’re ready
to graduate from ACT-informed exposure. Normalize the recurrence of anxiety, making a
distinction between a lapse (e.g., temporary and short-term return of symptoms) and relapse
(e.g., engagement in avoidance behaviors and decline in functioning) to help prepare clients
for any future return of anxiety. Review treatment gains with each client to help them con-
cretize what you’ve done in your therapy together.
Ending Treatment107
This ends our series of chapters on how to orient to, conduct, and end ACT-informed
exposure. In the next chapter, we’ll walk you through how to create procedures, forms, and
worksheets that are tailored for your own practice, and that will help guide you and keep
you on track in implementing ACT-informed exposure.
CHAPTER 8
Create Your Own ACT-Informed

Exposure Forms
If you’ve attended more than one ACT training, you know that there’s a variety of ways of
doing ACT. One goal of this book is to help you adapt ACT-informed exposure using lan-
guage that, while ACT-consistent, matches your own style and the context in which you
work. We have deliberately stopped short of providing you with a treatment protocol or too
many examples of forms because we want to encourage you to think more functionally
about how you use forms. How will the specific forms and worksheets you use with your
clients help them develop their skills or take steps toward their particular goals? With every
form or worksheet that you develop, think about behavior and languaging that is consistent
with how you practice and the clients with whom you work. And consider the reason for
any decisions you make. Because behavior change is hard for therapists too, creating new
forms for your practice is one way to shape how you develop your skills in facilitating ACT-
informed exposure. This part cannot be overstated. Without forms and written procedures
to guide you, it’s easy to fall into doing what’s familiar and comfortable. Consider your
written materials as a way to keep both your client and you, the therapist, on target during
treatment.
Creating your own materials helps in:
• keeping you on track (otherwise, it’s easy to fall into bad habits);
• developing a structure that you may modify over time; and
• maintaining clarity about the model that you are using.
This chapter will focus on helping you develop two types of forms to support your ACT-
informed exposure practice:
• client self-monitoring forms; and
• exposure forms.
A few additional notes before we dive in. If you were trained in CBT and traditional
exposure, you are probably comfortable giving clients a variety of worksheets and out-of-
session assignments. If you don’t have a CBT background, integrating the use of forms and
worksheets into your practice may feel less familiar. If you’re completely new to CBT and
exposure, you may even consider first practicing with a structured protocol—even one
based on traditional exposure—to learn the basics, and then integrating the approach we
outline here. Also, although this chapter emphasizes developing your own written materi-
als, we also encourage you to continue to use any ACT-related forms or worksheets that you
already find helpful. If you’re new to ACT, the website for the main organization of ACT,
the Association for Contextual Behavioral Science, has places where members may down-
load worksheets and other forms (https://contextualscience.org), and we’ll point you toward
other ACT resources as well.
With that said, let’s begin.
Behavior Tracking as Intervention

Has anyone ever asked you what you did over the weekend, and you couldn’t remember—
on a Monday! Have you ever thought you were doing more or less of something until you
began paying attention and writing it down? Self-monitoring or tracking behaviors is
common in cognitive behavioral approaches, and it lies at the heart of behavior change
whether you’re changing a diet, losing weight, increasing exercise, or improving procrastina-
tion. The worksheets you provide your clients for homework are an essential tool for gather-
ing information about clinically relevant behaviors. They provide clinically useful
information for the therapist, and they strengthen client awareness of their habits and
patterns.
In fact, tracking behavior can be an important intervention in itself. Observation alone
can influence behavior and the process of discussing observations can create a context for
behavioral change (e.g., McFall, 1970; Ramnerö & Törneke, 2008). For example, if you
were asked to make a hashmark for every snack chip you ate, you would probably find you
ate far fewer than when you mindlessly reach into the bag and grab a fistful.
Tracking Strengthens Awareness

Through tracking their behaviors, clients increase their awareness of them (Orji et al.,
2018). They may discover aspects of behaviors such as antecedents or consequences of
which they were unaware. For example, after a week of tracking the consequences of their
Create Your Own ACT-Informed Exposure Forms111
efforts to control their anxiety, many clients notice that their control strategies are even less
successful than they originally thought, helping to foster creative hopelessness! Clients are
more likely to take responsibility for behavior change when they’re asked to pay attention
to target behaviors. This helps to subtly orient clients to active treatment approaches such
as ACT-informed exposure.
Tracking Provides Data to the Therapist

The tracking that’s made possible by forms and written records also helps sharpen
clients’ experience of therapeutic interventions and their ability to pay attention to, put
words to, and process these experiences. Without writing things down, client self-report is
more likely to be vague or general. Though clients may offer verbal descriptions of their
behaviors, having them collect actual data or accounts shortly after the behaviors take
place can be more revealing to both client and therapist. For instance, with a client who
claims, “I’m always anxious,” tracking may indicate fluctuations in anxiety within or across
days. Or a client who tracks mood daily over the course of a month might notice their mood
dips every Thursday, suggesting something predictable about their environment that was
previously unknown. Overall, information gathered through self-monitoring tends to be
more context specific and more accurate (Orji et al., 2018).
Key elements of self-monitoring forms for ACT-informed exposure may include the
following:
• A trigger (e.g., “I walked into the supermarket and found it was more crowded than
I expected.”)
• A sample of thoughts, feelings, and bodily sensations (e.g., “I thought, Oh no! People
are going to stare at me! I felt my heart race.”)
• Attempts to deal with discomfort (e.g., “I left the store and returned after eleven
that night, when I was certain there would be fewer people.”)
• Consequences of avoidance behavior (e.g., “I had to make an extra trip. It would be

so much easier to go to the store on my way home from work. Because I went to the
store so late, I was tired at work the next day.”)
Here is an example of a self-monitoring form from a client, Shanice, seeking treatment

for social anxiety disorder. (A blank version of this form that you can use in your own prac-
tice can be downloaded at http://www.newharbinger.com/50812.)
Table 8.1
Date Describe a situation What did you do in What happened? How effective
that caused response? was the response? Why or why
discomfort. not?
XX/XX/ Messed up during I went into the I left work early, despite having
XXXX a work presentation bathroom and cried. a lot of work to do. I spent the
because I was so I felt too scared to rest of the day worrying that
nervous. face my coworkers my coworkers would judge me
because of what for that too.
they must think
of me.
XX/XX/ I misjudged my timing I felt so guilty that I think my partner started to

XXXX and started dinner I spent the rest become annoyed at my
later than I should of the evening apologizing. I then began to worry
have. When my partner apologizing to her. that she thinks I’m weak and
asked what time dinner wants to leave me. I stayed up
would be ready, I late and spent hours reading
snapped at her. relationship forums to see if this
has happened to anyone else.
In this form, Shanice was able to see more clearly how her anxiety interferes at work
and at home. As clients become more aware of how their “solutions” to problems (i.e., avoid-
ance) create more problems, they may be more willing to let go of efforts to control, sup-
press, or change their anxiety or more open to trying something new such as exposure. In
these ways, self-monitoring helps enhance work with creative hopelessness.
Creating Exposure Forms

This task involves developing forms that are versatile for different types of exposure and
include key parts of the exposure process: what to guide your clients to track, how often,
how to use your forms to ensure clients set up exposures comprehensively, what to track
during exposure, what to track after exposure, and clarifying procedures for between-ses-
sion practice.
What to Track
In traditional exposure, as we discussed in chapter 5, the therapist and client typically
track changes in client distress across exposure exercises using the subjective units of
discomfort (or distress) scale (SUDS). This scale ranges from 0 (no anxiety) to 100 (extreme
anxiety), although a 0–10 scale is also common. Abramowitz, Deacon, & Whiteside (2019)
have a section on SUDS for more information. Tracking scores of “anxiety” or “distress”
also works.
In ACT-informed exposure, exposure is an opportunity to practice psychological flex-
ibility; consequently, one could track any or all core ACT hexaflex processes during expo-
sure. Eifert and Forsyth’s (2005) ACT-informed exposure forms include multiple items to
assess during exposure: sensation intensity, anxiety, willingness, struggle, and avoidance.
As we noted in chapter 5, perhaps the most common alternative to SUDS in the ACT-
informed exposure literature is willingness scores. In a comparison of habituation-based
exposure and ACT-informed exposure for OCD, researchers substituted willingness scores
for traditional SUDS on a 0–100 scale (Twohig et al., 2018). Willingness (i.e., acceptance)
is an experience distinct from that of symptoms because willingness involves how we relate
to discomfort. We should acknowledge here that sometimes clients mistake willingness for
an inverse of SUDS, or they may be more willing when SUDS are lower or less willing when
SUDS are higher. However, the therapist should be clear that willingness and SUDS are
distinct processes.
Another study of ACT-informed exposure for OCD asked participants to rate and
track their daily psychological flexibility with a focus on thoughts and emotions (B. L.
Thompson et al., 2021). Interestingly, participants tended to provide almost identical ratings
of flexible responding to thoughts and feelings such that these two separate items were
combined for data analysis.
In sum, you are not limited to a standard way of practice and can conceivably track
anything you feel is clinically and functionally relevant to psychological flexibility in ACT-
informed exposure.
What We Use
The three authors of this book have experimented with different approaches to what we
track. Two of the authors (Brian T; Joanne) initially abandoned traditional SUDS or dis-
tress scores in favor of willingness scores. However, each eventually reincorporated SUDS
along with willingness scores. One argument in favor of retaining SUDS scores is that will-
ingness can be a tricky concept for some clients to understand. As we noted, some clients
mistake willingness for lack of distress. Other clients may be overly perfectionistic, under-
rating their willingness because they underestimate their commitment to exposure exercises
or fear that they do not sufficiently grasp the concept of willingness. In our experience, the
concept of willingness may not click for some clients until they’ve had more experience
working with it across multiple sessions of ACT-informed exposure. By contrast, it’s easier
to be on the same page with distress-related scores from the beginning of treatment.
In some forms of exposure, it’s helpful to collect a different type of rating: similarity. To
create a context to practice psychological flexibility, we want to be certain that the expo-
sure exercise evokes repertoire-narrowing stimuli to create a context for practicing psycho-
logical flexibility; in other words, that it triggers similar private events with which clients
struggle with out of session. If this is not the case, an exposure exercise may be uncomfort-
able for clients but fall short of evoking the specific context which they want to address. For
example, interoceptive exposure exercises are generally uncomfortable for people—includ-
ing therapists—but they may or may not contain the contextual cues with which clients
struggle (e.g., panic symptoms). For these reasons, we may ask for similarity scores with
clients (e.g., 0 = “not similar experience of panic”; 10 = “as if you were experiencing a panic
attack”). If an exposure exercise is too dissimilar, it will not sufficiently create the contex-
tual conditions for practice, and it may not feel meaningful to clients.
Regardless of what you choose to track, ratings help orient clients to their experience
and initiate conversations between you and your clients about what they observe during
exposure. We caution that each rating you ask of clients increases the complexity of expo-
sure and burden of homework, so we encourage you to think carefully about what is most
important. Even asking clients to rate both SUDS and willingness can feel complicated at
times—especially when a client struggles with understanding these concepts. For that
reason, we recommend using the minimum number of ratings that provide clinically mean-
ingful information, or to interchange them throughout treatment to fit with whatever you
are currently working on.
When to Track and How Often?

There are no standard guidelines about how often to ask for ratings during exposure,
and each of the authors varies in their approaches depending on the client. You may ask for
ratings every five to ten minutes, or you may simply ask for pre-, peak, and post-exposure
ratings. Some exposures are more amenable to frequent assessment. For example, you prob-
ably don’t want a client to jot down frequent ratings while conducting a driving exposure.
Alternatively, an exposure may last all day or multiple days (e.g., placing a kitchen knife on
a nightstand and leaving it there until the client strengthens psychological flexibility in its
presence). In creating your exposure practice forms, consider versatility: are you able to use
your forms with a wide variety of exposures? You may want to have more than one type of
form. For example, some of the authors use the same form for in vivo and imaginal expo-
sures but a separate form for interoceptive exposure.
Setting Up the Exposure

As mentioned in chapter 6, setting up exposure exercises is important for every expo-
sure therapist, regardless of theoretical orientation; and as precisely as possible, the expo-
sures you have your clients do should evoke repertoire-narrowing stimuli. It can be helpful
to transcribe the exposure exercise on the homework tracking sheet so that clients are less
likely to forget:
Example: Describe the exposure practice.
Each day around six in the evening, I will drive on Interstate 12 from exit 3 to exit 6. Drive at least
55 mph. May stay in same lane without changing.
Identifying the fear. It is also important to clarify the fear that the exposure is targeting.
Sometimes there is a specific feared consequence, but some clients may have a vague fear
that “something bad will happen” without being able to be more specific. Quite often,
clients are more concerned that they will become overwhelmed with anxiety than of a
specific catastrophic outcome. Whatever the nature of the fear, be sure there’s space on
your form for you and the client to write it out in some detail.
Note that in the example below, we include ACT languaging to foster defusion from
the fear (e.g., “What does your mind tell you will happen…?”)
Example: What is your fear about this practice? What does your mind tell you will happen
as a result?
I will have a panic attack and crash my car.
Targeting other ACT processes. With the exposure procedure defined and the core fear(s)
identified, you may include other questions on your forms to strengthen other core ACT
processes. For example, it can be useful to connect exposure to values.
Example: What is meaningful to you about this practice? What is it a step toward doing?
I want to be able to visit friends and take my daughter to parks without limiting myself to places that
I can reach on side streets. I have turned down so many invitations because of my anxiety.
During Exposure
In addition to the ratings you have chosen, you may also ask clients to make qualitative
observations of their experience during exposure.
Thoughts, feelings, and bodily sensations. To continue to strengthen client awareness, it

can be useful to ask clients to pay attention to private events. There are many benefits to
this. Clients may observe discrepancies between their predictions and what actually happens
during exposure. Putting words to experience helps to strengthen self-as-context and foster
defusion.
Example: Describe your thoughts, feelings, and bodily sensations during the exposure.
When entering the freeway, I immediately felt my anxiety spike. My heart began racing, and I felt
tightness in my chest. I wanted to pull over. I thought, “I’m going to have an accident.” However, when
I shifted my attention outward and noticed the passing trees, I was better able to be present with
my anxiety.
After Exposure
To consolidate learning, it’s useful to include debriefing questions on the forms you
provide. These could be questions clients complete after each exposure exercise or just once
at the end of the week. You may also ask them to reflect on what they observed during their
regular practice. Again, this is an opportunity to target and strengthen ACT processes.
Examples: What did I learn from this exposure?
I learned that, although I experienced panic, I was able to focus on driving and did not crash. I found
it helpful to orient to the scenery around me rather than get caught up in my thoughts. When I paid
attention to the trees, I didn’t feel so consumed by panic.
What is important to me about this practice? How will this help me live the life I want?
I can actually imagine being able to eventually drive my daughter on the freeway to the beach. I don’t
think I’m there yet, but it feels like a possibility for the first time in years.
How did your experience with the practice change over time (if at all)?
Every time I drove, I had the thought, “I’m going to have an accident!” However, the thought started to
feel quieter over time. It didn’t take so much of my attention. I could ignore it and refocus on my
driving. I even had moments where I enjoyed driving again. I used to love to take road trips, and I was
a pretty aggressive driver when I was younger. I started to connect with my enjoyment of driving again.
Activity: Creating Your Own Exposure Form

Now that you’ve had a chance to explore the elements of a useful tracking form for ACT-
informed exposure, reflect on what components you would like to include in your exposure
forms. Which ratings do you think are important (SUDS, willingness, similarity)? What
questions do you want to ask? What feedback do you want to elicit? If you are uncertain
where to start, begin by writing down ACT processes you may want to target on a sheet of
paper and develop questions from there.
Once you have a rough outline, create an electronic document based on your sketch.
Here, you can begin the process of refining your form. And the great thing about creating
an electronic document is that you can edit it over time—and it takes less time than you
might predict!
It’s okay if you’re not happy with your first draft. You may continue to refine over time
forms that will work for you and your clients. We encourage you to think of this as a fun,
creative process. This is a place to develop materials that bring out your best skills as a
clinician.
Tips for Developing Your Own Forms

As you develop your stable of ACT-informed exposure forms:
• Try them yourself. The best way to understand ACT is through doing. Identify a
fear with which you could practice exposure or imagine you are a client. Make
notes about what it’s like to complete your forms. What questions come up? How
does this provide perspective on what your clients will be doing?
• Role play your ideas with colleagues. If you have a colleague or consultation
group also interested in learning ACT-informed exposure, practice with role plays
(clients) and real plays (bringing yourself into practice). Gather feedback from col-
leagues and incorporate changes to your materials.
• Listen to client feedback. When giving clients forms to complete, it’s important to
go over their data in session. If you don’t, clients may feel as if their efforts don’t
matter (e.g., Lindgreen, Lomborg, & Clausen, 2018). Notice what clients connect
with and what they find confusing. For example, one of us (Brian T) initially tried
teaching willingness as a binary concept (e.g., a client is either willing or not
willing). Although this is a valid view and is advocated by other ACT people, he
found it was a hard sell to clients, so he eventually altered his exposure forms,
placing willingness on an interval scale of 0 to 10.
Do they complete the forms as you expect them to? Do clients understand the
forms? When clients do not fill out forms in the way you intended—or leave sec-
tions entirely blank—there can be several reasons, including unclear instructions
or prompts that do not fit the exercise. Explore their process of filling out the form.
Ask about what might be confusing or seemingly irrelevant.
• Assess if the information clients provide is clinically useful. One reason we

have chosen not to provide a treatment protocol is that the therapist may use forms
without regard to clinical utility, because they are trying to adhere to a protocol.
Consider what you learn about clients from the forms. How is the information
useful? To what degree does discussing the worksheets result in fruitful
discussions?
What is clinically useful may evolve during treatment. One of us (Joanne)
begins treatment by assigning homework focused on client responses to triggers. As
clients begin practicing new skills (e.g., through exposure), she modifies the form to
include additional prompts for how to track the practice of these skills in
exposure.
• How versatile are your forms? Are there exposure exercises that do not fit well in
your format? No form will be perfect for every client and every problem, but some
are more versatile than others. There may never be a “one-size-fits-all” form—but
it doesn’t hurt to see how close you can get. You may have a standard form, or you
may tailor your forms to specific clients. One of us (Joanne) uses electronic versions
of forms that can be easily modified and filled out by the client online or on paper.
• Listen to clients about what they consider meaningful. If your form specifies
that clients tally the number of times they perform a targeted behavior, and a client
tells you it would be easier to tally time spent (e.g., minutes), consider adopting that
change. While not all clients will offer specific suggestions—some may feel over-
whelmed if you try to place this responsibility on them—some will appreciate your
openness to modifying forms based on their feedback, enhancing the collaborative
process.
• Assess whether the language in your materials is ACT-consistent. For thera-

pists trained in traditional exposure, perhaps the biggest shift is avoiding language
that communicates a focus on symptom reduction (e.g., habituation). As language
that emphasizes decreasing distress is reassuring to clients, it can be difficult to
resist urges to reassure clients they will feel less anxious. One of us (Joanne) catches
herself still using phrases such as “less anxiety” or “feel better” because that style of
speech has been deeply practiced. Forms can help us all be more disciplined in our
languaging of ACT-informed exposure. For more in-depth discussion on the topic
of languaging, refer to chapter 5.
• Consider how you may convey to clients the importance of completing the
forms. Your ability to present a strong rationale for out-of-session assignments may
influence compliance. If you find your clients don’t follow through with assign-
ments, consider the larger context: Was the assignment clear to the client? Did the
client indicate that they felt fully understood? Have you overloaded them with too
much to do? When you’re familiar with a form, it’s easy to forget that the instruc-
tions may not be clear to clients. Also, in our experience, the more assignments you
give to clients, the less likely they are to complete anything. For example, be cau-
tious about assigning more than one exposure exercise at a time; you may quickly
overwhelm your client this way.
Conclusions
Make time to develop forms and assess their effectiveness on a consistent basis. If you’re
used to practicing traditional exposure, your forms are one way for you to help shape your
ACT-informed exposure practice and keep you on track. You may then revise your forms
based on your experiences and client response. Be sure to consider the wording you want to
use to integrate core elements of ACT-informed exposure into your forms. You may con-
tinually revise your forms from time to time. This is another reason we did not want to
create a protocol. As authors we continue to tweak and improve our own forms over time.
Now that you have learned about how tracking can support your exposure work and
help to enhance psychological flexibility, let’s take some time to delve into some case exam-
ples to help illustrate many of the principles that you have learned in the book so far. While
we have given many shorter examples so far, the next chapter is an opportunity to dive into
more examples of how ACT-informed exposure is applied to typical clients with anxiety.
CHAPTER 9
Case Examples of ACT-Informed

Exposure
We’ve spent much of this book orienting you to ACT theory and describing ways to imple-
ment ACT-informed exposure. So what does ACT-informed exposure actually look like?
How different is it from traditional exposure in actual practice? While we’ve emphasized
the importance of theory in ACT-informed exposure (chapter 3), we also believe it’s impor-
tant to understand how a course of treatment might actually unfold. Although we’ve inter-
woven brief clinical vignettes throughout the book, here we’ll take a deeper dive into some
clinical cases to illustrate what’s unique about ACT-informed exposure. As there are many
areas where traditional exposure therapists might do things that overlap with ACT in form,
if not in function, we’ve made efforts to select cases that demonstrate features of the ACT
psychological flexibility model and case conceptualization that differ from a traditional
exposure approach both in form and function.
Cases Illustrations
We’ll note here that key client details have been changed to mask client identities. Even
material presented as direct quotes was reworked. Below we include the ratings systems we
use in some of the example cases of ACT-informed exposure. For more detail on setting up
the subjective units of discomfort scale (SUDS) and willingness scores, please refer back to
chapter 5.
Table 9.1. Reference for client ratings in case illustrations

Name Description Rating = 0 Rating = 10
Similarity How similar were the thoughts, Not similar Matches

feelings, and bodily sensations experience of
triggered by the exposure to your anxiety or like a
experience of anxiety and panic? panic attack
Willingness How willing were you to experience Not willing Completely willing
discomfort without struggle?
SUDS subjective units of discomfort scale No discomfort Most discomfort
Maria—Improvising with the Willingness Scale

Background
Maria was a cisgender Black female in her late twenties who was struggling with panic
attacks. She reported experiencing panic attacks upon arriving to work at a medical center
before her shifts. Although Maria was still able to complete her work without issue, the
panic attacks were increasing in intensity and frequency. And they were starting to occur
earlier—sometimes during the drive to work. In addition to fear of having another panic
attack, Maria reported panic attacks triggered fears of (A) having a heart attack, (B) passing
out, and (C) being too overwhelmed to work.
Exposure
Treatment began with an orientation to ACT-informed exposure using experiential
exercises and metaphors to develop a common language for ACT processes and set the
foundation for exposure work. Next, we agreed to create the context for practicing psycho-
logical flexibility during panic using interoceptive exposure to private events that Maria
associated with panic. We created a list of common panic symptoms that Maria experi-
enced and identified unhelpful thoughts that appeared to be cued by Maria’s panic. We
tried various interoceptive exercises to match Maria’s experience of panic, with Maria
rating them on a scale of 0 (not similar) to 10 (most similar) on how closely the symptoms
matched her experience of panic. Maria also rated her ability to practice willingness during
interoceptive practice on a scale of 0 (not willing) to 10 (completely willing).
Typically, hyperventilation is practiced for sixty seconds with one breath approximately
every two seconds. However, when Maria practiced hyperventilation for sixty seconds, she
found she struggled with willingness. As the exposure approached the sixty-second mark,
she would increasingly fuse with thoughts such as I can’t handle this! and tense up, struggling
to be open and present. Even after a few practice trials, her willingness remained in the
Case Examples of ACT-Informed Exposure 123
middle of the range, about 4–5. When a client engages in exposure exercises where they feel
like they need to “just get through it,” they are less likely to be practicing psychological flex-
ibility. Consequently, we experimented with reducing the length of the practice in order to
increase her openness to experience discomfort. In our clinical experience, it can be more
effective to adjust an exposure exercise to match client willingness than to try to get a client
to increase their willingness to match the exposure.
Like Goldilocks, we were looking for an exposure length that was “just right”—creating
a context similar to Maria’s experience of panic but with an intensity at which she could
practice flexible responding. We tried reducing the hyperventilation trial from sixty to
thirty seconds. At thirty seconds, Maria was able to increase her willingness from a 4–5 to
a 9. Now we’re getting somewhere! From thirty seconds, we experimented with increasing
the length of the hyperventilation practice in five- to ten-second increments to find an
optimal balance between evoking panic-related private events at an intensity that Maria
could maintain willingness. At forty seconds, Maria observed physical sensations such as
sweating palms, lightheadedness, and tingling in the extremities, as well as panic-related
thoughts such as Am I having a heart attack? By contrast, at thirty seconds, hyperventilation
triggered the physical sensations but not the panic-related thoughts. When we increased
practice to forty-five seconds, Maria experienced both the physical sensations and the
thoughts but struggled with willingness (6–7) and fused with thoughts such as I can’t handle
this. As a result of our experimentation, we decided that forty-second trials of hyperventila-
tion offered a nice balance of triggering contextual cues related to panic and private events
that Maria associated with panic. See table 9.2 for a summary of Maria’s scores.
Table 9.2. Interoceptive exposure to hyperventilation

Trial # Similarity Willingness What Happened? (number of seconds, e.g., 60s,
plus bodily sensations, thoughts, feelings,
(0–10) (0–10)
impressions)
1 8–9 4–5 60s. Sweating palms, lightheadedness, tingling.
2 8 8 30s. Sweating palms, lightheadedness, tingling.
3 7–8 8 40s. Sweating palms, lightheadedness, tingling,

similar thoughts as panic attack (fear of heart
attack).
4 8–9 6–7 45s. More intense. Sweating palms, lightheadedness,

tingling “same” thoughts (heart attack) and I can’t
handle this.
For home practice, Maria agreed to practice five consecutive trials of hyperventilation
at forty seconds per trial each day. At the following session, Maria reported struggling more
with willingness during out-of-session practice. This happens. Sometimes clients are more
willing in the presence of the therapist but struggle with exposure on their own. Maria also
reported she had experienced higher anxiety in general during the following week due to
other stressors, which may have amplified the intensity of the exposure. After talking
through options, we reduced the hyperventilation practice further from forty to twenty
seconds. At twenty seconds, Maria expressed increased confidence she could practice on
her own with greater willingness.
Success! At the following session, Maria reported greater willingness and felt ready to
increase the length of the hyperventilation practice. Whereas she had felt overwhelmed at
forty-five seconds the prior session (see table 9.2), after a week of practicing at twenty
seconds, Maria reported increased willingness during forty-five seconds of hyperventilation.
We also tried fifty seconds, but her willingness dropped (see table 9.3). Forty-five seconds
offered the best balance.
As there’s evidence that adding contextual cues may help to deepen learning during
exposure (e.g., Craske, Treanor, et al., 2014), we decided to add an additional layer of com-
plexity to the interoceptive practice. Maria had reported she would often fuse with fears
that she was going to pass out during panic attacks and would consequently sit down. To
help Maria further expand her behavioral repertoire during exposure, Maria practiced
standing up immediately after hyperventilating. By deliberately standing up while experi-
encing the thought I need to sit down. I’m going to pass out!, Maria was able to further defuse
from these thoughts. Below in table 9.3 is a selection of Maria’s ratings.
Table 9.3. Interoceptive exposure to hyperventilation

(0–10) (0–10)
impressions)
1 8–9 9–10 40s + standing up. Sweating palms, lightheadedness,

tingling, thoughts such as I need to sit down. I’m
going to pass out.
2 10 8–9 45s + standing up. Similar bodily sensations and

thoughts comparable to 40s with increased intensity.
3 10 7–8 50s + standing up. Similar bodily sensations and

thoughts to 45s, and increased intensity. Begins
fusing with thought, Too intense.
Additionally in this session, we added a second interoceptive exercise in which Maria

held her breath. Again, in experimenting with the length of the interoceptive exposure, we
found that fifty seconds provided the optimal balance between triggering additional panic-
related cues, especially thoughts of passing out and not being able to get enough breath, at
an intensity that Maria could maintain willingness (see table 9.4)
Table 9.4. Interoceptive exposure to holding breath

(0–10) (0–10)
impressions)
1 8 9–10 50s. Panic-related thoughts: Am I having a heart

attack? I can’t breathe. I’m going to pass out.
2 7–8 7 60s. Similar panic-related thoughts with greater

intensity.
We continued to increase the length and intensity of interoceptive exposure exercises

as Maria strengthened her willingness and ability to defuse from panic-related thoughts.
Additionally, Maria identified values-based goals she wanted to accomplish, such as partici-
pating in a professional certification program and joining a work committee. At termina-
tion, she reported fewer panic attacks, lower anxiety, and increased ability to respond to
anxiety and panic with willingness.
Take-Home Points
This case example illustrates how to experiment and adjust exposure exercises to maxi-
mize training of psychological flexibility. Here we also demonstrated how to use willingness
scores to inform adjustments around exposure exercises. This is a departure from tradi-
tional exposure, where decisions are more typically based on just SUDS scores. However,
we’ll note that the importance of willingness is consistent with traditional exposure.
Whether one is conducting traditional exposure or ACT-informed exposure, if a client is
unable to be present with and practice willingness during exposure, they may struggle to
increase psychological flexibility in general, and the exposure may reinforce anxiety and
avoidance (e.g., Benito et al., 2018; Jordan et al., 2017; Ong et al., 2022). Because you can
adjust the duration so easily, interoceptive exposure exercises lend themselves particularly
well to being fine-tuned in working with client willingness.
Lucy—How to Build a Better Context

Background
A senior in high school, Lucy was a white, cisgender female whose primary therapist
encouraged her to seek exposure therapy when her anxiety began interfering with her
ability to focus on school. Lucy reported she’d always had a close relationship with her
father throughout childhood. But after she turned seventeen, Lucy began fusing with fears
that she was losing her close bond with her father. The main themes of her fears were (A)
she no longer felt as strong a connection with her father as a young adult as she had in child-
hood, and (B) she would not be able to cope with losing her father when he passed away.
Lucy avoided songs, television shows, and movies that depicted father-daughter rela-
tionships, as they triggered anxiety symptoms and fusion with her fear of losing her connec-
tion with her father. Lucy compulsively spent time with her father, constantly checking if
she still felt connected to him to try to reassure herself and reduce her anxiety.
Exposure
We engaged in ACT-informed exposure through telehealth, a detail that will be impor-
tant in this case example. After engaging in a functional analysis of Lucy’s triggers, we
couldn’t identify any reliable way of triggering Lucy’s fears when she was physically present
with her father. Lucy observed that when she was around her father, she sometimes felt
anxious about their relationship, but sometimes didn’t, and she could not identify any
stimuli that would predictably evoke these fears. Consequently, we identified other contexts
that could reliably trigger Lucy’s anxiety and fusion about her relationship with her father.
For example, we selected clips of songs and movies related to father-daughter relation-
ships—ones that Lucy had enjoyed previously but now avoided. Lucy practiced looking at
photos of her father and saying fear-inducing statements aloud, such as “I don’t feel any love
for you” and “We’ll never feel the same connection we used to.”
Lucy wrote imaginal scripts outlining feared consequences of losing connection with
her father. However, Lucy struggled with writing detailed and elaborate scripts—they were
often limited to three or four sentences. Brief imaginal scripts can be effective with some
clients. With Lucy, though, I was concerned that the lack of detail in Lucy’s script meant
they would not sufficiently create the context to practice psychological flexibility. Her dif-
ficulty with writing the scripts was not for lack of trying. Lucy was a very organized and
conscientious client. She took notes during sessions and came to each appointment with
detailed questions to ask. She even researched information about writing imaginal scripts
on her own. I asked Lucy all sorts of questions to try to help her expand upon the content
in her imaginal scripts; however, Lucy was unable to add more detail. Nonetheless, we
moved forward with imaginal exposure. Lucy recorded herself reading the script aloud on
her phone and listened to the recordings between sessions. She reported she was able to
defuse from the content of her anxious thoughts (e.g., reporting that she “had perspective
on and distance from fear”). Throughout all exposures, Lucy reported high willingness—
usually a 10 on a 0–10 scale.
After completing all the exposure exercises on the exposure menu, Lucy stated she had
returned to baseline and felt ready to complete treatment. I had some concerns, however.
Although ACT-informed exposure doesn’t have to be difficult just for the sake of being dif-
ficult, and some clients move through exercises and strengthen psychological flexibility
quickly, I felt this course of ACT-informed exposure consistently fell short in creating the
context that narrowed Lucy’s behavioral repertoires in daily life. That is, I was worried that
the exposure exercises—especially the imaginal scripts—were not evocative enough, and
that they did not generate the intense anxiety Lucy experienced when she was fused with
fears about attachment to her father. For example, SUDS scores were rarely higher than
5–6 and dropped rapidly, often within two to four days of regular practice. Had we suffi-
ciently created contexts for practicing psychological flexibility? How well would learning
generalize when Lucy experienced similar private events again in the future? In sum, I was
concerned that Lucy hadn’t developed sufficient psychological flexibility to respond effec-
tively when the fears returned, and that she would resort to avoidance behaviors when trig-
gered again. Despite my reservations, Lucy was happy with her treatment progress.
Self-report measures also indicated minimal distress. I didn’t feel I was in place to make a
strong case for continuing treatment.
Relapse
Unfortunately, my intuition proved correct. Within three months after termination,
Lucy began emailing me that she was again struggling with fears about her attachment to
her father. Lucy had maintained some gains—she was able to make values-based decisions
about spending time with her father, no longer seeking his company to try to reassure
herself. However, I now realized she was and had been using coping skills compulsively.
Lucy described how she repeated helpful phrases (e.g., “I’m not my thoughts”) she had
learned during treatment to try to suppress uncomfortable thoughts. This was a theme in
treatment: Lucy frequently misused any insights and ACT-related skills as forms of experi-
ential avoidance. Initially, these phrases appeared to disrupt obsessions. In her heavy-
handed use of them, however, they eventually stopped disrupting the private events Lucy
was trying to avoid. On my end, I had taken Lucy’s interest in writing down core phrases as
a sign of her engagement in treatment and was also a little flattered that a client found what
I said so inspiring! My susceptibility to adulation initially blinded me to how Lucy was using
my pearls of wisdom as avoidance behaviors. We’ll note here the importance of function
over form: that ACT exercises and even exposure can function as avoidance. I also want to
be clear that Lucy did not realize she was engaging in avoidance behaviors. In her mind, she
was doing everything she could to get the most out of therapy.
We agreed to another course of treatment. Despite feeling disappointed, discouraged,
and depressed about this relapse, Lucy was eager to return to exposure. We started from
scratch and engaged in a functional analysis of problem behaviors associated with anxiety.
Based on the updated functional analysis, we agreed to revisit imaginal exposure. As Lucy
had increased her ability to be present and observe internal experiences, she was able to
notice that obsessing about whether she could feel her father’s love caused her to “numb
out” (i.e., low willingness and low contact with the present moment). This time, I listened
to my intuition and took a more active role in shaping her scripts. Initially Lucy expressed
resistance to spending more time on the scripts. Extremely anxious and dysphoric, Lucy
wanted to complete the exposure as quickly as possible to achieve relief. Here again is an
example of how exposure itself can sometimes function as experiential avoidance (i.e.,
rushing through exposure exercises to get better)!
I found I had to practice a willingness of my own! It would have been easier to go along
with Lucy’s preference to write her own scripts and quickly move into exposure. However, I
allowed myself to risk Lucy’s frustration as I slowed the process, patiently working with Lucy
to bring more contextual cues into the imaginal scripts.
Sharing my screen through our videoconferencing platform, Lucy and I could view the
document with her script together. I would suggest a sentence or two of how I imagined
Lucy might think or feel in the scenario and ask for her feedback. Although Lucy had
struggled to generate detailed content on her own, she was able to quickly identify whether
something I’d suggested resonated with her. When it didn’t, she also had an easier time
coming up with alternative content (e.g., “I wasn’t feeling angry. I was frustrated.”). Below
are examples of an initial script, and how we collaboratively expanded it:
Lucy’s script: I feel anxious that Dad is getting older. I imagine how old I would be
if he lives to ninety and passes away. I obsess about Dad passing away and can’t be
present. I fear that when he dies, I’ll forget my experience of his love, because he
won’t be around physically.
Therapist’s expansion of Lucy’s script: I feel anxiety when I think about Dad getting
older and eventually passing away. I notice more wrinkles on his skin, the sparse hair
on his head, and how easily he gets tired. These remind me that he is growing older.
I start obsessively calculating how many more years he might have to live, based on
my grandparents’ ages. When we spend time together, I feel my chest tighten, my
heart flutters, and I start to panic. I start to grieve that Dad won’t live forever. I think
about how when he dies, I won’t be able to connect with him physically, and
eventually, my love for him will fade. Because my memory of his love fades, I lose
touch with my ability to feel safe. I feel empty for the rest of my life with a void I can
never fill. My life has become meaningless since Dad died.
It worked! As Lucy began reading the revised imaginal script aloud, she immediately
experienced more intense physical sensations such as dizziness and queasiness in her
stomach. Whereas she had rated SUDS for the shorter scripts ranging as 3–6, she rated the
more detailed scripts as 8–10. These were signs that the expanded scripts were bringing
more contextual cues to the exposure in ways that allowed her to further strengthen psy-
chological flexibility. Lucy rose to the challenge and even expressed admiration for how
much more evocative these were (e.g., “Wow! I find myself trembling!”). Her willingness
remained high. I felt cautiously optimistic that we were getting somewhere.
More so than during the prior course of exposure, Lucy found that in being present
with her fears, they seemed less compelling (e.g., indicating increase in defusion and self-as-
context). With practice, Lucy learned that uncomfortable private events came and went if
she allowed them to. After completing a series of scripts, Lucy felt ready to end treatment
again. Being more cautious this time, we agreed to shift to monthly maintenance sessions
to assess the stability of her treatment gains.
After a few monthly maintenance sessions, at which Lucy had maintained her gains,
Lucy made an interesting observation. I had asked her to explain to me in her own words
what had been different about the second course of ACT-informed exposure compared to
the first. My hypothesis was that the greater intensity allowed Lucy to further strengthen
her ability to practice willingness with private events, and that through strengthening will-
ingness, she was able to resist urges to engage in compulsive checking. Lucy’s response
surprised me. Instead of confirming my hypothesis, she said, “It was the details in the newer
stories that gave me more distance from my thoughts.” The use of the word “distance” was
striking. In our ACT-informed exposure work, we repeatedly discussed willingness but
never talked about “defusion” explicitly. However, from Lucy’s reflection, it appeared that
defusion was the more relevant process in her treatment, and that expanding the scripts
and including more details was crucial in strengthening defusion.
It would be nice if this case example ended here. However, Lucy experienced a recur-
rence of anxiety a few months later. She returned to treatment a third time. As we were
exploring her relapse, Lucy had a realization. She noted that, “I’m afraid my love for my
father won’t stay the same.” I asked Lucy if she was trying to cling to the experience of love
she had for her father as a child, perhaps having difficulty accepting that her affection for
her father had evolved and matured in becoming an adult. Lucy turned quiet as she pon-
dered this. It was one of those rare lightbulb moments in therapy. Not only was this true,
she said, but because she was constantly checking her attachment to her father, she was
comparing her current feelings to how they were when she was a child—or at least remem-
bered them to be.
To analyze this using an ACT lens, Lucy had been fusing with self-as-content. Lucy
remembered the warm, loving feelings she’d had for her father as a child and found she
didn’t experience affection for him in the same way. No longer an avatar of fatherly wisdom
and warmth, her father had become a well-rounded human being with his own flaws and
shortcomings. She now found herself occasionally annoyed with her father, and though this
change in how a child sees their parent is developmentally normal, Lucy had difficulty
accepting those frustrations. She remained attached to her idealized view from childhood.
By acknowledging this struggle, Lucy was finally able to defuse from how she thought she
should feel and use present-moment focus to connect with the emotions that she currently
felt about him, even if that also included some periodic irritation. Lucy committed to jour-
naling her feelings daily. During the following session, she reported feeling a “quietness”
that was accompanied by greater acceptance of uncertainty and vulnerability in their rela-
tionship. Lucy felt comfortable terminating and did not return to treatment.
Take-Home Points
We offer this case for a few reasons. For one, we want to underscore the importance of
humility in ACT-informed exposure. The therapist had some blind spots of their own along
the way. Although an eager, diligent, and conscientious client, Lucy often used the ACT
exercises and metaphors she learned in therapy as ways to suppress and disrupt uncomfort-
able private events. These efforts worked until they didn’t, amplifying Lucy’s frustration.
Additionally, during the first course of exposure, the therapist did not create exposure
exercises that were evocative enough for Lucy as they didn’t sufficiently create the behavior-
narrowing contexts with which she struggled. The therapist intuited that something was
not working but had difficulty addressing it during the first course of ACT-informed expo-
sure, especially as Lucy seemed eager to tackle the exposure exercises as quickly as
possible.
Second, the therapist’s working hypotheses about treatment was not confirmed by
Lucy. The therapist had thought Lucy would benefit from strengthening willingness in
order to respond more flexibly to anxiety and panic. Lucy’s feedback about what she learned
from ACT-informed exposure, however, showed that she benefitted more from strengthen-
ing defusion. Of note, Lucy’s endorsement of defusion is consistent with one large-scale trial
that found that cognitive defusion was a particularly important process of change across
both ACT-informed exposure and traditional exposure for anxiety disorders (Arch,
Wolitzky-Taylor et al, 2012).
We chose this case example in part to dispel any illusions you might have about using
exposure with laser-like precision to target specific processes. Clients may have different
experiences with ACT-informed exposure than we predict. The good news is that a lot can
happen during ACT-informed exposure, whether the therapist intends it or not! When you
target one process, you’re likely to impact others, making exposure a great method for
strengthening multiple ACT processes at once. So while there is sometimes value in target-
ing specific ACT processes, we want to emphasize that none of these six processes are
completely distinct and that your intervention may not necessarily be impacting the process
that you think it is.
Last, this case provides an illustration for how exposure can be a useful tool to train
psychological flexibility in individuals who are experiencing relational issues. The process
of ACT-informed exposure helped Lucy develop greater awareness of these private events
until she experienced her epiphany, and the exposure work allowed her to practice willing-
ness with the sadness and vulnerability that came with this insight. During a brief email
check-in months later, Lucy stated she had maintained her treatment gains and was more
accepting of her evolving relationship with her father as she transitioned into adulthood.
Deacon—Eyes Without a Face

Background
Deacon was a cisgender, Latinx male in his late twenties who came to treatment to
address body dysmorphia. Deacon obsessed about his facial features, fusing with fears he
looked prematurely old. He was constantly checking his appearance in the mirror and wore
sunglasses to hide what he perceived as crow’s feet around his eyes. When eating out with
friends, he made certain they sat in an area with low lighting. If his friends planned to go
to a restaurant that he knew was too well lit, he sometimes backed out. These behaviors to
manage distress associated with his appearance were clearly getting in the way of valued
living.
Exposure
To target concerns about his appearance, Deacon agreed to spend time looking at his
face in the mirror each morning. Normally, Deacon focused on specific parts of his face
such as his eyes and nose. In focusing on specific features, Deacon fused with critical evalu-
ations of the features (e.g., “ugly,” “old”). To counteract this tendency, Deacon practiced
mirror retraining (e.g., Wilhelm, Phillips, & Steketee, 2012) or directing his attention to
view his face as a whole rather than hyper-focusing on the parts he didn’t like. He observed
that, when he viewed his face holistically, he found his features pleasant to look at (i.e., “not
too bad”). Deacon also practiced willingness with a feeling of “heaviness” in his chest that
occurred when looking at his physical appearance in the mirror. As he practiced willingness
with uncomfortable bodily sensations, he observed that he was less fused with thoughts
about his appearance.
After initially progressing in ACT-informed exposure, Deacon began experiencing
increased panic and anxiety. I was surprised, as the exposure work had seemed to be going
well. When Deacon allowed himself to experience this anxiety and panic, he became more
aware of larger patterns of emotional suppression. He noticed how he often pushed away all
uncomfortable emotions, especially shame and guilt. Deacon traced this pattern of habitual
suppression to his childhood, as his parents were critical of any emotional expression.
Thankfully, he also began to notice how his attempts at experiential avoidance toward
emotions such as shame and guilt backfired by leading to longer-term increases in distress.
Deacon had not initially been aware of these experiences of shame and self-criticism.
Instead, when he felt anxiety and panic, he typically attributed it to an external cause and
searched for some change he could make to resolve it. For example, Deacon noted a pattern
of breaking up with someone or quitting a job in hopes that it would end his distress. He did
these things almost blindly, hoping he would feel better after eliminating the perceived
cause of his anxiety. Indeed, Deacon often did feel a little better after a breakup or quitting
work, which reinforced these avoidance behaviors and helped maintain his belief that his
anxiety was caused by external stimuli. However, he began to suspect these decisions were
somewhat arbitrary and not based on values. He simply took action for the sake of taking
action in an attempt to resolve his anxiety. These impulsive changes reinforced his avoid-
ance because they gave him something else to focus on (e.g., the breakup, finding a new
job).
After Deacon was able to identify these patterns of experiential avoidance, we decided
to focus on helping him strengthen psychological flexibility when in contact with intense
emotional experiences associated with costly avoidance behaviors. He wrote out a list of
self-critical phrases such as You’re evil and You’re a liar that reliably triggered the emotions
he typically suppressed—especially shame. Using a recording app on his phone, Deacon
repeatedly read the list of thoughts aloud and created a fifteen-minute recording of them,
which he listened to between sessions.
At the following session, Deacon reported that by listening to the recording, he was
able to practice willingness with uncomfortable private events and defuse from the content
of these thoughts. In being present with these private events without trying to resolve them,
Deacon was able to connect with what was important to him (i.e., values). For example, he
had been on the fence about ending his relationship with his boyfriend. Because breakups
were part of this larger pattern of impulsively making radical changes in his life to resolve
periods of intense anxiety, Deacon was unclear as to his true feelings about the relationship
and, consequently, had delayed making a decision. In practicing exposure to previously
avoided private events, Deacon was able to see more clearly that his desire to end the rela-
tionship with his boyfriend was rooted in feeling they were incompatible rather than simply
an impulse to make his anxiety go away. Deacon ended the relationship “with more honesty”
than in prior breakups, as he was able to communicate his feelings after practicing sitting
with them and getting to know them in therapy. Across subsequent sessions, as Deacon
practiced exposure with the recording, Deacon continued to increase contact with and
clarify valued directions. He began to make plans to reduce his full-time work and grow his
consulting business.
Take-Home Points
In this case example, we want to illustrate how clients may become aware of other
forms of avoidance during ACT-informed exposure. When Deacon started to experience
greater anxiety and panic during exposure work, we could’ve continued to focus on his
body dysmorphia in a dutiful commitment to seeing the original treatment plan through.
However, the therapist’s application of functional analysis throughout treatment led to the
discovery of a previously unseen variable (shame) and how this contributed to the client’s
anxiety. In this instance, because Deacon’s emotional avoidance was broader than his dys-
morphia, the therapist’s own flexibility and decision to shift focus wound up being the more
effective choice. Additionally, Deacon was actively struggling with whether to end his rela-
tionship, and his pattern of avoidance appeared to interfere with his ability to make values-
based decisions. By strengthening his ability to be present with uncomfortable thoughts and
feelings, Deacon was able to clarify values-based actions.
More importantly, this case illustrates the core definition of ACT-based exposure: cre-
ating behavior-narrowing contexts in order to practice expanding behavioral repertoires.
Deacon became aware of how anxiety and panic appeared to be exacerbated by attempts to
suppress shame and self-critical thinking. By creating a context where Deacon could prac-
tice psychological flexibility with these private events, Deacon strengthened contact with
the present moment, willingness, defusion, and valuing. Through these periods of concen-
trated practice, Deacon was better able to respond more flexibly to these private events in
his daily life and increasingly orient his behaviors around values rather than emotional
avoidance, including breaking up with his partner and starting a consulting business. This
is another example of a client clarifying values after engaging in exposure, rather than start-
ing with a focus on values to motivate a client to engage in exposure.
Jamie—Revisiting Creative Hopelessness

Background
Jamie was a white, non-binary client in their early twenties who came to treatment to
address health-related fears. Their primary fear was that unexplained physical symptoms
(including dizziness, being easily fatigued, and mild throat soreness) were signs of serious—
and possibly terminal—illness. In fusing with these fears, they had visited the emergency
department four times in two months and had made appointments with their primary care
physician about once per month. In addition, fears around having an unexpected allergic
reaction led to avoidance of eating new foods and wearing cosmetics, as well as using newly
purchased bed sheets and clothing.
Exposure
Jamie initially progressed smoothly through a series of ACT-informed exposure exer-
cises. We didn’t spend a lot of time on creative hopelessness in the beginning, as they
seemed to buy into the value of exposure work and showed strong willingness to get started.
Early exposures involved eating new foods believed to cause an allergic reaction (e.g., nuts),
wearing new clothes without washing them first, and using new cosmetic products. Because
they valued going out to eat with friends, exposures also involved visiting new restaurants
and deliberately ordering new foods. As a defusion exercise, they repeatedly read articles
about feared medical issues, such as cancer.
After moving relatively smoothly through initial exposure work to fears of allergic reac-
tion, we worked up to Jamie’s core fear: that their experiences of dizziness, throat soreness,
and gastrointestinal issues were signs of cancer. They wrote an imaginal script in which
these vague physical symptoms prompted numerous visits to their primary care physician
who assured them nothing was wrong. In the script, the symptoms eventually worsen, and
additional testing leads to a diagnosis of terminal cancer, with only a few months to live.
What made this scenario so scary for Jamie was that in the face of death, they realize they
felt they had not lived a valued life. Jamie had a history of excelling in school. In college,
they’d taken pre-law courses, because their parents pushed them toward law school; upon
graduating, however, they realized they didn’t really want to become a lawyer. While search-
ing for a new career direction, they worked menial jobs that they didn’t find meaningful.
Jamie also had never traveled overseas or lived beyond their hometown, due to their strug-
gles with anxiety, and felt that they had missed out on having more excitement in their life.
Jamie committed to listening to a recording of the imaginal script for twenty minutes
daily but reported no progress upon returning to session the next week. Whereas they’d
been conscientious about practice with prior exposures, they reported listening to the
recording only a “couple of times” and had not completed their ACT-informed exposure
tracking form.
What could be going on? To assess avoidance behavior during exposure, I asked Jamie
to practice in session by reading the script aloud. Jamie observed that in reading the script
aloud, they were more present and engaged with the content. By contrast, when listening to
the recording at home, they had experienced the recording “like a thought.” In other words,
they functionally experienced little difference between listening to the imaginal exposure
recording and engaging in health-related worrying and rumination. As a result, listening to
the script led to fusion with its contents in a similar way that Jamie fused with worries about
their health. Consequently, we adjusted the exposure by having Jamie read the imaginal
script aloud instead, hoping this shift in context allowed them to engage in the exposure
with less fusion and experiential avoidance.
Problem solved! I thought. It was simply a procedural issue. The exposure hadn’t func-
tioned to create the conditions to allow Jamie to practice psychological flexibility and
needed some adjustment. Based on carefully observing how Jamie responded to the expo-
sure in session, I was confident we were on the right track now.
I was wrong.
At the next session, Jamie again reported no change in how they experienced the
script, which indicated to me that they were still fusing with its contents. What could be
the problem now? I scratched my head and engaged in additional functional assessment. In
discussing home practice, Jamie mentioned that they would “take breaks” (e.g., stop and
look at their phone) during the exposure whenever they felt uncomfortable. Whereas before,
it seemed like a simple, procedural problem, perhaps the issue was that Jamie was engaging
in deliberate avoidance behaviors during the exposure. This surprised me. As mentioned
earlier, Jamie appeared to have been on board with the rationale for ACT-informed expo-
sure and had progressed smoothly through initial exposure work. It had seemed that we
didn’t need to spend much time in creative hopelessness and demonstrating the costs of
avoidance. But here it was becoming clearer that Jamie was engaging in experiential avoid-
ance and potentially impeding progress. I began making an effort to functionally explore
the consequence of Jamie’s avoidance behaviors with them to strengthen creative hopeless-
ness. Anytime they mentioned something that sounded like experiential avoidance—such
as pausing the exposure to look at their phone—I would inquire about the consequences of
these actions. Often Jamie described these behaviors as a form of self-care or giving them-
selves “a break.” They found, however, that they were more often disappointed that they
didn’t experience the relief they craved. For example, when they would take breaks during
exposure to look at their phone, it would help reset them a little; however, they would also
feel increased stress at putting off the exposure.
After agreeing to not engage in distraction during homework practice, Jamie returned
the following week and reported that they still remained fused with the content during
exposure. This was the third session in a row in which I had thought we’d fixed the problem.
I sighed inwardly. I began to assess for additional avoidance behaviors. After some back-
and-forth with Jamie, I reviewed the exposure practice form more closely and found another
clue. Willingness scores were in the middle of the range (5–6). I wondered if there were
additional avoidance behaviors occurring during the exposure that we hadn’t identified. I
asked Jamie to read the script aloud in session slowly and more mindfully. Slowing down an
exposure exercise is a great way to increase engagement with it, because when a client
moves too quickly, it can be hard to be present and practice willingness.
As they were reading the script more slowly, Jamie began tearing up. They realized they
were able to fully contact feelings of fear and vulnerability for the first time. Contrary to
their expectation that experiencing these emotions would be unpleasant, they felt relief in
contacting these emotions during exposure. I also experienced relief, as it finally seemed we
were getting somewhere. Third time’s the charm.
At subsequent sessions, Jamie reported that in addition to making progress with the
imaginal exposure exercise, they had become more aware of daily patterns of avoidance.
They more clearly perceived their efforts to push away uncomfortable private events using
thought suppression and distraction. “I thought I was taking care of myself,” Jamie com-
mented, “that I deserved not to feel these things.” They would attempt to treat themselves
to relaxing activities such as warm baths and going to the sauna. However, these attempts
would backfire (e.g., more anxiety), and they would feel frustrated that they didn’t experi-
ence these activities as relaxing. This is a good example of form versus function. Jamie was
expecting these activities to function as self-care. Instead, they functioned as experiential
avoidance, as Jamie was trying to use them to suppress or relieve their anxiety. With this
greater awareness, Jamie became more aware of how their efforts at self-care functioned as
avoidance behaviors and contributed to increased anxiety and hopelessness.
We agreed to suspend exposure the following week while Jamie focused on developing
emotional awareness. Each evening they’d journal thoughts and feelings and note any
ongoing stressors. At the following session, Jamie reported journaling a greater variety of
emotions than they’d originally predicted and noted an experience of relief in allowing
themselves to be present with a fuller emotional range. After returning to the imaginal
exposure script, they observed that the script seemed “less of a true story” (e.g., increased
defusion) and were able to finish exposure practice and complete treatment.
Take-Home Points
We offer this case example for a few reasons. One is to illustrate the importance of
troubleshooting ACT-informed exposure practice. When clients do not appear to be
strengthening psychological flexibility through exposure practice, it’s important to engage
in a functional analysis of possible barriers. We recommend doing this in session, so that
you can directly observe the client’s behavior, develop a more informed conceptualization
of barriers impeding exposure work, and consequently make adjustments to the way the
client is engaging the exposure. For example, can the exposure exercise be adjusted to
undermine avoidance? To overcome Jamie’s barriers, we both needed to fine-tune the exer-
cise and take additional steps to increase Jamie’s awareness of avoidance behaviors and
their costs. As Ong and colleagues (2022) found, the quality of exposure exercises, specifi-
cally the degree to which clients are able to practice openness to and willingness with dis-
comfort, is particularly important in ACT-informed exposure—more so than quantity
(doing more) and duration (longer).
This case example also demonstrates how you may need to return to creative hopeless-
ness throughout ACT-informed exposure. It’s not a “one and done” process. In ACT, cre-
ative hopelessness involves helping clients understand how avoidance behaviors backfire. In
ACT treatment manuals, creative hopelessness is sometimes presented as something com-
pleted in the beginning of therapy. With Jamie, though, it was the reverse. Jamie needed
little focus on creative hopelessness initially and was willing to engage in the early expo-
sures. Although Jamie had completed twenty sessions of ACT-informed exposure and suc-
cessfully worked through several exposure exercises to possible allergens, targeting their
core fear of having an undiagnosed, terminal illness resulted in a greater narrowing of
behavioral repertoires (e.g., taking breaks when they felt uncomfortable; rushing through
it). Additionally, it became clearer that their “self-care” behaviors functioned as experiential
avoidance. As we became more aware of Jamie’s pattern of avoidance through functional
assessment, we engaged in more creative hopelessness work, carefully helping Jamie to
understand how these behaviors contributed to worsening anxiety, panic, and frustration.
Conclusions
In sum, we’ve chosen case examples that involve therapists working through difficulties
with ACT-informed exposure and using an understanding of ACT processes to illuminate
barriers to exposure practice. We also hope that these case examples demonstrate some of
what is unique about ACT-informed exposure.
We want to emphasize the importance of function (versus form) in ACT-informed
exposure—as it is in traditional exposure too. The therapists needed to be attuned to
moments when exposure was not functioning as intended, so that adjustments could be
made to the setup of the exposure. When exposure is not functioning to help clients prac-
tice psychological flexibility, it’s vital that the therapist revisit their treatment plan and
engage in a functional assessment of the client’s engagement with exposure to identify bar-
riers (e.g., covert avoidance behaviors; contextual issues). It can be particularly important
to pay attention to client willingness during exposure, such as in the example of Maria,
where interoceptive exposure exercises were titrated to match her willingness, or Jamie,
where middling willingness scores signaled avoidance behaviors. Additionally, although
many exposure exercises are only rough approximates of real-world triggers for clients, when
they insufficiently evoke the private events with which the client struggles—as with Lucy’s
initial imaginal exposure scripts, which were lacking in detail—the therapist may need to
adjust exercises to capture contextual cues that allow for deeper practice in enhancing psy-
chological flexibility.
In all instances, the therapists did not rigidly adhere to the exposure menu. Instead, the
therapist showed flexibility in making adaptations based on newly learned information and
functional assessment. When Deacon became more aware of how pervasive feelings of
shame and fusion with self-critical thinking contributed to patterns of avoidance, the ther-
apist suspended the traditional body dysmorphia exposures and targeted these private
events. By strengthening psychological flexibility while in contact with painful private
events, Deacon was able to clarify valued directions and act with greater intention and
deliberateness than he had in the past.
We’ll note, however, that in none of these examples did the therapist completely
abandon exposure. In each instance, the therapist worked collaboratively with the client to
troubleshoot issues and tweak procedures. Even in the case of Jamie, when the therapist
suspended formal exposure practice for a week, they agreed that Jamie would focus on
behavioral commitments to help strengthen awareness of the impact of avoidance behaviors
that would prepare them for returning to exposure.
In sum, we want to stress the importance of ongoing functional assessment during
ACT-informed exposure. In other words, good ACT-informed exposure relies on clinician
psychological flexibility: paying close attention to what is happening and resisting our own
tendencies to fuse with content, such as an initial treatment plan or how therapy “should”
work. We also hope that these case examples normalize the touch-and-go nature of expo-
sure work. It is rarely a neat and tidy linear path to growth. A client’s lack of progress in
completing exposures also might contribute to experiential avoidance in therapists with
their own anxiety, shame, or frustration. If a client struggles with a particular exercise after
a week or two of consistent practice, step back and collaboratively explore barriers. To get a
clearer picture of what might be going on, have the client perform the exposure in session,
so that you can offer guidance and test out hypotheses for what’s not working. Carefully
consider if the exposure has sufficient contextual cues to evoke relevant private events that
narrow client flexibility. Don’t be afraid to experiment. As scary as it can be to admit thera-
pist fallibility, be open with clients when you’re unsure if an intervention is having its
intended effect. In our experience, clients are very accepting when the therapist doesn’t
know the answer, so long as they feel they’re actively working together as a team. Assure
them that with their help and feedback, you’ll continue adjusting until you can create the
conditions to help them pursue the lives they want.
CHAPTER 10
ACT Fails and Other Pitfalls and

Barriers to ACT-Informed Exposure
One of us (Brian P) used to work in the trauma program at an ACT-based partial hospital
program for clients with acute needs. One of his clients, Cindy, came to the program with
a long history of complex trauma and was struggling with anxiety and depression. Cindy
was dedicated to the program, spending about six hours per day attending group and indi-
vidual sessions where she learned about PTSD and received ACT-informed exposure treat-
ment interventions for trauma. Cindy really pushed herself to engage with exposure and
opened up for the first time in her life about the very painful experiences that she’d kept
locked away from others. She was a model client in the program. However, over the course
of her stay, Cindy seemed to stop responding to treatment, even though she was clearly
working hard. She continued to have difficulty making changes that were important to her
and reported feeling just as “stuck” as when she first entered the program. During week-
ends, which were unstructured, Cindy would feel lost within her recovery process and
return to the program on Monday defeated and hopeless. Cindy’s account of feeling lost and
stuck were hard to reconcile with how she threw herself into exposure practice, how she
sang praises for the benefits of willingness among her peers, and how she appeared to be
able to defuse from depressive thoughts while in the program. Why wasn’t she getting
better?
Her treatment team noticed this pattern and began to investigate. While Cindy could
articulate ACT concepts and apply them during exposure-based sessions at the program, it
became apparent that she would engage in many of the same pre-treatment avoidance
behaviors upon returning home. Cindy was compartmentalizing her treatment. She thought
that if she practiced willingness and opened up about her trauma in the program—in
session—she wouldn’t have to work so hard at home, where it was much more difficult for
her, in the absence of the support of her peers and treatment team.
Once Cindy and her treatment team were able to identify this pattern of behavior, they
engaged in a collaborative conversation about how the skills she had learned to use in the
program also needed to be practiced at home to generalize her learning. Cindy was grateful
to understand why she was stalling in treatment. By practicing more willingness at home,
she was able to redirect her efforts away from avoidance and toward values-based actions.
She began to spend less time isolating and binge-watching television, and instead, spent
more time with her family and friends. Though she was initially terrified at taking steps
toward independence, she eventually applied to a college program. These meaningful
changes resulted in her returning to the treatment program each day reporting a greater
sense of fulfillment, meaning, and purpose in her life. No longer feeling stuck, Cindy cele-
brated her graduation from the program after many weeks of hard work.
ACT-Informed Exposure Can Be Messy

Many treatment manuals—especially ones on exposure—present treatment in a structured
and orderly fashion. This is important in helping orient readers toward what to do and in
what order. A downside of this is that it’s easy to get the impression that treatment is sup-
posed to proceed in a straightforward manner; therapeutic concepts may seem simple
enough in theory but are usually more complex to practice when using with actual clients.
Although many therapist manuals offer clinician vignettes of client difficulties, they some-
times leave out the (often messier) nuances of how the therapist worked through complex
issues. It’s also difficult to succinctly demonstrate interactions that may take several sessions
to come to fruition.
Sometimes ACT-informed exposure goes without a hitch. But, more often, there are
twists and turns. It may take several sessions of trying out different metaphors, experiential
exercises, and tweaking exposure exercises before clients grasp concepts such as willing-
ness. To put it mildly, helping clients learn to practice psychological flexibility can some-
times be a real grind. It is our experience that while every client may pose unique challenges,
there are commonly encountered difficulties when delivering ACT-informed exposure. In
this chapter, we describe many of the more frequent ones, so that you’ll be more prepared if
you encounter them yourself. We also offer some advice as to how to respond to these
obstacles in ways that hopefully will deepen your understanding of how to use the ACT
model in guiding exposure treatment.
Therapist Fails
The first set of barriers that we’ll discuss has to do with ourselves as therapists. When prac-
ticing ACT-informed exposure, there are several common pitfalls that therapists are sus-
ceptible to. Don’t worry—if you find yourself doing these things, it doesn’t make you a bad
therapist, it just means that you’re human. While it can be painful to face our mistakes or
shortcomings in the therapy room, we first need to be aware of what they are, if we are going
to grow into the best versions of ourselves.
ACT Fails and Other Pitfalls and Barriers to ACT-Informed Exposure141
Therapist Experiential Avoidance

“Sure, we can postpone our planned exposure to talk about your pet frog’s strange
mole. Again.”
As therapists, we are no different than our clients in our natural inclination to avoid
things that are uncomfortable or painful. Exposure therapy can be distressing to the client
and therapist alike! Therefore, perhaps the largest barrier that therapists face is avoidance.
In fact, therapist avoidance predicts suboptimal delivery of exposure therapy in general
(Farrell, Kemp, Blakey, Meyer, & Deacon, 2016; Scherr, Herbert, & Forman, 2015).
It’s not always obvious when we’re avoiding things. Sometimes clients have something
serious happen in their life (e.g., a breakup or an accident) that’s important to address. You
wouldn’t say to a client, “I’m sorry your grandmother passed away unexpectedly yesterday.
[Pause.] Anyhoo—are you ready to make farting noises in the public library today?”
However, it becomes harder when there always seems to be something compelling to talk
about each session until, suddenly, weeks have passed without doing any exposure work.
In ACT-informed exposure, the goal of the therapist is to help clients learn to willingly
remain in contact with previously avoided thoughts, feelings, and bodily sensations in order
to practice new ways of responding. This requires willingness on the part of the therapist to
experience their own discomfort. For example, on days when we may feel tired, stressed out,
or just not in the mood, it may be tempting to have an easier session with a client. The
clients fill the session talking about something interesting unrelated to exposure. They
seem happy, so we’re happy! Additionally, therapists are not immune to fusing with thoughts
such as, This client will drop out if I push them to do something uncomfortable.
Therapist avoidance also plays out in other areas of treatment. For example, we may let
it slide when a client comes to session not having completed their homework, rather than
working to understand what happened and the potential problem-solving barriers. As ther-
apists, we may fuse with fears that we’re nagging or shaming our clients if we address home-
work noncompliance. Or, perhaps more egregiously, we don’t ask the client to do the hardest
exposure on the exposure menu, because it will be very emotionally demanding for the
client (and therefore for us). Sometimes a therapist will hold back clients from doing more
challenging exposures and, instead, needlessly break down what could be a single exposure
exercise into several tiny steps. We should clarify that in previous chapters we have recom-
mended modifying exposures based on willingness. If a client needs an exposure split into
several steps, that’s different. What we mean here is not trusting clients’ judgment once
they have gained some experience with exposure and slowing them down unnecessarily.
In short, we should apply the ACT model to ourselves. None of us is perfect. When we
catch ourselves engaging in experiential avoidance, we can let go of judgment and think,
Oh, cool! I just caught myself doing that! Now I can be deliberate in making another choice right
now. In fact, noticing our own avoidance helps us bolster compassion for our clients and be
better able to take their perspective when they talk about their own avoidance behaviors. It
can be easy to forget how hard exposure work is for clients when it involves doing things
that don’t bother us (e.g., “Try to summon a demon by reciting a magical incantation.”
“Don’t mind if I do!”). Here are some additional tips for managing our own avoidance:
• Present-moment awareness: This may seem obvious, but it’s important to be mindful
of our own avoidance habits. Bring a present-moment focus to your exposure ses-
sions and try to catch any urges to avoid discomfort.
• Values: Contacting your values as a therapist can be motivating when therapy

becomes uncomfortable. Exposure, in and of itself, may begin to feel like an exer-
cise in torture at times, but reminding yourself what exposure is in service of can
be helpful in doing the hard work.
• Connect with what’s working: It’s helpful to notice the times when we, as well as
our clients, persist in values-driven behavior despite pain or discomfort. Paying
attention to small treatment successes along the way can be helpful in strengthen-
ing our capacity to persist in doing difficult work as exposure therapists.
Activity: In What Ways Do You Avoid?

Take out a piece of paper and reflect on your own practice. What are signs that you’re
engaging in experiential avoidance? Common behaviors include not following up on
missed homework or allowing clients too much time to talk about things that detract
from exposure in session. Take a few minutes to jot down some of the things that you
tend to do in your role as a therapist that can be labeled as avoidance.
As we mentioned in an earlier chapter, there are many advantages to doing exposure

alongside your clients. Are there types of exposure you could do with a client but then
choose not to because of your own discomfort? Make a note of these situations and
explore what might be coming up for you in these contexts.
Cartoon ACT, a.k.a. Therapist Inflexibility

Another common barrier, especially for therapists new to ACT, is fusing with ACT con-
cepts. Said another way, therapists new to ACT may be rigid in applying the ACT model.
We’re using the term “Cartoon ACT” to describe a version of ACT therapy that is rigid,
inflexible, and lacking in focus on underlying processes. It’s more akin to a cookie-cutter
manualized treatment than to a functional approach that is sensitive to context.
Overexplaining ACT
“Still struggling with willingness? Let’s review the definition…”
“That’s not a value!”
ACT is an experiential treatment, and what’s more experiential than exposure? One
sign we’re being rigid is when we find ourselves talking about ACT rather than doing ACT.
It’s easy to get caught up in talking about ACT rather than helping clients contact ACT
processes in session. Creating contexts in which a client can directly experience ACT pro-
cesses is usually going to be more fruitful than just talking or thinking about it. By the way,
this is a great way to think about exposure therapy! One of Brian T’s favorite sayings is: let
the exposure do the work for you. If a client doesn’t seem to understand ACT processes, it
just may take more repetition in practicing exposure until it really sinks in for them.
Dismissing Symptom Reduction

“You felt less anxious after our exposure? Remember what I keep telling you—that’s
not the goal…”
In ACT-informed exposure, we’re careful not to emphasize habituation or symptom

reduction. However, if treatment is going well, clients often feel better. Therefore, another
example of rigidly applying ACT is to treat symptom reduction like a nuisance. Clients tend
to like symptom reduction.
We may fuse with thoughts such as This isn’t ACT consistent! They aren’t supposed to feel
less anxious—they’re supposed to live a values-based life! It’s okay. We can allow clients this
victory. Failing to celebrate a positive experience risks clients feeling invalidated, like
they’ve done something wrong. Sometimes it can be helpful for clients to hear the message
that sometimes you may feel better and sometimes you may not. From an ACT perspective,
positive emotions or reductions in anxiety aren’t bad per se; it’s only the excessive seeking
of positive emotion at the expense of valued action that is unworkable.
Trying to Find the Perfect ACT Value

“It took us only forty-three minutes, but we finally crafted the perfect values-based
exposure for you to do for homework!”
“What do you value about this exposure exercise? How about this one? And that
one?”
“That’s not a value—that’s a goal. You’re going to give me an ACT-consistent value if

it takes all day!”
A third example of rigidity in ACT is related to values. Values in ACT are qualities in
behavior that are meaningful, such as curiosity, patience, or compassion. Values are differ-
ent from goals. For one, there’s no end to valuing, while goals are something that can com-
pleted. For example, if you value being a good friend, there’s no finite end point to that.
Additionally, we can engage in valuing in any moment, whereas we cannot always accom-
plish goals.
Many therapists new to ACT struggle with understanding values. Therefore, we should
be forgiving and gracious when we ask clients for a value, and they give us something that’s
not ACT-consistent. For example, when we ask clients what feels important to them about
engaging in ACT-informed exposure, a common answer is “to feel less anxious.” This would
not be a value, but a goal. As a goal, however, we might call it a “dead person goal,” which
is defined as something a corpse would be more successful at than the client (e.g., Luoma et
at., 2017). In ACT, “dead person goals” are less than ideal; instead, we want to help clients
focus on active goals aimed at broadening behavior. Again, though, we don’t want to punish
clients for not giving us a perfect, ACT-consistent response. We might help them reformu-
late the goal: “If you were feeling less anxious, what would you be doing with your life that
you’re not doing now?”
It can be helpful, and sometimes powerful, to link exposures with values in ACT-
informed exposure. For example, a client with social anxiety may feel inspired to engage in
exposures that reflect things that are really important to them (e.g., seeing friends or signing
up for a dating app). On paper, it may sound easy to link a value to an exposure; in reality,
however, this can be difficult to pull off, and it can unnecessarily eat up too much therapy
time. It can be laborious to require that all exposure exercises must be linked to values, or
to rigidly demand that clients offer you the perfect, ACT-consistent values. Link exposure
exercises to values when you can, but don’t get hung up on it. Sometimes exposure can help
client clarify values as they clear away the clutter of fusion and avoidance.
Imitating the Ideal ACT Therapist

Another example of Cartoon ACT occurs when we fuse with rigid ideas about what an
ACT therapist is or does. ACT is a model. Even among respected ACT trainers, everyone
has their own style. Some ACT therapists are intense and emotive, and some are fun and
playful. Perhaps we’ve attended an ACT workshop and were inspired by the trainer. Be
careful about fusing with the notion that theirs is the “right way” to do ACT. Instead, learn
how your style of ACT can be its best.
You may also think that you need to read all of the ACT books, attend many work-
shops, and receive formal supervision in order to begin applying ACT to clients. We want
to emphasize that the best way to learn ACT is through doing. You’ll definitely want to own
and read this book, though. Maybe get two copies, just to be sure...
Now that we’ve covered several common therapist fails, let’s shift to focusing on clients.
We’ll discuss common areas that ACT-informed exposure can go wrong with clients so that
you can be better prepared in the case that you run into similar situations.
Client ACT Fails

As we’ve noted, ACT-informed exposure, like any treatment, doesn’t always go smoothly. In
these next sections, we’ll outline common client difficulties that come with each of the core
ACT processes. While our list is not exhaustive, we hope it will be helpful in normalizing
clinical difficulties and offering guidance in responding to pitfalls in ACT-informed
exposure.
Rationale Malfunction
In a perfect world, clients would always be on board with the rationale behind ACT-
informed exposure and quickly internalize ACT concepts such as willingness or values.
However, that doesn’t always happen. Some clients really choke on the idea of “acceptance.”
For example, a client may nod that they understand willingness but later tell you that
they’re hopeful that exposure will finally get rid of anxiety once and for all. Or you may find
that a client demonstrates a strong understanding of ACT in the beginning of therapy but
struggles with willingness as you work toward more challenging exposures.
First, this is normal and not necessarily cause for concern. Remember: let the exposure
do the teaching. Through experiencing, clients may start to connect with ACT processes
during exposure. Some clients just need to get into direct contact with ACT concepts
before they get it.
Values Vortex
“What do you mean by values? I thought this was anxiety treatment!”
“I’d love to have greater meaning and purpose… Maybe we can tackle that after we
get to the bottom of my fears.”
Malcolm was married and had two young boys he totally adored. One of his sons had
behavioral issues and could be quite a handful at times. Malcolm was extremely hard on
himself for getting pulled into arguments with his son whenever his son acted out. At the
root of his argumentativeness, which clearly was a problem and negatively impacting his
son, was a deep-seated anxiety that he was not a good parent and that his son was
headed for a life of problems. This anxiety reflected how much Malcolm cared about
getting things right for his son in ways that his own father had failed to be a good parent
to him.
Pain and values are commonly thought of as two sides of the same coin in ACT. Often
(but not always) what we are anxious about is also what we care about. We care about
showing up for our loved ones, performing well at work, or being healthy. For clients who
are wedded to getting rid of their anxiety, it can be helpful to point this out. One of us asked
Malcolm if, in order to get rid of his anxiety and argumentativeness, he would have to stop
caring about his kids. Of course, the answer was an emphatic no. Helping clients see when
their anxiety is connected to values can be helpful in normalizing and increasing their
willingness to have anxiety. That is an interesting aspect of values—when our pain is con-
nected to meaning and purpose, it can change our perspective of the experience, and there-
fore make it more manageable.
Many clients with anxiety have completely lost touch with what’s important to them.
This can happen when clients struggle with severe anxiety for a long time. Their lives have
become so small that they struggle to think of anything other than feeling better. From a
contextual behavioral science (CBS) perspective, we would say that their behavior is under
“aversive control,” meaning that they are oriented toward escaping discomfort. When we
introduce values to clients like this, it can fall flat. It may even be painful to think of bigger
life directions. Still other clients are so anxious and emotionally aroused that they are
simply unable to have a conversation about any topic, let alone what they want their life to
be about.
As part of being a flexible ACT therapist, we recommend that when a client struggles
with values (or any of the ACT processes) and you’ve made attempts to help them better
understand them through metaphors and experiential exercises, consider letting go of it for
the moment. This doesn’t mean that you give up on values forever. In fact, there may be
opportunities to slip in values work later in treatment as clients increase psychological flex-
ibility. Listen for values as clients talk about their goals or plans. In some cases, clients may
spontaneously start engaging in values-related discussions. For example, a client who rejects
values may tell you many sessions later that they are debating going to a sports game but
aren’t sure if they are ready because treatment has only halfway helped their panic symp-
toms. This may be a moment when you help them to connect with what matters most to
them and use values in a way that is more useful.
Willingness Woes
“My last therapist told me to just accept things. That didn’t work.”
“I feel better when I push it away than when I try to make space for it.”
“If I don’t try to block my anxiety out, it will destroy me.”
It’s common for clients to struggle to varying degrees with the concept of willingness or
acceptance. For one, willingness can be a tricky concept for clients to fully grasp. In fact,
it’s a hard concept for therapists to fully grasp! One common client misunderstanding is
mistaking willingness for resignation—that we are suggesting that they give up or that
there is nothing to be done about their anxiety. Other clients may conflate willingness with
liking something (e.g., I must convince myself that I enjoy the experience of anxiety). Because
the word “acceptance” itself is loaded with cultural baggage, many ACT therapists prefer
the term “willingness,” since it does a better job at describing acceptance as active and a
choice.
Second, not only is willingness tricky for clients to understand, but it can also be hard
to implement fully and consistently. Clients may be saying “yes” to facing their feared stimuli
with their words while still saying “no” with their behavior. In these instances, it can be
counterproductive to push too hard in trying to convince them to be open to their anxiety.
For these reasons, conceptualizing willingness as a continuum, rather than a binary, can be
helpful. If willingness is on a spectrum, consider how you may shape clients to be progres-
sively willing. It also may be unrealistic to expect someone to practice willingness within all
contexts that induce anxiety. For clients, avoidance behaviors can be so habitual and auto-
matic, they don’t even realize that they are doing it in the moment! Consider willingness
like a muscle you’re strengthening, helping a client gradually take steps to bolster this
through exposure.
Some clients may pull you into a heady, philosophical conversation about willingness
yet avoid practicing it. You may find yourself reciting Zen proverbs and debating the meaning
of existence. Sometimes this feels nice. You, as a therapist, are having a stimulating back-
and-forth with your client and demonstrating your competence. There’s nothing wrong
with philosophy—except that it can easily serve as a distraction from the pragmatic focus
of exposure work. Again, we return to the point that intellectual understanding takes a
backseat to experiential learning. You can spend hours and hours refining a client’s concep-
tual understanding of acceptance but guiding them to an experience of acceptance is worth
more than its weight in gold.
Finally, it can be helpful to understand what types of histories clients have around
emotional control. A male client may have a tendency toward suppressing feelings such as
sadness because he grew up hearing that real men don’t cry. Some clients grow up in envi-
ronments where it’s not safe to express emotions. Beliefs or rules about emotions can come
from families, teachers, culture, media—really anywhere. Ideas around emotional control
may vary across cultures (see chapter 11). Understanding larger contexts and beliefs about
emotional control can be helpful in developing more compassion for obstacles clients have
in developing willingness.
Present-Moment Meltdowns
“I tried mindfulness, and it didn’t work.”
“I already know what the present moment is, and it sucks!”
“When I pay attention to my anxiety, it just makes me more anxious.”
One pitfall with encouraging clients to practice present-moment focus is that many
clients can quickly become discouraged or disappointed when they have trouble keeping
their attention on the present moment. For example, it is common for beginning meditators
to give up and say things like, “Meditation isn’t for me, I couldn’t do it.” Clients prone to
self-criticism may be hard on themselves, often feeling like a failure because they couldn’t
keep their attention on their breath for a ten-minute meditation. Normalizing mind-wan-
dering is key in helping clients develop realistic expectations about any attempt to be in the
present moment—whether that be formal meditation or simply a general intention to be
more grounded. For example, practicing present-moment awareness during routine activi-
ties like eating, driving, washing dishes, and walking may be more accessible to many
people.
You may also look for opportunities to enhance present-moment awareness in session.
For example, slowing things down, taking pauses, and encouraging time to reflect on what
is happening right now can all be present-moment interventions without necessarily having
to explicitly call them that. Sometimes that can be helpful to really “sell” clients on mind-
fulness, such as helping them see the costs of being on autopilot. When we are connected
to the present moment, we can usually perceive more choices. Therefore, a present-moment
focus may be framed as a strategy for getting us closer to an intentionally chosen values-
based life. Lastly, the present moment is filled with many hidden gems of reinforcement that
we may miss when we’re caught up in the future or the past. A hot cup of coffee. A warm
shower on a cold winter’s day. A slice of freshly baked cake. Are we really taking in and
being nourished by all these amazing experiences that fill our lives?
Many clients misuse present-moment strategies such as mindfulness to try to control
anxiety. This is often what is meant by “it didn’t work.” Feeling calm or relaxed is not
exactly what present-moment focus is all about. Unfortunately, there are also many thera-
pists who misunderstand mindfulness, instead teaching it as a relaxation practice. While
reduced anxiety may be a side effect of long-term mindfulness practice, mindfulness is really
just about showing up to the present moment as it is. If our present moment contains
anxiety, then that is our present moment.
In the book Ambivalent Zen (1995, p. 60), the author Lawrence Shainberg related this
encounter with his Zen teacher, Kyudo Roshi:
As I’m leaving the zendo after evening sitting, Roshi asks if I’ve come to a decision
about my girlfriend. It’s a question I’ve been dreading. “No. I can’t decide.”
“Can’t decide? Ah, great decision, Larry-san! My teacher, he says, ‘If confused,
do confused. Do not be confused by confusion.’ Understand? Be totally confused,
Larry-san, then I guarantee: no problem at all!”
In some ways, it is so simple and straightforward that many of us have trouble getting
it. In ACT, present-moment focus is simply the full awareness of what is happening right
now, which can include our thoughts, emotions, bodily sensations, and what is happening
around us.
Moreover, it can be helpful to frame this as a skill that can be practiced and improved
over time, and it helps to normalize that our natural state is usually low in being present. It
can also be helpful to set realistic expectations. Many clients believe that they should be
present 100 percent of the time, which is totally unrealistic. Actually, just noticing when we
aren’t present is mindfulness! If clients tell you that they weren’t able to be mindful, you can
reinforce them for noticing that and frame the observation as a success.
Defusion Disasters
“What do you mean that a thought is just a thought?”
“I’m doing my best to only think happy thoughts.”
“Why do you keep saying that my mind is talking to me?”
In chapter 4, we described a common defusion exercise involving the repetition of a

word until the sound loses its meaning, often used to demonstrate the arbitrariness of lan-
guage. For many clients, it’s a fun little exercise that they almost always get. We say “almost
always” because there are some clients who are so fused that they observe no change in how
they experience the word no matter how long they repeat it. They may stare at you in a state
of confusion or bewilderment—Why are you asking me to repeat this word again? As a thera-
pist, this can be disconcerting. At the same time, a client’s stuckness provides incredibly
valuable information about deficits in psychological flexibility.
Some clients really struggle with taking perspective of their thoughts. They may be so
strongly fused with thoughts that they can’t separate them from the observer who is able to
perceive them. Thoughts such as I can’t go on airplanes or I need to bring my Ativan
everywhere I go are experienced as literal truths, not transient mental events. Let’s look at
signs that a client may be highly fused with their thoughts.
First, a client may demonstrate narrowed attention and lack of awareness of other con-
textual features occurring at the same time as thoughts. For example, they may have trouble
listening to you because they are so focused on thoughts. Blank stares and googly eyes are
good indicators of this.
Another sign of fusion is when clients repeat certain statements or phrases to you. For
example, they say, “It’s too much for me!” or “I can’t seem to change no matter how hard I
try.” For these clients, these statements are hard facts about their reality.
Or you spend an entire session on various metaphors and experiential exercises only to
be disappointed when your client naively proclaims, “Oh I get it, I just need to stop thinking
all those anxious thoughts!” In other words, some clients interpret cognitive defusion inter-
ventions in a way other than you intend. Continuing with further explanations probably
won’t clarify the concept.
Finally, a major sign of fusion is when we get pulled into an argument over the truth of
a client’s thoughts. This signals both client fusion and therapist fusion. Even for seasoned
ACT therapists, some clients seem to have a knack for pulling us into debating their
thoughts. This happened to one of us with a client with health illness anxiety during the
beginning of the COVID pandemic in 2020. During one session, the therapist found himself
arguing with the client about what the CDC had said were safe and reasonable precautions
for avoiding COVID. Never get into a factual argument with someone whose compulsion is
researching on the internet—you will lose every time! Whereas in traditional CBT, you
might consider evidence for and against a thought to find the most rational, reality-based
version that you can think of, in ACT, we’re not interested in the true-false debate. Instead,
we’re interested in how a thought functions: what happens when a client buys into a thought
as literal reality?
Fusion can be hard to deal with in the moment when a client is highly fused. Instead,
we recommend that you proceed with treatment and look for opportunities to target this
process in later sessions. You might try informal prompting, such as saying, “I notice your
mind always comes up with a catastrophe when I ask you to predict what will happen.” Or
you might ask, “What is happening in this moment? Are there any thoughts present?”
Gently probe client attachment to thoughts, seeing what you can do to help loosen client
fusion.
Stuck in Our Stories

“What is this ‘observer self’ thing you keep telling me about?”
“I’m supposed to be the sky and not the weather?”

“Why do you keep calling my anxiety a ‘story’?”
Self-as-context can be tricky for many new ACT clinicians, as practically applying this
process in clinical work may be less straightforward. You may remember from chapter 4 that
“self-as-context” refers to the observing self that contains all of our experience. Sometimes
ACT clinicians can get too caught up in “teaching” clients about self-as-context, with
clients’ eyes glazing over like a freshly dipped donut. Some clients may be apt to pull you
into a deep philosophical discussion about the fundamental nature of consciousness or the
evolutionary purpose of anxiety. While at times such discussions can be fruitful, they can
often serve as an unwanted detour. Here are some practical examples of common situations
where clients can show weaknesses in self-as-context.
First, some clients have difficulty with observing their own experience and labeling the
differences between thoughts, feelings, and bodily sensations. For example, after asking a
client where they feel anxiety in their body, you might hear, “I don’t feel anxiety in my
body—I just feel anxious!” They have difficulty separating out thoughts and bodily sensa-
tions present in what they label as “anxious.” When we pay close attention, we will find that
what we call “anxiety” is really a changing stream of experiences including sensations in our
body (e.g., stomach turning, flushed face, tightness in throat, etc.), thoughts (e.g., This is
terrible! I can’t handle this! When will this end? ), and sometimes blends of other emotions
such as disgust, sadness, guilt, or anger. When this all gets lumped into one word—
“anxiety”—clients are less able to make direct sensory contact with their experience and
therefore have difficulty practicing psychological flexibility during exposure work. In addi-
tion to helping clients perceive more clearly the private events that show up during what
they call “anxiety,” it can be helpful to use self-as-context interventions to expand clients’
sense of self so that they realize that they are bigger than these experiences and can inhabit
a perspective in which they identify as the container in which anxiety is experienced.
The opposite of self-as-context is self-as-content or getting stuck in a story about our-
selves. Many sufferers of anxiety may fuse in their identification as being an anxious person.
“That’s just who I am—I’m neurotic!” Friends and family may further reinforce this iden-
tity. “That Bob—he’s a real hand wringer!” As much as their anxiety brings them suffering,
it can also bring a stable sense of self. One insight from relational frame theory is that
identifying with self-stories such as “I’m an anxious person” can be reinforcing because it
brings a sense of coherence to our experience (Törneke, 2010). Identifying with our story is
not always a bad thing. For example, we can look at how unpleasant experiences shaped us
for the better. However, rigid fusion with our stories can keep us stuck. “Because I’m an
anxious person, I’ll never be able to...” There are the infamous “I can’t” statements, such as
“I can’t go to parties” or “I can’t date.”
In addition, fusion with stories may lead clients to fear that they won’t function well if
not engaged in anxious behaviors. For example, many clients believe that their anxiety has
served them well in some domains: “If I give up this anxiety, I won’t be as productive or
driven.” Some clients genuinely believe that constant worrying about catastrophic outcomes
is preparing them for the future. It may be hard for clients to see how fusion with a concep-
tualized self limits their ability to respond flexibility to situations, and that anxiety-related
behaviors are less productive than clients believe.
While you may have an urge to try to dispute such unhelpful stories, an ACT approach
is more focused on changing a client’s relationship to such stories and to recognize them as
just that—stories. An ACT therapist may ask, “So when you believe that about yourself,
how much closer has that brought you to your goals?”
Stories can be compelling, both to ourselves and to others. Some clients are so fused
with their conceptualized self that we fuse with it too. If clients shoot down every sugges-
tion we make—every tiny challenge to their stories—we may start to believe it. Look for
cues that we might be fusing with our clients’ stories. Are you treating this client differently
than you treat other clients, perhaps handling them with kid gloves (e.g., reluctant to
encourage them to do exposure)? Are you feeling hopeless about the client (e.g., maybe
they’re too stuck and can’t change)?
The “ACT Parrot”

Throughout this book we’ve been mindful to remain respectful of the client’s experi-
ence. We’re going a little tongue-in-cheek with this section in calling it the “ACT parrot.”
Joking aside, we think this is an important client presentation to be aware of, as we risk
letting down the client if we fail to address it.
The ACT parrot can speak eloquently about ACT processes such as willingness and
values. Perhaps they seek out and read ACT books on their own, listen to ACT-themed
podcasts, and regularly use mindfulness apps on their phone. They dutifully take notes
during sessions and repeat back things you say for clarification. These clients say all the
things that you, as an ACT-informed exposure therapist, want to hear: “I just need to
accept my anxiety.” “I should just let my thoughts come and go without taking them seri-
ously.” Whether implicitly or explicitly, they’re letting you know they agree with everything
you’ve been telling them. This often feels great as a therapist! You may feel that this client
is going to be a treatment success. However, as time passes, this client struggles to apply
their knowledge outside of session. They fuse with unhelpful thinking and describe actions
that indicate attempts to control their anxiety. They know all the concepts but have diffi-
culty applying them. Why might this be?
One of the authors (Brian P) worked with a client who was like this. He was extremely
smart and really took to ACT. He even began constructing his own anxiety metaphors. For
example, he likened his anxiety to quantum physics, whereby the observer in a scientific
experiment can impact the results of a particle’s behavior simply by observing it. This client
compared this to his own anxiety in that the more he directly focused on his own anxiety
as a problem to be solved, the worse it got. He stated that by observing his anxiety in a
larger context that included valued action, he was able to experience his anxiety in a less
disruptive fashion. Brilliant!
Except that this client continued to remain stuck in his life and unchanged from session
to session.
With these clients, you need to get experiential. As comfortable as it can feel, it’s not
enough to keep talking about ACT. Exposure is one way to help these clients connect expe-
rientially with ACT processes. It may take some time, and trial and error. But keep trying.
You can try interoceptive exercises, even for clients without a diagnosis of panic disorder.
Have them write out imaginal scripts. Be experiential in session. Keep working with them
until ACT starts to “click.” That is how this client eventually made progress—after the
therapist caught on that too much time was spent reporting back on what the client did,
more time was devoted toward practicing a variety of exposure exercises in session. This
allowed for direct observation and feedback that helped the client to experientially practice
being more psychologically flexible.
Conclusions
Practicing ACT-informed exposure, like any other treatment, is rarely a straightforward,
linear process. Becoming familiar with common pitfalls can be helpful in recognizing them
when they first appear, so that you are more likely to respond in a flexible and effective
manner. With exposure work, simply relying on the repetition of exposure exercises can
often lead to successful resolution of emerging challenges. When that doesn’t work, case
conceptualization informed by ACT processes can be helpful in recalibrating treatment
when a client is struggling. Finally, remember to rely on experiential methods and pay atten-
tion to your own inner processes of psychological flexibility.
CHAPTER 11
Cultural Considerations in
ACT-Informed Exposure
To practice ethically requires awareness, sensitivity, and empathy for the patient as an
individual, including his or her cultural values and beliefs.
—Hoop et al., 2008
“Why do we have to keep going to diversity trainings at work year after year? We know what
to do; we don’t need to go over it again and again.” This is something a white cisgender male
friend said to me (Joanne, Chinese American cisgender female) many years ago. It sparked
a heated but eye-opening discussion about the importance of talking about culture and
diversity, especially in the workplace. After I provided a case for the importance of yearly
trainings, my friend responded: “But I already know all that… What’s the point in repeat-
ing the same thing?” To his point, I can empathize with the frustration one might have
when going to trainings year after year that don’t appear to offer anything new. However, as
with any type of learning, how open we are to embracing new information can influence
how much we gain from the experience. Whereas someone who embraces the learning
process as ongoing and evolving may bring curiosity about what more they can learn at each
training, someone who views learning about culture and diversity as finite (e.g., “one and
done”) might approach trainings with skepticism, believing they already have all the knowl-
edge and skills they need to be culturally sensitive.
When we refer to “culture” throughout this chapter, we mean to refer to all the cultural
identities outlined in Hays’s (2001) ADDRESSING framework: Age, Disability (develop-
mental or acquired), Religion, Ethnicity, Socioeconomic status, Sexual orientation,
Indigenous heritage, Nationality, and Gender. However, we want to acknowledge that our
chapter does not address all aspects of culture, as we are limited by the available literature
on cultural adaptations for ACT and exposure therapy, as well as our own clinical experi-
ences. Unfortunately, research on empirically supported treatment such as ACT-informed
exposure with diverse people is not as robust as it could be (e.g., Grau et al., 2022).
Nonetheless, we hope our exploration of culture in this chapter offers a starting point for
the importance of exploring cultural matters through the lens of an ACT-informed expo-
sure therapist.
Addressing cultural issues in ACT-informed exposure is not easy. Even therapists who
value continued learning about culture may be reluctant to bring culture up in the therapy
room. There is evidence that exposure therapists, many of whom have been trained in CBT,
may be less proactive in introducing issues of culture compared to therapists from other
treatment modalities. Maxie and colleagues (2006) found that CBT therapists were less
likely to reference culture (36.8 percent) compared to therapists of other backgrounds such
as psychodynamic (46.6 percent), humanistic (46.8 percent), and psychoanalytic (74.1
percent).
Why are therapists reluctant to address culture with their clients? There are many
reasons. Some therapists may avoid such discussions because they worry about potentially
offending or upsetting clients. They may fuse with thoughts such as We are so different that
I’ll never be able to help them or I don’t know enough about this client’s culture, so better to avoid
the topic altogether. Some therapists may be open to talking about culture but wait for clients
to bring it up first, perhaps believing this approach is more respectful to clients. However,
clients may be uncomfortable initiating these conversations. For example, BIPOC clients
with anxiety-related problems may be reluctant to bring up cultural issues for fear of rein-
forcing cultural stereotypes (e.g., Williams, Rouleau, La Torre, & Sharif, 2020), putting the
onus on the therapist to initiate these discussions.
Because ACT-informed exposure is a context-based treatment approach, talking about
and integrating cultural issues into exposure work may better inform your interventions
rather than applying the same general treatment approach with all clients. A psychologi-
cally flexible therapist is open to doing what works for their clients, such as talking about
differences between them—even when it’s uncomfortable (Luoma, Hayes, & Walser, 2017).
Conversely, low psychological flexibility is related to more prejudicial behaviors (Levin et
al., 2016).
Microaggressions
For those of us who have been brought up within a Western cultural context, it’s important
to be aware that, over the course of our lives, we have formed attitudes and perspectives
that are biased toward the white, majority culture. As a result, we may inadvertently do
things that make some clients feel marginalized. These behaviors are called “microaggres-
sions.” Microaggressions are “brief, everyday exchanges that send denigrating messages to
certain individuals because of their group membership (people of color, women, or LGBTs)”
(Sue, 2010, p. 24). They are normal human tendencies that we’re all susceptible to, but they
can be harmful, and in a clinical setting, they can cause harm to the client and the
Cultural Considerations in ACT-Informed Exposure157
therapeutic alliance. Being a psychologically flexible therapist means being aware of and
addressing microaggressions if we inadvertently engage in them. Microaggressions include:
• Any words or gestures that make someone feel like an outsider, less than, different,
or not part of the in-group
• Not bringing up issues of race and culture or acknowledging a client’s cultural

background
• Making assumptions about someone’s identity (e.g., gendering) or their needs (e.g.,
providing unwanted assistance to someone with a disability) based on appearance
Even a culturally sensitive therapist may inadvertently engage in microaggressions in

the midst of planning and implementing ACT-informed exposure. For example, a common
exposure for social anxiety is paying for something in pennies. Clients from impoverished
backgrounds, or who are unfairly stigmatized as being frugal, may experience greater shame
or humiliation in being encouraged to engage in this exposure. Also, exposures that involve
bringing attention to oneself in public may be riskier for BIPOC clients than for white
clients because, relative to people who are BIPOC, there are implicit protections for white
people in public. They belong to the majority culture and as such, they may be shielded
from many of the social consequences for engaging in a “social faux pas” that their BIPOC
counterparts would not be protected from. Consider also how one conducts an intake. For
example, asking a client during intake, “Where are you from?” may be triggering for
someone who is part of a marginalized group, as they may have been asked questions like
this in the past due to the assumption that they must have been born in a different country
because they do not look like other people from the majority population.
In the process of writing this book, we even stumbled across a phrase common in expo-
sure therapy that we had not before considered could be racially insensitive: “white knuck-
ling” (e.g., Cook, Simiola, Hamblen, Bernardy, & Schnurr, 2017). In a literal sense, “white
knuckling” refers to tensing up during an uncomfortable experience, gripping your hands so
tightly that your knuckles turn white. When an exposure therapist uses the term, they
usually mean the client is not being present with the exposure and instead engaging in
covert avoidance. It can mean rushing through exposure, trying to “get it over with.” Brian
T had included the term in an earlier draft of this book, but Brian P alerted us to the pos-
sibility of the racial implications of the metaphor, as not everyone’s knuckles turn white,
depending on their skin color.
To gather additional feedback from other clinicians, I (Joanne) posed the question
about use of the term on a members-only social media page for anxiety specialists. Responses
varied. Like us, the majority indicated that they commonly used the term “white knuck-
ling” in exposure work and had not considered the racial implications of it. The general
consensus was that if the term could potentially be perceived as insensitive and
marginalizing, it would be best to retire it and use a synonym. We decided to err on the side
of caution and excised the expression from our manuscript. We share our experience as an
example of the fast-changing norms within our sociopolitical culture and how commonly
used terms may be more culturally loaded than we realize.
Given our potential blind spots, it’s important we bring openness, curiosity, and sensi-
tivity to our clients’ cultural contexts so that we can bring greater sensitivity to treatment.
Consultation with colleagues can also be valuable in helping you see your blind spots and
expand your understanding of the common cultural norms and practices of clients with
whom you’re working. We also recommend that if you become aware of a microaggression
that you’ve made or a client brings it to your attention, that you adopt a non-defensive
stance, take responsibility for the action, and do what is necessary to repair the
relationship.
Cultural Adaptations to ACT-Informed Exposure

Unfortunately, the literature on cultural adaptations for exposure-based treatments for
anxiety disorders is sparse (Koydemir & Essau, 2018). It’s even rarer to find guidance on
cultural adaptations for ACT-informed exposure specifically. However, what we do know is
promising. Although culturally diverse clients may require more time to complete exposure
therapy, there’s evidence that exposure is as effective with BIPOC clients as it is with white
clients (Benuto & O’Donahue, 2015; Williams et al., 2015, 2020).
While standard exposure treatments may work pretty well across diverse clients, there’s
also evidence that cultural adaptations can enhance outcomes with exposure therapy com-
pared to treatment that doesn’t incorporate culture in its interventions (Griner & Smith,
2006; Pan, Huey, & Hernandez, 2011). Additionally, ACT may be successfully adapted to
different cultures for the treatment of anxiety disorders (Bahattab & AlHadi, 2021; Shabani
et al., 2019).
What does an ACT-informed therapist do in the absence of concrete guidance about
cultural adaptations? Do we try treatment as usual and hope for the best, or do we experi-
ment with making cultural adaptations that have not been empirically studied? We (the
authors) don’t have clear answers to these questions. In the following sections, we explore
these questions and offer examples of cultural adaptations taken from research and case
studies.
Culture and Emotional Control

In creative hopelessness, we explore with clients the workability of their control strate-
gies (see chapter 4). Although much of the ACT literature is predicated on the notion that
attempts at control or suppression of thoughts, feelings, and bodily sensations tend to back-
fire, there may be cultural variations in the degree to which control strategies are viewed as
adaptive.
Koydemir and Essau (2018) offer that, for collectivist cultures that are more oriented
toward group harmony (e.g., some Asian, Middle Eastern, Latinx), the function of how
emotions are expressed may be different than for clients from individualistic cultures where
more value is placed on the self (e.g., Western European). For example, Krieg (2020), writing
from a contextual behavioral perspective, argues that behaviors associated with social
anxiety may be more adaptive in a Japanese context (i.e., helps to gather social support)
compared to an European American context.
In a study of European American and Asian American women that compared the
impact of emotional suppression, Butler and colleagues (2007) found that for bicultural
women with Asian values, emotional suppression resulted in less intense negative emotions
compared to those with Western European values. Additionally, bicultural women with
Asian values were perceived as less hostile compared to Western European women.
Interestingly, these women exhibited greater flexibility in their use of emotional suppression
compared to women with predominately Western European values, who used suppression
more rigidly. In ACT terms, bicultural women with Asian values (e.g., Asian Americans)
may manage their emotions with greater psychological flexibility. As a result, emotional
suppression may have more deleterious consequences for those in some cultures (e.g.,
Western European) than in others (e.g., Asian). This study offers a useful reminder for ACT
therapists to be sensitive to cultural differences when engaging in creative hopelessness and
to approach the process with openness and humility. While there is literature on the detri-
mental effects of emotional suppression, it can be useful to suspend the belief that all emo-
tional suppression is ineffective, as there may be instances where it may be adaptive or
helpful. Moreover, it provides further support for the psychological flexibility model in that
it isn’t the behavior itself that is problematic (e.g., emotional suppression), but rather the
lack of flexibility and sensitivity to context with which one engages in the behavior.
To return to our earlier discussion about cultural insensitivity and the risk of engaging
in microaggressions, when assessing the workability of client behaviors in ACT-informed
exposure, consider the language you use in assessing the workability of client strategies. To
what degree does your language suggest cultural biases of your own? When inquiring about
the workability of certain behaviors, the way we phrase our questions can reveal our assump-
tions that these behaviors are not effective. Try to be as neutral as possible and frame your
explorations of creative hopelessness from a place of genuine curiosity (e.g., “When you do
that, what happens?” versus “How effective is that?”) to protect against making biased
assumptions about what works and doesn’t work for a client.
Use of Metaphors and Experiential Exercises

A quote attributed to the playwright George Bernard Shaw described America and
England as “two nations separated by a common language.” We offer this quote as a segue
into how ACT experiential exercises and metaphors from one culture may not translate in
another—even if there’s a shared language. Words that appear to be similar on the surface
may represent different corresponding ideas, and a metaphor that is commonly understood
by one group of speakers may be unfamiliar to another if translated verbatim.
For one, there may be ACT concepts that are not as easily understood by clients from
all cultures. For example, Sobczak and West (2013) suggest the concept of acceptance or
willingness may be harder to understand for clients from underserved backgrounds who are
struggling daily with the necessities of living (e.g., transportation; housing). Consequently,
we want to be sensitive to client context and try to adapt accordingly. Even if a client is able
to understand what we’re saying, we may still want to make adaptations to bring more
nuance to our work, as the use of imagery and language that aligns with a particular cul-
tural group (e.g., the image of water for Buddhist individuals) may resonate much more than
using standard, nonspecific imagery and language (Hinton, Pich, Hofmann, & Otto, 2013).
Payne (in press) suggests use of the phrase “living life like it’s golden” when talking about
values-based behavior to those who are part of the Black community, because she found
that it resonated much better than the term values.
ACT metaphors may have images or ideas that are completely unfamiliar to other cul-
tures. A quicksand metaphor for acceptance (e.g., Luoma et al., 2017) may be confusing for
clients unaware of this oddity of nature. The authors, for example, who’ve never actually
seen quicksand, grew up with it as an omnipresent threat, due to it being a common trope
on American television shows and movies in the 1980s! In adapting an ACT protocol
developed in the US for Brazil, Laurito and colleagues (2022) changed an ACT creative
hopelessness metaphor involving a jelly donut (“Don’t think of a jelly donut!”) to a common
Brazilian dessert. If you’re finding that clients you work with have trouble with particular
ACT metaphors or ideas, experiment!
It’s one thing for a metaphor to fall flat with a client. A greater concern is that some
ACT metaphors may come across as culturally insensitive with clients from other cultures.
They may even be perceived as microaggressions. For example, a common ACT metaphor,
“The Chessboard” metaphor involves using chess pieces to demonstrate a fight between
negative thoughts and positive thoughts (e.g., Hayes et al., 2012). As Masuda (2014) notes,
many chessboards have dark-colored pieces and light-colored pieces, and therapists may
inadvertently reinforce negative stereotypes about skin color by using the dark-colored
pieces to represent the negative thoughts. Another metaphor, “Joe the Bum” (Hayes et al.,
2012), may reinforce negative stereotypes about individuals who are houseless. In working
with Brazilians, Laurito and colleagues (2022) changed the metaphor from a “bum” to an
“unwanted neighbor” to reduce stigma toward anyone struggling with housing.
For some clients, religion and spirituality may be an important component of their care
in ACT-informed exposure. In adapting ACT-informed exposure for clients of different
religious backgrounds, it may be necessary to consider key terms and ideas to improve com-
patibility. Even terms such as “mindfulness” can be controversial in Western cultures.
When I (Joanne) first entered graduate school to pursue my doctorate degree, a Christian-
identified family friend warned me about how psychological approaches like mindfulness
and meditation could steer me away from Christianity (which is what I had been practicing
at the time) because it was “new age.” I recall feeling discomfort at this, because I respected
this family friend. I am reminded of this exchange when I work with clients who are deeply
spiritual or religious, wondering if they, too, have difficulty with aspects of ACT and, even
more broadly, psychotherapy. To mitigate possible conflicts between ACT-informed expo-
sure and your client’s religious or spiritual practice, we suggest consulting with a spiritual
leader in your client’s community (or having your client do so for homework) to understand
how ACT concepts and practices may or may not align with the client’s specific spiritual
beliefs. Fortunately, there’s evidence that ACT can be integrated with clients’ spiritual and
religious beliefs (Santiago & Gall, 2016). For example, it appears ACT psychological flexi-
bility model is consistent with tenets of Islam (Bahattab & AlHadi, 2021; Langroudi &
Skinta, 2019; Tanhan, 2019).
If you find that common ACT metaphors don’t resonate with one of your clients, exper-
iment with coming up with your own that are tailored to their perspective. Notice the
words, phrases, and examples they use when they’re conveying a thought to you. Pay par-
ticularly close attention to language when clients express a strong emotion. You may even
consider asking them to come up with a metaphor for an idea or concept: “Can we think of
a way to describe your anxiety? When you talk about it as something frightening or as
something hanging over you, it kind of sounds to me like an angry bear or a circling
vulture—do any images or ideas come to mind for you when you think about your anxiety?”
Inviting your client to make up their own metaphors may not only increase the likelihood
that the metaphor or phrase is something they will understand, it may also be an opportu-
nity for them to deepen their understanding of the concept you are teaching them.
Values
Of all the ACT processes, values are most likely to be culturally influenced. In helping
a client clarify and get in touch with values, ACT-informed exposure therapists typically
focus on how to move the individual closer to the life they want—as opposed to the life
that, for instance, clients imagine others want for them. In fact, the therapist may view a
client’s focus on the desires of others as a sign of psychological inflexibility: that they have
lived their life so focused on the opinions of others to the detriments of being able to
observe, connect with, and put words to what they want for themselves.
While this view may be productive when working with clients from individualistic cul-
tures, such as Western European, it may miss the mark when working with clients from
collectivistic cultures (e.g., Asian, more traditional Latinx cultures) which emphasize the
interdependent nature of self-identity, maintaining relationships, and the needs of the group
(Koydemir & Essau, 2018). For individuals from interdependent cultures, values may involve
prioritizing family over what’s meaningful for them as an individual (LeJeune & Luoma,
2019). Consequently, in engaging in values clarification with a client from a collectivistic
culture, instead of asking what’s important to them as an individual, you may want to be
open to the idea that for some clients, what is important to the group is genuinely important
to them. Considering the role of family with clients is an important adaptation in working
with clients from many different backgrounds. For example, a Brazilian adaptation of an
ACT protocol for OCD added an emphasis on family relationships traditionally valued in
Latin cultures (Laurito et al., 2022). Consider seeking out information about what’s impor-
tant within any cultural groups with which you work to get a sense of the kinds of values
important in those communities. A little preparation may help facilitate the questions you
ask and help you see any blind spots you might have.
Improving Access to Treatment

For much of this chapter, we’ve focused on cultural adaptations of ACT-informed exposure
in the service of strengthening cultural sensitivity. In addition to this, it’s important to
consider general practical adaptations that may improve access to treatment for clients from
underserved populations. For example, evidence suggests that clients from marginalized
groups are much less likely to access treatment for OCD at specialty clinics compared to
their majority-culture counterparts, even though both populations have similar rates of
OCD and obsessive-compulsive symptom characteristics (Katz et al., 2020). Reasons for
this disparity may include differences in cultural beliefs about therapy, financial and time
constraints, stigma and shame, language barriers, and the mistrust of the healthcare system
and behavioral health (Kolvenbach, Fernádez de la Cruz, Mataix-Cols, Patel, & Jassi, 2018;
Shea & Yeh, 2008; Turner et al., 2016). While not every issue can be addressed in this
chapter, we have offered some adaptations we think can be important in ACT-informed
exposure.
Utilizing Supplemental Support to Ease Financial Costs

The dominant model of exposure-based treatment is one session per week. Some
anxiety clients may even benefit from meeting more often than that. However, even in the
United States, where we live, weekly sessions may place treatment out of financial reach of
many clients with middle-class incomes, let alone people from a lower socioeconomic status.
In these situations, you may consider involving loved ones or other types of support (e.g.,
lower-cost clinicians-in-training, behavior-change coaches) to coach clients while engaging
in exposure practice to replace some of your sessions. These “exposure coaches” may require
an investment of time at first, but after they get going, you may only need to check in with
them intermittently. I (Joanne) have found this particularly helpful in using ACT-informed
exposure with clients who have hoarding and OCD behaviors, due to the significant amount
of time that is needed to engage in skills practice in order to make progress in treatment.
Adaptations for Nonnative Language Speakers

Sometimes we may find ourselves working with clients who don’t share our native lan-
guage. Even if a nonnative-speaking client is fluent in the therapist’s language, allowing
them to engage in ACT-informed exposure exercises in their native language may enhance
outcomes, even if the therapist doesn’t understand the client’s native language (Murrell,
Rogers, & Johnson, 2009; Szoke, Cummings, & Benuto, 2020). As the goal in ACT-
informed exposure is to get into contact with painful private events, conducting exposure
in a client’s native language may be particularly important in evoking contextual cues that
allow for the practice of psychological flexibility. In this discussion, we’ve pulled from both
the ACT and non-ACT exposure literature.
When working with clients with PTSD, for example, it may be helpful for clients to
engage in imaginal exposures to the traumatic events by talking through the trauma narra-
tive aloud or writing about it repeatedly in their native language. Szoke and colleagues
(2020) recount a case study of a Malaysian American female client who was traumatized by
an abusive husband. An important detail within the context of her trauma experiences was
that she and her husband communicated in her native language. The therapist noticed that
the client had difficulty fully engaging in imaginal exposure in English, while the intensity
of the exposure increased when the client switched to her native language. It appears that
conducting exposure in the client’s native language facilitated access to contextual cues
associated with narrowing behavioral repertoires.
In addition to exposure work, ACT cognitive defusion exercises may also be more pow-
erful when clients engage in them using their native language. Consider here that clients
are more likely fusing with thoughts in their native language; consequently, defusion exer-
cises using their nonnative language may lack the stimulus functions that contribute to
fusion. Murrell and colleagues (2009) found that, even if the therapist does not understand
the client’s language, they can attend to behavioral cues associated with client contact with
discomfort (e.g., shallow breathing; clenched fists) and can still help clients practice psycho-
logical flexibility (e.g., draw their feelings; open up to discomfort with their posture).
Activity: Bringing It All Together

In the exercise below, we invite you to bring together any reflections and insights you
have gathered throughout this chapter. Please write down your responses on a sheet of
paper or in a notebook as you proceed through the steps.
1. Take a moment to identify a client you have done either ACT or exposure therapy
with who is different from you culturally. It can be someone you’re working with
currently or someone you worked with in the past. Take a few moments to bring
them to mind. Imagine they’re standing or seated in front of you.
2. Take a moment to notice what’s coming up for you as you imagine being in the
same room as this client. Observe any thoughts, feelings, or bodily sensations.
How do you feel toward them now, having worked through this chapter? How is
what you feel now similar or different to what you felt then, when you last shared
space physically?
3. Get in touch with your experience of working with this client. How connected did
you feel? How was it to communicate with the client? How did you feel about
your working relationship?
4. Whether you did ACT, exposure, or both, consider any modifications you made
to treatment. What happened? Did you consult with anyone in their community
or consult with a trusted colleague about this client? If you did ACT, did you
make any cultural adaptations for common experiential exercises or metaphors?
If so, what? If you did exposure, consider any adaptations you made. If you could
go back in time, and the therapist you are here-and-now could consult with the
therapist you were then-and-there, what (if anything) would you recommend
doing differently? Consider these suggestions as part of your reflection:
Take more time to understand the client’s cultural norms, practices, and
values.
Take more time to discuss how you and the client can work together,
given the cultural differences between you.
Approach treatment with more openness and curiosity.
Consult with individuals in client’s community or with colleagues.
Consult the literature for any guidance related to the client’s cultural
norms, practices, and values.
Consult the literature for suggestions for cultural adaptations to experi-
ential exercises, metaphors, exposure exercises that may improve fit
with the client’s cultural context.
5. Now reflect on your own general process of understanding and approaching

culture.
How do you approach cultural awareness, sensitivity, and competence?
What—if any—discomfort do you observe in bringing up cultural issues
in therapy? What emotions do you experience? What are some thoughts
you may fuse with?
What’s your current involvement in culturally informed treatment? Are

you part of a diversity, equity, and inclusion (DEI) group? Do you attend
regular trainings on cultural issues or read literature on topics related to
culture in order to further your knowledge?
6. Depending on your experience in working with the client and how effective you
feel your process of understanding and approaching culture is, consider the fol-
lowing questions:
Is there an area of your practice that you would like to strengthen as you
work toward strengthening cultural sensitivity?
What’s one step you are willing to take toward changing how you
practice?
What might get in the way of following through with this step (e.g.,
thoughts, feelings, bodily sensations). How would you like to relate to
any barriers—especially internal ones?
Conclusions
As a treatment that emphasizes sensitivity to function and context, ACT-informed expo-
sure is well positioned to being adapted in working with culturally different groups. However,
as a treatment that was largely developed in a Western, individualistic culture, there may be
cultural biases encoded in the approach. In values clarification, for example, ACT texts
often focus on what the individual wants. Consequently, a focus on the needs of others may
be viewed by a Western European ACT therapist as a sign that the client is not in contact
with their values. For clients from collectivist cultures, a focus on others (e.g., family, com-
munity) may be what is most important to them, freely chosen. These caveats aside, while
research on cultural adaptation of ACT and exposure is not as robust as it could be, find-
ings suggest that ACT-informed exposure may be effective with clients from other cultures,
often with minimal adjustments.
We offer some suggestions and guidance about cultural adaptation that we’ve culled
from the ACT and exposure literature. We want to emphasize here that educating yourself
is no substitute for actually acknowledging and openly talking with your clients about cul-
tural differences. Additionally, as every client is unique, no one approach to ACT-informed
exposure will look the same across clients. As you continue to engage with the process of
expanding your understanding of cultural context in your practice (your own and others),
remember that this isn’t a finite process; it’s an ongoing journey that we’re all in different
stages of. Although difficult, if you value being a culturally sensitive therapist, embrace any
discomfort you experience as you take each step in your journey.
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Brian L. Thompson, PhD, is a licensed psychologist; and director of the anxiety clinic at
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Brian C. Pilecki, PhD, is a clinical psychologist at Portland Psychotherapy who specializes

in the treatment of anxiety disorders, trauma, post-traumatic stress disorder (PTSD), and
matters related to the use of psychedelics. Brian also has extensive experience in the areas
of mindfulness and meditation, and incorporates them into his therapy with clients. He is
an active researcher and has published on topics such as anxiety disorders, mindfulness,
and psychedelic-assisted therapy.
Joanne C. Chan, PsyD, is a licensed psychologist, and assistant professor of psychiatry at

Oregon Health and Sciences University (OHSU) where she provides psychological support
to medical and dental faculty, residents, and fellows. Joanne specializes in exposure therapy
for anxiety and obsessive-compulsive and related disorders, and regularly provides training
and education in her areas of expertise.
Foreword writer Steven C. Hayes, PhD, is Nevada Foundation Professor in the department
of psychology at the University of Nevada, Reno. He is originator and codeveloper of accep-
tance and commitment therapy (ACT), a powerful therapy method that is useful in a wide
variety of areas.
Index
A related to, 54–55, 75–76, 144; varying intensity

during, 83–84; Willingness Switch for, 62–64
about this book, 7
ACT parrot, 152–153
abuse clients, 31, 163
ADDRESSING framework, 155
acceptance: exposure related to, 35, 80;
Ambivalent Zen (Shainberg), 149
willingness as, 49, 147
American Psychological Association (APA), 5
Acceptance and Action Questionnaire (AAQ-II),
anxiety: avoidance related to, 16–17, 30, 31–32;
100
fear structures and, 20; observing the
acceptance and commitment therapy (ACT):
experience of, 151; panic attacks and,
behavioral basis for, 23; brief history of, 24–25;
122–125; relational framing and, 33; research
client misunderstandings about, 56–57;
on ACT vs. CBD for, 6; response to exposure
creative hopelessness in, 42–46; effectiveness
therapy for, 10–11; river metaphor for, 90–91;
of CBT vs., 6, 34; experiential avoidance in,
values connected to, 146; willingness practice
30; exposure in context of, v–vii, 3–5, 7, 21,
for, 62–64. See also fear
34, 35–36, 41–42; functional contextualism
assessment: in ACT-informed exposure, 66–68; of
and, 26, 28–29; hexaflex processes in, 46–55;
client behavior change, 99–103; empirically
overexplaining, 143; process-based approach
validated measures for, 100–101; exercises and
in, 6; psychological flexibility in, 29–32, 34,
metaphors for, 60
35, 36, 46; relational frame theory and, 32, 33;
Association for Contextual Behavioral Science
symptom reduction and, 4, 35, 36
(ACBS), 23
Acceptance and Commitment Therapy for
avoidance: adaptive value of, 30; anxiety
Anxiety Disorders (Eifert & Forsyth), 59
perpetuated by, 16–17, 30, 31–32; covert or
ACT-informed exposure therapy: ACT processes
subtle forms of, 49, 91; during exposure, 49,
and, 47–55; assessing the impact of, 66–68;
90–91; habitually engaging in, 98–99;
barriers to, 95–99, 140–153; case examples of,
rule-governed behavior and, 31–32. See also
121–138; choosing exercises for, 65–66;
experiential avoidance
clarifying therapist assumptions in, 41–46;
awareness: increasing through tracking, 110–111;
common problems in, 88–92; cultural
present-moment, 67, 80, 142, 148–149
considerations in, 155–165; debriefing clients
after, 84–85; developing a specific plan for,
72–73; ending treatment in, 93–106; forms B
created for, 109–119; improving access to, barriers to treatment, 95–99, 140–153; client-
162–163; length of exercises in, 74–76; related fails, 145–153; defusion struggles,
messiness of treatment with, 140; metaphors 149–150; engagement in avoidance behaviors,
and exercises for, 59–60, 160–161; moving on 98–99; fusion with ideas about progress, 98;
to new exposures in, 86; organizing exercises holding onto safety behaviors, 96–98;
for, 68–70; psychological flexibility and, 34, 35, non-generalization of exposure work, 95–96;
42, 83–84; rationale for using, 60–61, 65; parroting ACT principles, 152–153; present-
talking with clients during, 79–81, 82–83; moment meltdowns, 148–149; rationale
therapist behavior during, 76–83; traditional malfunction, 145; stuckness in our stories,
exposure vs., 34–35, 36–37, 41; 150–152; therapist-related issues, 140–145;
troubleshooting problems in, 86–88; values
values struggles, 145–146; willingness coaching clients, 163

problems, 147–148 cognitive behavioral therapy (CBT): effectiveness
behavior change: assessment of, 99–101; of ACT vs., 6, 34; exposure in context of,
committed action related to, 47; forms and vi–vii; third-wave of, 24–25, 34, 35
worksheets for, 109, 110; tracking of, 101–103, cognitive defusion: ACT exercise on, 51; client
110, 111 struggles with, 149–150; exposure as, 50–51,
behaviorism: ACT and exposure rooted in, 23; 78, 80; language considerations, 163
first wave of CBT as, 24 cognitive therapy, 24
behaviors: avoidance, 90–92, 98–99; contingency- collectivistic cultures, 159, 162, 165
shaped, 30–31; rule-governed, 30–32; safety, committed action, 47, 78
90–92, 96–98; tracking, 101–103, 110–112 common factors of treatment, 94
between-session habituation, 19, 20 conceptualized self, 53, 152
Big Book of ACT Metaphors, The (Stoddard & conditioned response (CR), 12
Afari), 59 conditioned stimulus (CS), 12
Big Book of Exposures, The (Springer & Tolin), conditioning: classical, 11–15; operant, 15–17
65 contact with the present moment: ACT exercise
bioinformational theory, 18 on, 48; client problems with, 148–149;
BIPOC clients, 156, 157, 158 exposure as, 48, 78, 80; rating distress as, 67;
body dysmorphia, 131–133 therapist avoidance and, 142
contextual behavioral science (CBS), 23, 32, 146
C contingency-shaped behavior, 30–31
control strategies, 43, 91
Cartoon ACT, 142–145
creative hopelessness, 42–46; case example on
case examples, 121–138; of body dysmorphia
revisiting, 133–136; cultural issues related to,
treatment, 131–133; of building a better
158–159; important points about, 46
context, 125–130; of failed practice behavior
cultural considerations, 155–165; access to
pattern, 139–140; of improvising with the
treatment, 162–163; ADDRESSING
willingness scale, 122–125; of revisiting
framework, 155; emotional control, 158–159;
creative hopelessness, 133–136; of
metaphor and exercise use, 160–161;
troubleshooting exposures, 86–87
microaggressions, 156–158; nonnative-
CBT. See cognitive behavioral therapy
speaking clients, 163; socioeconomic status,
change. See behavior change
162–163; therapist exercise on, 164–165;
Chessboard metaphor, 160
values, 161–162
classical conditioning, 11–15; learning theory
related to, 11–12; operant conditioning
integrated with, 17–18 D
clients: common pitfalls of, 145–153; cultural de Montaigne, Michel, 50
issues with, 155–165; debriefing after exposure, dead person goals, 144
84–85; experiential exercises to orient, 59–60; debriefing after exposure, 84–85
exploring expectations with, 98; listening to defusion. See cognitive defusion
feedback from, 117–118; misunderstandings dialectical behavior therapy (DBT), 24
about ACT, 56–57; moving onto new disclosure by therapists, 81–82
exposures with, 86; out-of-session practice distress scores, 66–68, 112–113
issues with, 89–90; participating in exposures
with, 76–78; refusal of exposure by, 88–89; E
self-monitoring forms for, 110–112; talking
elemental realism, 28
with during exposure, 79–81, 82–83;
emotional control: culture and, 158–159;
terminating treatment with, 93–106; therapist
willingness and, 147–148
self-disclosure with, 81–82
emotional processing theory (EPT), 18–20, 24, 35
Index183
emotional suppression, 159 flexible perspective-taking, 52–53, 81. See also

ending treatment, 93–106; assessing change for, self-as-context
99–103; client indications for, 93–95; potential Foa, Edna, 5, 35
barriers to, 95–99; reducing session frequency forms and worksheets, 109–119; ACT-informed
and, 103–104; referral process for, 106; relapse exposure, 112–119; tips for developing,
prevention and, 104–105; termination process 117–119; tracking or self-monitoring, 110–112
and, 105–106 functional analysis, 43, 136
evidence-based treatments, 5 functional analytic psychotherapy (FAP), 24
expectancy violation, 75 functional contextualism (FC), 23, 26–29, 36
experiential avoidance, 30; ACT-informed fusion: with personal stories, 151–152; with
exposure used as, 127, 128; self-care used as, thoughts, 98, 141, 149–150
135, 136; therapist issues with, 141–142; tips
for managing, 142 G
experiential exercises: ACT parrot and, 153;
generalization, 12, 95–96
assessing the impact of, 66–68; choosing for
goals: dead person, 144; values vs., 54, 144
ACT-informed exposure, 65–66; cultural
considerations for using, 160–161; organizing
for ACT-informed exposure, 68–70; orienting H
clients to ACT with, 59–60 habituation: emotional processing theory and,
exposure coaches, 163 18–20, 35; in-session and between-session,
exposure hierarchy, 14, 68–69 19–20; traditional focus on, 79
exposure menu, 69–70 Hayes, Steven C., vii
exposure therapy: ACT context for, v–vii, 3–5, 7, hierarchy, exposure, 14, 68–69
34, 35–36, 41–42; anxiety disorder treatment horse race studies, 5, 6
with, 3; classical conditioning and, 11–15; humor, judicious use of, 79–80
contextual approach to, 23; developing a hyperventilation practice, 122–124
specific plan for, 72–73; emotional processing
theory and, 18–20, 24, 35; importance of I
theory in, 10–11; inhibitory learning theory
idiographic measures, 101–102
and, 20; length of exercises in, 74–76;
imaginal exposure: case examples of, 126–128,
prolonged exposure as, 3, 5, 19, 74; rationale of
134–136; exercise duration for, 74; scripts
using ACT in, 60–61; rule-governed behavior
created for, 51, 126–128, 134; traditional use
and, 32; telehealth for conducting, 72;
of, 35–36
therapist behavior during, 76–83. See also
individualistic cultures, 162, 165
ACT-informed exposure therapy
inflexibility of therapist, 142–145
extinction learning, 14, 20
inhibitory learning theory (ILT), 20, 61
in-session habituation, 19–20
F interdependent cultures, 162
family relationships, 162 interoceptive exposure: to bodily sensations,
fear: different responses to, 28; emotional 77–78, 82; to breath holding, 124–125; to
processing of, 18–19; identification of, 115; hyperventilation, 122–124
learning theories of, 17–18; Wolpe’s hierarchy
of, 14. See also anxiety J
fear network, 18, 20
James, William, 27
fear structures, 18–19
Joe the Bum metaphor, 160
feedback from clients, 117–118
Jones, Mary Cover, 13
financial issues, 162–163
L Pavlov, Ivan, 11–12, 13

philosophical discussions, 147, 151
language considerations, 163
Popper, Karl, 27
lapse vs. relapse, 104, 106
positive punishment, 16
learning: consolidation of, 116; extinction, 14, 20
positive reinforcement, 15, 16
learning theory: classical conditioning and,
post-traumatic stress disorder. See PTSD clients
11–12; fear associations and, 17–18; inhibitory,
pragmatism, philosophy of, 27
20, 61
present-moment awareness. See contact with the
Little Albert study, 13
present moment
Little Peter experiment, 13–14
private events, 30, 35–36, 116
problems in ACT-informed exposure, 88–92;
M ambivalence about out-of-session practice,
meaningful living, 94–95 89–90; avoidance or safety behaviors, 90–92;
measures, assessment, 100–101 refusal of exposure exercises, 88–89;
mechanistic philosophy, 28 troubleshooting process for, 86–88
mentalism, 28 process-based approach, 6
metaphors: cultural considerations for using, prolonged exposure (PE), 3, 5, 19, 74
160–161; orienting clients using, 59–60 protocols, traditional focus on, 5
microaggressions, 156–158 psychological flexibility, 29–32; ACT processes
mind, thinking referred to as, 59 and, 36, 46–47; exposure and, 34, 35, 42,
mindfulness, 148–149; cultural issues with, 161; 83–84
guided exercises on, 60 PTSD clients: language considerations for, 163;
mindfulness-based cognitive therapy (MBCT), prolonged exposure for, 3, 5, 19, 74
24, 25 punishment: positive vs. negative, 16;
mirror retraining, 131 reinforcement vs., 15–16
N R
negative punishment, 16 rating discomfort, 66–68, 112–113
negative reinforcement, 15, 16 rationale malfunction, 145
nonnative language speakers, 163 referral process, 106
refusal of exposure exercises, 88–89
O reinforcement: classical conditioning and, 12;
operant conditioning and, 15; punishment vs.,
obsessive-compulsive disorder (OCD): ACT
15–16
treatments for, 34, 53; exposure treatments for,
relapse prevention, 104–105
3, 5, 34; marginalized groups and, 162
relational frame theory (RFT), 23, 32–33, 36
obstacles to treatment. See barriers to treatment
religious and spiritual beliefs, 161
operant conditioning, 15–18; classical
research: on ACT vs. CBT for anxiety, 6; on
conditioning integrated with, 17–18;
ACT-informed exposure, v–vi, 4, 6
reinforcement and punishment in, 15–17
rigidly applying ACT, 142–145
out-of-session practice: client ambivalence about,
river metaphor, 90–91
89–90; defining after client debriefing, 85
role plays, 117
overexplaining ACT, 143
rule-governed behavior, 30–32, 43
P
panic attacks, 122–125
S
safety behaviors, 90–92, 96–98
parroting ACT principles, 152–153
self-as-content, 53, 151
Index185
self-as-context: ACT exercise on, 53; client Thorndike, Edward L., 15

weakness in, 151–152; exposure as, 52–53, 78, thoughts: client struggles with, 149–150; mind
81 reference for, 59; native language and, 163;
self-as-process, 52 observation of, 116; therapist fusion with, 141,
self-care activities, 135–136 150
self-criticism, 33, 77, 148 Titchener, Edward, 50
self-disclosure, 81–82 tracking: behavior change, 99–103, 110; client
selfing process, 53 forms for, 110–112; data provided through,
self-monitoring, 110–112 111–112; increasing awareness through,
self-stories, 151–152 110–111; rating scales used for, 66–68,
sessions: practice outside of, 85, 89–90; reducing 112–113; times and frequency of, 114
frequency of, 103–104; telehealth, 72, 126 trauma clients, 33, 139, 163. See also PTSD
Shainberg, Lawrence, 149 clients
shaping, 27 troubleshooting exposure, 86–88; case example
Shaw, George Bernard, 160 of, 86–87; recommendations for, 87–88
similarity rating, 114 two-factor learning theory, 17
Skinner, B. F., 15, 23, 27, 30
socioeconomic status, 162–163 U
spiritual and religious beliefs, 161
unconditioned response (UR), 12
stories about self, 151–152
unconditioned stimulus (US), 12
SUDS scores, 66–68, 112–113
Suzuki Roshi, Shunryu, 49
symptoms: ACT de-emphasis on, 36, 42, 60, 61; V
dismissing the reduction of, 143; measuring values: ACT view of, 28, 54; anxiety connected
the severity of, 67, 100–101; traditional focus to, 146; cultural issues related to, 161–162;
on reducing, 4, 35, 42, 60 exercises connected with, 55, 66; exposure
systematic desensitization, 14 related to, 54–55, 75–76, 78, 81, 144; four
qualities of, 54; goals vs., 54, 144; therapist
T avoidance and, 142; trying to find perfect,
143–144
talking during exposure, 79–81, 82–83
telehealth sessions, 72, 126
termination process, 105–106. See also ending W
treatment Watson, John B., 13
theory in exposure therapy, 10–11 willingness: ACT exercise on, 50; client problems
therapists: behavior during exposure, 76–83; with, 147–148; exposure as, 49–50, 78, 80;
clarifying the assumptions of, 41–46; cultural improvising with scale for, 122–125; major
considerations for, 155–165; experiential points about, 63, 64; metaphor for exploring,
avoidance of, 141–142; exposure plan 62–63; organizing exercises by, 69; tracking
developed by, 72–73; imitating an ideal of, distress and, 66–67, 113
144–145; inflexibility of, 142–145; post- Willingness Switch, 62–63, 66
exposure debriefing by, 84–85; referring clients Wolpe, Joseph, 14
to other, 106; self-disclosure used by, 81–82 worksheets. See forms and worksheets
third-wave approaches, 24–25, 34, 35
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PSYCHOLOGY
A process-based approach to
ACT-Informed
ACT-Informed Exposure for Anxiety

exposure for anxiety disorders
Exposure therapy is a well-researched intervention for helping
Exposure
clients confront anxiety-provoking stimuli in order to resist engaging
in avoidance behaviors. Acceptance and commitment therapy
(ACT) is an evidence-based treatment model and provides a theory
for guiding the use of exposure therapy by encouraging clients to
connect with their values, remain in contact with the present moment,
and increase behavioral flexibility. This comprehensive book provides
for
a process-based approach for utilizing ACT-informed exposure in
session, and offers new ideas and tools to help your clients.
Anxiety
ACT-Informed Exposure for Anxiety synthesizes the latest research,
clinical experience, and theory into one powerfully effective
professional resource. You’ll find an overview of exposure therapy
and ACT, as well as cultural considerations to inform your work
with clients of diverse backgrounds. Also included are strategies to
help you create exposures tailored to clients’ specific needs, and
guidelines for addressing common client and therapist barriers to
treatment. Whether you’re new to ACT and exposure or experienced CREATING EFFECTIVE, INNOVATIVE
in other models of exposure and interested in incorporating ACT into
your practice, this is an essential addition to your professional library.
Thompson • Pilecki • Chan

“An intelligent and thoughtful integration, ACCEPTANCE & COMMITMENT THERAPY
providing clear recommendations for improving
treatment. I highly recommend this book.”
—Stefan G. Hofmann, PhD, Alexander von Humboldt Professor at the
Philipps University of Marburg, and author of The Anxiety Skills Workbook

Context Press
Foreword by Steven C. Hayes, PhD
Context
Press

ACT-Informed: Anxiety Exposure

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PSYCHOLOGY

ACT-Informed Exposure for Anxiety

Thompson • Pilecki • Chan

Brian L. Thompson, PhD

& VALUES-BASED EXPOSURES USING

ACCEPTANCE & COMMITMENT THERAPY

Brian L. Thompson, PhD

NEW HARBINGER PUBLICATIONS is a registered trademark

New Harbinger Publications is an employee-owned company.

All Rights Reserved

Cover design by Amy Daniel; Acquired by Jennye Garibaldi;

Library of Congress Cataloging-in-Publication Data

Foreword: Why ACT Needs Exposure and Exposure Needs ACT v

Background: History, Research, Current Trends

Chapter 1: A Process-Based Approach to Exposure for Anxiety Disorders 3

Chapter 2: A Brief History and Overview of Exposure 9

Chapter 3: An Acceptance and Commitment Therapy Primer 23

Clinical Application: ACT-Informed Exposure in Practice

Chapter 4: What the Therapist Needs to Know 41

Chapter 5: What the Client Needs to Know 59

Chapter 6: What to Do During and After Exposure 71

Chapter 7: Ending Treatment 93

Chapter 8: Create Your Own ACT-Informed Exposure Forms 109

Chapter 9: Case Examples of ACT-Informed Exposure  121

Chapter 11: Cultural Considerations in ACT-Informed Exposure 155

Why ACT Needs Exposure and

In other words, exposure is a way to do better ACT work! Exposure is a context; a

—Steven C. Hayes, PhD

A Process-Based Approach to Exposure

Exposure therapy involves the systematic confrontation of anxiety-provoking stimuli while

From Protocols to Processes

Getting the Most Out of This Book

A Brief History and Overview

The Importance of Theory in Exposure Therapy

Having a sound underlying theory is important in designing, implementing, and trou-

Neutral Stimulus (bees) No Response

Unconditioned Neutral Stimulus Unconditioned

In conclusion, classical conditioning theory is foundational to exposure theory.

Outside of a lab setting, determining what is reinforcement or punishment, and whether

How Avoidance Perpetuates Anxiety

Integrating Classical and Operant Conditioning

Emotional Processing Theory and Habituation

feared outcome or a decrease in physiological reactivity associated with a feared stimulus:

Our Current Understanding of Exposure

An Acceptance and Commitment

In our experience, a deeper understanding of FC and RFT allows us to use ACT-

A Brief History of ACT

Functional Contextualism and Contextual

From a functional contextualist perspective (Hayes, 1993), whether the experimenter is

Relational Frame Theory

Clarifying Processes of Change in Exposure

An ACT Understanding of Exposure

reduction in discomfort; instead, ACT-informed exposure focuses on increasing psychologi-

What the Therapist Needs to Know

From an ACT perspective, exposure is “organized presentation of previously repertoire-

Clarifying Therapist Assumptions in

process-based model, there’s no uniform protocol with which to conduct ACT-informed

Creative Hopelessness as Functional Analysis

Although it can be intense, the message of creative hopelessness can be empowering to

• The effectiveness of creative hopelessness is contingent upon client capacity to observe

Discriminating ACT Hexaflex Processes in

• Contact with the present moment

• Willingness to stay in contact with discomfort (e.g., feelings, bodily sensations)

Foreword: Why ACT Needs Exposure and Exposure Needs ACT v

Chapter 1: A Process-Based Approach to Exposure for Anxiety Disorders 3

Chapter 2: A Brief History and Overview of Exposure 9

Chapter 3: An Acceptance and Commitment Therapy Primer 23

Chapter 4: What the Therapist Needs to Know 41

Chapter 5: What the Client Needs to Know 59

Chapter 6: What to Do During and After Exposure 71

Chapter 7: Ending Treatment 93

Chapter 8: Create Your Own ACT-Informed Exposure Forms 109

Chapter 9: Case Examples of ACT-Informed Exposure 121

Chapter 11: Cultural Considerations in ACT-Informed Exposure 155

What ACT process do you contact when engaging in specific expo-

Values (e.g., I value joining clients in exposure even if I experience

Willingness (e.g., I am willing to feel nauseous and dizzy to join my

Self-as-context (e.g., My stomach feels nauseous, I’m starting to

Contact with the present moment (e.g., I can be present with my