Complete Set of Worksheets Handouts for ACT Questions and Answers

Dropping Anchor: A Script In the ideal scenario, before starting this exercise, you’ve asked the client what she’s experiencing and she’s been able to tell you what thoughts, feelings, emotions, and memories are showing up; this means you can refer to them specifically. You might say, for example, “There’s a very painful memory showing up right now, and a lot of sadness and a lot of anger.” But if the client is too distressed to speak, or unable or unwilling to say what thoughts and feelings are present, then you can refer to them with nonspecific terms such as pain, or painful thoughts and feelings, or emotional storm, as in the script that follows. Take your time with this exercise. You should allow a good ten seconds between instructions. And give your voice a kind and calming quality. The therapist should model all the actions for the client, to help reduce the client’s self- consciousness. • There’s a lot of emotional pain showing up for you right now. I can see how much you’re struggling with it, how difficult it is for you. And I really want to help you handle it. So please would you follow my instructions? Okay. First, just see if you can push your feet hard into the floor. Push them down. That’s it. Feel the ground beneath you. • Now sit forward in your chair, and straighten your back. Feel the chair beneath you; notice your back sup- • Now slowly press your fingertips together, and as you do that, gently move your elbows and your shoulders. • Feel your arms moving, all the way from your fingers to shoulder blades. • Take a moment to acknowledge there’s a lot of pain here that you’re struggling with… You didn’t ask for it… porting you. but here it is…and it’s challenging and it’s difficult and you want it to go away, and yet it’s not going… Silently acknowledge to yourself what type of pain it is… For example, say to yourself, Here’s sadness or Here’s anxiety or Here’s a painful memory. (If the therapist knows what the pain is, he can specifically mention it.) • Now notice that as well as this pain, there’s also a body around that pain—a body that you can move and control. Straighten your back again, and notice your whole body now—your hands, feet, arms, legs. Gently move them, and feel them moving… Have a good stretch… Notice your muscles stretching… Press your feet down and feel the floor. • Now also look around the room—up, down, and side to side—and notice five things that you can see. • And also notice three or four things you can hear—sounds coming from me or you or the room around you. • And also notice you and me, working here together, as a team. • So notice, there’s something very painful here that you’re struggling with, and at the same time see if you can also notice your body in the chair…and gently move that body, have a stretch…that’s it, take control of your arms and legs. • And also notice the room around you. • And also notice you and me here, working together as a team. The therapist continues to cycle through the exercise— acknowledging the pain, expanding awareness, establishing control over body movement—until the client is grounded and able to engage in the session. At this point, the therapist brings the exercise to an end by asking these types of debriefing questions: • Do you notice any difference now? Are you less caught up in the emotional storm? Are you less hooked by these difficult thoughts and feelings? Are you less “swept away” by the storm? Are you less “pushed around” or “jerked around” by these feelings? • Is it easier for you to engage with me, to be present, to focus? • Do you have more control over your actions now— over your arms and legs and mouth? Check it out, move your arms and legs, have a stretch; do you notice you have control? Note: in all these questions, the therapist never asks if the storm or the emotional pain has reduced or gone away— because this is not the purpose of the exercise. To ask such questions would send the wrong message: that the aim is to reduce or distract from emotional pain. Of course, this does often happen, but in ACT that’s a bonus, not the main aim; and there’s plenty of times that it won’t happen. APPENDIX 1 ACT Case Formulation Worksheet What does the client describe as the main problem(s)? What does the client want from therapy/coaching? Emotional Goals: What thoughts, images, feelings, emotions, sensations, memories, urges would he like to have less of? (Note: We convert these to behavioral goals with the reframe: “So we’ll be learning new skills to handle these difficult thoughts and feelings more effectively, so they have less impact and influence over you.”) Behavioral Goals: What would the client like to stop/start; do more/less of? How would she like to treat himself, others, the world differently? What goals would she like to pursue? What activities/skills would she like to start, resume, develop? What people, places, events, activities, challenges would she like to approach rather than avoid? What relationships does she want to improve, and how? What life problems does he want to solve? EXTERNAL BARRIERS: Are there any external barriers (as opposed to psychological barriers) to a rich and full life (e.g., legal, social, medical, financial, occupational problems) that require problem solving and/or skills training? UNWORKABLE ACTION: What is the client doing that makes life worse, keeps her stuck, worsens problems, inhibits growth, prevents healthy solutions, impairs health, damages relationships, etc.? (What would we see and/or hear on a video?) What IMPORTANT or MEANINGFUL people, places, events, activities, situations, goals, problems, and challenges is the client avoiding or escaping (e.g., withdrawing from, quitting, procrastinating, giving up on, or staying away from)? FUSION: (Include examples of specific thoughts, as well as of processes such as “worrying”) PAST & FUTURE: (rumination, worrying, fantasizing, blaming, predicting the worst, reliving old hurts, idealizing the past or the future, flashbacks, “if only…,” “why did it happen?,” catastrophizing, resentment, regrets, etc.) SELF-DESCRIPTION: (self-judgments, self-limiting ideas about “who I am” or “what I can and can’t do,” self-labels) REASONS: (reasons the client gives for why she can’t, won’t, or shouldn’t change, or why her life can’t be improved) RULES: (about how I, others, and life should be: look for key words such as should, have to, must, ought, right, wrong, always, never, can’t because, won’t until, shouldn’t unless, etc.) JUDGMENTS: (mostly these will be negative, but sometimes positive; may be about anyone or anything: other people, oneself, one’s job, one’s body, one’s thoughts and feelings, the past, the future, or even life itself) OTHER: EXPERIENTIAL AVOIDANCE: (Private experiences the client is trying to avoid or get rid of, or is unwilling to have) THOUGHTS, IMAGES, MEMORIES, EMOTIONS, FEELINGS, SENSATIONS, URGES, CRAVINGS, WITHDRAWAL SYMPTOMS: LOSS OF CONTACTING THE PRESENT MOMENT: The 4 Ds: Distractibility, Disengagement, Disconnection, Dissociation? Deficits in ability to narrow focus, broaden focus, sustain focus, or shift focus? VALUES & COMMITTED ACTION: IMPORTANT LIFE DOMAINS: What life domains and what people does the client care about (e.g., work, study, health, parenting, marriage or other intimate relationship, friends, family, spirituality, community, environment)? VALUES: What values seem important within those domains? GOALS & ACTIONS: What values-congruent goals and activities does he (a) already have, and (b) want to pursue? NEED FOR SKILLS TRAINING: What important skills does the client lack or fail to use (e.g., problem solving, goal setting, self-soothing, assertiveness, communication, conf lict resolution, relaxation, empathy)? RESOURCES: What strengths, skills, and other personal resources does the client have that could be utilized? What external resources could be accessed? Who can the client turn to for help and support? MY PERSONAL BARRIERS: What difficult thoughts and feelings show up for me regarding this client? BRAINSTORM: What questions, exercises, worksheets, metaphors, tools, techniques, and strategies can I use in the next session? What skills training may be required? Is values-based problem solving required for external barriers? APPENDIX 2 Informed Consent It’s essential that we get informed consent from our clients to do ACT—to explain the model, let the client know what to expect, and elicit agreement. Without it, we can expect problems. The brief guide that follows will help you approach this important task. Key Points At the bare minimum, I recommend you include the following points when obtaining consent (modifying the language to suit your way of speaking and your clientele): • The name “acceptance and commitment therapy” reflects a key message: accept what is out of your personal • It’s a very active form of therapy/coaching. It’s not just talking about your problems and feelings. Our aim control, and commit to action that improves your life. here is to work together as a team, to help you be the sort of person you want to be and build the sort of life you want to live. • Part of this approach involves learning skills to handle difficult thoughts and feelings more effectively, so they have less impact and influence over you. When we introduce these skills, I’ll ask you to practice them between sessions. You don’t have to do that, of course, but it’s like learning to play a guitar or drive a care: the more practice you do, the better you get. • ACT also involves clarifying your values: finding out what matters to you, what you want to stand for in life, what strengths and qualities you want to develop, how you want to treat yourself and others. And it also involves taking action to solve your problems, face your challenges, and do things that make life better. • I want you to leave here after each session with an action plan: something practical to take away and use to actively improve your life. Consider adding the following: • At times, therapy may seem like a roller-coaster ride, but I’ll be there in the roller-coaster car with you. • I will ask you at times to try new things that may pull you out of your comfort zone—like learning new skills to handle difficult thoughts and feelings—but you never have to do them. You are always free to say no to anything I suggest. Press Pause This isn’t essential, but I highly recommend you run through this in your first session because it will give you a very powerful way to interrupt problematic behavior and reinforce workable behavior as it arises in session. • Can I have permission to “press pause” from time to time, so if I see you doing something that looks like it might be really helpful or useful, in terms of dealing with your problems and improving your life, I can just slow the session down and get you to really notice what you are doing? • For example, I may ask you to pause or slow down, take a couple of breaths, and notice what you’re thinking or feeling or saying or doing. That way, you’ll be able to see more clearly what you’re doing, and we can look at ways you can use it outside of this room. Is that okay? • And can I also press pause if I see you doing something that looks like it may be contributing to your problems or making them worse, so we can address it? • And of course, this goes both ways—you can also press pause on me, any time you like. APPENDIX 3 The Bull’s-Eye I am behaving like the person I want to be. Work/Education Personal Growth/Health My behavior is far removed from the way I’d like it to be. Leisure Relationships Adapted from Living Beyond Your Pain by J. Dahl and T. Lundren, 2006, by permission of New Harbinger Publications (Oakland, CA), http://www.newharbinger.com. YOUR VALUES: What really matters to you, deep in your heart? What do you want to do with your time on this planet? What sort of person do you want to be? What personal strengths or qualities do you want to develop? 1. 2. Work/Education: includes workplace, career, education, and skills development. Relationships: includes your partner, children, parents, relatives, friends, coworkers, and other social contacts. 3. Personal Growth/Health: may include religion, spirituality, creativity, life skills, meditation, yoga, nature; exercise, nutrition, and health risk factors such as smoking, alcohol, drugs, or overeating. 4. Leisure: how you play, relax, stimulate, or enjoy yourself; activities for rest, recreation, fun, and creativity. THE BULL’S-EYE: make an X in each area of the dart board to represent where you stand today. APPENDIX 4 Defusion from Barriers to Therapy Many clients naturally come up with all sorts of reasons why therapy won’t or can’t work for them: I’ve tried before, I can’t do it, it’s too hard, this is bullshit, I’ve always been this way, this is who I am, I’m too depressed, I’m too anxious, I’m an addict, I’ve been diagnosed with X, my life is Y, other people are Z, I’m too A, I’m not B enough, therapy is useless, this won’t work, you can’t help me because of CDE, I have disorder FGH, I’ve got no motivation (or energy, or willpower, or discipline), I’ve been permanently damaged by IJK and can never recover, and so on. Luckily, in ACT, we don’t get into challenging the content or validity of cognitions by assessing whether they are true or false, valid or invalid, positive or negative, right or wrong, appropriate or inappropriate, warranted or unwarranted. If we had to try to convince clients that their doubts about therapy are false, invalid, or unwarranted, we’d be in trouble! Doubts about therapy are perfectly natural, and only to be expected. However, if clients (or their therapists) fuse with these doubts, it will get in the way of effective work. Thus, such cognitions are good candidates for defusion, right from the word go. So let’s take a look at how we can make this happen. I aim to create, as fast as possible, a context of defusion: a space where we can allow unhelpful cognitions to be present, and see them for what they are. I also want to facilitate a context of acceptance, where there is no fighting with or challenging of thoughts, no trying to invalidate or get rid of them. My first step is generally to use the simple but effective strategy of noticing and naming: noticing the presence of cognitions, and nonjudgmentally naming them. For example, I might say, “I can see there’s a bunch of thoughts (or concerns, worries, doubts, fears, objections, and so forth) showing up for you right now about why this won’t work for you.” Validate As therapists, it’s vital that we validate such cognitions. They are commonplace—among both clients that are new to therapy and those who have experienced a lot of it. And they are completely normal and natural thoughts to have. So I tend to say something like, “Those are all very common thoughts (or concerns, worries, doubts, fears, objections, and so forth). Many of my clients have similar thoughts when we first start working. It’s perfectly natural. And to be honest, I expect they’ll crop up again and again.” A big part of both defusion and acceptance in ACT is helping clients to understand that their mind is not irrational, weird, or defective; it’s basically just trying to help. This is both normalizing and validating for clients. I tend to say something like “These thoughts are basically your mind trying to look out for you, do you a favor. It’s basically trying to save you from something that might fail or go wrong or be unpleasant. What your mind is saying is: Hey, are you sure you want to do this? You might just be wasting your time, money, and energy. This might even make things even worse for you.” I continue: “And you know, the truth is, there’s probably nothing I can say that will stop your mind from doing that. It’s just doing its job—just trying to protect you.” I then, quite often, say something like this: “You know, there’s a part of me that really wants to reassure you, to say, ‘Hey! This will work for you!’ But the truth is, I can’t guarantee that it will work. And if you ever go to any type of health professional who guarantees you ‘This will work!’—my advice would be don’t go back, because that person is either lying or deluded. Because no one can ever guarantee that. I mean, sure, I could show you all the research. I mean, there are over a thousand papers published on the ACT model; it’s helped hundreds of thousands of people around the world. But that wouldn’t guarantee it will work for you. And I could tell you about all my other clients it’s helped, but again that won’t guarantee it will work for you. “But there are two things I will guarantee. I guarantee I’ll do my best to help you. And I guarantee, if we give up because your mind has doubts, we won’t get anywhere. So even though your mind will keep coming up with reasons as to why this can’t or won’t work for you—can we go ahead with it anyway?” By this point, many clients will be unhooking from their doubts, concerns, objections, and other barriers to therapy. But what if this isn’t happening? What if the client continues to insist that therapy can’t or won’t help? Well, before we go any further, there are three important cautions to keep in mind: First, the therapist must be compassionate, respectful, and incredibly validating of the client’s experience. If the techniques described in this document are delivered in a dismissive, impatient, uncaring, or otherwise-invalidating manner, this will obviously offend or upset the client. (And of course, this holds true for any type of intervention in any model of therapy!) My second caution is about language. Please: don’t stick to the script! The idea is to modify and adapt everything in ACT to suit your own way of speaking and working. The words I like to use may be vastly different from the words you’d prefer to use; if so, please change them! Mix, match, adapt, modify, add more, or cut back. In other words, make ACT your own; do it in your own way, true to your own personality and your own manner of speaking. My third caution is that there is not one intervention in any model of therapy that works predictably and favorably with all clients. So if you apply anything from this book (or from any other material I have written) and it’s not having the effect intended, then be flexible. Consider: Do you need to modify what you’re doing in some way? Or are you better to cease doing it, and do something else instead? Write It Down Now, if the previously mentioned strategies fail to help the client unhook from her objections, doubts, concerns, or other thoughts that act as barriers to therapy, my next step is very often to write those thoughts down. Doing this usually makes it a whole lot easier for any of us to take a step back and “look at” our thoughts—instead of getting caught up in them. Typically, I ask for permission to write the thoughts down: “So you have some real and valid concerns about whether this will work for you. And I think we need to address these concerns right now, or we’re not going to get anywhere. So is it okay if, as a first step, I quickly jot them all down, so I can make sure we address them all?” And now I write the thoughts down— every objection or concern the client has about why this won’t work: I’ve tried before, I can’t do it, it’s too hard, this is bullshit, I’ve got diagnosis ABC, I’m too depressed, my life is V, other people are X, I’m too Y, I’m not Z enough, and so on. And as I’m doing this, I’ll repeat some or all of my previous comments: “I just want to reiterate, these are all very common…”; “Many of my clients have similar thoughts when we first start working…”; “It’s perfectly natural—your mind is trying to help, to save you from something that might be unpleasant…”; “So really, we can expect these kinds of thoughts to keep cropping up, again and again.” I often then say, “You know, I don’t think I’ll be able to persuade you or convince you that this approach is the right for one you, that it’s going to work for you. In fact, my guess is, the harder I try to convince you, the more those thoughts are going to show up. What do you think?” At this point, most clients will reply along the lines of “Yeah, I guess you’re right.” (And often there’s a hint of amusement in this response, which is usually indicative of some defusion.) The door is now wide open to usher in the concept of workability. Following the previous step, I usually say something like “So here’s the thing. These thoughts (pointing to the thoughts written on the paper) are going to show up again and again and again as we do this work together. I have no idea how to stop that from happening. And each time they do, we have a choice to make about how we respond to them. “One choice is: we give up. We let your mind call the shots. Your mind says This won’t work, so we go along with that, we call it a day, and we pack it in. “A second choice is: we get into a debate. I try hard to convince your mind to stop thinking this way; I try to prove your thoughts are false and to convince you that this approach will work. The problem is, that kind of debating will eat up our valuable session time, and I can pretty much guarantee your mind will win the debate anyway—so we won’t be any better off. “A third choice is: we can let your mind say this stuff, and we can just carry on…we just keep on working together as a team…working away here, to help you build a better life…and even though your mind will keep saying all this (pointing to the thoughts on the paper), we just keep on working.” Finally, I ask, “So which of those options would you prefer?” If our client now agrees to option three, well, that’s defusion, right there: the thoughts are present, but they are no longer dominating the client’s behavior in self-defeating ways. And the client is also consciously allowing the thoughts to be present: a gentle first step toward acceptance of unwanted thoughts. If our client now comes up with more objections, we can add them to the list, and then repeat the same three choices. If our client tries to debate, we can notice and name it: “So it seems like you want me to debate this with you. But there’s just no point. I won’t win. I won’t convince your mind. So we really have just two choices here: give up and pack it in, or let your mind say this stuff and carry on.” If the client now agrees to option three— again, that’s defusion, right there! I’ve only ever twice had a client choose option one. Both times, I replied, “Okay. I get that’s the choice you’d like to make. But given that you’re already here, it seems a shame to give up now. Can we at least finish this one session, given you’re here? And for this one session, can we not get into a debate about these thoughts? Can we just let your mind say this stuff, and carry on?” Both times, the client agreed. (Obviously, this strategy may not work with a mandated client, but that’s a different issue.) Ongoing Defusion The therapist can now use this for ongoing defusion and acceptance throughout the session. For example, when new objections occur, the therapist can write them down and again ask the client to choose how to respond. If the same objections recur, the therapist can respectfully and compassionately acknowledge it and point to the paper: “We’ve got that one down already. So again, there’s a choice to make here…” An alternative to the above is to give the sheet to the client with a pen, and ask her to tick each thought as it recurs. The therapist can respectfully and compassionately acknowledge it each time. “Keeps showing up. So do we give up, or waste time debating, or do we acknowledge the thought just popped up again and carry on?” One option is for the therapist to keep the paper, and on the next session, present it to the client: “I expect these will all show up again today. Any of them showing up right now? Most of them? Cool. Can we let them be there, and carry on? Great. And let’s see if your mind comes up with any new ones today.” Reason-Giving Note that the strategies outlined above fit very neatly with the metaphor of the reason-giving machine. (Our mind is like a reason-giving machine. As soon as we even think about stepping out of our comfort zone into a challenging situation, the reason-giving machine starts cranking out all the reasons why we can’t do it, shouldn’t do it, or shouldn’t even have to do it…) Reason-giving (coming up with reasons why we can’t or shouldn’t change our behavior) is one of the main categories of problematic fusion we encounter in ACT. So in using the strategies above, the therapist is already helping the client to notice reason-giving and defuse from it. And we can of course use this strategy with any type of reasongiving that occurs later in therapy. It’s also a great way for helping clients defuse from helplessness and hopelessness. Finally, note just how much we’ve covered here in terms of defusion. We now have a wealth of strategies to draw on repeatedly and develop further in subsequent sessions. And note too that all of this could be done in the very first session, even as we’re getting to know the client: taking our initial history and formulating a treatment plan. APPENDIX 5 The Hands as Thoughts and Feelings Exercise This exercise is predominantly a metaphor for defusion, although it references all six core ACT processes. It’s evolved from my earlier Hands as Thoughts exercise (Harris, 2009a), and the instructions overlap a lot with the Pushing Away Paper exercise detailed in appendix 6. It’s very useful to help clients understand the rationale for and benefits of developing defusion skills, and to explicitly link these to the client’s therapy goals. However, it’s only a metaphor; it won’t give clients the ability to defuse. We need to follow it up with active training of defusion skills, in session. The script that follows is a generic version, suitable for just about anyone. It’s much more powerful if we can make it specific to each unique client, so that instead of saying things like “all the people you care about,” we’d say, for example, “your husband, Michael, and your teenage daughter, Sarah.” When I do this, I usually carry my chair over to the client, and we both sit side by side, with our backs to the wall, facing the room, and we both do all the actions simultaneously. You don’t have to do it this way, of course; like any exercise in ACT, you can modify and adapt it freely to suit yourself; I’ve just found it more powerful to do so. I also like to do two lovely variants on this exercise. One option is to write down some relevant thoughts and feelings on a sheet of paper, and use this instead of one’s hands; and yet another option is to write them down with an indelible all-surface marker on something thin, flexible, and transparent such as bubble wrap, acetate, or cellophane. Therapist: (sitting side by side with the client, both facing the room) Imagine that out there in front of you (gesturing to the contents of the room and the far wall) is everything that really matters to you, deep in your heart; everything that makes your life meaningful (or used to, in the past); all the people, places, and activities you love; all your favorite foods and drinks and music and books and movies; all the things you like to do; and all the people you care about and want to spend time with. But that’s not all. Also over there are all the problems and challenges you need to deal with in your life today, such as…(therapist gives some examples based on the client’s history, such as “your conflict with your son,” “your financial issues,” “your health problems,” “your court case,” “your search for a job,” “your chemotherapy for your cancer”). And also over there are all the tasks you need to do on a regular basis to make your life work: shopping, cooking, cleaning, driving, doing your tax return, and so on. Now please copy me as we do this exercise. Let’s imagine that our hands are our thoughts and feelings, and let’s put them together like this. (Therapist places his hands together, side by side, palms upward, as if they are the pages of a book. The client copies him.) Now, let’s see what happens when we get hooked by our thoughts. (The therapist slowly raises his hands toward his face, until they are covering his eyes. The client copies him. Both keep their hands over their eyes as the next section of the exercise unfolds.) Now notice three things. First, how much are you missing out on right now? How disconnected and disengaged are you from the people and things that matter? If the person you love were right there in front of you, how disconnected would you be? If your favorite movie were playing on a screen over there, how much would you miss out on? Second, notice how difficult it is to focus your attention on what you need to do. If there’s an important task in front of you right now, how hard is it to focus on it? If there’s a problem you need to address or a challenge you need to tackle, how hard is it to give it your full attention? Third, notice how difficult it is, like this, to take action, to do the things that make your life work, such as… (therapist gives some examples based on the client’s history, such as “to cook dinner,” “to drive your car,” “to cuddle your baby,” “to type on your computer,” “to hug the person you love”). So notice how difficult life is when we’re hooked. We’re missing out, we’re cut off and disconnected, it’s hard to focus, and it’s hard to do the things that make life work. Now, let’s see what happens as we unhook from our thoughts and feelings. (Therapist now slowly removes his hands from his face, and lowers them until they drop into his lap. The client copies him.) So notice what happens as we unhook. What’s your view of the room like now? How much easier is it to engage and connect? If your favorite person were in front of you right now, how much more connected would you be? If your favorite movie were playing, how much more would you enjoy it? If there were a task you needed to do or a problem you needed to address, how much easier would it be to focus on it, like this? Now move your arms and hands about—(therapist gently shakes his arms and hands around; client copies). How much easier is it now to take action: to drive a car, cuddle a baby, cook dinner, type on a computer, hug the person you love? (Therapist mimes these activities as he says them; the client usually will not copy this part, but that doesn’t matter.) Now notice these things (therapist indicates his hands, now once more resting in his lap) haven’t disappeared. We haven’t chopped them off and gotten rid of them. They’re still here. So if there’s something useful we can do with them, we can use them. You see, even really painful thoughts and feelings often have useful information that can help us, even if it’s just pointing us toward problems we need to address or things we need to do differently, or simply reminding us to be kinder to ourselves. And if there’s nothing useful we can do with them, we just let them sit there. APPENDIX 6 Pushing Away Paper Exercise This exercise is predominantly a metaphor for acceptance and experiential avoidance, although it references all six core ACT processes. It’s evolved from my earlier Pushing the Clipboard exercise (Harris, 2009a), and the instructions overlap a lot with the Hands as Thoughts and Feelings exercise detailed in appendix 5. “Pushing away paper” is a very useful metaphor to help clients understand the rationale for and benefits of developing acceptance skills, and to explicitly link this to the client’s therapy goals. However, it’s only a metaphor; it won’t give clients the ability to accept. We need to follow it up with active training of acceptance skills, in session. The script that follows is a generic version, suitable for just about anyone. It’s much more powerful if we can make it specific to each unique client, so that instead of saying things like “all the people you care about,” we’d say, for example, “your husband, Michael, and your teenage daughter, Sarah.” When I do this, I usually carry my chair over to the client, and we both sit side by side, each with a sheet of paper. Our chairs back up to the wall, we both face toward the room, and we both do all the actions simultaneously. You don’t have to do it this way, of course; like any exercise in ACT, you can modify and adapt it freely to suit yourself. The exercise is more powerful if we first write down on the paper the specific thoughts, feelings, emotions, memories, urges, cravings, and sensations that the client is trying to avoid or escape. A word of warning: this exercise is quite strenuous for most people, so don’t ever do this with clients who have painful neck, spine, and shoulder conditions! Therapist: (sitting side by side with the client, both facing the room, both holding sheets of paper) Imagine that out there in front of you (gesturing to the contents of the room and the far wall) is everything that really matters to you, deep in your heart; everything that makes your life meaningful (or used to, in the past); all the people, places, and activities you love; all your favorite foods and drinks and music and books and movies; all the things you like to do; and all the people you care about and want to spend time with. But that’s not all. Also over there are all the problems and challenges you need to deal with in your life today, such as…(therapist gives some examples based on the client’s history, such as “your conflict with your son,” “your financial issues,” “your health problems,” “your court case,” “your search for a job,” “your chemotherapy for your cancer”). And also over there are all the tasks you need to do on a regular basis to make your life work: shopping, cooking, cleaning, driving, doing your tax return, and so on. Now please copy me as we do this exercise. Let’s imagine that this sheet of paper is all those difficult thoughts, feelings, emotions, and memories that you’d like to get rid of. Now hold it tightly at the edges like this, and push it as far away from you as you possibly can. (Therapist holds the paper tightly at the edges with both hands, and stretches his arms out, pushing the paper as far away as possible. The client copies him.) This is what your culture tells you to do—get these thoughts and feelings away from you. Friends tell you to do this, doctors, therapists, counselors, women’s magazines; everyone. Right? But hey (therapist says this next part humorously), it looks like we aren’t really trying very hard here; let’s push harder. Push as hard as you possibly can. Straighten those elbows, dislocate those shoulders; let’s get these thoughts and feelings as far away as possible. (The therapist and client maintain this posture for the next section of the exercise: holding the paper tightly by the edges, arms straight, holding it as far from the chest as possible.) Now notice three things. First, how tiring is this? We’ve only been going for less than a minute, and already it’s tiring. Imagine doing this all day; how much energy it would consume? Second, notice how distracting it is. If the person you love were right there in front of you, how hard would it be to give her your full attention? If your favorite movie were playing on a screen over there, how much would you miss out on? If there’s an important task in front of you right now or a problem you need to address or a challenge you need to tackle, how hard is it to focus on it? Third, notice while all your effort and energy is going into doing this, how hard it is to take action, to do the things that make your life work, such as (therapist gives some examples based on the client’s history, such as “to cook dinner,” “to drive your car,” “to cuddle your baby,” “to type on your computer,” “to hug the person you love”). So notice how difficult life is when we’re struggling with our thoughts and feelings like this. We’re distracted, we’re missing out on life, it’s hard to focus, we’re exhausted, and it’s so hard to do the things that make life work. Now, let’s see what happens when we drop the struggle with our thoughts and feelings. (Therapist now relaxes his arms, drops the paper into his lap. The client copies him. Typically the client will express a sigh of relief “Ahh—that’s better”.) Big difference, huh? How much less tiring is this? How much more energy do you have now? How much easier is it to engage with and focus on what’s in front of you? If your favorite person were in front of you right now, how much more connected would you be? If your favorite movie were playing, how much more would you enjoy it? If there were a task you needed to do or a problem you needed to address, how much easier would it be to focus on it? Now move your arms and hands about—(therapist gently shakes his arms and hands around; client copies). How much easier is it now to take action: to drive a car, cuddle a baby, cook dinner, type on a computer, hug the person you love? (Therapist mimes these activities as he says them; the client usually will not copy this part, but that doesn’t matter.) Now notice these things (therapist indicates the paper in his lap) haven’t disappeared. We haven’t gotten rid of them. They’re still here. But we’ve got a new way of responding to them. We’re handling them differently. They’re no longer holding us back, or bringing us down, or jerking us around. And if there’s something useful we can do with them, we can use them. You see, even really painful thoughts and feelings often have useful information that can help us, even if it’s just pointing us toward problems we need to address or things we need to do differently, or simply reminding us to be kinder to ourselves. And if there’s nothing useful we can do with them, we just let them sit there. APPENDIX 7 Triggers-Behavior-Payoffs Worksheet Triggers Behavior Payoffs (situation, thoughts, and feelings that (what you do) (outcomes of the behavior that keep immediately precede the behavior) it going) Common payoffs include: Escape/avoid people, places, situations, events; escape/avoid unwanted thoughts & feelings; get your needs met/get what you want; feel good; feel safe or familiar; feel like you deserve it; feel like you are right and others are wrong; feel powerful or in control; gain attention; look good to others; make sense (of life, the world, yourself, others) ACT Exposure Crib Sheet Contacting the Present Moment Dropping anchor, Expansive awareness, Mindful stretching, breathing, moving 0–10, how present are you right now? Notice you and me, working together, as a team Acceptance Notice & Name Open up, allow Let it flow through you Hold yourself kindly 0–10, how much are you fighting this? Are you willing to make room for this? Defusion Notice & Name difficult thoughts & memories I’m having a memory of: Notice size, shape, location, movement 0–10, how hooked are you? People Places Objects Situations Events Activities RepertoireNarrowing Stimuli Thoughts Images Memories Emotions Sensations Self-as-Context There’s a part of you noticing everything T.I.M.E.S. change – and this part of you can step back and notice it happening Use this part to bring up the lights on the stage show Values What’s this work in the service of? What matters enough that you are willing to do this? What values are you living, simply in doing this challenging work? 0–10, how in touch with those values are you right now? Committed Action What goals will this help you with? 0–10, how much control do you have over your actions right now? Mindfully move your arms, legs, body Are we okay to keep going with this? APPENDIX 9 A Clinician’s Guide to Getting Unstuck from Just About Anything ACT practitioners will all get stuck at times, no matter how experienced and knowledgeable they may be. In this appendix, I’ll recap the strategies that I have found to be the most useful for helping therapists to get themselves and their clients unstuck. And I’ll remind you where you can find them within this book. Any time you find yourself confused, stuck, worried, frustrated, or hopeless about how to work with a client, I encourage you to run through this guide, step by step, and actively apply it. I’m confident that if you do, you’ll find something useful. Case Formulation Whenever you are stuck with a client, take at least ten to fifteen minutes to fill out an ACT Case Formulation worksheet (appendix 1). This will usually (a) give you a wealth of ideas for where you can intervene, and (b) highlight important areas of information you are missing. When doing this, we always want to ensure that we complete the section on our own personal barriers and apply ACT to ourselves to deal with our own fusion and avoidance. After all, the more fused and avoidant we are in session, the less effective we’ll be with our clients. The Choice Point The choice point (chapter 1: Playing with the Choice Point) is a great tool for quickly plotting out any issue or problematic behavior, from suicidality and aggression to addiction and anorexia, and generating an action plan to deal with it. It will help you to identify the difficult thoughts and feelings that “trigger” the behavior, which you’ll then target with unhooking skills (defusion, acceptance, present moment, self-compassion, self-as-context). It will enable you to pinpoint difficult situations and problems that you’ll target with values-guided problem solving and committed action. And it’ll aid you in identifying alternative, values-congruent behaviors to replace the away moves. Even if you don’t use the choice point overtly in session with your client, it can be very useful for you to draw one out as part of your own case formulation: either as a broad snapshot of all the client’s problems, or as a detailed map of one specific client behavior. Informed Consent and Behavioral Goals By far the most common issues I encounter in supervision are due to omission by the therapist of these two essential steps: obtaining informed consent to do ACT (appendix 2) and establishing behavioral goals for therapy (chapter 3: Ghastly Goals). If you’ve skipped over either or both of these fundamentals, your client may want something completely different from therapy than what you are offering, in which case you can expect confusion, resistance, or sessions without any sense of direction. Remember, if you don’t establish behavioral goals (what the client wants to do), your client will almost always have emotional goals (what the client wants to feel), and if so, he will assume that the purpose of therapy is to get rid of unpleasant thoughts and feelings and replace them with pleasant ones. So ask yourself: • Have I obtained informed consent for ACT? (If yes, has the client forgotten or misunderstood? Do I need to obtain it again?) • Have I clearly established behavioral goals (as opposed to emotional goals) for therapy? Press Pause In session, is your client behaving in ways that interfere with therapy? If so, get permission to “press pause” (appendix 2) and start using this as an active intervention. Use “press pause” to interrupt the behavior as it occurs, then respectfully and compassionately explore it. Bring openness and curiosity to the behavior, and look at it in terms of workability. Explore whether it is towards or an away move. Does it help you and the client work together as a team? Does it help the client move toward or away from the behavioral goals established for therapy (chapter 3: Ghastly Goals)? Once the client agrees that the therapy-interfering behavior is an away move or is getting in the way of working together effectively, one option is to plot the behavior itself on a choice point diagram. This enables you to identify the antecedent thoughts and feelings that trigger the behavior, target them with unhooking skills, and generate more effective behaviors. Setting an Agenda If you’re not getting much accomplished in a session, then you’d be wise to set an agenda at the start of each session (chapter 11: Sticky Structure). Agree on an area of life to work on, or a skill to practice, or a quadrant of the bull’s-eye or an aspect of the choice point to focus on. Use the agenda itself to train focusing, refocusing, and commitment: every time the client goes off track, respectfully notice and name it, and gently and respectfully guide him back to the agenda. Creative Hopelessness When a client is fixated on feeling good or getting rid of unwanted thoughts, feelings, sensations, memories, and so on, we will need to introduce (or reintroduce) creative hopelessness (chapter 8: Crummy Creative Hopelessness). This opens the client to new, more flexible ways of responding to difficult thoughts and feelings. After creative hopelessness, we usually move to dropping the struggle (also in chapter 8), and from there, we can segue into any unhooking skill, such as defusion, acceptance, self-compassion, or dropping anchor. All these mindfulness skills teach clients new ways of responding to their painful thoughts and feelings, with an attitude of openness and willingness rather than avoidance. Overcoming Our Own Self-Doubt and Fear of Failure Do you have self-doubt about introducing experiential exercises to clients? Are you worried that the techniques will be ineffective or the client will see them as lame or feel invalidated? The inconvenient truth is, such unwanted outcomes are always possible. (And this is nothing special about ACT; it’s true for any intervention in any model of therapy.) So if fear of failure or self-doubt is holding us back, we want to apply ACT to ourselves. We might say to the client: I really want to help you to XYZ. (XYZ are the client’s behavioral goals for therapy.) And I have an idea of something that could help. The problem is, my mind is trying to talk me out of it. My mind is saying, You’ll find this lame or silly or invalidating. And I’m feeling anxious about introducing it to you; I notice my heart is racing, and my stomach is churning. And my mind is saying, Shut up! Don’t say anything else. Change the topic. But I’m also listening to my values as a therapist; my aim is to help people. And if I don’t introduce this to you because I’m not willing to make room for my own anxiety about it, then I’m not being true to my values, and I don’t think I’m doing you the service you came for. So even though I feel anxious, and my mind’s saying you won’t like this, I’d like to introduce you to something that I think can really help you to XYZ. Again, notice how the fundamentals must be in place: we need to have established behavioral goals for therapy, and have informed consent for ACT, in order to make this work. We also want to introduce the idea of experiments: “Can we treat this as an experiment? I never know what will happen in advance. I think it will be helpful for you; otherwise I wouldn’t suggest it. It usually is for most people, but I can never know for sure. Can we do this as an experiment and see what happens? And afterward, you tell me if it’s helpful or not.” Overcoming Resistance to Exercises If your client seems unwilling to do experiential exercises or learn new skills in session, check: Have you gotten informed consent? Have you established behavioral goals? Are you giving a clear rationale for each and every exercise—making it clear as to how it will help the client with her behavioral goals? Are you setting up each exercise up as an experiment? Are you responding effectively when interventions backfire? For more on these topics, read chapter 4: Beastly Barriers. If the client is hesitant to do exercises due to her anxiety, then first validate and normalize the anxiety. Then ask if you can focus the session on learning new skills to handle anxiety; be clear that the reason for doing this is to help your client achieve her therapy goals. Explicitly tease out that the way she is responding to her anxiety in session is preventing her from achieving those very goals. Once she agrees, your next step will usually need to be creative hopelessness (chapter 8). Doing ACT vs. Talking About ACT Check with yourself: are you actively practicing core skills in session with your client? Or are you just talking about ACT? Don’t fall into the trap of thinking metaphors are enough. If you introduce a metaphor such as hands as thoughts and feelings (appendix 5) or pushing away paper (appendix 6), you must then go on to actively practice defusion skills or acceptance skills. (If your client doesn’t want to practice skills, then see the previous point.) Get crystal clear: what does the client want from therapy? If she doesn’t want ACT, then you have to make a choice: use a different model or refer her to someone else. Dropping Anchor If your client is experiencing extreme fusion, emotional dysregulation, dissociative states, flashbacks, or other intense emotional and cognitive reactions that interfere with therapy, then make your sessions about dropping anchor (chapter 7: Dodgy Dropping Anchor). Build anchoring skills first, before going on to other aspects of the model. Defusion from Hopelessness If your client is feeling hopeless about himself, life, the future, or therapy itself, this is obviously going to interfere with progress. So our first step is usually going to involve defusion from the hopelessness itself. See chapter 12: Measly Motivation. See also chapter 9: Dastardly Defusion, especially the Q&A on “What techniques work best with extreme fusion?” Building Motivation If your client is lacking motivation to do the challenging work of therapy, first get buy-in through informed consent (appendix 2) and establishing behavioral goals (chapter 3). Then work on defusion from hopelessness and other barriers to therapy as described in the previous point. And then, as soon as possible, bring in values to build motivation. For more on this topic, see chapter 12: Measly Motivation. Reinforcing Change Between Sessions If your client is failing to make changes between sessions, then your first step is to find out why. Start your next session by exploring what the barriers are, and then target them. For failure to do “homework,” use the strategies in chapter 12: Measly Motivation. Keeping Sessions Focused and Productive If your client keeps going off topic, switching problems, jumping from worry to worry, changing the subject, or filling up the session with worrying and ruminating, there are a few steps to take. Assuming you have informed consent and have established behavioral goals for therapy, the next two steps are to (a) get permission to “press pause” and start using it to interrupt such fused behavior as it arises, and (b) set an agenda for the session. Once all this is in place, use press pause to interrupt fused behavior, and then target the fusion itself. Often, for such extreme fusion, it’s good to start with simple but powerful exercises such as those in chapter 9: Dastardly Defusion, especially the ones described in the Q&A on “What techniques work best with extreme fusion?” Functional Analysis Last but definitely not least, don’t forget about good old-fashioned functional analysis (chapter 5: Freaky Functional Analysis). If you’re finding it difficult to constructively influence any type of problematic behavior—whether it’s happening in session or between sessions—take the time and effort to analyze it in terms of ABCs (antecedents, behavior, and consequences). This will usually give you a wealth of ideas for effectively interrupting the problematic behavior and reinforcing a more workable behavior as an alternative.