Acceptance and Commitment Therapy Distinctive Features (CBT Distinctive Features)

Acceptance and Commitment Therapy

What are the distinctive theoretical and practical features of acceptance and commitment therapy? Acceptance and commitment therapy (ACT) is a modern behaviour therapy that uses acceptance and mindfulness interventions alongside commitment and behaviour change strategies to enhance psychological ¯exibility. Psychological ¯exibility refers to the ability to contact the present moment and change or persist in behaviour that serves one's personally chosen values. Divided into two sections, The Distinctive Theoretical Features of ACT and The Distinctive Practical Features of ACT, this book summarizes the key features of ACT in 30 concise points and explains how this approach differs from traditional cognitivebehaviour therapy. Acceptance and Commitment Therapy provides an excellent guide to ACT. Its straightforward format will appeal to those who are new to the ®eld and provide a handy reference tool for more experienced clinicians. Paul E. Flaxman is Senior Lecturer in Psychology, City University, London. J. T. Blackledge is Assistant Professor of Psychology at Morehead State University, USA. Frank W. Bond is Professor of Psychology at Goldsmiths, University of London.

Cognitive-behaviour therapy (CBT) occupies a central position in the move towards evidence-based practice and is frequently used in the clinical environment. Yet there is no one universal approach to CBT and clinicians speak of ®rst-, second-, and even third-wave approaches. This series provides straightforward, accessible guides to a number of CBT methods, clarifying the distinctive features of each approach. The series editor, Windy Dryden, successfully brings together experts from each discipline to summarize the 30 main aspects of their approach divided into theoretical and practical features. The CBT Distinctive Features Series will be essential reading for psychotherapists, counsellors, and psychologists of all orientations who want to learn more about the range of new and developing cognitive-behavioural approaches. Titles in the series: Acceptance and Commitment Therapy by Paul E. Flaxman, J. T. Blackledge and Frank W. Bond Beck's Cognitive Therapy by Frank Wills Behavioral Activation by Jonathan Kanter, Andrew M. Busch and Laura C. Rusch Compassion Focused Therapy by Paul Gilbert Constructivist Psychotherapy by Robert A. Neimeyer Dialectical Behaviour Therapy by Michaela A. Swales and Heidi L. Heard Metacognitive Therapy by Peter Fisher and Adrian Wells Mindfulness-Based Cognitive Therapy by Rebecca Crane Rational Emotive Behaviour Therapy by Windy Dryden Schema Therapy by Eshkol Rafaeli, David P. Bernstein and Jeffrey Young For further information about this series, please visit www.routledgementalhealth.com/cbt-distinctive-features

Acceptance and Commitment Therapy Distinctive Features

Paul E. Flaxman, J. T. Blackledge and Frank W. Bond

First published 2011 by Routledge 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USA and Canada by Routledge 270 Madison Avenue, New York NY 10016

Routledge is an imprint of the Taylor & Francis Group, an Informa business This edition published in the Taylor & Francis e-Library, 2011. To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk. Ø 2011 Paul E. Flaxman, J. T. Blackledge and Frank W. Bond Cover design by Sandra Heath All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. This publication has been produced with paper manufactured to strict environmental standards and with pulp derived from sustainable forests.

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Flaxman, Paul Edward. Acceptance and commitment therapy : distinctive features / Paul E. Flaxman, J. T. Blackledge, and Frank W. Bond. p. cm. ISBN 978-0-415-45065-2 (hardback) Ð ISBN 978-0-415-45066-9 (pbk.) 1. Acceptance and commitment therapy. I. Blackledge, J. T. (John T.) II. Bond, Frank W. III. Title. RC489.A32F55 2011 616.89©1425Ðdc22 ISBN 0-203-83468-2 Master e-book ISBN

ISBN: 978±0±415±45065±2 (hbk) ISBN: 978±0±415±45066±9 (pbk)

Contents

Preface Dedications and acknowledgements Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF ACT 1 ACT, human suffering, and experiential avoidance 2 Developments within CBT: ACT and the Third Wave of behaviour therapy 3 Functional contextualism 4 Relational frame theory 5 Acceptance 6 Cognitive defusion 7 Self-as-context 8 Contact with the present moment 9 Values 10 Commitment 11 Mindfulness and behaviour change: Toward psychological ¯exibility 12 ACT and CBT: Assumptive differences

vii xi

1 3 7 11 15 21 25 29 33 37 41 45 53 v

CONTENTS

13 ACT and CBT: Strategic and technical differences 14 Empirical matters

vi

57 61

Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF ACT 15 Overview of ACT's therapeutic strategies 16 ACT-based case conceptualization 17 Examining the workability of the control/avoidance agenda 18 Creative hopelessness 19 Control is the problem, not the solution 20 Introducing willingness as the alternative to control 21 Promoting active acceptance 22 Cognitive defusion I: Altering language conventions 23 Cognitive defusion II: Objectifying psychological content 24 Cultivating mindfulness to promote contact with the present moment 25 Contacting the self-as-context 26 Clarifying values 27 Values-based goal and action planning 28 Building larger patterns of committed action 29 ACT in groups and non-clinical contexts 30 Therapeutic stance

115 121 127 135 139 145 151

References Index

159 168

65 67 71 75 79 85 89 95 103 111

Preface

Acceptance and Commitment Therapy (ACT; pronounced as a word: `àct'') is a modern behaviour therapy that uses acceptance and mindfulness interventions in combination with commitment and behaviour change strategies to help clients build more vital, purposeful, and meaningful lives. Unlike more traditional cognitive-behaviour therapy (CBT) approaches, ACT does not seek to change the form or frequency of people's unwanted thoughts and emotions. Rather, the principal goal of ACT is to cultivate psychological ¯exibility, which refers to the ability to contact the present moment and, based on what the situation affords, to change or persist with behaviour in accordance with one's personal values. To put it another way, ACT focuses on helping people to live more rewarding lives even in the presence of undesirable thoughts, emotions, and sensations. ACT possesses a number of unusual and distinctive features. Most notably, ACT is intimately linked to a theory and programme of basic research on the nature of human language and cognition (known as Relational Frame Theory or RFT). This link to basic behavioural principles has led to the creation of a unique and empirically based model of human functioning that vii

PREFACE

comprises six interrelated therapeutic processes: acceptance, defusion, contact with the present moment, self-as-context, values, and committed action. In the present volume, we describe each of these processes, along with some core ACT interventions that can be used in their service. However, it should be noted at the outset that the process-driven nature of the ACT approach allows for considerable technical ¯exibility. ACT practitioners are by no means restricted to the interventions we describe in this volume, and are instead encouraged to be creative when it comes to choosing, designing, or adapting techniques. From an ACT perspective, many psychological or behavioural intervention methods are worthy of consideration, as long as they function in a way that strengthens one or more of the six core processes. The worldwide interest in the ACT/RFT model of behavioural change is already supported by an impressive body of research. RFT is one of the most extensively researched behaviour analytic theories of human behaviour, and the ef®cacy of ACT interventions has to date been demonstrated in over 30 randomised controlled trials involving various clinical (and non-clinical) populations. Two features of ACT's empirical base deserve mention here. First, the ef®cacy of ACT has been demonstrated across an unusually wide range of human dif®culties, including anxiety, depression, psychosis, eating disorders, trauma, substance abuse, chronic pain, and workrelated burnout, to name but a few. Similarly, ACT has been used to improve the self-management of chronic health conditions such as diabetes and epilepsy. Experiential avoidance, an important feature of psychological in¯exibility, is increasingly being viewed as a generalised risk factor with implications for human functioning in general. As a result, ACT interventions are also being successfully delivered on a preventive basis in schools, colleges, and workplaces. A second notable feature of this empirical work concerns ACT's processes of change. Considering the range of settings, client populations, and delivery formats examined in ACT viii

PREFACE

research, the observed patterns of mediation are remarkably consistent. Indeed, there is now compelling evidence that ACT outcomes are mediated by increases in psychological ¯exibility and/or its facets (such as cognitive defusion or improved mindfulness/acceptance skills). The reliability of these ®ndings supports the utility of ACT's uni®ed theoretical model for guiding the measurement of process variables and identifying active mechanisms of change. In line with the other books in this Distinctive Features Series, the present volume is divided into two broad sections. Part I of the book reveals ACT's theoretical and philosophical roots, and offers a description of each of the six core processes that combine to promote psychological ¯exibility. We also consider the key assumptive and strategic differences between ACT and more conventional CBT. The second half of the book focuses on ACT in practice. We describe some of the metaphors, experiential exercises, and other interventions that can be used to promote ACT's therapeutic processes. The practice section is supported by brief extracts from ACT sessions (amended to ensure anonymity), which were deliberately chosen for their potential to illustrate ACT processes as they unfold. The volume concludes with a consideration of ACT's distinctive therapeutic stance, which requires ACT practitioners to pursue an intimate and personal experience of psychological ¯exibility. The book has been designed to provide a concise and accessible route into ACT theory and practice. As a result, the book targets a wide readership, including those who already have some experience with ACT, and experienced therapists new to ACT but trained in other approaches (such as traditional CBT). The book is also intended as an important resource for those new to therapy and ACT, such as trainee therapists and students. Whatever the background of the reader, the book has the same broad aim: to present the theory and practice of ACT as a highly distinctive approach to enhancing the human condition. ix

Dedications and acknowledgements

PEF Dedication To Mum, Dad, and Pete, for your continued presence and support; and to Sherylin, for bringing me back to life when I least expected it.

Professional acknowledgements PEF would like to begin by thanking his two co-authors. First, his heartfelt thanks go to Frank for introducing him to ACT and for his continued supervision and guidance. Thanks also to JT for being an effective, knowledgeable, and ¯exible coauthor. Further thanks go to Steve Hayes and Robyn Walser for visiting the UK to deliver powerful and accessible workshops. Finally, an acknowledgement to the UK's ACT special interest group, particularly Mark Webster, Eric Morris, Joe Oliver, Jo Lloyd, Fiona Kennedy, Martin Brock, Joe Curran, David Gillanders, and Sue Hart (to name but a few), for doing such a great job promoting ACT in the UK. xi

DEDICATIONS AND ACKNOWLEDGEMENTS

JTB Dedication To Cyndy, Ava, Mom, and Dad, who have always believed in me.

Professional acknowledgements JTB would especially like to thank Steve Hayes for the primary development of what have become two (ACT and RFT) lifelong passions, as well as for his continued mentorship. He would also like to thank Dermot Barnes-Holmes for his encouragement, support, and respect. Finally, he would like to extend thanks to Joseph Ciarrochi, DJ Moran, Jennifer Gregg, and Robyn Walser for their encouragement and collegialityÐ and to Paul and Frank for bringing him aboard this project.

FWB Dedication To Aidan, for continuing to make me more psychologically ¯exible.

Professional acknowledgements FWB would like to thank Steve Hayes and all of his colleagues and friends in the ACT community. They have provided him with nothing less than the meat of his career, and the passion to pursue a greater scienti®c understanding of ACT and its processes. He remains indebted to Jo Silvester for her support, guidance, and friendship since the start of his career; and, ®nally, thanks to Sonja Batten, an inspiring colleague and, more importantly, a great friend.

xii

Part 1 THE DISTINCTIVE THEORETICAL FEATURES OF ACT

DISTINCTIVE THEORETICAL FEATURES OF ACT

1 ACT, human suffering, and experiential avoidance Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) was designed as an alternative to more traditional brands of psychotherapy (such as conventional cognitivebehaviour therapy: CBT), which place a primary emphasis on decreasing the intensity and frequency of aversive emotions and cognitions. Rather than direct attempts to decrease such levels, ACT focuses on increased behavioural effectiveness, regardless of the presence of unpleasant thoughts and emotions of varying degrees of intensity. In other words, the ACT therapist does not attempt to change the client's distressing thoughts or attenuate their distressing emotionsÐthough, perhaps ironically, psychological distress does typically decrease when ACT is successful. While it might at ®rst appear bizarre to design a psychological treatment that does not attempt to make clients feel better and think differently, there is an arguably sound rationale for doing so. The assumption that marked degrees of psychological distress are a normal part of the human experience is central to ACT. This assumption stands in contrast to the majority view in clinical psychology and psychiatry, where degrees of distress equated with psychological disorders are viewed as statistically deviant. The majority view that distress severe enough to warrant psychological diagnosis is statistically abnormal, however, may well be in error. For example, Kessler et al. (1994) estimated that 50% of the US population between the ages of 15 and 54 quali®ed for at least one DSM-IIIR diagnosis, with 80% of those qualifying for two or more diagnoses. Mof®tt et al. (2009) presented an even grimmer estimate, ®nding in a longitudinal 3

ACCEPTANCE AND COMMITMENT THERAPY

study that between 57% and 65% of US and New Zealand samples had been diagnosable with at least one psychological disorder by the age of 32. Studies such as these suggest that while a diagnosis of any speci®c psychological disorder remains statistically abnormal, the marked degrees of psychological distress indicated by psychological disorders as a whole appear to be encountered by most at least once in their lives. From an ACT and relational frame theory (RFT) perspective, this high prevalence of human suffering is not surprising. Non-human animals appear to require very little in order to thrive and appear relatively happy: food, water, warmth, shelter, a modicum of physical contact, and a relative lack of physical abuse. RFT (see Point 4) describes how normal human language processes dramatically change the human experience by resulting in the ability to readily and frequently evaluate virtually all of its aspects negatively. Once humans develop the uniquely verbal capacity to re¯ect on their existence, consider its eventual end, compare it to imagined `ìdeals'', identify personal ``¯aws'', and use these ``¯aws'' as evidence of `ùnworthiness'', the potential for psychological distress appears to dramatically increase (even though, as will be discussed in Point 6, many aspects of these ``verbal constructs'' are literally constructed, rather than serving as immutable re¯ections of reality). RFT posits that this verbal ability sets up a drive and capacity for experiential avoidance (see, for example, Hayes et al., 1999, pp. 58±69), the act of attempting to avoid unpleasant thoughts, emotions, memories, and other private experiences. The human capacity for experiential avoidance is signi®cant for at least two reasons. First, many experientially avoidant behaviours either cause physical harm or compound the problem(s) that engendered them in the ®rst place. Drinking, drugging, overeating, and lack of exercise are often prime examples of physically harmful experiential avoidance (EA); behaviours involving procrastination and avoidance of constructive con¯ict often simply make the precipitating distress even worse. In other words, many instances of EA may offer 4


some initial relief, but make our problems and our distress worse over the long run. Second, many instances of EA prevent us from living life in a meaningful, purposeful, and vital way. If one values a close, caring, and loving relationship, for example, yet consistently disengages from one's partner when unpleasant emotions arise, one will be unlikely to develop and maintain such a relationship. Or, if one values a ful®lling professional career yet typically balks at the stressful demands entailed, the ful®lling career is unlikely to come to fruition. When life is lived in such a manner, life satisfaction and well-being would be expected to markedly decrease over the long run. The conclusion comes readily: increased degrees of EA, along with typically failing to reduce distress in the long or even short term (see Point 18), move one increasingly away from a meaningful, purposeful, and vital life. These ACT/RFT assumptions suggest that a different way of approaching human suffering may be indicated. If marked psychological distress is a part of normal human life that can often not be avoided, and if frequent experiential avoidance tends to both exacerbate distress and decrease quality of life, then perhaps psychotherapy should help clients ®nd ways to accept the distress that arises in the course of pursuing a meaningful, purposeful, and vital life. This suggestion is nothing new, and in one form resembles the all-too-dif®cult-to-follow advice many of us received from our grandparents: keep a stiff upper lip, carry on, and discharge one's responsibilities. But ACT's basis in RFT suggests a different prescription more viable and attractive than sheer perseverance. At the core of RFT's account of language and cognition is the assumption that the kinds of abstract, evaluative words we struggle with that claim to capture reality, in fact cannot. Thus, the acceptance asked of an ACT client is not an acceptance of his experience as he literally perceives it, but rather an acceptance of his experience as it is, and not as his mind says it is. Points on RFT, acceptance, cognitive defusion, and self-as-context later in this book will explain how this distinction is put into action. 5


2 Developments within CBT: ACT and the Third Wave of behaviour therapy The behaviourism of John Watson and B. F. Skinner arose, in part, as a reaction to the relatively introspective, non-empirical approach Freud took toward psychology (e.g. Watson, 1913). The principles of operant and respondent (or classical) conditioning relied solely on directly observable variables, and both Skinner and Watson placed primary emphasis on pragmatics. In other words, rather than `èxplaining'' behaviour at multiple levels of analysis, their parsimonious theories of behaviour largely sought to enhance the degree to which one could predict what organisms would do under particular circumstances and control or systematically change those behaviours using operant and respondent principles (e.g. Smith, 1992). Perhaps not surprisingly, exposure-based behavioural treatments for problems like anxiety and fear proved to be relatively brief and effective from early on (e.g. Jones, 1924; Wolpe, 1958), with operant approaches to the treatment of depression (e.g. Ferster, 1973) and a variety of developmental disabilities (e.g. Baer, Wolf, & Risley, 1968) arising as similarly effective treatments later on. This tide of empirically supported behavioural momentum eventually came to be known as the ``First Wave'' of behaviour therapy (Hayes, 2004a). Beginning in the late 1950s (e.g. Chomsky, 1959; Ellis, 1957), the tides began to change. Proponents of the newly founded sub®eld of cognitive psychology had grown increasingly dismissive of the behavioural insistence on con®ning psychology to the study of only directly observable behaviour. Additionally, the continuity hypothesis (where learning principles observed in the animal laboratory were presumed to hold 7


inviolably for human beings as well) advocated by behaviourists like Skinner and Watson essentially came under question (e.g. White, Juhasz, & Wilson, 1973). Initial objections to the continuity hypothesis, such as Chomsky's (1959) very negative review of Skinner's Verbal Behavior (1957), were largely not empirically based, but rather focused on the apparently obvious observation that human language and cognition granted human beings learning and processing abilities far beyond those of other animals. (Ironically, even empirical research produced by behavioural psychologistsÐsuch as stimulus equivalence research conducted by Sidman & Tailby, 1982, and research conducted on rule governance cited in Point 4Ðlater began to very strongly suggest that human and animal learning appeared to have some very marked differences.) As a result, cognitive therapyÐwith the premise that potentially changeable irrational and distorted cognitions produced the lion's share of psychopathologyÐbegan to take centre stage beginning in the late 1970s (e.g. Beck, 1976). Cognitive interventions focused on changing dysfunctional and/or irrational thoughts, attributions, and self-talk began to be provided more or less alongside tried and true behavioural treatment components such as exposure, skills training, and behavioural activation. This marked change in direction came to be called the ``Second Wave'' of behaviour therapy. Spurred by a desire to both improve upon the effects of conventional CBT and to parsimoniously extend behavioural principles to account for the apparent effects of human language and cognition (see Hayes, 2004a, for an extended account), Steven C. Hayes and colleagues began formulating relational frame theory (RFT; Hayes & Hayes, 1989) and comprehensive distancing (now called acceptance and commitment therapy; Zettle & Hayes, 1986). RFT posited a relatively unique set of directly observable operant-based learning processes intended to account for the effects of language on human behaviour. The approach avoided criticisms of mentalism (e.g. Hayes & Brownstein, 1986) and the inclusion of unobservable 8


constructs in psychological theories (Wilson, 2001) that have been levelled against cognitive psychology, and at present reportedly over 180 published, peer-reviewed studies (personal communication, S. C. Hayes, 8 September 2009) have uniformly supported its tenets and indicated how RFT-based processes interact with and often supersede conventional operant and respondent conditioning processes. Perhaps more importantly, RFT suggests that a more viable way of addressing problematic thoughts and emotions may involve interventions that help one experience them in a different manner (or within a different context), rather than systematic attempts to change them or reduce their frequency. It is this focus on changing the context in which distressing thoughts and emotions are experienced (rather than conventional CBT's focus on changing the content of thoughts and feelings) that is perhaps the leading hallmark of the ``Third Wave'' of behaviour therapy, and de®ning this ``wave'' in this manner includes other contemporary brands of psychotherapy, such as dialectical behaviour therapy (Linehan, 1993) and mindfulness-based cognitive therapy for depression (Segal, Williams, & Teasdale, 2002), under the moniker as well. However, ACT arguably differs from Second Wave cognitive and cognitive-behavioural treatments in an additional way. The developmental trajectory of ACT bears a striking resemblance to the First Wave years of behaviour therapy. ACT co-emerged with a basic experimental account of human behaviour (RFT) and its applications re¯ect the tenets of RFT to no small degree. Basic lab-based RFT explorations of core ACT constructs like cognitive defusion, self-as-context, acceptance, and commitment to values-driven behaviour have been published and continue to be conducted. These studies, as with RFTbased studies on the effects of metaphorical thinking, have arguably impacted the development of ACT, just as ACT has impacted the research agenda of experimental psychologists well versed in RFT. In other words, the relatively close linkage between basic experimental and applied science evidenced in the First Wave of behaviour therapy is again being evidenced by 9


ACT and RFT in the Third Wave. These similarities are not a coincidence. Rather, they are a product of the assumption that a focused and consistent integration of basic and applied research, as well as explicit empirical assessment of the processes that drive behavioural change, will more quickly move our ability to predict and change human behaviour forward. To put it more succinctly, it is hoped this wave of behaviour therapy can produce a family of treatments ``more adequate to the challenge of human suffering'' (Hayes, 2008a). Whether these rather enthusiastic goals can be achieved still remains to be seen.

10


3 Functional contextualism At the most fundamental level, the scienti®c method is simply a set of tools and procedures used to ®nd more reliable answers to a great variety of questions. What greater purpose this process should be put toward is a matter of opinion, and what these answers say about the world around us depends, in part, on the different assumptions we make about knowledge and what it can tell us about reality. Philosopher Stephen Pepper (1942) maintained that all scientists make one of four sets of relatively adequate pre-analytic assumptions about how scienti®c ®ndings re¯ect or do not correspond to objective reality in an absolute sense. By ``pre-analytic'', Pepper meant that these assumptions are not scienti®cally testable, but rather simply subjective, philosophical beliefs about how knowledge does or does not re¯ect universal truth. One is free to adopt any of these four sets of goals as the ``purpose'' of science, given that they are simply assertions about how science can and should be used. Pepper stated that the most common set of assumptions among scientists, mechanisms, iterate that one knows a scienti®c theory is true when it corresponds accurately to the real world. In other words, a mechanist (or realist) would assume that the ultimate goal of psychological theory and experimentation is a complete understanding of what all the human psychological processes really are and how they really work together, an understanding that would result in perfect prediction of what humans will do under an in®nite variety of circumstances By contrast, Pepper (1942) stated that contextualists assume that an objective reality is not conclusively knowable. Due to a number of factors, such as human perceptual errors, measure-


ment error, errors in data interpretation, and observational effects on subjects of study, contextualists assume that scienti®c theories cannot capture objective Truth (with a capital ``T''), but can organize the way we think about the world in ways that allow us to act more effectively within the theory's domain. In other words, a contextualist would assume that the ultimate goal of psychological theory and experimentation is to develop ways of talking about human psychological processes that maximize our ability to accurately predict and control (change) human behaviour. The goal is purely pragmaticÐuse theories and research to ®nd increasingly better ways to change people's behaviour for the better. While a contextual psychologist would certainly believe there is a ``real'' world, they are not concerned with determining what the real components and interactions of that world are. Rather, they tentatively assume the True nature of the worldÐand of human psychologyÐis unknowable, and that a psychological theory is ``true'' to the extent that it allows us to accurately predict and control human behaviour. To add an important caveat, contextualists concerned with prediction and control are called functional contextualists, while those who hold to contextualism's a-realist stance but are concerned only with prediction are called descriptive contextualists. The notion of prediction and control can sound rather sinister, and even overly ambitious. Ethical considerations are paramount here. The consensus of every well-meaning contextualist should be that we all strive to make certain that the behaviours we try to change are in the best and desired interests of the people we work with. And given the great complexity of human behaviour, the term `ìn¯uence'' is typically used as a more modest and realistic term. ACT and relational frame theory (RFT) are both prime examples of functional contextual theories (behavioural theories in general often have functional contextual underpinnings, though some behaviourists would describe themselves as descriptive contextualists or mechanists). Since ``successful working'' (Pepper, 1942) is the assumed goal of science from 12


this philosophical perspective, rigorous and repeated empirical examination of the treatment's (ACT) and the theory's (RFT) ability to accurately predict and in¯uence human behaviour is a core aspect of the combined ACT/RFT international research programme. ACT and RFT's status as functional contextual theories leads to answers to some questions that may surprise some. Does RFT capture what language and cognition really are? No. Does ACT capture universal truths about human psychological functioning? No (though perhaps, in both cases, the more appropriate functional contextual answer to both questions would be some combination of `Ì don't know'' and `Ì don't care''). Can ACT and RFT help change a variety of people's behaviour under a variety of circumstances? So far, published empirical studies on both answer ``Yes''. Finally, functional contextual assumptions can prove to be relatively refreshing when explicitly held. Dogma is minimized, when not eliminated. Since there are no assumptions that one's theory is really ``True'', one may be more likely to hold ideas more tentatively and ¯exibly. Since it is assumed that ideas are only ``true'' in the sense that they drive successful working, a primary eye looks toward data that empirically suggests when, how, and with whom interventions/experiments based on one's theory actually result in successful prediction and in¯uence. And, it is explicitly acknowledged that one's own theories (including ACT and RFT) will, sooner or later, be abandoned in favour of theories that more effectively drive successful action (or, perhaps, will simply have aspects of them absorbed into more effective theories). Much of the essence of this aspect of functional contextualism is re¯ected in a colleague's saying: `Èvery theory ever invented by man is wrong. The theories that we currently subscribe toÐwe just don't know how they're wrong yet (personal communication, K. G. Wilson, 21 August 2009).

13


4 Relational frame theory Underlying ACT is a behavioural theory of human language and cognition called relational frame theory (RFT). As RFT is relatively complex and space here is very limited, the speci®c technical components of RFT will not be discussed (instead, see Blackledge, 2003, for introductions to the theory, or Hayes, Barnes-Holmes, & Roche, 2001a, for an extended treatment). However, the essence of the theory and its relevance to ACT will be discussed. Radical behavioural accounts of human language and cognition (e.g. Skinner, 1957) proved not to be empirically viable (Hayes, Blackledge, & Barnes-Holmes, 2001b). Repeated laboratory experiments (some of which are discussed in Hayes et al., 2001b) that strongly suggested the verbal abilities of humans markedly compromised the ability of conventional behavioural theory (as exempli®ed by Skinner, 1974) to predict or control human behaviour (relative to nonhuman behaviour) were conducted from the 1970s onwards. RFT was developed by Steven Hayes and colleagues, beginning in the mid-1980s, as an attempt to preserve the strengths of conventional behavioural theory while parsimoniously extending its concepts to account for the peculiarities of human language and cognition. The premises of RFT are relatively simple. Language, or verbal behaviour, is considered to be operant behaviourÐthat is, we basically say or think what we do because of a history of reinforcement for saying or thinking those things under similar circumstances. But while Skinner (1957) conceived verbal behaviour as an operant just like any other operant behaviour, Hayes and colleagues viewed language as a relational operant that displayed derivational abilities mirrored by some very basic 15


principles of formal logic. In other words, from an RFT perspective, language use involves relating stimuli (objects, people, things, thoughts, memories, emotions, etc.) in ways that change how we perceive and react to these stimuli. These relations can involve any way of relating stimuli one could think of: hierarchically, temporally, co-ordinatively, comparatively, spatially, and so on (see Hayes et al., 2001c, for a description of such relations). For example, imagine Thomas lost his job (stimulus) where, based on his learning history, he verbally framed the situation like this (words in italics refer to speci®c stimuli, while words/symbols in bold refer to relations between those stimuli): men with jobs are providers; men who don't provide are inadequate; I lost my job; my friend Jerry still has his job. While he had never been told he was inadequate or less adequate than his friend Jerry, Thomas would still derive the following conclusions: I am inadequate and I am less adequate than Jerry. Given how most people verbally frame inadequacy, it would be a short step from there for Thomas to additionally derive thus I am bad. The derivations are simple, but the process represents something that non-human, non-language-able creatures have not demonstrated the ability to do: bring simple logical derivations to bear on stimuli to come to arbitrary, abstract, and often very tenuous conclusions. Stated with more technical precision, relational responding involves relating stimuli in ways that change the function of those stimuliÐin ways that change how one responds overtly, emotionally, and/or cognitively to those stimuli. At least 150 empirical RFT studies have uniformly demonstrated that these functional changes come about in ways that classical and operant conditioning cannot explain. How, then, is RFT relevant to ACT? Perhaps ®rst and foremost, RFT conceptualizes the content of language/cognition/ thinking (the terms can be used as equivalent from an RFT perspective) to be largely arbitrary. People learn arbitrary ways of evaluating themselves and their experiences in culturally agreed-upon ways (e.g. ``being inadequate is bad ''; ``belching in 16


public to signify satisfaction with a meal is good ''; ``having no partner means you are undesirable''; and so on) and often act as if these evaluations and rules are absolute truths. Indeed, the veracity of such evaluations and rules may not even be culturally agreed upon, but simply subculturally, familially, or even far more idiosyncratically based on how the evaluative meanings of various stimuli have been ascribed or derived throughout one's learning history. Take a limited set of derivational inferences like: ``Weak people are bad. Depressed people are weak. I'm depressed, therefore I'm bad.'' Such sets of relations between stimuli present as logical and binding, while masking their subjectivity and horribly incomplete analysis. Arguably, because language is ubiquitous in human societies and typically solves so many human problems, humans come to overestimate the veracity of their thoughts. What is verbally believed is consumed as solid fact. Perhaps more accurately, what is believed is typically not even recognized as a belief or a thought, but rather as a simple re¯ection of how the world really is. Language begins to override direct experience, even when direct experience repeatedly disputes the veracity of one's thoughts. This applies not only to thoughts involving evaluative or categorical relations, but also to thoughts that impart verbal rules about how one should/should not behave under particular circumstances. An experiment conducted by Matthews, Shimoff, Catania, and Savgolden (1977), for example, indicated that human subjects verbally instructed about how to press computer keys in an experiment in order to maximize reinforcement were less ¯exible than non-instructed subjects in adjusting to unannounced changes in how those keys must be pressed. In other words, the verbally instructed subjects tended to hold on to that verbal rule regardless of its ineffectiveness, while non-instructed subjects responded more ¯exibly to direct experience in a way ``comparable to those of infrahuman organisms'' (p. 453). Thus, as scores of published empirical RFT articles have consistently demonstrated, language brings with it the ability to 17


rapidly relate stimuli in a vast variety of formal and abstract ways that can greatly accelerate and improve our ability to act effectively in the world. But, as scores of these studies also demonstrate, relational responding can also enhance our distress and lead to increasingly in¯exible and ineffective behaviour. While conventional forms of CBT attempt to rectify these phenomena by changing the way clients relationally respond (i.e. by changing the way they think), ACT largely takes a different approach: disrupt the processes by which relational responding changes the functions of the verbal stimuli involved with problematic behaviour. How this is accomplished will be discussed in the point on cognitive defusion (Point 6).

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ACT's core processes The following points detail ACT's six core therapeutic processes as they are currently conceptualized: acceptance, cognitive defusion, self-as-context, contact with the present moment, values, and commitment. These mindfulness and behaviourchange processes combine to produce psychological ¯exibility, discussed in Point 11 (also see Figure 1). Due to the experiential nature of ACT and the dif®culty in conveying the nature of some of these processes verbally, Points 5 and 6 contain somewhat experiential (versus purely theoretical) treatments of their respective topics with the intention of producing a more thorough understanding. Additionally, many of these points build on the concepts discussed in this section's earlier points. Thus, it is strongly recommended that you engage the brief experiential exercises contained in these points, and that you read Points 5±11 in order.

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5 Acceptance The word `àcceptance'' conjures up a variety of connotations: resignation, grim persistence, ``grinning and bearing it'', ``pulling oneself up by one's bootstraps'', and so on. A running theme in ACT involves the notion that words cannot capture the full depth and breadth of direct experience. It may thus come as no surprise that these connotations do not capture the essence of what is meant by acceptance from an ACT perspective. Often, the term willingness is used to circumvent such connotations. Acceptance in ACT is not about wanting aversive emotions and experiences, not about simply tolerating it, not about ``soldiering on''. Rather, it involves a willingness to experience those distressing emotions and experiences that are encountered in the process of behaving consistently with one's values. Acceptance (or willingness) is thus the polar opposite of experiential avoidance, a key ingredient of psychological in¯exibility. In fact, however, even the word willingness typically cannot impart the speci®c actions and qualities of action involved with ACT-consistent acceptance. As a result, an understanding of acceptance is typically experientially shaped. The following experiential exercise (the reader is strongly encouraged to engage in the exercise, as it will likely impart an understanding of acceptance far better than the words in this point) provides an example. Pick out an ice cube from your freezer (one about the size of the ``Shift'' key on your desktop computer keyboard). Hold it in your hand, gently enclosing it between your ®ngers and palm so that you maximize your exposure to it. Your task now, if you are willing, is to simply hold the ice cube like that until it melts. There are two stances you can take 21


toward the rising coldness occurring in your hand: tense up against it and push your hand away from your body, or gently cradle your arm on your leg and relax into the sensations in your hand (let the water drip wherever you like). Try to take this latter stance. When you are distracted from focusing on the sensations occurring in your hand, gently focus your attention back onto it, as many times as it takes. Notice the thoughts you are having about the experienceÐsimply as thoughts, not as factsÐand gently focus attention back onto your hand, again, as many times as it takes. You will likely notice that, perhaps unexpectedly, the sensations involved will change over time, that thoughts and worries will come and go . . . and that your hand will not become frostbitten and require amputation by the end of the exercise! This exercise typically conveys a metaphorical understanding of psychological acceptance. It illustrates that sometimes, when we wish to move in a particular direction in life that is important to us (presumably, you engaged in the exercise because learning about acceptance matters to you), we will encounter pain or psychological distress. If we are not willing to experience that pain, we will not move closer to what we value (Hayes et al., 1999). If we are willing to experience that pain by letting it be free to wax and wane of its own accord, by letting go of our resistance to it, and by focusing on what the experience actually is (rather than what our minds say it is), then we can move toward what matters to us. A pivotal, summary, question sometimes posed to ACT clients whose values-driven actions are being derailed by avoidance can be paraphrased as: `Àre you willing to have this experience as it is and not as your mind says it is, and act in a way consistent with what you value?'' From an ACT perspective, it is assumed that human language/ cognition distort and often enhance emotion-laden experiences, and that efforts must often be taken to ``short-circuit'' these language-based processes when they prove problematic. Thus, acceptance work is typically done alongside cognitive defusion and self-as-context work, discussed in Points 6 and 7. If an 22


aversive experience can be metaphorically likened to standing in the middle of a large rose bush with razor sharp thorns, defusion/ self-as-context work can be described as removing those thorns. Discomfort and distress remain, though perhaps to more manageable degrees. From this perspective, acceptance may be seen as a realistic option. Of course, the thoughts themselves are not removedÐsimply taken less seriously. Additionally, acceptance work in ACT is virtually always yoked to client values (discussed in Point 9). That is, clients are not asked to consider actively experiencing distress unless doing so is instrumental in living a more meaningful, vital, and purposeful life. Realistically, acceptance often waxes and wanes across the duration of a distressing experience. Given an elementary understanding of acceptance and the role cognitive defusion plays in facilitating it, this should not come as a surprise. First, and most obviously, aversive experiences are by de®nition unpleasant. Even when one is willingly experiencing them in order to more effectively pursue personal values, this fact alone is reason enough for the depth of willingness to ¯uctuate from moment to moment. Further, greater degrees of fusion with negative evaluations of aversive experiences would be expected to drive down levels of willingness. As discussed in Point 6, defusion strategies cannot be expected to fully and permanently ``de-literalize'' these evaluations, given the pervasiveness of literal language use and the long learning history behind it. The tendency for acceptanceÐand defusionÐto ¯uctuate is not necessarily a problem. In the long run, client improvement can be expected when a client simply emits more values-consistent behaviour than she or he is currently receiving and improves quality of life over time (see Point 9) and less frequently avoids aversive experiences on the path toward valued ends. Logically, more frequent and sustained acceptance and values-consistent behaviour would be expected to yield more robust change, but may not be necessary for less robust changes. A related issue brings up an important caveat that applies when helping clients understand the nature and purpose of 23


acceptance within the context of ACT. As previously stated, aversive experiences tend to become less aversive when cognitive defusion and self-as-context strategies are successfully used. When clients realize this, they may begin to use these strategies expressly to minimize distress, rather than as tools to maintain effective values-consistent action even when distress arises. The change in agenda is critical, and points to a foundational aspect of ACT. If one's primary agenda involves direct attempts to reduce psychological distress, less effort is directed toward values-consistent behaviourÐtoward behaviours that will increase the frequency of positive reinforcement and improve quality of life in the long run. Additionally, when defusion and self-as-context strategies fail to reduce distress to `àcceptable levels'', `ùnacceptable'' degrees of distress will preclude values-consistent behaviour. Acceptance, to be a consistently useful process, must involve a willingness, in principle, to experience any degree of psychological distress. For these reasons, ``creative hopelessness'' strategies are typically used to help client's exchange an agenda of psychological change for an agenda of acceptance in service of values (see Point 18 for an applied discussion of creative hopelessness).

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6 Cognitive defusion From an ACT/RFT perspective, words hold meaning, and appear to drive our behaviour, only under speci®c circumstances. Consider the following sentence: Quispiam est superstes vox secundum vos procul is valde moment. Notice how you responded when reading the previous sentence. Unless you are ¯uent in Latin, the words hold little or no meaning. Now notice how an English translation of those words function: Someone is standing right behind you at this very moment. Even though it is clear the authors of this book could have no idea of whether or not someone is standing behind you, this translation of a largely meaningless stream of letters still may have elicited a bit of anxiety or even caused you to turn around and look. In and of themselves, letters and words are simply arbitrary symbols, scratches on paper or unique sounds. They ``mean'' nothing until those who are verbally capable have a suf®cient history with them and use them in particular ways. When one has learned a language (including its grammatical and syntactical rules) and been taught that each of these symbols refer to real ``things'', these verbal stimuli will function as expected. In other words, when the rules of language are followed, words have power. Now notice what happens when some simple syntactic rules are broken: 25


Behind very standing is moment right you someone at this. While this is but a single example, it helps to illustrate the concept at hand. At its core, cognitive defusion simply involves breaking the rules of language in ways that cause problematic words to lose much or all of their meaningÐthat cause thoughts to function simply as words or thoughts, rather than facts. Put more technically, ``cognitive defusion techniques attempt to alter the undesirable functions of thoughts and other private events, rather than trying to alter their form, frequency or situational sensitivity'' (Hayes, Luoma, Bond, Masuda, & Lillis, 2006, p. 8). From an RFT perspective, all words are simply arbitrary symbols that have relations of rough equivalence to other stimuli. The symbol ``car'' corresponds to an actual car; the symbol ``justice'' corresponds to the abstract concept/stimulus of justice; the sound ``yellow'' corresponds to a particular bandwidth of visible light; the sound ``worthless'' corresponds to a state of being without value. These symbols tend to `èvoke'' the stimuli they are related to when spoken or thought under ``lawabiding'' circumstances. But when contextual conditions change and key aspects of the ``laws of literal language'' are violated, these symbols start to function quite differently than before (see Blackledge, 2007). When one speaks a sentence much too quickly (like an auctioneer) or much too slowly (like a 78 r.p.m. record slowed down to 33 r.p.m.), sings a thought in a manner entirely inconsistent with its mood, repeats the same word or short phrase rapidly 30 times or more, or dramatically breaks grammatical rules, the processes involved with relational responding have a very dif®cult time in changing the functions of words in the expected ways. Words begin to ``lose their meaning'' (at least temporarily) and ultimately their illusory ability to drive our behaviour. Among other things, defusion techniques tend strongly to highlight the con¯ation between descriptive and evaluative language and undermine our beliefs that evaluative words correspond to some objective reality. Descriptive words (e.g. ``car'', ``house'', ``wood'', ``solid'', 26


``rectangular'', ``red'') refer loosely to objects or properties that can be formally perceived with one of the ®ve senses. Evaluative words refer to abstract concepts or properties that cannot be formally perceived with the senses (e.g. ``honour'', `èvil'', ``worthless'', `ìnadequate'', ``justice''). Verbal humans often operate as if abstract, evaluative concepts have the same, `ìmmutable'' basis in physical fact that descriptive words have, such that calling someone a ``bad person'' can function as an `ìmmutable truth'' much as correctly labelling a chair a ``wooden chair'' can. This is not to say that descriptive words completely capture ``reality'' (e.g. a ``chair'' that one describes in detail probably still is not exactly what one perceives it to be). Rather, it simply strongly suggests that evaluative language (as well as prescriptive language like, ``You must always be nice to people'', and proscriptive language like, ``You must not hurt people's feelings'') is arbitraryÐthat it has no absolute basis in truth. Defusion techniques help clients to experientially contact this notion, with the intention of undermining the sanctity of language and reducing its impact on their behaviour. Defusion, however, is not intended to undermine a client's reliance on all language, as indeed it would likely be impossible and, more importantly, highly undesirable to do so. Modern humans are steeped in language and require it to effectively function and thrive. As previously discussed, the ability to think and speak confers a multitude of advantages. Its disadvantages, however, include a propensity for in¯exible and ineffective behaviour arising from rigid adherence to verbal rules, and an enhancement of human suffering arising from belief in negatively evaluative language (see Points 4 and 5 for elaborations on these points). Defusion strategies in ACT are thus typically used to experientially shape a healthy scepticism about evaluative and prescriptive/proscriptive language in general, while encouraging the client to continue ``buying into'' thoughts they ®nd bene®cial. Most often, speci®c negatively evaluative thoughts that clients ®nd particularly distressing and disabling (as well as verbal rules that lead to ineffective or counter27


productive behaviour) receive more focused attention. Ultimately, as with each of the six core ACT processes, defusion strategies are used to help the client more consistently and more effectively live in values-consistent ways.

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7 Self-as-context Relational frame theory predicts that virtually any stimulus can enter into a relation with any other stimulus (Hayes et al., 2001a). As these relational networks grow more complex, what constitutes a ``stimulus'' can grow increasingly complex as well. These facts culminate in a conceptualization of ``self'' quite different from the way many psychological theories have viewed the de®ning aspects of self. From an RFT perspective, three different senses of self can be delineated: self-as-content, self-as-context, and self-as-process (Barnes-Holmes, Hayes, & Dymond, 2001). The ®rst two of these senses of selfÐand their relevance to ACT and psychopathology in generalÐwill now be described. The ``most readily accessible verbal sense of self'' (BarnesHolmes et al., 2001, p. 126) is referred to as self-as-content. When adopting a sense of self-as-content, a person views his or her self as roughly equivalent to the content of his or her currently experienced thoughts, emotions, memories, and physical sensations. In other words, aspects of what one is currently thinking, feeling, and remembering are viewed as selfde®ning characteristics. It is important to emphasize that not all aspects of one's experience are framed as equivalent to one's self when a sense of self-as-content is adopted. Rather, it is likely more common that frequently experienced feelings, thoughts, and memoriesÐor perhaps more salient or intense experiencesÐ are viewed as self-de®ning characteristics. For example, a person with frequent feelings of guilt and regretful thoughts would be more likely to de®ne her- or himself as a ``bad'' and ``sel®sh'' personÐevaluative characteristics that tend to adhere quite tightly to such emotions and thoughts. Additionally, a 29


person adopting a sense of self-as-content and experiencing very high levels of anxiety might readily de®ne her- or himself as roughly equivalent to the negatively evaluative language that often co-occurs with anxiety (e.g. `Ì'm weak . . . out of control . . . crazy . . . incompetent'', etc.). Given the great variety of negatively evaluative talk that adheres to distressing emotions and other distressing thoughts, implicitly or explicitly viewing oneself as equivalent to these elaborated ``networks of distress'', it may become readily apparent how disabling and distressing things become when a sense of self-as-content is adopted. Holding a literal sense of self-as-content during a distressing experience often increases the degree of distress, as the general ``badness'' of the negatively evaluative language attached to the initial experience then becomes attached to one's self. At such points, experiential avoidance would be expected to increase, even when active engagement with such experiences may be necessary to live a more meaningful and vital life. After all, if the negative content of one's experiences de®nes one's self, attempting to avoid circumstances that elicit that negative content can appear as a very enticing option. Self-as-context strategies are used in ACT to help counter fusion with a sense of self-as-content and facilitate valuesconsistent action. In its simplest fashion, a sense of self-ascontext de®nes the self as that stable, ever-present part of you that notices the transient thoughts, emotions, memories, and sensations that ¯ow in and out of awareness. When a sense of self-as-context is adopted, it means that one's self is not de®ned as the various thoughts, feelings, and sensations that are experienced, but rather as the person who is having or noticing those experiences. From a behavioural perspective (Skinner, 1974), one's sense of self-as-perspective comes to be abstracted, over time, as the one stable stimulus amidst a sea of transitory stimuli. From early youth, humans are bombarded with questions like: ``What do you want?'', ``How are you feeling?'', ``What are you thinking?'', ``What would you like to eat?'', and ``What would you like to do?'' In response, we reply with 30


answers like: `Ì am bored'', `Ì am tired'', and `Ì am scared''. Over many years and across all such questions and answers, only one commonality remains: the perspective from which these questions are answered remains the same. You (or I) want, feel, and think a great variety of very different things from moment to moment, but it is always you (or me) who does that wanting, feeling, and thinking. Thus, the self has been traditionally de®ned (behaviourally speaking) as a locus of perspective. RFT builds on this conceptualization, in part, by postulating that when a sense of self-as-context is adopted it involves relating one's ``self'' or `Ì '' here and now (physically and temporally) to experienced or perceived thoughts, emotions, and sensations that are there and then. In other words, adopting a sense of self-as-context involves noticing that I, right here and right now (from this locus of perspective), am noticing the occurrence of correspondingly non-self-de®ning emotional and cognitive events that are necessarily there and thenÐnecessarily simply because they cannot be noticed and where you are noticing them from at the same time. To paraphrase Jon Kabat-Zinn (2005), ``wherever you go, there you are'', regardless of what you are thinking, feeling, or remembering. When one is not de®ned by the content of one's experiences, distressing situations and the verbal evaluations they engender become potentially less threatening and less disabling. The literal ``badness'' or `ìnadequacy'' (for example) verbally attached to our experiences begin to appear more as ``words'' out there, rather than self-de®ning truths. And distressing emotions begin to appear more as relatively transitory feelings that are the function of current circumstances rather than inviolable pronouncements of one's character. It should be emphasized that no claims are made within ACT or RFT that a sense of self-as-context (or content, for that matter) corresponds to what the self ``really'' is from an ontological perspective. Rather, these terms describe two different ways of verbally framing or viewing one's experience, and both ways are readily shaped by verbal learning histories. While a 31


sense of self-as-content tends to be more explicitly shaped by the typical verbal learning history, a sense of self-as-context tends to be more implicit. ACT aims, in part, to shape clients to become more explicitly aware and capable of adopting a sense of self-as-context. Thus, a client's sense of self-as-context is not treated as some version of ``who the client really is'' in a literal sense, but rather as a sort of observation platform the client can step back onto in order to defuse from a sense of self-as-content and more effectively act in a values-consistent manner.

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8 Contact with the present moment All learning happens in the present moment. Since learning, from a behavioural perspective, is all about reinforcement and punishment, we can rephrase this statement to read that when a consequence, such as a potential reinforcer or punisher, operates on a behaviour, it happens now. In order for that consequence to have an effect on subsequent behaviour, it needs to actually ``register'' (or more precisely, function) as a reinforcer or punisher. In other words, unless you are closely attending to the current consequences of your behaviour, you can remain oblivious to the fact that certain actions are routinely punished or routinely reinforcedÐthat some things you do are effective in the moment, and some are ineffective. When you remain oblivious to these consequences, no learning occurs. A person in this situation is doomed to make the same mistakes repeatedly. Attending more closely to the present moment is one antidote to the situation. If you can more closely track how effectively or ineffectively you are behaving in the moment, you are in a much better position to change your behaviour, and, indeed, may be more motivated to do so as well. Unfortunately, our thoughts are experts at pulling us away from the present moment. Thoughts are about anything and everything except now. Thoughts focus on things like planning for, dreaming about, or being afraid of the future, and remembering, reminiscing, or ruminating about the past. Even when we categorize or evaluate a current experience or perceived object, the categorization/evaluation must by necessity come directly after the experience, and may even lead to a cascade of comparisons that take us even further away from the present moment. For example, imagine the experience of mindfully 33


walking through a parking lot and feasting your eyes on a brand new red BMW sports car. Even though it might be a very rich sensory experience in the moment, your mind will (most likely) very quickly begin to throw out categorizations and evaluations: ``BMW''; ``convertible''; ``beautiful car''; `èxpensive''. And then, the comparative trip down memory lane (or down the road toward the future) begins: ``That's a lot nicer than my car''; `Ì wonder what it's like to drive it''; ``Maybe someday . . .''; `Ìt reminds me a bit of that car my uncle used to have . . .''; and so on. Now imagine that while you have taken this little cognitive trip, you have managed to remain oblivious to the large diesel pickup truck that has crept up behind you and is now loudly blasting its horn for you to get out of the way. Overly attending to our thoughts can yield some markedly unpleasant outcomes when one comes back to the here and now. This is not to say there is no utility in thinking. Indeed, our cognitive ability to plan, remember, categorize, evaluate, and compare has bene®ted us greatly as a species. Virtually every technological advancement made by man (including those as simple as clothing, agriculture, and secure shelters) is the direct result of language. Your ability to think is essential in helping you complete your education, plan and navigate your career, and read this book. But as the example in the last paragraph hopefully demonstrated, there is a time for being carried away by thinking, and a time for actingÐand acting with full awareness of what is going on in the moment is arguably a precursor for increasingly effective action. As alluded to above, a lack of contact with the present moment can cause problems beyond missing present-centred learning opportunities or simply responding ineffectively to current stimulation. Rumination about failures or bad experiences from the past can elicit feelings of sadness, guilt, regret, embarrassment, anxiety, anger, and a whole host of emotions that might not arise (or arise at such strength) if one was focused more consistently on the present moment. Worrying 34


about the future can elicit some similar emotions. Preoccupation with distressing thoughts about the past and future, or even with distressing evaluative thoughts about the present, can not only enhance distress, but also contribute to ineffective action. When one experiences a need to eliminate or attenuate increased aversive stimulation from such thoughts and feelings, one's behaviour can very quickly become all about that, rather than about responding effectively to moment-to-moment situations of importance. When these past- and future-oriented efforts to address these thoughts and feelings are at least somewhat successful, they might be considered time well spent. But when past events and future possibilities (and the thoughts and feelings attached them) cannot be changed, repeated attempts to change them can carry a heavy response cost.

Inconsistent contact with the present moment If you are not a proverbial meditating monk on the mountain, an expectation to remain consistently and completely in contact with the present moment for long periods of time would be unrealistic. Human beings are verbal creatures, steeped in language since birth. With such a long and pervasive history of using language, and with language use having so many bene®ts, it would be impossible and undesirable to be a part of the modern world and ``turn off the chatter'' permanently. Contact with the present moment is a largely intermittent endeavour. To test this proposition, try a simple experiment for the next couple of minutes. Simply close your eyes and focus your attention on the physical act of breathing. When thoughts or other distractions come, note their presence, allow them to do whatever they want to do, and gently focus your attention back on your breath, as many times as it takes. When you have done this for approximately two minutes, open your eyes and come back to this page. If you are like most people, you found the simple act of consistently focusing on your breathing to be incredibly 35


dif®cult. Likely, you experienced dozens of distractions during that two-minute period, and were at least a couple of times ``carried away by a train of thought'', such that you temporarily forgot about the exercise and entered into a world of abstract thought. The reality is that such a task is anything but simple. In our fast-moving modern world, we are consistently reinforced for being `òff in our heads'', planning, preparing, remembering, moving from one place or task to another as expediently as possible. Our schools and our jobs reward us for thinking, not for ``being in the moment'', and modern machines like computers, televisions, video games, and iPhones require thought in order for us to use them. Any behaviour (in this case, thinking) reinforced so frequently, so pervasively, and for so long should be expected to continue at high frequency. However, hope is not lost. It seems more than plausible that even inconsistent contact with the present momentÐabove and beyond the degrees to which we may currently attend to the presentÐcan teach some valuable lessons about the insubstantiality of thought and the richness of direct experience. And attention appears to be a trainable capacity. The more one practices attending to the present moment, the better one will get at it. And, ultimately, for the purposes of ACT, it seems that the task at hand is not of constantly or even consistently staying focused on the present moment, but rather more consistently returning to it when one is repeatedly pulled away by thoughts during times of distress.

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9 Values Hayes et al. (1999) offered an initial de®nition of values as ``verbally construed global desired life consequences'' (p. 206). In other words, values are verbal statements about what states of affair an individual desires to repeatedly experience throughout his life. This de®nition sets a valuable guideline for how to most usefully conceptualize values from an ACT perspective, though it somewhat de-emphasizes how values are operationalized within ACT therapy. For practical purposes, values are typically approached by an ACT therapist as process variables (ways of behaving) rather than outcome variables (desired life consequences). For example, if an ACT client stated that she or he valued close, intimate relationships (an outcome), her or his ACT therapist would help her or him clarify qualities that are brought to bear within the context of a close relationshipÐ qualities or ways of behaving that she or he can unilaterally bring to bear in her or his relationships that increase the likelihood of developing and maintaining close relationships. The reason for this is that (colloquially speaking), while the consequences for any given behaviour are ultimately `òut of one's hands'', one always has the ability to act unilaterally in a pre-determined fashion. Thus, thinking of values as ways of behaving affords more utility to a behaviour therapist attempting to shape the increased emission of speci®c responses in a client.

Valued living: A definition Wilson and Murrell (2004) coined a progressive turn of phrase on values (a static noun that implies a focus on outcome) by emphasizing that the ultimate goal of ACT is increasing the 37


frequency of valued living (which implies a focus on the process of behaving consistently with one's values). From our perspective, valued living (and, by implication, values) might be technically viewed as ways of responding that give increased access to relatively stable, long-term sources of positive non-verbal and verbal reinforcement. An emphasis on stable and long-term sources of positive reinforcement as an adequate way of de®ning a value is highlighted for several reasons. First, it is obviously assumed that for any set of consequences (exempli®ed by personally held values) to maintain behaviour instrumental in achieving them, these consequences are by de®nition reinforcers. However, competent ACT therapists go to great pains to make values-directed behaviour come under appetitive control rather than aversive control, due to a long experimental behaviour analytic tradition documenting the undesirable sideeffects of aversive control (see, for example, Sidman, 2001). In other words, value-driven behaviour is not about ``musts'' and ``shoulds'' and ``have tos'' (which imply escaping negative consequences), but about ``want tos'' (which imply approaching positive consequences). Thus, values re¯ect sources of positive reinforcement rather than reinforcement writ large. Given only the de®nition of values and valued living proposed in the last paragraph, it would be appropriate to speculate that values refer to nothing more than the kinds of tangible reinforcers and attention that can be achieved through a basic token economyÐthat, essentially, the ACT construct of values adds nothing to the basic behavioural approach of reinforcing desirable, appropriate, and effective behaviours. However, ACT therapists conducting values clari®cation with clients seek to help the client identify ways of valued living that confer an increased sense of vitality, meaning, and purpose in them. As might be inferred, such a personalized view of values stands in contrast to a common Western conceptualization of values as prescriptions for good behaviour that are passed down and enforced by the dominant culture. While any given client's genuine values might indeed mirror any number of 38


predominant cultural values, great care should be taken by the therapist to ensure that a client-endorsed value actually does engender at least a marked degree of meaning, vitality, and purpose in the client. ``Values'' without this characteristic typically involve behaviours the client feels he or she must emit in order to avoid punishment in the form of censure, ridicule, disappointment, etc. In other words, such ``prescribed'' values typically involve behaviour under aversive controlÐa set of in¯uences on behaviour quite opposite to the increasingly positive reinforcement-based in¯uences desired for an ACT client. Use of the phrase valued living, as opposed to values, highlights another important aspect of this all-important ACT component. At times, behaviours that will facilitate one's values over the long run are not pleasant to engage in. A father who greatly values acting in loving, caring, and supportive ways toward his daughter might sometimes ®nd acting in this way unpleasantÐsay, during a disagreement or an activity enjoyed by the daughter, but not the father. RFT predicts that, even at these times, such behaviours might actually be immediately reinforced simply because they are in a verbal equivalence class with the stated value. In other words, once clarity has been gained about the general qualities of action one genuinely valuesÐand a variety of previously enjoyable and unenjoyable speci®c behaviours that embody these qualitiesÐthe unenjoyable behaviours may actually become `ìntrinsically'' reinforcing simply because they have been verbally related to an overarching set of behaviours that bring meaning, purpose, and vitality. For example, the father mentioned above (actually the second author) may occasionally ®nd repeated interruptions by his three-year-old daughter during weeknights far less than desirable. However, when listening to and fully engaging with his daughter at such times is framed as equivalent to enacting a very reinforcing, heartfelt parenting value, RFT-based processes may actually help him frame the interaction as reinforcing. Thus, when a value is fully ``¯eshed out'' and a good variety of its co-ordinate behaviours are identi®ed, the sense of 39


meaning, purpose, and vitality that infused preferred enactions of the value can spread to activities that were previously unpleasant or neutral. One ®nal note deserves mention. Defusion strategies often play a very important role in clarifying values and in maintaining them as ``want-tos'' rather than ``have-tos''. Once a genuine value is clari®ed, it is easy to frame it as something one ``must'' behave in accordance with. When such a thought is fused with, values-consistent behaviour comes under aversive control, and there is little or no enjoyment involved. Defusion strategies can be employed to help the client view valuesconsistent behaviour not as a duty imposed from without, but rather a moment-by-moment free choice that the client makes. Negative evaluations that follow a momentary choice not to engage in such behaviours can then be treated like any other verbal evaluationÐsimply as words, not as facts. Given the intersection between values and positive reinforcement, as well as the caveats to this notion supplied in the last few paragraphs, one can quite readily de®ne values as ``freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns of activity, which establish predominant reinforcers for that activity that are intrinsic in engagement in the valued behavioral pattern itself'' (Wilson & DuFrene, 2009, p. 66). In other words, living consistentlyÐin an increasing variety of different waysÐwith one's values tends to make the process of living in that manner reinforcing even at times when valued outcomes may not be achieved moment to moment.

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10 Commitment Clari®cation of individually held values would mean next to nothing without putting these values into action. From an ACT perspective, the term ``commitment'' actually refers to several discrete behavioural processes and actions, and invokes a number of issues that are relevant to treatment. At one level, commitment may simply involve publicly committing to a speci®c value or values-consistent behaviour, with the intent of ``keeping oneself honest'', enlisting support, and inviting reminders. At its most fundamental level, commitment involves actually behaving consistently with one's values, not simply promising or agreeing to do so. As indicated in Point 9, any number of speci®c behaviours consistent with a value might be emitted in any given moment. Commitment involves emitting more of those behaviours and less of behaviours inconsistent with one's values. At a closely related level, commitment might involve a demonstrated willingness to experience the distressing thoughts and emotions that may often arise in the midst of living those values. At another level, commitment in ACT involves planning one's values-consistent behaviour in a more systematic manner. Since values refer to long-term ways of living that are often progressive in nature, forward planning may at times be needed to keep one's behaviour `òn track''. Setting values-consistent goals can help serve this purpose. In some cases, goals may be relatively short term, such as when a father who values being loving and supportive of his son sets a goal of attending the boy's Saturday football games, or when a woman valuing a close, caring, loving relationship sets a goal of reserving three nights a week for one-on-one time with her partner. In other 41


cases, goals may be longer term. For example, a high-school graduate who values a career where he or she can be creative, help others, and contribute to the ®eld might likely need to set goals involving applying to colleges, graduating, applying for graduate schools, etc. At times, the goal-setting aspect of ACT may thus resemble what occurs during the behavioural activation component of conventional CBT (see, for example, Kanter, Busch, & Rusch, 2009): identify pleasurable activities (or, in ACT's case, valued activities and behaviours), then ``programme'' these activities by setting goals for their completion. It should be emphasized, however, that values-consistent behaviours are often not so formally ``programmed''. Rather, the ACT client may often be assisted in simply identifying a variety of ways to ``live'' a given value so that the client can emit those behaviours when opportunities naturally occur. Commitment may also involve specifying concrete actions that can be taken to move toward one's goals. Such planning may involve the identi®cation of strategies useful in solving problems likely to be encountered while pursuing valuesconsistent goals. Often, this involves a commitment to use ACTconsistent mindfulness strategies when sizeable cognitive and affective barriers present themselves. At times, a commitment to use more concrete problem-solving strategies may be indicated. For example, a single man who values being a loving, supportive, honest, caring romantic partner might need to identify and commit to some strategies likely to put him in increased contact with compatible partners, such as volunteering at a community centre or joining a co-educational club focused on an interesting topic. Alternatively, the same man might need to commit to rectifying any variety of skills de®cits or excesses that he ®nds interfere unacceptably with his prospects. A ®nal set of issues relevant to commitment arise in ACT and deserve mention here. In ACT, commitment is viewed as a moment-by-moment choice. Clients overwhelmed by the gravity of a commitment to act according to a value can be reminded that the notion that a value is some sort of overwhelming and 42


never-ending commitment is simply a thought. What remains is a situation where the client simply has clarity about ways of living that matter to them, and can freely choose in each moment whether to act consistently with a given value. On a related note, sooner or later, an attempt to behave consistently with a value will fail, or a behaviour sharply inconsistent with a value will occur. In such cases, it is not uncommon for the client to react as if the ``game has ended''Ðas if the value has been inexorably violated and cannot be revived. And the agenda remains the same: the next moment is an opportunity to choose whether to act consistently with that value or not, in whatever way might be best suited to the circumstances. Metaphorically, these instances are like falling off a bicycle, then choosing to remount and continue riding, or not. From this perspective, valuesÐand commitmentÐare viewed as helpful but nonbinding guidelines about how to live a life that matters, rather than oppressive, prescriptive ideals that must be lived up to.

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11 Mindfulness and behaviour change: Toward psychological flexibility While all six of ACT's core processes overlap with each other at times, more recent conceptualizations often combine them into mindfulness and acceptance processes and commitment and behaviour change components, and propose that they act together to enhance psychological ¯exibility (e.g. Hayes, Strosahl, Bunting, Twohig, & Wilson, 2004b). The rationale for combining components in this manner warrants discussion.

Mindfulness and acceptance processes The mindfulness and acceptance processes include contact with the present moment, self-as-context, acceptance, and cognitive defusion. While a more detailed discussion of why the label of ``mindfulness'' applies to these four processes is provided by Fletcher and Hayes (2005), the discussion below focuses on some of the substantial overlap between these four indiscrete processes.

Cognitive defusion and self-as-context Defusion techniques very often appear to confer a sense of selfas-context. When standard language conventions are violated to the point where thoughts start to lose meaning, those thoughts essentially become objects of analysisÐwords out there that are being noticed from here. This stands in sharp contrast to the sense of self-as-content that occurs when selfevaluative thoughts are taken literally. In the latter case, thoughts are typically not even experienced as thoughts, but 45


rather as simple re¯ections of an immutable reality. Breaking up the literality inherent to a sense of self-as-content shines a spotlight on those words. It clearly identi®es words to be looked at from a place where they are not self-de®ning, but are rather bits of ``verbal behaviour'' that one emits and observes. Metaphorically, the shift from self-as-content to context is like losing oneself in a very engaging and realistic DVD movie, then defusing and sliding into a sense of self-as-context when one views the documentary feature showing all the cinematographic nuts and bolts that conspired to make this ®ctional work appear undeniably real. Thus, while speci®c self-as-context strategies often look different than speci®c defusion strategies (see Points 22, 23, and 25 for differential examples), it appears that the experience of defusing one's thoughts and adopting a sense of self-as-context co-occur very often.

Contact with the present moment and cognitive defusion As discussed in Point 6, defusion techniques are posited to disrupt the ordinary functions of language (i.e. the ``meaning'' of words and the effects they have on subsequent behaviour) by changing key aspects of the context in which language (or thinking) is experienced. As established above, one ubiquitous aspect of thoughts is that they focus on the past or the future. Since a focus on the present is obviously at odds with this past/ future focus, this may be one aspect of present-centredness that serves a defusive function. There is a second reason (involving a differential focus on formal versus abstract stimulus properties between presentcentredness and thinking) that contact with the present moment may serve a defusive function. To understand this reason, however, several terms must ®rst be discussed. Wilson, Hayes, Gregg, and Zettle (2001, pp. 219±222), among other authors, have suggested that evaluative language is at the core of psychological distress and psychopathology. In other words, 46


our verbal capacity to label things and aspects of our experience as good or bad, desirable or undesirable, worthy or unworthy, forgivable or unforgivable (and so on) is a primary culprit in leading us to feel bad about ourselves, our potential, and the world around us. In the present context, what is most interesting about this idea is that none of these evaluative terms refer to formal stimulus properties. Formal stimulus properties refer to stimuli that can be directly perceived with one of the ®ve sensesÐthat can be directly seen, touched, tasted, smelled, or heard. ``Goodness'' or ``badness'', for example, is not a formal property of a person or thing. Rather, such evaluations represent at least a partial convergence of subjective social opinions about the relative usefulness or desirability of a person or thing. If a ``red apple'' was placed on a table, every Englishspeaking person in the room would instantly agree on its formal properties, on its redness, roundness, its brown-coloured stem, etc. These stimulus properties can be directly perceived by the senses. They are, loosely speaking, inherent qualities of the appleÐthey are ``part of'' or `ìn'' the apple. If it was then called a ``bad apple'', one would be moving from stimulus properties that are directly sensible to one that is subjective and not directly sensed. Some who prefer red apples would disagree, some who hate them would agree. Some might differ on the qualities they prefer in an apple (crispness, softness, sweetness, sourness) and agree or disagree with the evaluation based on those preferences. But hopefully all would agree, upon re¯ection, that goodness or badness is not a formal property of an apple, but rather a subjective judgement (either shared or not) placed on an apple by a human being according to his or her preferences. Evaluative terms like ``good'' or ``bad'' are abstract, in that they do not refer to sensory qualities of an object but rather involve more subjective but generally socially agreed upon judgements involving preference, usefulness, and/ or desirability. Now that the distinction between formal and abstract stimulus properties has been examined, a second reason why 47


contact with the present moment may serve a defusive function can be discussed. Those who have dabbled in meditation or mindfulness exercises know that what is contacted in the present involves formal stimulus properties. Thoughts will come and go during a mindfulness exercise, but forms of sensory experience are nearly always the target of attention. When in touch with the present moment, one might focus on the sensory experiences involved with breathing, on the physical sensations in one's legs and feet while walking down a sidewalk, or on the in-themoment sights, sounds, tastes, smells, or tactile experiences one is present with. Pure contact with the present moment involves a focus on formal stimulus properties. By contrast, in the world of thinking and ideas we swim in an abstract sea. Beyond the fraction of words that simply identify various physical objects, people, or actions (e.g. chair, book, mother, ¯ying, running), every other word in our lexicon invokes relatively abstract concepts that cannot be directly perceived. And even when we start with a simple, formally descriptive word, we very quickly begin to think of a variety of other related words (evaluative and beyond) that move far beyond the direct physical properties of what we experienced moments ago (see Hayes et al., 2001c, pp. 35±39, for a review of other, non-evaluative, abstract ways of thinking). Thus, one nearly ubiquitous contextual feature of using ``language as usual'' involves its focus on abstract thought. Increased contact with the present moment, with its focus on formal stimulus properties, would seem to displace this focus on abstract stimulus properties, providing a relative (if only temporary or incomplete) escape from what our thoughts may often ``push us'' to do.

Acceptance and the three remaining mindfulness processes From an ACT perspective, acceptance of sizeable psychological distress often (if not always) requires the other three mindfulness processes. At a minimum, since acceptance requires a 48


willingness to have what is being experienced right now, one must be in at least intermittent contact with the present moment to accept one's current experience. The connection between acceptance and the remaining two mindfulness processes is perhaps a little less obvious. Acceptance involves willingly having one's ``present experience as it is, not as [one's] mind says it is'' (Forsyth & Eifert, 2007, p. 158). This implies that one may often need to defuse from verbal evaluations of one's experience in order to fully accept it. As defusion and selfas-context appear to operate in concert with extreme frequency, both processes are often necessary to facilitate complete acceptance. As such, ``mindfulness''Ðan ancient term with multiple de®nitionsÐcan be readily conceptualized as the con¯uence of acceptance, contact with the present moment, self-as-context, and cognitive defusion.

Commitment and behaviour change processes ACT is, at its core, a behavioural (albeit modern behavioural) approach to treatment. As such, its primary goal is behaviour change. After reading Points 9 and 10, it should be clear how the commitment and values components combine to address this goal. Values set the personalized parameters for speci®c behaviour changes linked to a life of increased meaning, purpose, and vitality. Non-coerced commitment and recommitment to engaging in these behaviours, moment by moment, helps facilitate these behavioural changes. Mindfulness and acceptance processes help one ``cut through'' (or perhaps more appropriately, transform) the cognitive and emotional barriers that appear to stand in the way of increased values-driven movement.

Psychological flexibility All six of ACT's core processes combine to produce increased psychological ¯exibility, technically de®ned as ``the ability to 49


contact the present moment more fully when doing so serves valued ends'' (Hayes et al., 2004b, p. 5). The entire ``hexa¯ex'' model is shown in Figure 1. The same authors (pp. 12±13) provide a more thorough operational de®nition of psychological ¯exibility as: . . . an answer [of ``yes''] to this question, which involves all six ACT processes:

· Given a distinction between you as a conscious human · · · · ·

being and the psychological content that is being struggled with (self-as-context) . . . are you willing to experience that content fully and without defence (acceptance) . . . as it is and not as what it says it is (defusion), AND . . . do what takes you in the direction (committed action) . . . of your chosen values (values) . . . at this time and in this situation (contact with the present moment)?

As forecast in Point 2, this summary de®nition of the goals of ACT provides a view of psychological health substantially different from most models of psychotherapy. Increased psychological health, from an ACT perspective, essentially involves increased psychological ¯exibilityÐnot necessarily the increasing absence of psychopathological symptoms. Decreased psychological health involves psychological in¯exibility, ``the inability to persist or change behaviour in the service of longterm valued ends'' (Hayes et al., 2006, p. 6).

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Commitment and behaviour change processes

Contact with the present moment

Acceptance

Values

Psychological flexibility

Committed action

Defusion

Self-as-context

Mindfulness and acceptance processes Figure 1 A model of ACT's six core processes

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12 ACT and CBT: Assumptive differences Though there are many speci®c differences in the techniques and strategies used in ACT and conventional CBT, perhaps the most profound differences can be seen in the assumptions each treatment model holds regarding the nature of thoughts and emotions, the purpose of psychotherapy, and the therapeutic stance one should take toward a client.

Assumption 1: Thoughts and/or feelings must change for overt behaviour to change Deeply embedded in cognitive or cognitive-behavioural models of psychotherapy is the notion that maladaptive thoughts (or in some cases, thoughts or distressing emotions, depending on the speci®c model) typically must change before overt problematic behaviours can be expected to change (e.g. Beck, 1991). This assumption is clear at virtually every phase of CBT. Therapeutic goals are set at the beginning of treatment. In cases where these goals involve things other than simply feeling better or thinking differently (e.g. when an anxious client sets goals of following through with a public-speaking commitment or regularly attending his or her daughter's public recitals), a variety of cognitive restructuring techniques are used to correct relevant maladaptive thoughts, and relevant exposure opportunities are arranged to reduce levels of anxiety. ACT embodies a different assumption, one where thoughts and feelings do not need to change in order for overt behaviour to change. Of course, it is not assumed that nothing need be done to instantiate such a state of affairs. In a state of cognitive fusion, evaluative and prescriptive thoughts will most likely 53


lead to concordant action, and relatively high levels of emotional distress will likely lead to experiential avoidance. Thus, ACT employs mindfulness-based processes to help clients view thoughts and feelings as experiences to be noticed and willingly carried, rather than as concrete barriers to effective action.

Assumption 2: When thought change can expedite other forms of behavioural change, logical/ rational change strategies are the best choice Conventional cognitively-oriented models of psychotherapy are also based on the assumption that strategies designed to help a client think more logically and rationally about her or his experience will most effectively change these thoughts and arrive at meaningful emotional and overt behavioural change. Unfortunately, process evidence has yet to convincingly support the assumption that cognitive restructuring techniques successfully mediate positive clinical outcomes (Longmore & Worrell, 2007). It could plausibly be the case that the kinds of long-standing, emotion-laden thinking common in clients distressed enough to report for psychotherapy are resistant to the kinds of logical/rational change strategies employed in cognitive restructuring. Aspects of the ACT model appear to initiate thought change, though the strategies used do not involve rational/logical change strategies. Metaphors are used in ACT to help the client consider an alternative view of his or her experience. Such metaphors involve a relatively loose, non-literal comparison between the client's experience and a previously unrelated set of actions designed to help the client think about and approach his or her experience in a more ACT-consistent way. Other ACT strategies that may bene®t, at least in part, from thought change include values clari®cation, where a client is shaped to think more speci®cally and expansively about what ways of living and acting bring increased meaning and vitality to her or him, and self-as-context strategies that shape a client to adopt a 54


sense of self that is distinct from the content of his or her thoughts and feelings. In both cases, the client's direct experience is repeatedly highlighted before and alongside potential changes in thinking that are occurring, as will become apparent in the applied points of this book.

Assumption 3: The primary goal of psychotherapy is symptom reduction Reductions in the frequency and intensity of unwanted feelings and thoughts are a major goal in CBT. An ACT therapist, by contrast, would place a priority on getting the client off an agenda of feeling better and thinking differently. The agenda of ACT's entire creative hopelessness phase is geared toward this end (see Point 18), and the message is typically revisited many times throughout treatment. Within an ACT model, the desired outcome is for the client to more effectively, constructively, and consistently live a life in line with her or his values, even when any potential degree of psychological distress is present. Ironically, distress levels typically do go down once clients drop a control agenda and more successfully pursue their values. The difference in process (feeling better by trying to feel better vs. feeling better and living a more vital and meaningful life by letting go of trying to feel better) remains a critical distinction between ACT and CBT, however.

Assumption 4: Preferred temporal focus in session The primary temporal focus within most CBT sessions (those, for example, that do not include in vivo exposure) is on the review or planning of activities or experiences occurring outside of session (see, for example, Wright, Basco, & Thase, 2006, pp. 78±79). The ACT model prompts a different temporal focus. A typical ACT session would more often than not exhibit a ``here and now'' focus on thoughts, feelings, and other aspects of 55


experience. To be sure, an in vivo focus on such experiences would often be prompted by discussion of events occurring outside of session (``there and then''), but the focus typically would move to thoughts and feelings arising now as the client re¯ects on the out-of-session event. Then, any number of techniques instantiating defusion, acceptance, or other core ACT processes would be used with these thoughts and feelings. From an ACT perspective, since the client must learn to use these strategies in the moment as new thoughts and feelings arise, the best way to teach them is in the present moment, as applied to thoughts and feelings arising now (even when they are a response to what happened ``then'').

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13 ACT and CBT: Strategic and technical differences In addition to the assumptive differences discussed previously, ACT and conventional CBT often use a variety of different treatment strategies, or use similar strategies with differential intent. Many of these differences should be readily apparent after reading descriptions of ACT's six core processes, but some of these additional differences and similarities warrant discussion.

Exposure A number of core treatment strategies used in CBT are used in ACT, though typically with a different purpose or a different form. Exposure, a core behavioural treatment component used in behaviour therapy (BT) and CBT in the treatment of anxiety disorders, is commonly employed in ACT as well. However, while the purpose of exposure in BT and CBT is the reduction of anxiety levels, the purpose in ACT is to shape an increased ability in the client to willingly experience anxiety (from a relatively defused, self-as-context perspective) when anxiety threatens to serve as a barrier to values-driven action. Such `èxposure'' is also practised with any other aversive emotion the client might experience. Finally, while exposure from a conventional behavioural perspective is typically thought of as classical extinction (where a client is repeatedly exposed to conditioned stimuli that elicit anxiety in order to extinguish those conditioned responses), exposure from an ACT/RFT perspective might be alternatively conceptualized as the willing (i.e. accepting) experiencing of aversive emotion, in a relatively 57


defused state, from a self-as-context perspective. Add in increased contact with the present moment (thought to facilitate the other three cornerstones of ACT's version of mindfulness), and exposure becomes a process arguably applicable to any emotion or experience.

Behavioural activation Behavioural activation is used in BT, CBT, and ACT alike, but again to a somewhat different purpose, in a different form, and to a much broader set of targets. Behavioural activation is traditionally used as a treatment for depression, or more speci®cally as a way to reduce depression by increasing engagement in positively reinforcing activities (from a straight BT or even CBT perspective, these two factors may be viewed as parallel goals rather than simply being related in a process ! outcome fashion). Behavioural activation conventionally involves the client identifying a number of ``pleasant events'' or desirable activities, and then programming progressively larger steps that provide more consistent and eventually more robust access to these events and activities. From an ACT perspective, behavioural activation involves the clari®cation of values, actions, and goals consistent with these values, and the programming of progressively larger steps that involve more consistent and eventually more robust demonstrations of these values. Further, such a strategy would also not only be used with depression, but with any emotion and concomitant thoughts that appeared to prevent values-consistent activity. The result, when successful, is a version of behavioural activation that arguably involves more organized movement toward, and with, a set of ultimately more meaningful and vital values. Interestingly, some current versions of behavioural activation (e.g. Kanter et al., 2009) have apparently been in¯uenced by ACT, focusing more explicitly on helping clients engage in more values-consistent behaviour rather than simply accessing more pleasant events. 58


Skills training As with CBT, forms of skills training and more didactic instruction might also be coherently incorporated within an ACT model. From an ACT perspective, any signi®cant barriers that exist toward more effective and consistent movement toward values need to be addressed. Most typically, such barriers involve dif®cult thoughts, emotions, and other experiences that must be willingly experienced when they arise in the course of valued living. Skills de®cits not attributable to experiential avoidance involving communication, problem solving, identifying emotions and developing empathy, other social skills, or even the acquisition of more effective daily-living skills or knowing how and where to acquire skills instrumental in pursuing a viable and valued career may need to be addressed during the course of successful ACT therapy. It is not uncommon, however, for an apparent skills de®cit or excess to occur primarily or solely due to experiential avoidance. A given person might, for example, have adequate social skills in his or her repertoire, yet fail to use them because his or her thoughts and emotions ``push'' him or her in a different direction. Thus, an ACT therapist should typically investigate the emotions, thoughts, and other experiences that arise for a client (as well as his or her knowledge of any past demonstrations of appropriate skills) at times when a possible skills de®cit arises to determine if a skills-training intervention is really necessary.

Defusion vs. cognitive restructuring Interestingly, the initial stages of cognitive restructuring might well be conceptualized as cognitive defusion. Before one attempts to attend to and weigh evidence for and against a problematic thought, or identify the thinking error exempli®ed by such a thought, one must ®rst identify it as a thought and metaphorically ``set it on the table'' for examination. Hollon and Beck (1979) referred to this initial phase of restructuring as 59


``cognitive distancing'' (p. 189), a phrase that led to ACT's initial name, ``comprehensive distancing'' (Zettle, 2005). However, two critically important differences between defusion and restructuring exist. First, Hollon and Beck (1979) identify cognitive distancing as a necessary component of cognitive restructuring, but not a suf®cient one. From a cognitive perspective, one must learn to appraise one's thoughts more logically and rationally such that problematic or dysfunctional thoughts are ultimately changed. From an ACT perspective, one must simply learn to defuse from one's thoughts so that they are taken less seriously. Logical/rational change strategies are not used, and problematic thoughts need not change in order for subsequent behavioural change to occur. Second, a great variety of defusion techniques are used in ACT, as opposed to an apparently singular way of conducting cognitive distancing during restructuring. While identifying a thought as a thoughtÐas opposed to a static and immutable description of realityÐis certainly one of these techniques, it is one of many ACT-consistent defusion techniques.

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14 Empirical matters ACT and its mechanisms of action have been empirically evaluated at a variety of levels. A brief review of research of note is provided below. Given space limitations, the reader will at times be referred to external sources for speci®c references.

Randomized controlled trials At present, at least 30 randomized controlled trials (RCTs) comparing ACT to various interventions have been published in peer-reviewed scienti®c journals (Hayes, 2005b). As ACT was designed, in part, to impact psychological processes presumed to be operative across a wide variety of psychological disorders (e.g. experiential avoidance), the impact of ACT on 20 different sets of clinical and non-clinical problems was examined across these 30 studies. Five studies comparing ACT to alternative therapies for chronic pain have been published, with one of these studies using a paediatric sample. Two studies comparing ACT to conventional CBT in the treatment of depression have been published, along with two studies comparing ACT to treatment as usual (TAU) for psychosis, and one study comparing ACT to TAU for psychotic depression. Additionally, RCTs comparing ACT to alternative interventions for substance abusing, socially anxious, borderline personality disordered, and trichotillomanic clients have been published, as well as two RCTs investigating ACT with smoking cessation. ACT has also been evaluated with clients experiencing distress related to a number of medical issues, including tinnitus, diabetes, breast cancer, obesity, and epilepsy (two published studies). ACT RCTs investigating the treatment's effect on a 61


variety of non-clinical issues and processes have been published as well, including prejudice, stigma, psychotherapist burnout, maths anxiety, worksite stress, and substance abuse counsellors' willingness to implement evidence-based drug treatments (two studies). In virtually all cases, ACT was found to have superior effects relative to the comparison treatments (except in the case of maths anxiety, where ACT was somewhat better than systematic desensitization for high experiential avoiders, but slightly worse for low experiential avoiders). It should be noted that a number of these studies had relatively small sample sizes (primarily due to limited budgets), and that more research is needed to make more conclusive estimates of ACT's effects with these various populations. It should also be noted that a variety of single-subject, aggregated single-subject, and nonrandomized studies on ACT have also been published in peerÈ st (2008) for a meta-analysis of selected reviewed journals. See O ACT outcome studies, and Gaudiano (2009) for a reply to this meta-analysis.

Process research on ACT At least 46 experimental psychopathology and analogue component studies testing various aspects of the ACT model have been published in peer-reviewed journals (Hayes, 2005a). Typically, these studies compare the effects of one method of instantiating a single ACT process, such as defusion, acceptance, or (more broadly) mindfulness, on subject responses to aversive stimulation. For example, Masedo and Esteve (2007) investigated the effectiveness of acceptance versus suppression and spontaneous coping instructions during a cold pressor task (where subjects immerse their hands in ice cold water), and found that those in the acceptance condition reported increased pain tolerance and decreased pain ratings. While these 46 studies are of varying methodological quality, all lend support to various aspects of the ACT model. Additionally, at least 10 published, peer-reviewed ACT outcome studies have included formal 62


meditational analyses uniformly concluding that ACT-speci®c processes were responsible for a signi®cant amount of positive post-treatment client changes, with at least an additional 10 published studies using less formal meditational analyses reaching the same conclusion (Hayes, 2008b; see Baron & Kenny, 1986, for an independent discussion of meditational analysis). Finally, Hayes et al. (2006) provided a relatively recent printed review of ACT process and outcome evidence. Taken together with ACT's published outcome studies, the body of evidence supporting the ACT model and its general effectiveness is compelling, though ongoing research is of course required to achieve more conclusive answers. The number of process studies (20) uniformly suggesting that ACT-speci®c processes mediate treatment gains are perhaps particularly compelling, especially when compared to the number of published process studies indicating that cognitive restructuring failed to mediate positive posttreatment gains (see Longmore & Worrell, 2007, for a summary of these studies). This discrepancy appears to suggest that mindfulness-based approaches to problematic thoughts and feelings may well be more viable than logical/rational thoughtchange strategies.

ACT process and outcome measures Psychotherapeutic process measures attempt to assess changes in treatment-speci®c mechanisms of change, and can be used not only in meditational analysis as part of a psychotherapy outcome study, but also to aid the individual clinician in determining if she or he is successfully enacting treatment-speci®c processes with individual clients. The Acceptance and Action Questionnaire (AAQ; Hayes et al., 2004c), a 9-item self-report measure (a 16-item version exists as well), has typically been used to assess the client's degree of experiential avoidance. Interestingly, a variety of studies using the AAQ have found that higher degrees of experiential avoidance correlate with a great variety of psychological problems, including anxiety, depression, 63


substance abuse, and overall psychopathology (Hayes et al., 2004c), lending support to the ACT assumption that experiential avoidance is a key process involved with the production of psychological problems. Due to the AAQ's marginal reliability, a new, more reliable version has been developed (AAQ-II; Bond et al., 2010). Both versions of the AAQ are available on line (Hayes, 2009b). Population-speci®c instruments capable of assessing experiential avoidance and/or psychological ¯exibility exist as well (Hayes, 2009a). Several measures have been developed to assess values and values-consistent behaviour in an ACT-consistent manner. Wilson and DuFrene (2009) present the Valued Living Questionnaire II (VLQ-II), an apparent improvement on the original VLQ (Wilson, 2006; Wilson, Sandoz, Kitchens, & Roberts, 2010). Dahl, Plumb, Stewart, and Lundgren (2009) described the Bulls-Eye Values Survey, another self-report instrument currently being tested in validation studies internationally and also available online (Hayes, 2005d). Finally, Blackledge, Ciarrochi, and Bailey (Hayes, 2005c) developed the Personal Values Questionnaire I and II (PVQ-I, PVQ-II). Both versions are relatively lengthy self-report questionnaires probably more suitable to research, but provide a more comprehensive assessment of various issues related to values-consistent behaviour than other currently existing instruments.

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Part 2 THE DISTINCTIVE PRACTICAL FEATURES OF ACT

DISTINCTIVE PRACTICAL FEATURES OF ACT

15 Overview of ACT's therapeutic strategies We begin the second half of this volume by providing an overview of ACT's therapeutic strategies. Our aim is to introduce the reader to some of the de®ning practical features of ACT, which will be further illustrated in the subsequent sections. First, we show how ACT's therapeutic strategies map onto the six core processes outlined in Part 1. We then highlight the various formats that can be used when delivering ACT, and re-emphasize the process-driven nature of the ACT approach. ACT therapists utilize the following interrelated therapeutic strategies (adapted from Hayes, 2004b): 1 2 3 4 5 6

highlight the costs and ineffectiveness of experiential avoidance; establish psychological acceptance and defusion skills in order to break down the literal meaning of cognition and encourage full contact with dif®cult psychological content; distinguish a sense of self that is distinct from, and therefore not threatened by, dif®cult psychological content (selfas-context); promote contact with present-moment experience; help to clarify values as chosen life directions, and distinguish values from goals and actions; and build increasingly larger patterns of committed action that are linked to chosen values.

The ®rst therapeutic strategy listed aboveÐundermining experiential avoidanceÐis not explicitly stated within the model of psychological ¯exibility illustrated in Figure 1 (see p. 51), but it is a common starting point in ACT interventions. This strategy 67


is designed to contact the client's experience of the effects, costs, and ``workability'' of experiential control, and is described in more detail in Points 17 and 18. The remaining therapeutic strategies map directly onto the six core processes that promote psychological ¯exibility. When considering the practical features of ACT, it can be useful to conceptualize acceptance, defusion, self-as-context, and contact with the present moment as forming a larger set of mindfulness and acceptance skills, while contact with the present moment, self-as-context, values, and committed action together delineate values-based action skills (Hayes, 2004b). The overlap between these two skill sets is deliberate, and highlights the reciprocal and interrelated nature of ACT's processes. That is, targeting one process (such as defusion) activates other processes (such as acceptance, self-as-context, contact with the present moment). Indeed, in any particular session, an ACT therapist might be focusing on one or two core processes, or weaving a number of processes together in response to current client material (Luoma, Hayes, & Walser, 2007). ACT is often described as a mindfulness-based treatment approach, re¯ecting the importance afforded to mindfulness and acceptance processes in the hexa¯ex model. Hence, consistent with other mindfulness interventions (e.g. Baer, 2006; Kabat-Zinn, 1990; Segal et al., 2002), ACT seeks to alter the function of people's internal events (i.e. thoughts, feelings, memories, behavioural urges, and bodily sensations) without attempting to modify the content or frequency of those events. In other words, ACT, like other mindfulness interventions, changes how an individual relates or responds to his or her dif®cult psychological content. ACT differs from other mindfulness-based approaches, however, in that it cultivates mindfulness and acceptance skills in order to help clients pursue more vital, purposeful, and meaningful lives. This intimate link between mindfulness and values-based behavioural change processes lies at the very heart of ACT practice, and it will be highlighted throughout the following points. 68


Delivery format ACT can be structured and delivered in different ways according to the therapeutic context and presenting client problem. For example, ACT is often conducted over the more typical 10 or 12 treatment sessions, but it has also been successfully delivered in briefer formats outside of the traditional clinical context (e.g. workshops delivered in health, occupational, or educational settings). ACT interventions often occur in one of two basic formats (Luoma et al., 2007). The ®rst generally follows the sequence of therapeutic strategies listed above, and re¯ects the structure of many ACT texts (including this one). In the second format, formal values assessment and clari®cation occur at the beginning of therapy, and all other processes are then targeted in the context of enhancing a client's ability to pursue valued behavioural directions (see Dahl, Wilson, Luciano, & Hayes, 2005). In addition to these delivery variations, speci®c ACT techniques, metaphors, and experiential exercises vary in terms of how and when they are employed. For example, ACT includes structured mindfulness work, during which clients practice meditative exercises designed to promote contact with the present moment, defusion, and acceptance. However, mindfulness is also employed spontaneously by ACT therapists, such as when a client is asked to spend some time just sitting with a dif®cult thought or emotion that has shown up during a session (see Point 24). In sum, ACT is fundamentally a process-driven approach, in that ACT practitioners target and cultivate the six processes that promote psychological ¯exibility. As a result, ACT involves much more than the delivery of the various metaphors, interventions, and techniques that we describe over the following points. In particular, ACT requires a quite distinctive therapeutic stance that models and reinforces psychological ¯exibility, along with a therapeutic relationship that is equal, compassionate, and connected (see Point 30). It is therefore 69


considered essential that ACT practitioners develop not only a broad and ¯exible repertoire of ACT-consistent techniques, but also an experiential and personal understanding of psychological ¯exibility (Strosahl, Hayes, Wilson, & Gifford, 2004).

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16 ACT-based case conceptualization Several lengthy published examples of ACT-based case conceptualization are available, including a book-length treatment by Bach and Moran (2008), and chapters by Luoma et al. (2007) and Wilson and DuFrene (2009). Case conceptualization in ACT differs from more conventional methods where determination of the presence or absence of ICD-10 or DSM-IV diagnostic symptoms is the primary goal. While identi®cation of diagnostic symptoms (which essentially equate to problematic thoughts, emotions, and other behaviours) is important, behavioural approaches to psychotherapy view the identi®cation of these problematic behaviours as merely the ®rst step. From a behavioural (and an ACT-based) perspective, it is also necessary to determine what functions problematic behaviours serve in order to effectively change them. Behaviours that function to avoid distressing experiences comprise one critical functional class that must be assessed in ACT. A wide variety of behaviours can occur with the intent of dampening or eliminating distress, and these topographically different behaviours form the basis of separate psychological disorders (e.g. people with obsessive-compulsive disorder may engage in a variety of rituals to avoid distress; people with substance abuse disorders use drugs to avoid distress; people with anxiety disorders attempt to avoid situations that induce anxiety; and so on). However, from an ACT perspective, these different behaviours are treated as functionally equivalent if their shared goals include experiential avoidance. From a therapeutic perspective, once a variety of different behaviours are identi®ed as a member of this functional class, they can be treated in virtually the same ways. If, for example, the client 71


identi®es several avoidant behaviours as ineffective and hampering values-consistent action, the same set of mindfulnessbased strategies (mindfulness being the opposite of experiential avoidance) could potentially be brought to bear on any of them, regardless of what separate diagnostic categories the behaviours represent. Though topographically different, they are functionally equivalent. They are all instances of experiential avoidance, and thus the same interventions can theoretically be used with all of them. Assessment of experientially avoidant behaviours occurs in full force during the creative hopelessness portions of ACT (see Point 18), though it is often revisited throughout the course of therapy. From this perspective, it may come as no surprise that the great variety of values-consistent behaviours one could engage in could be said to comprise a functional class of their own. Wilson and DuFrene (2009) encourage clients to develop a whole ``menu'' of values-consistent behaviours, large and small, which they can choose to engage in from moment to moment. For example, a father who valued being a supportive, loving, caring, and actively engaged parent to his young daughter could ®nd a variety of different ways to enact this value: striving to be in the moment when with her, listening to her talk about her day, teaching her to do a variety of things, playing together, watching television together, praising her when she behaves appropriately, telling her `Ì love you'', and so on. Topographically, these behaviours look different, but functionally they all serve to impart increased meaning, purpose, and vitality into the father's life by demonstrating the support, love, care, and active engagement of this particular value. Thinking of this wide variety of different behaviours as functionally similar and ultimately guided by the parameters of the underlying value can help clients more effectively improvise behaviours that are consistent with the underlying values but not previously considered. And having clearly delineated ``classes'' of values and corresponding behaviours provides explicit benchmarks to help therapist and client determine when and 72


if speci®c means of experiential avoidance are hampering values-consistent living. Wilson and DuFrene (2009, pp. 149±196) described an ACT conceptualization scheme that focuses on the speci®c sub-processes that make up ACT's mindfulness and change components: acceptance, contact with the present moment, cognitive defusion, self-as-context, values, and commitment. The approach (the Hexa¯ex Functional Dimensional Experiential Interview, or HFDEI) appears well-suited to focusing a therapist's attention on the speci®c ACT processes thought to produce change. The HFDEI provides behaviourally speci®c anchors that allow the therapist to provide a Likert rating indicating how well or poorly the client embodied each process. For example, a client who reported avoiding many experiences, who frequently attempted to change his or her thoughts or feelings in session, and who made frequent implicit and explicit requests for reassurance from the therapist during the assessment interview might receive a score of one in the acceptance domain, indicating very low rates of acceptance. Conversely, a client who shifted his or her attention easily and gently, who demonstrated little or no rumination or worry, and who readily provided rich detail when describing experiences during the interview would rate quite highly in the present-moment domain. The HFDEI also prompts the therapist to provide speci®c examples of various behaviours qualifying the client for ratings received on each of the six process domains. For example, a therapist rating a client high on cognitive fusion might note that there were several times during the interview where the client dwelled heavily and seriously on a past divorce and the dramatic effect it continues to have on his or her life, indicating high degrees of fusion with thoughts about this historical event. A therapist rating a client low in the commitment domain might note that the client reported a series of false starts in important areas of her or his life, along with several instances where she or he spoke about longstanding plans that she or he had yet to put into action. 73


The variety of the HFDEI's behavioural anchors for each process do much to operationalize concepts (e.g. self-ascontext, cognitive fusion) that can appear quite vague or abstract to those who do not yet have a working familiarity with them. Overall, the instrument helps the therapist tentatively determine which ACT components or processes will need greater or lesser degrees of enaction with each particular client. A client with a high degree of values clarity, for example, will likely need little values clari®cation over the course of therapy, while a client with a rigid sense of self-as-content might well bene®t from more concentrated and expanded doses of self-ascontext work. In summary, the HFDEI (available online: Sandoz, 2007) appears to do much in providing an ACTconsistent functional assessment system that culminates in a case conceptualization that directly and explicitly informs what the therapist will very likely need to do with each client.

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17 Examining the workability of the control/ avoidance agenda The initial assessment process helps the ACT therapist understand what the client wants and expects from therapy. Client expectations often consist of a mixture of ``process'' goals (e.g. the removal or reduction of dif®cult thoughts and emotions) and `òutcome'' goals (e.g. re-engagement with valued life roles and activities). From the outset, ACT therapists look out for information concerning the form and extent of the client's experiential avoidance repertoire. As the initial conversations unfold, the therapist explores the client's avoidance/control strategies in more detail, and begins contacting the client's experience of how these strategies have worked. This phase of ACT has two concurrent aims. First, the therapist is seeking to ``draw out'' the client's experiential avoidance/control system. This requires a collaborative exploration of the various methods the client has employed in an attempt to solve or manage the problem(s) being presented. For example, an ACT therapist might begin this process by asking an anxious client what he or she typically does when experiencing anxiety, and generating a list of strategies the client has employed in the service of managing anxiety. A second aim is to examine the client's experiences of the workability (or utility) of previous or ongoing attempts to reduce psychological and emotional suffering. In ACT, workability refers to the extent to which an action or coping strategy moves the client in a valuedlife direction (Twohig & Hayes, 2008). The following extract illustrates an example of this phase of ACT. The client in this example is a mother in her forties, who 75


has been discussing dif®culties with worry and anxiety, particularly concerning the safety of her two children. Therapist: What I'm hearing is that you are looking for something to help you deal with this worry and stress? Client: That's the problem. I'm a terrible worrier, always have been. But it has become worse now with the kids. I know that mums are supposed to worry about their kids, but I seem to be much worse than most people. That's why I felt it was time I got some proper help. Therapist: Human minds do love a good worry. My mind's the same, so we may well be ®nding ourselves in the same boat. Client: Really? I'm glad it's not just me. Therapist: So, I'm interested in the sorts of things you have already tried to deal with it. Client: Oh God, where do I start? Therapist: Perhaps you could give me some examples? Client: Well, I tell myself the way I worry about them is just stupid and is making me stressed and ill. I do try to be rational about it, you know, like telling myself that the things I worry about probably won't happen . . . like the kids being kidnapped or being in an accident or something. Therapist: Right. So your mind tells you that worrying is stupid, and tries to rationalize what's going on. Client: I guess so. I just try to get it in some sort of perspective. I know worrying about the kids isn't going to keep them safe. Therapist: What do you hope will happen from talking yourself out of it or rationalizing with the worries? Client: Well, I suppose I'm hoping for a bit of peace from the constant fear of things going wrong. I 76


need a way of dealing with all this stuff in my head so that I don't keep getting so worked up about things. Therapist: And how does this rationalizing, this trying to get it in perspective, work for you? I mean, do you ®nd that it actually helps you deal with your worry? Client: It does sometimes, at least until the next episode. Therapist: So, talking yourself out of worrying helps sometimes, but maybe only for a while. How about over a longer time period? Has this reduced the extent to which you worry about things? Client: I guess not. As Julie and Robert [the client's children] have gotten older it's been getting worse. ACT assesses workability against two criteria. First, clients are asked to consider the extent to which particular coping strategies have led to a change or reduction in undesirable internal events (such as negatively evaluated thoughts, selfevaluations, memories, emotions, physical sensations, and so on). This is assessed over the short and long term to address the fact that avoidance strategies (e.g. thought suppression or situational avoidance) may give short-term relief from unwanted thoughts and feelings while producing few life bene®ts over the longer term. Workability is also examined in terms of the client's quality of life. The ACT therapist listens out for activities or areas of life that are valued by the client, but which may have been abandoned or neglected as a result of the presenting problem and/or experiential avoidance. Such information can often be elicited by simply asking how the client's life has changed as a result of current dif®culties. The therapist maintains a non-judgemental and curious posture when enquiring about the workability of the client's previous coping attempts. The intention is to understand the 77


form and function of the client's problem-solving strategies, while remaining open and neutral as to whether those strategies have been useful or not. Such a posture is crucial in this work as clients may become defensive (or alternatively self-blaming) if they sense that well-established coping efforts or safety behaviours are being undermined, particularly during the early stages of therapy (Eifert & Forsyth, 2005). To ensure the appropriate posture, an ACT therapist continually encourages clients to look to their own experience when evaluating problem-solving strategies (e.g. `Ànd how has that worked for you?''). At no point is the ACT therapist trying to insinuate or persuade clients that they have been using ineffective coping methods. Rather, the ACT approach seeks to validate the client's experience, and assist the client in making experiential contact with the purpose and utility of control/avoidance attempts.

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18 Creative hopelessness The ACT therapist is focused on gradually revealing the client's existing change agenda. Usually, this agenda is naturally revealed by asking three key questions: 1 2 3

What do you want from therapy? What have you previously tried? How has that worked?

From an ACT perspective, the agenda fuelling most clients' internal struggles can be stated along the following lines: Reducing or removing undesirable thoughts and feelings will solve the problem and lead to a more successful life. In other words, the problem is construed as one of troublesome content (i.e. too many unpleasant thoughts and feelings). It is this potentially unworkable (yet culturally endorsed) change agenda that ACT seeks to highlight and confront. In ACT, the term creative hopelessness refers to the process of letting go of an unworkable experiential control agenda to create some space for trying an alternative approach. Hayes et al. (1999) described this process as follows: ``Clearing away the old system is, in part, a process of confrontation, but the confrontation is not between the therapist and client. Rather, it is between the client's change agenda and the client's experience of the workability of that system'' (p. 99). Part of this process is illustrated in the following extract, which involves the same anxious client. Here the therapist validates and normalizes the client's efforts to manage her worry, and uses the client's own experience to begin dragging the underlying agendaÐthat one should be able to control unwanted thoughts and feelingsÐinto the spotlight: 79


Therapist: It seems that you've already tried a number of sensible strategies to get a handle on your worry. This list we've created includes talking yourself out of it, getting it in perspective, seeking reassurance from Simon and the kids, relaxation exercises, shopping, and avoiding the other mums. But I'm hearing that most of these strategies haven't really paid off for you in the way you would like. I'm sensing that you've reached a useful point where you could step back a bit and ask yourself this: Have all my efforts so far reduced the worry and stress, or helped me build a more satisfying and ful®lling life? Client: Well, my answer to that would be ``no''. That's why I ended up coming to see you. Therapist: And here we are. There's something strange in all this though, don't you think? I mean all the strategies you've used to tackle worry and stress seem reasonable, and I sense that you've done what you can to deal with it. But it seems as if you're still waiting for those desired effectsÐless worry, less stress, your old life back . . . Client: But there must be something in there that helps? Therapist: Forgive me for responding to that with another question, but has your mind raised that question before? Client: I suppose it must have; probably many times. It's become such a problem I'm always wondering what I should do to sort it out, whether I can even sort it out. Therapist: So your mind continues to search for something that will help sort it out, wondering what might work. The question is the same as beforeÐhas the search produced the goods? 80


An intervention commonly used during this phase of ACT is the Person in the Hole metaphor (adapted from Hayes et al., 1999, pp. 101±104): Therapist: Imagine for a moment that life is like wandering around a ®eld full of holes. At some point, and for whatever reason, imagine that you fell down this one hole that we shall label `ànxiety''. You reach into the bag of tools that you've been given during your lifetime and all you ®nd is a shovel. At ®rst glance, that seems perfectly reasonable, so you don't think twice about it. I mean, hole/shovelÐit sort of makes sense doesn't it? So, you get to work digging. You spend plenty of time and effort trying to dig yourself out of this hole because it seems the only thing to do to get your life back on track. So, you've tried talking yourself out of your worry (dig), you've sought reassurance from your kids that they will always be safe (dig), you've avoided the other mums (dig), and so on. The problem is, because these things involve trying to dig your way out, the anxiety hole just becomes larger and deeper . . . Client: That's what it feels like sometimes, like I've fallen down a deep hole and I can't ®nd my way out. Therapist: There it is. So, maybe part of the problem stems from what shovels are for. When we have a shovel in our hands the only thing to do is dig, dig, dig. But what if digging is not the best move when wanting out of an anxiety hole? Client: So, what are you saying I should do? Climb out of my hole? How the hell do I do that? Therapist: Right now, I don't have a simple answer to that. But a useful starting place would be noticing 81


when and how you dig. What I mean by that is noticing any parts of your struggle with worry and stress that get you nowhere or even seem to dig you in deeper. This metaphor and dialogue are designed to communicate the following key messages:

· ·

The problem does not stem from the client's lack of effort. The problem may instead reside within a change agenda that supports futile struggle with undesirable psychological content.

The aim here is not to persuade the client that experiential control is unworkable, but instead to facilitate a confrontation between what the client's mind says should work to solve the problem, and the client's more direct experience of workability. The fact that the client is in therapy itself highlights that something is not working, and is therefore a powerful ally during this process. A desired outcome of this phase of ACT is for clients to begin noticing the relationship between internal struggle and unworkability (Twohig & Hayes, 2008). This work is supported by early homework assignments (such as daily diaries) designed to help clients become more aware of the form and frequency of internal struggle, the underlying purpose of that struggle, and any costs and bene®ts associated with the struggle. Such selfmonitoring exercises help clients notice the considerable effort that can be lavished upon internal control attempts, despite the absence of any signi®cant life bene®ts.

Creative hopelessness is not a feeling When ®rst encountering ACT, it may seem strange to see the term ``hopelessness'' being used to describe a desirable therapeutic process. However, creative hopelessness should not be 82


confused with the feeling of hopelessness that has received much attention in the wider clinical literature. Instead, creative hopelessness refers to the action of letting go of behaviours or strategies that have not worked in the client's experience (Luoma et al., 2007; Zettle, 2004). It should always be emphasized that it is the experiential control agenda that is being viewed as hopeless, not the client (Hayes et al., 1999). This process is creative because it helps to loosen a client's grip on the control/avoidance agenda, therefore opening up the possibility of trying something different. Creative hopelessness interventions tend to vary in duration and frequency. Some clients are less attached to experiential control, and the control agenda can be undermined relatively quickly and ef®ciently. For other clients, such as those with multiple problems or extensive histories of experiential avoidance, the creative hopelessness process may need more time (Luoma et al., 2007). For some client groups, such as those at risk of suicide, the creative hopelessness process may need to be adjusted and tailored accordingly (see, for example, Varra & Follette, 2004; Zettle, 2007). Clients often experience and express confusion in response to creative hopelessness interventions. Far from being a problem, confusion is taken as a positive sign in ACT that the control agenda is being successfully undermined. As Twohig and Hayes (2008) note, confusion is often the ``gateway'' through which the mind begins to open up to other, as yet unknown, possibilities. ACT clients might also respond to this process with curiosity, resignation, calmness, and even hope (Eifert & Forsyth, 2005; Luoma et al., 2007). It is not uncommon for a sense of relief or lightness to enter the room during or following this work, as the burden of an unwinnable struggle begins to lift from a client's shoulders.

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19 Control is the problem, not the solution The control-oriented change agenda is slowly being revealed as part of the problem. Initially, the ACT therapist conducts this work in a gradual and indirect way, helping the client examine workability within her or his own experience. As things progress, the control agenda is placed more ®rmly on the table and undermined more explicitly. This feature of ACT often includes the following therapeutic strategies:

· · ·

Collaboratively naming the control agenda. Normalizing and validating the client's attempts to control private events. Highlighting the futility and paradox of experiential control.

A useful strategy at this stage of ACT is to organize the client's problem-solving or coping strategies into one functional (experiential avoidance) class (Twohig & Hayes, 2008). The workability of that entire class can then be questioned (Hayes et al., 1999). In the following example (still with the same client), the therapist initiates this process by revisiting the purpose underpinning the client's attempts to deal with the presenting problem: Therapist: Last time we spent a bit of time looking at all the speci®c things you've tried to deal with your worry and anxiety. One way to sort of summarize what's going on here is to take a look at the broader purpose lurking there in the 85


background. What have you been most hoping for in all this? Client: Well obviously I want my kids to be safe. That's the priority. But for myself I've been trying to deal with all this awful stuff going around inside my head, and to stop getting so anxious all the time. I'm just so exhausted with it. And, if I'm honest, I want to stop pestering Simon and the kids about being safe. I know it irritates them and that makes me feel horrible, but at the same time I can't stop myself. Therapist: OK, I think we have something here. The purpose is something like getting control over what's going on in your mind and inside your skin, so that you can change how you are with your loved ones? Client: It's interesting that you use the word control. I think it probably does boil down to that in the end. I used to feel much more in control than I am now. Now it's like I've lost control and it's gotten the better of me. Here the therapist is working with the client to give form to, and label, the underlying control/avoidance agenda. The agenda itself is then more rigorously undermined with constant reference to the client's personal experience. To facilitate this process, ACT includes various metaphors and interventions designed to illustrate the fundamental unworkability of the control/avoidance system within which humans so often become stuck.

Thought suppression exercise A brief thought suppression exercise provides a useful experiential demonstration of the paradoxical effects of the control agenda. Such exercises are particularly helpful with clients who 86


are struggling with ruminative or intrusive cognitions. Clients are asked to close their eyes and to try hard not to think of a particular object (e.g. ``Don't think about . . . a banana''). During the exercise the therapist interjects with things like: ``Don't think about a banana's yellow skin''; ``Don't think about how you peel the skin off a banana''; ``Certainly don't think about eating a banana''; and so on (see Hayes et al., 1999, pp. 124±125). The exercise helps to illustrate that trying not to think about something rarely leads to the elimination of that thought, as well as the effort required by cognitive control attempts.

Polygraph metaphor The futility of emotional control is often illustrated with the Polygraph metaphor (Hayes et al., 1999, p. 123): Therapist: Imagine that I have you hooked up to the world's most sensitive polygraph machine [a cartoon picture of a polygraph is shown]. This machine indicates even the smallest change in your internal stateÐany change in mood, any sign of anxiety. Now, all I need you to do is stay calm. Don't get anxious. That's your task. To make sure you do what I ask, I have a gun pointing at your head. If I see any slight change in your internal state, any sign of anxiety, I will shoot you. OK? . . . What do you think would happen in this scenario? Client: I de®nitely wouldn't be able to stay calm. You'd see that on the machine and you'd shoot me. Therapist: Right. I don't know anyone who wouldn't get anxious in this situation. When it's really important not to experience anxiety, you'd notice even the faintest signs of anxiety, become anxious about that, and it's all over! 87


The polygraph metaphor illuminates the important distinction between applying control inside and outside of the skin. For example, the client can be asked if the outcome would be any different if the task were ``clean my house or I will shoot you'', instead of ``stay calm or I will shoot you'' (Hayes et al., 1999). The inside the skin/outside the skin distinction also helps to validate and normalize the client's use of experiential control. The message being conveyed is that humans have a natural tendency towards experiential control because (a) control works so well outside of the skin, and (b) our social-cultural conditioning seems to suggest that experiential control is the route to a healthy and successful life (Luoma et al., 2007). To support this work, ACT therapists highlight features of our social-cultural conditioning that tend to reinforce experiential avoidance. For example, it can be noted that as children we may have often been told not to be angry/afraid/ sad, so that we receive the message that it is not OK to experience anger/fear/sadness, and that dif®cult private events can (and perhaps should) be eliminated at will (Hayes et al., 1999). This type of psychoeducative dialogue helps to validate and normalize the client's dif®culties by placing them in a wider context. To summarize, the work described in Points 17, 18, and 19 helps to reveal and undermine the workability of the experiential avoidance agenda. Once clients are beginning to show signs of reduced attachment to experiential control, the alternative can be introduced.

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20 Introducing willingness as the alternative to control In ACT, being willing involves making full and undefended contact with one's present-moment experience while pursuing valued behavioural directions (Luoma et al., 2007). Hence, acceptance, willingness, and values-based action are intimately related therapeutic processes, and willingness is always cultivated within the context of helping the client pursue lifeenhancing behaviour. When ®rst introducing willingness as the alternative to experiential control, the ACT therapist seeks to convey the following messages:

· · · ·

Psychological discomfort combined with unwillingness leads to suffering. Willingness involves actively letting go of an unworkable control agenda. Willingness does not mean wanting or liking. Willingness is a choice that one makes repeatedly.

To re¯ect the fact that willingness does not seem the natural or logical thing to do, ACT employs various metaphors to highlight the costs of unwillingness, and raise the possibility of letting go of unwinnable struggles with undesirable private events. In this point we outline three of ACT's willingness metaphors: Two Scales; Tug-of-War with a Monster; and Clean vs. Dirty Discomfort.

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Two Scales metaphor The Two Scales metaphor (Hayes et al., 1999) promotes willingness as a viable alternative to control by illustrating the relations between experiential control, willingness, and distress. In this piece, the metaphor is being introduced alongside a picture of two numerical sliding scales: Therapist: One way of looking at your experience with anxiety is by using this scale, which ranges from 0 to 10 [therapist shows picture of the scale]; 0 equals no anxiety and 10 equals overwhelming anxiety. Where would you say your anxiety has been over the last couple of months? Client: I'd say that on occasion it has been around 7 to 10. Sometimes it drops down to, say, 5 but I'm usually fretting about something. Therapist: OK, so your anxiety scale is generally up here at the higher end. Now imagine that there is another scale that we have only just started looking at that's been hiding in the background [therapist reveals picture of a second scale]. You can see that this scale is labelled ``Willingness''. It re¯ects how willing you have been to experience the various components of your anxietyÐ the worries about your kids, the feelings of panic you've had at work, and so on. This is a very important scale because it is actually the one that you are in control of. You have been struggling with your anxiety, and yet that anxiety scale has remained quite high. The fact that you've been trying hard to control your anxiety suggests that your willingness to experience anxiety scale may have been low. I think that you may have been experiencing this particular combinationÐhigh anxiety and low willingness. But, as with our 90


polygraph machine, if it is really important not to experience anxiety, then the anxiety itself can become even more of a problem in your life. Client: I'm not so sure what you're getting at. You're saying that if I just learn to put up with it then I won't be so anxious? Therapist: I know this might sound a bit odd at the moment, but can you see the trap lurking in what you just said? If you're only willing to experience anxiety in order to get rid of anxiety then you are back to being unwilling again. Client: So, what will happen if I am willing to live with this? Won't it just get worse, and be with me forever more? Therapist: Hard to say at this stage. When we choose to increase our willingness scale, then the anxiety scale is at least free to move. So, sometimes anxiety is high, sometimes low. Actually, during these sessions, I'd like us to look at something that is much more important than whether your anxiety level is high or low. I'm most interested in those areas of your life where you feel anxiety is getting in the way of you living the kind of life you want to live. A couple of points about this excerpt are worth noting. First, towards the end of this example, notice how the therapist shifts emphasis to the quality of the client's life. This highlights the fundamental nature of willingness, which should be thought of not as a feeling, but as the action of letting go of an internal struggle that has probably produced few bene®ts in the client's life (Eifert & Forsyth, 2005). Second, notice that the client initially thinks the therapist is suggesting mere toleration of anxiety. This misinterpretation is not uncommon when the concepts of acceptance and willingness are ®rst introduced. Typically, the nature of acceptance and willingness will become 91


clearer once the client has engaged with some of the experiential exercises that we shall discuss shortly. Suf®ce to say at this stage that ACT promotes an active form of acceptance that is ultimately in the service of helping the client move toward valued life goals, and is therefore distinct from passive tolerance or resignation (Eifert & Forsyth, 2005; Luoma et al., 2007).

Tug-of-War with a Monster metaphor The notion of letting go of the struggle with unwanted thoughts and feelings is often played out with a Tug-of-War with a Monster metaphor (Hayes et al., 1999, p. 109). When introducing this scenario (particularly in ACT groups), the ACT therapist might physically act out a tug-of-war with the client (the therapist assumes the role of the monster). Such activities can inject some humour into the process, as well as illustrate experientially the considerable effort and costs involved in trying to control unwanted thoughts and feelings (Eifert & Forsyth, 2005). This metaphor proceeds as follows. The client is viewed as being in a tug-of-war with a large and apparently deadly monster, which represents whatever the client has been struggling with (e.g. anxiety, depression, pain, urge to use drugs, disturbing thoughts, feelings of panic, etc.). Between the monster and the client stands a bottomless pit; it seems as if the monster is trying to pull the client into the pit, and vice versa. The move in ACT is not to help the client pull the monster into the pit, but to encourage the client to let go of the rope. This versatile metaphor also illustrates the link between struggling with unwanted private events and the ability to pursue valued life goals. For example, when physically performing the tug-of-war, the therapist can point out the dif®culty of fully participating in valued life activities (e.g. being a supportive spouse or parent) while both hands and considerable attention are focused on struggling with the monster (Eifert & Forsyth, 2005). 92


Clean vs. Dirty Discomfort metaphor The costs of unwillingness can also be communicated by drawing a distinction between ``Clean'' and ``Dirty'' discomfort (Hayes et al., 1999, p. 136). Clean discomfort represents dif®cult thoughts, feelings, and physical sensations when they ®rst show upÐperfectly normal and adaptive human responses. Clean discomfort is transformed into the more pernicious dirty discomfort only by struggling with or trying to avoid the initial discomfort. In this way, clients may create secondary anxiety about anxiety, depression about depression, worry about worry, guilt about depression, and so on. The message being conveyed in ACT is that even the most undesirable thoughts and feelings are not necessarily toxic to human health. Rather, from an ACT perspective, it is initial (clean) discomfort + unwillingness and struggle that lead to suffering (Bond & Hayes, 2002; Hayes et al., 1999; Robinson, Gregg, Dahl, & Lundgren, 2004).

Willingness is not wanting Willingness to experience dif®cult private events does not mean that clients must learn to like or want those events. Instead, willingness involves choosing to experience what is already there to be experienced. A useful ACT metaphor is that of inviting an annoying neighbour to an open house-warming party (Orsillo, Roemer, Block-Lerner, LeJeune, & Herbert, 2004; a variation of the Joe the Bum metaphor described by Hayes et al., 1999). In this metaphor, the client has invited all of his neighbours to a house-warming party only for a very annoying neighbour to show up. The client has choicesÐhe can choose to stand guard at the front door in an attempt to ensure that the annoying neighbour does not gain entry (therefore missing his own party); he can open the door and then follow the neighbour around to make sure the neighbour stays only in certain rooms (still not being the greatest host); or he can 93


choose to practice willingness by actively welcoming in the annoying neighbour and participating in the party. To summarize, the concept of willingness is introduced in ACT as the alternative to internal control, avoidance, and struggle. Willingness is a core skill that is practised throughout ACT, and which is cultivated within the context of each of ACT's six core processes (Luoma et al., 2007). It is important to emphasize that willingness is not a one-off event; it is likely that clients will be repeatedly pulled back into the control and struggle agenda during the course of therapy. Rather than being viewed as a setback, such moments provide further opportunities for clients to notice the struggle and ``drop the rope'' (Zettle, 2007). When willingness is ®rst introduced, the aim is not for the client to fully comprehend the nature of what is being proposed, but to create the space and rationale for the acceptance, defusion, mindfulness, and values work that follows.

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21 Promoting active acceptance At the same time as encouraging clients to let go of an unworkable change agenda (i.e. by undermining experiential avoidance), ACT therapists cultivate their clients' acceptance skills and behaviours. In this way, experiential control is viewed as a behavioural excess that needs to be weakened, and acceptance as a behavioural de®cit that simultaneously needs to be strengthened (Zettle, 2007). The Quicksand metaphor (Hayes et al., 1999) illustrates willingness and acceptance as an active process of embracing experiences that may have previously been avoided. This metaphor is particularly useful for introducing acceptance work, because many clients have at some point heard the message that struggling in quicksand is counterproductive. Surviving quicksand requires ®rst letting go of the strong urge to ®ght and struggle, and then spreading out to maximize contact with the surface in order to stay a¯oat (see Luoma et al., 2007, pp. 37± 38). These same two behavioural moves exemplify the active acceptance of unwanted private events. In order to build clients' acceptance skills, ACT therapists employ various experiential strategies that foster undefended present-moment contact with dif®cult private events (Strosahl et al., 2004). The acceptance interventions discussed in this point focus primarily on increasing clients' willingness to experience undesirable emotions and bodily sensations, while the defusion work discussed in Points 22 and 23 aims to reduce excessive entanglement with the literal content of unwanted cognitions. However, acceptance and defusion are functionally related processes (defused thoughts are easier to accept), and the interventions described here can be easily extended to 95


incorporate cognitive content and hence promote defusion (Zettle, 2007).

Physicalizing exercise The physicalizing exercise, which has been adopted from Gestalt therapy, makes use of the distance that exists between an observer and physical objects (Hayes et al., 1999). During the exercise, a client is asked to relate to a dif®cult emotion or sensation as if it were an object that has been placed temporarily outside of the skin. To prepare for the exercise, the client is asked to close her or his eyes, bring present-moment awareness to body sensations, and then connect to a recent or ongoing situation or event that is associated with unwanted emotion. The following extract begins a short way into a physicalizing exercise involving a client who had been struggling with a strong feeling of anger towards an estranged sister: Therapist: And as you allow yourself to think about this situation with your sister, do you notice the angry feeling arise? Client: It's always right there, as soon as I think about Marion. [The therapist asks the client to notice whereabouts in the body she feels this emotion, and if she would be willing to just sit with that feeling for a few moments. The therapist then continues with the following instructions] Therapist: Good. Now, if you're willing to, I'd like you to step back a bit and take a close look at this feeling. To do this, imagine you've popped the anger feeling out of you, just for a moment. Imagine that it's out there on the ¯oor, a foot or so in front of you. 96


Client: OK. Therapist: If this anger were a physical object, what would it look like? Client: It's like a burning red ball, spinning fast and out of control. Therapist: Sounds like you've really got it out there. How big is it? Client: I don't know, it looks like it might be getting bigger. It's about the size of a football. Therapist: Nice. What sort of texture does it have? Client: It's ®zzing and buzzing. A ball of ®ery energy. Looks like it would be hot to the touch. Therapist: And what does it feel like when you get it out there like this? Client: I don't know. It's not pleasant. I don't want to feel this way anymore because it stops me forgiving my sister. Out there it doesn't look so bad. Therapist: OK. Now take another close look at your anger. Is it the same or has it changed in any way? Clients can be asked to describe a wide range of physical properties during this exercise, including size, shape, weight, colour, texture, power, and speed. Once an initial emotion has been described in this way, clients are asked to notice any strong reaction or response (e.g. fear, distaste, or resistance) to that emotion. If a reaction is noticed, the client is asked to place this reaction outside of the skin, next to the original emotion object, and to describe its physical properties in the same way as before. This secondary reaction essentially represents the perspective, or context, from which the client is viewing the ®rst emotion (e.g. as something to be feared or avoided). The client can then be asked to go back to the ®rst object to see if it has changed in any way. At the end of the exercise, the therapist asks the client to ``welcome back'' the physicalized emotion(s) inside the skin. This ®nal move encourages the client to adopt 97


an accepting posture toward the private experiences that have been described. Following a physicalizing exercise, clients will sometimes report a reduction in the size or power of an unpleasant emotion. However, ACT therapists never suggest this is the purpose or expectation of the exercise (Hayes et al., 1999). Rather, the aim is for clients to make undefended contact with emotions that have previously been avoided, while at the same time cultivating some healthy psychological distance between the person experiencing the emotion and the emotion itself. As well as promoting acceptance and willingness, this type of intervention raises contact with the self-as-context (see Point 25), and facilitates defusion by objectifying psychological content (see Point 23).

Just sitting with difficult emotion Dif®cult emotion that shows up during the session provides an excellent opportunity for practising and developing acceptance skills. Possible cues that a client is avoiding dif®cult emotion include a sudden change in topic or tone of the conversation, increased bodily tension, shifting uncomfortably in the chair, aggression towards the therapist, or repetitive forms of thinking and speaking (Luoma et al., 2007; Pierson & Hayes, 2007). At such moments, ACT therapists seek to slow things down and help the client to ``just sit'' with the dif®cult experiences showing up in that particular moment. The client in the following example had been showing signs of avoiding the strong feelings associated with the break-up of a long-term relationship: Therapist: I'm sensing that this is bringing up some dif®cult stuff for you Sophie. To be honest, some discomfort is showing up for me right now as well as we progress through this. So, let's slow things down for a moment in order to really notice 98


what's showing up. Would you be willing to close your eyes for a moment or two? [both client and therapist close their eyes]. Take a moment to notice the sensations in your body as you sit there in the chair; notice what sensations you have in your hands right now; notice the sensations in your feet pressing against the ¯oor; just get a real strong sense of your entire body in this moment . . . Now, see if you can notice what feelings or sensations are showing up for you as we talk about Aaron. What are you noticing? Client: [crying] I just feel so humiliated by the way he treated me. Therapist: OK. Take your time with this Sophie. Could you allow yourself to notice this feeling of humiliation for a moment or two here in this room? Where in your body are you feeling it? Client: Umm . . . there's a heavy sort of sour feeling right in the pit of my stomach. It actually hurts, like a stabbing pain. Therapist: OK. Stay with it a little bit more. Spend a couple of moments just noticing that feeling. There's no need to do anything with it. Could you open up a bit to the feeling so that you can really notice it? See if you can be willing to just sit here with that feeling without struggling with it . . . . In the same way, clients can be asked to notice other private events being experienced in the moment, such as thoughts, memories, evaluations, behavioural urges, or changes in bodily sensation. These experiential pauses can be quite brief (e.g. a couple of minutes), or extended into more lengthy mindfulness exercises designed to increase present-moment awareness (see Point 24). The goal is to provide clients with frequent opportunities to practise being fully present with dif®cult private events without trying to change their form or frequency. 99


Tin-Can-Monster exercise Another core acceptance/willingness intervention is known as the Tin-Can-Monster exercise (Hayes et al., 1999). In this experiential exercise, the ACT therapist helps the client to make prolonged contact with a variety of undesirable thoughts, sensations, feelings, and memories in a context where it is OK to have those experiences (Twohig & Hayes, 2008). The exercise title re¯ects the practice of breaking up a psychological dif®culty (such as anxiety) in order to increase willingness to experience each of its individual elements (i.e. the various thoughts, emotions, and physical sensations that constitute anxiety). The exercise is introduced as follows (adapted from Hayes et al., 1999): Therapist: Facing up to anxiety can be a bit like facing a giant tin-can-monster. The monster looks pretty scary when it is standing there, 30 feet tall, and you may feel you have no choice but to spend time and energy ®ghting with it to prevent it from overwhelming you. However, when you break up the monster into its different partsÐ old rusty cans, bits of string, and wireÐit tends to appear much less threatening. When it is broken up into its different parts, it can be much easier to let go of the constant struggle so that you can get on with building a life that you value. The therapist then asks the client to think about a dif®cult situation or event in order to elicit undesirable bodily sensations, feelings, behavioural urges, and thoughts. The client is encouraged to be open to, notice, and describe each of these domains in turn, and to spend some time actively letting go of any resistance or struggle with each experience. The client is by no means passive during this process, but is instead answering 100


the therapist's requests to brie¯y describe each experience. The therapist models acceptance throughout the exercise, by adopting a genuine stance of non-judgemental curiosity towards all of the private events described by the client. This stance conveys the message that there is no need to escape from, reduce, or change any of the experiences elicited by the exercise (see Hayes at al., 1999, pp. 171±174, and Twohig & Hayes, 2008, pp. 115± 132, for more detailed illustrations of this intervention). The use of imaginal exposure in the Tin-Can-Monster exercise makes it a useful supplement to the more direct exposure that is a feature of ACT's values work (Varra & Follette, 2004). Because of its length and wide remit, the exercise has the potential to cultivate a number of ACT's interrelated processes. As a result, it may not be introduced until the later stages of ACT, once clients have had the opportunity to develop a strong enough base of defusion, acceptance, and mindfulness skills.

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22 Cognitive defusion I: Altering language conventions ACT assists clients in defusing from cognitive content that functions as a barrier to pursuing valued behavioural directions. Defusion can be applied to various verbal relations including automatic thoughts, self-conceptualizations, reason giving, and even more elaborate material such as the client's life story. ACT includes an impressive array of metaphors, experiential exercises, and language conventions that promote defusion. In this point, we focus on how ACT utilizes certain language conventions to loosen clients' attachment to the literal content of troublesome thoughts, so as to increase behavioural ¯exibility in the presence of such thoughts. Then, in Point 23, we describe interventions that treat the ``Mind'' (and its products) as a separate entity, therefore establishing some healthy psychological distance between clients and their psychological content. Prior to illustrating these interventions, it is worth noting some of the language employed in ACT to illuminate the experiential distinction between fusion and defusion. First, ACT draws a distinction between buying and having thoughts. ``Buying'' indicates fusionÐa psychological context in which thoughts are responded to at the level of literal meaning. For example, a client might buy into the thought `Ì'm boring'', and behave in the world as if that were literally true (e.g. by avoiding social contact). ``Having'' a thought, on the other hand, indicates defusionÐuntangling from the thought's literal meaning and experiencing thinking as an ongoing behavioural process (e.g. `Ì am now having the thought that says `Ì'm boring''; Luoma et al., 2007). Similarly, ACT portrays the 103


experiential nature of defusion as looking at one's thought content (i.e. defusion), as opposed to looking at the world from or through that content (i.e. fusion).

Milk, Milk, Milk exercise Perhaps the most widely recognized ACT defusion technique is the Milk, Milk, Milk exercise (Hayes et al., 1999, pp. 154±156). The following extract involves a male client who had been struggling with a sense of being weak in his personal and professional relationships: Therapist: Would you be willing to try another little exercise? Client: OK. Therapist: In a moment, I'm going to say an everyday word and I want you to tell me whatever meaning pops into your mind. OK, the word is ``Milk''Ð what meaning or associations do you have for that word? Client: It's what I put in my tea . . . it's white and creamy . . . it comes from cows. Therapist: OK, nice. Even though we have no actual milk here, it's almost as if we just brought milk psychologically into the room by simply saying and thinking the word. Now, here's the odd part of this exercise. I want us to repeat the word ``Milk'' out loud over and over again for about a minute to see what happens. Would you be willing to do that with me? Client: [laughing] Out loud? Sure. Therapist: So, during the exercise I want you to focus on saying the word. Listen to yourself and experience the word on your lips. OK? Let's begin. [Client and therapist repeat the word Milk for about 1 minute. During this time, the therapist 104


Therapist: Client: Therapist: Client: Therapist: Client: Therapist:

Client: Therapist:

Client: Therapist: Client: Therapist: Client:

periodically encourages the client to speed up, to say it louder, and to really listen to the sound] And stop. Thanks for doing that rather strange exercise! What did you notice as we did that? It didn't sound like milk at all. What did it sound like? I don't know, like ``muul, muul muul''. I found it hard to say it and breathe at the same time; as we got quicker it sort of lost the `ìlk'' at the end. What about the meaning of the wordÐthe white and creamy stuff that goes in your tea? Where was that? Oh. I suppose I forgot all about that. I wasn't thinking about milk, I was just listening to myself trying to say the word, making the sound. I found that too. The meaning of the wordÐthe milkÐsort of evaporated, if you'll excuse the pun. Now, if you're willing, I'd like to take this a bit further. I'd like to do the same thing with this piece your mind gives you about being weak in your relationship with Shelley [the client's partner] and with some of your work colleagues . . . . Mmmm. [Client appears less enthusiastic about this] Let's boil that down to one wordÐ``Weak''. Would you be willing to do the same exercise? Only this time we'll repeat the word ``Weak'' over and over again? I'll give it a try. [Client and therapist repeat ``weak'' for one minute] What did you notice? Weird. [Client is frowning and goes quiet] [after a moment or two] What are you sensing John? I'm not sure. It's odd . . . . It's like, you know, I really didn't want to say that at all. But saying it 105


again and again like that made it like . . . well, less important or something. You do that and it's like just a word. The Milk, Milk, Milk exercise deliberately creates a context in which the derived function of a word (the word's literal meaning) dissolves into the background, while the more direct functions (e.g. what the word sounds and feels like) become more prominent (Hayes & Smith, 2005). The aim is to temporarily deliteralize the word, so that the client can experience it for what it actually is (Hayes et al., 1999). The intention is not to reduce the frequency with which this client experiences thoughts about being weak, but rather to reduce the extent to which such thoughts interfere with value-consistent behaviour. Other related defusion strategies include encouraging clients to repeat provocative automatic thoughts or self-conceptualizations very slowly and then very quickly; saying negative thoughts in a comic voice (e.g. as Donald Duck, Tweety Pie, or Darth Vader); or singing thoughts to the tune of well-known nursery rhymes (see Hayes & Smith, 2005; Strosahl et al., 2004). Such techniques tend to inject some humour into the process, and will often elicit a change in the way a client reacts to previously disturbing cognitive content. This defusion work is always linked to the client's values. For example, the previous client would be encouraged to experience the thought `Ì'm weak'' as a thought, while identifying and engaging in behaviours consistent with the type of partner and work colleague he would choose to be. The message is that, in a context of defusion, private events do not have to function as barriers to valued living.

Undermining reason giving It is common for clients to report the presence of dif®cult psychological content as a reason for not engaging in valuesconsistent action. This can be indicated by the use of the 106


explanatory words but or because in clients' self-referential language: `Ì do want to get back to work, but I'm still too depressed.'' `Ì didn't go to the wedding because I was worried no-one would talk to me.'' `Ì love my partner, but he/she makes me so angry.'' `Ì really didn't want to have a drink, but I just felt so wound up.'' From an ACT perspective, such statements illustrate the way that language supports cognitive fusion and experiential avoidance. The use of the word but in the above statements effectively rules out the possibility of valued behaviour occurring (e.g. being a loving partner) in the presence of dif®cult thoughts and feelings (such as anger and frustration). The underlying message is, for example, `Ì cannot be loving towards my partner and feel angry with him''. Such verbal traps suggest that dif®cult content must ®rst be modi®ed before life-enhancing behaviour can occur. In contrast, ACT posits that a valued and vital life can be pursued even in the presence of undesirable thoughts and emotions. Thus, ACT therapists will often ask clients to replace all self-referential uses of the word but or because with and (Hayes et al., 1999): `Ì really want to get back to work, and I'm still feeling depressed.'' `Ì didn't go to the wedding, and I was worried no-one would talk to me.'' This modi®cation of language serves a number of useful functions. First, the use of and provides a much better re¯ection of actual experienceÐthe client is, after all, experiencing a desire to get back to work and a cluster of negative thoughts and emotions. Second, but or because statements are more 107


likely to draw clients into a futile struggle with the thoughts and feelings that apparently stand in the way of taking valued action. Finally, and opens up many more options for effective action that simply do not exist when private events are taken as valid reasons for behaviour (Eifert & Forsyth, 2005; Hayes et al., 1999).

Defusing unhelpful life stories A more elaborated form of reason giving is evident in the explanations or ``stories'' that clients provide for the origins or maintenance of current dif®culties. This tends to involve fusion with a well-rehearsed historical analysis of why problems emerged in the ®rst place (e.g. relationship breakdown, experience of abuse, mistreatment by others, etc.; Zettle, 2004). For example, consider a depressed and socially isolated client who values being close and connected to others, and yet remains trapped in a story that says, `Ì cannot have intimate relationships because of the way I was treated when I was a child''. Engagement in close interpersonal activities is less likely to occur while the client is rigidly attached to the ``truth'' of this type of story. To undermine excessive fusion, ACT focuses on the function rather than the speci®c content of a client's story. The issue is not so much whether a story is true or not, but whether excessive fusion with the story is supporting rigid and avoidant patterns of behaviour. One of ACT's defusion strategies asks clients to write out a summary of their stories to explain current dif®culties. Any facts and events contained in the story are underlined (reasons, often indicated by the word because, are ignored). Clients are then requested to create an alternative narrative using the same facts and events, only this time with a completely different meaning and outcome. If necessary, a number of different stories and outcomes can be created using the same facts from the original story. By creating alternative stories, clients can begin to view autobiographical narratives as 108


verbally constructed, and storytelling can then be assessed in terms of its workability (e.g. `Ànd what is this story in the service of?'') rather than at the level of literal truth or belief (Hayes et al., 1999; Luoma et al., 2007). This process aims to reduce the dominance that unhelpful life stories exert over client behaviour, thereby enhancing behavioural ¯exibility. Defusion from this type of material must be conducted with genuine empathy and compassion for the client's life history and dif®culties; some useful examples of how to introduce and conduct this work can be found in Luoma et al. (2007), Hayes and Smith (2005), and Zettle (2007).

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23 Cognitive defusion II: Objectifying psychological content As we have already seen, ACT makes use of defused language practices that treat the mind (and its products) almost as a separate entity. For instance, ACT therapists routinely ask questions such as, `Ànd what does your Mind have to say about this?'' or ``Who is in charge hereÐyou, or your Mind?'', and will frequently encourage clients to ``Thank your Mind'' for particular pieces of evaluative chatter. To support defusion, an ACT client might even be invited to give his mind a playful nickname (such as ``Chatterbox'' or ``Grumpy''; Luoma et al., 2007; Zettle, 2007). In this point, we consider additional defusion interventions that function in a similar way by asking clients to relate to thoughts and other private experiences as if they were external objects (the physicalizing exercise described in Point 21 is also relevant here). These interventions highlight the healthy psychological ``space'' that exists between thoughts and the conscious person having those thoughts, and encourage clients to observe dif®cult psychological content from a more nonjudgemental perspective.

Thoughts on Cards exercises Having the client write dif®cult thoughts on small cards serves a number of ACT's processes. For example, to illustrate the effort involved in trying to avoid such thoughts (i.e. to undermine experiential avoidance), the therapist rapidly ¯ips the cards, one after the other, towards the client's lap; the client is ®rst instructed to bat each card away to ensure that none 111


actually make contact with his or her lap. Following this, the client is asked to be willing to have the thought cards land wherever they will without trying to avoid them. The client is asked to notice the contrast in effort between the two strategies. In a gesture of willingness, an ACT client might be asked to engage in purposeful daily activity outside of the session while carrying thought cards around in a pocket. This provides a physical metaphor for being willing to experience even provocative thoughts as thoughts, while at the same time engaging in behaviour that is consistent with one's values.

Taking Your Mind for a Walk exercise The Taking Your Mind for a Walk exercise (Hayes et al., 1999, pp. 162±163) provides a powerful experiential demonstration of defusion. This exercise tends to facilitate the following learning experiences (adapted from Luoma et al., 2007):

· · ·

The Mind emits a constant stream of evaluative (and often unhelpful) ``chatter''. Minds are not in charge; the client can take direction no matter what the Mind is saying. Wherever you go, you take your Mind with you.

To conduct the exercise, the therapist adopts the role of the client's ``Mind''. The client is instructed to walk outside for ®ve minutes; the therapist follows very closely behind, chattering almost constantly (as minds tend to do): describing, doubting, evaluating, analysing, problem solving, encouraging, predicting, worrying, criticizing, warning, and so on. Ideally, the therapist will already be aware of some of the client's cognitive content, and will weave this into the exercise. The client is instructed not to engage or communicate with the Mind, but simply to stay present and go wherever he or she chooses while nonjudgementally noticing the Mind's verbal chatter. After ®ve minutes, the therapist and client swap roles so that the client 112


experiences being the Mind. Finally, the client is asked to take a mindful walk for another ®ve minutes, this time nonjudgementally noticing the familiar chatter of his or her own mind.

Passengers on the Bus metaphor The Passengers on the Bus metaphor is another highly versatile ACT intervention (Hayes et al., 1999, pp. 157±158). In this metaphor the client is the driver of a bus (the ``Bus of Life''), which is full of passengers (some of whom seem scary and unpleasant). The passengers represent the client's thoughts, emotions, memories, sensations, behavioural urges, and so on. Clients are encouraged to view the direction of the bus as representing their chosen values, and the `ùnhelpful'' passengers as the dif®cult psychological content that will inevitably be encountered along the way. The idea is that some passengers attempt to bully the driver into stopping the bus or taking directions that do not serve the driver's values. Trying to placate or remove unruly passengers is portrayed in the metaphor as counterproductive and costlyÐthe driver is not in a position to take the bus in a chosen direction while struggling or making deals with unwanted passengers. As with the previous defusion exercises, the Passengers on the Bus metaphor promotes defusion by objectifying provocative psychological content. Moreover, the same metaphor simultaneously activates ACT's other core processes. For example, experiential avoidance is undermined by highlighting how humans tend to lose control of their lives by trying to control dif®cult thoughts and feelings (Orsillo et al., 2004). Similarly, the metaphor promotes valued living by helping clients disentangle from literal psychological content that would otherwise function as an obstacle to values-directed action (see Point 28).

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24 Cultivating mindfulness to promote contact with the present moment Increasing clients' ability to contact the present moment is a core ACT process, which in turn serves every other process within the hexa¯ex model. Accordingly, ACT employs a rich array of mindfulness exercises that foster an accepting and nonjudgemental awareness of one's experience as it unfolds in the here and now (Luoma et al., 2007; Wilson & DuFrene, 2009). The mindfulness strategies used in ACT tend to progress from relatively simple awareness exercises, such as bringing full attention to everyday tasks, through to more formal mindfulness meditation practices, such as mindfulness of breathing and ``just noticing'' thinking and feeling as an ongoing process (Eifert & Forsyth, 2005; Zettle, 2007). As well as introducing clients to these structured and daily mindfulness exercises, ACT therapists become skilled at spontaneously shifting their clients' attention to present-moment experience when it is deemed therapeutically useful to do so.

Introducing mindfulness When ®rst introducing mindfulness interventions, it can be helpful to provide some brief psychoeducation about the fundamental nature of the skill. This typically involves providing the following information:

·

Mindfulness involves bringing awareness to the present moment, and experiencing internal events from a more non-judgemental perspective. 115


· · · ·

Mindfulness is a skill that can be honed with regular practice; to develop the skill, it can be helpful to practise some form of mindfulness every day. Mindfulness exercises are not designed to help you reduce, control, or avoid unwanted thoughts and emotions. Similarly, relaxation is not the goal of mindfulness (even though the exercises sometimes produce feelings of calmness or relaxation). When practising mindfulness, it doesn't matter whether your current internal experience is pleasant or undesirable; the important thing is that you practise consciously observing your experience as it unfolds from one moment to the next.

This type of rationale is designed to ensure that clients do not perceive mindfulness as an experiential control strategy (Zettle, 2007). This can be an issue during the early phases of ACT, when clients are likely to be ®rmly attached to a control/ avoidance agenda. Moreover, some clients may have previously been taught meditative or breathing exercises alongside a control-oriented rationale (e.g. as strategies for `èmptying the mind'' or reducing dif®cult emotion). The above rationale is therefore aimed at undermining experiential avoidance, and reducing the likelihood that clients will judge the value of mindfulness against its ability to reduce unwanted thoughts, feelings, or sensations (Zettle, 2007).

Cultivating daily mindfulness The simplest mindfulness exercises can be introduced from the earliest stages of ACT to help clients begin contacting presentmoment experiences more frequently and fully. Initial mindfulness exercises might include bringing moment-to-moment awareness to routine daily activities such as drinking, eating, and walking. 116


One of the most widely recognized introductory practices involves mindfully eating a raisin or other small edible (such as a jelly baby). This technique was introduced by Jon Kabat-Zinn (1990) and has since become a prominent feature of Mindfulness-based cognitive therapy (MBCT; Crane, 2009; Segal et al., 2002) as well as being incorporated into ACT protocols (Hayes & Smith, 2005; Zettle, 2007). The client is asked to pay close and curious attention to all the features of a raisinÐits shape, size, colour, texture, smell, feelÐbefore slowly eating the raisin in a state of full awareness, mindfully noticing the sensations of chewing, tasting, and swallowing the food item. Such exercises can easily be extended into homework assignments. For example, the therapist might collaborate with clients to identify routine activities (e.g. brushing one's teeth) to be performed mindfully every day for the next week (see Hayes & Smith, 2005, for example instructions). As a gentle introduction to more formal mindfulness meditations, a client can be asked to scan bodily sensations while sitting in the therapy room. The client is encouraged to sit in an upright meditative posture with shoulders relaxed, eyes closed, and with hands resting naturally on the arms of the chair or in the lap. The client is then requested to simply notice tingling, temperature, and sensation in each part of the body in turn (e.g. ®ngers, hands, arms, head, abdomen rising and falling with each breath, sensation of the body in the chair, legs, feet and toes, and entire body; Hayes & Smith, 2005). The therapist provides gentle and well-paced instructions for the client to return again and again to present bodily sensation each time attention is captured by thought content (including fusion with internal commentary about the exercise itself ). Such exercises may be quite brief (e.g. 5 minutes) at ®rst, but can be gradually extended as the client's mindfulness skills develop. ACT therapists often begin their sessions with this type of brief mindfulness exercise to ensure that the client (and indeed the clinician) is centred and psychologically present (Eifert & Forsyth, 2005; Luoma et al., 2007). 117


Mindfulness of breathing Once clients are beginning to show an increased capacity for contacting the present moment, more formal (and potentially more challenging) mindfulness meditations can be introduced. A typical next step would be to introduce the practice of mindful breathing. As noted by Zettle (2007), this is an important step in the progression of mindfulness work in ACT as it involves a shift of attention towards internal experiences (i.e. the sensations associated with breathing). Mindfulness of breathing practices tend to unfold in the following way. To begin, the client is asked to adopt a meditative posture (e.g. back straight, spine infused with energy, hands and arms in a comfortable resting position, eyes closed or cast downwards). The client is centred by focusing for a couple of minutes on the sensations of the body contacting the chair or ¯oor, and/or the sounds and temperature in the room. The therapist then provides slow and gentle instructions to help clients anchor present-moment awareness to the breath. This type of meditative exercise is often recorded on CDs to support between-session practice (some excellent audio guides have been developed by Harris, 2008; and Williams, Teasdale, Segal, & Kabat-Zinn, 2007). As therapy progresses, dependence on such external resources can be gradually reduced to ensure that the ability to return to the present moment becomes a natural, spontaneous, and ¯exible part of each client's skill repertoire. During debrie®ng, ACT therapists elicit clients' experiences of mindfulness but tend to avoid engaging in an elaborate analysis or intellectual explanation of those experiences. Initially, it is not uncommon for clients to believe that being distracted by thoughts indicates that they are not performing the exercises correctly. Such misperceptions can be corrected by emphasizing that being ``hooked'' by thought content is perfectly normal and to be expected. Indeed, noticing moments or periods of fusion with thoughts, and then gently returning non-judgmental awareness to a present-moment focus (e.g. 118


current bodily sensation), is perhaps the sine qua non of mindfulness practice.

Mindfulness of thought and emotion The ®nal stage in the progression of mindfulness interventions involves bringing non-judgemental awareness to the ongoing process of thinking and feeling. In ACT, this work can take on an exposure-like quality, as clients practise mindful awareness of unwanted thoughts and emotions without seeking to change the content or frequency of those experiences. It is often at this stage that ACT's ``classic'' mindfulness interventions, such as leaves on the stream or soldiers in the parade, are introduced (Hayes et al., 1999). During these exercises, clients are asked to notice the ¯ow of thoughts and images, as if each consecutive thought or image were attached to leaves ¯oating by on the surface of a stream or, alternatively, viewed on a series of placards being carried by marching soldiers. As with the earlier mindfulness practices, clients are guided to notice those moments when attention has been hooked by thought content, and to return each time to a nonjudgemental observer perspective, just noticing the process of thinking as it unfolds moment to moment. When clients lose the experiential ¯ow of the exercise, they can be instructed to use the breath as an anchor to the present moment (Zettle, 2007). As well as strengthening present-moment awareness, such exercises promote defusion by objectifying the ¯uctuating content of consciousness. Various other images can be used during this experiential work, such as watching thoughts drifting by on clouds in the sky (Luoma et al., 2007), or observing thought content being projected onto a screen as if one were an audience member in an empty movie theatre (Flaxman & Bond, 2006). ACT therapists would typically introduce a range of such exercises, and consult with clients on which scenario seems most helpful. 119


In sum, various mindfulness techniques are employed in ACT to increase present-moment awareness. These interventions simultaneously promote defusion and acceptance, by fostering a non-judgemental stance toward thought, feeling, and sensation. Moreover, mindfulness practices naturally support contact with a sense of self as a consistent and stable observer of changing psychological content (i.e. self-as-context). We examine additional self-as-context interventions in the next point.

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25 Contacting the self-as-context As we have seen, ACT seeks to increase people's willingness to experience even the most undesirable thoughts, emotions, and sensations as part of pursuing valued behavioural directions. Hence, it is essential that clients are able to access a psychological perspective, or sense of self, from which dif®cult psychological content appears less threatening. In ACT, this transcendent sense of self is variously referred to as ``self-as-context'', the `òbserving self'', or ``self-as-perspective'', and represents a core therapeutic process (Hayes et al., 1999). Although words rarely do it justice, the self-as-context might be described to clients as the conscious ``place'' or ``space'' from which humans observe internal and external events. Importantly, this sense of self can be experienced as an unchanging aspect of the human condition. That is, the content of consciousness changes from one moment to the next, while the locus from which we view that content remains constant. This sense of continuity in the self-as-context holds considerable therapeutic utility, particularly for clients who believe that they have been psychologically damaged by dif®cult internal and/or external experiences. Various metaphors and experiential exercises are introduced in ACT to help clients contact the self-as-context. These interventions impart the following therapeutic messages (adapted from Hayes et al., 1999; Strosahl et al., 2004):

· ·

There is a sense of self that is distinct from your thoughts, images, emotions, memories, roles, and sensations; we might call this your `òbserving self''. Your thoughts, feelings, memories, and sensations are constantly changing, while the observer part of you is a 121


·

constant; this perspective has been there since you were a very small child. This perspective offers a place from which you can safely and non-judgementally observe your private experiences; when viewed from this perspective, undesirable thoughts, feelings, and sensations appear less threatening.

Chessboard metaphor The chessboard metaphor provides a useful illustration of the distinction between the observing self (self-as-context) and the content of one's psychological experiences. The metaphor can be physically played out, using either a real chess set or a homemade version. The pieces on the chessboard represent the client's thoughts, feelings, and sensations. The board extends in®nitely in all directions. One set of chess pieces is used to represent negative psychological content, while the opposing set of pieces represents more positive content. The metaphor might be introduced as follows: Therapist: So, imagine that these pieces on the left represent all your negative thoughts and emotionsÐyour depressed moods, your feelings of loneliness, your thoughts that say you are worthless and that no-one respects you. The pieces on the other side represent the more positive thoughts and feelings that you sometimes experienceÐ thoughts that say, actually, you are doing OK; feelings of hope that your life might get better; feeling worthwhile when you do something good for your family: and so on. Notice how the pieces tend to hang around together in teams. Your negative thoughts associate with other negative thoughts and negative moods, and vice versa for your positive pieces. We humans can get into a bit of a pickle when we work hard to 122


have more positive pieces and less of the negative ones. It's a bit like riding into battle in an attempt to remove as many of the negative pieces from the board as possible. Sometimes it might feel as though we must keep ®ghting otherwise the negative pieces will overwhelm us. Unfortunately, this is a war that can never be won. After all, it means we are ®ghting with a large chunk of our own experience. Engaging in the war at piece level is usually pretty stressful, and it inevitably interferes with you moving your life in a direction that you really care about. At some point the therapist asks, `Ìf the chess pieces are all your thoughts and feelings, then who are you in this chessboard scenario?'' If the client responds with `Ì'm the player'', the therapist gently undermines this perspective by pointing out how dif®cult it is to simply remove unwanted thoughts and emotions from the board. Also, the player is inevitably invested in the outcome of the war being played out at the level of the pieces. Similarly, identifying with the pieces (i.e. self-as-content) means that the client is living a restricted life at piece level, ®ghting a continuous, exhausting, and futile war. Ultimately, the ACT therapist encourages the client to adopt the perspective of the board as a metaphor for contacting the self-as-context. The client is asked to notice how the chessboard can easily support all the pieces without effort or struggle. The board is in no way harmed or threatened by any of the pieces. By taking the perspective of the board, the client may let go of the endless struggle to win the war; at board level, the client steps out of the war altogether and observes it from a fundamentally different perspective. Finally, as the board, the client is better able to move in a valued life direction, taking all the pieces along for the ride (Zettle, 2007). To illustrate this last point, the therapist might pick up the chessboard (with all the pieces still in place) and move it around the room. 123


Various other metaphors illustrate this same core process. For example, the client's thoughts, feelings, and sensations can be portrayed as different pieces of furniture within a house, while the house itself is the broader self-as-context (Luoma et al., 2007). Similarly, psychological content can be viewed as changeable clouds and weather, while the observing self is the sky (Hayes et al., 1999). Alternatively, one's ¯uctuating thoughts, feelings, and sensations can be seen as a stage show, with the observing self being the perspective of an audience member (Harris, 2009). As with the chessboard, some clients bene®t when such metaphors are illustrated with physical props (e.g. pictures showing the expanse of sky that permanently exists above and beyond clouds and weather).

The Observer exercise The chessboard metaphor often serves as a precursor to the Observer exercise (Hayes et al., 1999). This can be a powerful ACT intervention that targets experiential contact with the selfas-context. A brief form of the observer exercise can be introduced as a natural extension of the ongoing mindfulness work. For example, while guiding the client through a mindfulness-ofbreathing exercise, an ACT therapist might include the following self-as-context instructions (adapted from Harris, 2008, 2009; Zettle, 2007): `Às you notice your breathing, be aware that you are noticing.'' ``Notice that there are two things going on here; there's your breathing, and there you are, a conscious human being, noticing your breathing.'' `Às you notice your breathing, also notice who is noticing.'' As part of this experiential work, the ACT therapist can make good use of the natural distance between the client and physical objects in the room. For instance, the therapist might begin an 124


exercise by asking the client to observe a physical object and develop a sense of the self as the observer of that object. The mindfulness exercises that underpin this self-as-context work would vary according to the client's mindfulness skills. Simpler exercises include awareness of breathing and other bodily sensations, while more challenging exercises extend to mindfulness of thought, emotion, and sensation alongside additional instructions to help the client locate a sense of self-as-observer of these experiences. In addition to this augmented mindfulness work, ACT incorporates a more elaborate observer exercise that places clients in experiential contact with the continuity and stability of the self-as-context. Because of space limitations we do not present the full instructions here, and instead refer the reader to the following sources: Hayes et al. (1999; pp. 193±195); Zettle (2007, pp. 151±155); and Harris (2009, pp. 178±180). Ideally, instructions should be adapted to re¯ect the client's particular life experiences, roles, and psychological content. Debrie®ng is generally kept to a minimum following self-ascontext interventions. This underscores the experiential nature of the work, and ensures that clients do not become overly entangled in attempts to understand self-as-context at a logical or intellectual level. Unlike the mindfulness practices presented earlier, interventions such as the observer exercise do not necessarily have to be practised repeatedly (Zettle, 2007). However, the observer perspective can be contacted and referred to throughout ACT to remind clients that there is much more to them than the pieces on the board. It is not uncommon for ACT clients to report a sense of calm, peace, stillness, or transcendence following self-as-context interventions. Through this work, clients who have struggled (and/or identi®ed) with dif®cult psychological content can catch a glimpse of an enduring aspect of self that is not threatened or harmed by such experiences. Such moments in ACT usually indicate an important step en route to increased psychological ¯exibility (Strosahl et al., 2004). 125


26 Clarifying values ACT employs a broad range of values interventions, including conversations about life goals and aspirations, in-depth writing exercises, experiential and exposure work, activity scheduling, and the use of standardized values-assessment tools. Whichever methods are used, the development of clients' values-based action skills typically includes the following key steps: 1 2 3

Clarifying values. Values-based goal setting and action planning. Building larger and more persistent patterns of committed action.

In this point, we cover the ®rst step by outlining some of the conversations, interventions, and tools used to help ACT clients contact and de®ne their values. We also consider methods for helping clients grasp the important distinction between goals and values. In Point 27, we show how identi®ed values are used as the basis for collaborative goal and action planning; and, in Point 28, we describe strategies for helping clients keep behavioural commitments in the presence of unwanted psychological content.

Initial values assessment One of the ®rst questions ACT therapists ask is, ``What do you want from therapy?'' Client responses to this question often contain a desire for change in the form, frequency, or intensity of undesirable psychological content (e.g. `Ì want be less anxious''; `Ì want more self-con®dence; or `Ì just want to be 127


happy''). These responses can be used to enquire further into underlying values or life aspirations. For example, the therapist might ask, `Ànd if you felt less anxious, what would you like to do more of in your life''; or `Ìf you did feel happier inside, in what ways would your life/behaviour be different?'' These probing questions often provide early indications of desired life directions or goals that have been neglected in the service of experiential avoidance. Also as part of the initial assessment, ACT therapists routinely expand the conversation beyond the presenting problems to incorporate clients' life aspirations, dreams, and hopes. This process is facilitated by posing the following questions (adapted from Luoma et al., 2007):

· · · · ·

What do you most want your life to be about? What sorts of things do you most want to do? What type of person do you most want to be? How do you want to be in your various relationships? What do you want your life to stand for?

When presented during the early stages of ACT, clients are not expected to have immediate and well-formed answers to these values-oriented questions. Rather, the purpose is to open up initial conversations about values, and to communicate that the work ahead will ultimately be in the service of helping the client pursue a more meaningful and vital existence. Focusing on values from the outset also supports ACT's mindfulness and acceptance processes by providing clients with the motivation and justi®cation required for contacting dif®cult and previously avoided experiences (Wilson & Byrd, 2004).

Introducing the nature and function of values When introducing values, ACT practitioners seek to convey the following key messages: 128


· · · · ·

Values are not feelings; they are about what you do; valued living (or valuing) means pursuing what matters to you with your hands and feet. Values are personally chosen life directions, rather than what you feel you should, must, or have to do. Values provide the direction, while goals and actions help you move in that direction. Valuing tends to bring a sense of vitality, purpose, and meaning to life. Unlike goals, values have no end point; they re¯ect the quality of your actions (e.g. how you choose to be in your various relationships and roles).

ACT employs various journeying metaphors to support these messages. For example, values can be portrayed as the points on a compass for the journey of life (Hayes & Smith, 2005; Hayes et al., 1999). Using this scenario, one might value heading east. Easterly landmarks in the distance are akin to the speci®c goals we aim for in order to maintain a valued direction. Once we have a landmark in sight, we do not have to keep checking the compass every step of the way. Goals can be achieved along the way (i.e. we reach the next landmark), but we never achieve values (i.e. we never actually reach east). As soon as we reach a landmark, we face east once again and locate the next suitable landmark. A valued path is not necessarily a straight oneÐsometimes we may need to head south to avoid an obstacle in order to head east again. When in contact with the value, each actionÐchoosing to head east, looking at the compass, identifying a landmark, and taking the next small stepÐis in the service of heading east. In this way, facing and heading east describes the overall quality and direction of the journey itself.

Distinguishing values from goals As illustrated in the compass metaphor, helping clients distin129


guish between goals and values is an important part of this work. Goals are designed to be achieved and marked off as we step along a valued path, whereas values are desired qualities of behaviour that we tend to hold as important throughout our lives. Stated more simply, `Àm I done yet?'' is a question that can be asked in relation to goals but not values (Hayes & Smith, 2005). When ®rst discussing behavioural values, clients often state outcome goals (e.g. I want to see my kids more often) rather than the underlying valued direction (e.g. to be an available, supportive, and nurturing father). In such cases, clients are encouraged to ask themselves, `Ìn which direction is this goal taking me?'' ``What is this goal in the service of?'' or ``Why is this goal important to me?'' as a way of contacting the underlying value.

Process vs. outcome Discriminating between values and goals helps clients focus on the process of living a valued life, rather than being overly attached to achieving favourable outcomes or goal attainment. A Skiing metaphor is often used to help clients grasp this important distinction (adapted from Hayes et al., 1999, pp. 220±221): Therapist: Imagine you are on your skiing holiday. You take the chair-lift to the top of a wonderful slope. You are just about to ski down it when a man suddenly arrives in a helicopter and asks you where you are going. You explain that you are heading down to the lodge at the bottom of the slope. The person in the helicopter says he can help you out, and promptly grabs you, throws you in the helicopter, and ¯ies you straight down to the lodge. You look around kind of dazed and confused, and then once again 130


take the lift to the top of the slope; as you are just about to ski down it, the man in the helicopter appears again and the same thing happens! As you came here to ski, you would probably start to feel quite frustrated by this. The point is this: SkiingÐjust like livingÐis not just about achieving the goal of reaching the lodge. It's about the journey, the process, how we get there. Reaching the lodge is important, but only because it allows us to engage in the process of skiing. Hayes et al. (1999) summarize the message contained in this skiing metaphor as follows: `Òutcome is the process through which process becomes the outcome'' (p. 220). From an ACT perspective, focusing only on goals tends to draw clients' attention away from present-moment experiences, in that goals encourage a focus on outcomes that may or may not be achieved in the future. In contrast, the process of valuing is manifested in current behaviour, and is more about the journey than the destination. Accordingly, ACT clients are encouraged to ``hold goals lightly'', and to use goal setting as a means for increasing engagement in the ongoing process of living a valued life (Luoma et al., 2007).

Contacting values exercises Various experiential exercises can be used to help clients contact chosen behavioural directions. For example, clients can be asked to imagine reaching the end of a long and fruitful life, and being able to attend one's own funeral in spirit form (see Hayes et al., 1999, pp. 215±218). Clients then consider the various eulogies they would most like to hear from friends, partner, family members, neighbours, and work colleagues (e.g. ``What would you most want your spouse to say about you, as a partner?''). Similarly, clients can be asked to write their own 131


tombstone epitaph, to indicate what they would most want to be remembered for. Such exercises are often powerful, as clients make contact with painful discrepancies between current or historical behavioural patterns and chosen values.

Values clarification tools More formal values clari®cation is supported by various forms and rating instruments. For example, Hayes et al. (1999, pp. 224±225) developed a values-assessment handout that asks clients to de®ne values within nine life domains: 1 2 3 4 5 6 7 8 9

marriage/couples/intimate relations; family relations; friendships/social relations; career/employment; education/personal growth and development; recreation/leisure; spirituality; citizenship; and health/physical well-being.

The exercise encourages clients to de®ne their most desired behavioural directions across a number of these life areas, along with more speci®c goals. This work may be completed collaboratively across a number of sessions, and administered as a written homework assignment. Another useful tool is the Values Compass (Dahl et al., 2009), which provides a visual summary of the clients' values, along with importance ratings and the extent to which current behaviour is values-consistent. Speci®cally, clients are asked to summarize their values in each of ten life domains. Clients then provide ratings for the importance of each value, and ratings of recent or current behavioural consistency with each value. In each life area, the discrepancy between the value and behaviour is computed by subtracting the behavioural rating from the 132


importance rating. In this way, a positive discrepancy indicates a valued direction with a high importance rating but a low level of values-consistent behaviour. Similarly, a negative discrepancy indicates values-consistent behaviour, but where the value is rated as relatively unimportant. Both positive and negative discrepancies may indicate areas of non-vitality or life restriction for the client, therefore warranting attention from the ACT practitioner. Finally, questionnaires such as the Valued Living Questionnaire (VLQ; Wilson et al., 2010), Personal Values Questionnaire (PVQ; Blackledge & Ciarrochi, 2006), and the Survey of Life Principles (SLP; Ciarrochi & Bailey, 2008) have been speci®cally designed to help de®ne clients' values. All of these tools assess value importance and behavioural consistency, and may be used to track client progress or as part of an ACT treatment evaluation.

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27 Values-based goal and action planning The values clari®cation process is designed to provide the client and therapist with a shared sense of the client's most valued behavioural directions (Luoma et al., 2007). The next step involves working with the client to translate these abstract values into more concrete goals and actions in order to promote committed action. This phase of ACT makes use of a range of more traditional behaviour therapy methods such as activity scheduling, behavioural homework assignments, and exposure (Eifert & Forsyth, 2005). In ACT, the principal function of these interventions is not for the client to engage in more pleasurable activities or to reduce symptoms of distress; rather, the aim is to help the client actively pursue valued behavioural directions while applying mindfulness and acceptance skills to the dif®cult private events that arise. To begin this process, the therapist and client focus on just one or two valued life domains. The idea is for clients to make some initial progress before generalizing acquired values-based action skills to a broader range of activities and life domains. Ideally, the initial focus will be on the valued domain showing the greatest discrepancy between importance and behavioural consistency. As the ultimate purpose is to increase psychological ¯exibility, it is important that ACT clients pursue goals and actions that have the potential to elicit unwanted thoughts and emotions.

Goal setting Clients will often bene®t from some coaching in effective goal setting. This typically includes the following messages (adapted from Luoma et al., 2007): 135


· · · · ·

Goals should be selected on the basis of their potential to move the client in a valued direction. Goals should be speci®c and measurable, including details of when, where, and how they will be achieved. Goals should be active (as opposed to stating what one is trying to avoid or do less of ). Goals should be practical and within the client's ability. It can be helpful to make a public commitment to values, goals, and actions.

These features of goal setting serve a number of useful functions. For instance, ensuring that goals are measurable allows the therapist and client to track whether goals have been achieved. Additionally, setting goals that are practical and realistic encourages clients to pursue small yet consistent steps in a valued direction, rather than seeking heroic leaps of achievement. Clients should be discouraged from setting ``dead-person goals'' (that is, ``less than'' goals that could be achieved by a dead person; Luoma et al., 2007). For example, consider a client who stated a value of being a supportive, loving, and patient husband, along with the following goal: ``To stop arguing with my wife''. In this particular case, the therapist encouraged the client to set more vital and speci®c goals that he would wish to pursue instead of arguing. Following this intervention, the client generated the following value-based goal, which became the focus of a committed action assignment: ``To have dinner with my wife twice this week, with the intention of ®nding out how her day was and helping her unwind after work''. It is common ACT practice to ask clients to make a public commitment to valued goals (sometimes referred to as Taking a Stand; Strosahl et al., 2004). Goal commitments can be spoken aloud in front of the therapist, other members of an ACT group, or family and friends. The rationale is that clients are more likely to follow through with behavioural commitments that have been publicly expressed. This process may also trigger negatively evaluated reactions for the client (e.g. anxiety, doubt, 136


or embarrassment), therefore providing an opportunity for applying mindfulness, acceptance, and defusion skills (Orsillo et al., 2004). Moreover, public statements of values between client and therapist can empower the therapeutic alliance. For example, when a client has stated a valued goal, the therapist can make a similar commitment to helping the client move in that desired life direction (also see Point 30). Client goals should also be recorded on one or more of the various values, goals, and actions forms that are available in the ACT literature (or therapists can simply create their own versions). A written record of goal achievement serves as a reminder of the daily or weekly goals that clients set for themselves, provides a valuable source of self-reinforcement when progress is made, and assists therapists in monitoring engagement in behavioural homework assignments. Useful examples of these handouts and diaries can be found in Eifert and Forsyth (2005, pp. 218, 244) and Hayes and Smith (2005, pp. 181±183).

Activity scheduling One of the main tasks for ACT therapists involves helping clients break down general or long-term goals into more proximal and manageable tasks. For example, one ACT participant valued being a lifelong learner. Having de®ned and stated this value, the client had set a long-term goal of obtaining a degree by part-time study while continuing to work and raise her two children. The client revealed that this particular goal had been lying dormant for more than ten years as she battled with depression, and expressed doubts that it would now ever be achieved. To initiate some behavioural movement, the therapist worked with the client to deconstruct the value and goal into a series of simple and concrete tasks to be completed before the next session. The tasks (which were recorded on a homework handout) included downloading a prospectus from a particular 137


university's website, ®nding out the next submission date for applications along with the entry requirements, and purchasing a text book in the chosen area of study. The client became noticeably more animated and alive with the realization that valued living is something to be pursued from this moment, in the form of a commitment to taking these next small steps. ACT therapists develop an antenna for detecting such signs of vitality, as they tend to indicate that the client is making contact with a highly valued life direction (Luoma et al., 2007). This process of graduated goal setting and activity scheduling is ultimately designed to help clients engage in committed action in the service of their chosen values. At no point does the ACT therapist attempt to coerce the client into performing values-based actions. Instead, the therapist's role involves collaborating with the client to develop a workable and valuesbased goal and action plan, and monitoring and reinforcing client engagement in committed action assignments. An important feature of this work involves identifying the client's thoughts, feelings, and sensations that function as psychological barriers to the pursuit of valued actions. As we discuss in the next point, ACT addresses these barriers through mindfulness and acceptance processes in order to help the client build increasingly larger and more consistent patterns of committed action.

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28 Building larger patterns of committed action In the ®nal phase of ACT, clients are supported as they practise actively pursuing patterns of committed action that are linked to chosen values. As clients engage in this process, they will inevitably make contact with both external and psychological barriers that have the potential to interrupt or halt behavioural movement in valued directions. These barriers are not viewed as problems in ACT, but rather as powerful learning opportunities for cultivating even greater levels of psychological ¯exibility (Luoma et al., 2007). To enhance engagement in committed action, ACT therapists tend to support their clients in the following ways:

· · · · · ·

Helping clients prepare for the presence of barriers, and differentiate external from internal barriers. Applying mindfulness, defusion, and acceptance interventions to help clients keep valued commitments in the presence of psychological barriers. Keeping clients focused on the process of moving in valued life directions rather than on the attainment of particular outcomes or goals. Showing that the quality of committed action matters more than the size of the action. Creating opportunities for exposure work that has a valuesbased purpose. Helping clients recommit to valued directions whenever slips or failures occur.

Committed action work sees a close interplay between all six of ACT's therapeutic processes. Engagement in previously 139


neglected or avoided activities typically provides the cognitive and emotional material required to test and strengthen clients' mindfulness and acceptance skills. This entire process can be neatly summarized in the following willingness question (Strosahl et al., 2004): `Àre you willing to have this barrier and keep going in a valued direction, or will you stop?'' This is not a one-off question, but rather something that life asks of us each and every day of our lives. The question illustrates the willingness move that ACT clients are encouraged to make when faced with dif®cult thoughts and feelings posing as obstacles to life-enhancing action. As noted by Eifert and Forsyth (2005), the ACT move is not so much `òvercoming'' or ``coping'' with these dif®cult private experiences, but rather willingly `èmbracing'' or ``making room for'' them and continuing along a valued path.

External and internal barriers ACT therapists encourage clients to anticipate the potential barriers that may arise during committed action assignments, and to record the barriers actually encountered on the values, goals, and action handouts mentioned previously. Although the distinction is not always obvious, clients will often encounter external barriers to committed action (e.g. time, money, lack of opportunity, skill, or knowledge de®cits), as well as psychological (or internal) barriers in the form of unwanted private events. To help clients navigate through external obstacles, ACT therapists might use a range of methods, such as psychoeducation, problem solving, and social skills training. From an ACT perspective, the most common and powerful barriers to committed action are the automatic thoughts and emotional reactions (e.g. self-doubts, fear of failure, feelings of vulnerability, worry, anxiety, painful memories) that arise as one moves from inaction to action in a valued life domain. Indeed, psychological barriers may be at play even when clients 140


are reporting what appear to be external or environmental barriers. For example, one client reported that she did not complete a committed action assignment of calling an old friend because she had been too busy with work that week. Some gentle probing from the therapist quickly revealed that the client could have found time for the call, but was being halted by anxiety and thoughts about what her friend might think. During the same session, the client practised going through the motions of picking up the phone, looking at the friend's number in her address book, and dialling (using the therapist's phone as a prop); the therapist sat just out of view quietly repeating aloud the client's cognitive barriers to making the call (e.g. `Ìt might be awkward because I haven't called for so long''; ``What will my friend think of me?''; ``She might not even want to hear from me''; and so on). The client was asked to remain mindful of this chatterÐakin to having a radio playing in the backgroundÐwhile focusing on the process of making the call. This defusion intervention was designed to cultivate some distance between the client and her cognitive content, and to provide an experiential demonstration that valued action can occur in the presence of unhelpful automatic thoughts.

Recommitting after setbacks Helping clients break down larger goals into sub-goals and concrete tasks increases the likelihood that some committed action will occur. However, both clients and therapists should be prepared to deal with setbacks. Many clients may have habitual patterns of giving up on valued goals after only one or two unsuccessful attempts (Zettle, 2007). The task of the ACT therapist is to help clients develop more effective patterns of behaviour that involve recommitting to values when commitments are not followed through, or when goals are not achieved on time. ACT employs various interventions to establish these new behavioural patterns including helping clients link their 141


actions to a broader pattern of a valued life direction, ensuring goals and actions are realistic, raising expectations that slips and relapses will occur, and showing that valuing is not always a straight road (Hayes & Smith, 2005; Luoma et al., 2007). Consider the client mentioned in Point 27 who valued being a lifelong learner and committed to a series of actions related to pursuing a part-time degree course. The client returned the following week in a despondent mood. Having contacted the university, she discovered that she would need to complete a year-long foundation course before being eligible to apply for the degree. At that point, the client was prepared to give up on the goal, and did not complete the other tasks she had set for herself. The client's general response to this setback was as follows: `Ìt's not going to happen if I keep ®nding out it will take longer and longer to get there''. In this case, the therapist ®rst reinforced the client for taking a step in a valued direction that had been neglected for several years (i.e. contacting the university). He then used the skiing metaphor (see Point 26) to show that valuing is not about the outcome achieved but the process of engaging in a series of actions consistent with being a lifelong learner. The therapist also posed the following defusion question to untangle the client from the cognitive content (i.e. `Ì'll never achieve this''; ``What's the point?''; ``Do I really want to do this?''; and so on) that was pulling her in the direction of giving up: Therapist: And say you choose to follow the advice of these thoughts, do they lead you towards or away from being a lifelong learner? Client: They lead me away from being that person. They are telling me I might as well just give up now. Therapist: Right. These delightful passengers are telling you to stop your bus just as soon as you've got back behind the wheel. You can pretty much expect them to do that. And what if you looked towards your chosen direction of being a lifelong 142


Client:

learnerÐwhat advice would that give you right now? It would say go for it. Even if you have to do another course you'd still be on the right track.

Ensuring the stakes are high It is important that committed action work is closely aligned with a life direction that is personally valued by the client. If goals and actions are not explicitly connected to an underlying value, the client will lack the motivation to take bold steps or embrace undesirable psychological content. Hence, an important feature of values work involves ensuring that stated values are the client's own, and are not overly in¯uenced by social pressures or a desire to please others (including the therapist). Some of the value-assessment tools mentioned earlier, such as the PVQ, are designed to detect instances of social in¯uence over values. In addition, ACT therapists might ask a series of probing questions, such as: `Ìf no-one else ever knew you were pursuing this direction, would you still choose to pursue it?''; ``What if no-one else knew this about you, would it still be important to you?''; and `Àre you doing this for you or for someone else?'' (Eifert & Forsyth, 2005; Zettle, 2007).

Generalizing committed action skills The committed action process usually starts with the client taking small steps in just one valued life domain. Psychological ¯exibility is gradually increased as the driver wins back control of the bus from the unruly passengers. As progress is made, the client is encouraged to build larger and more consistent patterns of behaviour and to extend committed action into other (and new) valued life areas. The aim is for the client to pursue a wide range of activities in the service of various values, rather than becoming stuck in a rigid repertoire. It is useful for 143


clients to experience some setbacks and incorporate these into broader patterns of values-based living. Ultimately, ACT encourages clients to compare the direction and vitality obtained from an increased willingness to engage in committed action, with the non-vital, restricted, or harmful experiences that result from a life lived in the service of experiential avoidance. As Strosahl et al. (2004) note, `ònce patterns of committed action develop, life takes over and the therapist's role is done'' (p. 48).

144


29 ACT in groups and non-clinical contexts ACT is based on the assumption that many forms of psychological distress and dysfunctional behaviour are underpinned by the same core processes (e.g. cognitive fusion and experiential avoidance). This theoretical assumption is supported by empirical demonstrations of ACT's ef®cacy across a wide range of human dif®culties. The broad applicability of the ACT model, along with its high level of technical ¯exibility, means that ACT can be applied in groups, and translated into brief training programmes for delivery outside of the traditional clinical arena (e.g. in occupational and educational settings; cf. Biglan, Hayes, & Pistorello, 2008).

ACT in groups ACT groups have been used successfully in the treatment of a wide range of client dif®culties including substance misuse, coping with illness, psychosis, parental distress, worker distress and burnout, trauma, various forms of anxiety, depression, and pain (see Hayes et al., 2006, for a review). Walser and Pistorello (2004) have highlighted a number of advantages to delivering ACT in groups:

· ·

Examples shared in groups can help to normalize people's experiences, placing problems within the context of the wider control/avoidance ``system''. Clients often learn from other people's experiences with ACT principles and techniques; group discussions therefore provide a useful adjunct to therapist dialogue. 145


· · · · ·

Group members can be encouraged to create and share new ACT metaphors and exercises. Many ACT interventions are well suited to being physically played out in group settings (e.g. Tug-of-War; Milk, Milk, Milk; Taking Your Mind for a Walk). Observing others displaying acceptance and willingness can be an encouraging, powerful, and moving experience. The group context often stimulates dif®cult psychological content providing a social context for cultivating core ACT skills. The group provides an ideal setting for clients to publicly commit to values, goals, and actions.

Despite these advantages, facilitating ACT groups also poses a number of challenges for the practitioner. One consideration relates to group composition, particularly the range of problems and functioning within the group. Walser and Pistorello (2004) suggest that some clients might bene®t from preparatory coaching prior to entering the group setting. Other practical considerations include whether the ACT group is used alone or as an adjunct to individual therapy (and in which order), establishing an effective balance of experiential and didactic content, and whether the group follows a structure that builds over sessions or allows clients to join at different points (Glaser, Blackledge, Shepherd, & Deane, 2009; Walser & Pistorello, 2004). Aside from these considerations, the de®ning features of ACT discussed throughout this volume also apply to ACT groups. The group facilitator needs to adopt the basic ACT therapeutic stance (see Point 30) in order to detect, model, and reinforce psychological ¯exibility. This includes adopting an equal and compassionate role within the group, creating a group context where it is OK to experience dif®cult psychological content, focusing on the function rather than the form of group member's stories and dialogue, and generally 146


facilitating frequent opportunities for experiential contact with ACT's core processes.

ACT in the workplace ACT has been applied successfully in work settings to improve the psychological well-being of various employee groups (e.g. Bethay, Wilson, & Moyer, 2009; Bilich & Ciarrochi, 2009; Bond & Bunce, 2000; Flaxman & Bond, 2006, 2010a, 2010b; Hayes et al., 2004a). For example, two of the present authors (FB and PF) have developed a brief ACT training programme that utilizes a two-plus-one format (Bond, 2004; Bond & Hayes, 2002; Flaxman & Bond, 2006). This involves the delivery of two training sessions in consecutive weeks, and a third booster session two or three months later (each session lasts from 2.5 to 3 hours). Table 1 illustrates how ACT's therapeutic strategies might be delivered across these three sessions. The programme incorporates many of ACT's core interventions such as Milk, Milk, Milk, the Polygraph metaphor, Physicalizing, Leaves on the Stream, Passengers on the Bus, the Observer exercise, Tin-Can-Monster, and Taking Your Mind for a Walk, along with various values-clari®cation exercises. As discussed in Point 24, the programme aims to develop participants' mindfulness skills in a graduated fashion over the three sessions.

ACT for performance enhancement Frank Gardner and Zella Moore have employed ACT for enhancing the performance of individual athletes and sports teams (Gardner & Moore, 2004, 2007). Their mindfulness± acceptance±commitment (MAC) protocol includes the following seven modules: 1 2

prepare the client with (acceptance-based) psychoeducation; introduce mindfulness and cognitive defusion; 147


Table 1 Delivery of ACT's therapeutic strategies over three training sessions

148

Session

Key strategies

One (week 1)

1 Orientation to the training; 2 Brief mindfulness exercise to illustrate the nature of the work and promote contact with present moment; 3 Discuss mindfulness/acceptance as the alternative to control/avoidance (aimed at undermining experiential avoidance); 4 Writing exercise to contact one or two valued directions and goals; and 5 Further mindfulness practice.

Two (week 2)

1 Mindfulness exercise and review of homework; 2 Building mindfulness into daily life; 3 Contrast mindfulness/acceptance with experiential control/avoidance; 4 Discussion of values, goals, and actions, and completion of formal values assessment; 5 Defusion exercise; 6 Mindfulness exercise to contact the self-ascontext; and 7 Clarify the link between mindfulness and valuesbased action skills.

Three (2 or 3 months later)

1 Mindfulness practice and review of progress; 2 Goal and action planning around two core values; 3 Discussion of barriers to values-based action; 4 Defusion and active acceptance exercises; 5 Public commitment to a highly valued goal and next action; 6 Again clarifying the link between mindfulness and values-based action skills.


3 4 5 6 7

introduce values and values-driven behaviour; introduce acceptance; enhance commitment; combine mindfulness, acceptance, and commitment skills; and maintain and enhance these skills.

A series of case studies has demonstrated the ef®cacy of the MAC approach for enhancing athletes' well-being and performance (see Gardner & Moore, 2007, for a review).

149


30 Therapeutic stance The brief nature of the present volume poses a real danger that readers will come to view ACT in practice as no more than the collection of strategies, metaphors, and interventions that have been described over the previous points. In reality, delivering ACT interventions in a manner consistent with its underlying philosophy requires much more than a familiarity with its theory and technical content. ACT is a powerful, expressive, painful, empowering, emotional, intensive, and intimate form of therapy, not only for clients but also for clinicians. As a result, the work requires a distinctive posture on the part of the practitioner that re¯ects, cultivates, and models ACT's underlying principles, as well as a willingness to enter into a therapeutic relationship that is accepting, open, compassionate, warm, equal, and deeply connected. The de®ning features of the ACT stance emanate naturally from ACT's principles and model of human suffering (Hayes et al., 1999). In particular, one of the fundamental assumptions of the ACT approach is that therapist and client are ``cut from the same cloth'' (Hayes et al., 1999). That is, therapists (who are also human beings) inevitably face many of the same obstacles to valued living as are being faced by their clients. Adopting this stance has an equalizing effect on the relationship, creating a powerful therapeutic alliance, which is purposefully utilized in the service of cultivating greater psychological ¯exibility.

Competencies of the ACT therapeutic stance Adopting the appropriate stance requires ACT practitioners to apply the ACT model of human functioning not only to their 151


clients' psychological processes, but also to their own personal and professional life experiences. To help therapists develop the necessary demeanour and skills for this work, Strosahl et al. (2004, p. 53) have identi®ed the following core competencies (also see Luoma et al., 2007, for a detailed description of each of these competencies):

·

·

· · · · ·

·

· 152

The therapist speaks to the client from an equal, vulnerable, genuine, and sharing point of view and respects the client's inherent ability to move from unworkable to effective responses. The therapist actively models both acceptance of challenging content (e.g. what emerges during treatment) and a willingness to hold contradictory or dif®cult ideas, feelings, or memories. The therapist helps the client get in contact with direct experience and does not attempt to rescue the client from painful psychological content. The therapist does not argue with, lecture, coerce, or attempt to convince the client of anything. The therapist introduces experiential exercises, paradoxes, and/or metaphors as appropriate and de-emphasizes literal ``sense making'' when debrie®ng them. The therapist is willing to self-disclose about personal issues when it makes a therapeutic point. The therapist avoids the use of ``canned'' ACT interventions, instead ®tting interventions to the particular needs of particular clients; the therapist is ready to change course to ®t those needs at any moment. The therapist tailors interventions and develops new metaphors, experiential exercises, and behavioural tasks to ®t the client's experience, language practices, and the social, ethnic, and cultural context. The therapist can use the physical space of the therapy environment to model the ACT posture (e.g. sitting side


·

by side, using objects in the room to physically embody an ACT concept). ACT-relevant processes are recognized in the moment and where appropriate are directly supported in the context of the therapeutic relationship.

Applying the ACT model to the therapeutic relationship As indicated in the above list of competencies, the ACT model is applied to three aspects of the therapeutic relationship: (1) the psychological processes of the client; (2) the psychological processes of the therapist; and (3) the quality of moment-tomoment client±therapist interactions (Luoma et al., 2007). Previous points in this volume have focused primarily on how the model applies to clients. Hence, in the sections below we describe some of the ways in which ACT's six core processes apply to the therapist's own psychology, and how this personal application of the ACT model serves to enhance the quality of therapeutic interactions. This material is drawn mainly from two recent accounts of the intimate link between the ACT model and effective therapeutic relationships (Pierson & Hayes, 2007; Vilardaga & Hayes, 2009).

Acceptance Experiential avoidance on the part of the ACT therapist functions as a barrier to open, connected, and effective therapeutic interactions. For example, an avoidant therapist may be unwilling to explore important client material that resonates with his or her own psychological pain or life history. Similarly, a therapist may be unwilling to experience uncertainty about how to proceed with a client or associated thoughts and feelings of incompetence. The therapist might then attempt to escape from these unwanted private events by suddenly launching into a familiar ACT metaphor, or by lecturing the client on some 153


technical feature of the ACT approach (hence playing the role of ``the competent therapist''). Such moves are likely to result in a disconnected relationship, while also subtly modelling a lack of psychological acceptance for the client. It is important, therefore, that ACT therapists develop a strong and ¯exible repertoire of acceptance skills. This increases therapists' ability to sit with the pain being experienced by their clients, while also making room for their own dif®cult psychological content that shows up during the course of therapeutic interactions.

Defusion Even the most experienced ACT therapists can become trapped by fusion in session. Fusion is a natural process, which under many circumstances is perfectly benign and adaptive (Wilson & DuFrene, 2009). However, fusion also has the potential to in¯uence behaviour in ways that do not support the pursuit of valued living. For example, therapists and clients can both become overly entangled in the literal content of clients' wellrehearsed stories about presenting problems (particularly when a client is strongly attached to the truth and importance of a particular explanation). In a context of literality, such stories may function as signi®cant psychological barriers to valuesbased behavioural change. Therapists might also become fused with evaluations and judgements about their clients (e.g. `Ì can't bear this client''; ``This client will never improve, no matter what I do''; and so on). Finally, therapists can become fused with their own self-evaluations or worries about how they are performing (e.g. ``What the hell am I going to do with this client?''; `Ì'm an incompetent therapist''). In those moments when such content is being taken literally, rather than held lightly, effective contact with the conscious human being sitting opposite is likely to be lost. In order to promote defusion, ACT therapists instinctively learn to focus more on the functional utility of clients' (as well 154


as their own) thoughts and verbalizations rather than on literal meaning (Luoma et al., 2007). For example, when sensing fusion in the ongoing therapeutic dialogue, an ACT therapist might shift focus from literal content to function by asking, `Ànd what is that story in the service of?'', or ``When you buy into this thought, does it lead you towards or away from your valued direction?''

Self-as-context A strong sense of self-as-context is posited to have a powerful in¯uence on the development of connected, empathic, and compassionate therapeutic relationships (Pierson & Hayes, 2007; Wilson & DuFrene, 2009). First, contacting the viewpoint of `Ì/Here/Now'' that is inherent to a transcendent sense of self leads to the realization that this same perspective is available to the other. To put it another way, contacting the self-as-context helps the therapist make compassionate contact with the client's other-as-context (Vilardaga & Hayes, 2009). Second, a personal awareness of self-as-context ensures that therapists are not overly attached to or identi®ed with a particular self-concept or role (e.g. attachment to always seeing oneself as a con®dent and competent therapist; Pierson & Hayes, 2007). Such attachments may impact negatively on the relationship if the therapist modi®es his behaviour in ways that are not necessarily helpful to the client or the work, but are rather aimed at defending, reinforcing, or avoiding a particular conceptualized self. Because of the potential bene®ts to the therapeutic relationship, it is essential that ACT therapists have personal experience of contacting the self-as-context. This contact can be cultivated via the mindfulness and other experiential practices described in Point 25. In addition, Vilardaga and Hayes (2009) have developed a brief deictic framing exercise that utilizes the self-as-context process to help therapists cultivate stronger human connections with their clients. 155


Present moment The capacity to bring a quality of awareness to present-moment experience is a de®ning feature of ACT and of the effective therapeutic relationship (Wilson & DuFrene, 2009). When client or therapist attention drifts away to a conceptualized past or future there will inevitably be a lack of connection with the other person in the room. For the therapist, contact with the present moment (and hence with the client) is likely to be lost when absorbed in what to do next or when monitoring how one is performing (Pierson & Hayes, 2007). ACT therapists are therefore required to become adept at attending to and residing in the present moment with their clients (Luoma et al., 2007). An important part of this process involves gently returning attention to here-and-now experience whenever that contact has been lost.

Values ACT is ultimately about helping clients pursue values-based living. Accordingly, ACT's mindfulness and acceptance processes are not ends in themselves, but instead provide the means by which clients are empowered to build more vital, meaningful, and purposeful lives. At various points in therapy, ACT practitioners seek to demonstrate that they personally value their clients' valuing. In this way, the therapist models values-clari®cation and committed-action processes and strengthens the therapeutic alliance in the service of the client's values. For example, once a client has publicly stated a deeply desired value, the ACT therapist might express a strong and authentic commitment to ensuring that the work will be about that.

Committed action This ®nal process involves the active pursuit of chosen values. As we have seen, the therapist works collaboratively with the 156


client to identify values-consistent goals and patterns of behaviour, and provides support for applying mindfulness and acceptance skills to the psychological barriers that arise. This process generally supports the therapeutic relationship because therapist and client are united by a clear and common purpose (Pierson & Hayes, 2007).

Summation ACT practitioners seek to develop and personify the same psychological ¯exibility they wish to cultivate in their clients. This helps to explain why learning ACT is as much about experiential work for the practitioner as it is about developing a conceptual understanding of ACT's core processes and ¯uency with ACT techniques. This personal application of the ACT model naturally supports the adoption of ACT's distinctive therapeutic stance, helping to create therapeutic relationships that are powerful, empathic, and deeply connected by the shared experience of being human.

157

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167

Index

Please note: Numbers given in italic refer to ®gures and tables. acceptance 21±4, 48±50; dif®cult emotion 98±9; experiential exercise 21±2; physicalizing exercise 96±8; promoting active acceptance 95±101; Quicksand metaphor 95; therapeutic stance 153±4; Tin-CanMonster exercise 100±1; and values 23±4; willingness 21; see also mindfulness and acceptance processes Acceptance and Action Questionnaire (AAQ) 63±4 Acceptance and Commitment Therapy (ACT) vii±ix, 3, 8; case conceptualization 71±4; commitment and behaviour change 49, 51; core processes 19±43, 51; empirical research 61±4; functional contextualism 12±13, 154±5; goals 50; in groups 145±7; inital assessment 168

75±8, 127±8; mindfulness and acceptance processes 45±9, 51; for performance enhancement 147, 149; psychological ¯exibility vii, 49±50, 51, 70, 143; therapeutic stance 151±7; therapeutic strategies 67±70; in the workplace 147, 148 ACT and CBT: assumptive differences 53±6; strategic and technical differences 57±60 ACT and RFT vii, 4±5, 9±10, 12±13, 16±18 activity scheduling 137±8 anxiety 57±8 assessment 75±8, 127±8 attention see contact with the present moment Bach, P. A. 71 Bailey, A. 133 Barnes-Holmes, D. et al. 29

INDEX

Beck, A. T. 59±60 behaviour: change and commitment 49; problematic behaviours 71±2; valuesconsistent behaviours 41±3, 72±3 behaviour change and commitment 51 behaviour therapy (BT) 7±10; First Wave 7±8, 9; Second Wave 8±9; Third Wave 9±10; treatment strategies 57, 58 behavioural activation 58 Blackledge, J. T. 15, 26, 64, 133 Bond, F. W. et al. 64, 147 breathing 118±19 Bulls-Eye Values Survey 64 case conceptualization: HFDEI approach 73±4; problematic behaviours 71±2; valuesconsistent behaviours 72±3 Chessboard metaphor 122±4 Chomsky, N. 8 Ciarrochi, J. 64, 133 Cognitive-Behaviour Therapy (CBT) 3, 8, 9, 42; assumptive differences 53±6; treatment strategies 57, 58 cognitive defusion 22±3, 25±8; and acceptance 49; altering language conventions 25±7, 103±9; and contact with the present moment 46±8; defusing unhelpful life stories 108±9; Milk, Milk, Milk exercise 104±6; objectifying psychological content 111±13; Passengers on the Bus metaphor 113; and self-ascontext 45±6; Taking Your Mind for a Walk exercise

112±13; therapeutic stance 154±5; Thoughts on Cards exercises 111±12; undermining reason giving 106±8; vs. cognitive restructuring 59±60 cognitive distancing 60 cognitive psychology 7, 9 cognitive restructuring 59±60, 63 cognitive therapy 8 commitment: and behaviour change processes 49, 51; goal setting 41±2, 136±7; valuesconsistent behaviour 41±3 committed action 139±44; ensuring stakes are high 143; external and internal barriers 140±1; generalizing skills 143±4; recommitting after setbacks 141±3; therapeutic stance 156±7; willingness 140 confusion 83 contact with the present moment 33±6; and acceptance 49; and cognitive defusion 46±8; inconsistent contact 35±6; mindfulness 115±20; therapeutic stance 156 continuity hypothesis 7±8 control agenda 85±8; creative hopelessness 79±83; Polygraph metaphor 87±8; thought suppression exercise 86±7; workability 75±8 core processes 19; acceptance 21±4; cognitive defusion 25±8; commitment 41±3; contact with the present moment 33±6; hexa¯ex model 51; self-ascontext 29±32; values 37±40 creative hopelessness 79±83; Person in the Hole metaphor 81±2; terminology 82±3 169

INDEX

Dahl, J. C. et al. 64, 132 defusion see cognitive defusion depression 58 descriptive contextualism 12 diagnostic symptoms 71 Dialectical Behaviour Therapy 9 DuFrene, T. 40, 64, 71, 72, 73 Eifert, G. H. 49, 137, 140 emotion: dif®cult emotion 98±9; mindfulness 119±20 Esteve, M. R. 62 ethical considerations 12 experiential avoidance 4±5, 21, 30, 67±8 exposure 57±8 Flaxman, P. E. 147 Fletcher, L. 45 formal stimulus properties 47±8 Forsyth, J. P. 49, 137, 140 functional contextualism 11±13, 154±5 Gardner, F. L. 147, 149 goals 50; achievement 137; goal setting 41±2, 135±7; goals vs. values 129±30 groups 145±7 Harris, R. 124, 125 Hayes, L. J. 8 Hayes, S. C. 3, 8, 10, 15, 26, 37, 45, 50, 63, 64, 67, 79, 81, 83, 87, 90, 92, 93, 95, 100, 104, 109, 112, 113, 119, 124, 125, 130±1, 132, 137, 151, 155 Hexa¯ex Functional Dimensional Experiential Interview (HFDEI) 73±4 hexa¯ex model of core processes 51 170

Hollon, S. D. 59±60 human suffering 3±5 Kabat-Zinn, J. 31, 117 Kessler, R. C. et al. 3 language 15±18, 25±7, 46±7, 103±9 learning 33 life stories 108±9 Luoma, J. B. et al. 69, 71, 88, 94, 95, 103, 109, 111, 112, 135±6, 152 Masedo, A. I. 62 Matthews, B. A. et al. 17 Milk, Milk, Milk exercise 104±6 mindfulness 115±20; breathing 118±19; daily mindfulness 116±17; thought and emotion 119±20 mindfulness and acceptance processes 45±9, 51; cognitive defusion and self-as-context 45±6; contact with the present moment and cognitive defusion 46±8 mindfulness and acceptance skills 68 Mindfulness-Based Cognitive Therapy (MBCT) 9, 117 mindfulness±acceptance±commitment (MAC) protocol 147, 149 Mof®tt, T. E. et al. 3±4 Moore, Z. E. 147, 149 Moran, D. J. 71 Murrell, A. T. 37±8 Observer exercise 124±5 Orsillo, S. M. et al. 93 Passengers on the Bus metaphor 113

INDEX

Pepper, S. C. 11±12 performance enhancement 147, 149 Person in the Hole metaphor 81±2 Personal Values Questionnaires (PVQ-I, PVQ-II) 64, 133, 143 Physicalizing exercise 96±8 Pistorello, J. 145±6 Polygraph metaphor 87±8 process and outcome measures 63±4 process research on ACT 62±3 process vs. outcome 130±1 psychological ¯exibility vii, 49±50, 51, 70, 143 Quicksand metaphor 95 randomized controlled trials 61±2 reason giving 106±8 Relational Frame Theory (RFT) viii, 8±9; and ACT vii, 4±5, 9±10, 12±13, 16±18; functional contextualism 12±13; language 15±18, 25±7; self 29±32 research: ACT process and outcome measures 63±4; process research on ACT 62±3; randomized controlled trials 61±2 self-as-content 29±30, 32, 45±6 self-as-context 22±3, 29±32, 121±5; and acceptance 49; Chessboard metaphor 122±4; and cognitive defusion 45±6; mindfulness 120; Observer exercise 124±5; therapeutic stance 155

self-as-perspective 30±1 Sidman, M. 8 Skiing metaphor 130±1 skills training 59, 68 Skinner, B. F. 7, 8, 15, 30 Smith, S. 109, 130, 137 Strosahl, K. D. et al. 136, 140, 144, 152±3 Survey of Life Principles (SLP) 133 Tailby, W. 8 Taking A Stand 136 Taking Your Mind For A Walk exercise 112±13 therapeutic stance 151±7; acceptance 153±4; committed action 156±7; competencies 151±3; defusion 154±5; present moment 156; self-as-context 155; summation 157; values 156 therapeutic strategies 67; delivery format 69±70; mindfulness and acceptance skills 68; over three training sessions 148; undermining experiential avoidance 67±8; values-based action skills 68 thought suppression exercise 86±7 thoughts and feelings 33±4, 48, 53±6; mindfulness 119±20 thoughts on cards exercises 111±12 Tin-Can-Monster exercise 100±1 Tug-of-War with a Monster metaphor 92 Two Scales metaphor 90±2 Twohig, M. 83 171

INDEX

Valued Living Questionnaire-II 64, 133 values 37±40; and acceptance 23±4; clari®cation tools 132±3, 143; clarifying values 127±33; contacting values exercise 131±2; de®nition 37, 40; initial assessment 127±8; nature and function of values 128±9; process vs. outcome 130±1; therapeutic stance 156; valued living 37±40; values vs. goals 129±30 values-based action skills 68 values-based goal and action planning 135±8; activity scheduling 137±8; goal achievement 137; goal setting 41±2, 135±7 Values Compass 132±3

172

values-consistent behaviours 41±3, 72±3 Vilardaga, R. 155 Walser, R. D. 145±6 Watson, J. B. 7, 8 willingness 21, 89±94; clean vs. dirty discomfort 93; committed action 140; not wanting 93±4; Tug-of-War with a Monster metaphor 92; Two Scales metaphor 90±2 Wilson, K. G. et al. 13, 37±8, 40, 46, 64, 71, 72, 73, 133 workability of control/avoidance strategies 75±8 workplace settings 147, 148 Zettle, R. D. 8, 60, 109, 111, 118, 124, 125

Acceptance and Commitment Therapy Distinctive Features (CBT Distinctive Features)

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