LinkFest! Top 10 links – October 2015

The top ten most-clicked links from my Twitter account in October 2015:

1] Steve Hayes discusses the future of Cognitive Behavioral Therapy – The Situation Has Clearly Changed: So What Are We Going to Do About It?

Whether or not you agree with him, when Steve Hayes writes about challenges in the broader CBT field, people read what he has to say!

2] What do you want your life to stand for? A collection of online values exercises

A blog post, based on Jason Luoma’s collection of online values tools, including some handy videos.

3] Playing it safe: why therapists don’t do exposure [new post]

Blog post describing a recent study, which showed that therapist experiential avoidance plays a role in how much CBT therapists offer exposure.

4] The Biomedical Model of Psychological Problems [Special issue of the Behavior Therapist; PDF]

This special issue of The Behavior Therapist has a veritable “who’s who” of researchers and thinkers critiquing the biomedical model, and describing psychological alternatives

5] Mechanisms of change: Exploratory outcomes from a RCT of acceptance and commitment therapy for anxious adolescents

Mechanisms papers always get plenty of interest, CBT, ACT or otherwise. First ACT mechanisms paper I’ve seen with this population.

6] What contributes to therapeutic confidence for clinical psychologists?

Interesting experience of training paper.

7] It’s complicated: relation between cognitive change methods, cognitive change, & symptom change in Cognitive Therapy for depression

Great mechanisms paper – demonstrating how tricky it is to test processes of change in therapy. Plenty to consider for psychotherapy research, cognitive therapy or otherwise.

8] Feasibility & acceptability of a brief Acceptance and Commitment Therapy group intervention for people with psychosis

 Paper from my research team, describing our first ACT groups study.

9] Therapeutic Alliance Predicts Outcomes of CBT but Not Mindfulness-Based Cognitive Therapy for Depressive Symptoms

Perhaps “therapeutic alliance” measures something other than the alliance?

10] Integrating self-care instruction into professional psychology training using Acceptance & Commitment Therapy

Overview of some impressive work being done by Kenneth Pakenham and colleagues at the University of Queensland. Important implications for the training of clinical psychologists.


Playing it safe: why therapists don’t do exposure

Therapy involves lots of decisions. Which interventions are introduced by the therapist – and when – can be influenced by a number of factors. Recent studies suggest some of this decision making is to do with how willing the therapist is to experience distress – either the client’s or their own (or, indeed, both!).

In a previous post I suggested that therapist experiential avoidance* may play a role in the low rates of exposure being offered by therapists in clinical practice. This is despite the solid evidence base for offering exposure as a core component of CBT for anxiety and obsessive-compulsive disorders. Unfortunately, even among therapists well-trained in CBT, there may be limited use of exposure.

A recent paper supports this perspective:

Scherr, S. R., Herbert, J. D., & Forman, E. M. (2015). The role of therapist experiential avoidance in predicting therapist preference for exposure treatment for OCD. Journal of Contextual Behavioral Science, 4(1), 21-29.


Despite the overwhelming evidence that the behavioral components of cognitive-behavior therapies (CBTs) are critical for patient improvement, particularly in the case of anxiety disorders, there remains a wide gap between science and practice in their consistent use. In particular, exposure therapy for anxiety is under-used, even among self-proclaimed cognitive-behavior therapists. Some have speculated that this under-use is related to therapist discomfort with and avoidance of the temporary increase in distress that patients often experience during exposure therapy, and the secondary distress that this may cause in therapists themselves. Recent studies have begun to examine therapist characteristics that are associated with the use of evidence-based psychotherapies, but this research has focused on evidence-based practice as a whole rather than on specific interventions such as exposure, and have not addressed therapist psychological variables. We examined the role of therapists׳ experiential avoidance in the hypothetical use of exposure-based interventions to treat fictional patients for whom exposure therapy is clearly indicated. A total of 172 therapists watched simulated therapy intake sessions and were asked to designate the percentage of time they would allot toward various therapeutic modalities, including exposure. Results suggested that participants exhibiting higher experiential avoidance tended to allot less time to exposure therapy for the fictional patient. Additional therapist personality factors, such as intuitive personality style and attitudes toward evidence-based treatments, were associated with self-reported use of exposure therapy as well.

In this study, the participants were therapists who self-identified as having a CBT orientation. The majority of the CBT therapist participants were psychology trainees or qualified psychologists (a doctoral-level US sample), limiting investigation of differences across disciplines.

The research team used a neat method of assessing therapist choices – showing video vignettes of the intake interviews of fictional clients with obsessive-compulsive disorder, and then asking therapists to indicate how much time they would spend using various methods to help these clients (from CBT, and other approaches). (The clients’ clinical presentations were independently rated by experts as indicating the use of exposure as the treatment of choice). [This sounds like an excellent method to assess the clinical judgement of trainee therapists!]

It was found that therapists who were scored higher in experiential avoidance allotted less time to exposure: the result held whether or not the therapist was inexperienced (licensed psychologists high in EA showed similar decision making). The authors report several secondary analyses, suggesting that in this sample:
• therapists who were more favourable to evidence-based practice tended to be less experientially avoidant;
• therapists who were more intuitive in personality style tended to allot less time to exposure, be less favourable to evidence-based practice, and were more experientially avoidant; [an intuitive style does not mean being open to distressing experiences… or evidence, it seems!]

Several clinical implications are discussed in this paper, including the potential for training CBT therapists in greater awareness, openness and flexibility to uncomfortable feelings, to promote persistence in using evidence-based practice. The authors also suggest that the process of conducting exposure with clients may be helpful for therapists. By learning to tolerate client distress, along with their own uncomfortable feelings, therapists may become more psychologically flexible in their role. Seeing clients improve in this learning context, may increase therapist confidence in offering exposure as part of CBT.

This paper encourages me to think that in my role – supervising psychologists in training – it may be useful to find ways to promote psychological flexibility for my trainees.

Helping trainee psychologists to be open to their experiences, particularly the discomfort of inviting clients to step into feared situations, and finding ways to “flexibly persist” with offering exposure, may increase the likelihood that they offer evidence-based interventions later in their career.

If you are a therapist, what is your experience of doing exposure? Please share your comments and views below.

Also: check out my post on how training in psychological flexibility can help therapists here

* experiential avoidance =  attempts to reduce distressing thoughts, feelings, or other negative subjective experiences even when doing so is ineffective and causes problems. Experiential avoidance is amplifies suffering and contributes to a range of problems.


What is it that you care about? Online Values Exercises and Videos

What is it that you care about? And what do you want your life to stand for?

These are pretty typical questions asked when you are engaged in Acceptance and Commitment Therapy.

The choices and actions we take, deliberately, mindfully, as life directions, can provide meaning and purpose… even when we are faced with unwanted and troubling feelings, thoughts and urges.

Recently on the ACT for Professionals mailing list, Jason Luoma (Portland Psychotherapy Clinic) shared a great set of links to online values exercises.

Jason stated that he had been searching for resources that focused mainly on values, and were totally self contained/ self explanatory (rather than needing a therapist or trainer to guide you through them).

Below is the list of resources, along with a few additions of my own (including some video links).

In this video, David Gillanders (University of Edinburgh) describes values as chosen life directions, and the choices and actions we can take through practicing willingness and mindfulness:

And finally… Russ Harris has been busy, producing new videos for his online training venture. Here are a couple: 1) about the difference between a life focused on values vs one focused on goals, and 2) the Choice Point, a way of noticing moments where you can take valued actions.

What values exercises have you found useful?  Do you know of other online resources that help with values work?

Please feel free to comment below!


How to do Acceptance and Commitment Therapy in groups: the Passengers on the Bus metaphor

Acceptance and Commitment Therapy frequently involves engaging participants in experiential exercises and metaphors. These metaphors can really have impact when they are acted out, instead of simply being described and talked about in a session. Using physical movement is a great way of doing this, as participants can relate to moving toward and away, struggling and letting go, being disconnected and connected, moving deliberately in a direction etc. Great examples of “physicalising” metaphors include Russ Harris’ clipboard exercise, Tug of War with the Monster, and JoAnne Dahl and colleagues’ Life Line exercise.

There is a terrific new resource available, a video demonstration of how to lead the Passengers on the Bus metaphor in a group format (below). This has been produced by the BABCP ACT Special Interest Group and is based on the “ACT for Recovery” study, recently conducted in South London (I was on the research team). Our study engaged people recovering from psychosis and carers in 6 group sessions, with “Passengers…” being a central metaphor. In group sessions we introduce participants to the metaphor, show an animation (another useful resource, below and available here), and then invite participants to act out the metaphor, using their own experiences and valued directions. The randomised controlled trial of this intervention has shown promising well-being outcomes.

Joe Oliver has provided a detailed description of the steps to do this exercise in a group, taken from our ACT for Recovery treatment manual.The video, plus the instructions, will give you an excellent framework for running this exercise in your group work.

We are pleased to share that our manual will be published by New Harbinger Publications in 2016, with updated content, including new illustrations, and details on how to train peer supporters and professionals in running successful ACT groups.

What are your experiences of doing this exercise?  Please feel free to comment below or contact us.


How to make the most of clinical supervision as a psychologist

It is the start of internal placement for a new cohort of provisional psychologists at my university. I prepared the following tips to help trainees know what to expect, and prepare for, their first supervision sessions.

Learning to make the most of supervision is a core professional skill for psychologists. Throughout your career, participating in supervision will ensure you practice ethically and competently, provide perspectives that compensate for your blind-spots and biases, and strengthen your capacity to be a reflective practitioner. A good supervisory relationship can support you during the challenging times of working as a psychologist.

Here are a few tips to make the most of your supervision sessions:

  • Do some contracting – when you first meet a supervisor discuss what you would like to achieve from supervision. As a supervisor I find it useful to hear about your previous experiences of supervision and clinical practice, your reflections on how you respond to feedback, and your personal goals for the placement. These discussions help to create a collaborative supervisory relationship. Contracting should also involve the practicalities: when and where you will meet, for how long, arrangements if supervision is cancelled, access to the supervisor outside of sessions, what happens if the supervisor is away, etc.
  • Be prepared – come into supervision having reviewed your session, and reflect on what has happened in light of your assessment and formulation. It helps to be ready to set an agenda at the start of each supervision session, to structure the discussion, while also accepting that during the session other issues may become evident to focus on.
  • Have a supervision question – one way to structure supervision is to have a clear question about the client(s) you are seeing: the best questions are ones that lead to a broader discussion of the case, the choices you are making, and what it is like to be doing the work you are doing (reflection). Don’t worry if early in your experience of supervision it is tricky to think of “a question” (you probably have many!); this skill develops over time.
  • Seek feedback – check in with your supervisor about your skills, including the use of supervision. It can be hard to hear that about the areas you need to improve upon: good supervision feedback is constructive in purpose. Check any areas that you don’t follow or are confused about.
  • Give feedback – the process goes two-ways: your supervisors will benefit from your feedback about the supervision, how you have found their views and advice, what you are discovering.
  • Show… and tell – Our Clinic placement involves video-recording your sessions. Most people find that they are pretty self-conscious when reviewing sessions, and feel intimidated (initially) to have a supervisor watch the recording. And yet… this may be one of the few times in your career where you have the opportunity to review what you are actually doing, notice the effect of this on clients, and get clear feedback from a supervisor. I invite you to seize the opportunity! Watching sessions is very informative for supervisors; sharing sections that you are pleased with, along with those where you wish for improvement, helps your supervisor to get a better sense of your developing competencies.
  • Show up, notice your own stuff, share your vulnerable side – learning how to be a competent psychologist is hard work. I am stating the obvious, eh? It is made harder if you try to hide in supervision: about feeling uncertain, any mistakes or errors you’ve made, struggles with perfectionism, strong reactions to sessions etc. Openness about your work will enable you to progress further and learn from experience. Developing supervisory relationships that are genuine and trusting, are likely to support your well-being and resilience in the face of the challenging (and meaningful) work that we do as psychologists.

LinkFest! January 2015

Papers most-clicked recently from my Twitter account.

Acceptance and Commitment Therapy etc

A Meta-Analysis of the Efficacy of Acceptance and Commitment Therapy

Acceptance and Commitment Therapy for adults who stutter: Psychosocial adjustment and speech fluency

Acceptance and Commitment Therapy as a Treatment for Scrupulosity in Obsessive Compulsive Disorder

Acceptance and Commitment Therapy for #OCD and OC Spectrum Disorders: A Review

Acceptance and Commitment Therapy group for treatment-resistant participants: A randomized controlled trial

Using acceptance and commitment therapy to increase self-compassion: RCT

Experiential avoidance mediates the link between maternal attachment style and theory of mind

‘Feel the Feeling’: Psychological practitioners’ experience of ACT well-being training in the workplace


General interest

Why don’t therapists use exposure? And how psychological flexibility can help.

Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence?

Categories That Should Be Removed From Mental Disorders Classifications: Perspectives of Clinicians From 8 Countries



A Systematic Review of Mindfulness and Acceptance-Based Treatments for Social Anxiety Disorder

Mindfulness-based training in residential settings: rationale, advantages and obstacles



The body image psychological inflexibility scale: Development and psychometric properties

Further development in the assessment of psychological flexibility: A shortened Committed Action Questionnaire

Validating Measures of Psychological Flexibility in a Population With Acquired Brain Injury


Behavioral Activation

Behavioral activation in acute inpatient psychiatry: A multiple baseline evaluation

A feasibility study of behavioural activation for depressive symptoms in adults with intellectual disabilities


Psychotherapy processes research: ways forward?

Assessing Functional Relations in Single-Case Designs – quantitative proposals

A translational approach to the functional analysis of language in #psychotherapy


Experimental analyses & RFT

Relational Frame Theory for clinical use: The example of metaphor

Empirical Investigation of the Role of Self, Hierarchy, and Distinction in a Common ACT Exercise (self as context)

Experimental analysis of defusion exercise in Acceptance and Commitment Therapy: The mechanism is not clear



The influence of thought control on the experience of persecutory delusions & auditory hallucinations in daily life

Towards a better understanding of caregiver distress in early psychosis: A systematic review of psychological factors

Self-affirmation and nonclinical paranoia – experimental study

Negative communication in #psychosis: understanding pathways to poorer patient outcomes



The Origins of a Worldwide Contextual Community: Steve Hayes on ACBS

In a recent blog post, Steve Hayes describes the origins of the Association for Contextual Behavioral Science (ACBS), the scientific organisation that promotes Acceptance and Commitment Therapy (ACT), Relational Frame Theory (RFT) and other contextual approaches. (For informative papers about the history of ACT & RFT, check out Zettle 2005 and Cullen 2008).
ACBS was founded in 2005, and to date, has over 7000 members world-wide. The organisation is active in developing a diverse membership – amongst other initiatives, ACBS has a scholarship fund to support people from developing nations to attend world conferences. The low cost to join and the wealth of clinical and scientific resources available on the organisation’s website ( are certainly attractive; for many, the ACBS community is also a strong draw, participating in a psychological organisation that reflects prosocial values (more on this below).

Steve describes the tragic events that shaped the formation of the organisation:

“…the actual spark that gave rise to ACBS was more specific and more emotional: the horrifying events of September 11, 2001. It think that matters that ACBS came in part from that event — and it makes more sense of why ACBS has the motto that it does [“creating a psychology more worthy of the challenge of the human condition.”]…

… I was set to go do two workshops in Sweden (one in Stockholm and one in Uppsala) organized by Ned Carter and Kenneth Nillsson, suitcase in hand, when I got a call saying to put down my suitcase on turn on the TV. I did and watched in horror as humans jumped from the twin towers like dust falling from a shaken tree, which then fell to the ground. All airlines were grounded. There would be no workshop in Sweden.

The next week I told my lab “we are going to study prejudice, bias, and stigma.” I told them to watch what was about to happen: we in the West will objectify and dehumanize others out of fear. I remember saying “there are not enough bullets and enough bomb and enough soldiers to make ourself safe in the world that is upon us. Soldiers and politicians are not enough. Behavioral scientists have to be part of the solution.” The whole lab was crying. We wanted to do something.

My lab did alter its focus, beginning basic and applied work on acceptance, mindfulness, perspective-taking and values as antidotes to prejudice and stigma. That work in ACT and RFT continues world wide to this day.
In early 2002 Ned, Kenneth and I started to talk about what to do about the cancelled workshop. I wanted to up the ante in response to the horrifying way that workshop was cancelled.  I’m not sure if Ned or I said it first but in a call with him we began to talk about not just a workshop but a world wide event on ACT, RFT, and the new behavioral psychology. I suspect it was Ned who raised the idea of a conference… I likely added the expansive vision behind a World Conference for ACT / RFT / Functional Contextualism because it was linked to the horror that starting this process. That call on September 11, 2001 was part the energy that led to the conference. It was not that we felt we had an answer — it was that we felt we have to care about developing one and that behavioral psychology in a new form could be part of that. We would meet hate with love; ignorance with knowledge; division with community.”

The blog post is well worth a read, to appreciate what has shaped several strands of contextual behavioural science (such as the contemporary research on stigma and prejudice) and the risk-taking involved in building communities. That risk-taking included organising the first world conference on ACT, RFT and CBS in Sweden in 2003, while it was a big unknown how many people would come!

In my view, along with what shaped the organisation, ACBS’ growth has been due to several factors:

An active and welcoming online community – the ACT/RFT community developed at a time when participating in online discussions became a mainstream activity (therapists are not exactly the most technologically forward as a group). Compared to other online forums, the ACT listservs are actively moderated to reflect the values of the community: to be respectful, non-hierarchical, and prosocial in outlook. Flamewars and trolling don’t really occur: quite a difference from other psychotherapy listserves I have joined. This doesn’t mean that there are no differences of opinion and robust discussions. Rather than collapsing into acrinomony and point-scoring, many times these conversations lead to important clarifications about conceptual and philosophical issues, along with sharing of research and clinical innovations. Following these discussions gives you a sense of people’s views and interests, and allows you to remain connected after you have been to a conference or training event. Some listserv participants write online in ways that are quite similar to how they behave at conferences! In recent years an added “layer” to interaction has been the increasing activity of ACBS members on social media (with Facebook groups in particular, and Twitter).

An open-source approach to science and clinical developments – from the start, the community has been about sharing resources, with an openness about the use of the model. There are stories that, prior to the publication of the 1999 ACT manual, floppy disks of book chapters were freely distributed at training events. Certainly, when I started researching for ACT resources in 2000, there was already plenty available online (papers, manuals, measures, presentations), and emailing the authors would usually result in receiving more resources. This sharing culture has continued as ACT has become more popular and visible, no largely through the ACBS website. Again, a breath of fresh air, in comparison to other psychotherapy communities where hierarchies can develop, usually in the form of credentialing or official endorsements of training by the host organisation, or resources are jealously guarded. The ACBS route of open source development means that you can easily research and practice ACT without needing permissions from anyone in the community.

An approach of the community modelling the values of ACBS – to me, ACBS is the kind of scientific/psychology community that I hoped I could be involved in when I trained as a clinical psychologist. My early career experience was different from my hopes: a number of psychological organisations I participated in were inwardly-focused, hierarchical, focused on guild issues, political in self-defeating ways, disengaged from the broader world etc. ACBS feels different. The community is inspiring, earnest in developing ways to improve the world for everyone, and encouraging of members to contribute in meaningful ways. No doubt the same unworkable processes that occur in any grouping of people happens in ACBS, it just seems that there are value-driven, prosocial ways to handle this. ACBS conferences and the online community are one of the few places in my life where people really do “walk the talk” and are compassionate  about how hard this is to do consistently. And we are all learning – ACBS is a work in progress in building a prosocial community. Experiencing this encourages you to do more in your own communities (family, neighbourhood, workplace etc) that reflects these values too.

These three factors help to create the worldwide connectedness that ACBS members experience, and I think will lead to further growth in membership. In response to the problems of humanity, and in many and varied ways, we can all contribute to “creating a psychology more worthy of the challenge of the human condition”.


LinkFest! August 2014

I regularly tweet new and interesting papers relevant to clinical psychology and my interests. These are the cool papers and links from August 2014. Follow me on Twitter for a daily update!

Acceptance and Commitment Therapy, RFT, CBS etc

  • “ACT is not yet a well-established treatment for any disorder” Öst 2014, updated meta-analysis
  • Physiological & behavioral indices of emotion dysregulation as outcome predictors from #CBT & ACT for anxiety @babcp
  • Does the AAQ-II measure psychological flexibility… or distress?
  • The Dark-Side of Rule Governed Behavior: experiment of problematic rule-following in adolescents with depressive Sx
  • Experiential avoidance & borderline personality disorder features in adolescents: a prospective relation
  • Acceptance and Commitment Therapy for Individuals With Problematic Emotional Eating: A Case-Series Study
  • Do counselor techniques predict quitting during #smoking cessation treatment? Component analysis: phone-delivered ACT
  • Using acceptance and commitment therapy with people with psychosis: A case study (PDF)
  • A longitudinal study of experiential avoidance in emotional disorders
  • Relational Frame Theory for clinical use: The example of metaphor
  • Psychological Flexibility: a framework for understanding & improving family reintegration after #military deployment
  • Measuring the Role of Psychological Inflexibility in Trichotillomania
  • Psychological interventions for patients with cancer: psychological flexibility & the potential utility of ACT
  • Evaluation of multiple exemplar instruction to teach perspective-taking skills to adolescents with Asperger Syndrome
  • Work stressors & distress in intellectual disability support staff: mediating role of psychological inflexibility
  • An Exploration of Acceptance and Commitment Therapy for Chronic Pain in Multiple Sclerosis
  • The Development of the Functional Analytic Psychotherapy Intimacy Scale –
  • Initial evidence for the efficacy of acceptance and commitment therapy in primary insomnia
  • Internet-based vs face-to-face? A RCT of two ways to deliver ACT for depressive symptoms: 18-month follow-up


  • Mediators of #CBT for Anxiety-Disordered Children and Adolescents: Cognition, Perceived Control, and Coping
  • Shifting the Focus of One’s Attention Mediates Improvement in Cognitive Therapy for Social Anxiety Disorder #CBT
  • Behavioral versus cognitive treatment of #OCD: An examination of outcome and mediators of change
  • Treatment failure in CBT: therapy alliance as a precondition for adherent & competent implementation of techniques.

Transdiagnostic Processes

  • Positive beliefs about rumination associated with ruminative thinking & affect in daily life… metacog & depression
  • Dispositional coping in individuals with anxiety disorder symptomatology: Avoidance predicts distress
  • Reductions in negative repetitive thinking & metacognitive beliefs during internet CBT for mixed anxiety & depression



  • Implementation of Mindfulness Training for Mental Health Staff: Organizational Context and Stakeholder Perspectives
  • Mindfulness-Based Approaches in the Treatment of Bipolar Disorder: Potential Mechanisms and Effects
  • Mindfulness training may potentiate the therapeutic effect of non-judgment of inner experience on smoking cessation
  • A Qualitative Analysis of Experiential Challenges Associated with Meditation Practice
  • Immediate effects of a brief mindfulness-based body scan on patients with chronic pain

Four ways Acceptance and Commitment Therapy can help people struggling with suspicious thoughts

Feeling on edge while walking down an empty street at night; thinking you are being gossiped about at work; feeling like you need to be on guard around certain people… Worrying that others are intending to do us harm is a surprisingly common experience.

Acting on these concerns can be helpful – checking things out with people, taking time to build trust in a new friend. Unfortunately there are times when being caught up with suspicions creates problems – making unfounded accusations, cutting off friends and family, even feeling afraid to leave the house or to trust anyone.

We are living in an age of increasing paranoia. We are regularly encouraged by society to be fearful and suspicious: exposed to daily news reports of violent crime and corruption, governments warning us to be vigilant of terrorism, the surveillance of our emails and internet use by corporations and intelligence agencies.

Surveys suggest that up to a third of the population are regularly troubled with suspicious thoughts. And yet it is not something that is easy to talk about. People can be afraid of being seen as “paranoid” if they express these concerns. The stigma attached to “being paranoid” may increase isolation and worry: the very things that can strengthen the impact of these experiences. It can be quite a brave step to seek help.

Acceptance and Commitment Therapy provides several ways to help clients struggling with suspicious thoughts. This is because ACT works to undermine the processes that amplify the power of thoughts, and encourages connection with meaning and purpose, which may transcend moments of fear and suspicion.

Here are four ways that the ACT therapist can help:

Improving Sleep – our ability to flexibly respond to our fears and suspicions is limited when we have poor sleep. Periods of insomnia appear to increase the frequency of suspicious thinking and unusual experiences. One of the most effective things the ACT therapist can do is to help the client increase the quality of their sleep. This could be through education and sleep hygiene, or a focused ACT intervention, if sleep problems are long-standing or the focus of over-control and worry.

Noticing Worry and Rumination Traps – like many other experiences, a suspicion is made larger by worry and rumination. A concern about whether a friend is undermining you can become much more upsetting and compelling by spending a lot of time going over past events or thinking over all the ways they could hurt you. Practicing present moment awareness and gently noticing the urges to worry and ruminate may allow for suspicions to be experiences, rather than threats that must be acted on. Exploring the workability of responses to suspicions can help the client to find ways to act that are guided by values rather than fear. This may even include skilful ways to respond when they are being undermined!

Activating rather than Avoiding –  suspicious thoughts can invite a variety of unhelpful ways of avoiding the situations and people that trigger them. This can strengthen their impact and maintain their sense of accuracy (i.e., by limiting contact with moments of  discovering when they are inaccurate). Suspicion can also intensified by depression: being fused with thoughts about deserving punishment or being powerless, negative thoughts about people and the world, and patterns of inactivity. The ACT therapist can encourage an activation approach, fostering choice in response to triggers that invite avoidance. Along with the client being in greater contact with rewarding moments, suspicions can be undermined as both guides to action (considering workability) and useful reflections of “reality” (through noticing occasions when they are disconfirmed).

Connecting rather than Isolating – Isolation can lead people to have unusual ideas and experiences. Having no-one around to check these ideas with can make them more compelling, especially if they relate to important concerns, such as being accepted by others or work performance. People who struggle with suspicions can be socially isolated, increasing the chance of unusual ideas and limited chances of checking them out. The ACT therapeutic relationship can be a powerful context: where it is safe to discuss unusual ideas and experiences with an accepting person, and to have modelled a defused and pragmatic way of responding to these. This may also help with developing more flexible perspective-taking (e.g., imagining another person’s point of view; access to more than one perspective on a situation; cultivating greater self-acceptance and compassion). Through values work, previously-avoided directions of connecting with others may also be encouraged, reducing isolation and fostering social supports.

Helping clients who struggle with suspicious thoughts can be challenging. There can be moments when the client treats the therapist with suspicion, with motives questioned, or sessions finished early due to client worries. Flexible persistence may be required: from experience, ACT creates a space where people can discover that even the most worrying thoughts about others can be responded to in a way that broadens their lives, rather than limits them.

Author’s note:  My opinion about how ACT may help with suspicious thinking and paranoia has been influenced by the ground-breaking research done by Prof Daniel Freeman and colleagues.


Why don’t therapists use exposure? And how psychological flexibility can help.

Exposure* is one of the most important and effective components in cognitive behavioural therapies for anxiety disorders, supported by decades of research. And yet it is under-used in clinical practice. Why?

Well, it isn’t just that many therapists use approaches that are not evidence-based. It seems that even those therapists who have been trained, end up not using exposure routinely. It is likely that exposure is the first empirically supported method that therapists stop doing soon after their training.

Some recent papers have explored this evidence-practice gap –

Meyer and colleagues (2013) assessed the beliefs therapists hold about exposure, in particular, when they decide to exclude exposure as part of treatment. They found that this was predicted by certain negative beliefs, combined with the therapist’s own fear of the sensations associated with anxiety (anxiety sensitivity). Therapist anxiety sensitivity has been found to predict less skilled delivery of exposure (such as terminating exposure sessions too early, or reassuring clients of safety) (Harned et al., 2014). The negative beliefs Meyer et al identified included concerns about harming clients, the ethics of exposure, and incorrect ideas about the effectiveness of exposure. Incorrect views involved believing that exposure is not helpful for clients who are diagnosed with a psychotic disorder, or for those deemed “emotionally fragile”; or those who are reluctant or ambivalent about engaging with an exposure program.

Deacon et al (2013) developed a scale to measure therapists’ beliefs about exposure. Alongside this measure, they asked therapists to respond to an exposure case vignette. The therapists that endorsed more negative beliefs about exposure also tended to respond to the case vignette in ways that would limit the benefit of exposure. This included using more strategies to reduce client distress during exposure sessions, or agreeing to client requests to use safety behaviours.

The same research team (Farrell, Deacon et al., 2013) designed an experiment to explore whether these negative beliefs  could influence the how cautiously aspiring therapists (university students) would approach the actual delivery of exposure. Participants received general information about conducting exposure, and then watched an information video about the beliefs that qualified therapists hold about using exposure. This video either presented negative beliefs about exposure, or described each of these negative beliefs and the research evidence to refute them (the positive condition). The participants were then asked to conduct an exposure session with a client (actually a confederate in the experiment, following a script of actions). The researchers found the participants in the negative belief condition conducted exposure in a more cautious fashion, compared to those who were presented exposure in a more positive light. This included trying to minimise the client’s anxiety, being less ambitious with creating an exposure hierarchy, and selecting a less-anxiety provoking task to do. Participants who held negative beliefs about exposure were also more anxious about conducting the session, both before and during exposure, and reported less interest in using exposure to treat anxious clients later in their careers!

So, it seems therapists’ beliefs about exposure, along with their anxiety sensitivity, may influence:
1) whether exposure is offered to certain clients,
2) how the therapist feels while doing exposure, and
3) the way that exposure is conducted (which can enhance or limit the treatment effect)

Considering this, are there ways that we can encourage therapists to remain committed to using exposure, and to deliver it in a way that optimises outcomes?

Checking out this literature got me wondering about whether contextual behavioural science may have something useful to add. In Acceptance and Commitment Therapy (ACT) the therapist’s behaviour is understood in terms of the same model of psychological flexibility as the client’s. This means that therapist beliefs that function as barriers to acting effectively can be worked with contextually – so that exposure may not be a matter of belief.

There have been a couple of studies which indicate that acceptance and commitment training is useful in increasing the openness and flexibility of learners to new material, and promoting the general effectiveness of therapists.

It seems to me that there may be mileage in promoting therapist psychological flexibility toward the use of exposure. As the exposure involves encouraging the client to engage in activities that put them in undefended contact with what they fear, this may benefit from flexible persistence on the part of the therapist, the kind that is promoted in ACT. Therapist rigidity about exposure (entanglement with unhelpful beliefs, unwillingness) may be addressed through using psychological flexibility skills, such as noticing, acceptance, defusion, and values clarification:
•    Doing exposure can involve the therapist witnessing client anxiety and being in contact with their own responses about this: there is the potential to get entangled with experiences, and act in ways  that limit the effect of exposure. As described above, this may include urges to avoid/ limit distress (by reassuring the client, suggesting “easier” steps on an exposure hierarchy).
•    Greater contact with the present moment may promote the therapist’s capacity to engage with offering and persisting with exposure. Present-moment noticing these thoughts and feelings about exposure, considering them in terms of workability, may help to build willingness toward these experiences as part of “doing exposure”.
•    Placing the exposure work within a larger frame of purpose (values clarification and committed action, rather than a primary aim of anxiety reduction), may strengthen client and therapist commitment to the process. Therapist motivation for exposure may be enhanced by deliberately connecting with the purpose of helping the client broaden their life – that exposure may allow the client to do more of the things that are important to them.

There are at least two ways that such psychological flexibility training could address the low take-up and persistence by therapists in using exposure:

1) For therapists in training, it may be pragmatic to introduce  skills in strengthening their own psychological flexibility prior to learning the theory and practice of exposure. Within this training could be acknowledgement of how doing exposure can put the therapist in contact with private experiences that invite  struggle and avoidance, and how being open to this and connecting with values may help the therapist to persist and remain effective.

2) For experienced therapists, it seems important to address the factors that influence the drift from using exposure. This could be tackled by workshops that present exposure skills alongside psychological flexibility training, with open exploration of what influences treatment decisions. This could also be reinforced through supervision and consultation.

These two ideas could also be the focus of research, extending the studies that I discussed above.

It’d be great to hear your views on how to help therapists to approach(!) and maintain using exposure in their clinical practice. Feel free to comment below!

*Exposure involves deliberate and repeated contact with cues that evoke a fear response while simultaneously engaging in behaviour that is incongruent with escape or avoidance – for a discussion, check out Moscovitch et al. 2009