Hayes. Learning ACT An Acceptance and Commitment Therapy Skills Training Manual for Therapists

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“In this authoritative text, Luoma, Hayes, and Walser present a clearly written and practical step-bystep guide for therapists who are using acceptance and commitment therapy (ACT). Firmly rooted in contextual behavioral science and derived from a well-articulated theory, this text clearly describes and illustrates the concrete strategies to target a set of key processes that are critical to improve the lives of people. Every clinician should be familiar with it. It is a masterful book. I highly recommend it.” —Stefan G. Hofmann, PhD, professor of psychology at Boston University, past president of the Association for Behavioral and Cognitive Therapies, and author of Emotion in Therapy

“This second edition is an exceptional guide for the skillful and flexible implementation of ACT principles. The chapters outline the six core flexible ACT processes and their methods, with case examples and dialogues that bring the information to life. The book includes a unique and invaluable set of training tools and tests of core competencies. This is a masterful ‘how to’ for ACT suitable for clinicians at any level of training and experience.” —Michelle G. Craske, PhD, distinguished professor, and director of the Anxiety and Depression Research Center at the University of California, Los Angeles

“Firmly grounded in contextual behavioral science (CBS), superbly organized with lucid and comprehensive explanation of all ACT concepts and competencies, and loaded with clinical pearls and pitfalls to avoid, this book lives up to the title and then some, as one of the best books for learning ACT. Further, the clinical vignettes and self-reflective exercises will deepen and advance the practice of more seasoned practitioners of ACT. The updated text and the new inclusion of an excellent chapter on culture and diversity make this edition more relevant and invaluable than ever in this diverse, globalizing world. This book is simply a ‘must-have’ for any serious ACT practitioner!” —Kenneth P. Fung, MD, FRCPC, MSc, associate professor in the department of psychiatry at the University of Toronto; clinical director of the Asian Initiative in Mental Health at the University Health Network; and president-elect of the Society for the Study of Psychiatry and Culture

“ACT has been at the forefront of the pioneering third-wave cognitive behavioral therapies for many years. Not only has it uniquely linked the human evolution of language and symbol formation to mental processes that can cause suffering (relational frame theory [RFT]), but it has articulated six clear processes for therapeutic intervention centered around developing psychological flexibility. For both novice and expert therapists of any orientation, you could not want for a more clearly articulated, easily accessible, and therapeutically wise approach than this by these leaders and pioneers in the field. Full of therapeutic transcripts with clear, insightful descriptions of the therapeutic process, this beautifully written book is an outstanding contribution to therapeutic literature that is bound to become a classic and an essential text.” —Paul Gilbert, professor at the University of Derby, creator of compassion-focused therapy (CFT), founder of the Compassionate Mind Foundation, and author of The Compassionate Mind

“The tremendous dedication of thought and care Luoma, Hayes, and Walser infused into this second edition of Learning ACT is evident in the breadth and depth of every chapter. Their labor of love resulted in a preeminent and indispensable guide for novice and advanced ACT practitioners alike. Especially valuable are the fifty core competency exercises that stimulate experiential engagement. The chapter on adapting ACT to cultural contexts makes this a cutting-edge treatment for individuals from every walk of life who want to move in valued directions while welcoming all their thoughts and feelings.” —Mavis Tsai, PhD, coauthor of A Guide to Functional Analytic Psychotherapy, and research scientist and clinical faculty at the University of Washington

Learning

ACT

SECOND EDITION An Acceptance & Commitment Therapy Skills Training Manual for Therapists

JASON B. LUOMA, P h D STEVEN C. HAYES, P h D ROBYN D. WALSER, P h D Context Press

An Imprint of New Harbinger Publications, Inc.

Publisher’s Note This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other professional services. If expert assistance or counseling is needed, the services of a competent professional should be sought. Distributed in Canada by Raincoast Books Copyright © 2017 by Jason B. Luoma, Steven C. Hayes, and Robyn D. Walser Context Press An imprint of New Harbinger Publications, Inc. 5674 Shattuck Avenue Oakland, CA 94609 www.newharbinger.com Cover design by Amy Shoup Acquired by Catharine Meyers Edited by Jasmine Star Indexed by James Minkin All Rights Reserved

Library of Congress Cataloging-in-Publication Data on file

        

  

  

  

  

  

  

  

  

To my partner, Jenna LeJeune, for your support, your sacrifice, and your faith in me. —­JBL I would like to dedicate this book to David H. Barlow, and to my fellow interns (Peter M. Monti, Kelly D. Brownell, A. Toy Caldwell-­Colbert, and Carol Heckerman Landau) who worked under him in the first class of clinical psychology at Brown University, Department of Psychiatry and Human Behavior, 1975–­1976 and who such showed patience and kindness in shaping up a wild man (that would be me) to be able to work with people. —­SCH I would like to dedicate this book to Susan L. Pickett. Thanks for the encouragement over the years and for always having faith in me. —­RDW

Contents



Acknowlegmentsvii



Introduction1

1

The Focus of ACT and Its Six Aspects13

2

Developing Willingness and Acceptance37

3

Undermining Cognitive Fusion88

4

Getting in Contact with the Present Moment132

5

Building Flexible Perspective Taking Through Self-­as-­Context163

6

Defining Valued Directions197

7

Building Patterns of Committed Action238

8

Conceptualizing Cases Using ACT272

9

The ACT Therapeutic Stance316

10

Adapting ACT to Cultural Contexts349

11

Bringing It All Together371



Appendix A: The ACT Core Competency Rating Form413



Appendix B: Resources for Further Development420



Appendix C: Using ACT in Different Settings422



Glossary425



References429



Index443

Acknowledgments

This book was a team effort. To all those who read and provided feedback on drafts of these chapters, thank you. The exercises were particularly improved by those who piloted chapters of this book, including Mary Englert, Anne Shankar, Lianna Evans, Ross Leonard, Brendan Sillifant, Kevin Handley, Laura Meyers, Joanne Hersh, Jennifer Boulanger, and Jennifer Plumb. Thanks to the Portland ACT peer consultation group for their ideas about how to organize the book, exercises, and videos. Thanks to Joe Parsons for discussions about shaping therapist behavior, which influenced the exercises in this book. Thanks to those who provided feedback on the first edition including Donna Read, Ana Gallego, Miguel Lewis, Hiba Giacoletto, Brady Henderson, Petra Berg, Andrea Sieg, Kathleen Thorndike, Fred Kane, Magda Permut, Kaylin Jones, Sonia Combs, and the therapists at Lutheran Community Services of Spokane. Your input resulted in some large improvements in this edition, and your efforts will touch the lives of thousands of future readers and their hundreds of thousands of clients. All those people will never know that they should thank you for the time you put into improving the book. To all of our clients who have honored us with their presence, trust, and courage. Without all of you, this book would not have been possible. Thanks to those students and professionals who allowed themselves to be supervised by us and who taught their supervisors so much. Thanks to our editors, Jude Berman and Jasmine Star, for smoothing out our language and making our jargon more understandable. Acknowledgment from individual authors: Thank you to all those who helped me (JBL) learn ACT. When I first began studying ACT, I was blown away by the rigor and scope of the theory and was thoroughly confused by the technical language. I was rapidly able to utilize many of the metaphors and exercises, but didn’t really understand how it all tied together. I needed a book about the in between moments. This is my attempt to write that book. I (SCH) would like to thank my wife, Jacqueline Pistorello, for her support, advice, and patience throughout, and to thank my lab for their input and encouragement. I (RDW) would like to thank my mom for providing some of the illustrations in this book. They look great, Mom! We appreciate your willingness and action on short notice. I love and miss you. And thank you to my brothers for being there in times of need and as well times of joy, much love to you and your families.

Introduction

Whenever Richard Cory went down town, We people on the pavement looked at him: He was a gentleman from sole to crown, Clean favored, and imperially slim. And he was always quietly arrayed, And he was always human when he talked; But still he fluttered pulses when he said, “Good-­morning,” and he glittered when he walked. And he was rich—­yes, richer than a king—­ And admirably schooled in every grace: In fine, we thought that he was everything To make us wish that we were in his place. So on we worked, and waited for the light, And went without the meat, and cursed the bread; And Richard Cory, one calm summer night, Went home and put a bullet through his head. —­Edwin Arlington Robinson

It is impossible to construct a human life untouched by suffering. Edwin Arlington Robinson’s well-­ known poem reminds us that, every day, people who seemingly have all the things a person could ever want, at least as viewed from the outside, end their existence rather than bearing up under another moment. We of the human species encounter many of the same painful events as do other species; humans and nonhuman animals alike are faced with loss, unexpected upsets, and physically painful experiences. Yet we do something with these encounters that other species do not: we think about them, analyze them, predict them, and ruminate about them, and through this process we amplify our suffering and bring it with us. The human ability to think and reason is truly amazing. Our system of language is unlike any other; as an ongoing process, it fills our awareness with a never-­ending stream of verbal connections.

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This ability is both a wonderful and a terrible thing. It sustains the capacity for human achievement: our ability to communicate, build, plan, and engage in problem solving. It is part of our ability to love deeply and commit to others, to dream of hoped-­for futures and work toward their realization. However, the same cognitive and verbal building blocks that enable these possibilities also allow us to struggle in the midst of plenty. They allow us to be Richard Cory. Human beings struggle in a number of ways that can be painful and life changing. When events occur that bring us into contact with difficult emotions and thoughts, we often work very hard to rid ourselves of these experiences, both by trying to avoid the event that triggered them and by attempting to remove the negatively evaluated emotions and thoughts that accompany the experience. For instance, we don’t want to feel anxiety about failure or sadness about loss, so when an event occurs that might occasion those emotions, we work to avoid the event and the resulting emotional reactions. It isn’t surprising that we take these steps. If something is unpleasant, it makes sense to figure out how to remove what is unpleasant. The problem with this strategy lies in the paradoxical effects of language—­those symbolic abilities that make up what we call in common terms the mind—­as we attempt to use these abilities to avoid or subtract that which cannot be avoided or subtracted. When it becomes important that we not think or feel a certain way and we nevertheless find ourselves thinking or feeling that way, our minds can become consumed with efforts to diminish or eliminate these experiences. Often, however, in the very effort to eliminate these experiences, we propagate and grow the demons we wish to destroy. Acceptance and commitment therapy (ACT, which is said as one word, not as A.C.T.; Hayes, Strosahl, & Wilson, 1999) offers a possible antidote to the harmful functions of this verbal capacity and its role in human suffering. ACT is an evidence-­based contextual cognitive behavioral intervention designed to create greater psychological flexibility and, as a result, human liberation. ACT addresses the paradoxes inherent in human cognitive processes and works to help people live meaningful and valued lives. ACT employs a number of strategies to alleviate people’s problems and promote their flourishing, including willingness or acceptance of experience; cognitive defusion; flexible attention to the present moment; contact with a transcendent or perspective-­taking sense of self (self-­as-­context); clarity and ownership of values; and fostering commitment to larger patterns of values-­based living. Each of these processes is applied with warmth and compassion for the client’s struggle and for the difficulties that unwanted experience can bring. ACT is a constructive approach to psychotherapy that helps people learn to compassionately embrace their internal experience for all that it is while also focusing on building repertoires of constructive behaviors that are values oriented. ACT is informed by all of the elements of what is now known as contextual behavioral science, or CBS (Zettle, Hayes, Barnes-­Holmes, & Biglan, 2016). CBS aims to recast behavioral science itself and takes a functional approach to the major elements needed for knowledge development in this domain. CBS includes functional contextualism as a philosophy of science (Biglan & Hayes, 2016), evolution science principles (Hayes, Monestès, & Wilson, in press), and behavioral principles as augmented by relational frame theory (RFT; Hayes, Barnes-­Holmes, & Roche, 2001). All of these various elements come together to define ACT as a contextual behavioral method. The relationship of ACT to this larger set of assumptions, principles, and strategies has been written about extensively in previous books, and we summarize some of this topic briefly in a more clinical way in this volume. In particular, we describe the manner in which ACT approaches how human language and cognition contribute to keeping human beings stuck. In this second edition, we

Introduction

3

also more clearly link psychological flexibility processes to evolutionary principles. But for the most part, this book centers around gaining familiarity and practice with the flexibility processes targeted by ACT, and doing so in a way that is accessible. It is our hope that reading this book will empower clinicians to begin to apply ACT’s psychological flexibility model and methods in their practices. That is what is most unique about this volume. It is designed to go beyond the philosophy, theory, concepts, and verbal knowledge of techniques to the actual production of skills and competencies that target flexibility processes. Therefore, we have deliberately written it in an accessible style because our focus is on the practical. This workbook: Is about increasing clinicians’ ability help their clients live more rewarding, full, vital lives Is about helping clinicians attain sufficient knowledge and skill with the six flexibility processes so that they can begin to implement the therapy Is intended as a skill-­building companion for other ACT texts that provide much more detail about the theory, philosophy, data, metaphors, exercises, and application of ACT, and about its relevance to various client problems, such as anxiety, depression, chronic pain, and psychosis Is designed to help build clinicians’ skills in the core competencies associated with ACT’s therapeutic processes so they can be more effective, regardless of client presentation ACT is not a cookbook approach; it is an enormously flexible model that is built from the ground up with a focus on processes of change that empower people, rather than proffering rigid protocols for syndromes. We not only want to provide practitioners with a clear sense of how ACT is conducted, but would also like to convey the vitality this therapy can bring to human experience. We strongly encourage personal involvement with the book, including engaging in the practices we offer. We ask this for a number of reasons, most importantly so that you, as a therapist, can experience what it means to personally engage ACT, just as you will be asking your clients to do. People playing the role of therapist are not fundamentally different from people playing the role of client. As we will outline in this workbook, we human beings all tend to get stuck in the same traps. It is essential to learn about these traps from the inside out, through practice. For that reason, this therapy can be difficult to do if you are not applying the same approaches in your own life. Take, for example, your own personal experience with emotion: what do you do when confronted with what is most painful to you? If your answer includes efforts to eliminate or control your experience, we would ask, “To what end?” Perhaps for you, as for most people, that end is to feel “better.” However, if your answer is to experience the pain for what it is, learn from it, and live better by doing so, then you are ahead of the game in learning the ACT approach and more likely to be effective at it. Many therapies focus largely on helping people feel better. The hope is that, at the end of the therapy, the client will have fewer symptoms and will feel better emotionally. The focus in ACT is explicitly on living better. Although this may involve feeling better, it also may not, especially in the short term. Sometimes living better actually calls for feeling the pain. If doing so promotes connection, choice, and living with vitality, ACT tries to provide clients with the skills needed to feel pain without needless defense. The ultimate goal of ACT is to support clients in feeling and thinking what they directly feel and think already, while also helping them move in a chosen, personally valued direction.

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Learning ACT, 2d edition

How to Use This Book Learning ACT is designed to be used with other books and resources on ACT concepts and methods. We particularly recommend in the following: Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. This is the second edition of the original ACT book. No ACT clinician should fail to read it and keep it at hand. Eifert, G., & Forsyth, J. (2005). Acceptance and Commitment Therapy for Anxiety Disorders. Although this is nominally oriented toward a specific population, it is also a strong, generally useful ACT protocol that demonstrates how to mix flexibility processes into a brief therapy. It provides excellent advice on how to use ACT to guide exposure. Hayes, S. C., Smith, S. (2005). Get Out of Your Mind and Into Your Life. This is the first general-­ purpose ACT workbook. It can be useful for therapists new to ACT, helping them contact the work experientially. It can also readily be used as homework for clients. Harris, R. (2008). The Happiness Trap: How to Stop Struggling and Start Living. This is a generalpurpose, highly accessible ACT book that can also be used as homework for clients. Stoddard, J. A., & Afari, N. (2014). The Big Book of ACT Metaphors: A Practitioner’s Guide to Experimental Exercises and Metaphors in Acceptance and Commitment Therapy. This book provides easy access to hundreds of ACT metaphors and exercises, arranged by flexibility process for easy reference. Wilson, K. G. (with DuFrene, T.). (2008). Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy. This book focuses on bringing mindfulness, a key aspect of psychological flexibility, to therapeutic interactions, challenging therapists to forgo standardized approaches and instead flexibly tune in to the client and the therapeutic opportunities afforded by the present moment in session. Hayes, S. C. (2007). ACT in Action. A six-­DVD series with some of the best ACT therapists showing how to do ACT. It dovetails well with the videos for the present volume (the latter available to view at http://www.newharbinger.com/39492). Should you need an initial introduction to ACT, we especially recommend these two books: Harris, R. (2009). ACT Made Simple: An Easy-­to-­Read Primer on Acceptance and Commitment Therapy. Hayes, S. C., & Lillis, J. (2012). Acceptance and Commitment Therapy. In addition, there are scores of ACT books for specialized populations, both for therapists and for individuals. One of the authors of this book (JBL) maintains an updated list of ACT books and other resources in the e-­book Learning ACT Resource Guide (available for download at http://www.learning act.com). The Association for Contextual Behavioral Science (ACBS) is the main gateway to ACT

Introduction

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research, clinical and theoretical publications, online discussions, trainings, institutes, conferences, manuals, protocols, metaphors, and networking; ACBS also keeps a list of ACT and RFT relevant titles at https://contextualscience.org/acbs_amazon_store. Keep in mind that if you go to the ACBS website, you won’t be able to see most of the materials if you aren’t a member who is logged into the website. More information on the ACBS and other resources is available in appendix B.

Organization of This Book ACT is an evidence-­based intervention, but we want to be clear about what that means in a contextual behavioral science approach so you can understand the organization of the book. ACT is not a protocol or a set of techniques; rather, it is an approach to therapy that targets a small set of key flexibility processes. This process-­based approach is a feature that distinguishes ACT from the many forms of therapy that emphasize protocols over processes. The introduction and first chapter of this workbook provide an overview of the theory behind ACT and some tools to help you think about cases from an ACT perspective. Specifically, chapter 1 outlines the ways in which basic processes of learning and evolution science, combined with the problematic effects of language, lead to increased suffering for humans. The ACT theory of change is also outlined in chapter 1. Chapters 2 through 7 and chapter 9 cover the knowledge and practices necessary for ACT clinicians, with chapters 2 through 7 focusing on the six flexibility processes. Each of those chapters includes a description of basic metaphors, stories, and techniques used in connection with that process, as well as vignettes demonstrating those methods, and ends with a practical writing assignment in which you’re asked to apply the principles you’ve learned to various sample client scenarios. Each of these chapters also addresses when to use the methods discussed, indicators that work with that particular process, and how to address problems that commonly arise when targeting given processes, and includes at least one experiential exercise. The goal of these chapters is to help you get what each process is about. No particular ACT technique is foundational, so the goal of these chapters is to help you abstract how to manipulate the underlying flexibility processes through reading and practice. In chapters 2 through 7, each of the psychological flexibility processes targeted by ACT is presented largely as if it were separate. In actual sessions with clients, however, a single process is rarely the sole focus; rather, multiple processes are explored and worked on within each session. Chapter 8 focuses on how case conceptualization and treatment planning can help you begin the task of integrating the six processes into a coherent treatment and gives you an opportunity to apply the ACT model to practice cases. Chapter 9 shows you how to utilize the flexibility processes in the context of the therapy relationship, and chapter 10 offers guidance on flexibly working with cultural factors during interventions and case conceptualization. Finally, chapter 11 is designed to help you integrate your use of the various flexibility processes in sessions and to be flexible in doing so. And just as ACT attempts to build psychological flexibility in clients, we hope this workbook will increase your flexibility as a clinician in the application of ACT. To that end, chapter 11 provides various exercises to help you develop this flexibility. We’ve also included three appendices. Appendix A presents the ACT Core Competency Rating Form, which you can use to assess your abilities in delivering ACT. In the core competency practices in chapters 2 through 7 and 9, we ask you to demonstrate these competencies. It’s only in appendix A

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Learning ACT, 2d edition

that you can see all the competencies in one place, so you may wish to review that appendix before diving into the chapters. Appendix B offers information on additional resources for deepening your knowledge about ACT, and appendix C addresses adapting ACT to different intervention settings.

Online Resources Various resources related to the book are available for download at http://www.newharbinger. com/39492. There, you’ll find the ACT Core Competency Rating Form (appendix A); a document of FAQs answering some of the most common questions of therapists new to ACT; and audio recordings of several client exercises described in the book (we’ll provide a reminder about the downloadable recordings where those exercises appear). Another downloadable resource is the document “Learning ACT in Classrooms and Peer Groups and via Peer Supervision.” Regarding the latter, experience has shown us that it’s important for ACT therapists to have a community that supports them in their ACT work. Whether it’s a group of friends or colleagues, a virtual community accessed through the Internet, a temporary course, or a relationship with a supervisor or mentor, this social/verbal community is essential in keeping you on track as a clinician, particularly as an ACT clinician. Fortunately or unfortunately, many of the ways of speaking or thinking that are part of the repertoire of an effective ACT clinician are not common outside of this context. Many of the messages of mainstream Western culture are so dominant and automatic, particularly those fostering feel-­goodism (i.e., experiential control) and literal ways of interacting with thoughts, that without support from a social/verbal community versed in ACT, newer, less practiced repertoires of behaving and thinking based on ACT are less likely to be maintained over time. In addition, we highly recommend that you visit http://www.newharbinger.com/39492 to find videos that complement the book, with experienced ACT clinicians role-­playing examples of the core competencies, using trained actors to play the clients. We have created these examples to show both relatively skilled and relatively unskilled applications of the ACT methods and principles. Not all the competencies are covered in the videos, but with the exception of chapter 8 (case conceptualization), examples are provided for approaches presented in chapters 2 through 10. We recommend reading the corresponding chapter before watching its video. The videos offer models of exercises and techniques that go beyond what we can adequately demonstrate in written form. One good way to use them is to play each clip and then pause the playback before the narrator describes what was being done. Try to determine what fit or did not fit with the ACT model in the clip, and only then resume the video to hear the narrator debrief the interaction. This start-­and-­stop method is especially recommended for workshops or classroom use of this book.

Using the Practice Exercises in This Book Although reading about ACT techniques and skills is important, to become an effective ACT clinician it is even more important to practice these skills. Having extensive mental knowledge about a therapy can clearly set the stage for implementation. However, it is not only verbal knowledge that will guide you through the therapy; experiential knowledge is also key to understanding the ACT

Introduction

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approach and providing quality implementation. This book is structured to give you that experiential knowledge through engagement with exercises. Learning to use ACT is like learning to play the violin. You can read a book about how to hold the bow or how musical scales are structured. However, reading about playing does not make you a violinist. Practice is essential. Although reading (verbal knowledge) can teach you how to hold the bow, the exercises in this book are designed to help you begin to play the violin (experiential knowledge). In ACT, we ask clients to engage in the process of experiential learning and to be willing to experience all that comes along with that learning, including painful failures and mistakes. We ask them to do this with the goal of learning from their own experience in the service of living a rich and valued life. We would like to ask you to do the same by engaging fully with the exercises presented in this workbook. Many of the exercises require a written response. If you’re reading an electronic version of this book or simply prefer not to write in the book, or if you need more space for your responses to any of the exercises, feel free to use a notebook or a computer or other electronic device to record your answers. At the end of chapters 2 through 7 and 9, we’ve included a section titled Core Competency Practice, in which we provide practice exercises based on dialogues with clients. (Many of the cases presented in this book are amalgamations of actual clients but have been altered and combined so that no one, not even the clients themselves, could recognize the material.) These exercises give you the opportunity to formulate and practice responses to hypothetical clients prior to doing so with real clients. In the exercises, you are asked to generate your own responses before comparing them with the suggested ACT-­ consistent responses provided at the end of the chapter. Feedback from readers of the first edition of this book indicates that they were often tempted to jump directly to the sample responses, skipping the process of generating their own responses. This is definitely the easier path and one way to engage with this workbook. However, this strategy has a major downside: it negates what is most unique about this book—­the opportunity to actually practice ACT and get feedback on your responses. Here’s what some of our previous readers have said about how important it was to actually do the exercises versus just reading them: “Actually doing the exercises makes all the difference. Doing them allowed me to test what I had learned in the chapter, and it was very useful to do them and then compare my responses to the answers.” “I enjoyed the core competency exercises, as they really made me think about my responses. They helped me integrate the material I’d just read in the chapter.” “I appreciated the core competency exercises. They nudged me to really think through how I would respond to very realistic situations.” Only you can decide whether learning ACT is worth the time and effort. If you decide that the answer is yes, we suggest that you give yourself the space to generate responses to the exercises, even if your mind thinks those responses will be wrong or of low quality. One thing that can help with sustaining motivation to do these practices is to reflect on what larger purpose this might serve. We suggest you take a minute or so to reflect on that right now. In fact, we’ll use that invitation to offer you an initial exercise.

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Learning ACT, 2d edition

Exercise:

Identifying Your Values in Working with This Book What honest, sincere, and heartfelt purpose would you have your engagement with this book serve? What larger patterns do you hope to feed by completing this workbook? For me, completing this workbook is in the service of     

BRINGING SELF-­COMPASSION TO THE LEARNING PROCESS There’s a saying we like in relation to learning something new: “If something is worth doing, it’s worth doing poorly at first.” Learning something new generally means that our performance will be poor; otherwise, it’s not really new. Doing the exercises in this workbook rather than simply reading them is not the easy way. You will make mistakes—­perhaps many mistakes. However, mistakes are our teachers. And even though mistakes are an inevitable part of learning, it’s often the case that the mind will beat us up for making mistakes or for our perceived lack of knowledge, even though this makes it harder to learn. Because this is an all-­too-­common thing for minds to do, it’s important to be able to find ways to respond to ourselves in a supportive and kind way when we’re learning. In line with this aim, we ask that you reflect for a bit on the kind of relationship you’d like to have with yourself as you complete the exercises in this workbook. So, once again, we’ll use that invitation as a context for you to begin engaging with the exercises in this book.

Exercise:

Envisioning Self-­Compassion If you were to be a caring friend to yourself as you practice, what qualities would you hope to have in your relationship with yourself? This isn’t about how you usually are with yourself around mistakes; it’s about your intentions. How do you want to treat yourself while you’re learning? In the following space, list the qualities you’d like to bring to yourself as you work with this book.

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As I make mistakes and struggle with learning, I would want to have a relationship with myself that is characterized by these qualities:     Here’s one thing I can do when I notice my mind getting down on me during these exercises:  

GETTING EXPERIENTIAL In addition to the core competency exercises, each chapter includes experiential exercises. By “experiential,” we mean that their purpose is to help you find the ACT space, stance, or psychological posture from which you as an ACT clinician are likely to be most effective. The nature of these exercises is both personal and deeply connected to the nature of the therapy. While we don’t recommend that you skip these exercises, it’s okay if you do. You are the expert on your own experience and what will help you achieve your valued goals. However, if you choose not to do them during your initial reading of the book, we suggest you come back and complete them later so you can extract the full value of this volume.

Beginning to Use ACT We have several recommendations about beginning to use an ACT approach to therapy, set forth in the following sections.

Consulting Other Texts to Round Out Your Understanding of ACT Before you begin using ACT with clients, we recommend that you have a good sense of the entire ACT model. This includes knowing a variety of core metaphors and exercises you can use and having a working understanding of the basic theory. While this book provides a good overview of the theory,

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Learning ACT, 2d edition

it does not provide many of the core metaphors you need or exercises you will want to use. Thus, you will need at least one other ACT book to supplement this volume and give you more specific instructions about how to sequence interventions and introduce the different processes, and to give you access to a range of metaphors and exercises. In short, this book is not meant to provide a comprehensive introduction to ACT; rather, it’s a practice guide that will allow you to apply the tools you gain during your learning process to all of the in-­between moments that aren’t specific to particular exercises or metaphors. Good books to consider for an introductory text that will give you more step-­by-­step instructions for using ACT with your clients include the second edition of the original ACT book, Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (Hayes et al., 2012), or ACT Made Simple (Harris, 2009). We usually recommend the original ACT book, as it is the most comprehensive. However, if you would prefer a simpler introduction and step-­by-­step guide that focuses on tools, tricks, and techniques and is lighter on theory, ACT Made Simple is an excellent alternative. If you have a strong background in more traditional CBT methods and are branching out into ACT, A CBT Practitioner’s Guide to ACT (Ciarrochi & Bailey, 2008) is another good starting place. To be clear, we don’t recommend Learning ACT as the first book you read on ACT. Instead, it is an excellent second book that will allow you to apply knowledge gained from more comprehensive books, like those suggested above. Then you can begin to branch out, delving into more specific ACT literature. There are now ACT books for most major categories of problems (e.g., eating disorders, anxiety, chronic pain, substance use, depression), as well as applications to particular professions (e.g., social work or pastoral counseling), settings (e.g., primary care), or types of practice (e.g., groups or couples).

Bringing Flexibility to the Process and Connecting with the ACT Community Second, we recommend allowing time for a period of growth with the theory and therapy. Although, as mentioned, the flexibility processes are initially presented in this book as if they were separate, they are actually interdependent. Lacking a basic understanding of one process could lead to difficulties in implementing other processes, as well as confusion and dead ends in therapy. In addition, without an overall understanding of the approach, therapists can easily introduce inconsistencies that might undermine the overall thrust of the intervention. It takes time to learn this complex and comprehensive model. We encourage you to be compassionate with yourself as you practice, and to give yourself time to reread sections on relevant concepts and approaches as you try to apply them. Also, be forewarned that you may experience some disruptions in your practice when you begin to use these approaches, particularly if you’ve been operating from control-­based theories of intervention. It is not at all uncommon for practitioners who are drawn to this work to initially feel awkward, confused, and anxious as they begin to apply ACT. A dissertation by Douglas Long (2015) examined the use of the videos in the first edition of this book and found that clinicians being able to detect competent ACT was predicted by workshop training, knowledge about ACT, reading books about ACT, supervision in ACT, and membership in the group most responsible for the continuing development of ACT, the Association for Contextual

Introduction

11

Behavioral Science. Competency improvement following training was also predicted by therapists’ psychological flexibility. These findings make perfect sense. To be good at ACT, you need to put in some effort, give yourself time, work on your own flexibility processes, and come into community with others on the same journey. Fortunately, we also know that feeling confident isn’t necessary for ACT competence. An effectiveness study done a few years ago with beginning therapists showed that, compared with traditional cognitive behavioral therapy, doing ACT tended to produce more anxiety in these therapists, who were new to ACT—­and also led to significantly better clinical outcomes in patients (Lappalainen et al., 2007). Based on these kinds of findings, we recommend that you try to make room for whatever discomfort you may experience as you learn to implement ACT. To that end, you may find ACT self-­help books helpful, allowing you to apply ACT to your discomfort in learning it. We now know that applying ACT to oneself as a therapist has broad benefits. It decreases the stress and burnout that can come from being a therapist or therapist in training (e.g., Brinkborg, Michanek, Hesser, & Berglund, 2011; Frögéli, Djordjevic, Rudman, Livheim, & Gustavsson, 2016) and helps therapists apply evidence-­based therapy methods even when doing so is psychologically difficult (Varra, Hayes, Roget, & Fisher, 2008; Scherr, Herbert, & Forman, 2015). Time and effort, combined with openness, will produce a greater sense of wholeness and empowerment. However, be aware that there is a sense of vulnerability when doing ACT that never completely disappears. ACT asks the clinician to stand with the client as another human being in a horizontal relationship, without needless defense. This brings great richness to the process, along with a rawness that can’t be avoided without undoing the work itself.

Incorporating ACT into Your Practice We recommend two basic ways of beginning to incorporate ACT into your practice. One is to start by implementing ACT based on one of the standardized manuals available. Many are listed under “Therapist Guides” in the e-­book Learning ACT Resource Guide (available for download at http://www. learningact.com); you’ll also find a list of many therapist manuals for specific client presentations on the ACBS website https://contextualscience.org/treatment_protocols. Ideally, you would follow the manual from beginning to end with a client who presents with problems matching the specific treatment discussed in that manual. This has the advantage of pushing you into corners of the work where you may still feel awkward. We also recommend the fairly common approach of first using ACT with a client with whom you find yourself struggling. If this client is difficult, which is often the case, this may seem like a counterintuitive place to begin; however, because your old repertoire has already been failing in an important way, if you continue with the same approaches you’ve been using, you’ll probably continue to find yourself in the same place as the client: stuck. Giving ACT a try can allow you to see whether something new can happen and free up the therapy process. After you’ve followed a detailed ACT protocol with a few clients, we suggest that you put the protocol aside and move to tracking and targeting flexibility processes based on clients’ needs and your case conceptualizations. This book will be especially helpful to you in continuing to develop your skills during this phase.

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Finally, we encourage you to attend an experiential ACT workshop. This is truly one of the best ways to learn the ACT approach. ACT is centered on living fully with all experience—­both negative and positive—­and on the freedom and richness that purposeful living can bring. Attending a workshop can help create these dynamics in your life, both in your personal way of being in the world and in your work with clients. It can also provide intuitive guidance about the function of flexibility processes, not just the form of these processes. ACT trainings and workshops are listed at http://www.contextual science.org.

CBS and the Research Context Surrounding ACT ACT is based on a now enormous body of scholarly and research work in the fields of philosophy of science, basic psychology, psychopathology, evolution science, and clinical intervention. As we were writing this second edition of Learning ACT, there had been almost two hundred randomized trials on ACT (for a partial list, minus some of those available only in non-­English languages, see http://contextualscience.org/ACT_Randomized_Controlled_Trials). These studies have looked at almost every conceivable area of mental health, behavioral health, and social functioning. About 83 percent of that literature is less than five years old, and over the last few years, a new randomized trial has been published every ten to eleven days, on average. Across all areas of CBS relevant to ACT and its foundations, there are nearly two thousand articles currently available. In this book, we deliberately use relatively informal language because our purpose is intensely practical and focused on skills. As your skills in ACT grow, however, you may find that exploring the broader body of research deepens your understanding. Practitioners who attend their first ACBS conference are often surprised to find workshops and sessions on RFT, behavioral principles, evolutionary extensions, and a contextualistic philosophy of science. Perhaps even more surprising, after gaining some experience clinicians themselves begin to demand such sessions and are often enthusiastic about their practical usefulness. In this book, we use clinical and commonsense terms, generally without stopping to link them to basic principles. For example, we speak easily of “mind” without delving into the work done in RFT labs to identify the component behavioral skills involved in this commonsense domain. If you’re interested in learning more about these aspects of ACT, you can start by reading more of the CBS literature. If you connect deeply to the work, you will eventually learn that ACT is part of an attempt to restructure psychology and, indeed, behavioral science itself. Although at this point you are probably concerned with immediate practical purposes, this book will help you learn enough about ACT to care about that larger context. Most importantly, we hope that reading—­or perhaps the better word would be “doing”—­this book will help you learn enough about ACT to begin to use these methods with clients who can benefit from them.

CHAPTER 1

The Focus of ACT and Its Six Aspects

If you always do what you’ve always done, you’ll always get what you’ve always got. —­Moms Mabley

From an ACT perspective, the core of psychopathology and human unhappiness is inflexibility. Stated in that way, it may not appear to be much of an insight. Seventy years ago, the concept of the neurotic paradox referred to mental health problems as a form of inflexibility: the odd inability of people struggling with psychopathology to do something different even when what they were doing led to very poor outcomes (Mowrer, 1947). Evolutionary theory tells us the same thing: systems evolve only when there is enough functional variation for successful adjustments to be selected and retained. Moms Mabley was right: inflexibility is the enemy of improvement. What’s unique about ACT is the content, precision, and scope of its analysis of why inflexibility occurs and what to do about it. From an ACT perspective, the blessing and the curse of human existence is language. Normal processes of human language tend to draw people into psychopathology, and only by learning new ways of relating to verbal events can people find a more healthy balance. In this chapter, we present an overview of the model upon which ACT is based, within which language plays a central role in how human beings get stuck. We’ve attempted to find a balance between being comprehensive and being accessible. Nevertheless, some readers of the first edition have told us that parts of this this chapter initially seemed too technical. If this is the case for you, be assured that the material in this chapter will be unpacked in the rest of the book, usually in a more complete and accessible way. So if you find yourself unable to understand certain passages at this stage, that’s okay. Just forge ahead and consider returning to those sections again after you’ve read the rest of the book, when you’ll be likely to understand them more fully. In particular, this first section is probably the most technical of the whole book, so feel free to skip ahead to the next heading if you find yourself lost. There is no doubt that language is a blessing. Imagine you went to sleep and woke up in a totally unfamiliar room with all of the exits locked. What would you do?

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You would almost certainly wonder how you got there and would soon turn to the task of getting out. As your mind clicked through various possible solutions, you would weigh the pros and cons. You might consider using your cell phone to call for help, but you might also worry that whomever put you in that room might listen in. You might think of kicking down the door, calling out, or breaking a window and jumping to the ground, but perhaps you’d worry that your captor would punish you if you did so. Using only thought, you could consider the risks associated with each of these plans. For example, What if the door is too sturdy to be kicked in? or If they hear me breaking out, what will happen to me? Using only your verbal and symbolic skills, you would be able to formulate a plan that might succeed. This example contains all the elements humans require to respond to the external world using their verbal and cognitive skills: A complex situation is broken down into its components and features. The past and future are considered and related to the present. Those components and features set the occasion for imagined actions, predictions, and evaluations, and a plan is chosen based on likely outcomes. Such a process of verbal problem solving offers a huge evolutionary advantage and has allowed human beings to take over the planet even though we are weak, slow, and poorly defended. Our powerful verbal abilities, however, can easily bestow a huge disadvantage. Suppose that, instead of being trapped in an unfamiliar room, you woke up one morning trapped in a feeling of intense anxiety or impending doom. You’d be likely to ruminate over how you got into that situation. And again, you’d probably soon set yourself to the task of trying to find a way out. The same problem-­solving abilities brought to bear on the physical environment in the first example would be turned to the psychological environment to generate solutions (e.g., take a tranquilizer, suppress the anxiety, engage in self-­injury) and possible outcomes, such as escaping from the feelings. All of this is extremely logical, but that doesn’t mean it’s extremely useful. The same things that work well in the external world can easily create harm when turned toward the internal world. If we don’t like peeling paint, we can scrape the wall and put on a fresh coat. But conversely, if we don’t like thinking of a past trauma and try to “scrape it away,” we may make it more central, salient, and influential. If we fear a future drought, we might save water to quench our future thirst. But if we fear future rejection and try to make sure no one will ever hurt us in that way again, we may limit our connections with others or avoid making commitments, thus amplifying the role of rejection in our lives. It’s quite possible to get out of a locked room and leave it behind. In contrast, the very attempt to escape from a difficult emotion may exacerbate it (Chawla & Ostafin, 2007; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). And, of course, we can never leave our history behind. Verbal problem solving isn’t good for everything. However, it is good for so many things that it’s hard to know when—­and how—­to use it only when it is useful to do so. Human language is a double-­ edged sword. All of the main processes that ACT targets flow from this insight, and from the basic research that led to it. ACT is based on basic behavioral and evolutionary principles and their expansion into human language and cognition, as explained by relational frame theory. RFT is a contextual behavioral approach to human language and cognition with broad empirical support (for a review, see Dymond & Roche, 2013). A short ditty summarizes RFT in four brief lines (Hayes, 2016): Learn it in one, derive it in two, put it in networks that change what you do.

The Focus of ACT and Its Six Aspects 

15

For example, even a normal human infant, after learning that an apple is called “apple,” will know to look for apples when hearing the word “apple.” In this case, the trained relation of seeing an apple and hearing “apple” has led to a relation that was not directly trained (at least not with this set of objects and names): hearing “apple” and looking for an apple. The relation is now mutual: the infant learned it in one direction and derived it in the other direction. Said in a more normal way, the infant has a name for an object. This simple act of creating names is where human language likely started, and it probably started in the tribe, not the individual (Hayes & Sanford, 2014). Humans are by far the most cooperative primates. The most credible reason for our cooperation appears to be multilevel selection (Nowak, Tarnita, & Wilson, 2010; D. S. Wilson, 2015), in which cooperation is selected for because it gives an advantage to competing bands or tribes, provided that individual selfishness is dampened down. Whatever the reason, our level of cooperation compared to that of other primates is extraordinary and ancient, and the ability to ask for resources using verbal names (such as calling for apples to a tribe member across a ravine) rapidly extended human cooperation and gave rise to a receptive verbal community primed for the next step: putting verbal relations into networks. Even young children know to put mutual verbal relations into networks. After learning that an “apple” is also a “jabuka” (as it is in Croatia), a normal listener will know that a “jabuka” is an apple and will be able to imagine what it tastes like to drink jabuka juice. That’s the essence of the meaning of “put it in networks that change what you do.” As this this type of verbal behavior moved from the tribal level to internalization by individuals, the structure of human symbolic thought was established. The properties of derived relations between events are arbitrarily applicable in the sense that they can occur with any set of related events regardless of their form as long as the right cues are present. Here’s an example to illustrate this concept: Before language abilities are strong, small children tend to prefer a nickel over a dime because the nickel is bigger, and they may cry when given a dime instead of a nickel. However, a more verbally mature child will prefer a dime over a nickel because the dime is purportedly “bigger” and may cry when given a nickel instead of a dime, even if the child has never actually used a dime to acquire goods. Thus, the functions of the coins (the related events in this example) are based solely on social whim or convention, which arbitrarily declares that a nickel is smaller than a dime. The flexibility of humans’ relational skills allows us to go beyond the nonarbitrary relations that exist in the physical world, but we do this so seamlessly that the world itself becomes thoroughly entangled in our symbolic verbal actions. If we say “Skinny is better than fat,” the “better than” relational cue in this statement looks very similar to the phrase “bigger than” in the statement “The elephant is bigger than the mouse.” Yet it is actually quite different because the relation of size in the second sentence is based on the formal properties of elephants and mice, whereas the relation of “better than” is based only on the history of the speaker, not on fat and skinny per se. The relation seems to be in the related events themselves, rather than in the arbitrary history of social training, and that illusion can hide potential response options. As these abilities grow stronger, we create vast relational networks and increasingly live in a world in which functions are verbally acquired, not based on direct experience. This can trap us into culturally and socially derived modes of living and relating that aren’t chosen and that may not always be workable. In this way, language works behind the scenes to structure our world, and it does this so seamlessly that the source of that structuring is usually invisible.

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ACT works to reveal the illusion of language produced by the mind, like Toto in The Wizard of Oz, pulling aside the curtain and causing Oz to thunder, “Pay no attention to that man behind the curtain!” From the perspective of RFT, the mind is not a thing at all; it’s just a collection of relational abilities. And although the ability to relate events—­for example, by thinking, planning, judging, evaluating, or remembering—­has both a light and a dark side, the process is remarkably similar on both sides. The differences lie in the context and the targeted domain. Literal language and cognition are tools, but they are not fitting tools for all purposes. RFT has led to the development of methods that have been shown to improve language abilities and intellectual performance (Dymond & Roche, 2013), but it is of equal importance in learning to rein in the excesses of language. RFT suggests not just how language and higher cognition develop and why they are a help and a hindrance, but also how to rein in these abilities so we can use them and not be used by them. The answer lies in the last line of the RFT ditty: we need to change what they do. Evolutionary theory gives us clear guidance about when we need to change what we do. We need keep track of only six things to unpack the challenge of intentional change: variation, context, selection, retention, level of organization, and dimension. (For a more extended discussion see D. S. Wilson, Hayes, Biglan, & Embry, 2015.) Intentional change requires variation in actions, and requires that successful variations in a given context be selected and retained. Selection has to be considered in terms of its level of organization. (For example, the growth of a cancer cell can be successful for the cell but not for the organism, and the success of an action can be fine for an individual but harmful for a couple.) Selection must also be considered in terms of the dimension that is selected, whether it is an emotion, thought, action, physiological state, gene, epigene, or so on. A multidimensional view requires that we consider a broad range of topics to determine whether we’re making progress; for example, experiencing success in work performance could come at the cost of a person’s need for sleep. These six features of evolution suggest that symbolic relations (and indeed, all psychological events) should be thought of as interfering with deliberate change when they needlessly restrict healthy variation, when they undermine contact with the current context, when they interfere with the selection of positive actions in the proper dimension or at the right level of organization, or when they interfere with the ability to retain gains. At the end of this chapter, after presenting the ACT model, we will return to those six features of deliberate change from within evolutionary theory and examine how the ACT model rises to the challenges they present.

The ACT Model of Psychopathology: Six Inflexibility Processes RFT concepts provide a foundation for the core processes that are thought to lead to human suffering from an ACT point of view. In essence, the problem is that literal language leads to increases in the pervasiveness of pain, which is further exacerbated by the tendency to overextend a problem-­solving mode of thinking as a way to get rid of that pain. Literal language processes encourage us to try to escape or avoid our feelings, lead us to become entangled in our thinking, cause us to lose flexible contact with the present moment, and tempt us into believing and defending our own stories about

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ourselves and others. Said in evolutionary terms, the overextension of language reduces healthy functional variation and also reduces our ability to respond adaptively to our internal and external environments. Meanwhile, what we really want to do is put on hold or drifts to the background, while creating patterns of action linked to chosen values becomes more difficult. In short, an overextension of human language leads to rigid, psychologically inflexible ways of living. From an ACT and RFT point of view, all of these dynamics together make up psychological inflexibility: a collection of processes that produce or exacerbate human suffering. Psychological inflexibility is the target of ACT, and establishing greater psychological flexibility is the immediate purpose of ACT. In the sections that follow, we turn to a more detailed examination of these processes. They are distilled into six aspects of a single focus, and can be combined into three vertical pillars that closely reflect the evolutionary basis of the ACT model. The overall ACT model of psychopathology can be illustrated in the form of a hexagon (figure 1), with each point on the hexagon corresponding to one of the six processes hypothesized to contribute to or cause many instances of human suffering and psychopathology. At the center of this diagram is psychological inflexibility, which refers to the combination and interactions of all these processes. Although ACT acknowledges that specific pathological processes may be associated with particular disorders and problem areas, it also holds that these inflexibility processes cut across traditional boundaries in psychopathology (and therefore may often play a role in comorbidity), and that they also apply to behavioral health and social functioning. Inflexible attention

Lack of contact with chosen values

Experiential avoidance

Psychological Inflexibility

Cognitive fusion

Inaction, impulsivity, or avoidant persistance Attachment to the conceptualized self (self-as-content)

Figure 1. The hexagon model of psychological inflexibility.

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Experiential Avoidance Experiential avoidance refers to attempts to control or alter the form, frequency, or situational sensitivity of internal experiences (i.e., thoughts, feelings, sensations, or memories), even when doing so causes behavioral harm (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). From an ACT and RFT point of view, experiential avoidance emerges naturally from our abilities to evaluate, predict, and avoid events. In other words, it is fed by an entanglement with the problem-­solving uses of language and cognition. As alluded to earlier, language is useful in the external and social world, in part because external events can be predicted, evaluated, and avoided. And nothing prevents these language skills from extending from the external world to the world within. There is essentially no difference between the cognitive processes involved in escaping a locked room and those used to escape feelings of anxiety, or between the cognitive processes used to predict an absence of food and those used to predict a panic attack. Our predictive and evaluative abilities lead us to sort emotions, thoughts, bodily sensations, and memories into positive and negative categories, and then to generate verbal rules that allow us to seek or avoid these experiences on this evaluative basis. Yet, as previously mentioned, direct attempts to avoid or alter experiences can have unfortunate and paradoxical effects in certain contexts. Let’s look at the process of avoiding a negative thought. Suppose someone feels that it is extremely important to not think of something in particular. Deliberate attempts to control the emergence of this thought will involve a verbal rule: Do not think X. However, no matter what X may be, specifying X tends to evoke X; for example, not thinking of a lake evokes thoughts of a lake, or not thinking of a baby evokes thoughts of a baby. This happens simply because these verbal events are related to the actual events and because some of the properties of the actual events transfer to the verbal event (e.g., when you hear the word “baby,” you might see an image of a baby in your mind). The same thing tends to occur with emotions. Part of this is due to a verbal rule similar to the one just discussed: Do not feel Y. Thus, trying to control anxiety involves thinking of anxiety, which tends to evoke anxiety. The verbal reasons that motivate these control efforts also have an impact. Usually, anxiety is considered to be something to avoid because of a long list of undesirable consequences. You may think, I’ll make a fool of myself, I’ll go crazy, I’ll have a heart attack, or I won’t not be able to function. But the natural emotional response to such imagined consequences includes—­you guessed it—­anxiety. For these reasons and several others, experiential avoidance tends to be both unhelpful and self-­ amplifying over the long term, although not necessarily over the short term. A person who handles anxiety by drinking may get away with it for years; a person who avoids fearful situations by turning down social invitations may feel relieved in the moment and only gradually notice that his life has become constricted. Furthermore, some experiential avoidance seems to feed and be fed by cultural processes. A person who seeks to avoid fear of rejection by buying fashionable clothes is seemingly supporting the culture and its economic engines. Perhaps for similar reasons, experiential avoidance is often amplified by the social or cultural community in order to sell products or control people’s behavior. The idea that healthy humans don’t have psychological pain (e.g., stress, depression, memories of trauma) can be used by economic interests to specify actions that that must be taken to avoid such negative private events—­actions that produce gain for those propagating the rule. Avoidant solutions, such as mindless consumerism or the use of alcohol, are often modeled in television shows and commercials. The general feel-­goodism in Western culture sells. Not only should we feel good; we’re entitled to feel good!

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Sadly, it seems that a goal of getting rid of difficult feelings is often at the very heart of the mental health model. The very names of our disorders and treatments reveal this connection (e.g., mood disorders, anxiety disorders). We diagnose disorders based on the presence of particular configurations of private events and experiences. For example, self-­critical thoughts, suicidal thoughts, and feelings of fatigue are part of depression. Then we construct treatments designed to eliminate these symptoms, ostensibly with the goal of returning the person to good health. Unfortunately, all of this has the risk of feeding the message of feel-­goodism. Perhaps as a reflection of this cultural convention, one in four women over forty in the United States takes antidepressants, an astounding number given the state of the science for these medications, which suggests that their benefits generally only outweigh their risks for very severe depression (Pratt, Brody, & Gu, 2011).

Cognitive Fusion In general terms, cognitive fusion refers to the tendency of human beings to get so caught up in the content of what they’re thinking that it predominates over other useful sources of behavioral regulation. By “thinking” we mean anything that is symbolic or relational in the sense used in RFT (see above); this includes, for example, words, gestures, thoughts, signs, images, and some properties of emotions. The word “fuse” comes from a Latin root that means “to pour.” Metaphorically, it is as if the content of cognition and the world about which we are thinking are poured together until they are one, in much the same way that lemons, water, and sugar can together become lemonade. But when thinking and the world about which we are thinking are treated as one thing, thinking habits can dictate how we react to the world, and we can fail to see that the structure being imposed on the world by thought is an active process—­that it’s something we do. It has long been known that behavior controlled by verbal rules is often rigid and inflexible (see Hayes, 1989, for a book-­length review). Most forms of psychological intervention take this into account by trying to change the verbal rules (i.e., changing the thoughts). Unfortunately, that can fail to address the core of the problem. It is not so much that an incorrect rule is being used, but that a verbally interpreted event tends to conflate the event and the interpretation of the event, overlooking the ongoing process of thinking itself. From an ACT and RFT point of view, it isn’t what we think that is most troublesome; it’s how we relate to what we think. Imagine that thoughts are like a pair of sunglasses you’ve forgotten you’re wearing. They color your view of the world, and you’re unaware it’s being altered. The trouble with this is that thoughts are then free to present you with a world structured through thought—­a world seen through colored lenses. You aren’t dealing with the world as it is directly experienced, and you’re missing that you’re “languaging” about it. For example, when people with obsessive-­compulsive disorder (OCD) think, If I don’t wash my hands, my family will be contaminated, they can become so focused on the world colored by that thought that they seemingly aren’t interacting with a thought at all. They’re dealing with contamination and its consequences (e.g., that their family will die), not with a thought. All languaging occurs in a context, and language and cognition only have particular functions within particular contexts. Symbolic thinking is broadly useful to human problem solving and to our success in adapting to our environment; however, cultural evolution has vastly overextended the contexts that give language its automatic functions. Of course, for most practical purposes, it’s useful to

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treat words as if they are what they say they are. When you think of walking on the beach, it usually doesn’t do any harm to experience reactions that are like those you’d experience on an actual walk on the beach, albeit in a less vivid form. You may see the water in your mind’s eye and feel the breeze on your skin. So, in part due to social training, we typically see the world from the vantage point of thoughts, rather than observing thoughts directly. This is fine for activities such as doing your taxes, repairing a car, or planting crops. However, it often isn’t as helpful for things like appreciating a sunset or figuring out how to achieve peace of mind. Think back to the earlier example of trying to figure out how to escape from a room. If you really became engaged in the task, you probably weren’t aware of what you were physically doing at the moment. You probably didn’t particularly notice your feet, the chair in which you sat, or the size and shapes of the words in this book. Your attentional focus narrowed to planning your escape. This is what happens with cognitive fusion. Verbal/cognitive constructions substitute for direct contact with events. We forget that we’re interacting with thoughts, rather than with the real thing. The past can present itself as if it’s occurring now even though it’s dead and gone. The future can become present here and now even though it’s there and then. The present moment is lost to the mind’s focus on the past and the future. We are constantly interacting with the world as we organize it cognitively—­without noticing that we’re constantly organizing it. When a depressed client imagines how she could fall apart because of the stress of another day at work, she is seemingly dealing with the problem of literally falling apart, just as, earlier, you were seemingly dealing with the problem of a locked room. If the literal functions of that thought dominate over all other possible functions, the issue may become how to avoid falling apart, rather than any of a thousand other possible responses or situational issues. Psychological and behavioral flexibility are lost. This might result in oversleeping, withdrawing from challenges or colleagues at work, or simply not going to work—­all typical behaviors in what we call “depression.” The danger is that when people fuse with verbal content, that content can have almost total dominance over their behavior, limiting other possible sources of influence, such as the therapist, new but still weak verbal repertoires, or direct contingencies in the environment. The overextension of language has several important contextual sources. Initially, language begins within a context of literality, which is the social/verbal context that establishes certain sounds we hear (the spoken word “lemon”) and certain pictures we see (an image of a lemon) as words or thoughts with meaning. The social community expands this repertoire in many ways. For example, most children are exposed to early demands to justify and explain their actions. This helps give the social/verbal community access to children’s reasoning skills and helps keep children’s actions within the bounds of what can be verbally justified within a cultural community. As an outgrowth of this, both children and adults are expected to have reasons to justify and explain their actions. These often take the form of verbal statements of cause and effect, such “I stayed in bed because I was depressed.” Unfortunately, this context of literality tends to support the idea that reasons are literal causes. For example, we think depression caused staying in bed. After all, this notion of a literal cause is what answers to “why” questions seem to address. In effect, verbally constructed “why” answers are considered to be true simply because the verbal community treats them that way. Eventually, reasons that begin as explanations for behavior come to exert control over our behavior because of this social context of reason giving. Our lives become entangled with an ever-­larger network of verbal formulations as we analyze and categorize every aspect of our lives.

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In addition, many answers to “why” questions point to private experiences people can’t control. For example, people may say they missed a meeting “because I forgot” or avoid tasks “because I’m afraid.” Such formulations are rarely challenged. It’s almost rude to ask, “Why did you forget?” or “Why didn’t you just feel the fear and still do it?” even though these questions are entirely relevant. Along the way, the context of reason giving quickly expands into a context of experiential control. The logical next step is to try to remove troublesome private experiences in order to gain more behavioral control by, for instance, getting rid of forgetting and being afraid. The dominant Western culture teaches us that private experiences need to be controlled. For example, think of the father who tells his son, “Don’t be afraid. Only babies are afraid.” In this way, cognitive fusion is enmeshed with culturally supported messages about the causal effect of private events, their dangerous nature, the need to control them, and our supposed ability to do so. For example, a person who thinks, I’ll fall apart, will believe that this thought is part of the process of literally falling apart—­thoughts are causes. We are taught such things as “Anxiety is bad,” as if feelings themselves were dangerous. As youngsters, we’re told “Stop crying or I’ll give you something to cry about,” as if controlling our emotions were a reasonable and obvious solution. It would be interesting if, as children, we could respond and show the impossibility of the command by saying something like “Stop being bothered by my crying, or I’ll give you something to be bothered about.” The point is, the kinds of cultural messages discussed here only serve to give our thoughts even more excessive influence and dominance over our actions.

Inflexible Attention We live our lives inside the present moment for a simple reason: there is nowhere else for life to happen. Despite that fact, fusion and avoidance tend to heighten attention to the conceptualized past and future in the form of rumination and worry, respectively. This is problematic, reducing our capacity for ongoing, flexible awareness of what the external environment affords, and thereby decreasing our knowledge about what we’re feeling, thinking, sensing, and remembering in the moment. This makes us less sensitive to the possibilities inherent in our environment and can manifest in problems such as alexithymia—­an inability to know what we are feeling or sensing. When the conceptualized past or future dominates over present-­moment awareness, behavior tends to be controlled by conditioned thoughts and reactions, resulting in more of the same behavior that occurred in the past. New possibilities are foreclosed. Daydreaming takes the place of effective action. Dissecting every minor hurt stands in the way of intimacy and connection in the moment. Attention becomes more rigid and programmed, further reducing healthy variation of behavior.

Attachment to Conceptualized Selves and Conceptualized Others Probably nothing is as great a focus of verbal processes as oneself. From an early age, children are asked many questions about themselves, such as how old they are, what they like, what they want to be when they grow up, and what they enjoy in school. Children are harassed into answering “why”

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questions as if the answers were already available and only shyness or reluctance prevented them from providing full and revealing answers. In fact, children have little to say at first about such things. “Why” questions are often met honestly with the answer “Just because,” and other complicated queries about self-­knowledge may elicit an equally honest “I don’t know.” Eventually, however, children learn to tell coherent stories to explain their behavior that are acceptable to others. The past is formulated and described. The future is predicted and evaluated. Within this storytelling process is a conceptualized self, or self-­as-­content: the individual and her attributes are described and analyzed. Because children quickly learn that changing stories without good cause is frowned upon, the stories become more stable over time. The conceptualized self creates stability in behavior, for good and ill. By the time a client comes in for therapy, this process has woven a spiderweb of categories, interpretations, evaluations, and expectations regarding the self. Often these “ego-­based” stories about oneself become events to be defended, making change even harder to produce. We all have stories to tell about what we’ve done and what we like, about why we have problems and what would function as solutions, and about how we are and how we differ from others. Typically, these stories have some truth to them. The problem is that the truth about which we are speaking is not necessarily useful or helpful; rather, it’s a truth that can be justified because it reflects correspondence between the verbal formulations and the supposedly objective facts of the matter. In other words, these stories are considered true because they’re “right,” not necessarily because they’re helpful in living. Consider a client who comes in saying something like “I am an agoraphobic. I’ve been this way for twelve years, ever since my husband beat me and then abandoned me with my then two-­year-­old child. My parents tried to help, but they were so critical that it only made it worse. Ever since, I’ve had terrible anxiety. I can’t function as a result of it, and I’m too fearful to handle it. I think about anxiety all the time.” All of these events could be 100 percent true, but what is more important is that the person has fused with a self-­focused story and is trying to solve problems within that story. Instead of being a flexible, complex human being, the person has become a self-­created cartoon: “I am an agoraphobic.” Instead of saying something like “I feel fear,” it’s as though she’s saying “I am a diagnostic category.” In the statement “I am too fearful,” the word “too” implies that “who I am” is somehow illegitimate. The problem is that real solutions may not exist within this story, and yet the story is so well supported that all possible ways out of it would be experienced as invalidating. The conceptualized self has become narrow and cage-­like, and inflexible patterns of behavior are the unavoidable result. We construct stories not only about ourselves, but also about others. Just as we can get entangled with a conceptualized self, we can become entangled with conceptualized others. We can become so caught up in our stories, evaluations, and judgments of others that we are unable to respond flexibly to them or accurately empathize with their experience. This process is at the core of objectification, dehumanization, and prejudice; indeed, fusion with inaccurate stories about other’s intentions, feelings, and thoughts is often a large contributor to interpersonal difficulties. At a basic level, these stories about self and others interfere with our ability to form cooperative and caring relationships.

Lack of Contact with Values or Lack of Clarity About Values Values are chosen qualities of being and doing that are reflected in ongoing patterns of behavior. Ultimately, values are about living in a chosen and meaningful way; they are compass headings we can

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use to guide our lives. Freely chosen values generally are not to be evaluated; rather, they serve as the standard by which other things can be evaluated. Valuing is a partially verbal process but not a fully logical or rational one because it involves choosing, assuming, creating, and postulating, not merely weighing or deciding. This is not how we typically set life goals. Often we establish goals somewhat mindlessly or create them by using evaluative reasons (e.g., making lists of pros and cons and then selecting the “best” goals). Although this may be useful, many of these reasons are tied to psychological processes that are ultimately unimportant or even interfering (e.g., being right, avoiding pain, or pleasing others), rather than being linked to pursuing a meaningful chosen path in life. To the extent that their behavior is tied up in experiential avoidance, people will have a hard time contacting what really matters in their life. It’s painful to care, and if a person has a life history filled with losses, regrets, or failures, it might be easier to avoid caring. People who were raised in chaotic families, in which life was unpredictable and often disappointing, may avoid constructing valued futures in order to avoid more loss and pain. They may never have solidly established a behavioral repertoire of verbally constructing valued qualities, or such values may have been suppressed by pain. Either way, valuing is absent or weak.

Inaction, Impulsivity, and Avoidant Persistence Associated with fusion, avoidance, attachment to a conceptualized self, and loss of flexible attention to the present moment is an inability to develop larger habits of values-­based action. Impulsivity or rigid persistence is manifested instead of a commitment to the continuous construction of larger and larger patterns of personally meaningful action. Short-­term goals, such as feeling good, being right, and defending a conceptualized self, can become so dominant that long-­term desired qualities of life (i.e., values) take a backseat. People lose contact with what they want in life beyond relief from psychological pain. People’s lives can become consumed by defending themselves from anxiety, handling depression, or defending their self-­esteem, rather than focusing on goals and values that could have greater meaning, depth, and vitality. In such situations, people are metaphorically consumed with sharpening the ax and never get the chance to actually put it to use chopping down trees and building the home in which they long to live. This often leads to the emergence of patterns of action that are detached from people’s desired qualities of being and doing—­disconnected from their values. Sometimes this appears in the form of a weak overall life direction or an inability to make and keep commitments. For example, people may not engage effectively with work, close relationships, healthy lifestyle habits, recreation and leisure activities, or meaningful spiritual practices. Often, this kind of pattern presents itself as a lack of vitality and a sense that people have checked out of their life.

Using the Inflexibility Processes in Assessment In ACT, these six inflexibility processes inform assessment to a high degree. A vast number of assessment devices now exist that allow specific inflexibility in specific content areas to be measured systematically, but throughout this book we will also mention features of clients’ behavior in session that

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reflect these specific inflexibility processes without the use of formal assessment devises. Because syndromes, and protocols that target them, are becoming less important in evidence-­based therapy, a new process-­based model of assessment and case conceptualization is emerging that very much fits with an ACT approach. In process-­based therapy (Hayes et al., in press), evidence-­based processes are linked to evidence-­based procedures to more effectively alleviate people’s problems and promote well-­being. Assessment of inflexibility processes can significantly contribute to that approach.

Six Core Flexibility Processes in ACT ACT targets each of the core inflexibility processes just described, with the general goal of increasing psychological flexibility—­the ability to contact the present moment more fully as a conscious human being and, based on what the situation affords, to change or persist in behavior in order to serve valued ends (Hayes & Strosahl, 2004). Psychological flexibility is established through the six positive processes shown in figure 2. Each of these areas is conceptualized as a positive psychological skill that is instigated, modeled, and supported in therapy. All of the competencies in ACT are designed to foster these flexibility features and thus this model can be thought of as a model of the therapy itself. As you can see, it closely parallels the model of psychopathology and suffering depicted in figure 1. These processes are worth noting not merely because they are the positive parallels to the psychopathology processes, but also because they can be scaled to the level of the dyad or group. This is one reason that flexibility processes are so closely linked to therapeutic competencies in ACT: the model suggests that, at the level of intervention, these processes need to be manifest in interactions between therapist and client. Said in another way, the flexibility processes in ACT comprise a model for an effective therapeutic relationship and effective interventions.

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Commitment and behavior change processes

Flexible attention to the now

Acceptance

Values

Psychological Flexibility

Defusion

Committed action

Flexible perspective taking (self-as-context)

Mindfulness and acceptance processes

Figure 2. The hexagon model of psychological flexibility. copyright © Steven C. Hayes. Used by permission.

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Acceptance Acceptance of private events is taught as an alternative to experiential avoidance. It involves the active and aware embrace of private events that are occasioned by our history without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm. For example, clients who struggle with anxiety are taught to feel anxiety as a feeling, fully and without defense, and let go of their struggle with the form of psychological pain. In ACT, acceptance is not an end in itself. Rather, acceptance is fostered as a method of increasing values-­based action. Acceptance is fostered through exercises that encourage rich, flexible interaction with previously avoided experiences. For example, emotions are turned into described objects, complex reactions are broken down into experiential elements, and attention is given to relatively subtle aspects of avoided events. To a certain extent, these look like exposure exercises, but they have the purpose of increasing willingness and response flexibility, rather than necessarily diminishing emotional responding. When acceptance is scaled to the level of the therapeutic relationship, it’s important for therapists to be accepting and to model acceptance when their own difficult moments enter into therapy. Acceptance can also be scaled to couples, families, or other groups by encouraging compassion toward others, which is why there is a natural alliance between ACT and compassion-­focused therapies.

Cognitive Defusion ACT is one of the cognitive and behavioral therapies, but like other so-­called third-­generation CBT approaches (Hayes, 2004), it does not embrace one core tenet of traditional CBT: that modifying distorted or unrealistic thoughts is a necessary precursor to profound behavior change. This central claim of traditional CBT has received very limited empirical support (Chawla & Ostafin, 2009). From an RFT point of view, that isn’t surprising. The problem is this: efforts to change relational networks (i.e., patterns of thinking) generally expand these networks and make the event on which the person is focused (e.g., the thought or emotion) even more important. In technical terms, a relational context is generally also a functional context. Generally, clients are overly focused on negative private experiences. They have, in effect, narrowed their behavioral repertoire. Focusing even more attention on these areas may not be maximally helpful. The job of permanently and thoroughly changing cognitive content is difficult because thoughts are historical, often automatic, and, in clinically relevant areas, generally well established. Altering them can take a long time, and even when the endeavor is “successful,” they still aren’t really gone, as indicated by the tendency for older verbal/cognitive networks to reemerge under stress (K. G. Wilson & Hayes, 1996). Furthermore, clients are generally quite willing to attempt to suppress or eliminate negative thoughts and feelings and may well have already tried to do so; however, this often has paradoxical effects, at times actually increasing the frequency and intensity of these experiences, as well as their power to regulate behavior (Wenzlaff & Wegner, 2000). Although cognitive change techniques typically aren’t meant to be suppressive, this tendency makes using such strategies riskier. Indeed, there is very little data suggesting that cognitive disputation and change are helpful or a key pathway to

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behavior change; to date, studies suggest these methods are relatively inert, or in some cases even harmful (Dimidjian et al., 2006). RFT suggests a different approach: that we need not change the content of thoughts in order to change the functions of thoughts in our lives. The social and cultural contexts of literality, reason giving, and emotional control normally determine the functions of thoughts on behavior. In contexts such as these, the effects of thinking on action are machinelike; thoughts or feelings seem to cause actions just as one billiard ball striking a second causes the second ball to move. In the culturally normative scenario, to change the action, we must change the thought. However, with a contextual view we can see that the effects of thinking only seem to be mechanical: they seem to cause actions but in truth do not. Rather, particular thoughts are tied to particular actions or thoughts only within a given context. Thus, by creating other contexts (e.g., through defusion or acceptance), the impact of thoughts can be altered without first having to change their form. There is no need to change certain thoughts. Indeed, studies suggest that contextual strategies may more quickly lead to lasting behavior change than strategies directly targeting the content of thoughts and feelings. (For a recent meta-­analysis of component studies of this kind see Levin, Hildebrandt, Lillis, & Hayes, 2012.) From an ACT perspective, when clients engage in struggling with their own private experiences as if their lives depended upon it (as appears to be the case when thoughts are taken literally) and create stories to justify and explain their actions, the result can be an amplification of suffering and a rigidity of responding, both of which can be difficult to overcome. A major reason for this effect is that these very efforts create pervasive and rigid contexts of literality, reason giving, and emotional control. It is these contexts that ACT techniques target. Defusion, an invented word meaning “to undo fusion,” refers to the process of creating nonliteral contexts in which language can be seen as an active, ongoing, relational process that is historical in nature and present in the current moment. In less technical terms, this means watching thoughts with an attitude of dispassionate curiosity. Language and thought can always be observed in the moment as language and thought: we can watch what the mind says rather than be a slave to it. A word is viewed as simply a word, not as what it seems to mean. Creating this nonliteral context loosens the relationship between words and action, allowing for greater behavioral flexibility. We don’t have to be driven by our words or let them dictate our behavior. Defusion is perhaps one of the most unique features of ACT. Scores of defusion techniques have been developed for a wide variety of clinical presentations. For example, a negative thought can be watched dispassionately; be repeated out loud until it becomes only a sound, devoid of meaning; or be treated as an externally observed event by giving it a shape, size, color, speed, form, or other physical attributes. The result of defusion is usually a decrease in the believability of the thought or attachment to it, rather than an immediate change in its frequency. Additionally, defusion is not a process of eliminating thinking or even of changing the impact of thoughts. The point is to have a more mindful perspective on thoughts, which increases behavioral flexibility linked to chosen values, not to promote mindlessness or reliance on intuition, or to eliminate rationality. Defusion techniques all have the goal of catching language processes in flight and bringing them under contextual control so that, when necessary, they can be looked at rather than looked from. When scaled to the therapeutic relationship, defusion fosters an open, nonjudgmental space in therapy in which all thoughts are open for examination. It means creating a relationship that’s nonjudgmental and in which evaluations don’t hook the therapist—­or if they do, the therapist acknowledges this and then moves on.

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Being Present ACT promotes ongoing, nonjudgmental contact with psychological and environmental events as they occur. The goal is present-­moment awareness, in which attention is allocated to the here and now in a way that is flexible, fluid, and voluntary. When in contact with the present moment, humans are flexible, responsive, and aware of the possibilities and learning opportunities afforded by the current situation. In comparison to living in a conceptualized past or future, present-­moment awareness is more direct and responsive and less conceptual and fused. When contact with the present moment is inadequate, behavior tends to be more dominated by fusion, avoidance, and reason giving and therefore typically results in more of the same behavior that occurred in the past. New possibilities are foreclosed. In ACT, being present is linked to the development of a sense of self called self-­as-­process (Hayes et al., 2012)—­a habit of open self-­awareness that is characterized by ongoing noticing and descriptive labeling of thoughts, feelings, and other private events in a defused and nonjudgmental fashion. A sense of mindfulness is encouraged as well, so people can more fully notice the rich set of interactions that are afforded in any given moment. When socially scaled, present-­moment awareness contributes to an atmosphere in which the ongoing process in the therapeutic relationship is itself noticed and used as a foundation for flexibility work. Both the therapist and the client are called upon to be present and to attend to whatever is of importance.

Self-­as-­Context and Flexible Perspective Taking From an RFT perspective, it is argued that language training includes relational frames that require perspective taking (technically called deictic framing in RFT), and that these skills in turn establish a sense of self as a boundaryless locus. From an RFT view, self is more like a context or arena for experience than like an experience itself. For example, consider what the following questions have in common: “What did you eat?” “What do you want?” “To whom did you talk?” “When did you do that?” “Why did you do that?” The only thing they have in common is the location of the answer: the “I” who will answer all the questions. Through experiential exercises and metaphors, ACT helps people contact this sense of selfas-context—­a continuous and secure “I” from which events are experienced, a self that contains but is also distinct from those events. This process helps people disentangle from the word machine in between our ears. The goal is to help people develop a more solid sense of themselves as observers or experiencers, independent of the particular experience being had in the moment. Additionally, because the limits of consciousness and awareness cannot be contacted within consciousness or awareness, the perspective taking fostered by human language can lead to a sense of transcendence, lending a spiritual aspect to normal human experience. Language is a double-­edged sword—­and facilitating a sense of transcendence is one of its most positive features. Establishing this transcendent sense of self can also be helpful in decreasing attachment to content. This idea was one of the seeds from which both ACT and RFT grew (Hayes, 1984), and there is evidence of its importance to the language functions that underlie such phenomena as empathy, compassion, and theory of mind (for a book-­length review, see McHugh & Stewart, 2012). In ACT, a transcendent sense of self is

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important, in part, because from this standpoint people can be aware of their ongoing flow of experiences without attachment to them. Defusion and acceptance are thus fostered by this naturalistic, spiritual side of human experience. The other reason that self-­as-­context and perspective taking are critical to ACT is that they are a primary source of the social extension of the model. The three primary perspective-­taking frames in RFT are I versus you, here versus there, and now versus then. These frames are central to how people develop a consistent sense of perspective and an awareness that their perspective is different from that of others. All relational frames are bidirectional, so learning to look at the world from the point of view of I-­here-­now necessarily gives people the ability to view the world from the point of view of you-­there-­ then. Metaphorically, you get to show up behind your eyes as a fully conscious member of the group at the same moment that you see that others are conscious behind theirs. A perspective-­taking sense of self links us to the perspectives of others and to perspectives from other times and other places. This expansion of awareness is why self-­as-­context is foundational to experiences of spirituality and transcendence (Hayes, 1984), empathy, compassion, and self-­compassion. These human capacities are partly nonverbal (the effect of mirror neurons, for example) but are greatly amplified by verbal relations now known to support perspective taking (McHugh & Stewart, 2012).

Defining Valued Directions The previously described flexibility processes are mostly aimed at undermining temporal and evaluative language in areas of living in which those forms of language are relatively ineffective. The processes of values clarification and committed action (discussed next) are focused on strengthening language in those areas in which language is most likely to be effectively applied. ACT asks people to step back from the everyday problems of life and take a look at what gives their lives meaning—­to look for the larger possibilities that can dignify their struggles and guide constructive action. Values are chosen qualities of actions that can never be obtained as an object, but can be instantiated moment by moment in actions of being and doing. They are combinations of verbs and adverbs, not nouns (e.g., to relate lovingly, or to participate honestly). ACT uses a variety of exercises to help clients choose valued life directions in various domains (e.g., family, career, spirituality), while also undermining verbal processes that might lead to choices based on experiential avoidance, social compliance, or cognitive fusion. So in the ACT sense, none of these statements reflects genuine values: “I would feel guilty if I didn’t value Q,” “I value Z because my mother wants me to,” “I should value X,” and “A good person would value Y.” The first is avoidant, the second is compliant, and the last two are fused. Values are choices. Values are the answer to the question “In a world where you could choose to have your life be about something, what would you choose?” (K. G. Wilson & Murrell, 2004, p. 135). Values are the linchpin of ACT because the truth and utility of ACT depend on them. In ACT, acceptance, defusion, being present, and the other core flexibility processes are not ends in themselves; rather, they clear the path for a more vital, values-­consistent life. ACT takes a stance toward truth that’s based on a particular form of pragmatic philosophy called functional contextualism (Biglan & Hayes, 2016). Truth is defined on the basis of workability, and workability in turn is linked to chosen values. In the more typical, mechanistic worldview, truth is a type of correspondence. Using the metaphor of a map, if the marks on the map accurately indicate where things are in the real world in relation to each other, then the map is true. Pragmatic truth finds its

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validation only within certain contexts, based on the workability of whatever is being evaluated in that context. So while a paper map of the world might work (be true) in order to figure out how to sail around the world, it will be pretty useless (not true) for finding your way around New York City; you’d need a city or regional map for that. Is one map less true than the other in the normal, correspondence-­ based sense? No. But one map certainly works better in the context of trying to find your way around New York City. This contextual approach informs how truth is defined in ACT. ACT forgoes truth that emerges from a context of literality (i.e., correspondence) in favor of truth defined by what’s useful in empowering people to live rich, meaningful lives, guided by their values. This radical stance toward truth allows ACT therapists to sidestep common therapeutic traps with clients who get caught up in arguments about whether their particular stories are right or wrong, or whether their view of the world is accurate or inaccurate. When it comes to clients, truth is local and is defined in terms of whether a particular way of thinking or behaving is helpful or unhelpful in the pursuit of a valued life. For example, suppose a client thinks he’s inherently unlikable, that his life has gone down the tubes, and that it will never be possible for him to have a life with caring relationships and a family, even though he feels that this is deeply important to him. An ACT therapist wouldn’t focus on the rational or irrational nature of these thoughts or on the evidence for and against them. Instead, the therapist will focus on what those thoughts are in the service of and whether experience shows them to be helpful in leading the client toward a life that reflects his chosen values. The issue in the room probably will be about whether the client is willing to have these thoughts when they occur and still move in the direction of his chosen values, not what the thoughts purport to indicate about the state of the world, the client, or the thoughts themselves. Values work is often socially oriented because of how integral social interaction and cooperation are to our species. Even aesthetic values (e.g., bringing beauty into the world) typically involve acts of sharing and giving (e.g., helping others appreciate beauty).

Committed Action Finally, ACT encourages clients to build larger and larger patterns of effective action linked to chosen values. The Latin roots of the word “commitment” involve a sense of carrying something forward with (com) a “sending” or a “mission” (mittere). In a sense, committed action simply means adopting a values-­based life as a mission in which establishing larger and larger patterns of action linked to chosen values is itself valued. Inside that mission, the “how” of building habits can then be a focus that has meaning. When a slip occurs, people have the option to make a new choice: will they build a pattern of valuing, slipping, and then abandoning the mission, or will they build a pattern of valuing, slipping, and committing to the mission once again? Planning for these moments and organizing one’s environment to foster values-­ based choices in such moments is what committed action looks like. In this work, ACT therapists can take advantage of any evidence-­based process known to foster behavior change: exposure, skills acquisition, shaping methods, goal setting, or anything else. Furthermore, it has been shown that flexibility processes can amplify the impact of these behavior change methods (e.g., Arch et al., 2012). Unlike values, which are constantly instantiated but never achieved as an object, concrete values-­ consistent goals can be achieved. ACT protocols almost always involve homework linked to short-­,

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medium-­, and long-­term behavior change goals. Behavior change efforts, in turn, lead to contact with psychological barriers, which are addressed through other flexibility processes (e.g., acceptance, defusion). When socially extended, committed action involves supporting the commitments of others. As a result, ACT research has naturally gravitated toward work in areas related to social justice, in part because seeing suffering in others requires a response.

Groupings of Processes Within the Model The six core flexibility processes are both overlapping and interrelated. Taken as a whole, each supports the other and all target psychological flexibility—­the process of contacting the present moment fully as a conscious human being and persisting or changing behavior in the service of chosen values. The six processes can be chunked into two large groupings, as shown in figure 2. The mindfulness and acceptance processes involve acceptance, defusion, contact with the present moment, and self-­as-­context, and taken together, these four processes provide a workable behavioral definition of mindfulness (Fletcher & Hayes, 2005). The commitment and behavior change processes involve contact with the present moment, self-­as-­context, values, and committed action. Contact with the present moment and self-­as-­context appear in both groupings because all psychological activity of conscious human beings involves the now; that is where we live, and all deliberate change involves consciousness awareness from one’s perspective.

The Pillars of Inflexibility: Closed, Mindless, and Disconnected The six core processes can also be grouped into three pillars, or response styles (Strosahl, Robinson, & Gustavsson, 2012; Hayes et al., 2012), each containing two points of inflexibility (figure 3). The two inflexibility points on the left side of the hexagon, avoidance and fusion, can be combined into one inflexibility pillar—­being closed—­because avoidance and fusion are repertoire narrowing. In any given context, many different behavioral options are usually possible in both a functional sense (what the behavior is for) and a topographical sense (what the behavior looks like). Evolutionarily speaking, we need variation in our lives because it provides the seeds for behavioral improvement and change. Furthermore, psychopathology often involves limits on variation, especially in terms of functionality. Suppose a person uses alcohol to reduce a sense of social anxiety. When alcohol isn’t available, the person may find topographical alternatives, perhaps smoking a joint or steering clear of meaningful conversations, with the functional purpose of those behaviors remaining the same. In the ACT model, such restriction in variability is fed by avoidance and fusion, and clinical work will therefore target these processes in order to create more openness and response flexibility. Evolutionary theory can help illuminate this dynamic. Among humans, cooperation has been selected for because success of the group is fostered by cooperation and restraints upon the selfish interests of individuals. Similarly, both of the processes in this pillar (avoidance and fusion) can be thought of as instances of selfishness within the individual, in which the demands of specific aspects of the person’s repertoire (e.g., particular thoughts and feelings) are given more time and attention than they are worth relative to the good of the whole person.

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Removing these unnecessary restrictions on variation and creating more cooperation among aspects of the individual’s repertoire frees up behavior and allows it to move to fit the context. Doing so deliberately, however, is difficult when the next two inflexibility points interfere with the process. The inflexibility points at the top and bottom of the hexagon, dominance of the conceptualized past and future and attachment to the conceptualized self, combine to form the second pillar, or response style: mindlessness. This pillar of inflexibility is extremely harmful to purposeful behavior change. When people are evolving behavioral repertoires on purpose, it’s important that they make conscious contact with the context in order to develop behaviors that are effective in that context. People who are changing need to know where they are and what to focus on in order to generate variations that are likely to be successful. Changing on purpose is much more difficult, and also likely to not be on target, if people miss important details of their external or internal environment, if they can’t keep their attention on what’s important or can’t shift it away from what isn’t important, or if they can’t disentangle themselves from rigid stories about themselves and others.

CLOSED

MINDLESS

DISCONNECTED

Inflexible attention

Lack of values clarity

Avoidance

Fusion

Disconnected action Attachment to self-concept Figure 3. The pillars of psychological inflexibility.

Finally, the two inflexibility points on the right side of the hexagon, unclear values and inaction, impulsivity, or avoidant persistence, combine to form the third pillar of inflexibility: disconnection, which is the inability to select positive changes or retain them through practice. Variation is not a positive goal in itself: rather, it’s a way for people to find ways to move in valued directions, and to move

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closer to desired ends, by selecting and retaining variations that work. This is the core of an evolutionary approach: change by selective retention. In an ACT approach, values are the selection criteria for action, and retention is produced by the deliberate creation and repetition of patterns of effective action, so this final inflexibility pillar inhibits positive behavior change.

The Pillars of Flexibility: Open, Aware, and Engaged Like the six inflexibility processes or points, the three pillars of inflexibility are mirrored by pillars of flexibility: processes that have positive implications for clinical methods. Each flexibility pillar contains two flexibility points on the hexagon (figure 4).

OPEN

AWARE

ENGAGED

Being present

Acceptance

Values

Defusion

Committed action Perspective-taking sense of self

Figure 4. The pillars of psychological flexibility.

Regarding the first pillar of flexibility, openness, any approach that fosters acceptance and defusion can be considered an ACT method, regardless of its school of origin. Openness offers greater access to one’s history without allowing it to dominate excessively, along with an opportunity for a sense of wholeness and peace of mind to emerge. With this pillar of flexibility, all reactions are welcome as they are, not as what they say they are, and no reaction is given a “selfish” or disruptive portion of a person’s time or attention. This pillar undermines rigid repertoires and increases healthy variation.

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Regarding the second pillar, awareness, ACT seeks to increase flexible, fluid, and voluntary attention to the internal and external events that are present and of importance, from the I-­here-­now point of pure awareness, or perspective taking. This is not just a target, but a key method that facilitates both of the other pillars, and is therefore the central pillar of ACT’s intervention method. In session, the therapist instigates, models, and supports this kind of awareness. The therapist is conscious of the consciousness of the client and is present with whatever is present, flexibly, fluidly, and voluntarily directing attention to whatever is of importance. Thus, the therapeutic relationship in ACT is itself characterized by a high degree of awareness, with the second pillar of flexibility ensuring that healthy variation is context sensitive. Finally, the third pillar, engagement, consists of values and committed action. In session, ACT therapists model a values-­based commitment to the good of the client, and do so in a way that never violates their own values. Willingness to be active in therapy in service of the client is matched by willingness to also be silent, listen, and allow. In other words, the commitment—­the mission—­is not to a particular form of action; it’s to an underlying function or quality of action that empowers the lives of others. This pillar ensures that healthy steps forward are selected and retained.

Fostering Healthy Psychological Evolution In summary, the six processes of evolution—­variation and selective retention in context, at the right dimension and level—­are fully integrated with the six flexibility processes. As we have already noted, the pillars and points of openness foster healthy variation; the pillars and points of engagement foster selective retention; and the pillar and points of awareness foster deliberately fitting development and change to context. Dimensionality and level are addressed by the psychological flexibility model as a whole. Consider dimensionality first. Dimensionality means that the interrelationships between multiple strands of healthy development are noted and addressed in a balanced way, rather than overemphasizing only a particular dimension or domain as being of importance while ignoring other key areas. Psychological inflexibility fosters a subtractive and judgmental approach to one’s own development, as experiential avoidance and cognitive fusion are given rein in a way that can even violate one’s values. Psychological flexibility, conversely, fosters a shift from life as a problem to be solved to life as a process to be experienced, which allows more balanced attention to the challenges and opportunities of development and change in all of their interrelated aspects. It would do little good to develop a healthy emotional life, for example, without also attending to health behaviors (e.g., diet, exercise, sleep) that facilitate a vital life. That same sense of balance and interrelationship applies to every domain, whether we are speaking of the balance between intellectual development and social development, or of the balance between employment and spiritual development. This explains why ACT is often included under the umbrella of positive psychology (Kashdan & Ciarrochi, 2013), and why the literature on ACT is so broad: psychological flexibility empowers all areas of life and encourages the maintenance of balance among them. ACT is not just about alleviating psychopathology. It’s about living well.

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Fostering evolution at the right level of selection means recognizing the nested nature of complex systems and understanding that cooperation at any level of organization can entail disruptive selfishness as a higher level of organization. Multilevel selection reminds us that “it’s groups all the way down,” and that that balancing development at multiple levels is therefore involved in any act of purposeful evolution. Because psychological flexibility applies to the individual, the goal of psychological growth involves accommodating the entire repertoire of the whole person without feeding selfish disruption by components of the individual’s repertoire, and without ignoring critical needs of parts of the individual. Encouraging development in this holistic way can be thought of as fostering personal growth with an eye toward peace of mind and personality integration. When this process is socially scaled into relationships and groups, it’s manifested as being able to focus on success at higher levels of organization while also promoting success but not selfish disruption at the level of the individual. This empowers individuals to participate in dyads and groups in positive, cooperative, compassionate, and loving ways. As an example, it’s natural for the perspective-­taking sense of self that fosters awareness to also remind us of the needs of others at other times in other places. The I-­here-­now of pure awareness is based on deictic relations (I/you, here/there, now/then) that intrinsically expand awareness across beings, places, and times. Therefore, it is natural to link the ACT model to such issues as prejudice, the needs of underdeveloped communities around the world, environmental concerns, and animal rights. In short, psychological flexibility is a scalable concept, which nests with parallel concepts in parenting, relationships, and organizations. And indeed, measures of flexibility are emerging in all of these areas. Furthermore, this expansive quality is now being expressed in organized efforts to develop new applications of contextual behavioral science that combine ACT methods with group development principles, such as Elinor Ostrom’s Nobel Prize–­winning design principles, in the PROSOCIAL method of fostering group effectiveness (http://www.prosocial.world).

A Definition of ACT We have now defined the six basic flexibility processes and examined their grouping into three pillars of flexibility, or into the two overarching groupings of mindfulness and acceptance processes and commitment and behavior change processes. We’ve also examined how they’re linked to evolutionary principles that govern development in every area of the life sciences. Having done so, we can now define ACT fairly simply: ACT is a psychological intervention based on modern behavioral and evolutionary principles, including RFT, that applies mindfulness and acceptance processes, and commitment and behavior change processes, to the creation of psychological flexibility. ACT is thus a model, not a specific technology. It offers a model of psychopathology processes that cuts across all traditional diagnostic categories and is thus profoundly transdiagnostic. It also offers a model of health and intervention processes that is naturally linked to positive growth and empowerment. It is an approach to psychological intervention, and to human functioning more generally, that is defined in terms of specific flexibility processes and is grounded in basic behavioral, cognitive, and evolutionary principles.

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For More Information For an overview of research about ACT, see Hooper & Larsson (2015). For an introductory overview of RFT, the theory of language and cognition that underlies ACT, see the excellent four-­hour online tutorial available for free at http://www.foxylearning.com. For a book-­length introduction to RFT, read Törneke (2010). For an article on the relevance of evolutionary principles to psychological flexibility and applied behavioral science, see Hayes, Monestès, & Wilson (in press). For a book-­length description of contextual behavioral science, see Zettle, Hayes, Barnes-­Holmes, & Biglan (2016). The hexagon model is a good way, both scientifically and practically, to summarize the processes that make up psychological flexibility, which is why we are using it in the organization of this book. However, RFT processes can be used directly to organize clinical work (see M. Villatte, Villatte, & Hayes, 2015), and other clinically useful tools are widely used in ACT, such as the matrix (Polk & Schoendorff, 2014).

CHAPTER 2

Developing Willingness and Acceptance

When suffering knocks at your door and you say there is no seat for him, he tells you not to worry because he has brought his own stool. —­Chinua Achebe

Key targets for willingness and acceptance: Help clients let go of the agenda of excessive control as applied to internal experience. Help clients see experiential willingness as an alternative to experiential control. Help clients come into contact with willingness as a choice, not a desire. Help clients understand willingness as a flexible process that is actively engaged in an ongoing fashion, not arrived at as an outcome.

A great deal of struggle and suffering arises from denial of the inevitability of human pain. When we feel fear, anxiety, sadness, hopelessness, or other emotions that cause distress or discomfort, or when we think of ourselves as less than worthy, we often engage in efforts to undo those experiences. With or without awareness of another option, we pick up the experiential control agenda and go to work. A battle with our internal experiences begins. Unfortunately, because we are largely the products of our history and cannot simply eliminate it or the content it contains, the agenda of experiential control is largely ineffective, and in many cases it backfires, trapping us in an unsuccessful struggle with ourselves. In addition, experiential avoidance often creates a self-­amplifying loop that leads to additional suffering. The result can be years of life consumed by fruitless efforts and potentially self-­destructive behavior directed toward unworkable ends.

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This tendency toward experiential avoidance is a basic part of being human; it is born out of language and amplified by culture. We all try to control painful experience to some degree or another, at times working feverishly to avoid painful events. However, because pain is also a basic part of the human condition, we don’t have long-­lasting or viable ways to escape the experiences that are elicited when we encounter loss, unmet desires, and other similar conditions. Although control methods sometimes work in the short run, they tend to have the paradoxical effect of increasing suffering in the long run. Amplification of suffering can occur both through the basic properties of language (for example, trying not to think about an unpleasant memory can evoke that memory) and through the loss and pain that can result from living outside of our closely held values (for example, a person with social anxiety who wants connection with others may avoid people out of fear of experiencing anxiety and shame). ACT specifically targets letting go of misapplied control, or control that is aimed at reducing or getting rid of experiences that cannot be gotten rid of in a healthy way. As an antidote to increasing suffering by engaging in ineffective control efforts, ACT offers an alternative that helps clients contact unwanted experiences, and helps them do so without excessive or rigid efforts to make the experience be other than what it is. This alternative is willingness.

What Is Willingness? “Willingness” can be defined as being open to the entirety of one’s experience while also actively and intentionally choosing to move in valued life directions. Developing willingness occurs through a process of contacting the present moment as it is, with whatever internal experience is present, while simultaneously taking action that is guided by values-­based intentions. It is foundational to the first of the three pillars of flexibility: openness. Willingness to experience is the seed of openness. The opposite of willingness, excessive and misapplied control of internal experience, also points to what we’re exploring when working with clients on this process: when people are unwilling, they may make choices based on a desire to avoid internal experiences, rather than on their personal values. Willingness is an action and has an all-­or-­none quality to it. It’s like a leap. For an action to be a leap, we need to momentarily be completely in the air, with no part touching the ground, allowing gravity to do its work. Leaping has a different quality than stepping, wherein each movement is controlled. A step can be a large step, but it’s still a step, and a step can only take us so far. We can step from a chair, but not from a roof. Conversely, leaps can be small, but they have no upper limit. The motion involved in a leap from a chair is identical to the motion involved in a leap from a roof. We are either in the air or not—­just as we are either willing or not. Although having tolerance can bring us a step closer to being willing, tolerance implies that negative experience is to be withstood until something better comes along. We might “white-­knuckle” our way through strong unwanted emotion as if to conquer the experience. This still has the quality of taking a step. Willingness, on the other hand, has qualities of openness, allowing, and being present with whatever is there to be felt, sensed, or observed. Willingness is experienced as an ongoing process, not as waiting for something to change for the better if we’re tolerant enough. Willingness to experience, then, is a stance that can be taken again and again; it is a lifelong series of choices related to how we will bear our experience.

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It’s also worth noting that people can seek to avoid or escape positive emotions. For example, people may have learned to not allow themselves to relax because doing so has previously been followed by painful experiences, or they may not allow themselves to experience or express joy because this has previously been followed by attention from others that leads them to feel uncomfortable. Thus, avoiding or controlling positive emotions and their expression can also create problems in terms of increasing suffering and harming interpersonal relationships (e.g., Gable, Reis, Impett, & Asher, 2004). In addition, avoiding positive emotions may interfere with maintaining committed action, since it may lead people to miss out on other sources of reinforcement that may be present when they live in a way that aligns with their values. Clients often confuse willingness with a feeling or way of thinking. However, people need not feel willing or think in a particular way in order to be willing. Willingness is also not about wanting. People don’t have to want to feel or think something to be willing to do so. The question is whether they would be willing to experience these feelings and thoughts fully and without defense if that meant new possibilities would be created in their life. Willingness is an inherently active process and arises from remaining aware of and open to the thoughts, feelings, and sensations that arise when taking action in the service of one’s values. This includes all forms of committed action. It may entail making a telephone call to an estranged friend, having a conversation with a loved one when fearing or not wanting to do so, laying down one’s defenses despite wanting to argue for something, or saying “I love you” even though it feels scary. For the purposes of this book, we use the terms “acceptance” and “willingness” interchangeably. Unfortunately, the term “acceptance,” in some contexts, can carry a lot of cultural baggage, which may make it less useful with some clients, particularly those who have been on the receiving end of lectures about how they have to accept something. Acceptance and willingness are not about loss, resignation, or stoicism. Yet for some people, “acceptance” sounds like resignation, and indeed, sometimes our culture defines it that way. Likewise, loss and resignation in the presence of pain can be viewed as giving up or submitting to it, and stoicism may be viewed as a kind of indifference to emotion. None of these is the kind of acceptance we’re talking about in ACT (Hayes et al., 2012). If a client reacts to the term “acceptance” in any of these ways, it is better to use the term “willingness.” In fact, it’s useful for therapists to keep an eye out for negative connotations clients may associate with both of these terms, or others. We want to use terms with connotations that are predominantly life affirming, empowering, and vitalizing and that support openness, awareness, and engagement—­the three pillars of flexibility. A fuller understanding of what ACT means by “acceptance” can be illuminated by the historical origins of the word. “Acceptance” can be traced back to a Latin word meaning “to take or receive what is offered.” This implies an action of embracing, holding, or taking what life offers—­and doing so willingly. Acceptance is ultimately a choice to embrace what is and what life offers, saying yes to life and its variability in experience. Before we turn our focus to clients, we want to highlight that willingness also applies to therapists. It’s common for therapists to find the process of learning an experiential therapy like ACT anxiety provoking. At times, doing so may increase your level of self-­doubt or self-­criticism. This is natural when learning something new, and even more so with a therapy that emphasizes experiential and nonlinear learning, as is the case with ACT. We hope you’ll be open to engaging the experiential learning process in this book while also making room for and learning from whatever reactions you have as you do so.

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Why Willingness and Acceptance? Willingness is foundational to ACT and is one of its key functional goals. Willingness, or acceptance, can’t just be described to clients with the hope that the descriptions will provide benefit (i.e., the client will be more accepting or willing based on the description); these are skills to be learned, not concepts to be understood. In ACT, therapists attempt to build the behavior of acceptance by engaging clients in specific activities structured to create the possibility of choosing to experience difficult thoughts, emotions, sensations, and so on. Rigid and misapplied attempts to control and manage unpleasant, unwanted, and difficult internal experiences can cost people in at least two ways. One is that the things people do in attempts to reduce or remove their painful emotions, thoughts, sensations, and memories often fail and, paradoxically, may produce even more distress. The pain and struggle caused by efforts to not have pain as it is, sometimes referred to as “suffering,” is added to the pain that is the natural and automatic result of living life. In fact, some research has shown that attempts to suppress troubling thoughts or emotions tend to result in rebound effects, wherein the emotion or thought becomes even more prominent (Hayes et al., 1996; Abramowitz, Tolin, & Street, 2001). Efforts to not think about a bad memory often tend to elicit that same memory (e.g., in PTSD; Shipherd & Beck, 2005). Similarly, depressed people who stay in bed all day to escape from the perceived meaninglessness of their life only further confirm their fears about the meaninglessness of their life. And panic, at least in part, is often the result of a struggle to not have panic. Many more examples of the paradoxical effects of experiential avoidance are given in other ACT texts (Eifert & Forsyth, 2005; Hayes et al., 2012) and reviews of the literature (Abramowitz et al., 2001). Another consideration is that living life in pursuit of feeling good generally isn’t living in the service of deeply held values. Doing what’s important or what matters is sometimes painful or can at least create a sense of vulnerability—­precisely because caring reveals where we can be, and have been, hurt. This connection between pain and values is part of why the costs of experiential avoidance are so high. It can lead people to turn away from valued directions, relationships, or activities in the service of modulating, controlling, or avoiding particular experiences. To return to an earlier example, a person with social anxiety may have very few friends because of a desire to avoid shame, yet that very shame may be an indication of how important others are to that person. Similarly, people who engage in chronic, persistent experiential avoidance may never develop a sense of what they desire in life because they’re so caught up in not feeling. In the end, a life lived in pursuit of feeling good may not feel very good.

The Link Between Willingness and Defusion Willingness is closely linked to cognitive defusion (see chapter 3), and an extended discussion of this link seems warranted here. Because we humans tend to become fused with language in a literal way, we often fail to distinguish between the world as we verbally conceive of it and the world that we directly experience. The world simply seems to occur as we perceive it. We don’t always realize that this is actually a result of a blending of direct experience and thought. We are fused—­entangled—­with our minds. Under these circumstances, the verbal content of the mind dominates over behavior, and the direct contingencies of experience are lost. For example, with fusion, a client who says, “I can’t stand this feeling another moment,” holds the ideas that he will fall apart, cease to exist, or be damaged if the

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experience of that feeling continues. However, with defusion or freedom from the literality that the mind presents, that same client can attend to his direct experience. He can and will stand the feeling for another moment, and will also experience that he doesn’t cease to exist. Furthermore, with attention to the ongoing flow of his present-­moment experience, he will learn that this feeling will pass and another will come along, time and again. One of the main issues with fusion, as it pertains to this chapter, is getting fused with culturally supported messages that negative thoughts and emotions are disordered and problematic and should be decreased or removed, as well as messages that wholeness and well-­being are largely defined by feeling good and that we should do what it takes to feel that way. bell hooks captured this well: “One of the mighty illusions that is constructed in the dailiness of life in our culture is that all pain is a negation of worthiness, that the real chosen people, the real worthy people, are the people that are most free from pain” (1992, p. 52). When people entirely buy into these cultural messages, they begin to engage in behaviors consistent with the messages—­behaviors that are designed to reduce or eliminate negative thoughts and emotions in the service of attaining well-­being. And when people view negative thoughts, emotions, and sensations as disordered and problems to be solved, they tend to engage in a logical problem-­solving process: figure how to get rid of it and then get rid of it. They plan, try to understand, and try to find solutions; they try to resolve, answer, unravel, decipher, and explain and may expend a lot of time on a host of behaviors designed to allow them to feel, think, and sense something other than the undesired experience. Years or decades can be spent in this very effort. These efforts seem to make sense; they seem logical. We humans have learned that problems are made to be solved, and indeed, in the world outside the skin, problem solving is an excellent strategy: If you don’t like the way the room is arranged, rearrange it. If you don’t like dirty dishes in the sink, wash them and put them away. If you don’t like long hair, get a haircut. Figure out how to fix the problem and then fix it. But when this strategy is applied to internal experiences—­the world inside the skin—­the very efforts to fix them may actually sustain and even increase the experiences we’re trying to eliminate. Nevertheless, we still engage the strategy: If you don’t want or like anxiety, figure out how to get rid of it, and then get rid of it. If you don’t like sadness, disappointment, thoughts, memories, or sensations, figure out how to get rid of them, and then get rid of them. But because the world inside the skin doesn’t work in the same way as the external world, trying to reduce and eliminate internal experiences may actually cause these experiences to linger and grow. A classic example is that not wanting anxiety is itself something about which to be anxious. So the “problem” grows. And because our logical, problem-­solving minds are so heavily involved, we conclude that what’s required is more strategies aimed at fixing the problem; we need more control. A major focus of acceptance, then, is to undermine the strategy of excessive internal control by examining the workability of this strategy. The focus is on clients’ experience with this strategy, not logic, as logic is part of the self-­perpetuating system that tells clients they should be able to control their emotions, thoughts, and sensations.

What Should Trigger Working with This Process? The clearest signal to engage willingness processes in session is experiential avoidance. When clients make efforts to control or escape difficult material that’s touched upon in session, willingness work can

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be helpful. That said, the clinician shouldn’t just jump into a willingness exercise haphazardly; it’s important to have the session flow, working in willingness processes and exercises as appropriate to meet the needs of the client. Recognizing experiential avoidance can be hard at times and easy at others. There are a number of ways that clients may demonstrate that they’re trying to control internal events. They may change the topic, become superficial, make jokes, deny that issues are present, look away, get angry, get very wordy, or use words that seem incongruent with their affect. If these behaviors occur when difficult topics or experiences come up, they are probably avoidance behaviors. Others signs of in-­session avoidance include physical postures indicative of hiding, fighting, or fleeing, such as freezing, clenching the jaw or fists, fidgeting, or looking away or down. Yet other signals include inaction, excessive planning and rumination, argumentativeness, lack of motivation, or passivity on the part of the client—­a sense that the client is trying to hand over responsibility to the therapist. Avoidance may also be an issue if the client has a hard time savoring positive experiences without a fear of them ending. These are just some of the many manifestations of avoidance behavior. Whatever the behavior, the key to recognizing what should trigger working with willingness is the function of the behavior: Does it function to avoid or escape unwanted internal experience in a way that is inflexible? The clinician’s reactions can also provide an effective guide to whether experiential avoidance is present in session. Client avoidance may be an issue if the therapist feels boredom or feels frustrated and has the urge to push the client to do something. Another possible signal is if the therapist has a sense of wanting to argue with the client or feels a need to convince the client. Sometimes the therapist might detect avoidance only after the fact, suddenly thinking, How did we get on this topic? only to realize that the client had previously deflected from a more difficult topic. Clinicians engage in emotional avoidance in session too. They sometimes avoid talking about potentially sensitive topics or fear that they may scare or harm a client. It’s important to pay attention to such experiences. They too should trigger working with willingness, not only for the client, but for the clinician as well.

What Is the Method? The process of developing acceptance usually involves two major focal points: creating an initial openness to willingness by undermining experiential control as a dominant method of relating to oneself and the world; and actively developing and choosing willingness through structured practice and committed action. Both of these steps are intended to foster psychological flexibility: the ability to contact the present moment more fully as a conscious human being and then to change or persist in behavior in order to serve valued ends. This conscious sensitivity to context makes room for choice. Creating an initial opening for willingness is often where ACT starts, and in many cases, these initial steps are integrated into the assessment process.

Creating an Opening for Willingness Experiential avoidance and control efforts can be so well practiced that they occur virtually without awareness. For many people, managing and controlling their internal experience is not viewed as a choice; rather, they see it as just “the way it is.” The idea that they might choose to take a stance of

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willingness and feel anxiety, sit with pain, rest in sadness, embrace fear, or relax into uncertainty is so unusual and novel that some may feel it’s a bit like suggesting they could live without breathing. Particularly for clients with pervasive and chronic histories of experiential avoidance, substantial work is needed to clear a space wherein willingness, acceptance, and compassion can grow. This process can be broken down into three steps: 1. Building awareness of experiential avoidance. This involves drawing out the system of control within which the client is implicitly operating. 2. Examining the workability of control. The effectiveness of the control agenda is assessed in terms of an extended timeline and with respect to whether it has actually reduced the client’s suffering in the long run, and also how it has worked in terms of the client’s valued life goals. 3. Capturing the experience in a metaphor. Typically, a metaphor is used to provide a shorthand way to refer to this pervasive and often automatic tendency to turn to control as a solution. These metaphors usually invoke situations in which the person has put in a great deal of effort but with little payoff or even with paradoxical effects. The outcomes of the process of undermining the control agenda are a loosened attachment to the eventual success of the experiential control agenda, decreased confidence in that success, and freeing up some space for clients to practice willingness and acceptance in such a way that these new strategies are less likely to get pulled back into the old system. The term confronting the system, which is sometimes used to describe this process, is helpful for orienting therapists to the idea that this isn’t about confronting the client, but about confronting the social, verbal, and cultural system of experiential control in which the client is stuck. The confrontation is not between client and therapist; rather, it’s a confrontation between the client’s lived experience and the mind’s proposed solutions to problems that are the result of social and cultural conditioning. Let’s take a detailed look at the stepwise process of creating an opening for willingness.

1. BUILDING AWARENESS OF EXPERIENTIAL AVOIDANCE Undermining the control agenda begins with developing an understanding of what clients are trying to control with respect to their internal experience. This is usually reflected in the presenting problem (e.g., “I’m too anxious” or “I don’t want to be sad anymore”). The therapist might ask, “What brings you to therapy?” Almost always, clients report a struggle with emotions (e.g., pain, anxiety, fear, a sense of emptiness), memories (e.g., trauma, family experiences), or thoughts such as self-­evaluations (e.g., self-­doubt, a sense of worthlessness). Once the therapist has a good idea of what the client is trying to control, it’s possible to move on to explicitly drawing out the strategies the client has used in an effort to solve the presenting problem. To be clear, in using the term “strategy,” we aren’t necessarily implying that clients are conscious of or intentionally choosing a particular behavior; we are simply highlighting the fact that their behavior has a purpose. The term “strategy” also draws attention to the function of the behavior. This is important because the target of change is the function of the behavior, not its form. For example, with an anxious client, the therapist can talk about things the client does when she feels anxious (e.g., “I stay home,” “I get quiet,” or “I drink alcohol.”). Similarly, with a depressed client, the therapist can identify what that person has done to try to get rid of or manage the depression

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(e.g., “I lie in bed” or “I try to build my self-­esteem.”). All methods of solving the problem should be explored, including seemingly healthy ones, such as counseling, getting help from others, and psychopharmacology. Clients often aren’t aware of the variety and extent of the ways in which they attempt to control their private experience, and they aren’t always able to describe or identify the purpose of their behavior. Thus, part of the therapist’s job is to identify the function of the client’s attempts at solutions and to suggest to the client that these behaviors are about experiential avoidance. For example, a client with depression may not immediately see how oversleeping or overeating is typically intended to help him avoid or modulate a mood state or to decrease unpleasant rumination. As clients become better at tracking the purpose of their behavior, this can help them develop more present-­moment awareness and better observe their behavior. All of that said, in many cases clients are aware of the function of their behavior and fully cognizant of what they’re doing when exercising internal control. However, they can still be invested in the strategy, believing that thus far they’ve failed to implement it correctly, that they aren’t strong willed enough, or that some other flaw is interfering with their capacity to fully control and manage their experience. Therefore, they often continue to engage in these strategies, hoping that they will eventually work.

2. EXAMINING THE WORKABILITY OF CONTROL Concurrent with drawing out the client’s system of control efforts, the therapist’s job is to examine the workability of the client’s behaviors, particularly over the long term. The basic question asked here is whether the various control-­oriented solutions to the client’s problems turned out as planned. There are two areas of workability to explore: actual or long-­term outcomes in terms of suffering, and personal costs in relation to values. Actual or long-­term outcomes in terms of suffering. One aspect of exploring workability with clients is examining whether their attempts have actually resulted in long-­term decreases in suffering. For example, has what the client did to reduce or eliminate anxiety actually reduced or eliminated anxiety in the short term and, more importantly, in the long run? Have steps the client has taken to manage depression reduced depression to a seemingly manageable level? Many clients recognize the paradoxical effects of experiential control fairly readily and see that as they’ve tried to control their suffering, it has actually increased over time or, at best, has remained unaffected. However, some clients won’t see the costs of experiential control as easily, even though they may have experienced lingering suffering. Consider, for example, a wiped-­out, anhedonic, depressed client with flat affect who, while not suffering very acutely, has a lingering sense of meaninglessness and loneliness in her life. Personal costs in relation to values. Another aspect of exploring workability relates to the ways in which clients have constricted or limited their life in an effort to deal with the problems (e.g., negatively evaluated thoughts, emotions, and sensations) that have been identified. The focus is on workability in terms of lived values. To draw out this aspect of workability, the therapist might ask questions along these lines (inspired by Eifert & Forsyth, 2005, p. 135): • “What have you noticed, over time, in terms of how things have worked with respect to what you would like to have in your life? Have you done what you would like to do?”

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• “Do you have more options, or have your options decreased? In other words, has your ‘life space’ narrowed over time?” • “What would you be doing with your time if you weren’t busy managing your difficult feelings [thoughts, sensations, images, urges, or memories]? What have you given up in an attempt to deal with this problem?” • “Have you found yourself moving in the direction of the kind of life you most want to live, or have you perhaps found yourself moving farther from it?” The reason to explore both of these aspects—­long-­term outcomes and personal costs—­is because the two are linked in the experiential control agenda (Hayes et al., 2012). The most obvious promise of this agenda is that through deliberate, conscious control, we can have more, better, or different emotions, self-­evaluations, thoughts, sensations, or images. The first aspect examines whether this promised outcome has been achieved. However, we don’t merely want to feel good; we also want to live well, enjoying full, rich, meaningful lives as defined by our particular dreams and life aspirations (i.e., values). The most enticing promise of the experiential control agenda is that it can deliver that kind of life. Our culture tells us that once we are able to feel more happy, joyful, and energetic, and less anxious, depressed, sad, regretful, tired, and angry—­or once we have different self-­evaluations and thoughts—­we will be able to live our dreams, have better relationships, lead a more vital life, live our values, find more meaningful work, and so on. Unfortunately, the reality is often the opposite; indeed, as alluded to earlier, people’s lives can become consumed with efforts to achieve the first goal of experiential control (decreased suffering), apparently in service of the second goal (living a valued life), but actually at the cost of the latter. We have a few important points regarding the therapist’s stance during this process of examining the workability of the client’s behavior. First, the therapist should take the position that whatever the client has done is understandable and reasonable—­which indeed it is, given the client’s history (Hayes et al., 2012). This stance also involves a genuine and compassionate approach, from a position of equality, that recognizes the very human desire to be happy and live well. If the therapist approaches workability from a one-­up or overly confrontational position, this may come across as shaming or blaming. This is why we refer to confronting the system. A person caught in the system is not to be blamed; rather, the therapeutic approach is to work together to explore the system that entangles humans lives to such a great extent that we suffer tremendously. It’s also important to focus entirely on the issue of workability, not whether the therapist or client is “right.” This work isn’t about proving to the client that the therapist has a better way. That would be fundamentally antithetical to the basic ACT stance. Rather, the therapist’s job is to help clients start applying the criterion of workability, given their life goals and aspirations. A word about pitfalls: For therapists doing this work, it can be hard not to get caught up in the content of what clients are saying. However, when focusing on undermining control, the therapist’s job is to consistently return to the issue of whether these strategies have worked in the client’s life. Because clients’ verbal formulations are well practiced and even at times cherished, clients may feel threatened and begin to defend their actions or give reasons for what they’ve done. This is a normal and understandable reaction to this process. There are several ways to respond to this kind of reaction. One is to continue to focus on what clients’ experience has shown, in contrast to what their mind promises should happen. Another way to respond is to ask clients, in a nonjudgmental and

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nondefensive way, to step back for a moment and consider defending the rightness of their views as a strategy, and particularly how well this strategy has worked in their life. For example, the therapist might say, “Let’s take a look at what’s happening. In this moment, it seems that you’re defending this approach. Has defending it worked in the long run? I’m not sure whether the approach is right or wrong, but has taking this position worked to get you where you want to be in your life?” When saying something like this, it’s important not to speak from a place of trying to be right and make the client wrong, but from an honest examination of whether this control strategy has worked for the client. Another common pitfall arises when clients say that a particular strategy has worked. In this context, clients are usually referring to the strategy’s short-­term effects, so the therapist’s job is to help the client examine its longer-­term workability. If the client also defends long-­term workability, the therapist can gently inquire about the need for therapy, saying something like, “Then help me better understand why you’re here. Why do you continue to seek therapy?” (For more about elucidating the client’s pattern of behavior and examining workability, see Hayes et al., 2012, pp. 167–­176.)

3. CAPTURING THE EXPERIENCE IN A METAPHOR Exploring past and current attempts at experiential control is likely to show that these solutions haven’t worked well or have come at considerable personal cost. To help clients move from recognizing the downsides of control to beginning to engage in willingness, ACT therapists foster a sense of creative hopelessness (Hayes et al., 2012, pp. 189–­197) and may use a number of metaphors and exercises to explore this experience with clients. It’s important that the clinician thoroughly understand the term “creative hopelessness” before embarking on this work. It doesn’t refer to making clients feel a sense of hopelessness in general; it’s about helping clients see the hopelessness of an agenda of internal control. The function of creative hopelessness work is to make room for something other than control: helping clients open to the possibility of willingness. Sometimes people who are learning ACT mistakenly believe that “creative hopelessness” refers to a feeling and therefore think they need to make clients feel hopeless. However, creative hopelessness is actually a profoundly validating stance. Therapeutically, it refers to the process of validating clients’ experience of the futility of the struggle in which they have been caught, and then helping them begin to open up to the entirely new possibilities that come from this self-­validation. Clients know that what they’ve been doing hasn’t been working. The possibility ACT therapists add to the mix is that this experience may be valid: perhaps it can’t work. Once the therapist and client have explored the workability of many different behaviors and both have a sense of the extensiveness of the problem and the client’s attempts to solve it, the therapist may attempt to develop creative hopelessness in that moment, generally using a metaphor to capture the experience that has been discussed. The therapist can use any of a number of stories and metaphors about situations in which a great deal of effort is put forward with little payoff or where the effort actually creates more problems. The key is to find a metaphor that’s apt for the specific client and resonates with her experience, taking into account the pervasiveness of experiential avoidance in her life, as well as the kinds of consequences she’s experienced as a result of her control efforts. For example, a client who’s experienced a great deal of suffering due to control strategies might benefit from a metaphor in which control efforts make things worse, whereas a client who has mostly experienced a sense of meaninglessness or exhaustion as a result of control efforts might benefit more from a metaphor that captures this quality.

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Ideally the metaphor will emerge naturally from what the client has already talked about; however, it’s useful to have a variety of established metaphors to pull from as needed. Examples include comparing the client’s situation to struggling to get out of quicksand (Hayes, 2005, pp. 3–­4), working with a bad investment adviser (Hayes et al., 2012, p. 173), being on a hamster wheel that goes nowhere, or gambling on a rigged game. Another popular metaphor involves a person who gives meat to a tiger to make it go away, only to find the tiger returning hungrier, as well as bigger and stronger (Eifert & Forsyth, 2005, pp. 138–­139). Many cultures have relevant stories that can be adapted to this purpose. Perhaps the metaphor most commonly used for this purpose in ACT involves a person who has fallen into a hole and has no tool for escape other than a shovel (Hayes et al., 2012, pp. 191–­196). This metaphor shows that digging (representing control efforts) to get out of the hole doesn’t work but instead makes the hole larger. Clients are asked to examine their unworkable change agenda (i.e., the tools they use to get out of the hole and how they use them) and to notice that they are quite stuck. Ultimately, the goal is to drop the shovel and stop digging. Acceptance or willingness is offered as the alternative to control. If a client can experience emotions, thoughts, and sensations from a chosen and open stance, then the function of those internal experiences is changed such that they no longer have the same degree of control over the client’s behavior. The personal costs associated with excessive control are reduced or eliminated. As therapy continues, images from the creative hopelessness metaphor can be referenced again when the client gets caught up in another control strategy. For example, the therapist can playfully ask, “Are you digging again?” or “Are you on the hamster wheel?”

Sample Dialogues In this section, we provide two dialogues demonstrating different strategies for undermining the control agenda. These dialogues provide examples of the process at two ends of the spectrum. The first demonstrates creative hopelessness with a client who has a long and pervasive history of experiential avoidance, as well as multiple experiences with previous treatments, and thus the process of undermining control is more intense, prolonged, and emotional. The second dialogue is a gentler, more tentative version with a client who has less of an attachment to and history with experiential avoidance, and who also has less experience of the costs of such behavior. Both of these dialogues involve clients with well-­ developed verbal skills. Therapists may need to simplify the process of undermining control and make it more concrete for clients who are less verbal or less abstract in their thinking. ACT should always be tailored to the client.

CREATIVE HOPELESSNESS WITH A CLIENT WHO HAS A PERVASIVE HISTORY OF EXPERIENTIAL AVOIDANCE The first dialogue begins after the therapist and client have had a couple of sessions together and have formed a therapeutic relationship. They’ve already had discussions about the client’s values and how the client has tried to manage his anxiety. Earlier in the session, they spent some time building the client’s awareness of his experiential avoidance and examining workability. This dialogue picks up as the therapist is working toward identifying a metaphor to capture the experience. As you read the following dialogue, keep in mind that this is an example of how the creative hopelessness process might

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look on one end of the spectrum: what might be effective with a more pervasively stuck client who has a long history of treatment and for whom a more typical approach to therapy isn’t likely to be successful. This vignette also assumes that the therapist will work with this client in subsequent sessions, so this dialogue is only a preliminary step aimed at creating an initial opening to acceptance. (For clients who are more open to acceptance, the approach in the second vignette would be a better fit.) We encourage you to see if you can identify the functions that are being targeted in the dialogue, rather than focusing on the content per se. We also encourage you to note any judgments or emotions that arise as you read through it.

Commentary Client:

Wow, I’ve really tried a lot of different things. I guess I’ve also tried therapy, and I’ve tried to just ignore it.

The therapist continues to draw out more examples of the client’s efforts to control his internal experiences.

Therapist: Let’s add those to the list—­therapy and ignoring. What else? Client:

Well, I guess I’ve tried to hide it by not letting people see my hands shake.

Therapist: Okay, hiding… Other things? Client:

I’m sure there are others. I just can’t think of them right now.

Therapist: There are probably a lot more. We may come across them as we keep working, and we can add them to the list then. So, here we have this pretty extensive list… One thing is clear: You’ve definitely put a lot of effort into fixing your anxiety. Client:

Yeah, I guess I have. Maybe I just haven’t put enough effort in yet. Maybe I need to try harder?

Therapist: Let me ask you, have you tried hard? From my perspective, you’ve tried tremendously hard. The list of things you’ve tried is very long. I wonder if we need to add “try harder” to the list of things you’ve tried?

Client:

When working on creative hopelessness, you want to validate the effort the client has put into trying to make things better while also beginning to undermine “more of the same” as a solution.

(Chuckles.) Yeah, even though I often think of myself as lazy, when I look at it now, I see that I’ve done a lot to try to deal with this.

While, on a literal level, any solution probably requires hard work, “trying harder” is currently functionally linked to the control agenda and therefore needs to be undermined. At the same time, the therapist validates the client’s effort.

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Therapist: Okay, so now we have “try harder” in this long list. Again, I want to be clear: it’s not that you haven’t put in enough effort… But something seems strange here. Look at all of these things you’ve tried, and yet here you are, still struggling with anxiety. In fact, can you name one thing on this list that has solved your anxiety problem in any long-­term kind of way?

The therapist asks the client to look at the workability of control efforts in a long-­term framework, rather than in the short term, where it may appear to work better.

Client:

The therapist appeals to the client’s experience, asking why the client is in therapy if these solutions worked in the long term.

(Sounds puzzled.) Well, I guess anxiety management worked.

Therapist: (Also sounds puzzled—­and nonjudgmental.) It seems as though if that had worked, you wouldn’t be here right now. Why not just do more anxiety management and call it good? Client:

I need you to remind me how to do anxiety management. I’ve forgotten most of it.

Therapist: Let’s look at that. Have you been reminded before? Client:

Yeah, lots of times.

Therapist: How about we add that to the list of things that you’ve tried that haven’t worked. I could remind you, but it seems you would need to be reminded again, and then again. Does that seem true to you? Client:

(Laughs.) Yeah, I do forget a lot. Can you see what a pain this is for me? I just need to figure it out.

Therapist: How long have you been trying to figure this out? Client:

Oh, about thirty years.

The therapist establishes that what the client is continuing to do, even in asking for help in remembering, is part of what he’s tried before, and therefore it must not have worked. Remembering is not the solution either and should be added to the list. A common response is to figure it out. But all of the client’s efforts have in some way been about that, so figuring it out should be addressed and added to the list of things that don’t work. The therapist addresses how long this strategy has been applied, again pointing to its long-­term workability.

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Therapist: It seems that you’ve spent a lot of time “figuring it out.” So I’ll add that to the list of things you’ve tried as well. If you’ve been trying to figure it out for thirty years, it seems that would have worked by now. Client:

The therapist identifies the functional category of the response and gives it a label.

(Sounds slightly impatient.) You’re the therapist, you tell me what works.

Therapist: Ah, that’s a great strategy: get information from someone else about how to solve this. Yet here we are. You said you’ve been to therapy and you’ve read books. You’ve tried to get information, and that didn’t solve it. So let’s add that one to the list, too: getting information from others. The list is growing.

The therapist identifies the functional category of the client’s current behavior and labels it. The therapist may be feeling anxious here too, but with an entrenched client, it’s important to stick with it.

Client:

Frustration at this stage isn’t necessarily a problematic reaction and in some cases is to be expected. It might even be part of the client’s avoidance repertoire.

This is frustrating. There must be something that works, right?

Therapist: I hear your frustration. Can we stick with this a bit longer? Client:

Yeah, we can, but I don’t see where this is going.

Therapist: Okay, so you asked me a question about what works. That’s another way to try to get information from someone else. Have you asked questions to try to get information before? How many questions have you asked about anxiety? Client:

Tons.

The therapist asks permission, wanting to check in on the alliance at this point. Responding to the client’s statement literally wouldn’t be useful here. The therapist instead labels this as another example of the kinds of things the client does to solve the problem: asking questions (another way to try to figure things out).

Therapist: So asking questions goes on the list. Client:

Something must work. Why would people go to therapy? You just need to help me understand.

Therapist: So, if you understand anxiety better, then that will solve your problem? (Smiles.) Client:

(Pauses.) I understand anxiety pretty well.

The therapist continues to label the function of the client’s behavior.

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Therapist: So it seems understanding this better isn’t working, either, and… Client:

I know, that goes on the list. (Pauses.) Well, maybe I should just go home if nothing works.

Therapist: I hear your mind suggesting that as a solution, but let me have you notice that staying home is already on the list. You’ve listened to that suggestion from your mind as well. So it seems that staying home hasn’t worked either. Client:

Well, hell then, there’s nothing left to do. I give up.

Often, giving up or resignation comes up as a strategy, but at this point it’s often still a strategy from within the old agenda. Although its form may look like acceptance, it’s probably a control strategy in disguise. Behind resignation is the hope that someday things will change.

Therapist: Have you given up before? Client:

Yes. (Sounds frustrated.) Go ahead, put that one on the list too.

Therapist: Yeah, giving up hasn’t solved this problem either. Client:

This is frustrating.

Therapist: I can see that. I imagine I might be frustrated too. Client:

I guess I just have to accept it.

Therapist: Hang in here with me… Have you tried just accepting it before? Client:

Oh no, not again. Isn’t this called acceptance and commitment therapy?

Expressing frustration has probably led to therapists backing off before. The client would probably feel better in the moment if the therapist simply backed off or gave a suggestion for a solution (e.g., a relaxation exercise). However, functionally, this would be feeding the old agenda. The therapist assumes that for this very stuck, pervasively avoidant client, anything the client is offering at this point isn’t new behavior and is probably part of the old agenda.

Therapist: Sure is. But have you tried acceptance before? Client:

Yes.

Therapist: And it didn’t work to solve your anxiety, or you wouldn’t be here. We’re kind of getting to a place where nothing works. You’ve tried all these things and nothing has worked to solve your anxiety. And you don’t have to believe it because I’m saying it. Look back across the years and tell me, based on your experience with all of these strategies, what has worked?

The therapist asks the client to check his experience. The therapist is trying to shift the client to a way of responding that’s more in contact with his experience and less bound to rules, even (or especially) rules generated by the therapist.

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Well, some of them work a little bit.

Therapist: Absolutely. A lot of things you’ve tried make you feel better in the short run. You can even drink and feel better for a bit. But then what happens? Client:

It comes back.

The therapist again draws the client’s attention to the longer-­term pattern. Clients usually want to focus on the short term.

Therapist: And then you have to do what? Client:

(Laughs.) Try harder.

Therapist: (Laughs with the client.) But we already know that trying harder doesn’t work. It isn’t because of lack of effort that you’re sitting here with me today. That’s for sure. Client:

I’m lost. I don’t know what to do.

Therapist: What do you bump up against when you feel lost? Client:

It’s hopeless. There is nothing to be done.

Therapist: Now we’re getting somewhere. Client:

The therapist’s suggestion that the client’s problem isn’t about not trying hard enough helps the client not fall into useless self-­blame.

You must be kidding me. I’m lost, and you think we’re getting somewhere?

Therapist: Maybe lost is a good place to be, at least right now. Not knowing means that perhaps something different can take place. If you did know, I suspect we’d have to add it to the list of things that don’t work because you would have already tried it. And I don’t want to take you back to what hasn’t worked. So for now, perhaps lost is a place to be. But it’s a creative place because from this place maybe, just maybe, something new can happen.

Contact with the present moment occurs when the client is asked to notice what’s showing up now. This is clearly not an expected response. It steps outside the bounds of literal discourse, where, if taken literally, “hopeless” and “lost” are places to be avoided. However, for this client, moving away from feeling hopeless and lost is part of what keeps him stuck. Feeling hopeless and lost at times will probably be part of engaging in new behavior for the client. Feeling lost is a normal part of learning new things, and hopelessness is likely to be a common reaction for someone who has repeatedly had a hard time accomplishing goals related to his values.

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Exercise:

Learning from Your Reactions to This Dialogue It’s common for beginning ACT therapists to feel apprehension at the thought of taking this kind of approach with a client. We invite you to see this as an opportunity to learn about your own psychological flexibility as a therapist. (We aren’t assuming that there’s any psychological inflexibility if you are anxious, as the presence of anxiety doesn’t necessarily mean you’d avoid it; rather, anxiety just sets the context for possible avoidance or fusion.) If you’re willing, we invite you take some time to explore your reactions to the dialogue, bearing in mind that the vignette is meant to serve as a model for how to foster acceptance. As you were reading the dialogue, what were your reactions? Was it uncomfortable for you in any way? If so, how? What emotions did you notice?     How about thoughts, particularly evaluations? Were there any parts of the dialogue that elicited judgments? What does your mind say would happen if you took an approach like that in the dialogue? What does your mind say it would mean if you chose not to take that kind of approach? How attached are you to any of these thoughts? How much do you see them as true or feel pulled to defend them, whether they’re “positive” or “negative”? Take some time to write about what you notice when you consider these questions.     Some therapists, especially those new to ACT who can’t yet see how this fits into the overall model, respond to this vignette with a reaction of “I can’t (or won’t) do this to a client.” Sometimes this is followed by doubts about whether ACT is a good match for them or their clients. These are natural reactions, and they need not be a barrier to learning ACT. (They would only become a barrier if you were fused with them and felt a need to defend them.) If you noticed a reaction like this, we encourage you to consider treating this reaction as potential data about yourself—­about your psychological flexibility and your values. We want to remind you that ACT is fundamentally about fostering choice and values-­ based behavior, including for the therapist.

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While there is no ACT litmus test that demands “good” ACT therapists to use any particular technique, we want to explore the possibility that there very well may be certain contexts in which taking an approach like that demonstrated in the preceding vignette might align with your values. As such, you may arrive at a point, perhaps after learning ACT more thoroughly, when you choose to interact with a client in this way, even if doing so feels uncomfortable for you. If you are open to exploring this possibility, here are some additional considerations to explore. What is painful for us is often linked to our values. If this vignette was difficult to read or consider, what might that tell you about your clinical work? What would you choose to have your work be about? Does this tell you anything about reorganizing your efforts to align with your values? Take some time to write about this now.     Now that you have a sense of some of your values as a therapist, we ask that you reread the preceding vignette with an eye to how you might do something similar—­in a way that aligns with your values. We also suggest that you practice awareness and willingness as you read it again to see whether you can get a feel for how the therapist’s methods might foster psychological flexibility, even if they could be interpreted as doing something else. Try to identify what might work to foster acceptance, and also notice what you evaluate as not working. As you write about these things, try to hold all of this lightly, seeing it as a process of learning about yourself and developing as a therapist.     This exercise explored common therapist reactions that could result in hesitancy to use a method along the lines of that demonstrated in the vignette. If you found yourself relating to the vignette differently, with excitement or hope that using such methods will result in a magical change for your clients, we ask that you hold those responses lightly, as well. Sometimes dramatic or radical change can happen, and yet acceptance is a process. We encourage therapists to let go of a focus on outcome. Trying to change clients or get clients somewhere through this process runs counter to what acceptance is about. In addition, harboring an unspoken motivation of trying to have a client get the point is likely to come out in your behavior, which could result in invalidation, coercion, or sense of falseness. Remember that creating an opening for acceptance is about responding to the client’s actual experience, in the moment, as you perceive that experience based on the client’s history and present-­moment

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reactions. This isn’t about getting anywhere other than where the client already is; rather, it’s about aligning with where the client already is. This work also isn’t about the therapist’s agenda for the client or what the therapist thinks the client should be doing. So if you find yourself trying to use these methods to coerce clients to be different, stop; you’re off track.

CREATIVE HOPELESSNESS WITH A CLIENT WHO HAS LESS OF A HISTORY OF EXPERIENTIAL AVOIDANCE Deciding how much emphasis to place on undermining control largely depends upon the pervasiveness of experiential avoidance and control efforts in the client’s life. For some clients, experiential control has been their dominant way of living for many years, leaving them entrenched in this pattern; for others, experiential control is less pervasive, less practiced, or less dominant, so they may be more inclined to give it up as a solution. The more chronic and pervasive avoidance has been, the more likely it is that the therapist will need to emphasize creative hopelessness. When working with clients who have relatively less pervasive patterns of experiential avoidance, therapists can probably quickly move to helping them develop mindfulness and acceptance skills in the context of pursuing their values. The following dialogue illustrates a brief approach to creative hopelessness that can be used in the latter case. The context is an early session with a bright, young, relatively functional client with social anxiety. Leading up to this dialogue, the therapist has reviewed the ways in which the client has tried to deal with his anxiety. Therapist: Let me suggest something: If this were an easy, obvious problem to solve, you would have figured it out. (The therapist is supporting the client, noting that his failure to solve the problem isn’t because he is unable, but because it can’t be figured out.) Client:

I think so. Yeah.

Therapist: You’re a smart, capable person. You’ve been struggling with this a good portion of your life. And you know directly that there’s something inherently tricky about this problem. For example, even noticing that something isn’t there is enough to create it. It’s like, “Oh, I’m feeling better… Oh no…no I’m not.” Let’s look at what was on this list of things you’ve done to manage anxiety. There was distracting, reassurance, talking yourself out of it, avoiding it, and perhaps some other things we haven’t talked about yet. See if they all have this characteristic in common: They can, at certain times, be a little helpful… And ultimately they’re not that helpful. (Defines and names the control agenda.) Client:

Yeah.

Therapist: They don’t solve it. Client:

No. I know that. (Laughs.)

Therapist: And see if even this isn’t true: They can work for a short period of time, and they might make it worse in a moderate or longer period of time. For example, if you do something to distract yourself, sooner or later you have to check to see if it worked. And then when you

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check to see if it worked, it will remind you of what you were trying to forget… And then it’s back. (Points to the paradox of control efforts.) Client:

Yeah, sometimes I’ll be thinking, “Okay, I’m going to distract myself. Let’s think about something fun.” So I think, “Skiing, riding down the hill, getting to the lodge, hanging with friends at the lodge… Oh crap! Okay, start over.”

Therapist: Yeah. Client:

Or sometimes I’ll notice I’m feeling better, and then it will be back.

Therapist: Yeah. And here’s the problem: You talked about the tricks your mind plays on you. The problem is, your mind is in the room, not just you. So you’re doing a lot of stuff your mind is telling you to do. And yet it’s in the room, listening to what we’re saying. Client:

It knows. (Laughs.)

Therapist: Yeah. It knows what’s going on, right? Client:

Yeah.

Therapist: But it doesn’t seem to be able to give you ultimate, final answers. If anything, it seems to torment you. It reminds you of some random memory you don’t want to think about. Client:

And I can’t logically make it go away. I think I understand what you’re saying. I know what I’m thinking isn’t logical, but it just doesn’t get through.

Therapist: Right, because this isn’t just a logical deal, it’s a psychological deal. And that’s not the same thing. So let’s put these things together. We need to carve out some space here in which to work. I want you to consider the possibility that you’ve pretty much exhausted the things that seem logical, reasonable, or sensible. They pay off like this. (Spreads hands toward client, making a gesture that implies that it hasn’t worked because the client is here, in therapy, looking for ways to control anxiety.) They don’t pay off in some other way. Client:

(Laughs.) No, they don’t.

Therapist: They pay off like this. And if that’s the case, then we’re going to have to open up the possibility that a whole other approach is needed. And yet we’ve got a mind in the room that will say, “Oh yeah, I get that,” and try to pull whatever we do back into the same system. (Pauses.) So, you know what quicksand is, right? Client:

Yeah.

Therapist: When people step in it, they do the normal, logical, reasonable, sensible thing: they try to get out of it. Client:

Which makes it worse.

Therapist: Yeah. The normal way to get out of things is to push to get out. The problem is, when you do that with quicksand, it just sinks you in deeper. Pushing on the one foot didn’t work, so

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you push on the other. Now you’ve got two of them in there. Maybe it’s like that. Maybe the things you’ve been doing are like the normal, logical, reasonable, sensible things people do when they are stuck in quicksand. And in fact, it’s not liberating you; if anything, it’s making you more stuck. So if that’s true, we have to find something that might work that’s outside the set of all the things that might work. (Here, the therapist has included some defusion in the metaphor.) You know what I mean? Client:

(Laughs.) Yeah. (Pauses.) So, what are we going to do, then?

Therapist: (Pauses and smiles.) Well, your experience is telling you, “I do something, and it doesn’t pay off. It pays off short term and it doesn’t pay off long term.” (The therapist is reflecting the client’s experience of workability.) And really, the problem just keeps hanging around. Sometimes it’s better and sometimes it’s worse, but here it is. And you’re trying not to let it grow. But it’s still here, and you’re stuck. Client:

Yeah.

Therapist: Well, I want to open the door and say, “You know that sense you have that you’re stuck? Well, maybe you have that because you really are stuck.” This game is a stuck game. It’s not going to work some other way. It works like this. You know in your experience how things have worked. If you back up and look at it, it almost seems like this is a rigged game. In other areas of your life, you put in the effort and get the outcome. Not here. So we’ll need to do something really different.

Guidelines for Working with Creative Hopelessness Ultimately, the idea in creative hopelessness work is to validate clients’ actual experience of control not working, to validate the emotions they’re experiencing, and to suggest that the social messages they’ve been given might be incorrect, rather than that clients are incorrect. So before the end of a session like this, be sure to establish that you’re suggesting that the agenda is hopeless, not that the client is hopeless. Also, note that the “creative” piece in creative hopelessness refers to an openness that comes when clients finally abandon needless experiential control and turn their attention to living a life that aligns with their chosen values. After all, the goal is not to create a feeling of hopelessness or belief in hopelessness; in fact, this process often creates a hopeful feeling. The goal is simply to speed the process of abandoning what isn’t working (Hayes et al., 2012). When clients fully contact the unworkability of old control agendas, they may feel lost or confused because the path they’ve been on no longer seems viable. This isn’t a negative sign; it’s a sign that old control behaviors are beginning to fall away. Occasionally, clients might feel upset or angry at this point, with a sense that they’ve been tricked by life or by the clinician. If so, you might validate this saying something like, “It makes sense that you’d feel upset after putting so much effort into something with so little payoff.” In order to forestall potential self-­blame, you might say, “It isn’t your fault that you fell into this hole. These were the tools you were given by society. But what if it’s the case that much of what we’re taught to do with our painful emotions and thoughts can actually make things worse? What if it’s the case that the things your mind tells you to do might actually get you more stuck?” Other common reactions, which may not require a specific response, include clients slowing down or being

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more thoughtful, periods of silence, a sense of lightness in the room, laughter, and a start-­and-­stop quality to clients’ speech, as if they’re catching habitual patterns of thinking. Because creative hopelessness is such an important piece of both the up-­front and the ongoing work in ACT, and because it typically begins early in therapy (and appears early in this book), we have additional key guidelines to share. A common mistake on the part of therapists is trying to convince clients that avoidance isn’t working or that they must give up their agenda of experiential control. Another is that therapists may try to push clients further than they’re currently ready to go. It’s essential that the client’s experience be the absolute arbiter. Creative hopelessness will only function as it should if the confrontation is between the client’s system of experiential control (the mind) and the client’s actual experience, not between the therapist and the client. The therapist is simply there to guide the process of helping clients examine their own experience and determine whether the solutions their minds have been putting forward have actually worked as they were supposed to, or whether their experience has shown otherwise. Another common therapist misstep at this point is getting caught up in the content of what clients say. For example, therapists may assume that a seemingly logical or healthy solution should be supported, without exploring its actual function. In this case, a therapist might encourage a depressed client to exercise more (a seemingly healthy behavior in depression) without knowing whether exercise functions primarily as avoidance for that client. So remember that the target of acceptance is undermining behaviors that serve as experiential avoidance, which is defined based on function, not form. In the example of exercise, a psychologically flexible route forward might involve either more exercise or less—­more if this behavior is linked to values, and less if it’s linked to avoidance. Responding based on content is especially tempting if strategies the client has tried are similar—­in form—­to ACT methods (e.g., mindfulness meditation). However, the purpose is not to endorse formally correct methods; it is to explore the functional impact of any and all solutions and let go of anything that isn’t working. Typically, what isn’t working is clients’ cognitive entanglement with their mind and the resulting control agenda, which may not be easily seen or logical. Clients’ experience is the biggest ally in determining the function of their behavior. Finally, we want to be clear that creative hopelessness isn’t about a one-­time, all-­or-­nothing shift in behavior; it’s about establishing the possibility of an approach other than control—­in this moment, the next moment, and then the next moment. It’s about helping clients see that each moment of existence offers an opportunity to say yes to their experience, feeding the vitality of a values-­based life, rather than continuing down the path of experiential avoidance.

Establishing Control as the Problem In the preceding dialogue with the client who had less of an attachment to experiential avoidance, you can see the therapist transition from working on the sense of creative hopelessness to more explicitly outlining how experiential or emotional control might be part of the problem, rather than the solution to the client’s current difficulties. Many clients come to therapy believing they need more control over their internal experience. However, misapplied control has already landed them in an unworkable agenda—­and it’s done so at the expense of their lives; they’ve put their lives on hold while they worked on getting their emotions or thoughts under control. All therapists have heard clients make statements such as “When I get my anxiety under control, I’ll get a job,” “When the pain stops, I’ll find another relationship,” or “When I don’t feel guilty anymore,

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I will reconnect with my children. I don’t want to subject them to my guilt.” These kinds of statements come in all shapes and sizes, but all versions are about the client beginning to live only after unwanted internal experiences are under control. Of course, the problem with this is that life occurs in the present moment. And as should be clear at this point, it’s difficult to change what happens internally in any lasting and meaningful way. It’s more likely that efforts at control will lead to more problems and costs. This can happen in obvious ways; for example, perhaps a client drinks heavily to avoid feeling sad. It can also play out in more subtle ways. Imagine a client who tends to change the subject whenever you begin to talk about painful issues yet desires more intimate communication with others. The following dialogue points to this issue. Therapist: So you had a good time this weekend at the lake? Client:

Yes, it was a lot of fun. I hiked and went swimming. I really got to take a break… But I was alone, and that was kind of a bummer.

Therapist: You were alone? I know it’s been hard for you to be alone. Was it painful? Client:

Yes, but you won’t believe what happened when I was hiking. I came across a bear on the side of the trail…

Therapist: (Interrupts.) I noticed that you skipped past that painful part. Client:

Yeah, but I wanted to be sure and tell you about the bear.

Therapist: It seems it just happened again. What do you think would happen if you showed up to the pain? Client:

(Gets tearful.) I’d start to cry, and I don’t want to do that.

Here you can see how the client is avoiding vulnerability at the expense of intimacy. The therapist’s goal in such cases is to point out the costs of this kind of control: loss of values-­based living. For this client, those costs include loss of intimacy, connecting, and lovingly participating in relationships. Misapplied control efforts can be tackled by an appeal to clients’ experience, just as described for creative hopelessness, and by using metaphors that model the problem of control. An often used metaphor is the Tug-­of-­War with a Monster (Hayes et al., 2012, p. 276), wherein the therapist and client engage an experiential exercise demonstrating the struggle with difficult emotions and thoughts by engaging in a mock tug-­of-­war. The therapist typically pretends to be the negative emotions and thoughts that the client would like to eliminate, while the client plays himself. The two pull on opposite ends of a rope (perhaps using a real rope as a prop), stretched between them over an imagined bottomless pit that represents what appears to be certain destruction if the client is unable to defeat the negative experiences by pulling them into the pit. During the exercise, the therapist works with the metaphor in such a fashion that the client experientially contacts or sees that this war is not being won (e.g., the difficult emotions remain). Tugging to win is equated with control. Clients often eventually realize that the only solution is to let go of trying to win the war—­to drop the rope. In some cases the therapist may need to point this out. The emotions and thoughts don’t disappear when the client lets go, but there is no longer a battle and the client is freer to move.

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The ACT literature has many other exercises and metaphors that demonstrate the problem of control: the Polygraph metaphor (Hayes et al., 2012, pp. 182–­183); the Chocolate Cake task (Hayes et al., 2012, pp. 185–­186); the Feeding the Tiger metaphor (Eifert & Forsyth, 2005, pp. 138–­139); the Chinese Finger Trap metaphor (Eifert & Forsyth, 2005, pp. 146–­149); and many others (Stoddard & Afari, 2014; Harris, 2009, pp. 89–­95). Each illustrates the paradox of control: the more you try to control your internal experience, the more you lose control. This paradox is captured by the message “If you aren’t willing to have it, you’ve got it” (Hayes et al., 2012, p. 185), or its variant, “If you aren’t willing to lose it, you’ve lost it.” If you aren’t willing to have anxiety, then anxiety is something about which to be anxious, leading to even more anxiety. If you’re not willing to lose love, then you can’t have love because you will constantly be trying to control your beloved. Those examples are focused on experiential control related to emotions, but this paradox also applies to thoughts. If you try to control what the mind is thinking, an immediate problem arises: you have to contact what you’d like to control in order to know that you want to control it—­and in order to try to do so. To help clients understand this, you could ask them not to think about a banana for thirty seconds, for example. Of course, many immediately think about a banana. And the harder they try not to think about a banana, the more they will be thinking “banana,” and then perhaps about banana splits, the color yellow, bunches of bananas, and so on. Some clients will report that they were able to distract themselves. Exploring what they did to accomplish this can usually show that there are significant costs to distracting themselves from thoughts about bananas. Distracting ourselves might work in the short run, but it results in a narrowing of awareness (i.e., we can’t think about anything related to bananas) and it takes energy, leaving us less free to focus on what we’d most want to—for example, our values. You can then discuss how this effort is likely to backfire when applied to thoughts that seem particularly important to control. And indeed, it has backfired; otherwise, the client wouldn’t be complaining about having difficult thoughts. Of course, the aversiveness of thinking about a banana is probably miniscule for most people. However, other thoughts can have a strong impact—­thoughts like “I’m damaged goods,” “There’s something wrong with me,” or “I’ve wasted my life.” Clients often want to get rid of these kinds of weighty thoughts, yet distracting themselves from these thoughts will be much more difficult or costly.

Teaching What Willingness Is Once you’ve explored workability and established control as the problem, you can turn to helping clients practice willingness. Occasionally, clients will already be open to this, in which case you can jump right to practicing willingness, as we’ll describe shortly. However, many clients are hesitant, often because they are unclear about what willingness is, in which case you’ll first need to teach them what it is. Where you start with a client is determined by your conceptualization of the case (see chapter 8). In the following dialogue, the therapist returns to the Quicksand metaphor, but this time for a slightly different purpose: as a way to begin to point to what willingness is like. Therapist: Do you remember the metaphor of falling into quicksand? Client:

Yeah. The harder I try to get out, the faster I sink?

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Therapist: Exactly… The harder you try to get out, the faster you go down. We didn’t talk about what to do when you get stuck in a situation like this—­besides struggle. With quicksand, in order not to sink, what you need to do is the opposite of what you’d naturally think to do. In order to stay afloat in quicksand, you have to gently spread out and let as much of your body contact the sand as possible. (The therapist slowly opens her arms to emulate spreading out in quicksand.) The more of your body you place in contact with the surface of the quicksand, the more you’ll float and not drown. What if getting rid of anxiety is like falling into quicksand? The harder and faster you try to get out of it, the more you sink into it and the worse things get. Maybe the thing to do is to stop struggling—­to get in contact with the emotion and learn to float in it. (The metaphor allows the therapist to point to willingness in a way that’s simple and intuitive, rather than getting caught up in complex descriptions. It also points to willingness as an alternative through the notion of floating in a feeling.) Client:

But floating in it doesn’t get me out of it either.

Therapist: That’s right. What you feel is still there to be felt, even as you let go of the struggle that makes things worse. Is that something you’d be willing to do if it meant you wouldn’t drown? Client:

Do you mean I have to float in order for the anxiety to go away?

Therapist: Two things: First, you don’t have to float; this is your choice about how you’ll be with your anxiety. And second, floating in quicksand isn’t about the anxiety going away… Spreading out in quicksand doesn’t make it stop being quicksand. Trying to spread out in order to get out isn’t spreading out; it’s a tricky way to struggle. Your mind is with you all the time and knows what you’re doing, so it will have the same quality as struggling. (The therapist is pointing out that willingness is chosen, and that anxiety will feel like it feels. It’s important not to get wordy at this point and overexplain. Letting the metaphor stand without additional explanation is likely to be more effective.) Client:

(Sounds disappointed.) But I don’t want to float in quicksand.

Therapist: (Speaks from a grounded and humble stance.) Of course you don’t. Who wants to be anxious? And yet what if this is the choice life is giving you? You’ve fallen into the quicksand. Struggle and get more stuck, or spread out and float? It’s a choice, an action. I’m not sure either of us knows what will happen when you float. But you do know what happens when you struggle, because that’s what you’ve been doing up until now. Client:

Yes, but how do I float?

This is just one example of how to introduce the idea of willingness as an alternative to control efforts. This opens the door to shifting the work to an explicit focus on building new behaviors that are about embracing, holding, and compassionately accepting one’s experience. Clients usually enter therapy with an agenda of wanting to feel better. Acceptance is the work of helping them feel better—­ meaning to get better at feeling (Hayes et al., 2012)—­in the service of living better. In this part of therapy, the clinician’s job is to guide clients in practicing willingness in various contexts, with various private events, and with the goal of developing the ability to apply it broadly in their lives. However,

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clients are generally unsure what will happen if they’re willing to experience their emotions. Letting go of control of internal events can and does feel like taking a step into the unknown—­almost like closing your eyes, taking a step, and hoping that your foot finds the ground. As you explore what willingness is with clients, there are two key points to elucidate: that willingness is a choice, and that willingness is an action.

WILLINGNESS IS A CHOICE “Choice” means making a selection simply because we can. Therefore, the choice to be willing is present in every moment. Often clients assume that they don’t have a choice and list several if not many reasons they can’t choose to be willing. You can work with such clients to help them defuse from or observe their reasons and still take action. There are a couple of quick ways to demonstrate this for clients. One is to give them a choice between two similar objects. For instance, you might ask clients, “Tea or coffee, which would you choose?” After they’ve made a choice, ask them to generate as many reasons as possible to explain why they made that choice, and stick with this until they’ve listed a fair number of reasons. For the purpose of this explanation, let’s assume that a client chose coffee. Then, no matter how good the client’s reasons, such as “I’m allergic to tea” or “The taste of tea makes me sick,” ask if it isn’t true that the client could still choose tea and drink it, despite all the reasons generated. The answer is, indeed, yes. It is not the reason that chooses, but the person. You can then bring this back to the larger issue at hand by asking, “Would you be willing to choose willingness if it meant you got to live your life?” The metaphor of an annoying neighbor (inspired by the Joe the Bum metaphor; Hayes et al., 2012, pp. 279–­280) can be useful in this type of situation. Therapist: Imagine you’ve just purchased a new home and you decide to hold an open house. You make invitations that say, “All are welcome,” and post them around the neighborhood. You’re excited about the party and begin to get ready by making everything look nice and by preparing the food and drinks. The big day comes, and everything is going well. The guests are arriving and enjoying themselves; everyone is laughing and having a good time. More guests are arriving. Then you hear a knock at the door. You open it with a smile, which rapidly changes to a look of distress. There before you stands Edna, a neighbor you’ve already found quite annoying. Edna makes obnoxious noises, is often rude to people, and has terrible manners. You quickly try to close the door, but Edna has placed her foot between the door and the jamb, so you can’t close the door. You ask her to leave, but she shakes her head and shows you one of the invitations you posted around the neighborhood. She repeats the words written in large letters: “All are welcome.” She tells you that she’s not leaving and will stand right there until you let her in. Given the situation—­that she’s not leaving and you aren’t interacting with your guests—­you decide to let Edna in, but you insist she needs to stay away from the guests and remain in the kitchen. You rapidly escort her to the kitchen and admonish her to stay there. You close the door to the kitchen and begin to walk away…and right behind you is Edna. She follows you out of the kitchen. You turn and say, “No, Edna, you must stay in the kitchen,” and escort her back. Once again, you turn to join the party, and…guess what happens. Client:

Edna comes pushing through the door again.

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Therapist: Right. And what you find is that you have to stay in the kitchen with your foot propped against the door to keep Edna out of sight. You’re locked in. What’s the problem here? Client:

I don’t get to be at the party.

Therapist: Yes. So, the big question is, would you be willing to let Edna wander around the house if it meant you got to be at the party too? Client:

It would be hard.

Therapist: Yes, but could you choose to do it and be at your party? Client:

Yeah, that’s what I’d want to do.

Working with clients in this area boils down to a single question, “Are you willing to feel what you feel, have the thoughts you have, and let your sensations be there, fully and without defense, and do what works for you according to what you value?” Though the answer may seem simple and clients often say they are willing, the path is potentially difficult. Clients may continue to struggle, getting entangled in reasons and losing the distinction between mind and self. When this happens, they may lose the experience of being able to choose. The intensity of thought and emotion that may arise when they’re presented with values-­based choices in the presence of negatively evaluated emotions may pull them back into a struggle. In ACT, the therapist’s job is to keep pointing to willingness and choice, linking them to values, and supporting clients’ efforts to take a stance of open engagement in the process of living. At the same time, the therapist validates and empathizes with the client’s experience in taking on this challenge.

WILLINGNESS IS AN ACTION Throughout this chapter, we’ve provided multiple descriptions of willingness. Willingness isn’t a feeling, and it isn’t something that can be directly instructed or described, just as you can’t directly describe how to ride a bicycle, play a musical instrument, or perform a highly skilled sport. This aspect of willingness can be captured, for some, by comparing willingness to something that happens when skiing. Therapist: Have you ever gone skiing? Client:

Yeah, a few times.

Therapist: Have you noticed how, when you’re skiing and you’re afraid you’re going too fast, your natural tendency is to lean away, to lean back into the hill? The problem is, as soon as you do that, you lose control of the direction in which you’re headed, and in fact, you even increase the chance that you’ll wipe out. In this situation, the natural response—­to lean back—­doesn’t work very well. What if this situation in regard to your thoughts and feelings is similar? What if the natural reaction—­to lean away from your own experience—­is actually part of the problem? What if what’s needed here is to practice leaning downhill, leaning into your experience, so you can have more control over where you’re headed in your life?

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Practicing Willingness Having established what willingness is, the next step is to assist clients in practicing willingness, shaping their progress by recognizing and reinforcing even small acts of willingness. Ideally, willingness is practiced throughout therapy and is interwoven with all the other flexibility processes. For example, any time an ACT therapist asks a client to do an exercise or discuss a topic that might evoke difficult content, this provides a chance for the client to choose between willingness and struggle. In-­session and out-­of-­session exercises can be used to structure opportunities for clients to practice willingness. For examples, see chapter 7 (committed action) or exercises in other books, such as the Looking for Mr. Discomfort exercise (Hayes et al., 2012, pp. 285–­296) or exposure-­like exercises (see Eifert & Forsyth, 2005). It is worth noting here that, from the ACT perspective, exposure work isn’t done in the service of reducing fear (i.e., for habituation). Rather, it is engaged as a process of helping clients practice willingness to contact uncomfortable experiences without struggling against them (see Thompson, Luoma, & LeJeune, 2013). Such practices can be utilized at any time in treatment, as long as they are flexibly applied and responsive to the context or situation of the client. ACT willingness exercises often take the form of in-­session exposure exercises in which difficult material is elicited, and then therapist and client work with this material together in session (for more on this topic, see chapter 7). And although willingness tends to have an all-­or-­none quality, the context in which willingness is practiced can be chosen, at least in part (Strosahl, Hayes, Wilson, & Gifford, 2004). For example, clients can choose to be willing for five seconds or for an hour. They can choose to be willing in a mall but not in a bookstore. They can work on willingness with one emotion but not another. Because clients can choose the situation (but not the level of willingness), the therapist can titrate willingness work to the client’s current situation and context. And just as therapists conducting exposure typically create an exposure hierarchy, ACT therapists usually encourage clients to start with small acts of willingness, perhaps for a few moments in a session or with relatively unchallenging private events. They can then move to larger acts of willingness, such as calling an estranged sibling and willingly feeling whatever shows up during that call.

Willingness Depends upon the Other Flexibility Processes Clearly, willingness or acceptance is a process and not an outcome, and it’s so foundational that it is integrated into all aspects of ACT. It isn’t as if clients “get willing” and their work is finished. There is always more willingness to do—­in life and throughout the course of treatment. This isn’t fully possible without the other flexibility processes. However, at this point in the book we can only provide a broad overview of the application of acceptance that occurs later in therapy. Because willingness involves embracing the moment as it unfolds in the here and now, willingness is an important subtext when working with present-­moment awareness, which is discussed in chapter 4. And

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because willingness is a choice that entails letting go of fusion with reasons while simultaneously selecting among alternative courses of action, the fully developed form of willingness incorporates defusion as a necessary component, as discussed in chapter 3. Willingness also interacts with self-­as-­context, discussed in chapter 5, as contact with self-­as-­context, a safe place that transcends one’s experience, facilitates willingness. Having a larger sense of self that transcends emotions, thoughts, and sensations allows people to contact the broad set of experiences they encounter in life without the need to control or eliminate those experiences. Furthermore, willingness to experience difficult thoughts and feelings is generally done in the service of values; this is part of what makes willingness different from wallowing. We’ll explore this further in chapter 6. Finally, willingness is key to committed action, so chapter 7 includes important strategies for bringing willingness to this process.

Core Competency Practice This section is intended to provide practice in working with willingness in response to sample dialogues based on ACT sessions. There is one exercise for each of the eleven ACT core competencies for willingness and acceptance. For each, we present a description of a clinical situation and a brief dialogue. (Some of the dialogues continue across multiple competencies.) Most of the dialogues also include other elements of the ACT model because a single process is seldom used in isolation. Each dialogue ends after a client statement, at which point we ask that you provide a response that reflects that competency. Then we ask you to describe the basis for your response. For each exercise, focus on providing a response that illustrates the target competency, rather than responses that are consistent with ACT in general. You can also describe any steps as part of the response that would contribute to implementing the competency most effectively. After you provide a response and your explanation, turn to the end of the chapter, where we provide model responses that you can compare your response to, typically two for each exercise. The model responses are not the only correct responses, and we don’t offer them as perfect or ideal responses. Often there may be scores of well-­conceived ACT-­consistent alternatives. Our main purpose in providing models is to give you a sense of what a high level of competency might look like. If your response aligns with one of the models, that’s an especially good sign. If your response seems to fit the explanation and competency just as well as the models do, you’re doing fine. If you think the model responses might be more powerful than your response, try to learn from them. If you don’t understand the model responses or they suggest that your response is off track, reread the relevant portions of this chapter or consult other texts. We strongly recommend that you not read the model responses until after you’ve written your own response. Coming up with your own responses first creates the greatest opportunity for learning and allows you to maximally benefit from the feedback inherent in the model responses. If you really want to stretch your flexibility, you can write multiple possible responses before looking at the samples. Before you get started, we’ll offer the following example of how you might complete one of these exercises.

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Competency 2:  The therapist helps clients make direct contact with the paradoxical effects of emotion control strategies.

Completed Sample Exercise The client is a nineteen-­year-­old female college student who complains of social anxiety and a general lack of color or excitement in her life. She feels that this is related to her childhood history of sexual abuse. Through therapy, she’s been able to see how memories of the abuse surface when she finds herself feeling close to people. In response, she distances or numbs herself. This dialogue occurs in her sixth session. Therapist: So, let me see if I get the sequence. You’re sitting around with your boyfriend; he touches you; you start to feel anxious and really unsafe; and then you feel ashamed that you feel that way. Right? Then you find some excuse to get out of there and go home and drink so you don’t have to think about it. Is that the sequence? Client:

Yeah, I just can’t think about it. It’s too hard. I’m so tired. I just need a way to get over this.

Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 2: Therapist:

If talking about this experience could make it possible for you to have the open, loving relationship you so want, would you be willing to do that?

Client:

Yes.

Therapist:

So let me ask you then: The more and more you’ve tried to make these anxious and guilty feelings go away, what have you found? Have they decreased over time, or have they perhaps even gotten stronger, and in the meantime you still find yourself feeling distant, lonely, and cut off?

In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish? Her avoidance clearly isn’t working given what she wants in life. I’m linking up this issue with her values and getting permission to talk about what’s likely to be a painful and sensitive subject, one in which the client might feel challenged and perhaps even intruded upon. Then I’m having her check out whether this strategy has actually worked out the way it was supposed to, or whether perhaps it has, paradoxically, made things worse.

(After writing your own response, you would then check it against the models at the end of the chapter before going on to the next exercise.)

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Core Competency Exercises Competency 1:  The therapist communicates to clients that they are not broken but are using unworkable strategies.

Exercise 1 A fifty-­six-­year-­old man has come to therapy seeking relief from anxiety associated with PTSD. He has been in a number of treatment programs and worked with at least three other therapists and two psychiatrists. He complains that he can’t do regular, everyday kinds of things because his anxiety is too high. He isolates himself and wishes things were different and also uses other avoidance strategies. Just prior to the start of this dialogue, the client has listed about ten strategies he uses to get rid of anxiety. Client:

What I’d really like to do is find a way to get this anxiety under control.

Therapist: It seems you’ve tried a lot of different things. You’ve certainly made an effort. Client:

Yeah, I just need to try harder…to figure out what will make this different.

Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 1:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 2:  The therapist helps clients make direct contact with the paradoxical effects of emotion control strategies.

Exercise 2 This dialogue continues where the dialogue for competency 1 left off. Therapist: So trying harder seems like the thing to do. But haven’t you tried hard in the past? You’ve gone to treatment programs, therapists, and psychiatrists. You’ve listed numerous things you’ve tried. You’ve tried hard, yes? Look at your experience. What do you know from there (points to the client’s heart) and not there (points to the client’s head)? What does your experience say about the results of trying hard? Client:

It hasn’t worked so far.

Therapist: Right. And what if that’s because it can’t? What if you really did give it a good attempt, but this is how trying hard actually works in this area? (Points to the client’s chest again.) Client:

I see what you mean, but I just want things to be different. I’m feeling anxious all the time. I can’t stand being like this.

Therapist: If things were different with your anxiety, what would you be doing? Client:

Everything would be different. I’d be able to be around people. I could work. Everything would be a lot better.

Write here (or in a notebook) what your response would be, demonstrating competency 2:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 3:  The therapist actively uses the concept of workability in clinical interactions.

Exercise 3 This dialogue continues with the same client as in the competency 2 exercise but occurs later in the session. Therapist: How successful have you been at making things different when you try harder? Client:

Well, it works for a little while, and then the problems start all over again. The anxiety comes back.

Write here (or in a notebook) what your response would be, demonstrating competency 3:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 4:  The therapist actively encourages the client to experiment with stopping the struggle for emotional control and suggests willingness as an alternative.

Exercise 4 A forty-­one-­year-­old woman is seeking therapy to alleviate anger and sadness around the breakup of a relationship. The breakup occurred three years before she entered therapy. In her initial session, the client explained that she feels betrayed and unable to move past the pain of the breakup. She notes that her anger is interfering with her ability to move on. She also notes that she’s angry with herself for being duped in the relationship. This dialogue occurs in her fourth session.

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I feel overwhelmed by my anger…and I feel stupid. It’s been three years. Why can’t I get over this? It’s embarrassing.

Therapist: Somehow getting over this seems like the thing to do, and then embarrassment and “stupid” will go away, in addition to the anger? Client:

Silly, isn’t it?

Write here (or in a notebook) what your response would be, demonstrating competency 4:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 5:  The therapist highlights the contrast between the workability of control and willingness strategies.

Exercise 5 For this exercise, assume you have the same client as in the exercise for competency 4, but the session goes like this instead: Client:

I feel overwhelmed by my anger…and I feel stupid. It’s been three years. Why can’t I get over this? It’s embarrassing.

Therapist: Somehow getting over this seems like the thing to do, and then embarrassment and “stupid” will go away, in addition to the anger? Client:

Silly, isn’t it?

Therapist: I can see you have a lot of judgment about your anger. You think it’s silly and stupid.

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It is. I just can’t believe I’m still angry about this. It doesn’t make any sense to me.

Write here (or in a notebook) what your response would be, demonstrating competency 5:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 6:  The therapist helps the client investigate the relationship between willingness and suffering.

Exercise 6 This dialogue continues with the same client as in the exercise for competency 5 but occurs later in the session. Therapist: What kind of effort have you put into making the anger go away? Client:

A lot. I can’t even begin to describe how hard it’s been.

Write here (or in a notebook) what your response would be, demonstrating competency 6:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 7:  The therapist helps the client make contact with the cost of unwillingness relative to valued life directions.

Exercise 7 This dialogue continues where the dialogue for competency 6 left off. Therapist: What are some of the things that have happened because of this difficulty? How has your life changed as a result of how hard this has been? Client:

Well, I’m suspicious of men. I think they’re all trying to pull the wool over my eyes. I’ve stopped dating completely. I tried it a couple of times, but found myself being cranky on the dates. I’m incredibly lonely and feel angry at men… I blame men for that. I’m just out of control about men… How can I ever trust them?

Write here (or in a notebook) what your response would be, demonstrating competency 7:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 8:  The therapist helps the client experience the qualities of willingness.

Exercise 8 This dialogue continues with the same client as in the exercise for competency 7 but occurs in a later session. Therapist: How important is it to you to have another relationship? Client:

I would really like one, but I just don’t think it’s possible. Something really significant would have to change.

Write here (or in a notebook) what your response would be, demonstrating competency 8:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 9:  The therapist uses exercises and metaphors to demonstrate willingness as an action in the presence of difficult internal experiences.

Exercise 9 A fifty-­year-­old man is in therapy because his wife has insisted he get help for his withdrawn and irritable style of interacting with her. He reports that he feels distant from his wife and has wanted her to leave him alone ever since a misunderstanding that resulted in a financial loss. He notes that he’s extremely disappointed in his wife, even though he recognizes that the financial loss was not her fault.

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Therapist: What would you choose to have happen with this relationship? Are you wanting it to end? Client:

No, I don’t want a divorce or anything like that. I just can’t bring myself to talk to her. I almost can’t even look at her. I know that losing the money wasn’t her fault, but I still blame her. I want the money back.

Write here (or in a notebook) what your response would be, demonstrating competency 9:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 10:  The therapist models willingness in the therapeutic relationship and helps the client generalize these skills outside therapy.

Exercise 10 This dialogue continues with the same client as in the exercise for competency 9 but occurs later in the session. Client:

I am ashamed that I’m so focused on the money. It’s hard to admit. I’m worried that you might think I’m an asshole.

Therapist: It’s hard to admit these things. It can be anxiety provoking. Client:

Yeah, I’m having a hard time talking about it with you… I’m not sure you can help.

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Write here (or in a notebook) what your response would be, demonstrating competency 10:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 11:  The therapist can use a graded and structured approach to willingness assignments.

Exercise 11 This dialogue continues with the same client as in the exercise for competency 10 but occurs later in the session. Client:

I don’t even know where to begin. It’s like, now that I’ve started ignoring her, I can’t find a way to stop. I feel like it’s impossible to get out of this.

Therapist: It seems like even a small gesture toward your wife feels hard. Client:

Just looking at her feels hard.

Write here (or in a notebook) what your response would be, demonstrating competency 11:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Core Competency Model Responses Competency 1 Model Response 1a Therapist: Another way to say what you just said is “I’ve got to try trying harder.” Have you tried to try harder before? Client:

Sure. And harder, and harder.

Therapist: So, I want you to consider that maybe the problem here isn’t that you haven’t tried hard enough. Maybe the problem is something about the tools you’ve been given by society, by your parents, and by your history—­the things you’ve been taught to do to deal with this. Maybe they just don’t work here. It’s as if you’ve been trying to use a hammer to paint a masterpiece. Now I’m also not saying I have a different, better tool, because you’ve done that, too—­looked for a better tool. This trap you’re in is trickier than that. Explanation: It’s important for the therapist to openly recognize that control of internal experience is a socially trained phenomenon. It isn’t the client’s fault that he would try such a maneuver. He’s been taught by his social/verbal context that he should be able to solve the problem of anxiety. He’s been taught that these maneuvers should work. Trying harder is just another part of that social/verbal context, as evidenced by sayings like “If at first you don’t succeed, try, try, again.” Model Response 1b Therapist: So trying harder seems like the thing to do. But haven’t you tried hard in the past? You’ve gone to treatment programs, therapists, and psychiatrists. You’ve listed numerous things you’ve tried. You’ve tried hard, yes? Look at your experience. What do you know from there (points to the client’s heart) and not there (points to the client’s head)? What does your experience say about the results of trying hard? Client:

It hasn’t worked so far.

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Therapist: Right. And what if that’s because it can’t? What if you really did give it a good attempt, but this is how trying hard actually works in this area? (Points to the client’s chest again.) Explanation: Here the therapist validates the client’s effort while pointing to the fruitlessness of this effort. ACT therapists don’t ask clients to believe these efforts are fruitless because the therapist says so; rather, clients are asked to examine their own experience to see whether these efforts have paid off. These kinds of statements aren’t made in an attempt to gain a one-­up position in relation to the client or to shame the client for trying hard and failing. In this response, the therapist simply points to a system that doesn’t work, from a humble stance.

Competency 2 Model Response 2a Therapist: I see that these things are important to you: to work and have people around you. It seems like getting control over the anxiety is the route there. But something seems strange here. You’ve been working at trying hard to control your anxiety for quite some time, and as far as I can tell, things haven’t turned out as you’ve hoped. In fact, here you are, sitting in front of me seeking yet another way to make your anxiety go away—­to make your anxiety different. And these things you hope for—­work, relationships—­aren’t getting closer. Explanation: The therapist states that something is strange, as if to say this isn’t the client’s fault but the way it works is odd. This is a relatively defused contact with workability. The therapist also points out that the client seems to be doing the same thing he’s done in the past: work with a therapist to come up with yet another strategy for eliminating anxiety. This statement points to the paradox inherent in control efforts. This can be a tricky place for the therapist, who probably feels a pull to rescue the client and reassure him that there is a way. However, this would be premature at this point and would undo the effects of contacting the unworkability of control. Model Response 2b Therapist: Do you see what’s happening here? Here you are working to make your anxiety go away, but it stays. In fact, it seems that if you don’t want it, you’ve got it. If you don’t want your anxiety, you’re going to get anxiety. In fact (speaks somewhat playfully), not being able to get rid of your anxiety is something to be anxious about. In your experience, as you’ve worked on this has your problem seemed to be getting larger or smaller? Explanation: The therapist shares an idea with the client that reflects the paradox of control—­that if you don’t want it, you’ve got it—­and asks the client whether this fits with his experience. Appealing to the client’s experience is particularly important here. None of what the therapist says should come across as an effort to convince the client about the problems with control. Convincing is content heavy and moves clients away from the experience that everything they’ve tried hasn’t worked. Here, the therapist directly points to the issue of what the client’s experience says about how control has worked for him in reducing his anxiety over time.

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Competency 3 Model Response 3a Therapist: In your experience, has there ever been a significant amount of time when you didn’t experience anxiety? Client:

No.

Therapist: Is this struggle with anxiety opening up your life or closing it down? Explanation: One of the goals of ACT is to help clients move toward a workable agenda that’s guided by their values. Clients can actively bring willingness to taking steps intended to build a better life. Again, workability is about living better, as defined by the client, not necessarily feeling “better.” Model Response 3b Therapist: You’ve hired me. So I’m here to work for you. Client:

Yeah, I guess.

Therapist: Is part of my job to tell you what I see? Client:

Yeah. What do you see?

Therapist: From what you’ve told me, you’ve done many if not most of the reasonable, sensible, logical things you could do to get your anxiety under control. You’ve worked very hard and tried many, many sensible and reasonable options. But something seems strange here. It seems like nothing has worked. The bottom line is that this—­what you’ve been doing—­isn’t working. Not in terms of reducing your anxiety: it’s still there. And not in terms of your life working: you still aren’t around people, still aren’t working. Explanation: The therapist directly addresses the issue of workability, both in terms of gaining control over unwanted internal experiences and also in terms of larger life goals. This is a fairly direct response. Some clients won’t react well to such directness, but some will. If you choose to use this kind of approach, it’s important to do so in alignment with the ACT therapeutic stance, which includes compassion—­recognizing that sometimes compassion means helping people see when their behavior is leading to more suffering over the long term. Model Response 3c Therapist: So you say you do something and it works for a little while. Let’s follow this out a bit. What happens next? Client:

Things go okay for a period of time, but the anxiety comes back and I’m right back in it.

Therapist: And then what happens? Client:

The same thing… It just starts all over again.

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Therapist: And when it starts all over again, what does it seem like the thing to do is? Client:

Try harder.

Explanation: As in the previous model response, the therapist is directly addressing the issue of workability, but this time pointing to the repetition of failed strategies. From here, the therapist might move to why we humans keep trying to control our internal experience even though that doesn’t work. This could be followed by a discussion about why we keep using control: that it works outside the skin, that we’ve been taught it should work, and so on. This will help clients understand that they aren’t to blame for continuing to engage in an ineffective approach.

Competency 4 Model Response 4a Therapist: Feeling silly is tied to this, too…another thing to get over. It seems that there’s a lot of work to be done. First you have to get over feeling anger, and then the feeling that you shouldn’t have the anger, and then the feeling of embarrassment and the thought that you’re stupid about the anger…and then silly. This is a big struggle, and also it seems to be growing… It’s as if you’re in a tug-­of-­war with your emotions. If they win, you lose. And you keep trying to win, but it seems that no matter how hard you pull, your emotions don’t ever lose… I wonder if there’s a different way to play this game? Maybe this isn’t about winning the tug-­of-­war but about learning how to drop the rope. Explanation: Here the therapist is working with the client to help her see that the problem is the struggle with internal content, not the content itself. The therapist should stay grounded in compassion for the client’s protracted struggle. These feelings of anger and embarrassment and thoughts of being stupid are natural reactions to being betrayed in a relationship. The difficulty isn’t that they occur, but the attachment to them and struggle against them. The therapist is directly encouraging the client to practice acceptance through the metaphor of dropping the rope. If the client is willing to feel these things as they are, then she can step out of the struggle and focus on her life direction instead. This isn’t a simple thing; it’s difficult to drop the rope because battling to make unwanted experiences go away feels like the thing to do. So when taking this approach, it’s important for the therapist to maintain compassion for the client and to communicate recognition of the difficulty of the struggle and how easy it is to engage in it. Model Response 4b Therapist: Well, let’s take a look at the anger for a moment. If I could reach over and peel the anger out of you and see what’s left behind, what do you think I’d discover? Client:

(Hesitates.) More anger.

Therapist: And if I could peel that away, too? I wonder if I might discover a very powerful feeling of hurt and betrayal… Is it possible that the anger is a way to escape the pain? Client:

Yes.

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Therapist: What if all of this struggle you’ve been experiencing is about avoiding pain, but the only way to move forward is to turn toward the pain, rather than away from it? Explanation: The therapist is addressing the problem of avoidance as part of the struggle, in this case by looking at the function of the client’s anger: avoidance of pain. The therapist is leading the client in the direction of willingness to experience pain as an alternative to the long-­standing struggle to escape it. The goal is to help the client recognize and even welcome the pain (perhaps using the Annoying Neighbor metaphor to support this kind of welcoming), rather than staying focused on escaping it. If she’s willing to experience pain, she has functionally dropped the rope.

Competency 5 Model Response 5a Therapist: Do you know what would happen if you went inside the anger and tried to see what’s there? Maybe it doesn’t need to go away for you to do something different with it. Explanation: Just raising the possibility of a different approach undermines an agenda of avoidance and control. Model Response 5b Therapist: I can see why it doesn’t make sense to you. But maybe it depends on your goal. If your goal is to feel better, to not be angry anymore, then it seems trying harder to fix the anger would be a reasonable thing to do. It’s logical, right? However, if your goal is to find another relationship, then focusing on getting rid of anger may interfere with doing whatever there is to be done. There are other things people do to find relationships: go to parties, make phone calls, have friends introduce them to someone—­things like that. It seems you’re trading away finding a relationship for getting rid of anger. Explanation: This response points to how the endeavor to control internal events often comes at the expense of vitality. The client believes that when she doesn’t feel angry anymore, she’ll be able to find someone. In the meantime, years of her life are slipping away. If she’s willing to feel the anger and hurt while also making choices that lead to vitality, she might not feel so stuck. It’s important to note that the therapist isn’t asking the client to be angry. Rather, the therapist is supporting moving forward and creating the opportunity to be in a relationship without insisting that a different feeling be there first.

Competency 6 Model Response 6a Therapist: What do you think would happen if you stopped putting so much effort into making the anger go away? It seems like a lot of suffering accompanies this effort. Is there a potential for less suffering?

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Explanation: By using this kind of questioning, the therapist is pointing out the difference between willingness and suffering. The effort alone has become burdensome and weighs on the client. Simply suggesting “no effort” opens the door to willingness and can potentially lead to a decrease in suffering. Model Response 6b Therapist: Does the difficulty of trying to make your anger go away make you angry? (The client nods and laughs.) I thought it might. A strange thing happens when we’re working to control certain emotions. If you really don’t want to be anxious, for example, then you feel anxious about getting anxious. Or if you really don’t want to feel stupid and silly, then you feel stupid and silly about feeling stupid and silly. Do you see what I’m talking about? Client:

Yes.

Therapist: And now you have anger about your anger. We could distinguish it by calling it “suffering anger,” as opposed to “natural anger.” “Natural anger” is the anger that shows up when you feel betrayed…and hurt is in there too. “Suffering anger,” on the other hand, is anger about the anger. Explanation: As in the previous model response, the therapist is helping the client investigate the difference between willingness and suffering. Willingness to experience the initial and natural anger and hurt while also noticing thoughts of being duped is much different from having these experiences and then insisting on not having them while also being angry for having them. The insistence creates more pain. The therapist is setting the stage for willingness as an alternative. Model Response 6c Therapist: You say you can’t even begin to describe how hard it’s been. It’s as if getting rid of this anger is almost more challenging to deal with than the anger itself. Explanation: This is a straightforward way to point to the distinction between willingness and suffering. The client’s use of the word “hard” is itself an indication of the difficulty brought about by suffering.

Competency 7 Model Response 7a Therapist: If we work this out logically, it seems as though you’ll have to trust men again before you can have the relationship and life you’d like. Client:

Yeah.

Therapist: I sense a problem here. In my experience, trust doesn’t work that way. It doesn’t just show up. Trust is a process. In the meantime, while you’re waiting to be trusting, you find

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yourself alone. I’m wondering… When you’re sitting there feeling lonely, does your trust of men grow or get smaller? Explanation: Here the therapist is pointing to the difficulty of trying to make a particular feeling show up as a way out of another experience. This too can be costly. If the client is waiting to feel trust, she could be waiting a long time. And as the therapist points out, sitting alone being angry doesn’t build trust in men; it builds mistrust. The cost of the client’s unwillingness to feel whatever is there to be felt when she goes out with men doesn’t allow the process of building trust to happen. Model Response 7b Therapist: If you were able to trust men, what would you hope would happen? Client:

(Speaks in a sarcastic tone.) Well, then I’d be able to at least have a shot at being in a decent relationship—­if I could actually find a decent guy.

Therapist: So what you want is to get over this guy so you can have a decent relationship, right? Client:

Yeah.

Therapist: Can I ask you a question about that? (The client nods.) And I’d like you to check your experience as you answer it. Don’t just check your head; notice what your experience has to say. As you work hard to get over that breakup, are things working out the way you hoped they would? You know, as you’ve worked to get over it, have you been getting closer to having the kind of relationship that you want, or have you found yourself paradoxically moving further away from it? Explanation: The therapist helps the client examine the paradox of control and its costs in terms of not engaging in values-­based actions. The client is waiting, and in the meantime she’s putting what’s important to her on hold.

Competency 8 Model Response 8a Therapist: I invite you to notice how your mind is pulling you into the future. It’s saying you need to feel and think something completely different—­that something significant would have to happen. What if instead we stay here, in this moment? What if it were okay to feel what you feel and think what you think? Not “okay” meaning you like it, but “okay” meaning you’re present to it. What if there were no need for it to be different, not in this moment or any other moment in the future. Experiencing fear of loss or betrayal will show up when it shows up. We can’t predict the future. If this makes sense to you, the question really is this: What is present for you now, and are you willing to experience that more fully? If you let yourself contact these emotions, here and now, what is your experience?

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Explanation: Willingness isn’t about the future; it’s about the present, and there are always feelings and thoughts to be experienced. Orienting the client to this notion and bringing her into the present helps her see one of the qualities of willingness experientially, not just through explanation. Model Response 8b Therapist: So, here it is. It feels like something significant would have to occur, like never being duped again. “Duped” would have to go. Client:

Yeah, I don’t want to feel stupid like that. I don’t ever want to be in that position again.

Therapist: Can you contact “duped”? What are the qualities of “duped”? It sounds like “stupid” is in there. What else is in there? What else is in “duped”? Client:

Well, I guess I feel a little shame and embarrassment, like I should have known better.

Therapist: So there’s betrayal—­which is painful stuff—­and what comes along with it is embarrassment and shame, and your mind is giving you “stupid” and “should have known better.” Client:

Yeah. I even feel it a bit as we talk about it.

Therapist: Ah, and as you feel that and think that, is it possible to carry that stuff with you willingly, and to head into a relationship or into the stuff that you do to get a relationship? Client:

I suppose I could, but I don’t want to.

Therapist: That’s understandable. Client:

I mean, I don’t want to have to feel that again.

Therapist: I hear you. And yet here you are feeling it a little even as we talk about it. You have a good sense of what these experiences feel like. Client:

I know them all too well.

Therapist: Will those be the things that keep you out of relationships? Or given that you know these experiences, could you feel them and think them and still do the stuff that gets you into relationships? Client:

You mean, like feel embarrassed and still go out with someone?

Therapist: Yeah, would you be willing? I’m not asking you to like it, but if it got you headed toward connection and a relationship, would you be willing to hold this stuff as you know it and take some kind of action? Explanation: The client’s statement that something would have to change suggests experiential avoidance. The therapist makes a guess at what the client is avoiding by saying, “‘Duped’ would have to go.” The therapist then proceeds to bring the avoided emotional experience into the room and leads the client to explore it, make room for it, and experience it willingly. In addition, the therapist works to

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change the function of the word “duped”; if the client is willing to have “duped,” it is no longer in control of her behavior. Finally, the therapist is careful to differentiate willingness from wanting or liking and also ties willingness to valuing. Model Response 8c Therapist: What if possibility isn’t based on how you feel but is instead based on what you do? Explanation: This response points to the central quality of willingness: that it entails actions taken by choice. Willingness is embodied by doing; it’s a stance taken toward emotions, thoughts, and sensations while engaging in values-­based actions.

Competency 9 Model Response 9a Therapist: So, one thing we could do is focus on the money, but that doesn’t seem as though it would be useful right now. If you’re interested in keeping this relationship, it seems we need to work on the things that would make that happen. You’re saying you can’t bring yourself to talk to your wife or look at her, as if the disappointment were holding you back. Client:

Yes.

Therapist: Is it possible to feel disappointed and actively choose to talk to and look at your wife? Client:

No, I don’t think that’s possible.

Therapist: If it were possible, would you choose it? Client:

Yes.

Therapist: So here’s the deal… Would you be willing to feel disappointed and talk to your wife if it meant you got to keep the marriage? (Pauses.) Have you ever thought something in your mind but done something different with your actions? For example, have you ever thought, “I don’t feel like getting out of bed today and going to work,” and then you did it anyway? This is a bit like that: you have the feeling of disappointment, and you talk to your wife. Explanation: Multiple things are happening in this response. In addition to establishing willingness as a choice, the therapist addresses engaging in values-­based action and could then continue to work with the client on taking action while accepting the disappointment. In other words, the disappointment need not be resolved before the client can begin to interact with his wife. And in a dynamic similar to that in other examples for this core competency, it’s likely the client’s disappointment will grow if he continues to choose not to interact with his wife. Using the metaphor of the Annoying Neighbor, described earlier in this chapter, could be helpful at this point. If used, this metaphor shouldn’t be delivered in a trivializing or lighthearted manner. A relationship is at stake, and any metaphor used should reflect the gravity of the situation.

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Model Response 9b Therapist: (Stands up and walks around.) I can’t stand up and walk around right now. There is no way for me to do this. I am incapable of walking at this moment. (Sits back down.) And I certainly don’t want to sit down. (Pauses.) See how that happened? I had the thought that I didn’t want to do something, and I did it. You have the thought that you can’t talk to your wife, and you could do it…if you choose to. I know it doesn’t seem as easy as what I just did, but I want to point out that this might be both easy and hard at the same time. It’s hard because your mind says it is, and it’s easy because it’s simply a chosen action. Probably lots of thoughts and feelings will come and go as you choose to talk to your wife. These things work like that—­they come and go, yet they aren’t what chooses your behavior. Explanation: The therapist’s small, experiential demonstration helps the client see that thoughts don’t control behavior. They’re associated, but not causal. The client can choose to take action with respect to his relationship: he can choose to look at his wife and talk to her while also experiencing disappointment and all the other emotions and thoughts that are likely to show up in such a situation. Some readers of the first edition of this book expressed concern that this kind of approach could lead clients to feel like the therapist was mocking them, and this is a possibility to watch out for. If something like this does result in an alliance rupture or misunderstanding, this can be a good context for learning about how attachment to a particular story or unwillingness to feel particular emotions can lead to relationship difficulties for the client (including with the therapist).

Competency 10 Model Response 10a Therapist: I can feel myself wanting to move away from this topic because I can see how much pain it’s causing you. I can see the tears in your eyes. I almost want to change the subject and talk about the lost money, but I think it’s important to stay with the shame and disappointment. I wonder if we could take a moment and stay present to what’s in the room? Explanation: Here the therapist demonstrates willingness by asking herself and the client to stay present to the different emotions in the room. It would be easy to shift the topic to the money or to a conversation about the client’s wife. It’s important, however, for both therapist and client to remain present to the emotion as the therapist models willingness. Model Response 10b Therapist: Lots of judgments and thoughts can show up around issues of money. I notice it in my own relationship. I wonder if there’s a way to see these stories for what they are—­thoughts—­ and to not let them dictate how you and I interact with each other. Maybe we can recognize that judgment is a part of this process of talking about money and make space for these judgments as part of our relationship, instead of trying to make judgments something that have to be kept out of our relationship. I’m willing to have you experience these

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judgments and the things that triggers in me as part of caring about you. Are you willing to have your judgments and work to stay present with me? Explanation: Here the therapist’s self-­disclosure normalizes judgments about money, an approach that can foster acceptance. The therapist also demonstrates willingness to experience judgments and thoughts and still remain engaged in the session with the client. Making room for judgment without buying into it and moving forward in the session provides a model of willingness. In addition, the therapist frames the current, in-­session situation in terms of acceptance of judgments in the context of the relationship itself. The idea is that judgments can be included in the relationship, rather than being a barrier that must be eliminated or removed before connection is possible.

Competency 11 Model Response 11a Therapist: I wonder if starting small makes sense. Would you be willing to feel what you feel when you look at your wife and still look at her, even if for just a few moments, if it meant you got to have your connection with her back? Explanation: Here, the therapist is linking a small display of willingness to the client’s values. She’s helping the client open up to the difficult emotions he experiences when looking at his wife—­not just for the sake of feeling difficult emotions, but in the service of values-­based living. The therapist is also using a graded approach by suggesting “a few moments” as a starting point. Model Response 11b Therapist: Let’s look at not knowing where to begin. Finding that initial place to reengage can be challenging. Your mind will say, “I’m too disappointed. I can’t.” But if you were to take your mind with you and not let it be in charge of your actions or your willingness, what might you choose to do as a small start? Explanation: The therapist is using defusion to support willingness while also turning to the client for a suggestion about where to begin. Again, this is a graded approach because the clinician is asking for a small action the client might take to reengage with his wife. If the client were to offer something fairly major, like showing affection, the therapist would assess the likelihood of the client being able to do this and, if it seemed unfeasible, work with the client to dial the task back. For instance, with the therapist’s help, the client might decide to start by saying a few kind words. Model Response 11c Therapist: When you say it feels impossible to get out of this, it makes sense in terms of the way your mind might be working it out. But is it possible that your mind doesn’t have an accurate assessment of this situation? If it truly is impossible, where do we go?

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I see what you mean, but I just feel so stuck.

Therapist: Well, maybe the answer isn’t in figuring it all out now—­knowing the outcome. Perhaps it can be done in a step-­by-­step fashion, bringing willingness to doing each action in a more planned way. This will present its own challenges. It will probably feel awkward and hard at times, but it would be a process of open engagement, not an all-­or-­none deal. Explanation: Here, the therapist is working with the client to set up a more structured path he can follow to reengage with his wife. This helps create a sense that the client can get unstuck by choosing to be willing in the presence of a well-­planned strategy while also addressing the process. There is no particular outcome that can be predicted, but ongoing engagement in the process is a way of engaging in values-­based actions no matter what the outcome. The therapist also acknowledges the awkwardness than can show up when approaching an interpersonal relationship in a planned way. Ultimately, the therapist and client can work together to come up with a structured approach, such as starting with a few kind words, moving to eye contact, then to touch, and so on.

For More Information For more information about acceptance, including exercises and metaphors, see Hayes et al., 2012, chapters 6 and 10, or Harris, 2009, chapters 5, 6, and 8. You’ll also find a wide range of exercises and metaphors related to acceptance in Stoddard and Afari, 2014. For acceptance-­related exercises and worksheets that you can use for yourself or for clients, see Hayes, 2005, chapters 3, 4, 9, and 10.

CHAPTER 3

Undermining Cognitive Fusion

I used to think that the brain was the most wonderful organ in my body. Then I realized who was telling me this. —­Emo Philips

Key targets for cognitive defusion: Help clients see thoughts as what they are—­thoughts—­so they can respond to those thoughts in terms of their workability relative to client values, rather than in terms of their literal meaning. Help clients attend to thinking and experiencing as an ongoing behavioral process; look at their thoughts, rather than from thoughts; and notice their thinking, rather than being overly attached to or trapped in thinking.

In relation to thinking, people are a bit like fish who don’t know they’re swimming in water. We swim in a river of thought but rarely notice the river itself. And whether we are aware of it or not, language often overregulates our behavior, meaning we get caught up in thinking, giving it control, rather than observing thinking while also making healthy choices. While verbal regulation is often helpful, as when following verbal directions to a new location, at other times this largely automatic, unintentional, and historical process of relating one event to another can lead us in unhelpful directions. The flexibility process called cognitive defusion works to balance out the excesses of verbal behavior, allowing clients to choose whether or not to respond to thoughts and freeing them to pursue desired directions in life. When the impact of thinking on behavior is less automatic, behavior can be determined by context, experience, and chosen values.

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What Is Cognitive Defusion? ACT argues that the problem with human suffering as it relates to thoughts is not that we have the wrong thoughts, but rather that we spend too much time in them or looking from them, rather than simply looking at them or observing them. Cognitive defusion attempts to circumvent this problem by drawing clients’ attention to thinking as an ongoing behavioral process and helping them spend more time seeing thoughts as thoughts. This is done in the service of being able to respond to thoughts in terms of their workability, rather than as though they were literally true. We humans generally respond to thoughts and feelings as if they directly cause our behavior. For example, if you ask someone why she stood alone in a corner the whole time at a party, an acceptable answer might be, “I was too worried; I thought I might embarrass myself.” In this way of thinking, the thought (“I might embarrass myself”) caused the behavior (standing alone in a corner). However, it’s easy to think of contexts in which this relationship might be quickly altered, for example, if someone at the party shouted “Fire!” At that point, “I might embarrass myself” would no longer be a reason to stay in the corner, but perhaps a reason to leave it. From the ACT perspective, the idea that the thought caused withdrawal is only one way of speaking about the situation, and perhaps a disempowering one. ACT also views human emotions through this same lens. Thoughts and feelings are always seen in context, and only in certain contexts are particular thoughts or feelings tied to particular behaviors. In ACT, the focus is not on the specific content of clients’ thoughts and feelings; it’s on clients’ relationship to those thoughts and feelings or the functions of those private experiences. Then, by altering the context, we can help clients alter the function of a thought or feeling. Thus, in cognitive defusion, rather than trying to directly change the form or frequency of thoughts or emotions, the therapist targets the context that relates the thoughts and feelings to undesirable overt behavior, thereby creating greater response flexibility. An example of a specific defusion technique, the exercise Milk, Milk, Milk (Hayes et al., 2012, pp. 248–­250) can clarify this point. If a person rapidly says a word over and over again for thirty to sixty seconds, two things usually happen: the word temporarily loses some or most of its meaning, and other functions of the word tend to emerge more dominantly, such as its sound or how it feels to move one’s mouth when saying the word. You can try it yourself quite easily. First, imagine a gallon of milk for a few moments, and then repeat the word “milk” out loud for at least sixty seconds. Listen to and notice what happens. Among the most common reactions is that the word seems to lose its meaning. In addition, the imagery elicited by the word often weakens or disappears. As in some other defusion techniques, the word or phrase is still present, but a nonliteral context is created that diminishes its normal symbolic functions and increases its more direct functions (in this example, its auditory or kinesthetic functions). Used clinically, this technique can be demonstrated as just shown, and then be repeated with a self-­referential word that appears to be important based on case conceptualization—­“worthless,” for instance. Stated another way, defusion techniques help clients see thoughts as thoughts and be less fused with what the thoughts imply. Importantly, defusion is not accomplished through logical argument or instruction, but rather through modifying the context in which thoughts are experienced. As a result, the literal functions of problematic thoughts are less likely to dominate as a source of influence over behavior, allowing more helpful, direct, and varied sources of control over action to gain ground.

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Why Cognitive Defusion? Stated simply, cognitive defusion focuses on freeing clients from the dictates of thinking. Defusion techniques are most useful when clients are engaged with their thinking in a number of potentially problematic ways. Examples include when clients are holding the literal meaning of a word to be true, when they’re trying to control their thinking, when they’re generating reasons to justify their behaviors, or when they insist on being right, even at personal expense. Defusion techniques used in ACT include meditative exercises, experiential exercises, metaphor, and language conventions. Once defusion has been established, clients are encouraged to focus on effective action in current situations. The following example illustrates how this might be helpful. John’s alarm doesn’t go off, and he wakes up late. He immediately thinks of his wife and a thought appears: She set the alarm wrong. If he doesn’t catch that this is a thought, he may begin to look at the situation as structured by that thought. He need not be aware of this process in order for it to occur. If he were, in that moment, aware of the process of thinking and of the fact that he just had a thought, he might not turn to his wife and say, “You forgot to set the clock again. Now I’m late.” But he does, and then his wife feels blamed and an argument ensues. If John had been able to observe the thought, he might have caught that it was just that—­a thought—­potentially allowing him to respond more flexibly. He might have noticed the thought and then chosen to focus on what would probably be more effective in this situation—­following his values to be open and loving. In that case, he might have said, “Honey, do you know what happened with the alarm? Did I forget to set it?” Being able to simply observe the process of thinking in the moment, or in flight as it’s sometimes described in ACT, can begin to create an opening for people to step out of their habitual patterns and engage in more effective and values-­based actions. Therapists learning ACT often struggle with implementing defusion in effective ways because it’s inherently challenging to use the main tool at our disposal—­language—­to weaken language. The situation is similar to how oil-­well fires are extinguished. An explosion (itself fire) is created at the source of the fire that momentarily uses up all the available oxygen. In the absence of oxygen, the remaining oil ceases to burn. Similarly, ACT uses language, and loopholes in its functioning, to extinguish the problematic effects of language in certain areas of our lives. It’s not that language itself is eliminated, but that some of its less useful functions are weakened in certain contexts so more flexible ways of knowing can have greater influence over clients’ behavior. It would be nice if fusion could be weakened by simply explaining the dilemma, much as we have done in this chapter thus far. Unfortunately, this type of explanation depends entirely upon literal meaning for its impact, and to promote defusion we must step outside of literal meaning. To do this, ACT uses language in nonliteral ways, such as the way a coach might speak to a player. For example, an ACT therapist might say, “See if you can hold that thought like you might hold a butterfly that has landed on your finger” or “Imagine that you’re hovering over this feeling, observing it as if from a helicopter hovering above a spot on the ground.” With such approaches, the literal functions of problematic thoughts are less likely to dominate as a source of influence over behavior, and more helpful, direct, and varied sources of control over action can gain ground.

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What Should Trigger Working with This Process? Fusion is not a constant; it comes and goes across time and situations. As a clinician, you’ll want to work on defusion when it is needed. Simply working on defusion because it’s part of an ACT protocol or applying it to thinking that isn’t significant may not prove useful. Focusing on this process is most appropriate when clients are believing, buying, holding on to, or clinging to particular thoughts or sets of words and doing so is limiting or preventing flexible movement in the direction of client values. In such cases, clients often seem to be heavily saddled or trapped by certain thoughts or feelings and find themselves unable to take values-­based action based on those thoughts or feelings. For instance, a client might say, “I’ll never be able to find a partner because I’m worthless. Who would want me?” Clearly, this client is trapped by the word “worthless.” If she holds it to be literally true, it seems that finding a partner would be impossible: who would want a worthless human being as a partner? However, if the client can come to see that “worthless” is a word that’s said under certain conditions and given a particular history, and that it isn’t something she literally is, then “I’ll never be able to find a partner because I’m worthless” will have less control over her behavior. This doesn’t mean the client has to stop thinking that she’s worthless or start thinking that she’s worthy; rather, if she can see the thought as a thought, then its power to control her actions is lost, even if that thought continues to occur. There are a number of specific indications that clients are fused in a given area. Not all are likely to apply; generally only one or two are present: • You get the sense that the client is too interested in being right or looking good, especially if that pursuit is overwhelming the behavioral flexibility needed in the situation. • Truth with a capital T has become more important than workability. For example, if you ask the client about how useful a thought is, the client says, “It’s not useful, but it’s true!” • The client doesn’t notice thinking as an ongoing process. When you ask about thoughts, the client pauses and has a hard time reporting on internal processes in an open way. • As the client addresses an issue, the words feel well practiced, as if they’ve been said many times. That doesn’t just come from overt practice; it often happens because more fused stories are internally supported. The client may have ruminatively told these stories internally for years. • Often this sense of well-­practiced stories can be detected by a rigidity of rhythm. Some clients’ suffering is like a dirge; for others it’s frenzied. In either case, the mark of fusion is rigidity, constancy, and insensitivity of speech, pace, and pattern. • New information disappears or is integrated into an underlying theme. Often the client will have a handful of themes that repeat across situations, and the conversation keeps looping back to these same basic points over and over again. Contradictory information or experiences are reinterpreted to fit the previous pattern.

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It’s worth noting that this list is not just relevant to clients; it also applies to therapists. As a therapist, you may sense you’re trying to be right in a session, or you may see that you’re holding tightly to a defense of “correct” and “true” opinions in session, rather than workable thoughts. If so, you’re picking up on your own fusion. You’re also engaged in fusion if you disappear into mental analysis and don’t notice your own thoughts with some space, especially if you’ve disappeared into familiar, well-­practiced themes. When you find yourself engaged in fusion, it’s worth working on personal defusion skills, such as stepping back from your thoughts and noticing who is noticing. As an ACT therapist, knowing that all of the flexibility processes are personally relevant to you will greatly expand your ability to be clinically flexible and less controlled by your automatic reactions or unworkable habits. Recognizing your own fusion is also useful in other ways. For example, you may engage in fusion in response to a client’s fusion, because fusion is, in part, a social process. At the very least, being aware of your own fusion will soften any sense of arrogance when targeting fusion in others; one-­upmanship can easily show up in defusion work and is one of the places where both seasoned and newer clinicians can struggle. The following dialogue, which occurred about five sessions into the client’s therapy, demonstrates an interaction that triggers working with defusion. Therapist: You seem pretty blue today. What’s happening for you? Client:

It’s just always the same story. I try to do something to make things better and it fails… It always fails. It’s always like that.

Therapist: So there’s this place where you get stuck when this same story, “I try and nothing works,” shows up. Client:

(Hangs head and speaks softly.) Let’s face it, I’m doom and gloom.

Therapist: You’ve mentioned that several times now—­that you’re doom and gloom. Client:

It’s true. I am doom and gloom.

Therapist: I want to recognize the pain of this thought and the struggle that’s built around it, and I’m wondering if you might be willing to be a bit playful with me for a moment. (Using the “and-­ but” verbal convention mentioned later in this chapter, the therapist is trying to be validating and also carve out space for defusion work.) Client:

Sure… Might as well.

Therapist: This might sound a little silly, but would you sing the words “I am doom and gloom” for me? Client:

(Chuckles.) What?

Therapist: Let’s just work with this for a minute. Give it a try. Client:

(Sings the words “I am doom and gloom.” Unbeknownst to the therapist, the client has quite a good voice and sings solemnly and with heartfelt pain.)

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Therapist: Great. You really captured something. I can feel the heaviness in this. Now could you sing it again? Only this time, sing it with great enthusiasm, as if you’re in a Broadway play. Client:

(Chuckles again.) Okay. (Sings the words, but from the new perspective.)

The client is then asked to sing the words from several other perspectives: as a woman, as a small child, and as Mickey Mouse. With each new rendition, the therapist can see the client beginning to defuse from the words. Client:

The words just seem kind of funny to me now.

Therapist: Interesting how that works. When we’re really trapped in words, it seems that they paralyze us. But now that we’ve loosened the trap a little, what do you notice? Client:

They don’t seem to have the same power. They’re even kind of funny now.

Therapist: From this place, being loosened from those words, I wonder if we can start to work on where you’re headed? (Links defusion with values.) This is just one example of the many ways defusion can be brought into session. In this dialogue, the therapist identified a self-­evaluation that occurred in session and targeted it directly with a defusion exercise. It’s important to note that such exercises are designed to take the meaning out of the words (deliteralize them), not to change the number of times the client thinks them or to change them into positive words (e.g., “I am great and good”). Also, defusion should be done from a compassionate stance, which can be either playful or serious. As a reminder, it should never be done from a position of one-­upmanship or in a way that makes the client feel silly or humiliated for having particular thoughts.

What Is the Method? Scores of defusion techniques have been developed for a wide variety of clinical presentations, and clients and therapists are thinking of new ones all the time. Anything that can be observed can be a metaphor for defusion. For example, negative thoughts can be observed dispassionately by having clients watch them as if watching an uninteresting, nonprovocative television commercial. Clients can be encouraged to treat a thought as an externally observed event by giving it a shape, size, color, speed, or form. Clients can thank their mind for such an interesting thought; label the process of thinking (e.g., “I’m having the thought that I am doom and gloom”); or mindfully observe the thoughts, feelings, and memories that arise in their consciousness. Such techniques attempt to reduce the literal quality of thoughts, weakening the tendency to treat thoughts as what they refer to (e.g., the experience “I am doom and gloom”) rather than what the client is directly experiencing (e.g., the thought “I am doom and gloom”). The result of defusion is usually a decrease in the believability of private events or clients’ attachment to them, rather than an immediate change in their frequency or form. Here’s an exercise to help you start exploring this in relation to one of your clients.

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Exercise:

Working with Client Defusion, Part 1 Bring one of your clients to mind, preferably a difficult one. Think of three thoughts this person has about herself, her life, or her future that are difficult for her. Try to be specific. Thought 1:   Thought 2:   Thought 3:  We’ll come back to these later in the chapter.

An Overview of Defusion Principles In the following sections, we illustrate the major types of defusion techniques, organized by the general principle at play. By arranging them in this way, we hope to show what lies beneath the methods themselves. Defusion isn’t about specific techniques; it’s a functional process, and it is this kind of knowledge that moves ACT from a mere collection of procedures to a clinical model. Some popular ACT books for the general public, such as Get Out of Your Mind and Into Your Life (Hayes, 2005), even teach people how to generate their own novel defusion techniques. The purpose of this section is similar. The techniques we describe are examples; they aren’t an exhaustive list of ACT defusion techniques. The full list is limited only by your own creativity and that of the ACT and RFT community worldwide. Before we move into describing defusion techniques, it’s important to remember that defusion shouldn’t be conducted in a confrontational way. It can be powerful, and it’s an excellent means for helping clients observe their minds. However, clients sometimes report feeling confused, disjointed, or out of sorts during and after sessions that focus heavily on defusion. These feeling states are perfectly acceptable. Artful defusion work often has the qualities of a light-­footed dancer or an aikido master. Neither meets a partner’s movements with force; rather, they join with and redirect their partner’s movements in more useful directions. In defusion, clients’ verbalizations are bounced around, mixed up, and played with so that clients can see them from varying viewpoints and explore their many qualities. Again, this

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is done without direct confrontation or refutation. For example, an ACT therapist might appreciate the beautiful creativity of a client’s mind by congratulating him for coming to a bleak conclusion. For example, if a client says, “So then I thought I’d completely blown it,” the therapist might respond, while joking and smiling warmly, “Ah, such a good conclusion. Isn’t your mind amazing, finding it’s way to such dire places?” Be playful with defusion while always maintaining compassion. In the following sections, we present some principles you can use in fostering defusion: teaching clients about the limits of language; creating distance between the thought and the thinker, or the feeling and the feeler; revealing the hidden properties of language; and undermining larger sets of verbal relations. If you understand these principles, the specific methods we set forth are less important, because there are a vast number of alternative methods and creating additional ones isn’t difficult.

TEACHING THE LIMITS OF LANGUAGE IN REDISCOVERING EXPERIENCE ACT therapists often introduce defusion by pointing to the limits of conscious thought. We tend to rely so much on thinking and informal problem solving to guide all our actions such that “an illusion is created that all knowledge is verbal” (Hayes et al., 2012, p. 248). Various metaphors and exercises are used to demonstrate that our minds do not hold all the answers—­that there are, in fact, ways of knowing that operate beyond the mind. The therapist can tentatively suggest, “Although language and rational thought can be helpful in some areas, what if there are other aspects of life in which being logical and following what one’s mind has to say is actually problematic?” This can be illustrated by an appeal to clients’ experience in areas of their life in which what the mind knows may not be enough or can even be detrimental. For example, some tasks involve very well-­regulated verbal knowledge, such as how to find a certain website on the Internet. Other tasks are less so, such as learning how to play a musical instrument or perform a skilled sport. Clients also may have had experiences wherein language actually interfered with effective functioning, such as in performance anxiety, sexual difficulties, or choking on the golf green. This basic idea can be illustrated by asking clients to verbally instruct you in engaging in a physical movement, as demonstrated in the following dialogue. As you’ll see, the therapist responds to the client’s instructions by asking the client how to do each movement instructed. This exercise nicely points to the arrogance of language because physical movement is generally learned through experience, not through instruction. The basic idea of the exercise is to show clients that some of the things we know how to do are not known through conscious knowledge but rather were learned through experience. Therapist: Can you tell me how to walk from my chair to the door? Client:

Well, first stand up, and then put one foot in front of the other until you’re standing over in front of the door.

Therapist: Good. How do I do that? Client:

What? Oh, push with your hands on the arms of the chair until you’re standing up, and then move the muscles in your leg so that you’re stepping forward. Let your weight move with you.

Therapist: Great. How do I do that?

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(Chuckles.) Tell your brain to tell your hands and legs to move.

Therapist: How do I do that? The therapist continues in this way, playfully, asking, “How do I do that?” after each instruction, until the client says, “I don’t know.” Therapist: And after anything you tell me to do, I’m going to say, “How do I do that?” You see, it was a bit of a trick. I asked you to tell me how to walk, and your mind went to work thinking it knew how to tell me that. All minds do that. But the deal is that neither you nor I learned how to walk by someone telling us how. You probably learned how to walk before you even had words. We learned to walk by experience. We tried to stand up, we fell down, we bonked our heads, but eventually learned how to walk. Experience taught us how. Many things are like that, but we lose touch with them because our minds get so arrogant and think they know everything. There are many things that you know by experience; for instance, you know feelings won’t harm you, even if your mind tells you they will. Following such an exercise, the therapist can extend the approach to the client’s difficulties. Therapist: What if your struggle with anxiety is similar? Your mind keeps telling you how to solve the problem, but it just doesn’t know how to get out of a situation like this. What if we need some other way of responding to the situation you’re in, something that’s a bit more like learning how to walk than it is like reading about how to do these things? Another way to explore the limits of language is to examine how we learn any new skilled activity. For example, you can ask clients to remember how they learned to ride a bike. Clients usually report some combination of simply getting on the bike, trying to find their balance, falling down, and trying again. Having a parent tell us to stay balanced doesn’t teach us to balance. Knowing with the mind that the pedals turn the wheels doesn’t make anyone a cyclist. In most cases, clients easily get the point that logical understanding and knowledge can take them only so far. At some point, developing certain skills depends upon getting engaged in the activity and letting the consequences shape one’s actions. Doing these kinds of exercises with clients points to something that’s often inaccessible to the mind or hidden from its view: experiential knowledge. We humans know many things based on this kind of knowledge, and part of what ACT attempts to do is get clients back in touch with experiential knowing. It is from the vantage of experiential knowledge that clients can come to see their emotions, thoughts, memories, and sensations as ongoing events that rise and fall, that come and go and then come and go again. From this vantage point, clients also learn that they aren’t broken, and that fear and anxiety don’t literally harm or kill them. These are simply experiences (e.g., thoughts) that they’re having at a given moment. In this work, it’s important to remind clients that these counterintuitive and nonliteral skills require practice. Clients need to implement what they’ve learned in session outside of session. To this end, you might suggest that coming to ACT sessions and not engaging in exercises outside of sessions is a bit like going to the hardware store, buying a new table saw, and then leaving it at the checkout counter. Other examples of teaching the limits of language include the Milk, Milk, Milk exercise described earlier and attempting to e-­mail orders to a person who doesn’t speak the client’s language.

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CREATING DISTANCE BETWEEN THOUGHT AND THINKER, FEELING AND FEELER When the literal, evaluative functions of language dominate, we aren’t aware of the distinction between ourselves as the experiencer of these private events and the events themselves. This is the usual human state: “I am what I think and feel.” A number of ACT strategies are aimed at helping clients increase the distinction between the experiencing self and what is experienced. That is, thoughts and feelings are something clients have, rather than something they are. Making these distinctions brings forward nondominant qualities of language, such as its aesthetic or functional qualities, and increases the flexibility of ways in which people interact with their minds. There are several primary avenues for applying this principle: objectifying language; looking at thoughts rather than from them; and revealing the hidden properties of language. Objectifying language. We humans have a lot of experience dealing with objects in our environment as separate from ourselves. ACT therapists can teach clients to deal with thoughts and feelings similarly: as objects to be viewed. The idea is to create a healthy distance between the self and thoughts and other private events, which are described as objects. This is not to say that clients don’t contact these internal events; they are still present but are viewed from a different perspective. Using metaphors and exercises can help with this process. Objectifying thoughts can help clients interact with them in more flexible and practical ways, in much the same way that external objects can be used in multiple ways. In the following dialogue, the therapist takes this approach by asking the client to consider whether his thoughts are like tools in some ways. Therapist: If thoughts were like a tool, how might we work with them? We don’t usually sit around thinking, “I’m not sure this hammer is the right hammer for me. I don’t usually use this kind of hammer. I think I’m a two-­pound hammer kind of person.” We just pick up the hammer and start pounding nails, or we don’t use it at all. In contrast, when you have the thought “I’m not sure I can do this. I don’t usually live my life this way. I’m pretty much a loser kind of person,” that thought probably doesn’t seem at all like a tool to you. It’s more like “This is true. This is who I am.” In this stance, it’s like a hammer that you have no choice but to use. Before you know it, the “I’m not sure I can do this” hammer or the “I’m a loser kind of person” hammer is in your hands and you’re pounding away. Now, would it be possible to step back and look at which thoughts are useful as tools for you to construct a life of value for yourself, rather than having to evaluate them in terms of their truth or untruth? Client:

What do you mean by truth or untruth?

Therapist: Would you be willing to do an exercise to see if we can unpack this? We’ve talked before about how starting dating means that thoughts like “I’ll never be able to find a partner” will show up. What other thoughts show up for you when you take action toward finding a partner—­something I know you really, really want in your life? At this point, the therapist might elicit a variety of thoughts and feelings that show up when the client tries to date, writing each one down on a card as a way of starting to use a thoughts-on-cards

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exercise to illustrate responding to thoughts in terms of their utility, rather than as literal truth (e.g., Harris, 2009, pp. 101–­107). This is just one approach among a wide variety of powerful ACT experiential exercises that can help clients objectify thoughts. For example, private experiences can be compared to bullying passengers on a bus (Hayes et al., 2012, pp. 250–­252), either as part of a role-­play, as an eyes-­closed exercise, or in the form of a metaphor. Particular thoughts or feelings can be written down on cards, and then the client can interact with them in various ways, such as fighting to keep them away instead of accepting them (Harris, 2009, pp. 101–­107). Clients can be led through eyes-­closed exercises in which they imagine thoughts as physical objects or people, picturing their color, weight, texture, voice, density, movements, and so on (Hayes et al., 2012, pp. 286–­287). Often, ACT therapists refer to the client’s mind as if it were speaking to the client or reframe the client’s thoughts to highlight the distinction between the person and the mind. For instance, the therapist might say, “So, your mind said to you…” or “Who’s talking to me now: you or your mind?” Sometimes therapists or clients playfully give the client’s mind a name. For example, a therapist might give a client’s mind the name Bob and then say, “So, what will Bob say when you get up tomorrow, knowing you’re going to do this exposure exercise?” Another way of objectifying language is to introduce the concept of “mind” and help clients relate to the mind as an external entity that follows them around, always judging, evaluating, predicting, and influencing them and otherwise commenting on their actions. This serves two purposes: to help clients obtain a healthy distance from their own verbal repertoire, with which they are usually heavily identified, and to create space to begin to discriminate between being present and being caught up in their internal chatter. An effective exercise to this end is Taking Your Mind for a Walk (Hayes et al., 2012, p. 259). It requires that two people pair up, with one playing the role of the mind (this could be the client and therapist or, in group therapy, two clients). Initially, one person plays the role of the mind and the other plays the role of the person. When done in a group therapy format, it often works better to do the exercise in groups of three, with two people teaming up to play the mind at the same time. This usually helps the mind keep up a constant stream of chatter and brings a little fun to the exercise. For those playing the role of the mind, the job is to continuously speak to the person in an evaluative, second-­guessing, wondering, judging way to demonstrate what the mind typically does almost constantly. In the role of the person, the client takes a mindful walk, in silence, going wherever the person chooses to go. The mind doesn’t get to pick where the person goes, and the person doesn’t get to lose the mind. After walking for about five minutes, they switch roles and then walk again for about five minutes. Finally, they split up and each takes a mindful walk alone, again for about five minutes. Generally, what clients learn in this exercise is that, first, the mind is busy and has a lot to say, and second, the mind isn’t in charge—­it doesn’t get to dictate where they go. Clients also learn that no matter where they go, their mind goes with them. This shows up during the final phase of the exercise, when they walk alone and typically begin to hear their mind babbling on about things. Looking at thoughts, rather than from thoughts. A number of strategies are oriented toward helping clients develop the capacity to look at thoughts, rather than from thoughts. This is sometimes referred to as the difference between having a thought and buying a thought. One way of beginning this process of just observing mental content is to help clients notice the simple fact that we are all constantly speaking to ourselves. Here’s an example of how a therapist can introduce this idea.

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Therapist: Now, all of us are constantly speaking to ourselves. Often, however, we’re not even aware of the fact that we’re doing this. In the background, there’s a voice constantly narrating things: “I agree with that. I like that. I don’t like that. That’s true. That’s not. I don’t know that I like that. What’s he saying?” Even right now—­check and see if your mind isn’t doing that with what I’m saying right now. (Pauses.) It might be saying, “I’m not sure I agree with that” or “Yup, I am doing that.” If you’re thinking, “I’m not doing that,” then that’s the voice! I invite you to close your eyes for a second and just notice how you’re constantly talking to yourself. Simply notice what thoughts come up as you close your eyes. (Pauses for ten seconds.) Notice how your mind has an opinion, comment, or question about everything. For example, think about your car. What comes up around that? (Pauses.) Think about your parents. What does your mind have to say about them? (Pauses.) Notice how you don’t even need to do anything—­it constantly keeps going, doing its thing. Now think about the part of yourself you like the least. What comments does your mind have about that? (Pauses.) It’s constantly going, yet most of the time we aren’t even aware of its presence. The therapist also can introduce the idea that thoughts are like colored bubbles over the client’s head, as illustrated in this dialogue. Therapist: You can think of thoughts as similar to wearing colored sunglasses. These glasses are so comfortable and you’re so used to them that you completely forget you’re wearing them. You don’t even notice that they are there. You can only see through the thoughts. For example, if you were wearing red glasses but didn’t realize it, and I had you look at this white wall, what would you think the color of the wall was? Client:

Red.

Therapist: Exactly. Our thinking is just like that. We totally miss that we’re seeing the world through our thinking; the world just seems to be how it is. But what if the view through the lens isn’t so helpful? For example, the view through thoughts such as “I’m not okay” or “I’m worthless” limits how you live in the world. The point here is not to get rid of the glasses. We can’t really do that anyway, because we’re constantly having more thoughts. The point is to practice taking them off and looking at them with some awareness. (Mimes taking off glasses and holding them out from her face.) That way you can see them clearly, for what they are. This makes it easier to do what works when the situation calls for it. It’s usually helpful to follow this metaphor with practice in looking at thoughts. The Floating Leaves on a Moving Stream exercise (Hayes, 2005, pp. 76–­77), Soldiers in the Parade exercise (Hayes et al., 2012, pp. 255–­258), and other similar exercises can be used for such practice in session and between sessions. Revealing the hidden properties of language. One area in which language disguises important discriminations involves evaluation versus description. All stimuli with which we interact have various properties. Certain properties are primary, experienced directly through the senses. For example, we might see that a rose is red or feel that concrete is rough. These properties belong to the realm of description. Secondary properties, on the other hand, are derived from language and belong to the

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realm of evaluation (e.g., “good,” “useful,” “ugly,” “right”). Primary properties are inherent in the stimuli, whereas secondary “properties” aren’t really properties of the stimuli at all; rather, they occur in the interaction between the person and the stimuli and are the result of language. Ordinarily, the difference between these two types of properties is obscured. Clients usually come to therapy with a whole host of evaluations about themselves, their world, and the people in their lives. They treat these evaluations as if they were primary, inherent properties of themselves or others. For example, a client might have evaluations such as “I’m bad,” “I’m worthless,” or “I’m evil.” Held literally, these would indeed be very difficult to accept. Willingness would be difficult to adopt if these evaluations were actually a description of the client’s essence. Change would be virtually a necessity. The only way to change the primary properties of a stimulus is to literally break it down and reconstitute it into something else; for example, if you don’t like the red rose, you could burn it and transform it into ashes. However, if a distinction can be made between description and evaluation, that which evokes evaluation doesn’t necessarily have to be changed to be acceptable because the properties aren’t in the thing itself, but only in thought. Various exercises that help illustrate the difference between evaluation and description in regard to the self are described in chapter 5. Another ACT strategy for revealing the hidden properties of language involves creating contexts in which language can be experienced more directly and with its literal symbolic functions weakened. In these exercises, the therapist isn’t attempting to eliminate the derived functions of words (e.g., their meaning) in any permanent way. Rather, the therapist is trying to bring other, possibly more flexible functions to the fore, such as those based on the direct stimulus properties of the word (e.g., the way the word looks or sounds, or the effort it takes to create it). Bringing forward the direct stimulus functions of language can help make it easier to observe the process of languaging without fusing as much with its products. The Milk, Milk, Milk exercise described earlier leads to hearing the word “milk” as a sound, rather than interpreting it as the substance to which it refers. There are many techniques to create this effect, including saying a thought in a cartoon character’s voice, singing thoughts, speaking them as a sports announcer would (all in Hayes, 2005), or having contests with clients to see who can come up with the worst evaluations. The point of these exercises is not to ridicule particular thoughts, but to expand their functions beyond those typically experienced and to help clients develop flexibility in relation to mental content so that thoughts need not always be experienced in old, habitual, literal ways, which often leads to yet more struggle and inflexible behavior. Another approach for accomplishing this involves speaking thoughts very slowly, as demonstrated in the following dialogue. Therapist: I notice that when you start talking about what’s happened over the last year with respect to trying to date, you quickly get caught up in the story “I’ll never find a girlfriend. I am completely incompetent.” Client:

I know I keep saying that, but it’s true. I have proof. It never works out. I must be incompetent.

Therapist: This story your mind tells about you is pretty powerful. It’s kept you from dating for a long time now. Client:

Yes. I need to find a way to stop being incompetent, and then I can go on a date.

Therapist: Seems you have been working on that for a while. True?

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Over a year.

Therapist: Would you be willing to try something out with me? Client:

Sure.

Therapist: Let’s disassemble this, not as a way to figure out how you landed in incompetence, but as a way to take the power out of this story so that you can have your power back. I want to help you see the words in this story for what they are: words. Let’s start with slowing the sentence way down. Let’s try to say “I am incompetent” as slowly as possible. (Client and therapist say the words very slowly together.) Now slower. Sound it out, really drawing out the vowels. (They say the words together even more slowly.) Now let’s slow it down even more and say “incompetent” almost as if it were four separate words—­“in,” “comp,” “e,” and “tent”—­ and let’s exaggerate it just a tiny bit. (The therapist keeps working with the client in this fashion for a few minutes.) Client:

(Chuckles a little.) Why do we keep doing this?

Therapist: Well, let’s check. Did you hear the sets of sounds and feel the mechanics of speaking the words? Client:

Yes. It was odd.

Therapist: Sure, because we don’t typically engage with words in this way. Usually we get lost inside them and forget that they’re sets of sounds that are spoken using the mechanics of the vocal cords and muscles. I’m simply helping us contact words in a different way, noticing them for what they are and not being right inside them so much. This creates a little possibility for you to relate to your words in a different way.

UNDERMINING LARGER SETS OF VERBAL RELATIONS Most of the strategies just discussed are aimed at undermining literal attachment to smaller sets of mind chatter, such as individual thoughts, words, or phrases. Different strategies are required to work on more complex forms of mental behavior. The mind engages in extended and interconnected forms of verbal behavior, such as creating clients’ stories about who they are, how they came to be the way they are, and the reasons for doing what they do. These stories and reasons provide the verbal glue that creates the confounding stability of many unworkable patterns of behavior and therefore are central to the conceptualized self, or self-­as-­content (addressed further in chapter 5). When we’re growing up, our social world teaches us that we must have explanations for our behaviors, and that these explanations must be coherent. And in the realm of behavior that doesn’t work, we are especially expected to have good explanations. For example, the social community demands that a person with depression have a really good reason for not getting out of bed, not having worked for three months, and so on. For some people, having a “chemical imbalance” seems to afford a good reason for depressed behavior. Interestingly, research suggests that people who think they have good reasons for their depression tend to be more depressed and less responsive to therapy (Addis & Jacobson, 1996).

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Through fusion with or attachment to our stories, these verbal networks come to control our behavior. Our past becomes our future, with the potential for very negative outcomes. If a client is attached to a story that she can’t have good relationships because of being abused as a child, then that client is truly stuck because she cannot have any other childhood. If the client is unable to see this story as one of many possible stories and instead fuses with it and sees it literally, as “the truth,” you can easily see how she might not even engage in trying to find a relationship. This dynamic becomes particularly difficult if clients are also fused with the belief that they’re right about their stories. This can lead people to not get well and truly stay stuck in difficult and unworkable patterns of behavior. Consider Jessica. A few years ago, she was diagnosed with bipolar disorder following an episode of manic behavior. Since then, she’s engaged in extensive reading about what people diagnosed with bipolar disorder are like and has learned that bipolar disorder is a genetic problem that results in a chemical imbalance in the brain. Now Jessica feels that because bipolar disorder is biological, she’s doomed to repeat endless cycles of excruciating lows and out-­of-­control highs for the rest of her life, and that there’s not much she can do about it. Although her acknowledgment of the diagnosis of bipolar disorder could potentially be helpful in some ways, her story suggests that she can’t recover, and therefore she feels she has no reason to try. As with most clients in such a situation, Jessica has good evidence for her story, in this case in the form of research, as well as personal anecdotes about medications helping her. She’s been living under the dictates of this story for several years, with the outcome that she takes her medications but doesn’t take many other active steps to improve her life. From an ACT perspective, the question is not whether this story is literally true, but whether it’s helpful. Does it lead Jessica toward the kind of life she wants? ACT tries to undermine attachment to unhelpful stories by helping clients make experiential contact with the constructed nature of those stories so they can turn their focus from the literal truth of a story to its workability. These strategies are aimed at helping clients develop a healthy skepticism about the mind’s ability to evaluate and explain aspects of their personal history in a useful way. The following dialogue (inspired by Hayes, 2005, pp. 19–­20) provides an example of how a therapist can introduce this idea. Therapist: We’re constantly telling ourselves a story about our lives. In the background, there’s a voice that is always narrating about things—­telling us about who we are, what we like, how things are going, and so on. The question is, is that story necessarily true? Where did it come from? For instance, if I ask you what happened three days after your eleventh birthday and I want to know in detail about that day, would you be able to tell me? Client:

Hmm. No.

Therapist: (Speaks playfully.) How about four days after or five days after? (Pauses.) We could try one hundred days and you might catch one or two details, but we really know very little about what’s gone on in our lives. We remember just a few snippets, and we string these little pieces together into a story. Do you see this? We have these little snippets of things we remember, and massive portions of what happened are missing. We try to string it all together to create stories that make sense of the pieces we remember, and then we tell these stories to ourselves frequently. We conclude things about ourselves—­what we are capable of, who we are—­and then we live out of our stories. Client:

I see.

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Therapist: Interestingly, these stories grow. The mind just keeps taking in new stuff. And this isn’t something that’s only happened way in our past; it’s happening right now. Let’s do an exercise about new content being added all the time, and about how we usually don’t even recognize it. I’m going to tell you about an imaginary creature called a gub-­gub. If you remember what the gub-­gub says, I’ll give you a million dollars. Are you ready? Here it is: gub-­gubs go “Wooo.” What do gub-­gubs say? Client:

Wooo.

Therapist: Now don’t forget it. Because if I ask you tomorrow and you get that one million bucks, it’s worth it. What do gub-­gubs say? Client:

Wooo.

Therapist: Okay, so now I have to let you know that there’s no million dollars. So you can just forget it. What do gub-­gubs say? Client:

(Laughs.) Wooo.

Therapist: Suppose I came back in a month. Would you know what gub-­gubs say? Client:

Sure.

Therapist: How about two months? A year? What do gub-­gubs say? (The client chuckles.) Therapist: If we spent a bit more time talking about gub-­gubs, it might be that I could visit you at your deathbed and ask, “What do gub-­gubs say?” Would you remember? Now think about what this means. We spend a few minutes on something, and you carry it around in your head for the rest of your life. You have things like this that reach way back across your history. You may not be sure where they came from, but this is the stuff that’s your story. These are the thoughts you have about yourself. For example, “The worst thing about me is…” (Pauses and directs the client to answer.) Client:

I’m weak.

Therapist: The best thing about me is… (Pauses.) Client:

I’m kind.

Therapist: The reason I am so weak is… Client:

I never learned how to stand up for myself.

Therapist: (While smiling warmly.) Good! That’s a beauty. Magical! (Speaks in an upbeat tone that reflects friendly teasing.) See how fun this is? Your mind generates explanations, stories, and reasons for everything. We could go on, right? There’s a story for everything. Another approach involves having clients write two versions of their autobiography to explore the largely arbitrary connections between events in their life stories (Hayes, 2005, pp. 91–­93). To conduct

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this two-­part exercise, first ask clients to write their life story on a couple of pages as homework. In the following session, help them identify all the events in the story, and then, as another homework exercise, ask them to rewrite the story, keeping all the events unchanged but shifting the meaning and outcome of the story. This exercise doesn’t challenge the client’s story directly but hopefully helps the client see it as just one of many possible life stories that are available. This is a more advanced approach that’s often brought into therapy after other defusion practices have already been introduced and the client has some capacity to pause and step back from thoughts. As with all aspects of ACT, the pacing and sequence of interventions depends upon the client and case conceptualization. ACT therapists are sometimes challenged by clients on the grounds that their reasons are literally true. Arguing is almost always unhelpful in such cases, especially as clients may experience this as invalidating. Instead, you can acknowledge the client’s reasons as possibly helpful verbal formulations and then turn to the question: “What does your experience say? How helpful is this?” Alternatively, you might say, “Well, that sounds right. But which would you rather be: correct or living a vital life?” As you target these more extended sets of verbal networks, it’s important to keep in mind that the point isn’t to help clients find a better story or to suggest that we humans have control over the stories we tell; rather, the point is to help clients see that the ongoing process of generating these stories is usually hidden from view and automatic, and that our lives are not 100 percent determined by the events we can recall (the ones that make it into the stories). The goal is mindfulness and liberation from entrenched and constricting stories. Fortunately, research indicates that defusion seems to reduce attachment to thoughts, and that it’s more effective than cognitive disputation and reappraisal (Levin et al., 2012), so it isn’t really necessary to change clients’ stories anyway.

Working with Defusion in an Ongoing Way In order to use defusion metaphors and exercises powerfully, therapists must integrate them into the ongoing flow of the session. A common mistake for ACT therapists is to use the metaphors and exercises in a piecemeal fashion, creating a defused space during the exercises, but responding to clients’ words and stories on a literal level during other parts of the session. Bringing a focus to the functional utility of thinking and to languaging as an ongoing behavioral process must occur throughout therapy, even in regard to the therapist’s speech. In any given situation, the primary focus is on whether buying a thought would move the client (or therapist) toward a more vital, values-­based life. In the sections that follow, we offer specific techniques for practicing defusion in the ongoing flow of the session, addressing persistent highly fused behavior on the part of the client, and maintaining a defused space in the room. These techniques fall into three broad categories: establishing verbal conventions, referring back to metaphors and exercises, and teaching clients to recognize when they’re caught up in fusion.

ESTABLISHING VERBAL CONVENTIONS ACT therapists sometimes ask clients to adopt simple verbal conventions that can then be called on to help clients step out of some of the traps of literal language, creating distance between clients and the contents of their mind. One such approach is to ask clients to state things as experiences they are currently having, rather than as something they actually are, for example, saying, “I am having the

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thought that I am worthless” rather than “I am worthless,” or saying, “I am having the feeling of anxiety” rather than “I feel anxious.” Although this practice often feels awkward at first, it can become more natural if repeated over an extended period of time, perhaps thirty minutes of a session or across multiple sessions. This can help create a healthy sense of separation between clients and the content of their thoughts. Another way clients can be trapped in needless struggle is through use of the word “but.” As an example, consider the statement “I wanted to tell him I loved him, but I was too scared.” The word “but” literally means to “be out” the thing that came before (Hayes et al., 2012, pp. 262–­263). It suggests that the two things can’t coexist or be reconciled. In the example, the word “but” implies that the client must feel less scared in order to say important words. This can feed an agenda of getting rid of fear before fully living life. Or consider a client who says, “I love my husband, but he makes me angry.” This wording implies that these two emotional states are incompatible and one of them must change. Asking clients to substitute “and” for “but” can remind them that both things are true: the client loves her husband, and he makes her angry. Multiple meanings are present, and there’s no need for one to negate the other. Particularly with a client who uses the word “but” frequently, asking the client to replace it with the word “and” can free up some space for acceptance.

REFERRING BACK TO METAPHORS AND EXERCISES The power of metaphors is that they can quickly bring new functions to bear on a situation without requiring excessive description. Therefore, referring back to familiar metaphors can catalyze defusion. Earlier, as an example of language that promotes defusion, we used the statement “See if you can hold that thought like you might hold a butterfly that has landed on your finger.” Looking at a butterfly on one’s finger suggests attention, curiosity, gentleness, and observation without running away. Compare this to saying something like “You should respond to your thinking in a defused way, with detachment and acceptance; and willingly, with openness, fascination, and curiosity; and not with violence, s­ truggle, battle, possession, argument, wanting to be right about it, or trying to figure out whether it’s true and criticizing it if it isn’t.” While that might add some didactic information, it would probably fail to communicate the deep qualities of defusion. In contrast, the brief butterfly analogy can communicate many of these qualities without the need for an exact description. Once you’ve used a defusion exercise or metaphor with a client, you can rapidly bring defusion into the room by referring back to it. This is illustrated in the following dialogue. In an earlier session, the therapist had introduced the concept of “having a thought” versus “buying a thought” using the metaphor of salesperson offering unwanted goods. Now the therapist can refer back to that work to help the client respond to her thoughts based on the functional utility of those thoughts, rather than their literal truth. Client:

I don’t know what to do. I can’t connect with people. I get in social situations and I just can’t do it. I have nothing to say.

Therapist: Let’s take a look at this. You’ve just shaken someone’s hand, and your salesperson mind shows up and sells you the thought “I can’t connect with people.” It looks as if you’ve been buying that so far. Maybe the important question here is whether that’s a thought you want to continue to buy. Let me ask it this way: When you follow that thought, where does it lead you in terms of your values in this area?

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It leads me away… I just stay at home. Or when I’m at a party, I don’t talk much to people.

Therapist: I’m guessing there’s a story related to the idea that you can’t connect with people. Client:

Yeah, it’s true, I don’t connect with people.

Therapist: So then your mind sells you “It’s true.” When you buy that, where does it lead you? Client:

Again, not where I want to go.

Therapist: So, we’ve talked before about how one of your values is that you want to connect with people, right? Client:

Yeah.

Therapist: And now your mind is selling you the thought that you can’t do it. And it can even marshal evidence. Now let me ask you another question: Suppose you were to go out tomorrow and actually be able to connect with people. Suppose there were people out there who really could get you, and you could really get them, open up to them, and let them know you. Let’s say you did that tomorrow. Who would be made wrong by that? Client:

Huh? I’m not sure… (Pauses for ten seconds.) What do you mean?

Therapist: Tomorrow you connect. Today you’ve bought the story that says, “I can’t connect.” So who’s wrong tomorrow? Client:

I guess I would be.

Therapist: Yeah. You’d have to give up this story that you can’t connect with people. You’d be wrong about that story. Your choice here seems to be either to defend your story or get your life back. What do you think would come up for you that would be painful if you were to do this? Client:

It would mean I could have done it all along…

Therapist: Yeah. let’s stay with that. When you say that, I notice some sadness coming up. Can we make room for you to have that right now? Client:

(Speaks quietly.) Okay.

Therapist: If having this sadness, this sense of loss, could make it possible for you to really connect with people, and to be able to be there for your sister in a way you’ve never been able to before, would it be worth it? (At this point, the therapist might guide the client into an exercise in which she could be present with her sadness and practice willingly holding it.) If carefully timed, asking, “Who would be made wrong by that?” can be a powerful intervention for clients whose story about who they are or about how their life works is in conflict with a valued direction they wish to take. When asked this question, clients often pause before responding, and sometimes they appear confused because the question seems to have come out of nowhere. However, do note that

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this question may sound accusatory if poorly timed or if the client and therapist don’t have a compassionate, accepting relationship built around agreement about the client’s values. This question isn’t meant to blame clients for their difficulties; rather, it’s intended to help them see how being correct, logical, or coherent (i.e., being right) can stand in the way of living a vital life. Done skillfully, the confrontation is between the client’s mind and the client’s experience or values, not between the client and the therapist.

TEACHING CLIENTS TO RECOGNIZE FUSION Another useful technique is to help clients learn to identify, or discriminate, when they’re getting caught up in fusion with verbal relations in their mind. To do so, therapists make use of a broader dynamic: we humans can learn to recognize patterns in our environment that weren’t previously apparent, and once we do, we generally don’t “unsee” them in the future. To get a feel for this, take a look at figure 5. What do you see in this drawing? If you haven’t seen this optical illusion before, you probably saw only a random bunch of dots. Now look again and see if you can make out a dalmatian. Once you’ve gotten it, try to not see the dalmatian. It’s quite hard to do without distorting the image. In fact, if you’ve seen this image before and were able to make out the dalmatian, you’ll probably always see it, no matter how many years elapse. Once a discrimination is well learned, it’s available to operate on behavior forever. In the same way, if you can teach clients to recognize when they’re caught up in old, highly verbal, entrenched ways of thinking, this can provide an enduring cue to take a step back and apply any of the defusion strategies they’ve learned. However, in order to teach clients to observe fused qualities of thinking, you need to be able to detect it first. K. G. Wilson (2008) offers pointers on how to identify “mind-­y” conversaFigure 5. Dalmation tions that indicate fusion and avoidance. If these characteristics can be recognized in session, this can be a cue for both therapist and client to practice returning to the present, to practice defusion, or both. When any of the following patterns occur in repetitive, inflexible, tired, old, or stereotyped ways, fusion may be an issue (K. G. Wilson, 2008, pp. 105–­113): • Comparison and evaluation: Situations, things, or people are judged and evaluated or deemed better or worse than other situations, things, or people. • Complexity or busyness: Analyses are fast and furious, complex explanations seem to be required, and problems must be ferreted out. Sometimes this takes the form of confusion that must be clarified. • An adversarial quality: This could be a conflict between aspects of the client, or between the client and some individual, including the therapist. In this case, taking sides just tends to prolong the conversation—­and the client’s fusion.

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• A strong future or past orientation: It may seem as though the client is worrying out loud or ruminating about the past, almost as if the therapist weren’t there. Words like “must,” “should,” “can’t,” and “shouldn’t” are about future consequences that are seemingly problems to be solved. • A strong problem-­solving orientation: The client speaks as if some problem must be solved before life moves ahead, but strangely, the client has been trying to solve this problem for a long time. • Generalization versus specifics: The client speaks in terms of general categories, concepts, ideas, and evaluations. This can include overgeneralization, black-­and-­white thinking, or use of terms like “always” and “never.”

Bringing Flexibility to Applying Defusion As a therapist, it is important to keep in mind that defusion is a process, not any particular form of behavior. Becoming overly attached to the concept of defusion can lead therapists to get stuck in explaining defusion in a literal manner. In ACT, the focus is on shaping and engendering defused client behavior, which will arise primarily from more experiential modes of learning. Effective defusion work requires attention to tact, timing, pacing, and context. Key among these is that the therapist must be aware of client behaviors that indicate a need to work on defusion. Such awareness helps therapists steer clear of a common pitfall: something that could be called “defusion whack-­a-­mole.” The therapist gets so attuned to fusion such that nearly every client utterance is interpreted as fused thinking and becomes the target of yet another defusion exercise, concept, or metaphor. Although fusion is often an ongoing issue, trying to catch and remedy every instance of it is a form of inflexibility. Ideally, the aim is to help clients learn to defuse flexibly when doing so can loosen up rigid repertoires of behavior. The point is to provide an opportunity for variability in rigid patterns of behavior, along with the possibility of contacting new, more effective contingencies. In addition, the goal isn’t for clients to understand the concept of defusion, but to be able to defuse from thinking at times when that’s likely to lead to new options and possibilities. There are two pathways to choosing what to target with defusion. One is via case conceptualization, wherein the therapist identifies core patterns of unhelpful thinking that can be systematically targeted with defusion. (This is discussed further in chapter 8, on case conceptualization.) The second pathway involves watching the variability and flow of fusion as it occurs in session. Working with clients can be a bit like traveling through a dense thicket. It’s easy to lose direction, get caught on a bramble, or get stuck. Some clients will talk for hours about what has happened to them, eating up the session with complaints, explanations, and descriptions. When a session becomes thick with reasons, justifications, and stories, you can sometimes open up some space by asking yourself or the client questions that focus on the functional utility of what the client is talking about or thinking (Hayes et al., 2012, p. 260): “And what is that story in the service of?” “Is this helpful, or is this what your mind does to you?”

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“Have you said these kinds of things to yourself or to others before? Is this old?” “Okay, let’s all have a vote and vote that you are correct. Now what?” This moves the focus back to the immediate implications of the client’s story and away from attempting to figure out or analyze the situation or be correct. Again, it’s important that such questions not be asked from an apparent one-­up position or sarcastically. Rather, they should be asked from a place of humility and understanding about why human beings get attached to stories: because we’re taught to give reasons. Also be aware that asking these kinds of questions isn’t about the truth of the story. The events may very well be true. These are questions about the utility of the story: is it functioning to keep the client stuck? Another way to cut through fusion is to help clients contrast what their minds say will work with what their experience says about what has worked. For example, a therapist might say, “I don’t want you to see this as a matter of belief, but to examine it against your experience” or “What does your experience say?” The goal of this approach is to move clients out of literal, evaluative thinking and into a stance that’s more oriented to the opportunities afforded by their environment and directed by their values. Another option is to acknowledge the situation directly. Here are a few examples of how you might do so: “Hmm. Have you noticed that it’s getting awfully ‘mind-­y’ in here?” “I notice I’m fighting here, trying to figure it out and persuade you. Is it okay if we just take a deep breath and notice that we’re both just here in this moment, each with our chattering mind?” “I have no idea what to do or say next. My mind is being pretty harsh with me for saying this. Apparently it thinks that therapists are supposed to always know these things. Do you have thoughts about how to proceed?”

Exercise:

Working with Client Defusion, Part 2 Go back to the three client thoughts you listed in the exercise at the beginning of this chapter. Now that you’ve read about various defusion techniques, come up with one technique you could use for each of the thoughts you recorded before. Defusion technique for thought 1:   Defusion technique for thought 2:  

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Defusion technique for thought 3:  Consider using these techniques in session with that client. If you find yourself hesitating, notice what shows up when you consider taking this action. What emotions, action urges, thoughts, or reasons do you notice?     If you find yourself hesitating, ask yourself a question in relation to these thoughts and reasons: If you decided that these thoughts were 100 percent correct and followed them, where would that lead in terms of your behavior with the client? What would this behavior show you were valuing?   Next, consider what defusion exercises you’d be willing to do with your thoughts and reasons, then do one or more of them with these thoughts. It might be useful to do one of those exercises right now. Alternatively, you could make a plan for which strategy to use when or if those thoughts and reasons show up in session with a client.

Core Competency Practice This section is intended to provide practice in using defusion techniques in response to sample dialogues based on ACT sessions. Comments on the previous edition of this book indicated that readers found the defusion competencies among the trickiest to learn. So although we still recommend that you choose to fully engage in the exercises and generate your own responses before looking at the model responses, we do acknowledge that you’ll probably find this work quite difficult. However, this makes sense, as many people find defusion the most counterintuitive part of the ACT model and thus the hardest to learn. However, for clients and therapists alike, it’s best learned through practice and repetition, rather than through intellectual understanding. These exercises will give you a chance to engage in that practice and repetition.

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There is one exercise for each of the nine ACT core competencies for defusion. For each competency, we present a description of a clinical situation and a brief dialogue. The dialogue ends after a client statement, at which point we ask you to provide a response that reflects that competency, and then the basis for your response. For each exercise, focus on providing a response that illustrates the target competency, rather than responses that are consistent with ACT in general. After you complete each exercise, turn to the end of the chapter to see our model responses. As a reminder, the model responses aren’t the only right responses; they’re just examples of ACT-­consistent responses. If your responses are different, that doesn’t necessarily make yours wrong or less useful. Instead, see if you can remain open to learning, bringing curiosity to comparing the model responses to your own.

Core Competency Exercises Competency 12:  The therapist identifies the client’s emotional, cognitive, behavioral, or physical barriers to willingness.

At first glance, this competency may seem to be more about acceptance and willingness than about defusion. However, acceptance depends on defusion. We first need to differentiate thinking that’s important to target (i.e., that serves as a barrier to values-­based action) from thinking that may elicit fusion but isn’t serving as a barrier. In addition, external barriers are differentiated from private experiences because external barriers require action out in the world, such as problem solving. In contrast, in ACT, thoughts, feeing, sensations, urges, and other private behaviors are targeted with defusion and acceptance.

Exercise 12 The client is a thirty-­four-­year-­old woman who has panic attacks, particularly in social situations. She wants to go back to school but feels she’s too anxious. This dialogue occurs in the third session, following a discussion in which she has related how hard it is for her to participate in classes, particularly in terms of raising her hand. Therapist: What stands in the way of raising your hand in class? Client:

I just can’t do it. When I even think about it, I get scared.

Therapist: Okay, you have the thought “I can’t do it” and the feeling of being scared. What else stands in the way of raising your hand? Client:

I’m afraid I’ll panic.

Therapist: Anything else? Client:

No. Isn’t that enough?

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Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 12:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 13:  The therapist suggests that attachment to the literal meaning of these experiences makes willingness difficult to sustain (in other words, the therapist helps clients see private experiences for what they are, rather than what they advertise themselves to be).

Exercise 13 This dialogue continues where the dialogue for competency 12 left off. Therapist: What’s important is your actual experience. So you’re going along, and this thought shows up: “I can’t do it.” And a feeling shows up: fear. It’s also saying its buddy is coming along for the ride: “I’ll panic.” Notice that panic isn’t here yet. In that moment, what you’re having is the thought “I’ll panic.” So let me ask you this: could you have that thought, “I just can’t do it,” and the other thought, “I’ll panic,” as thoughts and still raise your hand? Client:

I guess, but I just can’t do it. I’d be too scared. I’d just end up embarrassed.

Write here (or in a notebook) what your response would be, demonstrating competency 13:  

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  In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 14:  The therapist actively contrasts what the client’s mind says will work with what the client’s experience says is working.

Exercise 14 This dialogue continues where the dialogue for competency 13 left off. Therapist: The thought “I can’t do it,” held literally, does indeed make it hard to be willing. So, for example, when you feel anxious and “I can’t do it” shows up, if that’s literally true, you’re stuck. On the other hand, if it’s a thought, you might be able to react to it in a different way. What if thoughts are kind of like a tool, like a hammer or something? We don’t spend time trying to figure out whether a hammer is a true hammer; we just use it or we don’t. Now, in this situation, would picking up the thought “I can’t do it” and using it lead you to engage in your values? Client:

But I can’t do it. I know that if I raise my hand and I haven’t been able to get my breathing under control, I won’t be able to say anything when the professor calls on me. If I could just get my breathing under control, I could probably do it without panicking.

Therapist: So, let’s check this out. Your mind says, “I need to get my breathing under control.” Right? That’s a thought. Is that a familiar one? Client:

Yeah.

Therapist: Now, let’s look at what your experience has to say about this. How long have you been following what that thought has to say? Client:

A long time…

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Write here (or in a notebook) what your response would be, demonstrating competency 14:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 15:  The therapist uses language tools (e.g., verbal conventions),

metaphors, and experiential exercises to create a separation between the client and the client’s conceptualized experience.

Exercise 15 A forty-­four-­year-­old male client is struggling with alcohol addiction. One of his biggest triggers of alcohol use is being at home alone. He was on disability for a long time and has spent a fair amount of his life sitting at home, drinking and watching TV. He’s been sober for the past two months and just started a new job after several years of unemployment. He’s beginning to question his commitment and wondering whether the job is really worth the stress. The therapist and client discussed the Passengers on the Bus metaphor in a previous session; this dialogue is from the client’s sixth session. Client:

It’s just that I go to work and they don’t pay me enough, so it’s stressful. I feel like I screw up and don’t work fast enough. I’m not sure it’s really worth it. I get home at the end of the day, and there’s no one there. I want to do better, but I just want a drink…so badly.

Write here (or in a notebook) what your response would be, demonstrating competency 15:  

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  In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 16:  The therapist works to get the client to experiment with “having” difficult private experiences, using willingness as a stance.

Exercise 16 This dialogue continues where the dialogue for competency 15 left off. Therapist: Would you be willing to do an exercise with me? Client:

Sure.

Therapist: I’ll invite you to shut your eyes, and I’ll bring you back to that moment. (The client shuts his eyes.) Think of the last time you were at home, sitting there after work, exhausted and feeling lonely. Do you remember the bus metaphor we talked about before? Client:

Yeah.

Therapist: What passengers show up there and start pushing you around? See if you can notice what feelings show up. Client:

I’m feeling a little anxious.

Therapist: Simply notice the experiences, being present to what you feel and observing where you feel it in your body. And while you’re noticing, see whether you can notice thinking, coming into contact with what it’s like to experience thoughts and anxiety. Client:

I feel lonely. I feel anxious, like I need to do something.

Therapist: So, lonely shows up… Anxious shows up. If those passengers could speak to you, what would they tell you to do?

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They would tell me to have a drink to take the edge off.

Therapist: So these are old passengers, ones who are very familiar. You know them well. What do they say they’ll do if you just do as they say? Client:

They say they’ll go away—­they’ll shut up for a while. And they do.

Write here (or in a notebook) what your response would be, demonstrating competency 16:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 17:  The therapist uses various exercises, metaphors, and behavioral tasks to reveal the hidden properties of language.

Exercise 17 The client is a depressed forty-­year-­old man who constantly compares himself with other people in social situations and often sees himself as less worthy than others. A common pattern for him is being in a conversation with someone and simultaneously thinking, This person seems to have it pretty together. If he knew how much of a loser I am, he wouldn’t want to be friends with me. He can’t really be as together as he seems. I’m sure there’s some way in which he has problems. I don’t know what it is, but I’m sure I’ll find it eventually. The client is talking about this situation in the fourth session. Client:

I’m just so sick of comparing myself with others, feeling bad, and then tearing them down.

Therapist: What’s the thought that is most troublesome? That you’re bad? Client:

Hmm. I guess it’s that I think, “He’s better than me.”

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Therapist: “He’s better than me.” And that makes you… Client:

Bad. Worse.

Therapist: Which one feels more at the heart of it? (Attempts to identify the more functionally important thought to target.) Client:

Hmm. Bad.

Therapist: So, are you willing to do a little exercise with me around this thought that shows up for you, “I’m bad”? Client:

Sure.

Therapist: What I’d like us to do is play around with this thought a little. Let’s try something out. How about we sing a song? I’ll go first. “I’m bad, I’m bad, you know it.” Your turn. Client:

Um, okay. (Sings in a high, funny voice.) “I’m bad, I’m bad. I’m the worst there is.”

Therapist: And, let’s do a duet of it. (Sings a few more rounds with the client.) So tell me, what was your experience of that? Client:

Well, at first it was pretty weird. I didn’t like making fun of something that felt so personal. But then it got a little lighter. It wasn’t such a big deal.

Write here (or in a notebook) what your response would be, demonstrating competency 17:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 18:  The therapist helps clients elucidate their story and helps them make contact with the evaluative and reason-­giving properties of the story, as well as the arbitrary nature of causal relationships within the story.

Exercise 18 This dialogue continues where the dialogue for competency 17 left off. Therapist: What happened to the meaning of it? Client:

It didn’t mean much after a little while, beyond seeming a little funny.

Therapist: So, when you say to yourself, “I’m bad,” in addition to the meaning your mind gives to those words, isn’t it also true those words are just words? In some way, they’re kind of like smoke—­there’s nothing solid there. Client:

Yeah, but it seems really solid when I’m there. It’s like I think that’s really true about me. I feel like I really am bad in some ways. It feels like believing something else would be a lie.

Write here (or in a notebook) what your response would be, demonstrating competency 18:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 19:  The therapist detects fusion in session and teaches the client to detect it as well.

Exercise 19 The client is a fairly intellectual woman in her forties who’s considering leaving a dispassionate relationship with her spouse, Fatima, whom she describes as alternating between being withdrawn and being verbally overbearing and critical. The client has read dozens of self-­help books, has spent years in counseling with other therapists, and displays a lot of insight into her problems and Fatima’s. Nevertheless, she continues to be very passive in her relationship and avoidant of conflict. This dialogue picks up near the beginning of the seventh session, after the client has been talking for several minutes about what Fatima did that week to intimidate and bully her. The therapist has noted that the conversation feels very lifeless, old, and stale. Client:

I just don’t know what to do. I’ve been thinking about leaving, and yet I know if I leave, it also means I’ll lose the kids. I feel so stuck. What do you think I should do?

Write here (or in a notebook) what your response would be, demonstrating competency 19:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 20:  The therapist uses various interventions to reveal both the flow of private experience and that such experience is not toxic.

Exercise 20 This dialogue continues where the dialogue for competency 19 left off. Therapist: Let me ask you something about this conversation you’re having with yourself right now. Does this feel alive, new, and different, or does it feel old, lifeless, and familiar? Client:

It’s old. Fatima has been doing this forever and doesn’t have any interest in changing.

Therapist: And there it is again. We’re still talking about Fatima and how she won’t change. How many hours have you spent talking about her, thinking about her, and trying to analyze things? And here we are again. How do you feel in your body as you talk about her? Client:

Old, familiar. I’ve thought about this a million times.

Therapist: And your mind is here, yet again, suggesting ways to figure this out. Can you notice your mind right now? What’s it saying right now? (Highlights the distinction between the client and her mind.) Client:

It’s saying, “Okay, so what do I do, then?”

Therapist: And what’s next? (Points to the ongoing process of thinking.) Client:

Um, I’m not sure.

Therapist: Next your mind gave you a thought with the words “I’m not sure.” Did you notice that was a thought? Client:

Um, no, I guess not.

Therapist: So what’s next? What thought comes up next? (Points to the ongoing process of thinking again.) Client:

I don’t like this.

Therapist: And…did you notice that’s a thought? (Invites defusion.) Client:

Yeah.

Therapist: And what shows up next? See if you can simply notice each thought as it comes up—­not get stuck on what it says it is, but simply notice it as a thought. See if you can let each one simply be there as a thought, just letting each one pass in and pass out again. (Pauses for ten seconds.) Okay, so what thought is next? (Distinguishes between the mind and the client and promotes noticing of ongoing thinking.) Client:

I’m having the thought that I don’t know where this is going.

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Therapist: Good. A thought that looks like “I don’t know where this is going.” That’s a really good one. Isn’t the mind a great machine? (Smiles and pauses.) Do you notice how automatic this verbal machine is? You don’t even need to do anything; it just keeps producing these words and sentences that then structure your world. So what we’ve been practicing here is simply noting when you move in and out of seeing the world as structured by your thoughts, versus being able to see thoughts as thoughts. One skill we want to practice is to be able to notice when you’re caught up in this world of thought, with all its judgments, planning, and evaluations—­for example, “If I only did this, then that would happen”—­and then simply come back to the moment and observe what’s there. Client:

Yeah, but I still don’t know what to do about Fatima.

Therapist: Yeah, that thought is still there. So, you’ve gone around and around about what to do here, and yet you find yourself stuck. I’d like us to step outside of this a bit and look at the bigger picture. You’ve told me before that a value you have is respecting yourself. And another value you have is connecting with your partner. Have those values changed? (The therapist did work earlier to evaluate the risk of violence, and all signs suggest it’s minimal.) Client:

No.

Therapist: Okay, so they haven’t. Yet in what happens with Fatima, do you respect yourself in how you respond to her? Client:

No, not really. I let her walk all over me.

Therapist: Right. It seems as if something stands in the way of respecting yourself when she’s talking to you. What stands in your way? (Points to thoughts as barriers.) Client:

Well… I feel so small. And I think about saying something, but I’m really scared. I know she’ll blow up and just walk away and sulk or something if I don’t let her have her way.

Therapist: And when that happens, you feel…? Client:

I’m scared that I just made things worse. And then I walk around on eggshells for a couple of days, waiting for her to blow up again or leave me.

Therapist: And how is that for you? Client:

It’s just terrible. I feel like…like…I can barely stand it.

Write here (or in a notebook) what your response would be, demonstrating competency 20:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Core Competency Model Responses Competency 12 Model Response 12a Therapist: We want to be open to anything that’s there, and sometimes things float around that aren’t noticed. So in addition to the “I can’t do it” thought, the fearful feelings, and the “I’ll panic” thought, let me ask you about some other dimensions that might be part of not raising your hand. What do you feel in your body? (The client answers.) Good, and does this remind you of anything in the past? (The client answers.) Cool. And what kind of judgments and evaluations show up? (The client answers.) And when you have all of that, what do you want to do? (The client answers.) Explanation: This response amplifies the client’s observations of her experience and treats each observation in a defused way. The therapist specifically asks about particular types of experience that the client might not otherwise identify in order to help her see them more clearly and thereby be less caught up in them. Experiences that could be categorized as potential barriers include evaluations, memories, images, sensations, emotions, moods, and action tendencies or urges. Linking these observations to action tendencies categorizes them as possible barriers to moving forward in a valued direction. The goal is to communicate that all of these barriers are acceptable—­that none is to be avoided or taken literally. Model Response 12b Therapist: What’s important is your actual experience. So you’re going along, and this thought shows up: “I can’t do it.” And a feeling shows up: fear. It’s also saying its buddy is coming along for the ride: “I’ll panic.” Notice that panic isn’t here yet. In that moment, what you’re having is the thought “I’ll panic.” So let me ask you this: could you have that thought, “I just can’t do it,” and the other thought, “I’ll panic,” as thoughts and still raise your hand?

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Explanation: This response outlines how these emotions and thoughts present themselves as barriers to moving forward in valued directions. The goal is to orient the client to the way these barriers function and to help her step back from seeing them as being reality and instead start to notice how they manifest for her. The context of nonliterality is assumed in the answer because the thoughts are treated more as objects that can be had, rather than as something to be believed literally.

Competency 13 Model Response 13a Therapist: Hmm. Let me just ask you this: How old is that thought, “I’d be too scared?” Client:

I don’t know, I’ve been scared for as long as I can remember.

Therapist: You’ve been living inside that story that you’re too scared for a long time, yes? Buying into that thought has cost you a ton. (Points to workability.) How about this? Do you know where that thought, “I’d be too scared,” comes from? What if these are just bits of programming—­your history showing up in the present—­and in buying into them, you’re amplifying them into events that run your life. Gub-­gubs go… Client:

Wooo.

Therapist: Yeah. And I can’t raise my hand because I’m too… Client:

Scared.

Therapist: So who’s in charge here, you or your mind? Explanation: By focusing the client on the historical fact that buying into certain thoughts can contribute to problematic patterns of behavior, the costs of fusion are made more evident. Appeals to history make it clear that the client can expect these thoughts to continue as they have for some time. The issue, however, is their role in overt behavior. Highlighting the client’s ignorance as to the source of these thoughts and drawing an analogy with a current, trivial source of a thought can help the client see her thoughts as an ongoing, historically produced process, not as literal events that must be complied with, argued with, resisted, or avoided. Model Response 13b Therapist: The thought “I can’t do it,” held literally, does indeed make it hard to be willing. So, for example, when you feel anxious and “I can’t do it” shows up, if that’s literally true, you’re stuck. On the other hand, if it’s a thought, you might be able to react to it in a different way. What if thoughts are kind of like a tool, like a hammer or something? We don’t spend time trying to figure out whether a hammer is a true hammer; we just use it or we don’t. Now, in this situation, would picking up the thought “I can’t do it” and using it lead you to engage in your values?

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Explanation: The therapist suggests that buying the thought, or holding it literally, is going to make it hard for the client to do anything with respect to the values at hand. The therapist compares the thought to an object to help the client relate to it in a more pragmatic way—­based on its usefulness rather than what it literally says it is. The therapist then asks the client to evaluate whether this thought is useful in relation to her values.

Competency 14 Model Response 14a Therapist: So now we’ve heard from your mind. What does your experience have to say? Has it turned out the way your mind said it would—­that if you just keep trying, eventually you’ll get your breathing under control and you’ll be able to speak in class and participate in the way you want? In your experience, has it worked out that way? Explanation: The therapist examines whether the verbal rule implied by the client’s thoughts—­“If you just try to get your breathing under control, you eventually will, and then you’ll be able to raise your hand”—­actually turns out as the rule specifies. Model Response 14b Therapist: (Speaks gently.) So let’s just notice that. Your mind is trying to protect you, and yet when you do what it has told you to do—­try to get your breathing under control—­look at what’s happened. You haven’t been able to do it, and your panic has only gotten worse over time. If your mind were an investment advisor, you would have fired it a long time ago. It seems as if your experience shows that things don’t work out as your mind predicts. So which are you going to believe: your mind or your experience? Explanation: The explanation for this response is the same as that for sample 14a; the therapist is just using a slightly different style.

Competency 15 Model Response 15a Therapist: It’s worth noticing that word “but.” You know, the word “but” long ago came from a contraction of two words: “be” and “out.” “But” is a fighting word. You’re saying that the fact you want a drink somehow invalidates wanting to do better, and wanting to do better should somehow remove the urge to drink. Yet check and see whether that was what you experienced. I’m guessing that what you experienced was two things: the thought that you want to do better and a feeling that you want to drink. Is there anything I said there that you cannot have? “I want to do better and I want a drink.” Both things are so. Now, what are you going to do with your feet? (Shifts from a focus on thinking to pragmatic action focused on values.)

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Explanation: The therapist is trying to draw out the hidden struggle and help the client see that there’s really nothing to fight about. As often happens, defusion work is followed by a shift toward values-­based action. Model Response 15b Therapist: Would you be willing to do an exercise with me? Client:

Sure.

Therapist: I’ll invite you to shut your eyes, and I’ll bring you back to that moment. (The client shuts his eyes.) Think of the last time you were at home, sitting there after work, exhausted and feeling lonely. Do you remember the bus metaphor we talked about before? Client:

Yeah.

Therapist: What passengers show up there and start pushing you around? See if you can notice what feelings show up. Client:

I’m feeling a little anxious.

Therapist: Simply notice the experiences, being present to what you feel and noticing where you feel it in your body. And while you’re noticing, see if you can also notice thinking, coming into contact with what it’s like to experience thought and anxiety. Explanation: The therapist is trying to make the work as experiential as possible, helping the client observe his thinking more broadly and from the perspective of noticing his experience. To do this, the therapist needs to get the avoided content out into the room. So the therapist does a short experiential exercise that helps the client make contact with his avoided content. Then the therapist refers back to an earlier metaphor (Passengers on the Bus) in which thoughts and feelings were compared to bullies that push the client around. The goal is to bring the bullies into the present, but in an altered context in which the avoided private experiences can be met with more willingness and with some healthy distance.

Competency 16 Model Response 16a Therapist: Well, they will sit down, sure—­as you say, for a while. When they come back, are they bigger or smaller? Are they weaker or stronger? (Pauses.) Bigger and stronger, right? So it has a cost. Here’s my question: what do you have to be willing to experience in order to let them be there and not sit down? Explanation: The therapist is asking the client to consider the possibility of having these experiences by being more willing to have whatever shows up when he takes that step.

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Model Response 16b Therapist: Right, they sure do. So, one way to work with them is to do things so they’ll agree to sit down. Let’s check this out, though. If you do that, what happens with respect to your values? Do you head toward or away from your values? Client:

Away. But even then, they’re just as powerful.

Therapist: Yeah, powerful…and old…and familiar. And you’ve been fighting with these passengers for a long time. How has it worked to fight them? And how has it worked to turn the direction of your life over to their demands? Client:

It hasn’t worked.

Therapist: So maybe it’s time to do something different. How about this? Just let them be there as thoughts, as feelings. Don’t do anything with them except notice them. Client:

I don’t know if I could do that.

Therapist: Right, so your mind gives you the thought “I don’t know if I could do that.” Let me ask you something: what is your experience of how well trying to fight these passengers has worked? Client:

Not well.

Therapist: How about this? Do you know, from experience, whether learning how to simply notice and make space for the passengers works? You know what it’s like to struggle with them and try to get rid of them, and that’s led to lots of pain. I guess the question is, have you had enough pain to be willing to try something else even if you don’t know how it will work out? Another way to say this is, are you going to pay attention to your experience or your mind? Explanation: The therapist is asking the client to examine the workability of his old solutions and to consider willingness as an alternative. When the client says, “I don’t know if I could do that,” this represents fusion with a cognitive barrier to willingness. The therapist identifies the client’s presented barrier as another thought and then proceeds to ask the client whether he would be willing to try a new behavior—­the behavior of willingness. The therapist refers back to the client’s experience of struggle and asks whether that has worked. If the client agrees to try something else, this could segue into willingness and exposure work.

Competency 17 Model Response 17a Therapist: And even if it didn’t feel lighter, there is a point in here. At one level, this is also just language. Mary had a little… Client:

Lamb.

Therapist: And gub-­gubs go…

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Wooo.

Therapist: And he is better than… Client:

Me.

Therapist: These words are worth restricting your life over? Explanation: The therapist highlights the automaticity of thought and the difference between literal meaning and pragmatic meaning. Model Response 17b Therapist: What happened to the meaning of it? Client:

It didn’t mean much after a while, beyond seeming a little funny.

Therapist: So, when you say to yourself, “I’m bad,” in addition to the meaning your mind gives to those words, isn’t it also true that those words are just words? In some way, they’re kind of like smoke—­there’s nothing solid there. Explanation: As often happens in debriefing experiential exercises, the therapist highlights aspects that the client may have experienced but not taken note of. In this case, the therapist highlights how the meaning evaporated during the exercise, revealing the words as simply words, without all the extra meaning attached through fusion.

Competency 18 Model Response 18a Therapist: Yeah, minds don’t like us just letting go of the story; it has to be true or proven false. If you just let it go, it’s like a lie, like you aren’t genuine. And even right now your mind is doing it. Even in this very conversation you’re trying to figure whether you’re bad or good. How long have you been trying to figure this out? Client:

I don’t know… A long time.

Therapist: And based on the fact that we’re still talking about it, it seems you haven’t figured it out. What if the question in front of us is something different? What if it’s about whether you want to figure this out or you want to live a full and meaningful life? Suppose you can only pick one. Which do you choose? Explanation: The client is trying to move the issue to the literal truth of the story. The therapist is drawing that out and moving the focus back to functional truth (i.e., whether the story helps the client move toward his values-­based life goals). If the client agrees that he’s interested in letting go of investment in this story, a follow-­up might be to develop an agreement to notice when his mind tends to drift back into that territory in session and then return to more values-­based discussions.

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Model Response 18b Therapist: I’m not asking you to believe something else. In fact, I’d recommend that you not try to believe something else. That would just be more of the same thing. You’ve already tried that, right? Telling yourself you’re basically a good person—­has that worked to the extent that you now don’t worry about being a bad person? Could you just have that thought, “I’m bad,” as a thought, and still do what matters to you? Explanation: The client seems to be hearing the therapist saying that he shouldn’t believe these things. This wouldn’t be an ACT-­consistent message because it remains within the context of literality. So the therapist says something that steps outside of literal understanding and includes the dimension of belief versus nonbelief by saying, “I’d recommend that you not try to believe something else.” Then the therapist refers back to the issue of workability and the client’s experience and suggests a way of relating to the thought.

Competency 19 Model Response 19a Therapist: Have you said to yourself before that you need help? Does this feel old? Client:

Yeah.

Therapist: Let’s say I gave you a definitive answer. Let’s say I said, “You need to stay and work this out.” Would that help? Explanation: The therapist highlights one of the characteristics of fused thinking: it feels old, tired, and repetitive. The therapist then takes the additional step of pointing to the functional utility of the client’s thoughts (i.e., does this pattern of thinking move the client toward her values-­based life goals?). Model Response 19b Therapist: Let me ask you something about this conversation you’re having with yourself right now. Does this feel alive, new, and different, or does it feel old, lifeless, and familiar? Client:

It’s old. Fatima has been doing this forever and doesn’t have any interest in changing.

Therapist: And there it is again. We’re still talking about Fatima and how she won’t change. How many hours have you spent talking about her, thinking about her, and trying to analyze things? And here we are again. How do you feel in your body as you talk about her? Explanation: The therapist is trying to highlight some of the qualities of “mind-­y” conversations, in this case, their tendency to drag on and feel lifeless. The therapist contrasts this with vital conversations. The client’s initial response doesn’t indicate much in the way of defusion, so the therapist’s second response is a further attempt to help the client notice her ongoing pattern of thinking. The therapist then refocuses the client on stimuli in the present moment, in this case her body, in order to move in a more experiential direction.

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Competency 20 Model Response 20a Therapist: And so you do what it takes to make that feeling go away. You shrink, you get small, you give in, you distract yourself, you walk on eggshells. But something’s weird here: Your mind says you can barely stand it, yet you’ve been standing it for years. And you go on standing it, struggling with it, for years. I’m wondering, would you be willing to have the thought “I can barely stand it” and make some more room for these scary feelings next time they show up? Your job would be to feel thoroughly terrible, to do a really good job at feeling that, rather than trying to feel differently. Then you can find out whether these thoughts and feelings can hurt you—­whether you come out injured and beaten up, or whether getting beaten up comes from your struggle with these experiences. You can pick how long. Would you be willing, even for five minutes, to just notice what thoughts and feelings show up and to just feel your feelings and watch your thoughts without doing anything about them? Afterward you can always go back to doing what you were doing before. Are you willing? Client:

Five minutes? That’s too long. I’ll try one minute.

Therapist: Cool. One minute. And then you can come back to the next session and tell me whether you were able to stand it or whether it really injured you. Instead of suggesting a between-­session exercise, another option is to conduct an in-­session exposure-­like exercise (see chapter 7) such as the Mr. Discomfort exercise (Hayes et al., 2012, pp. 285–­ 286) to practice willingness and defusion with her fears related to being respectful of herself during difficult interactions with her partner. Another option could be a role-­play with the client in which the client practices getting in contact with these feelings and noticing that, while they are painful, she isn’t damaged by experiencing them. Explanation: In the vignette, the therapist guided the client to acknowledge a value in relation to her partner (“respecting yourself”) and avoided mental content related to that value. This sets the context for an experiential exercise or between-­session practice in which the client contacts the avoided material in an open, accepting, and compassionate way. Rather than talking about defusion, the therapist directs the session in such a way that the client will hopefully experience defusion. It’s not important that clients understand defusion conceptually; they just need to be able to engage in defusion. Model Response 20b Therapist: I want to go back a little to something you said: “I’m not sure.” This story seems to be showing up throughout this entire process. How many times would you say you’ve encountered this thought? Client:

Many, many times.

Therapist: It’s as if it’s passed through you again and again, and a significant portion of the time it captures you. You get hooked. Client:

I get hooked by it a lot.

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Therapist: I wonder if it would be possible to really connect to its repetitive, almost circular nature. It flows around and around. Can I invite you to close your eyes for just a minute and imagine the words “I’m not sure” simply passing by? See if you can put the words in the shape of clouds, and have them pass by, again and again. (The client closes her eyes and the therapist pauses for a minute.) Now as you notice these passing thoughts, I also want you to notice that you’re encountering them, just like you always have, and you are still here, safe, whole, and sound. Explanation: The therapist is highlighting the ongoing flow of internal experience by using imagery and also establishing that this flow of thoughts and feelings isn’t dangerous by connecting the client to her here-­and-­now experience as she contacts a difficult thought.

Experiential Exercise:

Defusion If you’re like many people, engaging in this core competency practice may have evoked some difficult private experiences. Perhaps you even fused with a story about what your “performance” on these exercises says about you as a therapist or as a person. So we’ll bring this chapter to a close with an experiential exercise to help you defuse from that content. What was the most difficult thought about your professional practice or your learning that you had while working with this chapter?   Now identify which of the principles of defusion seems most relevant to this thought:  What exercise or activity can you do to apply this principle to your own difficult thought? Describe your plan here and then try it out, noticing especially how this approach affects your entanglement with the thought.    

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For More Information For more about defusion, including exercises and metaphors, see Hayes et al., 2012, chapter 9. You’ll also find a wide range of exercises and metaphors related to defusion in Stoddard and Afari, 2014. For an entire book devoted to learning about defusion, see Blackledge, 2015. For defusion-­related exercises and worksheets that you can use for yourself and clients, see Hayes, 2005, chapters 5 through 7.

CHAPTER 4

Getting in Contact with the Present Moment

Our true home is in the present moment. —­Thich Nhat Hanh

Key targets for contact with the present moment: Help clients discover that life is happening in the here and now and assist them in returning to the now from the conceptualized past or future. Help clients make contact with life as it’s happening in the moment, whether it is filled with sorrow or joy. Help clients develop the ability to attend to their experience in a more flexible, fluid, and voluntary manner. Help clients notice what’s happening in their relationships in the moment.

Life is always lived right here and right now. There is nothing that can be directly experienced other than the present moment. Everything else is a conceptual rendering—­a sketch, a thought, a plan, a memory, a picture drawn. And even though all of these refer to imagined futures or pasts, they can only be experienced in the present moment. The ability to consider the past and plan for the future is essential for humans, and it’s helpful a good deal of the time. However, problems arise because people tend to get excessively and rigidly engrossed in the future or past and lose contact with the present. When under the sway of cognitive fusion, people tend to interact with these conceptualized futures and pasts as if they were really happening and, as a result, may end up spending little time in the here and now. ACT suggests that the problem isn’t that we need to eliminate thinking about the future or past, but

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that people need to be flexible: being in the present when a present focus works best, being in the future when planning works best, and being in the past when remembering works best. However, helping clients be in the here and now is particularly important because this is where new learning occurs. It is where opportunities afforded by the environment can be discovered. One of the key targets of ACT is to help clients let go of the struggle with their personal history, as well as unwanted feelings, thoughts, and sensations, so they can show up to engage in the ongoing process of life that occurs moment by moment. Contact with the present moment therefore refers to the process of helping clients routinely step out of the world as structured by their thoughts and to more directly, fully, and mindfully contact the here and now, including both sensory contact with the external world and contact with the ongoing processes of thinking, feeling, sensing, and remembering.

What Is Contact with the Present Moment? Showing up for the present moment involves bringing awareness to internal and external experiences as they occur in the here and now. This kind of focus is created by observing or noticing what arises within awareness on a moment-­by-­moment basis. For instance, when attending to your external and internal experience, you might first hear the sound of a bird, followed by the sight of a yellow color in the petal of a flower, followed by the feel of your foot touching the ground, followed by a thought (This is nice), followed by the sensation of an itch, and so on. Each one of these experiences is noticed as it occurs. In this effortless process characterized by nonattachment, experiences arise and then fall away. Contacting the present moment is easy and difficult at the same time. It’s easy to turn attention to an experience, yet it’s difficult to maintain attention on ongoing experiencing. Our minds are quickly pulled away from the moment as we’re repeatedly drawn into a virtual world structured by thought. Because this happens rapidly, it takes practice to stay present. In ACT, clients are asked to practice numerous defusion, acceptance, and mindfulness exercises to help increase their capacity to stay present. It should be noted that not even those who practice intensively can stay present at all times. Indeed, the process of present-­moment awareness involves developing the ability and skill to observe when the mind has wandered and then return to the present moment, while also recognizing that it’s nearly impossible to stay present at all times. Also note that ACT therapists help clients develop the ability to be focused and present not because clients should always be in the present moment, but so they can do this when it works to do so (e.g., in the presence of an aversive experience that constricts behavior in unworkable ways). Present-­moment awareness is encouraged not only because it’s the place where life is truly lived, but also because it promotes values-­based living by increasing psychological flexibility. One of the important aims of working with present-­moment awareness is to help clients develop the ability to attend to their experience in a more flexible, fluid, and voluntary manner. For example, focused attention on a particular stimulus is needed at times (such as when reading a textbook), but sometimes breadth of attention is also needed, wherein awareness is expanded to include stimuli other than the current focus (such as noticing that class has begun and turning attention to the teacher). As with all of the flexibility processes, one of the key goals of working with present-­moment attention is increasing clients’ flexibility in ways that lead to effective behavior in context.

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Why Contact with the Present Moment? As noted in chapter 3, a great deal of suffering can result from fusion with thoughts, or getting enmeshed with one’s thinking. When thoughts are seen as negative, they’re often evaluated as detrimental, leading people to engage in efforts to eliminate or reduce these unwanted experiences. At times, it is as if thoughts and experiences cease to flow as we almost become these experiences and are puppets to their demands. We become so heavily invested in understanding a “problem” and finding the solution that we begin to get lost in our past and our beliefs in an effort to figure it all out. We may also spend large amounts of time in the future, thinking or worrying about what might happen next. When we’re caught in these conceptualized worlds, we tend to miss the opportunities that are present in the here and now. Coming back to the present moment and mindfully and nonjudgmentally observing and describing our current experience places us back in contact with our context and helps us be present, creating the conditions necessary for us to act on our values. Contact with the here and now also undermines avoidance and struggle. If we’re connected to the present moment, we usually have nothing to fight against. Much of what is present is, in and of itself, nonthreatening. Feelings, thoughts, sensations, urges, and so on are simply experiences to be observed. When we lose contact with the present, we can lose awareness and end up entangled with the mind, overly absorbed in evaluations, judgments, and assessments about our feelings, thoughts, and sensations, creating needless suffering. Therefore, contact with the present moment undermines fusion, including attachment to a conceptualized self. Establishing the capacity for flexible and fluid awareness of one’s ongoing experience is essential in responding effectively to life’s challenges. There is no specific rule for how to live effectively in every situation; individuals have to find their own way to live a life that works for them. Accordingly, in order to respond flexibly to life’s challenges, it’s important that people know something about their idiosyncratic patterns of behavior, inclinations, emotional responses, and vulnerabilities. It is present-­moment awareness (often in the context of others who are responsive to us) that allows us to know ourselves. Indeed, making space for and embracing difficult emotions allows us to learn from what they have to tell us. For instance, awareness of deep sadness may point to something we’ve lost (e.g., an important friend has moved away) and indicate what’s important (e.g., that we value close relationships). Thus, present-­moment awareness involves curiosity about and learning from our emotions and other behaviors. In contrast, ignoring or suppressing our emotions typically leads to lack of self-­awareness and an inability to respond to ourselves in a manner that’s caring, kind, and sensitive to our own difficulties and vulnerabilities. Being present has a vital, creative, and connected quality. If we are in the moment, rather than in the past or future, our capacity to receive or take in what occurs in life, while letting go of the desire to make it come or go, is expanded. When we’re present, we learn through experience that difficult emotions can be felt and that they aren’t destructive. It’s when we fight against thoughts or feelings, wishing they were otherwise, that harm occurs. At one extreme, this destructive battle can take the form of suicidal behavior spurred by fusion with a seemingly bleak and hopeless future; at the other end of the spectrum, it can take subtle forms, such as quietly withdrawing from a relationship in order to avoid pain. By experiencing thoughts and emotions from the point of view of “I am having this experience now,” we are freed from being controlled by our pain and history. From this stance, the need to understand, solve, and eliminate difficult internal experiences is diminished or dissolved; we can choose

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based on our values, rather than on the notion that something must first be different in our lives before we can choose. Indeed, “there is as much living in a moment of pain as in a moment of joy” (Strosahl et al., 2004, p. 43). Yet clients often take the position that their lives can only begin when they finally feel better—­a position that fails to recognize that their life is occurring right now. Each moment is here to be lived. Whatever historical events have happened, have happened. There is no going back and undoing those events. History is unidirectional, proceeding from one moment to the next. People can’t go back and have some other history. From an ACT standpoint, we would argue that time is better spent in the present moment, and it is from this perspective that you can help your clients bring their values to life. Equally important as letting go of the past is letting go of the conceptualized future. Whatever events may happen in the future have not yet happened. Furthermore, no one can accurately predict what will happen, and people are often surprised by what the future brings. It is often not what we hoped for or expected. We can, however, take specific actions toward creating a fuller, deeper, richer life. In the moment, we can choose to engage in values-­consistent actions, bringing personal meaning to each moment. This doesn’t mean things will turn out just as we intend or imagine. However, that doesn’t make the endeavor less worthwhile. Suppose you could choose to either spend a year living in alignment with your values, even with pain, or spend that year struggling with pain. Which would you choose? This question is generally easy to answer, including for clients. If people spend their time trying not to feel or think something, then they’re essentially trying to be something other than what they are. However, if they devote their time to living with awareness and with intentions to take actions guided by their values, their life will be imbued with meaning and purpose. Additionally, it is in the present moment that people develop flexible and fluid self-­knowledge (Hayes et al., 2012). Because much of private experience can be painful, people often avoid awareness of their own thoughts, feelings, and responses. This has significant costs in terms of living well and responding flexibly. By attending to the present, people learn more about themselves, what their reactions are, and how to respond to and regulate their behavior in a skillful manner.

What Should Trigger Working with This Process? ACT therapists spend a significant amount of time helping clients develop a stronger ability to return to the present moment through structured exercises, such as mindfulness meditation and in-­session present-­moment work. Focusing on present-­moment awareness is likely to be especially useful when clients display the following behaviors: • They seem out of touch with their feelings or lost in thought. • They’re unable to describe their own experience, indicating chronic avoidance or fusion. • They become too intellectual in therapy, wishing to understand with the mind rather than through experience. • They fail to respond to what’s happening in the relationship with the therapist.

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• Speaking of the past or future produces their entanglement with worry, rumination, or anxious predictions about the future. • They fail to notice opportunities for choice and values-­based living in their current contexts. • They blame others, rather than noticing their own behavior and its effects. Therapists can also use their own reactions in session as indicators that a present-­moment focus may be warranted. One possible indicator is when the clinician’s attention is wandering, which could be due to the client being distant, to the session feeling predictable or wordy, or to the session being dominated by discussion about other times and places. Clinician reactions such as wandering attention or boredom may also arise from idiosyncratic aspects of the therapist’s own history or life context (e.g., something happening in the therapist’s personal life), not necessarily anything related to the client. However, clinician reactions may indicate something about the client, so it’s wise to use yourself as a barometer to conceptualize the case and help guide treatment. Present-­moment awareness skills are developed to assist clients in routinely contacting the here and now. However, clients aren’t expected to be in contact with literal present-­moment stimuli at all times (e.g., hearing sounds as sounds, seeing thoughts as thoughts, feeling sensations as sensations). Indeed, it’s useful to be able to consider the future or think about the past. The goal is to be able to do so flexibly—­without getting stuck in rumination or worry, and when returning to the present helps support values-­based goals. The decision to focus on present-­moment awareness in session is influenced by the therapist’s conceptualization of in-­session client behaviors at multiple levels (for more on this, see chapter 8, on case conceptualization). To illuminate this, let’s look at an example. Imagine a client who’s just started talking about how frustrated she is with her child. This could be viewed as simply a report of what’s happening in the client’s life and used solely for informational purposes. Alternatively, it could be seen as a sample of the client’s social behavior, indicating that she tends to engage in harsh and critical commentary about others, which harms her social relationships. Or, if the behavior of talking about her frustration with her child immediately followed cues that could have elicited difficult emotions, it could be viewed functionally as avoidance behavior. And finally, it could be a subtle commentary on the therapeutic relationship, with the client implying that the therapist isn’t being helpful or that the therapy isn’t addressing her concerns. Depending upon what level the therapist chooses to attend to, moving the therapeutic focus to present-­moment awareness could be more or less relevant. For example, if the therapist primarily sees this as an example of experiential avoidance, he might gently interrupt the client and ask, “What happened right before you started talking about your son?” to bring the client back to the present-­moment processes occurring in the room.

What Is the Method? Perhaps the method that most therapists are familiar with to build present-­moment awareness is through formal practices, such as various mindfulness meditation techniques. While ACT includes these kinds of structured exercises and ACT therapists generally encourage clients to develop a formal mindfulness meditation practice if they’re interested in doing so, ACT also provides guidance on other ways to build

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present-­moment awareness. Below we explore three contexts designed to support awareness of the here and now: doing structured exercises, contacting the present moment during the ongoing flow of therapy, and contacting the present moment in the context of the therapy relationship. However, before embarking on these approaches, it’s often necessary to introduce clients to the process and importance of present-­moment awareness. Here’s one way to do so (inspired by Wilson, 2008). Therapist: Part of what happens when we’re struggling is that we interact with our internal life as if we were a math problem to be solved. However, it’s not always useful to treat everything in life as if it were a math problem. A lot of things are more like sunsets. It doesn’t work well to treat sunsets like math problems. If we do, what do we get? It might look like chatter in our head that goes something like this: “Hmm, that red isn’t as nice as the red I saw the other day on that painting. It would be nice if it were just a little lighter. And if that cloud were up just a little bit, that would be better. And if I could move that purple hue over there, I would like this sunset even more.” Can you see how that way of relating to a sunset doesn’t work too well? It seems that what a sunset needs is for us to simply show up to it, be present, and witness it. What if a lot of the things you struggle with in your internal world don’t need your attention in a math problem sort of way? What if they simply need you to show up as you would with a sunset? If that’s the case, then part of what we want to do in therapy is slow down…to look…feel…and see what actually shows up in your experience and learn from that, rather than simply operating in life based on what your mind has to say.

Using Structured Exercises to Develop Present-­Moment Awareness Clients typically have a difficult time connecting with a sense of self that isn’t focused on evaluations or qualities of the self (e.g., “I’m sad,” “I’m Ralph,” “I’m tall”). The ubiquity and persistence of humans’ private verbal commentary obscures the distinction between the self as knower and the self as known. Contact with the present moment helps clients develop a connection with an ever-­changing, flowing, and therefore flexible sense of self, or self-­as-­process, meaning a nonjudgmental, present, ongoing description of thoughts, feelings, and other private events (Hayes et al., 2001). One of the easiest ways to help clients contact self-­as-­process is through structured mindfulness exercises, in which the client is asked to gently observe, without judgment, a specific event or an ongoing set of events occurring either inside the skin or in the environment. Mindfulness of thinking is often the target. To that end, one helpful eyes-­closed exercise is Floating Leaves on a Moving Stream (Hayes, 2005, pp. 76–­77; visit http://www.newharbinger.com/39492 for a downloadable audio recording of this exercise). In this exercise, clients are asked to imagine themselves sitting next to a creek or stream. They are then asked to picture leaves floating down the stream. As these leaves pass, clients are invited to place each thought they have on one of the leaves and then watching it float by. If clients notice that they’re getting hooked by a thought (entangled or caught up in it) and pulled away so that they’re no longer observing their thoughts, they are asked to acknowledge what happened and then

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gently return to placing thoughts on leaves and watching them pass by. At well-­paced moments, the therapist can offer guidance in this regard, saying something like “Notice if your mind has drifted to other things. Notice if it got caught by a thought. If so, gently bring it back, place the thought that hooked you on a leaf, and let it flow down the stream too.” This kind of exercise can be done using a variety of images, including having thoughts attached to vehicles passing by on a road or displayed on signs carried by people marching in a parade. If clients come up with their own images, using those can work well. For example, one client imagined a futuristic city with vehicles that ran on electricity on roads that were floating in the sky and running all over the place. Another common image is clouds floating by in the sky, as illustrated in the following example. Therapist: I invite you to take in a deep breath, and when you exhale, allow your eyes to close. Take a few more deep breaths, then gently settle into your normal breathing pattern and just rest there for a moment. (Pauses.) Now I invite you to imagine that you’re lying in a field—­a field of your choice. It could be one with grass or flowers. Simply picture yourself lying there and imagine that you can see the blue sky above you. In this sky, clouds of many shapes and sizes are gently floating by. (Allows a few moments for the client to create and connect to these images.) Now I invite you to imagine that every thought you experience is magically attached to a cloud. It can rest in the cloud as a word or an image, or the cloud itself can take on the image of your thought. The key here is to take each thought as it occurs and attach it to a cloud and then allow it to gently float by. If you lose the image or your attention drifts to something else, that’s fine. When you notice that this has happened, then, without judgment, gently bring yourself back to lying on your back watching each cloud float by, and attach the thought that took you away to a cloud and let it float by too. I’m going to be quiet for a few minutes and let you practice this, just noticing each thought that arises and placing it in or on a floating cloud. (Pauses for a few minutes.) Remember, if you get lost in thought and are no longer viewing your thoughts, gently come back to putting your thoughts on clouds and watching them pass by. (Pauses for few more minutes.) Now I’d like you to gently leave this field in which you’ve been lying and, mindfully paying attention to the transition, come back to the room. After conducting this kind of exercise, take time to debrief, talking with the client about the ongoing nature of thinking and pointing out how thoughts change and seem to be in motion—­coming and going, sometimes chaotic and all over the place, sometimes more linear, sometimes appearing as images, and sometimes being difficult to view. You can also discuss the client’s experience in regard to going from looking at thoughts to looking from thoughts (being fused with or lost in thoughts). A different type of mindfulness exercise expands awareness of ongoing experience beyond the flow of thoughts to include the flow of all experience. In this exercise, akin to the traditional practice of choiceless awareness meditation, the client is asked to pay attention to moment-­ by-­ moment experience. Therapist: Let’s do an exercise that points to the sense of self as an ongoing experiencer. First, I invite you to get comfortable in your chair, and when you’re ready, to close your eyes. As your eyes

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close, notice that your ears tend to open. Take a moment and listen to what you hear. (Pauses for about ten seconds.) Now gently turn your attention to your breathing and simply follow your breathing as you inhale and exhale. Allow yourself to be your breathing for just a few moments. (Pauses for about ten seconds.) Now I’d like you to follow—­just as you followed your breathing—­any sensation, thought, or emotion that arises. Be aware of each new sensation or thought or emotion, simply observing each as it comes and goes. For instance, in one moment you may be aware of an itch, next a feeling of anxiety, next a thought, next a muscle pain or discomfort, next a sound, and so on. Your job in this exercise is to simply observe each new experience as it arises and comes into your awareness. (Pauses.) Now I invite you to notice the you that is an ongoing experiencing being—­the you that senses, feels, and thinks in an ongoing fashion. Just let each new experience be there as you observe and simply rest in awareness of experience. (Pauses for about five minutes.) Now I invite you to gently return to your breathing, spending the next few moments focusing on the rise and fall of the breath. (Pauses.) And now open your eyes and return your attention to the room. The key here is to help clients sustain a pattern of ongoing attention to or awareness of their immediate, ongoing, changing experience without having to retreat from it or get pulled into it. Clients can also practice this skill through mindful awareness of simple daily activities, such as eating, washing the dishes, driving, and waiting in line. As an in-­session activity, you could ask clients to practice eating a raisin mindfully (Kabat-­Zinn, 1991, pp. 27–­29). This helps clients develop an ongoing awareness of sensations, and as the exercise continues, they can also notice how experience continues to occur even as the content of experience shifts over time. For example, at first the client doesn’t have a raisin, then he does, then it is tasted and chewed and swallowed, and finally the client doesn’t have a raisin anymore. Time moves forward, and with each passing moment a new awareness arises. Formal and informal mindfulness practice outside of session can help clients cultivate present-­ moment awareness in everyday life. For clients who are receptive to developing a formal mindfulness practice, a large evidence base suggests that mindfulness meditation can help alleviate a wide variety of client difficulties and conditions (Hofmann, Sawyer, Witt, & Oh, 2010; Keng, Smoski, & Robins, 2011). Many excellent resources are available to guide and support clients in their practice: smartphone apps, websites, online courses, CDs and other audio recordings, mindfulness centers, and more. However, it’s important to preview such resources before recommending them to ensure that they’re ACT consistent. Sometimes mindfulness exercises are framed in terms of getting rid of difficult thoughts or attaining happiness as a feeling, rather than simply observing and accepting one’s experience. Informal exercises can also be helpful, such as focusing on the breath, walking meditation, mindfully doing a daily activity, movement-­based approaches like yoga or tai chi, journaling reactions to daily events, or paying particular attention to feelings, sensations, and thoughts. Clients may benefit from starting with basic awareness exercises and meditation and progressing to more exposure-­like exercises in which they are asked to invite and be aware of distressing content (e.g., anxious thoughts). However, there are a few considerations around working with mindful awareness in session and recommending that clients practice it more formally. For instance, when working with individuals with a history of trauma, you may want to consider eyes-­open practices, as they may get

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caught up in trauma imagery when they close their eyes. Use your best judgment about this or talk with the client about the process. Finally, it is recommended that any therapist using mindfulness meditation extensively with a client also engage in some form of ongoing mindfulness practice of their own. Understanding mindfulness from the inside out is part of doing this kind of work with fidelity, competence, and understanding. (We provide a list of resources for developing a mindfulness meditation practice at the end of this chapter.) Perhaps the most widely cited definition of mindfulness is “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-­Zinn, 1994, p. 4). Based on this definition, it can be argued that mindfulness includes not only present-­moment awareness but also defusion and acceptance. In mindfulness meditation, practitioners don’t just return to the present moment; they also make room for experiences as they come and go (i.e., acceptance) and notice rumination, worry, images, judgments, and evaluations as they arise, without entanglement (i.e., defusion). Practitioners also experience that mindfulness practice involves consciously assuming an observing stance (i.e. selfas-context). Therefore, mindfulness meditation incorporates all four of the flexibility processes on the left side of the hexagon model (acceptance, defusion, self-­as-­context, and present-­moment awareness). And indeed, as you learned in chapter 1, in ACT these four processes are sometimes referred to as the mindfulness and acceptance processes. All of that said, one of the benefits of ACT is that it provides a variety of methods to build mindfulness, beyond formal and informal mindfulness practice. This can be an advantage when working with people who aren’t willing or able to engage in formal mindfulness meditation practice. So although formal meditation is one way to develop the fluid, flexible, and voluntary attention involved in present-­ moment work, ACT offers other alternatives for developing this capacity.

Discovering the Moment in Session The point of mindfulness exercises is not just to develop mindfulness during the exercises themselves, but also to develop attention that’s flexible, fluid, and voluntary more generally. As such, ACT therapists work to weave mindfulness into the fabric of sessions in an ongoing manner. One common way to bring more present-­moment focus into sessions is to begin sessions with a brief mindfulness exercise. (For an excellent example, see Eifert & Forsyth, 2005, pp. 125–­126. Or visit http://www .newharbinger.com/39492 for a downloadable audio recording of an exercise you’re welcome to use.) Starting sessions in this way is particularly appropriate for those (clients and therapists alike) who are more entangled with their minds and can help both therapists and clients become present, allowing them to psychologically show up to the session ready to work. We recommend doing mindfulness exercises along with the client if possible. This generally leads to more fluid and better-­timed exercises, helps the therapist be mindful and present, and promotes equality in the therapeutic relationship. Contact with the present moment is also an essential skill for fostering acceptance, defusion, and values in session. Experiential work with all of these processes requires that clients bring their experiences into the room in order to work with them. One way to do this is to have clients pause and check in with their here-­and-­now experience during moments when it appears that something is showing up that the client is avoiding or fused with, either consciously or unconsciously. Cues that indicate it may be helpful to have a client pause and attend to what’s showing up include shifts in tone of voice or hoarseness in the client’s voice, sudden changes in the direction of the

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conversation, apparent physical tension, repetitiveness in thinking or speaking (e.g., worry, obsessiveness, or rumination), signs of a potential rupture in the therapeutic alliance, or, more broadly, anything that suggests restriction, tension, or inflexibility. When you note such behaviors, you can gently ask clients to slow down, tune in to the present moment, and notice what they’re feeling, sensing, or thinking. It can be useful during these moments to direct clients’ attention to various aspects of their experience (e.g., emotions, thoughts, bodily sensations, urges to act, memories) and ask them what they notice within each realm. Sometimes it can be helpful to have clients slowly and carefully repeat a particularly poignant phrase to heighten whatever is present and make it easier to identify. Here’s an example of that approach. Therapist: You’ve been talking a lot about your difficulties at work, yet you don’t seem too bothered. The situation must be frustrating. (Therapist empathy can foster client contact with present-­ moment experiences.) Client:

It is frustrating. It makes me really mad.

Therapist: It seems as if it might be painful, too. This is the third job you’ve had this year, and it’s unfolding just like the last two. Client:

(Turns red.) They’re just so stupid. I mean, I’m doing what they tell me to do. If they would just leave me alone and let me do my job, things would be better. (Appears to be caught up in fusion.)

Therapist: It seems you wish for that quite a bit—­to be left alone—­and yet it never seems to happen. (Draws attention to the workability of spending time caught up in fusion with thinking.) Client:

(Pauses.) Oh, yeah, I just remembered. I wanted to let you know I went to see the psychiatrist. She thinks I should get some more testing done.

Therapist: Did you see what just happened? We started to talk about pain, and you changed the topic. (Highlights the abrupt shift of topic.) Client:

Yeah, I see… But I don’t want to cry. I look silly when I cry. I feel stupid.

Therapist: (Pauses to slow down the process.) I wonder if you could notice those thoughts…silly, stupid…and let yourself show up to what’s happening with your feelings right now. (The client gets tearful.) All I want you to do is just notice this experience as it’s unfolding right now. (Pauses.) Notice what’s happening. What are you feeling in your body? Take a slow moment to look. Look and see exactly where you feel it. Client:

(Pauses for quite a while.) I feel a welling up behind my eyes.

Therapist: And what kind of judgments and evaluations show up? Before you answer, pause and take a careful, calm look. Client:

(Pauses.) My mind is saying that that it’s stupid to cry about this. (The way the client is talking about her judgments and labeling them as “my mind” suggests that some defusion is occurring.)

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Therapist: Good. And does this experience remind you of any situations from the past? (The therapist is drawing attention to different areas of experience to help the client build her ability to notice what arises in each area.) Client:

Hmm… Yeah. It reminds me of when my dad would yell at me if I didn’t do my chores.

Therapist: And when you have all of that, what do you notice yourself wanting to do? Client:

I’m feeling like I want to run out of the room or…disappear or something.

Therapists can use a number of other approaches to work with clients to help them discover the moment in therapy: asking them to simply be aware of thoughts, feelings, and memories as they arise; asking them to identify when being present is needed; directing them to pay attention to the shift between being present and getting pulled into the future or the past; or doing an experiential exercise in which they notice the sights, sounds, and sensations that are present in the room. (For a more complete list, see Strosahl et al., 2004, p. 44.) If clients aren’t very skilled at noticing what’s present, it’s a good idea to start with simple, structured exercises focused on bodily sensations. For example, you can ask clients to describe out loud what sitting in the chair feels like or how it feels to hold their breath, extend an arm, or rub their face with a cloth.

Relating in the Moment Within the Therapy Relationship Because many clients’ problems are, at least in part, due to difficulties in their relationships with others, it’s particularly important to develop their abilities to be present, open, and nonjudgmental when relating to others. Humans tend to be caught up in a near-­constant process of evaluation, classification, and comparison that’s applied to everything: objects, other people, ourselves, and more. As a result, we tend to interact with the people around us in terms of our ideas about them, which places a barrier between ourselves and our direct experience of others. Many of our reactions to others are dominated by the stories we tell ourselves about them. In essence, we are responding to them as conceptualized others, rather than to our direct experience of them or connecting to an awareness that they too have ongoing present-­moment experiences. Metaphorically, it can be as if we’re interacting with a cartoon of the person, rather than the living being in front of us, who has a rich and complex history. In the therapy room, the client’s most immediate relationship is with the therapist. Present-­moment work focused on this relationship has the potential to be a powerful context for increasing clients’ ability to stay present, be more aware of the ongoing experiences of those around them (see chapter 9), and be more responsive to others in a manner that fits with clients’ values. To that end, you can guide clients to notice and be aware of their internal experiences, moment by moment, in relating to you. This is particularly important when clients are engaging in interpersonal behaviors that parallel problematic interactions that occur in their daily life. This kind of work provides an important opportunity for clients to learn and practice newer, more flexible ways of relating to others. One approach is to ask, “Are you willing to notice what’s happening right now, within you and between us?” Focusing on relating in the moment gives clients the opportunity to experience connectedness and presence. Furthermore, learning to notice their present-­moment reactions when relating to

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others helps them show up in relationships and can also be a meaningful values-­based action. In the dialogue that follows, the therapist takes this kind of approach, helping the client notice his present-­ moment reactions to the therapist that parallel difficult reactions he has to his wife. Client:

It’s lurking in the background all the time. It’s like I’m tiptoeing.

Therapist: You’re feeling defensive? Client:

Yeah. My wife just seems to criticize everything I do. I can never get it right.

Therapist: (Pauses.) Do you feel like that in here sometimes? Client:

Like I’m tiptoeing around you?

Therapist: Yes. Client:

(Pauses and moves in his chair as if uncomfortable.) I don’t know.

Therapist: And what are you feeling right here, right now? Client:

Should I feel something?

Therapist: Just look. Take your time. Client:

To be honest, I’m feeling defensive. I don’t know why. I know you aren’t doing anything… But I feel like I’m being criticized.

Therapist: Where do you feel that? Let’s start with your body. Client:

(Remains silent for a bit.) I feel tense in my stomach…almost as if I’m tensing to be hit there.

Therapist: Good. Okay, any other sensations?

Experiential Exercise:

Free Choice Meditation This exercise takes about ten minutes. Sit in a quiet place where you won’t be distracted or interrupted. Make yourself comfortable, sitting straight but not rigid. When you’ve found a comfortable position, gently close your eyes. Notice that your ears tend to open and become more alert when you do this. Be aware of sounds for a few moments. Then gently turn your attention to your breathing. Spend a few moments just paying attention to your breath. You can be aware of your breath at the tip of your nose and nostrils or in the rise and fall of your chest. If you find that your mind begins to wander, as minds tend to do, gently say to yourself, “Wandering,” and then, without judgment, refocus your attention on your breath. After following your breathing for one to two minutes, gently release your attention from breathing and begin to attend to whatever arises

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in your awareness next. This may be a sound or a sensation. It may be a thought or a feeling. Your job is to simply notice it, whatever it may be, and then let it go, moving on to the experience of the next moment. For instance, you may notice the sound of the air-­conditioning, then pain in your foot, then your breath, then a twitch, then a thought. Don’t let any of these experiences capture you; just notice each one and let it go. Next a sensation, then a sound, then a taste, and so on. Simply observe whatever comes into your awareness from moment to moment without clinging to any experience. Gently observe each and notice how they come and go. After about six minutes, return your attention to your breath and, as before, follow your breathing for about two minutes. Then gently open your eyes, completing your meditation. Remember, your mind will hook you over and over again, taking your focus away from your direct experience in the moment. When this happens, bring yourself back to simply noticing. If it happens a hundred times, bring yourself back a hundred times. This is part of the process.

Using Present-­Moment Awareness to Build Self-­as-­Context Contact with the present moment is intimately connected with the development of self-­as-­context (see chapter 5). Being aware of the content of one’s experience in an ongoing way undermines attachment to a static, conceptualized self and requires a more fluid sense of consciousness. For this reason, contact with the present moment can be fostered by encouraging clients to adopt a conscious sense of self-­ observation. So when conducting mindfulness exercises, include instructions such as “And as you notice that, also notice that there’s a part of you noticing all these things” or “Just for a moment, I’d like you to connect with the sense that you are here now, noticing what you feel in your body and what emotions you’re having.” For some clients, doing mindfulness exercises is challenging because they have a difficult time locating a sense of self as observer. In such cases, you may want to work on a sense of perspective in smaller and more immediate ways while working with present-­moment processes. For instance, at appropriate times you can ask clients, “As you’re speaking, who is saying these words?” or “As I speak to you, can you tell that someone is there listening, and in a moment is going to have the experience of speaking as you answer this question?” or “As you observe this emotion, can you notice that there is a part of you that is observing it? You are not the same as the emotion.” This kind of questioning can help clients begin to connect with self-­as-­context, or the observer self—­the self that is encountering experiences in each new moment. In addition, the therapist can model both processes: contact with the present moment and self-­as-­ context. For example, you can say, “And even as you say that, I notice my heart rate picking up a bit and my thoughts becoming more evaluative. That gives me a sense that if I were in your shoes looking out at this set of difficulties, I’d be feeling more anxious and be inclined to be judgmental.” The latter part of that statement is deictic and thus fosters a sense of self-­as-­context, something we’ll discuss further in chapter 5.

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Using Contact with the Present Moment to Foster Experiential Learning As discussed previously, ACT is an approach to therapy that emphasizes learning through experience. In experiential learning, discussions of how to do things, such as those found in skills instruction or psychoeducation, are deemphasized because they depend on literal language; instead, the emphasis is on contact with experiences and the consequences of behaviors. In the context of ACT, experiential learning is more focused on asking clients good questions than on clients giving the “right” answers. The focus also tends to be on specific experiences and situations, rather than generalities. Experiential learning usually occurs from a present-­moment perspective; therefore, the therapist must be able to readily shift into a here-­and-­now perspective to successfully do experiential work with clients. Although ACT therapists often engage in didactics or psychoeducation to lay some groundwork, experiential learning should play a major role in most sessions. Experiential learning involves at least four steps: orienting or moving toward experiential work; actually engaging in experiential work; debriefing experiential work; and determining how to generalize experiential learning to the client’s life. It can sometimes be difficult for therapists to maintain a consistent focus on experiential learning, as it generally goes against the grain of the more direct and instructional approach that’s typical when teaching or interacting with others. Therefore, we’ll provide some guidelines to help you use the flexibility processes to lead you toward increased time spent in experiential learning activities. The table below outlines two discriminations that can guide therapists in including more experiential work in session. The vertical dimension of the rows discriminates whether the content of the therapy conversation is focused on events that occur in session versus events outside of session. The horizontal dimension of the columns discriminates the perspective from which events are reported: from the here-­and-­now perspective (self-­as-­process) versus a there-­and-­then perspective or speaking in terms of generalities (e.g., clients’ descriptions of their qualities or intellectual conversations about themselves, the future, the world, or the past). The latter would include statements like “Yesterday I went to the store and had a panic attack,” “I have no future,” “I hate myself,” or “In the last session, we talked about how numb I am.” This creates four quadrants into which clients’ in-­session behavior can be divided. Here’s a basic diagram representing this model. Shortly, we’ll provide an expanded version that includes pointers on how to move into each quadrant.

Perspective Talking about the there and then or generalities

Noticing the here and now (mostly present tense)

Content

(future or past tense, generalizations) Out of session

Quadrant 1

Quadrant 2

In session

Quadrant 3

Quadrant 4

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Clients tend to gravitate toward quadrant 1, and sessions often start here, as clients talk about events from their life, usually in general terms (e.g., reason giving, explaining, or figuring things out). This is also often the quadrant where fusion occurs. In general, this is the least experiential mode. In order to move toward more experiential work when in this quadrant, it can be helpful to elicit specific examples from the client or to focus on specific events, steering away from generalities and concepts. This might include helping clients track what happened during specific events by conducting a functional analysis so they can become more aware of the antecedents for their behavior, how they respond, and the consequences of their behavior. This is particularly effective if you can help them notice antecedents they hadn’t recognized or track consequences they hadn’t been aware of (e.g., the effects of their behavior on values-­based living in the long term). Most people are socialized to speak largely in terms of there and then, so therapy conversations tend to drift back to this quadrant unless the therapist persists in moving the conversation to the other quadrants. To be clear, there’s nothing wrong with spending time in this quadrant. It can be helpful to do so when attempting to generalize new learning, such as planning how to implement a new behavior outside of session or discussing how in-­session behavior relates to out-­of-­session behavior. Of course, this quadrant is also where more didactic forms of learning or skills instruction occur. Moving from quadrant 1 to quadrant 2 requires a shift from talking about events that are not present to taking the perspective of being in the there and then. This can be accomplished in many ways: through experiential exercises in which clients imagine being back in the events they’re reporting on; by asking clients to visit a childhood version of themselves struggling with a difficult event from their past or having them revisit a troubling memory from the perspective of their adult self; or via imaginal exposure in which they revisit a troubling event and practice making room for difficult emotions and defusing from thoughts that arise as they put themselves in that event. This could also involve visiting a scene in a conceptualized future, such as conducting a role-­play involving talking to a supervisor while engaging in values-­based action or imagining themselves encountering an obstacle while attempting a new behavior. Once clients are in the there-­and-­then perspective, any of the other flexibility processes can be integrated. For example, you can help clients make room for difficult emotions (i.e., acceptance) or guide them in reflecting on what they wish they had chosen in the situation and imagining what would have happened if they had done so (i.e., values). Moving from quadrant 1 to quadrant 3 involves a shift from an out-­of-­session or general focus to a specific, in-­session focus. This typically includes identifying times when problematic behavioral repertoires show up in session, along with the contingencies surrounding these events (which in-­session events trigger the response, and the consequences of the response in session). For example, if a client typically engages in behavior that involves fusion with self-­critical thoughts, you might ask, “Does your mind ever get critical with you in our sessions?” Or if a client avoids anxiety related to social situations outside of session, you might ask, “Do you ever get anxious in here in the same way you do in social situations?” The ensuing discussions can be useful because they help build a therapeutic agreement to identify fusion and avoidance when they show up in session; then therapist and client can work with that behavior directly by moving into quadrant 4.

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Quadrant 4 typically involves working with problematic behaviors (e.g., fusion or avoidance) or supporting improvements in flexibility as they occur in session to help clients build new repertoires of behavior. For example, a therapist might shift the focus to quadrant 4 if the client engages in clinically relevant avoidance or fusion while reporting on out-­of-­session behavior. One way of moving into quadrant 4 is to help clients engage in present-­moment awareness and acceptance when they experience painful (and typically avoided) emotions when talking about something that occurred out of session. Alternatively, the therapist might purposefully evoke fusion in order to give the client a chance to defuse (e.g., saying a statement that’s evocative, such as expressing warmth toward a client who’s self-­ critical). The therapist can also keep the session more grounded in quadrant 4 by noticing and pointing out opportunities for valued action as they arise in the context of the therapeutic relationship, for example, opportunities to act in keeping with how the client wants to behave with the therapist. Other approaches involve noticing various forms of self-­as-­content as they arise in session and shifting perspective to self-­as-­context, and conducting experiential exercises, such as mindfulness practices and defusion techniques. Quadrant 4 is generally the most productive one for experiential work, but it’s also where clients and therapists are at the greatest risk of shying away. Even so, ideally, you’d spend at least part of every session in this quadrant. The concepts embedded in this diagram can be useful for any therapist, but they’ll be especially helpful if you notice that your sessions tend to be primarily composed of more didactic and instructional approaches, with relatively little time spent in more experiential modes of learning. To help you put these ideas into practice, we’ve provided an expanded version with notes on what you might say to clients to move the session into quadrant 2, 3, or 4. (A downloadable version is available at http://www. newharbinger.com/39492 so you can print it out.) As an example of how to use the chart, you could review it immediately before sessions to identify ways you could move from quadrant 1 into quadrant 4, and then commit to practicing one or two of those moves during the session. Alternatively, after a session you can review the chart and reflect on what percentage of time you spent in each quadrant during that session. You might also take some notes about how you could move the focus from one quadrant to another when similar topics or behavioral patterns recur in future sessions with the client. However you use it, the primary goal is to promote devoting more session time to experiential learning.

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How to Be More Experiential in Session Perspective Talking about the there and then or generalities

Noticing the here and now (mostly present tense)

(future or past tense, generalizations) Out of session

Quadrant 1

Quadrant 2

(nonexperiential quadrant)

• “Imagine you’re really in that situation. What are you seeing, feeling, hearing, and so on? What are you doing?”

Move toward a more experiential mode by eliciting specific examples rather than speaking in generalities. For example, ask the client for a specific example of the behavior or situation at hand, and then conduct a functional analysis.

• “Imagine that you’ve magically been transported to that situation and are looking at yourself. What would you say to the person who is there and then?”

Content

• “Imagine looking back ten years from now. What would you say to the person you are now?” • “How old does that feel? Picture yourself as a child, having that experience, and interact with that child as your current self.” In session

Quadrant 3

Quadrant 4

• “How does that play out in here?”

• “What’s showing up for you as we talk about this?”

• “Have you noticed that happening here?” • “Does that ever happen with me in our sessions? If so, what brings it up?” • “Would you be willing to notice when that shows up here?”

• “Where is it in your body?” • “Are you okay with doing an exercise right now?” If the client says yes, lead a defusion, present-­ moment, acceptance, or perspective-­taking exercise. • “What thoughts is your mind coming up with right now? What do they look like or sound like?” • “You be X and I’ll be Y. Show me what you did.” Then role-­play the situation.

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Core Competency Practice This section is intended to provide practice in using techniques designed to increase clients’ contact with the present moment. As in previous chapters, for each exercise we present a description of a clinical situation and a bit of dialogue. The dialogue ends after a client statement, at which point you’ll provide a sample response that reflects the core competency at issue and then an explanation supporting your response. After completing each exercise, turn to the end of the chapter to read the model responses we provide and compare them to your response. Remember, the model responses are not the only valid responses.

Core Competency Exercises Competency 21:  The therapist can defuse from client content and direct attention to the moment.

Exercise 21 The client is a sixty-­seven-­year-­old veteran of the Vietnam War who is seeking therapy to work on issues related to PTSD. He has been in and out of therapy for about twenty years. He has complaints about the government and its response following the war and feels his life has been permanently changed by his experience. Client:

I have a lot of resentment about the government. I mean, they should have done something. It has been how many years? I still have all this anger.

Therapist: It seems like the past has taken over your life. Client:

It has, every day. I mean, every damn day this is with me.

Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 21:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 22:  The therapist brings his or her own thoughts or feelings in the moment into the therapeutic relationship.

Exercise 22 This dialogue continues with where the dialogue for competency 21 left off. Therapist: So, one of the things we could do in here is focus on how the government messed up so many years ago. Do you think that would be helpful? Client:

Not really.

Therapist: Is it possible that this focus is problematic, and what we need to do is focus on what you can do now—­work on finding out what’s available to you in this moment, today? Client:

It’s just that I’ve been working on this for so long that I’ve forgotten what it’s like to be normal, to not have a problem. I know I said this, but all I think about is the government and how they screwed me. They really did a number on me.

Therapist: It’s hard for me to imagine the level of frustration you must have felt across the years. Client:

You can’t even begin to know. There’s a strong part of me that wants to get back at them. This grudge is really strong.

Therapist: It really does linger, and even in here it has lingered. We’ve spent quite a bit of time talking about it… It even has a grip in here. Client:

Yeah… (Sighs.)

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Write here (or in a notebook) what your response would be, demonstrating competency 22:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 23:  The therapist uses exercises to expand the client’s sense of

experience as an ongoing process (e.g., mindfulness exercises or imagery exercises that support the client in focusing on the ongoing flow of internal experiences).

Exercise 23 This dialogue continues with the same client as in the dialogue for competency 22 but occurs a little later in the session. Therapist: It seems that part of the struggle is related to how much this issue has consumed your life. Client:

Yeah, I hate it. This is all I think about.

Write here (or in a notebook) what your response would be, demonstrating competency 23:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 24:  The therapist detects when clients are drifting into a past or future orientation and teaches them how to come back to the present moment.

Exercise 24 This dialogue continues with the same client as in the dialogue for competency 23 but occurs in a later session. Therapist: What could you do today to take one specific action with respect to your value about your wife? Is there something you could do to let her know you love her? Client:

She’s been asking me to fix the handle on the closet door for months now. I guess I could do that.

Therapist: Great. I can see how that might bring more appreciation into the relationship. Client:

I don’t know. She asks me to do stuff, and then I wait so long to do it that I’m not even sure she knows I’ve done it. She doesn’t comment on it, anyway. She just kind of leaves me alone…except to ask me to do stuff. I think I’ve been a “leave me alone” kind of guy for so long that she just keeps her distance. Ever since I got out of the service, things have been different. If the government just would have recognized what a lousy deal it was to be in Vietnam…

Write here (or in a notebook) what your response would be, demonstrating competency 24:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 25:  The therapist conceptualizes client behavior at multiple levels and emphasizes the present moment when doing so is useful.

A bit of background is warranted, as this competency links present-­moment work to the therapist’s ongoing case conceptualization (see chapter 8) and functional analysis of the client’s behavior in session. Sometimes it’s helpful to be focused on the future, such as when discussing homework or generalizing learning to other situations. Sometimes it’s helpful to focus on the past, as in exposure-­like exercises related to traumatic experiences or hearing about situations from the client’s week that relate to treatment targets. The basic idea of this competency is that there are several levels at which client behavior can be conceptualized: 1. Overt content. For example, if a client says he had a panic attack after the previous session, this can be taken as simply information about what has happened. 2. As an example of social behavior. Reporting a panic attack could be part of a larger pattern of unhelpful and chronic complaining that interferes with the client’s relationships. 3. In terms of the therapeutic relationship. The client could be indirectly communicating that he feels therapy isn’t helping. 4. As a functional process. Reporting the panic attack could be functioning as avoidance of anxiety that just occurred in the room. Maintaining awareness of these different levels can help you determine whether returning to the present moment is warranted and how to respond. Now that we’ve provided that context, here are the details of the case for this exercise: The client is a thirty-­three-­year-­old woman who says she wants to hurt herself. She feels depressed and anxious and has come to this session angry at her boyfriend. She’s extremely emotionally avoidant and hasn’t shown any signs of emotional pain since the beginning of therapy five weeks earlier. Client:

(Speaks matter-­of-­factly.) On top of all of my other problems, I’m now having problems with my boyfriend. I hate to say this, but he’s getting under my skin. Don’t get me wrong, I love him. But, man, I don’t think I can take this anymore.

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Exercise 25.1 Write here (or in a notebook) what your response would be if you thought the statement was an example of the second level of conceptualization, functioning as part of a larger pattern of social behavior, keeping in mind that the focus here is on competency 25.     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 25.2 Write here (or in a notebook) what your response would be if you thought the statement was an example of the third level of conceptualization, functioning as indirect communication about the therapeutic relationship, keeping in mind that the focus here is on competency 25.    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 25.3 Write here (or in a notebook) what your response would be if you thought the statement was an example of the fourth level of conceptualization, functioning as avoidance in the room, keeping in mind that the focus here is on competency 25.     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 26:  The therapist practices and models getting out of his or her own mind and coming back to the present moment in session.

Exercise 26 This dialogue continues with the same client as in the dialogue for competency 25.

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Yeah, I can see that, but you don’t know how upset he’s making me. I really think I’m going to go over the edge if he doesn’t stop. This week alone, he asked me for more than a hundred dollars. I don’t have that kind of money. He’s draining me dry. I have to pay bills. I have to get my car paid off. He just doesn’t get it. I think I’m going to snap.

Write here (or in a notebook) what your response would be, demonstrating competency 26:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Core Competency Model Responses Competency 21 Model Response 21a Therapist: The pull is to try to figure this out. But you’ve been doing that for years, and you told me it did little to move things forward. I want to see if we can connect to a space that might be more useful in terms of moving forward. Let’s shift from the past for a moment. Tell me: What are you aware of right now? What do you notice in this moment? Explanation: It can be easy for therapists to get caught up in clients’ content. Many clients have compelling stories that can lead the therapist down a path that may function to help clients continue to be avoidant. This is not to say that therapists shouldn’t listen to what their clients have to say. However, ACT isn’t a therapy in which the therapist provides supportive listening most of the time; it’s a very active approach. Furthermore, if the client engages with the kind of response modeled here, he will immediately be pulled out of the past and into the here and now. And if the client can stay with being aware of what he’s currently feeling, the therapist can point to how the client is not in the past but is

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here in the moment, feeling his emotions and being aware of whatever is present. Even if the emotion is anger, the therapist can work with it, exploring how anger is affecting the client’s life and looking at whether there’s something underneath the anger, such as sadness. These strategies are much more focused on the present moment than staying with the client’s story. Model Response 21b Therapist: So, one of the things we could do in here is focus on how the government messed up so many years ago. Do you think that would be helpful? Client:

Not really.

Therapist: Is it possible that this focus is problematic, and what we need to do is focus on what you can do now—­work on finding out what’s available to you in this moment, today? Explanation: Here, the therapist suggests that the strategy of focusing on the past isn’t going to be helpful. Although many clients are aware that this is true, helping them show up in the here and now and do what can be done from this moment forward is a useful step, especially if they’ve been stuck in the past for a long time.

Competency 22 Model Response 22a Therapist: So, I’m feeling this sense of frustration. (Pauses.) I really want you to be able to move forward, but we keep landing back here. I don’t want you to rescue me. I just want to share the feeling that’s showing up for me. It feels hopeless. What shows up for you as I say that? Explanation: This is an honest, in-­the-­moment response to the client being stuck, with the therapist directly modeling showing up to one’s personal experience and being willing to state that experience, exactly as she’s asking the client to do. It’s a riskier move, and probably only appropriate after there is a solid therapeutic alliance, but valuable for modeling willingness to experience the moment while also pointing to the feelings of hopelessness that arise when we try to undo history. Model Response 22b Therapist: When I mentioned that this story seems to have a grip on us here in the room, I felt a sense of tightness, like there’s no room for us to explore or work on other things until this issue is solved… Yet we’ve already explored the impossibility of solving this. Do you feel a sense of tightness? Can you feel the grip? Explanation: The therapist is self-­disclosing about her in-­the-­moment experience and touching upon the workability of spending more time inside this rumination. This focuses the client back into the here and now and also models the process of showing up to experiences in general and working to explore present-­moment processes rather than remaining stuck in the past.

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Competency 23 Model Response 23a Therapist: I wonder if we could work to find the cracks in this idea that this is all you think about. A while ago, you told me something about your wife and children. So your thoughts, and I suspect your feelings, change across time. It’s just when you’re stuck in this piece about the government that it feels like nothing changes… Would you be willing to do an exercise with me? Client:

Yes.

The therapist then guides the client through an exercise in which the client draws a line down the center of a page and writes “Thoughts” at the top of the left column and “Feelings” at the top of the right column. The therapist then suggests that the client observe his thoughts and feelings moment by moment and record them in the appropriate column. Alternatively, any other present-­moment awareness exercise can be used here, such as the Observer exercise (Hayes et al., 2012, pp. 233–­237). Explanation: The therapist is working with the client to help him see that he’s more than his single experience with the government. Indeed, he’s had countless experiences (thoughts, emotions, sensations, and so on). It’s just that he’s been stuck on this single experience, and his efforts to fix it have made it increase rather than decrease. Doing an experiential exercise at this point helps the client directly contact a sense of an ongoing experiencing self (self-­as-­context) that has numerous experiences, not simply one. Model Response 23b Therapist: Would you be willing to explore with me the possibility that you’re larger than this experience… That it isn’t everything? Client:

Sure.

Therapist: I invite you to close your eyes. (The client closes his eyes.) Tell me what you become aware of when you do that. Notice what’s happening in the moment. Client:

I hear the sound of your voice.

Therapist: Good. Now focus your attention. Stay in the moment and tell me what you notice with each moment that passes. I’ll sit quietly for the next minute while you do that. Client:

I hear a car outside… I feel uncomfortable with my eyes closed… I notice my leg feels stiff and I want to stretch it. (The client continues to report; if he doesn’t the therapist may need to be more directive and repeatedly ask, “What do you notice now?”)

Explanation: The therapist is working with the client in the moment to help him discover that he’s an ongoing, evolving, experiencing being. This helps loosen the grip of his story (“I’m an angry person, and I hate the government”) so the client can see that he has many more experiences than he believes he does. Pointing to the ongoing process of moment-­by-­moment experiencing can help clients discover this larger sense of self.

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Competency 24 Model Response 24a Therapist: (Interrupts the client.) Notice what just happened. We were talking about ways you could bring your values linked to your relationship with your wife alive today, and you drifted right back into the past. Did you see it happening? What feelings might show up for you if we shifted back to working on your values? Explanation: Here, the therapist has detected the client’s shift back to the past and makes the client aware of that shift. It’s helpful to work with clients on noticing these shifts. Sometimes they happen so quickly and naturally that clients are barely aware of them. After the therapist helps the client notice the shift, she guides him back to the present by noticing the current experience of making another shift and then refocusing on values work. The therapist also explores any emotions that show up in relation to refocusing on values, in part to determine whether the shift back to the past functions to avoid the emotional pain associated with years of not living in a values-­based way. This too can be felt, observed, and experienced—­while also making the choice to fix the closet door. Model Response 24b Therapist: Do you recognize where you’re going now? Client:

Yeah.

Therapist: (Speaks with curiosity.) Is that a place you want to go? Client:

No.

Therapist: Where would you like to be now? Client:

Anywhere but there.

Therapist: Just prior to this, we were talking about how you might show your love for your wife. Would you prefer to talk about that? Explanation: Again, the therapist draws the client back to the here and now and helps him notice what’s happening, because it would be helpful for the client to learn to catch these shifts into past-­ focused thinking when they occur. The therapist then reorients the client to the values work, a present-­ oriented focus.

Competency 25 Model Response 25.1 (wherein the client’s statement is conceptualized as reflecting a larger pattern of social behavior) Therapist: Right now I’m having the experience of finding myself wanting to tell you to move on and let go. My mind is really working on me. I wonder if this is what happens to other people in your life—­they tell you to move on or let go?

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Explanation: The therapist reports honestly on the content of his mind, and does so in a manner that models defusion by using the convention “I’m having the experience of…” and referring to his mind as a separate entity. The therapist’s direct report of his experience also models present-­moment awareness and can help elucidate possible consequences of the client’s behavior on important others in her life. If they feel similarly, learning about this can help the client become more sensitive to her effects on others and see how her behavior may be causing difficulties in relationships. After the therapist offers this model response, he might explore whether what happened in the room is in some ways similar to what happens with others in the client’s life—­and whether the results she’s getting fit with her values and how she wants to be in relationships. Model Response 25.2 (wherein the client’s statement is conceptualized as indirect communication about the therapeutic relationship) Therapist: I’m hearing something in your voice, frustration or maybe anger. And I’ve been thinking about how much work we do in here and the comments you’ve made about the pressure you feel at times. I’m wondering if any part of what you’re saying is actually about what’s happening between you and me? As I refocus us and move away from problem solving, I wonder if I’m getting under your skin in any way. Explanation: The therapist is tracking the client’s behavior in several realms: emotional, thoughts, and relationship dynamics. If he detects distancing or frustration and anger that don’t quite fit the situation, or if the client has been resisting his input in ways that haven’t been helpful, the therapist might view the comment as relevant not just to the client’s relationship to her boyfriend, but perhaps also to the therapeutic relationship. If the client can acknowledge an interpersonal struggle with the therapist, the work in session can focus on whatever is present (e.g., feelings of pressure, things not happening as planned, how it feels when the therapist changes the topic). In this case, the focus may turn to exploring ways to open up the process between the therapist and client in the service of modeling and shaping more effective behavior in the here and now. Model Response 25.3 (wherein the client’s statement is conceptualized as avoidance) Therapist: Yeah, you feel right on the edge, like there’s nowhere else to go… Can I ask you a question? Client:

Sure.

Therapist: What are you noticing in your body right now? Client:

Nothing.

Therapist: Take a second. Let yourself slow down and look inside. What’s showing up? If you need to, you can close your eyes. And as you do this, see if you can let go of any resistance you feel to letting this stuff show up. See if there might be a sense of something important in sticking with whatever you feel right now. What does your mind say would happen if you were to simply sit, holding these reactions, without doing anything to make them go away?

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Client:

161

It says I can’t do it.

Therapist: Good. And can you notice that thought as a thought and still stay here, stay present? Explanation: The therapist could engage with what the client has said at the level of content by talking to her about problems in her relationship. However, the therapist suspects that the client is contacting some feelings that she isn’t expressing and uses this as an opportunity to help this emotionally distant client contact a reaction at a different level than the purely cognitive by noting something very concrete—­her bodily reactions. Then, when the emotion is present, the therapist suggests taking a stance of acceptance while also being aware of the mind. This is important, as the mind might pull the client back into a struggle.

Competency 26 Model Response 26a Therapist: I can sense the frustration, and I find myself wanting to get involved in problem solving. But in this moment I feel helpless to fix it. I wonder if your mind telling you that you’re going to snap is about that same helplessness? Client:

Yeah. I feel it too.

Therapist: Let’s take this moment to notice that sense of helplessness, showing up to what it feels like when it seems there is no answer. (Pauses to allow silence. The client becomes very quiet and seems about to cry.) And also notice that you don’t snap (said gently). Explanation: Perhaps the most obvious thing to do in this situation is help the client engage in problem solving, which could include teaching her to be assertive. However, doing so would miss an opportunity for the client to experience the feeling of helplessness (i.e., acceptance) and learn experientially that she won’t snap (i.e., defusion). The therapist is conceptualizing the client’s stuckness as being at least partially due to avoiding feelings of helplessness and fusion with thoughts that occur when those feelings arise. Bringing the process back to the moment helps the client defuse from the content of her mind. From this place, the therapist can help her identify and track the costs of being unwilling to feel helpless, which could potentially include financial losses, distance from her boyfriend, and passive behavior. Then the focus can turn to what will work for the client, given her values with respect to her boyfriend. This could include problem solving, but that wouldn’t be the first road taken. Model Response 26b Therapist: I notice my brow furrowing…a tension in my neck…and I have a feeling of helplessness as I reflect on all the frustration you must be feeling, both with your boyfriend and right now with me, for not understanding. I wonder if you could take a second and notice what you’re feeling right now, in this moment. (The therapist then asks the client to notice whatever feelings, sensations, and thoughts are present in the moment, in the therapeutic relationship.)

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Explanation: The therapist begins by modeling his own process of observing personal sensations and feelings out loud. He also acknowledges the client’s expression of tension in the therapeutic relationship as reflected by her statement “You don’t know how upset he’s making me.” The therapist then explicitly focuses the client on her experience in the moment, stepping out of the stream of thoughts the client is caught up in and moving into a more present-­oriented, relational, and direct mode of experiencing.

For More Information Many mindfulness exercises created for use in ACT sessions can be found in Eifert & Forsyth, 2005; Hayes, 2005; Harris, 2009, chapter 9; and Hayes et al., 2012, chapter 7. You’ll also find a wide range of exercises and metaphors related to present-­moment awareness in Stoddard & Afari, 2014. For an approach to ACT that focuses heavily on present-­ moment processes, see Wilson, 2008. Audio recordings of some ACT exercises can be found at http://www.contextualscience.org. For anyone (therapists and clients alike) interested in developing a mindfulness meditation practice to support present-­moment awareness, several books provide an accessible introduction: Meditation for Dummies (Bodian, 2016), Zen-­Master (Hardy, 2001), Wherever You Go, There You Are (Kabat-­Zinn, 1994), and A Mindfulness-­Based Stress Reduction Workbook (Stahl & Goldstein, 2010). Tara Brach, a well-­known meditation teacher and psychologist, has an online guide at http://www.tarabrach.com/howtomeditate. Excellent audio recordings of guided imagery, breathing, and body scan mindfulness exercises narrated by Jon Kabat-­Zinn are available at http://www.mindfulnesscds.com. There are a number of useful smartphone apps that can serve as reminders and guides in practicing mindful awareness, but these are constantly changing. At the time of this writing, Headspace, Insight Timer, Buddhify, ACT Companion, and Stop, Breathe, and Think are all worth considering. We recommend that you preview apps before recommending them to clients to make sure they don’t contradict the work you’re doing in session and don’t directly or subtly provide messages advocating internal control or stating that happiness is the ultimate goal or outcome. Most apps include automated reminders for formal practice as well as help in integrating mindfulness into daily life. Another resource for updated information on mindfulness resources, including apps, and learning to meditate is the free e-­book Learning ACT Resource Guide (available for download at http://www.learningact.com). There are also quite good online courses and resources, but they are too extensive to list here. But if you wish to support your clients in practicing mindfulness, it’s worth doing an online search and reviewing some of the resources available. Finally, many communities have local meditation centers where people can follow a traditional path to learning to meditate, with support from real people as a part of a community. We encourage you to be familiar with such resources in your area, as belonging to a supportive community can be one of the best ways to support practice.

CHAPTER 5

Building Flexible Perspective Taking Through Self-­as-­Context

You can see a lot just by observing. —­Yogi Berra

Key targets for building flexible perspective taking: Help clients distinguish a sense of self that is continuous, safe, and consistent, and from which they can observe and accept the flow of internal experiencing. Help clients identify this sense of self that is continuous as the context, arena, or location in which all experience happens, distinguishing it from the content of that experience (e.g., emotions, thoughts, sensations, memories). Help clients flexibly take perspective toward themselves, others, and their own experiences to facilitate the other five flexibility processes, as well as compassion and empathy.

“Who are you?” This seems like a simple question, yet issues such as “What is the self?” and “Who are we at our most basic level?” have long been entertained by scientists, philosophers, and theologians, as well as clients and therapists, as part of an effort to understand our existence and meaning. These fundamental questions are now being explored by researchers and clinicians in the rapidly growing realm of theory and research on perspective taking that’s emerging from relational frame theory (McHugh & Stewart, 2012). This theory holds that there is no concrete entity we can point to that forms a firm self and that the self, the “I” in “Who am I?” doesn’t exist as a literal entity; rather, the self is seen as a set of verbal behaviors that are central to how humans develop a consistent perspective from which to view the world—­a kind of verbal “selfing.” This verbally learned experience is what is

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occurring when people reference a location called “me,” “myself,” or “I.” Recognizing selfing as behavior is central to assisting clients in contacting the perspective of self as a location where experience occurs. Working with self-­as-­context and perspective taking in ACT can be challenging, but it’s fundamental to establishing a state where acceptance of experience is possible. Helping clients connect with a sense of self that’s continuous, safe, and consistent also reduces the tendency to fuse or overidentify with internal experiences or attach to them in problematic ways. Finally, flexible perspective taking promotes empathy and compassion (and by extension, self-­ compassion)—­ all vital aspects of well-­being.

What Is Flexible Perspective Taking? RFT purports that there are three contextual cues that serve to control perspective taking: interpersonal (I/you), spatial (here/there), and temporal (now/then). These cues, which can be indicated by words but can occur in other ways, such as through pointing, control how we shift between a psychological sense of our own perspective (I) and that of others (you) and between our psychological location (here) and another perspective at a different location (there). These cues also allow us to experience events as occurring in the present moment (now) or at a different time (then). The ability to shift between these perspectives is learned during the normal course of social development and acquiring language. Children are asked a remarkable number of questions about their experiences, and children’s reports of these experiences are reinforced when they come from a particular perspective (I). In the simplest form of this process, children might be asked to report from their own present-­moment perspective: I-­here-­now (e.g., with the question “What are you feeling?”). They may also be asked to report on the experiences of others in the present: you-­here-­now (e.g., with the question “How do you think Tommy feels when you take his toy away?”). Alternatively, they may be asked to report on the experiences of others at a different time: you-­there-­then (e.g., with the question “Where did your mom go yesterday?”). They may also be asked about their own past perspective: I-­there-­then (e.g., with the question “What did you eat at your birthday party last week?”); or be asked about their future perspective: you-­there-­then (e.g., with the question “Where is your dad going this afternoon?”). Early on, children have difficulty answering questions involving perspective. When asked about their own experience, they may not report it accurately. When asked about the experiences of others, they often substitute their own. When asked about the future, they may report what’s happening in the present. Accurate perspective taking is shaped through practice and extensive interactions with the social world, and eventually a sense of self and other emerges. Over time, children learn to respond consistently to perspective-­related questions from a particular point of view. They learn to distinguish their own sense of perspective (I) from the perspective of others (you), with the three key perspective-­ framing cues (I/you, here/there, now/then), creating a sense of self. From the ACT perspective, this largely social training process leads to the emergence of three senses of self: self-­as-­content (or the conceptualized self), self-­as-­process (or the knowing self), and self-­ as-­context (or the observer self). Self-­as-­process, discussed in chapter 4, refers to the ability to report on one’s own experience from a consistent perspective. This chapter focuses more heavily on the other two senses of self—­ self-­ as-­ content and self-­ as-­ context—­ along with flexible perspective taking more generally.

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Self-­as-­Content: The Conceptualized Self Through an ongoing awareness of our experiences, preferences, thinking, and other psychological events, we begin to abstract a sense of a self that appears to have qualities (fair, smart, fun, etc.), just like an object has qualities (color, texture, size, etc.). We develop a conceptualized self—­a concept of ourselves. This sense of self is self-­as-­content. This sense develops as we make statements like “I am       ,” declaring beliefs about who we are and descriptions of our being. For instance, you might say, “I’m a professional,” “I am someone who suffers,” “I’m a victim,” or “I am intelligent [or dumb].” Associated with this content are all kinds of images, thoughts, and behaviors that seem to indicate these senses of self are true. Altogether, this mental content makes up our identity. There’s nothing inherently problematic with building, categorizing, and discovering identities; indeed, this is part of languaging itself in our social world. Self-­as-­content is multilayered and contextually emergent and can serve several functions. Operating at the level of the conceptualized self even creates a healthy kind of inflexibility that supports consistency over time and is often associated with workable behavior. For instance, a person’s professional identity, and all of the verbal information that comes along with it, may be helpful in getting him to build his career and go to his job even on days when he doesn’t feel like it. For example, he might tell himself, “I’m a good worker,” “I don’t want to disappoint my boss,” “I need the money,” or “My success depends on this,” and then proceed to engage in behavior that’s consistent with his professionalism. In this way, our conceptualized self allows us to evaluate, assess, and control situations and engage in problem solving—­typically healthy behaviors under a large set of circumstances. From the perspective of the social community, fusion with the conceptualized self is useful because it allows others to better predict and understand our behavior and engage with us in ways that influence our behavior. Unfortunately, this same fusion that is useful for the social community may be troublesome for the individual because it can lead to unworkable and destructive behaviors, trapping people in patterns of living that are problematic. Through the mind’s desire to be consistent, to justify and explain, and to evaluate and assess, people can end up in a kind of verbal straightjacket that limits their life. Fusion with the conceptualized self leads to consistency in behavior, sometimes to a fault, and even when the consistency is with an identity of being inconsistent, as for people who have a story that they are impulsive or unreliable. And in the same way that people might behave in accordance with the identity “professional,” they might also behave in accordance with other identities, including “damaged,” “broken,” or “unacceptable.” The consistency that fusion with the conceptualized self fosters isn’t inherently good or bad; however, it can greatly impair people’s ability to make needed changes. If their conceptualized self clashes with what their values suggest is called for in a situation, they may find themselves constricted. The result can be continued patterns of behavior that, while consistent with an individual’s self-­stories, result in much suffering. For example, consider a client who fully embraces a conceptualized self that he defines as being a proud man. His “proud man” self-­concept includes the idea that he’s a person who deserves respect no matter what. He feels that his family should listen to him at all times and do so without disagreement because, as a proud man, he thinks he should never have to admit he was wrong. But in the process of clinging to this conceptualized self, his relationships with his family suffer. This identity is costing him intimacy and closeness in relationships, yet he’s so glued to his self-­perception that he becomes angry and even more prideful, insisting that others need to change and see things his way for the relationships to work. He engages in this behavior in a persistent and inflexible way instead of working on what he

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most desires: close family relationships. In the end, most of his children hardly speak to him, and his grandchildren choose not to be around him at all. He traded his family for attachment to a story. It isn’t uncommon for people’s lives to be ruled by a particular conceptualized self. Consider a child who was abused and becomes a lifelong victim or “damaged goods,” or a self-­sacrificing mother who has become “the martyr.” These kinds of self-­made concepts can lead to pain and struggle, especially if other things the person values are lost as a result. Lastly, the verbal knowledge that gives rise to the conceptualized self is greatly limited; these stories play only a small role in the vast experience of an individual’s being. None of us can truly know all the personal history and contexts that have affected our behavior and continue to do so. Rather, we have an imperfect understanding of our lives, leaving us with stories, justifications, and descriptions that, despite referencing many facts and providing descriptions of patterns of behavior, can greatly restrict our ability to flexibly respond to situations or change as needed.

Self-­as-­Context: Observer Self, Transcendent Self The same social training process that leads to a sense of self-­as-­content also typically leads to another sense of self: a self that is continuous and stable, yet hard to define. When children are asked questions such as “What did you see?” “Are you worried?” and “What would you like to eat?” they learn to provide responses such as “I saw a doggie,” “I feel scared,” and “I want a cookie.” The content of the answers continuously varies (e.g., “I see,” “I feel,” “I want”), but the word “I” taps into a constant: the conscious place from which events are known. This is self-­as-­context, a perspective from which one perceives, speaks, acts, and lives. In RFT terms, I-­here-­now becomes the context, space, or container for the content of experience. This sense of self has been referred to in a number of ways in clinical work and the ACT literature—­self-­as-­context, the observer self, the transcendent self, or pure awareness. The term used is not particularly important. Each points to a helpful relational repertoire and the resulting experience that ACT therapists strive to evoke in clients. The sense of self-­as-­context is transcendent and inherently social. It’s transcendent because the limits of pure awareness cannot be consciously noted. Everywhere you go, there you are, and it isn’t possible to be conscious of unconsciousness. Said in another way, this experience isn’t thing-­like, and from the inside, it doesn’t seem to have spatiotemporal limits. Thus, it provides a naturalistic basis for experiences of transcendence or spirituality (Hayes, 1984). And this sense of self is social because it isn’t possible to have relational frames that aren’t bidirectional. In order to understand “here,” you must understand “there.” In order to understand “now,” you must understand “then.” And to contact a sense of “I,” you must be able to contact a sense of “you.” To be aware that you see through your eyes, you have to be aware that others see through theirs. This is why empathy and a transcendent sense of self are so closely linked. The same relational framing processes that give rise to this sense of self give rise to a sense of what others’ experience must be like. This sense of self-­as-­context begins to emerge in the preschool years (McHugh & Stewart, 2012) and soon becomes part of everything we consciously experience. For instance, if you were asked what you ate for dinner last night, where you went on vacation last year, and what high school you attended, you would be able to answer each question by seeing through the eyes of the one who ate the dinner, the one who went on vacation, and the one who attended a certain high school. You would be able to view each of these events from a stable sense of self that stretches across each event and remains

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present across time. However, in a profound sense, self-­as-­context is not a thing (or perhaps we should say it is “nothing” or it is “everything”) because this locus, or arena, in which all the content of experience unfolds is hard to define and has no edges. In addition, it is not a concept or belief; it’s a perspective from which you observe the content of your life, including thoughts, feelings, memories, and sensations. The observer self is a larger, timeless, interconnected context that holds all of a person’s experiences and yet is not any one of them.

Self and Other As just mentioned, in order for there be an “I,” there must be a “you.” Therefore, each type of psychological self implies a corresponding type of psychological other. Other-­as-­content involves describing and evaluating others in the same way one might describe and evaluate an object. Other-­as-­process refers to an ongoing awareness of others’ experience and associated descriptions of their thinking, feeling, behaving, and sensing. And other-­as-­context refers to having an awareness of others as conscious beings, along with the ability to flexibly shift perspective to include others’ perspectives in one’s social context.

I

You

Self-­as-­content

Other-­as-­content

Self-­as-­process

Other-­as-­process

Self-­as-­context

Other-­as-­context

This ability to both have a sense of self and also take the perspective of others allows for the complex empathic abilities we have as humans. Empathy is basically the ability to imagine the experiences of others, which allows human beings to connect, joining with each other in shared understanding and concern. Cooperation, caregiving, and other such social repertoires are highly linked to this ability. If a person can imagine the experience of others, including pain and need, then that person can offer supportive care or cooperation. We can also construct verbal others in ways that are unhelpful. For example, we can relate to others in terms of other-­as-­content, responding to them as objects rather than conscious beings, which leads to prejudice, dehumanization, and objectification. And other-­as-­process can be inaccurate if we imagine that others are experiencing things they aren’t. For example, people with an extensive history of mistreatment may frequently see others as neglectful, hurtful, or malevolent and have difficulty tracking how people are actually responding to them in the context of relationships. Fusion with these kinds of inaccurate stories about others’ experience can result in confusing and problematic interpersonal behavior. Clients can become so caught up in their stories, evaluations, and judgments of themselves and others that they are unable to respond flexibly. This makes it difficult to have empathy and compassion for themselves and others, as empathy and compassion require the capacity to experience pain as tolerable and ephemeral, along with the ability to step back from limiting stories of self or other. Reconnecting with or building flexible perspectives can reverse this process. Clients can learn to develop more frequent contact with others as aware beings (other-­as-­context), to notice and resist the

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tendency to objectify others and get stuck in stories about them (other-­as-­content), and to develop a more accurate sense of the feelings, thoughts, behavior, and sensory experiences of others in the moment (other-­as-­process).

Why Build Flexible Perspective Taking and a Transcendent Sense of Self? Ultimately, the purpose of perspective-­taking work is to free clients to flexibly respond and adapt to different contexts and experiences. The ability to flexibly take multiple and varied perspectives on themselves and their experience liberates people to act on their values. Building flexible perspective taking involves three key clinical activities: using hierarchical framing to create a sense of self-­­ as-context; contacting the transcendent self and distinguishing it from self-­as-­content; and using perspective taking to develop a flexible view of self and other. Helping clients make the distinction between the experiencer and what is experienced empowers them to observe the ongoing flow of their experience while also making choices linked to behaving consistently with their values. Flexible perspective taking can also benefit relationships as clients become more conscious of others as aware beings, get less caught up in their stories about others, and develop more accurate empathy and compassion. Self-­as-­context can also help clients find a secure and safe place from which to contact and confront feared emotions, memories, thoughts, and sensations, which often seem to threaten a person’s sense of self. Becoming familiar with the ongoing, ever-­changing nature of their experience will help clients understand that these experiences won’t devastate them; rather, another moment will pass and another experience will come along. When clients are fully present in directly experiencing the moment, they gain the opportunity to learn that thoughts and emotions aren’t destructive. Making contact with the transcendent self can help them see that there is a place—­in fact, that they are a place—­that is unchanging and stable and therefore isn’t threatened by passing internal experiences. Note that flexible perspective taking is inherent in each of the other flexibility processes and therefore is necessary to implement them. Here are some examples: • Present-­moment awareness involves returning to a here-­and-­now perspective when a person is rigidly caught up in a constructed future or past. • The development of a consistent and stable place from which to observe experience can facilitate acceptance, thereby decreasing suffering as the person contacts a sense of expansive awareness. • Contact with a transcendent self that is distinct from content facilitates defusion by, for example, promoting equanimity in the face of self-­evaluations. • Flexible perspective taking and conscious awareness facilitate a sense of choice and freedom that is essential for values-­based living. • Loosened attachment to the conceptualized self facilitates behavior change, which is often necessary for people to engage in committed action. Additionally, flexible perspective taking

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and self-­compassion support willingness to make the inevitable mistakes and experience the associated thoughts and feelings that are part of learning new behavior. Flexible use of perspective taking is also central to making the learning that happens in session more experiential, rather than didactic or instructional (see chapter 4 for more on experiential learning).

What Should Trigger Working with This Process? In ACT, therapists work with clients in an ongoing way to explore the problem of being overly attached to the conceptualized self and to develop other perspectives that may promote greater flexibility. However, sometimes increasing the focus on these issues is warranted in response to certain patterns of client behavior. One example is when clients’ attachment to and defense of a particular conceptualized self interferes with their ability to make needed changes in their life. For instance, a client might defend the stance that she’s “a victim,” indicating fusion with this conceptualized self. As a result, she may mistrust others and refuse to engage in intimate relationships—­even if intimacy in relationships is one of her values. In such cases, the therapist’s job is to help clients make contact with self-­as-­context, embracing a larger and more encompassing sense of self that’s separate from the content of the mind. So in this example, the therapist would support the client in making contact with a sense of self that’s separate from her conceptualized victim self. The goal is to increase flexibility and support the client in engaging in new behavior related to her values, rather than remaining stuck in behavioral patterns related to her victimhood. A second indicator that it would be helpful to focus on perspective taking is when clients’ behaviors suggest a sense of detachment from others or lack of empathy and compassion. This can take the form of externalizing behavior wherein the client rigidly blames others or is harshly or rigidly judgmental. Other examples include stigmatizing or prejudiced behavior or objectification. Each of these difficulties connotes inflexible perspective taking, particularly fusion with a conceptualized other (e.g., “He’s stupid”) or inaccurate assessments of other-­as-­process (e.g., thinking, “She’s angry at me” when the person is actually sad); in either case, the dynamic is probably fed by avoidance (e.g., staying away from others). Similarly, clients who have an unstable sense of self or who tend to confuse their own experiences with those of others can benefit from a greater focus on flexible perspective taking, and particularly on developing a more stable sense of self-­as-­process and self-­as-­context. This extends to dissociation, wherein the sense of self is so disrupted that “no one is home.” Clients who suffer from an unstable sense of self and dissociation may have a hard time with exercises related to creating self-­as-­context and may get lost in thought or rigidly stuck in one perspective. Because dissociation involves a disruption in the continuity of the self, these clients have a greater need for work on both present-­moment awareness and flexible perspective taking. Such clients may benefit from an emphasis on present-­moment work that assists them in staying connected to the here and now while also being able to report on what is happening. When focusing on this process with clients who are particularly prone to self-­loathing, a sense of inadequacy, self-­doubt, or strong self-­criticism (all indicators of pervasive fusion), it may be advisable to emphasize self-­compassion. And given that many of these clients also struggle with intimacy and the ability to be empathic and emotionally connected with others, perspective taking centered around empathy and compassion can also be helpful.

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In addition, we recommend that you attend to your own experience and look for signs that suggest it would be useful to implement this flexibility process. These signs may include a sense of disconnection from the client, lack of empathy, boredom, arguing with the client, or feeling a pull to protect the client’s self-­image. All of these therapist responses suggest the need for perspective-­taking work in session.

What Is the Method? In the sections that follow, we describe the ways in which perspective-­taking frames (I/you, here/there, now/then) can be combined with other relational frames to develop a more flexible sense of self. In particular, we focus on using hierarchical framing to help clients connect to a transcendent, continuous, and socially interconnected sense of self that is involved in noticing or observing the moment-­by-­ moment flow of thoughts and emotions as ongoing experience. We also discuss how to use relational frames that involve shifting perspective in person, space, or time to help people develop a flexible sense of self that’s less tied to rigid conceptualizations of self or others.

Using Hierarchical Framing to Create a Sense of Self-­as-­Context In addition to working with perspective-­taking frames, you can use interventions that involve hierarchical framing to develop perspective taking. Hierarchical framing occurs when we refer to one thing as part of something else (A is an attribute of or a member of B). This includes talking about one thing containing something else, being the context for something else, or being part of something else. Hierarchical frames are involved in categorizing specific experiences as part of an emotional state. For example, if you ask a client, “What are you feeling?” and the client notes a feeling of tension in his chest and images of feared future events, he may label these events collectively as “anxiety,” with feelings of tension and images of feared events being seen as part of anxiety or categorized as anxiety. Hierarchical frames are also used when people refer to aspects of their experience, such as feelings, thoughts, and sensations, as part of their self. Hierarchical framing is central to helping clients contact a sense of themselves as the container for their experience—­in other words, self-­as-­context. Hierarchical framing is also useful for developing self-­as-­process. Let’s look at a few examples that illuminate how hierarchical framing is involved in the shift from self-­as-­content to self-­as-­process. Consider the statement “I am broken.” This reflects self-­as-­content. Simply restating this as “I evaluate myself as broken” shifts the perspective by noting “broken” as a type of evaluation. Similarly, the statement “I’m anxious” comes from the perspective of self-­as-­content. By rephrasing this as “I feel my heart beating fast and I have the urge to run away from this situation,” anxiety is noted in terms of the parts that make it up, rather being an abstract, indivisible category. This also applies to perspectives on others, as in the statement “You’re obnoxious,” a clear communication of other-­as-­content. By rephrasing this as “I’m having the thought that you’re obnoxious,” the person is able to note that “You’re obnoxious” is a type of thought. Hierarchical relations are an important part of many metaphors and exercises used to establish a sense of self-­as-­context, a container for all of one’s experiences. Hierarchical relations occur whenever

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people view their thoughts, feelings, sensations, or other internal experiences as part of a self that is having those experiences.

METAPHORS THAT USE HIERARCHICAL FRAMING A metaphor that uses hierarchical framing to contact this sense of self that is more expansive than any given experience is the Sky and the Weather metaphor (Harris, 2009, p. 175). In this metaphor, the sky is likened to the person’s larger sense of self, which contains all of the shifting weather, and the weather is likened to the shifting content of experience: thoughts, feelings, sensations, and so on. This metaphor can be worked into various other exercises and used at any point where it might be helpful to have clients contact a sense of self that’s distinct from and larger than their experience. Here’s an example of how it might be employed at the start of an exercise. Note that the pacing, which isn’t indicated in this script, should allow time for clients to experience the metaphor. Also, begin by devoting a few minutes to helping clients get centered, perhaps by following the breath. Therapist: I’d like you to imagine that you’re lying on your back on a warm, summer night in the middle of a field. You’re gazing up into a black night sky and see countless stars in the expanse of the sky. Give yourself a moment to imagine what you would see… Now I invite you to imagine that you are the sky, looking down on the earth below you. As the sky, you might notice that the weather is constantly changing. You might also notice that even as the weather changes—­for example, black clouds roll in and pass—­the sky doesn’t change… There’s a part of you that’s like the sky. The clouds and weather are like your feelings and thoughts, constantly changing. Sometimes your thoughts and feelings are dark and frightening, like a thunderstorm. Sometimes they’re light and warm, like a sunny spring day. What’s certain about the weather is that it will change… And what’s certain about your thoughts and feelings is that they will change too, just like the weather… Notice how from the beginning of this exercise you’ve had many different thoughts, floating through you like clouds through the sky. Yet the sky is unaffected by the clouds, just as it’s unaffected by any type of weather… Similarly, the “you” that contains thoughts and feelings isn’t affected by or harmed by these experiences, no matter how difficult, painful, or scary they are… There’s a part of you that’s like the sky, containing all of your experiences—­ thoughts, feelings, sensations—­but isn’t the same as your experiences. It’s larger than them. Even if sometimes the clouds are so thick that you can’t see the sky that contains them, the sky is always there, unchanged. Through practice, you can learn to access this part of you that’s like the sky, unharmed by experience. It is from this part that you can make room for difficult thoughts and feelings—­and all other thoughts and feelings. Once you’ve introduced this metaphor, you can incorporate it into future exercises in a briefer format by using the first few sentences of the script and then asking the client to observe what comes next from the perspective of being the sky. The well-­known Chessboard metaphor (Hayes et al., 2012, pp. 231–­233) also makes use of hierarchical framing to promote perspective taking. In this metaphor, the self (i.e., the arena or context in which experience takes place) is likened to a chessboard. The chess pieces correspond to the client’s thoughts, feelings, sensations, and so on. After you present this metaphor, you can elaborate it in many ways. For example, you could talk about how chess is a game of war and strategy and point out that the

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board (self-­as-­context) has no real investment in strategy or even how the war turns out. You can also note that although the various pieces are threatening to each other, they aren’t threatening to the board. The board is simply in contact with them. You can even use an actual chessboard to make the metaphor more concrete, an approach that’s especially helpful for clients with limited abilities to engage in abstraction. The following dialogue illustrates how, after establishing this metaphor, you can make it more experiential by integrating it into the flow of the session. This dialogue occurs immediately after the Chessboard metaphor was described using an actual chessboard with pieces. Client:

So, I’m the board and my thoughts and feelings are the pieces? But what about my thoughts about who I am?

Therapist: (Picks up more chess pieces and sets them on the board.) More pieces to be added to the board. Client:

But when I feel things, it’s real. It’s overwhelming.

Therapist: (Picks up another chess piece.) Yes, it is definitely an experience you are having. (Sets the chess piece on the board to represent the feeling.) And that thought you just had, the one that said, “But when I feel things, it’s real. It’s overwhelming”? That’s another piece, too, another experience. (Sets another chess piece on the board.) Client:

So everything I say will become another piece?

Therapist: Yes, each experience you have, whether it’s a feeling or a thought, is another piece on the board. And as the board, notice that you’re in touch with the pieces, in contact with them. (Slides pieces around on the board to demonstrate contact.) Yet the pieces are not the board. Client:

Well, I think I’d like to just dump the board over.

Therapist: And that thought too is another piece on the board. (Sets another piece on the board.) See how this works? Client:

I know, but I don’t want those bad pieces.

Therapist: (Speaks compassionately.) I can understand why. But, again, check your experience and see. Have you ever been able to kick the pieces you didn’t want off the board? Have those bad memories and feelings disappeared? Client:

No.

Therapist: So even “I don’t want those bad pieces” goes on the board. (Puts another piece on the board.) Remember, though, that the board is not the pieces. The board is larger than any single piece. You, the experiencer, are in contact with your thoughts and feelings. You are aware of having them, and yet you are not them. You experience them, and you are continually adding to your board…and the pieces are not the board. The board can hold the pieces and remain intact and whole, even if a piece says, “This is overwhelming.” Here, the therapist is using hierarchical frames by pointing to the board as the holder of experience (the pieces) and the observer of experience, while also demonstrating that experience is ongoing and

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additive. Experience flows from one moment to the next, and each new experience is to be observed, simply as new pieces to be added to the board. It is worth noting at this point that, just like clients, therapists aren’t always in contact with this sense of self. It takes practice to be aware of the observer self, and it’s difficult to remain in this perspective. Still, it’s an inherently freeing perspective. If clients are not their experience but rather the context where their experiences occur, then they are free to choose their behavior while allowing the pieces to be. It isn’t necessary to change any of the pieces before engaging in values-­based action.

SEEING THE SELF AS PART OF SOMETHING LARGER The preceding section focused on helping clients see their experiences as part of themselves. The self is the whole, and their experiences are the parts. In contrast, this section focuses on helping them see themselves as part of a larger whole. The self is the part and the larger whole is a group of people, all of humanity, or the universe itself. In this type of approach, hierarchical framing is used to create a sense of membership in the group and common humanity. These subtle shifts in perspective taking result in a transformation of functions wherein people are more likely to see themselves and their difficulties as similar to those of others, creating a context in which they can recognize that they are part of something larger than themselves. The goal is to build a sense of intertranscendence (Villatte, Villatte, & Hayes, 2012), a connection with the perspectives of other people, times, and places. The subjective experience such approaches target is eliciting a shift from my (isolated) experience to our (shared) experience. Instead of my suffering, it’s the suffering that we all experience. The following exercise, which was created for a group setting, demonstrates how hierarchical framing can be used in this way. To help participants see themselves as part of the group, the therapist guides them to be aware of themselves as conscious human beings (using I/you frames) and also helps them take the perspective of others (also using I/you frames). (Again, note that pacing, which isn’t indicated in this script, should allow time for clients to fully experience the exercise, and that here too you would begin by devoting a few moments to helping clients get centered, perhaps by having them notice the sounds around them.) In the script that follows, the words written in italics are those that serve as cues for interpersonal perspective taking, and the words written in bold italics serve as cues for hierarchical framing. Therapist: Take a few moments to notice what you’re feeling in your body as you sit here. Notice any places of discomfort, itching, aching, or other sensations. Notice any emotions, thoughts, or judgments you may be having. In addition to these thoughts, feelings, and judgments, see if you can connect with your own sense of conscious awareness—­seeing that you see, noticing the you that notices these experiences. You are more than the content of your reactions Now, I have several questions, and I’d like you to see what shows up in response when I ask them and to just sit with whatever shows up. Is it okay to be a person who has experiences? … Have you ever noticed that we all have experiences? … And here you are, having experiences like everyone else in this room. It’s likely that you’ve had these experiences or ones like them before—­in other times and places. And here you are, here in this moment, having them again. Can it be okay to have them? … Are you allowed to be a person who has experiences? … Is it okay for you to have these experiences in the future?

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… You are having them now and you will likely have them again. Are you allowed to have them whenever they occur? Now I’d like you to take a few moments to connect with the fact that there are six other people with you here in this room. Notice that each one is conscious, just like you. Each person has experiences, just like you. Each of these people has felt happy at times, just like you. Each of these people has felt unworthy or inadequate in their work or in their life, just like you. Each of these people wants to be happy or content with their life or feel like their life has meaning, just like you. And each of them has found these things difficult to achieve… Each of these people suffers more than they want to…just like you. Each of them will likely have these experiences again in the future. Are they allowed to have them? … Are you allowed to have these experiences in the future as well, as a fellow human being? … See if you can connect with how hard it is to live a human life. Being human isn’t easy. Here we are, each of us, faced with this situation of how to live a human life. Is it okay for us, all of us, to have difficulty with that at times? Is it okay for you? This exercise shares similarities with self-­compassion exercises related to common humanity (Neff, 2011), wherein individual suffering is seen as part of the larger experience of humankind. By observing oneself and one’s own experience in this way, the tendencies that most people have to treat others with compassion and kindness are more likely to transfer to treating themselves with compassion and kindness. This exercise may be modified for individual therapy by referring to the therapist instead of the group or by imagining other people, whether those in the building or people in some other setting. The central idea is that clients see themselves and their experiences as part of something larger—­as one person among many, having experiences that are shared by many, which cuts through the sense of isolation and otherness that many clients experience.

Contacting the Transcendent Self In this section, we focus on combining hierarchical relations with what RFT calls distinction relations. Distinction relations involve responding to the differences between stimuli based on cues like “is different from.” In the context of perspective taking, distinction relations involve cues that help clients distinguish between the experiencer and that which is experienced. Exercises focusing on the distinction between what is observed and who is observing typically have a similar structure. Clients are first led to notice some aspect of their experience, for example, their five senses, thoughts, feelings, roles, or memories. Cues are then used to help clients notice that the observer is not the same as the experience itself. Here’s an example. (Again, pause and adjust the pacing as needed so clients can fully engage in the exercise.) In this example, the therapist has just related the Sky and the Weather metaphor. Therapist: Take a moment to draw a large breath. Notice how you feel it in your body, your nose, or the rise and fall of your chest or belly… Simply watch the breath as it flows in and out… And as you notice your breath, take a moment to notice who’s noticing… Now take a few moments to become aware of your emotions. You might notice emotions in your belly, your chest, your throat, or your shoulders. Find an emotion and see if you can scan the area

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where it seems to be located…and notice what you’re feeling as you do this. Try to zoom in on where you feel this emotion most strongly. As you do this, notice who’s noticing. There’s your emotion there, and then there’s part of you that’s watching that emotion. This exercise can be extended using other aspects of experience, such as thoughts, memories, urges, or sounds as experiences to notice. Later, this can be paired with cues to help clients notice the difference between themselves and their experience with statements like these: “Recognize who is hearing this sound [having this thought, etc.].” “Notice that you are there, behind your eyes, noticing this. Notice that your thoughts are constantly changing, but the ‘you’ that notices them does not. The ‘you’ that observes stays the same.” “Be aware that it is you who is noticing this feeling.” “Notice that you are not the same as this thought. If you have a thought, you can’t be that thought.” All of these verbal cues include elements to help clients distinguish themselves from the content of their experience.

THE OBSERVER EXERCISE Another ACT exercise that taps into noticing and drawing distinctions is the Observer exercise (Hayes et al., 2012, pp. 233–­237), a frequently used method that helps clients contact a sense of self that’s larger than any single experience. This is generally done as an eyes-­closed exercise and often takes twenty to thirty minutes. (Consult Hayes et al., 2012, for the full process, or for a downloadable audio version, visit http://www.newharbinger.com/39492.) Here, we will simply note that the core of the exercise is to guide clients to notice the continuity of consciousness itself, as illustrated in this dialogue, which starts after the therapist has already helped the client get centered. Therapist: Now I’d like you to take a moment and think back to a memory of something you did this morning, such as eating breakfast or getting ready for work. Take a look around that memory; notice what you were doing and who was there, if anyone. See if you can remember the sights and sounds of this memory.… (Allows the client time to reflect on the memory.) Now, as you notice this memory, as you observe it, also notice who is noticing… Now release this memory and travel back in time to find another one—­from perhaps a month or a year ago. Once you have found this memory, also take a look around this one. What are the sights and sounds of this memory? (Pauses.) And again, as you notice this memory, notice who is noticing. Notice there is a “you” there who is observing that you have this memory. The strategy is then to contrast that sense of continuity with dimensions of experience, such as roles, sensations, emotions, thoughts, and behavioral urges. In each case, the therapist asks the client to note how the specific dimension ebbs and flows and is constantly changing, yet the sense of consciousness itself doesn’t change. The bottom line is that the experiences with which we struggle are not really us anyway. Examples of similar exercises include the Continuous You exercise (Harris, 2009, pp. 178–­180) and Talking and Listening (Harris, 2009, pp. 177–­178).

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For clients with a severe disruption of the continuity of self, these exercises need to be modified. Those with early trauma or abuse may tend to dissociate during exercises focused on developing a transcendent sense of self, or the exercise may elicit fear, anxiety, shame, or avoidance. Since problems with effective perspective taking are actually central to these individuals’ difficulties, it’s important to engage in exercises aimed at building flexible perspective taking while also respecting how difficult they can be and how much rigidity they can evoke. In such cases, engage in perspective-­taking work in a measured way. It might be more appropriate to think of these exercises as a type of exposure (for more on exposure, see chapter 7), using them to supportively help clients intentionally develop flexibility while they’re in contact with avoided stimuli that typically lead to inflexible responding (e.g., dissociation).

DECREASING FUSION WITH SELF-­EVALUATIONS Evaluation is useful in many aspects of life. It can keep us from danger, guide our decisions, and help us know culturally defined rights and wrongs. Yet it can also be fairly damaging in other aspects of life, particularly when directed at oneself. More broadly, fusion, including fusion with self-­evaluations, disrupts people’s capacity to contact self-­as-­context because fusion causes the context in which evaluations occur to disappear. Many clients have a tendency to state—­privately, publicly, or both—­negative evaluations of themselves and to buy those evaluations. In many cases, these evaluations have been around for a long time, often starting at a young age. Such self-­evaluations may plague people almost continuously, or they might just show up when problems arise. You can detect the harm caused by fusion with self-­evaluations by reviewing negative self-­statements that clients bring to session and discovering how these evaluations have impacted their life—­statements like “I’m worthless,” “I’m evil,” “I’m pitiful,” “I’m ugly,” “I’m undeserving,” “I’m a failure,” “I’m a lost soul,” “I’m a creature, not even human,” “I’m damaged goods,” and so on. Finding an effective way to work with fusion with self-­evaluations can be difficult because this is a natural and well-­rehearsed part of human language (thus the plethora of defusion techniques offered in chapter 3 and other sources). Furthermore, clients sometimes come to therapy with the idea that their self-­evaluations are problematic and need to change—­that they need to have better, more positive self-­evaluations (e.g., higher self-­esteem) in order to live a better life. But as discussed in earlier chapters, this is a battle that clients are unlikely to win. In fact, the battle to eliminate negative self-­evaluations points to the difficulty. Clients’ evaluations are part of their learning experience, so in order to change or eliminate these evaluations, clients have to go to battle against their own history. The result is often a self-­attacking or self-­critical stance that further reinforces the evaluations. Therefore, rather than helping clients change the content of these evaluations, the ACT therapist guides clients to see them for what they are: evaluations occurring in a context. The therapist can then help clients dispassionately observe their experience and develop a friendlier, gentler way of relating to themselves. To help clients see that these evaluations are part of their verbal learning history, the therapist might liken them to programming in a computer: when certain buttons are pushed, programmed evaluations show up on the screen. This points to the automaticity of evaluations and the low likelihood that they’ll go away. Alternatively, this can be conveyed using the Chessboard metaphor, with the programming or evaluations simply being pieces on the board, not part of the board. The client is a whole human being with the evaluations, and as with reasons, evaluations need not determine the client’s choices or quality of life.

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In addition to perspective-­taking exercises, a number of defusion exercises (see chapter 3) are useful for helping clients notice evaluations, rather than holding them to be actual qualities of the contextual self. The first step in this work is for the therapist to make a distinction between description and evaluation. Here’s a dialogue that illustrates one way to do so. Therapist: (Holds up a pen.) This pen is white, with black letters and a black cap. The tip is metal and has black ink. Agreed? Client:

Yes.

Therapist: Now, suppose I say this is the best pen in the world. There is no better pen. Agreed? Client:

Well, I don’t know. I own a pretty darn good pen.

Therapist: Right. You can see how the description is different than the evaluation. “Best pen in the world” isn’t in the pen. It is something I’m saying about the pen. It’s an evaluation I have about it… It doesn’t exist in the pen. (Pauses.) And “worthless” is an evaluation that doesn’t exist in you. It’s just something you say about yourself. It has nothing to do with whether you are whole or not. You can accomplish something similar with the Milk, Milk, Milk exercise described in chapter 3, substituting a negative self-­evaluation for the word “milk.” Even though clients can imagine milk, see it in their mind’s eye, and perhaps even feel the cold glass or taste the milk, the literal milk isn’t there. Saying “milk” and describing milk doesn’t make milk suddenly appear. Likewise, saying “I’m bad” and feeling “I’m bad” don’t create bad in the person; rather, this is just something the person is saying about herself. The client is the context for the content “I am bad,” nothing more. After asking the client to say the self-­evaluation repeatedly, debrief the exercise and explore how it relates to self-­as-­context: that there is a self that has evaluations, can defuse from them, and is larger than them.

LETTING GO OF CONCEPTUALIZED SELVES Connecting to a larger sense of self that isn’t defined by one’s experience involves letting go of conceptualized selves. This includes not just identities that are considered to be negative, but also those considered to be positive. Because the latter can be somewhat counterintuitive, let’s take a closer look at that. A positive conceptualized self could be equated with a set of thoughts linked to high self-­ esteem. Yet attachment to this positive content can be just as problematic as attachment to a set of thoughts and negative evaluations linked to low self-­esteem. Problematic positive self-­conceptualizations are readily apparent in some clinical presentations, such as an overly inflated sense of self that might be linked to narcissism. However, this can also show up in other, less obvious presentations. Consider a client who has a strong conceptualized self linked to a set of positive notions about her personality. Speaking of herself, she says, “I always look on the bright side,” and says she works hard to “stay positive.” However, she engages in this behavior at least in part because it helps assuage pain associated with a long history of abusive treatment by her husband. Furthermore, her attachment to “being a positive person” interferes with her ability to clearly see the abuse and the harm it’s causing. By identifying the costs of clinging to this “positive” identity and the behaviors it leads to, she can begin to let go of this story, contact the pain of what has occurred, and take action to leave her destructive marriage.

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One way to strengthen the distinction between the conceptualized self, or self-­as-­content, and self-­ as-context is by using imagery. For example, you can ask clients to imagine that their thoughts are being written on a whiteboard in front of them, on signs carried by people in a parade (Hayes et al., 2012, pp. 255–­258), or on leaves floating by on a stream (Hayes, 2005, pp. 76–­77). Alternatively, chair work such as that used in Gestalt therapy can help create a distinction between one perspective and another. The following exercise provides yet another example of how imagery can be used to reduce attachment to self-­as-­content. Therapist: Each of us has stories that we tell about ourselves, for example, who we are, what our capabilities are, and so on. This is normal behavior, and it’s something we all do. The difficulty occurs when we become overly attached to these stories because then they can start to constrict what we’re capable of in our lives. I’m hoping we can do an exercise today to explore how this works. Are you willing to do an exercise with me? (The client agrees.) Okay, to begin I’d like you to do some writing about three different selves you have. For today, how about working with your best self, your critical self, and your hurting self. (Choose whatever selves seem relevant to the particular client, as long as these are selves the client seems fused with.) Take a minute or so and write down a few descriptions of you when you are your best self. What is your best self like? What does she look like? What does she think, feel, and do? (Gives the client a minute to write.) Now take another minute to jot down some descriptions of your critical self. Think about an area in your life in which you criticize yourself. What does this side of you look like? What does she say? What does her voice sound like? What does she think, feel, and do? (Gives the client a minute to write.) Finally, take a minute more to write about your hurting self. This is the self that feels small, hurt, and helpless. What are you like in those moments? What are your qualities? What do you think, feel, and do? (Gives the client a minute to write.) Okay, now that you have finished, let’s do an eyes-­closed exercise that involves imagery. (As always, adjust the pacing as needed so the client can fully experience the exercise.) I invite you to close your eyes and get centered, focusing on a few breaths as you settle. Now I invite you to imagine the first image you wrote about, the image of your best self. See if you can fully picture that self out in front of you, noticing how she looks, thinks, and feels… Now imagine that by some twist of fate this self couldn’t stay—­she could no longer be a part of you. What would you find yourself clinging to? … What might you find easy to let go of? … It doesn’t matter. This isn’t you anyway. You are larger than this self. Hold this self lightly, like you might hold a butterfly that’s landed on your finger. You are more than this self. (The therapist repeats the same instructions for the other two images and then moves on.) Now notice and hold each of these three selves lightly. They are not you anyway. You are larger than them. See if you can allow all of these selves to gently rest in the vastness that is you… And now gently bring yourself back to the room. After the visualization, you can collaboratively explore the client’s experience of this exercise. You might note that although the exercise involved imagining that the three selves could no longer be, they still exist. And while these selves aren’t likely to go away, the client is free to move in and out of them

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and notice that she’s bigger than any single conceptualized self. If the client asks, “If I’m not these, then who am I?” simply remind her that these selves are always available, and that new selves can be constructed and often are. Holding them lightly is the goal, and it’s an endeavor undertaken in the service of freedom. There’s no need to fuse with or rigidly hold on to any particular self; all can be held lightly.

Experiential Exercise:

Distinguishing Self-­as-­Content from Self-­as-­Context Describe two of your conceptualized selves (e.g., professional self, self as parent, self as victim), then write a description of these selves: what they feel, how they think, and how they appear. (Ignore the “Opposite behavior” and “Reactions” prompts for now.) Conceptualized self 1:  Description:    Opposite behavior:   Reactions:   Conceptualized self 2:  Description:    Opposite behavior:   Reactions:  

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Now consider each self and think of a behavior that’s directly opposite what you would expect this conceptualized self to do. Be creative, wild, or extreme in coming up with these opposites. Describe those opposite behaviors in the spaces above. Now get into a comfortable position, close your eyes, and imagine each of these conceptualized selves. You don’t have to imagine them as yourself, although you can if you want. More importantly, give them whatever form seems to best represent the way that self feels to you. Then, in your imagination, picture each self engaging in the opposite behavior you described. Notice what happens in each case and briefly describe your reactions to each scenario.

Using Perspective Taking to Develop a Flexible View of the Self The strategies set forth thus far in this chapter primarily involve using frames of distinction to help clients distinguish their observer self (self-­as-­context) from the content of their experience (self-­ as-content), and using hierarchical frames to construct a sense of self that transcends, is larger than, and contains all of the individual’s experience or is part of something larger than the self. The exercises in this section emphasize using temporal perspective taking (now/then) in combination with personal (I/ you) and spatial (here/there) framing to help clients develop new and more flexible ways of relating to themselves. These strategies are a bit more advanced, as they typically build upon a basic ability to notice one’s experience and contact a sense of conscious awareness. From this place of awareness, clients can shift perspectives to evoke more flexible and compassionate ways of responding to themselves.

WORKING WITH THE CONCEPTUALIZED PAST Temporal frames can be used to help clients contact conceptualized pasts in ways that promote greater flexibility in responding to themselves. These exercises often take the form of asking clients to transport themselves to past events and interact with the self that was there in that situation. In addition to temporal perspective taking, these exercises tend to use spatial and personal frames extensively as clients interact with themselves from an imagined second perspective. In the following example, the context is a session in which a young woman seeks therapy after engaging in self-­harm the previous weekend. Client:

On nights like that I feel so incredibly lonely and empty, like I’m crawling out of my skin. I just can’t stand it. The only way I can make it stop is to cut myself.

Therapist: At those times you feel like there’s nothing that can help or soothe you. But the cutting makes it better for a little while. Client:

But then I feel so terrible after I do it because I know it’s bad. I hate being so weak and needy.

Therapist: It seems like you’re really stuck. In those times you feel so empty and alone, but then when you do the one thing you know to do that helps, even if only for a little bit, you beat

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yourself up for being too weak. That’s a really tough spot to be in. How long do you think this pattern has been going on? (Begins the exercise by building a sense of continuity between the self today and an earlier self.) Client:

Well, I started cutting about five years ago.

Therapist: And is that when the feelings of loneliness and emptiness started? Or do you remember times of feeling alone and empty before that? Client:

Oh no, I’ve felt that way since I was a little kid. But I did other things then, like overeating, or when I was really young, I can remember curling up under the covers in my bed and pretending that I was in a make-­believe world. I’d just sort of lose myself in that world.

Therapist: And how old were you then, when you’d be under the covers trying to escape to another world? Client:

I don’t know, maybe six or seven.

Therapist: Wow, so you’ve been suffering with this for a really long time. I’m wondering if you’d be willing to do a brief exercise with me so we can maybe see what’s happening from another perspective? Client:

Sure.

Therapist: Okay. If you’re willing, can you close your eyes? (The client closes her eyes.) Notice the feeling of your feet on the floor. Just follow the natural rhythm of your breath breathing itself, in and out… Now I want you to imagine that you’re there on your bed in your childhood bedroom and you are your six-­year-­old self. Look down at your hands and notice what they look like… See what you’re wearing as your six-­year-­old you… Feel your hair… Notice the bedding and what it feels like to sit on your bed. Is it hard or soft? … What does it smell like in that room? … What does the light look like? … See if you can hear any sounds that are around you as you sit there on your bed… (Uses first-­person and present-­ tense terms to help the client adopt the perspective of being herself as a young child.) Are you there? Can you picture it? Client:

(Responds without opening her eyes.) Yes.

Therapist: Okay, now see if you can feel what it feels like to be this six-­year-­old and be so alone… You don’t know what to do; you’re only six. And here you are, this little kid on her bed, in her room, all alone and feeling very empty and scared. What does it feel like to be this little girl? Client:

I feel really overwhelmed and scared.

Therapist: Yes. And you just want to hide under the covers and escape to your make-­believe world. (The client nods.) Okay, so now I want you to imagine that you’re standing outside your childhood house but you’re the age you are now. You’re wearing what you’re wearing now, and you are just as you are now… You start walking into your house and you go to the

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bedroom you had as a child… You open the door, and you see this little six-­year-­old girl who looks exactly like you. You can tell she’s scared and overwhelmed. She looks like she’s been crying. Notice what it feels like to look at this little girl, this little kid. How do you feel when you look at her? (The therapist is using personal frames prominently in this section, leading the client to imagine interacting with her child self as a “you” from the perspective of her adult self.) Client:

I feel sad for her. I want to go give her a hug.

Therapist: Okay, go do that. See what it feels like to go to this scared, overwhelmed, little girl who is so lonely and give her a hug. Client:

It feels right.

Therapist: Yes. So now you’re hugging the little girl. Imagine that she just kind of disappears into your chest. She becomes part of you again, because she is a part of you. You’re holding her in your heart… And now notice your feet back on the floor again here. Notice your body in the chair. You can picture in your mind’s eye what you will see when you open your eyes, and whenever you’re ready, you can open your eyes. Many of the patterns of behavior that clients struggle with can be traced back to early adolescence or childhood. Tracing difficulties back in time can allow clients to interact with a younger, more vulnerable version of themselves. This is likely to evoke caring and compassionate responses that can be used in the future by building them into sessions or homework. In the example presented above, the therapist can work with the client to explore new ways to interact with the struggling child whenever she feels like she wants to self-­injure. Perhaps it would be helpful for the therapist to recommend that the client explore “hugging the child” rather than cutting. A more general example of homework to build on this exercise could entail asking the client to look for times when the struggling child shows up and then to notice how she’s interacting with the child and whether this aligns with how she interacted in the visualization. Assuming clients evidenced a self-­compassionate response in the visualization, they can be encouraged to interact with the child as they did in the visualization in an ongoing way. And if clients are quite engaged with the ACT approach, they could be coached to identify an ACT exercise that they can practice when this struggling child shows up, such as a defusion or acceptance exercise. Ultimately, this work is linked to clients’ values, including how they’d like to live their values with respect to themselves. The previous vignette offers a relatively straightforward application of this technique, done with a client who’s relatively flexible and able to contact a new, more compassionate response. It’s important to remember that all exercises are also assessments, with the client’s response providing important data that can be used to refine the case conceptualization. For example, a client who responds to her younger self with rejection and contempt is probably showing strong fusion with a conceptualized self, which may indicate the need for further work on perspective taking and defusion toward that conceptualized self. If a client has difficulty bringing compassion and flexibility to interacting with the struggling child, you might coach her to imagine a future self that’s older and wiser, or you might give the client access to your perspective by speaking directly to the child self with compassion and empathy.

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Once this alternative perspective is contacted, the client can bring that perspective into the exercise to interact with her younger self.

USING PERSPECTIVE TAKING TO SUPPORT FUTURE BEHAVIOR Perspective taking that emphasizes temporal frames can also be a useful way to generalize what has been learned in session to future situations. This can help make the session more experiential and less didactic and may also help reduce the chances of clients making commitments that are based on the presence of the therapist. Helping clients develop the ability to take values-­based action in the future, when the therapist is no longer there, is an important treatment goal. The following dialogue, which provides an example of using perspective taking to support committed action, includes the three key deictic frames. This kind of approach is generally used after a client generates a plan for a future action to help the client overcome barriers to implementing the plan. Broadly speaking, this approach brings conceptualized future barriers into the here and now so they can be explored from a present-­moment perspective. In this vignette, the client is a gay man who’s working on drinking less in social situations, particularly in relation to dating and sex. He has this goal because alcohol has caused a fair number of difficulties for him in the past. He’s identified a plan to refrain from drinking alcohol during an upcoming date. His values-­based goal is to be present with his date, someone he met online and is meeting in person for the first time. Therapist: Would you be willing to close your eyes and imagine that you’re there at dinner? Go to the moment where you think you might be most tempted to drink. What are you seeing when you’re sitting there? Talk to me about it in the first person, like you’re there. (Uses temporal and spatial frames to transport the client to the there and then with a here-­ and-­ now perspective.) Client:

I see Pedro across from me. We’re sitting at the table about to order.

Therapist: You’re doing a great job. Remember to keep talking in the present tense. What are you thinking? (Helps the client build self-­as-­process by noticing thoughts.) Client:

I’m thinking that I really want a drink. I’m getting nervous, and I’m afraid that I’m going to say something awkward. A drink would really help me settle down.

Therapist: And what are you feeling? (Helps the client build self-­as-­process by noticing feelings.) Client:

I’m feeling nervous. Jittery.

Therapist: Okay. Let’s imagine that I could magically transport the you that is here now into that situation there so you could talk to yourself. (Uses interpersonal, temporal, and spatial frames to help the client access a new perspective on himself in the imagined context.) So now you’re there with yourself and you can see how hard it is for you. You see how anxious this future you is and how painful it is for him. At the same time, you also know how important it is for him to connect with Pedro and give himself a chance to explore a more connected relationship this time. (Uses interpersonal frames to try to evoke the same kind of empathy that the client might feel for another person in a similar situation.) So you’re here with the future

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you. What would you want to say to this person who’s having such a hard time in this moment? Client:

(Speaks sternly.) I’d say, “Don’t do it. Don’t take a drink. Keep your promise.”

Therapist: And now be the future you again, in that situation. What’s it like when you hear that? What would you say in response? (Rather than trying to intervene on the unempathic response directly or coach a new response, the therapist helps the client track its workability by exploring its impact. The therapist is coaching the client to respond directly, as if the situation were actually happening.) Client:

(Speaks from the perspective of being on the date to his current self.) “That’s not making it better. You’re pressuring me…I feel like I’m going to freak out if I don’t have a drink.”

Therapist: Okay, so now go back to you looking at yourself in this situation again. What do you say in response? It seems like what you said actually made it harder on him… Client:

(Remains silent for a moment and then speaks directly to the self on the date.) “You’re right. I hadn’t really thought about what I was saying. But I can see how that made things harder. I see how scared you are. I know how much you like Pedro, and it makes sense that you’d want to drink to chill out. It’s really tempting.”

Therapist: Okay, switch to the you that’s on the date. How do you react to what was said now? Client:

(Speaks from the perspective of the self on the date.) “That helps. I feel more understood. Thanks for understanding. That makes it a little easier.”

Therapist: “Okay, back to you again. How do you respond to that?” Client:

“I’m glad. I don’t want this to be so hard. The thing is, we know where drinking goes. It feels better now, but makes it harder in the long run. You said you wanted to start this relationship off differently so you can really get a chance to see where it goes. Maybe you take that chance this time and see how it goes to make room for the anxiety and not drink?”

Therapist: Okay, now switch back again. Client:

“Yeah, I can see that. I think you’re right.”

Therapist: So, what does the you that is on the date do now? Client:

It would be hard, but I think I could not drink and still go on the date if I were able to talk to myself this way.

At this point, the therapist might debrief the exercise with the client and explore whether he would be likely to engage in this process and switch perspectives in this way in the future. Contrasting this method with a more typical approach, wherein clinicians work with clients by talking about the situation, the barriers, their values, and what they plan to do, illuminates the more experientially based

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approach afforded by engaging in perspective-­taking work. Clients may more fully experience the situation in their here and now through imagery. They can mindfully notice their reactions and, through perspective taking, generate new perspectives on the self. The main point of the preceding exercise is not to have the client talk to himself in a particular way, but to help him have an experience of taking a different perspective. Alternative versions of this exercise might involve having the client imagine that the therapist visits him in a difficult moment, or having him take the perspective of a caring friend while interacting with himself. (If you’re interested in additional examples of how to use perspective taking in similar ways, see Polk, Schoendorff, Webster, & Olaz, 2016, chapter 6.)

Flexible Perspective Taking and Self-­Compassion Research shows that self-­compassion is associated with many positive psychological and behavioral outcomes (MacBeth & Gumley, 2012). Indeed, at least one study shows that outcomes of ACT for patients with chronic pain are at least partially mediated by changes in self-­compassion (Vowles, Witkiewitz, Sowden, & Ashworth, 2014). From an ACT perspective, self-­compassion emerges from the ability to see ourselves as conscious, aware beings and respond using the same caregiving repertoires we might use in response to someone else (Luoma & Platt, 2015). Said simply, a self-­compassionate response involves responding to oneself in the same manner as we would respond to a good friend. Self-­compassion depends upon having a robust and flexible perspective-­taking repertoire. In order to be self-­compassionate, we need to be able to shift from fusion with our current thinking (self-­ as-­content) to awareness of the observer self (self-­as-­context). From this perspective, we can notice that we are conscious beings who are suffering. This shift may evoke behavioral repertoires related to cooperation and caretaking, in this case in relation to ourselves, rather than in relation to others. Flexible perspective taking also involves contact with a transcendent sense of self that is larger than the constricting self-­stories that self-­compassion addresses, including those related to shame and judgment. Additionally, flexible perspective taking can promote more empathic ways of relating to oneself and a sense of interconnection with others. Although flexible perspective taking is perhaps most central to the development of self-­compassion, all six of the flexibility processes are involved. Acceptance includes self-­acceptance, or embracing one’s experience as it is. Defusion involves learning to observe self-­critical thinking with less attachment to the conceptualized self. Present-­moment awareness includes noticing and responding sensitively to one’s current state, needs, and goals, rather than judging them or rigidly following internalized rules for behavior. Values work includes identifying the kind of relationship we would choose to have with ourselves. And committed action taken in relation to oneself might flow from these chosen values and could include extending kindness and care to ourselves and seeking support from others as needed.

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Core Competency Practice The rest of this chapter is devoted to exercises focused on the core competencies related to self-­ as-­context and flexible perspective taking. As in previous chapters, for each core competency we provide a brief case description and dialogue. Remember to write out your own responses and your explanations for them before comparing them to the model responses at the end of the chapter.

Core Competency Exercises Competency 27: The therapist uses metaphors and exercises to help clients

distinguish between the content of consciousness and consciousness itself so as to increase a sense of self as an arena, location, container, or context for all experience, fostering a greater ability to act with these experiences, rather than for or against them.

Exercise 27 The client is a fifty-­one-­year-­old woman seeking therapy after a divorce from her husband. She has never been in therapy and has often used avoidance strategies to deal with difficult emotions. She’d like to explore how she can pursue her new life, given that she hasn’t been alone for more than thirty years. She’s fearful of trying new things and wants the fear to go away. She’s tried multiple types of avoidance to escape the fear, including isolating at home, drinking alcohol while alone, and avoiding new situations and activities. The client makes the following statement immediately after the Chessboard metaphor has been set forth. Client:

But isn’t there any way to win this war? I would really like this fear to go away. Can’t I just push the pieces over on the board?

Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 27:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 28:  The therapist uses metaphors and exercises to reduce clients’ attachment to conceptualized selves or conceptualized others that create problematic rigidity or interfere with flexible responding.

Exercise 28 This dialogue continues with the same client as in the dialogue for competency 27 but occurs in a later session. Therapist: It seems that you were in that relationship for so long that you’ve come to see yourself as “the housewife.” Client:

It’s the way I’ve always been. I’m the one who does the dishes, cleans the house, stays at home, and takes care of other people. I just can’t do anything else.

Write here (or in a notebook) what your response would be, demonstrating competency 28:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 29:  The therapist helps clients contact an expansive and

interconnected sense of self through building a sense of being part of a larger whole that extends across time, place, and person, whether that be a group, humanity as a whole, or the continuity of consciousness itself.

Exercise 29 The client is Aliyeh, a twenty-­eight-­year-­old woman who’s having difficulty with colleagues at work. She feels intimidated and wants to quit her job but thinks she can’t due to financial pressures. She wishes her feelings wouldn’t get hurt by these interactions. She reports keeping a stiff upper lip but struggles silently at work and cries at home about difficult work interactions. She’s angry at herself for feeling this way. The following dialogue occurs near the end of the session. Therapist: How is this stiff upper lip thing working? Client:

Not very well. I’m really trying, but it’s getting harder and harder. I feel like I’m going to break down in tears all the time, but I’ve been able to fight them off so far.

Therapist: What kinds of things do you say to yourself about breaking down in tears? Client:

That I’m weak and that I shouldn’t let these petty things bother me.

Write here (or in a notebook) what your response would be, demonstrating competency 29:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 30:  The therapist helps clients flexibly take perspectives toward

themselves, others, and their own experience that build flexible and compassionate ways of responding; such perspectives include but are not limited to viewing the self from different conceptualized selves (e.g., loving self), the perspectives of others (real or imagined), perspectives of time (past, future), and perspectives of place.

Exercise 30 This dialogue continues with the same client as in the dialogue for competency 29 but occurs a few sessions later. Client:

These interactions make me feel so awful. I feel like I’m worthless to them, and I’m starting to believe that I am worthless, that something is wrong with me or it wouldn’t be this way. God, I wish I could just snap out of it. You must think I’m such a whiner.

Exercise 30.1 Write a response that uses temporal framing (guided by competency 30):     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Exercise 30.2 Write a response that uses spatial framing (guided by competency 30):     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 30.3 Write a response that uses interpersonal framing (guided by competency 30):     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Core Competency Model Responses Competency 27 Model Response 27a Therapist: Notice that you’ve been in this war and have been trying to win it. Your battle has included staying at home to eliminate the fear piece, and drinking alcohol to try to quash the fear piece. The result is that you’ve limited your life to this battle, this war to try to push the fear piece down. Meanwhile, let me just ask you this: Are you still you through all this? Can you notice the part of you that is aware of all this? As the chessboard, maybe you don’t need to win this war with these pieces in order to live a full life. Explanation: The therapist is helping the client connect to her experience and then points to the distinction between the content of the struggle and the context of this struggle—­consciousness itself. Model Response 27b Therapist: Wanting to push the pieces over—­I think that might be another piece to add to the board. What happens when you get attached to that piece and try to win the war? Client:

That’s when I drink and stay home.

Therapist: Does that help you win the war? Client:

No, I haven’t been able to win the war.

Therapist: Can you notice that the chessboard is the context where the battle unfolds? Client:

Yeah, I guess.

Therapist: Can you notice that you are the context in which your thoughts and feelings unfold? Client:

(Pauses.) Yeah, I guess I can see that.

Therapist: So what would happen if you weren’t the player trying to win the war, but instead you were the board? What would that look like? Explanation: Here the therapist helps the client see that the desire to push the pieces over is just another chess piece—­another bit of content for the board. The therapist helps the client contact the consequences of trying to win the war (which reflects fusion) and then guides her to contact the sense of herself as the place where the battle unfolds. The last question starts to shift attention toward values and what the client might do if she could be more of an observer and less attached to her conceptualized self.

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Competency 28 Model Response 28a Therapist: So it really seems as if no other sense of you exists; there’s only the housewife you. But you also told me you have a sister, and of course you’ve been a daughter. You shared that you volunteered at one point. So we could describe each of these senses of you too, and I imagine that they’d look different from the housewife you. Client:

Yes.

Therapist: But also notice that there’s a you who’s aware that you were a housewife, that you are a sister, and that you were a volunteer. And you’re here right now. Who’s aware of all of these aspects? Explanation: Again, the therapist is helping the client connect with self-­as-­context by pointing to other conceptualized selves the client has mentioned or could formulate. He’s also helping her notice that she’s aware of these selves and is more than them. From this place, the therapist can encourage the client to take actions that aren’t about continuing to cling to her conceptualized housewife self. Model Response 28b Therapist: I’m wondering if you’d be willing to do a little exercise with me? Client:

Sure.

Therapist: I’d like you to close your eyes and imagine yourself in your home as the housewife. When you have that image in your head, raise your right hand. (The client raises her hand.) Okay, now silently describe her appearance to yourself. What does she look like? … Now notice how she’s feeling. What emotions does this self—­self as housewife—­experience? … What does this housewife say about the world and the way it operates? … How does she define herself? … Now, as you have the full image of this self in your mind, with all of her thoughts and feelings and ways of being, what would it mean if you had to let her go? … What emotions show up for you as you think about letting go of her? … And if you find any resistance there, see if you can notice that she isn’t you anyway. She’s just a role you play. Now imagine you could hold her lightly, like you might hold a butterfly that’s landed on your finger, and choose to live the values you would like to bring to life. Explanation: The therapist conducts an experiential exercise to help the client disentangle from a conceptualized self. This provides a small window through which the client may be able to free herself from the housewife role and make different choices about how she’ll live.

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Competency 29 Model Response 29a Therapist: “Stiff upper lip”? That’s a familiar one. I sometimes say things like that to myself too when I’m feeling helpless or overwhelmed and I feel like I just need to get through it. Often I feel pretty alone in those situations. Is that how you feel? Client:

Yeah.

Therapist: Yeah. And do you think that you and I are the only two people who would feel overwhelmed or alone in those situations? Client:

No, I guess not.

Therapist: Me either. I bet there are a bunch of people like us, even right now, who are feeling helpless and are trying to tell themselves to keep a stiff upper lip. What would you wish for those people who, right now in this very moment as you and I are talking, are trying to keep a stiff upper lip in the face of feeling oppressed or helpless? Client:

I guess I wish that they wouldn’t feel so alone.

Therapist: Me too. Explanation: The therapist picks out the evocative statement “stiff upper lip” that the client appears to be fused with. Then he creates a sense of shared experience by disclosing that he and the client have similar experiences. Perspective taking is further extended by engaging the client in imagining all the people around the world who could be saying similar things to themselves in that moment. Next steps might include helping the client figure out how to bring this more compassionate perspective into her life when the identified situation occurs. Model Response 29b Therapist: Can you tell me about a time when you felt intimidated at work this week? Client:

Yes. I was about to go to a meeting where I was presenting the results of a survey my department had created, when this male employee who’s only been working there for six months came in and asked if I was prepared. It felt condescending. I know what I’m doing. Why is he taking it on himself to ask me that?

Therapist: Can you clearly re-­create that memory in your mind and put it right here in the middle of the room, almost as if it’s happening here all over again? Client:

Sure, but it still gives me the creeps. Why should I have to face condescending males constantly?

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Therapist: Would you be willing to walk over here with me? Leave yourself and that memory over there and come with me. (Walks with client to one side of the room. The act of physically moving is a cue for spatial perspective taking, creating a psychological sense of distance.) Now look back at yourself sitting there, remembering. What do you feel about her? Client:

(Pauses.) She’s a trooper. Always has been. But she’s trying to carry this all by herself.

Therapist: And take a second to look at that memory from way over here. Is there anything you see from here that you missed when it was happening? Client:

She’s not the only one; women are talked over and down to constantly. This guy has only been here a few months, and he’s already thinking he should be in charge. He’s not a bad guy—­it’s invisible privilege to him. Anyway, I sometimes forget that I’m not the only one who experiences these things. That’s something I didn’t notice at the time that I see better now.

Explanation: Perspective taking is built on time, place, and person. By using physical movement in space as a cue for spatial perspective taking (“Walk over here”) and asking the client to look at herself almost as another person (“What do you feel about her?”), the therapist promotes perspective taking that can link the client’s current struggles to those of others, in other places, thus promoting greater psychological flexibility. This results in the client seeing how she shares common experience with other women (“She’s not the only one; women are talked over and down to constantly”) which includes hierarchical framing. If the client hadn’t derived this herself, the therapist could have more explicitly tried to help the client build a sense of intertranscendence by connecting with other women’s experience by saying something like, “And can you see this isn’t just her experience—­that this is an experience that women have all over the world, being talked down to by the men around them? Can you compassionately connect with all those women who are engaged in that important struggle, including yourself?”

Competency 30 Model Response 30a (emphasizing temporal framing) Therapist: This is really painful. Are you willing to do an exercise with me? Client:

Sure.

Therapist: I want us to take a little journey in time. I’d like you to imagine yourself in ten years. Let’s say you’ve given some attention to living in a way that’s kinder, gentler, and more self-­ compassionate throughout those ten years, even if it was just one little thing you did each week to be a little kinder and a little more loving to yourself. I’m not asking you to imagine some perfect you in the future, just a wiser, more seasoned you that maybe has a bit more perspective on life. Can you imagine what it might be like to be behind the eyes of someone with the wisdom gained simply from living another decade of life? Can you try on that perspective and see what it feels like?

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Now try to look back on yourself from the perspective of you in the future. Think about the situation you just talked about, feeling stuck at work, overwhelmed, and picked on. How does this situation appear from ten years in the future? What do you feel toward yourself? Do you feel any compassion for yourself? Just give yourself some space to consider this situation from the perspective of ten years in the future. Explanation: The therapist uses temporal perspective taking to contact a future self that might be a bit wiser than the client is now, with a broader perspective on her life. A next step might be to help the client enact this more concretely in the form of a supportive letter to herself. Homework might involve reading this letter to herself at work and remembering this different perspective on herself. Model Response 30b (emphasizing spatial framing) Therapist: You imagine me over here looking at you and thinking, “What a whiner”? (Moves from other-­as-­content to other-­as-­process.) That must be scary. (Displays empathy to support acceptance.) Client:

Yeah, I guess.

Therapist: Could you come over here? (Invites the client to sit in the therapist’s chair as a means of facilitating spatial perspective taking.) How would you feel if you were in this chair and you could see Aliyeh, who has been hurt so much before, wincing and fearing that even her therapist, who she thought would be the one person she could be safe with, thinks she’s pathetic? Client:

I could feel for her a little bit. She doesn’t want to be afraid of her own therapist.

Explanation: The client appears to be fused with other-­as-­content when she imagines her therapist is thinking poorly of her. The therapist elicits spatial framing by having the client sit in his chair. This movement in space aims to help the client develop some psychological space or distance from which to view her struggles. In this position, the client can contact what it might be like to view herself from a different perspective. This elicits a more compassionate response that could then be built on in session. If the client had been unable to imagine this different perspective, the therapist could offer to tell her his perspective and then help her imagine what it might be like to think and feel that way toward herself. Model Response 30c (emphasizing interpersonal framing) Therapist: Those are some painful thoughts coming up for you right now. (Models other-­as-­process.) How would you feel in this chair if you were to see Aliyeh (uses the client’s name in the third person to elicit a shift to the you perspective) getting bullied by those thoughts while she’s feeling so hurt and lonely? (Directly invites I/you perspective taking.) Client:

I don’t know. That’s really hard to imagine.

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Therapist: Aliyeh is sitting right there, across from you, and you can see that she’s just getting pummeled. And maybe it’s a bit heartbreaking because you know how hard it is for her to have been left alone, and here she is getting beat up right in front of your eyes. (Elaborates on his perspective to help the client with perspective taking.) What do you imagine you would feel from over here? Client:

That feels sad to me. Maybe I would feel sad over there.

Therapist: And if you could speak from that sadness, from your heart, what would you say to Aliyeh? Client:

(Pauses.) I’d tell her she’s okay and that I’ll be her friend.

Explanation: The therapist has the client imagine what it would be like to be the therapist watching the client engaging in this self-­critical thinking while feeling so hopeless and stuck. The goal is to help the client contact a different perspective on herself, perhaps similar to how caring others might respond if she were able to share openly with them. The goal isn’t to elicit any particular kinds of thoughts, feelings, or actions, but to help the client develop the ability to flexibly shift perspective in time, space, and interpersonally.

For More Information For more about self-­as-­context, including exercises and metaphors, see Hayes et al., 2012, chapter 8; and Harris, 2009, chapter 10. You’ll also find a wide range of exercises and metaphors related to self-­as-­context in Stoddard & Afari, 2014. This chapter has been written from a clinical perspective, but there is a growing behavior analytic science of self and deictic frames. For an orientation to the basic literature, see Barnes-­Holmes, Hayes, & Dymond, 2001. For contemporary basic research in this area, see McHugh & Stewart, 2012; Rehfeldt & Barnes-­Holmes, 2009.

CHAPTER 6

Defining Valued Directions

When I dare to be powerful, to use my strength in the service of my vision, then it becomes less important whether I am afraid. —­Audre Lorde

Key targets for defining valued directions: Help clients contact and clarify the values that give their life meaning. Help clients focus on the process of living and loosen their attachment to unworkable goals or outcomes.

Working with clients to bring purpose and meaning into their lives is one of the more salient and distinguishing aspects of ACT, and in many ways, this sets it apart from interventions that primarily focus on symptom reduction. Clarifying and supporting meaningful life directions by helping clients engage in personally chosen values-­based activities, along with measuring well-­being based on effective functioning that’s guided by these same values, is fundamental to the clinical work done in ACT. In this chapter we explore how to assist clients in discovering and defining their values in and out of session; however, we also believe that it’s essential for therapists to consider their own values as professionals. Therefore, we begin this chapter by inviting you to reflect on your values as a therapist in the following exercise. It will help you clarify your values as a therapist and will also give you an experiential sense of the work clients are asked to do in defining their valued directions.

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Experiential Exercise:

Defining Valued Directions Move through this exercise slowly, giving yourself time to fully engage with each question and completing each element before you move on. Take a few moments to connect with what you hold as most important in your role as a mental health professional. What do you want to stand for or be about in your work? Assume that choosing what you value in your role as a therapist is as simple as choosing an item from a restaurant menu. If you could choose anything at all, what would you want your work to be dedicated to? List several values and write about their meaning for you:     Now consider whether your actions are largely consistent with the values you listed and note whether there are aspects of your work where you aren’t acting on your values in the way you intend. Identify the value you struggle with the most (even if you didn’t list it above), then write it here, along with the internal barriers (thoughts, feelings, and so on) that seem to be holding you back:    What did you notice as you wrote about this value and where you stand with respect to it? Did you find yourself being judgmental about yourself or your skills as a therapist? Write about what you noticed and felt:    Now consider what kind of relationship you want to have with yourself in terms of the emotions and thoughts you might encounter when taking steps toward this value. If you could be a good and wise friend to yourself during times when you turn away from this value or you’re having difficulty taking

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action on this value, what kind of qualities would you hope to exhibit toward yourself? At times when you doubt yourself, how would you hope to respond? On tough days, what would you want to offer yourself? Take a bit of time to consider the kind of relationship you want to have with yourself as a therapist and write about those qualities:   Bring a current client to mind, perhaps a client whom you find challenging or difficult or who triggers difficult feelings, thoughts, or memories for you. If you were going to live the values you’ve written about in this exercise, what actions would you take in your therapeutic relationship with that person and how would you interact with the client? Is there anything you aren’t doing that you would do, or anything you are doing that you wouldn’t? If you were going to take whole and heartfelt action on your values with this client, what are one or two things that would change?    Given your usual way of doing things, what internal barrier is most likely to stand in the way of choosing to make these changes?   Is there any way in which buying into these barriers or avoiding them has cost you and your clients in the past? See if you can reflect on this in a deep and honest way:   Now review the implications you noted and the changes you’d need to make if you were to take action in the service of your values. Suppose you had an opportunity to commit to these actions. Would you accept the opportunity and be willing to notice barriers without giving them veto power over your behavior? Write at least one concrete action you could commit to that’s in keeping with the changes you wrote about: I commit to [behavior]  

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as an expression of [value]   This exercise is similar to those that ACT clients are often asked to do. It presented you with a choice about your values in some area of your life and guided you to consider the implications of that value for your behavior, the barriers you might encounter and how to handle them, and the costs of not acting on your value. It also provided an opportunity for you to commit to a value and its behavioral implications. In a very real sense, this exercise covered all the major aspects of ACT discussed in this chapter and chapter 7, on committed action.

What Are Values? The job of the ACT therapist is to help clients be more aware, mindful, and intentional in their pursuit of their life goals and values. In ACT, values have been defined as “verbally constructed, global, desired, and chosen life directions” (Dahl, Wilson, Luciano, & Hayes, 2005, p. 61). The metaphor of a direction highlights the intentionality that is potentially embodied in every purposeful act. Valuing does not exist separately from human action; it is a continuous quality of behavior. Therefore, values are ideally stated as a combination of verbs and adverbs, reflecting that they are embraced as qualities of ongoing action across time. To relate to others lovingly is a value. To raise one’s children kindly and attentively is a value. To some degree, we engage in an act of valuing each time we do something purposeful or instrumental. We value various qualities of outcomes; we value ways of living; we value ideals; we value what kind of friend, lover, partner, parent, child, worker we are. These implicit purposeful qualities of any instrumental behavior are elevated to values by the act of choosing these qualities. In a very real sense, individual values must be freely chosen, rather than reasoned out, because values provide the metric for meaning in life. If you try to justify a value, you must appeal to some other metric, but then that metric must be justified, and so on forever. At some point, you need to just take a stand and say, “I hold this to be important.” Verbal reasons may still be present in the form of thoughts and opinions about why you choose a particular value, but your choice isn’t defended by these reasons; otherwise, you’d end up back in the justification loop. Ultimately, a vital life imbued with committed action means simply choosing what you will value and then taking steps in that direction, with reasons coming along for the ride. This doesn’t mean choices relating to values aren’t deeply considered; in fact, we recommend exploring them in depth. Scientifically speaking, it also doesn’t mean choices about values have nothing to do with a person’s history or context. Choices are historically and contextually situated, as all human actions are, but they aren’t specifically linked to and defended by verbal rules in the form of reasons and justifications. In the same way, values are (hopefully) chosen with profound intentionality but are beyond justification.

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Indeed, values are the very heart of meaning and purpose for humans. They often guide and define our lives. Furthermore, we often engage in these behaviors even when our actions don’t lead to the results we hope for. For nonverbal animals, discrete consequences are fairly adequate for explaining behavior. A pigeon pecks a key to get a food pellet; a rat presses a bar to get a drink of water. For verbally capable humans, the situation isn’t so simple. Discrete external reinforcers only go so far. Money can be a reinforcer, but given the choice between ten thousand dollars and a rich, loving relationship with their child, many people would leave the money behind. More broadly speaking, meaning is found in the textured and connected moments of our lives, whether that connection is to nature, animals, other humans, or exploration, when such moments lead to contact with a life worth living as personally defined. Therefore, ACT therapists work with clients to build more of these moments into their lives. The ACT approach to values isn’t about teaching clients any particular set of morals or “correct” values or virtues. Rather, it is about helping clients develop a process of valuing that can guide them in making life choices long after therapy has ended. In this process, clients explore meaning and purpose, search for what is intrinsically reinforcing, and use all of the flexibility processes to assist them in engaging in values-­based action while also savoring the experiences that flow from taking values-­based actions. This entails working with clients to find life directions that resonate with their deepest longings, and then assisting them in establishing goals in keeping with their values, which will ultimately be more workable than setting goals that aren’t informed by their values. As mentioned in chapter 1, when working with this process ACT therapists focus on this central question: “In a world where you could choose to have your life be about something, what would you choose?” (Wilson & Murrell, 2004, p. 135). You can explore this question with clients in a number of ways, including conversation, writing exercises, eyes-­closed imagery, and experiential exercises. Versions of this basic question are asked over and again, to turn clients’ attention to the question of purpose in their lives, help them discover what really matters to them, and clarify what a well-­lived life would look like for them.

Why Values? Values are important in the ACT model for several reasons: they offer constructive direction; they provide consistent direction; they promote behavioral flexibility and provide motivation; they support all of the flexibility processes in the ACT model; they allow for effective and pragmatic goal setting; and they provide a contextual purpose for behavior change. Providing constructive direction: Values work involves helping clients define what their lives can be about when escape, avoidance, and fusion aren’t controlling their behavior. Avoidance and escape are fundamentally about getting rid of some experience and keeping it away. They aren’t about moving toward anything in particular. Values-­oriented behavior is constructive; it’s about moving in a particular direction or fostering a particular quality in life. One client elucidated constructive direction in this way: “It’s as if I’ve spent my life on the open ocean swimming away from this one island that I don’t want to be on. Ultimately, it doesn’t lead anywhere… What I want to do is start swimming toward something, not away from that island.”

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Providing consistent direction: Defining a valued direction creates a consistent compass heading that can be used to direct action during the storms of life. Amidst waves of emotion and crosscurrents of thought, we can still chart a course in keeping with our values. Anyone who has engaged in mindfulness meditation for any period of time is aware of the changing nature of emotions and thoughts. However, values tend not to change frequently. Once clients clarify, state, and commit to their values, those values become a lighthouse that can help them steer clear of the rocks during psychological storms. Promoting behavioral flexibility and motivation: Values are inherently linked to choice. From a functional contextual point of view, free choice in the realm of valuing is “true” because it’s useful to speak in that manner, not because it’s literally true. Scientifically, we would guess that values are largely culturally conditioned. However, from the perspective of the individual human, it can be more empowering and life affirming to see our behavior as a choice because it loosens the largely artificial link between actions and verbal storytelling. This loosening leads to greater behavioral flexibility and to the possibility of contacting desired and chosen life directions that have an intensely vitalizing, motivational quality. Research supports the idea that values based on experiential avoidance, social compliance, or cognitive fusion typically don’t lead to positive outcomes (Sheldon & Elliot, 1999); examples would be “I need to stay with my husband because I’d feel guilty if I left” (probably experiential avoidance), “I want to be a doctor because it’s what my mother wants” (probably social compliance), and “Good people are kind to others” (probably fusion with a verbal rule). Choosing life directions based on the intrinsic properties of actions tends to work better. Supporting other flexibility processes: Practicing acceptance and defusion often means wading into swamps of anxiety, loss, confusion, or sadness. Values provide the context for inviting clients to contact these difficult experiences. They aren’t being asked to experience pain for pain’s sake, but to experience pain in the service of values. From an ACT perspective, values are what make willingness and acceptance more than simply wallowing in difficulties or attempting to reduce unpleasant experiences through exposure. Similarly, having clarity about their chosen values provides clients with a guide for workable action when they aren’t responding literally to their thoughts. Allowing for effective and pragmatic goal setting: Values work helps clients establish goals that are flexible and pragmatic and increases the likelihood that they will engage in effective action across time. Many therapies work to help clients develop goals. ACT, however, explores values first and then links behaviors to these values, connecting action to a meaningful purpose. Values provide the direction, and valuing is walking in that direction. Values-­based behavior is present from the first steps a person takes in that direction. Thus, if working toward a particular goal does not effectively further values, it may be time to reconsider the goal. ACT’s focus on values helps clients engage in the process of vital living, whereas a focus on goals tends to encourage evaluation of the discrepancies between the current situation and the goal, or between actual and desired outcomes. Providing contextual purpose: Values work is central to ACT for important philosophical reasons. In this contextual approach, what is true is what is workable relative to stated values. Workability becomes the truth criterion, and living in alignment with values is the measure of success. Without values, we can’t define what works. This criterion of workability also informs the other flexibility processes. For example, in defusion, functional truth replaces literal truth. In the same way that literal truth is linked to conventional meaning within a language community, functional truth is linked to values.

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What Should Trigger Working with This Process? Values and values-­based behavior are typically worked on throughout therapy; however, there are a few situations in which an additional focus on defining valued directions is warranted. Both values and committed action have a constructive aspect to them that is not as present in the other four flexibility processes (defusion, acceptance, self-­as-­context, and present-­moment awareness), which are more oriented toward ameliorating or responding to rigid, inflexible, or problematic behaviors. Values are also central to motivation, both in the sense that they may provide an inexhaustible source of positive reinforcement and in the sense that contact with discrepancies between values and one’s current pattern of living can elicit painful feelings that people are typically motivated to escape or avoid. A primary indicator that values clarification is needed is when clients are out of contact with the cost of avoidance in their life or when they are numb, distant, overly intellectual, or uninvolved. Other indicators include clients expressing a sense of purposelessness, or when they note that they can’t care about others, themselves, or their lives because of past pain or pain that arises when they allow these aspects of their lives to matter (e.g., “It hurts when I care”). Discussing clients’ hopes, dreams, and desires for their life can bring them psychologically into contact with the discrepancy between their current path and the directions in which they’d like to travel. This tends to evoke internal reactions or barriers that, when brought into the room, can be worked on using the other flexibility processes. Another key sign indicating that a focus on values is warranted occurs when willingness is low, when behavior is largely motivated by avoidance, or both. For example, a trauma survivor who is white-­ knuckling her way through exposure-­type exercises as a way to get rid of something might benefit from a focus on values. Bringing values into the room at such times can create a larger context that facilitates willingness to do the hard work of developing flexibility in responding to difficult experiences. A focus on values can help clients get to a place where they would actually choose to undertake this challenging work because doing so allows them to move forward in bringing their values to life. This is the difference between a client begrudgingly contacting a difficult trauma memory as part of therapy versus one who is truly leaning into this work in the service of something larger. Yet another indicator of the need for values work is when clients are overly focused on immediate goals at the expense of larger patterns of values-­based behavior that could inform their goals. A variety of difficulties with motivation, consistency, decision making, and avoidance can occur when goals are disconnected from a larger sense of purpose. Values can provide the glue that binds smaller moments into a larger and enduring sense of life purpose. A final pattern that suggests a need for values-­oriented work is when stated values seem to be linked to compliance, avoidance, or fusion. This may take the form of a strong focus on “shoulds,” “have-­tos,” or rigid high standards, or an excessive focus on what others want. In these cases, fusion and avoidance are interfering with making authentic choices because standards and rules are standing in for values. This allows people to avoid the pain and sense of responsibility associated with focusing on and identifying what would matter to them if they were free to choose what would be important in their life. In these cases, values conversations often focus on creating small moments of choice and freedom that can serve as kernels from which to build an awareness of larger and more enduring patterns of chosen action. Finally, be aware that clients who aren’t experiencing acute pain often don’t feel the push to change that can come from a drive to escape an aversive state. In these cases, motivation to change can instead come from the pull that values exert on behavior.

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What Is the Method? Defining valued directions almost always begins with conversations that have an overarching goal of helping clients imagine what sort of life would give them a sense of integrity, depth, and vitality. The idea of values is usually introduced early in therapy, either in a more limited fashion (as discussed in chapter 2) or in a more extended way, depending on the case conceptualization. From an ACT perspective, values are the “why” of therapy and are at the core of the therapeutic alliance. They provide the reason for doing all the other hard work of therapy. However, clients are often so focused on their problems that turning their attention to the larger context of their dreams, hopes, and aspirations for their lives is unexpected. A bit of an introduction to values work can be helpful for orienting them to this aspect of therapy, perhaps using a statement along these lines. Therapist: You’ve told me a bit about your problems, and I feel like I have a good initial sense of them. Your problems are important, and we’ll certainly respond to them in here, but your life is more than your problems. I’d like us to spend some time focusing on the larger context of your life, which includes your dreams, hopes, and aspirations. These are a large part of what makes life worth living, and they’re also the context in which you experience your problems. What I’m suggesting we talk about is what you really want in life. What do you want your life to be about? What do you want to do? Would it be okay if we spent some time focusing on that? The breadth, depth, and focus of initial values work can vary greatly depending on the needs of the client and the clinical situation. Sometimes the focus can be as narrow as helping clients specify what they value in a given life situation, as might happen in a brief clinical encounter. At the other end of the spectrum, it can be as broad as helping clients specify valued directions across all major life domains, as might happen in more extended therapy.

Common Values Assessments and Tools An extended values assessment process (e.g., Hayes et al., 2012, chapters 11 and 12) can take multiple sessions and include between-­session work in which clients write out descriptions of valued directions and goals in multiple life domains (e.g., family, intimate relationships, parenting, friends and social life, work, education, recreation, spirituality, community, and self-­care). In addition to engaging in discussions focused on clarifying their values, clients develop and write specific, succinct statements of their values in each domain and then assign ratings of how important each domain is and how consistent their actions are in regard to each value. Finally, they develop values-­based goals in each domain and initiate actions to work toward those goals (as described in chapter 7). Brief values assessments are also available, ranging from a few minutes to a session in duration. (Some of these assessments are available at http://www.contextualscience.org/values_measures.) We haven’t attempted to review the full body of available techniques or methods for doing this work, but instead focus on some of the most central skills for helping clients define their values and also address common roadblocks. Here, we’ll just list some of the more important exercises, metaphors, stories, worksheets, and procedures available in other resources. However, there are many books and chapters that include effective approaches to values work, so we encourage you to explore further.

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Valuing as a choice. This is a structured conversation that helps clients distinguish choices from reasoned judgments (Hayes et al., 2012, pp. 300–­302, 347). Distinguishing process from outcome, and direction from goals. Several interventions can help clients see values as a process of living, not outcomes to be achieved: the Skiing metaphor and the Path Up the Mountain metaphor (Hayes et al., 2012, pp. 331–­333). Also see Harris, 2009, pp. 191–­ 193, for an extended discussion of this topic. Sweet Spot exercise. In this exercise, clients imagine a sweet moment in their life and consider how it illuminates their values (Wilson, 2008, pp. 200–­209). Values compass assessments. These tools involve worksheets and procedures for clarifying values and looking at how clients’ behaviors align with their values; they may take up to an entire session to complete (Eifert & Forsyth, 2005, pp. 186–­187; Dahl, Plumb, Stewart, & Lundgren, 2009, chapter 9). Bull’s-­Eye Worksheet. This is a brief values assessment covering four key life domains: work and education, leisure, personal growth and health, and relationships (Dahl et al., 2009, pp. 120–­131). Comprehensive values assessments. Several sources provide worksheets and guidelines for conducting a comprehensive conversation about values that may stretch across multiple sessions and multiple life domains (Wilson, 2008, pp. 169–­171; Hayes et al., 2012, pp. 308–­317). “What do you want your life to stand for” exercises. There are quite a few variations on this theme, wherein people imagine their funeral, epitaph, or tombstone, or a birthday late in life, and visualize or identify how their life, well lived, would be described (e.g., Hayes et al., 2012, pp. 304–­ 307; Harris, 2009, pp. 202–­203; Eifert & Forsyth, 2005, pp. 154–­155). Although more or less extensive, all of these approaches include certain steps that are important in helping clients define valued directions: guiding clients to contact their values and state them explicitly; coaching clients to take a stand for their values; helping clients examine their current life directions in relation to their values; and teaching clients some key discriminations in regard to values. Along the way, it’s often helpful for therapists to state their own therapy-­related values. In the sections that follow, we discuss all of these aspects in detail. But before we turn to these specific methods, we need to first outline the qualities of effective values conversations.

Qualities of Effective Values Conversations Effective values conversations have discrete qualities: vitality, choice, orientation to the present moment, and willing vulnerability. All of the methods described in this chapter should be guided by these qualities. They will help you focus on valuing as an ongoing experiential process while also decreasing clients’ tendencies to become inflexible and rule bound when working with values assessments, worksheets, procedures, and exercises. Use these qualities as a compass to provide more intuitive guidance on effective values work, rather than getting stuck at a procedural level. If a procedure, process, or exercise lacks these qualities, it’s important to reformulate, refocus, or otherwise change direction. In the sections that follow, we describe these qualities in detail and also address common barriers to developing these qualities and how to work with these barriers.

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VITALITY Making psychological contact with what we most value in life tends to evoke a certain qualitative reaction often described as vital, alive, or meaningful. Clients (and often therapists, empathically) can sense the value in the room, even if they haven’t yet taken any action in that direction. Just as a dog begins to lick its chops when somebody gets out its food bowl, people begin to psychologically taste the outcome of valuing when it’s present. They light up or wake up. An essential job of ACT therapists is to monitor the vitality of conversations about values, drawing out clients’ hopes and dreams and helping them detect the life directions they would freely choose, not those they’d select in order to avoid guilt, anxiety, shame, or the negative opinions of others. When working on values, therapists may sometimes have the experience that the conversation is becoming small, lifeless, grinding, intellectual, or constricted. When this happens, both client and therapist are probably stuck in a pattern of experiential avoidance and fusion. The session has become about the concept of values, rather than being an active process of contacting and choosing values in the moment. Discussions, analysis, and interpretations of values are often dry and boring; experientially contacting actual valuing in the moment is not. Therefore, ACT therapists seek to bring values into the present moment, and that requires clinical creativity. We’ll offer a few examples here, but note that prescriptive methods are unlikely to be successful. Recalling past experiences that relate to the client’s values can help set the emotional tone for therapy and bring some of the functions of valuing forward into the present moment. For example, therapists can help clients locate past experiences in which they felt intense vitality, presence, or purpose. Eyes-­closed exercises in which clients re-­create such an event via imagination and then consider its meaning may provide guidance about how to live life now. Be sure to have clients recall events that are both important and specific. Here are a few examples of how you can target such events: “Tell me about the day you met your wife,” “Tell me about the day you left home,” “Tell me about the most moving event in your life,” or “What did that feel like inside? Help me see it the way you saw it and feel it the way you felt it. I want to understand.” This can set the stage for a more meaningful exploration of values. There are a number of different approaches that can bring this kind of liveliness into therapy sessions. For example, therapist and client might listen to meaningful music together at the start of a session as a way to promote contact with values. Poetry, moments of silence, or mindfulness exercises can serve the same purpose. Alternatively, you could ask clients whom they admire or find noble, or ask, “Who inspires you?” If clients are unable to identify anyone, inquire about characters in movies or other fictional characters. Once they’ve identified someone, ask them to specify what they find admirable about this individual. Finally, you can ask, “If this person knew you really well, what would he or she want for you in your life?” The following dialogue illustrates this process. The client is a high school student who’s prone to procrastination. She’s been struggling in school and is at risk for dropping out. At the time of this session, she’s been having trouble starting work on a term paper. Therapist: If you think of all the people you’ve known and looked up to, does anyone particularly stand out? Client:

My third-­grade teacher, Ms. Schweibert.

Therapist: And what was Ms. Schweibert about? What did you admire about her?

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She was always upbeat, always having fun. We always knew she cared about us kids.

Therapist: So what would Ms. Schweibert want for you now? Client:

She’d want me to learn something, and to graduate at the head of the class.

Therapist: Yeah, head of the class. She’d want that for you. I have a sense that is something you deeply respect about her—­her attitude toward people and learning. (Pauses.) Is there anything else she’d want for you, in addition to being head of the class? Client:

She’d want me to be happy. She’d want me to do this because I enjoy it, because I want to, not because I have to or because she told me to.

Therapist: Is there a way you could make writing your paper live up to that—­for yourself, I mean? Client:

Yeah, something a little bigger than writing a paper. Not so much what I have to do, but why I would want to do it.

Therapist: Yeah. What are you here for—­here and now in this life? If you could have a say in it, what would you want your tombstone to say? … And now consider how what you’re doing now lines up with that. I have a sense that what you’ve been working for is others’ regard for you, but it sounds like what they want for you is for you to be yourself. I want you to look for something that’s yours. It will probably be bigger than you, but it comes from you. And “I don’t know” is not an answer. As a kind of homework, would you be willing to write about this on your own this week and bring it in next time? Client:

Yeah.

Therapist: What you might want to write about is something that would make you think, “I’d be inspired by a person who could do this.” (Writes this on a piece of paper to remind the client what to write about.) What could you do that would be inspiring to you? In this dialogue, the therapist is helping the client link schoolwork to the larger context of her life: her values and life direction. There’s a reason the client respects Ms. Schweibert. By guiding the client to contact qualities of this teacher whom she admires, the therapist helps the client come into closer contact with the qualities she wants in her life. Hopefully, this exercise will allow her to see how something small can be related to a much more important and life-­transforming issue. Newer ACT therapists sometimes get stuck because they think values work largely involves talking about values and coming up with the right words or phrases to represent them. It’s important to remember that values aren’t things or even statements, but a way of speaking about an ongoing flow of behavior that’s active and purposeful. The work here is about seeing the bigger picture of what values bring to people’s lives in terms of meaning, giving their actions a sense of purpose by linking them to larger patterns that involve intrinsic reinforcement. So although attending to the content of what clients say about their values is part of what’s important, it’s also essential to attend to clients’ tone of voice, their body language, and the pace of their speech as you explore what’s important to them. Signs of vitality include a widening of the eyes, physically leaning in, a sense of excitement or curiosity, a softer tone of voice, slowing down, pausing instead of falling into well-­trodden and overlearned patterns of responding, or broken speech or an exploratory or searching vocal quality when clients are trying to articulate

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new possibilities or meanings. These are some of the indicators of the kind of vitality you want to foster, and they’re at least as important as the content of what is said. In addition, if the therapist displays these qualities, this can help elicit vitality in the client due to the human tendency to mirror the emotion-­related behaviors of others.

CHOICE By “choice” we mean the experience of values being selected freely and not under the sway of avoidance, rigid rules, or social manipulation. ACT works to disrupt fusion with “shoulds” and “musts” and to create a sense of expansive possibilities. Clients often feel coerced by others or by their own history, feelings, and thoughts, and even by their values. In ACT, it’s important for therapists to be alert to this sense of coercion and the alternative: choice. For example, it’s common for clients to say they have to value certain things. This is almost always a verbal trap. Values are not a stick with which to beat anyone into submission.; they are chosen qualities of action. Among the many common barriers to such free choice is fusion with the idea that we need to coerce ourselves in some manner, that unless we control or contain our feelings, thoughts, or other private experiences, what we will choose to value will be harmful, dangerous, toxic to others, or even evil. This story implies that if we allow ourselves to choose freely, we may be inclined to choose selfishly or poorly. If you can disrupt fusion with this story and help clients connect with the possibility of being able to choose their own path, they often have a sense of innocence refound despite the harshness with which they may have learned to treat themselves in order to cope. They may come into contact with parts of themselves (i.e., their values) that feel untouched, unjaded, and pure. Sometimes tears of gratitude emerge. Sometimes clients feel embarrassment over being observed by the therapist while feeling something so innocent or earnest as to seem naive. If such experiences arise during values work, help clients recognize and embrace them as part of the process of reclaiming buried values or discovering new ones. Sometimes clients provide vague or noncommittal answers to questions about values because they don’t have a history that taught them how to effectively identify or describe their needs and wants or their desires for their lives. For clients with this problem, you may need to build their ability to make choices by focusing on micro-level, moment-­to-­moment, situation-­to-­situation needs and desires, rather than on broader values. Accordingly, the place to start such work is in the moment, in session. You can ask, “In this session, right now, if anything could happen here, what would you want? Aim high.” Often clients state some kind of goal, such as “I’d want to feel better” or “I’d want to understand this problem better.” In order to get to the underlying value, you need to look for ways of living that are blocked because a client believes a particular goal must be attained first. Possible responses to such client statements include “And if that were to happen, what would you do?” or “If that were to happen, what do you imagine life would be like?” You can also ask questions that bring perspective taking into the session. For example, in the previous dialogue, the therapist might say, “If Ms. Schweibert were here watching you work so hard to understand this problem, how would she want you to treat yourself? How would she be toward you as you struggled to understand it?” Questions like these can guide clients to describe the kind of life they want to live, rather than stating more common responses about what they’d like to feel, be right about, or know. Most values have a social component, so the therapeutic relationship can provide one of the more immediate areas for exploring values. Strategies to help clients make values-­based choices can be

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intensified by focusing on them in session, with the therapist modeling, instigating, and reinforcing flexibility processes in ways that are immediate, vital, and vulnerable. For example, in the preceding dialogue, the therapist could have said, “If our therapeutic relationship, right now, had the qualities you most want, what would they be?” As mentioned, sometimes clients feel coerced by their chosen values, particularly when values-­ based choices lead to pain. Consider a client with a history of abuse who knows the uncle who abused her will be at her sister’s wedding. The client might take the stance of “I have to be willing to suffer through it,” reflecting a belief that living her values means she has to endure or fight her way through suffering. This takes the heart out of values work, which is more about choice and meaning than “have-­ tos” and “shoulds.” The goal in a situation like this is not begrudging tolerance of difficult emotions, but instead a full embracing of one’s experience as part of living a valued life. In this case, a therapeutic goal might be to help the client bring a sense of choice into the situation. Therapist: Well, you don’t have to go to the wedding. You could choose not to go. It’s a matter of what you hold as important. Let’s say I could offer you a choice. On the one hand, you could send a perfect robot replica of yourself to the wedding so no one would ever know you weren’t there. Your sister would be happy and so would your relatives. You wouldn’t have to face your uncle. Of course, you’d miss out on this important event in your sister’s life. On the other hand, if you go to the wedding, you get to be right there next to your sister when she says, “I do.” However, if you make this choice, in order to fully be there for the wedding, you’ll also have all of the discomfort and anxiety of facing your uncle. Consider this for a moment before answering: if this were the choice, which would you choose? The manner in which therapists deliver these types of comments is important. This kind of work can’t be done from a one-­up position, or it may seem to communicate judgment and a sense of “rightness,” implying that the latter choice is best. Linking this work to freely chosen values is always paramount. Even carefully worded presentations of choices like in the preceding example can be misread or misinterpreted. Ultimately, what’s right depends on workability with respect to a particular client’s values in a particular situation. The client in this example may choose the robot option. The workability of this option is not for the therapist to determine; it’s something for the client to notice and learn from.

PRESENT ORIENTED Although conversations about values often have a future orientation, they are also about the present. Something that is values-­based is valued in the present moment. Values work brings the future into the present moment in the service of building larger and larger patterns of action linked to valued directions. This present-­moment focus can provide a powerful prophylactic to avoidance. Normally, immediate consequences are much more important in controlling behavior than delayed consequences are. Part of what makes experiential avoidance powerful is that its impact is often immediate. For a person with social anxiety, retreating from a difficult social situation is immediately reinforcing because it results in a reduction of anxiety. The consequences, such as loneliness and lack of intimacy, are only felt later, often as a result of a pattern of social avoidance over time. Values work pulls extended appetitive consequences forward in time. For example, for the client in the preceding vignette, choosing to go to the wedding in order to be with her sister is a value not simply when the wedding occurs, but also in the moment in session. Values work can help this client notice that even the work of actively

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choosing what she would value in her relationship with her sister and attending her wedding is valuing that relationship. Valuing doesn’t just happen at the ceremony; it’s happening in the moment in the therapy room.

WILLING VULNERABILITY One of the best indicators of an effective values conversation is when their bittersweet qualities show up in the room. When clients open up to their values, one of the more common emotional reactions is crying. These tears aren’t about resisted and unwelcome pain, but about caring and vulnerability. They generally occur due to past pain but honor present values. People tend to be hurt in relation to things they care about; therefore, when people turn away from valuing in order to avoid pain, greater pain is often created—­the pain that comes from not living a vital, values-­based life. When therapy helps clients adjust their course and return to moving in a valued direction, the emotional vulnerability of that transition is often present. However, any pain associated with this shift will be pain carried for a purpose. Inside this pain we humans find our values, and inside our values we find our pain—­and also our joy. A classic example is a person who’s been hurt in a romantic relationship. When that person chooses to love again, vulnerability will be a part of that choice. Risking love means risking loss. In session, if you sense willing vulnerability on a client’s part, that’s a beacon to be followed, as it generally indicates contact with values and the things that the client holds dear.

Guiding Clients to Contact Their Values and State Them Explicitly Effective values conversations take values out of the abstract and make them clear and explicit. It’s often worthwhile to encourage clients to distill their values in various domains down to what is most essential to them in those domains. Such statements are often recorded on a form or handout that clients can keep with them. However, these statements are not values per se; rather, they are an explicit guide to the qualities clients intend to bring to the moments that make up their life. It’s important to keep in mind the four qualities of effective values conversations when helping clients articulate these desired qualities of action. Sometimes moving too quickly to come up with a word or phrase can kill the vitality in the process of discovering and explicating values. With some clients, it may be more effective to ask them to identify pictures, images, or objects that represent their values, at least initially.

Coaching Clients to Take a Stand for Their Values Often, publicly stating a value is the first step down a new values-­based path. In ACT, therapists create structured opportunities for clients to make an explicit commitment to bringing their values more fully into their lives. To that end, you might encourage clients to make commitments to you, or to other people in their lives, about what they intend to do in regard to their values. Chapter 7, on committed action, offers more specifics on helping clients develop concrete actions and goals that will allow them to move in valued directions.

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Helping Clients Examine Current Life Directions in Relation to Their Values Living without attention to closely held values typically generates a great deal of suffering. In therapy, this is abundantly evident, as the current behavior of many clients is inconsistent with what they value. Therefore, an essential part of values work is to help clients determine how closely their current behavior aligns with their values. Because this requires looking at the ways in which they aren’t living in alignment with their values, it can potentially create a sense of shame, which is usually counterproductive. So it’s important that clients not fuse with thoughts such as I’m bad in the process of looking at the pain that comes from not living life as they truly intend. When leading clients to notice this discrepancy, take the stance that whatever they’ve been doing is understandable given their history, while also helping them courageously examine whether their current behavior aligns with their valued directions. The focus is on guiding clients to contact the pain of not living as they intend, while also helping them move in new directions rather than engaging in further avoidance. The following example illustrates this approach. The client is Elisha, a lonely, defensive woman with an overly intellectual orientation. Her homework from the previous session had been to write two epitaphs for herself: one summarizing what her life would have stood for if she were to die at this point, and one that would reflect her life after twenty years if it could say anything she wanted. Therapist: So, how did the writing go? What did you come up with? Client:

I didn’t like doing the one about what it would say if I died today. But I did come up with something. What I wrote was “She spent a lot of time trying to figure out what would make her happy.” And what I wanted on the tombstone if it could say anything is “She was happy.”

Therapist: Do you mind if we focus on the first one for a minute? Client:

Okay.

Therapist: So you would say the best summary of what your life has been about so far is that you spent a lot of time trying to figure out what would make you happy. And how has it turned out? Client:

Not well. I haven’t figured it out.

Therapist: And so maybe the tombstone would say something like “Here lies Elisha. She spent her whole life trying to be happy and never made it.” How do you feel about that tombstone? Client:

I don’t like it. It sucks. I don’t want to be a failure.

Therapist: I invite you to sit for a minute with this… Are you willing to do that? (Creates a sense of choice by asking permission.) Client:

Okay.

Therapist: Just close your eyes and notice for a moment what it’s like to have that be on your tombstone. (Speaks slowly and deliberately.) “Here lies Elisha, she spent her whole life trying to be happy and never made it.” Notice what feelings come up… What your body feels like…

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What you feel in your stomach…your arms…your shoulders… What thoughts come up? … Notice if there are any memories associated with this. (Pauses.) Okay, you can open your eyes. Client:

It sucks. I feel terrible. I don’t want to think about it.

Therapist: Go into it a little further. Client:

It seems so impossible. And I can’t imagine what it would be for anyway. The world’s all going to end someday. Ultimately, it won’t matter anyway. (Appears to be fused with a story that serves to keep her from contacting the gap between her values and her current life.)

Therapist: You’re building a wall of words. What do you want? Your pain is your biggest ally here. Go into it. What are you defending yourself against? Look there… What do you really, really want? (The therapist doesn’t address the fusion directly, but sidesteps it to keep the focus on values.) Client:

(Cries.) People. I want people in my life.

Teaching Relevant Discriminations It can be helpful to teach clients three key discriminations in regard to values. The first is the distinction between values as directions versus goals, alluded to earlier. The second is the distinction between process versus outcome (Hayes et al., 2012, pp. 331–­333). The third is the distinction between values as qualities of actions versus feelings (Ibid., pp. 298–­300).

DISTINGUISHING BETWEEN VALUES AND GOALS When you ask clients what they want in life, you’re likely to get responses that contain a mixture of goals and values. The goals are often process goals, meaning they are things clients believe they must acquire or achieve in order to have the wished-­for values. In many cases, these goals are some variation on the theme of feeling better (e.g., experiencing less anxiety, pain, or loneliness or having higher self-­esteem). ACT helps clients distinguish between values, which can be seen as ongoing patterns of behavior that take a consistent direction, and goals, which are concrete achievements or events that can be accomplished and finished. When clients present a goal as a value, the therapist’s job is to dig around and abstract the value that underlies or informs the goal. The following exercise will give you some practice in distinguishing between values and goals in a client’s statements.

Exercise:

Values and Goals In the following dialogue, circle elements of the client’s speech that reflect values, and underline those that are goals. Do this before you read on to see our interpretations.

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Therapist: So, tell me, if this anxiety were to just magically go away and your life was how you want it to be, what would your life be like then? Client:

Hmm. I’d be happier. I’d have at least two or three friends with whom I really share things. I’d go out and do things I like, such as going to the movies or riding my bike. I might be in a community theater, or at least go to plays. I’d stay more in touch with art. It helps me appreciate beauty. I’d have a good relationship with my boyfriend. There’d be a lot less fighting and crying. I’d probably have a better relationship with my mom; I’d try to be there more for her. And I’d be making more money.

Now we’ll walk through the client’s response, sentence by sentence, trying to tease apart her goals and values. Client:

I’d be happier.

You might think being happier is a value, and if you define it as eudaemonia, or the happiness that comes from living in a way that’s consistent with one’s values, it is the very essence of values. But if you define happiness as an emotional reaction, happiness is a goal, not a value. Looked at that way, happiness is an event that comes and goes as a result of action, not a chosen quality of action. Emotionally, it isn’t possible to simply choose happiness. Client:

I’d have at least two or three friends with whom I really share things.

“Having two or three friends” is a goal because it can be completed, but this sentence includes the explicit value of sharing in relationships. Client:

I’d go out and do things I like, such as going to the movies or riding my bike.

This is primarily a values statement. The statement “things I like” could use some clarification. If it refers primarily to an emotional result, it isn’t a value. But people often use this kind of wording to refer to things that engage them in the joy of living, in which case it is a value, albeit one that could bear further clarification. Client:

I might be in a community theater, or at least go to plays. I’d stay more in touch with art. It helps me appreciate beauty.

Appreciating beauty by participating in art is a value. Being in a community theater or going to plays is a goal. Client:

I’d have a good relationship with my boyfriend.

“Good relationship” is not yet a value because it doesn’t specify the qualities of relationship the client holds as important. The therapist can help the client clarify this. Client:

There’d be a lot less fighting and crying.

This is a goal. Client:

I’d probably have a better relationship with my mom. I’d try to be there more for her.

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Again, “better relationship” is not yet a value because it doesn’t specify the qualities of relationship that are important to the client. However, “be there more for her” is a value, if a bit vague. Again, the therapist can help the client clarify this value. Client:

And I’d be making more money.

This is a goal, not a value. Of course, when clients report a goal, one or more values often underlie that goal. It’s important for the therapist to abstract the important valued directions that underlie the goal and help the client make them explicit. The remainder of the exercise will help you practice this. We’ll present some of the goal statements from the preceding example and ask you to generate questions that might help the client get to the values that underlie these goals. For each, write two questions you could ask before looking at the model questions that follow. Client goal: “I’d have a good relationship with my boyfriend.” Question 1:   Question 2:   Models for comparison Question 1: What would a good relationship with your boyfriend look like? Describe it for me, drawing a detailed picture. Question 2: If you could be the kind of person you most want to be with your boyfriend, what would that person be like? Client goal: “There’d be a lot less fighting and crying.” Question 1:   Question 2:  

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Models for comparison Question 1: What is “less fighting and crying” about? Why is that important? Question 2: If I could wave a magic wand and fighting and crying were no longer an issue in your relationship, what would that make possible? What do you hope would happen? Client goal: “I’d be making more money.” Question 1:   Question 2:   Models for comparison Question 1: Imagine you had more money. What would you be doing with it? Question 2: Let’s say you won the lottery and had all the money you needed. What would you do then?

DISTINGUISHING BETWEEN PROCESS AND OUTCOME The main purpose of teaching clients to distinguish between values and goals is to help them become more focused on the process of living and less attached to the outcomes of their actions. Many people become attached to the idea of achieving goals as the way to lead a fulfilling life. In ACT, goals can be used pragmatically to provide an indicator of effective action, but only if clients hold their goals lightly, as a guide for values-­based action, not as an end in themselves. The problem with having too strong of an attachment to goals is that this tends to draw attention away from the present moment. We humans generally aren’t satisfied with achieving a single goal; rather, as soon as a goal is achieved, another goal must be established, so we are once again short of the goal. Values, on the other hand, draw our focus to the process of living and valuing in whatever situation life has handed to us. The opportunity for valuing is always here and now, in our behavior. There is nowhere we need to go before we can value, and nothing we need to wait for to begin valuing. From the ACT perspective, what’s important is a meaningful process of living. Connection to what matters to us is possible in every moment and every situation. We can control our choices and what we do with our hands and feet, but we can’t always control how life turns out. For example, a daughter may value being loving in her relationship with her mother, but her mother may refuse all contact. That doesn’t mean the value isn’t present for the daughter and

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that she can’t manifest it, whether through a thought, a card, a conversation with a sibling, or other means. Consider water held back by a dam. The force of the water on the dam is like the value. Unable to move, the water can’t express this latent energy. But given an opening, the force of the water (i.e., the value) will be fully revealed. Simply because behavior is constrained by a situation doesn’t mean the value cannot still be held.

VALUING AS AN ACTION AS OPPOSED TO A FEELING The third key distinction is between values as qualities of actions versus feelings. Clients often think values are how they feel about a given situation—in other words, their desires or sense of motivation. Let’s consider the example of exercise. Sometimes you may feel like exercising, so in normal parlance, you’re motivated to exercise; other times you may not feel like exercising. If you tie the action of exercising to feelings of motivation or desire, this is likely to lead to inconsistency in action or, if you rarely feel motivated, perhaps complete inaction. However, if engaging in health-­promoting behaviors is consistent with one of your chosen values, you might exercise even when you don’t feel motivated to do so. Feelings, thoughts, and preferences come and go. Obstacles to living life in line with what’s most important to us invariably arise. Nevertheless, in many areas of life it’s important to be able to do what matters to us even when we don’t feel like doing it. The intent isn’t to ignore our feelings and follow rigid rules about what we should do, but to build flexible and workable patterns of action that take into account the larger picture, in addition to the shorter-­term contingencies that are typically reflected in preferences and desires. If we think of values as chosen life directions, they can be seen as compass headings that we follow. The value (i.e., the direction) is there, even if we don’t feel like heading in that direction, and it keeps us oriented as we move forward. Although our feelings and thoughts in the moment often have a bearing on what we do and can lead to twists and turns in the path, ultimately our values are revealed through the overall direction we take. The value isn’t revealed by how we feel about the direction, but by our pattern of living.

Directly Stating Your Therapy-­Relevant Values ACT therapists implicitly value their clients’ valuing. They value redirecting clients’ energy away from futile and ultimately costly goals (e.g., reducing unwanted feelings and thoughts) and toward living a life defined by what they most want to be about. By making this therapeutic value explicit and committing to it with clients, you can both model and instigate valuing and commitment, just as you’re asking clients

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to do. In the process, it’s important to cast commitment as an opportunity that clients can take advantage of, rather than something they must do. In early sessions, before clients’ values are clear, this commitment can take the form of a somewhat generic statement: “I want this therapy to be connected to what you most want your life to be about. I want you to know that I’m committed to working with you during our sessions to help you discover what you most want in life, and that I’ll dedicate our work to that.” Therapists can also make more specific commitments depending upon what they know about a given client’s values and life situation. It can be especially effective to make such a commitment after the client has taken a public stand for a value. Consider the following dialogue from a session in which the client has just engaged in an imaginal exercise that involved attending his own funeral. Therapist: So you don’t think your daughter would say those kinds of things about you now? Client:

Nope.

Therapist: Because of the past? You haven’t always been there for her. You’ve spent time in prison, you abandoned her and her mom, and drugs got in the way. What did you notice when she said those nice things about you in this exercise? Client:

That’s exactly what I’d want her to say about me. It felt good, but it also felt fake because that’s not how it really is.

Therapist: Yeah, it was how you want it to be. Client:

Right, but she won’t let me be close to her.

Therapist: She sometimes makes it hard for you to love her. You call, and the first thing she does is ask for money. She doesn’t trust you. It’s tough to be loving when she’s like that. By the way, you know that whether or not people will say things like that about you at your funeral depends on how you live your life. I can’t guarantee how it’s going to turn out, but I can guarantee that if you’re a loving dad—­if you’re there for her when she calls and you’re supportive, as you said—­it will increase the chances that someday she might feel that way about you and even say something like that. But not if you keep withdrawing from her. Let me ask you this: Are you willing to stand up here, look me in the eye, and tell me the kind of father you’d like to be with your daughter—­even though she makes it difficult, and even though you feel crappy a lot of the time when she calls and all she seems to want is money? How do you want to be in this relationship? (Helps the client commit to his values.) Client:

I want to be loving and supportive when she calls, regardless. That doesn’t necessarily mean I’m going to just give her money. But I’m going to be there for her as a dad.

Therapist: Are you willing to stand up and say that this is what you’re going to be about in relation to your daughter, even knowing there will be times when she makes it hard, when you feel used, and when you feel disappointed or angry? Will you stand up and commit to that, even knowing it will be extremely difficult at times?

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Yeah, I want to be that kind of father.

Therapist: Okay then, I invite you to stand up and tell me what kind of father you want to be. Client:

(Stands up and looks the therapist in the eye.) I want to be a loving, supportive father even when she makes it difficult.

Therapist: Awesome! I’m inspired by that. I want our work to be about that. I’m committed to making that possible for you. (The therapist shares her therapy-­relevant values.) As an ACT therapist, you’ll benefit from working to identify your values in relation to your clients and also in relation to yourself as a therapist—­facets of the work that sometimes remain unexamined by therapists. How many times during your professional training did you have a conversation with a supervisor or mentor about what kind of therapist you most wanted to be or what you hold as most important in working with clients? This isn’t a common topic. If you had more than a conversation or two about it during your training, your experience was unusual. Yet if you aren’t clear about your values in your work with clients, you’ll probably have difficulty making commitments to clients that are consistent with the ACT framework. Being clear on your values as a therapist and developing practices that help you more consistently make your work be about those values will benefit your work and make it more vital for you. To that end, we offer the following two exercises to help you identify your values as a therapist.

Experiential Exercise:

Identifying Your Values as a Therapist When you are at your best during sessions, what are you like?   If you could give your clients anything as a result of your work with them, what would you give them? Would it be particular skills, behavioral changes, knowledge, a quality of relationship, certain experiences, or something else?   

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Now, to offer you a more experiential way of approaching this question, we’ll ask you to do a brief eyes-­ closed exercise in which you imagine you’re at your retirement party. Begin by closing your eyes and taking some time to get centered. Next, imagine that you’re at the party and take time to picture some of the details: where the party would be held, who might show up, and so on. Finally, imagine that three of your favorite clients, ones with whom you did your best work, are at this party, and each gives a short speech about you. (We know this probably wouldn’t happen, but since this is happening in your imagination, you get to choose.) Give those clients a chance to say what you meant to them, what was most memorable about your sessions together, or what was most important about how you were with them. When you’ve completed the visualization, write a short summary of what each client said:      

Experiential Exercise:

Committing to Your Values as a Therapist Take a moment to recall a very difficult day you had as a therapist. Remember what happened that day that made it difficult. Maybe you felt as though you failed a client. Maybe you felt exhausted under the weight of all the suffering. Maybe you felt shame or guilt over something you did or didn’t do. Take a moment to recall how you felt and what you were thinking that day, including any self-­evaluations that came up. Briefly describe that day and your feelings:     Now imagine that a dear colleague, someone you really care about, comes into your office one afternoon and shares about having that same kind of terrible day. How would you want to respond to that

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colleague? What would you say? What might your face look like as you heard that colleague tell you about those feelings of shame, exhaustion, or incompetence? How would your voice sound when you respond? Write down what you might say and how you might say it:     Now that you’ve thought about what matters to you as a therapist from all of the angles in this exercise and the previous one, see if you can summarize the essence of what you value in a succinct statement. What kind of therapist do you want to be? What do you want to create? What do you want to do? Write a preliminary statement here. As a therapist, I most want to   How important is this to you? (0 = not at all important, 10 = very important):         Over the past two weeks, how consistent have your actions been with respect to this value? (0 = not at all consistent, 10 = very consistent)         What is one thing you could do this week that’s in line with this value?   Now we invite you to practice how you might make a values-­related commitment to your current clients. Bring two of your current clients to mind. When you consider them, think about what the two of you are working on together, what these clients most value, and what you value. Then answer this question: If you were going to make a commitment to each client that expresses a value you have in terms of your work with that client, what would you say? (An example of how you might phrase this is “I want you to know that in our work together, I am committed to…”) Client 1:  

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Client 2:   Finally, consider whether you’ll actually make these statements to your clients. Will you tell client 1?        Will you tell client 2?       

Values? What Values? One common but tricky barrier is worth mentioning. Sometimes clients deny that they have any values at all. This denial often results from fear of the pain that might be associated with having a conversation about their values. Clients who respond like this may be hopeless about the possibility of expressing their values or find it too painful to contact what they care about most. Such clients tend to be focused on how things will turn out. They’re afraid to step out of the safety zone of “I don’t care,” “I don’t know,” or “It doesn’t matter.” Undermining this type of avoidance often requires an exploration of the pain associated with caring, using questions along these lines: “What did you value before this cloud descended on you?” “When you were a child, is this how you dreamed your life would turn out? What did you dream it would look like?” “In the past, what kind of person have you dreamed of being? Was there any sense of creating kindness, for example, or maybe strength, love, or curiosity? Were there any other ways of being you dreamed of?” With such clients, it’s helpful to ask them to temporarily set the barrier of “not having values.” Here are some questions you can ask to facilitate this: “Pretend you’re someone who knows what you want. What would you want?” “What kind of life would you be creating if you stood for what you want?” One small caution about asking these kinds of questions: You want to be sure the question focuses on creating and standing for a value as something the client does, not something they simply wish they could be. Although it’s rare, you may occasionally encounter a client who truly seems to have no values. This definitely makes the work more challenging. In such cases, the best place to begin may be with what the client doesn’t want in her life (e.g., to be in jail). Here’s an example that illustrates such an approach. Julie is a thirty-­five-­year-­old woman who has an extensive history of sexual trauma, both as a child and as an adult. She works as an exotic dancer

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and print designer and is constantly chasing the next dollar to make ends meet. She perceives herself as living on the edge of financial disaster. She has no close friends, and most of her time outside of work is taken up by smoking marijuana, exercise, and masturbation. The few relationships she has are filled with conflict, and she’s chronically angry. She says that years ago she gave up hope that her life could be better, and now she just wants to learn how to get by without being victimized again. This dialogue is from her fourth session. Therapist: I want you to consider a question I think might be difficult for you. It’s a central question for this therapy, so I hope you’ll be willing to consider it. What I’d like to know is, what do you want to do in your life that you aren’t doing now? Client:

What? There’s no point in thinking about that. I don’t care about anything anymore. I just get disappointed whenever I hope for something. (As is frequently the case, the values question elicits fusion and avoidance.)

Therapist: I can see that it’s painful for you to hope for something. You’ve had many experiences of things not working out. I’m just asking, if you could have it be some other way, what would that be? What would you rather be doing with your life that you aren’t now? Client:

I don’t know. I don’t care anymore. Nothing.

Therapist: You could follow this path out for the next five years, ten years, fifteen years. You could continue the way you’ve been going. Take a second to picture what that would be like. (Pauses for a long moment.) Are you okay with that? (Uses temporal perspective taking to extend the current pattern of living into the future and increase a sense of psychological contact with the consequences of that pattern.) Client:

(Pauses.) It’s awful.

Therapist: I can see that you feel so hopeless about anything turning out the way you want. Your mind wants to protect you by saying it’s easier not to care. (Includes a bit of defusion by referring to the client’s mind as a separate entity.) That’s what you just saw in those five, ten, and fifteen years, yes? And apparently it doesn’t look good… Are you willing to play with me for a minute around this? Let’s pretend: If you were someone who cared, what would you care about? What would you want? Client:

It’s hard to think about. (Sighs.) I guess…uh…I’d want to have someone in my life whom I could trust. I’ve never had that. (Starts to cry. Some vitality shows up and perhaps some willing vulnerability.)

Therapist: I can see how much you want that, and how much it feels like that’s missing from your life. I want to help you have that in your life. In this example, the client was hesitant to speak about what she might want not because she doesn’t have ideas about the future, but because it’s painful for her to consider her values. Due to chronic avoidance, she’s unclear about what she feels or wants. In such situations, all of the ACT flexibility processes are needed to support clients in learning how to contact their values.

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Core Competency Practice In this section we provide an opportunity for you to practice what you’ve learned in this chapter. As in previous chapters, for each core competency we provide a brief case description and sample dialogues. Be sure to write out your responses and your explanations for them before comparing them to the model responses at the end of the chapter. There is no exercise for competency 36: “The therapist respects client values and, if unable to support them, offers a referral or other alternative.” This issue is discussed in detail in chapter 11, as this typically needs to be considered in a larger cultural context. Note that the exercise for competency 31 (the first values competency), is structured differently than most of the other core competency exercises. For this competency, we present a series of brief dialogues that reflect client statements about values that can lead down a dead end. This provides you with multiple opportunities to test your capacity to work with common issues, with the model responses providing examples of how to get out of common traps.

Core Competency Exercises Competency 31:  The therapist helps the client clarify values-­based life directions.

Exercise 31.1 The following client is a fifty-­eight-­year-­old woman with severe social anxiety. Therapist: What do you want in your life that you feel you don’t have today? Client:

I want to have less of this anxiety. I just want to be able to go out of my house and be like a normal person.

Therapist: And why do you want to be able to get out of your house? Client:

Because the life I live is not much of a life.

Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 31:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 31.2 The client is a forty-­six-­year-­old chronically depressed man who has no friends and no job and is generally disengaged from life. Therapist: What dreams do you have for your life? Client:

I don’t know.

Write here (or in a notebook) what your response would be, demonstrating competency 31:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Exercise 31.3 This dialogue continues with the same client as in the previous exercise. Therapist: When was the last time you had dreams for your life? How far back do we need to go? Client:

It’s been so long that I don’t want to think about it.

Write here (or in a notebook) what your response would be, demonstrating competency 31:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 31.4 The client is a seventeen-­year-­old woman who is highly emotionally avoidant and has few life goals. Therapist: What is it you want? What do you really want? Client:

Happiness. That’s what I want more than anything.

Write here (or in a notebook) what your response would be, demonstrating competency 31:    

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In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 31.5 This exercise and the next, the last two for competency 31, reflect somewhat trickier barriers to identifying or contacting values. Your job is to generate responses that will help these clients temporarily set aside the barrier and perhaps get more in contact with what is important to them. In this first exercise, the client is a forty-­five-­year-­old man with psychosis. Therapist: What would you most want your life to be about? Client:

Becoming president of the United States.

Write here (or in a notebook) what your response would be, demonstrating competency 31:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Exercise 31.6 The client is a twenty-­eight-­year-­old depressed woman. Therapist: What dreams do you have for your life? Client:

I guess I’d dream of pleasing my parents.

Write here (or in a notebook) what your response would be, demonstrating competency 31:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 32:  The therapist helps clients commit to what they want their life to stand for and focuses the therapy on this process.

Exercise 32 The client is a forty-­three-­year-­old man with lifelong dysthymia and difficulty in initiating and maintaining intimate relationships. The therapist and client have already identified key values for the client and recently identified an important value in the area of couple relationships that the client is neglecting. In this dialogue, the therapist is working toward helping the client move toward committing to what he wants his life to stand for.

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Therapist: You’ve identified that it’s important to you to be in a relationship that’s supportive, close, and fun. Yet you still find yourself without a partner, and you aren’t even headed in that direction. Is this what you want for your life? Client:

Of course not. But I really don’t know anyone who would want to be with me. Reaching out is hard. I think I’ll be rejected.

Therapist: (Speaks gently, in an inviting way.) So I have some important questions for you. First, I want you to take a moment and connect with the intention toward which you want to work: being in a supportive, close, fun relationship. Here are my questions: What are you going to be about in your life? Are you going to be about keeping away rejection and preventing failure in relationships? Or are you going to be about being in a supportive, close, fun relationship? Are you willing to take a stand for this value in your life? What would you be doing if you weren’t busy avoiding rejection? Client:

But I’m not sure if I can do it.

Write here (or in a notebook) what your response would be, demonstrating competency 32:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 33:  The therapist teaches the client to distinguish between values and goals.

Exercise 33 Earlier in this chapter, you practiced distinguishing between values and goals. Take time now to apply this same kind of practice to two clients you’ve been working with for a while. For each, list a value you believe that client has. Then, considering the client, list some goals that would be supportive of that value. Client 1 Value:  Goals:    Client 2 Value:  Goals:   

Competency 34:  The therapist distinguishes between outcomes achieved and involvement in the process of living.

Exercise 34 A twenty-­six-­year-­old male client is about to begin dating for the first time in several years. The previous week he described a value of wanting to be “someone who was reaching out, loving, involved, and real in relationships.” He committed to sending out at least one e-­mail every day in response to an online personal ad as a way of moving in this direction. He came to the current session having sent out an e-­mail every day and feeling disappointed that no one had responded yet.

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Yeah, I did it. But no one has responded. It didn’t work.

Therapist: (Speaks in a curious, nonjudgmental tone.) Okay, hold on a minute. Let’s go back to the point of this exercise. Why were you sending these e-­mails? What is it about? Client:

Getting a new girlfriend. And it didn’t work out. I’m not getting any responses. It feels like this is a total waste of time.

Write here (or in a notebook) what your response would be, demonstrating competency 34:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 35:  The therapist states his or her own therapy-­relevant values and models their importance.

Exercise 35 Write three sentences that describe your therapy-­relevant values. State them as if you were talking to a client:   

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Core Competency Model Responses Competency 31 Model Response 31.1a Therapist: And what feels as though it’s missing from your life? What did you wish for in your life that you don’t have now? When you’re sitting at home, afraid to go out, what are you wishing you could have or be about in your life? Take a moment and consider it. Sometimes your pain itself is a guide. Explanation: Getting out of the house is a goal, not a value. The therapist needs to get the issue focused on what the client wants, but the client is giving defended answers. So the therapist works to move closer to her pain. Model Response 31.1b Therapist: Would you be willing to close your eyes and picture that life? You wake up in the morning in this new life where you’re able to get out and interact with people. Tell me what you notice. What’s different? Explanation: The therapist uses a perspective-­taking exercise to help the client see and feel a life where she’s living according to her values. Rather than talking about values, which would be less experiential, the therapist is leading the client to feel her way into it and, in her imagination, sample some of what this new pattern of action might be like. Model Response 31.2a Therapist: When you were a child, did you imagine your life would turn out like this? Is this what you imagined for yourself? Explanation: The client’s answer is defended. Connecting the client with his childhood dreams and hopes can make his defense begin to feel self-­invalidating. Many clients let go of avoidance and defense at this point. Model Response 31.2b Therapist: Who do you admire? … Tell me what you admire about that person. Explanation: If the client is extremely low functioning, he may not have much experience with articulating his needs, desires, values, and goals, or he may have given up on goals that seem out of reach. By leading a discussion about who the client admires, it may be possible for the therapist, the client, or both to abstract out what’s important to him regarding how he wants to live.

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Model Response 31.3a Therapist: Yeah, it’s painful to think about how your life is so far from what you wanted for yourself. I get that. (The client begins to cry.) You’ve given up on so many dreams and hopes for your life. I really want to hear about the dreams you’ve given up on. Are you willing to talk about those dreams? Explanation: The therapist thinks the client isn’t willing to contact his values because of the loss and pain associated with caring. So the therapist makes an empathic comment that helps the client contact the pain of a life not fully lived. Model Response 31.3b Therapist: It makes sense that you don’t want to think about it. Often there’s a lot of pain in our values. It hurts to have dreams and to care about them, especially when they don’t work out. And yet this pain gives us useful information about what’s really important to us—­ about what can help us lead a more meaningful life. Would you be willing to explore this pain together for a bit if that could open up some new possibilities for you? Explanation: The therapist validates the experience that it’s often hard to think about our values because it can bring up pain. The therapist then recasts the pain as an ally—­as something that can point us toward what’s meaningful to us—­thereby redirecting the client back toward values and simultaneously supporting acceptance. Model Response 31.4a Therapist: Of course you want to be happy. That’s a basic part of being human. We all want to feel happy. And yet take a closer look. Is happiness something you can do? Let’s try something right now. I’d like you to make yourself feel really happy right now. (Pauses.) Were you able to do it? Client:

No, it doesn’t work like that.

Therapist: Right. So, what I’m wondering is what you’d want to be about, how you’d want to live—­ not exactly how you’d want to feel. For example, if you could intend to do anything with your hands, your feet, and your words, what would those actions be about? Explanation: Happiness is a feeling or goal, something that may happen to the client, rather than a direction in which the client can head, or a value. So the therapist sidesteps this comment and does a short exercise with the client to illustrate the problem with choosing an emotional state as a goal. Emotions aren’t under our direct control. Values are more about what we directly approach or aim toward as qualities of action.

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Model Response 31.4b Therapist: How long have you been trying to be happy? Client:

I don’t know. Most of my life.

Therapist: You know how they put an epitaph on a tombstone that says what a person’s life was all about? Have you heard of that? Client:

Yeah, like he was a good dad or whatever.

Therapist: (Speaks with curiosity and without condescension.) Right. So what you’re saying is that your epitaph would read, “Here lies Mia. She spent most of her life trying to be happy.” How does that sound for an epitaph? If you could choose anything to have on an epitaph, is that what you’d choose? Explanation: Happiness as a central goal in life is usually a sign of pervasive experiential avoidance. The therapist is trying to help the client be aware of what she’s currently valuing. If she clearly sees what her behavior is in the service of, she may choose something else. Model Response 31.5a Therapist: What would being president allow you to do? Client:

Take care of people…people like me.

Therapist: And if you were helping in that way, whether or not you were president, would that still be something you’d value? Explanation: Even grandiose goals often contain values. One major advantage to discussing values is that the therapist usually doesn’t have to talk clients out of grandiose goals and can instead dig down to the embedded values. This is likely to reveal implications for action. Then, by addressing workability, the therapist can gently rein in any excesses (even psychotic ones), without shaming clients or making them appear to be wrong or deluded. Model Response 31.5b Therapist: What kind of president would you want to be? Client:

I’d want to be a good president.

Therapist: What’s your idea of a good president? Client:

Someone who helps people and doesn’t lead us into more wars.

Therapist: So it sounds like helping people is something that matters to you. Is that right?

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Explanation: ACT therapists generally don’t directly contradict clients’ goals but instead use them as opportunities for learning. One possible route is to see whether more abstract values inform specific goals, as the therapist does here. These overarching values can then be used to identify goals that are likely to be more workable. Model Response 31.6a Therapist: Imagine that your parents have passed away and no one in your life remembers what they wanted you to do. What would you most want to change in your life? Client:

Nothing really. I want to have a family and raise my children in a loving way. I think that’s what would please my parents, but it’s what I want to do, too.

Explanation: ACT is often targeted at undermining pliance (following rules to achieve the approval of others). In this model response, the therapist assessed for pliance by asking the client to imagine conditions in which social approval would be less of a direct issue. Another way to do this would be to have the client imagine that her parents somehow magically approved of her no matter what. What would she do then? It’s important to use such approaches in a way that doesn’t assume any social goal is necessarily pliance. We are social creatures and tend to care about the same things our communities and families care about. The issue is freedom of choice and a sense of personal connection to what is most meaningful to us in living well. Model Response 31.6b Therapist: I can tell that your parents are very important to you. Tell me: What kind of a life would please your parents? (The client answers.) Great. So tell me, on a scale of one to five, how important are these things to your parents? Client:

They’re a five.

Therapist: Good. And can you rate how important they are to you? Client:

Hmm. Probably a three.

Therapist: So maybe the dreams that your parents have for you aren’t exactly the same as the dreams you have for yourself. So I’d like to ask you again: What dream do you have for your life? Explanation: People can often fall into the trap of orienting their lives around pleasing others or following their rules. It isn’t inherently bad to want to please others, but when people live in a way that’s focused on the outcomes of their behavior, they lose contact with what is intrinsically important in their pattern of living. The therapist’s questions in this model response begin the process of helping the client differentiate between what she imagines her parents want and what she would choose.

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Competency 32 Model Response 32a Therapist: I’m not asking you if you can do it. The result will turn out one way or another—­you don’t have complete control over that. And you will have scary feelings and worrisome thoughts. What I’m asking is, what are you going to stand for in your life? What I’m presenting here is an opportunity to make a commitment to a new direction in your life, not knowing how it’s going to turn out. I want you to consider whether this is a commitment you’re willing to make. And if so, then tell me, what do you want to be about? Client:

Yeah, I want to make this commitment. I’m going to do it. I want to be about having a supportive, close relationship. I want to give myself a chance to have a relationship with passion!

Therapist: Yes! I want that for you, too. I want our work to be about that. Explanation: The therapist has to use work with defusion and acceptance to keep the client focused. The client presents common barriers: fear of rejection, failure, and inability. The therapist sidesteps these obstacles and continues to present an opportunity for the client to commit to a new direction. Notice that in her final statement, the therapist shares her own values, including that she values the client’s valuing, which also demonstrates competency 35. Model Response 32b Therapist: This is true. You don’t know whether or not you can. Let me put this another way: What if life is offering you a choice about what you’re going to stand for? On the one hand (puts out her right hand), you could play it safe and avoid intimacy. However, the downside of this choice is that you won’t have supportive, close, fun relationships. On the other hand (holds out her left hand), you take a risk on intimacy and have the chance to develop supportive, close, fun relationships. This choice means that sometimes you’ll feel rejected, hurt, and scared. What if this is the way it works? What will you choose? Explanation: The client is focused on the outcome: whether or not he will be rejected. This draws his attention to the future and away from the process of valuing. The therapist has the client imagine a choice that combines willingness and values in the hope that this will foster a sense of choice (one of the four qualities of an effective values conversation). If the client picks the choice associated with avoidance, the next step will be to examine workability: What has the outcome been when he’s chosen the safe path in the past? Has he avoided feeling rejected and alone or whatever else he fears, or has it actually made things worse?

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Competency 33 Given the nature of the exercise for this competency, there are no model responses.

Competency 34 Model Response 34a Therapist: I want to remind you about what you wrote as your intention in this domain. You wrote that you wanted to be someone who was reaching out, loving, involved, and real in relationships. What we’re working on is the process of moving in that direction. Sometimes you’ll enjoy how it turns out. Other times it will work out in ways you don’t like. But what we’re working on is what you want to stand for. It seems as though you got off track here for a little while and got attached to the goal of having a girlfriend. While that would be nice, we’re not working on that. Right? Client:

Okay, I think I get you. I forgot for a minute.

Therapist: So, by sending out these e-­mails, did you move further in your direction of reaching out and being loving, involved, and real in relationships? Client:

Yeah, actually, I did. Just by sending out the e-­mails I was being real because I normally pretend I don’t really want relationships. But I went even further than that. I normally work really hard to be witty and impressive in my e-­mails. You know, I worry that if I don’t play that game, they won’t like the real me. What was cool was that I was more real. I said what I thought and responded more genuinely to what they wrote, commenting on what interested me about it.

Therapist: Cool. I think it’s really great that you made that commitment last week and fulfilled it during the past week, even with all those barriers that came up. Let’s keep our eye on the ball of how you’re living and let the outcomes fall how they may. Explanation: The client seems to be overly focused on the outcome instead of on the process of living his value. He has become attached to a particular goal. As a result, he’s evaluating all his behaviors in relation to his perceived distance from his goal, rather than in relation to whether he has kept moving in the direction of that goal. The therapist reminds the client that his value is not about the outcome but about how he’s living his life, and then checks in with the client to see whether he understands. Model Response 34b Therapist: Are you interested in my reaction? (The client says yes.) I think what you did was pretty awesome. This has been a real challenge for you in your life and something you’ve been avoiding for quite a long time. Congratulations on taking this step. Client:

Thanks.

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Therapist: From where I sit, it looks like you took a stand for something that really matters this week. You dedicated your time and energy toward living a life with loving, involved, and real relationships. That’s something worth doing—­a noble pursuit. And it isn’t easy to do either, as taking action on something that really matters to us means we’ll sometimes experience failure. I know it didn’t work out this week, and that’s disappointing, but just because it didn’t work out, does that mean that this activity, living a life oriented toward loving, involved, and real relationships, wasn’t worth doing? Explanation: The therapist focuses on validating the client’s struggle and congratulating him on his involvement in the process of valuing while simultaneously encouraging him to let go of the outcome. The therapist tries to reconnect the client with the meaningfulness of the value and normalize the pain that’s likely to attend valuing, thereby also promoting acceptance. A possible next step in therapy would be to help the client learn from his committed action to inform next steps in this chosen direction.

Competency 35 Given the nature of the exercise for this competency, there are no model responses.

For More Information More information about values, including exercises and metaphors, can be found in Hayes et al., 2012, chapter 11; and Harris, 2009, chapter 11. For an entire book dedicated to this topic, see Dahl et al., 2009. You’ll also find a wide range of exercises and metaphors related to values in Stoddard & Afari, 2014. Eifert & Forsyth, 2005 (pp. 154–­155, 186–­187) might be of interest, as well as some of the resources listed earlier in this chapter. For values-­related exercises and worksheets that you can use for yourself or clients, see Hayes, 2005, chapter 12.

CHAPTER 7

Building Patterns of Committed Action

It takes a deep commitment to change and an even deeper commitment to grow. —­Ralph Ellison

Key targets for building patterns of committed action: Work with clients for behavior change in the service of their chosen values while making room for all of their automatic reactions and experiences. Help clients take responsibility for their patterns of action, building them into larger and larger units that support effective values-­based living.

A core problem for many clients who present for therapy is that they’ve dropped out of important activities, relationships, or pursuits in their lives or only engage in these in a limited way. Consider Leonard, a client with depression who has friends but doesn’t seem to really connect with them or only calls them when he feels desperate and alone; or Kirsten, who no longer goes to her son’s football games or drives alone due to fear of panic attacks; or Jose, a client with psychosis who spends most of his time alone in his living room watching TV and fears that if he goes out, it will trigger the voices he hears. Given the option, Leonard would choose to be more connected with friends, Kirsten would choose to go to her son’s football games and have her independence back, and Jose would choose to spend more time in the world outside his living room. All of these people have visions of a full life that they wish to inhabit, but they find themselves stuck in lives that generally feel imposed upon them, not of their own choosing.

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What Is Committed Action? Committed action is a step-­by-­step process of acting to create a life of integrity, true to one’s deepest wishes and longings. Commitment involves both persistence and change—­whichever is called for to live in alignment with one’s values in specific contexts. Commitment also includes engaging in a range of behaviors. This is important because moving in valued directions often requires being flexible, rather than rigidly persevering in unworkable actions. Committed action is inherently responsible in the sense that it is based on the view that people always have an ability to respond. This isn’t idealistic. It refers to the ability to link one’s actions to one’s values in any situation. For example, a person in a prison may have a limited ability to show an overt commitment to family. However, that person can still take certain actions that reflect this commitment, like being helpful so that parole becomes more likely, writing letters to family members, or being prepared for family visits. Commitments can be revealed through all sorts of chosen behaviors. The specific form of committed action called for in a given situation depends on what that situation affords and what action would be most effective. Committed action is the core process through which therapists can best incorporate traditional behavioral methods into the ACT model. Exposure can be used for anxiety problems, skills training for social problems, behavioral activation for depression, scheduled smoking for smoking cessation, and so on. Because behavioral methods are so diverse, we can only deal with them in this chapter in the broadest sense. However, these behavioral methods are an essential part of ACT and should be included whenever called for in therapy. Although research on ACT has occasionally excluded traditional behavioral approaches, this has been done in order to make a scientific point. For example, in one study, obsessive-­compulsive disorder was treated successfully without any in-­session exposure (Twohig, Hayes, & Masuda, 2006) merely because positive results would otherwise be dismissed as nothing more than the well-­known effect of exposure. However, ACT is based in clinical behavior analysis, and behavioral technologies are a key feature of ACT. As just one example, in-­session exposure would normally be part of an ACT approach for OCD. In clinical practice, there is no reason to limit full implementation of the model.

Why Committed Action? If defining valued life directions provides the compass bearing for one’s route through life, committed action describes the steps of the journey. A well-­lived life is ultimately the goal of all the other flexibility processes (developing acceptance and present-­moment awareness, defusing from entangling thoughts, developing a transcendent sense of self, and clarifying one’s chosen directions). These processes promote psychological flexibility and help clients persist in or change behavior, as needed, in the service of their valued life directions. Committed action encompasses the behaviors and therapy targets that are specifically aimed at helping clients move from inaction to action in the realm of overt behavior and from unworkable action to workable action, and to helping them maintain their new, more flexible behavior over time.

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The Link Between Willingness and Committed Action Willingness and committed action are so deeply intertwined that one could argue that commitment depends 100 percent on willingness. This is because values are often linked to difficult internal experiences, and difficult internal experiences can illuminate or point to an individual’s values. Any committed action can evoke a whole host of private experiences, at least some of which will be evaluated as negative. If a person is entirely determined to not experience any unpleasant or difficult thoughts, feelings, sensations, or images, that person will be unable to commit to and maintain a course of action because any course of action will eventually evoke something that’s unpleasant. With valuing loving relationships comes the experience of loss; with valuing participating in community comes the possibility of rejection; and with valuing the sharing of one’s art comes the potential for negative evaluations of one’s abilities. Metaphorically, it’s as if people are on a journey called “living well” and sometimes run into a swamp that stretches as far as they can see (Hayes et al., 1999, pp. 247–­248). Swamps are challenging. They’re often smelly and sometimes scary, yet swamps are part of the journey. Life asks, “Will you wade into the swamp, or will you abandon your journey?” In order to choose to act on our values, willingness to experience difficult events is necessary. The action of willingness has the quality of a leap of faith. The job of the therapist is to create situations in which clients engage in a leap of faith in the direction of their values and into a future that is unknown. A leap of faith implies willingness to have whatever happens when one makes that leap, to touch down wherever one lands. This is the quality ACT therapists are looking for in client commitments. In a scene from Indiana Jones and the Last Crusade, Indiana is at the final stage of his quest to find the mythical Holy Grail. He finds himself just short of his goal, with a seemingly bottomless chasm between himself and his goal and no apparent way across. He faces the choice of either giving up his goal and turning back or confronting his fear and stepping into the chasm in a leap of faith. With trepidation, he steps into space, seemingly to fall to his death. Unbeknownst to him, a bridge is there, painted to blend perfectly with the chasm below. Supported by this bridge, he makes it safely across to his destination. Committed action is like that. Willingness to face fear allows people to move toward their goals, and their commitment makes sense of their willingness. Committed action also provides the opportunity to practice and build the capacity to choose to be willing over and over again, across time. Clients should never be coerced to make commitments. Rather, ACT therapists work to build opportunities for clients to choose to commit to values-­based actions because these actions provide opportunities for clients to pursue the kind of life they want to live. Ideally, commitments are made with 100 percent willingness. In Indiana Jones and the Last Crusade, Indiana’s leap of

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faith was seemingly into a chasm that could end his life. Private events can sometimes seem just as threatening, and clients may attempt to avoid them just as they would try to avoid actual death. However, through ongoing committed action they can experience that thoughts, feelings, and sensations cannot literally harm them, and that in fact, such private events are only harmful if they control how clients live their lives.

What Should Trigger Working with This Process? Engaging in committed action typically follows work on defining valued directions. A focus on committed action could follow a quick exploration of one values-­based area of living for a client seen in a primary care setting, or it could begin after multiple sessions spent helping a client articulate her values, as might happen in a more conventional therapy setting. What’s important is that client and therapist begin committed action work with a shared sense of what the client values. Working on committed action may be especially useful when therapy becomes lifeless or dull or when clients are talking about values rather than acting on them. If clients aren’t in contact with the barriers to values-­based action, beginning to work on this process will evoke those barriers. So in a sense, committed action is a process that can illuminate the emotional and cognitive barriers to be addressed using the other flexibility processes. For example, if a client is talking about the importance of intimacy and openness but the therapist senses some lifelessness in the room, shifting to specific actions the client is willing to commit to can open up a more vital process. Moving directly to the therapeutic relationship is also a useful way to explore values-­based action. For instance, to create the opportunity for committed action in the therapeutic relationship itself, the therapist might say, “Could you apply your values in this moment? What is a difficult and more open thing you could say right now about our relationship?” Patterns of client behavior that suggest a focus on committed action is needed include impulsivity, inability to identify specific goals for action, inaction, avoidance of making commitments, and inability to keep commitments. Impulsivity indicates that the client’s behavior is largely driven by short-­term contingencies and is relatively disconnected from more extended forms of reinforcement, such as those linked to values. This may show up as a lack of awareness of the larger context of action that gives the client’s life a sense of meaning and purpose. If clients are unable to generate specific goals related to their values, this might also be an indicator that they need support in strengthening their ability to do the practical work of setting goals and keeping them. Lack of action in valued domains also suggests that a focus on committed action might be useful, in this case to elicit fusion and avoidance linked to their behavioral inflexibility, which can then be loosened up with other flexibility processes. Finally, an inability to make and keep commitments might be indicated if the client tends to engage in fusion and avoidance when the topic of specific goals comes up.

What Is the Method? Once therapist and client have a shared sense of what’s important to the client, work on committed action can be broken down into four steps:

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1. Identifying goals based on values. In this initial step, the therapist might help the client pick one or two high-­priority life domains (family, romantic relationships, etc.) and develop an action plan for behavior change in those domains. 2. Coaching clients to make and keep commitments to values-­based actions. The therapist helps clients put their values-­based behaviors into action in daily life, outside of session, while also attending to the larger patterns of behavior that are being assembled. 3. Working with barriers using other flexibility process. Barriers almost always arise when clients engage in committed action. The therapist attends to this and assists clients in overcoming barriers using acceptance, defusion, and mindfulness skills. 4. Repeating steps 1 through 3 until the client is taking steady committed action. To help clients become more skillful and generalize an orientation toward committed action, the therapist can switch the focus to different domains of living, to larger patterns of action (e.g., not just committing to exercise this week, but building a pattern of regular exercise), to goals that entail facing other feared or avoided experiences, or to goals that will elicit other aspects of psychological inflexibility. The goal is to give clients sufficient practice that they can maintain a pattern of flexible and values-­based committed action without the therapist’s support. This process forms the core of translating abstract values, such as being healthy or engaging in a spiritual practice, into concrete actions that express and instantiate these values in the world. Note that although we have identified a stepwise process here, the organization of the sections below don’t exactly parallel this process. The process itself is straightforward to understand, so we’ve chosen to focus on some of the most important aspects of this work.

Identifying Effective Values-­Based Goals and Linking Them to an Action Plan Typically, therapist and client work together to identify one or two high-­priority areas as the initial focus for committed action. It’s usually helpful to focus on areas of living in which the client feels a loss of engagement, choice, or vitality and in which this constriction appears to result in ongoing suffering (Wilson & Murrell, 2004). Therefore, the therapist would ideally suggest areas of high importance to the client. The goals selected should include actions that are likely to occasion private experiences that the client tends to fear and avoid, as this will maximize the client’s opportunity to build psychological flexibility. After identifying an initial focus, therapist and client work together to develop specific plans, including the place and time for engaging in the chosen actions. Workable goals can be characterized by the six key qualities: • They are clearly linked to the person’s values. • They are specific and measurable. • They are practical and are things the person is able to accomplish.

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• They are active, not framed as “dead person’s goals.” • They are committed to in a public way. • They are linked to the evidence and a functional analysis of the person’s behavior.

LINKED TO VALUES Any goals or actions clients commit to need to be on target, meaning linked to the client’s values. Then, as clients move toward their goals, they need to attend to how well their actions align with their valued directions. Typically, when people move in a valued direction, natural feedback occurs in the form of a sense of vitality, freedom, and flexibility. Clients can begin to develop a sense of this vitality and use it as a guide, helping them know whether they’re traveling in their chosen direction or off course. It’s also important that goals reflect the qualities of the values clients intend to reflect in their actions. For example, “Calling my brother this week” might be specific and measurable (the next topic), but what the client says while on the phone and how he listens will be a big part of whether he’s being a loving brother. In this instance, the client might seek to listen attentively or to vulnerably share something in order to bring valued qualities to his action, rather than simply complying with the form of the action.

SPECIFIC AND MEASURABLE A common error is to set vague goals, making it difficult to assess whether they’ve been accomplished. Here are some examples of vague goals: “Engaging more with friends,” “Calling my brother more,” and “Being more accepting of my daughter.” Although the activities specified may be values consistent, it would be difficult to determine whether the client had accomplished these goals. It’s more effective to have specific, measurable goals, such as “Call my friend Jake on Saturday at 2 p.m. and ask him to go to a movie of his choice,” “Go to coffee with Rebecca on Sunday at 10 a.m. at the cafe,” “Call my brother two times this week, once on Tuesday before dinner and once on Friday right when I get home from work,” and “Get my daughter a greeting card while at the grocery store on Sunday and, by the end of the day, write in it how much I love her.” Goals should be clarified by specifying when, where, and even how the actions will be done. Therapists often need to initially work with clients to help them come up with specific, measurable goals until clients are able to do this on their own.

PRACTICAL AND WITHIN THE CLIENT’S CAPABILITIES Goals also need to be practical and things that the client can actually accomplish. Taking steps with intention and consistency is generally more doable than heroic leaps, especially if those leaps occur only sporadically, though big leaps are sometimes necessary. It can be helpful to start with goals that are actually easier than what the client is capable of to facilitate building a pattern of consistency between commitment and action. When clients lack the skills to accomplish particular goals, therapists can support them in developing the needed skills as an intermediate goal, as this too is a values-­consistent step. A quick way to assess whether a client first needs to learn additional skills is to ask, “How confident are you that you

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can accomplish this goal on a scale of 0 to 100 percent?” Answers to this question can serve as an important assessment tool, indicating both client commitment and the difficulty of the goal. If a client reports a low number, therapist and client can work together to revise the goal. Here’s one way to broach this topic: “The size of the goal here isn’t important. What’s important is that you’re taking steps in the direction of what matters, that you’re moving forward in a way that counts. How fast isn’t important. So let’s find an action you can commit to that you’ll be able to do before the next session.”

ACTIVE, NOT FRAMED AS DEAD PERSON’S GOALS Avoid “dead person’s goals” (Lindsley, 1968): objectives that a dead person could do better. For example, a dead person would almost always do better than a client if the goal is something like “Withdraw less from my mom,” “Be less lazy,” or “Argue less with my husband.” Put another way, dead person’s goals are like giving someone directions by only telling the person which streets not to go down (Heffner & Eifert, 2004). Dead person’s goals specify what someone is trying to avoid. In ACT, the focus is on building the ability to approach a chosen goal. Generally, dead person’s goals can be reformulated fairly easily. Using the previous examples, reformulated statements might be “Spending time connecting with my mom,” “Being productive at work,” and “Being supportive toward my husband.” However, these examples are still somewhat vague, so to make them more useful, they can be further reformulated to be more specific and measurable: “Having dinner with my mom this week and telling her how much I miss her,” “Spending at least two hours every day working on computer code,” and “Helping my husband during this stressful week by mowing the lawn.”

COMMITTED TO PUBLICLY Research has shown that when people make public commitments, they’re more likely to follow through and accomplish their goals (Hayes et al., 1985). So ideally, clients would commit to specific goals in the presence of the therapist, and together they would record the goals in a way that allows them to be checked later. For example, a goal can be written on a card, diary sheet, or goals document. This also provides a physical reminder to prompt clients to remember their commitment. Without a physical reminder, clients often don’t remember exactly what they intended to do. It’s helpful to provide forms on which clients can track their goals and achievements over time; documenting their progress in this way can provide effective reinforcement. (For an example, see Eifert & Forsyth, 2005, pp. 218, 244).

BUILT ON FUNCTIONAL ANALYSIS Finally, goals are best linked to the evidence base and to a functional analysis of client behavior. This requires that the therapist have knowledge of and skill with evidence-­based methods of behavior change, guided by a functional analysis linked to basic principles of behavior. ACT expands on basic behavioral principles such as operant and respondent conditioning by adding additional principles based on RFT. The literature on functional analysis and behavioral methods for specific problems is so vast that it’s is impossible to cover here, even in a cursory way. For those interested, The ABCs of Human Behavior (Ramnerö & Törneke, 2008) provides an accessible introduction to functional analysis and the use of behavioral principles in clinical work. In addition, when working on establishing client goals it can be useful to incorporate evidence-­based interventions that are rooted in behavioral

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principles, such as exposure therapy, various forms of skills training, contingency management, stimulus control strategies, and behavioral activation. Other evidence-­based interventions not based on behavioral principles might also be used if they’re consistent with the flexibility processes.

INTEGRATING ALL SIX QUALITIES INTO GOALS AND ACTION PLANS The six qualities of goals described above are relevant to every ACT case. Suppose a client values being intimate and supportive in friendships. For a client with those values who doesn’t have close friendships, a long-­term goal might be developing such a relationship with two people. Various intermediate actions and steps would be necessary to achieve this longer-­term goal. For example, the client could join a sports league. Smaller substeps toward that intermediate goal might include finding information about leagues that are available, choosing one, and then enrolling. In addition, it may be necessary to focus on small, precise skills to enable the client to achieve even intermediary goals. Continuing with the preceding example, this self-­isolating client may need to practice how to make such a phone call or how to interact with fellow players in a way that could lead to friendship. It’s important to keep in mind that committed action is not simply about achieving goals; more accurately, it’s about the process of living a meaningful life. Goals serve as signposts that let clients know they’re headed in the right direction and staying on track. Another therapeutic purpose of goals and larger action plans is to help clients engage in a process of values-­based living while simultaneously developing greater psychological flexibility. The focus is not on attaining goals per se, but on working toward them in a certain way: staying grounded in the present, using defusion skills, being willing, and noticing the workability of each step.

WORKING WITH UNWILLINGNESS TO ESTABLISH GOALS A common problem is that clients are unwilling to generate goals because they feel nothing new is possible for them. This is less likely to occur if clients have already done some work on defusion, acceptance, and values. So if you encounter unwillingness to set goals, defusion and acceptance techniques will probably be helpful. In the following dialogue, the therapist uses defusion as a way to overcome verbal barriers to commitment by focusing on the functional utility of the client’s thinking. Client:

Why should I write down goals? I never follow through on them anyway. It just seems like a waste of time.

Therapist: If you were to listen to the advice of that thought—­that you never follow through on your goals—­would that lead you toward or away from this value of making a difference with your life? Client:

Hmm. Away.

Therapist: And if you were considering this value and it were to give you advice, what would it say with respect to setting goals? Client:

It would say, “Go ahead and set the goals, then go for it!”

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Therapist: So, if you could choose between those two directions, which would you choose? Client:

I’d choose to set goals.

Therapist: I guess I am left with this question: Will you? Here with me now? Client:

(Sighs.) Okay.

Therapist: I can hear the hesitance, but let’s see what happens. Let’s start with the first step: setting goals. If you were living your life in the service of this value, what’s one thing you would be doing that would be about that? Another common problem is that clients are able to identify a broad goal linked to a value but need help in setting more concrete intermediary goals. In such cases, the therapist can provide guidance on how to divide larger goals into more manageable steps. The following dialogue illustrates one way of doing this. Client:

Yeah, I know I want a job that’s more rewarding, that requires more from me than the one I have now, but I don’t know what to do to get there.

Therapist: Okay, so let’s break this down a bit. You don’t need to leap all the way to the goal of having a new job in one step. Can you think of one action that, if you completed it, would put you one step closer to that new job? Maybe something you’ve been thinking about doing but are afraid of doing?

Keeping Commitments in the Presence of Emotional Barriers ACT assumes that a common barrier obstructing clients from taking action with respect to their values is a desire to first eliminate unpleasant and difficult private experiences. After all, working on goals and building patterns of committed action usually brings people into contact with previously avoided thoughts and feelings. So when clients do engage in committed action, they are also engaging in exposure to feared and avoided stimuli. This is beneficial in many ways—­among them that it gives clients opportunities to practice other ACT skills and develop greater psychological flexibility. When working with clients on committed action, the focus is on helping them learn to lean in toward their experience, including negatively evaluated experiences such as anxiety, sadness, depression, boredom, negative thoughts, or unpleasant memories, along with positively evaluated experiences, such as happiness, fun, relaxation, or excitement, as clients may also avoid the latter. Through the process of choosing goals and taking action on them despite difficult internal experiences, clients build new patterns of perseverance in the face of difficulty and get the chance to build breadth and flexibility of responding by interacting more richly or intimately with avoided experiences. As they pursue valued directions, life provides the material for practicing acceptance and defusion. So in a very real sense, ACT is an exposure-­based method. But there are several key differences in how ACT approaches this work, discussed in the following section.

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EMPHASIZING RESPONSE FLEXIBILITY Because defusion and acceptance enable exposure to the process of thinking and feeling, not just the products of thinking and feeling, ACT allows for engaging in a type of exposure that would otherwise be impossible. For example, a client who thinks I’m bad doesn’t need to expose himself to being bad, but rather to the process of thinking I’m bad. A key distinction between exposure in ACT versus in traditional approaches is that in ACT exposure is always linked to values. For example, a between-­session commitment for a client with a germ phobia could be to go to a restaurant with a friend and work on being present and engaged with her friend and to share freely about herself. A form of deliberate exposure could be included as part of this goal, such as by limiting hand washing to once before the meal and once again before leaving the restaurant. This exposure wouldn’t be about the goal of reducing anxiety per se, but about the goal of increasing behavioral flexibility linked to the client’s value of being present and engaged with her friend and sharing freely about herself. This value necessarily involves not spending excessive time engaging in compulsive rituals aimed at eliminating thoughts about contamination; thus, the exposure is in the service of the client’s values. Finally, the model of exposure that is embraced in ACT is not as much about response elimination and emotion reduction as it is about response flexibility and breadth of repertoire. Thus, exposure would never be presented to an ACT client as a method of reducing arousal or distress; rather, it offers clients situations in which they can practice willingness, committed action, and psychological flexibility. Because ACT is based on a response-­flexibility model of exposure, ACT therapists deliberately create variable responses during exposure. The goal is to watch for subtle forms of avoidance and undermine both avoidance and fusion. The following dialogue offers an example of conducting an in vivo exposure in session. However, a similar dialogue could also be used for out-­of-­session exposure work. The client is a man with social anxiety who’s planning to attend an upcoming family reunion with his wife. Therapist: This reunion has been weighing on you. I know that even thinking about it has been causing you some distress. Client:

My wife will throw a fit if I don’t go, but I really don’t want to. Her relatives ask me questions. I have to be in a good mood. I just don’t want to go.

Therapist: Yeah, it makes sense to want to stay away from things bring anxiety. Client:

Even just talking about it now makes me feel hot.

Therapist: I’m wondering if you might be willing to lean into that experience—­let yourself feel this heat and notice its qualities. Client:

It makes me want to run. I want to get cooled off.

Therapist: Is your mind telling you anything right now? Client:

Yes, it’s saying that this is too much, like the heat is going to kill me.

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Therapist: Let’s see if it’s possible to notice what your mind is doing in this moment of heat, and then whether you can simply let yourself feel it. (Brings in defusion by helping the client notice his thoughts.) Notice how you experience the heat. Client:

I feel it in my face and hands, like I’m red and burning up.

Therapist: Okay, see if you can move to your hands first. Turn your attention to sensations of heat in your hands. (Slows down, adding pauses.) Notice the sensation… See if you can stay with the experience there… Gently observe it without making any effort to make it come or go… Are you with me? Client:

Yes, I can feel it. My hands want to move.

Therapist: Go ahead and let them move, but do it with awareness, following the movement and heat. Client:

(Moves his hands slowly.) Okay, I can feel it.

Therapist: Great, just stay with the experience of your hands moving and feeling the heat. Client:

(Takes a deep breath and sighs.) Okay.

Therapist: Now take a look at me… Okay, good. Now, can you remember why we are doing this right now? Client:

Um… Because this is what happens when I’m in social situations?

Therapist: Right. We’re practicing opening up to this experience now so that you can be there at that reunion for your wife. Doing this difficult exercise now is in the service of your relationship with your wife. (Reconnects the client to his values as the context for willingness.) Client:

Right.

Therapist: So while you keep in mind why you’re doing this, can you also notice any urges? Client:

Yeah, I want to run out of here.

Therapist: Excellent. See if you can just observe that urge. See if your attention can hover over it, observing it, like a helicopter hovering over a spot on the ground… Just watching it, whatever it’s doing. (The therapist continues this exposure for another minute.) Therapist: Now I’m going to invite you to gently shift your attention to your face. Do you still feel the heat there? Client:

Yes, but not as much as I did at first.

Therapist: Okay, go ahead and let yourself turn your focus to your face, becoming aware of what you feel there. Where do you feel the heat? Client:

In my cheeks and neck.

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Therapist: Let’s start with your cheeks. Are you able to feel the heat there? Client:

Yes.

Therapist: Okay, just like you did with your hands, let yourself gently focus on and be present to the heat in your cheeks. Client:

It’s uncomfortable. I feel like people can see my anxiety.

Therapist: Okay, let’s welcome this discomfort, this thought “I feel like people can see my anxiety,” not just for its own sake, but for what it’s important to you to do. (Connecting with the ­client’s values again.) See if you can open up and just let the feeling of heat be there. You’re carrying it now in the service of going to your wife’s family reunion. This dialogue shows how ACT exposure seeks to create response flexibility in the context of values-­based action, acceptance, defusion, and mindfulness. It includes elements of interoceptive exposure (i.e., exposure to feared bodily sensations), which is entirely consistent with ACT. The goal of this approach is not to reduce the anxiety or symptoms the client is feeling, but to practice defusion from anxiety-­related thoughts, develop awareness of experience as a conscious observer, and promote acceptance of urges and other unpleasant experiences. These are all nested inside the larger context of building psychological flexibility in the service of the client’s values.

PREPARING CLIENTS FOR BARRIERS As with any good exposure procedure, it can be useful to prepare clients for experiential barriers they may encounter as they engage in committed actions. Without awareness of potential barriers, clients who choose to engage in committed actions probably won’t willingly accept these barriers. Helping clients consider likely barriers enhances their sense of choice, as demonstrated in the following dialogue with a socially anxious male college student. Therapist: One thing I can pretty much guarantee is that as soon as you head in this direction you value, some uncomfortable thoughts and feelings will start to show up. For example, as soon as you start to make moves to develop friendships with people, those passengers on your bus who say, “It’s not worth it; people are disappointing and will hurt you,” are almost certainly going to show up. The question life is asking you in these moments is “Will you have those feelings, thoughts, images, and sensations—­will you say yes to those passengers when they show up?” Remember, this isn’t about whether you want them there; it’s about whether you’re willing to have them there. It’s a bit as if you just got out of bed feeling really depressed, and your friend Craig, whom you haven’t seen in several years, knocks on your door and asks if he can come in. Now, you might not want him there, but could you be willing to let him in? Similarly, with this goal of asking the guy you met in your English class to play racquetball, would you be willing to do that, knowing it means you’ll need to make room for those passengers who say, “It’s not worth it,” “He’s going to disappoint you anyway,” and “You’re eventually going to be hurt”? The question I have is this: Are you 100 percent willing to have these passengers show up and to ask this guy to play racquetball?

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Yeah, but I’ve done this before, and people don’t want to be friends with me. Why should I be willing when it’s not likely to work out?

Therapist: What’s not likely to work out? Client:

He’s probably not going to say yes.

Therapist: Well, there’s no guarantee of a particular outcome. What I’m asking you is if you’re going take a stand in your life for what’s important to you. You told me before that you want more friends in your life. The outcome will be what it will. And if you don’t ask, you definitely know how that will turn out: very little possibility of making a new friend. Asking creates the possibility, doesn’t it? From there, it will either work out or it won’t. What I’m asking is this: What are you going to stand for? If you ask this person to do something, is it about working toward making friends? Client:

Yeah, I guess so… Yeah, it is.

Therapist: Then, not knowing whether it will work out, and knowing that it’s possible you may feel rejected—­and that you will certainly feel anxious and worried—­are you 100 percent willing to feel and think all these things and take steps in the direction of making more friends by asking this guy to play racquetball? Client:

Yeah, I’m going to do it, and I’m willing to feel whatever I need to feel.

As you can see, the therapist helped the client be aware of his barriers to committed action. Such barriers can generally be divided into two categories: internal barriers, such as difficult emotions, traumatic memories, fear of failure, or a desire to be right, and external barriers, such as lack of financial resources, lack of connections, an unsupportive spouse, or lack of effective skills. We use “external barriers” to refer to any situation in which a change of overt behavior is needed to address the problem. Internal barriers generally call for acceptance, mindfulness, and defusion, whereas external barriers usually call for setting goals that will facilitate moving in valued directions. Overcoming external barriers often requires hard work and some sort of practice. Change strategies such as skills training, psychoeducation, problem solving, behavioral homework, and exposure are appropriate here as long as they’re targeted at an overt behavioral level. For example, a client may value intimacy in social relationships but lack the social skills to engage effectively with others. In this case, a subgoal could be to engage in social skills training in order to develop these skills prior to engaging in broader goals. At times, it can be hard to differentiate between internal and external barriers. For example, the client statement “I don’t know” may function as an internal barrier that keeps the client from moving ahead, such as when “not knowing” is seen as justifying not engaging in a difficult social situation. However, the statement “I don’t know” could indicate a problem in regard to actual knowledge. In this case, the problem might be solved by taking preliminary steps such as gathering more information about the subject at hand. If in doubt as to the function, you may be able to clarify the nature of the problem by asking the client to gather information. Then you can see whether acquiring information moves the process along. Another indicator provided by this strategy is whether the client pursues

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additional knowledge in a way that’s vital and represents growth. If so, the barrier is probably external rather than internal. Occasionally, a barrier to committed action arises when a goal isn’t connected to the client’s values but is instead a result of avoidance, trying to be right, trying to make others happy, or social pressure (e.g., from parents or the therapist). When committed action isn’t linked to values, clients have little motivation to engage in the hard work of therapy and the process of contacting feared states. If you think this may have happened, your job is to return to the process of defining valued directions, searching for values that are vital, present oriented, and freely chosen by the client.

Highlighting the Qualities of Committed Action Committed action is about the qualities of chosen actions, not the speed with which they are accomplished. What matters most is maintaining growth and forward movement, not the amount or rate of movement. Drawing attention to this can help clients learn to discriminate the sense of expansion generated by committed action from the sense of constriction or loss of choice and possibility generated by avoidance or fusion. For example, an ACT therapist might help a client savor or linger with the experience of the moment when engaging in a values-­based behavior. This serves two functions. First, it increases the chance that any potentially positive reinforcing consequences will actually function as such, and second, noticing the qualities that are intrinsic to values-­based actions can help clients become more clear about what’s important to them, helping them further clarify their values. ACT uses various metaphors about journeying, sports, or growth to help clients recognize the qualities of vitality and growth in their behavior. If clients can discriminate these qualities, they can use them as guides for effective action. The following dialogue demonstrates a metaphor that can be used for this purpose. Client:

I feel as if I’ve been playing it safe for so long, as if I’m always scared.

Therapist: I’d like to share a metaphor and see if you feel it fits the experience you’re talking about here. The metaphor is of a basketball game. There are two basic groups of people at a basketball game: the people in the stands and the people on the court. People in the stands have certain sorts of conversations. They sit there and talk, analyzing the game, trying to figure out what’s happening, cheering sometimes, eating, whatever. They do lots of talking. But, ultimately, how much impact does this have on how the game turns out? Very little, right? Let’s contrast that with the people on the court. The kinds of conversations the people on the court have are all about advancing the game. They aren’t doing a lot of judging and predicting how it’s going to turn out. In order to play well, they’re working on being present, staying fully invested, and moving the game along. The kinds of conversations they have affect the game strongly and make a big difference. And ultimately, they are the ones taking the risks. How the game turns out matters most to them. Where do you find yourself in your own life: Are you sitting in the stands, watching and evaluating? Or are you on the court, working and having conversations that will advance the game? Client:

In the stands.

Therapist: Where do you want to be?

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Of course I want to be on the court.

Therapist: If you were going to be on the court this week, what would that look like? What’s one thing you could do that would let you know you were on the court? The above metaphor might be used if the therapist wants to highlight the qualities of engagement and vitality that are part of values-­based action. In contrast, the metaphor below might be used to help clients discriminate between a sense of expansion versus constriction in the choices they’re making. It also clearly links committed action to willingness. Therapist: (Draws the image at right.) The dominant metaphor of the good life in our society is that life is always supposed to be going up, getting better over time, until the moment you die, preferably in your sleep or some such. I want to suggest that you’ve been following this metaphor without knowing it for a long time, always trying to get better, achieve the next goal, have better self-­ esteem, reduce your anxiety, rack up the next accomplishment, whatever. Okay, that seems about right.

Therapist: In therapy here, we’ve been working on a bit of a different metaphor for what it means to live a good life. This metaphor is more like an expanding circle. It isn’t about things getting better in life, but about how much space you have to live your life in, how much room you have to move around; it’s about having freedom. (Draws the image at right.) The way this metaphor works is that you’re always either expanding or contracting in your life, growing or retreating. And on the outer edge of this circle, there’s always some experience. Part of the time it’s something difficult. Let’s say that for you it takes the form of fearing you’ll panic or go crazy. So, here’s the thought “I’ll go crazy,” and here’s the feeling “anxiety.” Now imagine that in a particular moment in your life, your bubble happens to bump up against these. The question life is asking you at that moment is this: Are you willing to have this—­are you going to say yes to this experience and have it inside you, as part of

Anxiety

Growth edge

Client:

I’ll go crazy

Panic

Life Space

TENSION

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you? Or will you say no, which means your bubble will shrink a little and limit your life space? If you say no enough times, your bubble could get so small that you don’t have much room to live in at all. Now, in this metaphor, some things are always on the outside, always asking yes or no, and life is waiting for you to answer. The question we are working on here is, are you going to say yes or no to life? ACT therapists also help clients discriminate between these qualities in their behavior during sessions. In session, the therapist might notice a shift from client behavior that reflects avoidance, fusion, or reason giving to behavior that embodies committed action (e.g., making a choice to do something life affirming or exploring a possibility) or that involves opening up to fear or judgmental thoughts. In such moments, the role of the therapist is to help clients notice the differences between their experience of these forms of behavior so they can better discriminate between them in the future. For example, a therapist could let a client talk for a minute or so about why she’s stuck in a current pattern of behavior, and then say, “You’ve spent the last couple of minutes talking about all the reasons you’re stuck. As you did this, did you feel freer and more open, as if your life were expanding, or did you feel more stuck, as if the life were draining out of the room? Slow down for a second and check out your experience at this moment before you answer the question.”

Building Patterns of Values-­Based Action Over Time To help clients build patterns of committed, values-­based action over time, it’s best to start small and encourage clients to act more consistently as their willingness increases. It’s kind of like learning to drive a car with a manual transmission. When you’re first learning, every little action is awkward and requires attention: how hard to push down the clutch, which gear to shift into, how to coordinate the release of the clutch while pressing down on the gas, and so on. However, with practice and time, these small patterns of behavior become almost automatic and you only need to attend to the larger pattern. Similarly, supporting clients in engaging in small patterns of committed action is important because when practiced regularly, small behaviors can eventually become automatic and part of larger patterns. One key element of focusing on larger patterns over time is to help clients see how their present behavior influences where their life is heading. The goal is to verbally tie current actions to larger patterns they’re creating and to bring active, intentional valuing into as many moments of their life as possible. For example, part of what leads to drug addiction is that short-­term consequences are a stronger determinant of behavior than the long-­term consequences. Therefore, an ACT therapist working with addiction endeavors to bring long-­term consequences into the moment by helping clients see the larger pattern of behavior linked to drug use and how this behavior relates to their life goals and values. Linking behavior in the moment to larger patterns brings the influence of the latter to bear on current behavior, weakening the influence of short-­term consequences. Consider a situation in which a client with a weight problem is beginning a new program of diet and exercise. Part of the program involves eliminating sugary snacks between meals. After two days, the client has a candy bar between meals. Building larger patterns of committed action requires that this moment be integrated into a healthy pattern. The client may be tempted to quit based on the thought I can’t keep my commitments, which can fuel an ineffective pattern of making a commitment,

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keeping it for two days, breaking it, fusing with the thought I can’t do it, and abandoning it. A more effective pattern would be to make a commitment, keep it for two days, break it, notice the thought I can’t do it, and then renew the commitment and keep it for at least three days. If the client is mindful of the process and chooses the second option, and if he then breaks the second commitment, say after a week, the cycle can continue—­a much more workable approach than abandoning the commitment. Such slips or relapses are a fairly common difficulty in committed action, so we’ll take a more in-­depth look at this issue in the following section.

Handling Slips and Relapses Fusion, avoidance, dominance of the conceptualized future or past, and attachment to the conceptualized self are all heavily supported by our culture at large and therefore tend to be highly practiced by clients, resulting in an ongoing recurrence of these processes. In addition, research has shown that old patterns of behavior, both verbal and nonverbal, are likely to reappear when new patterns of behavior are put under stress or challenged (Wilson & Hayes, 1996). For these reasons, and others, clients are likely to relapse into old patterns of behaving. The job of the ACT therapist is to help clients learn how to integrate relapses into the larger patterns of effective action that they’re trying to build into their lives. One way to approach setbacks is to teach clients to expect them as a part of being human. Relapse often occurs in the form of a return to an old control agenda in the face of negative self-­evaluations, unpleasant emotions, or painful memories. The role of the ACT therapist is to support the client’s deepest wishes and dreams, especially during times when the client is out of contact with them. The therapist aligns with the client’s desires, even when the client’s mind isn’t being supportive, and encourages the client to return to engaging in values-­based action while working with thoughts, feelings, and other difficult private events with acceptance, mindfulness, and compassion. Another approach is to use metaphors related to journeys to emphasize that life is not a perfectly straight road toward continuous improvement, but rather a meandering path—­one that can take a person in a certain direction despite its many twists and turns (see the Path Up the Mountain metaphor in Hayes et al., 2012, p. 332). Detours can be seen either as times the client got off the road or as turns in the path that were chosen by the client. In this metaphor, the client may sometimes even be facing in a direction opposite that intended but still be on the path. This metaphor can help clients give themselves a break when they make mistakes or don’t follow through on committed actions. When clients return to old behaviors (e.g., depressive behavior, anxious avoidance, judgmental and distant interpersonal behavior, addiction), they may find themselves dispirited and confused about what they want in the moment. Such clients have fused with current evaluations, have gotten caught up in worries about the future, are ruminating about past mistakes or regrets, or are living out a story about how their life “should” or “must” be. Clients who have slipped back into old behavioral patterns may think that their values have changed simply because their actions in the moment aren’t taking them in valued directions. While values may change with time, they don’t go away simply because a person fails to live by them consistently. Here’s one way you might address this with a client. Therapist: Given everything that’s happened, it’s not surprising that you feel hopeless and helpless. You feel that you’re unsure about what you want and unsure about what to do. Given this,

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I have one question for you: Have your values changed? What I mean is, a few weeks ago you told me that what’s really important to you is having a good relationship with your wife—­one that’s more connected and intimate. Has that value changed? Is she still important to you, or has going back to drinking resulted in your not valuing that anymore? And if she is still important to you, what stands between you and getting back on track right here and now? The therapist may also want to use a metaphor about what to do when starting to skid while driving. If we find ourselves in a skid and headed toward a telephone pole, the natural thing to do is to turn and look at the object as it comes toward us. But the thing we need to do instead is to keep our eyes focused in the direction we want to head and turn the wheel in that direction. Then the therapist can ask the client, “What would keeping your eyes on the road look like for you in this situation? And how would you know you were looking at the telephone pole?” Finally, therapists help clients prepare for and steer clear of setbacks by identifying high-­risk situations and developing ACT-­consistent plans for dealing with these situations. It’s a good idea to record these plans on paper so the client has a reminder when those situations arise. These plans generally involve applying particular ACT techniques or strategies that the client has learned during therapy. The purpose of therapy is the empowerment of a human life. And that can ultimately be tested only in the world of behavior. Behavior is the bottom line.

Experiential Exercise:

Committed Action Please write your responses to the following questions. Give yourself time to be thoughtful and seriously consider your answers. What would be a bold, values-­based move for you to make in your life? Think big, be creative, and consider taking a risk. Choose something you currently aren’t doing.   What are the barriers to making that move?    

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Imagine what your life would look like if you were to make that move, and describe it here:     Name one thing you could do today that would be in the direction of making this bold move.   See if you can take this one action while intentionally making space for whatever shows up during the action. Once you’ve done so, describe your reactions here.    

Core Competency Practice This section is intended to provide practice in helping clients engage in committed action, with a focus on demonstrating ACT’s core competencies for this process. These exercises take a wider variety of forms than in previous chapters; instructions on how to complete each exercise are provided.

Core Competency Exercises Competency 37:  The therapist helps the client identify values-­based life goals and build an action plan linked to them.

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Key to implementing this competency is recognizing the qualities of effective goals. In the following three exercises, we invite you to consider the client’s goal in terms of the six key qualities of effective behavioral goals within the ACT model (specific and measurable, practical, active, publicly committed to, aligned with client values, and linked to the evidence and a functional analysis). You might want to review the section “Identifying Effective Values-­Based Goals” prior to completing this exercise. Then, for each goal, describe all the problems you can see in it in terms of the six properties. You may find as many as six.

Exercise 37.1 A client with an anxiety disorder wants to begin to face anxiety-­provoking situations by worrying about them less.    

Exercise 37.2 A socially withdrawn client has the goal of calling thirty women each week to ask them out on dates.    

Exercise 37.3 A father states that he’s going to make a commitment to be less critical of his daughter over the next week.    

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Competency 38:  The therapist encourages the client to make and keep

commitments in the presence of perceived barriers (e.g., fear of failure, traumatic memories, sadness, being right) and to expect additional barriers as a consequence of engaging in committed action.

Exercise 38.1 The client is a thirty-­four-­year-­old woman with a lifelong history of panic disorder. The therapist has already worked on the other core flexibility processes with her and has developed a plan during the last session to go with the client to the mall for five minutes to practice willingness to be present with anxiety. The therapist and client have just arrived at the mall when the following dialogue occurs. Therapist: So, are you ready to go in? The only commitment is that you will stay physically present for five minutes. Anything else is gravy. Client:

I don’t want to go.

Therapist: Okay. So notice that thought. What else are you feeling? Client:

My heart is pounding really fast. Can I go home? I really want to leave.

Write here (or in a notebook) what your response would be, demonstrating competency 38:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Exercise 38.2 This dialogue continues with the same client. Therapist: What are you feeling now? Client:

Sick.

Therapist: Where exactly? Client:

In my stomach… There’s a kind of tightness. (Closes her eyes.) Jeez. I’m losing it completely. I can’t even think. I’m losing my mind!

Write here (or in a notebook) what your response would be, demonstrating competency 38:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 38.3 This dialogue continues with the same client. Therapist: What are you afraid will happen? Client:

I’ll just fall down. I can’t go on. I’m going to make a complete fool of myself.

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Write here (or in a notebook) what your response would be, demonstrating competency 38:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Competency 39:  The therapist helps the client appreciate the qualities of committed action (e.g., vitality, sense of growth) and to take small steps while maintaining contact with those qualities.

Exercise 39.1 A fifty-­six-­year-­old client reports that his PTSD is causing him to experience a lot of anger and preventing him from interacting with his children. He fears that his children have come to hate him and reports that they don’t understand what he’s dealing with when he flies into a rage. He’s identified his values in relation to his children and the therapist is now working on helping him identify behavioral goals that are in line with his values. Client:

I’m not going to let my anger push me around anymore. I’m going to make a phone call to my youngest daughter and tell her how I feel about her and that I’m not going to yell at her anymore.

The client has said this several times before in session and hasn’t followed through. As his therapist, you think this is because it’s too big of a step, given his current level of willingness, and you want to help him break the goal down into smaller steps in an ACT-­consistent way.

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Write here (or in a notebook) what your response would be, demonstrating competency 39:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Exercise 39.2 What are two smaller, concrete actions the client could take that would lead him in the direction of his values regarding his daughter and also prepare him for the eventual conversation with his daughter? Action 1:   Action 2:  

Competency 40:  The therapist keeps the client focused on larger and larger patterns of action to help the client act on goals with consistency over time.

Exercise 40 The client is a forty-­seven-­year-­old single man who, in the previous session, contacted a value of wanting to be understood by and have a deep and rich relationship with a woman. His three previous significant relationships were marginal and unsatisfying, with women he felt little connection with or attraction to, but he stayed with them because he didn’t want to be alone. About a month ago, he found himself

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alone after once again fading out of a relationship, in this case with a woman he’d been seeing for four years. His pattern of excessively focusing on issues about money, work, and financial security draws him away from relationships. In the previous session, he made a commitment to write a personal, open, heartfelt personal ad in preparation for participating in a professional dating service. When he arrives at the next session, the following exchange occurs. Therapist: So, how did it go with the ad? Client:

(Speaks quickly.) I wasn’t able to do it. Things blew up at work. All I’ve been doing is working to keep from being overwhelmed.

Therapist: Let me slow you down for a moment. How do you feel as you tell me this? Client:

I…um…okay…I mean, I would have done it if I had time, but I didn’t.

Therapist: That thought—­that you don’t have time—­is that a familiar one? An old one? Client:

Yeah, that happens all the time.

Therapist: And when you follow that thought—­that you don’t have time—­where does it lead you? Client:

Away from what I value. But I really didn’t have time.

Therapist: (Speaks jokingly.) Ooh, there it is again! That passenger on your bus is back! And where does that lead you? Client:

Away… But I don’t know what else to do.

Write here (or in a notebook) what your response would be, demonstrating competency 40:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

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Competency 41:  The therapist nonjudgmentally integrates client slips or relapses into the process of keeping commitments and building larger patterns of effective action.

Exercise 41 A thirty-­four-­year-­old single man who’s been abusing alcohol since the age of fifteen is in his seventeenth session. He’s had several periods of sobriety lasting a few years, but none in the past decade, since his wife divorced him. For the last five years, he’s had no friends and has been living with his parents. His only income is from disability payments related to a diagnosis of schizophrenia he received at the age of twenty-­three. He reports that his family members are jerks and that they take advantage of him frequently, for example, by borrowing money and not paying him back. He isn’t on any medication and doesn’t currently show any symptoms of psychosis. Over the past few months he’s started volunteering at the local humane society and has developed a friendship with a fellow volunteer named James. The two of them have gone to baseball games together three times. He’s been able to successfully make room for his social anxiety and intense fears of humiliation for the past four weeks without drinking. Client:

I…uh…uh…I didn’t do well this week.

Therapist: Didn’t do well? Client:

Yeah, James… He turned out to be a jerk.

Therapist: A jerk? (Pauses.) What happened? Client:

Well, I was supposed to go to the baseball game with him on Saturday, and he never showed. So I went home and got hammered. It always turns out like this. I should just stay home… I’m an idiot.

Therapist: And then what happened? Client:

Well, I kept drinking and didn’t stop until this morning because I was supposed to come in here.

Therapist: And how were you able to do that? Client:

I just did. It’s important for me to keep these appointments.

Therapist: So, where do you go from here with your value of having friends? Client:

I’m done. I give up. It always turns out like this.

Therapist: Yeah, it’s hard to meet people you connect with. It’s going to be painful. Lots of them will reject you. But if you keep trying, you’re more likely to find some who won’t. It seems as if your mind is saying James is one of those who’s rejecting you.

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Yeah, well, he ditched me. I’m tired of trying. I should just go back home and stay there. It’s just not that important. It’s not worth it.

Write here (or in a notebook) what your response would be, demonstrating competency 41:     In your response, how are you conceptualizing the client’s behavior and what are you hoping to accomplish?    

Core Competency Model Responses Competency 37 Exercise 37.1: This goal has strong problems in the area of specificity and measurability. It isn’t an active goal, and the link to the client’s values is unclear. The stated goal doesn’t reflect an empirically supported approach, and the link to the functional needs of the client is unclear. Exercise 37.2: The goal is specific, measurable, and active but impractical. It’s hard to imagine finding that many women to call and making calls at that rate, and even harder to imagine going on the number of dates that could be called for if the client is successful. Smaller steps are needed. It’s also not clear how the goal links to the client’s values. Exercise 37.3: This isn’t an active goal: a dead person could be even less critical than the client. This kind of goal is also unlikely to feel vital or be on target in terms of the client’s values. A more active, vital, values-­consistent goal might be scheduling a father-­daughter dinner at which the client makes a point of telling his daughter how much he loves her and what he appreciates about her. Finally, this goal is neither specific nor measurable. A week later, it could be hard to tell whether he’s accomplished his goal.

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Competency 38 Model Response 38.1a Therapist: And you can leave. But before you choose to do that, would you be willing to watch your mind scream, “I want to leave”? Just listen to it. How familiar is this place? How old is this? Client:

Very old. Very familiar.

Therapist: Good. Let’s take advantage of this moment. Here we get a chance to take an up-­close-­and-­ personal look at something that’s been troublesome for you. What shows up in your body as you hear the words “I want to leave”? Explanation: Never try to stop a client from leaving, especially not physically. It has to be the client’s choice. At the same time, therapists should try to guide clients toward whatever they’ve been avoiding. Every minute that a client stays and goes into the experience a little more deeply is a minute of progress. Small steps are a great opportunity and are in no way a failure. Model Response 38.1b Therapist: We came here to find something. We came to find exactly what’s coming up right now so we can learn ways to do something truly different with it. It’s not bad that fear is here now. So let’s just reconnect with why we’re here. Are we here to not be anxious? Client:

No. But I wish I could be.

Therapist: Right. And attachment to that is the core of the whole system. How much suffering is enough? Have you had enough? Client:

More than enough.

Therapist: Cool. Let’s take a turn right here, right now, in a new direction. Are you willing? Explanation: The barriers appear as problems, but they aren’t; they’re opportunities. Taking the client into them is something new and gives the client an opportunity for growth. Model Response 38.2a Therapist: “Help, I’ve fallen and I can’t get up!” So, would you be willing to lose your mind for a few minutes? Just a few. I’ll be here to rescue you if need be. How would you go about losing your mind? Explanation: Humor is a powerful ally if well timed. In this response, the therapist uses some humor but then returns to the client’s avoidance right away.

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Model Response 38.2b Therapist: So just open your eyes. Look around for a moment. If you’re going to lose your mind, let’s at least see where you are when you lose it. Where are you? Client:

At the mall.

Therapist: Right. And as you notice that, notice who is aware of that. Who’s at the mall? Client:

I am.

Therapist: Right. And notice that you are not the mall. Now go back into those thoughts and feelings deliberately. Notice a tightness. And deliberately think, “I’m losing it completely. I can’t even think. I’m losing my mind.” And, once again, notice who is aware of that. Client:

Okay. I’m here. I’m just having thoughts and feelings.

Therapist: And they are not your enemy. Explanation: In this response, the therapist uses acceptance, defusion, a transcendent sense of self, and contact with the present moment to situate the frightening feelings and thoughts in a different context, one in which they operate differently and need not undermine the client’s commitment. Model Response 38.3a Therapist: Would you be willing to lie down on the ground with me here? Maybe we could both make total fools of ourselves. How could we do that? Explanation: This is an advanced move, but if the therapist is willing to do it and it’s well timed—­and if the therapist can manage the client’s waves of emotion—­going exactly where the client doesn’t want to go can be a powerful move. The client’s urges to move away from difficult experiences can be like a reverse compass: whatever the mind says to move away from is exactly where it’s necessary to go—­with willingness. This can help the therapist identify where exposure practice is needed. Model Response 38.3b Therapist: Super. There goes Mr. Mind again. Elegant. And before we spend more time making fools of ourselves, what else is there to do here at the mall? Client:

Other than have a lot of anxiety?

Therapist: (Chuckles.) Right. And other than watching Mr. Mind scare us. Client:

I could do some shopping.

Therapist: Super. So, let me ask you a question, but don’t answer this right away. Would you be willing to have the thought “I’ll just fall down. I can’t go on. I’m going to make a complete fool of

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myself” and go buy things, if that meant you were now free to shop? Don’t answer. Just sit with the question. And would it be okay if we went and bought something while you considered the answer? Explanation: This is a move in which acceptance and defusion lead quickly to yet another commitment—­a small one, but one that’s probably linked to the client’s values. By asking the client to sit with the question, the therapist facilitates defusion because this guides the client to observe her thinking while simultaneously engaging in action that appears, from a fused standpoint, to depend on the answer to that very question (buying something).

Competency 39 Model Response 39.1a Therapist: I know you’re frustrated right now and want to jump to make big changes. But we’re not here to win a race. What’s more important is making small, consistent steps in that direction, rather than huge heroic leaps. Those tend to be a lot harder to accomplish. What I’d suggest is that we develop some intermediate goals that may seem a bit easier and that would take you in the direction of eventually making a call like that to your daughter. Do you have any ideas for some steps? If not, I could suggest a couple. Explanation: Without blaming or shaming the client or questioning the importance of the client’s value or larger goal, the therapist simply suggests backing off on the size of the commitment while keeping it connected to the client’s values. The size of the step is not important; rather, the focus is on getting the pattern started. Model Response 39.1b Therapist: I can hear the urgency in your voice indicating how badly you want to change how you’ve been with your daughter. You really want to leap into this with guns blazing! I think maybe we can use that energy to our advantage, but we also need to keep the long-­term picture in mind. My sense is that if you really want to make some changes here, it’s going to take time. Yes? Client:

Yeah.

Therapist: It seems we can be pretty sure that your daughter isn’t going to respond the way you’d like right away, and that the relationship is only going to change if you’re consistent in acting on your value over a good bit of time. To do this, it’s probably going to be important to keep your eye on how you want to be with your daughter and let go of how you think she should respond, at least for now. In coming up with a longer-­term strategy, we’ll need to consider a number of goals you might want to have in addition to phoning her and making this commitment to her. Some of these goals may seem easier than phoning her. That seems like a pretty big step right now. I wonder, would you be willing to brainstorm about other

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actions you could take that would lead you in the direction of having a better relationship with your daughter? Explanation: The client seems to be a bit constricted in his selection of possible actions and goals to take him further in his valued direction. Opening him up to multiple possible goals could increase his flexibility and give him more of a sense of choice in the matter. Additionally, the therapist orients the client toward the process of living his value while simultaneously letting go of the outcome. Model Response 39.2 Action 1: Ask the client to make a list of five feelings he has with respect to his daughter. Ask him to practice stating these out loud to his wife before making the call to his daughter, for example, “I love you,” “I feel happy to be around you,” “I feel sad when I get angry and push you away,” and so on. Ask the client to do this practice while being mindful of other thoughts and feelings that come up and making room for them. Action 2: Ask the client to write one paragraph about how he thinks his anger toward his daughter has affected both of them. Ask him to try to let go of any defense and self-­judgments that show up. Have him to bring what he’s written to session the following week so you can review it together. Explanation: These actions, or subgoals, have the qualities of effective goals set forth in this chapter. They’re likely to be helpful in the sense that they give the client a chance to practice approaching avoided thoughts and feelings in a context that hopefully won’t surpass his current level of willingness.

Competency 40 Model Response 40a Therapist: Well, this is a bit tricky because, in some ways, you do know what to do. We’ve been spending time talking about it. The thought “Time is a problem; I’m too busy” appears to keep getting in the way. So, would it be fair to say that knowledge about what to do isn’t standing in your way? Client:

Yeah, that would be fair.

Therapist: So, here we are, reaching an important point in your therapy, asking what sorts of patterns you’re going to build into your life by your actions. What I’m wondering about is what pattern you’re going to build here, with this commitment, in this very moment. Over the last week, you’ve strengthened an old pattern slightly: make a commitment, have thoughts, break the commitment. Right now you have a choice. What kind of pattern do you want to build? Client:

I want to remake the commitment.

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Therapist: Okay. I want us to spend some time getting back in contact with what this is about for you. Are you willing to do that? Client:

Yes.

Therapist: What are you working for here? Client:

I want to learn how to have love in my life.

Therapist: Okay. But what kind of pattern gets in the way of that? Client:

I start focusing on all the things I have to do and gradually my relationships fade away.

Therapist: Similar in some ways to this week, yes? Client:

(Speaks softly.) Yeah. I don’t want to continue that. I know where it leads.

Therapist: So what are you going to do this week? Client:

I’m going to write that ad.

Therapist: And if something comes up? Client:

I’m going to feel however I feel about it, and then write the ad.

Therapist: I’ve got your back. Explanation: The therapist sees that if the client doesn’t recommit to this values-­based goal, he’ll build a pattern of “make a commitment, give up on the commitment.” This is a dangerous pattern when people are trying to create a life in which they can keep their commitments in the face of difficulties. The therapist points out this pattern to the client and suggests that he choose to establish a new pattern that includes recommitting after breaking a commitment. After all, values are a choice and a direction, so they inherently entail recommitting to values-­based action time and time again. Building a pattern of recommitting after a slip is necessary for everyone; we all get off track sometimes. Model Response 40b Therapist: The patterns we’re trying to build are big, but they’re built from tiny moments, like this one, right now. And old patterns are hard to change. But if we can take them moment by moment, we have a chance. So what are you pulled to do right now? Client:

(Pauses.) Explain myself.

Therapist: Good. That’s not new. Right? Client:

(Pauses.) Right.

Therapist: So that’s not it. What else are you pulled to do? Right now. Take your time. Try to look for more subtle things, as well.

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Give up. Get angry. Go to work. (Pauses.) Cry.

Therapist: Perfect. The first three came easily, so they can’t be it either. I’m not sure about that last one. What’s inside that? Client:

I want to have love in my life. I just don’t think anyone really will love me. They’ll all reject me. It will hurt too badly.

Therapist: It may hurt. And this doesn’t? Which would you rather have: the pain of love and loss, or the pain of closing yourself off from what you most deeply desire? Slow down before you answer. You’re building a pattern right now—­right now in this very moment. Explanation: Acknowledging patterns, taking responsibility for them, and constructing new ones may sound like a dry and intellectual process. However, it’s anything but. It’s an active, often emotional process that occurs moment by moment in the present and requires and is enhanced by every aspect of the ACT model.

Competency 41 Model Response 41a Therapist: Yeah, this feeling of it being really disappointing is a familiar one. These thoughts are familiar too, right? “It’s not worth it.” “It’s not that important.” It seems as if these thoughts are trying to protect you from something, right? It’s almost as if they’re saying, “Hey, buddy, we’ll keep you safe. Just hang out with us. Those guys are all jerks anyway.” But let’s check your experience. When you do what these thoughts tell you to do, where does that lead you? Client:

I don’t know… To being alone.

Therapist: Yeah. This thought, “It’s not worth it.” This is an old thought, yes? Client:

Very old.

Therapist: And that’s great because it gives us a chance to break an old pattern, to do something new, really new. Explanation: The therapist doesn’t take the statement “It’s not worth it” as a literal example of what the client would choose, given a variety of options. Rather, she first helps the client gain a little distance from this thought by objectifying it, and then she moves back to the original commitment. Model Response 41b Therapist: Let me ask one thing: as a result of your slip, which of your chosen values has changed? Client:

I don’t understand the question.

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Therapist: Which of your values has changed? Which one is fundamentally different today than it was two weeks ago? Client:

None of them has changed.

Therapist: But notice that your mind is telling you that you have to stop caring about what you care about, that you can’t move in the direction of what you care about. All very old stuff, yes? So, let me ask a second question: What would you need to have or what would you need to let go of in order to turn in the direction of what you value? Client:

I’d have to have the pain of being let down.

Explanation: The logical, problem-­solving mind can’t help but be oriented toward avoidance. But it carries a cost: the client has to pretend he doesn’t care about what he does actually care about. A slip means he can’t be sober. A rejection means he can’t have relationships. The therapist is quickly cutting through this thicket with questions that focus on the heart of the matter, as is called for by this competency.

For More Information For more information about committed action, including exercises and metaphors, see Hayes et al., 2012, chapter 12. You’ll also find a wide range of exercises and metaphors related to committed action in Stoddard & Afari, 2014. For exercises and worksheets related to committed action that you can use for yourself or clients, see Hayes, 2005, chapter 13. For more about functional analysis and behavioral principles as applied to clinical work, see Ramnerö & Törneke, 2008.

CHAPTER 8

Conceptualizing Cases Using ACT

There is nothing so practical as a good theory. —­Kurt Lewin

Learning to conceptualize cases from an ACT perspective is fundamental to the skillful and consistent use of the approach. Developing a coherent picture of how a given client’s behavior is functioning in context will guide you not only in what to do in therapy across time but also in moment-­to-­moment, in-­session interventions. Case conceptualization can range from a formal procedure that includes assessment, history taking, understanding the presenting problem, human diversity considerations, and treatment planning to brief and rapid conceptualization to guide an intervention in a fifteen-­minute encounter in a primary care setting. Regardless of the context, ACT therapists must be able to develop an initial working conceptualization of clients and also engage in ongoing work to keep the conceptualization updated. The key to conceptualizing cases from an ACT perspective lies in understanding the function, or purpose, of clients’ behavior.

Looking Through a Functional Lens in ACT Case Conceptualization In this chapter, our orientation toward case conceptualization is guided by what might be called a middle-­level theory, in which we use language that is only moderately technical compared with a more rigorous analytical account of client behavior. We focus on understanding client behavior in terms of the processes described in chapter 1 that either detract from psychological flexibility (experiential avoidance, fusion, and so on) or promote it (acceptance, defusion, and so on). Case conceptualization can also be conducted using a more technical approach that relies on the principles of operant and classical conditioning, RFT, or other principles from behavior analysis. There are other resources that

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can guide you in learning more about functional analysis, basic behavioral principles, and RFT if you are inclined to understand the theory at that level (e.g., Ramnerö & Törneke, 2008; Törneke, 2010; Villatte et al., 2015). ACT favors the use of general principles of behavior over the DSM-­guided model of diagnosis and treatment and, as such, is a transdiagnostic approach. Case conceptualization from this perspective refers to applying these general principles to client behavior and then using the understanding gleaned to guide the selection of treatment interventions and evaluation of their outcomes. By “behavior,” we mean everything a person does, including thinking, feeling, and sensing, in addition to overt action. All behavior is observed through the lens of ACT’s six core processes, with a central goal of increasing psychological flexibility in the service of the client’s values. From the ACT perspective, when psychological flexibility is present, life experiences (i.e., what behavior theorists call contingencies) tend to lead to effective behavior and a life filled with meaning, vitality, and well-­being (see Kashdan & Rottenberg, 2010). Said more plainly, psychological flexibility allows people to learn from what life has to teach. Therefore, it’s important to explore behaviors linked to psychological flexibility as part of the conceptualization process. For instance, the ACT clinician will want to assess clients’ ability to adapt to various situational demands or modify their behavior when their well-­being is becoming compromised, as well as assessing their capacity to shift perspective or balance multiple desires and needs across a variety of life domains. To that end, conceptualization involves examining the learning history and current life context of clients and thinking through which ACT methods can be used to target the functional processes that may support or reduce the i­ ndividual’s psychological flexibility. In essence, an ACT approach to case conceptualization seeks to answer the following question: What unique factors in a particular client’s life have given rise to her particular problems and led to her specific version of psychological inflexibility and life constriction? In other words, how is the client’s behavior functioning to keep her stuck in suffering and disengaged from living in accordance with her values? With functional analysis, interventions can be selected based on the purpose of the client’s behavior, rather than its form. Less technically stated, understanding the function of behavior means understanding where the behavior comes from (e.g., learning history) and what that behavior is for (e.g., purposes such as escape or avoidance), rather than what it looks like (e.g., specific symptoms). This approach allows for the possibility that different interventions will be effective for sets of client problems that look similar but are functionally distinct. Functional analysis has traditionally referred to the direct manipulation of antecedents and consequences of behavior to observe their function on behavior. In ACT, the term “functional analysis” is typically used more loosely to refer to attempts to understand the function of behavior, particularly in relation to the presence or absence of flexibility processes. For example, a growing body of evidence (Hayes et al., 2006) suggests that most anxiety disorders are maintained, at least in part, by the same functional process: experiential avoidance. In PTSD, clients are attempting to avoid thoughts and feelings related to a trauma; in panic disorder, clients are attempting to avoid the experience of panic (i.e., the thoughts, feelings, and sensations that arise during a panic attack); and in OCD, clients are attempting to avoid obsessive thoughts. (Although PTSD is no longer considered to be an anxiety disorder, it is defined—in part—by experiences of anxiety and fear.) Although the form of what is avoided and how it is avoided can vary a great deal from client to client, the common functional process is experiential avoidance—­escape from internal events. In these examples, behaviors that appear different share the same function.

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Yet it is also true, as just noted, that clients can perform behaviors that appear the same but are functionally different. For example, one client might throw a barbecue for friends to show off and avoid feelings of inferiority, while another client might throw a barbecue because he’s following a rule learned from his father about holiday barbeques and would feel guilty if he didn’t host the gathering. Both sets of behavior are similar in form, and both even appear to be under aversive control, with avoidance or escape from a negative experience maintaining the behavior. However, a third purpose for hosting a barbecue might be to express appreciation for friends and act on values related to connection and community. This is a quite different function, even though the form of the behavior is similar. In this case, the behavior appears to be under appetitive control and is maintained by positive contact with valued ends. In sum, in the ACT approach to case conceptualization, the therapist’s job is to look beyond the particular form of a client’s behavior, whether it be an action, a thought, or a feeling, and to make intelligent guesses, which are then tested in therapy, about the function of that behavior, given the client’s unique life history and context. The therapist works to understand the history that gave rise to the behavior, why it occurs in particular contexts, and what continues to maintain it. This functional analysis is then used to guide the selection of interventions, rather than to provide clients with insight into the meaning of their behaviors.

Functional Thinking as an Ongoing Process As mentioned, in ACT, case conceptualization isn’t solely undertaken early in therapy as a formal process, such as we’ll outline shortly; it also occurs on an ongoing basis throughout therapy. As noted in the core competency practice in chapter 4, when attempting to understand the functions of client behaviors in an ongoing way, it’s useful to conceptualize client behavior at four levels: Overt content: Perhaps most obviously, what a client says can be taken at face value, or literally. For example, if a client says he’s anxious, you can deal with this as a literal report of anxiety. As a sample of the client’s social behavior: Client in-­session behaviors can be seen as samples of their social behavior. Because all therapy interactions are also social interactions, whatever clients do in session may reflect more general patterns of interaction with their social world. (We’ll discuss this further in chapter 9.) For example, a client who’s complaining about anxiety may be showing you how he regulates the behavior of others by talking about being anxious. In terms of the therapeutic relationship: Whatever a client says might also be relevant to the therapy relationship itself. At this level, the focus is on the quality of the therapeutic alliance and includes attention to the client’s feedback about how the therapist is affecting him. Attention to this level requires that the therapist be open to the feedback and aware of ways in which the therapist’s own history and behavior might be contributing to difficulties in the relationship. An example of this level would be if a client makes complaints that subtly communicate therapy isn’t helping, that he wants you to back off, or that he wants you to take the role of an authority in the moment. As a functional process: Client behavior can be analyzed in terms of functional themes. For example, a complaint of anxiety may be a way to avoid discussing another topic.

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Ongoing case conceptualization asks clinicians to actively practice the skill of tracking multiple levels of client communication, listening for all four levels at once. For example, suppose a client who’s usually excessively quiet and compliant says, “Gee, it’s cold in here.” You could consider this in terms of overt content (a report of the temperature of the room); as a sample of social behavior (perhaps this is a step forward for the client in terms of learning to ask for things); as a move in the therapeutic relationship (perhaps the client is asking, “Are you noticing my needs?” or stating, “I’m feeling more equal to you”); and in terms of a functional process (changing the topic to avoid something or using the temperature as a metaphor for emotion or sexuality). Depending upon the broader case conceptualization, the therapist might emphasize responding to the behavior at different levels. For example, if a client has so many interpersonal difficulties that he’s unable to form a productive therapeutic relationship, the therapist may pay more attention to the social behavior and therapeutic relationship levels to develop the client’s psychological flexibility and a strong working alliance. In this event, the case conceptualization might focus heavily on behavior that’s evoked in response to the therapist and that relates to the social and functional aspects of the case conceptualization. Looking through a functional lens means repeatedly asking yourself during session, including in the initial intake and assessment, “What is the client’s current behavior in the service of?” or “What is the purpose of this behavior?” In addition, if you’re seeing the client’s behavior through a functional lens, you should be able to quickly describe the purpose of what you are doing from an ACT perspective and state how this matches your conceptualization of the client. A useful practice for beginning ACT therapists is to pause in session and reflect on these questions: “Why am I doing what I’m doing right now?” “What process am I targeting?” “What is it about what the client is doing that tells me this is a good intervention to be conducting at this time?” A good case conceptualization will guide you to clear and fluid answers to these sorts of questions. If you aren’t able to answer such questions rapidly, you probably need to consider more deeply how your choice of interventions relates to your conceptualization of the client’s problems.

Why Case Conceptualization? Case conceptualization is useful in at least three clear ways. First, it can help you learn ACT theory in a deeper and more nuanced way. Having a thorough understanding of the theory underlying ACT is essential for using it fluidly and flexibly. Practicing ACT case conceptualization can help you see clients’ behavior through a functional lens and aid in developing your theoretical understanding, which in turn will allow you to select, modify, and present techniques to fit the needs of individual clients. Second, solid case conceptualization leads to more focused, consistent, and thorough interventions. This is particularly important for complex, difficult, or multiproblem clients, who often push therapists to the limits of their abilities and frustrate a more linear implementation of ACT. Furthermore, without a good case conceptualization linked to a practical theory, therapists tend to be erratic and unfocused in choosing interventions. Interventions selected in this way can sometimes work, but if they

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fail the therapist hasn’t learned much to inform a decision about what to try next. Practiced and ongoing case conceptualization provides ideas about what to do when a technique fails, falls flat, or misses. If you can assess which functional processes are most important for a particular client, you can be creative, persistent, and flexible in working with various individual processes, interwoven processes, and exercises and techniques that support those processes. Finally, case conceptualization will guide your understanding of and approach to cases across time. Identifying important patterns of behavior to target will help you keep a better focus on those patterns from session to session and allow you to notice which variables affect their occurrence and when those patterns of behavior change. You’ll know where to start, which processes to target in any given session, and how to sequence interventions over the course of therapy. As crucial as this process is, we must point out that the case conceptualization process described in this chapter would be just one part of a more general assessment. It’s also necessary to consider mental status, physical health, family functioning, developmental history, and the like. Indeed, you may encounter clients for whom the flexibility processes aren’t central. For example, a child with problems stemming primarily from a deficit in reading skills that doesn’t involve experiential avoidance or cognitive fusion would be more appropriately treated with an intervention that directly addresses those deficits.

Using Self-­Report Measures to Assess Psychological Flexibility Administering self-­report measures on a regular basis can help you track clients’ progress across time and better understand clients’ perspective on what is changing. Symptom-­focused measures, such as standard instruments assessing the degree of anxiety people are feeling or how much distress they’re experiencing in relation to a trauma, can be informative in terms of understanding the degree of clients’ difficulties and can also tell you something about their functioning. However, we also encourage you to consider using assessments that illuminate client functioning in terms of the flexibility processes. If you see improvements in psychological flexibility and mindfulness over time, then you’ll probably see subsequent improvements in other realms, such as symptom reduction or improved quality of life and functioning (Gloster, Klotsche, Chaker, Hummel, & Hoyer, 2011; Spinhoven, Drost, de Rooij, van Hemert, & Penninx, 2014). If, on the other hand, these measures show no improvements, it’s probably time to revise your case conceptualization, revisit treatment goals (including whether you and the client have the same goals), and adjust the intervention. In the remainder of this section, we’ll provide descriptions of a few key self-­report instruments. For a larger list of ACT-­related assessments, visit http://www.contextualscience.org/act-specific_measures. For a global assessment of psychological flexibility, the Acceptance and Action Questionnaire-­II (AAQ-­II; Bond et al., 2011), is a measure that assesses the degree to which an individual fuses with thoughts, avoids feelings, and is unable to act in the presence of difficult private events. Higher scores indicate greater experiential acceptance and psychological flexibility. Importantly, this measure has been found to mediate outcomes for a number of client problems and disorders. The AAQ has been adapted to a number of populations and translated into many languages. The Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, & Allen, 2004; Baer, Smith, Hopkins, Krietemeyer, & Toney,

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2006) assesses present-­moment awareness, the ability to defuse, and observing without judgment. At the ACBS website, you’ll also find information on measures of values-­based action (some of which were discussed in chapter 6), fusion and defusion, and mindfulness. If you employ self-­report measures of psychological flexibility in your practice, we encourage you to follow general guidelines for using them effectively to monitor progress (e.g., Persons, 2008). We won’t cover those guidelines here, other than to briefly say that they call for comparing scores to norms, charting scores to monitor change across time, discussing the results with clients, not assuming scores are correct but checking them against clients’ experience, reviewing individual items to see if they might lead to additional information, and utilizing all of this information to guide case conceptualization.

Conceptualizing Cases in Terms of Flexibility and Inflexibility Processes The remainder of this chapter sets forth an ACT-­consistent method of case conceptualization in detail and provides a case conceptualization worksheet to structure the process. We’ll guide you through this process of analyzing client behavior with a focus on the flexibility processes and explain how to use this analysis to tailor interventions employing the methods outlined in chapters 2 through 7. We also provide guidance on incorporating other, non-­ACT interventions that could be helpful. The overarching goal in case conceptualization is to help clients move from behavior (including thoughts, feelings, sensations, etc.) that’s relatively rigid, insensitive to context, and disengaged from values to behavior that’s more open, aware, and engaged—­ACT’s three pillars of flexibility.

Overview of the ACT Case Conceptualization Process What follows is a concrete, nine-­step process you can use to conduct an ACT case conceptualization. While you probably wouldn’t use such an intensive process with all of your clients, we encourage you to work through the full process with at least a couple of clients. We’ve received feedback from many readers and trainees indicating that completing this case conceptualization process can deepen and expand clinicians’ understanding of ACT theory and increase the flexibility and fluidity of interventions. You might also consider using the full process when you feel that treatment isn’t progressing for a particular client. Here are the steps, which we’ll explain in detail in the sections that follow. The ACT Case Conceptualization Form we provide later in the chapter is organized around these steps. 1. Identify the presenting problem as understood by the client. 2. Detect rigidity related to private experiences (inflexibility: being closed).

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3. Detect insensitivity to the present moment and limited perspective taking (inflexibility: being mindless). 4. Detect disengagement (inflexibility: disconnection). 5. Consider factors that may limit motivation to change. 6. Consider the client’s cultural, social, and physical environments and their influence on the client’s ability to change (see chapter 11 for an in-­depth discussion). 7. Identify client strengths that can contribute to psychological flexibility. 8. Describe a comprehensive treatment plan. 9. Reevaluate the conceptualization throughout treatment, and revise functional analyses, targets, and interventions as appropriate.

1. Identify the Presenting Problem as Understood by the Client A key focus of ACT early in therapy is drawing out the client’s conceptualization of the problem that brings her to therapy and considering how psychological inflexibility is involved in that problem. A variety of questions can facilitate this exploration: • “How do you see your problem at the present time?” • “How long have you been struggling with this issue?” • “What do you think you need to do to make things better?” • “What are your goals for therapy, and for your life?” • “What have you done to try to deal with or solve this problem?” It often helps to get descriptions of presenting complaints in fairly concrete terms. Open-­ended questions generally elicit more information than closed questions, for example, “If I could hear what you were saying to yourself during an anxiety attack, what would I hear?” or “What do you notice happening in your body when you’re anxious? What are the physical sensations?” In ACT, the general assumption is that many of the things clients have been doing to solve the problem are often part of the problem. As outlined in chapter 2, the therapist’s job involves drawing out the verbal system that has kept the client stuck in the presenting problem (e.g., needing more confidence or better self-­esteem; needing to feel better or stop having negative thoughts, and so on). Although this process informs assessment, it’s also an intervention wherein therapist and client collaboratively gain more insight into the functions of the client’s behavior. To facilitate this, it’s important to take an open, nonjudgmental stance, and to avoid either buying into or challenging the initial formulation presented by the client. From a case conceptualization perspective, the goal is to understand the client’s formulation of the problem and then reformulate that understanding in ACT-­consistent terms.

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As the preceding list of suggested questions indicates, one aspect of identifying the client’s presenting problem is getting a sense of the client’s initial goals for therapy. As you consider these goals in this first step of the process, remember that clients’ cultural backgrounds can affect their goals for therapy (see Step 6). At this early stage, just be aware of this consideration, particularly if a client’s background doesn’t match your own. Clients usually describe a range of goals for therapy, some of which can be considered outcome goals and some of which can be considered process goals. In an ACT formulation, outcome goals refer to desired end states linked to the client’s values, such as having a better relationship with a partner, being more engaged at work, being a supportive and loving parent, living with integrity, developing close and fun friendships, or growing spiritually. Process goals seem to serve outcome goals in the sense that clients think attaining their process goals will make it possible to achieve their outcome goals. Clients often put forward process goals such as reducing anxiety (e.g., “I need to be less anxious so I can meet new people”); being less self-­critical (e.g., “In order for me to be close to people, I need to stop comparing myself to them”); having less pain (e.g., “I can’t do the things I used to do because it’s too painful”); and feeling less depressed (e.g., “I can’t reengage in life until I get past this depression”). Some clients initially appear to lack goals, as reflected by statements like “I don’t know what’s wrong with me. I’m useless and can’t do anything right.” However, further exploration often reveals that they’re attached to process goals: “If I didn’t have this depression, then maybe I’d feel better. But that’s not possible.” What appears to be a lack of goals is actually unclear values coupled with fusion with stories about the hopelessness of achieving process goals, leading to a lack of outcome goals. In the ACT view, that kind of linkage between process goals and outcome goals is often a key part of what’s keeping clients stuck, and this linkage therefore must be targeted during therapy. An ACT reformulation usually focuses on helping clients live better and feel better (i.e., get better at feeling) while reducing the emphasis on feeling good. At a deeper level, any reformulation must be consistent with the client’s most cherished life goals and values (the outcome goals) and be detailed enough to create a treatment contract focused on initial goals and methods of treatment. Clients typically identify negative feelings, thoughts, memories, or sensations as the problem. In ACT, these “­problems” are fundamentally reformulated in the case conceptualization. The target becomes the client’s relationship to these experiences (e.g., not wanting them, being overly attached to them, or having rigid rules about them), rather than the experiences themselves. For example, a client may come into therapy complaining, “I don’t care about anything anymore. My relationships are terrible, and my job sucks. It’s hopeless.” This complaint might be reformulated as “The client undermines close relationships and work commitments in an effort to avoid feelings of rejection and failure.” In other words, pushing people away and underperforming at work function to avoid rejection and failure. As another example, a client may come to therapy with the presenting complaint “I want help feeling better about myself. I need to have higher self-­esteem.” An ACT reformulation here might be “The client is fusing with negative evaluations of self, and as a part of that process, declines opportunities to expand social engagement.” In other words, being fused with negative thoughts about the self functions to keep the person from developing meaningful relationships. Finally, you’ll want to score and review any self-­report assessment measures given to clients, considering their current level of psychological flexibility, mindfulness, and defusion as you begin to collate information about their situation. You might consider using such measures as part of the exploratory process with clients.

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2. Detect Rigidity Related to Private Experiences Clients often identify difficult private experiences as part of their presenting problem. It isn’t unusual for clients to be experiencing a combination of avoidance and fusion that has gotten them stuck in psychological or behavioral rigidity. (This is the first pillar of inflexibility: being closed.) Clients are often avoidant of thoughts, feelings, memories, sensations, and situations or fused with thoughts in ways that lead to limitations or excesses in behavior. Such avoidance and fusion may be obvious in many cases, but sometimes you may have to do a bit more exploration. This is also the time to start looking through a functional lens to see how these behaviors are operating in the client’s life. For example, you might ask, “What do you do when you feel anxious?” as a means of exploring the client’s forms of escape behavior. Or you could ask, “Can you give me some examples of what happens to you before, during, and after an anxiety attack?” to better understand the antecedents and consequences of the behavior. Usually, both therapist and client need to develop their ability to track the particular patterns of behavior that are leading to rigidity in the client’s life. Recording avoidance behaviors and fused thoughts formally as part of your case conceptualization can help you begin the work of planning treatment and selecting ACT interventions. At this early point, the purpose of recording the content of avoided or fused content is not to change or modify that content, but to make it available for use later in treatment as a target for experiential learning focused on increased acceptance and defusion. Nonetheless, at this point you may be able to identify acceptance and defusion interventions that could be effective for the client.

AVOIDANCE Avoidance of experience, which shows up as efforts to decrease, eliminate, or otherwise control emotions, thoughts, or sensations, is one of the more prominent forms of psychological rigidity. A great deal of suffering is found in the denial of pain. In addition, experiential avoidance often creates a self-­ amplifying loop, leading to additional suffering. Clients may report intense anxiety related to the experience of anxiety or even imagining anxiety. Experiential avoidance takes many forms, including overt behavior, internal verbal behavior, or a combination of the two, and is a key component of case conceptualization. At times, you may see patterns of avoidance behavior directly in session, and at other times you may have to rely on client reports. Here are the three primary types of avoidance to look for, with examples of each: • Internal avoidance behaviors: distraction, excessive worry, dissociation, attempting to think differently, daydreaming • Overt emotional control behaviors: drinking, using drugs, self-­injury, thrill seeking, gambling, overeating, avoiding physical situations or physical reminders • In-­session avoidance behaviors: changing the topic, being argumentative or aggressive, dominating the conversation, dropping out of therapy, coming to sessions late, always having an acute crisis that demands attention, arguing against feedback, focusing exclusively on the positive

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In assessing these experiences for your case conceptualization, it’s important to look beyond content and notice patterns of behavior, for example, when a question goes unanswered. Avoidance also shows up in body language. Pay attention to the client’s gestures and body language, including such things as looking away when asked about difficult topics, smiling during moments of sadness, sitting with shoulders slumped, fidgeting, and so on. By extension, changes in such body language can be an indicator of change during treatment, such as when a client no longer smiles when feeling sad. In some cases, avoidance behaviors may not occur at the beginning of therapy, but you might be able to predict them based on behaviors that are functionally the same, allowing you to address them before they happen. For example, imagine you discover that a client has the tendency to flee relationships when he begins to feel threatened by intimacy. In order to decrease his risk of dropping out, you might have a conversation at the start of therapy in which you predict the appeal of dropping out, casting it as experiential avoidance and talking about what the client could do instead of leaving therapy should this arise. Finally, assess the pervasiveness of experiential avoidance in the client’s life. Is it a major controlling variable for behavior across most domains of the client’s life or only a few? Or is the client’s life consumed by experiential avoidance to the extent that almost everything the client does is tied to it?

FUSION Fusion works together with experiential avoidance to create psychological rigidity. We humans don’t just avoid uncomfortable thoughts, emotions, sensations, and memories; we constantly talk to ourselves about this process. We create stories about why we’re having these experiences (reason giving) and explain, justify, and link our actions to these reasons. Sometimes we develop plans and goals that focus on experiential avoidance. We can get so caught up in this conceptualized world that we miss our experience of life in the here and now and all of the opportunities it affords. A more rigid form of cognitive fusion can be seen in clients who come to therapy with a strong belief that unworkable control strategies will eventually work or who continue to engage in unworkable strategies despite being aware that they aren’t working. If you see this, it’s important to address it early in therapy through creative hopelessness interventions targeted at undermining strong beliefs about the ultimate workability of these strategies. Another highly fused pattern occurs when clients are attached to excessively logical or rigid thinking patterns. For some clients, this can take the form of a strong attachment to being right, even at significant personal cost. For others, it may manifest as a great deal of reason giving for their behaviors or having an excessive focus on understanding or insight. Some clients tend toward overconfidence in their evaluations of themselves, others, or situations. They may then hold rigid expectations of themselves and others despite the unworkability of these expectations. The primary interventions for this pattern of behavior include undermining reason giving through defusion strategies, reducing attachment to the conceptualized self, and helping clients examine the costs in terms of their vitality and life direction. Another type of fusion with thoughts that may show up early in therapy and inform case conceptualization is clients’ evaluations of themselves, their experiences, or their situations. Typically, these kinds of thoughts include self-­judgments such as “I’m worthless” or “I’m incompetent,” which are often stated as part of the presenting problem. That said, fusion with some forms of evaluation can be tricky

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to detect, as it’s presented not as a thought but as an implicit characteristic of whatever is being described (e.g., “I have social anxiety”). If a client tends to focus strongly on the behavior of others or chronically engages in avoidance, it can be hard to find key targets for defusion. For example, a client who doesn’t call a friend to ask him to get together may do this to avoid thinking he’s a loser and having the feelings that could arise if his friend were to say no; however, he may explain that he simply was unable to make the call. In this example, fusion with the self-­concept of “loser” is probably an important target to identify in the case conceptualization, but it may not be disclosed unless the therapist inquires about it. So if a client avoids particular situations or people, try to uncover the feelings, thoughts, or other experiences associated with it that may be difficult for the client. This can illuminate “hidden” fusion. Fusion can occur with other kinds of thoughts, beyond judgments and evaluations. A client might be fused with rules, rigidly following them to the point of suffering. For example, a client who strictly follows a learned family rule that anger is not allowed may find it difficult to stand up for herself when necessary. Or a client following the rule “I must be happy” may find himself unable to conform with the rule after repeatedly encountering disappointment. Ultimately, the key to detecting fusion in clients involves noticing when their thinking leads to rigid and inflexible patterns of behavior that generate suffering and interfere with values-­based living, and for whom there is little or no awareness of the distinction between the person and the mind. Lastly, be aware that clients can become fused with positively evaluated thoughts in ways that are problematic, even though such thoughts typically aren’t presented as a problem. For instance, a client who’s fused with the thought “I’m better than others” may find himself struggling in the social world.

KEY CONSIDERATIONS IN ASSESSING AND WORKING WITH AVOIDANCE AND DEFUSION Here are some questions to consider as you assess for avoidance and fusion and choose interventions to target these processes: Of the various private experiences identified in the case conceptualization, which are most central and important to target? Which private experiences lead to the most rigid and problematic patterns of avoidance? Which patterns of avoidance tend to be the most problematic in terms of creating suffering or interfering with flexible, values-­based behavior? Are there particular evaluations of self or others that structure how this client responds to herself, or rules that this client tends to follow in a rigid or inflexible manner? If so, what exercises, metaphors, or techniques would be best for working with this particular client’s behavior? If you identified avoided situations, do you know what thoughts the client fuses with in those situations and what emotions or other private experiences she tends to avoid? If not, how can you investigate this further? Are there any in-­session forms of avoidance or fusion that you need to attend to because they may threaten the therapeutic relationship itself? If so, what can you do to address these possibilities?

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Does the client display gestures, body language, or vocal qualities (e.g., tone of voice, pace) that might point to hidden avoidance or fusion? If so, what are they, and have you explored the client’s present-­moment experience when these behaviors occur? How are you affected by this client’s avoidance or fusion? Are there any moments that are particularly difficult for you with this client? What might this tell you about the client? What might this tell you about what you need to do or techniques you might need to use to maintain your psychological flexibility with this client? Is there anyone you might want to consult with about the reaction you’re having?

3. Detect Insensitivity to the Present Moment and Limited Perspective Taking The third step of this case conceptualization process focuses on tracking patterns of insensitivity to events occurring in the present moment that might influence the client’s behavior, difficulty with shifting perspective, or an inability to take perspectives other than self-­as-­content. (This is the second pillar of inflexibility: mindlessness.) Clients who are focused on what happened in the past, who are persistently worried about the future, or who have little self-­awareness or perspective on the self may repeatedly suffer due to reliving past pains and worrying about imagined futures or from consequences of this behavior. In addition, clients who have a reduced capacity to observe themselves, others, and situations from different points of view run the risk of clinging so tightly to a single point of view (e.g., “I’m a failure”) or identity (e.g., “I’m a soldier”) that flexibility is compromised, potentially leading to consequences that intensify suffering. In short, being out of touch with the present moment or being attached to conceptualized selves can lead to limitations or excesses in behavior.

LACK OF CONTACT WITH THE PRESENT MOMENT There are three primary types of behavior patterns related to lack of contact with the present moment to be considered when conceptualizing a case. First, clients may poorly track their ongoing, moment-­to-­moment experience. They may generally be unaware of what they’re thinking, feeling, or sensing in the moment, or if they are somewhat aware of these experiences, they may lack the ability to put words to them. This can take a variety of forms, from an alexithymic client who says he doesn’t have feelings to a client who responds to all questions about what she’s feeling by saying, “I’m stressed.” Such clients may provide socially acceptable but hollow answers that are unrelated to their current experience or what’s happening in therapy. One sign of this would be if you believe you’ve observed an emotional reaction in a client but, upon inquiry, the client is unable to describe feeling anything. Clients exhibiting such patterns of behavior tend to stay at a conceptual level in therapy and rarely use emotional terms, particularly in response to their current experience. You can address this issue by naming emotions when possible or by catching clients’ emotions in flight and helping clients slow down enough to contact these experiences. You can also invite clients to notice sensations or experiences in the body (e.g., heaviness in the chest). In addition, you

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might consider using mindfulness techniques and experiential exercises to promote in-­the-­moment experiencing of emotions. Second, lack of contact with the present moment can show up as a narrowness of focus, with inattention to the broad range of events in the environment. For example, such clients may not notice that you have a new pair of glasses or that your office has changed, or they may frequently ask you to repeat yourself. Exercises targeted at contact with the present moment, including simply observing and describing current experiences in a relatively safe context, will help such clients learn how to track their ongoing, moment-­to-­moment experience and allow them to open up to other relevant contingencies that could shape their behavior. This might include focusing on bodily sensations and experiences in the here and now, as well as Gestalt-­type exercises that allow clients to take a closer look at their experience by describing bodily sensations, emotions, and thoughts. You can also recommend exercises designed to increase regular contact with the present moment (e.g., daily mindfulness practice). It’s often effective to help clients become more mindful during situations in which they’re trying something new or experiencing a difficulty; this might entail approaches such as diaries or worksheets for tracking private experiences and difficulties in the moment or in-­session experiments in which difficult private events are brought into the room and clients notice how they react. Finally, clients who are excessively caught up in the conceptualized past or future tend to engage in patterns of pervasive worry, anticipatory fear, resentment, or regret, all of which function to block constructive behavior. This will generally be exhibited in reports of events that occur outside of therapy, but it can be seen in session when clients repeatedly engage in lifeless storytelling or cycles of ruminative thinking. For such clients, extensive work may be necessary to help them practice contact with the present moment, in and out of session. You may need to frequently interrupt them (after a discussion about why this is important) and bring them back to what’s happening in the moment. To that end, you might engage such clients in brief mindfulness exercises that help them be more aware of their present-­ moment experience at the start of each session and during sessions as needed. Consider identifying feared, evocative content at the end of the “worry chain” or identifying uncomfortable past memories linked to regret, and then conduct imaginal or in vivo exposure or willingness exercises using these scenes or related stimuli, in combination with a focus on values and perspective taking. It will also be important to help these clients develop a sense of self-­as-­context, as described in the next section, so they can observe their thoughts about the past or future without buying into them or rejecting them.

ATTACHMENT TO THE CONCEPTUALIZED SELF People can live so tightly within their self-­concepts that they lose contact with the experiencing self. Clients may get trapped in notions of who they are and, in trying to live up to their own or others’ ideas of themselves, pay great personal costs. This particular kind of insensitivity is often linked to fusion, as clients get drawn into defending the conceptualized self as if it were their physical self. This can lead to behavioral rigidity and trap them in patterns of living that are limiting and unworkable. In conceptualizing cases, consider how strongly attached clients are to particular roles. For instance, if you’re working with a war veteran who’s complaining about how others don’t follow rules, you might consider whether the client is overly attached to the identity “soldier.” Is he a soldier at work, at home, and in play? Is he a soldier in his relationship with his wife and children? Is he a soldier in all aspects of his life? If the answer is yes, then he’s probably found himself in unworkable situations with respect to rule following. If clients are unable to observe that they are more than a single or small subset of roles

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or identities, it will be helpful to work on flexible perspective taking and contacting the perspective of self-­as-­context—­in other words, the self as experiencer of these roles. If this isn’t addressed, it may continue to interfere with clients’ flexibility in bringing their personal values to life. Attachment to the conceptualized self can also be observed in clients who are strongly identified with a particular view or story about themselves or others. For example, a client can be very attached to a description such as “I’m cheerful…peppy. I bounce back.” Although this self-­assessment is seemingly positive, it can be a problem if the client distorts or interprets events to make them consistent with this conceptualization, rather than acknowledging and addressing situations in which she didn’t act cheerful or bounce back. Alternatively, clients can be wedded to a self-­concept such as “I’m broken, defective, and weak” and defend this conceptualization and the story that supports it, despite its superficially negative form. Another manifestation of attachment to conceptualized self shows up when clients are unable to consider alternative perspectives on their problems or the possibility that others may have views that differ from their own. A considerable amount of experiential work on self-­as-­context and perspective taking, blended with defusion, may be necessary to address all of these types of attachment to the conceptualized self. In particular, the therapist needs to work on differentiating primary, directly observed qualities of events (descriptions) from secondary, verbally derived qualities of events (evaluations). The client can be asked to take on different perspectives, acting out different roles or self-­concepts, or be invited to contact a felt sense of self that is larger than experiencing. Other aspects of this work include helping such clients develop more compassionate ways of responding to themselves by connecting with the experiences of others and seeing themselves as part of something larger than themselves. All of these approaches are aimed at freeing clients from limiting roles and self-­concepts, which will make choice and behavioral flexibility more available. A final consideration pertains to clients with chronic and pervasive problems as well as those with an extensive history of trauma. Such clients often come to therapy with a strong belief that they can’t change or that a better life isn’t possible for them, combined with a strong attachment to a life story that supports this belief. This can be combined with an identity that is defined in simplistic or black-­ and-­white terms (e.g., “I’m weak,” “I’m evil,” or “I’m broken”). It can also appear as a victim stance that manifests in frequently blaming others for the client’s actions. For these clients, it’s particularly important to engage in defusion and self-­as-­context work targeted at undermining attachment to limiting life stories. Without directly challenging such life stories, you can help clients examine the cost of following the story (e.g., in terms of living a full and meaningful life) and determine whether they want to continue this pattern. Consider autobiographical rewrite exercises (see Strosahl et al., 2004). Also conduct behavioral experiments to see whether even small changes could occur. Later in therapy, you may want to consider working more directly with forgiveness and victimization (Walser & Westrup, 2007).

KEY CONSIDERATIONS IN ASSESSING AND WORKING WITH LACK OF PRESENT-­MOMENT AWARENESS AND SELF-­AS-­CONTENT Here are some questions to consider as you assess for lack of present-­moment awareness and attachment to the conceptualized self and choose interventions to target these processes: In what life situations or contexts does this client most lose contact with the present or get caught up in self-­as-­content, both in and out of session? How can you target those contexts?

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Are there particular moments in therapy when the client seems to lose contact with the present moment (or when you can anticipate that happening), for example, by ruminating about the past, worrying about the future, or being insensitive to your presence? What can you do to more regularly notice those moments and respond to them? Does the client have particular stories about the self or others that tend to lead to the most restricted patterns of living? When do these tend to show up? What strategies can you use to address attachment to these stories? When do you tend to leave the present moment with this client? For example, when do you begin to zone out, get caught up in content, passively listen, or otherwise lose an experiential learning or present-­moment focus? What might this tell you about what you need to do or techniques you might need to use to maintain your psychological flexibility with this client? How can you remind yourself to do those things?

4. Detect Disengagement ACT is fundamentally about helping clients create full, meaningful, vital lives. In therapy, this work is accomplished by helping clients clarify their values and supporting them in making and keeping behavioral commitments tied to those values. Thus, in a complete case conceptualization, the therapist should consider a broad range of life domains (e.g., family, health, relationships, spirituality, and work) to get an overview of the client’s functioning, learn about what’s meaningful to the client, and identify behaviors that would instantiate the client’s values. The completeness of this part of the conceptualization will vary depending on the context of the intervention and the extent to which values are a focus of treatment. For example, if values only become a major focus later in treatment, your case conceptualization in this regard might not be fully fleshed out initially. Nevertheless, even in very brief treatment it’s important to give some consideration to areas in which behavior is excessively narrowed or in which valued living is highly constricted. When people respond with avoidance and fusion, are overly identified with the conceptualized self, or are out of contact with the present moment, their behavior tends to become excessively rigid and narrow, resulting in a lack of flexibility in engaging in values-­based living. (This is the third pillar of inflexibility: disconnection.) Behavior that isn’t working may persist, and conversely, in areas where persistence is needed, behavior may change impulsively. It’s common for clients to be so thoroughly adjusted to these patterns that they no longer notice them. Clients’ time and energy may be primarily oriented toward relief from psychological pain, resulting in a loss of contact with their values and values-­based action.

UNCLEAR VALUES There are a number of different strategies you can use to discover and delineate values. However, it may take time to explore values and committed action sufficiently to get a clear understanding of a client’s disengagement in these areas. At an extreme, clients may have completely abandoned some or all of their valued life domains. Alternatively, their engagement may be excessively narrowed, inflexible, or inconsistent. This may result in limited effectiveness, expression, or vitality. These actions exist

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on a continuum, so be on the lookout for subtle forms of these processes. For example, two quite different dynamics could be maintained by avoidance of vulnerability: one client may cut off any sort of interaction with potential romantic partners, whereas another has a partner but engages in the relationship in a superficial or limited way. Clients who struggle with these processes may be unable to describe what they want, be unclear about what holds meaning for them, or engage values in a way that’s heavily socially determined or influenced by the presence of the therapist or other major figures in their lives. When clients’ behavior is dominated by pliance, or following social rules because of a history of being reinforced for rule following, they often present as motivated and seek to be “good” clients. Their behavior tends to be oriented toward “shoulds” and looking for the “right” answer to the therapist’s questions. What they want in life may be drastically influenced by the person to whom they are currently responding. In conducting values clarification with such clients, closely track your own behavior and do your best to remove cues that could seem to suggest what the right thing to do is or what the best values are. It may be necessary to help such clients gradually build their ability to contact and describe their needs and desires. Some clients’ behavior may be so dominated by escape and avoidance that they’re unable to articulate goals and values that are heartfelt or meaningful. Alternatively, clients may describe tightly held but unexamined goals (e.g., being popular or making money) as if they were values. To the extent that clients’ behavior is tied up in experiential avoidance, they will have a hard time saying what they really want in life because doing so produces a sense of vulnerability. You may need to devote additional work and attention to helping such clients clarify and develop values that are solid and strongly held. Here, it’s important to contrast their current life direction with their values-­based directions, to help them engage in committed actions that reflect their values, and to assist them in examining the costs of engaging in behaviors that are rewarding only in the short term. The key is to bring the extended verbal consequences related to values into the present moment so those consequences can more actively influence clients’ behavior in situations where avoidance is likely, allowing longer-­term desired qualities to exert greater control over their behavior. Creative hopelessness exercises can be helpful here. Other helpful interventions include focusing on the most important areas of clients’ lives, particularly domains in which they experience a lack of engagement, choice, or vitality. It may be useful to initially target one or two domains in which a client’s behavior is most narrow and inflexible and wherein this constriction appears to result in ongoing suffering. You’re more likely to have leverage for facilitating behavior change in these domains.

LACK OF COMMITTED ACTION In part because of experiential avoidance, clients can develop ever-­larger patterns of action that are detached from their long-­term goals and values. Behavior is narrowed to getting by or surviving the moment, rather than broadened toward building a life that would be more rewarding, meaningful, or workable in the long run. In such cases, clients are typically less sensitive to learning opportunities and the possibility of putting their values into action in the here and now. Their disengagement can take many forms, including low quality of life and impulsive or self-­defeating behaviors. For these clients, your case conceptualization should include a description of how their behavior is constricted in the life domains you explore. Finally, it can be helpful to ask, “If a miracle were to occur and you could do what

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you wanted, what would that be?” Clients’ answers provide a good starting point for beginning to understand which behaviors to target for committed action goals. As you assess whether clients are disengaged from healthy action (stated this way to include impulsive behavior), you may learn that a client’s life is relatively free of the acute experience of pain, but also fairly narrow and unsatisfying. This pattern is often seen in clients who feel stuck in unsatisfying jobs or relationships due to fear of the unknown or of the consequences of change, and in clients who have chronic physical pain. Clients with this pattern will benefit from learning about the qualities of committed action, such as holding goals lightly, and from focusing on the process of living rather than on the outcome of particular actions. Working with clients to clarify the distinction between choices (freely made or selected simply because they can be) and decisions (made after the pros and cons have been weighed) can free them to make new or different choices, rather than continuing to live out old stories. When clients are engaged in novel actions, you can provide support by helping them develop a mindful, nonjudgmental, compassionate, and accepting stance toward themselves in those situations. Finally, paying attention to whether clients engage in impulsive or self-­defeating behavior is important. Avoidance behaviors result in powerful short-­term reinforcement, which can overshadow behavior that’s ultimately more workable but potentially more painful in the short run. This dynamic can show up as chronic self-­control problems, such as impulsivity, substance use, aggression, or risky or self-­injurious behavior. Clients may have problems delaying gratification or have an extremely low tolerance of difficult emotional experiences. Impulsive clients tend to have limited practice in engaging in planned, step-­by-­step patterns of action, and this can show up in many ways—­procrastination, underperformance, poor health behaviors, and difficulty completing homework in therapy, to name a few. When such clients begin to engage in committed action, start small and reinforce them for being willing to commit and for following through, no matter how small those initial actions may seem. Additionally, when such clients are disengaged from values-­based behaviors, or are engaged in impulsive behaviors or inflexible behaviors in session, turning the focus to contact with the present moment, acceptance, and defusion can help them develop greater flexibility to persist in or change their behavior as required by the situation.

KEY CONSIDERATIONS IN ASSESSING AND WORKING WITH UNCLEAR VALUES AND LACK OF COMMITTED ACTION Here are some questions to consider as you assess for unclear values and lack of committed action and choose interventions to target these processes: When you talk to the client about valued areas of living, how much do the four qualities of effective values conversations show up (i.e., present-­moment orientation, vitality, choice, and willing vulnerability)? What does this say about what you need to do with this client during values conversations? Which exercises or metaphors might be most useful? What’s getting in the way of fostering these qualities? What qualities do you need to bring to these conversations as a therapist? How much should you focus on values early in treatment? Would it be better to focus on other processes first? What can inform this choice?

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Which domains of valued living should be targeted first? How can you work collaboratively with the client to identify which should be the initial focus? How can the two of you begin translating more of the client’s values into practical action steps? What sort of changes in this client’s life would be most meaningful or inspiring to you as a therapist? Does this align with the client’s goals? If not, what does this say about the client or about your relationship? What might you need to do or understand in order to address this discrepancy?

5. Consider Factors That May Limit Motivation to Change As you assess the preceding inflexibility processes, also consider the client’s motivation to change. For example, experiential contact with the costs of avoidance is essential before doing acceptance or exposure work that requires significant motivation. For clients who aren’t in contact with the costs of experiential avoidance, and especially if their values are unclear, it can be helpful to begin with a heavier than usual focus on values and then to examine the discrepancy between clients’ current behavior and their personally meaningful life directions and goals. It also can be helpful to link work that requires significant motivation to valued goals and relationships. For example, you could ask, “If allowing yourself to feel anxious could make it possible for you to be the kind of teacher you really want to be, would you be willing to feel anxious?” Another kind of motivational problem occurs when clients are strongly attached to fears about the consequences of confronting challenging events. This may call for focusing on defusion and self-­ as-­context prior to any work that involves facing feared situations. Be sure to titrate exposure or willingness exercises to a level at which the client is willing to experience them fully and without defense. Small steps with 100 percent willingness are much better than white-­knuckling it through larger steps. Research has shown that the therapeutic relationship can be a powerful motivator for change. In the ACT model, relationships are built using flexibility processes (something we’ll discuss at length in chapter 9). In assessing the quality of the therapeutic relationship, look for signs that the client is present, caring, and engaged, as well as signs that the client feels coerced or misunderstood. If you detect any problems, check on the integrity of the therapeutic contract. Are you and the client working toward agreed-­upon goals, or is there a mismatch between your goals and the client’s? Consider your level of commitment to the client. Are you lacking investment, or do you feel distracted when working with this client? Also consider whether the client is triggering emotions or thoughts that are difficult for you. For example, are you engaging in avoidance and undermining the relationship yourself? If your own reactions are a cause for concern, generate an action plan that addresses those reactions (e.g., consultation).

6. Consider the Client’s Environments and Their Influence on the Client’s Ability to Change Clients do not live in a vacuum. You need to know whether any of the ACT-­relevant processes that apply to the individual are being played out at the cultural level (discussed in chapter 11), social level,

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or even the physical level. Clients may be reinforced for engaging in behaviors that promote the status quo in many realms: financial, social, cultural, familial, and institutional. For example, a client may be motivated to remain disengaged in order to keep receiving disability payments; a client’s spouse may find change on the client’s part difficult and therefore be unsupportive; or an addicted client may not have any friends who are sober. Considering how cultural, social, and physical environments bear on an individual’s case may influence decisions around committed action. If possible, consider direct interventions that could change the environment either by engaging people who can support the client in new behaviors or by directly reducing behaviors that impede growth (e.g., engaging in couples therapy if the client’s spouse is unsupportive or fearful, referring to support or therapy groups, or including important people from the client’s social network in therapy).

7. Identify Client Strengths That Can Contribute to Psychological Flexibility Be sure to explore whether clients have engaged with past difficulties in ACT-­consistent ways. Sometimes these previous experiences can be used to catalyze rapid change in therapy. Past experiences of acceptance, mindfulness, and committed action can serve as models for how the client might behave in the current situation. Drawing parallels between the current struggle and a struggle the client previously overcame can facilitate transferring useful action tendencies and perspectives from the past event to the new one. If a client has had positive experiences with mindfulness, 12-­step programs, spirituality and religion, or other approaches that appear to conform with the ACT perspective, you can explicitly link current experiences to these. For example, if a client practiced letting go of a struggle with uncontrollable thoughts, memories, or feelings in the past and had positive results, or if a client has evidenced a healthy sense of humor or irony regarding a past difficulty, you can bring these experiences to bear on the current situation in a helpful way. Likewise, sometimes effective behavior in one life domain can serve as a template for effective behavior in a domain in which the client’s current behavior isn’t as effective. For example, a client may have facility with acceptance or mindfulness, or with setting step-­by-­step goals and following through in one domain (e.g., work) but not in another (e.g., relationships). The domain in which this skill is strong can serve as a template for action in the other domain. Or a client may have a prior experience of setting out in one direction and then switching course to another, more rewarding direction. Such experiences can be used as models for acceptance, flexibility, and persistence in moving in a valued direction.

8. Describe a Comprehensive Treatment Plan After completing steps 1 through 7, you should have the information you need to develop an ACT-­ consistent treatment plan. Although most treatment plans address all six flexibility processes in some fashion, the level of emphasis on each process should be tailored to the case conceptualization. As you complete this section, we recommend reviewing steps 1 through 7 of the case conceptualization, particularly the treatment implications.

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Finally, as part of your treatment plan, you may want to incorporate the following types of resources: • Find and adapt a specific, relevant treatment manual that has been shown to be effective with this type of client (see http://www.contextualscience.org/treatment_protocols or various ACT books). • Obtain flexibility process and outcome measures, determine which are relevant, and score, record, and interpret as appropriate (see http://www.contextualscience.org/act-specific _measures). • Identify resources available to the client to support treatment: financial, vocational (e.g., training or education), or social (e.g., family therapy, couples therapy, spiritual guides or ministers, mentors or advisors, support groups). • Consider other compatible techniques and treatments that may be relevant but aren’t obviously theorized about in ACT (e.g., contingency management, cue exposure, education). • Determine whether the client has life skills deficits. If so, consider direct change or education efforts (e.g., training in social skills, time management skills, study skills, assertiveness skills, parenting skills, or problem-­solving skills).

9. Reevaluate and Revise the Conceptualization Throughout Treatment As discussed earlier in this chapter, case conceptualization is not a process that ends after the formal assessment and initial treatment plan have been completed. Rather, it’s important to engage in ongoing assessment, reevaluation of treatment targets, and conceptualization throughout treatment, and sometimes moment to moment.

Using the ACT Case Conceptualization Form Here, we present a case conceptualization form that we’ve designed to guide you through the steps outlined in this section and to help you document your conceptualization. This version is primarily for illustrative purposes. For a downloadable version of the form that provides more space for writing, visit http://www.newharbinger.com/39492.

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ACT Case Conceptualization Form 1. Presenting problem in the client’s own words: The client’s initial goals (what the client wants from therapy): ACT reformulation of the presenting problem: Assessment measures (including scores and interpretation):

2. Inflexibility: Assess rigidity due to avoidance and fusion related to private experiences. What thoughts, emotions, memories, and sensations is the client avoiding? What stories or thoughts is the client fused with?

What behaviors is the client engaging in to avoid or escape these experiences? Check those that apply and give examples from the client’s behavior. …… Internal emotional control strategies (e.g., distraction, excessive worry, numbing): …… External emotional control strategies (e.g., drugs, self-­harm, avoided situations): …… In-­session avoidance or emotional control patterns (e.g., topic changes, dropout risk): Pervasiveness of experiential avoidance:  Limited 1  2  3  4   5  Very extensive What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client?

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3. Inflexibility: Assess insensitivity to the present moment and limited perspective taking (e.g., dominance of the conceptualized past and future, limited self-­knowledge, or attachment to the conceptualized self).

What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client?

4. Inflexibility: Assess disengagement (e.g., unclear values or limited committed action as reflected by inaction, impulsivity, or avoidant persistence).

What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client?

5. Factors that may limit motivation (e.g., the client’s experience of unworkability, unclear values, or issues in the therapeutic relationship):

How should these factors affect what I do in treatment?

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6. Cultural, social, environmental, and other contextual variables that may influence treatment:

7. Client strengths and how they might be used in treatment:

8. Integrate the information from all of the previous sections to develop a comprehensive treatment plan.

Sample Case Conceptualization: Carlos In this section, we present some introductory information about a client (Carlos), a dialogue from his first session with comments on elements of the dialogue that are relevant to case conceptualization, and a model case conceptualization based on this information. We have intentionally chosen a relatively complex case in order to illustrate some of the subtleties in the ACT model. As you read through the case conceptualization, you may want to refer back to the preceding sections to consolidate your understanding of the process. Carlos is a twenty-­six-­year-­old divorced Latino man on disability related to back pain and chronic depression resulting from an injury that occurred at his construction job three years ago. Carlos was referred by a therapist from a chronic pain group who said that Carlos had a hard time connecting with other group members, frequently appeared angry in group, and often stated that others were misunderstanding him. The referral reported that Carlos seemed quite rigid and inflexible in his thinking and

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unwilling to entertain others’ ideas or opinions. When he arrived at his first session, his left arm was noticeably emaciated and hung limply at his side. The following dialogue ensued.

Commentary Therapist: So, what brings you in to see me today? Carlos:

I’m depressed. I was told you might be able to help. (Stares at the therapist.)

Therapist: I hope so, but first can you tell me a little more about your depression—­like how long you’ve been depressed and why you think you’re depressed? Carlos:

Staring at the therapist could perhaps be conceptualized on the social level as an example of the kind of behavior Carlos exhibited in group that caused interpersonal difficulties.

Well, I’ve been having a hard time of it ever since I hurt my back on the job three years ago. I think I’m just down because I can’t work anymore. I was really good at what I did, and now I’m useless because of my damn arm and the pain in my back.

Therapist: Your arm and your back? Did that happen because of the injury? Carlos:

No. Only my back was injured. I’ve had about four surgeries to try to fix it. I’ve spent maybe ten months of the past three years in the hospital. The first three surgeries worked pretty well but I was still having some problems, so they did one more. It was supposed to be the last one, but the damn doctor screwed it up and damaged the nerve that goes to my arm. Now I can barely use it.

Therapist: How much use do you have?

The therapist might begin to wonder whether Carlos is ruminating about how the surgeon “screwed up” his arm and whether fusion with this thought is keeping him from moving forward. Issues of right and wrong may be feeding fusion.

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Well, I can lift it up about a foot. (Demonstrates.) They told me it was hopeless and I’d never get any movement back, but I knew I could. I’ve been working out in the pool almost every day, and I’ve gotten to the point where I can close my hand and lift my arm to shoulder height when I’m in the pool. It’s taken a lot of work, but I made it happen. I’m the kind of person who, when I set my mind to doing something, I get it done. (Grins.) Like with the pain from this injury—­I don’t use any drugs. I control it with self-­hypnosis. It works pretty good to keep the pain manageable. But it doesn’t matter, anyway, because I can’t do anything because of my back and arm… Now I’m like a piece of crap. I’m just worthless. I don’t know why I even try.

Carlos’s ability to exercise regularly suggests strength in being able to make and keep commitments, which could be useful in therapy. “I get it done” suggests possible fusion with a self-­identity as someone who doesn’t fail, but it could also be a strength. Carlos is using hypnosis as a control method. It will be necessary to assess the workability of this solution, although it seems relatively innocuous at this point. Carlos is probably fused with the evaluations “I’m a piece of crap” and “I’m worthless.”

Therapist: When I hear you say you can’t do much of anything, what I hear you saying is that you can’t do anything important. If you’re not doing anything important, what are you doing with your time?

The therapist is stepping around some fusion and drawing Carlos’s attention to what he’s valuing with his current behavior.

Carlos:

Carlos’s reference to his son indicates that parenting may be a domain where it would be useful to investigate his values.

Well, I have a schedule I follow pretty much every day. I’ve always been really disciplined. I get up, I do my self-­hypnosis, I eat breakfast, I watch a little TV. I get ready and go to the pool and work out. By the time that’s done, I’m tired and I come back home, take a nap, fix some dinner, watch some TV, and go to bed. A lot of nights, I also talk to my son. That’s about it. I’m a loser, huh?

The statement “I’m loser” suggests fusion with this evaluation and concern about how others are evaluating him. It may also be a test of the therapist’s reactions in this area.

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Therapist: That thought “I’m a loser” has been around for a while, huh? Carlos:

Yeah.

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The therapist does a defusion move with the thought “I’m a loser” and also tries to draw out other thinking Carlos may be fused with.

Therapist: Is that one of the things you say to yourself when you’re feeling down? Carlos:

Yeah.

Therapist: What other things do you say to yourself? Carlos:

Hmm. That my life is ruined… That the bastard doctor did it. I think a lot about how he screwed up that surgery… I think about my son.

Carlos spends a significant amount of time out of contact with the present moment and in thoughts about the physician and his son, who aren’t present.

Therapist: You think about your son?

The therapist is investigating a valued domain.

Carlos:

Carlos indicates avoidance in regard to what appears to be an important value: taking care of his son.

Yeah, Casey is six. He’s the greatest. He stays with my parents a few hours away. They take care of him because I can’t anymore. I need my time to fix my arm, and I can’t take care of him anyway in the physical shape I’m in. I used to be able to help him put his shirt on in the morning, but I can’t even do that right anymore, with my arm and all… If I can’t do that, how can I do what I need to be a father?

Fusion is evident in the statement “I can’t take care of him anyway.” Saying he can’t take care of his son because he’s unable to help him get dressed is a somewhat rigid and seemingly illogical statement.

Therapist: How do you feel about not taking care of him?

The therapist is probing for whether or how avoidance might lead to pain due to not living his values.

Carlos:

Carlos doesn’t seem to be in contact with the cost of avoidance in this domain. This could suggest a chronic pattern of avoidance.

(Sighs.) I’m okay with it. I wish I could take care of him, but I just can’t. He’s better off with my parents. Ever since Casey’s mother and I split up, it’s been just him and me. His mom’s an addict and took off when we separated. I haven’t talked to her in a year.

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Therapist: Do you get to visit him much? Carlos:

No, he lives too far away. But I talk to him most nights on the phone. That helps… I’m not so sure about my parents taking care of him, but I don’t have much of a choice. I can’t do it the way I should.

Therapist: You’re not sure about your parents? Carlos:

They…uh…they were pretty physically and mentally abusive to me as a kid. A lot of hitting, yelling… When I was younger, I used to spend a lot of time thinking about that. I got pretty out of control around that. I was even suicidal until I figured out how to get it under control. I don’t think about it much anymore… Anyway, they’ve mellowed as they’ve gotten older and they don’t hit him.

The therapist is assessing Carlos’s functioning in the domain of his relationship with his son. Contact seems fairly limited and constricted. The statement “I can’t do it the way I should” probably reflects more fusion. Carlos’s statement suggests that interacting with his abusive parents (an external barrier to change) could be challenging. He says he experienced some success with control of painful memories in the past. The therapist needs to examine how this works: it may be okay, or it may be a problem if it’s part of a larger pattern of avoidance.

Therapist: You’ve got the memories of abuse under control?

The therapist is probing for Carlos’s assessment of the success of this control move.

Carlos:

Carlos sees the short-­term effects of this strategy as quite positive but is clearly still experientially avoidant of his abuse memories. He seems unaware of the costs to his flexibility (e.g., even in these first few moments, he feels he must warn the therapist away). The therapist should pay attention to the other valued domains in which avoidance of these memories might block action.

Yeah, I used to think about it all the time and have nightmares and stuff. But I learned to block it all out… We’re not going to have to talk about that, are we? I don’t want to. If I remember that stuff, I’ll get out of control again and maybe hurt someone or myself.

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Therapist: We don’t have to talk about anything you’re not willing to talk about. My intention here is to never make you do anything you’re not willing to do, and if I ever do think that’s something we should talk about, I’ll ask permission first to see if you’re willing. I want this therapy to be about what you want most in your life. And if remembering those memories would be part of this work, I’d want us to take a look at that. If they don’t need to be remembered, then your experience will show you that. Either way, we’ll see what your experience has to say.

The therapist sets a context of acceptance and client choice in the therapeutic relationship.

Carlos:

This is a good sign. Values trump avoidance, at least at the level of what Carlos says overtly.

I’m okay with that. So we’ll see, then?

Therapist: Yeah. Carlos:

So then, what do we talk about?

Therapist: Hmm… It sounds as though you spend a lot of time alone. What are your friendships like? Carlos:

I don’t really have any friends—­not for the last couple years. I used to hang out with some guys at work, but ever since I left no one wants to be around me.

Therapist: That sounds pretty lonely. Carlos:

Yeah.

Therapist: What do you think about when you’re at home alone?

The therapist sets client values as central to the therapeutic relationship. The therapist begins to define client values as the ultimate goal of therapy and as a higher guide than immediate comfort, starts to link values to willingness, and begins to appeal to Carlos’s experience.

The therapist is probing for functioning in another important life domain and situates the struggle in values, not in avoidance. Carlos reports very restricted behavior in the domain of friendships. These processes need to be tracked in the level of social behavior. The therapist probes for costs experienced on a daily basis.

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I wish my son was there… I don’t know. I think a lot about my surgery and my arm. I think about getting back at that surgeon who screwed up. I think about how I can win my court case. I just can’t let it go. I think about how I could try to get them to do one more surgery to fix my arm. But they keep saying there’s nothing they can do.

Therapist: Anything else you think about?

Carlos:

I think about how worthless my life is now that I can’t work. I try to figure out how this happened…where I went wrong. I just can’t see a way out. I used to be good at what I did. That was who I was. Now I can’t do it anymore. I don’t do anything anymore. I don’t know who I am without my work.

Carlos expresses some costs, mainly in terms of parenting his son. Carlos describes spending a fair amount of time in the conceptualized past and needing to be right, not wrong. Fusion may be evident in the story that the doctors need to fix his arm. Carlos shows attachment to physical solutions and indicates possible avoidance. Fusion dominates. Indications of fusion include heavy evaluations, spending a lot of time in the past, and repetitive mental problem solving. Carlos shows more attachment to the conceptualized self and rigidity around perspective taking.

Therapist: And you feel as if the pain you’re in from your back and arm is what stands between you and working. You feel it needs to change, yet you say you don’t use any medication.

The therapist is probing for whether Carlos sees pain control as a goal that needs to be accomplished before he can live. The therapist begins to draw out the system of experiential control.

Carlos:

Carlos’s pill taking is contingent on his level of pain. The therapist should be careful of that control strategy because it may increase over time.

Yeah, after the surgeries I used morphine for a while, but then I got the pain under control with self-­hypnosis a doctor taught me. I sometimes take a pill after I work out if the pain is too bad, but that’s about all. I don’t like to take pills because that would mean I can’t handle it.

Therapist: Can’t handle it?

Carlos displays attachment to a conceptualized self in which pain equals weakness.

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Yeah, you know, that I’m weak. That I can’t take the pain.

Carlos fears that he’s weak and “can’t handle it” and could be fused with this self-­concept, or the opposite (i.e., that he is strong). This could create rigidity.

Therapist: I see. And if you had to rate your usual pain level without hypnosis on a scale from one to ten?

The therapist is trying to get a sense of the success of Carlos’s pain control strategies.

Carlos:

Seven.

Therapist: And with it? Carlos:

Most of the time, like a four. It’s not too bad.

Therapist: Okay, thanks. So, let me ask you something: What do you think you need to do to have things get better? How do you imagine therapy helping you?

The therapist is beginning to draw out the system Carlos is in, his goals for therapy and for his life, and how these are linked to valued outcomes.

Carlos:

Carlos seems fairly caught up in his experiential avoidance agenda. Once again, he displays “right versus wrong” thinking and is more in the future than the present.

I need to feel better and not be so negative all the time. I’d be more motivated to work on getting my arm back in shape. I didn’t used to be like this. I think if I won my court case against the doctor who screwed me, that would help.

Therapist: Let me ask you another question. It’s kind of a silly question. If you were to wake up tomorrow and a miracle had happened—­ like your fairy godmother came down and granted all your wishes—­what would your life look like then?

The therapist is trying to get to statements about values in addition to goals in the service of Carlos’s agenda of avoidance.

Carlos:

Carlos is exhibiting in-­session avoidance of the pain of talking about what he wants in his life.

Ah… I don’t want to think about that. I’ve lost too much… (Speaks quietly.) It can’t happen.

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Therapist: Would you be willing to play with me for a minute? Just imagine. If a miracle happened, what would your life be like?

The therapist persists and tries to sidestep avoidance and not confront it directly, which would probably increase avoidance.

Carlos:

Carlos expresses a mixture of process goals (not being depressed, his arm working, having more money) and outcome goals (taking care of his son and working again), along with some fusion with his conceptualized self.

Okay… I wouldn’t be depressed, I’d have my arm working again, and I’d be working as a carpenter and taking care of my son… I’d have more money… But that can’t happen. Why should I think about this?

Therapist: Yeah, it’s painful to think about what you want but feel you can’t have. If thinking about it in here could make it possible for you to find some new, meaningful work and have your son back, would you be willing to do it? Carlos:

Of course, but I don’t see how it would help.

The therapist again ties willingness to values-­based action and compares the agenda of avoidance to Carlos’s values in relation to his son in order to increase the salience of his values.

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ACT Case Conceptualization Form: Carlos 1. Presenting problem in the client’s own words: The client’s initial goals (what the client wants from therapy): The client says he’s depressed and needs to have his depression get better.

ACT reformulation of the presenting problem: Although more assessment is needed, the client is probably struggling with avoidance of sadness and fear, hopeless thoughts, self-­critical thoughts, trauma memories, fear of more pain in the future, and continuing loss. This struggle consumes almost all of his time, to the point that he engages in few valued activities or even actively avoids them, e.g., having his parents raise his son.

Assessment measures (including scores and interpretation): None delivered.

2. Inflexibility: Assess rigidity due to avoidance and fusion related to private experiences. What thoughts, emotions, memories, and sensations is the client avoiding? What stories or thoughts is the client fused with?

The client is demonstrating fusion with the following thoughts: “I’m a piece of crap.” “I’m worthless.” “I’m a loser.” “No one wants to be around me.” “I can’t handle it.” He’s potentially avoiding sadness, loss, embarrassment or shame, fear (particularly of intimacy), and memories from his childhood. He has a history of extensive abuse as a child. These memories appear to be avoided, with the client noting that he doesn’t want to talk about them. And although it didn’t come up in this session directly, he may avoid thinking about his son. Additional areas of avoidance include physical pain from injury, rejection by others, work-­related activities, and the sense of failure and difficulty he feels in this life area. At times, the client showed concern about therapist evaluations, potentially indicating avoidance of being wrong or wronged.

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What behaviors is the client engaging in to avoid or escape these experiences? Check those that apply and give examples from the client’s behavior. ;; Internal emotional control strategies (e.g., distraction, excessive worry, numbing): The client uses distraction, hypnosis, rigid positive self-­statements, TV watching to “zone out,” and oversleeping.

;; External emotional control strategies (e.g., drugs, self-­harm, avoided situations): The client avoids taking care of his son, intimacy, and friendship. He doesn’t work or engage in activities to develop future work. He avoids tasks related to physical ability other than swimming and range of motion exercises. Other potential control strategies: takes occasional opioid medications and has a highly routinized schedule.

;; In-­session avoidance or emotional control patterns (e.g., topic changes, dropout risk): The client says he doesn’t want to talk about his childhood in session—­direct avoidance through verbal pronouncement. He may be at risk for dropout due to feeling misunderstood and angry. He may also fear getting close to people. He’s shown a history of anger in group therapy and often feels others are misunderstanding him. Consider cultural factors that could be promoting avoidance of emotion.

Pervasiveness of experiential avoidance:  Limited  1  2   3  4    5  Very extensive What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client? The client has reported some success with control strategies (e.g., hypnosis), so control as the problem work will need to take this into account, to weed through what has worked and retain that and let go of what isn’t working. It may also be important to help the client distinguish between actual willingness and “white-­knuckling” when engaging in willingness exercises, as this client appears to have fairly well-­developed abilities to coerce himself to persist in the face of pain. Experiential avoidance seems to be very pervasive for this client, suggesting a stronger focus on creativeness hopelessness and control as the problem. He seems to have some fairly rigid, even illogical, thinking at times and attachment to being right. This suggests a stronger focus on defusion, particularly from reason giving, and a focus on reducing attachment to the conceptualized self. The client’s avoidance of nearly all relationships is probably an important target of therapy because he seems to have strong contact with values in that area, particularly in relation to his son. His rigid rules around how to respond to physical problems and pain probably need to be targeted with defusion. His somewhat confrontational style of interaction could result in dropout if I’m not flexible and responsive to these interpersonal patterns. These patterns could also be tracked on a more social level and be a target for change in order to improve his relationships. I occasionally felt anxious and had urges to keep my distance in reaction to his tendency to stare in a hostile manner and his suspiciousness of my motives. It might be helpful for me to connect with my values before session and engage in a brief mindfulness or loving-­kindness meditation beforehand so I can stay more grounded and focused on being open and vulnerable in the face of his hostility.

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3. Inflexibility: Assess insensitivity to the present moment and limited perspective taking (e.g., dominance of the conceptualized past and future, limited self-­knowledge, or attachment to the conceptualized self).

The client is overly attached to past experience of failed surgeries and is particularly focused on a surgery that injured his arm. This attachment is functioning to keep the client stuck in current problematic patterns of behavior. He appears to be unwilling, at this time, to forgive. Although he is experiencing legitimate anger about the loss, his anger and desire to seek retribution or yet another surgery indicate both a dominance of the past and a desire to make things different in the future—­although this future appears to be linked to getting his arm working again despite what he has learned about this being unlikely. At this point, his anger appears to be causing significant personal difficulty. The client is rigidly attached to his self-­concept as a carpenter. He’s limited in his capacity to view himself as anything other than a carpenter and doesn’t fully connect to his ability to take perspective on his role as a father, community member, and son. Although he’s able to connect with these aspects of himself to a small degree, he views these senses of himself as limited due to his injury. He may also be having difficulty connecting to a sense of self beyond his injury and fused thoughts, perhaps contributing to a reduced capacity for self-­compassion. The client appears to be spending a lot of time in the conceptualized past, closing off opportunities to live now. He also exhibits a narrowness of focus, which could be an ally in some ways if used well. However, it could interfere with his ability to respond flexibly. For example, his statement about not being able to help his son change clothes due to his limited arm function suggests that he’s out of contact with his environment and other possible ways of responding that differ from what he did in the past.

What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client? The client appears to have significant problems with simple attention to the present moment, suggesting formal mindfulness exercises in and out of session may be helpful. In particular, exercises to increase mindfulness during situations in which the client is trying something new or experiencing a difficulty could be useful for building his ability to notice aspects of the situation outside of what he normally attends to and to broaden his attention. Self-­as-­context and perspective-­taking work should probably focus on the client’s anger and rumination directed at the surgeons and others he thinks have contributed to his current difficulties. For example, it may be effective to help him contact memories of past losses and the thoughts and feelings that emerge during these exercises, and then switch perspective to observing himself or others in those moments from an outside, observer perspective in order to facilitate forgiveness. His attachment to his former role as a carpenter and what that meant to him probably needs to be a focus, helping him let go of the attachment and identify the values that were part of that job so he can set new goals to instantiate those values in his life. Perspective-­taking work also probably needs to target his sense of self as defective and a loser.

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4. Inflexibility: Assess disengagement (e.g., unclear values or limited committed action as reflected by inaction, impulsivity, or avoidant persistence).

The client has mostly stopped parenting. He makes daily phone calls to his son but is no longer caring for him on a regular basis. He finds this extremely painful and is fused with the idea he can’t be a good father due to his disability. This indicates loss of contact with important values related to his son. In addition, the client may be out of contact with values regarding friendships and relationships. He appears to have no friends or social support and isn’t working to develop any. Although he is active in regaining function in his arm, the rest of his day appears to be largely devoid of meaningful activity.

What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client? The client’s in-­session behavior suggests that he has some contact with important values and is even willing, with support, to contact pain related to those values. This is a strength that suggests contextualizing willingness in terms of values (particularly in relation to his son) can be useful in building willingness. His awareness of the importance of his son suggests that the domain of parenting might be a good place to start in terms of identifying his values and practicing willingness in the service of effective action. At this point, it’s too early to focus on the qualities of effective values conversations, but the client does display some willingness to be vulnerable in relation to his son, which showed up as he related his pain about not being there for his son on a daily basis. I feel moved by his visible caring for his son and think that working to help him become an active father again would be inspiring for me. It would probably be helpful to directly share this with him as a way of modeling how my values are guiding my work as a therapist.

5. Factors that may limit motivation (e.g., the client’s experience of unworkability, unclear values, or issues in the therapeutic relationship): The client’s motivation appears to be centered around regaining his abilities in his arm. He exhibits steady and committed activity around rebuilding the mobility and strength of his arm, and these efforts have demonstrated some payoff. It may be helpful to see whether this motivation could be harnessed in other areas of his life. In addition, his son may prove to be a motivator for action if the client’s parenting values can be clarified. It’s currently unclear whether the therapeutic relationship will be motivating. Further assessment of this is needed.

How should these factors affect what I do in treatment? Some focus on values at the start of therapy might be helpful for linking the client’s avoidance to costs in terms of his values. This could help situate treatment in the context of his apparently strong values around being a parent. I probably need to attend to the therapeutic alliance carefully, given that the client has reported interpersonal difficulties that have interfered with his connections to others in the past, including in his previous experience with health care providers—­and given the fact that he exhibited some difficult interpersonal behaviors even in the first session. It may be useful to share my commitment to helping him see if he can have his son move back home with him. I might also predict the possibility that he may want to drop out of treatment and discuss how to respond to those urges. Throughout treatment, I’ll work to elicit and be open to feedback about how he thinks treatment is going.

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6. Cultural, social, environmental, and other contextual variables that may influence treatment: Variables to further assess include cultural influences. The client is Latino, and loss of his job and use of his arm may have a bearing on his experience of being a whole man. Cultural influences regarding being a strong male and a provider may be generating shame and anger. Consider how cultural variables might influence experiential avoidance as a coping mechanism. Additional contextual factors that need to be explored include a potentially low payoff for being more responsible. The client’s unwillingness to take different actions may be functioning to keep his freedom high and responsibility low. Further assessment of secondary gain related to any financial compensation should be explored. His parents abused him when he was a child, so ongoing interaction with them is likely to be particularly difficult. The client has no social support.

7. Client strengths and how they might be used in treatment: The client has shown the ability to engage in problem solving and carry out plans of action in the midst of chronic pain. He regularly exercises his injured areas, even with pain, and makes room for this discomfort in order to do something he thinks will probably be helpful in the long run. This could become a metaphor for values-­based possibilities and actions in other areas of his life. The client is likable in session. My reactions, feeling connected and caring, suggest that the client could draw people into relationships with him. His ability to follow through on commitments in the face of pain suggest that developing ongoing daily practices that promote psychological flexibility may be a useful target for committed action (e.g., daily mindfulness practice or review of values).

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8. Integrate the information from all of the previous sections to develop a comprehensive treatment plan. Assessment: Consider using the Acceptance and Action Questionnaire-II and Automatic Thoughts Questionnaire–­Believability Scale for measures of believability and acceptance. The Chronic Pain Acceptance Questionnaire may also be worth considering. Assess across time to evaluate for improvement (i.e., increased psychological flexibility, reduced believability of thoughts). Skills and potential referrals: The client may have deficits in problem-­solving skills and might benefit from practice with problem solving in interpersonal and job-­related areas. He might also benefit from vocational referral if he commits to progress in the area of employment. Treatment: Help the client become more psychologically and behaviorally flexible in order to help him achieve desired goals related to his values. Take time in initial sessions to clarify the work of therapy and get consent to move forward with respect to values-­based living. Additional treatment goals: • Begin with some focus on valuing, especially in relation to how his current patterns of behavior relate to his desired life directions. Pay particular attention to his relationship with his son and costs he’s experienced in that domain. A focus on his values related to his son may be a good place to start, as the client shows both contact with values in that domain and pain related to not living them. • Then focus on undermining the client’s control agenda, with a particular focus on attempts to control emotions and thoughts related to depression, job loss, self-­criticism, and his relationship with his son. Creative hopelessness as a gateway to willingness will likely be an important intervention for undermining control. This may be challenging due to the client’s extensive learning history wherein control was useful with respect to pain. Differentiating his success in pain control from his lack of success in other areas will be important. Be sure to differentiate willingness from “white-­knuckling.” • Make willingness to experience sadness associated with loss, anger, and hurt manageable by practicing exposure to emotional content in small doses and through appropriate experiential exercises. Be sure to connect willingness to values in this context in order to increase motivation and provide meaning for contacting difficult things. • The client’s rigid thinking suggests entrenched fusion. It may be helpful to place a strong focus on reason giving and reducing attachment to the conceptualized self. Rigid rules around how to respond to physical problems and pain should probably be targeted with defusion. Determine whether the client is willing to engage in an ongoing mindfulness practice or other daily practices related to defusion. • The client is likely to benefit from brief present-­moment exercises during session, perhaps as a way to start each session. And again, mindfulness exercises may be helpful between sessions to broaden his attention so he can take in more of his environment and what it affords. Include exercises to increase mindfulness during situations in which the client is trying something new or experiencing a difficulty. • Conduct values clarification to help identify life directions with workable goals while also reducing attachment to current goals. Develop specific goals to assist the client in getting social support, improving his relationship with his son, and building a different work future. The client’s isolation and interpersonal problems suggest that a focus on interpersonal values may be particularly important. Focusing on process versus outcome, and on holding goals lightly, could help decrease the client’s attachment to his current goals around working as a carpenter and caring for his son.

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• An early way to strengthen the therapeutic alliance may be for me to share my interest in helping him become a more active father. His somewhat confrontational interaction style and the likelihood of dropout need attention, perhaps through predicting the possibility that he may want to drop out of treatment and discussing how to respond to those urges, and also by eliciting feedback about how he perceives treatment to be going and being open to that feedback. • Before session, spend time connecting with my values as a therapist, or do mindfulness or loving-­ kindness meditation to promote my own flexibility.

•  Consider exploring the role of cultural context, particularly in terms of the client’s identity as a provider and as a man. Be sure to address the possible role of secondary gain from potential financial compensation related to injuries that may interfere with parenting or return to work.

Case Conceptualization Practice: Sandra Now we invite you to practice case conceptualization with a sample case. Sandra is a thirty-­eight-­year-­ old married woman who was referred for therapy because she hadn’t benefited from traditional CBT treatment or several other therapeutic approaches. She describes herself as having been a worrier for her whole life and says, “They called me a nervous Nellie as a child. I’ve always been this way. I’m oversensitive.” She exhibits intense emotionality, becoming easily overwhelmed by the problems in her life. She meets the criteria for a diagnosis of generalized anxiety disorder and exhibits nearly constant worry about a variety of concerns, including never having a loving relationship, becoming financially destitute, and having a stroke. She’s concerned that her friends and family will develop severe illnesses and her friends will reject her. Her sleep is disrupted by her near-­constant worry about the future. She often notices sensations in her body, such as tightness in her chest or tingling in her hands, and wonders whether they signal that she’s having a heart attack. She says that when she feels she’s getting too anxious at work or in social situations, she retreats from the room until she’s calmed down a bit. Sandra’s presenting concern is that she wants help in being less oversensitive. She says, “I push people away. I also want to do something about my worry. It’s incapacitating at times.” When asked to describe what she hopes for from therapy, she says, “I want to deal with my life better so I’m not so anxious all the time and can do better at work.” Further inquiry reveals that she’d also like help figuring out what to do about her relationships. Her most central current concern is that she’ll be fired from her job as a secretary at a law firm, a position she’s held for the past six months. She feels that she’s performing poorly because she’s so anxious. She has previously been fired from several jobs and has a history of taking jobs below her level of training. Her current job consists of mostly secretarial duties even though she has a master’s degree in design. She’s currently in a fifteen-­year marriage that she finds distant and unsatisfying and has no children. Her husband doesn’t work and she’s the sole provider. She does report that she has multiple

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solid friendships. She says she doesn’t drink alcohol at all and that she exercises for at least an hour almost every day. She’s very creative and frequently expresses herself through drawing and writing. In session, if the therapist doesn’t interrupt her, she talks endlessly about her worries, her current strategies for dealing with them, or how she got to be the way she is. She cries easily and often appears anxious and distraught. She’s very friendly and frequently apologizes for taking up too much session time. When doing exercises in session or between sessions, she often expresses worry that she’s doing the exercises wrong or messing them up. *** Now, using a copy of the blank case conceptualization form that appeared earlier in this chapter or a printout of the downloadable form, fill it out as best you can, using the preceding information about Sandra. Your background might suggest approaches that are different from an ACT approach, but for the purpose of this exercise, try to conceptualize the case from an ACT perspective. When you’re finished, compare what you’ve come up with to the model case conceptualization that follows. Be sure to take the time to fully consider the case and fill out the form before examining the model. When comparing your conceptualization with the model, particularly note where your answers diverge from those in the model. In those instances, consider the ways in which your responses are consistent or inconsistent with ACT. If they’re different but still clearly consistent with ACT, that’s fine. If not, notice where the inconsistencies lie, reexamine the processes linked to the model case conceptualization, and consider why they differ from your response. Perhaps review sections of this chapter or earlier chapters for guidance. As you compare your responses with the model, consider these two key questions: Are there any portions of the model conceptualization where you don’t understand what’s being conveyed? And do you disagree with some aspects of the model conceptualization?

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ACT Case Conceptualization Form: Sandra 1. Presenting problem in the client’s own words:

The client reports being a worrier and nervous Nellie, being overly sensitive, and being fired several times in the past.

The client’s initial goals (what the client wants from therapy): The client would like to be able to deal with her life better, not be anxious all the time, do better at work, and not be so sensitive.

ACT reformulation of the presenting problem: The client seems to avoid thoughts, feelings, and images relating to several feared outcomes (e.g., being destitute, being rejected, experiencing health problems) through constant worrying (a form of fusion with ineffective problem solving), which serves to keep her life focused on these worries and not on living a values-­based life.

Assessment measures (including scores and interpretation): None delivered.

2. Inflexibility: Assess rigidity due to avoidance and fusion related to private experiences. What thoughts, emotions, memories, and sensations is the client avoiding? What stories or thoughts is the client fused with?

The client is demonstrating fusion with the following thoughts or variations of them: “I’m oversensitive.” “Perhaps I push people away.” “I’m a failure.” “I’m inadequate.” She’s attempting to avoid rejection, fear, and uncertainty in interpersonal relationships and work. She avoids setting high expectations for herself or allowing expectations to be placed on her (e.g., by taking a job with more responsibility, engaging in social situations, or talking with her husband about their marriage) and says that she’s unable to tolerate the consequences of not being able to meet these expectations. Any awareness of anxiety-­related sensations appears to elicit catastrophic thinking, for example, about having a heart attack.

What behaviors is the client engaging in to avoid or escape these experiences? Check those that apply and give examples from the client’s behavior. ;; Internal emotional control strategies (e.g., distraction, excessive worry, numbing): The client uses internal control strategies of worrying, telling herself to stop being so sensitive, and distraction.

;; External emotional control strategies (e.g., drugs, self-­harm, avoided situations): The client avoids challenging work and social situations and seeks reassurance from others by constantly talking about her problems.

;; In-­session avoidance or emotional control patterns (e.g., topic changes, dropout risk): The client is overly talkative in session, difficult to interrupt, and wandering in her verbal style. She uses storytelling, reassurance seeking, and trying to do things “right” to control her anxiety and fears of rejection.

Pervasiveness of experiential avoidance:  Limited  1  2   3  4    5  Very extensive

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What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client? Target self-­evaluations, conceptualized self as oversensitive, and attachment to self-­critical thoughts, such as “I’m a failure” with defusion. As part of creative hopelessness, help the client notice how she responds to these self-­evaluative thoughts and what outcomes these responses lead to. Consider willingness, defusion, or exposure to feared images at the end of her worry chain, or interoceptive exposure to feared sensations. Worry seems to be a primary target of treatment, and seeking reassurance by sharing her worries is probably an important target due to its interpersonal consequences. More assessment is needed regarding whether aspects of the client’s behavior may have contributed to her being fired from previous jobs. Because reason giving is a large component of her in-­session behavior, this should be a target for defusion. This client elicits a lot of frustration for me due to her near-­constant focus on anxious worrying and how I must repeatedly interrupt her to be able to speak and have any chance at helping. It would probably be helpful for me to practice acceptance exercises with myself in session when I notice my own frustration. At those times, I might also take a moment to reconnect with my values related to this client and in relation to my own struggle in being with her.

3. Inflexibility: Assess insensitivity to the present moment and limited perspective taking (e.g., dominance of the conceptualized past and future, limited self-­knowledge, or attachment to the conceptualized self).

The client appears to have little self-­knowledge about the impact her anxious behavior has on others. She has some sense that it’s problematic because she’s aware that it’s affecting her job. However, this awareness seems limited and currently isn’t being used to interrupt those behaviors in the service of taking more effective action. Additionally, her behavior is dominated by a conceptualized future characterized by rejection and other feared outcomes. The client may also be overly identified with a sense of self as “overly sensitive.”

What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client? The client’s tendency to talk at length without allowing input from me suggests that I need to gain permission to interrupt her after providing a rationale, and then make this a target of therapy. She could track this on a social level by noticing the impact of her incessant talk about her worries on her relationships. Compassionately sharing how this behavior impacts me could perhaps help the client become more aware of how her behavior affects others. Developing a daily mindfulness practice is probably worth exploring to help with her pattern of getting lost in worry. Helping her develop a stronger sense of self-­as-­context will give her a safe place from which to observe feared images. Perspective-­taking exercises can loosen her attachment to a conceptualized self that’s “oversensitive,” “a failure,” and “inadequate.” Keep an eye out for variation in her tendency to worry or engage in storytelling in session and begin to notice stimuli that precede shifts into those states. Those stimuli may be worth targeting with acceptance or defusion exercises.

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4. Inflexibility: Assess disengagement (e.g., unclear values or limited committed action as reflected by inaction, impulsivity, or avoidant persistence).

The client appears to be complacent in an unsatisfying marriage and job. Fear of rejection could be constricting values-­based action in friendships and in being assertive at work.

What do these observed patterns reveal about how to contextualize treatment for this client? What methods and interventions should I use? What do I need to do differently for this client? Much of this client’s valuing behavior is probably driven by pliance. When conducting values work, be sure to modify as needed to address this issue. Consider how creative hobbies function for this client. Are they primarily a form of escape or avoidance, or is the client in contact with her values when doing them? Either way, what might this tell her about what she needs to do in other valued domains? Focusing on the qualities of committed action, such as holding goals lightly, along with focusing on the process of living rather than on the outcome of actions, is likely to be important due to the client’s strong focus on the outcomes of her behavior for much of her life. It will be important to focus on some of the other flexibility processes before engaging in work on values and committed action. Otherwise, any values-­based actions will probably be tied to avoidance and fusion, rather than being chosen and reinforced by more intrinsic qualities of the pattern of action.

5. Factors that may limit motivation (e.g., the client’s experience of unworkability, unclear values, or issues in the therapeutic relationship): The client appears to be motivated by connection with others. In addition, the therapeutic relationship may also be a motivating factor for change.

How should these factors affect what I do in treatment? I’ll need to attend to my frustration with the client’s persistent storytelling so it doesn’t harm the alliance. Exposure to feared imagery and sensations may be highly aversive to this client, so I should probably wait to conduct this work until after engaging in acceptance, defusion, perspective-­taking, and values work, as these are likely to provide a context for undertaking the challenge of exposure.

6. Cultural, social, environmental, and other contextual variables that may influence treatment: More assessment is needed. The client’s husband may be unsupportive of change, in which case couples therapy could be useful. The client may be encountering barriers at work that are outside of her control.

7. Client strengths and how they might be used in treatment: The client states that she’s capable of establishing and maintaining solid friendships. These might be enlisted as support for change strategies. She also may be demonstrating a capacity for committed action in the form of regular exercise and art, which could be used as a model for other forms of committed action, but this needs further assessment.

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8. Integrate the information from all of the previous sections to develop a comprehensive treatment plan. Consider using an ACT self-­help book for anxiety, and an anxiety-­specific ACT treatment manual. Potential assessments: Use the Acceptance and Action Questionnaire-II, Anxiety Sensitivity Index, and Penn State Worry Questionnaire as outcome or process measures. Treatment: • It could be useful to begin with undermining control by focusing on the workability of worry versus what the mind has to say about the strategy of trying to prepare for and solve every problem it identifies. Also be sure to help the client notice how she responds to self-­evaluative thoughts and the outcomes these responses lead to. • Use defusion to target self-­evaluations, self-­critical thoughts like “I’m a failure,” and the conceptualized self as oversensitive. • Wait to focus on values until after acceptance, defusion, and flexible perspective-­taking work is accomplished, to reduce the extent to which values work will primarily elicit pliance and fusion, rather than freely chosen values. When conducting values work, be sure to attend to my own behaviors that could result in pliance and choose strategies that can increase the sense of choice in the room. Explore whether the client’s exercise and creative hobbies function as valuing, or as avoidance and escape. • When exploring values, be sure to gather more information in the domains of marriage and work, and help the client examine the long-­term costs of her control-­driven behaviors in these domains. Assist the client in contrasting the current direction of her life in these areas with her valued directions and goals. • In terms of the client’s fusion with the conceptualized self as a worrier and oversensitive, have her act out different self-­concepts: worrier, oversensitive person, insensitive person, and confident person. Ask her to take the perspective of other and observer in relation to these selves. • Target in-­session storytelling. Provide a rationale for interrupting and develop an agreement on the need to do so. Experiment with compassionately sharing the impact of her storytelling on me to help build more awareness of how her behavior affects others. • Track variation in the client’s tendency to worry or engage in storytelling in session and notice stimuli that precede shifts into those states, which could be targets for acceptance and defusion. • Eventually include imaginal exposure to feared images or situations at the end of the client’s worry chain; consider interoceptive exposure to feared sensations. • Help the client take committed actions, and consider calling on her friends for support or bringing in her husband for couples work if he’s serving as a barrier. Also elucidate the qualities of committed action, such as holding goals lightly and focusing on the process of living, rather than the outcome of actions.

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• Assess the client’s willingness to experience nervousness and uncertainty, and to refrain from storytelling or reassurance seeking as she takes committed actions. Help the client identify committed actions small enough that she’s willing to take them, especially in the area of interpersonal behaviors, which will probably elicit anxiety and rule-­following behavior. Reinforce all instances of being willing to commit and following through. • When the client engages in reassurance seeking in session, help her contact the present moment, make room for her emotional experience, and defuse from her fear-­based thoughts. Test the hypothesis that the client is seeking reassurance from others when she engages in storytelling by exploring her present-­moment experience when storytelling. • Consider helping the client develop a daily mindfulness practice so she can notice her ability to keep up patterns of committed action, such as exercising. • Whenever I notice my own frustration in session, practice acceptance exercises and take a moment to reconnect with my values.

Case Conceptualization Pr actice:

Conceptualizing One of Your Own Cases Now we invite you to conceptualize one of your own cases using this same process. Fill out a case conceptualization form for one of your clients, preferably one with whom you’re willing to implement some ACT interventions, as this will make the conceptualization more relevant. If you’re new to ACT, this process may reveal some holes in your assessment process. Perhaps you’ll notice you need to do more assessment for the flexibility processes, or that you don’t understand the client’s patterns of experiential avoidance or fusion. If so, consider how you can assess this more thoroughly. Stick with the practice; it will pay off.

For More Information For more about ACT case conceptualization, see Hayes et al., 2012, chapter 4; and K. G. Wilson, 2008, chapter 7. For clinician-­friendly information about basic behavior analytic concepts, such as rule-­governed behavior and classical and operant conditioning, see Ramnerö & Törneke (2008). For more information about similarities and differences between ACT other forms of CBT, see Herbert & Forman, 2005; and Ciarrochi & Bailey, 2008.

CHAPTER 9

The ACT Therapeutic Stance

When you begin to touch your heart or let your heart be touched, you begin to discover that it’s bottomless, that it doesn’t have any resolution, that this heart is huge, vast, and limitless. You begin to discover how much warmth and gentleness is there, as well as how much space. —­Pema Chödrön

Decades of research examining virtually all types of psychotherapy have found that the therapeutic relationship is consistently positively correlated with clinical outcome (Martin, Garske, & Davis, 2000). However, it isn’t clear that this empirical fact has resulted in more effective therapies or therapists. Knowing this information might help training programs select warm and caring people to become therapists in the first place, but it doesn’t tell us much about how to train therapists to create effective therapeutic relationships. Of course, almost all therapists believe that a strong alliance is important, but caring about the relationship isn’t enough; for example, it could easily lead therapists to foster unhealthy forms of dependence. We need to know both that the alliance is important and how to create powerful alliances that support clinical change. ACT’s psychological flexibility model helps provide such guidance. In ACT, the therapeutic relationship is both a model of psychological flexibility processes and a means by which they are built. Relationships that are empowering tend to be accepting and nonjudgmental. You can assess that assertion now by thinking of the people in your own life who powerfully lift you up. Such relationships tend to be conscious and grounded in the present moment. A true ally is not someone who’s only half there, getting caught up in distractions or impatiently waiting for an interaction to end. And a person who cares about you will want to understand your values—­what you care about deeply—­and would never mindlessly ask you to violate your values. In short, empowering relationships tend to be psychologically flexible. Therefore, ACT’s psychological flexibility model can be used to provide clear suggestions about how to improve the therapeutic relationship: by becoming more accepting, nonjudgmental, conscious, flexibly present, and engaged, and doing so in a way that is profoundly values based. Data exist to support the idea that an effective therapeutic alliance involves the instantiation of these flexibility processes. Specifically, two studies have replicated previous findings that a strong alliance was associated with good therapy outcomes in

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ACT, but this association disappeared when psychological flexibility was accounted for, suggesting that a strong alliance is a psychologically flexible alliance (Gifford et al., 2011; Walser, Karlin, Trockel, Mazina, & Taylor, 2013). The lesson is not that the relationship is unimportant; it’s that the relationship is important because it’s the vehicle through which psychological flexibility is instigated, modeled, and supported. A powerful therapeutic relationship is a means to an end, and it is the client’s internalization of these flexibility processes that makes the ultimate difference in outcome. In this chapter, we first outline the basic competencies of the ACT therapeutic stance that have been identified by a consensus of ACT trainers, and then we present a theoretical analysis of the therapeutic relationship.

Core Competencies of the ACT Therapeutic Stance Ideally, ACT therapists take an open, aware, active, and values-­based stance in interactions with clients. We recognize the potential loftiness of this ideal stance, yet we encourage ACT therapists to strive for it. Speaking more technically, the function of the therapeutic relationship in ACT is to increase clients’ psychological flexibility by responding effectively to their expressions of psychological flexibility or inflexibility as they occur during therapeutic interactions. This can occur in many ways. For example, therapists can model psychological flexibility (e.g., by saying, “I’m noticing that I’m thinking, ‘I don’t know what to say.’ You don’t need to rescue me. I just thought I’d share that.”). Or they can support psychological flexibility on the part of the client (e.g., by asking, “And would you be willing to notice that anxiety and still call your dad?”). Therapists can also target psychological flexibility in relation to whatever is currently happening in session (e.g., by asking, “Instead of pushing away the tears, I invite you to open up to them. They are welcome here.”). Achieving such flexibility is a potentially difficult task for therapists, as we all bring our own histories, quirks, and interpersonal limitations to the therapy room. Because we may misjudge whether any given instance of client behavior represents a psychologically flexible or inflexible response, it’s useful to maintain a therapeutic stance that tends to instigate and reinforce psychologically flexible responding on the part of the client. The core competencies presented below are linked to this stance and to the therapeutic relationship that flows from the ACT model. In this chapter, rather than presenting the core competencies at the end of the chapter, in the core competency practice, we lay them out up front and discuss them at length. In some cases, we list several competencies in a row and discuss them together because they’re intricately related and the explanation addresses their interconnection. The first core competency may sum up the ACT therapeutic stance better than any other single statement: The ACT therapist speaks to the client from an equal, vulnerable, compassionate, genuine, and sharing point of view and respects the client’s inherent ability to move from unworkable to workable responses. This most basic aspect of the ACT therapeutic stance naturally arises when therapists apply the ACT model of language and human functioning to their professional and personal life. The contextual

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philosophy underlying ACT holds that concepts such as sick versus well, whole versus broken, weak versus strong, disordered versus ordered, and dysfunctional versus functional are not inherent in any person, but rather are all ways of speaking or thinking propagated by our culture that can be more or less useful depending upon the context. ACT therapists are encouraged to adopt a stance consistent with the phrase “there but for fortune go I,” cognizant of the possibility that, given a slightly different history, the therapist could easily be the one with problems similar to those of the client and could be sitting in the client’s chair. This competency also reflects ACT’s emphasis on context, recognizing that radical or transformational change is possible for anyone, given a shift in their verbal or social context, or even a shift in their historical context, as the person accumulates new experiences. People don’t need to rewrite their past, have different thoughts, or have better feelings before a full, deep, meaningful life is possible. Here is the second ACT core competency related to the therapeutic stance: The therapist is willing to self-­disclose when it serves the interest of the client. Although inappropriate and poorly timed self-­disclosure may harm the therapeutic relationship (Ackerman & Hilsenroth, 2001), well-­timed, well-­crafted self-­disclosure that is responsive to the c­ lient’s behavior in session may be helpful (Safran & Muran, 2000). ACT therapists are emotionally accessible and responsive and are willing to use self-­disclosure judiciously in the service of clients. If carefully done, self-­disclosure tends to have an equalizing effect on the therapeutic relationship, decreasing the divide between therapist and client and bringing the therapist’s own humanity into the room. This is particularly important in ACT because it allows therapists to model an accepting stance toward their own struggles while also modeling the ability to be effective in living their values. Here are the third and fourth ACT core competencies related to the therapeutic stance: The therapist avoids the use of formulaic ACT interventions, instead fitting interventions to the particular needs of particular clients. The therapist is ready to change course to fit those needs at any moment. The therapist tailors interventions and develops new metaphors, experiential exercises, and behavioral tasks to fit the client’s experience and language practices and the social, ethnic, and cultural context. Both of these core competencies reflect the need for behavioral and psychological flexibility on the part of the ACT clinician. ACT therapists are responsive to client needs and behaviors and don’t rigidly follow protocols or rules about what should be done. The key is to see and address client complaints and the unworkability of behaviors in terms of their underlying function, which often necessitates new and creative ways of responding. Any therapeutic techniques that foster psychological flexibility are considered ACT consistent. Artful application of the ACT model allows for and encourages making up new metaphors and exercises or adapting existing techniques to fit the needs of specific clients. When first learning the ACT approach, it’s generally helpful to follow one of the available protocols or treatment manuals and carefully practice the metaphors and exercises before applying them to a client. However, because the model is focused on implementing the six flexibility processes with contextual sensitivity, it doesn’t mandate using any particular metaphor, exercise, or method. Indeed,

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overreliance on prescribed metaphors, exercises, and methods can create a mechanical-­feeling interaction that isn’t responsive to clients’ needs or the functions of their behaviors. And eventually, it’s usually best to leave topographical treatment protocols behind when entering the therapy room and to instead aim for functional adherence to the ACT model. If therapists are focused on the content of techniques rather than their functions and engage in rote attempts to get a metaphor or exercise correct, they can lose sight of the needs of the client. The content is important and plays a role in the learning process, but understanding the purpose of doing a particular exercise is paramount. While there are certain exercises and metaphors that are frequently presented in treatment manuals and ACT texts (including this book), and many of them are commonly used by therapists, they are not necessary ingredients of ACT. Furthermore, individual therapists will, of course, have their favorite methods—­ approaches that fit their personal style and seem to work better for them in terms of bringing the flexibility processes to bear in session. Tailoring your ACT interventions to match the needs of a given client can enhance the therapeutic relationship and allow the therapy to flow in a natural manner. For instance, you might choose to spend more time on control as the problem and less time on creative hopelessness. Or you could decide, given the client’s needs, to forgo creative hopelessness as an independent exercise. You may choose to start with values, or you may bring in values later in therapy. Ongoing awareness of the client, yourself, and the function of client behaviors in session can guide you in targeting particular processes and choosing particular methods. Tailoring the intervention to the client, including the client’s cultural context, is key to these competencies (we’ll discuss this further in chapter 11). Some metaphors or exercises may be perceived as culturally insensitive or have the potential to function as a microaggression. Additionally, some metaphors or exercises may not make sense within a given cultural or language context. Therefore, therapists may need to adapt or forgo particular metaphors or exercises depending on the client’s background. In addition, recognizing environmental, social, and community factors relevant to a client’s well-­being is an important part of meeting the client’s specific needs. Stigma or discrimination related to identity or group membership must also be considered. Finally, the level or target should be considered, because ACT can also be used to work with the psychological flexibility processes at various levels, including in couples, families, groups, and organizations, and at even larger scales. Here is the fifth ACT core competency related to the therapeutic stance: The therapist models acceptance of challenging content (e.g., what emerges during treatment) while also being willing to hold the client’s contradictory or difficult ideas, feelings, and memories without any need to resolve them. It’s important for ACT therapists to directly practice willingness in session. This can pose some difficulty, as many therapists have been taught that good therapy means helping clients resolve difficult emotions or troubling thinking. For instance, when a client is confused, therapists may slip into problem solving, giving lots of information to help the client “fix” the situation, without adequately considering whether more fully experiencing confusion would be the better course in the long term. In such situations, therapists must be willing to experience their own anxiety or discomfort arising from not trying to fix what the culture or system considers to be negative content. As noted in the introduction, beginning ACT therapists tend to be anxious about the counter­ intuitive nature of the model, a reaction that may change only slowly. Fortunately, beginning ACT

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therapists can achieve good outcomes even if their anxiety remains high (Lappalainen et al., 2007), perhaps because their own anxiety helps them model and be in touch with the flexibility processes, rather than simply transmitting theoretical material. Self-­doubt is part of learning a new therapy and is common in therapists. A recent study even suggests that self-­doubt may make therapists more effective, especially if they are also loving toward themselves (Nissen-­Lie et al., 2015). We encourage you to embrace your self-­doubt and hold it gently, as it may actually be your ally. Here are the sixth, seventh, and eighth ACT core competencies related to the therapeutic stance: The therapist introduces experiential exercises, paradoxes, or metaphors as appropriate and deemphasizes literal sense making of the same. The therapist always brings the issue back to what the client’s experience is showing and does not substitute his or her opinions for that genuine experience. The therapist does not argue with, lecture, coerce, or attempt to convince the client. These competencies focus on experiential learning, which is fundamental to ACT. The potential for growth inherent in uncertainty is prized, and adopting a nonliteral, defused, present, accepting stance is encouraged. Yet sense making exerts a powerful pull on human behavior, sometimes to the detriment of being and doing. The point of ACT exercises, metaphors, and stories is not so much to help clients understand their problems in a new light, but rather to promote their development of psychological flexibility while supporting behavior that’s inspired by their values. Sometimes working to create greater understanding is helpful, but the function of explaining and understanding should be considered in terms of the flexibility processes. Particularly for clients who are pervasively stuck, trying to understand how they landed in a particular problem and then working to figure out how to get out of it could well be part of how they got stuck in the first place. For example, a person with chronic PTSD may believe he needs to know a lot more about PTSD in order to solve the problem of PTSD. This can result in many years in therapy pursuing understanding, rather than learning more flexible ways of living with a trauma history. In ACT, the aim is not to add to this process. If you find yourself attempting to change a client’s mind rather than trying to liberate the client’s life, stop: you aren’t doing ACT. And finally, here is the ninth and final competency, which is perhaps the broadest: ACT-­relevant processes are recognized in the moment and, when appropriate, are directly supported in the context of the therapeutic relationship. The rest of this chapter focuses on how to implement this competency. To that end, we’ll examine ACT theory as it relates to the therapeutic relationship.

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Experiential Exercise:

Finding Level Ground This exercise is aimed at practicing the stance that you and your clients are not fundamentally different, but rather are cut from the same cloth. Who was the most difficult client you ever had? Write the client’s initials here:        Come up with a list of adjectives that describe this person. Try to generate six to twelve:   Reflect back on your family, childhood, and history, and consider whether any of these attributes remind you of your own past. Spend a few moments writing about that:     Now reflect on yourself and consider whether any of these qualities are somewhere in you. Could any of this be said about you? If so, write about that for a few minutes:     Now answer the following questions: How was it to do this exercise?  

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Did you notice any hesitation or resistance about doing it? If so, what were you resisting feeling? Can you open up to that?   If you see parts of this client in yourself, how do you relate to these parts of yourself? Are you warm, welcoming, or compassionate, or have you worked to change these parts of yourself or given up on them?  

Flexibility Processes at Three Levels: Client, Therapist, and Relationship In order to build an ACT model of the therapeutic relationship, we need to distinguish three levels, or aspects, of the relationship: the psychological processes of the client, the psychological processes of the therapist, and the nature of the interaction between the therapist and client.

The Client Because most of this book focuses on the level of the psychological processes of the client, we won’t address this level here, other than to say that this level involves exploring which processes are harmful to the client’s psychological flexibility and how these processes can be altered clinically.

The Therapist ACT researchers and clinicians have long argued that all of ACT’s core processes apply to the psychology of the therapist as well as the client, and that in order for therapists to most flexibly adopt the basic ACT therapeutic stance, they must necessarily be working with the flexibility processes in regard to their own psychological experience. Even though this book doesn’t focus heavily on steps clinicians need to take to promote their own psychological flexibility, much if not most of the material in chapters 2 through 7 applies equally to the therapist. The ACT community has a tradition of using experiential workshops to help therapists apply ACT methods to their own life and practice. It’s also

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common for ACT therapists to learn ACT from the inside out by using client workbooks such as Get Out of Your Mind and Into Your Life (Hayes, 2005), applying them to their own personal struggles. Ongoing practice in working with the core processes to promote your own psychology flexibility is essential for maintaining an ACT-­consistent therapeutic stance. To that end, in the sections that follow we’ll briefly address some key considerations regarding how each core process informs the therapeutic stance.

ACCEPTANCE When doing clinical work, painful feelings or memories sometimes emerge for therapists. It hurts to watch others hurt, and furthermore, the pain clients are experiencing often overlaps with and touches upon similar pain experienced by their therapists. Clinical work can be challenging in other ways, as well. For example, there is the pain that comes from not being certain about how to help someone, or the aversiveness of self-­critical thoughts in response to perceived mistakes or failures. Therapists who are unwilling or unable to sit with their own discomfort may tend to structure sessions in ways that help them avoid these experiences. Clients can detect this, whether consciously or unconsciously, and the inconsistency it reveals can undermine therapy. For example, suppose an ACT therapist is asking a client to sit with anxiety but is unwilling to sit with the anxiety of not knowing whether the client’s situation is getting better. The client may then attempt to rescue the therapist by hiding her anxiety in session. So although the client is explicitly encouraged to sit with anxiety, she is functionally encouraged to control it. That is an impossible situation for clients. Therefore, ACT therapists need to develop and maintain proficient acceptance skills in order to do ACT effectively.

COGNITIVE DEFUSION Defusion presents similar problems. Therapists are tempted to defend the correctness of their thoughts in much the same way clients are. This can include thoughts about therapy itself. Suppose a therapist is asking a client to simply notice thoughts, instead of treating them as true or false or as events to be believed or disbelieved, but is also subtly demanding that the client treat the therapist’s clinical interpretations as factual, not as merely useful to the extent that they are useful. This also places the client in a difficult situation. In effect, the therapist is asking the client to “just notice your thoughts as thoughts, except when they disagree with my thoughts, in which case I’m right.” Therefore, ACT therapists must take care to treat their own thoughts as thoughts and to hold their ideas lightly, and be willing to do so when it serves a valued purpose in therapy.

PRESENT-­MOMENT AWARENESS Presence, compassion, liveliness, spontaneity, fun, and laughter are all found in contact with the present moment. When working with clients, the present moment includes awareness of client behavior (e.g., what is being said, how it’s being said, the function of what’s being said) and awareness of the therapist’s own feelings, thoughts, memories, and sensations. If the therapist isn’t able to consistently return to the present moment, therapy may have a distant, predictable, rule-­governed quality, and the therapist may be insensitive to the effects of his behavior on the client. For example, the therapist may miss times when a client feels invalidated or when important emotional reactions emerge. Alternatively,

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therapists who don’t notice their own experience in therapy may lack self-­awareness of their own stuck points, be unable to use their own reactions as helpful information, or miss instances when their own inflexibility interferes with therapy.

SELF-­AS-­CONTEXT ACT seeks to undermine attachment to the conceptualized self and build contact with a transcendent sense of self that allows people to flexibly take perspective on themselves and their experience. Contacting self-­as-­context can facilitate acceptance and thereby allow therapists to be more flexible in the service of their clients, particularly by letting go of limiting self-­concepts and modeling this for clients. In addition, flexible perspective-­taking skills are important for therapist empathy and compassion, which are both important factors in therapeutic outcomes more generally. Self-­compassion also emerges from perspective-­taking work and tends to be helpful in responding to and learning from the inevitable mistakes and failures that are part of any therapist’s career. In addition, opening to a larger sense of self allows both joy and pain to be present without attachment to either. Modeling this for clients may be an essential part of helping them see that this applies to them, as well.

DEFINING VALUED DIRECTIONS Engaging in values-­based behavior is central to effectively doing ACT. Values dignify the other aspects of the ACT model and make them coherent. For example, the purpose of accepting difficult experiences is not acceptance for its own sake, but to empower values-­based living. When clinicians have clarity about and dedication to their own values in therapy and in life, this empowers them in stepping into psychologically difficult places in the service of clients. For therapists, clear values related to therapy can provide guidance through the sometimes stormy waters that are part of trying to help clients, especially in the presence of unpredictable or difficult client behaviors.

COMMITTED ACTION Having the ability to actively pursue chosen values is the bottom line in the ACT model. Therefore, commitment isn’t about the topography of actions, but about the function of actions, namely, that they are aimed at instantiating the individual’s values. For therapists, the commitment to act on therapy-­ relevant values (as well as broader values) may imply either persistence in or change in behavior, depending on the situation. The key is that these behaviors be engaged for the good of the client. When therapists display willingness to acknowledge ways in which their own therapy-­relevant behavior may have been counter to their values, followed by a return to their commitment, this can be a helpful model for clients. It is also the very definition of workable behavior in ACT. ACT therapists must be aware of when their own psychological inflexibility may be interfering with therapy and then take steps to redress the situation. This might take the form of consulting with colleagues who can provide assistance in exploring the function of any emotional reactions that arise for the therapist in session. Ideally, if you’re practicing ACT, you will have trusted colleagues who respond to you in ways that model psychological flexibility and support you in being more psychologically flexible with your clients.

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Experiential Exercise:

Therapist Flexibility Many of the places therapists get stuck when working with clients involve their own emotional and cognitive reactions that lead to inflexibility. Each therapist brings a unique history to therapy, and at times, this history makes particular clients more difficult on a personal level, which can potentially trigger psychological inflexibility. This exercise will help you help build awareness of situations in which you may get caught in inflexible responding with a client who’s difficult for you. In it, you’ll take inventory of the kinds of situations in which you tend to get stuck with clients. Consider using it any time you find yourself at an impasse in a case and suspect that part of the reason might be your own inflexibility. (For a downloadable version of this exercise, visit http://www.newharbinger.com/39492.) Start by identifying a client you’re working with whom you find challenging. For example, you might choose a client who elicits uncomfortable emotions for you, for whom you feel like therapy isn’t progressing, or whom you feel distant from or uncaring toward. Then take a few moments to think about what you experience during sessions with this client. What are the different thoughts, feelings, evaluations, and urges that arise? See if you can identify the situations in which you most seem to get stuck. Below are some questions to help you reflect. Take the time to write out your answer to each question, and consider bringing the psychological flexibility processes to bear where appropriate. What are some topics you avoid with this client?   What difficult feelings arise for you when you’re with this client? What do you do in session in response to these feelings?   What thoughts or stories about the client do you struggle with when you’re with this client? (For example, She’s hopeless or I’m not incompetent.)   What’s typically going on in session when these thoughts come up?  

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Do you ever disengage, give up, or zone out with this client? If so, when? What does this tell you?   Do you ever find yourself wanting to argue with the client or, conversely, trying to avoid arguments? If so, what seems to trigger this?   How might the stories or behavior you identified in response to the previous questions affect this client?   What might it look like if you could remain present during these moments and be most fully who you want to be for this client? How might your presence be of service to this client?   When you’re struggling with this client, what kind of relationship do you have with yourself? What kind of qualities would describe that relationship?   What qualities do you want to bring to your relationship with this client and with yourself?   If you could see five years into the future, what is the main thing you hope this client would have taken away from your work together?  

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What might it mean both to you and to your client if you could more fully bring the qualities you hope for into your sessions?   What kind of actions do you need to take to be the kind of therapist you want to be with this client (including toward yourself when with this client)?   If you find yourself turning away from these directions and possibilities, how can you gently return to them? What would that look like for you?  

STAYING FLEXIBLE AND PREPARING FOR SESSIONS There are a number of strategies that therapists can use to help themselves stay in a flexible space when approaching sessions. At a broad level, there is no substitute for personal practices that maintain one’s health and psychological flexibility. These might include a daily mindfulness or loving-­kindness meditation practice or attending to basic self-­care activities that promote psychological flexibility, such as getting exercise, eating well, carving out leisure time, sleeping well, connecting with others socially, and so on. During your workday, it may also be helpful to incorporate brief practices focused on attending to the present moment. For example, you may find it helpful to engage in a short period of reflection prior to sessions. This may take the form of brief ACT or mindfulness meditations, quietly reflecting on the client and her values and vulnerabilities, or practicing a loving-­kindness meditation. Even simply slowing down mindfully for a couple of minutes prior to sessions can greatly influence the tone of therapy. If you’re unable to make time for such practices before sessions, consider starting sessions with a brief exercise to help both you and the client find a more workable space from which to begin. Many clients appreciate starting sessions in this way, and over time, you can develop a large range of brief exercises to use. Ultimately, it’s up to you to discover which practices and behavioral strategies help you maintain and expand your psychological flexibility. Below, we present a brief exercise, inspired by Vilardaga and Hayes (2010) as a specific example of something you might do before a session if you find yourself feeling disconnected from or at odds with

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a client or unable to see the client’s perspective (For a downloadable audio version of this exercise, visit http://www.newharbinger.com/39492.) Imagine that you are this client on his or her way to today’s session. Imagine what this client would see while traveling to your setting. What would this client see, hear, and smell while sitting in the waiting room? While continuing to imagine your client’s perspective, consider what he or she might be thinking or feeling in anticipation of the session with you. Notice any hopes or anxieties. Also notice how long these reactions have been around, how old they are. This client may have been feeling and thinking these kinds of things for months or years and in many different situations and places. Now, gently shifting, see if you can be aware of this client’s sense of conscious awareness. This client is more than his or her suffering. Now notice whether you experience any feelings, thoughts, or judgments about the client, his or her problems, or this upcoming session. Notice your own hopes for the client as you connect to his or her fears. Take a moment to recall times when you’ve had similar thoughts and feelings, perhaps with other clients or with other people, in other places, and at other times. Be aware of your own sense of conscious awareness. You are more than all of the shifting content of your feelings, thoughts, and judgments. Now notice that both you and this client are conscious and aware. Both of you have feelings and thoughts. Both of you have people and principles that you care about. And both of you are more than the content of those experiences. Finally, consider what is most important to this client and what you would hope to bring to this client in his or her journey through life. If therapy went well, what do you most hope would be different for this client five years from now?

The Therapeutic Relationship Finally, the third level of an ACT model of the therapeutic relationship involves applying all six of ACT’s core processes to the context and content of the therapeutic relationship as it occurs in the moment. As an example, consider acceptance. ACT therapists aren’t simply targeting acceptance in clients, nor are they simply accepting their own feelings as they emerge during therapy; they are also accepting of the client in moment-­to-­moment interactions. The context and content of the therapeutic relationship will ideally reflect this key process in a vital, moment-­to-­moment way. The other five core processes would be expressed similarly, through therapeutic interactions that are defused, present, conscious, values-­based, active, and, ultimately, flexible. As we reviewed the core processes in regard to the therapist earlier in this chapter, you may have noticed that some of them are probably important regardless of the type of therapy being done. For example, therapists need to be able to be present, use their own reactions as input, and respond flexibly to the situation irrespective of the model of treatment they’re using. However, there are some core relationship processes that are especially important in the context of ACT. For example, clients can benefit when therapists model the flexibility processes in their own behavior. And, of course, targeting acceptance in an avoidant way or defusion in a fused way would be counterproductive.

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AN ACT MODEL OF THE THERAPEUTIC RELATIONSHIP An ACT model of a powerful therapeutic relationship is shown in figure 10. You can see all three levels of the therapeutic relationship simultaneously: the client, the therapist, and the interactions between them. All of these levels acting together constitute an effective therapeutic relationship. As discussed in chapter 1, psychological flexibility is an expression of the six core flexibility processes working together. It is represented as a circle at the center of the hexagon that emerges from all the processes (the points on the hexagon) and their interactions (the lines between them). When this model is extended to the therapeutic dyad, the number of interactions within and between the core processes increases exponentially, as seen in figure 10.

Figure 9.1: A Model of the ACT Therapeutic Relationship

Figure 10. An ACT model of a powerful therapeutic relationship.

Applying ACT to the Therapeutic Relationship

No practitioner could possibly hold all of the relationships in figure 9-1 in his or her head. That is ACT THE THERAPEUTIC not APPLYING the point. Rather, ourTO general message is that ACT can RELATIONSHIP be applied to the therapeutic relationship itself. Here we provide a model of how ACT therapists can detect instances of psychological flexibility or Basically, the task of ACT therapists is to detect instances of psychological flexibility and inflexiinflexibility in client behavior in the session and can reinforce or challenge that behavior in the moment. bility in their use psychologically responses to establish therapeutic a therapeutic relationship Through this clients process,and we hope to enhance yourflexible sense of how ACT-consistent relationships that models, instigates, and reinforces client psychological flexibility. The complexity of the therapeutic feel. If you carry this sense into your clinical work, clients can become your teachers and trainers, while relationship demonstrated in figure 10 may appear daunting to therapists who are new to ACT. greater psychological flexibility in those clients supports your actions that produce it. However, no therapist holdrelationship all of the relationships in figure 10able in her it isn’tofour Applying ACT tocan the possibly therapeutic requires that you first are to head, detect and instances intention to give that message. Rather, our general message is that ACT can be applied to the therapsychological flexibility and inflexibility in your clients. We spend some time discussing how to detect peutic relationship itself. Our hope is to enhance your sense of how ACT-­ c onsistent therapeutic relathese processes, but perhaps less time than might otherwise be the case because this part of the model is tionships feel, helping you growthe your the process and8.bring your clinical work more fully covered extensively throughout restconnection of the book,toincluding chapter the client’s action is a step forward with respect to psychological flexibility, the ACT therapist’s in lineIfwith the model. job is to reinforce that step forward, while simultaneously modeling and instigating additional flexibility, by using psychologically flexible therapist responses. Conversely, if the client’s action is psychologically inflexible, the ACT therapist’s job is to not reinforce that inflexibility, while simultaneously modeling and instigating flexible client responses through psychologically flexible therapist responses. This analysis is a core focus of much of the rest of the chapter.

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If you carry this sense into your clinical work, your clients can become your teachers and trainers, with greater psychological flexibility in your clients reinforcing your own actions that help produce that flexibility. If a client’s action reflects an increase in psychological flexibility, your job is to reinforce that behavior—­while simultaneously modeling and instigating additional flexibility through your own psychologically flexible responses. Conversely, if a client’s action is psychologically inflexible, your job is to not reinforce that inflexibility—­while simultaneously modeling and instigating flexible client responses through your own psychologically flexible responses. In the next section, we discuss how to detect these processes; however, we address this topic only briefly because this is covered extensively throughout the rest of the book.

WHEN TO FOCUS ON THE THERAPEUTIC RELATIONSHIP Although all ACT methods in psychotherapy occur in the context of a therapeutic relationship, that doesn’t mean you need to focus on the relationship per se in any given moment. Doing so should be guided by need and function. We explored four levels at which to conceptualize behavior in chapter 8. Tracking these in therapeutic interactions is part of the work. A client’s statement can be addressed in terms of overt content, as a sample of social behavior, as a statement about the therapeutic relationship, or in terms of the function of that verbal behavior. At each of these levels an ACT analysis is possible, but some avenues may be more interesting than others depending on the situation. Focusing on the therapeutic relationship is typically most useful in two circumstances. The first, which is fairly obvious, is when working on the therapeutic relationship is necessary for the therapist to be effective. For example, if the client’s degree of avoidance in the therapeutic relationship is so high that important topics can’t be discussed, the therapist would need to address this in order to work with the client effectively. This is especially important when difficulties in the therapeutic relationship interfere with the ability of the therapist and client to work together cooperatively. Such difficulties are sometimes termed “alliance ruptures.” Research shows that these kinds of problems predict client dropout (Eubanks-­ Carter, Muran, & Safran, 2010) and are therefore important to attend to. Furthermore, addressing ruptures provides an opportunity for both therapist and client to learn about relationships and the development of psychological flexibility. Here are a few indicators of a possible rupture: when clients express that they feel misunderstood or invalidated; when clients feel that the treatment isn’t relevant to their concerns; when they complain about the therapy or the therapist; or when they make demands of the therapist. Specific processes for addressing such ruptures exist (e.g., Eubanks-­Carter et al., 2010). Here, we’ll simply outline a general approach: First, the therapist draws attention to the in-­session client behavior that indicates a rupture may have occurred. Then the therapist expresses willingness to explore the possible rupture, including acknowledging ways in which the therapist may have contributed to the problem. Along the way, any of the flexibility processes may be used gain insight into what’s happening within the relationship. The second context in which it’s especially helpful to focus on the therapeutic relationship is when the client’s in-­session behavior reflects broader patterns of social engagement that are problematic or that are improvements to be supported. For example, if a client is anxious and avoidant and displays these behaviors in the therapeutic relationship itself, working on them at that level has an immediacy and directness that cannot otherwise be attained. To illuminate the effectiveness of this approach, we’ll briefly return to the evolutionary principles that inform ACT.

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Human beings are a highly social species. Much of the reason we are so successful as a species is our ability to cooperate, and language is our primary tool for cooperation. People who are unable to cooperate with others and form close, trusting bonds often experience a great deal of suffering. Language and cognition can either foster these bonds or interfere with the development of intimate, secure, and trusting relationships. As therapists, we all understand this intuitively. You’ve undoubtedly observed how clients who are caught in rigid beliefs and closed to the input of others have trouble in relationships. Likewise, you’ve probably also seen that clients who are unable to contact, experience, describe, and express their emotions have a hard time connecting with others. Or you may have observed that clients who are caught up in their internal verbal world, who rigidly blame others, or who are unable to take others’ perspective often find themselves in relationship conflicts or feeling lonely or ostracized. These are just a few of the many ways that psychological inflexibility interfaces with more directly shaped social repertoires to cause interpersonal difficulties. These behaviors are also prime targets for fostering interpersonal effectiveness inside the ACT relationship using the flexibility processes. Focusing on the therapeutic relationship is a powerful experiential move when psychological inflexibility that emerges in the therapy relationship is functionally related to psychological inflexibility in other realms of the client’s life. Perhaps not surprisingly, many clients afford frequent opportunities to take this approach. Clients often respond to their therapists in the same way they respond to other important people in their lives. By targeting psychological flexibility as it unfolds in the therapeutic relationship, therapists can help clients work with these behaviors and then generalize positive changes to other significant relationships. Sometimes clients’ interpersonal behavior may be so inflexible that it greatly interferes with the therapeutic relationship, just as it interferes with their other relationships. For these clients, the therapeutic relationship may become the primary target of therapy and the main context within which the development of psychological flexibility occurs. A number of ACT and functional analytic psychotherapy books provide additional guidance on how to work with interpersonal behavior using the therapeutic relationship as the primary catalyst for change (see Tsai et al., 2009, as well as http://functionalanalyticpsychotherapy.com/books-on-fap).

Targeting the Therapeutic Relationship In this section, we bring together the approach and competencies discussed in this chapter by examining a characteristic moment in clinical practice when it would be useful to focus on the therapeutic relationship. Given ACT’s functional contextual perspective, we take two completely different tacks on the same basic client behavior: saying that therapy isn’t going well. First, we look at how the therapist might respond if that statement represents an improvement on the client’s part, then we look at how the therapist might respond if the statement reflects problematic behavior for the client. (At the end of the chapter, we provide exercises that give you the opportunity to work through additional examples.) Because the ACT model of the therapeutic relationship isn’t limited to times when that relationship is specifically targeted, some of the sample therapist responses don’t have an exclusive focus on the therapeutic relationship; however, all of them have a bearing on the therapeutic relationship. Here’s the background on the scenario we’ll examine. The client is in therapy for an anxiety disorder and says, “I’m not getting any better in here. This just seems like psychobabble to me.”

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This complaint may well reflect increased psychological flexibility. For example, if the client’s long-­ standing strategy for experiential avoidance is agreeing with authority figures or denial, she could be stepping into new and healthier territory by admitting to being upset with the therapist. Conversely, the complaint could be a psychologically inflexible expression of avoidance or fusion. The client could be fused with ideas that change isn’t possible, in which case this outward focus on the therapist is functioning to support this story. Or this could be an instance of a pattern of unworkable interpersonal behavior in which the client attacks and blames others when she feels frustrated with herself and her inability to meet internalized standards. Note that although we’ve organized the following potential therapist responses by the primary core ACT process involved, the model responses often employ more than one flexibility process. Responses targeting only one flexibility process would be artificial, given that in ACT most clinical responses have multiple functions. This is a natural expression of the interrelationships of all of the processes within the model.

The Client’s Statement Is an Improvement We’ll begin by supposing that the therapist views the complaint as a small step forward in the c­ lient’s ability to share difficult feelings or be direct about her concerns in a relationship. In this case, the goal of the therapist is to respond in a way that reinforces the client’s step forward while also modeling and strengthening flexibility. As a reminder, the client has just said, “I’m not getting any better in here. This just seems like psychobabble to me.” Acceptance response: “Thanks for telling me that. What do you feel as you put that into this room?” Analysis: A number of commonsense therapist responses could be problematic from the ACT perspective. A fused response might involve the therapist trying to resolve the sense that this is psychobabble or even defending against that idea with a response such as, “Actually, your anxiety scores are way down. Why do you feel you aren’t getting any better?” The client probably knows that her statement could be upsetting to the therapist; therefore, any move by the therapist to undermine or question the literal truth of the complaint could be seen as or could actually be an attempt on the part of the therapist to not feel inadequate. In contrast, the therapist’s response of “Thanks for telling me that” indicates that he’s willing to feel upset. This response is designed to reinforce the emotional opening the therapist thinks he detects. Then, the question “What do you feel?” invites the client to explore the process the therapist is trying to support—­acceptance. Defusion response: “Ouch. That must be a painful thought to have.” Analysis: Done crudely, defusion in this situation is likely to be emotionally invalidating, which would undermine the purpose of the therapist’s response. In this case, the therapist has inserted just enough defusion (by labeling the thought a thought) to make the point that the client is expressing a thought, not necessarily an event that must be objectively true or false. At the same time, the therapist is supporting the client’s step forward. This statement also has an acceptance aspect: by acknowledging the pain, the therapist hopes to validate and support the client’s expression of emotionally difficult material.

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Present-­moment awareness response: “That must have been hard to bring up. [Pauses.] Maybe before we respond, we can both just take a second to get present with what it feels like to be here with that in the room.” Analysis: This response acknowledges that both the client and the therapist face a challenge in the present moment: it’s hard to say what the client said, and it’s hard to hear it as a practitioner. By suggesting that they both come into the present moment together while actively embracing the challenge, the therapist models acceptance and the importance of being mindful of the present moment, and hopefully also reinforces the client’s step forward in expressing a difficult feeling. Present-­moment awareness response with an explicit focus on the therapeutic relationship: “I can hear the tension in your voice as you bring that up. I bet that’s hard to do… [The client endorses this.] I wonder if we could explore that for a bit and see if we can understand what’s going on between us. For example, maybe you could tell me what I’ve said that sounds like psychobabble to you.” Analysis: This response is based on the idea that the client’s statement might indicate a possible alliance rupture, with the client expressing that she’s experiencing the treatment as unhelpful. By responding with empathy and expressing a desire to take the complaint seriously, the therapist is trying to reinforce this avoidant client for being direct. Subsequently, it will be important for the therapist to be open to the client’s feedback and the possibility that his behavior may actually be overly intellectual, indirect, or otherwise inaccessible for this client and that he may need to change his approach to this client. Self-­as-­context response: “If I felt like that, it would be really difficult. It would be hard for me to say what you just said to a therapist.” Analysis: A transcendent sense of self is based on deictic relational frames. In RFT studies, one of the ways children are trained to use these frames is by asking them questions like, “If I were you and you were me, what would you have in your hands?” The therapist’s simple act of putting himself in the ­client’s shoes promotes a sense of shared human experience and also has the desirable effect of supporting the client’s positive step. Values clarification response: “I hear you and will try to be more clear in the future. I also want you to know that I feel grateful that we’ve been able to create the kind of relationship where you can share critical feedback like that. And before we unpack it, let me just say that I’m here for you and what you really want in your life, not so I can get applause for saying clever things.” Analysis: This response makes the therapist’s values explicit. It defines therapy in terms of a contract that’s about the client, not about the therapist’s comfort or getting to be right. It also explicitly eschews an attachment to psychobabble (e.g., “saying clever things”) and makes an effort to reinforce the positive step in the client’s behavior, even if the therapist will later need to return to this repertoire to help the client learn to be direct in ways that are less harsh.

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Committed action response: “I hear you. And before we begin to unpack this, is it okay for me to share my reaction to what you’ve said? Sharing my reaction would feel like a risk with you and would also be in the direction of how I want to be with you. [The client consents.] I want you to know that it’s hard for me to hear that, and I notice some anxiety showing up. At the same time, I also want you to know that I care about you and am 100 percent willing to feel whatever I’ll feel as part of knowing you.” Analysis: This response represents a committed action on the therapist’s part and models the link between committed action and willingness. The therapist is demonstrating his willingness to feel difficult emotions in the service of the therapeutic relationship.

The Client’s Statement Is Problematic If the therapist sees the client’s statement as psychologically inflexible, his goal would be to model and instigate positive processes without reinforcing negative processes. For example, if he views the statement as a reflection of experiential avoidance, the presumed reinforcer is avoidance of difficult private experiences. Therefore, he won’t want to offer a response that provides that functional outcome. For example, if he goes into an extended analysis of why the client hasn’t made progress, the emotions she’s avoiding may never be contacted. Avoidance can be difficult to address clinically because if it works, whatever is functionally important isn’t immediately present. So the therapist needs to make an astute determination of what’s going on. Suppose, for example, that the client’s statement is designed to help her avoid anxiety. In that case, the therapist wouldn’t want to inadvertently respond in a way that could forestall feelings of anxiety. Similarly, in the case of fusion, the presumed reinforcer could be defense of an extended, coherent relational network—­in other words, being right. In this case, any response that draws the client and therapist deeper into that relational network is undesirable. Disagreement and agreement both can have that effect, as can logical challenges, compliance, resistance, or analysis. For these reasons, some of the responses that follow may appear to be non sequiturs. This occurs when the clinical response is designed to step out of normal but unhelpful contingencies and into flexibility processes. In constructing these model responses, we assumed that the same avoidant and fused patterns hypothesized to be expressed in the client’s complaint are also evident in the therapeutic relationship itself. Therefore, in some of these responses, the therapist shifts levels from the content to the relationship per se. Also note that because the therapist must link his response to his functional analysis, it’s especially important to view the model responses as just one possible approach. Finally, we want to point out that the examples in this section provide a template you can use when dealing with ruptures in the therapeutic relationship. Therapists must take responsibility for their role, fully and without defense, and need to do so in a way that models the flexibility processes and doesn’t defensively attempt to shift the focus to the client. Then, based on shared values, the therapist can work to reassemble and reaffirm the therapeutic contract, again modeling and instigating the flexibility processes in every stage of the process. As a reminder, the client has just said, “I’m not getting any better in here. This just seems like psychobabble to me.”

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Acceptance response: “I’m guessing you’ve felt like this before with other therapists. Yes? [The client agrees.] Okay, so could I ask you this? What did you do in the past when you felt like this? And how did it ultimately unfold?” Analysis: This response asks the client to look at the function of her statement by reflecting on similar situations in the past. It’s an acceptance-­based question because it illuminates experiential avoidance. Note that the therapist doesn’t defend himself; rather, he first checks to make sure there were past instances, and then links the complaint to workability for the client, not to truth or falsity in a literal sense. The therapist isn’t attempting to influence the client’s answer; he honestly wants to know. Acceptance response with an explicit focus on the therapeutic relationship: “Are you feeling afraid that I’ll disappoint you and let you down?” Analysis: The therapist parses the complaint as a statement about the therapeutic relationship itself. By guessing about the possible function of the statement, he both models and instigates acceptance of difficult emotions. Even if his guess is incorrect, the client is likely to see and appreciate the risk he’s taken and can potentially define the relationship as a place where difficult feelings can be stated. Defusion response: “I want to really pay attention to this, but first I want to see if we need to look at it from a different angle. It sounds like things you’ve said in here before… It has that mind-­y quality to it, the kind we’ve explored, where your mind swoops in and snags you under certain conditions. I’m wondering if your mind is here doing that now…like it’s really close to you and has you?” Analysis: This is a straightforward defusion response because it looks at the process of thinking, not just the products of thinking that led to the complaint. The therapist is talking about the client’s mind as if it were a separate entity, distinguishing the client from her mind. Relationship-­oriented therapists sometimes see defusion as inherently invalidating because it is so far outside of typical social interactions. However, this response seems unlikely to have an invalidating effect. Doing defusion well depends on timing and skill, and should never be done in a dismissive fashion. Defusion response with an explicit focus on the therapeutic relationship: “Interesting. Well, if we take that thought literally, I suppose we would need to deal with whether you are in fact progressing. And we can do that if your gut-­level sense is that doing so would have value. But I wonder if another area to look at would be our relationship and what we might plan to do when we have thoughts about the process itself that are scary or difficult.” Analysis: This response assumes that the client’s complaint is at least partly focused on the therapeutic relationship. It specifically links defusion to flexibility in terms of being able to address the worry in multiple ways—­literal or not—­and positions this process inside the relationship. Present-­moment awareness response: [The therapist moves his chair next to the client’s so they’re both looking in the same direction.] “Would it be possible for us to both get into contact with what it feels like to think therapy is going nowhere, right here, right now? Let’s put that thought out there on the floor in front of us and both watch in more detail what comes up as we look at it.”

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Analysis: This response mixes perspective taking, defusion, and contact with the present moment. At a literal level, the client’s complaint is an apparent barrier between the therapist and client. Placing the two chairs together, combined with putting the material out in front of both of them, is a metaphor for a defused, present-­focused therapeutic alliance. It is as if the therapist is saying, “Our worries and judgments are not a barrier to our relationship; they can instead be part of the legitimate focus of our therapeutic work.” This move also pulls the work from talk about another time and place and puts the reactions of both client and therapist in the present moment. Present-­moment awareness response with an explicit focus on the therapeutic relationship: “I’m aware you look angry as you say that to me. Your brows are furrowed and you raised your voice a bit. Were you aware of that? [The client says no.] Are you aware of that now? [The client says yes.] Do you think you’re angry, or are you feeling something else? Take a minute to look.” Analysis: The therapist is conceptualizing the client’s response as a form of harsh criticism that functions to keep others at a distance. Perhaps this reflects an ongoing pattern that has been repeated in therapy multiple times. Disengaging from the client at this time would be likely to reinforce this response. Therefore, it’s important that the therapist engage the client and help her find a more adaptive or flexible response to her experience. The therapist starts by helping the client focus on her experience (which is what her complaint was functioning to draw attention away from) and the possibility that other feelings may be there along with the anger or may even have preceded it (e.g., disappointment). From there, the therapist might help the client identify what she’d like to say if she could feel the other emotion and express it more directly. Self-­as-­context response: We offer this response in the form of a brief dialogue. Therapist: I have something that may sound like a strange question, but how old do you feel right now? Client:

(Pauses.) About seven.

Therapist: Okay, can we take a moment to climb into the skin of that seven-­year-­old? Would it be okay if we do that as an eyes-­closed exercise? Client:

Okay.

Therapist: Good. Let’s do that, and then we can unpack this more afterward. I’d like you to picture where you lived when you were seven, and in your mind’s eye… (Continues with an exercise using temporal frames as described in chapter 5, in which the client is taken through an examination of what it felt like to be feeling something similar at a young age and is asked to talk to the child and hear what she needs.) Analysis: This move treats the avoidance as a historically situated event. By moving the client into the body of herself as a seven-­year-­old, the exercise moves the client’s I-­here-­now perspective into a different context, which allows her a greater sense of perspective on the current struggle.

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Self-­as-­context response with an explicit focus on the therapeutic relationship: Again, we offer this response in the form of a brief dialogue. Therapist: Would it be okay if I asked you a question right now? Client:

Sure.

Therapist: What do you imagine I’m feeling right now? (The therapist is trying to help the client track other-­as-­process.) Client:

I’m guessing you’re probably pissed at me and want to kick me out of therapy.

Therapist: Are you interested in hearing what I’m aware of feeling? Client:

(Pauses, then speaks grudgingly.) I guess.

Therapist: What I’m aware of is a feeling of tension in my chest as I share this. It’s not easy for me to be vulnerable and share what’s going on with me. I notice a pull to defend myself, but I’m not going to do that because I think that would result in us moving further apart. I also notice feeling anxious. As I look over at you over there, I see you looking unhappy. That makes me sad. (Pauses.) What do you notice inside yourself as you hear me say this? Analysis: The client appears to be responding to the therapist in terms of an imagined other-­ as-­content, having viewed the therapist as probably being angry in response to her complaint. The therapist shares his experience in a defused and accepting way and expresses openness to hearing the client’s experience. This approach focuses on developing the client’s ability to accurately track the experiences of others and the effects her behavior has on them. At the end, the therapist gives a cue that will hopefully foster a present-­moment, self-­as-­context stance for the client. Values clarification response: “Let’s just go with that. Let’s go with ‘This isn’t working.’ What do you want in your life that you’d be losing if that were true?” Analysis: Inside our values we often find our pain, and inside our pain we often find our values. This move situates the struggle in values, which can give a different meaning to the struggle itself. Committed action response: “Okay. Let me just ask you this: What do you suspect you’d have to let go of to move therapy along? [The client replies.] And if it were painful but you saw what needed to be done, what would it take for us to move together in that direction?” Analysis: This response, in essence, asks if the client is willing to commit to a therapeutic relationship that would be effective if she could see how it could be useful.

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Summary To some degree, the preceding model responses were artificial, especially in the sense that each attempts to highlight a single flexibility process. Most clinical responses during the course of ACT target a combination of ACT’s core processes. Building an effective therapeutic relationship is at the heart of ACT, and all of the initial skills needed to do so exist within the ACT model itself. The basic strategic rule is to apply ACT in the process of creating a context in which you can do ACT, and to apply ACT to the therapeutic relationship itself as you model, instigate, and support psychological change.

Core Competency Practice This core competency is structured differently than the practices in earlier chapters. We’ve provided a number of exercises to help you experientially engage with ACT’s therapeutic stance. In some cases, we ask you to generate responses to client statements. As in previous chapters, be sure to write your own response before looking at the model responses. Throughout these exercises, challenge yourself to remain ACT consistent. If it feels a bit difficult, that’s a good sign; it probably means you’re trying something new and learning. The first seven exercises are all based on the same scenario: responding to a depressed client who says things are going well in therapy. The final three involve clients who want something explained. These scenarios are all set forth in more detail below, along with the instructions for completing each exercise.

The Client’s Statement Reflects Improvement A depressed twenty-­three-­year-­old woman comes to therapy with a history of bulimia. She tends to be self-­critical and to hide herself behind a wall of superficial positive statements (e.g., “I’m just fine”). In the previous session, the therapist devoted a great deal of work to encouraging the client to be honest in session about how she’s actually doing, rather than trying to be upbeat. At the beginning of this session, she reports, “This has been a great week, and I think it’s due to our work together. I feel good. I’m more open, and my eating problems are under control.” For the purposes of the following exercise, assume that the client’s statement reflects progress toward greater psychological flexibility. The therapist is pretty sure that “I feel good. I’m more open” is not a way of speaking about avoidance. Based on knowledge of the client and the current context in therapy, the therapist thinks she primarily means that she’s more open to her own thoughts and feelings, but he has a slight worry that the client’s statement “I feel good” might reflect a focus on positive emotional content, rather than on doing a good job of feeling her emotions.

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Ther apeutic Stance Exercise 1 Read through the following list of responses, each of which primarily illustrates one of ACT’s six core processes: acceptance, cognitive defusion, present-­moment awareness, self-­as-­context, defining valued directions, and committed action. Your job is to identify the most dominant process in each response. (Be aware that some of the responses contain multiple flexibility processes.) Response 1: “Neat. And what shows up here as you say that?” Response 2: “Thanks. I actually see you not just feeling good, but feeling good based on what we’ve done together. That’s especially meaningful to me—­to see you stepping into places that are difficult and then finding new things to do there.” Response 3: “I see how you’ve been stepping forward. I want you to know I’ll be there for you in this next stage of work, as well, whatever it takes.” Response 4: “Sometimes my mind gives me a lot of things to worry about in here. I know that’s happened with you, too, and I think we’re starting to see what’s possible if we give ourselves some room to work above and beyond all of that chatter.” Response 5: “What is important to me is that this is about you and what you want in your life. It’s great to see that happening and to see you letting yourself be guided by what you care about, instead of what your history is giving you.” Response 6: “There’s a part of you that has the capacity to just notice all of this programming and still make choices, yes? I’m not sure, but that seems to be part of the changes you’re noticing: you’re allowing yourself to show up as a more conscious person.” Match the responses to the flexibility processes by writing the response numbers in the blank spaces.     Acceptance      Cognitive defusion      Being present      Self-­as-­context      Defining valued directions      Committed action The answer key is at the bottom of this page.

Answer key: 2, 4, 1, 6, 5, 3

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The Client’s Statement Is Problematic The next six exercises are based on the assumption that the client’s statement primarily reflects psychological inflexibility. Again, the client says, “This has been a great week, and I think it’s due to our work together. I feel good. I’m more open, and my eating problems are under control.” The therapist believes that this statement reflects the client’s ongoing pattern of presenting a falsely positive front—­to herself and especially to the therapist. The therapist guesses that “This has been a great week” means she didn’t face many challenges, and that “I think it’s due to our work together” is intended to keep the therapist from looking more closely. The therapist thinks the statement “I feel good. I’m more open” is just the client’s old emotional control agenda in new ACT clothing, and that “my eating problems are under control” suggests avoidance. In the exercises that follow, assume that you want to build the relationship while modeling and instigating the flexibility processes and without reinforcing unhealthy processes. Each exercise provides a few possible therapist responses, among which one or two best address the process that’s the focus of the exercise. As for the other responses, sometimes they’re adequate but don’t exemplify the flexibility process. Other times they fit the flexibility process but allow for reinforcement of the inflexibility. And yet other times they are simply weak responses. In each case, remember the purpose and the core process under consideration, and then pick the response that seems best.

Ther apeutic Stance Exercise 2 Check off the response that best exemplifies acceptance: …… “Yeah, I also feel great when things are going well.” …… “Hmm. I’m a bit nervous when I hear that. Is feeling good what we’re trying to do in here?” …… “You just need to accept your feelings. If you don’t do that, the research suggests that nothing good is going to happen in here.” Explanation: The third response is preachy. It is about acceptance, but it seems fused and critical and doesn’t model or instigate acceptance. The first response reinforces avoidance, given the initial analysis. The second response acknowledges a difficult emotion the therapist is having and undermines the hypothesized avoidance function; thus, it is the most ACT-­consistent way to target acceptance.

Ther apeutic Stance Exercise 3 Check off the response that best exemplifies cognitive defusion: …… “If you had the thought ‘Things aren’t going well,’ would you be able to say that to me too? It could be hard. You’d probably run into that habitual ‘I’m fine’ thought, for instance.” …… “Hmm. I’m noticing that I’m having two thoughts. One is all about how great we’ve been doing. The other is whether I should dig into this a bit more because I have a sense that some of what you’re saying is linked to wanting to please me. If you take a moment to look, what thoughts come up as you look at this overview of the last week?”

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…… “Would you mind saying what your evidence is for the idea that this was a great week?” Explanation: The last response asks for evidence to prove a thought is true. This isn’t prohibited in ACT, but it would be best to use this approach only rarely. In any case, it isn’t a defusion technique. Both of the other responses are focused on defusion, and both seem to confront the hypothesized avoidance. Both are reasonable responses from an ACT perspective.

Ther apeutic Stance Exercise 4 Check off the response that best exemplifies being present: …… “What is it about our work that you think is most helpful?” …… “So, how are you feeling right here, in the present, about getting your eating under control?” …… “Before we even get into that, let’s just take three deep breaths and show up to what it feels like to be here and working together. Would that be okay?” Explanation: The first response is relatively fused and seems to assume that things actually are going well, so it might reinforce what’s conceptualized as an avoidance move. The second response is a somewhat awkward attempt to get into the present moment. It links to the client’s idea of getting her eating under control, so it could reinforce potential avoidance. The last response isn’t especially elegant, but it does situate whatever comes next in the present moment and avoids specifically reinforcing the negative aspects of the client’s statement. Therefore, it’s the best alternative.

Ther apeutic Stance Exercise 5 Check off the response that best exemplifies self-­as-­context: …… “And who is saying that? Is this coming from the part of you that likes to present a positive front even when things are difficult? Or is this coming from a core aspect of you that’s open to whatever you experience, whether it is called good or bad?” …… “If I were you and you were me, I’d want to please my therapist, and it feels like you’re trying to impress me with how great things are even though they aren’t great.” …… “Is this the people pleaser talking?” Explanation: The first two responses both contain an appeal to self-­as-­context. The second one does so through a deictic relation (“If I were you and you were me”), but it’s also riskier because it moves strongly toward an assumption that the therapist’s guesses about the client’s motivation are correct, rather than trying to help the client contact a more open sense of self. Unless the client’s statement fits into a long-­standing pattern that has been worked on repeatedly in therapy, the therapist probably would be wisest to say something softer, such as the first response. The third response could be fine, but it’s linked to self-­as-­context more obliquely, in a way that encourages defusion from a conceptualized self.

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Ther apeutic Stance Exercise 6 Check off the response that best exemplifies defining valued directions: …… “I see how important it is to you to move forward. And when you thank me for this progress, I get a feeling I’m being held at bay. I could be way off, but that’s what comes up. I’m in here for you, not for me. I want to know what your actual experience is, whether or not it’s easy for me to hear.” …… “It seems important to do what works in your life right now, and openness is a more workable value than is being closed. So are you being open with me right now?” …… “Okay. Could I ask you to look at something? As you say that to me, what do you think that statement is in the service of? Don’t answer right away. See if you can open up to whatever you’re reaching for—­what you really want, as reflected in that small moment.” Explanation: In the second response, the therapist is telling the client what to value, which is a serious misstep in ACT. The first and third responses are better choices. The therapist could use either, depending on the context. The first is more definitive and directed, whereas the third is more tentative and exploratory.

Ther apeutic Stance Exercise 7 Check off the response that best exemplifies committed action: …… “If you’re committed to recovering from your eating disorder, you really need to be committed to following the eating plan we’ve devised.” …… “Could we do something in here? I’m not saying this is true and what you said isn’t, but I want to see if we can go into some hard places together. I’d like you to look me in the eye and see what it feels like to say—­and for me to hear you say it—­‘I try to make you think I’m fine even when I’m engaging in old patterns.’” Explanation: These responses were a bit more difficult to envision and write because committed action is a broad pattern of behavior. The first response isn’t of high quality because it pushes the client to commit to an eating plan and is preachy. It would probably result in the client continuing to try to please the therapist. The second response is risky because the therapist could be seen as insinuating that the client is lying, even though the therapist explicitly stated otherwise. Thus, a response like this should probably only be attempted when the therapeutic relationship is strong. The therapist’s statement presents the client with the possibility of engaging in committed action through either agreeing with the therapist and directly expressing that she is sometimes inauthentic (which could be an authentic action) or disagreeing with the therapist (which could also be authentic if she truly disagrees).

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The Client Wants Something Explained The next two exercises may be among the most difficult in the book. In these exercises, we ask that you generate responses targeting each of the core flexibility processes, first for a client statement that indicates increased psychological flexibility and then for that same statement when it indicates a clinically relevant problem. You may find yourself struggling to respond in ways that seem fluid and effective. (When we did this exercise ourselves, that’s what we experienced.) It might even be a bit dangerous to include such an exercise because you may notice your struggles and presume they indicate that you aren’t getting the material or developing facility with it, or that ACT isn’t for you. We want to assure you that this is a somewhat artificial exercise designed to broaden and smooth out your repertoire. As you generate responses, remember that the general target of this process is to increase the psychological flexibility of the client by responding effectively to client statements that reflect flexibility or inflexibility in the moment in the therapy relationship. You can respond at several levels: modeling psychological flexibility (e.g., “I’m noticing that I’m thinking I don’t know what to say. You don’t need to rescue me; I can sit with it. Still, I wanted to share that. Do you sometimes feel that way with this?”); targeting the relationship directly (e.g., “And what feelings about our relationship are associated with that thought?”); or responding to the relevant instance of behavior in an ACT-­consistent manner (e.g., being accepting of a challenging remark). Here are a few hints about completing these exercises. One way to generate responses is to look at the models presented earlier in this chapter. Imitating these responses fairly closely can give you an initial idea of how to respond effectively. Although this can be an easier route, it’s also likely to result in less learning and less of an increase in your sense of what it means to conduct ACT in the moment. To build more flexibility, we encourage you to generate responses that are more divergent from the models in form but that still target the same process. Try to bring your own voice into your responses. Another resource you might use is the ACT Core Competency Rating Form in appendix A, which lists the competencies for each process. That might provide some general guidance without overly restricting your creativity. You can also consider generating responses that model flexibility in terms of your own psychological processes, as long as you can do this in a genuine way. Finally, consider generating multiple responses for each process to further expand your flexibility. We decided not to provide model responses for this last series of exercises because we felt that such a large variety of responses could be appropriate and that providing particular responses could inadvertently lead to a sense of narrower options. Now that we’ve explained the details of the next two exercises, here’s the context: A thirty-­nine-­ year-­old man who was recently in a twenty-­eight-­day program for detoxification and substance abuse treatment comes to therapy. He’s married and has two teenage children, and he abuses alcohol, marijuana, and speed. In the past, he’s been prone to overthinking things, and in this almost obsessive state he tends to use drugs. He presents himself as being hardworking and motivated to change, and then makes the following statement. Client:

I’m doing it. I’m doing it. One day at a time. I’m even using that Get Out of Your Mind book. That’s a real trip. This week I was reading the part about values. But I have a question: It seems to me that goals are more important than values because goals are things

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you can really achieve—­and I’m clear about what mine are—­but values are kind of off in the distance, and I can’t be sure what mine really are. And I don’t understand how I can choose them. Could you explain to me why values are so important? And how do I know what my values are, anyway?

Ther apeutic Stance Exercise 8 For this exercise, assume the client’s statement reflects progress toward greater psychological flexibility. For example, you’re pretty sure the client is opening up to the possibility of values as a choice. In this case, you want to model, instigate, and reinforce flexibility processes. Your responses can encompass multiple flexibility processes, but write six different responses, each emphasizing the targeted process. Acceptance:     Cognitive defusion:     Present-­moment awareness:     Self-­as-­context:    

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Defining valued directions:     Committed action:    

Ther apeutic Stance Exercise 9 Now assume the client’s statement mostly indicates psychological inflexibility. In this case, you think the client is becoming enmeshed in trying to figure out values without really acting in a values-­based way. You think the intellectual question is a ruse to fill therapy with trying to figure things out, rather than stepping up to make changes. Again, your responses can encompass multiple flexibility processes, but write six different responses, each emphasizing the targeted process. Acceptance:     Cognitive defusion:    

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Present-­moment awareness:     Self-­as-­context:     Defining valued directions:     Committed action:    

Ther apeutic Stance Exercise 10 Identify a statement by one of your own clients that you found interesting, but that was also difficult for you, and work through the same process. Consider things clients have said that you didn’t know how to respond to, instances where you felt put on the spot, and even actions in session that were challenging to manage. Once you’ve identified one particular statement from a past clinical encounter, write it here:  

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Before moving on, be sure to identify whether you’re attempting to reinforce a positive step while simultaneously modeling and instigating flexibility processes, or whether you’re trying not to reinforce ACT-­ inconsistent steps while still modeling and instigating flexibility processes. Now write ACT-­consistent responses that highlight each of the core processes. In each case, also consider which level of behavior you’re choosing to address. In other words, are you tracking the overt content, the statement as a sample of the client’s social behavior, the statement in terms of what it might reveal about the therapeutic relationship, or the statement in terms of the symbolic and functional processes it instantiates? Acceptance:     Cognitive defusion:     Present-­moment awareness:     Self-­as-­context:    

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Defining valued directions:     Committed action:    

For More Information For more on the therapeutic relationship, see Hayes et al., 2012, chapter 5. For more on using ACT to target interpersonal inflexibility, see Polk et al., 2016, chapter 7. For a behavior analytic take on creating powerful therapy relationships, see Tsai et al., 2009; and Holman, Kanter, Tsai, & Kohlenberg, 2017.

CHAPTER 10

Adapting ACT to Cultural Contexts

I think…if it is true that there are as many minds as there are heads, then there are as many kinds of love as there are hearts. —Leo Tolstoy

ACT is situated inside the larger framework of contextual behavioral science (CBS), which aims to create a science of human behavior that is relevant far beyond the therapy room. From a CBS point of view, psychology is focused on the study of the actions of individuals in contexts defined in terms of their history and internal and external situations. Part of that context is social, and it’s often important to understand clients’ behavior at the social level. Couples, families, organizations, and communities instigate and support patterns of action. Some of these actions may extend beyond the lifetime of individual actors, providing a good reminder that some social actions, such as cultural practices, can only be appreciated at the level of the group—­a view that’s common in fields such as sociology and anthropology. This chapter is intended to provide guidance on this larger social context. In it, we discuss how to take into account social factors such as culture and group membership. We recognize that settings (e.g., inpatient, outpatient, nonclinicial contexts, etc.) are also important in adapting ACT; however, in this chapter we focus on culture. (Guidance on how the setting and level of intervention—for example, groups or organizations—affects application of the flexibility processes is covered in appendix C.) As we’ve emphasized throughout this book, doing ACT effectively means adhering to the model in a functional sense, not a topographical sense. The ACT model is focused on process and context, not on protocol or topography. ACT does not dictate using any particular content, method, technique, metaphor, or exercise, but instead is distinguished by emphasizing its model of psychological flexibility as the source of guidance on how to target psychological flexibility in clients. As such, the theory that underlies ACT can guide therapeutic interventions in a manner that’s ideographic and focused on understanding the contextual aspects relevant to helping particular clients in their particular life contexts. This includes social and cultural aspects of their context.

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Because the model is functional, it’s unwise to view cultural competence or any other contextual adaptation of ACT as a trait that applies uniformly or automatically. In other words, we can’t assume that cultural competence with one client, or even the skills that are useful on one day or in one context, will necessarily translate to cultural competence with the next client or even with the same client in the next session or in another context. Adapting ACT to context is an ongoing process to be guided by functional adherence to the model while bearing in mind the impact on the individual client. Each subsection of this chapter could easily be the topic of an entire book (and in some cases a book does indeed exist on that topic), so our goal is not to offer a comprehensive analysis of this topic, but to provide some guidance on how ACT might be modified to address clients’ personal, political, cultural, and economic contexts. These contexts include language spoken, religion and spirituality, disability status, illness, mental health diagnoses, racial identity, ethnicity, age, socioeconomic status, literacy, gender, sexual orientation, and nationality, among others. While the diversity of contexts and settings is endless, we will cover enough variations in this chapter to allow for generalizing the main themes to other specific settings or social features.

A Functional Contextual Model of Culture Functional contextualism, the philosophy of science underlying ACT, holds that an understanding of human behavior requires an understanding of its current and historical context. This analysis interweaves the history and goals of an action with the action itself. No one, not even the person behaving, can know or understand all aspects of this context. Instead, functional thinking requires only that we access enough information about cultural, social, and other contexts to tailor interventions to accomplish purposes linked to client values. Therefore, ACT therapists frequently ask questions and note changes in flexibility processes in order to guide the implementation of ACT in a way that’s sensitive to the history of the client. From a functional contextual viewpoint, “culture” refers to the prevalence of behaviors in a group over time and the features that select how those behaviors will increase in probability or stabilize within that group. The variables that maintain a cultural practice may not be the same variables that result in good outcomes for a given individual who is influenced by that culture (Hayes, Muto, & Masuda, 2011). For example, a culture may promote certain normative behaviors as moral and punish actions that are aberrant in relation to those norms. This may be beneficial for those whose values align with the specific guidelines of that culture, but not for those whose values differ. For example, a client who’s gay and wants to get married, and who lives within a culture that views this sexual orientation as a sin and forbids gay marriage, is likely to be negatively impacted by these cultural guidelines. Because ACT therapists are, by design, instigating, modeling, and supporting flexibility processes, they often need to be flexible in relation to the reactions evoked by their own cultural background, noticing reactions that could be unhelpful and applying an ACT approach to these very reactions. This chapter focuses primarily on working with individuals in their social and cultural contexts, but some behaviors only make sense at a higher level of organization, so there are times when it’s best to also consider the behavior of groups, such as couples, families, or organizations. In addition, groups can be nested inside groups, which adds more complexity. For example, the behavior of a family is nested inside larger social and cultural groups, such as a faith community or a nation. Psychological

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flexibility processes are known to apply to groups, as well as to individuals. For example, parental modeling of inflexibility processes predicts adolescent depression (Mellick, Vanwoerden, & Sharp, 2017); in this way, families can become inflexibility systems. The same dynamic holds for businesses and organizations (Bond, Lloyd, & Guenole, 2013). What this implies is that ACT can be used to target both the actions of individuals in a cultural context, and the prevalence of behaviors within a group and the contextual features that maintain that behavior. Said in another way, ACT can target the culture itself, and indeed, randomized and pilot trials have applied an ACT model to stigma, prejudice, interpersonal violence, and other social problems. For example, ACT interventions have been created that reduce mental health stigma (Masuda et al., 2007) and improve positive behavioral intentions related to reducing racial discrimination (Lillis & Hayes, 2007). The psychological flexibility model can be used to orient therapists toward key issues that are central to working with individuals who identify with different cultural groups, regardless of the form of therapy being deployed. Taking a flexible stance toward client choices and being open to what clients say their experience tells them about what works for them in their life contexts entails a commitment to supporting diversity. This is not just our opinion; psychological inflexibility is known to be related to a wide variety of specific forms of prejudice and objectification (Levin et al., 2016).

Clinician Processes in Context: Key ACT Competencies As is often stated in ACT trainings, doing ACT well with clients involves living ACT in your own life. As a therapist, being willing to experience difficult emotions, defusing from thoughts, connecting to the moment, and operating from a larger perspective of self-­as-­context, while making and keeping commitments related to values, enables you to deliver ACT with more integrity and from an experiential perspective. Put simply, this means you must have experiential knowledge of and contact with what it means to live mindfully and in alignment with your values. From this position, you can recognize both the possibility of choice and its complexity. Most importantly, you’ll be able to recognize, verbally and experientially, psychological flexibility itself. This kind of awareness can be helpful when considering different cultures and contexts. It points to an exciting feature of ACT: that ameliorating cultural bias and fostering cultural competency can be promoted by applying ACT concepts to clinicians. Fostering a defused awareness of their own personal history, psychological experiences, and concepts of the self may help therapists engage clients in a more open way. As historically situated beings, all therapists sometimes make assumptions about clients based on particular aspects of their identities or contexts. Difficulties can arise when we allow certain labels or categories to dominate over other aspects of clients’ experience or when we miss the larger context and complexity of their lived experience. In addition, to the extent that we oversimplify clients’ experience by seeing them only through the lens of a particular identity, such as gender, race, class, age, or sexual orientation, we may lose sight of their unique and complex identities. The goal is to increase our capacity to recognize our own personal biases while letting go of any rigidly held ideas about clients who have different cultural experiences. Flexible perspective taking is particularly important in cross-­cultural understanding, as it facilitates taking the perspective of other individuals and noticing their personal struggles, values, strengths, and

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suffering. Connecting with clients’ experiences of what it’s like to be viewed as a category, object, or stereotype across time and place can help therapists empathize with their clients and also strengthen compassion for them. This may be painful for the therapist, so it’s important that therapists have an ability to embrace uncomfortable emotions in the service of their clients. Limitations in any of these areas (perspective taking, empathy, and emotional openness) has been shown to lead to objectification and dehumanization (Levin et al., 2016). Of all the ACT competencies set forth in appendix A, three of the competencies central to the ACT therapeutic stance may provide the best guidance for how to adapt ACT in flexible and sensitive ways: Competency 42: The ACT therapist speaks to the client from an equal, vulnerable, compassionate, genuine, and sharing point of view and respects the client’s inherent ability to move from unworkable to workable responses. Competency 44: The therapist avoids the use of formulaic ACT interventions, instead fitting interventions to the particular needs of the particular clients. The therapist is ready to change course to fit those needs at any moment. Competency 45: The therapist tailors interventions and develops new metaphors, experiential exercises, and behavioral tasks to fit the client’s experience and language practices and the social, ethnic, and cultural context. As we consider these competencies, it’s important to keep in mind that these are not meant to prescribe a particular therapeutic style that must be adopted at a topographical level; instead, the therapist is free to select a therapeutic style that will best facilitate the development of psychological flexibility. Below we review how these three competencies can organize adaptation of ACT with greater sensitivity to cultural context and setting.

Competency 42: Flexible Perspective Taking and Shared Humanity We begin with competency 42: “The ACT therapist speaks to the client from an equal, vulnerable, compassionate, genuine, and sharing point of view and respects the client’s inherent ability to move from unworkable to workable responses.” The links between flexible perspective taking, empathy, compassion, and experiences of connection all suggest that flexible perspective taking is central in working with and contextualizing diversity. Cognitive abilities that involve categorization and evaluation lead humans to create conceptualized groups and place people in or out of those groups. As a result, people tend to separate each other into “we” versus “they,” wherein one group that’s considered to be more valued (“we”) is pitted against another that’s less valued (“they”). Recognizing this “we” versus “they” problem and learning to mindfully observe unhelpful categorization or stereotypes and labeling can help all of us be more aware of the pain of social exclusion and ostracism. Because inclusion in social groups is key to the survival of social animals, we humans, at a very basic level, experience social exclusion and ostracism as a threat to our very safety (MacDonald & Leary, 2005). Being a member of a devalued group has a number of

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psychological implications. In addition to suffering from stigma and other forms of discrimination, the social exclusion that members of devalued groups are subject to may lead to a number of difficult emotional experiences, including grief, longing, jealousy, shame, embarrassment, anger, envy, and a sense of abandonment, each of which might create or further a sense of being less valued. Stepping behind the eyes of such individuals to see their experience is key to considering how to adapt ACT to diverse individuals who suffer from social exclusion and marginalization. Therapist and client each have sets of conceptualized selves that differ, different histories, and different current contexts, and all will play a role in their interactions. There may be inequalities (e.g., socioeconomic status, level of education), yet at the same time, without denying the experience of these differences, at the fundamental level of being, we are the same: Therapist and client are both conscious human beings. Both experience suffering. Both are inextricably bound to their historical and current contexts and to their stories about these contexts. Each has personally meaningful goals and values. Recognizing this fundamental shared experience of connection can help therapists stand together with their clients as human beings while still recognizing differences. We aren’t suggesting that clients’ historical pain or current contexts should be ignored; rather, we’re saying that connecting with clients at the level of self-­as-­context can help therapists cut through tendencies toward categorization that can trap any of us and limit our possibilities in life. That said, we caution you to recognize the potential for difficulties to unfold. For instance, we don’t recommend that white therapists think of or refer to themselves as equal to people of other ethnicities in terms of historical experiences. Rather, from the position of being itself, therapists can sit with the very difficult pain and suffering of their clients—­human to human—­remaining open to clients’ historical and present experiences related to culture and discrimination or stigma and intervening as appropriate.

WORKING WITH ONE’S OWN BIASES Recognizing one’s own personal vulnerabilities and cultivating a genuine presence are also part of competently doing ACT. With respect to diversity, this may entail confronting and admitting to unsettling stigmatizing and racist responses within yourself; remaining open to yourself and others as part of the process; acknowledging hidden or automatic thoughts, emotional reactions, or behavior; and seeing those for what they are—­learned reactions resulting from your own history and its interaction with the current context. Part of this process involves being willing to acknowledge any stereotypes or rigid interpretations regarding cultural characteristics or beliefs, seeking awareness of any divisive categories, and striving to develop a respectful, open, and authentic behavioral stance. From an ACT perspective, the goal is not to eliminate biased thinking, just as the goal in ACT is never to avoid or eliminate difficult thoughts; rather, it is to observe and see how such thinking might influence us and then to let our values guide our actions. Over time this tends to reduce bias. If you identify a bias in your behavior, thoughts, or feelings, it’s important to acknowledge the issue, typically privately—­at least at first. Therapists must be open to their own bias, including feelings and thoughts that may sometimes arise in response to this awareness, such as self-­judgments or self-­doubts. It’s difficult and painful to recognize aspects of our own experience that dehumanize or objectify others or are otherwise prejudiced. As always with ACT, acceptance of these private events doesn’t mean accepting their validity or content; rather, it means “receiving the gift that is offered.” In this case, the gift is a painful one: awareness of the degree of bias in our culture and that we’ve internalized that culture. This awareness can then be put to prosocial use, provided we also cultivate an ability to see biased thoughts

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and feelings as events, and not as what they say they are (by defusing from them), and develop an awareness of ourselves as conscious human beings who are not alone in this experience of having unwanted and difficult emotions and thoughts (i.e., developing self-­as-­context). From this place of gently observing what our minds bring us in terms of evaluations regarding those who aren’t like us, we are enabled to more fully appreciate the identities, cultures, and ethnicities of others and gain access to the richness inside the varied experiences our clients encounter. That, in turn, can foster such values as appreciation of diversity and empowerment of others in our therapeutic work.

PERCEIVED THERAPIST VALUES CONFLICTS A common question posed by therapists learning the ACT model is “What do you do when your values conflict with a client’s values?” Such situations can often be addressed by following standard ethical and culturally competent counseling practices. However, because ACT is more overt about values than many other therapies are, we feel it’s important to address this topic specifically in the context of ACT. From an ACT perspective, a prerequisite for clients freely choosing their own values is an absence of coercion, or a sense of coercion, from the therapist. If ACT therapists find themselves in a situation where they believe their values conflict with a client’s in a fundamental way, this provides them with a chance to more fully explore how their own history, current context, and culture may be contributing to the perceived conflict. Perceived values conflicts can be highly charged for therapists and evoke powerful emotional responses, such as moral disgust, contempt, fear, or anger. These kinds of reactions are often signs that the conflict is more about fusion, avoidance, or other forms of inflexibility on the part of the therapist than about values. Furthermore, behavior that arises from these emotional reactions may reinforce existing social hierarchies or inequities; therefore, any such action urges should be considered carefully before carrying them out in therapy. Note that we refer to these as perceived values conflicts. We do so because although they are often framed as values conflicts by therapists, especially those less familiar with what values mean in an ACT context, they often are not values conflicts; they’re usually more about therapist inflexibility processes that arise in the context of a particular cultural background. One potential and frequently recommended solution to perceived values conflicts is to simply refer the client out. This is not a decision to be taken lightly. While we do offer a few brief suggestions of things to consider before referring, we strongly suggest that if you find yourself in this situation, you first consult more extensive resources, including reliable written sources, as well as applicable ethical and legal codes. Because most perceived values conflicts can be seen as conflicts between cultural practices, we suggest first consulting with a trusted colleague or another person who has rich knowledge of the cultural practice, behavior, or group identity that you feel you can’t support. Learning more about cultural practices or valued paths that differ from your own can help you develop a richer perspective-­taking repertoire and allow you to see the situation in a new way and continue with therapy. It can also increase your own psychological flexibility. It’s often the case that when we encounter others who seem different from us, we tend to objectify them or respond to them in ways that reflect fusion with our own internalized rules or societal norms, rather than our underlying values. In addition, perceived values conflicts often interface with difficult social topics, such as prejudice, power, marginalization, oppression, and discrimination. Therefore, therapists should consider whether any of these dynamics may be manifesting in the context of the therapy relationship.

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We also suggest that before referring a client out, you consider further collaboratively exploring two topics with the client: the abstract values underlying the particular goals and values statements that you believe you’re in conflict with, and the particular life experiences that are linked to these values and goals. If you understand the more abstract values and the life experiences that have shaped these choices, you may be able to find a workable way through the seeming impasse. Ultimately, referral may be in the best interest of the client, but that would typically be due to a therapist’s inability to be able to be effective with the client due to the therapist’s own psychological inflexibility or limited competency, rather than an actual values conflict. ACT neophytes or critics regularly raise imagined values conflicts where it seems referral would be necessary but actually may not be. Common examples include asking what a therapist should do about a Nazi client who wants help in accepting discomfort while acting on a value of trying to kill people of color, or whether to refer a pedophile who wants help in accepting guilt so he can molest children. Although such situations could exist, they often disappear in light of the ACT model. For example, a pedophile may want support for his actions, but that would probably reflect extreme experiential avoidance and inflexible perspective taking, both necessary to keep the client from feeling what it’s like to be a molested child. When those inflexibility processes have been addressed, the client’s underlying value may not be to molest children. Thus, while we recognize the possibility that some perceived values conflicts may be irresolvable, we suggest that the therapist first try to find common ground and see whether a healthy therapeutic contract is possible.

Exercise:

Noticing the Experience of Exclusion and Assessing Self-­Compassion How you relate to yourself is relevant to how you relate to others. Complete the following eyes-­closed exercise and write about your experience. Close your eyes and think back to a time when you first recognized that you were different from those around you. Consider a time or place where you didn’t fit in or where you were excluded. See if you can create the full scenario in your imagination, noticing your thoughts, feelings, and sensations. In that place, notice what it was that you wanted most. Give yourself two to three minutes to explore this scene and its experiences. What did you notice?   

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What did you want?    How can this knowledge assist you in therapy with clients who have different cultural experiences or identities than you?    Take a moment now to test how self-­compassionate you are by completing a questionnaire developed by Kristen Neff at http://self-compassion.org/test-how-self-compassionate-you-are. How did the self-­assessment turn out? It’s difficult to be aware of and address our own biases and discriminatory behaviors if we don’t have self-­compassion. Beating ourselves up over thoughts, feelings, and actions that are biased or prejudiced will make it harder to acknowledge them when these experiences show up, and therefore may make it difficult to respond to them consciously. Harshness toward these experiences may also contribute to avoiding experiences with individuals who are different from us, decreasing our awareness of and contact with diversity. What did the self-­compassion questionnaire reveal about how self-­compassionate you are? And how do you think this might affect your ways of responding to your own tendencies toward racism, stereotyping, and discrimination? Take a few minutes to write about this.   

Competency 44: Adapting ACT to the Needs of the Client Competency 44 states, “The therapist avoids the use of formulaic ACT interventions, instead fitting interventions to the particular needs of particular clients. The therapist is ready to change course to fit those needs at any moment.” This competency requires both in-­session awareness of where

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clients are emotionally and psychologically and an awareness of your reactions to clients. Being able to change course and adapt to clients’ needs at any moment requires mindfulness of in-­session processes as well as knowledge of clients’ context and history. It also requires that therapists flexibly put themselves in clients’ shoes, seeing the world from their eyes and feeling what it’s like to be them. Fusion and avoidance can interfere with this if we get caught up in our reactions to clients’ experiences. It can be very difficult to step into and feel another’s pain, especially pain related to oppression and marginalization. This pain can bring up concerns about our own roles as oppressors or shame about our identities or behaviors as they relate to the aspect of diversity in question. If we’re unable to defuse from our own stories and show up to the lived pain of clients’ experience, we can’t be fully present in ways that allow us to adapt our approach to fit the needs of specific clients. It’s important to be culturally humble in this process (Skinta & Curtain, 2016). It’s dangerous to fuse with our thoughts in this regard, for example, about our own superior perspective-­taking abilities or the superiority (or inferiority) of our culture and values. It’s far better to assume that there are things we don’t understand and to continuously revisit our interpretations, being mindful of our own cultural limits and that we do not know what we do not know. Because ACT isn’t about delivering any particular topography of therapy, but instead is about functional adherence to the model, effective implementation of ACT may look very different in different cultural contexts or with different clients, depending upon what’s needed to develop psychological flexibility with particular clients. Simply doing an exercise or metaphor because it’s called for in a particular protocol or because it’s recognized as a part of delivering any of ACT’s six core processes can sometimes be culturally insensitive. For example, deictic exercises based on “I/you” in English are better understood in some Asian languages as “we/they” because of a more communitarian cultural context (Hall, Hong, Zane, & Meyer, 2011; Hayes et al., 2011). There is some indication that even small adaptations to therapy to meet the needs of different cultural and ethnic perspectives can be helpful in terms of outcomes (Griner & Smith, 2006). However, beyond obvious solutions like speaking the same language or matching client and therapist ethnicity, deeper changes that incorporate beliefs, ideas, and values from specific cultures may sometimes be needed. Because ACT is based on broad behavioral, evolutionary, and RFT principles, these can be used to guide multicultural knowledge and adjust methods in the interest of functional adherence rather than literal adherence. Thus, when translating ACT to different languages, new metaphors will be needed to match the way those languages tend to structure how people view the world or the dominant cultural experiences of people who use that language. For example, therapists might not use the exercise Soldiers in the Parade (Hayes et al., 2012) with people from cultures with a traumatic history relating to the military. As another example of functional adherence, imagine an Asian client who has learned within a Buddhist context that acceptance is essential at all times. In this case, the client may inflexibly accept his circumstances despite a need for problem solving in order to move in certain valued directions. For this client, psychological flexibility may involve learning to engage in less acceptance in some situations and being willing to practice more active problem solving and change strategies. Common ACT metaphors can inadvertently be experienced as microaggressions. As just one example, the Chessboard metaphor (Hayes et al., 2012) is often presented as if the black chess pieces represent the “bad” thoughts, feelings, memories, or other private experiences and the white pieces are the “good” thoughts, feelings, and so on. Using the metaphor in this fashion may represent a micro­ aggression for some clients or may implicitly reinforce racial stereotypes. In addition to potentially

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causing a rift between therapist and client, this may result in the client missing the therapeutic point of the metaphor. In other cases, standard approaches simply may not make sense within a given cultural or language context, and the further clients’ cultures are from one’s own, the harder this may be to detect. For example, in most Western cultures, time is treated in a highly linear fashion—­like a sequence of ticks on a clock—­while in many Asian or Native American cultures it is treated more as a pool or space. Considering a choice over an extended time might be seen as a waste of time or a delay by a Western therapist working with an Asian client who’s circling around a problem before committing to an action, much as one might circle around a pool of water before diving in. The range and extent of such issues is daunting, but ACT has built-­in advantages for cultural adaptation. One advantage is that the principles of behavioral science, RFT, and evolution science apply to all human beings and help explain culture itself. Thus, cultural issues can be considered in ACT without a fundamental change in vocabulary and analysis. From a functional contextual point of view, the goal of understanding is a pragmatic one. The ACT therapist’s job isn’t to understand all the cultural aspects of a given client’s experience, but rather to understand enough to be able to help the client develop more psychological flexibility as a means to making desired life changes. Another advantage is that in ACT goals aren’t set by the therapist, but instead are guided by clients’ values. Therefore, not imposing therapists’ values on clients’ choices is built into the model. In addition, no particular thought, feeling, way of speaking, or opinion is given priority, allowing for greater flexibility in pursuing the meaning and function of specific cultural practices. Perspective taking and a present-­moment focus also reduce the likelihood of inadvertent cultural domination, because these processes provide space to explore the world from the client’s perspective as it arises in therapy. No set of features can guarantee an absence of cultural coercion, but these aspects of ACT are helpful. Including culturally sensitive metaphors and sayings may be part of a healing experience (Hwang, 2011). Indeed, helping others develop flexibility by adapting metaphors or choosing metaphors to fit their experience and background is an important part of the therapeutic process. For example, flexibility can be illuminated with an aphorism of Asian origin: “If the mountain doesn’t turn, the road turns; if the road doesn’t turn the person turns; if the person doesn’t turn, then the heart and mind turn.” And although therapists should be careful about assuming that any particular cultural practice applies to a given member of a cultural group, we do know that cultural practices are carried in part via the symbolic meaning systems described by RFT. One implication of this is that RFT training can help therapists better adapt interventions to individuals by focusing on the terms clients use to describe their experiences, especially metaphors and analogies. By listening carefully for client-­generated metaphors and analogies and incorporating them into therapy, therapists can learn more about what’s meaningful within a given cultural context and potentially be more effective.

Exercise:

Identifying Formulaic ACT Interventions Read the following dialogues and then, before checking the answer for each, circle whether the ­therapist’s intervention is formulaic or not formulaic. Consider your responses in terms of the flexibility that may be needed depending on cultural context.

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1. Ther apist Speaking to an Ethnic Minority Client Client:

I feel excluded, like I have a disease and no one wants to be around me.

Therapist: It seems you’re struggling with the thought that you’re diseased. Let’s try an exercise where you hold a piece of paper up to your face and imagine that the paper is your thought. (Takes a piece of paper and hands it to client.) See how it’s taking up your view? Client:

(Starts to cry and holds the piece of paper so it covers his face.) I guess so.

Circle the answer that best characterizes the therapist’s approach: Formulaic        Not formulaic Answer: The therapist in this scenario could potentially be using an ACT defusion technique in a formulaic and culturally insensitive way. The in-­the-­moment function of the exercise, holding up a piece of paper to obscure the face, may actually serve to make the client feel more cut off, bringing the feeling of exclusion into the therapeutic relationship itself. This issue could be amplified in more collectively oriented cultures, in which saving face is a more dominant issue, making the simple act of covering one’s face far more evocative than intended. The therapist could do present-­moment work around the feelings of exclusion and the impact of exclusion on the client’s life. Or if it’s clear that defusion should be the target, the therapist can use interventions that amplify social inclusion, such as sitting together and looking at the “disease” thought from a distance.

2. Ther apist Speaking to a Female Client Client:

When my boss interrupts every time I try to talk, I get so frustrated. It’s like I don’t exist.

Therapist: Can you tell me where you feel the frustration in your body? Client:

What? (Sounds perplexed.) Where do I feel the frustration?

Therapist: Yes, when this frustration arises, where does it seem to be in your body? Where do you feel it? Client:

How will this help me with my boss interrupting me?

Therapist: If you can learn to accept the frustration, to be with it in your body and stop fighting with it, you won’t struggle so much. Circle the answer that best characterizes the therapist’s approach: Formulaic        Not formulaic

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Answer: The therapist in this scenario is most likely making an ACT present-­moment move in a formulaic and culturally insensitive way. The client is saying that she feels like she doesn’t exist, that she isn’t being seen as a whole person with important contributions to make. Present-­moment work could be helpful, but it needs to be situated in a context in which the client knows the therapist sees her. Taking the time to show compassion and empathy can validate her experience of the challenge of being frequently interrupted and may model flexibility processes that can then be used to explore the emotional impact of the client’s predicament.

3. Ther apist Speaking to a Sexual Minority Client Client:

I’ve decided to come out to my mom and dad.

Therapist: Wow, big decision. Client:

I get anxious just thinking about it.

Therapist: I get that. I had a little twinge of anxiety as you said it, too. Before we get into the decision itself, can we take a little time to sit with that anxiety? It may even tell us something about what you hope for in the process of coming out when you choose to do that. Circle the answer that best characterizes the therapist’s approach: Formulaic        Not formulaic Answer: This response isn’t formulaic: The therapist is opening the door to a values conversation based on exploring an emotional barrier. By first sharing a parallel emotional reaction and then using “we” language, the therapist conveys an open, supportive stance. Working with the client to explore all of his values related to coming out to family members may reveal values that conflict with coming out (i.e., maintaining his connection with his family may be at risk). Supporting him in making a choice once the possible consequences have been identified, from a compassionate and concerned stance, puts flexibility processes into the therapeutic interaction.

Competency 45: Functional Implementation and Tailoring to Context Competency 45 states, “The therapist tailors interventions and develops new metaphors, experiential exercises, and behavioral tasks to fit the client’s experience and language practices and the social, ethnic, and cultural context.” A strength of ACT is that it draws attention to the role of language and language practices, in the form of culture, in shaping people’s experience of the world and emphasizes the importance of understanding how clients frame their experience in multiple and alternative ways. Every culture is multifaceted and encompasses a variety of different values and beliefs. As therapists, engaging in efforts to educate ourselves about nondominant cultures is an important part of

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applying ACT sensitively, fitting interventions to the needs of individual clients. Being a competent therapist for clients from diverse cultural backgrounds means making an ongoing commitment to learning about and understanding the cultural experiences of others, especially the client populations with whom we work, as well as gaining a sense of what it’s like to have identities and values that are counter to the norms of the cultures in which people are embedded. As noted, culture is built largely through language. Self-­as-­context can allow clients and therapists to work together to sometimes step outside of language and thereby temper the effects of culture when it creates inflexibility. For example, ACT might be used to observe, from a curious and open perspective, the cultural messages and verbal rules that are influencing the client. From this stance, individuals can choose to follow cultural norms or not, as guided by their chosen values. Part of the role of values work in ACT is helping clients differentiate between the influence of culture through social pressure versus more intrinsically valued patterns of action. Therapists must conduct this work in a way that isn’t implicitly biased toward a specific cultural viewpoint, while also recognizing that all “individual” choices and values are influenced by the social groups in which clients have been embedded. Furthermore, the language of free choice in ACT is clinical, not scientific, and avoiding pliance doesn’t mean ignoring socialization. Therefore, when working with clients from cultures that emphasize greater social interdependence, it’s important not to use excessively individualistic rationales. This is especially important when working with clients who find themselves between cultures. For instance, a therapist might see a client who was born in the United States but whose parents grew up in China. Now the client may find herself caught between two cultures, a member of both but perhaps not fully affiliated with either. She might feel torn about respecting her parents’ culture or about being more independent in a way that’s more connected to mainstream American culture. Part of therapy with this client would be to help her view both cultures from a larger perspective so she can develop more of a sense of freedom in choosing how to live her life, with less constraint due to fusion, compliance, or aversive control. The goal is not for the client to find the “right” path, but to have a greater sense of freedom in choosing what she values in this life lived between cultures. Sometimes cultural factors require significant modifications of interventions or not using certain techniques. Some Muslim cultures prohibit women from touching men, for example, so an exercise that involves touching (e.g., pushing one hand against the therapist’s as a metaphor for the effort involved in experiential avoidance) would have to be dropped or modified (e.g., by putting a book between the two hands). Similarly, in some cultures extended eye contact is seen as highly aggressive, disrespectful, or sexually suggestive, in which case the therapist may need to steer clear of exercises that involve prolonged eye contact. These exercises can enhance a sense of conscious interconnection while also giving rise to minor discomfort due to the violation of norms regarding physical space and eye contact, creating a kind of physical metaphor for acceptance and defusing in the context of observing difficult thoughts and feelings. However, culturally induced reactions could be strong enough to overwhelm the purpose of the exercise, and some clients may even feel that participating violates their culture in some way. In these kinds of situations, it’s important to provide options for clients who feel that an action would violate their chosen cultural norms. In individual therapy, this issue can be discussed openly, working with clients to determine whether to use a given exercise, alter it, or abandon it based on its functional purpose and the specific cultural issues. Some clients may choose to honor cultural rules and therefore opt out of certain exercises, whereas others from the same cultural background may choose to engage in those exercises in order to develop psychological flexibility around the discomfort that emerges as they deliberately disobey an internalized rule.

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Exercise:

Exploring Your Cultural Context By recognizing your own cultural background, you’ll put yourself in a better position to see others’ cultural context. To that end, take some time to write your answers to the following questions. (This exercise is inspired by one offered in an online course on cultural sensitivity; Luckmann, 2006.) What country were you born in?  Where were your parents born? Your grandparents?   Where did you grow up? Was it a rural area, small town, or city?   What was the dominant culture, ethnicity, or race in the area where you grew up, and what minority cultures did you have contact with?   What was your socioeconomic status as you were growing up?   What were some of the most significant events in your family life during your childhood?   How did being a member of your particular family influence you?    What is your view with respect to the following aspects of life? Time:   Relationships and independence versus dependence: 

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Technology:  Religion and spirituality:  Personal space:  What racial group do you identify with? What ethnic group?  Describe a memory of being included or belonging to a group:  Describe a memory of being excluded or separate from others:   Do you have any memory of participating in excluding others from a group? If so, briefly describe that memory here:   Looking back at your answers, what do these responses potentially indicate about how bias might show up for you in psychotherapy? One thing that can help in answering this question is to imagine that these responses were given by someone else. What biases might that person have if this information were all you knew about the person?   

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ACT, Cultural Competency, and Diversity Beyond the ACT core competencies related to supporting diversity, there are additional considerations for adapting ACT to various cultures, norms, backgrounds, and identities. Obviously we can’t begin to cover every culture and context, so instead we’ll simply consider several aspects of being culturally sensitive and engaging a flexible, client-­oriented stance: stigma and bias; culture, race, and ethnicity; gender; age; sexual orientation; and religion. Some of the concepts and approaches we discuss stretch across these categories. Therefore, what we’ve written in one section might apply to other sections; however, we won’t repeat these concepts. Rather, we encourage you to reflect on how all of these ideas can inform your approach more broadly when working with culture and context. Note that although the information we provide isn’t comprehensive, it is designed to engage you in a thoughtful process that represents a commitment to supporting sensitive interventions with diverse individuals and settings. For a more comprehensive overview, consider reading Mindfulness and Acceptance in Multicultural Competency (Masuda, 2014) and some of the other works referred to in the following sections.

Stigma and Bias Stigma is a Greek word that refers to a physical mark or brand that was once placed on slaves or other devalued individuals to set them apart from the rest of the populace. Today, “stigma” refers to social disapproval or devaluation of a person based on some perceived characteristic. Social stigma is constructed based on certain attributes that are perceived to distinguish targeted individuals from social norms. These characteristics can relate to age, gender identity, sexual orientation, education, ethnicity, culture, race, obesity, religion, socioeconomic status, criminal background, mental health difficulties, and many other aspects of identity. Those who are stigmatized may feel devalued by others; may be rejected and discriminated against based upon their stigmatized identity; may encounter inequities in employment, education, and health care; and may have poorer health outcomes. Stigmatization is important in the field of mental health, as it has been shown to have adverse consequences for personal and social well-­being. The experience is often associated with problems ranging from fear and hopelessness to shame and self-­blame. Members of stigmatized groups often face prejudice and are subject to discrimination and loss of status (Jacoby, Snape, & Baker, 2005). We are typically socialized to stigmatize devalued groups at an early age, with research indicating that most children are aware of cultural stereotypes by ten years of age, and that children who are members of stigmatized groups are aware of these stereotypes at younger ages (Major & O’Brien, 2005). Even as children, members of stigmatized groups are aware that they’re treated differently, and they may begin to buy into stories about themselves that say they’re undesirable and worthy of rejection. When people internalize negative stereotypes, they often suffer from self-­stigma, which involves self-­devaluation, shame, and fear of rejection and ostracism. Many members of stigmatized groups, whether that group membership is obvious to others or not, experience stigma-­related distress and have internalized a sense of self-­contempt related to that identity (Heatherton, Kleck, Hebl, & Hull, 2000). Part of the work of being a culturally responsive therapist is personally connecting with the long-­standing nature of clients’ experience of being stigmatized and the impact of that stigma, and also helping clients connect with and work with these aspects of stigma.

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The term attributional bias refers to the tendency for those in an in-­group to have their positive behavior viewed in terms of their disposition and their negative actions viewed situationally, whereas the reverse is true for those in out-­groups (Hewstone, 1990). Though this is a somewhat controversial form of bias because it’s exhibited in certain contexts and not in others (Spitzberg & Manusov, 2008), it underlines the importance of recognizing out-­group stereotypes (Hewstone, Rubin, & Willis, 2002). For therapists, attributional bias could easily enter into the work, for example, in case conceptualization. We are all subject to the cultural conditioning of society and are therefore likely to internalize negative stereotypes, attitudes, and emotional reactions to people in a stigmatized group, despite our best intentions. However, this doesn’t mean we’re helpless in the face of our own biases, as evidenced by research showing that ACT-­based training in perspective taking decreases the likelihood of displaying attributional bias (Hooper, Erdogan, Keen, Lawton, & McHugh, 2015). Of course, if therapists are unwilling to encounter their own bias, they’re likely to avoid contacting what they need to know or do in order to increase inclusivity. To make progress, we all need to be willing to consider or reconsider how our beliefs and emotions may affect how we respond to stigma. Here’s a brief example of how this manifested in one therapist’s experience: Early in my career, I was inspired to volunteer to work with people suffering from stigma related to HIV. Guided by this value, I volunteered to lead a support group for HIV+ individuals at a local LGBTQ community center. Acting on this value of ameliorating oppression and prejudice brought me into contact with my own internalized stigma. This manifested in anxiety and hesitancy when group members sought to shake my hand or give me a hug. Even though I intellectually understood that there was no chance of contracting HIV, I still experienced urges to wash my hands after these encounters. I also felt shame over this reaction. I knew it was based on stigma and prejudice, yet I couldn’t control the presence of these thoughts and feelings. The most comfortable thing to do would have been to stop volunteering and thereby escape the discomfort of my internalized prejudice. However, the consequence would have been losing an opportunity to live my values, so I stuck with the situation, and over time, as I simply noticed these urges and the accompanying shame, and as I continued to do my best to not act on those urges, they eventually abated. The diversity of the individuals I was working with came to the fore, and HIV became just one of many parts of their experience and identity. Today I regularly work with people with HIV, and these reactions rarely occur. And when they do, they have little power. I treasure having gone through this experience, as it’s given me a deeper appreciation for the longing for physical contact that some HIV+ individuals experience as a result of stigma. Self-­stigma, or internalized stigma, has been the target of multiple ACT studies. A group-­based ACT intervention for self-­stigma was shown to result in decreased shame and increased treatment attendance in people seeking treatment for substance use disorders (Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008; Luoma, Kohlenberg, Hayes, & Fletcher, 2012). And a daylong ACT intervention for people with obesity led to improved quality of life and reduced self-­stigma and body mass as compared to a control group (Lillis, Hayes, Bunting, & Masuda, 2009). In a study of people with concerns about their sexual orientation, ACT led to improvements in sexuality-­related distress and internalized homophobia after six to ten sessions (Yadavaia & Hayes, 2012). And as a final example, HIV-­related stigma and psychological distress decreased following an intervention combining ACT and compassion-­focused therapy (Skinta, Lezama, Wells, & Dilley, 2015). These data are preliminary,

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but they do support the notion that targeting self-­stigma in mental health contexts can contribute to better outcomes, and that a contextualized ACT intervention can be used for this purpose.

Culture, Race, and Ethnicity Many of the general considerations reviewed earlier in this chapter and those in relation to stigma also apply when considering culture, race, and ethnicity. Research shows that ethnic minorities experience barriers to health care access that result in underutilization of mental health treatment, while at the same time suffering from negative mental health consequences due to discrimination and prejudice (Kessler, Mickelson, & Williams, 1999). Nevertheless, members of oppressed and stigmatized groups often show a great deal of resilience in the face of discrimination (Jackson et al., 2004). When considering culture, race, and ethnicity, therapists should make efforts to learn more about the cultures of the populations with which they work while also refraining from overgeneralizing their knowledge of the cultures in which clients appear to be embedded. We can’t assume that we have an in-­depth understanding of constantly evolving cultures and how they influence individual members of those groups, especially if we aren’t part of those cultures. Some therapists may attempt to suppress stereotyped thinking in an effort to achieve therapeutic or cultural neutrality; however, this can result in rebound effects (Geeraert, 2013) or may even encourage behavior that’s concordant with the stereotype (Follenfant & Ric, 2010). In fact, stripping individuals of their contextual experience (“It doesn’t matter; I’m color-­blind”), ignoring the effects of historical injustices related to race or ethnicity, or pretending to be neutral can be just another form of bias. Therefore, we recommend a position of cultural humility, in which therapists intentionally take the perspective that we all have more to learn and that we are all