4 ACT "twists" for flexible & impactful Graded Exposure Work
Have you ever felt stuck when attempting to apply Graded Exposure principles to your work with clients with persistent pain or other complex symptoms? I have!
As an Occupational Therapist that has historically used A LOT of traditional Cognitive Behavioral Therapy to address anxiety and avoidance in many different forms in mental health settings, when I began working with folks with persistent pain and other often unpredictable and distressing physical symptoms, I felt a bit stuck in how to effectively apply these same principles.
In traditional CBT models, we use gradual and incremental exposures to challenge the connections that have been built over time or with a significant experience that a specific situation, environment, experience, activity or movement is threatening. We support folks with identifying the beliefs connected to their strong emotional reactions, and we collaboratively create experiments that support them to edge into their discomfort at their pace and to build evidence that challenges those beliefs they have identified as unfounded or unhelpful.
But what happens when avoidance runs deep and the hot thought is…”but this is going to hurt!”? Can I say with certainty that it won’t…NOPE! No crystal ball here when it comes to complex and persistent pain.
A lot of therapists (rehab pros & mental health clinicians alike) avoid engaging in exposure work when a client’s symptoms are unpredictable because we, too, might have the automatic thought, “Is this going to hurt them?” This was certainly me early on in my journey supporting folks in pain. I was struggling with my own fear and, in truth, ignorance regarding pain principles, and wanted to avoid at all costs the possibility of guiding my clients into more pain. I certainly benefited from a greater understanding of pain alongside the ACT twists that we will dive into here!
So…How is Acceptance and Commitment Therapy different?
While traditional CBT approaches tend to focus on the contents of our thoughts, beliefs, and experiences, ACT focuses on the relationship that we have with our thoughts, beliefs and experiences and is much less concerned with the content. When we are applying an ACT framework or lens to the work that we are doing, we are NOT getting sucked into the often frustrating and invalidating battle of trying to change the contents of our clients’ beliefs, but are instead curiously and compassionately focused on supporting them with developing more psychological flexibility in response to the uncomfortable sensations, emotions, or that disruptive internal dialogue.
What does Psychological Flexibility mean?
It is human nature to want to resolve our painful experiences. Our “go-to” strategies are therefore to avoid the things that seem to bring about the pain or to push it aside, push it away, push through it or distract ourselves from it. In ACT, this phenomenon is often referred to as “experiential avoidance” or “the control agenda”. This natural reaction, however, comes at a cost. It turns out that while this problem-solving strategy is often very effective when applied to the problems happening around us, it is not quite as effective when applied to the uncomfortable experiences within us, and in fact often leads to more pain and suffering.
Psychological Flexibility involves building our capacity to be present with and turn towards our uncomfortable internal experiences with compassionate curiosity (pain willingness) in service of finding ways to move forward with valued roles and activities (valued activity engagement).
ACT principles can be a bit abstract! If your interest is piqued and you want to learn more, I highly recommend reading A Liberated Mind by Stephen Hayes AND staying tuned for ACT learning opportunities coming up at AMP! I have found that a great way to comfy with ACT, is simply by starting to “sprinkle” some of the concepts into the work that you are doing bit by bit. Let me walk you through what this might look like in Graded Exposure work!
4 ACT-informed “twists” to bring into your Graded Exposure Work
Planning - Forecast & plan for discomfort.
Let’s lay the uncertainty on the table and get clear on a common goal from the onset!
When introducing folks to the nature and purpose of graded exposure work, traditional CBT-informed therapists often emphasize the concept of habituation. That is, that over time, with gradual and repeated exposure in safe context, your brain and body “should” get used to the stimulus and therefore we should see a reduction in the intensity and duration of that alarm (whether it is fear or the pain itself) over time. Sure! This might happen. However, when we lay this out as the goal of the work, the client remains focused on and perhaps even hypervigilant about their pain response. In other words, we could be re-enforcing their control agenda..
When setting up graded exposure work from an ACT perspective, I like to de-emphasize habituation as the goal and, instead, emphasize returning to valued activity engagement (Occupational Drive) as the goal:
Let’s pick something that is relevant and meaningful to you.
Tell me why this activity is important to you!
Let’s go at your pace to use graded exposure work to gradually build up your confidence and capacity to engage in this activity in ways that are meaningful to you.
It might be uncomfortable. Let’s make sure we are planning this work for a time when you are feeling more resilient and have the capacity to take care of your nervous system afterwards.
What are some things that you could put in place to care for your nervous system if the pain flares up?
I will be curious to hear more about how you manage discomfort as it arises in this work (emphasize self-efficacy) and…
whether or not the discomfort involved in this “edging forward” was worth it to you in service of moving towards your goals (self-determination).
2. Guide the narrative - Model curiosity
A key opportunity for us to have an impact on psychological flexibility is in the meaning making process that comes after an experience. When we are de-emphasizing changing or controlling pain or beliefs about pain as the goal of exposure work, any outcome becomes a successful outcome as it brings with it an opportunity to learn more about oneself, one’s reactions, and approaches that are working or not working in service of moving towards that valued activity. It’s an opportunity to gather more information that can help to guide next best steps.
If a client comes back to say, “nope it didn’t work” or “nope that hurt”, I want to tease apart what that means for them:
Walk me through what you noticed
Tell me more about the sensations that you experienced before, during, and after the experience. How long did they last?
How were you feeling prior to trying this? What was going on for you (sleep, stress, etc.)
That’s fair. Does this give us any information about what you might need or how we might adapt this step to make it a more accessible next step?
By delving into the experience and asking the client questions that help them reflect a bit further, we are modeling and guiding them towards a more curious relationship with their pain.
3. Guide the narrative - Pivot to self-efficacy
Tell me more about what you did to manage the discomfort as it arose.
You noticed some discomfort, were you still able to accomplish the task or engage in the activity?
What might this say about your capacity to engage in this activity with or without the pain?
When we pivot to asking about how the pain was managed vs. focusing primarily on its presence, absence, and intensity, we can support our clients with capturing key learning that might bolster their self-efficacy, in turn supporting them with continuing to edge forward towards their goals vs. remaining stuck in avoidance in service of controlling the pain.
4. Guide the narrative - Pivot back to relevance
Was it worth it?
This is my all time favorite question within the post-experiment reflection process that gives the work that lovely “ACT twist”. This question gives our clients the opportunity to reflect on whether or not they felt that making space for some discomfort was worth taking a step towards their “getting back to living” goals. Ultimately, we don’t get to decide, they do. Our clients get to decide when to edge forward, when to pull back, and when to plunge ahead despite the pain because they just want to dance at their best friend’s wedding and it is totally worth it to be laid up for a day afterwards.
The most impactful lessons that I have gleaned from the application of ACT to my work with folks who have pain are
Leaning into uncertainty & complexity can be incredibly empowering for folks and
Pivoting towards valued activity engagement when the control agenda is strong not only supports my clients, but also helps to keep me grounded in those lovely OT roots!
As you delve deeper into ACT, play with these Graded Exposure pivots and let me know how it goes!
lara@amphealthcare.ca
