Using Acceptance and Commitment Therapy to Guide Exposure-Based Interventions for Posttraumatic Stress Disorder

Abstract

Exposure is considered one of the most effective interventions for PTSD. There is a large body of research for the use of imaginal and in vivo exposure in the treatment of PTSD, with prolonged exposure (PE) therapy being the most researched example. Acceptance and commitment therapy (ACT) has sometimes been called an exposure-based treatment, but how exposure is implemented in ACT for PTSD has not been well articulated. Although support for the use of ACT in PTSD treatment is limited to a handful of case studies and open trials, research suggests ACT is particularly useful in flexibly targeting avoidance behavior—arguably the most important process in the continued maintenance of PTSD symptoms. The purpose of this paper is to explore the use of exposure within ACT in PTSD treatment. Through an overview of PE and ACT, and with the use of case examples, we describe how ACT principles and techniques may inform exposure-based treatments for PTSD in order to create more flexible approaches. In addition, understanding exposure within an ACT framework may also contribute to clarifying processes of change.

Full text

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Journal of Contemporary
Psychotherapy
On the Cutting Edge of Modern
Developments in Psychotherapy
ISSN 0022-0116
Volume 43
Number 3
J Contemp Psychother (2013)
43:133-140
DOI 10.1007/s10879-013-9233-0
Using Acceptance and Commitment
Therapy to Guide Exposure-Based
Interventions for Posttraumatic Stress
Disorder
Brian L.Thompson, Jason B.Luoma &
Jenna T.LeJeune

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ORIGINAL PAPER
Using Acceptance and Commitment Therapy to Guide
Exposure-Based Interventions for Posttraumatic
Stress Disorder
Brian L. Thompson •Jason B. Luoma •
Jenna T. LeJeune
Published online: 13 March 2013
ÓSpringer Science+Business Media New York 2013
Abstract Exposure is considered one of the most effective
interventions for PTSD. There is a large body of research for
the use of imaginal and in vivo exposure in the treatment of
PTSD, with prolonged exposure (PE) therapy being the most
researched example. Acceptance and commitment therapy
(ACT) has sometimes been called an exposure-based treat-
ment, but how exposure is implemented in ACT for PTSD
has not been well articulated. Although support for the use of
ACT in PTSD treatment is limited to a handful of case studies
and open trials, research suggests ACT is particularly useful
in flexibly targeting avoidance behavior—arguably the most
important process in the continued maintenance of PTSD
symptoms. The purpose of this paper is to explore the use of
exposure within ACT in PTSD treatment. Through an
overview of PE and ACT, and with the use of case examples,
we describe how ACT principles and techniques may inform
exposure-based treatments for PTSD in order to create more
flexible approaches. In addition, understanding exposure
within an ACT framework may also contribute to clarifying
processes of change.
Keywords Posttraumatic stress disorder Exposure 
Acceptance and commitment therapy Prolonged exposure
Exposure involves deliberate and repeated contact with
cues that evoke a fear response while simultaneously
engaging in behavior that is incongruent with escape or
avoidance (Moscovitch et al. 2009). Through decades of
research, exposure remains one of the most—if not the
most—important components in cognitive-behavioral
approaches to anxiety disorders. Additionally, exposure is
an important component in most treatments of posttrau-
matic stress disorder (PTSD; Institute of Medicine 2007).
Although exposure therapy is a gold standard treatment
for PTSD, not everyone benefits from exposure therapy.
Controlled studies of exposure therapy for PTSD indicate
dropout rates ranging from 20.5 to 32 % (Hembree et al.
2003; van Minnen et al. 2002), and only about 60 % of
people with PTSD respond well to exposure therapy when
defined by post-treatment outcome scores below specific cut-
offs for PTSD symptoms and depressive symptoms (Foa
et al. 1999; Hagenaars et al. 2010). This leaves a large
number of people in clinically significant distress. Addi-
tionally, although exposure as a procedure has been suc-
cessfully used for decades, researchers continue to
illuminate and refine our understanding of how exposure
works. For example, there is evidence that treatments impact
processes other than those indicated in the underlying
models on which they are based (Twohig et al. 2010b).
Newer models of exposure (e.g., Craske et al. 2008)
have potential to bring greater precision toward under-
standing mechanisms of change in exposure. For example,
the work of Craske and colleagues suggests acceptance or
toleration of distress may be more important in facilitating
new learning than habituation to feared stimuli (e.g.,
Craske et al. 2008; Kircanski et al. 2012). Advances in
understanding core processes may increase the range of
exposure-based interventions, allowing procedures to be
more flexibly tailored to particular clients and thereby
enhancing clinical response. The purpose of this paper is to
explore how ideas and research from acceptance and
commitment therapy (ACT; Hayes et al. 1999) may help
guide the application of traditional exposure procedures
and contribute to understanding processes of change.
B. L. Thompson (&)J. B. Luoma J. T. LeJeune
Portland Psychotherapy Clinic, Research, & Training Center,
1830 NE Grand Ave, Portland, OR 97212, USA
e-mail: brian.l.thompson@gmail.com
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DOI 10.1007/s10879-013-9233-0
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Consistent with earlier exposure therapy models, ACT
builds upon models of classical and operant conditioning.
Unlike earlier behavioral models, ACT attempts to address
the complexity of human language and cognition through
its foundation in relational frame theory, a behaviorist
understanding of language and cognition (Hayes et al.
2001). Most traditional behavior therapy procedures fit
well within an ACT model, and ACT has even been called
an exposure-based treatment (e.g., Luoma et al. 2007).
There is growing research support for the use of ACT in
treating anxiety disorders (e.g., Arch et al. 2012; Twohig
et al. 2010a) but only limited outcome data specific to ACT
for PTSD (Cukor et al. 2009). At this time, the only pub-
lished empirical evidence for the use of ACT for PTSD
consists of case studies and one uncontrolled trial. In an
open trial, researchers found reductions in PTSD symptoms
and depressive symptoms in an ACT-based inpatient
treatment program for veterans with comorbid PTSD and
substance abuse (Batten et al. 2009). In a case study of a
woman with drug abuse, PTSD, and a history of childhood
sexual abuse who was treated using ACT, post-treatment
improvements were maintained at a 12-month follow-up
(Batten and Hayes 2005). The other case studies include a
veteran with PTSD who refused prolonged exposure ther-
apy but willingly engaged in imaginal exposure within an
ACT context (Orsillo and Batten 2005), and a client with
PTSD who had not responded to 20 sessions of cognitive-
behavioral therapy but responded to 21 sessions of ACT
(Twohig 2009). Results from these preliminary studies
demonstrate clinically significant improvements in out-
comes such as PTSD symptoms, depression, thought sup-
pression, substance abuse, and quality of life following
ACT treatment.
A process account of the use of ACT to reduce experi-
ential avoidance offers further support for the relevance of
ACT to PTSD (Thompson and Waltz 2010). Experiential
avoidance occurs when an individual attempts to avoid or
escape private events such as thoughts, memories, bodily
sensations, and feelings (Hayes et al. 1996). In dozens of
studies covering areas such as depression, stress, burnout,
anxiety, psychosis, pain, disease management, weight
management, stigma, and smoking, ACT has been shown
to decrease experiential avoidance, with these changes
mediating outcomes (e.g., Hayes et al. 2006). Targeting
experiential avoidance is a core focus of ACT.
Of the three symptom clusters comprising diagnostic
criteria for PTSD, research suggests avoidance symptoms
(i.e., cluster C) are the most central to the maintenance of
PTSD (Marshall et al. 2006; Nemeroff et al. 2006). One study
found that reductions in avoidance behaviors preceded
improvements in PTSD re-experiencing and arousal symp-
toms, suggesting that avoidance mediated clinical gains
(S¸ alcıog
˘lu et al. 2007). There may be several pathways
through which changes in avoidance may result in
improvements in PTSD. For one, particular forms of
avoidance, such as substance use, self-harm, and high-risk
sexual behavior, may be particularly costly and lead to
downstream negative life impacts (Polusny and Follette
1995). Literature also suggests that attempts to avoid private
experiences, such as through thought suppression, may make
trauma-related thoughts more salient, creating a rebound
effect that contributes to the continued maintenance of PTSD
(Shipherd and Beck 2005). In addition, experiential avoid-
ance leads to disengagement from activities that are both
personally meaningful and potentially distressing (e.g.,
social situations that provoke anxiety), contributing to a
general decrease in quality of life (Kashdan et al. 2006).
This article focuses on the use of exposure for PTSD
within the larger context of an ACT model. We highlight
theoretical and practical differences in the ways exposure
procedures are utilized in ACT compared with prolonged
exposure (PE) therapy, an exposure-based treatment for
PTSD with a strong research base (Powers et al. 2010). As
many clinicians are already using both ACT and PE to treat
PTSD, we hope to provide guidance on how therapists
trained in PE might utilize ACT to flexibly adapt inter-
ventions to address barriers to effective exposure through
targeting avoidance and broadening behavioral repertoires.
Secondarily, we hope this article contributes to the devel-
opment of theory and research on exposure-based treat-
ments for PTSD.
Our view is that ACT as a context for exposure is a
promising avenue to improving the treatment of PTSD,
especially in instances where trauma survivors are partic-
ularly avoidant and may be initially resistant to imaginal
and in vivo exposure. ACT offers an expanded range of
methods that target avoidance and other processes that
inhibit effective exposure and increase client willingness to
engage in exposure procedures. ACT also offers a different
account of processes of change than the emotional pro-
cessing theory that underlies PE (Foa et al. 2006). As ACT
emphasizes the flexible targeting of processes over partic-
ular therapeutic techniques, familiarity with ACT processes
may help therapists adapt their use of exposure to achieve
greater success with clients who have difficulty with tra-
ditional exposure interventions.
Outline of Treatment and Theory
Prolonged Exposure for PTSD
With more than 20 years of empirical support, PE is argu-
ably the intervention for posttraumatic stress disorder
(PTSD) with the largest evidence base supporting its effec-
tiveness (e.g., Hagenaars et al. 2010; Powers et al. 2010).
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PE treatment centers on the use of exposure to target trauma-
related avoidance in order to facilitate the effective pro-
cessing of trauma memories. In PE, exposure typically
begins with in vivo exposure exercises. In vivo exposure
involves engaging in safe but distress-evoking activities or
situations that are typically avoided. Following the intro-
duction of in vivo exposure, the therapist begins imaginal
exposure. Imaginal exposure is conducted in session and
involves repeated recitation in the present tense of the target
trauma memory followed by a debriefing of the exposure.
Treatment mostly consists of engaging in in vivo and
imaginal exposure and overcoming barriers to the same.
Procedurally, PE is elegant in its relative simplicity.
Acceptance and Commitment Therapy for PTSD
In contrast to PE, which has a relatively concrete, topo-
graphically defined procedure to guide its application (Foa
et al. 2007), ACT utilizes six functionally-defined core
processes with a range of experiential exercises and met-
aphors that vary in their application depending upon case
conceptualization. The primary target of ACT is enhancing
psychological flexibility, the ability to be psychologically
present and change or persist in behavior to serve valued
ends (Bond et al. 2011). People with PTSD are typically
low in psychological flexibility, as their behavior is dom-
inated by the avoidance of trauma-related stimuli and pri-
vate events (i.e., experiential avoidance; Thompson and
Waltz 2010; Twohig 2009). ACT seeks to expand behav-
ioral repertoires through acceptance and mindfulness pro-
cesses and by encouraging more direct contact with
intrinsically meaningful and rewarding patterns of behavior
through engagement in workable action.
ACT often begins with developing an initial openness to
acceptance of thoughts, feelings, and physical sensations
through experiential contact with the costs and unwork-
ability of avoidance strategies (Hayes et al. 1999). Clients
are encouraged to observe ways in which control strategies
(e.g., experiential avoidance) are often ineffective in that
they may lead to short-term gains (e.g., brief reduction of
anxiety) but long-term costs (e.g., increased distress,
restricted activity). The goal is the development of psy-
chological acceptance; that is, the willingness to let go of
avoidance and contact one’s immediate experience, even if
that experience includes fear, anxiety, unpleasant thoughts,
or trauma-related memories (Luoma et al. 2007).
Concurrently, ACT strengthens a second process—
contact with the present moment, defined as being present
with one’s immediate experience, as opposed to being
preoccupied with the conceptualized past or future (Luoma
et al. 2007). Individuals with PTSD may rely on escape/
avoidance behaviors that interfere with discriminating and
remaining in contact with private experiences such as
thoughts, emotions, and interoceptive sensations (Thomp-
son and Waltz 2010). ACT attempts to foster an attentional
flexibility that is more voluntary, open, and effective.
ACT also promotes what is called self-as-context, or the
observer self. This aspect of the ACT model involves uti-
lizing various exercises and techniques to improve per-
spective-taking. These perspective-taking exercises can
help clients contact a continuous sense of self that,
although the occasion for one’s experiences, is distinct
from those experiences (Luoma et al. 2007). Through
fostering self-as-context, ACT encourages development of
a form of perspective-taking through which one can be
aware of personal experiences without the content of those
experiences defining the self (i.e., self-as-content or the
conceptualized self).
A fourth process, cognitive defusion—the antithesis to
cognitive fusion—involves observing the process of one’s
thinking without taking the content of thinking as literal
reality (Luoma et al. 2007). For example, rather than
experiencing the self as damaged when having the thought
‘‘I’m damaged,’’ the person is able to observe the thought
‘‘I’m damaged’’ as a passing experience that will come and
go. Thoughts are not disputed so much as recognized as
transient products of language that may or may not be
helpful. The aim of cognitive defusion is to loosen rigid
attachment to verbal rules, predictions, or self-evaluations
in order to increase behavioral flexibility.
The identification of values is another important process
in ACT. Values are freely chosen patterns of purposive
action tied to longer-term goals and outcomes (Luoma
et al. 2007). From an ACT perspective, values are chosen
life directions that provide a sense of meaning and purpose
in life and serve as an ongoing guide for action. As indi-
viduals practice contacting and articulating their values in
various domains of living (e.g., relationships, health,
work), they are encouraged to engage in committed action,
the final core ACT process. Through developing concrete
goals targeted towards valued directions, clients are
encouraged to take steps towards those goals (Luoma et al.
2007). Together these six processes are promoted in order
to reduce experiential avoidance and foster greater psy-
chological flexibility. Through these processes, ACT ther-
apists help shift behavior from being dominated by
aversive control (i.e., avoidance of painful stimuli) to
having greater contact with appetitives and positive rein-
forcers (i.e., action towards meaningful goals and life
directions).
Although ACT incorporates a variety of exposure-like
exercises, ACT writers have generally not used the term
‘‘exposure’’ when describing these procedures in ACT.
Reasons include wanting to avoid the somewhat negative
connotation of the word exposure and because the term
implies meanings that do not fit within an ACT
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conceptualization (Eifert and Forsyth 2005). For example,
PE is rooted in an extinction model of exposure: the
reduction of fear responding (i.e., habituation) over time
through repeated contact with aversive stimuli (Foa et al.
2006). By contrast, ACT focuses on the expansion of
behavioral repertoires regardless of whether there is a
reduction in distress (e.g., Hayes et al. 1999). In this way
ACT is consistent with newer models of exposure that
emphasize maintaining contact with high levels of distress
even in the absence of habituation in order to promote new
learning with feared stimuli (Craske et al. 2008).
Exposure procedures in ACT are used in the context of
values-based committed action as a way to practice mind-
fulness and acceptance with whatever experiences are
encountered. Acceptance-based treatments such as ACT
appear to differ from traditional cognitive-behavioral
approaches in their emphasis on how one relates to private
experiences rather than on the content of those experiences
(Moscovitch et al. 2009).An emphasis on distress reduction is
inconsistent within the ACT model because it focuses on
changing private events rather than changing how one relates
to private events. In sum, exposure—defined as contact with
aversive stimuli—is used in ACT as an opportunity to expand
behavioral repertoires rather than as a means to promote
habituation or extinction. In the next section, we demonstrate
the use of ACT for PTSD with two case examples.
Application of ACT and Exposure in
Two Case Examples
Client 1
Client 1, a Caucasian female in her forties, presented with
complaints about her inability to maintain consistent
employment and feelings of sadness over her lack of an
intimate relationship. She stated she had ‘‘already dealt
with’’ trauma previously in therapy and had ‘‘put it behind
[her].’’ Upon further assessment, Client 1 reported multiple
traumas including childhood sexual abuse, bullying as a
child, witnessing a friend die in a car accident, and sexual
assaults as an adult. Her avoidance patterns included sub-
stance use (e.g., binge drinking), problematic sexual
behavior (e.g., recurrent unprotected sex with strangers),
dissociative behavior, self-harm behavior (e.g., cutting),
hypersomnia, and avoidance of trauma-related stimuli (e.g.,
did not drive a car).
Client 1 engaged in frequent rumination about past
memories and anticipation of future encounters with
trauma reminders. This lack of contact with the present
moment interfered with opportunities for new learning and
positive reinforcement. As Client 1 frequently dissociated
in the presence of trauma-related cues, mindfulness exer-
cises were used to improve her ability to stay present. Each
session began with a mindfulness exercise, typically
focused on concrete physical sensations. To reduce disso-
ciation, rather than silently noticing bodily sensations and
her breath, the client’s eyes remained open, and she
reported her observations aloud. By saying, ‘‘in breath’’
and ‘‘out breath’’ and performing the exercises with her
eyes open, Client 1 was able to direct attention to sensa-
tions in the present and reduce dissociative episodes. She
was given an audio recording of several mindfulness
exercises for daily practice outside of session.
In her attempts to manage her distress, Client 1 had
stopped taking action toward longer-term life directions
and goals. Client 1 was led through a variety of values
definition and identification exercises to help her define a
meaningful life direction. She engaged in a values card
sorting task to help her discriminate among specific values
statements she could choose to act on across life domains.
Helping Client 1 increase contact with chosen values
became motivation for her to engage in exposure exercises.
Values created a larger context for trauma-focused work
beyond the reduction of suffering. Motivation to engage in
exposure was also augmented through helping the client
develop awareness of how her avoidance behaviors (e.g.,
substance misuse) impeded her ability to move in valued
directions (e.g., meaningful employment, relationships).
Next, the focus turned toward increasing acceptance of
aversive stimuli where avoidance interfered with taking action
in valued directions. The word ‘‘willingness’’ may be a more
useful synonym for ‘‘acceptance’’ when working with trauma
survivors, as it emphasizes the element of choice in practicing
acceptance. The therapist used a metaphor of holding a prickly
cactus: the cactus, similar to Client 10s trauma-related expe-
riences, could be held gently, with willingness, and without
struggle. Asa reminder, Client 1 purchased a small cactus and
practiced holding the cactus lightly, as she might hold painful
thoughts, feelings, memories, and sensations.
The therapist then introduced imaginal exposure as a
means of practicing willingness with trauma-related
memories. Imaginal exposure sessions typically began with
a discussion, exercise, or metaphor to help the client con-
tact her values and choose to practice willingness with her
traumatic memories in the service of moving towards those
values. The experience of choice must be made explicit.
The larger context of knowing she was working towards
chosen values served to increase her willingness to move
forward with the exposure.
As Client 1 easily dissociated and became emotionally
disengaged during recall of traumatic memories, a focus on
making contact with the present moment during exposure
was explicitly emphasized. Additionally, exposure was
conducted in a slow, deliberate fashion with careful
attention to detail. The client’s tendency to dissociate was
further managed by alternating periods of contact with
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distressing images with periods focused on her present
sensory experience (e.g., bodily sensations, sounds, and
objects in the therapy room).
In addition to daily practice of mindfulness exercises,
between each session Client 1 also committed to one spe-
cific physical action directly linked with her values. These
behavioral commitments (i.e., committed action) can serve,
in ACT, a similar role as in vivo exposure exercises in PE.
The emphasis in ACT is on the expansion of behavioral rep-
ertoires and increased contact with positive reinforcement.
Engaging in these behavioral commitments provided Client 1
with the opportunity to practice willingness, defusion, and
contact with the present moment when encountering trauma
triggers.
Client 10s case utilized exposure primarily to facilitate
contact with the present moment and acceptance. Therapy
lasted nearly 2 years and was terminated upon mutual
agreement between the client and therapist. Upon termi-
nation, Client 1 demonstrated an increased willingness to
contact difficult emotions, thoughts, and memories, as well
as a reduction in the avoidance behaviors that had inter-
fered with her ability to function effectively. At the
beginning of treatment, for example, Client 1 stated that
she was not able to maintain steady employment because
she ‘‘couldn’t stand being around men.’’ At termination,
she had been employed for approximately 4 months in a
job she found meaningful and stimulating. This was her
longest period of employment in her adult life. At termi-
nation, Client 1 was also engaging in more values-consis-
tent behavior with friends and family. Prior to therapy,
Client 1 had been estranged from her family and experi-
enced intense feelings of anger and betrayal towards her
parents. Through the emphasis on willingness and values,
Client 1 was able to visit her grandfather on several dif-
ferent occasions even though these visits triggered feelings
of anger and disappointment towards her parents. Client 1
spoke proudly about her ability to reestablish a connection
with her grandfather. She identified this pattern of valued
action as one of the most important outcomes of therapy
for her.
Client 2
Whereas the case above focused mostly on willingness,
values clarification, and committed action as contexts for
exposure, we chose our second case to highlight the role of
defusion and self-as-context in exposure. When fused,
individuals are ensnared in the process of thinking but
unaware of how this process of interpreting their experi-
ence impacts their perceptions and actions. Flashbacks, for
example, are an extreme form of fusion in which the
trauma survivor loses contact with the present and is unable
to distinguish the memory of the trauma from the actual
experience of trauma. Exposure aimed at increasing cog-
nitive defusion focuses on contacting verbally-conditioned
aversive stimuli while increasing behavioral variability.
Exercises aimed at strengthening self-as-context, or the
observer self, focus on increasing contact with a form of
perspective-taking (an ‘‘I’’) that can observe experiences
but is separate from these experiences. Exposure in this
context involves bringing this sense of self into contact
with trauma cues while coaching the client to observe the
distinction between one’s self as the observer and the
trauma-related images and thoughts being observed.
Through this process, the client learns to discriminate the
distinction between self-as-context and self-as-content.
Client 2 was a female college student in her early
twenties who presented to treatment two months after
being sexually assaulted by an acquaintance. Unlike Client
1, Client 2 did not have a trauma history prior to the
assault. Client 2 exhibited fusion with trauma-related
thoughts such as ‘‘This isn’t right,’’ ‘‘This doesn’t make
sense,’’ ‘‘I’m disgusting,’’ ‘‘It’s my fault,’’ and ‘‘I’m
damaged.’’ Trauma-related images were experienced as
flashbacks, with little ability to distinguish between the
actual trauma and her memory of the trauma.
One exercise used to target cognitive fusion is ‘‘taking
inventory.’’ The client was taught that when she observed a
thought or feeling, she could say quietly to herself, ‘‘I’m
having the thought that X,’’ or ‘‘I’m noticing I’m having
the feeling of X.’’ This was practiced in session and as
homework (e.g., walking between classes). Another defu-
sion exercise involved Client 2 writing down three brief
trauma-related thoughts on index cards (e.g., ‘‘Men are
dangerous,’’ ‘‘I am damaged,’’ ‘‘I’m unlovable’’), carrying
these with her in her wallet, and reading them aloud twice a
day. Client 2 reported finding this exercise particularly
useful in helping her observe that: (1) she could take these
thoughts along as she engaged in valued living; and (2) her
attempts to escape or avoid these thoughts interfered with
her daily living more than the thoughts themselves. Prac-
tice with both trauma and non-trauma related thoughts
helped to generalize the defusion process to a greater
variety of stimuli across multiple contexts.
In addition to defusion exercises, treatment focused on
strengthening self-as-context. Client 2 learned to observe
trauma-related thoughts and feelings without defining
herself by the content of these private experiences. For
example, the therapist introduced a common ACT exercise
called the Chessboard metaphor (Hayes et al. 1999; Varra
and Follette, 2004). Using an actual chessboard to visually
demonstrate the exercise, the therapist helped Client 2
observe unpleasant trauma-related thoughts and emotions
as parts of her experience (i.e., pieces on the board) rather
than the entirety of her experience. Talking through the
metaphor, the client observed that she was the context for
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her thoughts and feelings (i.e., like the chessboard) but was
not defined by the content of her thoughts and feelings (i.e.,
any more than the chessboard was defined by the pieces on
the board). Through these exercises, Client 2 began to
strengthen her ability to observe trauma-related thoughts
and feelings without taking the content of those experi-
ences as literal reality (i.e., cognitive defusion) or by
defining herself by those experiences (i.e., self-as-context).
Once the client had developed her ability to defuse from
thinking and observe the ongoing process of private
experiences, these skills were drawn upon in imaginal
exposure exercises. The goal of exposure for Client 2 was
not to change the frequency, intensity, or content of
thinking, but to increase flexible responding to trauma-
related cognitions and imagery. Said another way, expo-
sure was used to help the client look at rather than from
trauma-related thoughts (Luoma et al. 2007). In contrast to
Client 1, where the therapist emphasized focus on the
minute details of the trauma-related images with the goal
of improving contact with the present moment, the thera-
pist encouraged Client 2 to recount the trauma memory in a
relatively rapid fashion several times per session. Through
repeated contact with the trauma images and thoughts,
Client 2 began to discriminate the trauma-related stimuli as
thoughts (e.g., memories, images) as opposed to something
‘‘dangerous.’’
Client 2 completed 12 sessions of therapy across
4 months. At termination, she no longer met DSM-IV cri-
teria for PTSD. Client 2 reported a reduction in intrusive
images, nightmares, and physiological hyperarousal, as
well as a return to pre-morbid functioning in academic and
social contexts. By the end of treatment, she had discon-
tinued the prescription sleep aids she had been taking since
the assault. Although Client 2 continued to experience
some trauma-related memories, she reported she had
learned to experience those thoughts and images mindfully,
without struggling to avoid them. During the termination
session, Client 2 remarked that she no longer identified
with being a sexual assault victim/survivor (i.e., self-as-
content); instead, she saw herself as a person who had been
sexually assaulted (i.e., self-as-context). Per her report, this
shift in perspective-taking was profound and empowering
for her.
Discussion
The main purpose of this paper was to explore how ACT
techniques and processes for addressing psychological
inflexibility could guide the adaptation and augmentation
of exposure-based interventions for PTSD. A primary tar-
get of ACT is experiential avoidance: the inability or
unwillingness for an individual to remain in contact with
private experiences (Hayes et al. 1996). Several studies
offer strong support that experiential avoidance may be a
central process in the maintenance of PTSD (e.g., Kashdan
et al. 2006; Polusny and Follette 1995). ACT emphasizes
the enhancement of psychological flexibility and expansion
of behavioral repertoires in order to increase action towards
valued activities and goals, even in the absence of changes
in subjective experience of distress and trauma-related
cognitions. The use of exposure in ACT focuses on
undermining fused verbal processes that contribute to
avoidant responding and create obstacles to valued living.
Currently, published evidence supporting ACT in the
treatment of PTSD remains modest, relying on indirect
arguments based on a core process account of ACT’s
ability to reduce avoidance, a few case studies, and an open
trial (e.g., Batten et al. 2009; Batten and Hayes 2005;
Orsillo and Batten 2005; Twohig 2009). By contrast, PE is
an established treatment for PTSD with a large body of
research. Consequently, PE remains a first-line intervention
for PTSD.
However, not all potential clients are willing to engage
in traditional exposure, at least initially (e.g., Orsillo and
Batten 2005). The variety of ACT methods for undermin-
ing avoidance may help to increase willingness to engage
in exposure. For example, there is evidence that ACT
interventions may increase the palatability of exposure for
individuals with panic disorder (Levitt et al. 2004). As a
consequence, targeting ACT processes in individuals with
PTSD could increase willingness to engage in exposure
work. Additionally, there is some initial evidence that ACT
treatment without deliberate exposure can result in out-
comes comparable to exposure treatments in conditions
such as obsessive–compulsive disorder, where exposure-
based treatments remain the gold standard (Twohig 2010a).
Consequently, ACT offers other means for targeting
avoidance in the absence of deliberate exposure. This
suggests ACT may be an attractive alternative for people
who drop out of or who do not respond to traditional
exposure therapy.
As the case examples illustrate, ACT relies on a func-
tional understanding of presenting problems, rather than
diagnostic classification. ACT is fluid, whereas PE is more
procedural. This may make ACT treatment for PTSD more
difficult to manualize. Some have argued, however, that the
identification of principles of change in addressing PTSD is
more important than treatment packages (e.g., Rosen and
Davison 2003). We believe ACT may offer additional
insights into understanding the processes that lead to the
development and maintenance of posttraumatic stress
symptoms. As PE is the much more established interven-
tion, it is the onus of the ACT clinicians and researchers to
demonstrate ACT’s effectiveness and the processes of
change that clearly articulate how ACT may differ from
138 J Contemp Psychother (2013) 43:133–140
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more established exposure-based therapies for PTSD such
as PE. We hope this article moves along the conversation.
Acknowledgments We would like to thank Amy Wagner and
Michael Twohig for reading and commenting upon earlier drafts of
this manuscript. We would also like to thank Monica Bahan for
proofreading the final draft.
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