Brian Thompson, PhD - The Portland Psychotherapy Clinic, Research, and Training Center
Exposure therapy is a major success story with an extensive research base in the treatment of anxiety and obsessive-compulsive and related disorders (Norton & Price, 2007). Throughout the decades since exposure was first demonstrated in Mary Cover Jones’ pioneering work (Kazdin, 1978), there have been several models developed to better understand how exposure works. For over 30 years, the most dominant model of exposure—to a degree that it is almost synonymous with exposure—has been the emotional processing theory (EPT; Foa & Kozak, 1986). According to EPT, exposure to the feared stimulus activates response and meaning elements of an emotion network and allows for the incorporation of newer corrective information through decreases in fear across exposures—what is called between-session habituation (Rupp, Doebler, Ehring, & Vossbeck‐Elsebusch, 2017). Newer research, however, has found that fear reduction is a poor predictor of whether people benefit from exposure therapy (Baker et al, 2010; Kircanski, et al, 2012). Consequently, EPT does not appear to fit with contemporary exposure research (Craske et al., 2008).
Acceptance and commitment therapy (ACT) is a newer cognitive behavioral treatment that emphasizes increasing psychological flexibility—taking action towards what is important to us even when in contact with uncomfortable thoughts, feelings, and bodily sensations—as a target of treatment. ACT has been described as an “exposure-based therapy” because it encourages people to remain in contact with difficult experiences they may otherwise avoid (Luoma, Hayes, & Walser, 2017). As it explicitly deemphasizes symptom reduction, in contrast to EPT, viewing a focus on symptom reduction as fostering a “fear of fear,” ACT theory is one alternative model for guiding exposure therapy that is consistent with new research. Additionally, ACT is a more process-based treatment in its focus on broader transdiagnostic processes of change compared to other cognitive behavioral evidence-based treatments that are more protocol-driven, (Hayes & Hofmann, 2021).
Within ACT, psychological flexibility has been described as both a single process, and it has also been broken down into smaller processes. The ACT hexaflex is the most common grouping of ACT processes that comprise psychological flexibility:
- Contact with the present moment
- Willingness (or acceptance) to stay in contact with discomfort (e.g., emotions; bodily sensations).
- Defusion, or the ability to be aware of thoughts with some distance without necessarily believing in their literal reality
- Self-as-context, or the ability to flexibly shift between perspectives rather than fusing with a particular self-concept or perspective
- Values, meaningful life directions in which we may choose to orient behavior
- Committed action, or taking action based on our values
Exposure appears to strengthen psychological flexibility whether delivered in an ACT context or not (Thompson, Twohig, & Luoma, 2021; Twohig et al., 2018), and the ACT process of acceptance or willingness appears to be a better predictor of change in exposure therapy than habituation (Reid et al., 2017). Overall, psychological flexibility appears to be an important transdiagnostic process of change even in other non-ACT treatments (e.g., Arch et al., 2012).
When compared against exposure therapy based on EPT, ACT-informed exposure performs about as well on primary outcomes (Arch et al., 2012; Craske, Niles, et al., 2014) Twohig et al., 2018). Rates of relapse in ACT-informed exposure are also comparable to those of traditional exposure (Arch et al., 2012; Twohig et al., 2018). There is some evidence that clients in ACT-informed exposure demonstrate additional improvements in symptom severity and psychological flexibility between treatment completion and follow-up, whereas those in traditional exposure simply maintain gains at follow-up (Arch et al., 2012; Craske, Niles, et al., 2014).
In our recently published pandemic project, a therapist guide on using ACT-informed exposure, ACT-Informed Exposure for Anxiety: Creating, Effective, Innovative, Values-Based Exposures Using Acceptance and Commitment Therapy, (Thompson, Pilecki, & Chan, 2023), my coauthors and I make a case for how the ACT psychological flexibility model has advantages over traditional exposure based on EPT in offering an expanded nomenclature for understanding and targeting processes common to exposure therapy. For example, acceptance of discomfort during exposure is important in facilitating new learning in any type of exposure. When clients engage in covert avoidance behavior such as rushing through an exposure exercise or tensing up, we know these behaviors can interfere with learning because, if clients are unable to be present and practice acceptance with feared stimuli, this behavior may reinforce anxiety and avoidance (e.g., Benito et al., 2018; Ong et al., 2022). ACT has a variety of exercises and metaphors for orienting clients to this process (e.g., Hayes, Strosahl, & Wilson, 2012; Eifert & Forsyth, 2005), offering the therapist and client a shared way of speaking about acceptance or willingness during exposure. In exposure approaches based on EPT, by contrast, acceptance tends to be more implicit (Moscovitch, Antony, & Swinson, 2009).
The research on ACT-informed exposure is still nascent—especially compared to exposure based on EPT. However, ACT-informed exposure appears promising and is consistent with emergent data on mechanisms of change during exposure. It offers a flexible, process-based alternative to traditional exposure.
Arch, J.J., Eifert, G.H., Davis, C., Plumb Vilardaga, J.C., Rose, R.D., & Craske, M.G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80, 750-765.
Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M.G. (2010). Does habituation matter? Emotional processing theory and exposure therapy for acrophobia. Behaviour Research and Therapy, 48(11), 1139-1143.
Benito, K.G., Machan, J., Freeman, J.B., Garcia, A.M., Walther, M., Frank, H., Wellen, B., Stewart, E., Edmunds, J., Kemp, J., Sapyta, J., & Franklin, M. (2018). Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD. Journal of Consulting and Clinical Psychology, 86(7), 615–630.
Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5–27.
Craske, M.G., Niles, A.N., Burklund, L. J., Wolitzky-Taylor, K.B., Vilardaga, J.C.P., Arch, J.J., ... & Lieberman, M.D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. Journal of Consulting and Clinical psychology, 82(6), 1034-1048.
Eifert, G.H., & Forsyth, J.P (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.
Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.
Hayes, S.C., & Hofmann, S.G. (2021). “Third‐wave” cognitive and behavioral therapies and the emergence of a process‐based approach to intervention in psychiatry. World Psychiatry, 20(3), 363-375.
Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.
Kazdin, A.E. (1978). History of behavior modification: Experimental foundations of contemporary research. Baltimore: University Park Press.
Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A.S., Mystkowski, J.L., Yi, R., & Craske, M.G. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745-751.
Luoma, J.B., Hayes, S.C., & Walser, R.D. (2017). Learning ACT: An acceptance & commitment therapy skills training manual for therapists (2nd ed.). Oakland, CA: Context Press.
Norton, P.J. & Price, E.C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. The Journal of Nervous and Mental Disease, 195(6), 521-531.
Moscovitch, D.A., Antony, M.M., & Swinson, R.P. (2009). Exposure-based treatments for anxiety disorders: Theory and process. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 461–475). Oxford University Press.
Ong, C.W., Petersen, J.M., Terry, C.L., Krafft, J., Barney, J.L., Abramowitz, J.S., & Twohig, M.P. (2022). The “how” of exposures: Examining the relationship between exposure parameters and outcomes in obsessive-compulsive disorder. Journal of Contextual Behavioral Science, 24, 87-95.
Reid, A.M., Garner, L.E., Van Kirk, N., Gironda, C., Krompinger, J.W., Brennan, B.P.,…Elias, J.A. (2017). How willing are you? Willingness as a predictor of change during treatment of obsessive-compulsive disorder. Depression and Anxiety, 34, 1057-1064.
Rupp, C., Doebler, P., Ehring, T., & Vossbeck‐Elsebusch, A.N. (2017). Emotional processing theory put to test: A meta‐analysis on the association between process and outcome measures in exposure therapy. Clinical Psychology & Psychotherapy, 24(3), 697-711.
Thompson, B.L., Luoma, J.B., & LeJeune, J.T. (2013). Using acceptance and commitment therapy to guide exposure-based interventions for posttraumatic stress disorder. Journal of Contemporary Psychotherapy, 43, 133-140.
Thompson, B.L., Pilecki, B.C., & Chan, J.C. (2023). ACT-informed exposure for anxiety: Creating, effective, innovative, values-based exposures using acceptance and commitment therapy. Oakland, CA: Context Press.
Thompson, B.L., Twohig, M.P., & Luoma, J.B. (2021). Psychological flexibility as shared process of change in acceptance and commitment therapy and exposure and response prevention for obsessive-compulsive disorder: A single case design study. Behavior Therapy, 52(2), 286-297.
Twohig, M.P., Abramowitz, J.S., Smith, B.M., Fabricant, L.E., Jacoby, R.J, Morrison, K.L., Lederman, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1-9.
