The process of exposure: harnessing transformation through values and mindfulness

Background: Epidemiological studies have estimated a lifetime prevalence rate of 28.8% for anxiety disorders (Kessler et al, 2005), and a recent meta-analysis of 87 studies across 44 countries estimated the global current prevalence of anxiety disorders at 7.3% (4.8–10.9%, adjusted for methodological differences across studies; Baxter, Scott, Vos, & Whiteford, 2012). While exposure-based treatment for anxiety and OCD in youth and adult populations has robust empirical support, there is room for improvement. In terms of outcomes, intent-to-treat analyses suggest that approximately 1 in 5 individuals drop out of exposure treatment (Hofmann and Smits, 2008; Ong et al. 2016), and a significant of proportion of youth either do not improve or relapse (eg Ginsburg et al., 2013; 2018). Moreover, clinicians are unlikely to use exposure-based treatment even when it is needed (Freihart et al, 2004; Deacon et al., 2013; Sars & Van Minnen, 2015), due to their own experiential avoidance (Meyer et al., 2014; Scher, Herbert & Forman 2015). To complicate matters, simply adding ACT to ERP does not lead to demonstrably improved outcomes (Twohig et al., 2018). So, while exposure works, it could work better, and clinicians could get much more skilled and flexible in its use. Very likely, this will take a patient-centered “microanalytic approach” (Twohig et al., 2018) to improve outcomes of exposure-based approaches for individual clients in their specific contexts. Specifically, this workshop will focus on a bottom-up, idiographic, behavior-analytic approach to shaping values guided alternative responses to fear cues.

Workshop Content: This two-day immersive workshop for clinicians based in Acceptance and Commitment Therapy (ACT) will teach clinicians how to use mindfulness, valuing, and perspective-taking strategies to enhance client engagement in exposure-based treatment. Clinicians will practice how to conceptualize and address skills deficits in participating in ERP from a process-based perspective; specifically, through strengthening curiosity, willingness, mindfulness, and values-guided trial and error learning.  The presenter will introduce a transdiagnostic process-based developmental model of ACT (the DNA-V; Hayes & Ciarrochi, 2015) to demonstrate how to shape psychological flexibility. Clinical examples, role plays, and opportunities for participants to practice will augment the workshop’s didactic content to illustrate case conceptualization and pragmatic applications of therapeutic techniques. Clinicians can expect to leave the workshop with an understanding of how to identify and address skills deficits contributing to psychological inflexibility in avoidance-based disorders, such as anxiety and OCD, across the lifespan. They will also gain practical skills in contextual behavioral, process-based assessment and treatment that may be used as stand-alone exposure-based intervention or incorporated into other cognitive behavioral or behavioral approaches.

Audience: Clinicians with some experience with either Acceptance and Commitment Therapy or Exposure-based treatments (e.g., Exposure and Response Prevention) who work with individuals of any age with anxiety, OCD, and related conditions

Learning Objectives:

After this presentation, participants will be able to

1. Describe how an approach to exposure based on ACT differs from exposure conducted from a traditional habituation rationale
2. Engage clients and their caregivers in effective rationales for exposure-based therapy, based on a psychological flexibility paradigm
3. Develop a therapeutic relationship characterized by acceptance, values, compassion and commitment, that supports the client in engaging in exposure-based treatment
4. Apply various methods suggested by the inhibitory learning paradigm to enhance exposure-based treatment, including using multiple contextual cues, stimulus variability. exposure menus, affect labelling, etc.
5. Engage clients using valuing as action and direction to “contextualise” exposure and place exposure-based tasks under appetitive control
6. Describe psychological flexibility as a set of behavioral skills that can be shaped as a target of contextual behavioral ACT intervention
7. Describe the DNA-V model and how to use it to shape flexible perspective-taking and behavioral variability in avoidance-based disorders
8. Explain how to shape the processes involved in psychological flexibility, including valuing and perspective-taking, to engage clients in exposure-based treatment
9. Prepare and utilize the process of a functional behavioural assessment and case conceptualization to develop a collaborative exposure plan with clients
10. Use clinical RFT methods to enhance tracking and contact with contingencies to usefully explore expectancy violation
11. Use clinical RFT methods to foster flexible perspective-taking to enhance engagement in exposure tasks and promote functional senses of self
12. Assess progress in exposure-based treatment using within-task and across-session methods
13. Describe the DNA-V model and the three classes of behavior it addresses
14. Use the Comfort vs Discovery Zone assessment tool to support exposure and response prevention practices

Day 1

I. Intro to workshop – about exposure and ERP

a. ACT as a process-based transdiagnostic approach

b. A contextual-behavioral account of suffering

c. Overview of exposure therapy

II. Augmenting ERP with ACT – An ACT approach to OCD

a. Building a secure base and setting the context

b. Providing an exposure rationale

c. Conducting a functional behavioral analysis

d. Overview of shaping flexible responding

III. Introducing the DNA-V

a. Overview of the 4 DNA-V perspectives

b. Assessing skills and performance deficits using the DNA-V

c. Using the DNA-V to facilitate values-guided exposure

Day 2

I. Shaping Mindfulness & Acceptance Processes: Coaching Curiosity

a. Inhibitory Learning & Exposure

b. ACT and Inhibitory Learning

II. Shaping Valuing and Behavior Change Processes: Coaching Discovery

a. Setting up exposures – values in action

b. Flexible perspective-taking

c. Self-compassion in exposure

d. Generalization and Troubleshooting

III. Case Consultation

About the presenter: Lisa W. Coyne, PhD is an Assistant Professor in the department of Psychiatry and Harvard Medical School and the CEO of the New England Center for OCD and Anxiety. She is a licensed clinical psychologist who has worked to improve the psychological well-being of children, teens and adults for nearly 25 years.  She is the past President of the Association for Contextual Behavior Science, and serves on the Pediatric and Clinical Advisory Boards of the International OCD Foundation (IOCDF). She has published numerous books, peer-reviewed articles, and chapters on anxiety, OCD, and parenting.