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“In this authoritative text, Luoma, Hayes, and Walser present a clearly written and practical step-bystep guide for therapists who are using acceptance and commitment therapy (ACT). Firmly rooted in
contextual behavioral science and derived from a well-articulated theory, this text clearly describes and
illustrates the concrete strategies to target a set of key processes that are critical to improve the lives of
people. Every clinician should be familiar with it. It is a masterful book. I highly recommend it.”
—Stefan G. Hofmann, PhD, professor of psychology at Boston University,
past president of the Association for Behavioral and Cognitive Therapies, and
author of Emotion in Therapy
“This second edition is an exceptional guide for the skillful and flexible implementation of ACT principles. The chapters outline the six core flexible ACT processes and their methods, with case examples
and dialogues that bring the information to life. The book includes a unique and invaluable set of
training tools and tests of core competencies. This is a masterful ‘how to’ for ACT suitable for clinicians at any level of training and experience.”
—Michelle G. Craske, PhD, distinguished professor, and director of the Anxiety
and Depression Research Center at the University of California, Los Angeles
“Firmly grounded in contextual behavioral science (CBS), superbly organized with lucid and comprehensive explanation of all ACT concepts and competencies, and loaded with clinical pearls and pitfalls
to avoid, this book lives up to the title and then some, as one of the best books for learning ACT.
Further, the clinical vignettes and self-reflective exercises will deepen and advance the practice of more
seasoned practitioners of ACT. The updated text and the new inclusion of an excellent chapter on
culture and diversity make this edition more relevant and invaluable than ever in this diverse, globalizing world. This book is simply a ‘must-have’ for any serious ACT practitioner!”
—Kenneth P. Fung, MD, FRCPC, MSc, associate professor in the department
of psychiatry at the University of Toronto; clinical director of the Asian Initiative
in Mental Health at the University Health Network; and president-elect of the
Society for the Study of Psychiatry and Culture
“ACT has been at the forefront of the pioneering third-wave cognitive behavioral therapies for many
years. Not only has it uniquely linked the human evolution of language and symbol formation to mental
processes that can cause suffering (relational frame theory [RFT]), but it has articulated six clear processes for therapeutic intervention centered around developing psychological flexibility. For both
novice and expert therapists of any orientation, you could not want for a more clearly articulated, easily
accessible, and therapeutically wise approach than this by these leaders and pioneers in the field. Full
of therapeutic transcripts with clear, insightful descriptions of the therapeutic process, this beautifully
written book is an outstanding contribution to therapeutic literature that is bound to become a classic
and an essential text.”
—Paul Gilbert, professor at the University of Derby, creator of compassion-focused
therapy (CFT), founder of the Compassionate Mind Foundation, and author of
The Compassionate Mind
“The tremendous dedication of thought and care Luoma, Hayes, and Walser infused into this second
edition of Learning ACT is evident in the breadth and depth of every chapter. Their labor of love
resulted in a preeminent and indispensable guide for novice and advanced ACT practitioners alike.
Especially valuable are the fifty core competency exercises that stimulate experiential engagement. The
chapter on adapting ACT to cultural contexts makes this a cutting-edge treatment for individuals from
every walk of life who want to move in valued directions while welcoming all their thoughts and
feelings.”
—Mavis Tsai, PhD, coauthor of A Guide to Functional Analytic Psychotherapy,
and research scientist and clinical faculty at the University of Washington
Learning
ACT
SECOND EDITION
An Acceptance & Commitment Therapy
Skills Training Manual for Therapists
JASON B. LUOMA, P h D
STEVEN C. HAYES, P h D
ROBYN D. WALSER, P h D
Context Press
An Imprint of New Harbinger Publications, Inc.
Publisher’s Note
This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It
is sold with the understanding that the publisher is not engaged in rendering psychological, financial, legal, or other
professional services. If expert assistance or counseling is needed, the services of a competent professional should be
sought.
Distributed in Canada by Raincoast Books
Copyright © 2017 by Jason B. Luoma, Steven C. Hayes, and Robyn D. Walser
Context Press
An imprint of New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
Cover design by Amy Shoup
Acquired by Catharine Meyers
Edited by Jasmine Star
Indexed by James Minkin
All Rights Reserved
Library of Congress Cataloging-in-Publication Data on file
To my partner, Jenna LeJeune, for your support, your sacrifice, and your faith in me.
—­JBL
I would like to dedicate this book to David H. Barlow, and to my fellow interns (Peter M. Monti,
Kelly D. Brownell, A. Toy Caldwell-­Colbert, and Carol Heckerman Landau) who worked under
him in the first class of clinical psychology at Brown University, Department of Psychiatry and
Human Behavior, 1975–­1976 and who such showed patience and kindness in shaping up a wild
man (that would be me) to be able to work with people.
—­SCH
I would like to dedicate this book to Susan L. Pickett. Thanks for the encouragement
over the years and for always having faith in me.
—­RDW
Contents
Acknowlegmentsvii
Introduction1
1
The Focus of ACT and Its Six Aspects13
2
Developing Willingness and Acceptance37
3
Undermining Cognitive Fusion88
4
Getting in Contact with the Present Moment132
5
Building Flexible Perspective Taking Through Self-­as-­Context163
6
Defining Valued Directions197
7
Building Patterns of Committed Action238
8
Conceptualizing Cases Using ACT272
9
The ACT Therapeutic Stance316
10
Adapting ACT to Cultural Contexts349
11
Bringing It All Together371
Appendix A: The ACT Core Competency Rating Form413
Appendix B: Resources for Further Development420
Appendix C: Using ACT in Different Settings422
Glossary425
References429
Index443
Acknowledgments
This book was a team effort. To all those who read and provided feedback on drafts of these chapters,
thank you. The exercises were particularly improved by those who piloted chapters of this book, including Mary Englert, Anne Shankar, Lianna Evans, Ross Leonard, Brendan Sillifant, Kevin Handley,
Laura Meyers, Joanne Hersh, Jennifer Boulanger, and Jennifer Plumb. Thanks to the Portland ACT
peer consultation group for their ideas about how to organize the book, exercises, and videos. Thanks
to Joe Parsons for discussions about shaping therapist behavior, which influenced the exercises in this
book. Thanks to those who provided feedback on the first edition including Donna Read, Ana Gallego,
Miguel Lewis, Hiba Giacoletto, Brady Henderson, Petra Berg, Andrea Sieg, Kathleen Thorndike, Fred
Kane, Magda Permut, Kaylin Jones, Sonia Combs, and the therapists at Lutheran Community Services
of Spokane. Your input resulted in some large improvements in this edition, and your efforts will touch
the lives of thousands of future readers and their hundreds of thousands of clients. All those people will
never know that they should thank you for the time you put into improving the book.
To all of our clients who have honored us with their presence, trust, and courage. Without all of
you, this book would not have been possible.
Thanks to those students and professionals who allowed themselves to be supervised by us and who
taught their supervisors so much. Thanks to our editors, Jude Berman and Jasmine Star, for smoothing
out our language and making our jargon more understandable.
Acknowledgment from individual authors:
Thank you to all those who helped me (JBL) learn ACT. When I first began studying ACT, I was
blown away by the rigor and scope of the theory and was thoroughly confused by the technical language. I was rapidly able to utilize many of the metaphors and exercises, but didn’t really understand
how it all tied together. I needed a book about the in between moments. This is my attempt to write
that book.
I (SCH) would like to thank my wife, Jacqueline Pistorello, for her support, advice, and patience
throughout, and to thank my lab for their input and encouragement.
I (RDW) would like to thank my mom for providing some of the illustrations in this book. They look
great, Mom! We appreciate your willingness and action on short notice. I love and miss you. And thank
you to my brothers for being there in times of need and as well times of joy, much love to you and your
families.
Introduction
Whenever Richard Cory went down town,
We people on the pavement looked at him:
He was a gentleman from sole to crown,
Clean favored, and imperially slim.
And he was always quietly arrayed,
And he was always human when he talked;
But still he fluttered pulses when he said,
“Good-­morning,” and he glittered when he walked.
And he was rich—­yes, richer than a king—­
And admirably schooled in every grace:
In fine, we thought that he was everything
To make us wish that we were in his place.
So on we worked, and waited for the light,
And went without the meat, and cursed the bread;
And Richard Cory, one calm summer night,
Went home and put a bullet through his head.
—­Edwin Arlington Robinson
It is impossible to construct a human life untouched by suffering. Edwin Arlington Robinson’s well-­
known poem reminds us that, every day, people who seemingly have all the things a person could ever
want, at least as viewed from the outside, end their existence rather than bearing up under another
moment. We of the human species encounter many of the same painful events as do other species;
humans and nonhuman animals alike are faced with loss, unexpected upsets, and physically painful
experiences. Yet we do something with these encounters that other species do not: we think about
them, analyze them, predict them, and ruminate about them, and through this process we amplify our
suffering and bring it with us.
The human ability to think and reason is truly amazing. Our system of language is unlike any
other; as an ongoing process, it fills our awareness with a never-­ending stream of verbal connections.
2
Learning ACT, 2d edition
This ability is both a wonderful and a terrible thing. It sustains the capacity for human achievement:
our ability to communicate, build, plan, and engage in problem solving. It is part of our ability to love
deeply and commit to others, to dream of hoped-­for futures and work toward their realization. However,
the same cognitive and verbal building blocks that enable these possibilities also allow us to struggle in
the midst of plenty. They allow us to be Richard Cory.
Human beings struggle in a number of ways that can be painful and life changing. When events
occur that bring us into contact with difficult emotions and thoughts, we often work very hard to rid
ourselves of these experiences, both by trying to avoid the event that triggered them and by attempting
to remove the negatively evaluated emotions and thoughts that accompany the experience. For
instance, we don’t want to feel anxiety about failure or sadness about loss, so when an event occurs that
might occasion those emotions, we work to avoid the event and the resulting emotional reactions.
It isn’t surprising that we take these steps. If something is unpleasant, it makes sense to figure out
how to remove what is unpleasant. The problem with this strategy lies in the paradoxical effects of
language—­those symbolic abilities that make up what we call in common terms the mind—­as we
attempt to use these abilities to avoid or subtract that which cannot be avoided or subtracted. When it
becomes important that we not think or feel a certain way and we nevertheless find ourselves thinking
or feeling that way, our minds can become consumed with efforts to diminish or eliminate these experiences. Often, however, in the very effort to eliminate these experiences, we propagate and grow the
demons we wish to destroy.
Acceptance and commitment therapy (ACT, which is said as one word, not as A.C.T.; Hayes,
Strosahl, & Wilson, 1999) offers a possible antidote to the harmful functions of this verbal capacity
and its role in human suffering. ACT is an evidence-­based contextual cognitive behavioral intervention designed to create greater psychological flexibility and, as a result, human liberation. ACT
addresses the paradoxes inherent in human cognitive processes and works to help people live meaningful and valued lives.
ACT employs a number of strategies to alleviate people’s problems and promote their flourishing,
including willingness or acceptance of experience; cognitive defusion; flexible attention to the present
moment; contact with a transcendent or perspective-­taking sense of self (self-­as-­context); clarity and
ownership of values; and fostering commitment to larger patterns of values-­based living. Each of these
processes is applied with warmth and compassion for the client’s struggle and for the difficulties that
unwanted experience can bring. ACT is a constructive approach to psychotherapy that helps people
learn to compassionately embrace their internal experience for all that it is while also focusing on
building repertoires of constructive behaviors that are values oriented.
ACT is informed by all of the elements of what is now known as contextual behavioral science, or
CBS (Zettle, Hayes, Barnes-­Holmes, & Biglan, 2016). CBS aims to recast behavioral science itself and
takes a functional approach to the major elements needed for knowledge development in this domain.
CBS includes functional contextualism as a philosophy of science (Biglan & Hayes, 2016), evolution
science principles (Hayes, Monestès, & Wilson, in press), and behavioral principles as augmented by
relational frame theory (RFT; Hayes, Barnes-­Holmes, & Roche, 2001). All of these various elements
come together to define ACT as a contextual behavioral method.
The relationship of ACT to this larger set of assumptions, principles, and strategies has been
written about extensively in previous books, and we summarize some of this topic briefly in a more
clinical way in this volume. In particular, we describe the manner in which ACT approaches how
human language and cognition contribute to keeping human beings stuck. In this second edition, we
Introduction
3
also more clearly link psychological flexibility processes to evolutionary principles. But for the most
part, this book centers around gaining familiarity and practice with the flexibility processes targeted by
ACT, and doing so in a way that is accessible.
It is our hope that reading this book will empower clinicians to begin to apply ACT’s psychological
flexibility model and methods in their practices. That is what is most unique about this volume. It is
designed to go beyond the philosophy, theory, concepts, and verbal knowledge of techniques to the
actual production of skills and competencies that target flexibility processes. Therefore, we have deliberately written it in an accessible style because our focus is on the practical.
This workbook:
Is about increasing clinicians’ ability help their clients live more rewarding, full, vital lives
Is about helping clinicians attain sufficient knowledge and skill with the six flexibility processes so
that they can begin to implement the therapy
Is intended as a skill-­building companion for other ACT texts that provide much more detail about
the theory, philosophy, data, metaphors, exercises, and application of ACT, and about its relevance
to various client problems, such as anxiety, depression, chronic pain, and psychosis
Is designed to help build clinicians’ skills in the core competencies associated with ACT’s therapeutic processes so they can be more effective, regardless of client presentation
ACT is not a cookbook approach; it is an enormously flexible model that is built from the ground
up with a focus on processes of change that empower people, rather than proffering rigid protocols for
syndromes. We not only want to provide practitioners with a clear sense of how ACT is conducted, but
would also like to convey the vitality this therapy can bring to human experience.
We strongly encourage personal involvement with the book, including engaging in the practices we
offer. We ask this for a number of reasons, most importantly so that you, as a therapist, can experience
what it means to personally engage ACT, just as you will be asking your clients to do. People playing
the role of therapist are not fundamentally different from people playing the role of client. As we will
outline in this workbook, we human beings all tend to get stuck in the same traps. It is essential to learn
about these traps from the inside out, through practice. For that reason, this therapy can be difficult to
do if you are not applying the same approaches in your own life. Take, for example, your own personal
experience with emotion: what do you do when confronted with what is most painful to you? If your
answer includes efforts to eliminate or control your experience, we would ask, “To what end?” Perhaps
for you, as for most people, that end is to feel “better.” However, if your answer is to experience the pain
for what it is, learn from it, and live better by doing so, then you are ahead of the game in learning the
ACT approach and more likely to be effective at it.
Many therapies focus largely on helping people feel better. The hope is that, at the end of the
therapy, the client will have fewer symptoms and will feel better emotionally. The focus in ACT is
explicitly on living better. Although this may involve feeling better, it also may not, especially in the
short term. Sometimes living better actually calls for feeling the pain. If doing so promotes connection,
choice, and living with vitality, ACT tries to provide clients with the skills needed to feel pain without
needless defense. The ultimate goal of ACT is to support clients in feeling and thinking what they
directly feel and think already, while also helping them move in a chosen, personally valued
direction.
4
Learning ACT, 2d edition
How to Use This Book
Learning ACT is designed to be used with other books and resources on ACT concepts and methods.
We particularly recommend in the following:
Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The
Process and Practice of Mindful Change. This is the second edition of the original ACT book. No
ACT clinician should fail to read it and keep it at hand.
Eifert, G., & Forsyth, J. (2005). Acceptance and Commitment Therapy for Anxiety Disorders. Although
this is nominally oriented toward a specific population, it is also a strong, generally useful ACT
protocol that demonstrates how to mix flexibility processes into a brief therapy. It provides excellent advice on how to use ACT to guide exposure.
Hayes, S. C., Smith, S. (2005). Get Out of Your Mind and Into Your Life. This is the first general-­
purpose ACT workbook. It can be useful for therapists new to ACT, helping them contact the work
experientially. It can also readily be used as homework for clients.
Harris, R. (2008). The Happiness Trap: How to Stop Struggling and Start Living. This is a generalpurpose, highly accessible ACT book that can also be used as homework for clients.
Stoddard, J. A., & Afari, N. (2014). The Big Book of ACT Metaphors: A Practitioner’s Guide to
Experimental Exercises and Metaphors in Acceptance and Commitment Therapy. This book provides
easy access to hundreds of ACT metaphors and exercises, arranged by flexibility process for easy
reference.
Wilson, K. G. (with DuFrene, T.). (2008). Mindfulness for Two: An Acceptance and Commitment
Therapy Approach to Mindfulness in Psychotherapy. This book focuses on bringing mindfulness, a
key aspect of psychological flexibility, to therapeutic interactions, challenging therapists to forgo
standardized approaches and instead flexibly tune in to the client and the therapeutic opportunities afforded by the present moment in session.
Hayes, S. C. (2007). ACT in Action. A six-­DVD series with some of the best ACT therapists
showing how to do ACT. It dovetails well with the videos for the present volume (the latter available to view at http://www.newharbinger.com/39492).
Should you need an initial introduction to ACT, we especially recommend these two books:
Harris, R. (2009). ACT Made Simple: An Easy-­to-­Read Primer on Acceptance and Commitment
Therapy.
Hayes, S. C., & Lillis, J. (2012). Acceptance and Commitment Therapy.
In addition, there are scores of ACT books for specialized populations, both for therapists and for
individuals. One of the authors of this book (JBL) maintains an updated list of ACT books and other
resources in the e-­book Learning ACT Resource Guide (available for download at http://www.learning
act.com). The Association for Contextual Behavioral Science (ACBS) is the main gateway to ACT
Introduction
5
research, clinical and theoretical publications, online discussions, trainings, institutes, conferences,
manuals, protocols, metaphors, and networking; ACBS also keeps a list of ACT and RFT relevant titles
at https://contextualscience.org/acbs_amazon_store. Keep in mind that if you go to the ACBS website,
you won’t be able to see most of the materials if you aren’t a member who is logged into the website.
More information on the ACBS and other resources is available in appendix B.
Organization of This Book
ACT is an evidence-­based intervention, but we want to be clear about what that means in a contextual behavioral science approach so you can understand the organization of the book. ACT is not a
protocol or a set of techniques; rather, it is an approach to therapy that targets a small set of key flexibility processes. This process-­based approach is a feature that distinguishes ACT from the many forms of
therapy that emphasize protocols over processes.
The introduction and first chapter of this workbook provide an overview of the theory behind
ACT and some tools to help you think about cases from an ACT perspective. Specifically, chapter 1
outlines the ways in which basic processes of learning and evolution science, combined with the problematic effects of language, lead to increased suffering for humans. The ACT theory of change is also
outlined in chapter 1.
Chapters 2 through 7 and chapter 9 cover the knowledge and practices necessary for ACT clinicians, with chapters 2 through 7 focusing on the six flexibility processes. Each of those chapters includes
a description of basic metaphors, stories, and techniques used in connection with that process, as well
as vignettes demonstrating those methods, and ends with a practical writing assignment in which
you’re asked to apply the principles you’ve learned to various sample client scenarios. Each of these
chapters also addresses when to use the methods discussed, indicators that work with that particular
process, and how to address problems that commonly arise when targeting given processes, and includes
at least one experiential exercise. The goal of these chapters is to help you get what each process is
about. No particular ACT technique is foundational, so the goal of these chapters is to help you
abstract how to manipulate the underlying flexibility processes through reading and practice.
In chapters 2 through 7, each of the psychological flexibility processes targeted by ACT is presented largely as if it were separate. In actual sessions with clients, however, a single process is rarely the
sole focus; rather, multiple processes are explored and worked on within each session. Chapter 8 focuses
on how case conceptualization and treatment planning can help you begin the task of integrating the
six processes into a coherent treatment and gives you an opportunity to apply the ACT model to practice cases. Chapter 9 shows you how to utilize the flexibility processes in the context of the therapy
relationship, and chapter 10 offers guidance on flexibly working with cultural factors during interventions and case conceptualization. Finally, chapter 11 is designed to help you integrate your use of the
various flexibility processes in sessions and to be flexible in doing so. And just as ACT attempts to
build psychological flexibility in clients, we hope this workbook will increase your flexibility as a clinician in the application of ACT. To that end, chapter 11 provides various exercises to help you develop
this flexibility.
We’ve also included three appendices. Appendix A presents the ACT Core Competency Rating
Form, which you can use to assess your abilities in delivering ACT. In the core competency practices
in chapters 2 through 7 and 9, we ask you to demonstrate these competencies. It’s only in appendix A
6
Learning ACT, 2d edition
that you can see all the competencies in one place, so you may wish to review that appendix before
diving into the chapters. Appendix B offers information on additional resources for deepening your
knowledge about ACT, and appendix C addresses adapting ACT to different intervention settings.
Online Resources
Various resources related to the book are available for download at http://www.newharbinger.
com/39492. There, you’ll find the ACT Core Competency Rating Form (appendix A); a document of
FAQs answering some of the most common questions of therapists new to ACT; and audio recordings
of several client exercises described in the book (we’ll provide a reminder about the downloadable
recordings where those exercises appear). Another downloadable resource is the document “Learning
ACT in Classrooms and Peer Groups and via Peer Supervision.” Regarding the latter, experience has
shown us that it’s important for ACT therapists to have a community that supports them in their ACT
work. Whether it’s a group of friends or colleagues, a virtual community accessed through the Internet,
a temporary course, or a relationship with a supervisor or mentor, this social/verbal community is
essential in keeping you on track as a clinician, particularly as an ACT clinician. Fortunately or unfortunately, many of the ways of speaking or thinking that are part of the repertoire of an effective ACT
clinician are not common outside of this context. Many of the messages of mainstream Western culture
are so dominant and automatic, particularly those fostering feel-­goodism (i.e., experiential control) and
literal ways of interacting with thoughts, that without support from a social/verbal community versed
in ACT, newer, less practiced repertoires of behaving and thinking based on ACT are less likely to be
maintained over time.
In addition, we highly recommend that you visit http://www.newharbinger.com/39492 to find
videos that complement the book, with experienced ACT clinicians role-­playing examples of the core
competencies, using trained actors to play the clients. We have created these examples to show both
relatively skilled and relatively unskilled applications of the ACT methods and principles. Not all the
competencies are covered in the videos, but with the exception of chapter 8 (case conceptualization),
examples are provided for approaches presented in chapters 2 through 10. We recommend reading the
corresponding chapter before watching its video.
The videos offer models of exercises and techniques that go beyond what we can adequately demonstrate in written form. One good way to use them is to play each clip and then pause the playback
before the narrator describes what was being done. Try to determine what fit or did not fit with the
ACT model in the clip, and only then resume the video to hear the narrator debrief the interaction.
This start-­and-­stop method is especially recommended for workshops or classroom use of this book.
Using the Practice Exercises in This Book
Although reading about ACT techniques and skills is important, to become an effective ACT
clinician it is even more important to practice these skills. Having extensive mental knowledge about
a therapy can clearly set the stage for implementation. However, it is not only verbal knowledge that
will guide you through the therapy; experiential knowledge is also key to understanding the ACT
Introduction
7
approach and providing quality implementation. This book is structured to give you that experiential
knowledge through engagement with exercises.
Learning to use ACT is like learning to play the violin. You can read a book about how to hold the
bow or how musical scales are structured. However, reading about playing does not make you a violinist. Practice is essential. Although reading (verbal knowledge) can teach you how to hold the bow, the
exercises in this book are designed to help you begin to play the violin (experiential knowledge). In
ACT, we ask clients to engage in the process of experiential learning and to be willing to experience
all that comes along with that learning, including painful failures and mistakes. We ask them to do this
with the goal of learning from their own experience in the service of living a rich and valued life. We
would like to ask you to do the same by engaging fully with the exercises presented in this workbook.
Many of the exercises require a written response. If you’re reading an electronic version of this book or
simply prefer not to write in the book, or if you need more space for your responses to any of the exercises, feel free to use a notebook or a computer or other electronic device to record your answers.
At the end of chapters 2 through 7 and 9, we’ve included a section titled Core Competency Practice,
in which we provide practice exercises based on dialogues with clients. (Many of the cases presented in
this book are amalgamations of actual clients but have been altered and combined so that no one, not
even the clients themselves, could recognize the material.) These exercises give you the opportunity to
formulate and practice responses to hypothetical clients prior to doing so with real clients. In the exercises, you are asked to generate your own responses before comparing them with the suggested ACT-­
consistent responses provided at the end of the chapter.
Feedback from readers of the first edition of this book indicates that they were often tempted to
jump directly to the sample responses, skipping the process of generating their own responses. This is
definitely the easier path and one way to engage with this workbook. However, this strategy has a major
downside: it negates what is most unique about this book—­the opportunity to actually practice ACT
and get feedback on your responses. Here’s what some of our previous readers have said about how
important it was to actually do the exercises versus just reading them:
“Actually doing the exercises makes all the difference. Doing them allowed me to test what I had
learned in the chapter, and it was very useful to do them and then compare my responses to the
answers.”
“I enjoyed the core competency exercises, as they really made me think about my responses. They
helped me integrate the material I’d just read in the chapter.”
“I appreciated the core competency exercises. They nudged me to really think through how I would
respond to very realistic situations.”
Only you can decide whether learning ACT is worth the time and effort. If you decide that the
answer is yes, we suggest that you give yourself the space to generate responses to the exercises, even if
your mind thinks those responses will be wrong or of low quality. One thing that can help with sustaining motivation to do these practices is to reflect on what larger purpose this might serve. We suggest
you take a minute or so to reflect on that right now. In fact, we’ll use that invitation to offer you an
initial exercise.
8
Learning ACT, 2d edition
Exercise:
Identifying Your Values in Working with This Book
What honest, sincere, and heartfelt purpose would you have your engagement with this book serve?
What larger patterns do you hope to feed by completing this workbook?
For me, completing this workbook is in the service of BRINGING SELF-­COMPASSION TO THE LEARNING PROCESS
There’s a saying we like in relation to learning something new: “If something is worth doing, it’s
worth doing poorly at first.” Learning something new generally means that our performance will be
poor; otherwise, it’s not really new. Doing the exercises in this workbook rather than simply reading
them is not the easy way. You will make mistakes—­perhaps many mistakes. However, mistakes are our
teachers. And even though mistakes are an inevitable part of learning, it’s often the case that the mind
will beat us up for making mistakes or for our perceived lack of knowledge, even though this makes it
harder to learn. Because this is an all-­too-­common thing for minds to do, it’s important to be able to
find ways to respond to ourselves in a supportive and kind way when we’re learning. In line with this
aim, we ask that you reflect for a bit on the kind of relationship you’d like to have with yourself as you
complete the exercises in this workbook. So, once again, we’ll use that invitation as a context for you
to begin engaging with the exercises in this book.
Exercise:
Envisioning Self-­Compassion
If you were to be a caring friend to yourself as you practice, what qualities would you hope to have in
your relationship with yourself? This isn’t about how you usually are with yourself around mistakes; it’s
about your intentions. How do you want to treat yourself while you’re learning? In the following space,
list the qualities you’d like to bring to yourself as you work with this book.
Introduction
9
As I make mistakes and struggle with learning, I would want to have a relationship with myself that is
characterized by these qualities:
Here’s one thing I can do when I notice my mind getting down on me during these exercises:
GETTING EXPERIENTIAL
In addition to the core competency exercises, each chapter includes experiential exercises. By
“experiential,” we mean that their purpose is to help you find the ACT space, stance, or psychological
posture from which you as an ACT clinician are likely to be most effective. The nature of these exercises is both personal and deeply connected to the nature of the therapy.
While we don’t recommend that you skip these exercises, it’s okay if you do. You are the expert on
your own experience and what will help you achieve your valued goals. However, if you choose not to
do them during your initial reading of the book, we suggest you come back and complete them later so
you can extract the full value of this volume.
Beginning to Use ACT
We have several recommendations about beginning to use an ACT approach to therapy, set forth in
the following sections.
Consulting Other Texts to Round Out Your
Understanding of ACT
Before you begin using ACT with clients, we recommend that you have a good sense of the entire
ACT model. This includes knowing a variety of core metaphors and exercises you can use and having
a working understanding of the basic theory. While this book provides a good overview of the theory,
10 Learning ACT, 2d edition
it does not provide many of the core metaphors you need or exercises you will want to use. Thus, you
will need at least one other ACT book to supplement this volume and give you more specific instructions about how to sequence interventions and introduce the different processes, and to give you access
to a range of metaphors and exercises. In short, this book is not meant to provide a comprehensive
introduction to ACT; rather, it’s a practice guide that will allow you to apply the tools you gain during
your learning process to all of the in-­between moments that aren’t specific to particular exercises or
metaphors.
Good books to consider for an introductory text that will give you more step-­by-­step instructions
for using ACT with your clients include the second edition of the original ACT book, Acceptance and
Commitment Therapy: The Process and Practice of Mindful Change (Hayes et al., 2012), or ACT Made
Simple (Harris, 2009). We usually recommend the original ACT book, as it is the most comprehensive.
However, if you would prefer a simpler introduction and step-­by-­step guide that focuses on tools, tricks,
and techniques and is lighter on theory, ACT Made Simple is an excellent alternative. If you have a
strong background in more traditional CBT methods and are branching out into ACT, A CBT
Practitioner’s Guide to ACT (Ciarrochi & Bailey, 2008) is another good starting place.
To be clear, we don’t recommend Learning ACT as the first book you read on ACT. Instead, it is
an excellent second book that will allow you to apply knowledge gained from more comprehensive
books, like those suggested above. Then you can begin to branch out, delving into more specific ACT
literature. There are now ACT books for most major categories of problems (e.g., eating disorders,
anxiety, chronic pain, substance use, depression), as well as applications to particular professions (e.g.,
social work or pastoral counseling), settings (e.g., primary care), or types of practice (e.g., groups or
couples).
Bringing Flexibility to the Process and Connecting with
the ACT Community
Second, we recommend allowing time for a period of growth with the theory and therapy. Although,
as mentioned, the flexibility processes are initially presented in this book as if they were separate, they
are actually interdependent. Lacking a basic understanding of one process could lead to difficulties in
implementing other processes, as well as confusion and dead ends in therapy. In addition, without an
overall understanding of the approach, therapists can easily introduce inconsistencies that might
undermine the overall thrust of the intervention. It takes time to learn this complex and comprehensive model. We encourage you to be compassionate with yourself as you practice, and to give yourself
time to reread sections on relevant concepts and approaches as you try to apply them. Also, be forewarned that you may experience some disruptions in your practice when you begin to use these
approaches, particularly if you’ve been operating from control-­based theories of intervention. It is not
at all uncommon for practitioners who are drawn to this work to initially feel awkward, confused, and
anxious as they begin to apply ACT.
A dissertation by Douglas Long (2015) examined the use of the videos in the first edition of this
book and found that clinicians being able to detect competent ACT was predicted by workshop training, knowledge about ACT, reading books about ACT, supervision in ACT, and membership in the
group most responsible for the continuing development of ACT, the Association for Contextual
Introduction
11
Behavioral Science. Competency improvement following training was also predicted by therapists’ psychological flexibility. These findings make perfect sense. To be good at ACT, you need to put in some
effort, give yourself time, work on your own flexibility processes, and come into community with others
on the same journey.
Fortunately, we also know that feeling confident isn’t necessary for ACT competence. An effectiveness study done a few years ago with beginning therapists showed that, compared with traditional
cognitive behavioral therapy, doing ACT tended to produce more anxiety in these therapists, who were
new to ACT—­and also led to significantly better clinical outcomes in patients (Lappalainen et al.,
2007). Based on these kinds of findings, we recommend that you try to make room for whatever discomfort you may experience as you learn to implement ACT. To that end, you may find ACT self-­help
books helpful, allowing you to apply ACT to your discomfort in learning it. We now know that applying
ACT to oneself as a therapist has broad benefits. It decreases the stress and burnout that can come
from being a therapist or therapist in training (e.g., Brinkborg, Michanek, Hesser, & Berglund, 2011;
Frögéli, Djordjevic, Rudman, Livheim, & Gustavsson, 2016) and helps therapists apply evidence-­based
therapy methods even when doing so is psychologically difficult (Varra, Hayes, Roget, & Fisher, 2008;
Scherr, Herbert, & Forman, 2015).
Time and effort, combined with openness, will produce a greater sense of wholeness and empowerment. However, be aware that there is a sense of vulnerability when doing ACT that never completely
disappears. ACT asks the clinician to stand with the client as another human being in a horizontal
relationship, without needless defense. This brings great richness to the process, along with a rawness
that can’t be avoided without undoing the work itself.
Incorporating ACT into Your Practice
We recommend two basic ways of beginning to incorporate ACT into your practice. One is to start by
implementing ACT based on one of the standardized manuals available. Many are listed under
“Therapist Guides” in the e-­book Learning ACT Resource Guide (available for download at http://www.
learningact.com); you’ll also find a list of many therapist manuals for specific client presentations on
the ACBS website https://contextualscience.org/treatment_protocols. Ideally, you would follow the
manual from beginning to end with a client who presents with problems matching the specific treatment discussed in that manual. This has the advantage of pushing you into corners of the work where
you may still feel awkward.
We also recommend the fairly common approach of first using ACT with a client with whom you
find yourself struggling. If this client is difficult, which is often the case, this may seem like a counterintuitive place to begin; however, because your old repertoire has already been failing in an important
way, if you continue with the same approaches you’ve been using, you’ll probably continue to find
yourself in the same place as the client: stuck. Giving ACT a try can allow you to see whether something new can happen and free up the therapy process.
After you’ve followed a detailed ACT protocol with a few clients, we suggest that you put the protocol aside and move to tracking and targeting flexibility processes based on clients’ needs and your
case conceptualizations. This book will be especially helpful to you in continuing to develop your skills
during this phase.
12 Learning ACT, 2d edition
Finally, we encourage you to attend an experiential ACT workshop. This is truly one of the best
ways to learn the ACT approach. ACT is centered on living fully with all experience—­both negative
and positive—­and on the freedom and richness that purposeful living can bring. Attending a workshop
can help create these dynamics in your life, both in your personal way of being in the world and in your
work with clients. It can also provide intuitive guidance about the function of flexibility processes, not
just the form of these processes. ACT trainings and workshops are listed at http://www.contextual
science.org.
CBS and the Research Context Surrounding ACT
ACT is based on a now enormous body of scholarly and research work in the fields of philosophy of
science, basic psychology, psychopathology, evolution science, and clinical intervention. As we were
writing this second edition of Learning ACT, there had been almost two hundred randomized trials on
ACT (for a partial list, minus some of those available only in non-­English languages, see http://contextualscience.org/ACT_Randomized_Controlled_Trials). These studies have looked at almost every conceivable area of mental health, behavioral health, and social functioning. About 83 percent of that
literature is less than five years old, and over the last few years, a new randomized trial has been published every ten to eleven days, on average. Across all areas of CBS relevant to ACT and its foundations, there are nearly two thousand articles currently available. In this book, we deliberately use
relatively informal language because our purpose is intensely practical and focused on skills. As your
skills in ACT grow, however, you may find that exploring the broader body of research deepens your
understanding.
Practitioners who attend their first ACBS conference are often surprised to find workshops and
sessions on RFT, behavioral principles, evolutionary extensions, and a contextualistic philosophy of
science. Perhaps even more surprising, after gaining some experience clinicians themselves begin to
demand such sessions and are often enthusiastic about their practical usefulness. In this book, we use
clinical and commonsense terms, generally without stopping to link them to basic principles. For
example, we speak easily of “mind” without delving into the work done in RFT labs to identify the
component behavioral skills involved in this commonsense domain. If you’re interested in learning
more about these aspects of ACT, you can start by reading more of the CBS literature.
If you connect deeply to the work, you will eventually learn that ACT is part of an attempt to
restructure psychology and, indeed, behavioral science itself. Although at this point you are probably
concerned with immediate practical purposes, this book will help you learn enough about ACT to care
about that larger context. Most importantly, we hope that reading—­or perhaps the better word would
be “doing”—­this book will help you learn enough about ACT to begin to use these methods with
clients who can benefit from them.
CHAPTER 1
The Focus of ACT and
Its Six Aspects
If you always do what you’ve always done, you’ll always get what you’ve always got.
—­Moms Mabley
From an ACT perspective, the core of psychopathology and human unhappiness is inflexibility. Stated
in that way, it may not appear to be much of an insight. Seventy years ago, the concept of the neurotic
paradox referred to mental health problems as a form of inflexibility: the odd inability of people struggling with psychopathology to do something different even when what they were doing led to very poor
outcomes (Mowrer, 1947). Evolutionary theory tells us the same thing: systems evolve only when there
is enough functional variation for successful adjustments to be selected and retained. Moms Mabley
was right: inflexibility is the enemy of improvement.
What’s unique about ACT is the content, precision, and scope of its analysis of why inflexibility
occurs and what to do about it. From an ACT perspective, the blessing and the curse of human existence is language. Normal processes of human language tend to draw people into psychopathology, and
only by learning new ways of relating to verbal events can people find a more healthy balance.
In this chapter, we present an overview of the model upon which ACT is based, within which
language plays a central role in how human beings get stuck. We’ve attempted to find a balance between
being comprehensive and being accessible. Nevertheless, some readers of the first edition have told us
that parts of this this chapter initially seemed too technical. If this is the case for you, be assured that
the material in this chapter will be unpacked in the rest of the book, usually in a more complete and
accessible way. So if you find yourself unable to understand certain passages at this stage, that’s okay.
Just forge ahead and consider returning to those sections again after you’ve read the rest of the book,
when you’ll be likely to understand them more fully. In particular, this first section is probably the most
technical of the whole book, so feel free to skip ahead to the next heading if you find yourself lost.
There is no doubt that language is a blessing. Imagine you went to sleep and woke up in a totally
unfamiliar room with all of the exits locked. What would you do?
14 Learning ACT, 2d edition
You would almost certainly wonder how you got there and would soon turn to the task of getting
out. As your mind clicked through various possible solutions, you would weigh the pros and cons. You
might consider using your cell phone to call for help, but you might also worry that whomever put you
in that room might listen in. You might think of kicking down the door, calling out, or breaking a
window and jumping to the ground, but perhaps you’d worry that your captor would punish you if you
did so. Using only thought, you could consider the risks associated with each of these plans. For example,
What if the door is too sturdy to be kicked in? or If they hear me breaking out, what will happen to me? Using
only your verbal and symbolic skills, you would be able to formulate a plan that might succeed.
This example contains all the elements humans require to respond to the external world using their
verbal and cognitive skills: A complex situation is broken down into its components and features. The
past and future are considered and related to the present. Those components and features set the occasion for imagined actions, predictions, and evaluations, and a plan is chosen based on likely outcomes.
Such a process of verbal problem solving offers a huge evolutionary advantage and has allowed
human beings to take over the planet even though we are weak, slow, and poorly defended. Our powerful verbal abilities, however, can easily bestow a huge disadvantage.
Suppose that, instead of being trapped in an unfamiliar room, you woke up one morning trapped
in a feeling of intense anxiety or impending doom. You’d be likely to ruminate over how you got into
that situation. And again, you’d probably soon set yourself to the task of trying to find a way out. The
same problem-­solving abilities brought to bear on the physical environment in the first example would
be turned to the psychological environment to generate solutions (e.g., take a tranquilizer, suppress the
anxiety, engage in self-­injury) and possible outcomes, such as escaping from the feelings.
All of this is extremely logical, but that doesn’t mean it’s extremely useful. The same things that
work well in the external world can easily create harm when turned toward the internal world. If we
don’t like peeling paint, we can scrape the wall and put on a fresh coat. But conversely, if we don’t like
thinking of a past trauma and try to “scrape it away,” we may make it more central, salient, and influential. If we fear a future drought, we might save water to quench our future thirst. But if we fear future
rejection and try to make sure no one will ever hurt us in that way again, we may limit our connections
with others or avoid making commitments, thus amplifying the role of rejection in our lives.
It’s quite possible to get out of a locked room and leave it behind. In contrast, the very attempt to
escape from a difficult emotion may exacerbate it (Chawla & Ostafin, 2007; Hayes, Luoma, Bond,
Masuda, & Lillis, 2006). And, of course, we can never leave our history behind.
Verbal problem solving isn’t good for everything. However, it is good for so many things that it’s
hard to know when—­and how—­to use it only when it is useful to do so. Human language is a double-­
edged sword. All of the main processes that ACT targets flow from this insight, and from the basic
research that led to it.
ACT is based on basic behavioral and evolutionary principles and their expansion into human
language and cognition, as explained by relational frame theory. RFT is a contextual behavioral
approach to human language and cognition with broad empirical support (for a review, see Dymond &
Roche, 2013). A short ditty summarizes RFT in four brief lines (Hayes, 2016):
Learn it in one,
derive it in two,
put it in networks
that change what you do.
The Focus of ACT and Its Six Aspects 15
For example, even a normal human infant, after learning that an apple is called “apple,” will know
to look for apples when hearing the word “apple.” In this case, the trained relation of seeing an apple
and hearing “apple” has led to a relation that was not directly trained (at least not with this set of
objects and names): hearing “apple” and looking for an apple. The relation is now mutual: the infant
learned it in one direction and derived it in the other direction. Said in a more normal way, the infant
has a name for an object.
This simple act of creating names is where human language likely started, and it probably started
in the tribe, not the individual (Hayes & Sanford, 2014). Humans are by far the most cooperative primates. The most credible reason for our cooperation appears to be multilevel selection (Nowak, Tarnita,
& Wilson, 2010; D. S. Wilson, 2015), in which cooperation is selected for because it gives an advantage
to competing bands or tribes, provided that individual selfishness is dampened down. Whatever the
reason, our level of cooperation compared to that of other primates is extraordinary and ancient, and
the ability to ask for resources using verbal names (such as calling for apples to a tribe member across
a ravine) rapidly extended human cooperation and gave rise to a receptive verbal community primed
for the next step: putting verbal relations into networks.
Even young children know to put mutual verbal relations into networks. After learning that an
“apple” is also a “jabuka” (as it is in Croatia), a normal listener will know that a “jabuka” is an apple and
will be able to imagine what it tastes like to drink jabuka juice. That’s the essence of the meaning of
“put it in networks that change what you do.” As this this type of verbal behavior moved from the tribal
level to internalization by individuals, the structure of human symbolic thought was established.
The properties of derived relations between events are arbitrarily applicable in the sense that they
can occur with any set of related events regardless of their form as long as the right cues are present.
Here’s an example to illustrate this concept: Before language abilities are strong, small children tend to
prefer a nickel over a dime because the nickel is bigger, and they may cry when given a dime instead of
a nickel. However, a more verbally mature child will prefer a dime over a nickel because the dime is
purportedly “bigger” and may cry when given a nickel instead of a dime, even if the child has never
actually used a dime to acquire goods. Thus, the functions of the coins (the related events in this
example) are based solely on social whim or convention, which arbitrarily declares that a nickel is
smaller than a dime.
The flexibility of humans’ relational skills allows us to go beyond the nonarbitrary relations that
exist in the physical world, but we do this so seamlessly that the world itself becomes thoroughly
entangled in our symbolic verbal actions. If we say “Skinny is better than fat,” the “better than” relational cue in this statement looks very similar to the phrase “bigger than” in the statement “The elephant is bigger than the mouse.” Yet it is actually quite different because the relation of size in the
second sentence is based on the formal properties of elephants and mice, whereas the relation of “better
than” is based only on the history of the speaker, not on fat and skinny per se. The relation seems to be
in the related events themselves, rather than in the arbitrary history of social training, and that illusion
can hide potential response options. As these abilities grow stronger, we create vast relational networks
and increasingly live in a world in which functions are verbally acquired, not based on direct experience. This can trap us into culturally and socially derived modes of living and relating that aren’t
chosen and that may not always be workable. In this way, language works behind the scenes to structure our world, and it does this so seamlessly that the source of that structuring is usually invisible.
16 Learning ACT, 2d edition
ACT works to reveal the illusion of language produced by the mind, like Toto in The Wizard of Oz,
pulling aside the curtain and causing Oz to thunder, “Pay no attention to that man behind the curtain!”
From the perspective of RFT, the mind is not a thing at all; it’s just a collection of relational abilities.
And although the ability to relate events—­for example, by thinking, planning, judging, evaluating, or
remembering—­has both a light and a dark side, the process is remarkably similar on both sides. The
differences lie in the context and the targeted domain. Literal language and cognition are tools, but
they are not fitting tools for all purposes.
RFT has led to the development of methods that have been shown to improve language abilities
and intellectual performance (Dymond & Roche, 2013), but it is of equal importance in learning to
rein in the excesses of language. RFT suggests not just how language and higher cognition develop and
why they are a help and a hindrance, but also how to rein in these abilities so we can use them and not
be used by them. The answer lies in the last line of the RFT ditty: we need to change what they do.
Evolutionary theory gives us clear guidance about when we need to change what we do. We need
keep track of only six things to unpack the challenge of intentional change: variation, context, selection, retention, level of organization, and dimension. (For a more extended discussion see D. S. Wilson,
Hayes, Biglan, & Embry, 2015.) Intentional change requires variation in actions, and requires that successful variations in a given context be selected and retained. Selection has to be considered in terms
of its level of organization. (For example, the growth of a cancer cell can be successful for the cell but
not for the organism, and the success of an action can be fine for an individual but harmful for a
couple.) Selection must also be considered in terms of the dimension that is selected, whether it is an
emotion, thought, action, physiological state, gene, epigene, or so on. A multidimensional view requires
that we consider a broad range of topics to determine whether we’re making progress; for example,
experiencing success in work performance could come at the cost of a person’s need for sleep.
These six features of evolution suggest that symbolic relations (and indeed, all psychological events)
should be thought of as interfering with deliberate change when they needlessly restrict healthy variation, when they undermine contact with the current context, when they interfere with the selection of
positive actions in the proper dimension or at the right level of organization, or when they interfere
with the ability to retain gains. At the end of this chapter, after presenting the ACT model, we will
return to those six features of deliberate change from within evolutionary theory and examine how the
ACT model rises to the challenges they present.
The ACT Model of Psychopathology:
Six Inflexibility Processes
RFT concepts provide a foundation for the core processes that are thought to lead to human suffering
from an ACT point of view. In essence, the problem is that literal language leads to increases in the
pervasiveness of pain, which is further exacerbated by the tendency to overextend a problem-­solving
mode of thinking as a way to get rid of that pain. Literal language processes encourage us to try to
escape or avoid our feelings, lead us to become entangled in our thinking, cause us to lose flexible
contact with the present moment, and tempt us into believing and defending our own stories about
17
The Focus of ACT and Its Six Aspects ourselves and others. Said in evolutionary terms, the overextension of language reduces healthy functional variation and also reduces our ability to respond adaptively to our internal and external environments. Meanwhile, what we really want to do is put on hold or drifts to the background, while creating
patterns of action linked to chosen values becomes more difficult. In short, an overextension of human
language leads to rigid, psychologically inflexible ways of living.
From an ACT and RFT point of view, all of these dynamics together make up psychological inflexibility: a collection of processes that produce or exacerbate human suffering. Psychological inflexibility
is the target of ACT, and establishing greater psychological flexibility is the immediate purpose of ACT.
In the sections that follow, we turn to a more detailed examination of these processes. They are
distilled into six aspects of a single focus, and can be combined into three vertical pillars that closely
reflect the evolutionary basis of the ACT model. The overall ACT model of psychopathology can be
illustrated in the form of a hexagon (figure 1), with each point on the hexagon corresponding to one of
the six processes hypothesized to contribute to or cause many instances of human suffering and psychopathology. At the center of this diagram is psychological inflexibility, which refers to the combination and interactions of all these processes. Although ACT acknowledges that specific pathological
processes may be associated with particular disorders and problem areas, it also holds that these inflexibility processes cut across traditional boundaries in psychopathology (and therefore may often play a
role in comorbidity), and that they also apply to behavioral health and social functioning.
Inflexible
attention
Lack of contact
with chosen
values
Experiential
avoidance
Psychological
Inflexibility
Cognitive
fusion
Inaction,
impulsivity, or
avoidant
persistance
Attachment to the
conceptualized self
(self-as-content)
Figure 1. The hexagon model of psychological inflexibility.
18 Learning ACT, 2d edition
Experiential Avoidance
Experiential avoidance refers to attempts to control or alter the form, frequency, or situational sensitivity of internal experiences (i.e., thoughts, feelings, sensations, or memories), even when doing so
causes behavioral harm (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). From an ACT and RFT
point of view, experiential avoidance emerges naturally from our abilities to evaluate, predict, and avoid
events. In other words, it is fed by an entanglement with the problem-­solving uses of language and
cognition.
As alluded to earlier, language is useful in the external and social world, in part because external
events can be predicted, evaluated, and avoided. And nothing prevents these language skills from
extending from the external world to the world within. There is essentially no difference between the
cognitive processes involved in escaping a locked room and those used to escape feelings of anxiety, or
between the cognitive processes used to predict an absence of food and those used to predict a panic
attack. Our predictive and evaluative abilities lead us to sort emotions, thoughts, bodily sensations, and
memories into positive and negative categories, and then to generate verbal rules that allow us to seek
or avoid these experiences on this evaluative basis. Yet, as previously mentioned, direct attempts to
avoid or alter experiences can have unfortunate and paradoxical effects in certain contexts.
Let’s look at the process of avoiding a negative thought. Suppose someone feels that it is extremely
important to not think of something in particular. Deliberate attempts to control the emergence of this
thought will involve a verbal rule: Do not think X. However, no matter what X may be, specifying X
tends to evoke X; for example, not thinking of a lake evokes thoughts of a lake, or not thinking of a
baby evokes thoughts of a baby. This happens simply because these verbal events are related to the
actual events and because some of the properties of the actual events transfer to the verbal event (e.g.,
when you hear the word “baby,” you might see an image of a baby in your mind). The same thing tends
to occur with emotions. Part of this is due to a verbal rule similar to the one just discussed: Do not feel
Y. Thus, trying to control anxiety involves thinking of anxiety, which tends to evoke anxiety.
The verbal reasons that motivate these control efforts also have an impact. Usually, anxiety is
considered to be something to avoid because of a long list of undesirable consequences. You may think,
I’ll make a fool of myself, I’ll go crazy, I’ll have a heart attack, or I won’t not be able to function. But the
natural emotional response to such imagined consequences includes—­you guessed it—­anxiety.
For these reasons and several others, experiential avoidance tends to be both unhelpful and self-­
amplifying over the long term, although not necessarily over the short term. A person who handles
anxiety by drinking may get away with it for years; a person who avoids fearful situations by turning
down social invitations may feel relieved in the moment and only gradually notice that his life has
become constricted. Furthermore, some experiential avoidance seems to feed and be fed by cultural
processes. A person who seeks to avoid fear of rejection by buying fashionable clothes is seemingly supporting the culture and its economic engines. Perhaps for similar reasons, experiential avoidance is
often amplified by the social or cultural community in order to sell products or control people’s behavior. The idea that healthy humans don’t have psychological pain (e.g., stress, depression, memories of
trauma) can be used by economic interests to specify actions that that must be taken to avoid such
negative private events—­actions that produce gain for those propagating the rule. Avoidant solutions,
such as mindless consumerism or the use of alcohol, are often modeled in television shows and commercials. The general feel-­goodism in Western culture sells. Not only should we feel good; we’re entitled
to feel good!
The Focus of ACT and Its Six Aspects 19
Sadly, it seems that a goal of getting rid of difficult feelings is often at the very heart of the mental
health model. The very names of our disorders and treatments reveal this connection (e.g., mood disorders, anxiety disorders). We diagnose disorders based on the presence of particular configurations of
private events and experiences. For example, self-­critical thoughts, suicidal thoughts, and feelings of
fatigue are part of depression. Then we construct treatments designed to eliminate these symptoms,
ostensibly with the goal of returning the person to good health. Unfortunately, all of this has the risk
of feeding the message of feel-­goodism. Perhaps as a reflection of this cultural convention, one in four
women over forty in the United States takes antidepressants, an astounding number given the state of
the science for these medications, which suggests that their benefits generally only outweigh their risks
for very severe depression (Pratt, Brody, & Gu, 2011).
Cognitive Fusion
In general terms, cognitive fusion refers to the tendency of human beings to get so caught up in the
content of what they’re thinking that it predominates over other useful sources of behavioral regulation. By “thinking” we mean anything that is symbolic or relational in the sense used in RFT (see
above); this includes, for example, words, gestures, thoughts, signs, images, and some properties of
emotions.
The word “fuse” comes from a Latin root that means “to pour.” Metaphorically, it is as if the
content of cognition and the world about which we are thinking are poured together until they are one,
in much the same way that lemons, water, and sugar can together become lemonade. But when thinking and the world about which we are thinking are treated as one thing, thinking habits can dictate
how we react to the world, and we can fail to see that the structure being imposed on the world by
thought is an active process—­that it’s something we do.
It has long been known that behavior controlled by verbal rules is often rigid and inflexible (see
Hayes, 1989, for a book-­length review). Most forms of psychological intervention take this into account
by trying to change the verbal rules (i.e., changing the thoughts). Unfortunately, that can fail to address
the core of the problem. It is not so much that an incorrect rule is being used, but that a verbally interpreted event tends to conflate the event and the interpretation of the event, overlooking the ongoing
process of thinking itself. From an ACT and RFT point of view, it isn’t what we think that is most
troublesome; it’s how we relate to what we think.
Imagine that thoughts are like a pair of sunglasses you’ve forgotten you’re wearing. They color your
view of the world, and you’re unaware it’s being altered. The trouble with this is that thoughts are then
free to present you with a world structured through thought—­a world seen through colored lenses. You
aren’t dealing with the world as it is directly experienced, and you’re missing that you’re “languaging”
about it. For example, when people with obsessive-­compulsive disorder (OCD) think, If I don’t wash my
hands, my family will be contaminated, they can become so focused on the world colored by that thought
that they seemingly aren’t interacting with a thought at all. They’re dealing with contamination and its
consequences (e.g., that their family will die), not with a thought.
All languaging occurs in a context, and language and cognition only have particular functions
within particular contexts. Symbolic thinking is broadly useful to human problem solving and to our
success in adapting to our environment; however, cultural evolution has vastly overextended the contexts that give language its automatic functions. Of course, for most practical purposes, it’s useful to
20 Learning ACT, 2d edition
treat words as if they are what they say they are. When you think of walking on the beach, it usually
doesn’t do any harm to experience reactions that are like those you’d experience on an actual walk on
the beach, albeit in a less vivid form. You may see the water in your mind’s eye and feel the breeze on
your skin. So, in part due to social training, we typically see the world from the vantage point of
thoughts, rather than observing thoughts directly. This is fine for activities such as doing your taxes,
repairing a car, or planting crops. However, it often isn’t as helpful for things like appreciating a sunset
or figuring out how to achieve peace of mind.
Think back to the earlier example of trying to figure out how to escape from a room. If you really
became engaged in the task, you probably weren’t aware of what you were physically doing at the
moment. You probably didn’t particularly notice your feet, the chair in which you sat, or the size and
shapes of the words in this book. Your attentional focus narrowed to planning your escape.
This is what happens with cognitive fusion. Verbal/cognitive constructions substitute for direct
contact with events. We forget that we’re interacting with thoughts, rather than with the real thing.
The past can present itself as if it’s occurring now even though it’s dead and gone. The future can
become present here and now even though it’s there and then. The present moment is lost to the mind’s
focus on the past and the future. We are constantly interacting with the world as we organize it
cognitively—­without noticing that we’re constantly organizing it.
When a depressed client imagines how she could fall apart because of the stress of another day at
work, she is seemingly dealing with the problem of literally falling apart, just as, earlier, you were seemingly dealing with the problem of a locked room. If the literal functions of that thought dominate over
all other possible functions, the issue may become how to avoid falling apart, rather than any of a
thousand other possible responses or situational issues. Psychological and behavioral flexibility are lost.
This might result in oversleeping, withdrawing from challenges or colleagues at work, or simply not
going to work—­all typical behaviors in what we call “depression.” The danger is that when people fuse
with verbal content, that content can have almost total dominance over their behavior, limiting other
possible sources of influence, such as the therapist, new but still weak verbal repertoires, or direct contingencies in the environment.
The overextension of language has several important contextual sources. Initially, language begins
within a context of literality, which is the social/verbal context that establishes certain sounds we hear
(the spoken word “lemon”) and certain pictures we see (an image of a lemon) as words or thoughts with
meaning. The social community expands this repertoire in many ways. For example, most children are
exposed to early demands to justify and explain their actions. This helps give the social/verbal community access to children’s reasoning skills and helps keep children’s actions within the bounds of what
can be verbally justified within a cultural community. As an outgrowth of this, both children and
adults are expected to have reasons to justify and explain their actions. These often take the form of
verbal statements of cause and effect, such “I stayed in bed because I was depressed.”
Unfortunately, this context of literality tends to support the idea that reasons are literal causes. For
example, we think depression caused staying in bed. After all, this notion of a literal cause is what
answers to “why” questions seem to address. In effect, verbally constructed “why” answers are considered to be true simply because the verbal community treats them that way. Eventually, reasons that
begin as explanations for behavior come to exert control over our behavior because of this social
context of reason giving. Our lives become entangled with an ever-­larger network of verbal formulations as we analyze and categorize every aspect of our lives.
The Focus of ACT and Its Six Aspects 21
In addition, many answers to “why” questions point to private experiences people can’t control. For
example, people may say they missed a meeting “because I forgot” or avoid tasks “because I’m afraid.”
Such formulations are rarely challenged. It’s almost rude to ask, “Why did you forget?” or “Why didn’t
you just feel the fear and still do it?” even though these questions are entirely relevant. Along the way,
the context of reason giving quickly expands into a context of experiential control. The logical next
step is to try to remove troublesome private experiences in order to gain more behavioral control by, for
instance, getting rid of forgetting and being afraid. The dominant Western culture teaches us that
private experiences need to be controlled. For example, think of the father who tells his son, “Don’t be
afraid. Only babies are afraid.”
In this way, cognitive fusion is enmeshed with culturally supported messages about the causal effect
of private events, their dangerous nature, the need to control them, and our supposed ability to do so.
For example, a person who thinks, I’ll fall apart, will believe that this thought is part of the process of
literally falling apart—­thoughts are causes. We are taught such things as “Anxiety is bad,” as if feelings
themselves were dangerous. As youngsters, we’re told “Stop crying or I’ll give you something to cry
about,” as if controlling our emotions were a reasonable and obvious solution. It would be interesting if,
as children, we could respond and show the impossibility of the command by saying something like
“Stop being bothered by my crying, or I’ll give you something to be bothered about.”
The point is, the kinds of cultural messages discussed here only serve to give our thoughts even
more excessive influence and dominance over our actions.
Inflexible Attention
We live our lives inside the present moment for a simple reason: there is nowhere else for life to
happen. Despite that fact, fusion and avoidance tend to heighten attention to the conceptualized past
and future in the form of rumination and worry, respectively. This is problematic, reducing our capacity
for ongoing, flexible awareness of what the external environment affords, and thereby decreasing our
knowledge about what we’re feeling, thinking, sensing, and remembering in the moment. This makes
us less sensitive to the possibilities inherent in our environment and can manifest in problems such as
alexithymia—­an inability to know what we are feeling or sensing.
When the conceptualized past or future dominates over present-­moment awareness, behavior
tends to be controlled by conditioned thoughts and reactions, resulting in more of the same behavior
that occurred in the past. New possibilities are foreclosed. Daydreaming takes the place of effective
action. Dissecting every minor hurt stands in the way of intimacy and connection in the moment.
Attention becomes more rigid and programmed, further reducing healthy variation of behavior.
Attachment to Conceptualized Selves and
Conceptualized Others
Probably nothing is as great a focus of verbal processes as oneself. From an early age, children are
asked many questions about themselves, such as how old they are, what they like, what they want to be
when they grow up, and what they enjoy in school. Children are harassed into answering “why”
22 Learning ACT, 2d edition
questions as if the answers were already available and only shyness or reluctance prevented them from
providing full and revealing answers. In fact, children have little to say at first about such things.
“Why” questions are often met honestly with the answer “Just because,” and other complicated queries
about self-­knowledge may elicit an equally honest “I don’t know.” Eventually, however, children learn to
tell coherent stories to explain their behavior that are acceptable to others. The past is formulated and
described. The future is predicted and evaluated. Within this storytelling process is a conceptualized self,
or self-­as-­content: the individual and her attributes are described and analyzed. Because children quickly
learn that changing stories without good cause is frowned upon, the stories become more stable over
time. The conceptualized self creates stability in behavior, for good and ill. By the time a client comes
in for therapy, this process has woven a spiderweb of categories, interpretations, evaluations, and expectations regarding the self. Often these “ego-­based” stories about oneself become events to be defended,
making change even harder to produce.
We all have stories to tell about what we’ve done and what we like, about why we have problems
and what would function as solutions, and about how we are and how we differ from others. Typically,
these stories have some truth to them. The problem is that the truth about which we are speaking is
not necessarily useful or helpful; rather, it’s a truth that can be justified because it reflects correspondence between the verbal formulations and the supposedly objective facts of the matter. In other words,
these stories are considered true because they’re “right,” not necessarily because they’re helpful in
living.
Consider a client who comes in saying something like “I am an agoraphobic. I’ve been this way for
twelve years, ever since my husband beat me and then abandoned me with my then two-­year-­old child.
My parents tried to help, but they were so critical that it only made it worse. Ever since, I’ve had terrible
anxiety. I can’t function as a result of it, and I’m too fearful to handle it. I think about anxiety all the
time.” All of these events could be 100 percent true, but what is more important is that the person has
fused with a self-­focused story and is trying to solve problems within that story. Instead of being a flexible, complex human being, the person has become a self-­created cartoon: “I am an agoraphobic.”
Instead of saying something like “I feel fear,” it’s as though she’s saying “I am a diagnostic category.” In
the statement “I am too fearful,” the word “too” implies that “who I am” is somehow illegitimate.
The problem is that real solutions may not exist within this story, and yet the story is so well supported that all possible ways out of it would be experienced as invalidating. The conceptualized self has
become narrow and cage-­like, and inflexible patterns of behavior are the unavoidable result.
We construct stories not only about ourselves, but also about others. Just as we can get entangled
with a conceptualized self, we can become entangled with conceptualized others. We can become so
caught up in our stories, evaluations, and judgments of others that we are unable to respond flexibly to
them or accurately empathize with their experience. This process is at the core of objectification, dehumanization, and prejudice; indeed, fusion with inaccurate stories about other’s intentions, feelings, and
thoughts is often a large contributor to interpersonal difficulties. At a basic level, these stories about self
and others interfere with our ability to form cooperative and caring relationships.
Lack of Contact with Values or Lack of Clarity About Values
Values are chosen qualities of being and doing that are reflected in ongoing patterns of behavior.
Ultimately, values are about living in a chosen and meaningful way; they are compass headings we can
The Focus of ACT and Its Six Aspects 23
use to guide our lives. Freely chosen values generally are not to be evaluated; rather, they serve as the
standard by which other things can be evaluated.
Valuing is a partially verbal process but not a fully logical or rational one because it involves choosing, assuming, creating, and postulating, not merely weighing or deciding. This is not how we typically
set life goals. Often we establish goals somewhat mindlessly or create them by using evaluative reasons
(e.g., making lists of pros and cons and then selecting the “best” goals). Although this may be useful,
many of these reasons are tied to psychological processes that are ultimately unimportant or even interfering (e.g., being right, avoiding pain, or pleasing others), rather than being linked to pursuing a meaningful chosen path in life.
To the extent that their behavior is tied up in experiential avoidance, people will have a hard time
contacting what really matters in their life. It’s painful to care, and if a person has a life history filled
with losses, regrets, or failures, it might be easier to avoid caring. People who were raised in chaotic
families, in which life was unpredictable and often disappointing, may avoid constructing valued futures
in order to avoid more loss and pain. They may never have solidly established a behavioral repertoire of
verbally constructing valued qualities, or such values may have been suppressed by pain. Either way,
valuing is absent or weak.
Inaction, Impulsivity, and Avoidant Persistence
Associated with fusion, avoidance, attachment to a conceptualized self, and loss of flexible attention to the present moment is an inability to develop larger habits of values-­based action. Impulsivity
or rigid persistence is manifested instead of a commitment to the continuous construction of larger and
larger patterns of personally meaningful action. Short-­term goals, such as feeling good, being right, and
defending a conceptualized self, can become so dominant that long-­term desired qualities of life (i.e.,
values) take a backseat. People lose contact with what they want in life beyond relief from psychological
pain.
People’s lives can become consumed by defending themselves from anxiety, handling depression, or
defending their self-­esteem, rather than focusing on goals and values that could have greater meaning,
depth, and vitality. In such situations, people are metaphorically consumed with sharpening the ax and
never get the chance to actually put it to use chopping down trees and building the home in which they
long to live. This often leads to the emergence of patterns of action that are detached from people’s
desired qualities of being and doing—­disconnected from their values. Sometimes this appears in the
form of a weak overall life direction or an inability to make and keep commitments. For example,
people may not engage effectively with work, close relationships, healthy lifestyle habits, recreation and
leisure activities, or meaningful spiritual practices. Often, this kind of pattern presents itself as a lack
of vitality and a sense that people have checked out of their life.
Using the Inflexibility Processes in Assessment
In ACT, these six inflexibility processes inform assessment to a high degree. A vast number of assessment devices now exist that allow specific inflexibility in specific content areas to be measured systematically, but throughout this book we will also mention features of clients’ behavior in session that
24 Learning ACT, 2d edition
reflect these specific inflexibility processes without the use of formal assessment devises. Because syndromes, and protocols that target them, are becoming less important in evidence-­based therapy, a new
process-­based model of assessment and case conceptualization is emerging that very much fits with an
ACT approach. In process-­based therapy (Hayes et al., in press), evidence-­based processes are linked to
evidence-­based procedures to more effectively alleviate people’s problems and promote well-­being.
Assessment of inflexibility processes can significantly contribute to that approach.
Six Core Flexibility Processes in ACT
ACT targets each of the core inflexibility processes just described, with the general goal of increasing
psychological flexibility—­the ability to contact the present moment more fully as a conscious human
being and, based on what the situation affords, to change or persist in behavior in order to serve valued
ends (Hayes & Strosahl, 2004). Psychological flexibility is established through the six positive processes
shown in figure 2. Each of these areas is conceptualized as a positive psychological skill that is instigated, modeled, and supported in therapy. All of the competencies in ACT are designed to foster these
flexibility features and thus this model can be thought of as a model of the therapy itself. As you can
see, it closely parallels the model of psychopathology and suffering depicted in figure 1.
These processes are worth noting not merely because they are the positive parallels to the psychopathology processes, but also because they can be scaled to the level of the dyad or group. This is one
reason that flexibility processes are so closely linked to therapeutic competencies in ACT: the model
suggests that, at the level of intervention, these processes need to be manifest in interactions between
therapist and client. Said in another way, the flexibility processes in ACT comprise a model for an
effective therapeutic relationship and effective interventions.
25
The Focus of ACT and Its Six Aspects Commitment and
behavior change
processes
Flexible attention
to the now
Acceptance
Values
Psychological
Flexibility
Defusion
Committed
action
Flexible perspective taking
(self-as-context)
Mindfulness and
acceptance
processes
Figure 2. The hexagon model of psychological flexibility.
copyright © Steven C. Hayes. Used by permission.
26 Learning ACT, 2d edition
Acceptance
Acceptance of private events is taught as an alternative to experiential avoidance. It involves the
active and aware embrace of private events that are occasioned by our history without unnecessary
attempts to change their frequency or form, especially when doing so would cause psychological harm.
For example, clients who struggle with anxiety are taught to feel anxiety as a feeling, fully and without
defense, and let go of their struggle with the form of psychological pain.
In ACT, acceptance is not an end in itself. Rather, acceptance is fostered as a method of increasing
values-­based action. Acceptance is fostered through exercises that encourage rich, flexible interaction
with previously avoided experiences. For example, emotions are turned into described objects, complex
reactions are broken down into experiential elements, and attention is given to relatively subtle aspects
of avoided events. To a certain extent, these look like exposure exercises, but they have the purpose of
increasing willingness and response flexibility, rather than necessarily diminishing emotional
responding.
When acceptance is scaled to the level of the therapeutic relationship, it’s important for therapists
to be accepting and to model acceptance when their own difficult moments enter into therapy.
Acceptance can also be scaled to couples, families, or other groups by encouraging compassion toward
others, which is why there is a natural alliance between ACT and compassion-­focused therapies.
Cognitive Defusion
ACT is one of the cognitive and behavioral therapies, but like other so-­called third-­generation
CBT approaches (Hayes, 2004), it does not embrace one core tenet of traditional CBT: that modifying
distorted or unrealistic thoughts is a necessary precursor to profound behavior change. This central
claim of traditional CBT has received very limited empirical support (Chawla & Ostafin, 2009). From
an RFT point of view, that isn’t surprising. The problem is this: efforts to change relational networks
(i.e., patterns of thinking) generally expand these networks and make the event on which the person
is focused (e.g., the thought or emotion) even more important. In technical terms, a relational context
is generally also a functional context.
Generally, clients are overly focused on negative private experiences. They have, in effect, narrowed their behavioral repertoire. Focusing even more attention on these areas may not be maximally
helpful. The job of permanently and thoroughly changing cognitive content is difficult because thoughts
are historical, often automatic, and, in clinically relevant areas, generally well established. Altering
them can take a long time, and even when the endeavor is “successful,” they still aren’t really gone, as
indicated by the tendency for older verbal/cognitive networks to reemerge under stress (K. G. Wilson
& Hayes, 1996).
Furthermore, clients are generally quite willing to attempt to suppress or eliminate negative
thoughts and feelings and may well have already tried to do so; however, this often has paradoxical
effects, at times actually increasing the frequency and intensity of these experiences, as well as their
power to regulate behavior (Wenzlaff & Wegner, 2000). Although cognitive change techniques typically aren’t meant to be suppressive, this tendency makes using such strategies riskier. Indeed, there is
very little data suggesting that cognitive disputation and change are helpful or a key pathway to
The Focus of ACT and Its Six Aspects 27
behavior change; to date, studies suggest these methods are relatively inert, or in some cases even
harmful (Dimidjian et al., 2006).
RFT suggests a different approach: that we need not change the content of thoughts in order to
change the functions of thoughts in our lives. The social and cultural contexts of literality, reason
giving, and emotional control normally determine the functions of thoughts on behavior. In contexts
such as these, the effects of thinking on action are machinelike; thoughts or feelings seem to cause
actions just as one billiard ball striking a second causes the second ball to move. In the culturally normative scenario, to change the action, we must change the thought. However, with a contextual view
we can see that the effects of thinking only seem to be mechanical: they seem to cause actions but in
truth do not. Rather, particular thoughts are tied to particular actions or thoughts only within a given
context. Thus, by creating other contexts (e.g., through defusion or acceptance), the impact of thoughts
can be altered without first having to change their form. There is no need to change certain thoughts.
Indeed, studies suggest that contextual strategies may more quickly lead to lasting behavior change
than strategies directly targeting the content of thoughts and feelings. (For a recent meta-­analysis of
component studies of this kind see Levin, Hildebrandt, Lillis, & Hayes, 2012.)
From an ACT perspective, when clients engage in struggling with their own private experiences as
if their lives depended upon it (as appears to be the case when thoughts are taken literally) and create
stories to justify and explain their actions, the result can be an amplification of suffering and a rigidity
of responding, both of which can be difficult to overcome. A major reason for this effect is that these
very efforts create pervasive and rigid contexts of literality, reason giving, and emotional control. It is
these contexts that ACT techniques target.
Defusion, an invented word meaning “to undo fusion,” refers to the process of creating nonliteral
contexts in which language can be seen as an active, ongoing, relational process that is historical in
nature and present in the current moment. In less technical terms, this means watching thoughts with
an attitude of dispassionate curiosity. Language and thought can always be observed in the moment as
language and thought: we can watch what the mind says rather than be a slave to it. A word is viewed
as simply a word, not as what it seems to mean. Creating this nonliteral context loosens the relationship
between words and action, allowing for greater behavioral flexibility. We don’t have to be driven by our
words or let them dictate our behavior.
Defusion is perhaps one of the most unique features of ACT. Scores of defusion techniques have
been developed for a wide variety of clinical presentations. For example, a negative thought can be
watched dispassionately; be repeated out loud until it becomes only a sound, devoid of meaning; or be
treated as an externally observed event by giving it a shape, size, color, speed, form, or other physical
attributes. The result of defusion is usually a decrease in the believability of the thought or attachment
to it, rather than an immediate change in its frequency. Additionally, defusion is not a process of eliminating thinking or even of changing the impact of thoughts. The point is to have a more mindful
perspective on thoughts, which increases behavioral flexibility linked to chosen values, not to promote
mindlessness or reliance on intuition, or to eliminate rationality.
Defusion techniques all have the goal of catching language processes in flight and bringing them
under contextual control so that, when necessary, they can be looked at rather than looked from.
When scaled to the therapeutic relationship, defusion fosters an open, nonjudgmental space in therapy
in which all thoughts are open for examination. It means creating a relationship that’s nonjudgmental
and in which evaluations don’t hook the therapist—­or if they do, the therapist acknowledges this and
then moves on.
28 Learning ACT, 2d edition
Being Present
ACT promotes ongoing, nonjudgmental contact with psychological and environmental events as
they occur. The goal is present-­moment awareness, in which attention is allocated to the here and now
in a way that is flexible, fluid, and voluntary. When in contact with the present moment, humans are
flexible, responsive, and aware of the possibilities and learning opportunities afforded by the current
situation. In comparison to living in a conceptualized past or future, present-­moment awareness is more
direct and responsive and less conceptual and fused. When contact with the present moment is inadequate, behavior tends to be more dominated by fusion, avoidance, and reason giving and therefore
typically results in more of the same behavior that occurred in the past. New possibilities are
foreclosed.
In ACT, being present is linked to the development of a sense of self called self-­as-­process (Hayes et
al., 2012)—­a habit of open self-­awareness that is characterized by ongoing noticing and descriptive
labeling of thoughts, feelings, and other private events in a defused and nonjudgmental fashion. A
sense of mindfulness is encouraged as well, so people can more fully notice the rich set of interactions
that are afforded in any given moment.
When socially scaled, present-­moment awareness contributes to an atmosphere in which the
ongoing process in the therapeutic relationship is itself noticed and used as a foundation for flexibility
work. Both the therapist and the client are called upon to be present and to attend to whatever is of
importance.
Self-­as-­Context and Flexible Perspective Taking
From an RFT perspective, it is argued that language training includes relational frames that require
perspective taking (technically called deictic framing in RFT), and that these skills in turn establish a
sense of self as a boundaryless locus. From an RFT view, self is more like a context or arena for experience than like an experience itself. For example, consider what the following questions have in common:
“What did you eat?” “What do you want?” “To whom did you talk?” “When did you do that?” “Why
did you do that?” The only thing they have in common is the location of the answer: the “I” who will
answer all the questions.
Through experiential exercises and metaphors, ACT helps people contact this sense of selfas-context—­a continuous and secure “I” from which events are experienced, a self that contains but is
also distinct from those events. This process helps people disentangle from the word machine in
between our ears. The goal is to help people develop a more solid sense of themselves as observers or
experiencers, independent of the particular experience being had in the moment.
Additionally, because the limits of consciousness and awareness cannot be contacted within consciousness or awareness, the perspective taking fostered by human language can lead to a sense of
transcendence, lending a spiritual aspect to normal human experience. Language is a double-­edged
sword—­and facilitating a sense of transcendence is one of its most positive features. Establishing this
transcendent sense of self can also be helpful in decreasing attachment to content. This idea was one
of the seeds from which both ACT and RFT grew (Hayes, 1984), and there is evidence of its importance to the language functions that underlie such phenomena as empathy, compassion, and theory of
mind (for a book-­length review, see McHugh & Stewart, 2012). In ACT, a transcendent sense of self is
The Focus of ACT and Its Six Aspects 29
important, in part, because from this standpoint people can be aware of their ongoing flow of experiences without attachment to them. Defusion and acceptance are thus fostered by this naturalistic,
spiritual side of human experience.
The other reason that self-­as-­context and perspective taking are critical to ACT is that they are a
primary source of the social extension of the model. The three primary perspective-­taking frames in
RFT are I versus you, here versus there, and now versus then. These frames are central to how people
develop a consistent sense of perspective and an awareness that their perspective is different from that
of others. All relational frames are bidirectional, so learning to look at the world from the point of view
of I-­here-­now necessarily gives people the ability to view the world from the point of view of you-­there-­
then. Metaphorically, you get to show up behind your eyes as a fully conscious member of the group at
the same moment that you see that others are conscious behind theirs. A perspective-­taking sense of
self links us to the perspectives of others and to perspectives from other times and other places. This
expansion of awareness is why self-­as-­context is foundational to experiences of spirituality and transcendence (Hayes, 1984), empathy, compassion, and self-­compassion. These human capacities are
partly nonverbal (the effect of mirror neurons, for example) but are greatly amplified by verbal relations
now known to support perspective taking (McHugh & Stewart, 2012).
Defining Valued Directions
The previously described flexibility processes are mostly aimed at undermining temporal and evaluative language in areas of living in which those forms of language are relatively ineffective. The processes of values clarification and committed action (discussed next) are focused on strengthening
language in those areas in which language is most likely to be effectively applied. ACT asks people to
step back from the everyday problems of life and take a look at what gives their lives meaning—­to look
for the larger possibilities that can dignify their struggles and guide constructive action.
Values are chosen qualities of actions that can never be obtained as an object, but can be instantiated moment by moment in actions of being and doing. They are combinations of verbs and adverbs,
not nouns (e.g., to relate lovingly, or to participate honestly). ACT uses a variety of exercises to help
clients choose valued life directions in various domains (e.g., family, career, spirituality), while also
undermining verbal processes that might lead to choices based on experiential avoidance, social compliance, or cognitive fusion. So in the ACT sense, none of these statements reflects genuine values:
“I would feel guilty if I didn’t value Q,” “I value Z because my mother wants me to,” “I should value X,”
and “A good person would value Y.” The first is avoidant, the second is compliant, and the last two are
fused. Values are choices. Values are the answer to the question “In a world where you could choose to
have your life be about something, what would you choose?” (K. G. Wilson & Murrell, 2004, p. 135).
Values are the linchpin of ACT because the truth and utility of ACT depend on them. In ACT,
acceptance, defusion, being present, and the other core flexibility processes are not ends in themselves;
rather, they clear the path for a more vital, values-­consistent life.
ACT takes a stance toward truth that’s based on a particular form of pragmatic philosophy called
functional contextualism (Biglan & Hayes, 2016). Truth is defined on the basis of workability, and workability in turn is linked to chosen values. In the more typical, mechanistic worldview, truth is a type of
correspondence. Using the metaphor of a map, if the marks on the map accurately indicate where
things are in the real world in relation to each other, then the map is true. Pragmatic truth finds its
30 Learning ACT, 2d edition
validation only within certain contexts, based on the workability of whatever is being evaluated in that
context. So while a paper map of the world might work (be true) in order to figure out how to sail
around the world, it will be pretty useless (not true) for finding your way around New York City; you’d
need a city or regional map for that. Is one map less true than the other in the normal, correspondence-­
based sense? No. But one map certainly works better in the context of trying to find your way around
New York City. This contextual approach informs how truth is defined in ACT. ACT forgoes truth
that emerges from a context of literality (i.e., correspondence) in favor of truth defined by what’s useful
in empowering people to live rich, meaningful lives, guided by their values.
This radical stance toward truth allows ACT therapists to sidestep common therapeutic traps with
clients who get caught up in arguments about whether their particular stories are right or wrong, or
whether their view of the world is accurate or inaccurate. When it comes to clients, truth is local and
is defined in terms of whether a particular way of thinking or behaving is helpful or unhelpful in the
pursuit of a valued life. For example, suppose a client thinks he’s inherently unlikable, that his life has
gone down the tubes, and that it will never be possible for him to have a life with caring relationships
and a family, even though he feels that this is deeply important to him. An ACT therapist wouldn’t
focus on the rational or irrational nature of these thoughts or on the evidence for and against them.
Instead, the therapist will focus on what those thoughts are in the service of and whether experience
shows them to be helpful in leading the client toward a life that reflects his chosen values. The issue in
the room probably will be about whether the client is willing to have these thoughts when they occur
and still move in the direction of his chosen values, not what the thoughts purport to indicate about
the state of the world, the client, or the thoughts themselves.
Values work is often socially oriented because of how integral social interaction and cooperation
are to our species. Even aesthetic values (e.g., bringing beauty into the world) typically involve acts of
sharing and giving (e.g., helping others appreciate beauty).
Committed Action
Finally, ACT encourages clients to build larger and larger patterns of effective action linked to
chosen values. The Latin roots of the word “commitment” involve a sense of carrying something
forward with (com) a “sending” or a “mission” (mittere). In a sense, committed action simply means
adopting a values-­based life as a mission in which establishing larger and larger patterns of action
linked to chosen values is itself valued.
Inside that mission, the “how” of building habits can then be a focus that has meaning. When a
slip occurs, people have the option to make a new choice: will they build a pattern of valuing, slipping,
and then abandoning the mission, or will they build a pattern of valuing, slipping, and committing to
the mission once again? Planning for these moments and organizing one’s environment to foster values-­
based choices in such moments is what committed action looks like.
In this work, ACT therapists can take advantage of any evidence-­based process known to foster
behavior change: exposure, skills acquisition, shaping methods, goal setting, or anything else.
Furthermore, it has been shown that flexibility processes can amplify the impact of these behavior
change methods (e.g., Arch et al., 2012).
Unlike values, which are constantly instantiated but never achieved as an object, concrete values-­
consistent goals can be achieved. ACT protocols almost always involve homework linked to short-­,
The Focus of ACT and Its Six Aspects 31
medium-­, and long-­term behavior change goals. Behavior change efforts, in turn, lead to contact with
psychological barriers, which are addressed through other flexibility processes (e.g., acceptance,
defusion).
When socially extended, committed action involves supporting the commitments of others. As a
result, ACT research has naturally gravitated toward work in areas related to social justice, in part
because seeing suffering in others requires a response.
Groupings of Processes Within the Model
The six core flexibility processes are both overlapping and interrelated. Taken as a whole, each supports the other and all target psychological flexibility—­the process of contacting the present moment
fully as a conscious human being and persisting or changing behavior in the service of chosen values.
The six processes can be chunked into two large groupings, as shown in figure 2. The mindfulness and
acceptance processes involve acceptance, defusion, contact with the present moment, and self-­as-­context,
and taken together, these four processes provide a workable behavioral definition of mindfulness
(Fletcher & Hayes, 2005). The commitment and behavior change processes involve contact with the
present moment, self-­as-­context, values, and committed action. Contact with the present moment and
self-­as-­context appear in both groupings because all psychological activity of conscious human beings
involves the now; that is where we live, and all deliberate change involves consciousness awareness from
one’s perspective.
The Pillars of Inflexibility: Closed, Mindless, and Disconnected
The six core processes can also be grouped into three pillars, or response styles (Strosahl, Robinson,
& Gustavsson, 2012; Hayes et al., 2012), each containing two points of inflexibility (figure 3). The two
inflexibility points on the left side of the hexagon, avoidance and fusion, can be combined into one
inflexibility pillar—­being closed—­because avoidance and fusion are repertoire narrowing. In any given
context, many different behavioral options are usually possible in both a functional sense (what the
behavior is for) and a topographical sense (what the behavior looks like). Evolutionarily speaking, we
need variation in our lives because it provides the seeds for behavioral improvement and change.
Furthermore, psychopathology often involves limits on variation, especially in terms of functionality.
Suppose a person uses alcohol to reduce a sense of social anxiety. When alcohol isn’t available, the
person may find topographical alternatives, perhaps smoking a joint or steering clear of meaningful
conversations, with the functional purpose of those behaviors remaining the same.
In the ACT model, such restriction in variability is fed by avoidance and fusion, and clinical work
will therefore target these processes in order to create more openness and response flexibility.
Evolutionary theory can help illuminate this dynamic. Among humans, cooperation has been selected
for because success of the group is fostered by cooperation and restraints upon the selfish interests of
individuals. Similarly, both of the processes in this pillar (avoidance and fusion) can be thought of as
instances of selfishness within the individual, in which the demands of specific aspects of the person’s
repertoire (e.g., particular thoughts and feelings) are given more time and attention than they are worth
relative to the good of the whole person.
32 Learning ACT, 2d edition
Removing these unnecessary restrictions on variation and creating more cooperation among
aspects of the individual’s repertoire frees up behavior and allows it to move to fit the context. Doing
so deliberately, however, is difficult when the next two inflexibility points interfere with the process.
The inflexibility points at the top and bottom of the hexagon, dominance of the conceptualized
past and future and attachment to the conceptualized self, combine to form the second pillar, or
response style: mindlessness. This pillar of inflexibility is extremely harmful to purposeful behavior
change. When people are evolving behavioral repertoires on purpose, it’s important that they make
conscious contact with the context in order to develop behaviors that are effective in that context.
People who are changing need to know where they are and what to focus on in order to generate variations that are likely to be successful. Changing on purpose is much more difficult, and also likely to not
be on target, if people miss important details of their external or internal environment, if they can’t
keep their attention on what’s important or can’t shift it away from what isn’t important, or if they can’t
disentangle themselves from rigid stories about themselves and others.
CLOSED
MINDLESS
DISCONNECTED
Inflexible
attention
Lack of values
clarity
Avoidance
Fusion
Disconnected
action
Attachment to
self-concept
Figure 3. The pillars of psychological inflexibility.
Finally, the two inflexibility points on the right side of the hexagon, unclear values and inaction,
impulsivity, or avoidant persistence, combine to form the third pillar of inflexibility: disconnection,
which is the inability to select positive changes or retain them through practice. Variation is not a positive goal in itself: rather, it’s a way for people to find ways to move in valued directions, and to move
33
The Focus of ACT and Its Six Aspects closer to desired ends, by selecting and retaining variations that work. This is the core of an evolutionary approach: change by selective retention. In an ACT approach, values are the selection criteria for
action, and retention is produced by the deliberate creation and repetition of patterns of effective
action, so this final inflexibility pillar inhibits positive behavior change.
The Pillars of Flexibility: Open, Aware, and Engaged
Like the six inflexibility processes or points, the three pillars of inflexibility are mirrored by pillars
of flexibility: processes that have positive implications for clinical methods. Each flexibility pillar contains two flexibility points on the hexagon (figure 4).
OPEN
AWARE
ENGAGED
Being
present
Acceptance
Values
Defusion
Committed
action
Perspective-taking
sense of self
Figure 4. The pillars of psychological flexibility.
Regarding the first pillar of flexibility, openness, any approach that fosters acceptance and defusion
can be considered an ACT method, regardless of its school of origin. Openness offers greater access to
one’s history without allowing it to dominate excessively, along with an opportunity for a sense of
wholeness and peace of mind to emerge. With this pillar of flexibility, all reactions are welcome as they
are, not as what they say they are, and no reaction is given a “selfish” or disruptive portion of a person’s
time or attention. This pillar undermines rigid repertoires and increases healthy variation.
34 Learning ACT, 2d edition
Regarding the second pillar, awareness, ACT seeks to increase flexible, fluid, and voluntary attention to the internal and external events that are present and of importance, from the I-­here-­now point
of pure awareness, or perspective taking. This is not just a target, but a key method that facilitates both
of the other pillars, and is therefore the central pillar of ACT’s intervention method. In session, the
therapist instigates, models, and supports this kind of awareness. The therapist is conscious of the consciousness of the client and is present with whatever is present, flexibly, fluidly, and voluntarily directing attention to whatever is of importance. Thus, the therapeutic relationship in ACT is itself
characterized by a high degree of awareness, with the second pillar of flexibility ensuring that healthy
variation is context sensitive.
Finally, the third pillar, engagement, consists of values and committed action. In session, ACT
therapists model a values-­based commitment to the good of the client, and do so in a way that never
violates their own values. Willingness to be active in therapy in service of the client is matched by
willingness to also be silent, listen, and allow. In other words, the commitment—­the mission—­is not
to a particular form of action; it’s to an underlying function or quality of action that empowers the lives
of others. This pillar ensures that healthy steps forward are selected and retained.
Fostering Healthy Psychological Evolution
In summary, the six processes of evolution—­variation and selective retention in context, at the right
dimension and level—­are fully integrated with the six flexibility processes. As we have already noted,
the pillars and points of openness foster healthy variation; the pillars and points of engagement foster
selective retention; and the pillar and points of awareness foster deliberately fitting development and
change to context. Dimensionality and level are addressed by the psychological flexibility model as a
whole.
Consider dimensionality first. Dimensionality means that the interrelationships between multiple
strands of healthy development are noted and addressed in a balanced way, rather than overemphasizing only a particular dimension or domain as being of importance while ignoring other key areas.
Psychological inflexibility fosters a subtractive and judgmental approach to one’s own development, as
experiential avoidance and cognitive fusion are given rein in a way that can even violate one’s values.
Psychological flexibility, conversely, fosters a shift from life as a problem to be solved to life as a process
to be experienced, which allows more balanced attention to the challenges and opportunities of development and change in all of their interrelated aspects. It would do little good to develop a healthy
emotional life, for example, without also attending to health behaviors (e.g., diet, exercise, sleep) that
facilitate a vital life. That same sense of balance and interrelationship applies to every domain, whether
we are speaking of the balance between intellectual development and social development, or of the
balance between employment and spiritual development. This explains why ACT is often included
under the umbrella of positive psychology (Kashdan & Ciarrochi, 2013), and why the literature on
ACT is so broad: psychological flexibility empowers all areas of life and encourages the maintenance of
balance among them. ACT is not just about alleviating psychopathology. It’s about living well.
The Focus of ACT and Its Six Aspects 35
Fostering evolution at the right level of selection means recognizing the nested nature of complex
systems and understanding that cooperation at any level of organization can entail disruptive selfishness as a higher level of organization. Multilevel selection reminds us that “it’s groups all the way
down,” and that that balancing development at multiple levels is therefore involved in any act of purposeful evolution. Because psychological flexibility applies to the individual, the goal of psychological
growth involves accommodating the entire repertoire of the whole person without feeding selfish disruption by components of the individual’s repertoire, and without ignoring critical needs of parts of the
individual. Encouraging development in this holistic way can be thought of as fostering personal growth
with an eye toward peace of mind and personality integration. When this process is socially scaled into
relationships and groups, it’s manifested as being able to focus on success at higher levels of organization while also promoting success but not selfish disruption at the level of the individual. This empowers individuals to participate in dyads and groups in positive, cooperative, compassionate, and loving
ways. As an example, it’s natural for the perspective-­taking sense of self that fosters awareness to also
remind us of the needs of others at other times in other places. The I-­here-­now of pure awareness is
based on deictic relations (I/you, here/there, now/then) that intrinsically expand awareness across
beings, places, and times. Therefore, it is natural to link the ACT model to such issues as prejudice, the
needs of underdeveloped communities around the world, environmental concerns, and animal rights.
In short, psychological flexibility is a scalable concept, which nests with parallel concepts in parenting, relationships, and organizations. And indeed, measures of flexibility are emerging in all of these
areas. Furthermore, this expansive quality is now being expressed in organized efforts to develop new
applications of contextual behavioral science that combine ACT methods with group development
principles, such as Elinor Ostrom’s Nobel Prize–­winning design principles, in the PROSOCIAL method
of fostering group effectiveness (http://www.prosocial.world).
A Definition of ACT
We have now defined the six basic flexibility processes and examined their grouping into three pillars
of flexibility, or into the two overarching groupings of mindfulness and acceptance processes and commitment and behavior change processes. We’ve also examined how they’re linked to evolutionary principles that govern development in every area of the life sciences. Having done so, we can now define
ACT fairly simply: ACT is a psychological intervention based on modern behavioral and evolutionary
principles, including RFT, that applies mindfulness and acceptance processes, and commitment and
behavior change processes, to the creation of psychological flexibility. ACT is thus a model, not a specific technology. It offers a model of psychopathology processes that cuts across all traditional diagnostic categories and is thus profoundly transdiagnostic. It also offers a model of health and intervention
processes that is naturally linked to positive growth and empowerment. It is an approach to psychological intervention, and to human functioning more generally, that is defined in terms of specific flexibility processes and is grounded in basic behavioral, cognitive, and evolutionary principles.
36 Learning ACT, 2d edition
For More Information
For an overview of research about ACT, see Hooper & Larsson (2015).
For an introductory overview of RFT, the theory of language and cognition that
underlies ACT, see the excellent four-­hour online tutorial available for free at
http://www.foxylearning.com.
For a book-­length introduction to RFT, read Törneke (2010).
For an article on the relevance of evolutionary principles to psychological flexibility
and applied behavioral science, see Hayes, Monestès, & Wilson (in press).
For a book-­length description of contextual behavioral science, see Zettle, Hayes,
Barnes-­Holmes, & Biglan (2016).
The hexagon model is a good way, both scientifically and practically, to summarize the
processes that make up psychological flexibility, which is why we are using it in the
organization of this book. However, RFT processes can be used directly to organize
clinical work (see M. Villatte, Villatte, & Hayes, 2015), and other clinically useful tools
are widely used in ACT, such as the matrix (Polk & Schoendorff, 2014).
CHAPTER 2
Developing Willingness
and Acceptance
When suffering knocks at your door and you say there is no seat for him, he tells you not to worry
because he has brought his own stool.
—­Chinua Achebe
Key targets for willingness and acceptance:
Help clients let go of the agenda of excessive control as applied to internal experience.
Help clients see experiential willingness as an alternative to experiential control.
Help clients come into contact with willingness as a choice, not a desire.
Help clients understand willingness as a flexible process that is actively engaged in an
ongoing fashion, not arrived at as an outcome.
A great deal of struggle and suffering arises from denial of the inevitability of human pain. When we
feel fear, anxiety, sadness, hopelessness, or other emotions that cause distress or discomfort, or when we
think of ourselves as less than worthy, we often engage in efforts to undo those experiences. With or
without awareness of another option, we pick up the experiential control agenda and go to work. A
battle with our internal experiences begins. Unfortunately, because we are largely the products of our
history and cannot simply eliminate it or the content it contains, the agenda of experiential control is
largely ineffective, and in many cases it backfires, trapping us in an unsuccessful struggle with ourselves. In addition, experiential avoidance often creates a self-­amplifying loop that leads to additional
suffering. The result can be years of life consumed by fruitless efforts and potentially self-­destructive
behavior directed toward unworkable ends.
38 Learning ACT, 2d edition
This tendency toward experiential avoidance is a basic part of being human; it is born out of language and amplified by culture. We all try to control painful experience to some degree or another, at
times working feverishly to avoid painful events. However, because pain is also a basic part of the
human condition, we don’t have long-­lasting or viable ways to escape the experiences that are elicited
when we encounter loss, unmet desires, and other similar conditions. Although control methods sometimes work in the short run, they tend to have the paradoxical effect of increasing suffering in the long
run. Amplification of suffering can occur both through the basic properties of language (for example,
trying not to think about an unpleasant memory can evoke that memory) and through the loss and
pain that can result from living outside of our closely held values (for example, a person with social
anxiety who wants connection with others may avoid people out of fear of experiencing anxiety and
shame).
ACT specifically targets letting go of misapplied control, or control that is aimed at reducing or
getting rid of experiences that cannot be gotten rid of in a healthy way. As an antidote to increasing
suffering by engaging in ineffective control efforts, ACT offers an alternative that helps clients contact
unwanted experiences, and helps them do so without excessive or rigid efforts to make the experience
be other than what it is. This alternative is willingness.
What Is Willingness?
“Willingness” can be defined as being open to the entirety of one’s experience while also actively and
intentionally choosing to move in valued life directions. Developing willingness occurs through a
process of contacting the present moment as it is, with whatever internal experience is present, while
simultaneously taking action that is guided by values-­based intentions. It is foundational to the first of
the three pillars of flexibility: openness. Willingness to experience is the seed of openness. The opposite of willingness, excessive and misapplied control of internal experience, also points to what we’re
exploring when working with clients on this process: when people are unwilling, they may make choices
based on a desire to avoid internal experiences, rather than on their personal values.
Willingness is an action and has an all-­or-­none quality to it. It’s like a leap. For an action to be a
leap, we need to momentarily be completely in the air, with no part touching the ground, allowing
gravity to do its work. Leaping has a different quality than stepping, wherein each movement is controlled. A step can be a large step, but it’s still a step, and a step can only take us so far. We can step
from a chair, but not from a roof. Conversely, leaps can be small, but they have no upper limit. The
motion involved in a leap from a chair is identical to the motion involved in a leap from a roof. We are
either in the air or not—­just as we are either willing or not.
Although having tolerance can bring us a step closer to being willing, tolerance implies that negative experience is to be withstood until something better comes along. We might “white-­knuckle” our
way through strong unwanted emotion as if to conquer the experience. This still has the quality of
taking a step. Willingness, on the other hand, has qualities of openness, allowing, and being present
with whatever is there to be felt, sensed, or observed. Willingness is experienced as an ongoing process,
not as waiting for something to change for the better if we’re tolerant enough. Willingness to experience, then, is a stance that can be taken again and again; it is a lifelong series of choices related to how
we will bear our experience.
Developing Willingness and Acceptance 39
It’s also worth noting that people can seek to avoid or escape positive emotions. For example,
people may have learned to not allow themselves to relax because doing so has previously been followed
by painful experiences, or they may not allow themselves to experience or express joy because this has
previously been followed by attention from others that leads them to feel uncomfortable. Thus, avoiding or controlling positive emotions and their expression can also create problems in terms of increasing suffering and harming interpersonal relationships (e.g., Gable, Reis, Impett, & Asher, 2004). In
addition, avoiding positive emotions may interfere with maintaining committed action, since it may
lead people to miss out on other sources of reinforcement that may be present when they live in a way
that aligns with their values.
Clients often confuse willingness with a feeling or way of thinking. However, people need not feel
willing or think in a particular way in order to be willing. Willingness is also not about wanting. People
don’t have to want to feel or think something to be willing to do so. The question is whether they would
be willing to experience these feelings and thoughts fully and without defense if that meant new possibilities would be created in their life.
Willingness is an inherently active process and arises from remaining aware of and open to the
thoughts, feelings, and sensations that arise when taking action in the service of one’s values. This
includes all forms of committed action. It may entail making a telephone call to an estranged friend,
having a conversation with a loved one when fearing or not wanting to do so, laying down one’s
defenses despite wanting to argue for something, or saying “I love you” even though it feels scary.
For the purposes of this book, we use the terms “acceptance” and “willingness” interchangeably.
Unfortunately, the term “acceptance,” in some contexts, can carry a lot of cultural baggage, which may
make it less useful with some clients, particularly those who have been on the receiving end of lectures
about how they have to accept something. Acceptance and willingness are not about loss, resignation,
or stoicism. Yet for some people, “acceptance” sounds like resignation, and indeed, sometimes our
culture defines it that way. Likewise, loss and resignation in the presence of pain can be viewed as
giving up or submitting to it, and stoicism may be viewed as a kind of indifference to emotion. None of
these is the kind of acceptance we’re talking about in ACT (Hayes et al., 2012). If a client reacts to the
term “acceptance” in any of these ways, it is better to use the term “willingness.” In fact, it’s useful for
therapists to keep an eye out for negative connotations clients may associate with both of these terms,
or others. We want to use terms with connotations that are predominantly life affirming, empowering,
and vitalizing and that support openness, awareness, and engagement—­the three pillars of flexibility.
A fuller understanding of what ACT means by “acceptance” can be illuminated by the historical
origins of the word. “Acceptance” can be traced back to a Latin word meaning “to take or receive what
is offered.” This implies an action of embracing, holding, or taking what life offers—­and doing so willingly. Acceptance is ultimately a choice to embrace what is and what life offers, saying yes to life and
its variability in experience.
Before we turn our focus to clients, we want to highlight that willingness also applies to therapists.
It’s common for therapists to find the process of learning an experiential therapy like ACT anxiety
provoking. At times, doing so may increase your level of self-­doubt or self-­criticism. This is natural
when learning something new, and even more so with a therapy that emphasizes experiential and nonlinear learning, as is the case with ACT. We hope you’ll be open to engaging the experiential learning
process in this book while also making room for and learning from whatever reactions you have as you
do so.
40 Learning ACT, 2d edition
Why Willingness and Acceptance?
Willingness is foundational to ACT and is one of its key functional goals. Willingness, or acceptance,
can’t just be described to clients with the hope that the descriptions will provide benefit (i.e., the client
will be more accepting or willing based on the description); these are skills to be learned, not concepts
to be understood. In ACT, therapists attempt to build the behavior of acceptance by engaging clients
in specific activities structured to create the possibility of choosing to experience difficult thoughts,
emotions, sensations, and so on.
Rigid and misapplied attempts to control and manage unpleasant, unwanted, and difficult internal
experiences can cost people in at least two ways. One is that the things people do in attempts to reduce
or remove their painful emotions, thoughts, sensations, and memories often fail and, paradoxically, may
produce even more distress. The pain and struggle caused by efforts to not have pain as it is, sometimes
referred to as “suffering,” is added to the pain that is the natural and automatic result of living life. In
fact, some research has shown that attempts to suppress troubling thoughts or emotions tend to result
in rebound effects, wherein the emotion or thought becomes even more prominent (Hayes et al., 1996;
Abramowitz, Tolin, & Street, 2001). Efforts to not think about a bad memory often tend to elicit that
same memory (e.g., in PTSD; Shipherd & Beck, 2005). Similarly, depressed people who stay in bed all
day to escape from the perceived meaninglessness of their life only further confirm their fears about the
meaninglessness of their life. And panic, at least in part, is often the result of a struggle to not have
panic. Many more examples of the paradoxical effects of experiential avoidance are given in other ACT
texts (Eifert & Forsyth, 2005; Hayes et al., 2012) and reviews of the literature (Abramowitz et al., 2001).
Another consideration is that living life in pursuit of feeling good generally isn’t living in the service
of deeply held values. Doing what’s important or what matters is sometimes painful or can at least create
a sense of vulnerability—­precisely because caring reveals where we can be, and have been, hurt. This
connection between pain and values is part of why the costs of experiential avoidance are so high. It
can lead people to turn away from valued directions, relationships, or activities in the service of modulating, controlling, or avoiding particular experiences. To return to an earlier example, a person with
social anxiety may have very few friends because of a desire to avoid shame, yet that very shame may be
an indication of how important others are to that person. Similarly, people who engage in chronic,
persistent experiential avoidance may never develop a sense of what they desire in life because they’re
so caught up in not feeling. In the end, a life lived in pursuit of feeling good may not feel very good.
The Link Between Willingness and Defusion
Willingness is closely linked to cognitive defusion (see chapter 3), and an extended discussion of this
link seems warranted here. Because we humans tend to become fused with language in a literal way,
we often fail to distinguish between the world as we verbally conceive of it and the world that we
directly experience. The world simply seems to occur as we perceive it. We don’t always realize that this
is actually a result of a blending of direct experience and thought. We are fused—­entangled—­with our
minds. Under these circumstances, the verbal content of the mind dominates over behavior, and the
direct contingencies of experience are lost. For example, with fusion, a client who says, “I can’t stand
this feeling another moment,” holds the ideas that he will fall apart, cease to exist, or be damaged if the
Developing Willingness and Acceptance 41
experience of that feeling continues. However, with defusion or freedom from the literality that the
mind presents, that same client can attend to his direct experience. He can and will stand the feeling
for another moment, and will also experience that he doesn’t cease to exist. Furthermore, with attention to the ongoing flow of his present-­moment experience, he will learn that this feeling will pass and
another will come along, time and again.
One of the main issues with fusion, as it pertains to this chapter, is getting fused with culturally
supported messages that negative thoughts and emotions are disordered and problematic and should be
decreased or removed, as well as messages that wholeness and well-­being are largely defined by feeling
good and that we should do what it takes to feel that way. bell hooks captured this well: “One of the
mighty illusions that is constructed in the dailiness of life in our culture is that all pain is a negation of
worthiness, that the real chosen people, the real worthy people, are the people that are most free from
pain” (1992, p. 52). When people entirely buy into these cultural messages, they begin to engage in
behaviors consistent with the messages—­behaviors that are designed to reduce or eliminate negative
thoughts and emotions in the service of attaining well-­being. And when people view negative thoughts,
emotions, and sensations as disordered and problems to be solved, they tend to engage in a logical
problem-­solving process: figure how to get rid of it and then get rid of it. They plan, try to understand,
and try to find solutions; they try to resolve, answer, unravel, decipher, and explain and may expend a
lot of time on a host of behaviors designed to allow them to feel, think, and sense something other than
the undesired experience. Years or decades can be spent in this very effort.
These efforts seem to make sense; they seem logical. We humans have learned that problems are
made to be solved, and indeed, in the world outside the skin, problem solving is an excellent strategy:
If you don’t like the way the room is arranged, rearrange it. If you don’t like dirty dishes in the sink,
wash them and put them away. If you don’t like long hair, get a haircut. Figure out how to fix the
problem and then fix it. But when this strategy is applied to internal experiences—­the world inside the
skin—­the very efforts to fix them may actually sustain and even increase the experiences we’re trying
to eliminate. Nevertheless, we still engage the strategy: If you don’t want or like anxiety, figure out how
to get rid of it, and then get rid of it. If you don’t like sadness, disappointment, thoughts, memories, or
sensations, figure out how to get rid of them, and then get rid of them. But because the world inside the
skin doesn’t work in the same way as the external world, trying to reduce and eliminate internal experiences may actually cause these experiences to linger and grow. A classic example is that not wanting
anxiety is itself something about which to be anxious. So the “problem” grows. And because our logical,
problem-­solving minds are so heavily involved, we conclude that what’s required is more strategies
aimed at fixing the problem; we need more control.
A major focus of acceptance, then, is to undermine the strategy of excessive internal control by
examining the workability of this strategy. The focus is on clients’ experience with this strategy, not
logic, as logic is part of the self-­perpetuating system that tells clients they should be able to control their
emotions, thoughts, and sensations.
What Should Trigger Working with This Process?
The clearest signal to engage willingness processes in session is experiential avoidance. When clients
make efforts to control or escape difficult material that’s touched upon in session, willingness work can
42 Learning ACT, 2d edition
be helpful. That said, the clinician shouldn’t just jump into a willingness exercise haphazardly; it’s
important to have the session flow, working in willingness processes and exercises as appropriate to
meet the needs of the client.
Recognizing experiential avoidance can be hard at times and easy at others. There are a number
of ways that clients may demonstrate that they’re trying to control internal events. They may change
the topic, become superficial, make jokes, deny that issues are present, look away, get angry, get very
wordy, or use words that seem incongruent with their affect. If these behaviors occur when difficult
topics or experiences come up, they are probably avoidance behaviors. Others signs of in-­session avoidance include physical postures indicative of hiding, fighting, or fleeing, such as freezing, clenching the
jaw or fists, fidgeting, or looking away or down. Yet other signals include inaction, excessive planning
and rumination, argumentativeness, lack of motivation, or passivity on the part of the client—­a sense
that the client is trying to hand over responsibility to the therapist. Avoidance may also be an issue if
the client has a hard time savoring positive experiences without a fear of them ending. These are just
some of the many manifestations of avoidance behavior. Whatever the behavior, the key to recognizing
what should trigger working with willingness is the function of the behavior: Does it function to avoid
or escape unwanted internal experience in a way that is inflexible?
The clinician’s reactions can also provide an effective guide to whether experiential avoidance is
present in session. Client avoidance may be an issue if the therapist feels boredom or feels frustrated
and has the urge to push the client to do something. Another possible signal is if the therapist has a
sense of wanting to argue with the client or feels a need to convince the client. Sometimes the therapist
might detect avoidance only after the fact, suddenly thinking, How did we get on this topic? only to
realize that the client had previously deflected from a more difficult topic. Clinicians engage in emotional avoidance in session too. They sometimes avoid talking about potentially sensitive topics or fear
that they may scare or harm a client. It’s important to pay attention to such experiences. They too
should trigger working with willingness, not only for the client, but for the clinician as well.
What Is the Method?
The process of developing acceptance usually involves two major focal points: creating an initial openness to willingness by undermining experiential control as a dominant method of relating to oneself
and the world; and actively developing and choosing willingness through structured practice and committed action. Both of these steps are intended to foster psychological flexibility: the ability to contact
the present moment more fully as a conscious human being and then to change or persist in behavior
in order to serve valued ends. This conscious sensitivity to context makes room for choice. Creating an
initial opening for willingness is often where ACT starts, and in many cases, these initial steps are
integrated into the assessment process.
Creating an Opening for Willingness
Experiential avoidance and control efforts can be so well practiced that they occur virtually without
awareness. For many people, managing and controlling their internal experience is not viewed as a
choice; rather, they see it as just “the way it is.” The idea that they might choose to take a stance of
Developing Willingness and Acceptance 43
willingness and feel anxiety, sit with pain, rest in sadness, embrace fear, or relax into uncertainty is so
unusual and novel that some may feel it’s a bit like suggesting they could live without breathing.
Particularly for clients with pervasive and chronic histories of experiential avoidance, substantial work
is needed to clear a space wherein willingness, acceptance, and compassion can grow. This process can
be broken down into three steps:
1. Building awareness of experiential avoidance. This involves drawing out the system of
control within which the client is implicitly operating.
2. Examining the workability of control. The effectiveness of the control agenda is assessed in
terms of an extended timeline and with respect to whether it has actually reduced the client’s
suffering in the long run, and also how it has worked in terms of the client’s valued life goals.
3. Capturing the experience in a metaphor. Typically, a metaphor is used to provide a shorthand way to refer to this pervasive and often automatic tendency to turn to control as a solution. These metaphors usually invoke situations in which the person has put in a great deal of
effort but with little payoff or even with paradoxical effects.
The outcomes of the process of undermining the control agenda are a loosened attachment to the
eventual success of the experiential control agenda, decreased confidence in that success, and freeing
up some space for clients to practice willingness and acceptance in such a way that these new strategies
are less likely to get pulled back into the old system. The term confronting the system, which is sometimes
used to describe this process, is helpful for orienting therapists to the idea that this isn’t about confronting the client, but about confronting the social, verbal, and cultural system of experiential control in
which the client is stuck. The confrontation is not between client and therapist; rather, it’s a confrontation between the client’s lived experience and the mind’s proposed solutions to problems that are the
result of social and cultural conditioning.
Let’s take a detailed look at the stepwise process of creating an opening for willingness.
1. BUILDING AWARENESS OF EXPERIENTIAL AVOIDANCE
Undermining the control agenda begins with developing an understanding of what clients are
trying to control with respect to their internal experience. This is usually reflected in the presenting
problem (e.g., “I’m too anxious” or “I don’t want to be sad anymore”). The therapist might ask, “What
brings you to therapy?” Almost always, clients report a struggle with emotions (e.g., pain, anxiety, fear,
a sense of emptiness), memories (e.g., trauma, family experiences), or thoughts such as self-­evaluations
(e.g., self-­doubt, a sense of worthlessness). Once the therapist has a good idea of what the client is
trying to control, it’s possible to move on to explicitly drawing out the strategies the client has used in
an effort to solve the presenting problem. To be clear, in using the term “strategy,” we aren’t necessarily
implying that clients are conscious of or intentionally choosing a particular behavior; we are simply
highlighting the fact that their behavior has a purpose. The term “strategy” also draws attention to the
function of the behavior. This is important because the target of change is the function of the behavior,
not its form. For example, with an anxious client, the therapist can talk about things the client does
when she feels anxious (e.g., “I stay home,” “I get quiet,” or “I drink alcohol.”). Similarly, with a depressed
client, the therapist can identify what that person has done to try to get rid of or manage the depression
44 Learning ACT, 2d edition
(e.g., “I lie in bed” or “I try to build my self-­esteem.”). All methods of solving the problem should be
explored, including seemingly healthy ones, such as counseling, getting help from others, and
psychopharmacology.
Clients often aren’t aware of the variety and extent of the ways in which they attempt to control
their private experience, and they aren’t always able to describe or identify the purpose of their behavior. Thus, part of the therapist’s job is to identify the function of the client’s attempts at solutions and
to suggest to the client that these behaviors are about experiential avoidance. For example, a client
with depression may not immediately see how oversleeping or overeating is typically intended to help
him avoid or modulate a mood state or to decrease unpleasant rumination. As clients become better at
tracking the purpose of their behavior, this can help them develop more present-­moment awareness
and better observe their behavior.
All of that said, in many cases clients are aware of the function of their behavior and fully cognizant of what they’re doing when exercising internal control. However, they can still be invested in the
strategy, believing that thus far they’ve failed to implement it correctly, that they aren’t strong willed
enough, or that some other flaw is interfering with their capacity to fully control and manage their
experience. Therefore, they often continue to engage in these strategies, hoping that they will eventually work.
2. EXAMINING THE WORKABILITY OF CONTROL
Concurrent with drawing out the client’s system of control efforts, the therapist’s job is to examine
the workability of the client’s behaviors, particularly over the long term. The basic question asked here
is whether the various control-­oriented solutions to the client’s problems turned out as planned. There
are two areas of workability to explore: actual or long-­term outcomes in terms of suffering, and personal
costs in relation to values.
Actual or long-­term outcomes in terms of suffering. One aspect of exploring workability with clients
is examining whether their attempts have actually resulted in long-­term decreases in suffering. For
example, has what the client did to reduce or eliminate anxiety actually reduced or eliminated anxiety
in the short term and, more importantly, in the long run? Have steps the client has taken to manage
depression reduced depression to a seemingly manageable level? Many clients recognize the paradoxical
effects of experiential control fairly readily and see that as they’ve tried to control their suffering, it has
actually increased over time or, at best, has remained unaffected. However, some clients won’t see the
costs of experiential control as easily, even though they may have experienced lingering suffering.
Consider, for example, a wiped-­out, anhedonic, depressed client with flat affect who, while not suffering very acutely, has a lingering sense of meaninglessness and loneliness in her life.
Personal costs in relation to values. Another aspect of exploring workability relates to the ways in
which clients have constricted or limited their life in an effort to deal with the problems (e.g., negatively
evaluated thoughts, emotions, and sensations) that have been identified. The focus is on workability in
terms of lived values. To draw out this aspect of workability, the therapist might ask questions along
these lines (inspired by Eifert & Forsyth, 2005, p. 135):
•
“What have you noticed, over time, in terms of how things have worked with respect to what
you would like to have in your life? Have you done what you would like to do?”
Developing Willingness and Acceptance 45
•
“Do you have more options, or have your options decreased? In other words, has your ‘life
space’ narrowed over time?”
•
“What would you be doing with your time if you weren’t busy managing your difficult feelings
[thoughts, sensations, images, urges, or memories]? What have you given up in an attempt to
deal with this problem?”
•
“Have you found yourself moving in the direction of the kind of life you most want to live, or
have you perhaps found yourself moving farther from it?”
The reason to explore both of these aspects—­long-­term outcomes and personal costs—­is because
the two are linked in the experiential control agenda (Hayes et al., 2012). The most obvious promise of
this agenda is that through deliberate, conscious control, we can have more, better, or different emotions, self-­evaluations, thoughts, sensations, or images. The first aspect examines whether this promised outcome has been achieved. However, we don’t merely want to feel good; we also want to live well,
enjoying full, rich, meaningful lives as defined by our particular dreams and life aspirations (i.e., values).
The most enticing promise of the experiential control agenda is that it can deliver that kind of life. Our
culture tells us that once we are able to feel more happy, joyful, and energetic, and less anxious,
depressed, sad, regretful, tired, and angry—­or once we have different self-­evaluations and thoughts—­we
will be able to live our dreams, have better relationships, lead a more vital life, live our values, find more
meaningful work, and so on. Unfortunately, the reality is often the opposite; indeed, as alluded to
earlier, people’s lives can become consumed with efforts to achieve the first goal of experiential control
(decreased suffering), apparently in service of the second goal (living a valued life), but actually at the
cost of the latter.
We have a few important points regarding the therapist’s stance during this process of examining
the workability of the client’s behavior. First, the therapist should take the position that whatever the
client has done is understandable and reasonable—­which indeed it is, given the client’s history (Hayes
et al., 2012). This stance also involves a genuine and compassionate approach, from a position of equality, that recognizes the very human desire to be happy and live well. If the therapist approaches workability from a one-­up or overly confrontational position, this may come across as shaming or blaming.
This is why we refer to confronting the system. A person caught in the system is not to be blamed;
rather, the therapeutic approach is to work together to explore the system that entangles humans lives
to such a great extent that we suffer tremendously. It’s also important to focus entirely on the issue of
workability, not whether the therapist or client is “right.” This work isn’t about proving to the client
that the therapist has a better way. That would be fundamentally antithetical to the basic ACT stance.
Rather, the therapist’s job is to help clients start applying the criterion of workability, given their life
goals and aspirations.
A word about pitfalls: For therapists doing this work, it can be hard not to get caught up in the
content of what clients are saying. However, when focusing on undermining control, the therapist’s job
is to consistently return to the issue of whether these strategies have worked in the client’s life.
Because clients’ verbal formulations are well practiced and even at times cherished, clients may feel
threatened and begin to defend their actions or give reasons for what they’ve done. This is a normal
and understandable reaction to this process. There are several ways to respond to this kind of reaction.
One is to continue to focus on what clients’ experience has shown, in contrast to what their mind
promises should happen. Another way to respond is to ask clients, in a nonjudgmental and
46 Learning ACT, 2d edition
nondefensive way, to step back for a moment and consider defending the rightness of their views as a
strategy, and particularly how well this strategy has worked in their life. For example, the therapist
might say, “Let’s take a look at what’s happening. In this moment, it seems that you’re defending this
approach. Has defending it worked in the long run? I’m not sure whether the approach is right or
wrong, but has taking this position worked to get you where you want to be in your life?” When saying
something like this, it’s important not to speak from a place of trying to be right and make the client
wrong, but from an honest examination of whether this control strategy has worked for the client.
Another common pitfall arises when clients say that a particular strategy has worked. In this
context, clients are usually referring to the strategy’s short-­term effects, so the therapist’s job is to help
the client examine its longer-­term workability. If the client also defends long-­term workability, the
therapist can gently inquire about the need for therapy, saying something like, “Then help me better
understand why you’re here. Why do you continue to seek therapy?” (For more about elucidating the
client’s pattern of behavior and examining workability, see Hayes et al., 2012, pp. 167–­176.)
3. CAPTURING THE EXPERIENCE IN A METAPHOR
Exploring past and current attempts at experiential control is likely to show that these solutions
haven’t worked well or have come at considerable personal cost. To help clients move from recognizing
the downsides of control to beginning to engage in willingness, ACT therapists foster a sense of creative
hopelessness (Hayes et al., 2012, pp. 189–­197) and may use a number of metaphors and exercises to
explore this experience with clients. It’s important that the clinician thoroughly understand the term
“creative hopelessness” before embarking on this work. It doesn’t refer to making clients feel a sense of
hopelessness in general; it’s about helping clients see the hopelessness of an agenda of internal control.
The function of creative hopelessness work is to make room for something other than control: helping
clients open to the possibility of willingness.
Sometimes people who are learning ACT mistakenly believe that “creative hopelessness” refers to
a feeling and therefore think they need to make clients feel hopeless. However, creative hopelessness is
actually a profoundly validating stance. Therapeutically, it refers to the process of validating clients’
experience of the futility of the struggle in which they have been caught, and then helping them begin
to open up to the entirely new possibilities that come from this self-­validation. Clients know that what
they’ve been doing hasn’t been working. The possibility ACT therapists add to the mix is that this
experience may be valid: perhaps it can’t work.
Once the therapist and client have explored the workability of many different behaviors and both
have a sense of the extensiveness of the problem and the client’s attempts to solve it, the therapist may
attempt to develop creative hopelessness in that moment, generally using a metaphor to capture the
experience that has been discussed. The therapist can use any of a number of stories and metaphors
about situations in which a great deal of effort is put forward with little payoff or where the effort actually creates more problems. The key is to find a metaphor that’s apt for the specific client and resonates
with her experience, taking into account the pervasiveness of experiential avoidance in her life, as well
as the kinds of consequences she’s experienced as a result of her control efforts. For example, a client
who’s experienced a great deal of suffering due to control strategies might benefit from a metaphor in
which control efforts make things worse, whereas a client who has mostly experienced a sense of meaninglessness or exhaustion as a result of control efforts might benefit more from a metaphor that captures
this quality.
Developing Willingness and Acceptance 47
Ideally the metaphor will emerge naturally from what the client has already talked about; however,
it’s useful to have a variety of established metaphors to pull from as needed. Examples include comparing the client’s situation to struggling to get out of quicksand (Hayes, 2005, pp. 3–­4), working with a
bad investment adviser (Hayes et al., 2012, p. 173), being on a hamster wheel that goes nowhere, or
gambling on a rigged game. Another popular metaphor involves a person who gives meat to a tiger to
make it go away, only to find the tiger returning hungrier, as well as bigger and stronger (Eifert &
Forsyth, 2005, pp. 138–­139). Many cultures have relevant stories that can be adapted to this purpose.
Perhaps the metaphor most commonly used for this purpose in ACT involves a person who has fallen
into a hole and has no tool for escape other than a shovel (Hayes et al., 2012, pp. 191–­196). This metaphor shows that digging (representing control efforts) to get out of the hole doesn’t work but instead
makes the hole larger. Clients are asked to examine their unworkable change agenda (i.e., the tools they
use to get out of the hole and how they use them) and to notice that they are quite stuck. Ultimately,
the goal is to drop the shovel and stop digging.
Acceptance or willingness is offered as the alternative to control. If a client can experience emotions, thoughts, and sensations from a chosen and open stance, then the function of those internal
experiences is changed such that they no longer have the same degree of control over the client’s
behavior. The personal costs associated with excessive control are reduced or eliminated. As therapy
continues, images from the creative hopelessness metaphor can be referenced again when the client
gets caught up in another control strategy. For example, the therapist can playfully ask, “Are you
digging again?” or “Are you on the hamster wheel?”
Sample Dialogues
In this section, we provide two dialogues demonstrating different strategies for undermining the
control agenda. These dialogues provide examples of the process at two ends of the spectrum. The first
demonstrates creative hopelessness with a client who has a long and pervasive history of experiential
avoidance, as well as multiple experiences with previous treatments, and thus the process of undermining control is more intense, prolonged, and emotional. The second dialogue is a gentler, more tentative
version with a client who has less of an attachment to and history with experiential avoidance, and who
also has less experience of the costs of such behavior. Both of these dialogues involve clients with well-­
developed verbal skills. Therapists may need to simplify the process of undermining control and make
it more concrete for clients who are less verbal or less abstract in their thinking. ACT should always be
tailored to the client.
CREATIVE HOPELESSNESS WITH A CLIENT WHO HAS A PERVASIVE
HISTORY OF EXPERIENTIAL AVOIDANCE
The first dialogue begins after the therapist and client have had a couple of sessions together and
have formed a therapeutic relationship. They’ve already had discussions about the client’s values and
how the client has tried to manage his anxiety. Earlier in the session, they spent some time building the
client’s awareness of his experiential avoidance and examining workability. This dialogue picks up as
the therapist is working toward identifying a metaphor to capture the experience. As you read the following dialogue, keep in mind that this is an example of how the creative hopelessness process might
48 Learning ACT, 2d edition
look on one end of the spectrum: what might be effective with a more pervasively stuck client who has
a long history of treatment and for whom a more typical approach to therapy isn’t likely to be successful.
This vignette also assumes that the therapist will work with this client in subsequent sessions, so this
dialogue is only a preliminary step aimed at creating an initial opening to acceptance. (For clients who
are more open to acceptance, the approach in the second vignette would be a better fit.)
We encourage you to see if you can identify the functions that are being targeted in the dialogue,
rather than focusing on the content per se. We also encourage you to note any judgments or emotions
that arise as you read through it.
Commentary
Client:
Wow, I’ve really tried a lot of different things. I
guess I’ve also tried therapy, and I’ve tried to just
ignore it.
Therapist:
Let’s add those to the list—­therapy and ignoring.
What else?
Client:
Well, I guess I’ve tried to hide it by not letting
people see my hands shake.
Therapist:
Okay, hiding… Other things?
Client:
I’m sure there are others. I just can’t think of
them right now.
Therapist:
There are probably a lot more. We may come
across them as we keep working, and we can add
them to the list then. So, here we have this pretty
extensive list… One thing is clear: You’ve
definitely put a lot of effort into fixing your
anxiety.
Client:
Yeah, I guess I have. Maybe I just haven’t put
enough effort in yet. Maybe I need to try harder?
Therapist:
Let me ask you, have you tried hard? From my
perspective, you’ve tried tremendously hard. The
list of things you’ve tried is very long. I wonder if
we need to add “try harder” to the list of things
you’ve tried?
Client:
(Chuckles.) Yeah, even though I often think of
myself as lazy, when I look at it now, I see that
I’ve done a lot to try to deal with this.
The therapist continues to draw out
more examples of the client’s efforts
to control his internal experiences.
When working on creative
hopelessness, you want to validate
the effort the client has put into
trying to make things better while
also beginning to undermine “more
of the same” as a solution.
While, on a literal level, any
solution probably requires hard
work, “trying harder” is currently
functionally linked to the control
agenda and therefore needs to be
undermined. At the same time, the
therapist validates the client’s effort.
Developing Willingness and Acceptance 49
Therapist:
Okay, so now we have “try harder” in this long
list. Again, I want to be clear: it’s not that you
haven’t put in enough effort… But something
seems strange here. Look at all of these things
you’ve tried, and yet here you are, still struggling
with anxiety. In fact, can you name one thing on
this list that has solved your anxiety problem in
any long-­term kind of way?
The therapist asks the client to look
at the workability of control efforts
in a long-­term framework, rather
than in the short term, where it
may appear to work better.
Client:
(Sounds puzzled.) Well, I guess anxiety
management worked.
Therapist:
(Also sounds puzzled—­and nonjudgmental.) It
seems as though if that had worked, you wouldn’t
be here right now. Why not just do more anxiety
management and call it good?
The therapist appeals to the client’s
experience, asking why the client is
in therapy if these solutions worked
in the long term.
Client:
I need you to remind me how to do anxiety
management. I’ve forgotten most of it.
Therapist:
Let’s look at that. Have you been reminded
before?
Client:
Yeah, lots of times.
Therapist:
How about we add that to the list of things that
you’ve tried that haven’t worked. I could remind
you, but it seems you would need to be reminded
again, and then again. Does that seem true to
you?
Client:
(Laughs.) Yeah, I do forget a lot. Can you see
what a pain this is for me? I just need to figure it
out.
A common response is to figure it
out. But all of the client’s efforts
have in some way been about that,
so figuring it out should be
addressed and added to the list of
things that don’t work.
Therapist:
How long have you been trying to figure this out?
Client:
Oh, about thirty years.
The therapist addresses how long
this strategy has been applied, again
pointing to its long-­term
workability.
The therapist establishes that what
the client is continuing to do, even
in asking for help in remembering,
is part of what he’s tried before, and
therefore it must not have worked.
Remembering is not the solution
either and should be added to the
list.
50 Learning ACT, 2d edition
Therapist:
It seems that you’ve spent a lot of time “figuring
it out.” So I’ll add that to the list of things you’ve
tried as well. If you’ve been trying to figure it out
for thirty years, it seems that would have worked
by now.
The therapist identifies the
functional category of the response
and gives it a label.
Client:
(Sounds slightly impatient.) You’re the therapist,
you tell me what works.
Therapist:
Ah, that’s a great strategy: get information from
someone else about how to solve this. Yet here we
are. You said you’ve been to therapy and you’ve
read books. You’ve tried to get information, and
that didn’t solve it. So let’s add that one to the
list, too: getting information from others. The list
is growing.
The therapist identifies the
functional category of the client’s
current behavior and labels it. The
therapist may be feeling anxious
here too, but with an entrenched
client, it’s important to stick with it.
Client:
This is frustrating. There must be something that
works, right?
Frustration at this stage isn’t
necessarily a problematic reaction
and in some cases is to be expected.
It might even be part of the client’s
avoidance repertoire.
Therapist:
I hear your frustration. Can we stick with this a
bit longer?
Client:
Yeah, we can, but I don’t see where this is going.
The therapist asks permission,
wanting to check in on the alliance
at this point.
Therapist:
Okay, so you asked me a question about what
works. That’s another way to try to get
information from someone else. Have you asked
questions to try to get information before? How
many questions have you asked about anxiety?
Client:
Tons.
Therapist:
So asking questions goes on the list.
Client:
Something must work. Why would people go to
therapy? You just need to help me understand.
Therapist:
So, if you understand anxiety better, then that
will solve your problem? (Smiles.)
Client:
(Pauses.) I understand anxiety pretty well.
Responding to the client’s statement
literally wouldn’t be useful here.
The therapist instead labels this as
another example of the kinds of
things the client does to solve the
problem: asking questions (another
way to try to figure things out).
The therapist continues to label the
function of the client’s behavior.
Developing Willingness and Acceptance Therapist:
So it seems understanding this better isn’t
working, either, and…
Client:
I know, that goes on the list. (Pauses.) Well,
maybe I should just go home if nothing works.
Therapist:
I hear your mind suggesting that as a solution,
but let me have you notice that staying home is
already on the list. You’ve listened to that
suggestion from your mind as well. So it seems
that staying home hasn’t worked either.
Client:
Well, hell then, there’s nothing left to do. I
give up.
Therapist:
Have you given up before?
Client:
Yes. (Sounds frustrated.) Go ahead, put that one
on the list too.
Therapist:
Yeah, giving up hasn’t solved this problem either.
Client:
This is frustrating.
Therapist:
I can see that. I imagine I might be frustrated
too.
Client:
I guess I just have to accept it.
Therapist:
Hang in here with me… Have you tried just
accepting it before?
Client:
Oh no, not again. Isn’t this called acceptance and
commitment therapy?
Therapist:
Sure is. But have you tried acceptance before?
Client:
Yes.
Therapist:
And it didn’t work to solve your anxiety, or you
wouldn’t be here. We’re kind of getting to a place
where nothing works. You’ve tried all these
things and nothing has worked to solve your
anxiety. And you don’t have to believe it because
I’m saying it. Look back across the years and tell
me, based on your experience with all of these
strategies, what has worked?
51
Often, giving up or resignation
comes up as a strategy, but at this
point it’s often still a strategy from
within the old agenda. Although its
form may look like acceptance, it’s
probably a control strategy in
disguise. Behind resignation is the
hope that someday things will
change.
Expressing frustration has probably
led to therapists backing off before.
The client would probably feel
better in the moment if the therapist
simply backed off or gave a
suggestion for a solution (e.g., a
relaxation exercise). However,
functionally, this would be feeding
the old agenda. The therapist
assumes that for this very stuck,
pervasively avoidant client,
anything the client is offering at this
point isn’t new behavior and is
probably part of the old agenda.
The therapist asks the client to
check his experience. The therapist
is trying to shift the client to a way
of responding that’s more in contact
with his experience and less bound
to rules, even (or especially) rules
generated by the therapist.
52 Learning ACT, 2d edition
Client:
Well, some of them work a little bit.
Therapist:
Absolutely. A lot of things you’ve tried make you
feel better in the short run. You can even drink
and feel better for a bit. But then what happens?
Client:
It comes back.
Therapist:
And then you have to do what?
Client:
(Laughs.) Try harder.
Therapist:
(Laughs with the client.) But we already know that
trying harder doesn’t work. It isn’t because of lack
of effort that you’re sitting here with me today.
That’s for sure.
Client:
I’m lost. I don’t know what to do.
Therapist:
What do you bump up against when you feel lost?
Client:
It’s hopeless. There is nothing to be done.
Therapist:
Now we’re getting somewhere.
Client:
You must be kidding me. I’m lost, and you think
we’re getting somewhere?
Therapist:
Maybe lost is a good place to be, at least right
now. Not knowing means that perhaps something
different can take place. If you did know, I
suspect we’d have to add it to the list of things
that don’t work because you would have already
tried it. And I don’t want to take you back to
what hasn’t worked. So for now, perhaps lost is a
place to be. But it’s a creative place because from
this place maybe, just maybe, something new can
happen.
The therapist again draws the
client’s attention to the longer-­term
pattern. Clients usually want to
focus on the short term.
The therapist’s suggestion that the
client’s problem isn’t about not
trying hard enough helps the client
not fall into useless self-­blame.
Contact with the present moment
occurs when the client is asked to
notice what’s showing up now.
This is clearly not an expected
response. It steps outside the
bounds of literal discourse, where,
if taken literally, “hopeless” and
“lost” are places to be avoided.
However, for this client, moving
away from feeling hopeless and lost
is part of what keeps him stuck.
Feeling hopeless and lost at times
will probably be part of engaging in
new behavior for the client. Feeling
lost is a normal part of learning
new things, and hopelessness is
likely to be a common reaction for
someone who has repeatedly had a
hard time accomplishing goals
related to his values.
53
Developing Willingness and Acceptance Exercise:
Learning from Your Reactions to This Dialogue
It’s common for beginning ACT therapists to feel apprehension at the thought of taking this kind of
approach with a client. We invite you to see this as an opportunity to learn about your own psychological flexibility as a therapist. (We aren’t assuming that there’s any psychological inflexibility if you are
anxious, as the presence of anxiety doesn’t necessarily mean you’d avoid it; rather, anxiety just sets the
context for possible avoidance or fusion.) If you’re willing, we invite you take some time to explore your
reactions to the dialogue, bearing in mind that the vignette is meant to serve as a model for how to
foster acceptance.
As you were reading the dialogue, what were your reactions? Was it uncomfortable for you in any
way? If so, how? What emotions did you notice?
How about thoughts, particularly evaluations? Were there any parts of the dialogue that elicited
judgments? What does your mind say would happen if you took an approach like that in the dialogue?
What does your mind say it would mean if you chose not to take that kind of approach? How attached
are you to any of these thoughts? How much do you see them as true or feel pulled to defend them,
whether they’re “positive” or “negative”? Take some time to write about what you notice when you
consider these questions.
Some therapists, especially those new to ACT who can’t yet see how this fits into the overall model,
respond to this vignette with a reaction of “I can’t (or won’t) do this to a client.” Sometimes this is followed by doubts about whether ACT is a good match for them or their clients. These are natural reactions, and they need not be a barrier to learning ACT. (They would only become a barrier if you were
fused with them and felt a need to defend them.) If you noticed a reaction like this, we encourage you
to consider treating this reaction as potential data about yourself—­about your psychological flexibility
and your values. We want to remind you that ACT is fundamentally about fostering choice and values-­
based behavior, including for the therapist.
54 Learning ACT, 2d edition
While there is no ACT litmus test that demands “good” ACT therapists to use any particular
technique, we want to explore the possibility that there very well may be certain contexts in which
taking an approach like that demonstrated in the preceding vignette might align with your values. As
such, you may arrive at a point, perhaps after learning ACT more thoroughly, when you choose to
interact with a client in this way, even if doing so feels uncomfortable for you. If you are open to exploring this possibility, here are some additional considerations to explore.
What is painful for us is often linked to our values. If this vignette was difficult to read or consider,
what might that tell you about your clinical work? What would you choose to have your work be about?
Does this tell you anything about reorganizing your efforts to align with your values? Take some time
to write about this now.
Now that you have a sense of some of your values as a therapist, we ask that you reread the preceding vignette with an eye to how you might do something similar—­in a way that aligns with your values.
We also suggest that you practice awareness and willingness as you read it again to see whether you can
get a feel for how the therapist’s methods might foster psychological flexibility, even if they could be
interpreted as doing something else. Try to identify what might work to foster acceptance, and also
notice what you evaluate as not working. As you write about these things, try to hold all of this lightly,
seeing it as a process of learning about yourself and developing as a therapist.
This exercise explored common therapist reactions that could result in hesitancy to use a method
along the lines of that demonstrated in the vignette. If you found yourself relating to the vignette differently, with excitement or hope that using such methods will result in a magical change for your
clients, we ask that you hold those responses lightly, as well. Sometimes dramatic or radical change can
happen, and yet acceptance is a process. We encourage therapists to let go of a focus on outcome.
Trying to change clients or get clients somewhere through this process runs counter to what acceptance is about. In addition, harboring an unspoken motivation of trying to have a client get the point
is likely to come out in your behavior, which could result in invalidation, coercion, or sense of falseness.
Remember that creating an opening for acceptance is about responding to the client’s actual experience, in the moment, as you perceive that experience based on the client’s history and present-­moment
Developing Willingness and Acceptance 55
reactions. This isn’t about getting anywhere other than where the client already is; rather, it’s about
aligning with where the client already is. This work also isn’t about the therapist’s agenda for the client
or what the therapist thinks the client should be doing. So if you find yourself trying to use these
methods to coerce clients to be different, stop; you’re off track.
CREATIVE HOPELESSNESS WITH A CLIENT WHO HAS LESS OF
A HISTORY OF EXPERIENTIAL AVOIDANCE
Deciding how much emphasis to place on undermining control largely depends upon the pervasiveness of experiential avoidance and control efforts in the client’s life. For some clients, experiential
control has been their dominant way of living for many years, leaving them entrenched in this pattern;
for others, experiential control is less pervasive, less practiced, or less dominant, so they may be more
inclined to give it up as a solution. The more chronic and pervasive avoidance has been, the more likely
it is that the therapist will need to emphasize creative hopelessness. When working with clients who
have relatively less pervasive patterns of experiential avoidance, therapists can probably quickly move
to helping them develop mindfulness and acceptance skills in the context of pursuing their values.
The following dialogue illustrates a brief approach to creative hopelessness that can be used in the
latter case. The context is an early session with a bright, young, relatively functional client with social
anxiety. Leading up to this dialogue, the therapist has reviewed the ways in which the client has tried
to deal with his anxiety.
Therapist:
Let me suggest something: If this were an easy, obvious problem to solve, you would have
figured it out. (The therapist is supporting the client, noting that his failure to solve the problem
isn’t because he is unable, but because it can’t be figured out.)
Client:
I think so. Yeah.
Therapist:
You’re a smart, capable person. You’ve been struggling with this a good portion of your life.
And you know directly that there’s something inherently tricky about this problem. For
example, even noticing that something isn’t there is enough to create it. It’s like, “Oh, I’m
feeling better… Oh no…no I’m not.” Let’s look at what was on this list of things you’ve
done to manage anxiety. There was distracting, reassurance, talking yourself out of it,
avoiding it, and perhaps some other things we haven’t talked about yet. See if they all have
this characteristic in common: They can, at certain times, be a little helpful… And ultimately they’re not that helpful. (Defines and names the control agenda.)
Client:
Yeah.
Therapist:
They don’t solve it.
Client:
No. I know that. (Laughs.)
Therapist:
And see if even this isn’t true: They can work for a short period of time, and they might
make it worse in a moderate or longer period of time. For example, if you do something to
distract yourself, sooner or later you have to check to see if it worked. And then when you
56 Learning ACT, 2d edition
check to see if it worked, it will remind you of what you were trying to forget… And then
it’s back. (Points to the paradox of control efforts.)
Client:
Yeah, sometimes I’ll be thinking, “Okay, I’m going to distract myself. Let’s think about
something fun.” So I think, “Skiing, riding down the hill, getting to the lodge, hanging
with friends at the lodge… Oh crap! Okay, start over.”
Therapist:
Yeah.
Client:
Or sometimes I’ll notice I’m feeling better, and then it will be back.
Therapist:
Yeah. And here’s the problem: You talked about the tricks your mind plays on you. The
problem is, your mind is in the room, not just you. So you’re doing a lot of stuff your mind
is telling you to do. And yet it’s in the room, listening to what we’re saying.
Client:
It knows. (Laughs.)
Therapist:
Yeah. It knows what’s going on, right?
Client:
Yeah.
Therapist:
But it doesn’t seem to be able to give you ultimate, final answers. If anything, it seems to
torment you. It reminds you of some random memory you don’t want to think about.
Client:
And I can’t logically make it go away. I think I understand what you’re saying. I know what
I’m thinking isn’t logical, but it just doesn’t get through.
Therapist:
Right, because this isn’t just a logical deal, it’s a psychological deal. And that’s not the same
thing. So let’s put these things together. We need to carve out some space here in which to
work. I want you to consider the possibility that you’ve pretty much exhausted the things
that seem logical, reasonable, or sensible. They pay off like this. (Spreads hands toward
client, making a gesture that implies that it hasn’t worked because the client is here, in therapy,
looking for ways to control anxiety.) They don’t pay off in some other way.
Client:
(Laughs.) No, they don’t.
Therapist:
They pay off like this. And if that’s the case, then we’re going to have to open up the possibility that a whole other approach is needed. And yet we’ve got a mind in the room that
will say, “Oh yeah, I get that,” and try to pull whatever we do back into the same system.
(Pauses.) So, you know what quicksand is, right?
Client:
Yeah.
Therapist:
When people step in it, they do the normal, logical, reasonable, sensible thing: they try to
get out of it.
Client:
Which makes it worse.
Therapist:
Yeah. The normal way to get out of things is to push to get out. The problem is, when you
do that with quicksand, it just sinks you in deeper. Pushing on the one foot didn’t work, so
Developing Willingness and Acceptance 57
you push on the other. Now you’ve got two of them in there. Maybe it’s like that. Maybe
the things you’ve been doing are like the normal, logical, reasonable, sensible things people
do when they are stuck in quicksand. And in fact, it’s not liberating you; if anything, it’s
making you more stuck. So if that’s true, we have to find something that might work that’s
outside the set of all the things that might work. (Here, the therapist has included some defusion in the metaphor.) You know what I mean?
Client:
(Laughs.) Yeah. (Pauses.) So, what are we going to do, then?
Therapist:
(Pauses and smiles.) Well, your experience is telling you, “I do something, and it doesn’t pay
off. It pays off short term and it doesn’t pay off long term.” (The therapist is reflecting the
client’s experience of workability.) And really, the problem just keeps hanging around.
Sometimes it’s better and sometimes it’s worse, but here it is. And you’re trying not to let it
grow. But it’s still here, and you’re stuck.
Client:
Yeah.
Therapist:
Well, I want to open the door and say, “You know that sense you have that you’re stuck?
Well, maybe you have that because you really are stuck.” This game is a stuck game. It’s
not going to work some other way. It works like this. You know in your experience how
things have worked. If you back up and look at it, it almost seems like this is a rigged game.
In other areas of your life, you put in the effort and get the outcome. Not here. So we’ll
need to do something really different.
Guidelines for Working with Creative Hopelessness
Ultimately, the idea in creative hopelessness work is to validate clients’ actual experience of control
not working, to validate the emotions they’re experiencing, and to suggest that the social messages
they’ve been given might be incorrect, rather than that clients are incorrect. So before the end of a
session like this, be sure to establish that you’re suggesting that the agenda is hopeless, not that the
client is hopeless. Also, note that the “creative” piece in creative hopelessness refers to an openness that
comes when clients finally abandon needless experiential control and turn their attention to living a
life that aligns with their chosen values. After all, the goal is not to create a feeling of hopelessness or
belief in hopelessness; in fact, this process often creates a hopeful feeling. The goal is simply to speed
the process of abandoning what isn’t working (Hayes et al., 2012).
When clients fully contact the unworkability of old control agendas, they may feel lost or confused
because the path they’ve been on no longer seems viable. This isn’t a negative sign; it’s a sign that old
control behaviors are beginning to fall away. Occasionally, clients might feel upset or angry at this
point, with a sense that they’ve been tricked by life or by the clinician. If so, you might validate this
saying something like, “It makes sense that you’d feel upset after putting so much effort into something
with so little payoff.” In order to forestall potential self-­blame, you might say, “It isn’t your fault that you
fell into this hole. These were the tools you were given by society. But what if it’s the case that much of
what we’re taught to do with our painful emotions and thoughts can actually make things worse? What
if it’s the case that the things your mind tells you to do might actually get you more stuck?” Other
common reactions, which may not require a specific response, include clients slowing down or being
58 Learning ACT, 2d edition
more thoughtful, periods of silence, a sense of lightness in the room, laughter, and a start-­and-­stop
quality to clients’ speech, as if they’re catching habitual patterns of thinking.
Because creative hopelessness is such an important piece of both the up-­front and the ongoing
work in ACT, and because it typically begins early in therapy (and appears early in this book), we have
additional key guidelines to share. A common mistake on the part of therapists is trying to convince
clients that avoidance isn’t working or that they must give up their agenda of experiential control.
Another is that therapists may try to push clients further than they’re currently ready to go. It’s essential that the client’s experience be the absolute arbiter. Creative hopelessness will only function as it
should if the confrontation is between the client’s system of experiential control (the mind) and the
client’s actual experience, not between the therapist and the client. The therapist is simply there to
guide the process of helping clients examine their own experience and determine whether the solutions
their minds have been putting forward have actually worked as they were supposed to, or whether their
experience has shown otherwise.
Another common therapist misstep at this point is getting caught up in the content of what clients
say. For example, therapists may assume that a seemingly logical or healthy solution should be supported, without exploring its actual function. In this case, a therapist might encourage a depressed
client to exercise more (a seemingly healthy behavior in depression) without knowing whether exercise
functions primarily as avoidance for that client. So remember that the target of acceptance is undermining behaviors that serve as experiential avoidance, which is defined based on function, not form.
In the example of exercise, a psychologically flexible route forward might involve either more exercise
or less—­more if this behavior is linked to values, and less if it’s linked to avoidance. Responding based
on content is especially tempting if strategies the client has tried are similar—­in form—­to ACT
methods (e.g., mindfulness meditation). However, the purpose is not to endorse formally correct
methods; it is to explore the functional impact of any and all solutions and let go of anything that isn’t
working. Typically, what isn’t working is clients’ cognitive entanglement with their mind and the resulting control agenda, which may not be easily seen or logical. Clients’ experience is the biggest ally in
determining the function of their behavior.
Finally, we want to be clear that creative hopelessness isn’t about a one-­time, all-­or-­nothing shift in
behavior; it’s about establishing the possibility of an approach other than control—­in this moment, the
next moment, and then the next moment. It’s about helping clients see that each moment of existence
offers an opportunity to say yes to their experience, feeding the vitality of a values-­based life, rather
than continuing down the path of experiential avoidance.
Establishing Control as the Problem
In the preceding dialogue with the client who had less of an attachment to experiential avoidance,
you can see the therapist transition from working on the sense of creative hopelessness to more explicitly outlining how experiential or emotional control might be part of the problem, rather than the solution to the client’s current difficulties. Many clients come to therapy believing they need more control
over their internal experience. However, misapplied control has already landed them in an unworkable
agenda—­and it’s done so at the expense of their lives; they’ve put their lives on hold while they worked
on getting their emotions or thoughts under control.
All therapists have heard clients make statements such as “When I get my anxiety under control,
I’ll get a job,” “When the pain stops, I’ll find another relationship,” or “When I don’t feel guilty anymore,
Developing Willingness and Acceptance 59
I will reconnect with my children. I don’t want to subject them to my guilt.” These kinds of statements
come in all shapes and sizes, but all versions are about the client beginning to live only after unwanted
internal experiences are under control. Of course, the problem with this is that life occurs in the
present moment. And as should be clear at this point, it’s difficult to change what happens internally
in any lasting and meaningful way. It’s more likely that efforts at control will lead to more problems and
costs. This can happen in obvious ways; for example, perhaps a client drinks heavily to avoid feeling
sad. It can also play out in more subtle ways. Imagine a client who tends to change the subject whenever
you begin to talk about painful issues yet desires more intimate communication with others. The following dialogue points to this issue.
Therapist:
So you had a good time this weekend at the lake?
Client:
Yes, it was a lot of fun. I hiked and went swimming. I really got to take a break… But I was
alone, and that was kind of a bummer.
Therapist:
You were alone? I know it’s been hard for you to be alone. Was it painful?
Client:
Yes, but you won’t believe what happened when I was hiking. I came across a bear on the
side of the trail…
Therapist:
(Interrupts.) I noticed that you skipped past that painful part.
Client:
Yeah, but I wanted to be sure and tell you about the bear.
Therapist:
It seems it just happened again. What do you think would happen if you showed up to the
pain?
Client:
(Gets tearful.) I’d start to cry, and I don’t want to do that.
Here you can see how the client is avoiding vulnerability at the expense of intimacy. The therapist’s goal in such cases is to point out the costs of this kind of control: loss of values-­based living. For
this client, those costs include loss of intimacy, connecting, and lovingly participating in
relationships.
Misapplied control efforts can be tackled by an appeal to clients’ experience, just as described for
creative hopelessness, and by using metaphors that model the problem of control. An often used metaphor is the Tug-­of-­War with a Monster (Hayes et al., 2012, p. 276), wherein the therapist and client
engage an experiential exercise demonstrating the struggle with difficult emotions and thoughts by
engaging in a mock tug-­of-­war. The therapist typically pretends to be the negative emotions and
thoughts that the client would like to eliminate, while the client plays himself. The two pull on opposite
ends of a rope (perhaps using a real rope as a prop), stretched between them over an imagined bottomless pit that represents what appears to be certain destruction if the client is unable to defeat the negative experiences by pulling them into the pit. During the exercise, the therapist works with the metaphor
in such a fashion that the client experientially contacts or sees that this war is not being won (e.g., the
difficult emotions remain). Tugging to win is equated with control. Clients often eventually realize that
the only solution is to let go of trying to win the war—­to drop the rope. In some cases the therapist may
need to point this out. The emotions and thoughts don’t disappear when the client lets go, but there is
no longer a battle and the client is freer to move.
60 Learning ACT, 2d edition
The ACT literature has many other exercises and metaphors that demonstrate the problem of
control: the Polygraph metaphor (Hayes et al., 2012, pp. 182–­183); the Chocolate Cake task (Hayes et
al., 2012, pp. 185–­186); the Feeding the Tiger metaphor (Eifert & Forsyth, 2005, pp. 138–­139); the
Chinese Finger Trap metaphor (Eifert & Forsyth, 2005, pp. 146–­149); and many others (Stoddard &
Afari, 2014; Harris, 2009, pp. 89–­95). Each illustrates the paradox of control: the more you try to
control your internal experience, the more you lose control.
This paradox is captured by the message “If you aren’t willing to have it, you’ve got it” (Hayes et al.,
2012, p. 185), or its variant, “If you aren’t willing to lose it, you’ve lost it.” If you aren’t willing to have
anxiety, then anxiety is something about which to be anxious, leading to even more anxiety. If you’re
not willing to lose love, then you can’t have love because you will constantly be trying to control your
beloved.
Those examples are focused on experiential control related to emotions, but this paradox also
applies to thoughts. If you try to control what the mind is thinking, an immediate problem arises: you
have to contact what you’d like to control in order to know that you want to control it—­and in order
to try to do so. To help clients understand this, you could ask them not to think about a banana for
thirty seconds, for example. Of course, many immediately think about a banana. And the harder they
try not to think about a banana, the more they will be thinking “banana,” and then perhaps about
banana splits, the color yellow, bunches of bananas, and so on. Some clients will report that they were
able to distract themselves. Exploring what they did to accomplish this can usually show that there are
significant costs to distracting themselves from thoughts about bananas. Distracting ourselves might
work in the short run, but it results in a narrowing of awareness (i.e., we can’t think about anything
related to bananas) and it takes energy, leaving us less free to focus on what we’d most want to—for
example, our values. You can then discuss how this effort is likely to backfire when applied to thoughts
that seem particularly important to control. And indeed, it has backfired; otherwise, the client wouldn’t
be complaining about having difficult thoughts. Of course, the aversiveness of thinking about a banana
is probably miniscule for most people. However, other thoughts can have a strong impact—­thoughts
like “I’m damaged goods,” “There’s something wrong with me,” or “I’ve wasted my life.” Clients often
want to get rid of these kinds of weighty thoughts, yet distracting themselves from these thoughts will
be much more difficult or costly.
Teaching What Willingness Is
Once you’ve explored workability and established control as the problem, you can turn to helping
clients practice willingness. Occasionally, clients will already be open to this, in which case you can
jump right to practicing willingness, as we’ll describe shortly. However, many clients are hesitant, often
because they are unclear about what willingness is, in which case you’ll first need to teach them what
it is. Where you start with a client is determined by your conceptualization of the case (see chapter 8).
In the following dialogue, the therapist returns to the Quicksand metaphor, but this time for a
slightly different purpose: as a way to begin to point to what willingness is like.
Therapist:
Do you remember the metaphor of falling into quicksand?
Client:
Yeah. The harder I try to get out, the faster I sink?
Developing Willingness and Acceptance 61
Therapist:
Exactly… The harder you try to get out, the faster you go down. We didn’t talk about what
to do when you get stuck in a situation like this—­besides struggle. With quicksand, in
order not to sink, what you need to do is the opposite of what you’d naturally think to do.
In order to stay afloat in quicksand, you have to gently spread out and let as much of your
body contact the sand as possible. (The therapist slowly opens her arms to emulate spreading
out in quicksand.) The more of your body you place in contact with the surface of the
quicksand, the more you’ll float and not drown. What if getting rid of anxiety is like falling
into quicksand? The harder and faster you try to get out of it, the more you sink into it and
the worse things get. Maybe the thing to do is to stop struggling—­to get in contact with
the emotion and learn to float in it. (The metaphor allows the therapist to point to willingness
in a way that’s simple and intuitive, rather than getting caught up in complex descriptions. It also
points to willingness as an alternative through the notion of floating in a feeling.)
Client:
But floating in it doesn’t get me out of it either.
Therapist:
That’s right. What you feel is still there to be felt, even as you let go of the struggle that
makes things worse. Is that something you’d be willing to do if it meant you wouldn’t
drown?
Client:
Do you mean I have to float in order for the anxiety to go away?
Therapist:
Two things: First, you don’t have to float; this is your choice about how you’ll be with your
anxiety. And second, floating in quicksand isn’t about the anxiety going away… Spreading
out in quicksand doesn’t make it stop being quicksand. Trying to spread out in order to get
out isn’t spreading out; it’s a tricky way to struggle. Your mind is with you all the time and
knows what you’re doing, so it will have the same quality as struggling. (The therapist is
pointing out that willingness is chosen, and that anxiety will feel like it feels. It’s important not to
get wordy at this point and overexplain. Letting the metaphor stand without additional explanation is likely to be more effective.)
Client:
(Sounds disappointed.) But I don’t want to float in quicksand.
Therapist:
(Speaks from a grounded and humble stance.) Of course you don’t. Who wants to be anxious?
And yet what if this is the choice life is giving you? You’ve fallen into the quicksand.
Struggle and get more stuck, or spread out and float? It’s a choice, an action. I’m not sure
either of us knows what will happen when you float. But you do know what happens when
you struggle, because that’s what you’ve been doing up until now.
Client:
Yes, but how do I float?
This is just one example of how to introduce the idea of willingness as an alternative to control
efforts. This opens the door to shifting the work to an explicit focus on building new behaviors that are
about embracing, holding, and compassionately accepting one’s experience. Clients usually enter
therapy with an agenda of wanting to feel better. Acceptance is the work of helping them feel better—­
meaning to get better at feeling (Hayes et al., 2012)—­in the service of living better. In this part of
therapy, the clinician’s job is to guide clients in practicing willingness in various contexts, with various
private events, and with the goal of developing the ability to apply it broadly in their lives. However,
62 Learning ACT, 2d edition
clients are generally unsure what will happen if they’re willing to experience their emotions. Letting go
of control of internal events can and does feel like taking a step into the unknown—­almost like closing
your eyes, taking a step, and hoping that your foot finds the ground.
As you explore what willingness is with clients, there are two key points to elucidate: that willingness is a choice, and that willingness is an action.
WILLINGNESS IS A CHOICE
“Choice” means making a selection simply because we can. Therefore, the choice to be willing is
present in every moment. Often clients assume that they don’t have a choice and list several if not many
reasons they can’t choose to be willing. You can work with such clients to help them defuse from or
observe their reasons and still take action. There are a couple of quick ways to demonstrate this for
clients. One is to give them a choice between two similar objects. For instance, you might ask clients,
“Tea or coffee, which would you choose?” After they’ve made a choice, ask them to generate as many
reasons as possible to explain why they made that choice, and stick with this until they’ve listed a fair
number of reasons. For the purpose of this explanation, let’s assume that a client chose coffee. Then,
no matter how good the client’s reasons, such as “I’m allergic to tea” or “The taste of tea makes me
sick,” ask if it isn’t true that the client could still choose tea and drink it, despite all the reasons generated. The answer is, indeed, yes. It is not the reason that chooses, but the person. You can then bring
this back to the larger issue at hand by asking, “Would you be willing to choose willingness if it meant
you got to live your life?”
The metaphor of an annoying neighbor (inspired by the Joe the Bum metaphor; Hayes et al., 2012,
pp. 279–­280) can be useful in this type of situation.
Therapist:
Imagine you’ve just purchased a new home and you decide to hold an open house. You
make invitations that say, “All are welcome,” and post them around the neighborhood.
You’re excited about the party and begin to get ready by making everything look nice and
by preparing the food and drinks. The big day comes, and everything is going well. The
guests are arriving and enjoying themselves; everyone is laughing and having a good time.
More guests are arriving. Then you hear a knock at the door. You open it with a smile,
which rapidly changes to a look of distress. There before you stands Edna, a neighbor
you’ve already found quite annoying. Edna makes obnoxious noises, is often rude to people,
and has terrible manners. You quickly try to close the door, but Edna has placed her foot
between the door and the jamb, so you can’t close the door. You ask her to leave, but she
shakes her head and shows you one of the invitations you posted around the neighborhood. She repeats the words written in large letters: “All are welcome.” She tells you that
she’s not leaving and will stand right there until you let her in. Given the situation—­that
she’s not leaving and you aren’t interacting with your guests—­you decide to let Edna in,
but you insist she needs to stay away from the guests and remain in the kitchen. You
rapidly escort her to the kitchen and admonish her to stay there. You close the door to the
kitchen and begin to walk away…and right behind you is Edna. She follows you out of the
kitchen. You turn and say, “No, Edna, you must stay in the kitchen,” and escort her back.
Once again, you turn to join the party, and…guess what happens.
Client:
Edna comes pushing through the door again.
Developing Willingness and Acceptance 63
Therapist:
Right. And what you find is that you have to stay in the kitchen with your foot propped
against the door to keep Edna out of sight. You’re locked in. What’s the problem here?
Client:
I don’t get to be at the party.
Therapist:
Yes. So, the big question is, would you be willing to let Edna wander around the house if it
meant you got to be at the party too?
Client:
It would be hard.
Therapist:
Yes, but could you choose to do it and be at your party?
Client:
Yeah, that’s what I’d want to do.
Working with clients in this area boils down to a single question, “Are you willing to feel what you
feel, have the thoughts you have, and let your sensations be there, fully and without defense, and do
what works for you according to what you value?” Though the answer may seem simple and clients
often say they are willing, the path is potentially difficult. Clients may continue to struggle, getting
entangled in reasons and losing the distinction between mind and self. When this happens, they may
lose the experience of being able to choose. The intensity of thought and emotion that may arise when
they’re presented with values-­based choices in the presence of negatively evaluated emotions may pull
them back into a struggle. In ACT, the therapist’s job is to keep pointing to willingness and choice,
linking them to values, and supporting clients’ efforts to take a stance of open engagement in the
process of living. At the same time, the therapist validates and empathizes with the client’s experience
in taking on this challenge.
WILLINGNESS IS AN ACTION
Throughout this chapter, we’ve provided multiple descriptions of willingness. Willingness isn’t a
feeling, and it isn’t something that can be directly instructed or described, just as you can’t directly
describe how to ride a bicycle, play a musical instrument, or perform a highly skilled sport. This aspect
of willingness can be captured, for some, by comparing willingness to something that happens when
skiing.
Therapist:
Have you ever gone skiing?
Client:
Yeah, a few times.
Therapist:
Have you noticed how, when you’re skiing and you’re afraid you’re going too fast, your
natural tendency is to lean away, to lean back into the hill? The problem is, as soon as you
do that, you lose control of the direction in which you’re headed, and in fact, you even
increase the chance that you’ll wipe out. In this situation, the natural response—­to lean
back—­doesn’t work very well. What if this situation in regard to your thoughts and feelings is similar? What if the natural reaction—­to lean away from your own experience—­is
actually part of the problem? What if what’s needed here is to practice leaning downhill,
leaning into your experience, so you can have more control over where you’re headed in
your life?
64 Learning ACT, 2d edition
Practicing Willingness
Having established what willingness is, the next step is to assist clients in practicing willingness,
shaping their progress by recognizing and reinforcing even small acts of willingness. Ideally, willingness
is practiced throughout therapy and is interwoven with all the other flexibility processes. For example,
any time an ACT therapist asks a client to do an exercise or discuss a topic that might evoke difficult
content, this provides a chance for the client to choose between willingness and struggle.
In-­session and out-­of-­session exercises can be used to structure opportunities for clients to practice
willingness. For examples, see chapter 7 (committed action) or exercises in other books, such as the
Looking for Mr. Discomfort exercise (Hayes et al., 2012, pp. 285–­296) or exposure-­like exercises (see
Eifert & Forsyth, 2005). It is worth noting here that, from the ACT perspective, exposure work isn’t
done in the service of reducing fear (i.e., for habituation). Rather, it is engaged as a process of helping
clients practice willingness to contact uncomfortable experiences without struggling against them (see
Thompson, Luoma, & LeJeune, 2013). Such practices can be utilized at any time in treatment, as long
as they are flexibly applied and responsive to the context or situation of the client.
ACT willingness exercises often take the form of in-­session exposure exercises in which difficult
material is elicited, and then therapist and client work with this material together in session (for more
on this topic, see chapter 7). And although willingness tends to have an all-­or-­none quality, the context
in which willingness is practiced can be chosen, at least in part (Strosahl, Hayes, Wilson, & Gifford,
2004). For example, clients can choose to be willing for five seconds or for an hour. They can choose
to be willing in a mall but not in a bookstore. They can work on willingness with one emotion but not
another. Because clients can choose the situation (but not the level of willingness), the therapist can
titrate willingness work to the client’s current situation and context. And just as therapists conducting
exposure typically create an exposure hierarchy, ACT therapists usually encourage clients to start with
small acts of willingness, perhaps for a few moments in a session or with relatively unchallenging private
events. They can then move to larger acts of willingness, such as calling an estranged sibling and willingly feeling whatever shows up during that call.
Willingness Depends upon the Other
Flexibility Processes
Clearly, willingness or acceptance is a process and not an outcome, and it’s so foundational that it is
integrated into all aspects of ACT. It isn’t as if clients “get willing” and their work is finished. There is
always more willingness to do—­in life and throughout the course of treatment.
This isn’t fully possible without the other flexibility processes. However, at this point in the book
we can only provide a broad overview of the application of acceptance that occurs later in therapy.
Because willingness involves embracing the moment as it unfolds in the here and now, willingness is an
important subtext when working with present-­moment awareness, which is discussed in chapter 4. And
Developing Willingness and Acceptance 65
because willingness is a choice that entails letting go of fusion with reasons while simultaneously selecting among alternative courses of action, the fully developed form of willingness incorporates defusion
as a necessary component, as discussed in chapter 3. Willingness also interacts with self-­as-­context,
discussed in chapter 5, as contact with self-­as-­context, a safe place that transcends one’s experience,
facilitates willingness. Having a larger sense of self that transcends emotions, thoughts, and sensations
allows people to contact the broad set of experiences they encounter in life without the need to control
or eliminate those experiences. Furthermore, willingness to experience difficult thoughts and feelings
is generally done in the service of values; this is part of what makes willingness different from wallowing. We’ll explore this further in chapter 6. Finally, willingness is key to committed action, so chapter
7 includes important strategies for bringing willingness to this process.
Core Competency Practice
This section is intended to provide practice in working with willingness in response to sample dialogues
based on ACT sessions. There is one exercise for each of the eleven ACT core competencies for willingness and acceptance. For each, we present a description of a clinical situation and a brief dialogue.
(Some of the dialogues continue across multiple competencies.) Most of the dialogues also include
other elements of the ACT model because a single process is seldom used in isolation. Each dialogue
ends after a client statement, at which point we ask that you provide a response that reflects that competency. Then we ask you to describe the basis for your response. For each exercise, focus on providing
a response that illustrates the target competency, rather than responses that are consistent with ACT in
general. You can also describe any steps as part of the response that would contribute to implementing
the competency most effectively. After you provide a response and your explanation, turn to the end of
the chapter, where we provide model responses that you can compare your response to, typically two
for each exercise.
The model responses are not the only correct responses, and we don’t offer them as perfect or ideal
responses. Often there may be scores of well-­conceived ACT-­consistent alternatives. Our main purpose
in providing models is to give you a sense of what a high level of competency might look like. If your
response aligns with one of the models, that’s an especially good sign. If your response seems to fit the
explanation and competency just as well as the models do, you’re doing fine. If you think the model
responses might be more powerful than your response, try to learn from them. If you don’t understand
the model responses or they suggest that your response is off track, reread the relevant portions of this
chapter or consult other texts.
We strongly recommend that you not read the model responses until after you’ve written your own
response. Coming up with your own responses first creates the greatest opportunity for learning and
allows you to maximally benefit from the feedback inherent in the model responses. If you really want
to stretch your flexibility, you can write multiple possible responses before looking at the samples.
Before you get started, we’ll offer the following example of how you might complete one of these
exercises.
66 Learning ACT, 2d edition
Competency 2: The therapist helps clients make direct contact with the
paradoxical effects of emotion control strategies.
Completed Sample Exercise
The client is a nineteen-­year-­old female college student who complains of social anxiety and a
general lack of color or excitement in her life. She feels that this is related to her childhood history
of sexual abuse. Through therapy, she’s been able to see how memories of the abuse surface when
she finds herself feeling close to people. In response, she distances or numbs herself. This dialogue
occurs in her sixth session.
Therapist:
So, let me see if I get the sequence. You’re sitting around with your boyfriend; he
touches you; you start to feel anxious and really unsafe; and then you feel ashamed
that you feel that way. Right? Then you find some excuse to get out of there and go
home and drink so you don’t have to think about it. Is that the sequence?
Client:
Yeah, I just can’t think about it. It’s too hard. I’m so tired. I just need a way to get over
this.
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on
competency 2:
Therapist:
If talking about this experience could make it possible for you to have the open, loving relationship you so want, would you be willing to do that?
Client:
Yes.
Therapist:
So let me ask you then: The more and more you’ve tried to make these anxious and guilty
feelings go away, what have you found? Have they decreased over time, or have they
perhaps even gotten stronger, and in the meantime you still find yourself feeling distant,
lonely, and cut off?
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Her avoidance clearly isn’t working given what she wants in life. I’m linking up this issue with her values
and getting permission to talk about what’s likely to be a painful and sensitive subject, one in which the
client might feel challenged and perhaps even intruded upon. Then I’m having her check out whether this
strategy has actually worked out the way it was supposed to, or whether perhaps it has, paradoxically,
made things worse.
(After writing your own response, you would then check it against the models at the end of the
chapter before going on to the next exercise.)
Developing Willingness and Acceptance 67
Core Competency Exercises
Competency 1: The therapist communicates to clients that they are not broken
but are using unworkable strategies.
Exercise 1
A fifty-­six-­year-­old man has come to therapy seeking relief from anxiety associated with PTSD. He has
been in a number of treatment programs and worked with at least three other therapists and two psychiatrists. He complains that he can’t do regular, everyday kinds of things because his anxiety is too
high. He isolates himself and wishes things were different and also uses other avoidance strategies. Just
prior to the start of this dialogue, the client has listed about ten strategies he uses to get rid of anxiety.
Client:
What I’d really like to do is find a way to get this anxiety under control.
Therapist:
It seems you’ve tried a lot of different things. You’ve certainly made an effort.
Client:
Yeah, I just need to try harder…to figure out what will make this different.
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 1:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
68 Learning ACT, 2d edition
Competency 2: The therapist helps clients make direct contact with the
paradoxical effects of emotion control strategies.
Exercise 2
This dialogue continues where the dialogue for competency 1 left off.
Therapist:
So trying harder seems like the thing to do. But haven’t you tried hard in the past? You’ve
gone to treatment programs, therapists, and psychiatrists. You’ve listed numerous things
you’ve tried. You’ve tried hard, yes? Look at your experience. What do you know from
there (points to the client’s heart) and not there (points to the client’s head)? What does your
experience say about the results of trying hard?
Client:
It hasn’t worked so far.
Therapist:
Right. And what if that’s because it can’t? What if you really did give it a good attempt, but
this is how trying hard actually works in this area? (Points to the client’s chest again.)
Client:
I see what you mean, but I just want things to be different. I’m feeling anxious all the time.
I can’t stand being like this.
Therapist:
If things were different with your anxiety, what would you be doing?
Client:
Everything would be different. I’d be able to be around people. I could work. Everything
would be a lot better.
Write here (or in a notebook) what your response would be, demonstrating competency 2:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Developing Willingness and Acceptance 69
Competency 3: The therapist actively uses the concept of workability in clinical
interactions.
Exercise 3
This dialogue continues with the same client as in the competency 2 exercise but occurs later in the
session.
Therapist:
How successful have you been at making things different when you try harder?
Client:
Well, it works for a little while, and then the problems start all over again. The anxiety
comes back.
Write here (or in a notebook) what your response would be, demonstrating competency 3:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 4: The therapist actively encourages the client to experiment with
stopping the struggle for emotional control and suggests willingness as an alternative.
Exercise 4
A forty-­one-­year-­old woman is seeking therapy to alleviate anger and sadness around the breakup of a
relationship. The breakup occurred three years before she entered therapy. In her initial session, the
client explained that she feels betrayed and unable to move past the pain of the breakup. She notes that
her anger is interfering with her ability to move on. She also notes that she’s angry with herself for being
duped in the relationship. This dialogue occurs in her fourth session.
70 Learning ACT, 2d edition
Client:
I feel overwhelmed by my anger…and I feel stupid. It’s been three years. Why can’t I get
over this? It’s embarrassing.
Therapist:
Somehow getting over this seems like the thing to do, and then embarrassment and
“stupid” will go away, in addition to the anger?
Client:
Silly, isn’t it?
Write here (or in a notebook) what your response would be, demonstrating competency 4:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 5: The therapist highlights the contrast between the workability of
control and willingness strategies.
Exercise 5
For this exercise, assume you have the same client as in the exercise for competency 4, but the session
goes like this instead:
Client:
I feel overwhelmed by my anger…and I feel stupid. It’s been three years. Why can’t I get
over this? It’s embarrassing.
Therapist:
Somehow getting over this seems like the thing to do, and then embarrassment and
“stupid” will go away, in addition to the anger?
Client:
Silly, isn’t it?
Therapist:
I can see you have a lot of judgment about your anger. You think it’s silly and stupid.
Developing Willingness and Acceptance Client:
71
It is. I just can’t believe I’m still angry about this. It doesn’t make any sense to me.
Write here (or in a notebook) what your response would be, demonstrating competency 5:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 6: The therapist helps the client investigate the relationship
between willingness and suffering.
Exercise 6
This dialogue continues with the same client as in the exercise for competency 5 but occurs later in the
session.
Therapist:
What kind of effort have you put into making the anger go away?
Client:
A lot. I can’t even begin to describe how hard it’s been.
Write here (or in a notebook) what your response would be, demonstrating competency 6:
72 Learning ACT, 2d edition
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 7: The therapist helps the client make contact with the cost of
unwillingness relative to valued life directions.
Exercise 7
This dialogue continues where the dialogue for competency 6 left off.
Therapist:
What are some of the things that have happened because of this difficulty? How has your
life changed as a result of how hard this has been?
Client:
Well, I’m suspicious of men. I think they’re all trying to pull the wool over my eyes. I’ve
stopped dating completely. I tried it a couple of times, but found myself being cranky on
the dates. I’m incredibly lonely and feel angry at men… I blame men for that. I’m just out
of control about men… How can I ever trust them?
Write here (or in a notebook) what your response would be, demonstrating competency 7:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Developing Willingness and Acceptance 73
Competency 8: The therapist helps the client experience the qualities of
willingness.
Exercise 8
This dialogue continues with the same client as in the exercise for competency 7 but occurs in a later
session.
Therapist:
How important is it to you to have another relationship?
Client:
I would really like one, but I just don’t think it’s possible. Something really significant
would have to change.
Write here (or in a notebook) what your response would be, demonstrating competency 8:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 9: The therapist uses exercises and metaphors to demonstrate
willingness as an action in the presence of difficult internal experiences.
Exercise 9
A fifty-­year-­old man is in therapy because his wife has insisted he get help for his withdrawn and irritable style of interacting with her. He reports that he feels distant from his wife and has wanted her to
leave him alone ever since a misunderstanding that resulted in a financial loss. He notes that he’s
extremely disappointed in his wife, even though he recognizes that the financial loss was not her fault.
74 Learning ACT, 2d edition
Therapist:
What would you choose to have happen with this relationship? Are you wanting it to end?
Client:
No, I don’t want a divorce or anything like that. I just can’t bring myself to talk to her. I
almost can’t even look at her. I know that losing the money wasn’t her fault, but I still
blame her. I want the money back.
Write here (or in a notebook) what your response would be, demonstrating competency 9:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 10: The therapist models willingness in the therapeutic
relationship and helps the client generalize these skills outside therapy.
Exercise 10
This dialogue continues with the same client as in the exercise for competency 9 but occurs later in the
session.
Client:
I am ashamed that I’m so focused on the money. It’s hard to admit. I’m worried that you
might think I’m an asshole.
Therapist:
It’s hard to admit these things. It can be anxiety provoking.
Client:
Yeah, I’m having a hard time talking about it with you… I’m not sure you can help.
Developing Willingness and Acceptance 75
Write here (or in a notebook) what your response would be, demonstrating competency 10:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 11: The therapist can use a graded and structured approach to
willingness assignments.
Exercise 11
This dialogue continues with the same client as in the exercise for competency 10 but occurs later in
the session.
Client:
I don’t even know where to begin. It’s like, now that I’ve started ignoring her, I can’t find a
way to stop. I feel like it’s impossible to get out of this.
Therapist:
It seems like even a small gesture toward your wife feels hard.
Client:
Just looking at her feels hard.
Write here (or in a notebook) what your response would be, demonstrating competency 11:
76 Learning ACT, 2d edition
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Core Competency Model Responses
Competency 1
Model Response 1a
Therapist:
Another way to say what you just said is “I’ve got to try trying harder.” Have you tried to
try harder before?
Client:
Sure. And harder, and harder.
Therapist:
So, I want you to consider that maybe the problem here isn’t that you haven’t tried hard
enough. Maybe the problem is something about the tools you’ve been given by society, by
your parents, and by your history—­the things you’ve been taught to do to deal with this.
Maybe they just don’t work here. It’s as if you’ve been trying to use a hammer to paint a
masterpiece. Now I’m also not saying I have a different, better tool, because you’ve done
that, too—­looked for a better tool. This trap you’re in is trickier than that.
Explanation: It’s important for the therapist to openly recognize that control of internal experience is
a socially trained phenomenon. It isn’t the client’s fault that he would try such a maneuver. He’s been
taught by his social/verbal context that he should be able to solve the problem of anxiety. He’s been
taught that these maneuvers should work. Trying harder is just another part of that social/verbal
context, as evidenced by sayings like “If at first you don’t succeed, try, try, again.”
Model Response 1b
Therapist:
So trying harder seems like the thing to do. But haven’t you tried hard in the past? You’ve
gone to treatment programs, therapists, and psychiatrists. You’ve listed numerous things
you’ve tried. You’ve tried hard, yes? Look at your experience. What do you know from
there (points to the client’s heart) and not there (points to the client’s head)? What does your
experience say about the results of trying hard?
Client:
It hasn’t worked so far.
Developing Willingness and Acceptance Therapist:
77
Right. And what if that’s because it can’t? What if you really did give it a good attempt, but
this is how trying hard actually works in this area? (Points to the client’s chest again.)
Explanation: Here the therapist validates the client’s effort while pointing to the fruitlessness of this
effort. ACT therapists don’t ask clients to believe these efforts are fruitless because the therapist says
so; rather, clients are asked to examine their own experience to see whether these efforts have paid off.
These kinds of statements aren’t made in an attempt to gain a one-­up position in relation to the client
or to shame the client for trying hard and failing. In this response, the therapist simply points to a
system that doesn’t work, from a humble stance.
Competency 2
Model Response 2a
Therapist:
I see that these things are important to you: to work and have people around you. It seems
like getting control over the anxiety is the route there. But something seems strange here.
You’ve been working at trying hard to control your anxiety for quite some time, and as far
as I can tell, things haven’t turned out as you’ve hoped. In fact, here you are, sitting in front
of me seeking yet another way to make your anxiety go away—­to make your anxiety different. And these things you hope for—­work, relationships—­aren’t getting closer.
Explanation: The therapist states that something is strange, as if to say this isn’t the client’s fault but
the way it works is odd. This is a relatively defused contact with workability. The therapist also points
out that the client seems to be doing the same thing he’s done in the past: work with a therapist to
come up with yet another strategy for eliminating anxiety. This statement points to the paradox inherent in control efforts. This can be a tricky place for the therapist, who probably feels a pull to rescue
the client and reassure him that there is a way. However, this would be premature at this point and
would undo the effects of contacting the unworkability of control.
Model Response 2b
Therapist:
Do you see what’s happening here? Here you are working to make your anxiety go away,
but it stays. In fact, it seems that if you don’t want it, you’ve got it. If you don’t want your
anxiety, you’re going to get anxiety. In fact (speaks somewhat playfully), not being able to get
rid of your anxiety is something to be anxious about. In your experience, as you’ve worked
on this has your problem seemed to be getting larger or smaller?
Explanation: The therapist shares an idea with the client that reflects the paradox of control—­that if
you don’t want it, you’ve got it—­and asks the client whether this fits with his experience. Appealing to
the client’s experience is particularly important here. None of what the therapist says should come
across as an effort to convince the client about the problems with control. Convincing is content heavy
and moves clients away from the experience that everything they’ve tried hasn’t worked. Here, the
therapist directly points to the issue of what the client’s experience says about how control has worked
for him in reducing his anxiety over time.
78 Learning ACT, 2d edition
Competency 3
Model Response 3a
Therapist:
In your experience, has there ever been a significant amount of time when you didn’t experience anxiety?
Client:
No.
Therapist:
Is this struggle with anxiety opening up your life or closing it down?
Explanation: One of the goals of ACT is to help clients move toward a workable agenda that’s guided
by their values. Clients can actively bring willingness to taking steps intended to build a better life.
Again, workability is about living better, as defined by the client, not necessarily feeling “better.”
Model Response 3b
Therapist:
You’ve hired me. So I’m here to work for you.
Client:
Yeah, I guess.
Therapist:
Is part of my job to tell you what I see?
Client:
Yeah. What do you see?
Therapist:
From what you’ve told me, you’ve done many if not most of the reasonable, sensible, logical
things you could do to get your anxiety under control. You’ve worked very hard and tried
many, many sensible and reasonable options. But something seems strange here. It seems
like nothing has worked. The bottom line is that this—­what you’ve been doing—­isn’t
working. Not in terms of reducing your anxiety: it’s still there. And not in terms of your
life working: you still aren’t around people, still aren’t working.
Explanation: The therapist directly addresses the issue of workability, both in terms of gaining control
over unwanted internal experiences and also in terms of larger life goals. This is a fairly direct response.
Some clients won’t react well to such directness, but some will. If you choose to use this kind of
approach, it’s important to do so in alignment with the ACT therapeutic stance, which includes
compassion—­recognizing that sometimes compassion means helping people see when their behavior is
leading to more suffering over the long term.
Model Response 3c
Therapist:
So you say you do something and it works for a little while. Let’s follow this out a bit. What
happens next?
Client:
Things go okay for a period of time, but the anxiety comes back and I’m right back in it.
Therapist:
And then what happens?
Client:
The same thing… It just starts all over again.
Developing Willingness and Acceptance Therapist:
And when it starts all over again, what does it seem like the thing to do is?
Client:
Try harder.
79
Explanation: As in the previous model response, the therapist is directly addressing the issue of workability, but this time pointing to the repetition of failed strategies. From here, the therapist might move
to why we humans keep trying to control our internal experience even though that doesn’t work. This
could be followed by a discussion about why we keep using control: that it works outside the skin, that
we’ve been taught it should work, and so on. This will help clients understand that they aren’t to blame
for continuing to engage in an ineffective approach.
Competency 4
Model Response 4a
Therapist:
Feeling silly is tied to this, too…another thing to get over. It seems that there’s a lot of work
to be done. First you have to get over feeling anger, and then the feeling that you shouldn’t
have the anger, and then the feeling of embarrassment and the thought that you’re stupid
about the anger…and then silly. This is a big struggle, and also it seems to be growing…
It’s as if you’re in a tug-­of-­war with your emotions. If they win, you lose. And you keep
trying to win, but it seems that no matter how hard you pull, your emotions don’t ever
lose… I wonder if there’s a different way to play this game? Maybe this isn’t about winning
the tug-­of-­war but about learning how to drop the rope.
Explanation: Here the therapist is working with the client to help her see that the problem is the
struggle with internal content, not the content itself. The therapist should stay grounded in compassion
for the client’s protracted struggle. These feelings of anger and embarrassment and thoughts of being
stupid are natural reactions to being betrayed in a relationship. The difficulty isn’t that they occur, but
the attachment to them and struggle against them. The therapist is directly encouraging the client to
practice acceptance through the metaphor of dropping the rope. If the client is willing to feel these
things as they are, then she can step out of the struggle and focus on her life direction instead. This isn’t
a simple thing; it’s difficult to drop the rope because battling to make unwanted experiences go away
feels like the thing to do. So when taking this approach, it’s important for the therapist to maintain
compassion for the client and to communicate recognition of the difficulty of the struggle and how easy
it is to engage in it.
Model Response 4b
Therapist:
Well, let’s take a look at the anger for a moment. If I could reach over and peel the anger
out of you and see what’s left behind, what do you think I’d discover?
Client:
(Hesitates.) More anger.
Therapist:
And if I could peel that away, too? I wonder if I might discover a very powerful feeling of
hurt and betrayal… Is it possible that the anger is a way to escape the pain?
Client:
Yes.
80 Therapist:
Learning ACT, 2d edition
What if all of this struggle you’ve been experiencing is about avoiding pain, but the only
way to move forward is to turn toward the pain, rather than away from it?
Explanation: The therapist is addressing the problem of avoidance as part of the struggle, in this case
by looking at the function of the client’s anger: avoidance of pain. The therapist is leading the client in
the direction of willingness to experience pain as an alternative to the long-­standing struggle to escape
it. The goal is to help the client recognize and even welcome the pain (perhaps using the Annoying
Neighbor metaphor to support this kind of welcoming), rather than staying focused on escaping it. If
she’s willing to experience pain, she has functionally dropped the rope.
Competency 5
Model Response 5a
Therapist:
Do you know what would happen if you went inside the anger and tried to see what’s
there? Maybe it doesn’t need to go away for you to do something different with it.
Explanation: Just raising the possibility of a different approach undermines an agenda of avoidance
and control.
Model Response 5b
Therapist:
I can see why it doesn’t make sense to you. But maybe it depends on your goal. If your goal
is to feel better, to not be angry anymore, then it seems trying harder to fix the anger would
be a reasonable thing to do. It’s logical, right? However, if your goal is to find another relationship, then focusing on getting rid of anger may interfere with doing whatever there is
to be done. There are other things people do to find relationships: go to parties, make
phone calls, have friends introduce them to someone—­things like that. It seems you’re
trading away finding a relationship for getting rid of anger.
Explanation: This response points to how the endeavor to control internal events often comes at the
expense of vitality. The client believes that when she doesn’t feel angry anymore, she’ll be able to find
someone. In the meantime, years of her life are slipping away. If she’s willing to feel the anger and hurt
while also making choices that lead to vitality, she might not feel so stuck. It’s important to note that
the therapist isn’t asking the client to be angry. Rather, the therapist is supporting moving forward and
creating the opportunity to be in a relationship without insisting that a different feeling be there first.
Competency 6
Model Response 6a
Therapist:
What do you think would happen if you stopped putting so much effort into making the
anger go away? It seems like a lot of suffering accompanies this effort. Is there a potential
for less suffering?
Developing Willingness and Acceptance 81
Explanation: By using this kind of questioning, the therapist is pointing out the difference between
willingness and suffering. The effort alone has become burdensome and weighs on the client. Simply
suggesting “no effort” opens the door to willingness and can potentially lead to a decrease in
suffering.
Model Response 6b
Therapist:
Does the difficulty of trying to make your anger go away make you angry? (The client nods
and laughs.) I thought it might. A strange thing happens when we’re working to control
certain emotions. If you really don’t want to be anxious, for example, then you feel anxious
about getting anxious. Or if you really don’t want to feel stupid and silly, then you feel
stupid and silly about feeling stupid and silly. Do you see what I’m talking about?
Client:
Yes.
Therapist:
And now you have anger about your anger. We could distinguish it by calling it “suffering
anger,” as opposed to “natural anger.” “Natural anger” is the anger that shows up when you
feel betrayed…and hurt is in there too. “Suffering anger,” on the other hand, is anger
about the anger.
Explanation: As in the previous model response, the therapist is helping the client investigate the difference between willingness and suffering. Willingness to experience the initial and natural anger and
hurt while also noticing thoughts of being duped is much different from having these experiences and
then insisting on not having them while also being angry for having them. The insistence creates more
pain. The therapist is setting the stage for willingness as an alternative.
Model Response 6c
Therapist:
You say you can’t even begin to describe how hard it’s been. It’s as if getting rid of this anger
is almost more challenging to deal with than the anger itself.
Explanation: This is a straightforward way to point to the distinction between willingness and suffering. The client’s use of the word “hard” is itself an indication of the difficulty brought about by
suffering.
Competency 7
Model Response 7a
Therapist:
If we work this out logically, it seems as though you’ll have to trust men again before you
can have the relationship and life you’d like.
Client:
Yeah.
Therapist:
I sense a problem here. In my experience, trust doesn’t work that way. It doesn’t just show
up. Trust is a process. In the meantime, while you’re waiting to be trusting, you find
82 Learning ACT, 2d edition
yourself alone. I’m wondering… When you’re sitting there feeling lonely, does your trust of
men grow or get smaller?
Explanation: Here the therapist is pointing to the difficulty of trying to make a particular feeling show
up as a way out of another experience. This too can be costly. If the client is waiting to feel trust, she
could be waiting a long time. And as the therapist points out, sitting alone being angry doesn’t build
trust in men; it builds mistrust. The cost of the client’s unwillingness to feel whatever is there to be felt
when she goes out with men doesn’t allow the process of building trust to happen.
Model Response 7b
Therapist:
If you were able to trust men, what would you hope would happen?
Client:
(Speaks in a sarcastic tone.) Well, then I’d be able to at least have a shot at being in a decent
relationship—­if I could actually find a decent guy.
Therapist:
So what you want is to get over this guy so you can have a decent relationship, right?
Client:
Yeah.
Therapist:
Can I ask you a question about that? (The client nods.) And I’d like you to check your
experience as you answer it. Don’t just check your head; notice what your experience has
to say. As you work hard to get over that breakup, are things working out the way you
hoped they would? You know, as you’ve worked to get over it, have you been getting closer
to having the kind of relationship that you want, or have you found yourself paradoxically
moving further away from it?
Explanation: The therapist helps the client examine the paradox of control and its costs in terms of
not engaging in values-­based actions. The client is waiting, and in the meantime she’s putting what’s
important to her on hold.
Competency 8
Model Response 8a
Therapist:
I invite you to notice how your mind is pulling you into the future. It’s saying you need to
feel and think something completely different—­that something significant would have to
happen. What if instead we stay here, in this moment? What if it were okay to feel what
you feel and think what you think? Not “okay” meaning you like it, but “okay” meaning
you’re present to it. What if there were no need for it to be different, not in this moment
or any other moment in the future. Experiencing fear of loss or betrayal will show up when
it shows up. We can’t predict the future. If this makes sense to you, the question really is
this: What is present for you now, and are you willing to experience that more fully? If you
let yourself contact these emotions, here and now, what is your experience?
Developing Willingness and Acceptance 83
Explanation: Willingness isn’t about the future; it’s about the present, and there are always feelings and
thoughts to be experienced. Orienting the client to this notion and bringing her into the present helps
her see one of the qualities of willingness experientially, not just through explanation.
Model Response 8b
Therapist:
So, here it is. It feels like something significant would have to occur, like never being duped
again. “Duped” would have to go.
Client:
Yeah, I don’t want to feel stupid like that. I don’t ever want to be in that position again.
Therapist:
Can you contact “duped”? What are the qualities of “duped”? It sounds like “stupid” is in
there. What else is in there? What else is in “duped”?
Client:
Well, I guess I feel a little shame and embarrassment, like I should have known better.
Therapist:
So there’s betrayal—­which is painful stuff—­and what comes along with it is embarrassment and shame, and your mind is giving you “stupid” and “should have known better.”
Client:
Yeah. I even feel it a bit as we talk about it.
Therapist:
Ah, and as you feel that and think that, is it possible to carry that stuff with you willingly,
and to head into a relationship or into the stuff that you do to get a relationship?
Client:
I suppose I could, but I don’t want to.
Therapist:
That’s understandable.
Client:
I mean, I don’t want to have to feel that again.
Therapist:
I hear you. And yet here you are feeling it a little even as we talk about it. You have a good
sense of what these experiences feel like.
Client:
I know them all too well.
Therapist:
Will those be the things that keep you out of relationships? Or given that you know these
experiences, could you feel them and think them and still do the stuff that gets you into
relationships?
Client:
You mean, like feel embarrassed and still go out with someone?
Therapist:
Yeah, would you be willing? I’m not asking you to like it, but if it got you headed toward
connection and a relationship, would you be willing to hold this stuff as you know it and
take some kind of action?
Explanation: The client’s statement that something would have to change suggests experiential avoidance. The therapist makes a guess at what the client is avoiding by saying, “‘Duped’ would have to go.”
The therapist then proceeds to bring the avoided emotional experience into the room and leads the
client to explore it, make room for it, and experience it willingly. In addition, the therapist works to
84 Learning ACT, 2d edition
change the function of the word “duped”; if the client is willing to have “duped,” it is no longer in
control of her behavior. Finally, the therapist is careful to differentiate willingness from wanting or
liking and also ties willingness to valuing.
Model Response 8c
Therapist:
What if possibility isn’t based on how you feel but is instead based on what you do?
Explanation: This response points to the central quality of willingness: that it entails actions taken by
choice. Willingness is embodied by doing; it’s a stance taken toward emotions, thoughts, and sensations
while engaging in values-­based actions.
Competency 9
Model Response 9a
Therapist:
So, one thing we could do is focus on the money, but that doesn’t seem as though it would
be useful right now. If you’re interested in keeping this relationship, it seems we need to
work on the things that would make that happen. You’re saying you can’t bring yourself to
talk to your wife or look at her, as if the disappointment were holding you back.
Client:
Yes.
Therapist:
Is it possible to feel disappointed and actively choose to talk to and look at your wife?
Client:
No, I don’t think that’s possible.
Therapist:
If it were possible, would you choose it?
Client:
Yes.
Therapist:
So here’s the deal… Would you be willing to feel disappointed and talk to your wife if it
meant you got to keep the marriage? (Pauses.) Have you ever thought something in your
mind but done something different with your actions? For example, have you ever thought,
“I don’t feel like getting out of bed today and going to work,” and then you did it anyway?
This is a bit like that: you have the feeling of disappointment, and you talk to your wife.
Explanation: Multiple things are happening in this response. In addition to establishing willingness as
a choice, the therapist addresses engaging in values-­based action and could then continue to work with
the client on taking action while accepting the disappointment. In other words, the disappointment
need not be resolved before the client can begin to interact with his wife. And in a dynamic similar to
that in other examples for this core competency, it’s likely the client’s disappointment will grow if he
continues to choose not to interact with his wife. Using the metaphor of the Annoying Neighbor,
described earlier in this chapter, could be helpful at this point. If used, this metaphor shouldn’t be
delivered in a trivializing or lighthearted manner. A relationship is at stake, and any metaphor used
should reflect the gravity of the situation.
Developing Willingness and Acceptance 85
Model Response 9b
Therapist:
(Stands up and walks around.) I can’t stand up and walk around right now. There is no way
for me to do this. I am incapable of walking at this moment. (Sits back down.) And I certainly don’t want to sit down. (Pauses.) See how that happened? I had the thought that I
didn’t want to do something, and I did it. You have the thought that you can’t talk to your
wife, and you could do it…if you choose to. I know it doesn’t seem as easy as what I just
did, but I want to point out that this might be both easy and hard at the same time. It’s
hard because your mind says it is, and it’s easy because it’s simply a chosen action. Probably
lots of thoughts and feelings will come and go as you choose to talk to your wife. These
things work like that—­they come and go, yet they aren’t what chooses your behavior.
Explanation: The therapist’s small, experiential demonstration helps the client see that thoughts don’t
control behavior. They’re associated, but not causal. The client can choose to take action with respect
to his relationship: he can choose to look at his wife and talk to her while also experiencing disappointment and all the other emotions and thoughts that are likely to show up in such a situation. Some
readers of the first edition of this book expressed concern that this kind of approach could lead clients
to feel like the therapist was mocking them, and this is a possibility to watch out for. If something like
this does result in an alliance rupture or misunderstanding, this can be a good context for learning
about how attachment to a particular story or unwillingness to feel particular emotions can lead to
relationship difficulties for the client (including with the therapist).
Competency 10
Model Response 10a
Therapist:
I can feel myself wanting to move away from this topic because I can see how much pain
it’s causing you. I can see the tears in your eyes. I almost want to change the subject and
talk about the lost money, but I think it’s important to stay with the shame and disappointment. I wonder if we could take a moment and stay present to what’s in the room?
Explanation: Here the therapist demonstrates willingness by asking herself and the client to stay
present to the different emotions in the room. It would be easy to shift the topic to the money or to a
conversation about the client’s wife. It’s important, however, for both therapist and client to remain
present to the emotion as the therapist models willingness.
Model Response 10b
Therapist:
Lots of judgments and thoughts can show up around issues of money. I notice it in my own
relationship. I wonder if there’s a way to see these stories for what they are—­thoughts—­
and to not let them dictate how you and I interact with each other. Maybe we can recognize that judgment is a part of this process of talking about money and make space for
these judgments as part of our relationship, instead of trying to make judgments something
that have to be kept out of our relationship. I’m willing to have you experience these
86 Learning ACT, 2d edition
judgments and the things that triggers in me as part of caring about you. Are you willing
to have your judgments and work to stay present with me?
Explanation: Here the therapist’s self-­disclosure normalizes judgments about money, an approach that
can foster acceptance. The therapist also demonstrates willingness to experience judgments and
thoughts and still remain engaged in the session with the client. Making room for judgment without
buying into it and moving forward in the session provides a model of willingness. In addition, the therapist frames the current, in-­session situation in terms of acceptance of judgments in the context of the
relationship itself. The idea is that judgments can be included in the relationship, rather than being a
barrier that must be eliminated or removed before connection is possible.
Competency 11
Model Response 11a
Therapist:
I wonder if starting small makes sense. Would you be willing to feel what you feel when you
look at your wife and still look at her, even if for just a few moments, if it meant you got to
have your connection with her back?
Explanation: Here, the therapist is linking a small display of willingness to the client’s values. She’s
helping the client open up to the difficult emotions he experiences when looking at his wife—­not just
for the sake of feeling difficult emotions, but in the service of values-­based living. The therapist is also
using a graded approach by suggesting “a few moments” as a starting point.
Model Response 11b
Therapist:
Let’s look at not knowing where to begin. Finding that initial place to reengage can be
challenging. Your mind will say, “I’m too disappointed. I can’t.” But if you were to take your
mind with you and not let it be in charge of your actions or your willingness, what might
you choose to do as a small start?
Explanation: The therapist is using defusion to support willingness while also turning to the client for
a suggestion about where to begin. Again, this is a graded approach because the clinician is asking for
a small action the client might take to reengage with his wife. If the client were to offer something fairly
major, like showing affection, the therapist would assess the likelihood of the client being able to do
this and, if it seemed unfeasible, work with the client to dial the task back. For instance, with the therapist’s help, the client might decide to start by saying a few kind words.
Model Response 11c
Therapist:
When you say it feels impossible to get out of this, it makes sense in terms of the way your
mind might be working it out. But is it possible that your mind doesn’t have an accurate
assessment of this situation? If it truly is impossible, where do we go?
Developing Willingness and Acceptance 87
Client:
I see what you mean, but I just feel so stuck.
Therapist:
Well, maybe the answer isn’t in figuring it all out now—­knowing the outcome. Perhaps it
can be done in a step-­by-­step fashion, bringing willingness to doing each action in a more
planned way. This will present its own challenges. It will probably feel awkward and hard
at times, but it would be a process of open engagement, not an all-­or-­none deal.
Explanation: Here, the therapist is working with the client to set up a more structured path he can
follow to reengage with his wife. This helps create a sense that the client can get unstuck by choosing
to be willing in the presence of a well-­planned strategy while also addressing the process. There is no
particular outcome that can be predicted, but ongoing engagement in the process is a way of engaging
in values-­based actions no matter what the outcome. The therapist also acknowledges the awkwardness
than can show up when approaching an interpersonal relationship in a planned way. Ultimately, the
therapist and client can work together to come up with a structured approach, such as starting with a
few kind words, moving to eye contact, then to touch, and so on.
For More Information
For more information about acceptance, including exercises and metaphors, see Hayes
et al., 2012, chapters 6 and 10, or Harris, 2009, chapters 5, 6, and 8. You’ll also find a
wide range of exercises and metaphors related to acceptance in Stoddard and Afari,
2014.
For acceptance-­related exercises and worksheets that you can use for yourself or for
clients, see Hayes, 2005, chapters 3, 4, 9, and 10.
CHAPTER 3
Undermining Cognitive Fusion
I used to think that the brain was the most wonderful organ in my body. Then I realized who was
telling me this.
—­Emo Philips
Key targets for cognitive defusion:
Help clients see thoughts as what they are—­thoughts—­so they can respond to those
thoughts in terms of their workability relative to client values, rather than in terms of
their literal meaning.
Help clients attend to thinking and experiencing as an ongoing behavioral process; look
at their thoughts, rather than from thoughts; and notice their thinking, rather than
being overly attached to or trapped in thinking.
In relation to thinking, people are a bit like fish who don’t know they’re swimming in water. We swim
in a river of thought but rarely notice the river itself. And whether we are aware of it or not, language
often overregulates our behavior, meaning we get caught up in thinking, giving it control, rather than
observing thinking while also making healthy choices. While verbal regulation is often helpful, as
when following verbal directions to a new location, at other times this largely automatic, unintentional,
and historical process of relating one event to another can lead us in unhelpful directions. The flexibility process called cognitive defusion works to balance out the excesses of verbal behavior, allowing
clients to choose whether or not to respond to thoughts and freeing them to pursue desired directions
in life. When the impact of thinking on behavior is less automatic, behavior can be determined by
context, experience, and chosen values.
Undermining Cognitive Fusion 89
What Is Cognitive Defusion?
ACT argues that the problem with human suffering as it relates to thoughts is not that we have the
wrong thoughts, but rather that we spend too much time in them or looking from them, rather than
simply looking at them or observing them. Cognitive defusion attempts to circumvent this problem by
drawing clients’ attention to thinking as an ongoing behavioral process and helping them spend more
time seeing thoughts as thoughts. This is done in the service of being able to respond to thoughts in
terms of their workability, rather than as though they were literally true.
We humans generally respond to thoughts and feelings as if they directly cause our behavior. For
example, if you ask someone why she stood alone in a corner the whole time at a party, an acceptable
answer might be, “I was too worried; I thought I might embarrass myself.” In this way of thinking, the
thought (“I might embarrass myself”) caused the behavior (standing alone in a corner). However, it’s
easy to think of contexts in which this relationship might be quickly altered, for example, if someone
at the party shouted “Fire!” At that point, “I might embarrass myself” would no longer be a reason to
stay in the corner, but perhaps a reason to leave it. From the ACT perspective, the idea that the
thought caused withdrawal is only one way of speaking about the situation, and perhaps a disempowering one. ACT also views human emotions through this same lens. Thoughts and feelings are always
seen in context, and only in certain contexts are particular thoughts or feelings tied to particular
behaviors. In ACT, the focus is not on the specific content of clients’ thoughts and feelings; it’s on
clients’ relationship to those thoughts and feelings or the functions of those private experiences. Then,
by altering the context, we can help clients alter the function of a thought or feeling.
Thus, in cognitive defusion, rather than trying to directly change the form or frequency of thoughts
or emotions, the therapist targets the context that relates the thoughts and feelings to undesirable overt
behavior, thereby creating greater response flexibility. An example of a specific defusion technique, the
exercise Milk, Milk, Milk (Hayes et al., 2012, pp. 248–­250) can clarify this point. If a person rapidly
says a word over and over again for thirty to sixty seconds, two things usually happen: the word temporarily loses some or most of its meaning, and other functions of the word tend to emerge more dominantly, such as its sound or how it feels to move one’s mouth when saying the word.
You can try it yourself quite easily. First, imagine a gallon of milk for a few moments, and then
repeat the word “milk” out loud for at least sixty seconds. Listen to and notice what happens. Among
the most common reactions is that the word seems to lose its meaning. In addition, the imagery elicited
by the word often weakens or disappears. As in some other defusion techniques, the word or phrase is
still present, but a nonliteral context is created that diminishes its normal symbolic functions and
increases its more direct functions (in this example, its auditory or kinesthetic functions). Used clinically, this technique can be demonstrated as just shown, and then be repeated with a self-­referential
word that appears to be important based on case conceptualization—­“worthless,” for instance. Stated
another way, defusion techniques help clients see thoughts as thoughts and be less fused with what the
thoughts imply.
Importantly, defusion is not accomplished through logical argument or instruction, but rather
through modifying the context in which thoughts are experienced. As a result, the literal functions of
problematic thoughts are less likely to dominate as a source of influence over behavior, allowing more
helpful, direct, and varied sources of control over action to gain ground.
90 Learning ACT, 2d edition
Why Cognitive Defusion?
Stated simply, cognitive defusion focuses on freeing clients from the dictates of thinking. Defusion
techniques are most useful when clients are engaged with their thinking in a number of potentially
problematic ways. Examples include when clients are holding the literal meaning of a word to be true,
when they’re trying to control their thinking, when they’re generating reasons to justify their behaviors,
or when they insist on being right, even at personal expense. Defusion techniques used in ACT include
meditative exercises, experiential exercises, metaphor, and language conventions. Once defusion has
been established, clients are encouraged to focus on effective action in current situations.
The following example illustrates how this might be helpful. John’s alarm doesn’t go off, and he
wakes up late. He immediately thinks of his wife and a thought appears: She set the alarm wrong. If he
doesn’t catch that this is a thought, he may begin to look at the situation as structured by that thought.
He need not be aware of this process in order for it to occur. If he were, in that moment, aware of the
process of thinking and of the fact that he just had a thought, he might not turn to his wife and say,
“You forgot to set the clock again. Now I’m late.” But he does, and then his wife feels blamed and an
argument ensues. If John had been able to observe the thought, he might have caught that it was just
that—­a thought—­potentially allowing him to respond more flexibly. He might have noticed the
thought and then chosen to focus on what would probably be more effective in this situation—­following
his values to be open and loving. In that case, he might have said, “Honey, do you know what happened
with the alarm? Did I forget to set it?” Being able to simply observe the process of thinking in the
moment, or in flight as it’s sometimes described in ACT, can begin to create an opening for people to
step out of their habitual patterns and engage in more effective and values-­based actions.
Therapists learning ACT often struggle with implementing defusion in effective ways because it’s
inherently challenging to use the main tool at our disposal—­language—­to weaken language. The situation is similar to how oil-­well fires are extinguished. An explosion (itself fire) is created at the source
of the fire that momentarily uses up all the available oxygen. In the absence of oxygen, the remaining
oil ceases to burn. Similarly, ACT uses language, and loopholes in its functioning, to extinguish the
problematic effects of language in certain areas of our lives. It’s not that language itself is eliminated,
but that some of its less useful functions are weakened in certain contexts so more flexible ways of
knowing can have greater influence over clients’ behavior.
It would be nice if fusion could be weakened by simply explaining the dilemma, much as we have
done in this chapter thus far. Unfortunately, this type of explanation depends entirely upon literal
meaning for its impact, and to promote defusion we must step outside of literal meaning. To do this,
ACT uses language in nonliteral ways, such as the way a coach might speak to a player. For example,
an ACT therapist might say, “See if you can hold that thought like you might hold a butterfly that has
landed on your finger” or “Imagine that you’re hovering over this feeling, observing it as if from a helicopter hovering above a spot on the ground.” With such approaches, the literal functions of problematic thoughts are less likely to dominate as a source of influence over behavior, and more helpful, direct,
and varied sources of control over action can gain ground.
Undermining Cognitive Fusion 91
What Should Trigger Working with This Process?
Fusion is not a constant; it comes and goes across time and situations. As a clinician, you’ll want to
work on defusion when it is needed. Simply working on defusion because it’s part of an ACT protocol
or applying it to thinking that isn’t significant may not prove useful. Focusing on this process is most
appropriate when clients are believing, buying, holding on to, or clinging to particular thoughts or sets
of words and doing so is limiting or preventing flexible movement in the direction of client values. In
such cases, clients often seem to be heavily saddled or trapped by certain thoughts or feelings and find
themselves unable to take values-­based action based on those thoughts or feelings.
For instance, a client might say, “I’ll never be able to find a partner because I’m worthless. Who
would want me?” Clearly, this client is trapped by the word “worthless.” If she holds it to be literally
true, it seems that finding a partner would be impossible: who would want a worthless human being as
a partner? However, if the client can come to see that “worthless” is a word that’s said under certain
conditions and given a particular history, and that it isn’t something she literally is, then “I’ll never be
able to find a partner because I’m worthless” will have less control over her behavior. This doesn’t mean
the client has to stop thinking that she’s worthless or start thinking that she’s worthy; rather, if she can
see the thought as a thought, then its power to control her actions is lost, even if that thought continues
to occur.
There are a number of specific indications that clients are fused in a given area. Not all are likely
to apply; generally only one or two are present:
•
You get the sense that the client is too interested in being right or looking good, especially if
that pursuit is overwhelming the behavioral flexibility needed in the situation.
•
Truth with a capital T has become more important than workability. For example, if you ask
the client about how useful a thought is, the client says, “It’s not useful, but it’s true!”
•
The client doesn’t notice thinking as an ongoing process. When you ask about thoughts, the
client pauses and has a hard time reporting on internal processes in an open way.
•
As the client addresses an issue, the words feel well practiced, as if they’ve been said many
times. That doesn’t just come from overt practice; it often happens because more fused stories
are internally supported. The client may have ruminatively told these stories internally for
years.
•
Often this sense of well-­practiced stories can be detected by a rigidity of rhythm. Some clients’
suffering is like a dirge; for others it’s frenzied. In either case, the mark of fusion is rigidity,
constancy, and insensitivity of speech, pace, and pattern.
•
New information disappears or is integrated into an underlying theme. Often the client will
have a handful of themes that repeat across situations, and the conversation keeps looping
back to these same basic points over and over again. Contradictory information or experiences
are reinterpreted to fit the previous pattern.
92 Learning ACT, 2d edition
It’s worth noting that this list is not just relevant to clients; it also applies to therapists. As a therapist, you may sense you’re trying to be right in a session, or you may see that you’re holding tightly to a
defense of “correct” and “true” opinions in session, rather than workable thoughts. If so, you’re picking
up on your own fusion. You’re also engaged in fusion if you disappear into mental analysis and don’t
notice your own thoughts with some space, especially if you’ve disappeared into familiar, well-­practiced
themes.
When you find yourself engaged in fusion, it’s worth working on personal defusion skills, such as
stepping back from your thoughts and noticing who is noticing. As an ACT therapist, knowing that all
of the flexibility processes are personally relevant to you will greatly expand your ability to be clinically
flexible and less controlled by your automatic reactions or unworkable habits.
Recognizing your own fusion is also useful in other ways. For example, you may engage in fusion in
response to a client’s fusion, because fusion is, in part, a social process. At the very least, being aware
of your own fusion will soften any sense of arrogance when targeting fusion in others; one-­upmanship
can easily show up in defusion work and is one of the places where both seasoned and newer clinicians
can struggle.
The following dialogue, which occurred about five sessions into the client’s therapy, demonstrates
an interaction that triggers working with defusion.
Therapist:
You seem pretty blue today. What’s happening for you?
Client:
It’s just always the same story. I try to do something to make things better and it fails… It
always fails. It’s always like that.
Therapist:
So there’s this place where you get stuck when this same story, “I try and nothing works,”
shows up.
Client:
(Hangs head and speaks softly.) Let’s face it, I’m doom and gloom.
Therapist:
You’ve mentioned that several times now—­that you’re doom and gloom.
Client:
It’s true. I am doom and gloom.
Therapist:
I want to recognize the pain of this thought and the struggle that’s built around it, and I’m
wondering if you might be willing to be a bit playful with me for a moment. (Using the “and-­
but” verbal convention mentioned later in this chapter, the therapist is trying to be validating and
also carve out space for defusion work.)
Client:
Sure… Might as well.
Therapist:
This might sound a little silly, but would you sing the words “I am doom and gloom” for me?
Client:
(Chuckles.) What?
Therapist:
Let’s just work with this for a minute. Give it a try.
Client:
(Sings the words “I am doom and gloom.” Unbeknownst to the therapist, the client has quite a
good voice and sings solemnly and with heartfelt pain.)
Undermining Cognitive Fusion 93
Therapist:
Great. You really captured something. I can feel the heaviness in this. Now could you sing
it again? Only this time, sing it with great enthusiasm, as if you’re in a Broadway play.
Client:
(Chuckles again.) Okay. (Sings the words, but from the new perspective.)
The client is then asked to sing the words from several other perspectives: as a woman, as a small
child, and as Mickey Mouse. With each new rendition, the therapist can see the client beginning to
defuse from the words.
Client:
The words just seem kind of funny to me now.
Therapist:
Interesting how that works. When we’re really trapped in words, it seems that they paralyze us. But now that we’ve loosened the trap a little, what do you notice?
Client:
They don’t seem to have the same power. They’re even kind of funny now.
Therapist:
From this place, being loosened from those words, I wonder if we can start to work on
where you’re headed? (Links defusion with values.)
This is just one example of the many ways defusion can be brought into session. In this dialogue,
the therapist identified a self-­evaluation that occurred in session and targeted it directly with a defusion
exercise. It’s important to note that such exercises are designed to take the meaning out of the words
(deliteralize them), not to change the number of times the client thinks them or to change them into
positive words (e.g., “I am great and good”). Also, defusion should be done from a compassionate
stance, which can be either playful or serious. As a reminder, it should never be done from a position
of one-­upmanship or in a way that makes the client feel silly or humiliated for having particular
thoughts.
What Is the Method?
Scores of defusion techniques have been developed for a wide variety of clinical presentations, and
clients and therapists are thinking of new ones all the time. Anything that can be observed can be a
metaphor for defusion. For example, negative thoughts can be observed dispassionately by having
clients watch them as if watching an uninteresting, nonprovocative television commercial. Clients can
be encouraged to treat a thought as an externally observed event by giving it a shape, size, color, speed,
or form. Clients can thank their mind for such an interesting thought; label the process of thinking
(e.g., “I’m having the thought that I am doom and gloom”); or mindfully observe the thoughts, feelings,
and memories that arise in their consciousness. Such techniques attempt to reduce the literal quality
of thoughts, weakening the tendency to treat thoughts as what they refer to (e.g., the experience “I am
doom and gloom”) rather than what the client is directly experiencing (e.g., the thought “I am doom
and gloom”). The result of defusion is usually a decrease in the believability of private events or clients’
attachment to them, rather than an immediate change in their frequency or form. Here’s an exercise to
help you start exploring this in relation to one of your clients.
94 Learning ACT, 2d edition
Exercise:
Working with Client Defusion, Part 1
Bring one of your clients to mind, preferably a difficult one. Think of three thoughts this person has
about herself, her life, or her future that are difficult for her. Try to be specific.
Thought 1: Thought 2: Thought 3:
We’ll come back to these later in the chapter.
An Overview of Defusion Principles
In the following sections, we illustrate the major types of defusion techniques, organized by the
general principle at play. By arranging them in this way, we hope to show what lies beneath the methods
themselves. Defusion isn’t about specific techniques; it’s a functional process, and it is this kind of
knowledge that moves ACT from a mere collection of procedures to a clinical model. Some popular
ACT books for the general public, such as Get Out of Your Mind and Into Your Life (Hayes, 2005), even
teach people how to generate their own novel defusion techniques. The purpose of this section is
similar. The techniques we describe are examples; they aren’t an exhaustive list of ACT defusion techniques. The full list is limited only by your own creativity and that of the ACT and RFT community
worldwide.
Before we move into describing defusion techniques, it’s important to remember that defusion
shouldn’t be conducted in a confrontational way. It can be powerful, and it’s an excellent means for
helping clients observe their minds. However, clients sometimes report feeling confused, disjointed, or
out of sorts during and after sessions that focus heavily on defusion. These feeling states are perfectly
acceptable.
Artful defusion work often has the qualities of a light-­footed dancer or an aikido master. Neither
meets a partner’s movements with force; rather, they join with and redirect their partner’s movements
in more useful directions. In defusion, clients’ verbalizations are bounced around, mixed up, and played
with so that clients can see them from varying viewpoints and explore their many qualities. Again, this
Undermining Cognitive Fusion 95
is done without direct confrontation or refutation. For example, an ACT therapist might appreciate the
beautiful creativity of a client’s mind by congratulating him for coming to a bleak conclusion. For
example, if a client says, “So then I thought I’d completely blown it,” the therapist might respond, while
joking and smiling warmly, “Ah, such a good conclusion. Isn’t your mind amazing, finding it’s way to
such dire places?” Be playful with defusion while always maintaining compassion.
In the following sections, we present some principles you can use in fostering defusion: teaching
clients about the limits of language; creating distance between the thought and the thinker, or the
feeling and the feeler; revealing the hidden properties of language; and undermining larger sets of
verbal relations. If you understand these principles, the specific methods we set forth are less important,
because there are a vast number of alternative methods and creating additional ones isn’t difficult.
TEACHING THE LIMITS OF LANGUAGE IN
REDISCOVERING EXPERIENCE
ACT therapists often introduce defusion by pointing to the limits of conscious thought. We tend
to rely so much on thinking and informal problem solving to guide all our actions such that “an illusion
is created that all knowledge is verbal” (Hayes et al., 2012, p. 248). Various metaphors and exercises are
used to demonstrate that our minds do not hold all the answers—­that there are, in fact, ways of
knowing that operate beyond the mind. The therapist can tentatively suggest, “Although language and
rational thought can be helpful in some areas, what if there are other aspects of life in which being
logical and following what one’s mind has to say is actually problematic?” This can be illustrated by an
appeal to clients’ experience in areas of their life in which what the mind knows may not be enough or
can even be detrimental. For example, some tasks involve very well-­regulated verbal knowledge, such
as how to find a certain website on the Internet. Other tasks are less so, such as learning how to play a
musical instrument or perform a skilled sport. Clients also may have had experiences wherein language
actually interfered with effective functioning, such as in performance anxiety, sexual difficulties, or
choking on the golf green.
This basic idea can be illustrated by asking clients to verbally instruct you in engaging in a physical
movement, as demonstrated in the following dialogue. As you’ll see, the therapist responds to the client’s instructions by asking the client how to do each movement instructed. This exercise nicely points
to the arrogance of language because physical movement is generally learned through experience, not
through instruction. The basic idea of the exercise is to show clients that some of the things we know
how to do are not known through conscious knowledge but rather were learned through experience.
Therapist:
Can you tell me how to walk from my chair to the door?
Client:
Well, first stand up, and then put one foot in front of the other until you’re standing over
in front of the door.
Therapist:
Good. How do I do that?
Client:
What? Oh, push with your hands on the arms of the chair until you’re standing up, and
then move the muscles in your leg so that you’re stepping forward. Let your weight move
with you.
Therapist:
Great. How do I do that?
96 Learning ACT, 2d edition
Client:
(Chuckles.) Tell your brain to tell your hands and legs to move.
Therapist:
How do I do that?
The therapist continues in this way, playfully, asking, “How do I do that?” after each instruction,
until the client says, “I don’t know.”
Therapist:
And after anything you tell me to do, I’m going to say, “How do I do that?” You see, it was
a bit of a trick. I asked you to tell me how to walk, and your mind went to work thinking
it knew how to tell me that. All minds do that. But the deal is that neither you nor I
learned how to walk by someone telling us how. You probably learned how to walk before
you even had words. We learned to walk by experience. We tried to stand up, we fell down,
we bonked our heads, but eventually learned how to walk. Experience taught us how.
Many things are like that, but we lose touch with them because our minds get so arrogant
and think they know everything. There are many things that you know by experience; for
instance, you know feelings won’t harm you, even if your mind tells you they will.
Following such an exercise, the therapist can extend the approach to the client’s difficulties.
Therapist:
What if your struggle with anxiety is similar? Your mind keeps telling you how to solve the
problem, but it just doesn’t know how to get out of a situation like this. What if we need
some other way of responding to the situation you’re in, something that’s a bit more like
learning how to walk than it is like reading about how to do these things?
Another way to explore the limits of language is to examine how we learn any new skilled activity.
For example, you can ask clients to remember how they learned to ride a bike. Clients usually report
some combination of simply getting on the bike, trying to find their balance, falling down, and trying
again. Having a parent tell us to stay balanced doesn’t teach us to balance. Knowing with the mind that
the pedals turn the wheels doesn’t make anyone a cyclist. In most cases, clients easily get the point that
logical understanding and knowledge can take them only so far. At some point, developing certain
skills depends upon getting engaged in the activity and letting the consequences shape one’s actions.
Doing these kinds of exercises with clients points to something that’s often inaccessible to the
mind or hidden from its view: experiential knowledge. We humans know many things based on this
kind of knowledge, and part of what ACT attempts to do is get clients back in touch with experiential
knowing. It is from the vantage of experiential knowledge that clients can come to see their emotions,
thoughts, memories, and sensations as ongoing events that rise and fall, that come and go and then
come and go again. From this vantage point, clients also learn that they aren’t broken, and that fear
and anxiety don’t literally harm or kill them. These are simply experiences (e.g., thoughts) that they’re
having at a given moment. In this work, it’s important to remind clients that these counterintuitive and
nonliteral skills require practice. Clients need to implement what they’ve learned in session outside of
session. To this end, you might suggest that coming to ACT sessions and not engaging in exercises
outside of sessions is a bit like going to the hardware store, buying a new table saw, and then leaving it
at the checkout counter.
Other examples of teaching the limits of language include the Milk, Milk, Milk exercise described
earlier and attempting to e-­mail orders to a person who doesn’t speak the client’s language.
Undermining Cognitive Fusion 97
CREATING DISTANCE BETWEEN THOUGHT AND THINKER,
FEELING AND FEELER
When the literal, evaluative functions of language dominate, we aren’t aware of the distinction
between ourselves as the experiencer of these private events and the events themselves. This is the
usual human state: “I am what I think and feel.” A number of ACT strategies are aimed at helping
clients increase the distinction between the experiencing self and what is experienced. That is, thoughts
and feelings are something clients have, rather than something they are. Making these distinctions
brings forward nondominant qualities of language, such as its aesthetic or functional qualities, and
increases the flexibility of ways in which people interact with their minds. There are several primary
avenues for applying this principle: objectifying language; looking at thoughts rather than from them;
and revealing the hidden properties of language.
Objectifying language. We humans have a lot of experience dealing with objects in our environment
as separate from ourselves. ACT therapists can teach clients to deal with thoughts and feelings similarly: as objects to be viewed. The idea is to create a healthy distance between the self and thoughts and
other private events, which are described as objects. This is not to say that clients don’t contact these
internal events; they are still present but are viewed from a different perspective. Using metaphors and
exercises can help with this process. Objectifying thoughts can help clients interact with them in more
flexible and practical ways, in much the same way that external objects can be used in multiple ways.
In the following dialogue, the therapist takes this approach by asking the client to consider whether his
thoughts are like tools in some ways.
Therapist:
If thoughts were like a tool, how might we work with them? We don’t usually sit around
thinking, “I’m not sure this hammer is the right hammer for me. I don’t usually use this
kind of hammer. I think I’m a two-­pound hammer kind of person.” We just pick up the
hammer and start pounding nails, or we don’t use it at all. In contrast, when you have the
thought “I’m not sure I can do this. I don’t usually live my life this way. I’m pretty much a
loser kind of person,” that thought probably doesn’t seem at all like a tool to you. It’s more
like “This is true. This is who I am.” In this stance, it’s like a hammer that you have no
choice but to use. Before you know it, the “I’m not sure I can do this” hammer or the “I’m
a loser kind of person” hammer is in your hands and you’re pounding away. Now, would it
be possible to step back and look at which thoughts are useful as tools for you to construct
a life of value for yourself, rather than having to evaluate them in terms of their truth or
untruth?
Client:
What do you mean by truth or untruth?
Therapist:
Would you be willing to do an exercise to see if we can unpack this? We’ve talked before
about how starting dating means that thoughts like “I’ll never be able to find a partner”
will show up. What other thoughts show up for you when you take action toward finding
a partner—­something I know you really, really want in your life?
At this point, the therapist might elicit a variety of thoughts and feelings that show up when the
client tries to date, writing each one down on a card as a way of starting to use a thoughts-on-cards
98 Learning ACT, 2d edition
exercise to illustrate responding to thoughts in terms of their utility, rather than as literal truth (e.g.,
Harris, 2009, pp. 101–­107).
This is just one approach among a wide variety of powerful ACT experiential exercises that can
help clients objectify thoughts. For example, private experiences can be compared to bullying passengers on a bus (Hayes et al., 2012, pp. 250–­252), either as part of a role-­play, as an eyes-­closed exercise,
or in the form of a metaphor. Particular thoughts or feelings can be written down on cards, and then
the client can interact with them in various ways, such as fighting to keep them away instead of accepting them (Harris, 2009, pp. 101–­107). Clients can be led through eyes-­closed exercises in which they
imagine thoughts as physical objects or people, picturing their color, weight, texture, voice, density,
movements, and so on (Hayes et al., 2012, pp. 286–­287).
Often, ACT therapists refer to the client’s mind as if it were speaking to the client or reframe the
client’s thoughts to highlight the distinction between the person and the mind. For instance, the therapist might say, “So, your mind said to you…” or “Who’s talking to me now: you or your mind?” Sometimes
therapists or clients playfully give the client’s mind a name. For example, a therapist might give a client’s mind the name Bob and then say, “So, what will Bob say when you get up tomorrow, knowing
you’re going to do this exposure exercise?”
Another way of objectifying language is to introduce the concept of “mind” and help clients relate
to the mind as an external entity that follows them around, always judging, evaluating, predicting, and
influencing them and otherwise commenting on their actions. This serves two purposes: to help clients
obtain a healthy distance from their own verbal repertoire, with which they are usually heavily identified, and to create space to begin to discriminate between being present and being caught up in their
internal chatter. An effective exercise to this end is Taking Your Mind for a Walk (Hayes et al., 2012,
p. 259). It requires that two people pair up, with one playing the role of the mind (this could be the
client and therapist or, in group therapy, two clients). Initially, one person plays the role of the mind
and the other plays the role of the person. When done in a group therapy format, it often works better
to do the exercise in groups of three, with two people teaming up to play the mind at the same time.
This usually helps the mind keep up a constant stream of chatter and brings a little fun to the
exercise.
For those playing the role of the mind, the job is to continuously speak to the person in an evaluative, second-­guessing, wondering, judging way to demonstrate what the mind typically does almost
constantly. In the role of the person, the client takes a mindful walk, in silence, going wherever the
person chooses to go. The mind doesn’t get to pick where the person goes, and the person doesn’t get
to lose the mind. After walking for about five minutes, they switch roles and then walk again for about
five minutes. Finally, they split up and each takes a mindful walk alone, again for about five minutes.
Generally, what clients learn in this exercise is that, first, the mind is busy and has a lot to say, and
second, the mind isn’t in charge—­it doesn’t get to dictate where they go. Clients also learn that no
matter where they go, their mind goes with them. This shows up during the final phase of the exercise,
when they walk alone and typically begin to hear their mind babbling on about things.
Looking at thoughts, rather than from thoughts. A number of strategies are oriented toward helping
clients develop the capacity to look at thoughts, rather than from thoughts. This is sometimes referred
to as the difference between having a thought and buying a thought. One way of beginning this process
of just observing mental content is to help clients notice the simple fact that we are all constantly
speaking to ourselves. Here’s an example of how a therapist can introduce this idea.
Undermining Cognitive Fusion Therapist:
99
Now, all of us are constantly speaking to ourselves. Often, however, we’re not even aware
of the fact that we’re doing this. In the background, there’s a voice constantly narrating
things: “I agree with that. I like that. I don’t like that. That’s true. That’s not. I don’t know
that I like that. What’s he saying?” Even right now—­check and see if your mind isn’t
doing that with what I’m saying right now. (Pauses.) It might be saying, “I’m not sure I
agree with that” or “Yup, I am doing that.” If you’re thinking, “I’m not doing that,” then
that’s the voice! I invite you to close your eyes for a second and just notice how you’re
constantly talking to yourself. Simply notice what thoughts come up as you close your eyes.
(Pauses for ten seconds.) Notice how your mind has an opinion, comment, or question
about everything. For example, think about your car. What comes up around that?
(Pauses.) Think about your parents. What does your mind have to say about them? (Pauses.)
Notice how you don’t even need to do anything—­it constantly keeps going, doing its
thing. Now think about the part of yourself you like the least. What comments does your
mind have about that? (Pauses.) It’s constantly going, yet most of the time we aren’t even
aware of its presence.
The therapist also can introduce the idea that thoughts are like colored bubbles over the client’s
head, as illustrated in this dialogue.
Therapist:
You can think of thoughts as similar to wearing colored sunglasses. These glasses are so
comfortable and you’re so used to them that you completely forget you’re wearing them.
You don’t even notice that they are there. You can only see through the thoughts. For
example, if you were wearing red glasses but didn’t realize it, and I had you look at this
white wall, what would you think the color of the wall was?
Client:
Red.
Therapist:
Exactly. Our thinking is just like that. We totally miss that we’re seeing the world through
our thinking; the world just seems to be how it is. But what if the view through the lens
isn’t so helpful? For example, the view through thoughts such as “I’m not okay” or “I’m
worthless” limits how you live in the world. The point here is not to get rid of the glasses.
We can’t really do that anyway, because we’re constantly having more thoughts. The point
is to practice taking them off and looking at them with some awareness. (Mimes taking off
glasses and holding them out from her face.) That way you can see them clearly, for what they
are. This makes it easier to do what works when the situation calls for it.
It’s usually helpful to follow this metaphor with practice in looking at thoughts. The Floating
Leaves on a Moving Stream exercise (Hayes, 2005, pp. 76–­77), Soldiers in the Parade exercise (Hayes
et al., 2012, pp. 255–­258), and other similar exercises can be used for such practice in session and
between sessions.
Revealing the hidden properties of language. One area in which language disguises important discriminations involves evaluation versus description. All stimuli with which we interact have various
properties. Certain properties are primary, experienced directly through the senses. For example, we
might see that a rose is red or feel that concrete is rough. These properties belong to the realm of
description. Secondary properties, on the other hand, are derived from language and belong to the
100 Learning ACT, 2d edition
realm of evaluation (e.g., “good,” “useful,” “ugly,” “right”). Primary properties are inherent in the stimuli,
whereas secondary “properties” aren’t really properties of the stimuli at all; rather, they occur in the
interaction between the person and the stimuli and are the result of language.
Ordinarily, the difference between these two types of properties is obscured. Clients usually come
to therapy with a whole host of evaluations about themselves, their world, and the people in their lives.
They treat these evaluations as if they were primary, inherent properties of themselves or others. For
example, a client might have evaluations such as “I’m bad,” “I’m worthless,” or “I’m evil.” Held literally,
these would indeed be very difficult to accept. Willingness would be difficult to adopt if these evaluations were actually a description of the client’s essence. Change would be virtually a necessity. The only
way to change the primary properties of a stimulus is to literally break it down and reconstitute it into
something else; for example, if you don’t like the red rose, you could burn it and transform it into ashes.
However, if a distinction can be made between description and evaluation, that which evokes evaluation doesn’t necessarily have to be changed to be acceptable because the properties aren’t in the thing
itself, but only in thought. Various exercises that help illustrate the difference between evaluation and
description in regard to the self are described in chapter 5.
Another ACT strategy for revealing the hidden properties of language involves creating contexts
in which language can be experienced more directly and with its literal symbolic functions weakened.
In these exercises, the therapist isn’t attempting to eliminate the derived functions of words (e.g., their
meaning) in any permanent way. Rather, the therapist is trying to bring other, possibly more flexible
functions to the fore, such as those based on the direct stimulus properties of the word (e.g., the way
the word looks or sounds, or the effort it takes to create it). Bringing forward the direct stimulus functions of language can help make it easier to observe the process of languaging without fusing as much
with its products. The Milk, Milk, Milk exercise described earlier leads to hearing the word “milk” as
a sound, rather than interpreting it as the substance to which it refers. There are many techniques to
create this effect, including saying a thought in a cartoon character’s voice, singing thoughts, speaking
them as a sports announcer would (all in Hayes, 2005), or having contests with clients to see who can
come up with the worst evaluations. The point of these exercises is not to ridicule particular thoughts,
but to expand their functions beyond those typically experienced and to help clients develop flexibility
in relation to mental content so that thoughts need not always be experienced in old, habitual, literal
ways, which often leads to yet more struggle and inflexible behavior.
Another approach for accomplishing this involves speaking thoughts very slowly, as demonstrated
in the following dialogue.
Therapist:
I notice that when you start talking about what’s happened over the last year with respect
to trying to date, you quickly get caught up in the story “I’ll never find a girlfriend. I am
completely incompetent.”
Client:
I know I keep saying that, but it’s true. I have proof. It never works out. I must be
incompetent.
Therapist:
This story your mind tells about you is pretty powerful. It’s kept you from dating for a long
time now.
Client:
Yes. I need to find a way to stop being incompetent, and then I can go on a date.
Therapist:
Seems you have been working on that for a while. True?
Undermining Cognitive Fusion 101
Client:
Over a year.
Therapist:
Would you be willing to try something out with me?
Client:
Sure.
Therapist:
Let’s disassemble this, not as a way to figure out how you landed in incompetence, but as
a way to take the power out of this story so that you can have your power back. I want to
help you see the words in this story for what they are: words. Let’s start with slowing the
sentence way down. Let’s try to say “I am incompetent” as slowly as possible. (Client and
therapist say the words very slowly together.) Now slower. Sound it out, really drawing out the
vowels. (They say the words together even more slowly.) Now let’s slow it down even more and
say “incompetent” almost as if it were four separate words—­“in,” “comp,” “e,” and “tent”—­
and let’s exaggerate it just a tiny bit. (The therapist keeps working with the client in this fashion
for a few minutes.)
Client:
(Chuckles a little.) Why do we keep doing this?
Therapist:
Well, let’s check. Did you hear the sets of sounds and feel the mechanics of speaking the
words?
Client:
Yes. It was odd.
Therapist:
Sure, because we don’t typically engage with words in this way. Usually we get lost inside
them and forget that they’re sets of sounds that are spoken using the mechanics of the
vocal cords and muscles. I’m simply helping us contact words in a different way, noticing
them for what they are and not being right inside them so much. This creates a little possibility for you to relate to your words in a different way.
UNDERMINING LARGER SETS OF VERBAL RELATIONS
Most of the strategies just discussed are aimed at undermining literal attachment to smaller sets of
mind chatter, such as individual thoughts, words, or phrases. Different strategies are required to work
on more complex forms of mental behavior. The mind engages in extended and interconnected forms
of verbal behavior, such as creating clients’ stories about who they are, how they came to be the way
they are, and the reasons for doing what they do. These stories and reasons provide the verbal glue that
creates the confounding stability of many unworkable patterns of behavior and therefore are central to
the conceptualized self, or self-­as-­content (addressed further in chapter 5).
When we’re growing up, our social world teaches us that we must have explanations for our behaviors, and that these explanations must be coherent. And in the realm of behavior that doesn’t work, we
are especially expected to have good explanations. For example, the social community demands that a
person with depression have a really good reason for not getting out of bed, not having worked for three
months, and so on. For some people, having a “chemical imbalance” seems to afford a good reason for
depressed behavior. Interestingly, research suggests that people who think they have good reasons for
their depression tend to be more depressed and less responsive to therapy (Addis & Jacobson, 1996).
102 Learning ACT, 2d edition
Through fusion with or attachment to our stories, these verbal networks come to control our
behavior. Our past becomes our future, with the potential for very negative outcomes. If a client is
attached to a story that she can’t have good relationships because of being abused as a child, then that
client is truly stuck because she cannot have any other childhood. If the client is unable to see this story
as one of many possible stories and instead fuses with it and sees it literally, as “the truth,” you can easily
see how she might not even engage in trying to find a relationship. This dynamic becomes particularly
difficult if clients are also fused with the belief that they’re right about their stories. This can lead
people to not get well and truly stay stuck in difficult and unworkable patterns of behavior.
Consider Jessica. A few years ago, she was diagnosed with bipolar disorder following an episode of
manic behavior. Since then, she’s engaged in extensive reading about what people diagnosed with
bipolar disorder are like and has learned that bipolar disorder is a genetic problem that results in a
chemical imbalance in the brain. Now Jessica feels that because bipolar disorder is biological, she’s
doomed to repeat endless cycles of excruciating lows and out-­of-­control highs for the rest of her life, and
that there’s not much she can do about it. Although her acknowledgment of the diagnosis of bipolar
disorder could potentially be helpful in some ways, her story suggests that she can’t recover, and therefore she feels she has no reason to try.
As with most clients in such a situation, Jessica has good evidence for her story, in this case in the
form of research, as well as personal anecdotes about medications helping her. She’s been living under
the dictates of this story for several years, with the outcome that she takes her medications but doesn’t
take many other active steps to improve her life. From an ACT perspective, the question is not whether
this story is literally true, but whether it’s helpful. Does it lead Jessica toward the kind of life she wants?
ACT tries to undermine attachment to unhelpful stories by helping clients make experiential
contact with the constructed nature of those stories so they can turn their focus from the literal truth
of a story to its workability. These strategies are aimed at helping clients develop a healthy skepticism
about the mind’s ability to evaluate and explain aspects of their personal history in a useful way. The
following dialogue (inspired by Hayes, 2005, pp. 19–­20) provides an example of how a therapist can
introduce this idea.
Therapist:
We’re constantly telling ourselves a story about our lives. In the background, there’s a voice
that is always narrating about things—­telling us about who we are, what we like, how
things are going, and so on. The question is, is that story necessarily true? Where did it
come from? For instance, if I ask you what happened three days after your eleventh birthday and I want to know in detail about that day, would you be able to tell me?
Client:
Hmm. No.
Therapist:
(Speaks playfully.) How about four days after or five days after? (Pauses.) We could try one
hundred days and you might catch one or two details, but we really know very little about
what’s gone on in our lives. We remember just a few snippets, and we string these little
pieces together into a story. Do you see this? We have these little snippets of things we
remember, and massive portions of what happened are missing. We try to string it all
together to create stories that make sense of the pieces we remember, and then we tell
these stories to ourselves frequently. We conclude things about ourselves—­what we are
capable of, who we are—­and then we live out of our stories.
Client:
I see.
Undermining Cognitive Fusion 103
Therapist:
Interestingly, these stories grow. The mind just keeps taking in new stuff. And this isn’t
something that’s only happened way in our past; it’s happening right now. Let’s do an exercise about new content being added all the time, and about how we usually don’t even
recognize it. I’m going to tell you about an imaginary creature called a gub-­gub. If you
remember what the gub-­gub says, I’ll give you a million dollars. Are you ready? Here it is:
gub-­gubs go “Wooo.” What do gub-­gubs say?
Client:
Wooo.
Therapist:
Now don’t forget it. Because if I ask you tomorrow and you get that one million bucks, it’s
worth it. What do gub-­gubs say?
Client:
Wooo.
Therapist:
Okay, so now I have to let you know that there’s no million dollars. So you can just forget
it. What do gub-­gubs say?
Client:
(Laughs.) Wooo.
Therapist:
Suppose I came back in a month. Would you know what gub-­gubs say?
Client:
Sure.
Therapist:
How about two months? A year? What do gub-­gubs say? (The client chuckles.)
Therapist:
If we spent a bit more time talking about gub-­gubs, it might be that I could visit you at your
deathbed and ask, “What do gub-­gubs say?” Would you remember? Now think about what
this means. We spend a few minutes on something, and you carry it around in your head
for the rest of your life. You have things like this that reach way back across your history.
You may not be sure where they came from, but this is the stuff that’s your story. These are
the thoughts you have about yourself. For example, “The worst thing about me is…”
(Pauses and directs the client to answer.)
Client:
I’m weak.
Therapist:
The best thing about me is… (Pauses.)
Client:
I’m kind.
Therapist:
The reason I am so weak is…
Client:
I never learned how to stand up for myself.
Therapist:
(While smiling warmly.) Good! That’s a beauty. Magical! (Speaks in an upbeat tone that
reflects friendly teasing.) See how fun this is? Your mind generates explanations, stories, and
reasons for everything. We could go on, right? There’s a story for everything.
Another approach involves having clients write two versions of their autobiography to explore the
largely arbitrary connections between events in their life stories (Hayes, 2005, pp. 91–­93). To conduct
104 Learning ACT, 2d edition
this two-­part exercise, first ask clients to write their life story on a couple of pages as homework. In the
following session, help them identify all the events in the story, and then, as another homework exercise, ask them to rewrite the story, keeping all the events unchanged but shifting the meaning and
outcome of the story. This exercise doesn’t challenge the client’s story directly but hopefully helps the
client see it as just one of many possible life stories that are available. This is a more advanced approach
that’s often brought into therapy after other defusion practices have already been introduced and the
client has some capacity to pause and step back from thoughts. As with all aspects of ACT, the pacing
and sequence of interventions depends upon the client and case conceptualization.
ACT therapists are sometimes challenged by clients on the grounds that their reasons are literally
true. Arguing is almost always unhelpful in such cases, especially as clients may experience this as
invalidating. Instead, you can acknowledge the client’s reasons as possibly helpful verbal formulations
and then turn to the question: “What does your experience say? How helpful is this?” Alternatively, you
might say, “Well, that sounds right. But which would you rather be: correct or living a vital life?” As
you target these more extended sets of verbal networks, it’s important to keep in mind that the point
isn’t to help clients find a better story or to suggest that we humans have control over the stories we tell;
rather, the point is to help clients see that the ongoing process of generating these stories is usually
hidden from view and automatic, and that our lives are not 100 percent determined by the events we
can recall (the ones that make it into the stories). The goal is mindfulness and liberation from
entrenched and constricting stories. Fortunately, research indicates that defusion seems to reduce
attachment to thoughts, and that it’s more effective than cognitive disputation and reappraisal (Levin
et al., 2012), so it isn’t really necessary to change clients’ stories anyway.
Working with Defusion in an Ongoing Way
In order to use defusion metaphors and exercises powerfully, therapists must integrate them into
the ongoing flow of the session. A common mistake for ACT therapists is to use the metaphors and
exercises in a piecemeal fashion, creating a defused space during the exercises, but responding to clients’
words and stories on a literal level during other parts of the session. Bringing a focus to the functional
utility of thinking and to languaging as an ongoing behavioral process must occur throughout therapy,
even in regard to the therapist’s speech. In any given situation, the primary focus is on whether buying
a thought would move the client (or therapist) toward a more vital, values-­based life.
In the sections that follow, we offer specific techniques for practicing defusion in the ongoing flow
of the session, addressing persistent highly fused behavior on the part of the client, and maintaining a
defused space in the room. These techniques fall into three broad categories: establishing verbal conventions, referring back to metaphors and exercises, and teaching clients to recognize when they’re
caught up in fusion.
ESTABLISHING VERBAL CONVENTIONS
ACT therapists sometimes ask clients to adopt simple verbal conventions that can then be called
on to help clients step out of some of the traps of literal language, creating distance between clients and
the contents of their mind. One such approach is to ask clients to state things as experiences they are
currently having, rather than as something they actually are, for example, saying, “I am having the
Undermining Cognitive Fusion 105
thought that I am worthless” rather than “I am worthless,” or saying, “I am having the feeling of
anxiety” rather than “I feel anxious.”
Although this practice often feels awkward at first, it can become more natural if repeated over an
extended period of time, perhaps thirty minutes of a session or across multiple sessions. This can help
create a healthy sense of separation between clients and the content of their thoughts.
Another way clients can be trapped in needless struggle is through use of the word “but.” As an
example, consider the statement “I wanted to tell him I loved him, but I was too scared.” The word
“but” literally means to “be out” the thing that came before (Hayes et al., 2012, pp. 262–­263). It suggests that the two things can’t coexist or be reconciled. In the example, the word “but” implies that the
client must feel less scared in order to say important words. This can feed an agenda of getting rid of
fear before fully living life. Or consider a client who says, “I love my husband, but he makes me angry.”
This wording implies that these two emotional states are incompatible and one of them must change.
Asking clients to substitute “and” for “but” can remind them that both things are true: the client loves
her husband, and he makes her angry. Multiple meanings are present, and there’s no need for one to
negate the other. Particularly with a client who uses the word “but” frequently, asking the client to
replace it with the word “and” can free up some space for acceptance.
REFERRING BACK TO METAPHORS AND EXERCISES
The power of metaphors is that they can quickly bring new functions to bear on a situation without
requiring excessive description. Therefore, referring back to familiar metaphors can catalyze defusion.
Earlier, as an example of language that promotes defusion, we used the statement “See if you can hold
that thought like you might hold a butterfly that has landed on your finger.” Looking at a butterfly on
one’s finger suggests attention, curiosity, gentleness, and observation without running away. Compare
this to saying something like “You should respond to your thinking in a defused way, with detachment
and acceptance; and willingly, with openness, fascination, and curiosity; and not with violence, s­ truggle,
battle, possession, argument, wanting to be right about it, or trying to figure out whether it’s true and
criticizing it if it isn’t.” While that might add some didactic information, it would probably fail to communicate the deep qualities of defusion. In contrast, the brief butterfly analogy can communicate many
of these qualities without the need for an exact description.
Once you’ve used a defusion exercise or metaphor with a client, you can rapidly bring defusion into
the room by referring back to it. This is illustrated in the following dialogue. In an earlier session, the
therapist had introduced the concept of “having a thought” versus “buying a thought” using the metaphor of salesperson offering unwanted goods. Now the therapist can refer back to that work to help the
client respond to her thoughts based on the functional utility of those thoughts, rather than their literal
truth.
Client:
I don’t know what to do. I can’t connect with people. I get in social situations and I just
can’t do it. I have nothing to say.
Therapist:
Let’s take a look at this. You’ve just shaken someone’s hand, and your salesperson mind
shows up and sells you the thought “I can’t connect with people.” It looks as if you’ve been
buying that so far. Maybe the important question here is whether that’s a thought you want
to continue to buy. Let me ask it this way: When you follow that thought, where does it
lead you in terms of your values in this area?
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Client:
It leads me away… I just stay at home. Or when I’m at a party, I don’t talk much to people.
Therapist:
I’m guessing there’s a story related to the idea that you can’t connect with people.
Client:
Yeah, it’s true, I don’t connect with people.
Therapist:
So then your mind sells you “It’s true.” When you buy that, where does it lead you?
Client:
Again, not where I want to go.
Therapist:
So, we’ve talked before about how one of your values is that you want to connect with
people, right?
Client:
Yeah.
Therapist:
And now your mind is selling you the thought that you can’t do it. And it can even
marshal evidence. Now let me ask you another question: Suppose you were to go out
tomorrow and actually be able to connect with people. Suppose there were people out
there who really could get you, and you could really get them, open up to them, and let
them know you. Let’s say you did that tomorrow. Who would be made wrong by that?
Client:
Huh? I’m not sure… (Pauses for ten seconds.) What do you mean?
Therapist:
Tomorrow you connect. Today you’ve bought the story that says, “I can’t connect.” So
who’s wrong tomorrow?
Client:
I guess I would be.
Therapist:
Yeah. You’d have to give up this story that you can’t connect with people. You’d be wrong
about that story. Your choice here seems to be either to defend your story or get your life
back. What do you think would come up for you that would be painful if you were to do
this?
Client:
It would mean I could have done it all along…
Therapist:
Yeah. let’s stay with that. When you say that, I notice some sadness coming up. Can we
make room for you to have that right now?
Client:
(Speaks quietly.) Okay.
Therapist:
If having this sadness, this sense of loss, could make it possible for you to really connect
with people, and to be able to be there for your sister in a way you’ve never been able to
before, would it be worth it? (At this point, the therapist might guide the client into an exercise
in which she could be present with her sadness and practice willingly holding it.)
If carefully timed, asking, “Who would be made wrong by that?” can be a powerful intervention for
clients whose story about who they are or about how their life works is in conflict with a valued direction they wish to take. When asked this question, clients often pause before responding, and sometimes
they appear confused because the question seems to have come out of nowhere. However, do note that
Undermining Cognitive Fusion 107
this question may sound accusatory if poorly timed or if the client and therapist don’t have a compassionate, accepting relationship built around agreement about the client’s values. This question isn’t
meant to blame clients for their difficulties; rather, it’s intended to help them see how being correct,
logical, or coherent (i.e., being right) can stand in the way of living a vital life. Done skillfully, the
confrontation is between the client’s mind and the client’s experience or values, not between the client
and the therapist.
TEACHING CLIENTS TO RECOGNIZE FUSION
Another useful technique is to help clients learn to identify, or discriminate, when they’re getting
caught up in fusion with verbal relations in their mind. To do so, therapists make use of a broader
dynamic: we humans can learn to recognize patterns in our environment that weren’t previously apparent, and once we do, we generally don’t “unsee” them in the future. To get a feel for this, take a look at
figure 5. What do you see in this drawing?
If you haven’t seen this optical illusion before, you probably saw only a random bunch of dots. Now look again and see
if you can make out a dalmatian. Once you’ve gotten it, try to
not see the dalmatian. It’s quite hard to do without distorting
the image. In fact, if you’ve seen this image before and were
able to make out the dalmatian, you’ll probably always see it,
no matter how many years elapse. Once a discrimination is
well learned, it’s available to operate on behavior forever.
In the same way, if you can teach clients to recognize
when they’re caught up in old, highly verbal, entrenched ways
of thinking, this can provide an enduring cue to take a step
back and apply any of the defusion strategies they’ve learned.
However, in order to teach clients to observe fused qualities of
thinking, you need to be able to detect it first. K. G. Wilson
(2008) offers pointers on how to identify “mind-­y” conversaFigure 5. Dalmation
tions that indicate fusion and avoidance. If these characteristics can be recognized in session, this can be a cue for both
therapist and client to practice returning to the present, to
practice defusion, or both. When any of the following patterns occur in repetitive, inflexible, tired, old,
or stereotyped ways, fusion may be an issue (K. G. Wilson, 2008, pp. 105–­113):
•
Comparison and evaluation: Situations, things, or people are judged and evaluated or deemed
better or worse than other situations, things, or people.
•
Complexity or busyness: Analyses are fast and furious, complex explanations seem to be
required, and problems must be ferreted out. Sometimes this takes the form of confusion that
must be clarified.
•
An adversarial quality: This could be a conflict between aspects of the client, or between the
client and some individual, including the therapist. In this case, taking sides just tends to
prolong the conversation—­and the client’s fusion.
108 Learning ACT, 2d edition
•
A strong future or past orientation: It may seem as though the client is worrying out loud or
ruminating about the past, almost as if the therapist weren’t there. Words like “must,” “should,”
“can’t,” and “shouldn’t” are about future consequences that are seemingly problems to be
solved.
•
A strong problem-­solving orientation: The client speaks as if some problem must be solved
before life moves ahead, but strangely, the client has been trying to solve this problem for a long
time.
•
Generalization versus specifics: The client speaks in terms of general categories, concepts,
ideas, and evaluations. This can include overgeneralization, black-­and-­white thinking, or use
of terms like “always” and “never.”
Bringing Flexibility to Applying Defusion
As a therapist, it is important to keep in mind that defusion is a process, not any particular form of
behavior. Becoming overly attached to the concept of defusion can lead therapists to get stuck in
explaining defusion in a literal manner. In ACT, the focus is on shaping and engendering defused client
behavior, which will arise primarily from more experiential modes of learning. Effective defusion work
requires attention to tact, timing, pacing, and context. Key among these is that the therapist must be
aware of client behaviors that indicate a need to work on defusion. Such awareness helps therapists
steer clear of a common pitfall: something that could be called “defusion whack-­a-­mole.” The therapist
gets so attuned to fusion such that nearly every client utterance is interpreted as fused thinking and
becomes the target of yet another defusion exercise, concept, or metaphor. Although fusion is often an
ongoing issue, trying to catch and remedy every instance of it is a form of inflexibility. Ideally, the aim
is to help clients learn to defuse flexibly when doing so can loosen up rigid repertoires of behavior. The
point is to provide an opportunity for variability in rigid patterns of behavior, along with the possibility
of contacting new, more effective contingencies. In addition, the goal isn’t for clients to understand the
concept of defusion, but to be able to defuse from thinking at times when that’s likely to lead to new
options and possibilities.
There are two pathways to choosing what to target with defusion. One is via case conceptualization, wherein the therapist identifies core patterns of unhelpful thinking that can be systematically
targeted with defusion. (This is discussed further in chapter 8, on case conceptualization.) The second
pathway involves watching the variability and flow of fusion as it occurs in session.
Working with clients can be a bit like traveling through a dense thicket. It’s easy to lose direction,
get caught on a bramble, or get stuck. Some clients will talk for hours about what has happened to
them, eating up the session with complaints, explanations, and descriptions. When a session becomes
thick with reasons, justifications, and stories, you can sometimes open up some space by asking yourself
or the client questions that focus on the functional utility of what the client is talking about or thinking
(Hayes et al., 2012, p. 260):
“And what is that story in the service of?”
“Is this helpful, or is this what your mind does to you?”
109
Undermining Cognitive Fusion “Have you said these kinds of things to yourself or to others before? Is this old?”
“Okay, let’s all have a vote and vote that you are correct. Now what?”
This moves the focus back to the immediate implications of the client’s story and away from
attempting to figure out or analyze the situation or be correct. Again, it’s important that such questions
not be asked from an apparent one-­up position or sarcastically. Rather, they should be asked from a
place of humility and understanding about why human beings get attached to stories: because we’re
taught to give reasons. Also be aware that asking these kinds of questions isn’t about the truth of the
story. The events may very well be true. These are questions about the utility of the story: is it functioning to keep the client stuck?
Another way to cut through fusion is to help clients contrast what their minds say will work with
what their experience says about what has worked. For example, a therapist might say, “I don’t want you
to see this as a matter of belief, but to examine it against your experience” or “What does your experience say?” The goal of this approach is to move clients out of literal, evaluative thinking and into a
stance that’s more oriented to the opportunities afforded by their environment and directed by their
values.
Another option is to acknowledge the situation directly. Here are a few examples of how you might
do so:
“Hmm. Have you noticed that it’s getting awfully ‘mind-­y’ in here?”
“I notice I’m fighting here, trying to figure it out and persuade you. Is it okay if we just take a deep
breath and notice that we’re both just here in this moment, each with our chattering mind?”
“I have no idea what to do or say next. My mind is being pretty harsh with me for saying this.
Apparently it thinks that therapists are supposed to always know these things. Do you have
thoughts about how to proceed?”
Exercise:
Working with Client Defusion, Part 2
Go back to the three client thoughts you listed in the exercise at the beginning of this chapter. Now
that you’ve read about various defusion techniques, come up with one technique you could use for each
of the thoughts you recorded before.
Defusion technique for thought 1: Defusion technique for thought 2: 110 Learning ACT, 2d edition
Defusion technique for thought 3:
Consider using these techniques in session with that client. If you find yourself hesitating, notice what
shows up when you consider taking this action. What emotions, action urges, thoughts, or reasons do
you notice?
If you find yourself hesitating, ask yourself a question in relation to these thoughts and reasons: If you
decided that these thoughts were 100 percent correct and followed them, where would that lead in
terms of your behavior with the client? What would this behavior show you were valuing?
Next, consider what defusion exercises you’d be willing to do with your thoughts and reasons, then
do one or more of them with these thoughts. It might be useful to do one of those exercises right now.
Alternatively, you could make a plan for which strategy to use when or if those thoughts and reasons
show up in session with a client.
Core Competency Practice
This section is intended to provide practice in using defusion techniques in response to sample dialogues based on ACT sessions. Comments on the previous edition of this book indicated that readers
found the defusion competencies among the trickiest to learn. So although we still recommend that
you choose to fully engage in the exercises and generate your own responses before looking at the model
responses, we do acknowledge that you’ll probably find this work quite difficult. However, this makes
sense, as many people find defusion the most counterintuitive part of the ACT model and thus the
hardest to learn. However, for clients and therapists alike, it’s best learned through practice and repetition, rather than through intellectual understanding. These exercises will give you a chance to engage
in that practice and repetition.
Undermining Cognitive Fusion 111
There is one exercise for each of the nine ACT core competencies for defusion. For each competency, we present a description of a clinical situation and a brief dialogue. The dialogue ends after a
client statement, at which point we ask you to provide a response that reflects that competency, and
then the basis for your response. For each exercise, focus on providing a response that illustrates the
target competency, rather than responses that are consistent with ACT in general. After you complete
each exercise, turn to the end of the chapter to see our model responses. As a reminder, the model
responses aren’t the only right responses; they’re just examples of ACT-­consistent responses. If your
responses are different, that doesn’t necessarily make yours wrong or less useful. Instead, see if you can
remain open to learning, bringing curiosity to comparing the model responses to your own.
Core Competency Exercises
Competency 12: The therapist identifies the client’s emotional, cognitive,
behavioral, or physical barriers to willingness.
At first glance, this competency may seem to be more about acceptance and willingness than about
defusion. However, acceptance depends on defusion. We first need to differentiate thinking that’s
important to target (i.e., that serves as a barrier to values-­based action) from thinking that may elicit
fusion but isn’t serving as a barrier. In addition, external barriers are differentiated from private experiences because external barriers require action out in the world, such as problem solving. In contrast, in
ACT, thoughts, feeing, sensations, urges, and other private behaviors are targeted with defusion and
acceptance.
Exercise 12
The client is a thirty-­four-­year-­old woman who has panic attacks, particularly in social situations. She
wants to go back to school but feels she’s too anxious. This dialogue occurs in the third session, following a discussion in which she has related how hard it is for her to participate in classes, particularly in
terms of raising her hand.
Therapist:
What stands in the way of raising your hand in class?
Client:
I just can’t do it. When I even think about it, I get scared.
Therapist:
Okay, you have the thought “I can’t do it” and the feeling of being scared. What else stands
in the way of raising your hand?
Client:
I’m afraid I’ll panic.
Therapist:
Anything else?
Client:
No. Isn’t that enough?
112 Learning ACT, 2d edition
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 12:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 13: The therapist suggests that attachment to the literal meaning
of these experiences makes willingness difficult to sustain (in other words, the therapist
helps clients see private experiences for what they are, rather than what they advertise
themselves to be).
Exercise 13
This dialogue continues where the dialogue for competency 12 left off.
Therapist:
What’s important is your actual experience. So you’re going along, and this thought shows
up: “I can’t do it.” And a feeling shows up: fear. It’s also saying its buddy is coming along
for the ride: “I’ll panic.” Notice that panic isn’t here yet. In that moment, what you’re
having is the thought “I’ll panic.” So let me ask you this: could you have that thought, “I
just can’t do it,” and the other thought, “I’ll panic,” as thoughts and still raise your hand?
Client:
I guess, but I just can’t do it. I’d be too scared. I’d just end up embarrassed.
Write here (or in a notebook) what your response would be, demonstrating competency 13:
Undermining Cognitive Fusion 113
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 14: The therapist actively contrasts what the client’s mind says will
work with what the client’s experience says is working.
Exercise 14
This dialogue continues where the dialogue for competency 13 left off.
Therapist:
The thought “I can’t do it,” held literally, does indeed make it hard to be willing. So, for
example, when you feel anxious and “I can’t do it” shows up, if that’s literally true, you’re
stuck. On the other hand, if it’s a thought, you might be able to react to it in a different
way. What if thoughts are kind of like a tool, like a hammer or something? We don’t spend
time trying to figure out whether a hammer is a true hammer; we just use it or we don’t.
Now, in this situation, would picking up the thought “I can’t do it” and using it lead you to
engage in your values?
Client:
But I can’t do it. I know that if I raise my hand and I haven’t been able to get my breathing
under control, I won’t be able to say anything when the professor calls on me. If I could just
get my breathing under control, I could probably do it without panicking.
Therapist:
So, let’s check this out. Your mind says, “I need to get my breathing under control.” Right?
That’s a thought. Is that a familiar one?
Client:
Yeah.
Therapist:
Now, let’s look at what your experience has to say about this. How long have you been following what that thought has to say?
Client:
A long time…
114 Learning ACT, 2d edition
Write here (or in a notebook) what your response would be, demonstrating competency 14:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 15: The therapist uses language tools (e.g., verbal conventions),
metaphors, and experiential exercises to create a separation between the client and the
client’s conceptualized experience.
Exercise 15
A forty-­four-­year-­old male client is struggling with alcohol addiction. One of his biggest triggers of
alcohol use is being at home alone. He was on disability for a long time and has spent a fair amount of
his life sitting at home, drinking and watching TV. He’s been sober for the past two months and just
started a new job after several years of unemployment. He’s beginning to question his commitment and
wondering whether the job is really worth the stress. The therapist and client discussed the Passengers
on the Bus metaphor in a previous session; this dialogue is from the client’s sixth session.
Client:
It’s just that I go to work and they don’t pay me enough, so it’s stressful. I feel like I screw
up and don’t work fast enough. I’m not sure it’s really worth it. I get home at the end of the
day, and there’s no one there. I want to do better, but I just want a drink…so badly.
Write here (or in a notebook) what your response would be, demonstrating competency 15:
Undermining Cognitive Fusion 115
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 16: The therapist works to get the client to experiment with
“having” difficult private experiences, using willingness as a stance.
Exercise 16
This dialogue continues where the dialogue for competency 15 left off.
Therapist:
Would you be willing to do an exercise with me?
Client:
Sure.
Therapist:
I’ll invite you to shut your eyes, and I’ll bring you back to that moment. (The client shuts his
eyes.) Think of the last time you were at home, sitting there after work, exhausted and
feeling lonely. Do you remember the bus metaphor we talked about before?
Client:
Yeah.
Therapist:
What passengers show up there and start pushing you around? See if you can notice what
feelings show up.
Client:
I’m feeling a little anxious.
Therapist:
Simply notice the experiences, being present to what you feel and observing where you feel
it in your body. And while you’re noticing, see whether you can notice thinking, coming
into contact with what it’s like to experience thoughts and anxiety.
Client:
I feel lonely. I feel anxious, like I need to do something.
Therapist:
So, lonely shows up… Anxious shows up. If those passengers could speak to you, what
would they tell you to do?
116 Learning ACT, 2d edition
Client:
They would tell me to have a drink to take the edge off.
Therapist:
So these are old passengers, ones who are very familiar. You know them well. What do they
say they’ll do if you just do as they say?
Client:
They say they’ll go away—­they’ll shut up for a while. And they do.
Write here (or in a notebook) what your response would be, demonstrating competency 16:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 17: The therapist uses various exercises, metaphors, and behavioral
tasks to reveal the hidden properties of language.
Exercise 17
The client is a depressed forty-­year-­old man who constantly compares himself with other people in
social situations and often sees himself as less worthy than others. A common pattern for him is being
in a conversation with someone and simultaneously thinking, This person seems to have it pretty together.
If he knew how much of a loser I am, he wouldn’t want to be friends with me. He can’t really be as together
as he seems. I’m sure there’s some way in which he has problems. I don’t know what it is, but I’m sure I’ll find
it eventually. The client is talking about this situation in the fourth session.
Client:
I’m just so sick of comparing myself with others, feeling bad, and then tearing them down.
Therapist:
What’s the thought that is most troublesome? That you’re bad?
Client:
Hmm. I guess it’s that I think, “He’s better than me.”
Undermining Cognitive Fusion 117
Therapist:
“He’s better than me.” And that makes you…
Client:
Bad. Worse.
Therapist:
Which one feels more at the heart of it? (Attempts to identify the more functionally important
thought to target.)
Client:
Hmm. Bad.
Therapist:
So, are you willing to do a little exercise with me around this thought that shows up for
you, “I’m bad”?
Client:
Sure.
Therapist:
What I’d like us to do is play around with this thought a little. Let’s try something out.
How about we sing a song? I’ll go first. “I’m bad, I’m bad, you know it.” Your turn.
Client:
Um, okay. (Sings in a high, funny voice.) “I’m bad, I’m bad. I’m the worst there is.”
Therapist:
And, let’s do a duet of it. (Sings a few more rounds with the client.) So tell me, what was your
experience of that?
Client:
Well, at first it was pretty weird. I didn’t like making fun of something that felt so personal.
But then it got a little lighter. It wasn’t such a big deal.
Write here (or in a notebook) what your response would be, demonstrating competency 17:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
118 Learning ACT, 2d edition
Competency 18: The therapist helps clients elucidate their story and helps them
make contact with the evaluative and reason-­giving properties of the story, as well as the
arbitrary nature of causal relationships within the story.
Exercise 18
This dialogue continues where the dialogue for competency 17 left off.
Therapist:
What happened to the meaning of it?
Client:
It didn’t mean much after a little while, beyond seeming a little funny.
Therapist:
So, when you say to yourself, “I’m bad,” in addition to the meaning your mind gives to
those words, isn’t it also true those words are just words? In some way, they’re kind of like
smoke—­there’s nothing solid there.
Client:
Yeah, but it seems really solid when I’m there. It’s like I think that’s really true about me. I
feel like I really am bad in some ways. It feels like believing something else would be a lie.
Write here (or in a notebook) what your response would be, demonstrating competency 18:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Undermining Cognitive Fusion 119
Competency 19: The therapist detects fusion in session and teaches the client
to detect it as well.
Exercise 19
The client is a fairly intellectual woman in her forties who’s considering leaving a dispassionate relationship with her spouse, Fatima, whom she describes as alternating between being withdrawn and
being verbally overbearing and critical. The client has read dozens of self-­help books, has spent years in
counseling with other therapists, and displays a lot of insight into her problems and Fatima’s.
Nevertheless, she continues to be very passive in her relationship and avoidant of conflict. This dialogue picks up near the beginning of the seventh session, after the client has been talking for several
minutes about what Fatima did that week to intimidate and bully her. The therapist has noted that the
conversation feels very lifeless, old, and stale.
Client:
I just don’t know what to do. I’ve been thinking about leaving, and yet I know if I leave, it
also means I’ll lose the kids. I feel so stuck. What do you think I should do?
Write here (or in a notebook) what your response would be, demonstrating competency 19:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
120 Learning ACT, 2d edition
Competency 20: The therapist uses various interventions to reveal both the
flow of private experience and that such experience is not toxic.
Exercise 20
This dialogue continues where the dialogue for competency 19 left off.
Therapist:
Let me ask you something about this conversation you’re having with yourself right now.
Does this feel alive, new, and different, or does it feel old, lifeless, and familiar?
Client:
It’s old. Fatima has been doing this forever and doesn’t have any interest in changing.
Therapist:
And there it is again. We’re still talking about Fatima and how she won’t change. How
many hours have you spent talking about her, thinking about her, and trying to analyze
things? And here we are again. How do you feel in your body as you talk about her?
Client:
Old, familiar. I’ve thought about this a million times.
Therapist:
And your mind is here, yet again, suggesting ways to figure this out. Can you notice your
mind right now? What’s it saying right now? (Highlights the distinction between the client and
her mind.)
Client:
It’s saying, “Okay, so what do I do, then?”
Therapist:
And what’s next? (Points to the ongoing process of thinking.)
Client:
Um, I’m not sure.
Therapist:
Next your mind gave you a thought with the words “I’m not sure.” Did you notice that was
a thought?
Client:
Um, no, I guess not.
Therapist:
So what’s next? What thought comes up next? (Points to the ongoing process of thinking
again.)
Client:
I don’t like this.
Therapist:
And…did you notice that’s a thought? (Invites defusion.)
Client:
Yeah.
Therapist:
And what shows up next? See if you can simply notice each thought as it comes up—­not
get stuck on what it says it is, but simply notice it as a thought. See if you can let each one
simply be there as a thought, just letting each one pass in and pass out again. (Pauses for
ten seconds.) Okay, so what thought is next? (Distinguishes between the mind and the client
and promotes noticing of ongoing thinking.)
Client:
I’m having the thought that I don’t know where this is going.
Undermining Cognitive Fusion 121
Therapist:
Good. A thought that looks like “I don’t know where this is going.” That’s a really good
one. Isn’t the mind a great machine? (Smiles and pauses.) Do you notice how automatic this
verbal machine is? You don’t even need to do anything; it just keeps producing these words
and sentences that then structure your world. So what we’ve been practicing here is simply
noting when you move in and out of seeing the world as structured by your thoughts,
versus being able to see thoughts as thoughts. One skill we want to practice is to be able to
notice when you’re caught up in this world of thought, with all its judgments, planning,
and evaluations—­for example, “If I only did this, then that would happen”—­and then
simply come back to the moment and observe what’s there.
Client:
Yeah, but I still don’t know what to do about Fatima.
Therapist:
Yeah, that thought is still there. So, you’ve gone around and around about what to do here,
and yet you find yourself stuck. I’d like us to step outside of this a bit and look at the bigger
picture. You’ve told me before that a value you have is respecting yourself. And another
value you have is connecting with your partner. Have those values changed? (The therapist
did work earlier to evaluate the risk of violence, and all signs suggest it’s minimal.)
Client:
No.
Therapist:
Okay, so they haven’t. Yet in what happens with Fatima, do you respect yourself in how you
respond to her?
Client:
No, not really. I let her walk all over me.
Therapist:
Right. It seems as if something stands in the way of respecting yourself when she’s talking
to you. What stands in your way? (Points to thoughts as barriers.)
Client:
Well… I feel so small. And I think about saying something, but I’m really scared. I know
she’ll blow up and just walk away and sulk or something if I don’t let her have her way.
Therapist:
And when that happens, you feel…?
Client:
I’m scared that I just made things worse. And then I walk around on eggshells for a couple
of days, waiting for her to blow up again or leave me.
Therapist:
And how is that for you?
Client:
It’s just terrible. I feel like…like…I can barely stand it.
Write here (or in a notebook) what your response would be, demonstrating competency 20:
122 Learning ACT, 2d edition
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Core Competency Model Responses
Competency 12
Model Response 12a
Therapist:
We want to be open to anything that’s there, and sometimes things float around that
aren’t noticed. So in addition to the “I can’t do it” thought, the fearful feelings, and the “I’ll
panic” thought, let me ask you about some other dimensions that might be part of not
raising your hand. What do you feel in your body? (The client answers.) Good, and does this
remind you of anything in the past? (The client answers.) Cool. And what kind of judgments and evaluations show up? (The client answers.) And when you have all of that, what
do you want to do? (The client answers.)
Explanation: This response amplifies the client’s observations of her experience and treats each observation in a defused way. The therapist specifically asks about particular types of experience that the
client might not otherwise identify in order to help her see them more clearly and thereby be less caught
up in them. Experiences that could be categorized as potential barriers include evaluations, memories,
images, sensations, emotions, moods, and action tendencies or urges. Linking these observations to
action tendencies categorizes them as possible barriers to moving forward in a valued direction. The
goal is to communicate that all of these barriers are acceptable—­that none is to be avoided or taken
literally.
Model Response 12b
Therapist:
What’s important is your actual experience. So you’re going along, and this thought shows
up: “I can’t do it.” And a feeling shows up: fear. It’s also saying its buddy is coming along
for the ride: “I’ll panic.” Notice that panic isn’t here yet. In that moment, what you’re
having is the thought “I’ll panic.” So let me ask you this: could you have that thought, “I
just can’t do it,” and the other thought, “I’ll panic,” as thoughts and still raise your hand?
Undermining Cognitive Fusion 123
Explanation: This response outlines how these emotions and thoughts present themselves as barriers
to moving forward in valued directions. The goal is to orient the client to the way these barriers function and to help her step back from seeing them as being reality and instead start to notice how they
manifest for her. The context of nonliterality is assumed in the answer because the thoughts are treated
more as objects that can be had, rather than as something to be believed literally.
Competency 13
Model Response 13a
Therapist:
Hmm. Let me just ask you this: How old is that thought, “I’d be too scared?”
Client:
I don’t know, I’ve been scared for as long as I can remember.
Therapist:
You’ve been living inside that story that you’re too scared for a long time, yes? Buying into
that thought has cost you a ton. (Points to workability.) How about this? Do you know
where that thought, “I’d be too scared,” comes from? What if these are just bits of
programming—­your history showing up in the present—­and in buying into them, you’re
amplifying them into events that run your life. Gub-­gubs go…
Client:
Wooo.
Therapist:
Yeah. And I can’t raise my hand because I’m too…
Client:
Scared.
Therapist:
So who’s in charge here, you or your mind?
Explanation: By focusing the client on the historical fact that buying into certain thoughts can contribute to problematic patterns of behavior, the costs of fusion are made more evident. Appeals to
history make it clear that the client can expect these thoughts to continue as they have for some time.
The issue, however, is their role in overt behavior. Highlighting the client’s ignorance as to the source
of these thoughts and drawing an analogy with a current, trivial source of a thought can help the client
see her thoughts as an ongoing, historically produced process, not as literal events that must be complied with, argued with, resisted, or avoided.
Model Response 13b
Therapist:
The thought “I can’t do it,” held literally, does indeed make it hard to be willing. So, for
example, when you feel anxious and “I can’t do it” shows up, if that’s literally true, you’re
stuck. On the other hand, if it’s a thought, you might be able to react to it in a different
way. What if thoughts are kind of like a tool, like a hammer or something? We don’t spend
time trying to figure out whether a hammer is a true hammer; we just use it or we don’t.
Now, in this situation, would picking up the thought “I can’t do it” and using it lead you to
engage in your values?
124 Learning ACT, 2d edition
Explanation: The therapist suggests that buying the thought, or holding it literally, is going to make it
hard for the client to do anything with respect to the values at hand. The therapist compares the
thought to an object to help the client relate to it in a more pragmatic way—­based on its usefulness
rather than what it literally says it is. The therapist then asks the client to evaluate whether this
thought is useful in relation to her values.
Competency 14
Model Response 14a
Therapist:
So now we’ve heard from your mind. What does your experience have to say? Has it turned
out the way your mind said it would—­that if you just keep trying, eventually you’ll get your
breathing under control and you’ll be able to speak in class and participate in the way you
want? In your experience, has it worked out that way?
Explanation: The therapist examines whether the verbal rule implied by the client’s thoughts—­“If you
just try to get your breathing under control, you eventually will, and then you’ll be able to raise your
hand”—­actually turns out as the rule specifies.
Model Response 14b
Therapist:
(Speaks gently.) So let’s just notice that. Your mind is trying to protect you, and yet when
you do what it has told you to do—­try to get your breathing under control—­look at what’s
happened. You haven’t been able to do it, and your panic has only gotten worse over time.
If your mind were an investment advisor, you would have fired it a long time ago. It seems
as if your experience shows that things don’t work out as your mind predicts. So which are
you going to believe: your mind or your experience?
Explanation: The explanation for this response is the same as that for sample 14a; the therapist is just
using a slightly different style.
Competency 15
Model Response 15a
Therapist:
It’s worth noticing that word “but.” You know, the word “but” long ago came from a contraction of two words: “be” and “out.” “But” is a fighting word. You’re saying that the fact
you want a drink somehow invalidates wanting to do better, and wanting to do better
should somehow remove the urge to drink. Yet check and see whether that was what you
experienced. I’m guessing that what you experienced was two things: the thought that you
want to do better and a feeling that you want to drink. Is there anything I said there that
you cannot have? “I want to do better and I want a drink.” Both things are so. Now, what
are you going to do with your feet? (Shifts from a focus on thinking to pragmatic action focused
on values.)
Undermining Cognitive Fusion 125
Explanation: The therapist is trying to draw out the hidden struggle and help the client see that there’s
really nothing to fight about. As often happens, defusion work is followed by a shift toward values-­based
action.
Model Response 15b
Therapist:
Would you be willing to do an exercise with me?
Client:
Sure.
Therapist:
I’ll invite you to shut your eyes, and I’ll bring you back to that moment. (The client shuts his
eyes.) Think of the last time you were at home, sitting there after work, exhausted and
feeling lonely. Do you remember the bus metaphor we talked about before?
Client:
Yeah.
Therapist:
What passengers show up there and start pushing you around? See if you can notice what
feelings show up.
Client:
I’m feeling a little anxious.
Therapist:
Simply notice the experiences, being present to what you feel and noticing where you feel
it in your body. And while you’re noticing, see if you can also notice thinking, coming into
contact with what it’s like to experience thought and anxiety.
Explanation: The therapist is trying to make the work as experiential as possible, helping the client
observe his thinking more broadly and from the perspective of noticing his experience. To do this, the
therapist needs to get the avoided content out into the room. So the therapist does a short experiential
exercise that helps the client make contact with his avoided content. Then the therapist refers back to
an earlier metaphor (Passengers on the Bus) in which thoughts and feelings were compared to bullies
that push the client around. The goal is to bring the bullies into the present, but in an altered context
in which the avoided private experiences can be met with more willingness and with some healthy
distance.
Competency 16
Model Response 16a
Therapist:
Well, they will sit down, sure—­as you say, for a while. When they come back, are they
bigger or smaller? Are they weaker or stronger? (Pauses.) Bigger and stronger, right? So it
has a cost. Here’s my question: what do you have to be willing to experience in order to let
them be there and not sit down?
Explanation: The therapist is asking the client to consider the possibility of having these experiences
by being more willing to have whatever shows up when he takes that step.
126 Learning ACT, 2d edition
Model Response 16b
Therapist:
Right, they sure do. So, one way to work with them is to do things so they’ll agree to sit
down. Let’s check this out, though. If you do that, what happens with respect to your
values? Do you head toward or away from your values?
Client:
Away. But even then, they’re just as powerful.
Therapist:
Yeah, powerful…and old…and familiar. And you’ve been fighting with these passengers
for a long time. How has it worked to fight them? And how has it worked to turn the direction of your life over to their demands?
Client:
It hasn’t worked.
Therapist:
So maybe it’s time to do something different. How about this? Just let them be there as
thoughts, as feelings. Don’t do anything with them except notice them.
Client:
I don’t know if I could do that.
Therapist:
Right, so your mind gives you the thought “I don’t know if I could do that.” Let me ask you
something: what is your experience of how well trying to fight these passengers has worked?
Client:
Not well.
Therapist:
How about this? Do you know, from experience, whether learning how to simply notice and
make space for the passengers works? You know what it’s like to struggle with them and try
to get rid of them, and that’s led to lots of pain. I guess the question is, have you had enough
pain to be willing to try something else even if you don’t know how it will work out?
Another way to say this is, are you going to pay attention to your experience or your mind?
Explanation: The therapist is asking the client to examine the workability of his old solutions and to
consider willingness as an alternative. When the client says, “I don’t know if I could do that,” this represents fusion with a cognitive barrier to willingness. The therapist identifies the client’s presented
barrier as another thought and then proceeds to ask the client whether he would be willing to try a new
behavior—­the behavior of willingness. The therapist refers back to the client’s experience of struggle
and asks whether that has worked. If the client agrees to try something else, this could segue into willingness and exposure work.
Competency 17
Model Response 17a
Therapist:
And even if it didn’t feel lighter, there is a point in here. At one level, this is also just language. Mary had a little…
Client:
Lamb.
Therapist:
And gub-­gubs go…
Undermining Cognitive Fusion Client:
Wooo.
Therapist:
And he is better than…
Client:
Me.
Therapist:
These words are worth restricting your life over?
127
Explanation: The therapist highlights the automaticity of thought and the difference between literal
meaning and pragmatic meaning.
Model Response 17b
Therapist:
What happened to the meaning of it?
Client:
It didn’t mean much after a while, beyond seeming a little funny.
Therapist:
So, when you say to yourself, “I’m bad,” in addition to the meaning your mind gives to
those words, isn’t it also true that those words are just words? In some way, they’re kind of
like smoke—­there’s nothing solid there.
Explanation: As often happens in debriefing experiential exercises, the therapist highlights aspects
that the client may have experienced but not taken note of. In this case, the therapist highlights how
the meaning evaporated during the exercise, revealing the words as simply words, without all the extra
meaning attached through fusion.
Competency 18
Model Response 18a
Therapist:
Yeah, minds don’t like us just letting go of the story; it has to be true or proven false. If you
just let it go, it’s like a lie, like you aren’t genuine. And even right now your mind is doing
it. Even in this very conversation you’re trying to figure whether you’re bad or good. How
long have you been trying to figure this out?
Client:
I don’t know… A long time.
Therapist:
And based on the fact that we’re still talking about it, it seems you haven’t figured it out.
What if the question in front of us is something different? What if it’s about whether you
want to figure this out or you want to live a full and meaningful life? Suppose you can only
pick one. Which do you choose?
Explanation: The client is trying to move the issue to the literal truth of the story. The therapist is
drawing that out and moving the focus back to functional truth (i.e., whether the story helps the client
move toward his values-­based life goals). If the client agrees that he’s interested in letting go of investment in this story, a follow-­up might be to develop an agreement to notice when his mind tends to drift
back into that territory in session and then return to more values-­based discussions.
128 Learning ACT, 2d edition
Model Response 18b
Therapist:
I’m not asking you to believe something else. In fact, I’d recommend that you not try to
believe something else. That would just be more of the same thing. You’ve already tried
that, right? Telling yourself you’re basically a good person—­has that worked to the extent
that you now don’t worry about being a bad person? Could you just have that thought, “I’m
bad,” as a thought, and still do what matters to you?
Explanation: The client seems to be hearing the therapist saying that he shouldn’t believe these things.
This wouldn’t be an ACT-­consistent message because it remains within the context of literality. So the
therapist says something that steps outside of literal understanding and includes the dimension of belief
versus nonbelief by saying, “I’d recommend that you not try to believe something else.” Then the therapist refers back to the issue of workability and the client’s experience and suggests a way of relating to
the thought.
Competency 19
Model Response 19a
Therapist:
Have you said to yourself before that you need help? Does this feel old?
Client:
Yeah.
Therapist:
Let’s say I gave you a definitive answer. Let’s say I said, “You need to stay and work this
out.” Would that help?
Explanation: The therapist highlights one of the characteristics of fused thinking: it feels old, tired,
and repetitive. The therapist then takes the additional step of pointing to the functional utility of the
client’s thoughts (i.e., does this pattern of thinking move the client toward her values-­based life goals?).
Model Response 19b
Therapist:
Let me ask you something about this conversation you’re having with yourself right now.
Does this feel alive, new, and different, or does it feel old, lifeless, and familiar?
Client:
It’s old. Fatima has been doing this forever and doesn’t have any interest in changing.
Therapist:
And there it is again. We’re still talking about Fatima and how she won’t change. How
many hours have you spent talking about her, thinking about her, and trying to analyze
things? And here we are again. How do you feel in your body as you talk about her?
Explanation: The therapist is trying to highlight some of the qualities of “mind-­y” conversations, in
this case, their tendency to drag on and feel lifeless. The therapist contrasts this with vital conversations. The client’s initial response doesn’t indicate much in the way of defusion, so the therapist’s
second response is a further attempt to help the client notice her ongoing pattern of thinking. The
therapist then refocuses the client on stimuli in the present moment, in this case her body, in order to
move in a more experiential direction.
Undermining Cognitive Fusion 129
Competency 20
Model Response 20a
Therapist:
And so you do what it takes to make that feeling go away. You shrink, you get small, you
give in, you distract yourself, you walk on eggshells. But something’s weird here: Your mind
says you can barely stand it, yet you’ve been standing it for years. And you go on standing
it, struggling with it, for years. I’m wondering, would you be willing to have the thought “I
can barely stand it” and make some more room for these scary feelings next time they show
up? Your job would be to feel thoroughly terrible, to do a really good job at feeling that,
rather than trying to feel differently. Then you can find out whether these thoughts and
feelings can hurt you—­whether you come out injured and beaten up, or whether getting
beaten up comes from your struggle with these experiences. You can pick how long. Would
you be willing, even for five minutes, to just notice what thoughts and feelings show up and
to just feel your feelings and watch your thoughts without doing anything about them?
Afterward you can always go back to doing what you were doing before. Are you willing?
Client:
Five minutes? That’s too long. I’ll try one minute.
Therapist:
Cool. One minute. And then you can come back to the next session and tell me whether
you were able to stand it or whether it really injured you.
Instead of suggesting a between-­session exercise, another option is to conduct an in-­session
exposure-­like exercise (see chapter 7) such as the Mr. Discomfort exercise (Hayes et al., 2012, pp. 285–­
286) to practice willingness and defusion with her fears related to being respectful of herself during
difficult interactions with her partner. Another option could be a role-­play with the client in which the
client practices getting in contact with these feelings and noticing that, while they are painful, she isn’t
damaged by experiencing them.
Explanation: In the vignette, the therapist guided the client to acknowledge a value in relation to her
partner (“respecting yourself”) and avoided mental content related to that value. This sets the context
for an experiential exercise or between-­session practice in which the client contacts the avoided material in an open, accepting, and compassionate way. Rather than talking about defusion, the therapist
directs the session in such a way that the client will hopefully experience defusion. It’s not important
that clients understand defusion conceptually; they just need to be able to engage in defusion.
Model Response 20b
Therapist:
I want to go back a little to something you said: “I’m not sure.” This story seems to be
showing up throughout this entire process. How many times would you say you’ve encountered this thought?
Client:
Many, many times.
Therapist:
It’s as if it’s passed through you again and again, and a significant portion of the time it
captures you. You get hooked.
Client:
I get hooked by it a lot.
130 Therapist:
Learning ACT, 2d edition
I wonder if it would be possible to really connect to its repetitive, almost circular nature. It
flows around and around. Can I invite you to close your eyes for just a minute and imagine
the words “I’m not sure” simply passing by? See if you can put the words in the shape of
clouds, and have them pass by, again and again. (The client closes her eyes and the therapist
pauses for a minute.) Now as you notice these passing thoughts, I also want you to notice
that you’re encountering them, just like you always have, and you are still here, safe, whole,
and sound.
Explanation: The therapist is highlighting the ongoing flow of internal experience by using imagery
and also establishing that this flow of thoughts and feelings isn’t dangerous by connecting the client to
her here-­and-­now experience as she contacts a difficult thought.
Experiential Exercise:
Defusion
If you’re like many people, engaging in this core competency practice may have evoked some difficult
private experiences. Perhaps you even fused with a story about what your “performance” on these exercises says about you as a therapist or as a person. So we’ll bring this chapter to a close with an experiential exercise to help you defuse from that content.
What was the most difficult thought about your professional practice or your learning that you had
while working with this chapter?
Now identify which of the principles of defusion seems most relevant to this thought:
What exercise or activity can you do to apply this principle to your own difficult thought? Describe
your plan here and then try it out, noticing especially how this approach affects your entanglement with
the thought.
Undermining Cognitive Fusion 131
For More Information
For more about defusion, including exercises and metaphors, see Hayes et al., 2012,
chapter 9. You’ll also find a wide range of exercises and metaphors related to defusion in
Stoddard and Afari, 2014.
For an entire book devoted to learning about defusion, see Blackledge, 2015.
For defusion-­related exercises and worksheets that you can use for yourself and clients,
see Hayes, 2005, chapters 5 through 7.
CHAPTER 4
Getting in Contact with
the Present Moment
Our true home is in the present moment.
—­Thich Nhat Hanh
Key targets for contact with the present moment:
Help clients discover that life is happening in the here and now and assist them in
returning to the now from the conceptualized past or future.
Help clients make contact with life as it’s happening in the moment, whether it is filled
with sorrow or joy.
Help clients develop the ability to attend to their experience in a more flexible, fluid,
and voluntary manner.
Help clients notice what’s happening in their relationships in the moment.
Life is always lived right here and right now. There is nothing that can be directly experienced other
than the present moment. Everything else is a conceptual rendering—­a sketch, a thought, a plan, a
memory, a picture drawn. And even though all of these refer to imagined futures or pasts, they can only
be experienced in the present moment. The ability to consider the past and plan for the future is essential for humans, and it’s helpful a good deal of the time. However, problems arise because people tend
to get excessively and rigidly engrossed in the future or past and lose contact with the present. When
under the sway of cognitive fusion, people tend to interact with these conceptualized futures and pasts
as if they were really happening and, as a result, may end up spending little time in the here and now.
ACT suggests that the problem isn’t that we need to eliminate thinking about the future or past, but
Getting in Contact with the Present Moment 133
that people need to be flexible: being in the present when a present focus works best, being in the future
when planning works best, and being in the past when remembering works best. However, helping
clients be in the here and now is particularly important because this is where new learning occurs. It is
where opportunities afforded by the environment can be discovered.
One of the key targets of ACT is to help clients let go of the struggle with their personal history, as
well as unwanted feelings, thoughts, and sensations, so they can show up to engage in the ongoing
process of life that occurs moment by moment. Contact with the present moment therefore refers to the
process of helping clients routinely step out of the world as structured by their thoughts and to more
directly, fully, and mindfully contact the here and now, including both sensory contact with the external world and contact with the ongoing processes of thinking, feeling, sensing, and remembering.
What Is Contact with the Present Moment?
Showing up for the present moment involves bringing awareness to internal and external experiences
as they occur in the here and now. This kind of focus is created by observing or noticing what arises
within awareness on a moment-­by-­moment basis. For instance, when attending to your external and
internal experience, you might first hear the sound of a bird, followed by the sight of a yellow color in
the petal of a flower, followed by the feel of your foot touching the ground, followed by a thought (This
is nice), followed by the sensation of an itch, and so on. Each one of these experiences is noticed as it
occurs. In this effortless process characterized by nonattachment, experiences arise and then fall away.
Contacting the present moment is easy and difficult at the same time. It’s easy to turn attention to
an experience, yet it’s difficult to maintain attention on ongoing experiencing. Our minds are quickly
pulled away from the moment as we’re repeatedly drawn into a virtual world structured by thought.
Because this happens rapidly, it takes practice to stay present. In ACT, clients are asked to practice
numerous defusion, acceptance, and mindfulness exercises to help increase their capacity to stay
present. It should be noted that not even those who practice intensively can stay present at all times.
Indeed, the process of present-­moment awareness involves developing the ability and skill to observe
when the mind has wandered and then return to the present moment, while also recognizing that it’s
nearly impossible to stay present at all times. Also note that ACT therapists help clients develop the
ability to be focused and present not because clients should always be in the present moment, but so
they can do this when it works to do so (e.g., in the presence of an aversive experience that constricts
behavior in unworkable ways). Present-­moment awareness is encouraged not only because it’s the place
where life is truly lived, but also because it promotes values-­based living by increasing psychological
flexibility.
One of the important aims of working with present-­moment awareness is to help clients develop
the ability to attend to their experience in a more flexible, fluid, and voluntary manner. For example,
focused attention on a particular stimulus is needed at times (such as when reading a textbook), but
sometimes breadth of attention is also needed, wherein awareness is expanded to include stimuli other
than the current focus (such as noticing that class has begun and turning attention to the teacher). As
with all of the flexibility processes, one of the key goals of working with present-­moment attention is
increasing clients’ flexibility in ways that lead to effective behavior in context.
134 Learning ACT, 2d edition
Why Contact with the Present Moment?
As noted in chapter 3, a great deal of suffering can result from fusion with thoughts, or getting enmeshed
with one’s thinking. When thoughts are seen as negative, they’re often evaluated as detrimental, leading
people to engage in efforts to eliminate or reduce these unwanted experiences. At times, it is as if
thoughts and experiences cease to flow as we almost become these experiences and are puppets to their
demands. We become so heavily invested in understanding a “problem” and finding the solution that
we begin to get lost in our past and our beliefs in an effort to figure it all out. We may also spend large
amounts of time in the future, thinking or worrying about what might happen next. When we’re
caught in these conceptualized worlds, we tend to miss the opportunities that are present in the here
and now. Coming back to the present moment and mindfully and nonjudgmentally observing and
describing our current experience places us back in contact with our context and helps us be present,
creating the conditions necessary for us to act on our values.
Contact with the here and now also undermines avoidance and struggle. If we’re connected to the
present moment, we usually have nothing to fight against. Much of what is present is, in and of itself,
nonthreatening. Feelings, thoughts, sensations, urges, and so on are simply experiences to be observed.
When we lose contact with the present, we can lose awareness and end up entangled with the mind,
overly absorbed in evaluations, judgments, and assessments about our feelings, thoughts, and sensations, creating needless suffering. Therefore, contact with the present moment undermines fusion,
including attachment to a conceptualized self.
Establishing the capacity for flexible and fluid awareness of one’s ongoing experience is essential in
responding effectively to life’s challenges. There is no specific rule for how to live effectively in every
situation; individuals have to find their own way to live a life that works for them. Accordingly, in order
to respond flexibly to life’s challenges, it’s important that people know something about their idiosyncratic patterns of behavior, inclinations, emotional responses, and vulnerabilities. It is present-­moment
awareness (often in the context of others who are responsive to us) that allows us to know ourselves.
Indeed, making space for and embracing difficult emotions allows us to learn from what they have to
tell us. For instance, awareness of deep sadness may point to something we’ve lost (e.g., an important
friend has moved away) and indicate what’s important (e.g., that we value close relationships). Thus,
present-­moment awareness involves curiosity about and learning from our emotions and other behaviors. In contrast, ignoring or suppressing our emotions typically leads to lack of self-­awareness and an
inability to respond to ourselves in a manner that’s caring, kind, and sensitive to our own difficulties
and vulnerabilities.
Being present has a vital, creative, and connected quality. If we are in the moment, rather than in
the past or future, our capacity to receive or take in what occurs in life, while letting go of the desire to
make it come or go, is expanded. When we’re present, we learn through experience that difficult emotions can be felt and that they aren’t destructive. It’s when we fight against thoughts or feelings, wishing
they were otherwise, that harm occurs. At one extreme, this destructive battle can take the form of
suicidal behavior spurred by fusion with a seemingly bleak and hopeless future; at the other end of the
spectrum, it can take subtle forms, such as quietly withdrawing from a relationship in order to avoid
pain. By experiencing thoughts and emotions from the point of view of “I am having this experience
now,” we are freed from being controlled by our pain and history. From this stance, the need to understand, solve, and eliminate difficult internal experiences is diminished or dissolved; we can choose
Getting in Contact with the Present Moment 135
based on our values, rather than on the notion that something must first be different in our lives before
we can choose.
Indeed, “there is as much living in a moment of pain as in a moment of joy” (Strosahl et al., 2004,
p. 43). Yet clients often take the position that their lives can only begin when they finally feel better—­a
position that fails to recognize that their life is occurring right now. Each moment is here to be lived.
Whatever historical events have happened, have happened. There is no going back and undoing those
events. History is unidirectional, proceeding from one moment to the next. People can’t go back and
have some other history. From an ACT standpoint, we would argue that time is better spent in the
present moment, and it is from this perspective that you can help your clients bring their values to life.
Equally important as letting go of the past is letting go of the conceptualized future. Whatever
events may happen in the future have not yet happened. Furthermore, no one can accurately predict
what will happen, and people are often surprised by what the future brings. It is often not what we
hoped for or expected. We can, however, take specific actions toward creating a fuller, deeper, richer
life. In the moment, we can choose to engage in values-­consistent actions, bringing personal meaning
to each moment. This doesn’t mean things will turn out just as we intend or imagine. However, that
doesn’t make the endeavor less worthwhile. Suppose you could choose to either spend a year living in
alignment with your values, even with pain, or spend that year struggling with pain. Which would you
choose? This question is generally easy to answer, including for clients. If people spend their time trying
not to feel or think something, then they’re essentially trying to be something other than what they are.
However, if they devote their time to living with awareness and with intentions to take actions guided
by their values, their life will be imbued with meaning and purpose.
Additionally, it is in the present moment that people develop flexible and fluid self-­knowledge
(Hayes et al., 2012). Because much of private experience can be painful, people often avoid awareness
of their own thoughts, feelings, and responses. This has significant costs in terms of living well and
responding flexibly. By attending to the present, people learn more about themselves, what their reactions are, and how to respond to and regulate their behavior in a skillful manner.
What Should Trigger Working with This Process?
ACT therapists spend a significant amount of time helping clients develop a stronger ability to return
to the present moment through structured exercises, such as mindfulness meditation and in-­session
present-­moment work. Focusing on present-­moment awareness is likely to be especially useful when
clients display the following behaviors:
•
They seem out of touch with their feelings or lost in thought.
•
They’re unable to describe their own experience, indicating chronic avoidance or fusion.
•
They become too intellectual in therapy, wishing to understand with the mind rather than
through experience.
•
They fail to respond to what’s happening in the relationship with the therapist.
136 Learning ACT, 2d edition
•
Speaking of the past or future produces their entanglement with worry, rumination, or anxious
predictions about the future.
•
They fail to notice opportunities for choice and values-­based living in their current contexts.
•
They blame others, rather than noticing their own behavior and its effects.
Therapists can also use their own reactions in session as indicators that a present-­moment focus
may be warranted. One possible indicator is when the clinician’s attention is wandering, which could
be due to the client being distant, to the session feeling predictable or wordy, or to the session being
dominated by discussion about other times and places. Clinician reactions such as wandering attention
or boredom may also arise from idiosyncratic aspects of the therapist’s own history or life context (e.g.,
something happening in the therapist’s personal life), not necessarily anything related to the client.
However, clinician reactions may indicate something about the client, so it’s wise to use yourself as a
barometer to conceptualize the case and help guide treatment.
Present-­moment awareness skills are developed to assist clients in routinely contacting the here and
now. However, clients aren’t expected to be in contact with literal present-­moment stimuli at all times
(e.g., hearing sounds as sounds, seeing thoughts as thoughts, feeling sensations as sensations). Indeed,
it’s useful to be able to consider the future or think about the past. The goal is to be able to do so
flexibly—­without getting stuck in rumination or worry, and when returning to the present helps
support values-­based goals.
The decision to focus on present-­moment awareness in session is influenced by the therapist’s conceptualization of in-­session client behaviors at multiple levels (for more on this, see chapter 8, on case
conceptualization). To illuminate this, let’s look at an example. Imagine a client who’s just started
talking about how frustrated she is with her child. This could be viewed as simply a report of what’s
happening in the client’s life and used solely for informational purposes. Alternatively, it could be seen
as a sample of the client’s social behavior, indicating that she tends to engage in harsh and critical commentary about others, which harms her social relationships. Or, if the behavior of talking about her
frustration with her child immediately followed cues that could have elicited difficult emotions, it could
be viewed functionally as avoidance behavior. And finally, it could be a subtle commentary on the
therapeutic relationship, with the client implying that the therapist isn’t being helpful or that the
therapy isn’t addressing her concerns. Depending upon what level the therapist chooses to attend to,
moving the therapeutic focus to present-­moment awareness could be more or less relevant. For example,
if the therapist primarily sees this as an example of experiential avoidance, he might gently interrupt
the client and ask, “What happened right before you started talking about your son?” to bring the client
back to the present-­moment processes occurring in the room.
What Is the Method?
Perhaps the method that most therapists are familiar with to build present-­moment awareness is through
formal practices, such as various mindfulness meditation techniques. While ACT includes these kinds
of structured exercises and ACT therapists generally encourage clients to develop a formal mindfulness
meditation practice if they’re interested in doing so, ACT also provides guidance on other ways to build
Getting in Contact with the Present Moment 137
present-­moment awareness. Below we explore three contexts designed to support awareness of the here
and now: doing structured exercises, contacting the present moment during the ongoing flow of therapy,
and contacting the present moment in the context of the therapy relationship.
However, before embarking on these approaches, it’s often necessary to introduce clients to the
process and importance of present-­moment awareness. Here’s one way to do so (inspired by Wilson,
2008).
Therapist:
Part of what happens when we’re struggling is that we interact with our internal life as if
we were a math problem to be solved. However, it’s not always useful to treat everything in
life as if it were a math problem. A lot of things are more like sunsets. It doesn’t work well
to treat sunsets like math problems. If we do, what do we get? It might look like chatter in
our head that goes something like this: “Hmm, that red isn’t as nice as the red I saw the
other day on that painting. It would be nice if it were just a little lighter. And if that cloud
were up just a little bit, that would be better. And if I could move that purple hue over
there, I would like this sunset even more.” Can you see how that way of relating to a sunset
doesn’t work too well? It seems that what a sunset needs is for us to simply show up to it,
be present, and witness it. What if a lot of the things you struggle with in your internal
world don’t need your attention in a math problem sort of way? What if they simply need
you to show up as you would with a sunset? If that’s the case, then part of what we want to
do in therapy is slow down…to look…feel…and see what actually shows up in your experience and learn from that, rather than simply operating in life based on what your mind has
to say.
Using Structured Exercises to Develop
Present-­Moment Awareness
Clients typically have a difficult time connecting with a sense of self that isn’t focused on evaluations or qualities of the self (e.g., “I’m sad,” “I’m Ralph,” “I’m tall”). The ubiquity and persistence of
humans’ private verbal commentary obscures the distinction between the self as knower and the self as
known. Contact with the present moment helps clients develop a connection with an ever-­changing,
flowing, and therefore flexible sense of self, or self-­as-­process, meaning a nonjudgmental, present,
ongoing description of thoughts, feelings, and other private events (Hayes et al., 2001).
One of the easiest ways to help clients contact self-­as-­process is through structured mindfulness
exercises, in which the client is asked to gently observe, without judgment, a specific event or an
ongoing set of events occurring either inside the skin or in the environment. Mindfulness of thinking
is often the target. To that end, one helpful eyes-­closed exercise is Floating Leaves on a Moving Stream
(Hayes, 2005, pp. 76–­77; visit http://www.newharbinger.com/39492 for a downloadable audio recording
of this exercise). In this exercise, clients are asked to imagine themselves sitting next to a creek or
stream. They are then asked to picture leaves floating down the stream. As these leaves pass, clients
are invited to place each thought they have on one of the leaves and then watching it float by. If clients
notice that they’re getting hooked by a thought (entangled or caught up in it) and pulled away so that
they’re no longer observing their thoughts, they are asked to acknowledge what happened and then
138 Learning ACT, 2d edition
gently return to placing thoughts on leaves and watching them pass by. At well-­paced moments, the
therapist can offer guidance in this regard, saying something like “Notice if your mind has drifted to
other things. Notice if it got caught by a thought. If so, gently bring it back, place the thought that
hooked you on a leaf, and let it flow down the stream too.”
This kind of exercise can be done using a variety of images, including having thoughts attached to
vehicles passing by on a road or displayed on signs carried by people marching in a parade. If clients
come up with their own images, using those can work well. For example, one client imagined a futuristic city with vehicles that ran on electricity on roads that were floating in the sky and running all over
the place.
Another common image is clouds floating by in the sky, as illustrated in the following example.
Therapist:
I invite you to take in a deep breath, and when you exhale, allow your eyes to close. Take
a few more deep breaths, then gently settle into your normal breathing pattern and just rest
there for a moment. (Pauses.) Now I invite you to imagine that you’re lying in a field—­a
field of your choice. It could be one with grass or flowers. Simply picture yourself lying
there and imagine that you can see the blue sky above you. In this sky, clouds of many
shapes and sizes are gently floating by. (Allows a few moments for the client to create and
connect to these images.)
Now I invite you to imagine that every thought you experience is magically attached
to a cloud. It can rest in the cloud as a word or an image, or the cloud itself can take on
the image of your thought. The key here is to take each thought as it occurs and attach it
to a cloud and then allow it to gently float by. If you lose the image or your attention drifts
to something else, that’s fine. When you notice that this has happened, then, without
judgment, gently bring yourself back to lying on your back watching each cloud float by,
and attach the thought that took you away to a cloud and let it float by too. I’m going to
be quiet for a few minutes and let you practice this, just noticing each thought that arises
and placing it in or on a floating cloud. (Pauses for a few minutes.)
Remember, if you get lost in thought and are no longer viewing your thoughts, gently
come back to putting your thoughts on clouds and watching them pass by. (Pauses for few
more minutes.)
Now I’d like you to gently leave this field in which you’ve been lying and, mindfully
paying attention to the transition, come back to the room.
After conducting this kind of exercise, take time to debrief, talking with the client about the
ongoing nature of thinking and pointing out how thoughts change and seem to be in motion—­coming
and going, sometimes chaotic and all over the place, sometimes more linear, sometimes appearing as
images, and sometimes being difficult to view. You can also discuss the client’s experience in regard to
going from looking at thoughts to looking from thoughts (being fused with or lost in thoughts).
A different type of mindfulness exercise expands awareness of ongoing experience beyond the flow
of thoughts to include the flow of all experience. In this exercise, akin to the traditional practice of
choiceless awareness meditation, the client is asked to pay attention to moment-­
by-­
moment
experience.
Therapist:
Let’s do an exercise that points to the sense of self as an ongoing experiencer. First, I invite
you to get comfortable in your chair, and when you’re ready, to close your eyes. As your eyes
Getting in Contact with the Present Moment 139
close, notice that your ears tend to open. Take a moment and listen to what you hear.
(Pauses for about ten seconds.)
Now gently turn your attention to your breathing and simply follow your breathing as
you inhale and exhale. Allow yourself to be your breathing for just a few moments. (Pauses
for about ten seconds.)
Now I’d like you to follow—­just as you followed your breathing—­any sensation,
thought, or emotion that arises. Be aware of each new sensation or thought or emotion,
simply observing each as it comes and goes. For instance, in one moment you may be
aware of an itch, next a feeling of anxiety, next a thought, next a muscle pain or discomfort, next a sound, and so on. Your job in this exercise is to simply observe each new experience as it arises and comes into your awareness. (Pauses.)
Now I invite you to notice the you that is an ongoing experiencing being—­the you
that senses, feels, and thinks in an ongoing fashion. Just let each new experience be there
as you observe and simply rest in awareness of experience. (Pauses for about five minutes.)
Now I invite you to gently return to your breathing, spending the next few moments
focusing on the rise and fall of the breath. (Pauses.)
And now open your eyes and return your attention to the room.
The key here is to help clients sustain a pattern of ongoing attention to or awareness of their immediate, ongoing, changing experience without having to retreat from it or get pulled into it. Clients can
also practice this skill through mindful awareness of simple daily activities, such as eating, washing the
dishes, driving, and waiting in line. As an in-­session activity, you could ask clients to practice eating a
raisin mindfully (Kabat-­Zinn, 1991, pp. 27–­29). This helps clients develop an ongoing awareness of
sensations, and as the exercise continues, they can also notice how experience continues to occur even
as the content of experience shifts over time. For example, at first the client doesn’t have a raisin, then
he does, then it is tasted and chewed and swallowed, and finally the client doesn’t have a raisin anymore.
Time moves forward, and with each passing moment a new awareness arises.
Formal and informal mindfulness practice outside of session can help clients cultivate present-­
moment awareness in everyday life. For clients who are receptive to developing a formal mindfulness
practice, a large evidence base suggests that mindfulness meditation can help alleviate a wide variety
of client difficulties and conditions (Hofmann, Sawyer, Witt, & Oh, 2010; Keng, Smoski, & Robins,
2011). Many excellent resources are available to guide and support clients in their practice: smartphone
apps, websites, online courses, CDs and other audio recordings, mindfulness centers, and more.
However, it’s important to preview such resources before recommending them to ensure that they’re
ACT consistent. Sometimes mindfulness exercises are framed in terms of getting rid of difficult
thoughts or attaining happiness as a feeling, rather than simply observing and accepting one’s experience. Informal exercises can also be helpful, such as focusing on the breath, walking meditation, mindfully doing a daily activity, movement-­based approaches like yoga or tai chi, journaling reactions to
daily events, or paying particular attention to feelings, sensations, and thoughts.
Clients may benefit from starting with basic awareness exercises and meditation and progressing to
more exposure-­like exercises in which they are asked to invite and be aware of distressing content (e.g.,
anxious thoughts). However, there are a few considerations around working with mindful awareness in
session and recommending that clients practice it more formally. For instance, when working with
individuals with a history of trauma, you may want to consider eyes-­open practices, as they may get
140 Learning ACT, 2d edition
caught up in trauma imagery when they close their eyes. Use your best judgment about this or talk with
the client about the process. Finally, it is recommended that any therapist using mindfulness meditation extensively with a client also engage in some form of ongoing mindfulness practice of their own.
Understanding mindfulness from the inside out is part of doing this kind of work with fidelity, competence, and understanding. (We provide a list of resources for developing a mindfulness meditation
practice at the end of this chapter.)
Perhaps the most widely cited definition of mindfulness is “paying attention in a particular way: on
purpose, in the present moment, and nonjudgmentally” (Kabat-­Zinn, 1994, p. 4). Based on this definition, it can be argued that mindfulness includes not only present-­moment awareness but also defusion
and acceptance. In mindfulness meditation, practitioners don’t just return to the present moment; they
also make room for experiences as they come and go (i.e., acceptance) and notice rumination, worry,
images, judgments, and evaluations as they arise, without entanglement (i.e., defusion). Practitioners
also experience that mindfulness practice involves consciously assuming an observing stance (i.e. selfas-context). Therefore, mindfulness meditation incorporates all four of the flexibility processes on the
left side of the hexagon model (acceptance, defusion, self-­as-­context, and present-­moment awareness).
And indeed, as you learned in chapter 1, in ACT these four processes are sometimes referred to as the
mindfulness and acceptance processes.
All of that said, one of the benefits of ACT is that it provides a variety of methods to build mindfulness, beyond formal and informal mindfulness practice. This can be an advantage when working with
people who aren’t willing or able to engage in formal mindfulness meditation practice. So although
formal meditation is one way to develop the fluid, flexible, and voluntary attention involved in present-­
moment work, ACT offers other alternatives for developing this capacity.
Discovering the Moment in Session
The point of mindfulness exercises is not just to develop mindfulness during the exercises themselves, but also to develop attention that’s flexible, fluid, and voluntary more generally. As such, ACT
therapists work to weave mindfulness into the fabric of sessions in an ongoing manner. One common
way to bring more present-­moment focus into sessions is to begin sessions with a brief mindfulness
exercise. (For an excellent example, see Eifert & Forsyth, 2005, pp. 125–­126. Or visit http://www
.newharbinger.com/39492 for a downloadable audio recording of an exercise you’re welcome to use.)
Starting sessions in this way is particularly appropriate for those (clients and therapists alike) who are
more entangled with their minds and can help both therapists and clients become present, allowing
them to psychologically show up to the session ready to work. We recommend doing mindfulness exercises along with the client if possible. This generally leads to more fluid and better-­timed exercises,
helps the therapist be mindful and present, and promotes equality in the therapeutic relationship.
Contact with the present moment is also an essential skill for fostering acceptance, defusion, and
values in session. Experiential work with all of these processes requires that clients bring their experiences into the room in order to work with them. One way to do this is to have clients pause and check
in with their here-­and-­now experience during moments when it appears that something is showing up
that the client is avoiding or fused with, either consciously or unconsciously.
Cues that indicate it may be helpful to have a client pause and attend to what’s showing up include
shifts in tone of voice or hoarseness in the client’s voice, sudden changes in the direction of the
Getting in Contact with the Present Moment 141
conversation, apparent physical tension, repetitiveness in thinking or speaking (e.g., worry, obsessiveness, or rumination), signs of a potential rupture in the therapeutic alliance, or, more broadly, anything
that suggests restriction, tension, or inflexibility. When you note such behaviors, you can gently ask
clients to slow down, tune in to the present moment, and notice what they’re feeling, sensing, or thinking. It can be useful during these moments to direct clients’ attention to various aspects of their experience (e.g., emotions, thoughts, bodily sensations, urges to act, memories) and ask them what they
notice within each realm.
Sometimes it can be helpful to have clients slowly and carefully repeat a particularly poignant
phrase to heighten whatever is present and make it easier to identify. Here’s an example of that approach.
Therapist:
You’ve been talking a lot about your difficulties at work, yet you don’t seem too bothered.
The situation must be frustrating. (Therapist empathy can foster client contact with present-­
moment experiences.)
Client:
It is frustrating. It makes me really mad.
Therapist:
It seems as if it might be painful, too. This is the third job you’ve had this year, and it’s
unfolding just like the last two.
Client:
(Turns red.) They’re just so stupid. I mean, I’m doing what they tell me to do. If they would
just leave me alone and let me do my job, things would be better. (Appears to be caught up
in fusion.)
Therapist:
It seems you wish for that quite a bit—­to be left alone—­and yet it never seems to happen.
(Draws attention to the workability of spending time caught up in fusion with thinking.)
Client:
(Pauses.) Oh, yeah, I just remembered. I wanted to let you know I went to see the psychiatrist. She thinks I should get some more testing done.
Therapist:
Did you see what just happened? We started to talk about pain, and you changed the topic.
(Highlights the abrupt shift of topic.)
Client:
Yeah, I see… But I don’t want to cry. I look silly when I cry. I feel stupid.
Therapist:
(Pauses to slow down the process.) I wonder if you could notice those thoughts…silly,
stupid…and let yourself show up to what’s happening with your feelings right now. (The
client gets tearful.) All I want you to do is just notice this experience as it’s unfolding right
now. (Pauses.) Notice what’s happening. What are you feeling in your body? Take a slow
moment to look. Look and see exactly where you feel it.
Client:
(Pauses for quite a while.) I feel a welling up behind my eyes.
Therapist:
And what kind of judgments and evaluations show up? Before you answer, pause and take
a careful, calm look.
Client:
(Pauses.) My mind is saying that that it’s stupid to cry about this. (The way the client is
talking about her judgments and labeling them as “my mind” suggests that some defusion is
occurring.)
142 Learning ACT, 2d edition
Therapist:
Good. And does this experience remind you of any situations from the past? (The therapist
is drawing attention to different areas of experience to help the client build her ability to notice
what arises in each area.)
Client:
Hmm… Yeah. It reminds me of when my dad would yell at me if I didn’t do my chores.
Therapist:
And when you have all of that, what do you notice yourself wanting to do?
Client:
I’m feeling like I want to run out of the room or…disappear or something.
Therapists can use a number of other approaches to work with clients to help them discover the
moment in therapy: asking them to simply be aware of thoughts, feelings, and memories as they arise;
asking them to identify when being present is needed; directing them to pay attention to the shift
between being present and getting pulled into the future or the past; or doing an experiential exercise
in which they notice the sights, sounds, and sensations that are present in the room. (For a more complete list, see Strosahl et al., 2004, p. 44.) If clients aren’t very skilled at noticing what’s present, it’s a
good idea to start with simple, structured exercises focused on bodily sensations. For example, you can
ask clients to describe out loud what sitting in the chair feels like or how it feels to hold their breath,
extend an arm, or rub their face with a cloth.
Relating in the Moment Within the Therapy Relationship
Because many clients’ problems are, at least in part, due to difficulties in their relationships with
others, it’s particularly important to develop their abilities to be present, open, and nonjudgmental
when relating to others. Humans tend to be caught up in a near-­constant process of evaluation, classification, and comparison that’s applied to everything: objects, other people, ourselves, and more. As
a result, we tend to interact with the people around us in terms of our ideas about them, which places
a barrier between ourselves and our direct experience of others. Many of our reactions to others are
dominated by the stories we tell ourselves about them. In essence, we are responding to them as conceptualized others, rather than to our direct experience of them or connecting to an awareness that
they too have ongoing present-­moment experiences. Metaphorically, it can be as if we’re interacting
with a cartoon of the person, rather than the living being in front of us, who has a rich and complex
history.
In the therapy room, the client’s most immediate relationship is with the therapist. Present-­moment
work focused on this relationship has the potential to be a powerful context for increasing clients’
ability to stay present, be more aware of the ongoing experiences of those around them (see chapter 9),
and be more responsive to others in a manner that fits with clients’ values. To that end, you can guide
clients to notice and be aware of their internal experiences, moment by moment, in relating to you.
This is particularly important when clients are engaging in interpersonal behaviors that parallel problematic interactions that occur in their daily life. This kind of work provides an important opportunity
for clients to learn and practice newer, more flexible ways of relating to others.
One approach is to ask, “Are you willing to notice what’s happening right now, within you and
between us?” Focusing on relating in the moment gives clients the opportunity to experience connectedness and presence. Furthermore, learning to notice their present-­moment reactions when relating to
Getting in Contact with the Present Moment 143
others helps them show up in relationships and can also be a meaningful values-­based action. In the
dialogue that follows, the therapist takes this kind of approach, helping the client notice his present-­
moment reactions to the therapist that parallel difficult reactions he has to his wife.
Client:
It’s lurking in the background all the time. It’s like I’m tiptoeing.
Therapist:
You’re feeling defensive?
Client:
Yeah. My wife just seems to criticize everything I do. I can never get it right.
Therapist:
(Pauses.) Do you feel like that in here sometimes?
Client:
Like I’m tiptoeing around you?
Therapist:
Yes.
Client:
(Pauses and moves in his chair as if uncomfortable.) I don’t know.
Therapist:
And what are you feeling right here, right now?
Client:
Should I feel something?
Therapist:
Just look. Take your time.
Client:
To be honest, I’m feeling defensive. I don’t know why. I know you aren’t doing anything…
But I feel like I’m being criticized.
Therapist:
Where do you feel that? Let’s start with your body.
Client:
(Remains silent for a bit.) I feel tense in my stomach…almost as if I’m tensing to be hit there.
Therapist:
Good. Okay, any other sensations?
Experiential Exercise:
Free Choice Meditation
This exercise takes about ten minutes. Sit in a quiet place where you won’t be distracted or interrupted.
Make yourself comfortable, sitting straight but not rigid.
When you’ve found a comfortable position, gently close your eyes. Notice that your ears tend to
open and become more alert when you do this. Be aware of sounds for a few moments. Then gently turn
your attention to your breathing. Spend a few moments just paying attention to your breath. You can
be aware of your breath at the tip of your nose and nostrils or in the rise and fall of your chest.
If you find that your mind begins to wander, as minds tend to do, gently say to yourself, “Wandering,”
and then, without judgment, refocus your attention on your breath. After following your breathing for
one to two minutes, gently release your attention from breathing and begin to attend to whatever arises
144 Learning ACT, 2d edition
in your awareness next. This may be a sound or a sensation. It may be a thought or a feeling. Your job
is to simply notice it, whatever it may be, and then let it go, moving on to the experience of the next
moment. For instance, you may notice the sound of the air-­conditioning, then pain in your foot, then
your breath, then a twitch, then a thought. Don’t let any of these experiences capture you; just notice
each one and let it go. Next a sensation, then a sound, then a taste, and so on. Simply observe whatever
comes into your awareness from moment to moment without clinging to any experience. Gently observe
each and notice how they come and go.
After about six minutes, return your attention to your breath and, as before, follow your breathing
for about two minutes. Then gently open your eyes, completing your meditation. Remember, your mind
will hook you over and over again, taking your focus away from your direct experience in the moment.
When this happens, bring yourself back to simply noticing. If it happens a hundred times, bring yourself
back a hundred times. This is part of the process.
Using Present-­Moment Awareness to Build
Self-­as-­Context
Contact with the present moment is intimately connected with the development of self-­as-­context (see
chapter 5). Being aware of the content of one’s experience in an ongoing way undermines attachment
to a static, conceptualized self and requires a more fluid sense of consciousness. For this reason, contact
with the present moment can be fostered by encouraging clients to adopt a conscious sense of self-­
observation. So when conducting mindfulness exercises, include instructions such as “And as you
notice that, also notice that there’s a part of you noticing all these things” or “Just for a moment, I’d
like you to connect with the sense that you are here now, noticing what you feel in your body and what
emotions you’re having.”
For some clients, doing mindfulness exercises is challenging because they have a difficult time
locating a sense of self as observer. In such cases, you may want to work on a sense of perspective in
smaller and more immediate ways while working with present-­moment processes. For instance, at
appropriate times you can ask clients, “As you’re speaking, who is saying these words?” or “As I speak
to you, can you tell that someone is there listening, and in a moment is going to have the experience of
speaking as you answer this question?” or “As you observe this emotion, can you notice that there is a
part of you that is observing it? You are not the same as the emotion.” This kind of questioning can help
clients begin to connect with self-­as-­context, or the observer self—­the self that is encountering experiences in each new moment.
In addition, the therapist can model both processes: contact with the present moment and self-­as-­
context. For example, you can say, “And even as you say that, I notice my heart rate picking up a bit
and my thoughts becoming more evaluative. That gives me a sense that if I were in your shoes looking
out at this set of difficulties, I’d be feeling more anxious and be inclined to be judgmental.” The latter
part of that statement is deictic and thus fosters a sense of self-­as-­context, something we’ll discuss
further in chapter 5.
145
Getting in Contact with the Present Moment Using Contact with the Present Moment to
Foster Experiential Learning
As discussed previously, ACT is an approach to therapy that emphasizes learning through experience.
In experiential learning, discussions of how to do things, such as those found in skills instruction or
psychoeducation, are deemphasized because they depend on literal language; instead, the emphasis is
on contact with experiences and the consequences of behaviors. In the context of ACT, experiential
learning is more focused on asking clients good questions than on clients giving the “right” answers.
The focus also tends to be on specific experiences and situations, rather than generalities. Experiential
learning usually occurs from a present-­moment perspective; therefore, the therapist must be able to
readily shift into a here-­and-­now perspective to successfully do experiential work with clients.
Although ACT therapists often engage in didactics or psychoeducation to lay some groundwork,
experiential learning should play a major role in most sessions. Experiential learning involves at least
four steps: orienting or moving toward experiential work; actually engaging in experiential work;
debriefing experiential work; and determining how to generalize experiential learning to the client’s
life. It can sometimes be difficult for therapists to maintain a consistent focus on experiential learning,
as it generally goes against the grain of the more direct and instructional approach that’s typical when
teaching or interacting with others. Therefore, we’ll provide some guidelines to help you use the flexibility processes to lead you toward increased time spent in experiential learning activities.
The table below outlines two discriminations that can guide therapists in including more experiential work in session. The vertical dimension of the rows discriminates whether the content of the
therapy conversation is focused on events that occur in session versus events outside of session. The
horizontal dimension of the columns discriminates the perspective from which events are reported:
from the here-­and-­now perspective (self-­as-­process) versus a there-­and-­then perspective or speaking in
terms of generalities (e.g., clients’ descriptions of their qualities or intellectual conversations about
themselves, the future, the world, or the past). The latter would include statements like “Yesterday I
went to the store and had a panic attack,” “I have no future,” “I hate myself,” or “In the last session, we
talked about how numb I am.” This creates four quadrants into which clients’ in-­session behavior can
be divided. Here’s a basic diagram representing this model. Shortly, we’ll provide an expanded version
that includes pointers on how to move into each quadrant.
Perspective
Talking about the there and
then or generalities
Noticing the here and now
(mostly present tense)
Content
(future or past tense,
generalizations)
Out of session
Quadrant 1
Quadrant 2
In session
Quadrant 3
Quadrant 4
146 Learning ACT, 2d edition
Clients tend to gravitate toward quadrant 1, and sessions often start here, as clients talk about
events from their life, usually in general terms (e.g., reason giving, explaining, or figuring things out).
This is also often the quadrant where fusion occurs. In general, this is the least experiential mode. In
order to move toward more experiential work when in this quadrant, it can be helpful to elicit specific
examples from the client or to focus on specific events, steering away from generalities and concepts.
This might include helping clients track what happened during specific events by conducting a functional analysis so they can become more aware of the antecedents for their behavior, how they respond,
and the consequences of their behavior. This is particularly effective if you can help them notice antecedents they hadn’t recognized or track consequences they hadn’t been aware of (e.g., the effects of
their behavior on values-­based living in the long term). Most people are socialized to speak largely in
terms of there and then, so therapy conversations tend to drift back to this quadrant unless the therapist persists in moving the conversation to the other quadrants. To be clear, there’s nothing wrong with
spending time in this quadrant. It can be helpful to do so when attempting to generalize new learning,
such as planning how to implement a new behavior outside of session or discussing how in-­session
behavior relates to out-­of-­session behavior. Of course, this quadrant is also where more didactic forms
of learning or skills instruction occur.
Moving from quadrant 1 to quadrant 2 requires a shift from talking about events that are not
present to taking the perspective of being in the there and then. This can be accomplished in many
ways: through experiential exercises in which clients imagine being back in the events they’re reporting
on; by asking clients to visit a childhood version of themselves struggling with a difficult event from
their past or having them revisit a troubling memory from the perspective of their adult self; or via
imaginal exposure in which they revisit a troubling event and practice making room for difficult emotions and defusing from thoughts that arise as they put themselves in that event. This could also
involve visiting a scene in a conceptualized future, such as conducting a role-­play involving talking to
a supervisor while engaging in values-­based action or imagining themselves encountering an obstacle
while attempting a new behavior. Once clients are in the there-­and-­then perspective, any of the other
flexibility processes can be integrated. For example, you can help clients make room for difficult emotions (i.e., acceptance) or guide them in reflecting on what they wish they had chosen in the situation
and imagining what would have happened if they had done so (i.e., values).
Moving from quadrant 1 to quadrant 3 involves a shift from an out-­of-­session or general focus to a
specific, in-­session focus. This typically includes identifying times when problematic behavioral repertoires show up in session, along with the contingencies surrounding these events (which in-­session
events trigger the response, and the consequences of the response in session). For example, if a client
typically engages in behavior that involves fusion with self-­critical thoughts, you might ask, “Does your
mind ever get critical with you in our sessions?” Or if a client avoids anxiety related to social situations
outside of session, you might ask, “Do you ever get anxious in here in the same way you do in social situations?” The ensuing discussions can be useful because they help build a therapeutic agreement to
identify fusion and avoidance when they show up in session; then therapist and client can work with
that behavior directly by moving into quadrant 4.
Getting in Contact with the Present Moment 147
Quadrant 4 typically involves working with problematic behaviors (e.g., fusion or avoidance) or
supporting improvements in flexibility as they occur in session to help clients build new repertoires of
behavior. For example, a therapist might shift the focus to quadrant 4 if the client engages in clinically
relevant avoidance or fusion while reporting on out-­of-­session behavior. One way of moving into quadrant 4 is to help clients engage in present-­moment awareness and acceptance when they experience
painful (and typically avoided) emotions when talking about something that occurred out of session.
Alternatively, the therapist might purposefully evoke fusion in order to give the client a chance to
defuse (e.g., saying a statement that’s evocative, such as expressing warmth toward a client who’s self-­
critical). The therapist can also keep the session more grounded in quadrant 4 by noticing and pointing
out opportunities for valued action as they arise in the context of the therapeutic relationship, for
example, opportunities to act in keeping with how the client wants to behave with the therapist. Other
approaches involve noticing various forms of self-­as-­content as they arise in session and shifting perspective to self-­as-­context, and conducting experiential exercises, such as mindfulness practices and
defusion techniques. Quadrant 4 is generally the most productive one for experiential work, but it’s also
where clients and therapists are at the greatest risk of shying away. Even so, ideally, you’d spend at least
part of every session in this quadrant.
The concepts embedded in this diagram can be useful for any therapist, but they’ll be especially
helpful if you notice that your sessions tend to be primarily composed of more didactic and instructional approaches, with relatively little time spent in more experiential modes of learning. To help you
put these ideas into practice, we’ve provided an expanded version with notes on what you might say to
clients to move the session into quadrant 2, 3, or 4. (A downloadable version is available at http://www.
newharbinger.com/39492 so you can print it out.) As an example of how to use the chart, you could
review it immediately before sessions to identify ways you could move from quadrant 1 into quadrant 4,
and then commit to practicing one or two of those moves during the session. Alternatively, after a
session you can review the chart and reflect on what percentage of time you spent in each quadrant
during that session. You might also take some notes about how you could move the focus from one
quadrant to another when similar topics or behavioral patterns recur in future sessions with the client.
However you use it, the primary goal is to promote devoting more session time to experiential
learning.
148 Learning ACT, 2d edition
How to Be More Experiential in Session
Perspective
Talking about the there and then
or generalities
Noticing the here and now
(mostly present tense)
(future or past tense, generalizations)
Out of
session
Quadrant 1
Quadrant 2
(nonexperiential quadrant)
• “Imagine you’re really in that
situation. What are you seeing,
feeling, hearing, and so on? What
are you doing?”
Move toward a more experiential
mode by eliciting specific examples
rather than speaking in generalities.
For example, ask the client for a
specific example of the behavior or
situation at hand, and then conduct a
functional analysis.
• “Imagine that you’ve magically
been transported to that situation
and are looking at yourself. What
would you say to the person who
is there and then?”
Content
• “Imagine looking back ten years
from now. What would you say to
the person you are now?”
• “How old does that feel? Picture
yourself as a child, having that
experience, and interact with
that child as your current self.”
In session
Quadrant 3
Quadrant 4
• “How does that play out in here?”
• “What’s showing up for you as we
talk about this?”
• “Have you noticed that
happening here?”
• “Does that ever happen with me
in our sessions? If so, what brings
it up?”
• “Would you be willing to notice
when that shows up here?”
• “Where is it in your body?”
• “Are you okay with doing an
exercise right now?” If the client
says yes, lead a defusion, present-­
moment, acceptance, or
perspective-­taking exercise.
• “What thoughts is your mind
coming up with right now? What
do they look like or sound like?”
• “You be X and I’ll be Y. Show me
what you did.” Then role-­play the
situation.
Getting in Contact with the Present Moment 149
Core Competency Practice
This section is intended to provide practice in using techniques designed to increase clients’ contact
with the present moment. As in previous chapters, for each exercise we present a description of a clinical situation and a bit of dialogue. The dialogue ends after a client statement, at which point you’ll
provide a sample response that reflects the core competency at issue and then an explanation supporting your response. After completing each exercise, turn to the end of the chapter to read the model
responses we provide and compare them to your response. Remember, the model responses are not the
only valid responses.
Core Competency Exercises
Competency 21: The therapist can defuse from client content and direct
attention to the moment.
Exercise 21
The client is a sixty-­seven-­year-­old veteran of the Vietnam War who is seeking therapy to work on
issues related to PTSD. He has been in and out of therapy for about twenty years. He has complaints
about the government and its response following the war and feels his life has been permanently
changed by his experience.
Client:
I have a lot of resentment about the government. I mean, they should have done something. It has been how many years? I still have all this anger.
Therapist:
It seems like the past has taken over your life.
Client:
It has, every day. I mean, every damn day this is with me.
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 21:
150 Learning ACT, 2d edition
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 22: The therapist brings his or her own thoughts or feelings in the
moment into the therapeutic relationship.
Exercise 22
This dialogue continues with where the dialogue for competency 21 left off.
Therapist:
So, one of the things we could do in here is focus on how the government messed up so
many years ago. Do you think that would be helpful?
Client:
Not really.
Therapist:
Is it possible that this focus is problematic, and what we need to do is focus on what you
can do now—­work on finding out what’s available to you in this moment, today?
Client:
It’s just that I’ve been working on this for so long that I’ve forgotten what it’s like to be
normal, to not have a problem. I know I said this, but all I think about is the government
and how they screwed me. They really did a number on me.
Therapist:
It’s hard for me to imagine the level of frustration you must have felt across the years.
Client:
You can’t even begin to know. There’s a strong part of me that wants to get back at them.
This grudge is really strong.
Therapist:
It really does linger, and even in here it has lingered. We’ve spent quite a bit of time talking
about it… It even has a grip in here.
Client:
Yeah… (Sighs.)
Getting in Contact with the Present Moment 151
Write here (or in a notebook) what your response would be, demonstrating competency 22:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 23: The therapist uses exercises to expand the client’s sense of
experience as an ongoing process (e.g., mindfulness exercises or imagery exercises that
support the client in focusing on the ongoing flow of internal experiences).
Exercise 23
This dialogue continues with the same client as in the dialogue for competency 22 but occurs a little
later in the session.
Therapist:
It seems that part of the struggle is related to how much this issue has consumed your life.
Client:
Yeah, I hate it. This is all I think about.
Write here (or in a notebook) what your response would be, demonstrating competency 23:
152 Learning ACT, 2d edition
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 24: The therapist detects when clients are drifting into a past or
future orientation and teaches them how to come back to the present moment.
Exercise 24
This dialogue continues with the same client as in the dialogue for competency 23 but occurs in a later
session.
Therapist:
What could you do today to take one specific action with respect to your value about your
wife? Is there something you could do to let her know you love her?
Client:
She’s been asking me to fix the handle on the closet door for months now. I guess I could
do that.
Therapist:
Great. I can see how that might bring more appreciation into the relationship.
Client:
I don’t know. She asks me to do stuff, and then I wait so long to do it that I’m not even sure
she knows I’ve done it. She doesn’t comment on it, anyway. She just kind of leaves me
alone…except to ask me to do stuff. I think I’ve been a “leave me alone” kind of guy for so
long that she just keeps her distance. Ever since I got out of the service, things have been
different. If the government just would have recognized what a lousy deal it was to be in
Vietnam…
Write here (or in a notebook) what your response would be, demonstrating competency 24:
Getting in Contact with the Present Moment 153
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 25: The therapist conceptualizes client behavior at multiple levels
and emphasizes the present moment when doing so is useful.
A bit of background is warranted, as this competency links present-­moment work to the therapist’s
ongoing case conceptualization (see chapter 8) and functional analysis of the client’s behavior in
session. Sometimes it’s helpful to be focused on the future, such as when discussing homework or generalizing learning to other situations. Sometimes it’s helpful to focus on the past, as in exposure-­like
exercises related to traumatic experiences or hearing about situations from the client’s week that relate
to treatment targets. The basic idea of this competency is that there are several levels at which client
behavior can be conceptualized:
1. Overt content. For example, if a client says he had a panic attack after the previous session,
this can be taken as simply information about what has happened.
2. As an example of social behavior. Reporting a panic attack could be part of a larger pattern
of unhelpful and chronic complaining that interferes with the client’s relationships.
3. In terms of the therapeutic relationship. The client could be indirectly communicating that
he feels therapy isn’t helping.
4. As a functional process. Reporting the panic attack could be functioning as avoidance of
anxiety that just occurred in the room.
Maintaining awareness of these different levels can help you determine whether returning to the
present moment is warranted and how to respond.
Now that we’ve provided that context, here are the details of the case for this exercise: The client is a
thirty-­three-­year-­old woman who says she wants to hurt herself. She feels depressed and anxious and
has come to this session angry at her boyfriend. She’s extremely emotionally avoidant and hasn’t shown
any signs of emotional pain since the beginning of therapy five weeks earlier.
Client:
(Speaks matter-­of-­factly.) On top of all of my other problems, I’m now having problems with
my boyfriend. I hate to say this, but he’s getting under my skin. Don’t get me wrong, I love
him. But, man, I don’t think I can take this anymore.
154 Learning ACT, 2d edition
Exercise 25.1
Write here (or in a notebook) what your response would be if you thought the statement was an
example of the second level of conceptualization, functioning as part of a larger pattern of social behavior, keeping in mind that the focus here is on competency 25.
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 25.2
Write here (or in a notebook) what your response would be if you thought the statement was an
example of the third level of conceptualization, functioning as indirect communication about the therapeutic relationship, keeping in mind that the focus here is on competency 25.
Getting in Contact with the Present Moment 155
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 25.3
Write here (or in a notebook) what your response would be if you thought the statement was an
example of the fourth level of conceptualization, functioning as avoidance in the room, keeping in
mind that the focus here is on competency 25.
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 26: The therapist practices and models getting out of his or her
own mind and coming back to the present moment in session.
Exercise 26
This dialogue continues with the same client as in the dialogue for competency 25.
156 Learning ACT, 2d edition
Client:
Yeah, I can see that, but you don’t know how upset he’s making me. I really think I’m going
to go over the edge if he doesn’t stop. This week alone, he asked me for more than a
hundred dollars. I don’t have that kind of money. He’s draining me dry. I have to pay bills.
I have to get my car paid off. He just doesn’t get it. I think I’m going to snap.
Write here (or in a notebook) what your response would be, demonstrating competency 26:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Core Competency Model Responses
Competency 21
Model Response 21a
Therapist:
The pull is to try to figure this out. But you’ve been doing that for years, and you told me
it did little to move things forward. I want to see if we can connect to a space that might
be more useful in terms of moving forward. Let’s shift from the past for a moment. Tell me:
What are you aware of right now? What do you notice in this moment?
Explanation: It can be easy for therapists to get caught up in clients’ content. Many clients have compelling stories that can lead the therapist down a path that may function to help clients continue to be
avoidant. This is not to say that therapists shouldn’t listen to what their clients have to say. However,
ACT isn’t a therapy in which the therapist provides supportive listening most of the time; it’s a very
active approach. Furthermore, if the client engages with the kind of response modeled here, he will
immediately be pulled out of the past and into the here and now. And if the client can stay with being
aware of what he’s currently feeling, the therapist can point to how the client is not in the past but is
Getting in Contact with the Present Moment 157
here in the moment, feeling his emotions and being aware of whatever is present. Even if the emotion
is anger, the therapist can work with it, exploring how anger is affecting the client’s life and looking at
whether there’s something underneath the anger, such as sadness. These strategies are much more
focused on the present moment than staying with the client’s story.
Model Response 21b
Therapist:
So, one of the things we could do in here is focus on how the government messed up so
many years ago. Do you think that would be helpful?
Client:
Not really.
Therapist:
Is it possible that this focus is problematic, and what we need to do is focus on what you
can do now—­work on finding out what’s available to you in this moment, today?
Explanation: Here, the therapist suggests that the strategy of focusing on the past isn’t going to be
helpful. Although many clients are aware that this is true, helping them show up in the here and now
and do what can be done from this moment forward is a useful step, especially if they’ve been stuck in
the past for a long time.
Competency 22
Model Response 22a
Therapist:
So, I’m feeling this sense of frustration. (Pauses.) I really want you to be able to move
forward, but we keep landing back here. I don’t want you to rescue me. I just want to share
the feeling that’s showing up for me. It feels hopeless. What shows up for you as I say that?
Explanation: This is an honest, in-­the-­moment response to the client being stuck, with the therapist
directly modeling showing up to one’s personal experience and being willing to state that experience,
exactly as she’s asking the client to do. It’s a riskier move, and probably only appropriate after there is a
solid therapeutic alliance, but valuable for modeling willingness to experience the moment while also
pointing to the feelings of hopelessness that arise when we try to undo history.
Model Response 22b
Therapist:
When I mentioned that this story seems to have a grip on us here in the room, I felt a sense
of tightness, like there’s no room for us to explore or work on other things until this issue
is solved… Yet we’ve already explored the impossibility of solving this. Do you feel a sense
of tightness? Can you feel the grip?
Explanation: The therapist is self-­disclosing about her in-­the-­moment experience and touching upon
the workability of spending more time inside this rumination. This focuses the client back into the here
and now and also models the process of showing up to experiences in general and working to explore
present-­moment processes rather than remaining stuck in the past.
158 Learning ACT, 2d edition
Competency 23
Model Response 23a
Therapist:
I wonder if we could work to find the cracks in this idea that this is all you think about. A
while ago, you told me something about your wife and children. So your thoughts, and I
suspect your feelings, change across time. It’s just when you’re stuck in this piece about the
government that it feels like nothing changes… Would you be willing to do an exercise
with me?
Client:
Yes.
The therapist then guides the client through an exercise in which the client draws a line down the
center of a page and writes “Thoughts” at the top of the left column and “Feelings” at the top of the
right column. The therapist then suggests that the client observe his thoughts and feelings moment by
moment and record them in the appropriate column. Alternatively, any other present-­moment awareness exercise can be used here, such as the Observer exercise (Hayes et al., 2012, pp. 233–­237).
Explanation: The therapist is working with the client to help him see that he’s more than his single
experience with the government. Indeed, he’s had countless experiences (thoughts, emotions, sensations, and so on). It’s just that he’s been stuck on this single experience, and his efforts to fix it have
made it increase rather than decrease. Doing an experiential exercise at this point helps the client
directly contact a sense of an ongoing experiencing self (self-­as-­context) that has numerous experiences, not simply one.
Model Response 23b
Therapist:
Would you be willing to explore with me the possibility that you’re larger than this experience… That it isn’t everything?
Client:
Sure.
Therapist:
I invite you to close your eyes. (The client closes his eyes.) Tell me what you become aware
of when you do that. Notice what’s happening in the moment.
Client:
I hear the sound of your voice.
Therapist:
Good. Now focus your attention. Stay in the moment and tell me what you notice with
each moment that passes. I’ll sit quietly for the next minute while you do that.
Client:
I hear a car outside… I feel uncomfortable with my eyes closed… I notice my leg feels stiff
and I want to stretch it. (The client continues to report; if he doesn’t the therapist may need to
be more directive and repeatedly ask, “What do you notice now?”)
Explanation: The therapist is working with the client in the moment to help him discover that he’s an
ongoing, evolving, experiencing being. This helps loosen the grip of his story (“I’m an angry person,
and I hate the government”) so the client can see that he has many more experiences than he believes
he does. Pointing to the ongoing process of moment-­by-­moment experiencing can help clients discover
this larger sense of self.
Getting in Contact with the Present Moment 159
Competency 24
Model Response 24a
Therapist:
(Interrupts the client.) Notice what just happened. We were talking about ways you could
bring your values linked to your relationship with your wife alive today, and you drifted
right back into the past. Did you see it happening? What feelings might show up for you if
we shifted back to working on your values?
Explanation: Here, the therapist has detected the client’s shift back to the past and makes the client
aware of that shift. It’s helpful to work with clients on noticing these shifts. Sometimes they happen so
quickly and naturally that clients are barely aware of them. After the therapist helps the client notice
the shift, she guides him back to the present by noticing the current experience of making another shift
and then refocusing on values work. The therapist also explores any emotions that show up in relation
to refocusing on values, in part to determine whether the shift back to the past functions to avoid the
emotional pain associated with years of not living in a values-­based way. This too can be felt, observed,
and experienced—­while also making the choice to fix the closet door.
Model Response 24b
Therapist:
Do you recognize where you’re going now?
Client:
Yeah.
Therapist:
(Speaks with curiosity.) Is that a place you want to go?
Client:
No.
Therapist:
Where would you like to be now?
Client:
Anywhere but there.
Therapist:
Just prior to this, we were talking about how you might show your love for your wife. Would
you prefer to talk about that?
Explanation: Again, the therapist draws the client back to the here and now and helps him notice
what’s happening, because it would be helpful for the client to learn to catch these shifts into past-­
focused thinking when they occur. The therapist then reorients the client to the values work, a present-­
oriented focus.
Competency 25
Model Response 25.1 (wherein the client’s statement is conceptualized as reflecting a larger pattern of
social behavior)
Therapist:
Right now I’m having the experience of finding myself wanting to tell you to move on and
let go. My mind is really working on me. I wonder if this is what happens to other people
in your life—­they tell you to move on or let go?
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Explanation: The therapist reports honestly on the content of his mind, and does so in a manner that
models defusion by using the convention “I’m having the experience of…” and referring to his mind as
a separate entity. The therapist’s direct report of his experience also models present-­moment awareness
and can help elucidate possible consequences of the client’s behavior on important others in her life. If
they feel similarly, learning about this can help the client become more sensitive to her effects on others
and see how her behavior may be causing difficulties in relationships. After the therapist offers this
model response, he might explore whether what happened in the room is in some ways similar to what
happens with others in the client’s life—­and whether the results she’s getting fit with her values and
how she wants to be in relationships.
Model Response 25.2 (wherein the client’s statement is conceptualized as indirect communication
about the therapeutic relationship)
Therapist:
I’m hearing something in your voice, frustration or maybe anger. And I’ve been thinking
about how much work we do in here and the comments you’ve made about the pressure
you feel at times. I’m wondering if any part of what you’re saying is actually about what’s
happening between you and me? As I refocus us and move away from problem solving, I
wonder if I’m getting under your skin in any way.
Explanation: The therapist is tracking the client’s behavior in several realms: emotional, thoughts, and
relationship dynamics. If he detects distancing or frustration and anger that don’t quite fit the situation,
or if the client has been resisting his input in ways that haven’t been helpful, the therapist might view
the comment as relevant not just to the client’s relationship to her boyfriend, but perhaps also to the
therapeutic relationship. If the client can acknowledge an interpersonal struggle with the therapist, the
work in session can focus on whatever is present (e.g., feelings of pressure, things not happening as
planned, how it feels when the therapist changes the topic). In this case, the focus may turn to exploring ways to open up the process between the therapist and client in the service of modeling and shaping
more effective behavior in the here and now.
Model Response 25.3 (wherein the client’s statement is conceptualized as avoidance)
Therapist:
Yeah, you feel right on the edge, like there’s nowhere else to go… Can I ask you a
question?
Client:
Sure.
Therapist:
What are you noticing in your body right now?
Client:
Nothing.
Therapist:
Take a second. Let yourself slow down and look inside. What’s showing up? If you need to,
you can close your eyes. And as you do this, see if you can let go of any resistance you feel
to letting this stuff show up. See if there might be a sense of something important in sticking with whatever you feel right now. What does your mind say would happen if you were
to simply sit, holding these reactions, without doing anything to make them go away?
Getting in Contact with the Present Moment Client:
It says I can’t do it.
Therapist:
Good. And can you notice that thought as a thought and still stay here, stay present?
161
Explanation: The therapist could engage with what the client has said at the level of content by talking
to her about problems in her relationship. However, the therapist suspects that the client is contacting
some feelings that she isn’t expressing and uses this as an opportunity to help this emotionally distant
client contact a reaction at a different level than the purely cognitive by noting something very
concrete—­her bodily reactions. Then, when the emotion is present, the therapist suggests taking a
stance of acceptance while also being aware of the mind. This is important, as the mind might pull the
client back into a struggle.
Competency 26
Model Response 26a
Therapist:
I can sense the frustration, and I find myself wanting to get involved in problem solving.
But in this moment I feel helpless to fix it. I wonder if your mind telling you that you’re
going to snap is about that same helplessness?
Client:
Yeah. I feel it too.
Therapist:
Let’s take this moment to notice that sense of helplessness, showing up to what it feels like
when it seems there is no answer. (Pauses to allow silence. The client becomes very quiet and
seems about to cry.) And also notice that you don’t snap (said gently).
Explanation: Perhaps the most obvious thing to do in this situation is help the client engage in problem
solving, which could include teaching her to be assertive. However, doing so would miss an opportunity
for the client to experience the feeling of helplessness (i.e., acceptance) and learn experientially that
she won’t snap (i.e., defusion). The therapist is conceptualizing the client’s stuckness as being at least
partially due to avoiding feelings of helplessness and fusion with thoughts that occur when those feelings arise. Bringing the process back to the moment helps the client defuse from the content of her
mind. From this place, the therapist can help her identify and track the costs of being unwilling to feel
helpless, which could potentially include financial losses, distance from her boyfriend, and passive
behavior. Then the focus can turn to what will work for the client, given her values with respect to her
boyfriend. This could include problem solving, but that wouldn’t be the first road taken.
Model Response 26b
Therapist:
I notice my brow furrowing…a tension in my neck…and I have a feeling of helplessness as
I reflect on all the frustration you must be feeling, both with your boyfriend and right now
with me, for not understanding. I wonder if you could take a second and notice what you’re
feeling right now, in this moment. (The therapist then asks the client to notice whatever feelings, sensations, and thoughts are present in the moment, in the therapeutic relationship.)
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Explanation: The therapist begins by modeling his own process of observing personal sensations and
feelings out loud. He also acknowledges the client’s expression of tension in the therapeutic relationship
as reflected by her statement “You don’t know how upset he’s making me.” The therapist then explicitly
focuses the client on her experience in the moment, stepping out of the stream of thoughts the client
is caught up in and moving into a more present-­oriented, relational, and direct mode of experiencing.
For More Information
Many mindfulness exercises created for use in ACT sessions can be found in Eifert &
Forsyth, 2005; Hayes, 2005; Harris, 2009, chapter 9; and Hayes et al., 2012, chapter 7.
You’ll also find a wide range of exercises and metaphors related to present-­moment awareness in Stoddard & Afari, 2014. For an approach to ACT that focuses heavily on present-­
moment processes, see Wilson, 2008. Audio recordings of some ACT exercises can be
found at http://www.contextualscience.org.
For anyone (therapists and clients alike) interested in developing a mindfulness meditation practice to support present-­moment awareness, several books provide an accessible
introduction: Meditation for Dummies (Bodian, 2016), Zen-­Master (Hardy, 2001), Wherever
You Go, There You Are (Kabat-­Zinn, 1994), and A Mindfulness-­Based Stress Reduction
Workbook (Stahl & Goldstein, 2010). Tara Brach, a well-­known meditation teacher and
psychologist, has an online guide at http://www.tarabrach.com/howtomeditate.
Excellent audio recordings of guided imagery, breathing, and body scan mindfulness
exercises narrated by Jon Kabat-­Zinn are available at http://www.mindfulnesscds.com.
There are a number of useful smartphone apps that can serve as reminders and guides
in practicing mindful awareness, but these are constantly changing. At the time of this
writing, Headspace, Insight Timer, Buddhify, ACT Companion, and Stop, Breathe, and
Think are all worth considering. We recommend that you preview apps before recommending them to clients to make sure they don’t contradict the work you’re doing in session and
don’t directly or subtly provide messages advocating internal control or stating that happiness is the ultimate goal or outcome. Most apps include automated reminders for formal
practice as well as help in integrating mindfulness into daily life. Another resource for
updated information on mindfulness resources, including apps, and learning to meditate is
the free e-­book Learning ACT Resource Guide (available for download at http://www.learningact.com).
There are also quite good online courses and resources, but they are too extensive to list
here. But if you wish to support your clients in practicing mindfulness, it’s worth doing an
online search and reviewing some of the resources available.
Finally, many communities have local meditation centers where people can follow a
traditional path to learning to meditate, with support from real people as a part of a community. We encourage you to be familiar with such resources in your area, as belonging to
a supportive community can be one of the best ways to support practice.
CHAPTER 5
Building Flexible Perspective
Taking Through Self-­as-­Context
You can see a lot just by observing.
—­Yogi Berra
Key targets for building flexible perspective taking:
Help clients distinguish a sense of self that is continuous, safe, and consistent, and from
which they can observe and accept the flow of internal experiencing.
Help clients identify this sense of self that is continuous as the context, arena, or
location in which all experience happens, distinguishing it from the content of that
experience (e.g., emotions, thoughts, sensations, memories).
Help clients flexibly take perspective toward themselves, others, and their own
experiences to facilitate the other five flexibility processes, as well as compassion and
empathy.
“Who are you?” This seems like a simple question, yet issues such as “What is the self?” and “Who are
we at our most basic level?” have long been entertained by scientists, philosophers, and theologians, as
well as clients and therapists, as part of an effort to understand our existence and meaning. These
fundamental questions are now being explored by researchers and clinicians in the rapidly growing
realm of theory and research on perspective taking that’s emerging from relational frame theory
(McHugh & Stewart, 2012). This theory holds that there is no concrete entity we can point to that
forms a firm self and that the self, the “I” in “Who am I?” doesn’t exist as a literal entity; rather, the self
is seen as a set of verbal behaviors that are central to how humans develop a consistent perspective from
which to view the world—­a kind of verbal “selfing.” This verbally learned experience is what is
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occurring when people reference a location called “me,” “myself,” or “I.” Recognizing selfing as behavior
is central to assisting clients in contacting the perspective of self as a location where experience occurs.
Working with self-­as-­context and perspective taking in ACT can be challenging, but it’s fundamental to establishing a state where acceptance of experience is possible. Helping clients connect with
a sense of self that’s continuous, safe, and consistent also reduces the tendency to fuse or overidentify
with internal experiences or attach to them in problematic ways. Finally, flexible perspective taking
promotes empathy and compassion (and by extension, self-­
compassion)—­
all vital aspects of
well-­being.
What Is Flexible Perspective Taking?
RFT purports that there are three contextual cues that serve to control perspective taking: interpersonal (I/you), spatial (here/there), and temporal (now/then). These cues, which can be indicated by
words but can occur in other ways, such as through pointing, control how we shift between a psychological sense of our own perspective (I) and that of others (you) and between our psychological location
(here) and another perspective at a different location (there). These cues also allow us to experience
events as occurring in the present moment (now) or at a different time (then). The ability to shift
between these perspectives is learned during the normal course of social development and acquiring
language.
Children are asked a remarkable number of questions about their experiences, and children’s
reports of these experiences are reinforced when they come from a particular perspective (I). In the
simplest form of this process, children might be asked to report from their own present-­moment perspective: I-­here-­now (e.g., with the question “What are you feeling?”). They may also be asked to report
on the experiences of others in the present: you-­here-­now (e.g., with the question “How do you think
Tommy feels when you take his toy away?”). Alternatively, they may be asked to report on the experiences of others at a different time: you-­there-­then (e.g., with the question “Where did your mom go
yesterday?”). They may also be asked about their own past perspective: I-­there-­then (e.g., with the question “What did you eat at your birthday party last week?”); or be asked about their future perspective:
you-­there-­then (e.g., with the question “Where is your dad going this afternoon?”).
Early on, children have difficulty answering questions involving perspective. When asked about
their own experience, they may not report it accurately. When asked about the experiences of others,
they often substitute their own. When asked about the future, they may report what’s happening in the
present. Accurate perspective taking is shaped through practice and extensive interactions with the
social world, and eventually a sense of self and other emerges. Over time, children learn to respond
consistently to perspective-­related questions from a particular point of view. They learn to distinguish
their own sense of perspective (I) from the perspective of others (you), with the three key perspective-­
framing cues (I/you, here/there, now/then), creating a sense of self.
From the ACT perspective, this largely social training process leads to the emergence of three
senses of self: self-­as-­content (or the conceptualized self), self-­as-­process (or the knowing self), and self-­
as-­context (or the observer self). Self-­as-­process, discussed in chapter 4, refers to the ability to report on
one’s own experience from a consistent perspective. This chapter focuses more heavily on the other two
senses of self—­
self-­
as-­
content and self-­
as-­
context—­
along with flexible perspective taking more
generally.
Building Flexible Perspective Taking Through Self-as-Context 165
Self-­as-­Content: The Conceptualized Self
Through an ongoing awareness of our experiences, preferences, thinking, and other psychological
events, we begin to abstract a sense of a self that appears to have qualities (fair, smart, fun, etc.), just
like an object has qualities (color, texture, size, etc.). We develop a conceptualized self—­a concept of
ourselves. This sense of self is self-­as-­content. This sense develops as we make statements like “I
am ,” declaring beliefs about who we are and descriptions of our being. For instance, you
might say, “I’m a professional,” “I am someone who suffers,” “I’m a victim,” or “I am intelligent [or
dumb].” Associated with this content are all kinds of images, thoughts, and behaviors that seem to
indicate these senses of self are true. Altogether, this mental content makes up our identity. There’s
nothing inherently problematic with building, categorizing, and discovering identities; indeed, this is
part of languaging itself in our social world. Self-­as-­content is multilayered and contextually emergent
and can serve several functions. Operating at the level of the conceptualized self even creates a healthy
kind of inflexibility that supports consistency over time and is often associated with workable behavior.
For instance, a person’s professional identity, and all of the verbal information that comes along with it,
may be helpful in getting him to build his career and go to his job even on days when he doesn’t feel
like it. For example, he might tell himself, “I’m a good worker,” “I don’t want to disappoint my boss,” “I
need the money,” or “My success depends on this,” and then proceed to engage in behavior that’s consistent with his professionalism. In this way, our conceptualized self allows us to evaluate, assess, and
control situations and engage in problem solving—­typically healthy behaviors under a large set of
circumstances.
From the perspective of the social community, fusion with the conceptualized self is useful because
it allows others to better predict and understand our behavior and engage with us in ways that influence our behavior. Unfortunately, this same fusion that is useful for the social community may be
troublesome for the individual because it can lead to unworkable and destructive behaviors, trapping
people in patterns of living that are problematic. Through the mind’s desire to be consistent, to justify
and explain, and to evaluate and assess, people can end up in a kind of verbal straightjacket that limits
their life. Fusion with the conceptualized self leads to consistency in behavior, sometimes to a fault, and
even when the consistency is with an identity of being inconsistent, as for people who have a story that
they are impulsive or unreliable. And in the same way that people might behave in accordance with
the identity “professional,” they might also behave in accordance with other identities, including
“damaged,” “broken,” or “unacceptable.” The consistency that fusion with the conceptualized self
fosters isn’t inherently good or bad; however, it can greatly impair people’s ability to make needed
changes. If their conceptualized self clashes with what their values suggest is called for in a situation,
they may find themselves constricted. The result can be continued patterns of behavior that, while
consistent with an individual’s self-­stories, result in much suffering.
For example, consider a client who fully embraces a conceptualized self that he defines as being a
proud man. His “proud man” self-­concept includes the idea that he’s a person who deserves respect no
matter what. He feels that his family should listen to him at all times and do so without disagreement
because, as a proud man, he thinks he should never have to admit he was wrong. But in the process of
clinging to this conceptualized self, his relationships with his family suffer. This identity is costing him
intimacy and closeness in relationships, yet he’s so glued to his self-­perception that he becomes angry
and even more prideful, insisting that others need to change and see things his way for the relationships
to work. He engages in this behavior in a persistent and inflexible way instead of working on what he
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most desires: close family relationships. In the end, most of his children hardly speak to him, and his
grandchildren choose not to be around him at all. He traded his family for attachment to a story.
It isn’t uncommon for people’s lives to be ruled by a particular conceptualized self. Consider a child
who was abused and becomes a lifelong victim or “damaged goods,” or a self-­sacrificing mother who has
become “the martyr.” These kinds of self-­made concepts can lead to pain and struggle, especially if
other things the person values are lost as a result.
Lastly, the verbal knowledge that gives rise to the conceptualized self is greatly limited; these
stories play only a small role in the vast experience of an individual’s being. None of us can truly know
all the personal history and contexts that have affected our behavior and continue to do so. Rather, we
have an imperfect understanding of our lives, leaving us with stories, justifications, and descriptions
that, despite referencing many facts and providing descriptions of patterns of behavior, can greatly
restrict our ability to flexibly respond to situations or change as needed.
Self-­as-­Context: Observer Self, Transcendent Self
The same social training process that leads to a sense of self-­as-­content also typically leads to
another sense of self: a self that is continuous and stable, yet hard to define. When children are asked
questions such as “What did you see?” “Are you worried?” and “What would you like to eat?” they learn
to provide responses such as “I saw a doggie,” “I feel scared,” and “I want a cookie.” The content of the
answers continuously varies (e.g., “I see,” “I feel,” “I want”), but the word “I” taps into a constant: the
conscious place from which events are known. This is self-­as-­context, a perspective from which one
perceives, speaks, acts, and lives. In RFT terms, I-­here-­now becomes the context, space, or container
for the content of experience. This sense of self has been referred to in a number of ways in clinical
work and the ACT literature—­self-­as-­context, the observer self, the transcendent self, or pure awareness. The term used is not particularly important. Each points to a helpful relational repertoire and the
resulting experience that ACT therapists strive to evoke in clients.
The sense of self-­as-­context is transcendent and inherently social. It’s transcendent because the
limits of pure awareness cannot be consciously noted. Everywhere you go, there you are, and it isn’t
possible to be conscious of unconsciousness. Said in another way, this experience isn’t thing-­like, and
from the inside, it doesn’t seem to have spatiotemporal limits. Thus, it provides a naturalistic basis for
experiences of transcendence or spirituality (Hayes, 1984). And this sense of self is social because it
isn’t possible to have relational frames that aren’t bidirectional. In order to understand “here,” you must
understand “there.” In order to understand “now,” you must understand “then.” And to contact a sense
of “I,” you must be able to contact a sense of “you.” To be aware that you see through your eyes, you
have to be aware that others see through theirs. This is why empathy and a transcendent sense of self
are so closely linked. The same relational framing processes that give rise to this sense of self give rise
to a sense of what others’ experience must be like.
This sense of self-­as-­context begins to emerge in the preschool years (McHugh & Stewart, 2012)
and soon becomes part of everything we consciously experience. For instance, if you were asked what
you ate for dinner last night, where you went on vacation last year, and what high school you attended,
you would be able to answer each question by seeing through the eyes of the one who ate the dinner,
the one who went on vacation, and the one who attended a certain high school. You would be able to
view each of these events from a stable sense of self that stretches across each event and remains
167
Building Flexible Perspective Taking Through Self-as-Context present across time. However, in a profound sense, self-­as-­context is not a thing (or perhaps we should
say it is “nothing” or it is “everything”) because this locus, or arena, in which all the content of experience unfolds is hard to define and has no edges. In addition, it is not a concept or belief; it’s a perspective from which you observe the content of your life, including thoughts, feelings, memories, and
sensations. The observer self is a larger, timeless, interconnected context that holds all of a person’s
experiences and yet is not any one of them.
Self and Other
As just mentioned, in order for there be an “I,” there must be a “you.” Therefore, each type of psychological self implies a corresponding type of psychological other. Other-­as-­content involves describing and evaluating others in the same way one might describe and evaluate an object. Other-­as-­process
refers to an ongoing awareness of others’ experience and associated descriptions of their thinking,
feeling, behaving, and sensing. And other-­as-­context refers to having an awareness of others as conscious beings, along with the ability to flexibly shift perspective to include others’ perspectives in one’s
social context.
I
You
Self-­as-­content
Other-­as-­content
Self-­as-­process
Other-­as-­process
Self-­as-­context
Other-­as-­context
This ability to both have a sense of self and also take the perspective of others allows for the
complex empathic abilities we have as humans. Empathy is basically the ability to imagine the experiences of others, which allows human beings to connect, joining with each other in shared understanding and concern. Cooperation, caregiving, and other such social repertoires are highly linked to this
ability. If a person can imagine the experience of others, including pain and need, then that person can
offer supportive care or cooperation.
We can also construct verbal others in ways that are unhelpful. For example, we can relate to
others in terms of other-­as-­content, responding to them as objects rather than conscious beings, which
leads to prejudice, dehumanization, and objectification. And other-­as-­process can be inaccurate if we
imagine that others are experiencing things they aren’t. For example, people with an extensive history
of mistreatment may frequently see others as neglectful, hurtful, or malevolent and have difficulty
tracking how people are actually responding to them in the context of relationships. Fusion with these
kinds of inaccurate stories about others’ experience can result in confusing and problematic interpersonal behavior. Clients can become so caught up in their stories, evaluations, and judgments of themselves and others that they are unable to respond flexibly. This makes it difficult to have empathy and
compassion for themselves and others, as empathy and compassion require the capacity to experience
pain as tolerable and ephemeral, along with the ability to step back from limiting stories of self or other.
Reconnecting with or building flexible perspectives can reverse this process. Clients can learn to
develop more frequent contact with others as aware beings (other-­as-­context), to notice and resist the
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tendency to objectify others and get stuck in stories about them (other-­as-­content), and to develop a
more accurate sense of the feelings, thoughts, behavior, and sensory experiences of others in the
moment (other-­as-­process).
Why Build Flexible Perspective Taking and a
Transcendent Sense of Self?
Ultimately, the purpose of perspective-­taking work is to free clients to flexibly respond and adapt to
different contexts and experiences. The ability to flexibly take multiple and varied perspectives on
themselves and their experience liberates people to act on their values. Building flexible perspective taking involves three key clinical activities: using hierarchical framing to create a sense of self-­­
as-context; contacting the transcendent self and distinguishing it from self-­as-­content; and using
perspective taking to develop a flexible view of self and other. Helping clients make the distinction
between the experiencer and what is experienced empowers them to observe the ongoing flow of their
experience while also making choices linked to behaving consistently with their values. Flexible perspective taking can also benefit relationships as clients become more conscious of others as aware beings,
get less caught up in their stories about others, and develop more accurate empathy and compassion.
Self-­as-­context can also help clients find a secure and safe place from which to contact and confront feared emotions, memories, thoughts, and sensations, which often seem to threaten a person’s
sense of self. Becoming familiar with the ongoing, ever-­changing nature of their experience will help
clients understand that these experiences won’t devastate them; rather, another moment will pass and
another experience will come along. When clients are fully present in directly experiencing the
moment, they gain the opportunity to learn that thoughts and emotions aren’t destructive. Making
contact with the transcendent self can help them see that there is a place—­in fact, that they are a
place—­that is unchanging and stable and therefore isn’t threatened by passing internal experiences.
Note that flexible perspective taking is inherent in each of the other flexibility processes and therefore is necessary to implement them. Here are some examples:
•
Present-­moment awareness involves returning to a here-­and-­now perspective when a person is
rigidly caught up in a constructed future or past.
•
The development of a consistent and stable place from which to observe experience can facilitate acceptance, thereby decreasing suffering as the person contacts a sense of expansive
awareness.
•
Contact with a transcendent self that is distinct from content facilitates defusion by, for
example, promoting equanimity in the face of self-­evaluations.
•
Flexible perspective taking and conscious awareness facilitate a sense of choice and freedom
that is essential for values-­based living.
•
Loosened attachment to the conceptualized self facilitates behavior change, which is often
necessary for people to engage in committed action. Additionally, flexible perspective taking
Building Flexible Perspective Taking Through Self-as-Context 169
and self-­compassion support willingness to make the inevitable mistakes and experience the
associated thoughts and feelings that are part of learning new behavior.
Flexible use of perspective taking is also central to making the learning that happens in session more
experiential, rather than didactic or instructional (see chapter 4 for more on experiential learning).
What Should Trigger Working with This Process?
In ACT, therapists work with clients in an ongoing way to explore the problem of being overly attached
to the conceptualized self and to develop other perspectives that may promote greater flexibility.
However, sometimes increasing the focus on these issues is warranted in response to certain patterns of
client behavior. One example is when clients’ attachment to and defense of a particular conceptualized
self interferes with their ability to make needed changes in their life. For instance, a client might defend
the stance that she’s “a victim,” indicating fusion with this conceptualized self. As a result, she may
mistrust others and refuse to engage in intimate relationships—­even if intimacy in relationships is one
of her values. In such cases, the therapist’s job is to help clients make contact with self-­as-­context,
embracing a larger and more encompassing sense of self that’s separate from the content of the mind.
So in this example, the therapist would support the client in making contact with a sense of self that’s
separate from her conceptualized victim self. The goal is to increase flexibility and support the client
in engaging in new behavior related to her values, rather than remaining stuck in behavioral patterns
related to her victimhood.
A second indicator that it would be helpful to focus on perspective taking is when clients’ behaviors
suggest a sense of detachment from others or lack of empathy and compassion. This can take the form
of externalizing behavior wherein the client rigidly blames others or is harshly or rigidly judgmental.
Other examples include stigmatizing or prejudiced behavior or objectification. Each of these difficulties
connotes inflexible perspective taking, particularly fusion with a conceptualized other (e.g., “He’s
stupid”) or inaccurate assessments of other-­as-­process (e.g., thinking, “She’s angry at me” when the
person is actually sad); in either case, the dynamic is probably fed by avoidance (e.g., staying away from
others). Similarly, clients who have an unstable sense of self or who tend to confuse their own experiences with those of others can benefit from a greater focus on flexible perspective taking, and particularly on developing a more stable sense of self-­as-­process and self-­as-­context.
This extends to dissociation, wherein the sense of self is so disrupted that “no one is home.” Clients
who suffer from an unstable sense of self and dissociation may have a hard time with exercises related
to creating self-­as-­context and may get lost in thought or rigidly stuck in one perspective. Because dissociation involves a disruption in the continuity of the self, these clients have a greater need for work
on both present-­moment awareness and flexible perspective taking. Such clients may benefit from an
emphasis on present-­moment work that assists them in staying connected to the here and now while
also being able to report on what is happening.
When focusing on this process with clients who are particularly prone to self-­loathing, a sense of
inadequacy, self-­doubt, or strong self-­criticism (all indicators of pervasive fusion), it may be advisable to
emphasize self-­compassion. And given that many of these clients also struggle with intimacy and the
ability to be empathic and emotionally connected with others, perspective taking centered around
empathy and compassion can also be helpful.
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In addition, we recommend that you attend to your own experience and look for signs that suggest it
would be useful to implement this flexibility process. These signs may include a sense of disconnection
from the client, lack of empathy, boredom, arguing with the client, or feeling a pull to protect the client’s
self-­image. All of these therapist responses suggest the need for perspective-­taking work in session.
What Is the Method?
In the sections that follow, we describe the ways in which perspective-­taking frames (I/you, here/there,
now/then) can be combined with other relational frames to develop a more flexible sense of self. In
particular, we focus on using hierarchical framing to help clients connect to a transcendent, continuous, and socially interconnected sense of self that is involved in noticing or observing the moment-­by-­
moment flow of thoughts and emotions as ongoing experience. We also discuss how to use relational
frames that involve shifting perspective in person, space, or time to help people develop a flexible sense
of self that’s less tied to rigid conceptualizations of self or others.
Using Hierarchical Framing to Create a Sense of
Self-­as-­Context
In addition to working with perspective-­taking frames, you can use interventions that involve hierarchical framing to develop perspective taking. Hierarchical framing occurs when we refer to one thing
as part of something else (A is an attribute of or a member of B). This includes talking about one thing
containing something else, being the context for something else, or being part of something else.
Hierarchical frames are involved in categorizing specific experiences as part of an emotional state. For
example, if you ask a client, “What are you feeling?” and the client notes a feeling of tension in his chest
and images of feared future events, he may label these events collectively as “anxiety,” with feelings of
tension and images of feared events being seen as part of anxiety or categorized as anxiety. Hierarchical
frames are also used when people refer to aspects of their experience, such as feelings, thoughts, and
sensations, as part of their self. Hierarchical framing is central to helping clients contact a sense of
themselves as the container for their experience—­in other words, self-­as-­context.
Hierarchical framing is also useful for developing self-­as-­process. Let’s look at a few examples that
illuminate how hierarchical framing is involved in the shift from self-­as-­content to self-­as-­process.
Consider the statement “I am broken.” This reflects self-­as-­content. Simply restating this as “I evaluate
myself as broken” shifts the perspective by noting “broken” as a type of evaluation. Similarly, the statement “I’m anxious” comes from the perspective of self-­as-­content. By rephrasing this as “I feel my heart
beating fast and I have the urge to run away from this situation,” anxiety is noted in terms of the parts
that make it up, rather being an abstract, indivisible category. This also applies to perspectives on
others, as in the statement “You’re obnoxious,” a clear communication of other-­as-­content. By rephrasing this as “I’m having the thought that you’re obnoxious,” the person is able to note that “You’re
obnoxious” is a type of thought.
Hierarchical relations are an important part of many metaphors and exercises used to establish a
sense of self-­as-­context, a container for all of one’s experiences. Hierarchical relations occur whenever
Building Flexible Perspective Taking Through Self-as-Context 171
people view their thoughts, feelings, sensations, or other internal experiences as part of a self that is
having those experiences.
METAPHORS THAT USE HIERARCHICAL FRAMING
A metaphor that uses hierarchical framing to contact this sense of self that is more expansive than
any given experience is the Sky and the Weather metaphor (Harris, 2009, p. 175). In this metaphor, the
sky is likened to the person’s larger sense of self, which contains all of the shifting weather, and the
weather is likened to the shifting content of experience: thoughts, feelings, sensations, and so on. This
metaphor can be worked into various other exercises and used at any point where it might be helpful
to have clients contact a sense of self that’s distinct from and larger than their experience. Here’s an
example of how it might be employed at the start of an exercise. Note that the pacing, which isn’t indicated in this script, should allow time for clients to experience the metaphor. Also, begin by devoting
a few minutes to helping clients get centered, perhaps by following the breath.
Therapist:
I’d like you to imagine that you’re lying on your back on a warm, summer night in the
middle of a field. You’re gazing up into a black night sky and see countless stars in the
expanse of the sky. Give yourself a moment to imagine what you would see… Now I invite
you to imagine that you are the sky, looking down on the earth below you. As the sky, you
might notice that the weather is constantly changing. You might also notice that even as
the weather changes—­for example, black clouds roll in and pass—­the sky doesn’t change…
There’s a part of you that’s like the sky. The clouds and weather are like your feelings and
thoughts, constantly changing. Sometimes your thoughts and feelings are dark and frightening, like a thunderstorm. Sometimes they’re light and warm, like a sunny spring day.
What’s certain about the weather is that it will change… And what’s certain about
your thoughts and feelings is that they will change too, just like the weather… Notice how
from the beginning of this exercise you’ve had many different thoughts, floating through
you like clouds through the sky. Yet the sky is unaffected by the clouds, just as it’s unaffected by any type of weather… Similarly, the “you” that contains thoughts and feelings
isn’t affected by or harmed by these experiences, no matter how difficult, painful, or scary
they are… There’s a part of you that’s like the sky, containing all of your experiences—­
thoughts, feelings, sensations—­but isn’t the same as your experiences. It’s larger than
them. Even if sometimes the clouds are so thick that you can’t see the sky that contains
them, the sky is always there, unchanged. Through practice, you can learn to access this
part of you that’s like the sky, unharmed by experience. It is from this part that you can
make room for difficult thoughts and feelings—­and all other thoughts and feelings.
Once you’ve introduced this metaphor, you can incorporate it into future exercises in a briefer
format by using the first few sentences of the script and then asking the client to observe what comes
next from the perspective of being the sky.
The well-­known Chessboard metaphor (Hayes et al., 2012, pp. 231–­233) also makes use of hierarchical framing to promote perspective taking. In this metaphor, the self (i.e., the arena or context in
which experience takes place) is likened to a chessboard. The chess pieces correspond to the client’s
thoughts, feelings, sensations, and so on. After you present this metaphor, you can elaborate it in many
ways. For example, you could talk about how chess is a game of war and strategy and point out that the
172 Learning ACT, 2d edition
board (self-­as-­context) has no real investment in strategy or even how the war turns out. You can also
note that although the various pieces are threatening to each other, they aren’t threatening to the
board. The board is simply in contact with them. You can even use an actual chessboard to make the
metaphor more concrete, an approach that’s especially helpful for clients with limited abilities to engage
in abstraction. The following dialogue illustrates how, after establishing this metaphor, you can make
it more experiential by integrating it into the flow of the session. This dialogue occurs immediately
after the Chessboard metaphor was described using an actual chessboard with pieces.
Client:
So, I’m the board and my thoughts and feelings are the pieces? But what about my thoughts
about who I am?
Therapist:
(Picks up more chess pieces and sets them on the board.) More pieces to be added to the board.
Client:
But when I feel things, it’s real. It’s overwhelming.
Therapist:
(Picks up another chess piece.) Yes, it is definitely an experience you are having. (Sets the
chess piece on the board to represent the feeling.) And that thought you just had, the one that
said, “But when I feel things, it’s real. It’s overwhelming”? That’s another piece, too, another
experience. (Sets another chess piece on the board.)
Client:
So everything I say will become another piece?
Therapist:
Yes, each experience you have, whether it’s a feeling or a thought, is another piece on the
board. And as the board, notice that you’re in touch with the pieces, in contact with them.
(Slides pieces around on the board to demonstrate contact.) Yet the pieces are not the board.
Client:
Well, I think I’d like to just dump the board over.
Therapist:
And that thought too is another piece on the board. (Sets another piece on the board.) See
how this works?
Client:
I know, but I don’t want those bad pieces.
Therapist:
(Speaks compassionately.) I can understand why. But, again, check your experience and see.
Have you ever been able to kick the pieces you didn’t want off the board? Have those bad
memories and feelings disappeared?
Client:
No.
Therapist:
So even “I don’t want those bad pieces” goes on the board. (Puts another piece on the board.)
Remember, though, that the board is not the pieces. The board is larger than any single
piece. You, the experiencer, are in contact with your thoughts and feelings. You are aware
of having them, and yet you are not them. You experience them, and you are continually
adding to your board…and the pieces are not the board. The board can hold the pieces
and remain intact and whole, even if a piece says, “This is overwhelming.”
Here, the therapist is using hierarchical frames by pointing to the board as the holder of experience
(the pieces) and the observer of experience, while also demonstrating that experience is ongoing and
Building Flexible Perspective Taking Through Self-as-Context 173
additive. Experience flows from one moment to the next, and each new experience is to be observed,
simply as new pieces to be added to the board. It is worth noting at this point that, just like clients,
therapists aren’t always in contact with this sense of self. It takes practice to be aware of the observer
self, and it’s difficult to remain in this perspective. Still, it’s an inherently freeing perspective. If clients
are not their experience but rather the context where their experiences occur, then they are free to
choose their behavior while allowing the pieces to be. It isn’t necessary to change any of the pieces
before engaging in values-­based action.
SEEING THE SELF AS PART OF SOMETHING LARGER
The preceding section focused on helping clients see their experiences as part of themselves. The
self is the whole, and their experiences are the parts. In contrast, this section focuses on helping them
see themselves as part of a larger whole. The self is the part and the larger whole is a group of people,
all of humanity, or the universe itself. In this type of approach, hierarchical framing is used to create a
sense of membership in the group and common humanity. These subtle shifts in perspective taking
result in a transformation of functions wherein people are more likely to see themselves and their difficulties as similar to those of others, creating a context in which they can recognize that they are part
of something larger than themselves. The goal is to build a sense of intertranscendence (Villatte,
Villatte, & Hayes, 2012), a connection with the perspectives of other people, times, and places. The
subjective experience such approaches target is eliciting a shift from my (isolated) experience to our
(shared) experience. Instead of my suffering, it’s the suffering that we all experience.
The following exercise, which was created for a group setting, demonstrates how hierarchical
framing can be used in this way. To help participants see themselves as part of the group, the therapist
guides them to be aware of themselves as conscious human beings (using I/you frames) and also helps
them take the perspective of others (also using I/you frames). (Again, note that pacing, which isn’t
indicated in this script, should allow time for clients to fully experience the exercise, and that here too
you would begin by devoting a few moments to helping clients get centered, perhaps by having them
notice the sounds around them.)
In the script that follows, the words written in italics are those that serve as cues for interpersonal
perspective taking, and the words written in bold italics serve as cues for hierarchical framing.
Therapist:
Take a few moments to notice what you’re feeling in your body as you sit here. Notice any
places of discomfort, itching, aching, or other sensations. Notice any emotions, thoughts,
or judgments you may be having. In addition to these thoughts, feelings, and judgments,
see if you can connect with your own sense of conscious awareness—­seeing that you see,
noticing the you that notices these experiences. You are more than the content of your
reactions
Now, I have several questions, and I’d like you to see what shows up in response when
I ask them and to just sit with whatever shows up. Is it okay to be a person who has experiences? … Have you ever noticed that we all have experiences? … And here you are,
having experiences like everyone else in this room. It’s likely that you’ve had these experiences or ones like them before—­in other times and places. And here you are, here in this
moment, having them again. Can it be okay to have them? … Are you allowed to be a
person who has experiences? … Is it okay for you to have these experiences in the future?
174 Learning ACT, 2d edition
… You are having them now and you will likely have them again. Are you allowed to have
them whenever they occur?
Now I’d like you to take a few moments to connect with the fact that there are six
other people with you here in this room. Notice that each one is conscious, just like you.
Each person has experiences, just like you. Each of these people has felt happy at times, just
like you. Each of these people has felt unworthy or inadequate in their work or in their life,
just like you. Each of these people wants to be happy or content with their life or feel like
their life has meaning, just like you. And each of them has found these things difficult to
achieve… Each of these people suffers more than they want to…just like you. Each of them
will likely have these experiences again in the future. Are they allowed to have them? …
Are you allowed to have these experiences in the future as well, as a fellow human being?
… See if you can connect with how hard it is to live a human life. Being human isn’t easy.
Here we are, each of us, faced with this situation of how to live a human life. Is it okay for
us, all of us, to have difficulty with that at times? Is it okay for you?
This exercise shares similarities with self-­compassion exercises related to common humanity (Neff,
2011), wherein individual suffering is seen as part of the larger experience of humankind. By observing
oneself and one’s own experience in this way, the tendencies that most people have to treat others with
compassion and kindness are more likely to transfer to treating themselves with compassion and kindness. This exercise may be modified for individual therapy by referring to the therapist instead of the
group or by imagining other people, whether those in the building or people in some other setting. The
central idea is that clients see themselves and their experiences as part of something larger—­as one
person among many, having experiences that are shared by many, which cuts through the sense of
isolation and otherness that many clients experience.
Contacting the Transcendent Self
In this section, we focus on combining hierarchical relations with what RFT calls distinction relations. Distinction relations involve responding to the differences between stimuli based on cues like “is
different from.” In the context of perspective taking, distinction relations involve cues that help clients
distinguish between the experiencer and that which is experienced.
Exercises focusing on the distinction between what is observed and who is observing typically have
a similar structure. Clients are first led to notice some aspect of their experience, for example, their five
senses, thoughts, feelings, roles, or memories. Cues are then used to help clients notice that the observer
is not the same as the experience itself. Here’s an example. (Again, pause and adjust the pacing as
needed so clients can fully engage in the exercise.) In this example, the therapist has just related the
Sky and the Weather metaphor.
Therapist:
Take a moment to draw a large breath. Notice how you feel it in your body, your nose, or
the rise and fall of your chest or belly… Simply watch the breath as it flows in and out…
And as you notice your breath, take a moment to notice who’s noticing… Now take a few
moments to become aware of your emotions. You might notice emotions in your belly, your
chest, your throat, or your shoulders. Find an emotion and see if you can scan the area
Building Flexible Perspective Taking Through Self-as-Context 175
where it seems to be located…and notice what you’re feeling as you do this. Try to zoom
in on where you feel this emotion most strongly. As you do this, notice who’s noticing.
There’s your emotion there, and then there’s part of you that’s watching that emotion.
This exercise can be extended using other aspects of experience, such as thoughts, memories,
urges, or sounds as experiences to notice. Later, this can be paired with cues to help clients notice the
difference between themselves and their experience with statements like these:
“Recognize who is hearing this sound [having this thought, etc.].”
“Notice that you are there, behind your eyes, noticing this. Notice that your thoughts are constantly changing, but the ‘you’ that notices them does not. The ‘you’ that observes stays the same.”
“Be aware that it is you who is noticing this feeling.”
“Notice that you are not the same as this thought. If you have a thought, you can’t be that thought.”
All of these verbal cues include elements to help clients distinguish themselves from the content of
their experience.
THE OBSERVER EXERCISE
Another ACT exercise that taps into noticing and drawing distinctions is the Observer exercise
(Hayes et al., 2012, pp. 233–­237), a frequently used method that helps clients contact a sense of self
that’s larger than any single experience. This is generally done as an eyes-­closed exercise and often
takes twenty to thirty minutes. (Consult Hayes et al., 2012, for the full process, or for a downloadable
audio version, visit http://www.newharbinger.com/39492.) Here, we will simply note that the core of the
exercise is to guide clients to notice the continuity of consciousness itself, as illustrated in this dialogue,
which starts after the therapist has already helped the client get centered.
Therapist:
Now I’d like you to take a moment and think back to a memory of something you did this
morning, such as eating breakfast or getting ready for work. Take a look around that
memory; notice what you were doing and who was there, if anyone. See if you can remember the sights and sounds of this memory.… (Allows the client time to reflect on the memory.)
Now, as you notice this memory, as you observe it, also notice who is noticing…
Now release this memory and travel back in time to find another one—­from perhaps
a month or a year ago. Once you have found this memory, also take a look around this one.
What are the sights and sounds of this memory? (Pauses.)
And again, as you notice this memory, notice who is noticing. Notice there is a “you”
there who is observing that you have this memory.
The strategy is then to contrast that sense of continuity with dimensions of experience, such as
roles, sensations, emotions, thoughts, and behavioral urges. In each case, the therapist asks the client
to note how the specific dimension ebbs and flows and is constantly changing, yet the sense of consciousness itself doesn’t change. The bottom line is that the experiences with which we struggle are not
really us anyway. Examples of similar exercises include the Continuous You exercise (Harris, 2009, pp.
178–­180) and Talking and Listening (Harris, 2009, pp. 177–­178).
176 Learning ACT, 2d edition
For clients with a severe disruption of the continuity of self, these exercises need to be modified.
Those with early trauma or abuse may tend to dissociate during exercises focused on developing a
transcendent sense of self, or the exercise may elicit fear, anxiety, shame, or avoidance. Since problems
with effective perspective taking are actually central to these individuals’ difficulties, it’s important to
engage in exercises aimed at building flexible perspective taking while also respecting how difficult
they can be and how much rigidity they can evoke. In such cases, engage in perspective-­taking work in
a measured way. It might be more appropriate to think of these exercises as a type of exposure (for more
on exposure, see chapter 7), using them to supportively help clients intentionally develop flexibility
while they’re in contact with avoided stimuli that typically lead to inflexible responding (e.g.,
dissociation).
DECREASING FUSION WITH SELF-­EVALUATIONS
Evaluation is useful in many aspects of life. It can keep us from danger, guide our decisions, and
help us know culturally defined rights and wrongs. Yet it can also be fairly damaging in other aspects
of life, particularly when directed at oneself. More broadly, fusion, including fusion with self-­evaluations,
disrupts people’s capacity to contact self-­as-­context because fusion causes the context in which evaluations occur to disappear.
Many clients have a tendency to state—­privately, publicly, or both—­negative evaluations of themselves and to buy those evaluations. In many cases, these evaluations have been around for a long time,
often starting at a young age. Such self-­evaluations may plague people almost continuously, or they
might just show up when problems arise. You can detect the harm caused by fusion with self-­evaluations
by reviewing negative self-­statements that clients bring to session and discovering how these evaluations have impacted their life—­statements like “I’m worthless,” “I’m evil,” “I’m pitiful,” “I’m ugly,” “I’m
undeserving,” “I’m a failure,” “I’m a lost soul,” “I’m a creature, not even human,” “I’m damaged goods,”
and so on. Finding an effective way to work with fusion with self-­evaluations can be difficult because
this is a natural and well-­rehearsed part of human language (thus the plethora of defusion techniques
offered in chapter 3 and other sources).
Furthermore, clients sometimes come to therapy with the idea that their self-­evaluations are problematic and need to change—­that they need to have better, more positive self-­evaluations (e.g., higher
self-­esteem) in order to live a better life. But as discussed in earlier chapters, this is a battle that clients
are unlikely to win. In fact, the battle to eliminate negative self-­evaluations points to the difficulty.
Clients’ evaluations are part of their learning experience, so in order to change or eliminate these
evaluations, clients have to go to battle against their own history. The result is often a self-­attacking or
self-­critical stance that further reinforces the evaluations. Therefore, rather than helping clients change
the content of these evaluations, the ACT therapist guides clients to see them for what they are: evaluations occurring in a context. The therapist can then help clients dispassionately observe their experience and develop a friendlier, gentler way of relating to themselves. To help clients see that these
evaluations are part of their verbal learning history, the therapist might liken them to programming in
a computer: when certain buttons are pushed, programmed evaluations show up on the screen. This
points to the automaticity of evaluations and the low likelihood that they’ll go away. Alternatively, this
can be conveyed using the Chessboard metaphor, with the programming or evaluations simply being
pieces on the board, not part of the board. The client is a whole human being with the evaluations, and
as with reasons, evaluations need not determine the client’s choices or quality of life.
Building Flexible Perspective Taking Through Self-as-Context 177
In addition to perspective-­taking exercises, a number of defusion exercises (see chapter 3) are
useful for helping clients notice evaluations, rather than holding them to be actual qualities of the
contextual self. The first step in this work is for the therapist to make a distinction between description
and evaluation. Here’s a dialogue that illustrates one way to do so.
Therapist:
(Holds up a pen.) This pen is white, with black letters and a black cap. The tip is metal and
has black ink. Agreed?
Client:
Yes.
Therapist:
Now, suppose I say this is the best pen in the world. There is no better pen. Agreed?
Client:
Well, I don’t know. I own a pretty darn good pen.
Therapist:
Right. You can see how the description is different than the evaluation. “Best pen in the
world” isn’t in the pen. It is something I’m saying about the pen. It’s an evaluation I have
about it… It doesn’t exist in the pen. (Pauses.) And “worthless” is an evaluation that
doesn’t exist in you. It’s just something you say about yourself. It has nothing to do with
whether you are whole or not.
You can accomplish something similar with the Milk, Milk, Milk exercise described in chapter 3,
substituting a negative self-­evaluation for the word “milk.” Even though clients can imagine milk, see it
in their mind’s eye, and perhaps even feel the cold glass or taste the milk, the literal milk isn’t there.
Saying “milk” and describing milk doesn’t make milk suddenly appear. Likewise, saying “I’m bad” and
feeling “I’m bad” don’t create bad in the person; rather, this is just something the person is saying about
herself. The client is the context for the content “I am bad,” nothing more. After asking the client to
say the self-­evaluation repeatedly, debrief the exercise and explore how it relates to self-­as-­context: that
there is a self that has evaluations, can defuse from them, and is larger than them.
LETTING GO OF CONCEPTUALIZED SELVES
Connecting to a larger sense of self that isn’t defined by one’s experience involves letting go of
conceptualized selves. This includes not just identities that are considered to be negative, but also those
considered to be positive. Because the latter can be somewhat counterintuitive, let’s take a closer look
at that. A positive conceptualized self could be equated with a set of thoughts linked to high self-­
esteem. Yet attachment to this positive content can be just as problematic as attachment to a set of
thoughts and negative evaluations linked to low self-­esteem. Problematic positive self-­conceptualizations
are readily apparent in some clinical presentations, such as an overly inflated sense of self that might
be linked to narcissism. However, this can also show up in other, less obvious presentations. Consider
a client who has a strong conceptualized self linked to a set of positive notions about her personality.
Speaking of herself, she says, “I always look on the bright side,” and says she works hard to “stay positive.” However, she engages in this behavior at least in part because it helps assuage pain associated
with a long history of abusive treatment by her husband. Furthermore, her attachment to “being a positive person” interferes with her ability to clearly see the abuse and the harm it’s causing. By identifying
the costs of clinging to this “positive” identity and the behaviors it leads to, she can begin to let go of
this story, contact the pain of what has occurred, and take action to leave her destructive marriage.
178 Learning ACT, 2d edition
One way to strengthen the distinction between the conceptualized self, or self-­as-­content, and self-­
as-context is by using imagery. For example, you can ask clients to imagine that their thoughts are
being written on a whiteboard in front of them, on signs carried by people in a parade (Hayes et al.,
2012, pp. 255–­258), or on leaves floating by on a stream (Hayes, 2005, pp. 76–­77). Alternatively, chair
work such as that used in Gestalt therapy can help create a distinction between one perspective and
another. The following exercise provides yet another example of how imagery can be used to reduce
attachment to self-­as-­content.
Therapist:
Each of us has stories that we tell about ourselves, for example, who we are, what our capabilities are, and so on. This is normal behavior, and it’s something we all do. The difficulty
occurs when we become overly attached to these stories because then they can start to
constrict what we’re capable of in our lives. I’m hoping we can do an exercise today to
explore how this works. Are you willing to do an exercise with me? (The client agrees.)
Okay, to begin I’d like you to do some writing about three different selves you have.
For today, how about working with your best self, your critical self, and your hurting self.
(Choose whatever selves seem relevant to the particular client, as long as these are selves the
client seems fused with.) Take a minute or so and write down a few descriptions of you when
you are your best self. What is your best self like? What does she look like? What does she
think, feel, and do? (Gives the client a minute to write.)
Now take another minute to jot down some descriptions of your critical self. Think
about an area in your life in which you criticize yourself. What does this side of you look
like? What does she say? What does her voice sound like? What does she think, feel, and
do? (Gives the client a minute to write.)
Finally, take a minute more to write about your hurting self. This is the self that feels
small, hurt, and helpless. What are you like in those moments? What are your qualities?
What do you think, feel, and do? (Gives the client a minute to write.)
Okay, now that you have finished, let’s do an eyes-­closed exercise that involves imagery.
(As always, adjust the pacing as needed so the client can fully experience the exercise.) I invite
you to close your eyes and get centered, focusing on a few breaths as you settle. Now I
invite you to imagine the first image you wrote about, the image of your best self. See if you
can fully picture that self out in front of you, noticing how she looks, thinks, and feels…
Now imagine that by some twist of fate this self couldn’t stay—­she could no longer be a
part of you. What would you find yourself clinging to? … What might you find easy to let
go of? … It doesn’t matter. This isn’t you anyway. You are larger than this self. Hold this
self lightly, like you might hold a butterfly that’s landed on your finger. You are more than
this self. (The therapist repeats the same instructions for the other two images and then moves
on.)
Now notice and hold each of these three selves lightly. They are not you anyway. You
are larger than them. See if you can allow all of these selves to gently rest in the vastness
that is you… And now gently bring yourself back to the room.
After the visualization, you can collaboratively explore the client’s experience of this exercise. You
might note that although the exercise involved imagining that the three selves could no longer be, they
still exist. And while these selves aren’t likely to go away, the client is free to move in and out of them
Building Flexible Perspective Taking Through Self-as-Context 179
and notice that she’s bigger than any single conceptualized self. If the client asks, “If I’m not these, then
who am I?” simply remind her that these selves are always available, and that new selves can be constructed and often are. Holding them lightly is the goal, and it’s an endeavor undertaken in the service
of freedom. There’s no need to fuse with or rigidly hold on to any particular self; all can be held lightly.
Experiential Exercise:
Distinguishing Self-­as-­Content from Self-­as-­Context
Describe two of your conceptualized selves (e.g., professional self, self as parent, self as victim), then
write a description of these selves: what they feel, how they think, and how they appear. (Ignore the
“Opposite behavior” and “Reactions” prompts for now.)
Conceptualized self 1: Description: Opposite behavior: Reactions: Conceptualized self 2: Description: Opposite behavior: Reactions: 180 Learning ACT, 2d edition
Now consider each self and think of a behavior that’s directly opposite what you would expect this
conceptualized self to do. Be creative, wild, or extreme in coming up with these opposites. Describe
those opposite behaviors in the spaces above.
Now get into a comfortable position, close your eyes, and imagine each of these conceptualized selves.
You don’t have to imagine them as yourself, although you can if you want. More importantly, give them
whatever form seems to best represent the way that self feels to you. Then, in your imagination, picture
each self engaging in the opposite behavior you described. Notice what happens in each case and
briefly describe your reactions to each scenario.
Using Perspective Taking to Develop a Flexible View of the Self
The strategies set forth thus far in this chapter primarily involve using frames of distinction to
help clients distinguish their observer self (self-­as-­context) from the content of their experience (self-­
as-content), and using hierarchical frames to construct a sense of self that transcends, is larger than, and
contains all of the individual’s experience or is part of something larger than the self. The exercises in
this section emphasize using temporal perspective taking (now/then) in combination with personal (I/
you) and spatial (here/there) framing to help clients develop new and more flexible ways of relating to
themselves. These strategies are a bit more advanced, as they typically build upon a basic ability to
notice one’s experience and contact a sense of conscious awareness. From this place of awareness, clients
can shift perspectives to evoke more flexible and compassionate ways of responding to themselves.
WORKING WITH THE CONCEPTUALIZED PAST
Temporal frames can be used to help clients contact conceptualized pasts in ways that promote
greater flexibility in responding to themselves. These exercises often take the form of asking clients to
transport themselves to past events and interact with the self that was there in that situation. In addition to temporal perspective taking, these exercises tend to use spatial and personal frames extensively
as clients interact with themselves from an imagined second perspective. In the following example, the
context is a session in which a young woman seeks therapy after engaging in self-­harm the previous
weekend.
Client:
On nights like that I feel so incredibly lonely and empty, like I’m crawling out of my skin.
I just can’t stand it. The only way I can make it stop is to cut myself.
Therapist:
At those times you feel like there’s nothing that can help or soothe you. But the cutting
makes it better for a little while.
Client:
But then I feel so terrible after I do it because I know it’s bad. I hate being so weak and
needy.
Therapist:
It seems like you’re really stuck. In those times you feel so empty and alone, but then when
you do the one thing you know to do that helps, even if only for a little bit, you beat
Building Flexible Perspective Taking Through Self-as-Context 181
yourself up for being too weak. That’s a really tough spot to be in. How long do you think
this pattern has been going on? (Begins the exercise by building a sense of continuity between
the self today and an earlier self.)
Client:
Well, I started cutting about five years ago.
Therapist:
And is that when the feelings of loneliness and emptiness started? Or do you remember
times of feeling alone and empty before that?
Client:
Oh no, I’ve felt that way since I was a little kid. But I did other things then, like overeating,
or when I was really young, I can remember curling up under the covers in my bed and
pretending that I was in a make-­believe world. I’d just sort of lose myself in that world.
Therapist:
And how old were you then, when you’d be under the covers trying to escape to another
world?
Client:
I don’t know, maybe six or seven.
Therapist:
Wow, so you’ve been suffering with this for a really long time. I’m wondering if you’d be
willing to do a brief exercise with me so we can maybe see what’s happening from another
perspective?
Client:
Sure.
Therapist:
Okay. If you’re willing, can you close your eyes? (The client closes her eyes.) Notice the
feeling of your feet on the floor. Just follow the natural rhythm of your breath breathing
itself, in and out… Now I want you to imagine that you’re there on your bed in your childhood bedroom and you are your six-­year-­old self. Look down at your hands and notice
what they look like… See what you’re wearing as your six-­year-­old you… Feel your hair…
Notice the bedding and what it feels like to sit on your bed. Is it hard or soft? … What does
it smell like in that room? … What does the light look like? … See if you can hear any
sounds that are around you as you sit there on your bed… (Uses first-­person and present-­
tense terms to help the client adopt the perspective of being herself as a young child.) Are you
there? Can you picture it?
Client:
(Responds without opening her eyes.) Yes.
Therapist:
Okay, now see if you can feel what it feels like to be this six-­year-­old and be so alone… You
don’t know what to do; you’re only six. And here you are, this little kid on her bed, in her
room, all alone and feeling very empty and scared. What does it feel like to be this little
girl?
Client:
I feel really overwhelmed and scared.
Therapist:
Yes. And you just want to hide under the covers and escape to your make-­believe world.
(The client nods.) Okay, so now I want you to imagine that you’re standing outside your
childhood house but you’re the age you are now. You’re wearing what you’re wearing now,
and you are just as you are now… You start walking into your house and you go to the
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bedroom you had as a child… You open the door, and you see this little six-­year-­old girl
who looks exactly like you. You can tell she’s scared and overwhelmed. She looks like she’s
been crying. Notice what it feels like to look at this little girl, this little kid. How do you
feel when you look at her? (The therapist is using personal frames prominently in this section,
leading the client to imagine interacting with her child self as a “you” from the perspective of her
adult self.)
Client:
I feel sad for her. I want to go give her a hug.
Therapist:
Okay, go do that. See what it feels like to go to this scared, overwhelmed, little girl who is
so lonely and give her a hug.
Client:
It feels right.
Therapist:
Yes. So now you’re hugging the little girl. Imagine that she just kind of disappears into your
chest. She becomes part of you again, because she is a part of you. You’re holding her in
your heart… And now notice your feet back on the floor again here. Notice your body in
the chair. You can picture in your mind’s eye what you will see when you open your eyes,
and whenever you’re ready, you can open your eyes.
Many of the patterns of behavior that clients struggle with can be traced back to early adolescence
or childhood. Tracing difficulties back in time can allow clients to interact with a younger, more vulnerable version of themselves. This is likely to evoke caring and compassionate responses that can be
used in the future by building them into sessions or homework. In the example presented above, the
therapist can work with the client to explore new ways to interact with the struggling child whenever
she feels like she wants to self-­injure. Perhaps it would be helpful for the therapist to recommend that
the client explore “hugging the child” rather than cutting. A more general example of homework to
build on this exercise could entail asking the client to look for times when the struggling child shows
up and then to notice how she’s interacting with the child and whether this aligns with how she interacted in the visualization.
Assuming clients evidenced a self-­compassionate response in the visualization, they can be encouraged to interact with the child as they did in the visualization in an ongoing way. And if clients are
quite engaged with the ACT approach, they could be coached to identify an ACT exercise that they
can practice when this struggling child shows up, such as a defusion or acceptance exercise. Ultimately,
this work is linked to clients’ values, including how they’d like to live their values with respect to
themselves.
The previous vignette offers a relatively straightforward application of this technique, done with a
client who’s relatively flexible and able to contact a new, more compassionate response. It’s important
to remember that all exercises are also assessments, with the client’s response providing important data
that can be used to refine the case conceptualization. For example, a client who responds to her
younger self with rejection and contempt is probably showing strong fusion with a conceptualized self,
which may indicate the need for further work on perspective taking and defusion toward that conceptualized self. If a client has difficulty bringing compassion and flexibility to interacting with the struggling child, you might coach her to imagine a future self that’s older and wiser, or you might give the
client access to your perspective by speaking directly to the child self with compassion and empathy.
Building Flexible Perspective Taking Through Self-as-Context 183
Once this alternative perspective is contacted, the client can bring that perspective into the exercise to
interact with her younger self.
USING PERSPECTIVE TAKING TO SUPPORT FUTURE BEHAVIOR
Perspective taking that emphasizes temporal frames can also be a useful way to generalize what has
been learned in session to future situations. This can help make the session more experiential and less
didactic and may also help reduce the chances of clients making commitments that are based on the
presence of the therapist. Helping clients develop the ability to take values-­based action in the future,
when the therapist is no longer there, is an important treatment goal.
The following dialogue, which provides an example of using perspective taking to support committed action, includes the three key deictic frames. This kind of approach is generally used after a client
generates a plan for a future action to help the client overcome barriers to implementing the plan.
Broadly speaking, this approach brings conceptualized future barriers into the here and now so they
can be explored from a present-­moment perspective. In this vignette, the client is a gay man who’s
working on drinking less in social situations, particularly in relation to dating and sex. He has this goal
because alcohol has caused a fair number of difficulties for him in the past. He’s identified a plan to
refrain from drinking alcohol during an upcoming date. His values-­based goal is to be present with his
date, someone he met online and is meeting in person for the first time.
Therapist:
Would you be willing to close your eyes and imagine that you’re there at dinner? Go to the
moment where you think you might be most tempted to drink. What are you seeing when
you’re sitting there? Talk to me about it in the first person, like you’re there. (Uses temporal
and spatial frames to transport the client to the there and then with a here-­
and-­
now
perspective.)
Client:
I see Pedro across from me. We’re sitting at the table about to order.
Therapist:
You’re doing a great job. Remember to keep talking in the present tense. What are you
thinking? (Helps the client build self-­as-­process by noticing thoughts.)
Client:
I’m thinking that I really want a drink. I’m getting nervous, and I’m afraid that I’m going
to say something awkward. A drink would really help me settle down.
Therapist:
And what are you feeling? (Helps the client build self-­as-­process by noticing feelings.)
Client:
I’m feeling nervous. Jittery.
Therapist:
Okay. Let’s imagine that I could magically transport the you that is here now into that
situation there so you could talk to yourself. (Uses interpersonal, temporal, and spatial frames
to help the client access a new perspective on himself in the imagined context.) So now you’re
there with yourself and you can see how hard it is for you. You see how anxious this future
you is and how painful it is for him. At the same time, you also know how important it is
for him to connect with Pedro and give himself a chance to explore a more connected
relationship this time. (Uses interpersonal frames to try to evoke the same kind of empathy that
the client might feel for another person in a similar situation.) So you’re here with the future
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you. What would you want to say to this person who’s having such a hard time in this
moment?
Client:
(Speaks sternly.) I’d say, “Don’t do it. Don’t take a drink. Keep your promise.”
Therapist:
And now be the future you again, in that situation. What’s it like when you hear that?
What would you say in response? (Rather than trying to intervene on the unempathic response
directly or coach a new response, the therapist helps the client track its workability by exploring
its impact. The therapist is coaching the client to respond directly, as if the situation were actually
happening.)
Client:
(Speaks from the perspective of being on the date to his current self.) “That’s not making it
better. You’re pressuring me…I feel like I’m going to freak out if I don’t have a drink.”
Therapist:
Okay, so now go back to you looking at yourself in this situation again. What do you say
in response? It seems like what you said actually made it harder on him…
Client:
(Remains silent for a moment and then speaks directly to the self on the date.) “You’re right. I
hadn’t really thought about what I was saying. But I can see how that made things harder.
I see how scared you are. I know how much you like Pedro, and it makes sense that you’d
want to drink to chill out. It’s really tempting.”
Therapist:
Okay, switch to the you that’s on the date. How do you react to what was said now?
Client:
(Speaks from the perspective of the self on the date.) “That helps. I feel more understood.
Thanks for understanding. That makes it a little easier.”
Therapist:
“Okay, back to you again. How do you respond to that?”
Client:
“I’m glad. I don’t want this to be so hard. The thing is, we know where drinking goes. It
feels better now, but makes it harder in the long run. You said you wanted to start this
relationship off differently so you can really get a chance to see where it goes. Maybe you
take that chance this time and see how it goes to make room for the anxiety and not
drink?”
Therapist:
Okay, now switch back again.
Client:
“Yeah, I can see that. I think you’re right.”
Therapist:
So, what does the you that is on the date do now?
Client:
It would be hard, but I think I could not drink and still go on the date if I were able to talk
to myself this way.
At this point, the therapist might debrief the exercise with the client and explore whether he would
be likely to engage in this process and switch perspectives in this way in the future. Contrasting this
method with a more typical approach, wherein clinicians work with clients by talking about the situation, the barriers, their values, and what they plan to do, illuminates the more experientially based
Building Flexible Perspective Taking Through Self-as-Context 185
approach afforded by engaging in perspective-­taking work. Clients may more fully experience the situation in their here and now through imagery. They can mindfully notice their reactions and, through
perspective taking, generate new perspectives on the self. The main point of the preceding exercise is
not to have the client talk to himself in a particular way, but to help him have an experience of taking
a different perspective. Alternative versions of this exercise might involve having the client imagine
that the therapist visits him in a difficult moment, or having him take the perspective of a caring friend
while interacting with himself. (If you’re interested in additional examples of how to use perspective
taking in similar ways, see Polk, Schoendorff, Webster, & Olaz, 2016, chapter 6.)
Flexible Perspective Taking and Self-­Compassion
Research shows that self-­compassion is associated with many positive psychological and behavioral
outcomes (MacBeth & Gumley, 2012). Indeed, at least one study shows that outcomes of ACT for
patients with chronic pain are at least partially mediated by changes in self-­compassion (Vowles,
Witkiewitz, Sowden, & Ashworth, 2014). From an ACT perspective, self-­compassion emerges from the
ability to see ourselves as conscious, aware beings and respond using the same caregiving repertoires we
might use in response to someone else (Luoma & Platt, 2015). Said simply, a self-­compassionate
response involves responding to oneself in the same manner as we would respond to a good friend.
Self-­compassion depends upon having a robust and flexible perspective-­taking repertoire. In
order to be self-­compassionate, we need to be able to shift from fusion with our current thinking (self-­
as-­content) to awareness of the observer self (self-­as-­context). From this perspective, we can notice that
we are conscious beings who are suffering. This shift may evoke behavioral repertoires related to cooperation and caretaking, in this case in relation to ourselves, rather than in relation to others. Flexible
perspective taking also involves contact with a transcendent sense of self that is larger than the constricting self-­stories that self-­compassion addresses, including those related to shame and judgment.
Additionally, flexible perspective taking can promote more empathic ways of relating to oneself and a
sense of interconnection with others.
Although flexible perspective taking is perhaps most central to the development of self-­compassion,
all six of the flexibility processes are involved. Acceptance includes self-­acceptance, or embracing one’s
experience as it is. Defusion involves learning to observe self-­critical thinking with less attachment to
the conceptualized self. Present-­moment awareness includes noticing and responding sensitively to
one’s current state, needs, and goals, rather than judging them or rigidly following internalized rules for
behavior. Values work includes identifying the kind of relationship we would choose to have with ourselves. And committed action taken in relation to oneself might flow from these chosen values and
could include extending kindness and care to ourselves and seeking support from others as needed.
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Core Competency Practice
The rest of this chapter is devoted to exercises focused on the core competencies related to self-­
as-­context and flexible perspective taking. As in previous chapters, for each core competency we
provide a brief case description and dialogue. Remember to write out your own responses and your
explanations for them before comparing them to the model responses at the end of the chapter.
Core Competency Exercises
Competency 27: The therapist uses metaphors and exercises to help clients
distinguish between the content of consciousness and consciousness itself so as to increase
a sense of self as an arena, location, container, or context for all experience, fostering a
greater ability to act with these experiences, rather than for or against them.
Exercise 27
The client is a fifty-­one-­year-­old woman seeking therapy after a divorce from her husband. She has
never been in therapy and has often used avoidance strategies to deal with difficult emotions. She’d like
to explore how she can pursue her new life, given that she hasn’t been alone for more than thirty years.
She’s fearful of trying new things and wants the fear to go away. She’s tried multiple types of avoidance
to escape the fear, including isolating at home, drinking alcohol while alone, and avoiding new situations and activities. The client makes the following statement immediately after the Chessboard metaphor has been set forth.
Client:
But isn’t there any way to win this war? I would really like this fear to go away. Can’t I just
push the pieces over on the board?
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 27:
Building Flexible Perspective Taking Through Self-as-Context 187
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 28: The therapist uses metaphors and exercises to reduce clients’
attachment to conceptualized selves or conceptualized others that create problematic
rigidity or interfere with flexible responding.
Exercise 28
This dialogue continues with the same client as in the dialogue for competency 27 but occurs in a later
session.
Therapist:
It seems that you were in that relationship for so long that you’ve come to see yourself as
“the housewife.”
Client:
It’s the way I’ve always been. I’m the one who does the dishes, cleans the house, stays at
home, and takes care of other people. I just can’t do anything else.
Write here (or in a notebook) what your response would be, demonstrating competency 28:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
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Competency 29: The therapist helps clients contact an expansive and
interconnected sense of self through building a sense of being part of a larger whole that
extends across time, place, and person, whether that be a group, humanity as a whole, or
the continuity of consciousness itself.
Exercise 29
The client is Aliyeh, a twenty-­eight-­year-­old woman who’s having difficulty with colleagues at work.
She feels intimidated and wants to quit her job but thinks she can’t due to financial pressures. She
wishes her feelings wouldn’t get hurt by these interactions. She reports keeping a stiff upper lip but
struggles silently at work and cries at home about difficult work interactions. She’s angry at herself for
feeling this way. The following dialogue occurs near the end of the session.
Therapist:
How is this stiff upper lip thing working?
Client:
Not very well. I’m really trying, but it’s getting harder and harder. I feel like I’m going to
break down in tears all the time, but I’ve been able to fight them off so far.
Therapist:
What kinds of things do you say to yourself about breaking down in tears?
Client:
That I’m weak and that I shouldn’t let these petty things bother me.
Write here (or in a notebook) what your response would be, demonstrating competency 29:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Building Flexible Perspective Taking Through Self-as-Context 189
Competency 30: The therapist helps clients flexibly take perspectives toward
themselves, others, and their own experience that build flexible and compassionate ways
of responding; such perspectives include but are not limited to viewing the self from
different conceptualized selves (e.g., loving self), the perspectives of others (real or
imagined), perspectives of time (past, future), and perspectives of place.
Exercise 30
This dialogue continues with the same client as in the dialogue for competency 29 but occurs a few
sessions later.
Client:
These interactions make me feel so awful. I feel like I’m worthless to them, and I’m starting
to believe that I am worthless, that something is wrong with me or it wouldn’t be this way.
God, I wish I could just snap out of it. You must think I’m such a whiner.
Exercise 30.1
Write a response that uses temporal framing (guided by competency 30):
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
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Exercise 30.2
Write a response that uses spatial framing (guided by competency 30):
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 30.3
Write a response that uses interpersonal framing (guided by competency 30):
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Building Flexible Perspective Taking Through Self-as-Context 191
Core Competency Model Responses
Competency 27
Model Response 27a
Therapist:
Notice that you’ve been in this war and have been trying to win it. Your battle has included
staying at home to eliminate the fear piece, and drinking alcohol to try to quash the fear
piece. The result is that you’ve limited your life to this battle, this war to try to push the
fear piece down. Meanwhile, let me just ask you this: Are you still you through all this?
Can you notice the part of you that is aware of all this? As the chessboard, maybe you don’t
need to win this war with these pieces in order to live a full life.
Explanation: The therapist is helping the client connect to her experience and then points to the
distinction between the content of the struggle and the context of this struggle—­consciousness itself.
Model Response 27b
Therapist:
Wanting to push the pieces over—­I think that might be another piece to add to the board.
What happens when you get attached to that piece and try to win the war?
Client:
That’s when I drink and stay home.
Therapist:
Does that help you win the war?
Client:
No, I haven’t been able to win the war.
Therapist:
Can you notice that the chessboard is the context where the battle unfolds?
Client:
Yeah, I guess.
Therapist:
Can you notice that you are the context in which your thoughts and feelings unfold?
Client:
(Pauses.) Yeah, I guess I can see that.
Therapist:
So what would happen if you weren’t the player trying to win the war, but instead you were
the board? What would that look like?
Explanation: Here the therapist helps the client see that the desire to push the pieces over is just
another chess piece—­another bit of content for the board. The therapist helps the client contact the
consequences of trying to win the war (which reflects fusion) and then guides her to contact the sense
of herself as the place where the battle unfolds. The last question starts to shift attention toward values
and what the client might do if she could be more of an observer and less attached to her conceptualized self.
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Competency 28
Model Response 28a
Therapist:
So it really seems as if no other sense of you exists; there’s only the housewife you. But you
also told me you have a sister, and of course you’ve been a daughter. You shared that you
volunteered at one point. So we could describe each of these senses of you too, and I
imagine that they’d look different from the housewife you.
Client:
Yes.
Therapist:
But also notice that there’s a you who’s aware that you were a housewife, that you are a
sister, and that you were a volunteer. And you’re here right now. Who’s aware of all of these
aspects?
Explanation: Again, the therapist is helping the client connect with self-­as-­context by pointing to
other conceptualized selves the client has mentioned or could formulate. He’s also helping her notice
that she’s aware of these selves and is more than them. From this place, the therapist can encourage the
client to take actions that aren’t about continuing to cling to her conceptualized housewife self.
Model Response 28b
Therapist:
I’m wondering if you’d be willing to do a little exercise with me?
Client:
Sure.
Therapist:
I’d like you to close your eyes and imagine yourself in your home as the housewife. When
you have that image in your head, raise your right hand. (The client raises her hand.) Okay,
now silently describe her appearance to yourself. What does she look like? … Now notice
how she’s feeling. What emotions does this self—­self as housewife—­experience? … What
does this housewife say about the world and the way it operates? … How does she define
herself? …
Now, as you have the full image of this self in your mind, with all of her thoughts and
feelings and ways of being, what would it mean if you had to let her go? … What emotions
show up for you as you think about letting go of her? … And if you find any resistance
there, see if you can notice that she isn’t you anyway. She’s just a role you play.
Now imagine you could hold her lightly, like you might hold a butterfly that’s landed
on your finger, and choose to live the values you would like to bring to life.
Explanation: The therapist conducts an experiential exercise to help the client disentangle from a
conceptualized self. This provides a small window through which the client may be able to free herself
from the housewife role and make different choices about how she’ll live.
Building Flexible Perspective Taking Through Self-as-Context 193
Competency 29
Model Response 29a
Therapist:
“Stiff upper lip”? That’s a familiar one. I sometimes say things like that to myself too when
I’m feeling helpless or overwhelmed and I feel like I just need to get through it. Often I feel
pretty alone in those situations. Is that how you feel?
Client:
Yeah.
Therapist:
Yeah. And do you think that you and I are the only two people who would feel overwhelmed or alone in those situations?
Client:
No, I guess not.
Therapist:
Me either. I bet there are a bunch of people like us, even right now, who are feeling helpless
and are trying to tell themselves to keep a stiff upper lip. What would you wish for those
people who, right now in this very moment as you and I are talking, are trying to keep a
stiff upper lip in the face of feeling oppressed or helpless?
Client:
I guess I wish that they wouldn’t feel so alone.
Therapist:
Me too.
Explanation: The therapist picks out the evocative statement “stiff upper lip” that the client appears to
be fused with. Then he creates a sense of shared experience by disclosing that he and the client have
similar experiences. Perspective taking is further extended by engaging the client in imagining all the
people around the world who could be saying similar things to themselves in that moment. Next steps
might include helping the client figure out how to bring this more compassionate perspective into her
life when the identified situation occurs.
Model Response 29b
Therapist:
Can you tell me about a time when you felt intimidated at work this week?
Client:
Yes. I was about to go to a meeting where I was presenting the results of a survey my
department had created, when this male employee who’s only been working there for six
months came in and asked if I was prepared. It felt condescending. I know what I’m doing.
Why is he taking it on himself to ask me that?
Therapist:
Can you clearly re-­create that memory in your mind and put it right here in the middle of
the room, almost as if it’s happening here all over again?
Client:
Sure, but it still gives me the creeps. Why should I have to face condescending males
constantly?
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Therapist:
Would you be willing to walk over here with me? Leave yourself and that memory over
there and come with me. (Walks with client to one side of the room. The act of physically
moving is a cue for spatial perspective taking, creating a psychological sense of distance.) Now
look back at yourself sitting there, remembering. What do you feel about her?
Client:
(Pauses.) She’s a trooper. Always has been. But she’s trying to carry this all by herself.
Therapist:
And take a second to look at that memory from way over here. Is there anything you see
from here that you missed when it was happening?
Client:
She’s not the only one; women are talked over and down to constantly. This guy has only
been here a few months, and he’s already thinking he should be in charge. He’s not a bad
guy—­it’s invisible privilege to him. Anyway, I sometimes forget that I’m not the only one
who experiences these things. That’s something I didn’t notice at the time that I see better
now.
Explanation: Perspective taking is built on time, place, and person. By using physical movement in
space as a cue for spatial perspective taking (“Walk over here”) and asking the client to look at herself
almost as another person (“What do you feel about her?”), the therapist promotes perspective taking
that can link the client’s current struggles to those of others, in other places, thus promoting greater
psychological flexibility. This results in the client seeing how she shares common experience with other
women (“She’s not the only one; women are talked over and down to constantly”) which includes hierarchical framing. If the client hadn’t derived this herself, the therapist could have more explicitly tried
to help the client build a sense of intertranscendence by connecting with other women’s experience by
saying something like, “And can you see this isn’t just her experience—­that this is an experience that
women have all over the world, being talked down to by the men around them? Can you compassionately connect with all those women who are engaged in that important struggle, including yourself?”
Competency 30
Model Response 30a (emphasizing temporal framing)
Therapist:
This is really painful. Are you willing to do an exercise with me?
Client:
Sure.
Therapist:
I want us to take a little journey in time. I’d like you to imagine yourself in ten years. Let’s
say you’ve given some attention to living in a way that’s kinder, gentler, and more self-­
compassionate throughout those ten years, even if it was just one little thing you did each
week to be a little kinder and a little more loving to yourself. I’m not asking you to imagine
some perfect you in the future, just a wiser, more seasoned you that maybe has a bit more
perspective on life. Can you imagine what it might be like to be behind the eyes of someone
with the wisdom gained simply from living another decade of life? Can you try on that
perspective and see what it feels like?
Building Flexible Perspective Taking Through Self-as-Context 195
Now try to look back on yourself from the perspective of you in the future. Think
about the situation you just talked about, feeling stuck at work, overwhelmed, and picked
on. How does this situation appear from ten years in the future? What do you feel toward
yourself? Do you feel any compassion for yourself? Just give yourself some space to consider
this situation from the perspective of ten years in the future.
Explanation: The therapist uses temporal perspective taking to contact a future self that might be a bit
wiser than the client is now, with a broader perspective on her life. A next step might be to help the
client enact this more concretely in the form of a supportive letter to herself. Homework might involve
reading this letter to herself at work and remembering this different perspective on herself.
Model Response 30b (emphasizing spatial framing)
Therapist:
You imagine me over here looking at you and thinking, “What a whiner”? (Moves from
other-­as-­content to other-­as-­process.) That must be scary. (Displays empathy to support
acceptance.)
Client:
Yeah, I guess.
Therapist:
Could you come over here? (Invites the client to sit in the therapist’s chair as a means of facilitating spatial perspective taking.) How would you feel if you were in this chair and you could
see Aliyeh, who has been hurt so much before, wincing and fearing that even her therapist,
who she thought would be the one person she could be safe with, thinks she’s pathetic?
Client:
I could feel for her a little bit. She doesn’t want to be afraid of her own therapist.
Explanation: The client appears to be fused with other-­as-­content when she imagines her therapist is
thinking poorly of her. The therapist elicits spatial framing by having the client sit in his chair. This
movement in space aims to help the client develop some psychological space or distance from which to
view her struggles. In this position, the client can contact what it might be like to view herself from a
different perspective. This elicits a more compassionate response that could then be built on in session.
If the client had been unable to imagine this different perspective, the therapist could offer to tell her
his perspective and then help her imagine what it might be like to think and feel that way toward
herself.
Model Response 30c (emphasizing interpersonal framing)
Therapist:
Those are some painful thoughts coming up for you right now. (Models other-­as-­process.)
How would you feel in this chair if you were to see Aliyeh (uses the client’s name in the third
person to elicit a shift to the you perspective) getting bullied by those thoughts while she’s
feeling so hurt and lonely? (Directly invites I/you perspective taking.)
Client:
I don’t know. That’s really hard to imagine.
196 Learning ACT, 2d edition
Therapist:
Aliyeh is sitting right there, across from you, and you can see that she’s just getting pummeled. And maybe it’s a bit heartbreaking because you know how hard it is for her to have
been left alone, and here she is getting beat up right in front of your eyes. (Elaborates on his
perspective to help the client with perspective taking.) What do you imagine you would feel
from over here?
Client:
That feels sad to me. Maybe I would feel sad over there.
Therapist:
And if you could speak from that sadness, from your heart, what would you say to Aliyeh?
Client:
(Pauses.) I’d tell her she’s okay and that I’ll be her friend.
Explanation: The therapist has the client imagine what it would be like to be the therapist watching
the client engaging in this self-­critical thinking while feeling so hopeless and stuck. The goal is to help
the client contact a different perspective on herself, perhaps similar to how caring others might respond
if she were able to share openly with them. The goal isn’t to elicit any particular kinds of thoughts, feelings, or actions, but to help the client develop the ability to flexibly shift perspective in time, space, and
interpersonally.
For More Information
For more about self-­as-­context, including exercises and metaphors, see Hayes et al.,
2012, chapter 8; and Harris, 2009, chapter 10. You’ll also find a wide range of exercises
and metaphors related to self-­as-­context in Stoddard & Afari, 2014.
This chapter has been written from a clinical perspective, but there is a growing
behavior analytic science of self and deictic frames. For an orientation to the basic
literature, see Barnes-­Holmes, Hayes, & Dymond, 2001. For contemporary basic
research in this area, see McHugh & Stewart, 2012; Rehfeldt & Barnes-­Holmes, 2009.
CHAPTER 6
Defining Valued Directions
When I dare to be powerful, to use my strength in the service of my vision, then it becomes less
important whether I am afraid.
—­Audre Lorde
Key targets for defining valued directions:
Help clients contact and clarify the values that give their life meaning.
Help clients focus on the process of living and loosen their attachment to unworkable
goals or outcomes.
Working with clients to bring purpose and meaning into their lives is one of the more salient and distinguishing aspects of ACT, and in many ways, this sets it apart from interventions that primarily focus
on symptom reduction. Clarifying and supporting meaningful life directions by helping clients engage
in personally chosen values-­based activities, along with measuring well-­being based on effective functioning that’s guided by these same values, is fundamental to the clinical work done in ACT. In this
chapter we explore how to assist clients in discovering and defining their values in and out of session;
however, we also believe that it’s essential for therapists to consider their own values as professionals.
Therefore, we begin this chapter by inviting you to reflect on your values as a therapist in the following
exercise. It will help you clarify your values as a therapist and will also give you an experiential sense of
the work clients are asked to do in defining their valued directions.
198 Learning ACT, 2d edition
Experiential Exercise:
Defining Valued Directions
Move through this exercise slowly, giving yourself time to fully engage with each question and completing each element before you move on.
Take a few moments to connect with what you hold as most important in your role as a mental health
professional. What do you want to stand for or be about in your work? Assume that choosing what you
value in your role as a therapist is as simple as choosing an item from a restaurant menu. If you could
choose anything at all, what would you want your work to be dedicated to? List several values and write
about their meaning for you:
Now consider whether your actions are largely consistent with the values you listed and note whether
there are aspects of your work where you aren’t acting on your values in the way you intend. Identify
the value you struggle with the most (even if you didn’t list it above), then write it here, along with the
internal barriers (thoughts, feelings, and so on) that seem to be holding you back:
What did you notice as you wrote about this value and where you stand with respect to it? Did you find
yourself being judgmental about yourself or your skills as a therapist? Write about what you noticed and
felt:
Now consider what kind of relationship you want to have with yourself in terms of the emotions and
thoughts you might encounter when taking steps toward this value. If you could be a good and wise
friend to yourself during times when you turn away from this value or you’re having difficulty taking
Defining Valued Directions
199
action on this value, what kind of qualities would you hope to exhibit toward yourself? At times when
you doubt yourself, how would you hope to respond? On tough days, what would you want to offer
yourself? Take a bit of time to consider the kind of relationship you want to have with yourself as a
therapist and write about those qualities:
Bring a current client to mind, perhaps a client whom you find challenging or difficult or who triggers
difficult feelings, thoughts, or memories for you. If you were going to live the values you’ve written about
in this exercise, what actions would you take in your therapeutic relationship with that person and how
would you interact with the client? Is there anything you aren’t doing that you would do, or anything
you are doing that you wouldn’t? If you were going to take whole and heartfelt action on your values
with this client, what are one or two things that would change?
Given your usual way of doing things, what internal barrier is most likely to stand in the way of choosing to make these changes?
Is there any way in which buying into these barriers or avoiding them has cost you and your clients in
the past? See if you can reflect on this in a deep and honest way:
Now review the implications you noted and the changes you’d need to make if you were to take action
in the service of your values. Suppose you had an opportunity to commit to these actions. Would you
accept the opportunity and be willing to notice barriers without giving them veto power over your
behavior? Write at least one concrete action you could commit to that’s in keeping with the changes
you wrote about:
I commit to [behavior] 200 Learning ACT, 2d edition
as an expression of [value] This exercise is similar to those that ACT clients are often asked to do. It presented you with a choice
about your values in some area of your life and guided you to consider the implications of that value for
your behavior, the barriers you might encounter and how to handle them, and the costs of not acting
on your value. It also provided an opportunity for you to commit to a value and its behavioral implications. In a very real sense, this exercise covered all the major aspects of ACT discussed in this chapter
and chapter 7, on committed action.
What Are Values?
The job of the ACT therapist is to help clients be more aware, mindful, and intentional in their pursuit
of their life goals and values. In ACT, values have been defined as “verbally constructed, global, desired,
and chosen life directions” (Dahl, Wilson, Luciano, & Hayes, 2005, p. 61). The metaphor of a direction
highlights the intentionality that is potentially embodied in every purposeful act. Valuing does not
exist separately from human action; it is a continuous quality of behavior. Therefore, values are ideally
stated as a combination of verbs and adverbs, reflecting that they are embraced as qualities of ongoing
action across time. To relate to others lovingly is a value. To raise one’s children kindly and attentively
is a value.
To some degree, we engage in an act of valuing each time we do something purposeful or instrumental. We value various qualities of outcomes; we value ways of living; we value ideals; we value what
kind of friend, lover, partner, parent, child, worker we are. These implicit purposeful qualities of any
instrumental behavior are elevated to values by the act of choosing these qualities.
In a very real sense, individual values must be freely chosen, rather than reasoned out, because
values provide the metric for meaning in life. If you try to justify a value, you must appeal to some other
metric, but then that metric must be justified, and so on forever. At some point, you need to just take
a stand and say, “I hold this to be important.” Verbal reasons may still be present in the form of
thoughts and opinions about why you choose a particular value, but your choice isn’t defended by these
reasons; otherwise, you’d end up back in the justification loop. Ultimately, a vital life imbued with committed action means simply choosing what you will value and then taking steps in that direction, with
reasons coming along for the ride.
This doesn’t mean choices relating to values aren’t deeply considered; in fact, we recommend
exploring them in depth. Scientifically speaking, it also doesn’t mean choices about values have nothing
to do with a person’s history or context. Choices are historically and contextually situated, as all human
actions are, but they aren’t specifically linked to and defended by verbal rules in the form of reasons and
justifications. In the same way, values are (hopefully) chosen with profound intentionality but are
beyond justification.
Defining Valued Directions
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Indeed, values are the very heart of meaning and purpose for humans. They often guide and define
our lives. Furthermore, we often engage in these behaviors even when our actions don’t lead to the
results we hope for. For nonverbal animals, discrete consequences are fairly adequate for explaining
behavior. A pigeon pecks a key to get a food pellet; a rat presses a bar to get a drink of water. For verbally capable humans, the situation isn’t so simple. Discrete external reinforcers only go so far. Money
can be a reinforcer, but given the choice between ten thousand dollars and a rich, loving relationship
with their child, many people would leave the money behind. More broadly speaking, meaning is found
in the textured and connected moments of our lives, whether that connection is to nature, animals,
other humans, or exploration, when such moments lead to contact with a life worth living as personally
defined. Therefore, ACT therapists work with clients to build more of these moments into their lives.
The ACT approach to values isn’t about teaching clients any particular set of morals or “correct”
values or virtues. Rather, it is about helping clients develop a process of valuing that can guide them in
making life choices long after therapy has ended. In this process, clients explore meaning and purpose,
search for what is intrinsically reinforcing, and use all of the flexibility processes to assist them in
engaging in values-­based action while also savoring the experiences that flow from taking values-­based
actions. This entails working with clients to find life directions that resonate with their deepest longings, and then assisting them in establishing goals in keeping with their values, which will ultimately
be more workable than setting goals that aren’t informed by their values.
As mentioned in chapter 1, when working with this process ACT therapists focus on this central
question: “In a world where you could choose to have your life be about something, what would you
choose?” (Wilson & Murrell, 2004, p. 135). You can explore this question with clients in a number of
ways, including conversation, writing exercises, eyes-­closed imagery, and experiential exercises. Versions
of this basic question are asked over and again, to turn clients’ attention to the question of purpose in
their lives, help them discover what really matters to them, and clarify what a well-­lived life would look
like for them.
Why Values?
Values are important in the ACT model for several reasons: they offer constructive direction; they
provide consistent direction; they promote behavioral flexibility and provide motivation; they support
all of the flexibility processes in the ACT model; they allow for effective and pragmatic goal setting;
and they provide a contextual purpose for behavior change.
Providing constructive direction: Values work involves helping clients define what their lives can be
about when escape, avoidance, and fusion aren’t controlling their behavior. Avoidance and escape are
fundamentally about getting rid of some experience and keeping it away. They aren’t about moving
toward anything in particular. Values-­oriented behavior is constructive; it’s about moving in a particular direction or fostering a particular quality in life. One client elucidated constructive direction in this
way: “It’s as if I’ve spent my life on the open ocean swimming away from this one island that I don’t
want to be on. Ultimately, it doesn’t lead anywhere… What I want to do is start swimming toward
something, not away from that island.”
202 Learning ACT, 2d edition
Providing consistent direction: Defining a valued direction creates a consistent compass heading that
can be used to direct action during the storms of life. Amidst waves of emotion and crosscurrents of
thought, we can still chart a course in keeping with our values. Anyone who has engaged in mindfulness meditation for any period of time is aware of the changing nature of emotions and thoughts.
However, values tend not to change frequently. Once clients clarify, state, and commit to their values,
those values become a lighthouse that can help them steer clear of the rocks during psychological
storms.
Promoting behavioral flexibility and motivation: Values are inherently linked to choice. From a
functional contextual point of view, free choice in the realm of valuing is “true” because it’s useful to
speak in that manner, not because it’s literally true. Scientifically, we would guess that values are largely
culturally conditioned. However, from the perspective of the individual human, it can be more empowering and life affirming to see our behavior as a choice because it loosens the largely artificial link
between actions and verbal storytelling. This loosening leads to greater behavioral flexibility and to the
possibility of contacting desired and chosen life directions that have an intensely vitalizing, motivational quality. Research supports the idea that values based on experiential avoidance, social compliance, or cognitive fusion typically don’t lead to positive outcomes (Sheldon & Elliot, 1999); examples
would be “I need to stay with my husband because I’d feel guilty if I left” (probably experiential avoidance), “I want to be a doctor because it’s what my mother wants” (probably social compliance), and
“Good people are kind to others” (probably fusion with a verbal rule). Choosing life directions based on
the intrinsic properties of actions tends to work better.
Supporting other flexibility processes: Practicing acceptance and defusion often means wading into
swamps of anxiety, loss, confusion, or sadness. Values provide the context for inviting clients to contact
these difficult experiences. They aren’t being asked to experience pain for pain’s sake, but to experience
pain in the service of values. From an ACT perspective, values are what make willingness and acceptance more than simply wallowing in difficulties or attempting to reduce unpleasant experiences
through exposure. Similarly, having clarity about their chosen values provides clients with a guide for
workable action when they aren’t responding literally to their thoughts.
Allowing for effective and pragmatic goal setting: Values work helps clients establish goals that are
flexible and pragmatic and increases the likelihood that they will engage in effective action across time.
Many therapies work to help clients develop goals. ACT, however, explores values first and then links
behaviors to these values, connecting action to a meaningful purpose. Values provide the direction,
and valuing is walking in that direction. Values-­based behavior is present from the first steps a person
takes in that direction. Thus, if working toward a particular goal does not effectively further values, it
may be time to reconsider the goal. ACT’s focus on values helps clients engage in the process of vital
living, whereas a focus on goals tends to encourage evaluation of the discrepancies between the current
situation and the goal, or between actual and desired outcomes.
Providing contextual purpose: Values work is central to ACT for important philosophical reasons. In
this contextual approach, what is true is what is workable relative to stated values. Workability becomes
the truth criterion, and living in alignment with values is the measure of success. Without values, we
can’t define what works. This criterion of workability also informs the other flexibility processes. For
example, in defusion, functional truth replaces literal truth. In the same way that literal truth is linked
to conventional meaning within a language community, functional truth is linked to values.
Defining Valued Directions
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What Should Trigger Working with This Process?
Values and values-­based behavior are typically worked on throughout therapy; however, there are a few
situations in which an additional focus on defining valued directions is warranted. Both values and
committed action have a constructive aspect to them that is not as present in the other four flexibility
processes (defusion, acceptance, self-­as-­context, and present-­moment awareness), which are more oriented toward ameliorating or responding to rigid, inflexible, or problematic behaviors. Values are also
central to motivation, both in the sense that they may provide an inexhaustible source of positive
reinforcement and in the sense that contact with discrepancies between values and one’s current
pattern of living can elicit painful feelings that people are typically motivated to escape or avoid.
A primary indicator that values clarification is needed is when clients are out of contact with the
cost of avoidance in their life or when they are numb, distant, overly intellectual, or uninvolved. Other
indicators include clients expressing a sense of purposelessness, or when they note that they can’t care
about others, themselves, or their lives because of past pain or pain that arises when they allow these
aspects of their lives to matter (e.g., “It hurts when I care”). Discussing clients’ hopes, dreams, and
desires for their life can bring them psychologically into contact with the discrepancy between their
current path and the directions in which they’d like to travel. This tends to evoke internal reactions or
barriers that, when brought into the room, can be worked on using the other flexibility processes.
Another key sign indicating that a focus on values is warranted occurs when willingness is low,
when behavior is largely motivated by avoidance, or both. For example, a trauma survivor who is white-­
knuckling her way through exposure-­type exercises as a way to get rid of something might benefit from
a focus on values. Bringing values into the room at such times can create a larger context that facilitates
willingness to do the hard work of developing flexibility in responding to difficult experiences. A focus
on values can help clients get to a place where they would actually choose to undertake this challenging
work because doing so allows them to move forward in bringing their values to life. This is the difference between a client begrudgingly contacting a difficult trauma memory as part of therapy versus one
who is truly leaning into this work in the service of something larger.
Yet another indicator of the need for values work is when clients are overly focused on immediate
goals at the expense of larger patterns of values-­based behavior that could inform their goals. A variety
of difficulties with motivation, consistency, decision making, and avoidance can occur when goals are
disconnected from a larger sense of purpose. Values can provide the glue that binds smaller moments
into a larger and enduring sense of life purpose.
A final pattern that suggests a need for values-­oriented work is when stated values seem to be
linked to compliance, avoidance, or fusion. This may take the form of a strong focus on “shoulds,”
“have-­tos,” or rigid high standards, or an excessive focus on what others want. In these cases, fusion
and avoidance are interfering with making authentic choices because standards and rules are standing
in for values. This allows people to avoid the pain and sense of responsibility associated with focusing
on and identifying what would matter to them if they were free to choose what would be important in
their life. In these cases, values conversations often focus on creating small moments of choice and
freedom that can serve as kernels from which to build an awareness of larger and more enduring patterns of chosen action.
Finally, be aware that clients who aren’t experiencing acute pain often don’t feel the push to change
that can come from a drive to escape an aversive state. In these cases, motivation to change can instead
come from the pull that values exert on behavior.
204 Learning ACT, 2d edition
What Is the Method?
Defining valued directions almost always begins with conversations that have an overarching goal of
helping clients imagine what sort of life would give them a sense of integrity, depth, and vitality. The
idea of values is usually introduced early in therapy, either in a more limited fashion (as discussed in
chapter 2) or in a more extended way, depending on the case conceptualization. From an ACT perspective, values are the “why” of therapy and are at the core of the therapeutic alliance. They provide the
reason for doing all the other hard work of therapy. However, clients are often so focused on their
problems that turning their attention to the larger context of their dreams, hopes, and aspirations for
their lives is unexpected. A bit of an introduction to values work can be helpful for orienting them to
this aspect of therapy, perhaps using a statement along these lines.
Therapist:
You’ve told me a bit about your problems, and I feel like I have a good initial sense of them.
Your problems are important, and we’ll certainly respond to them in here, but your life is
more than your problems. I’d like us to spend some time focusing on the larger context of
your life, which includes your dreams, hopes, and aspirations. These are a large part of
what makes life worth living, and they’re also the context in which you experience your
problems. What I’m suggesting we talk about is what you really want in life. What do you
want your life to be about? What do you want to do? Would it be okay if we spent some
time focusing on that?
The breadth, depth, and focus of initial values work can vary greatly depending on the needs of the
client and the clinical situation. Sometimes the focus can be as narrow as helping clients specify what
they value in a given life situation, as might happen in a brief clinical encounter. At the other end of
the spectrum, it can be as broad as helping clients specify valued directions across all major life domains,
as might happen in more extended therapy.
Common Values Assessments and Tools
An extended values assessment process (e.g., Hayes et al., 2012, chapters 11 and 12) can take multiple sessions and include between-­session work in which clients write out descriptions of valued directions and goals in multiple life domains (e.g., family, intimate relationships, parenting, friends and
social life, work, education, recreation, spirituality, community, and self-­care). In addition to engaging
in discussions focused on clarifying their values, clients develop and write specific, succinct statements
of their values in each domain and then assign ratings of how important each domain is and how consistent their actions are in regard to each value. Finally, they develop values-­based goals in each domain
and initiate actions to work toward those goals (as described in chapter 7). Brief values assessments are
also available, ranging from a few minutes to a session in duration. (Some of these assessments are
available at http://www.contextualscience.org/values_measures.)
We haven’t attempted to review the full body of available techniques or methods for doing this
work, but instead focus on some of the most central skills for helping clients define their values and also
address common roadblocks. Here, we’ll just list some of the more important exercises, metaphors,
stories, worksheets, and procedures available in other resources. However, there are many books and
chapters that include effective approaches to values work, so we encourage you to explore further.
Defining Valued Directions
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Valuing as a choice. This is a structured conversation that helps clients distinguish choices from
reasoned judgments (Hayes et al., 2012, pp. 300–­302, 347).
Distinguishing process from outcome, and direction from goals. Several interventions can help
clients see values as a process of living, not outcomes to be achieved: the Skiing metaphor and the
Path Up the Mountain metaphor (Hayes et al., 2012, pp. 331–­333). Also see Harris, 2009, pp. 191–­
193, for an extended discussion of this topic.
Sweet Spot exercise. In this exercise, clients imagine a sweet moment in their life and consider
how it illuminates their values (Wilson, 2008, pp. 200–­209).
Values compass assessments. These tools involve worksheets and procedures for clarifying values
and looking at how clients’ behaviors align with their values; they may take up to an entire session
to complete (Eifert & Forsyth, 2005, pp. 186–­187; Dahl, Plumb, Stewart, & Lundgren, 2009,
chapter 9).
Bull’s-­Eye Worksheet. This is a brief values assessment covering four key life domains: work and
education, leisure, personal growth and health, and relationships (Dahl et al., 2009, pp. 120–­131).
Comprehensive values assessments. Several sources provide worksheets and guidelines for conducting a comprehensive conversation about values that may stretch across multiple sessions and
multiple life domains (Wilson, 2008, pp. 169–­171; Hayes et al., 2012, pp. 308–­317).
“What do you want your life to stand for” exercises. There are quite a few variations on this
theme, wherein people imagine their funeral, epitaph, or tombstone, or a birthday late in life, and
visualize or identify how their life, well lived, would be described (e.g., Hayes et al., 2012, pp. 304–­
307; Harris, 2009, pp. 202–­203; Eifert & Forsyth, 2005, pp. 154–­155).
Although more or less extensive, all of these approaches include certain steps that are important
in helping clients define valued directions: guiding clients to contact their values and state them explicitly; coaching clients to take a stand for their values; helping clients examine their current life directions in relation to their values; and teaching clients some key discriminations in regard to values.
Along the way, it’s often helpful for therapists to state their own therapy-­related values. In the sections
that follow, we discuss all of these aspects in detail. But before we turn to these specific methods, we
need to first outline the qualities of effective values conversations.
Qualities of Effective Values Conversations
Effective values conversations have discrete qualities: vitality, choice, orientation to the present
moment, and willing vulnerability. All of the methods described in this chapter should be guided by
these qualities. They will help you focus on valuing as an ongoing experiential process while also
decreasing clients’ tendencies to become inflexible and rule bound when working with values assessments, worksheets, procedures, and exercises. Use these qualities as a compass to provide more intuitive guidance on effective values work, rather than getting stuck at a procedural level. If a procedure,
process, or exercise lacks these qualities, it’s important to reformulate, refocus, or otherwise change
direction. In the sections that follow, we describe these qualities in detail and also address common
barriers to developing these qualities and how to work with these barriers.
206 Learning ACT, 2d edition
VITALITY
Making psychological contact with what we most value in life tends to evoke a certain qualitative
reaction often described as vital, alive, or meaningful. Clients (and often therapists, empathically) can
sense the value in the room, even if they haven’t yet taken any action in that direction. Just as a dog
begins to lick its chops when somebody gets out its food bowl, people begin to psychologically taste the
outcome of valuing when it’s present. They light up or wake up.
An essential job of ACT therapists is to monitor the vitality of conversations about values, drawing
out clients’ hopes and dreams and helping them detect the life directions they would freely choose, not
those they’d select in order to avoid guilt, anxiety, shame, or the negative opinions of others. When
working on values, therapists may sometimes have the experience that the conversation is becoming
small, lifeless, grinding, intellectual, or constricted. When this happens, both client and therapist are
probably stuck in a pattern of experiential avoidance and fusion. The session has become about the
concept of values, rather than being an active process of contacting and choosing values in the moment.
Discussions, analysis, and interpretations of values are often dry and boring; experientially contacting
actual valuing in the moment is not. Therefore, ACT therapists seek to bring values into the present
moment, and that requires clinical creativity. We’ll offer a few examples here, but note that prescriptive
methods are unlikely to be successful.
Recalling past experiences that relate to the client’s values can help set the emotional tone for
therapy and bring some of the functions of valuing forward into the present moment. For example,
therapists can help clients locate past experiences in which they felt intense vitality, presence, or
purpose. Eyes-­closed exercises in which clients re-­create such an event via imagination and then consider its meaning may provide guidance about how to live life now. Be sure to have clients recall events
that are both important and specific. Here are a few examples of how you can target such events: “Tell
me about the day you met your wife,” “Tell me about the day you left home,” “Tell me about the most
moving event in your life,” or “What did that feel like inside? Help me see it the way you saw it and feel
it the way you felt it. I want to understand.” This can set the stage for a more meaningful exploration
of values.
There are a number of different approaches that can bring this kind of liveliness into therapy sessions. For example, therapist and client might listen to meaningful music together at the start of a
session as a way to promote contact with values. Poetry, moments of silence, or mindfulness exercises
can serve the same purpose.
Alternatively, you could ask clients whom they admire or find noble, or ask, “Who inspires you?” If
clients are unable to identify anyone, inquire about characters in movies or other fictional characters.
Once they’ve identified someone, ask them to specify what they find admirable about this individual.
Finally, you can ask, “If this person knew you really well, what would he or she want for you in your
life?” The following dialogue illustrates this process. The client is a high school student who’s prone to
procrastination. She’s been struggling in school and is at risk for dropping out. At the time of this
session, she’s been having trouble starting work on a term paper.
Therapist:
If you think of all the people you’ve known and looked up to, does anyone particularly
stand out?
Client:
My third-­grade teacher, Ms. Schweibert.
Therapist:
And what was Ms. Schweibert about? What did you admire about her?
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Client:
She was always upbeat, always having fun. We always knew she cared about us kids.
Therapist:
So what would Ms. Schweibert want for you now?
Client:
She’d want me to learn something, and to graduate at the head of the class.
Therapist:
Yeah, head of the class. She’d want that for you. I have a sense that is something you deeply
respect about her—­her attitude toward people and learning. (Pauses.) Is there anything
else she’d want for you, in addition to being head of the class?
Client:
She’d want me to be happy. She’d want me to do this because I enjoy it, because I want to,
not because I have to or because she told me to.
Therapist:
Is there a way you could make writing your paper live up to that—­for yourself, I mean?
Client:
Yeah, something a little bigger than writing a paper. Not so much what I have to do, but
why I would want to do it.
Therapist:
Yeah. What are you here for—­here and now in this life? If you could have a say in it, what
would you want your tombstone to say? … And now consider how what you’re doing now
lines up with that. I have a sense that what you’ve been working for is others’ regard for
you, but it sounds like what they want for you is for you to be yourself. I want you to look
for something that’s yours. It will probably be bigger than you, but it comes from you. And
“I don’t know” is not an answer. As a kind of homework, would you be willing to write
about this on your own this week and bring it in next time?
Client:
Yeah.
Therapist:
What you might want to write about is something that would make you think, “I’d be
inspired by a person who could do this.” (Writes this on a piece of paper to remind the client
what to write about.) What could you do that would be inspiring to you?
In this dialogue, the therapist is helping the client link schoolwork to the larger context of her life:
her values and life direction. There’s a reason the client respects Ms. Schweibert. By guiding the client
to contact qualities of this teacher whom she admires, the therapist helps the client come into closer
contact with the qualities she wants in her life. Hopefully, this exercise will allow her to see how something small can be related to a much more important and life-­transforming issue.
Newer ACT therapists sometimes get stuck because they think values work largely involves talking
about values and coming up with the right words or phrases to represent them. It’s important to remember that values aren’t things or even statements, but a way of speaking about an ongoing flow of behavior that’s active and purposeful. The work here is about seeing the bigger picture of what values bring
to people’s lives in terms of meaning, giving their actions a sense of purpose by linking them to larger
patterns that involve intrinsic reinforcement. So although attending to the content of what clients say
about their values is part of what’s important, it’s also essential to attend to clients’ tone of voice, their
body language, and the pace of their speech as you explore what’s important to them. Signs of vitality
include a widening of the eyes, physically leaning in, a sense of excitement or curiosity, a softer tone of
voice, slowing down, pausing instead of falling into well-­trodden and overlearned patterns of responding, or broken speech or an exploratory or searching vocal quality when clients are trying to articulate
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new possibilities or meanings. These are some of the indicators of the kind of vitality you want to foster,
and they’re at least as important as the content of what is said. In addition, if the therapist displays
these qualities, this can help elicit vitality in the client due to the human tendency to mirror the
emotion-­related behaviors of others.
CHOICE
By “choice” we mean the experience of values being selected freely and not under the sway of
avoidance, rigid rules, or social manipulation. ACT works to disrupt fusion with “shoulds” and “musts”
and to create a sense of expansive possibilities. Clients often feel coerced by others or by their own
history, feelings, and thoughts, and even by their values. In ACT, it’s important for therapists to be alert
to this sense of coercion and the alternative: choice. For example, it’s common for clients to say they
have to value certain things. This is almost always a verbal trap. Values are not a stick with which to
beat anyone into submission.; they are chosen qualities of action.
Among the many common barriers to such free choice is fusion with the idea that we need to
coerce ourselves in some manner, that unless we control or contain our feelings, thoughts, or other
private experiences, what we will choose to value will be harmful, dangerous, toxic to others, or even
evil. This story implies that if we allow ourselves to choose freely, we may be inclined to choose selfishly
or poorly. If you can disrupt fusion with this story and help clients connect with the possibility of being
able to choose their own path, they often have a sense of innocence refound despite the harshness with
which they may have learned to treat themselves in order to cope. They may come into contact with
parts of themselves (i.e., their values) that feel untouched, unjaded, and pure. Sometimes tears of gratitude emerge. Sometimes clients feel embarrassment over being observed by the therapist while feeling
something so innocent or earnest as to seem naive. If such experiences arise during values work, help
clients recognize and embrace them as part of the process of reclaiming buried values or discovering
new ones.
Sometimes clients provide vague or noncommittal answers to questions about values because they
don’t have a history that taught them how to effectively identify or describe their needs and wants or
their desires for their lives. For clients with this problem, you may need to build their ability to make
choices by focusing on micro-level, moment-­to-­moment, situation-­to-­situation needs and desires, rather
than on broader values. Accordingly, the place to start such work is in the moment, in session. You can
ask, “In this session, right now, if anything could happen here, what would you want? Aim high.” Often
clients state some kind of goal, such as “I’d want to feel better” or “I’d want to understand this problem
better.” In order to get to the underlying value, you need to look for ways of living that are blocked
because a client believes a particular goal must be attained first. Possible responses to such client statements include “And if that were to happen, what would you do?” or “If that were to happen, what do
you imagine life would be like?” You can also ask questions that bring perspective taking into the
session. For example, in the previous dialogue, the therapist might say, “If Ms. Schweibert were here
watching you work so hard to understand this problem, how would she want you to treat yourself? How
would she be toward you as you struggled to understand it?” Questions like these can guide clients to
describe the kind of life they want to live, rather than stating more common responses about what
they’d like to feel, be right about, or know.
Most values have a social component, so the therapeutic relationship can provide one of the more
immediate areas for exploring values. Strategies to help clients make values-­based choices can be
Defining Valued Directions
209
intensified by focusing on them in session, with the therapist modeling, instigating, and reinforcing
flexibility processes in ways that are immediate, vital, and vulnerable. For example, in the preceding
dialogue, the therapist could have said, “If our therapeutic relationship, right now, had the qualities you
most want, what would they be?”
As mentioned, sometimes clients feel coerced by their chosen values, particularly when values-­
based choices lead to pain. Consider a client with a history of abuse who knows the uncle who abused
her will be at her sister’s wedding. The client might take the stance of “I have to be willing to suffer
through it,” reflecting a belief that living her values means she has to endure or fight her way through
suffering. This takes the heart out of values work, which is more about choice and meaning than “have-­
tos” and “shoulds.” The goal in a situation like this is not begrudging tolerance of difficult emotions,
but instead a full embracing of one’s experience as part of living a valued life. In this case, a therapeutic
goal might be to help the client bring a sense of choice into the situation.
Therapist:
Well, you don’t have to go to the wedding. You could choose not to go. It’s a matter of what
you hold as important. Let’s say I could offer you a choice. On the one hand, you could
send a perfect robot replica of yourself to the wedding so no one would ever know you
weren’t there. Your sister would be happy and so would your relatives. You wouldn’t have
to face your uncle. Of course, you’d miss out on this important event in your sister’s life.
On the other hand, if you go to the wedding, you get to be right there next to your sister
when she says, “I do.” However, if you make this choice, in order to fully be there for the
wedding, you’ll also have all of the discomfort and anxiety of facing your uncle. Consider
this for a moment before answering: if this were the choice, which would you choose?
The manner in which therapists deliver these types of comments is important. This kind of work
can’t be done from a one-­up position, or it may seem to communicate judgment and a sense of “rightness,” implying that the latter choice is best. Linking this work to freely chosen values is always paramount. Even carefully worded presentations of choices like in the preceding example can be misread or
misinterpreted. Ultimately, what’s right depends on workability with respect to a particular client’s
values in a particular situation. The client in this example may choose the robot option. The workability of this option is not for the therapist to determine; it’s something for the client to notice and
learn from.
PRESENT ORIENTED
Although conversations about values often have a future orientation, they are also about the
present. Something that is values-­based is valued in the present moment. Values work brings the future
into the present moment in the service of building larger and larger patterns of action linked to valued
directions. This present-­moment focus can provide a powerful prophylactic to avoidance. Normally,
immediate consequences are much more important in controlling behavior than delayed consequences
are. Part of what makes experiential avoidance powerful is that its impact is often immediate. For a
person with social anxiety, retreating from a difficult social situation is immediately reinforcing because
it results in a reduction of anxiety. The consequences, such as loneliness and lack of intimacy, are only
felt later, often as a result of a pattern of social avoidance over time. Values work pulls extended appetitive consequences forward in time. For example, for the client in the preceding vignette, choosing to
go to the wedding in order to be with her sister is a value not simply when the wedding occurs, but also
in the moment in session. Values work can help this client notice that even the work of actively
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choosing what she would value in her relationship with her sister and attending her wedding is valuing
that relationship. Valuing doesn’t just happen at the ceremony; it’s happening in the moment in the
therapy room.
WILLING VULNERABILITY
One of the best indicators of an effective values conversation is when their bittersweet qualities
show up in the room. When clients open up to their values, one of the more common emotional reactions is crying. These tears aren’t about resisted and unwelcome pain, but about caring and vulnerability. They generally occur due to past pain but honor present values. People tend to be hurt in relation
to things they care about; therefore, when people turn away from valuing in order to avoid pain, greater
pain is often created—­the pain that comes from not living a vital, values-­based life. When therapy
helps clients adjust their course and return to moving in a valued direction, the emotional vulnerability
of that transition is often present. However, any pain associated with this shift will be pain carried for
a purpose. Inside this pain we humans find our values, and inside our values we find our pain—­and
also our joy. A classic example is a person who’s been hurt in a romantic relationship. When that person
chooses to love again, vulnerability will be a part of that choice. Risking love means risking loss. In
session, if you sense willing vulnerability on a client’s part, that’s a beacon to be followed, as it generally
indicates contact with values and the things that the client holds dear.
Guiding Clients to Contact Their Values and State
Them Explicitly
Effective values conversations take values out of the abstract and make them clear and explicit. It’s
often worthwhile to encourage clients to distill their values in various domains down to what is most
essential to them in those domains. Such statements are often recorded on a form or handout that
clients can keep with them. However, these statements are not values per se; rather, they are an explicit
guide to the qualities clients intend to bring to the moments that make up their life. It’s important to
keep in mind the four qualities of effective values conversations when helping clients articulate these
desired qualities of action. Sometimes moving too quickly to come up with a word or phrase can kill
the vitality in the process of discovering and explicating values. With some clients, it may be more
effective to ask them to identify pictures, images, or objects that represent their values, at least
initially.
Coaching Clients to Take a Stand for Their Values
Often, publicly stating a value is the first step down a new values-­based path. In ACT, therapists
create structured opportunities for clients to make an explicit commitment to bringing their values
more fully into their lives. To that end, you might encourage clients to make commitments to you, or
to other people in their lives, about what they intend to do in regard to their values. Chapter 7, on committed action, offers more specifics on helping clients develop concrete actions and goals that will allow
them to move in valued directions.
Defining Valued Directions
211
Helping Clients Examine Current Life Directions in
Relation to Their Values
Living without attention to closely held values typically generates a great deal of suffering. In
therapy, this is abundantly evident, as the current behavior of many clients is inconsistent with what
they value. Therefore, an essential part of values work is to help clients determine how closely their
current behavior aligns with their values. Because this requires looking at the ways in which they aren’t
living in alignment with their values, it can potentially create a sense of shame, which is usually counterproductive. So it’s important that clients not fuse with thoughts such as I’m bad in the process of
looking at the pain that comes from not living life as they truly intend. When leading clients to notice
this discrepancy, take the stance that whatever they’ve been doing is understandable given their history,
while also helping them courageously examine whether their current behavior aligns with their valued
directions. The focus is on guiding clients to contact the pain of not living as they intend, while also
helping them move in new directions rather than engaging in further avoidance.
The following example illustrates this approach. The client is Elisha, a lonely, defensive woman
with an overly intellectual orientation. Her homework from the previous session had been to write two
epitaphs for herself: one summarizing what her life would have stood for if she were to die at this point,
and one that would reflect her life after twenty years if it could say anything she wanted.
Therapist:
So, how did the writing go? What did you come up with?
Client:
I didn’t like doing the one about what it would say if I died today. But I did come up with
something. What I wrote was “She spent a lot of time trying to figure out what would
make her happy.” And what I wanted on the tombstone if it could say anything is “She was
happy.”
Therapist:
Do you mind if we focus on the first one for a minute?
Client:
Okay.
Therapist:
So you would say the best summary of what your life has been about so far is that you spent
a lot of time trying to figure out what would make you happy. And how has it turned out?
Client:
Not well. I haven’t figured it out.
Therapist:
And so maybe the tombstone would say something like “Here lies Elisha. She spent her
whole life trying to be happy and never made it.” How do you feel about that tombstone?
Client:
I don’t like it. It sucks. I don’t want to be a failure.
Therapist:
I invite you to sit for a minute with this… Are you willing to do that? (Creates a sense of
choice by asking permission.)
Client:
Okay.
Therapist:
Just close your eyes and notice for a moment what it’s like to have that be on your tombstone. (Speaks slowly and deliberately.) “Here lies Elisha, she spent her whole life trying to
be happy and never made it.” Notice what feelings come up… What your body feels like…
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What you feel in your stomach…your arms…your shoulders… What thoughts come up?
… Notice if there are any memories associated with this. (Pauses.) Okay, you can open
your eyes.
Client:
It sucks. I feel terrible. I don’t want to think about it.
Therapist:
Go into it a little further.
Client:
It seems so impossible. And I can’t imagine what it would be for anyway. The world’s all
going to end someday. Ultimately, it won’t matter anyway. (Appears to be fused with a story
that serves to keep her from contacting the gap between her values and her current life.)
Therapist:
You’re building a wall of words. What do you want? Your pain is your biggest ally here. Go
into it. What are you defending yourself against? Look there… What do you really, really
want? (The therapist doesn’t address the fusion directly, but sidesteps it to keep the focus on
values.)
Client:
(Cries.) People. I want people in my life.
Teaching Relevant Discriminations
It can be helpful to teach clients three key discriminations in regard to values. The first is the distinction between values as directions versus goals, alluded to earlier. The second is the distinction
between process versus outcome (Hayes et al., 2012, pp. 331–­333). The third is the distinction between
values as qualities of actions versus feelings (Ibid., pp. 298–­300).
DISTINGUISHING BETWEEN VALUES AND GOALS
When you ask clients what they want in life, you’re likely to get responses that contain a mixture
of goals and values. The goals are often process goals, meaning they are things clients believe they must
acquire or achieve in order to have the wished-­for values. In many cases, these goals are some variation
on the theme of feeling better (e.g., experiencing less anxiety, pain, or loneliness or having higher
self-­esteem).
ACT helps clients distinguish between values, which can be seen as ongoing patterns of behavior
that take a consistent direction, and goals, which are concrete achievements or events that can be
accomplished and finished. When clients present a goal as a value, the therapist’s job is to dig around
and abstract the value that underlies or informs the goal. The following exercise will give you some
practice in distinguishing between values and goals in a client’s statements.
Exercise:
Values and Goals
In the following dialogue, circle elements of the client’s speech that reflect values, and underline those
that are goals. Do this before you read on to see our interpretations.
Defining Valued Directions
213
Therapist:
So, tell me, if this anxiety were to just magically go away and your life was how you want
it to be, what would your life be like then?
Client:
Hmm. I’d be happier. I’d have at least two or three friends with whom I really share things.
I’d go out and do things I like, such as going to the movies or riding my bike. I might be in
a community theater, or at least go to plays. I’d stay more in touch with art. It helps me
appreciate beauty. I’d have a good relationship with my boyfriend. There’d be a lot less
fighting and crying. I’d probably have a better relationship with my mom; I’d try to be
there more for her. And I’d be making more money.
Now we’ll walk through the client’s response, sentence by sentence, trying to tease apart her goals
and values.
Client:
I’d be happier.
You might think being happier is a value, and if you define it as eudaemonia, or the happiness that
comes from living in a way that’s consistent with one’s values, it is the very essence of values. But if you
define happiness as an emotional reaction, happiness is a goal, not a value. Looked at that way, happiness is an event that comes and goes as a result of action, not a chosen quality of action. Emotionally,
it isn’t possible to simply choose happiness.
Client:
I’d have at least two or three friends with whom I really share things.
“Having two or three friends” is a goal because it can be completed, but this sentence includes the
explicit value of sharing in relationships.
Client:
I’d go out and do things I like, such as going to the movies or riding my bike.
This is primarily a values statement. The statement “things I like” could use some clarification. If
it refers primarily to an emotional result, it isn’t a value. But people often use this kind of wording to
refer to things that engage them in the joy of living, in which case it is a value, albeit one that could
bear further clarification.
Client:
I might be in a community theater, or at least go to plays. I’d stay more in touch with art.
It helps me appreciate beauty.
Appreciating beauty by participating in art is a value. Being in a community theater or going to
plays is a goal.
Client:
I’d have a good relationship with my boyfriend.
“Good relationship” is not yet a value because it doesn’t specify the qualities of relationship the
client holds as important. The therapist can help the client clarify this.
Client:
There’d be a lot less fighting and crying.
This is a goal.
Client:
I’d probably have a better relationship with my mom. I’d try to be there more for her.
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Again, “better relationship” is not yet a value because it doesn’t specify the qualities of relationship
that are important to the client. However, “be there more for her” is a value, if a bit vague. Again, the
therapist can help the client clarify this value.
Client:
And I’d be making more money.
This is a goal, not a value.
Of course, when clients report a goal, one or more values often underlie that goal. It’s important for
the therapist to abstract the important valued directions that underlie the goal and help the client
make them explicit. The remainder of the exercise will help you practice this. We’ll present some of the
goal statements from the preceding example and ask you to generate questions that might help the
client get to the values that underlie these goals. For each, write two questions you could ask before
looking at the model questions that follow.
Client goal: “I’d have a good relationship with my boyfriend.”
Question 1: Question 2: Models for comparison
Question 1: What would a good relationship with your boyfriend look like? Describe it for me, drawing a
detailed picture.
Question 2: If you could be the kind of person you most want to be with your boyfriend, what would that
person be like?
Client goal: “There’d be a lot less fighting and crying.”
Question 1: Question 2: Defining Valued Directions
215
Models for comparison
Question 1: What is “less fighting and crying” about? Why is that important?
Question 2: If I could wave a magic wand and fighting and crying were no longer an issue in your relationship, what would that make possible? What do you hope would happen?
Client goal: “I’d be making more money.”
Question 1: Question 2: Models for comparison
Question 1: Imagine you had more money. What would you be doing with it?
Question 2: Let’s say you won the lottery and had all the money you needed. What would you do then?
DISTINGUISHING BETWEEN PROCESS AND OUTCOME
The main purpose of teaching clients to distinguish between values and goals is to help them
become more focused on the process of living and less attached to the outcomes of their actions. Many
people become attached to the idea of achieving goals as the way to lead a fulfilling life. In ACT, goals
can be used pragmatically to provide an indicator of effective action, but only if clients hold their goals
lightly, as a guide for values-­based action, not as an end in themselves.
The problem with having too strong of an attachment to goals is that this tends to draw attention
away from the present moment. We humans generally aren’t satisfied with achieving a single goal;
rather, as soon as a goal is achieved, another goal must be established, so we are once again short of the
goal. Values, on the other hand, draw our focus to the process of living and valuing in whatever situation life has handed to us. The opportunity for valuing is always here and now, in our behavior. There
is nowhere we need to go before we can value, and nothing we need to wait for to begin valuing. From
the ACT perspective, what’s important is a meaningful process of living. Connection to what matters
to us is possible in every moment and every situation.
We can control our choices and what we do with our hands and feet, but we can’t always control
how life turns out. For example, a daughter may value being loving in her relationship with her mother,
but her mother may refuse all contact. That doesn’t mean the value isn’t present for the daughter and
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that she can’t manifest it, whether through a thought, a card, a conversation with a sibling, or other
means. Consider water held back by a dam. The force of the water on the dam is like the value. Unable
to move, the water can’t express this latent energy. But given an opening, the force of the water (i.e.,
the value) will be fully revealed. Simply because behavior is constrained by a situation doesn’t mean the
value cannot still be held.
VALUING AS AN ACTION AS OPPOSED TO A FEELING
The third key distinction is between values as qualities of actions versus feelings. Clients often
think values are how they feel about a given situation—in other words, their desires or sense of motivation. Let’s consider the example of exercise. Sometimes you may feel like exercising, so in normal parlance, you’re motivated to exercise; other times you may not feel like exercising. If you tie the action of
exercising to feelings of motivation or desire, this is likely to lead to inconsistency in action or, if you
rarely feel motivated, perhaps complete inaction. However, if engaging in health-­promoting behaviors
is consistent with one of your chosen values, you might exercise even when you don’t feel motivated to
do so. Feelings, thoughts, and preferences come and go. Obstacles to living life in line with what’s most
important to us invariably arise. Nevertheless, in many areas of life it’s important to be able to do what
matters to us even when we don’t feel like doing it.
The intent isn’t to ignore our feelings and follow rigid rules about what we should do, but to build
flexible and workable patterns of action that take into account the larger picture, in addition to the
shorter-­term contingencies that are typically reflected in preferences and desires. If we think of values
as chosen life directions, they can be seen as compass headings that we follow. The value (i.e., the
direction) is there, even if we don’t feel like heading in that direction, and it keeps us oriented as we
move forward. Although our feelings and thoughts in the moment often have a bearing on what we do
and can lead to twists and turns in the path, ultimately our values are revealed through the overall
direction we take. The value isn’t revealed by how we feel about the direction, but by our pattern of
living.
Directly Stating Your
Therapy-­Relevant Values
ACT therapists implicitly value their
clients’ valuing. They value redirecting
clients’ energy away from futile and ultimately costly goals (e.g., reducing unwanted
feelings and thoughts) and toward living a
life defined by what they most want to be
about. By making this therapeutic value
explicit and committing to it with clients,
you can both model and instigate valuing
and commitment, just as you’re asking clients
Defining Valued Directions
217
to do. In the process, it’s important to cast commitment as an opportunity that clients can take advantage of, rather than something they must do.
In early sessions, before clients’ values are clear, this commitment can take the form of a somewhat
generic statement: “I want this therapy to be connected to what you most want your life to be about. I
want you to know that I’m committed to working with you during our sessions to help you discover
what you most want in life, and that I’ll dedicate our work to that.”
Therapists can also make more specific commitments depending upon what they know about a
given client’s values and life situation. It can be especially effective to make such a commitment after
the client has taken a public stand for a value. Consider the following dialogue from a session in which
the client has just engaged in an imaginal exercise that involved attending his own funeral.
Therapist:
So you don’t think your daughter would say those kinds of things about you now?
Client:
Nope.
Therapist:
Because of the past? You haven’t always been there for her. You’ve spent time in prison, you
abandoned her and her mom, and drugs got in the way. What did you notice when she said
those nice things about you in this exercise?
Client:
That’s exactly what I’d want her to say about me. It felt good, but it also felt fake because
that’s not how it really is.
Therapist:
Yeah, it was how you want it to be.
Client:
Right, but she won’t let me be close to her.
Therapist:
She sometimes makes it hard for you to love her. You call, and the first thing she does is
ask for money. She doesn’t trust you. It’s tough to be loving when she’s like that. By the
way, you know that whether or not people will say things like that about you at your
funeral depends on how you live your life. I can’t guarantee how it’s going to turn out, but
I can guarantee that if you’re a loving dad—­if you’re there for her when she calls and you’re
supportive, as you said—­it will increase the chances that someday she might feel that way
about you and even say something like that. But not if you keep withdrawing from her. Let
me ask you this: Are you willing to stand up here, look me in the eye, and tell me the kind
of father you’d like to be with your daughter—­even though she makes it difficult, and even
though you feel crappy a lot of the time when she calls and all she seems to want is money?
How do you want to be in this relationship? (Helps the client commit to his values.)
Client:
I want to be loving and supportive when she calls, regardless. That doesn’t necessarily
mean I’m going to just give her money. But I’m going to be there for her as a dad.
Therapist:
Are you willing to stand up and say that this is what you’re going to be about in relation to
your daughter, even knowing there will be times when she makes it hard, when you feel
used, and when you feel disappointed or angry? Will you stand up and commit to that,
even knowing it will be extremely difficult at times?
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Client:
Yeah, I want to be that kind of father.
Therapist:
Okay then, I invite you to stand up and tell me what kind of father you want to be.
Client:
(Stands up and looks the therapist in the eye.) I want to be a loving, supportive father even
when she makes it difficult.
Therapist:
Awesome! I’m inspired by that. I want our work to be about that. I’m committed to making
that possible for you. (The therapist shares her therapy-­relevant values.)
As an ACT therapist, you’ll benefit from working to identify your values in relation to your clients
and also in relation to yourself as a therapist—­facets of the work that sometimes remain unexamined
by therapists. How many times during your professional training did you have a conversation with a
supervisor or mentor about what kind of therapist you most wanted to be or what you hold as most
important in working with clients? This isn’t a common topic. If you had more than a conversation or
two about it during your training, your experience was unusual. Yet if you aren’t clear about your values
in your work with clients, you’ll probably have difficulty making commitments to clients that are consistent with the ACT framework. Being clear on your values as a therapist and developing practices
that help you more consistently make your work be about those values will benefit your work and make
it more vital for you. To that end, we offer the following two exercises to help you identify your values
as a therapist.
Experiential Exercise:
Identifying Your Values as a Therapist
When you are at your best during sessions, what are you like?
If you could give your clients anything as a result of your work with them, what would you give them?
Would it be particular skills, behavioral changes, knowledge, a quality of relationship, certain experiences, or something else?
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Defining Valued Directions
Now, to offer you a more experiential way of approaching this question, we’ll ask you to do a brief eyes-­
closed exercise in which you imagine you’re at your retirement party. Begin by closing your eyes and
taking some time to get centered. Next, imagine that you’re at the party and take time to picture some
of the details: where the party would be held, who might show up, and so on. Finally, imagine that three
of your favorite clients, ones with whom you did your best work, are at this party, and each gives a short
speech about you. (We know this probably wouldn’t happen, but since this is happening in your imagination, you get to choose.) Give those clients a chance to say what you meant to them, what was most
memorable about your sessions together, or what was most important about how you were with them.
When you’ve completed the visualization, write a short summary of what each client said:
Experiential Exercise:
Committing to Your Values as a Therapist
Take a moment to recall a very difficult day you had as a therapist. Remember what happened that day
that made it difficult. Maybe you felt as though you failed a client. Maybe you felt exhausted under the
weight of all the suffering. Maybe you felt shame or guilt over something you did or didn’t do. Take a
moment to recall how you felt and what you were thinking that day, including any self-­evaluations that
came up. Briefly describe that day and your feelings:
Now imagine that a dear colleague, someone you really care about, comes into your office one afternoon and shares about having that same kind of terrible day. How would you want to respond to that
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colleague? What would you say? What might your face look like as you heard that colleague tell you
about those feelings of shame, exhaustion, or incompetence? How would your voice sound when you
respond? Write down what you might say and how you might say it:
Now that you’ve thought about what matters to you as a therapist from all of the angles in this exercise
and the previous one, see if you can summarize the essence of what you value in a succinct statement.
What kind of therapist do you want to be? What do you want to create? What do you want to do? Write
a preliminary statement here.
As a therapist, I most want to How important is this to you? (0 = not at all important, 10 = very important): Over the past two weeks, how consistent have your actions been with respect to this value? (0 = not
at all consistent, 10 = very consistent) What is one thing you could do this week that’s in line with this value?
Now we invite you to practice how you might make a values-­related commitment to your current
clients. Bring two of your current clients to mind. When you consider them, think about what the two
of you are working on together, what these clients most value, and what you value. Then answer this
question: If you were going to make a commitment to each client that expresses a value you have in
terms of your work with that client, what would you say? (An example of how you might phrase this is
“I want you to know that in our work together, I am committed to…”)
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Client 2: Finally, consider whether you’ll actually make these statements to your clients.
Will you tell client 1? Will you tell client 2? Values? What Values?
One common but tricky barrier is worth mentioning. Sometimes clients deny that they have any
values at all. This denial often results from fear of the pain that might be associated with having a
conversation about their values. Clients who respond like this may be hopeless about the possibility of
expressing their values or find it too painful to contact what they care about most. Such clients tend to
be focused on how things will turn out. They’re afraid to step out of the safety zone of “I don’t care,” “I
don’t know,” or “It doesn’t matter.” Undermining this type of avoidance often requires an exploration
of the pain associated with caring, using questions along these lines:
“What did you value before this cloud descended on you?”
“When you were a child, is this how you dreamed your life would turn out? What did you dream it
would look like?”
“In the past, what kind of person have you dreamed of being? Was there any sense of creating kindness, for example, or maybe strength, love, or curiosity? Were there any other ways of being you
dreamed of?”
With such clients, it’s helpful to ask them to temporarily set the barrier of “not having values.” Here
are some questions you can ask to facilitate this:
“Pretend you’re someone who knows what you want. What would you want?”
“What kind of life would you be creating if you stood for what you want?”
One small caution about asking these kinds of questions: You want to be sure the question focuses
on creating and standing for a value as something the client does, not something they simply wish they
could be.
Although it’s rare, you may occasionally encounter a client who truly seems to have no values. This
definitely makes the work more challenging. In such cases, the best place to begin may be with what
the client doesn’t want in her life (e.g., to be in jail).
Here’s an example that illustrates such an approach. Julie is a thirty-­five-­year-­old woman who has
an extensive history of sexual trauma, both as a child and as an adult. She works as an exotic dancer
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and print designer and is constantly chasing the next dollar to make ends meet. She perceives herself
as living on the edge of financial disaster. She has no close friends, and most of her time outside of work
is taken up by smoking marijuana, exercise, and masturbation. The few relationships she has are filled
with conflict, and she’s chronically angry. She says that years ago she gave up hope that her life could
be better, and now she just wants to learn how to get by without being victimized again. This dialogue
is from her fourth session.
Therapist:
I want you to consider a question I think might be difficult for you. It’s a central question
for this therapy, so I hope you’ll be willing to consider it. What I’d like to know is, what do
you want to do in your life that you aren’t doing now?
Client:
What? There’s no point in thinking about that. I don’t care about anything anymore. I just
get disappointed whenever I hope for something. (As is frequently the case, the values question elicits fusion and avoidance.)
Therapist:
I can see that it’s painful for you to hope for something. You’ve had many experiences of
things not working out. I’m just asking, if you could have it be some other way, what would
that be? What would you rather be doing with your life that you aren’t now?
Client:
I don’t know. I don’t care anymore. Nothing.
Therapist:
You could follow this path out for the next five years, ten years, fifteen years. You could
continue the way you’ve been going. Take a second to picture what that would be like.
(Pauses for a long moment.) Are you okay with that? (Uses temporal perspective taking to
extend the current pattern of living into the future and increase a sense of psychological contact
with the consequences of that pattern.)
Client:
(Pauses.) It’s awful.
Therapist:
I can see that you feel so hopeless about anything turning out the way you want. Your
mind wants to protect you by saying it’s easier not to care. (Includes a bit of defusion by
referring to the client’s mind as a separate entity.) That’s what you just saw in those five, ten,
and fifteen years, yes? And apparently it doesn’t look good… Are you willing to play with
me for a minute around this? Let’s pretend: If you were someone who cared, what would
you care about? What would you want?
Client:
It’s hard to think about. (Sighs.) I guess…uh…I’d want to have someone in my life whom
I could trust. I’ve never had that. (Starts to cry. Some vitality shows up and perhaps some
willing vulnerability.)
Therapist:
I can see how much you want that, and how much it feels like that’s missing from your life.
I want to help you have that in your life.
In this example, the client was hesitant to speak about what she might want not because she
doesn’t have ideas about the future, but because it’s painful for her to consider her values. Due to
chronic avoidance, she’s unclear about what she feels or wants. In such situations, all of the ACT flexibility processes are needed to support clients in learning how to contact their values.
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Defining Valued Directions
Core Competency Practice
In this section we provide an opportunity for you to practice what you’ve learned in this chapter. As in
previous chapters, for each core competency we provide a brief case description and sample dialogues.
Be sure to write out your responses and your explanations for them before comparing them to the
model responses at the end of the chapter. There is no exercise for competency 36: “The therapist
respects client values and, if unable to support them, offers a referral or other alternative.” This issue is
discussed in detail in chapter 11, as this typically needs to be considered in a larger cultural context.
Note that the exercise for competency 31 (the first values competency), is structured differently than
most of the other core competency exercises. For this competency, we present a series of brief dialogues
that reflect client statements about values that can lead down a dead end. This provides you with multiple opportunities to test your capacity to work with common issues, with the model responses providing examples of how to get out of common traps.
Core Competency Exercises
Competency 31: The therapist helps the client clarify values-­based life
directions.
Exercise 31.1
The following client is a fifty-­eight-­year-­old woman with severe social anxiety.
Therapist:
What do you want in your life that you feel you don’t have today?
Client:
I want to have less of this anxiety. I just want to be able to go out of my house and be like
a normal person.
Therapist:
And why do you want to be able to get out of your house?
Client:
Because the life I live is not much of a life.
Write here (or in a notebook) what your response would be, keeping in mind that the focus is on competency 31:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 31.2
The client is a forty-­six-­year-­old chronically depressed man who has no friends and no job and is generally disengaged from life.
Therapist:
What dreams do you have for your life?
Client:
I don’t know.
Write here (or in a notebook) what your response would be, demonstrating competency 31:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
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Exercise 31.3
This dialogue continues with the same client as in the previous exercise.
Therapist:
When was the last time you had dreams for your life? How far back do we need to go?
Client:
It’s been so long that I don’t want to think about it.
Write here (or in a notebook) what your response would be, demonstrating competency 31:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 31.4
The client is a seventeen-­year-­old woman who is highly emotionally avoidant and has few life goals.
Therapist:
What is it you want? What do you really want?
Client:
Happiness. That’s what I want more than anything.
Write here (or in a notebook) what your response would be, demonstrating competency 31:
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In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 31.5
This exercise and the next, the last two for competency 31, reflect somewhat trickier barriers to identifying or contacting values. Your job is to generate responses that will help these clients temporarily
set aside the barrier and perhaps get more in contact with what is important to them. In this first exercise, the client is a forty-­five-­year-­old man with psychosis.
Therapist:
What would you most want your life to be about?
Client:
Becoming president of the United States.
Write here (or in a notebook) what your response would be, demonstrating competency 31:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
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Exercise 31.6
The client is a twenty-­eight-­year-­old depressed woman.
Therapist:
What dreams do you have for your life?
Client:
I guess I’d dream of pleasing my parents.
Write here (or in a notebook) what your response would be, demonstrating competency 31:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 32: The therapist helps clients commit to what they want their life
to stand for and focuses the therapy on this process.
Exercise 32
The client is a forty-­three-­year-­old man with lifelong dysthymia and difficulty in initiating and maintaining intimate relationships. The therapist and client have already identified key values for the client
and recently identified an important value in the area of couple relationships that the client is neglecting. In this dialogue, the therapist is working toward helping the client move toward committing to
what he wants his life to stand for.
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Therapist:
You’ve identified that it’s important to you to be in a relationship that’s supportive, close,
and fun. Yet you still find yourself without a partner, and you aren’t even headed in that
direction. Is this what you want for your life?
Client:
Of course not. But I really don’t know anyone who would want to be with me. Reaching
out is hard. I think I’ll be rejected.
Therapist:
(Speaks gently, in an inviting way.) So I have some important questions for you. First, I want
you to take a moment and connect with the intention toward which you want to work:
being in a supportive, close, fun relationship. Here are my questions: What are you going
to be about in your life? Are you going to be about keeping away rejection and preventing
failure in relationships? Or are you going to be about being in a supportive, close, fun relationship? Are you willing to take a stand for this value in your life? What would you be
doing if you weren’t busy avoiding rejection?
Client:
But I’m not sure if I can do it.
Write here (or in a notebook) what your response would be, demonstrating competency 32:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
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Competency 33: The therapist teaches the client to distinguish between values
and goals.
Exercise 33
Earlier in this chapter, you practiced distinguishing between values and goals. Take time now to apply
this same kind of practice to two clients you’ve been working with for a while. For each, list a value you
believe that client has. Then, considering the client, list some goals that would be supportive of that
value.
Client 1
Value: Goals: Client 2
Value: Goals: Competency 34: The therapist distinguishes between outcomes achieved and
involvement in the process of living.
Exercise 34
A twenty-­six-­year-­old male client is about to begin dating for the first time in several years. The previous week he described a value of wanting to be “someone who was reaching out, loving, involved, and
real in relationships.” He committed to sending out at least one e-­mail every day in response to an
online personal ad as a way of moving in this direction. He came to the current session having sent out
an e-­mail every day and feeling disappointed that no one had responded yet.
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Client:
Yeah, I did it. But no one has responded. It didn’t work.
Therapist:
(Speaks in a curious, nonjudgmental tone.) Okay, hold on a minute. Let’s go back to the
point of this exercise. Why were you sending these e-­mails? What is it about?
Client:
Getting a new girlfriend. And it didn’t work out. I’m not getting any responses. It feels like
this is a total waste of time.
Write here (or in a notebook) what your response would be, demonstrating competency 34:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 35: The therapist states his or her own therapy-­relevant values and
models their importance.
Exercise 35
Write three sentences that describe your therapy-­relevant values. State them as if you were talking to a
client:
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Core Competency Model Responses
Competency 31
Model Response 31.1a
Therapist:
And what feels as though it’s missing from your life? What did you wish for in your life that
you don’t have now? When you’re sitting at home, afraid to go out, what are you wishing
you could have or be about in your life? Take a moment and consider it. Sometimes your
pain itself is a guide.
Explanation: Getting out of the house is a goal, not a value. The therapist needs to get the issue
focused on what the client wants, but the client is giving defended answers. So the therapist works to
move closer to her pain.
Model Response 31.1b
Therapist:
Would you be willing to close your eyes and picture that life? You wake up in the morning
in this new life where you’re able to get out and interact with people. Tell me what you
notice. What’s different?
Explanation: The therapist uses a perspective-­taking exercise to help the client see and feel a life where
she’s living according to her values. Rather than talking about values, which would be less experiential,
the therapist is leading the client to feel her way into it and, in her imagination, sample some of what
this new pattern of action might be like.
Model Response 31.2a
Therapist:
When you were a child, did you imagine your life would turn out like this? Is this what you
imagined for yourself?
Explanation: The client’s answer is defended. Connecting the client with his childhood dreams and
hopes can make his defense begin to feel self-­invalidating. Many clients let go of avoidance and defense
at this point.
Model Response 31.2b
Therapist:
Who do you admire? … Tell me what you admire about that person.
Explanation: If the client is extremely low functioning, he may not have much experience with articulating his needs, desires, values, and goals, or he may have given up on goals that seem out of reach. By
leading a discussion about who the client admires, it may be possible for the therapist, the client, or
both to abstract out what’s important to him regarding how he wants to live.
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Model Response 31.3a
Therapist:
Yeah, it’s painful to think about how your life is so far from what you wanted for yourself.
I get that. (The client begins to cry.) You’ve given up on so many dreams and hopes for your
life. I really want to hear about the dreams you’ve given up on. Are you willing to talk
about those dreams?
Explanation: The therapist thinks the client isn’t willing to contact his values because of the loss and
pain associated with caring. So the therapist makes an empathic comment that helps the client contact
the pain of a life not fully lived.
Model Response 31.3b
Therapist:
It makes sense that you don’t want to think about it. Often there’s a lot of pain in our
values. It hurts to have dreams and to care about them, especially when they don’t work
out. And yet this pain gives us useful information about what’s really important to us—­
about what can help us lead a more meaningful life. Would you be willing to explore this
pain together for a bit if that could open up some new possibilities for you?
Explanation: The therapist validates the experience that it’s often hard to think about our values
because it can bring up pain. The therapist then recasts the pain as an ally—­as something that can
point us toward what’s meaningful to us—­thereby redirecting the client back toward values and simultaneously supporting acceptance.
Model Response 31.4a
Therapist:
Of course you want to be happy. That’s a basic part of being human. We all want to feel
happy. And yet take a closer look. Is happiness something you can do? Let’s try something
right now. I’d like you to make yourself feel really happy right now. (Pauses.) Were you able
to do it?
Client:
No, it doesn’t work like that.
Therapist:
Right. So, what I’m wondering is what you’d want to be about, how you’d want to live—­
not exactly how you’d want to feel. For example, if you could intend to do anything with
your hands, your feet, and your words, what would those actions be about?
Explanation: Happiness is a feeling or goal, something that may happen to the client, rather than a
direction in which the client can head, or a value. So the therapist sidesteps this comment and does a
short exercise with the client to illustrate the problem with choosing an emotional state as a goal.
Emotions aren’t under our direct control. Values are more about what we directly approach or aim
toward as qualities of action.
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Model Response 31.4b
Therapist:
How long have you been trying to be happy?
Client:
I don’t know. Most of my life.
Therapist:
You know how they put an epitaph on a tombstone that says what a person’s life was all
about? Have you heard of that?
Client:
Yeah, like he was a good dad or whatever.
Therapist:
(Speaks with curiosity and without condescension.) Right. So what you’re saying is that your
epitaph would read, “Here lies Mia. She spent most of her life trying to be happy.” How
does that sound for an epitaph? If you could choose anything to have on an epitaph, is that
what you’d choose?
Explanation: Happiness as a central goal in life is usually a sign of pervasive experiential avoidance.
The therapist is trying to help the client be aware of what she’s currently valuing. If she clearly sees what
her behavior is in the service of, she may choose something else.
Model Response 31.5a
Therapist:
What would being president allow you to do?
Client:
Take care of people…people like me.
Therapist:
And if you were helping in that way, whether or not you were president, would that still be
something you’d value?
Explanation: Even grandiose goals often contain values. One major advantage to discussing values is
that the therapist usually doesn’t have to talk clients out of grandiose goals and can instead dig down
to the embedded values. This is likely to reveal implications for action. Then, by addressing workability,
the therapist can gently rein in any excesses (even psychotic ones), without shaming clients or making
them appear to be wrong or deluded.
Model Response 31.5b
Therapist:
What kind of president would you want to be?
Client:
I’d want to be a good president.
Therapist:
What’s your idea of a good president?
Client:
Someone who helps people and doesn’t lead us into more wars.
Therapist:
So it sounds like helping people is something that matters to you. Is that right?
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Explanation: ACT therapists generally don’t directly contradict clients’ goals but instead use them as
opportunities for learning. One possible route is to see whether more abstract values inform specific
goals, as the therapist does here. These overarching values can then be used to identify goals that are
likely to be more workable.
Model Response 31.6a
Therapist:
Imagine that your parents have passed away and no one in your life remembers what they
wanted you to do. What would you most want to change in your life?
Client:
Nothing really. I want to have a family and raise my children in a loving way. I think that’s
what would please my parents, but it’s what I want to do, too.
Explanation: ACT is often targeted at undermining pliance (following rules to achieve the approval of
others). In this model response, the therapist assessed for pliance by asking the client to imagine conditions in which social approval would be less of a direct issue. Another way to do this would be to have
the client imagine that her parents somehow magically approved of her no matter what. What would
she do then? It’s important to use such approaches in a way that doesn’t assume any social goal is necessarily pliance. We are social creatures and tend to care about the same things our communities and
families care about. The issue is freedom of choice and a sense of personal connection to what is most
meaningful to us in living well.
Model Response 31.6b
Therapist:
I can tell that your parents are very important to you. Tell me: What kind of a life would
please your parents? (The client answers.) Great. So tell me, on a scale of one to five, how
important are these things to your parents?
Client:
They’re a five.
Therapist:
Good. And can you rate how important they are to you?
Client:
Hmm. Probably a three.
Therapist:
So maybe the dreams that your parents have for you aren’t exactly the same as the dreams
you have for yourself. So I’d like to ask you again: What dream do you have for your life?
Explanation: People can often fall into the trap of orienting their lives around pleasing others or following their rules. It isn’t inherently bad to want to please others, but when people live in a way that’s
focused on the outcomes of their behavior, they lose contact with what is intrinsically important in
their pattern of living. The therapist’s questions in this model response begin the process of helping the
client differentiate between what she imagines her parents want and what she would choose.
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Competency 32
Model Response 32a
Therapist:
I’m not asking you if you can do it. The result will turn out one way or another—­you don’t
have complete control over that. And you will have scary feelings and worrisome thoughts.
What I’m asking is, what are you going to stand for in your life? What I’m presenting here
is an opportunity to make a commitment to a new direction in your life, not knowing how
it’s going to turn out. I want you to consider whether this is a commitment you’re willing
to make. And if so, then tell me, what do you want to be about?
Client:
Yeah, I want to make this commitment. I’m going to do it. I want to be about having a
supportive, close relationship. I want to give myself a chance to have a relationship with
passion!
Therapist:
Yes! I want that for you, too. I want our work to be about that.
Explanation: The therapist has to use work with defusion and acceptance to keep the client focused.
The client presents common barriers: fear of rejection, failure, and inability. The therapist sidesteps
these obstacles and continues to present an opportunity for the client to commit to a new direction.
Notice that in her final statement, the therapist shares her own values, including that she values the
client’s valuing, which also demonstrates competency 35.
Model Response 32b
Therapist:
This is true. You don’t know whether or not you can. Let me put this another way: What
if life is offering you a choice about what you’re going to stand for? On the one hand (puts
out her right hand), you could play it safe and avoid intimacy. However, the downside of this
choice is that you won’t have supportive, close, fun relationships. On the other hand (holds
out her left hand), you take a risk on intimacy and have the chance to develop supportive,
close, fun relationships. This choice means that sometimes you’ll feel rejected, hurt, and
scared. What if this is the way it works? What will you choose?
Explanation: The client is focused on the outcome: whether or not he will be rejected. This draws his
attention to the future and away from the process of valuing. The therapist has the client imagine a
choice that combines willingness and values in the hope that this will foster a sense of choice (one of
the four qualities of an effective values conversation). If the client picks the choice associated with
avoidance, the next step will be to examine workability: What has the outcome been when he’s chosen
the safe path in the past? Has he avoided feeling rejected and alone or whatever else he fears, or has it
actually made things worse?
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Competency 33
Given the nature of the exercise for this competency, there are no model responses.
Competency 34
Model Response 34a
Therapist:
I want to remind you about what you wrote as your intention in this domain. You wrote
that you wanted to be someone who was reaching out, loving, involved, and real in relationships. What we’re working on is the process of moving in that direction. Sometimes
you’ll enjoy how it turns out. Other times it will work out in ways you don’t like. But what
we’re working on is what you want to stand for. It seems as though you got off track here
for a little while and got attached to the goal of having a girlfriend. While that would be
nice, we’re not working on that. Right?
Client:
Okay, I think I get you. I forgot for a minute.
Therapist:
So, by sending out these e-­mails, did you move further in your direction of reaching out
and being loving, involved, and real in relationships?
Client:
Yeah, actually, I did. Just by sending out the e-­mails I was being real because I normally
pretend I don’t really want relationships. But I went even further than that. I normally
work really hard to be witty and impressive in my e-­mails. You know, I worry that if I don’t
play that game, they won’t like the real me. What was cool was that I was more real. I said
what I thought and responded more genuinely to what they wrote, commenting on what
interested me about it.
Therapist:
Cool. I think it’s really great that you made that commitment last week and fulfilled it
during the past week, even with all those barriers that came up. Let’s keep our eye on the
ball of how you’re living and let the outcomes fall how they may.
Explanation: The client seems to be overly focused on the outcome instead of on the process of living
his value. He has become attached to a particular goal. As a result, he’s evaluating all his behaviors in
relation to his perceived distance from his goal, rather than in relation to whether he has kept moving
in the direction of that goal. The therapist reminds the client that his value is not about the outcome
but about how he’s living his life, and then checks in with the client to see whether he understands.
Model Response 34b
Therapist:
Are you interested in my reaction? (The client says yes.) I think what you did was pretty
awesome. This has been a real challenge for you in your life and something you’ve been
avoiding for quite a long time. Congratulations on taking this step.
Client:
Thanks.
Defining Valued Directions
Therapist:
237
From where I sit, it looks like you took a stand for something that really matters this week.
You dedicated your time and energy toward living a life with loving, involved, and real
relationships. That’s something worth doing—­a noble pursuit. And it isn’t easy to do
either, as taking action on something that really matters to us means we’ll sometimes experience failure. I know it didn’t work out this week, and that’s disappointing, but just because
it didn’t work out, does that mean that this activity, living a life oriented toward loving,
involved, and real relationships, wasn’t worth doing?
Explanation: The therapist focuses on validating the client’s struggle and congratulating him on his
involvement in the process of valuing while simultaneously encouraging him to let go of the outcome.
The therapist tries to reconnect the client with the meaningfulness of the value and normalize the pain
that’s likely to attend valuing, thereby also promoting acceptance. A possible next step in therapy
would be to help the client learn from his committed action to inform next steps in this chosen
direction.
Competency 35
Given the nature of the exercise for this competency, there are no model responses.
For More Information
More information about values, including exercises and metaphors, can be found in
Hayes et al., 2012, chapter 11; and Harris, 2009, chapter 11. For an entire book
dedicated to this topic, see Dahl et al., 2009. You’ll also find a wide range of exercises
and metaphors related to values in Stoddard & Afari, 2014.
Eifert & Forsyth, 2005 (pp. 154–­155, 186–­187) might be of interest, as well as some of
the resources listed earlier in this chapter.
For values-­related exercises and worksheets that you can use for yourself or clients, see
Hayes, 2005, chapter 12.
CHAPTER 7
Building Patterns of
Committed Action
It takes a deep commitment to change and an even deeper commitment to grow.
—­Ralph Ellison
Key targets for building patterns of committed action:
Work with clients for behavior change in the service of their chosen values while
making room for all of their automatic reactions and experiences.
Help clients take responsibility for their patterns of action, building them into larger
and larger units that support effective values-­based living.
A core problem for many clients who present for therapy is that they’ve dropped out of important activities, relationships, or pursuits in their lives or only engage in these in a limited way. Consider Leonard,
a client with depression who has friends but doesn’t seem to really connect with them or only calls them
when he feels desperate and alone; or Kirsten, who no longer goes to her son’s football games or drives
alone due to fear of panic attacks; or Jose, a client with psychosis who spends most of his time alone in
his living room watching TV and fears that if he goes out, it will trigger the voices he hears. Given the
option, Leonard would choose to be more connected with friends, Kirsten would choose to go to her
son’s football games and have her independence back, and Jose would choose to spend more time in the
world outside his living room. All of these people have visions of a full life that they wish to inhabit,
but they find themselves stuck in lives that generally feel imposed upon them, not of their own
choosing.
Building Patterns of Committed Action 239
What Is Committed Action?
Committed action is a step-­by-­step process of acting to create a life of integrity, true to one’s deepest
wishes and longings. Commitment involves both persistence and change—­whichever is called for to
live in alignment with one’s values in specific contexts. Commitment also includes engaging in a range
of behaviors. This is important because moving in valued directions often requires being flexible,
rather than rigidly persevering in unworkable actions.
Committed action is inherently responsible in the sense that it is based on the view that people
always have an ability to respond. This isn’t idealistic. It refers to the ability to link one’s actions to one’s
values in any situation. For example, a person in a prison may have a limited ability to show an overt
commitment to family. However, that person can still take certain actions that reflect this commitment, like being helpful so that parole becomes more likely, writing letters to family members, or being
prepared for family visits. Commitments can be revealed through all sorts of chosen behaviors. The
specific form of committed action called for in a given situation depends on what that situation affords
and what action would be most effective.
Committed action is the core process through which therapists can best incorporate traditional
behavioral methods into the ACT model. Exposure can be used for anxiety problems, skills training for
social problems, behavioral activation for depression, scheduled smoking for smoking cessation, and so
on. Because behavioral methods are so diverse, we can only deal with them in this chapter in the
broadest sense. However, these behavioral methods are an essential part of ACT and should be included
whenever called for in therapy. Although research on ACT has occasionally excluded traditional
behavioral approaches, this has been done in order to make a scientific point. For example, in one
study, obsessive-­compulsive disorder was treated successfully without any in-­session exposure (Twohig,
Hayes, & Masuda, 2006) merely because positive results would otherwise be dismissed as nothing more
than the well-­known effect of exposure. However, ACT is based in clinical behavior analysis, and
behavioral technologies are a key feature of ACT. As just one example, in-­session exposure would normally be part of an ACT approach for OCD. In clinical practice, there is no reason to limit full implementation of the model.
Why Committed Action?
If defining valued life directions provides the compass bearing for one’s route through life, committed
action describes the steps of the journey. A well-­lived life is ultimately the goal of all the other flexibility
processes (developing acceptance and present-­moment awareness, defusing from entangling thoughts,
developing a transcendent sense of self, and clarifying one’s chosen directions). These processes promote
psychological flexibility and help clients persist in or change behavior, as needed, in the service of their
valued life directions. Committed action encompasses the behaviors and therapy targets that are specifically aimed at helping clients move from inaction to action in the realm of overt behavior and from
unworkable action to workable action, and to helping them maintain their new, more flexible behavior
over time.
240 Learning ACT, 2d edition
The Link Between Willingness and
Committed Action
Willingness and committed action are so deeply intertwined that one could argue that commitment
depends 100 percent on willingness. This is because values are often linked to difficult internal experiences, and difficult internal experiences can illuminate or point to an individual’s values. Any committed action can evoke a whole host of private experiences, at least some of which will be evaluated as
negative. If a person is entirely determined to not experience any unpleasant or difficult thoughts,
feelings, sensations, or images, that person will be unable to commit to and maintain a course of action
because any course of action will eventually evoke something that’s unpleasant. With valuing loving
relationships comes the experience of loss; with valuing participating in community comes the possibility of rejection; and with valuing the sharing of one’s art comes the potential for negative evaluations
of one’s abilities. Metaphorically, it’s as if people are on a journey called “living well” and sometimes run
into a swamp that stretches as far as they can see (Hayes et al., 1999, pp. 247–­248). Swamps are challenging. They’re often smelly and sometimes scary, yet swamps are part of the journey. Life asks, “Will
you wade into the swamp, or will you abandon your journey?” In order to choose to act on our values,
willingness to experience difficult events is necessary.
The action of willingness has the quality of a leap of faith. The job of the therapist is to create situations in which clients engage in a leap of faith in the direction of their values and into a future that is
unknown. A leap of faith implies willingness to have whatever happens when one makes that leap, to
touch down wherever one lands. This is the quality ACT therapists are looking for in client
commitments.
In a scene from Indiana Jones and the Last Crusade, Indiana is at the final stage of his quest to find
the mythical Holy Grail. He finds himself just short of his goal, with a seemingly bottomless chasm
between himself and his goal and no apparent way across. He faces the choice of either giving up his
goal and turning back or confronting his fear and stepping into the chasm in a leap of faith. With trepidation, he steps into space, seemingly to fall to his death. Unbeknownst to him, a bridge is there,
painted to blend perfectly with the chasm below.
Supported by this bridge, he makes it safely across to
his destination. Committed action is like that.
Willingness to face fear allows people to move toward
their goals, and their commitment makes sense of
their willingness.
Committed action also provides the opportunity
to practice and build the capacity to choose to be
willing over and over again, across time. Clients
should never be coerced to make commitments.
Rather, ACT therapists work to build opportunities
for clients to choose to commit to values-­based actions
because these actions provide opportunities for clients
to pursue the kind of life they want to live. Ideally,
commitments are made with 100 percent willingness.
In Indiana Jones and the Last Crusade, Indiana’s leap of
Building Patterns of Committed Action 241
faith was seemingly into a chasm that could end his life. Private events can sometimes seem just as
threatening, and clients may attempt to avoid them just as they would try to avoid actual death.
However, through ongoing committed action they can experience that thoughts, feelings, and sensations cannot literally harm them, and that in fact, such private events are only harmful if they control
how clients live their lives.
What Should Trigger Working with This Process?
Engaging in committed action typically follows work on defining valued directions. A focus on committed action could follow a quick exploration of one values-­based area of living for a client seen in a
primary care setting, or it could begin after multiple sessions spent helping a client articulate her values,
as might happen in a more conventional therapy setting. What’s important is that client and therapist
begin committed action work with a shared sense of what the client values.
Working on committed action may be especially useful when therapy becomes lifeless or dull or
when clients are talking about values rather than acting on them. If clients aren’t in contact with the
barriers to values-­based action, beginning to work on this process will evoke those barriers. So in a
sense, committed action is a process that can illuminate the emotional and cognitive barriers to be
addressed using the other flexibility processes. For example, if a client is talking about the importance
of intimacy and openness but the therapist senses some lifelessness in the room, shifting to specific
actions the client is willing to commit to can open up a more vital process. Moving directly to the
therapeutic relationship is also a useful way to explore values-­based action. For instance, to create the
opportunity for committed action in the therapeutic relationship itself, the therapist might say, “Could
you apply your values in this moment? What is a difficult and more open thing you could say right now
about our relationship?”
Patterns of client behavior that suggest a focus on committed action is needed include impulsivity,
inability to identify specific goals for action, inaction, avoidance of making commitments, and inability
to keep commitments. Impulsivity indicates that the client’s behavior is largely driven by short-­term
contingencies and is relatively disconnected from more extended forms of reinforcement, such as those
linked to values. This may show up as a lack of awareness of the larger context of action that gives the
client’s life a sense of meaning and purpose. If clients are unable to generate specific goals related to
their values, this might also be an indicator that they need support in strengthening their ability to do
the practical work of setting goals and keeping them. Lack of action in valued domains also suggests
that a focus on committed action might be useful, in this case to elicit fusion and avoidance linked to
their behavioral inflexibility, which can then be loosened up with other flexibility processes. Finally, an
inability to make and keep commitments might be indicated if the client tends to engage in fusion and
avoidance when the topic of specific goals comes up.
What Is the Method?
Once therapist and client have a shared sense of what’s important to the client, work on committed
action can be broken down into four steps:
242 Learning ACT, 2d edition
1. Identifying goals based on values. In this initial step, the therapist might help the client pick
one or two high-­priority life domains (family, romantic relationships, etc.) and develop an
action plan for behavior change in those domains.
2. Coaching clients to make and keep commitments to values-­based actions. The therapist
helps clients put their values-­based behaviors into action in daily life, outside of session, while
also attending to the larger patterns of behavior that are being assembled.
3. Working with barriers using other flexibility process. Barriers almost always arise when
clients engage in committed action. The therapist attends to this and assists clients in overcoming barriers using acceptance, defusion, and mindfulness skills.
4. Repeating steps 1 through 3 until the client is taking steady committed action. To help
clients become more skillful and generalize an orientation toward committed action, the therapist can switch the focus to different domains of living, to larger patterns of action (e.g., not
just committing to exercise this week, but building a pattern of regular exercise), to goals that
entail facing other feared or avoided experiences, or to goals that will elicit other aspects of
psychological inflexibility. The goal is to give clients sufficient practice that they can maintain
a pattern of flexible and values-­based committed action without the therapist’s support.
This process forms the core of translating abstract values, such as being healthy or engaging in a
spiritual practice, into concrete actions that express and instantiate these values in the world. Note
that although we have identified a stepwise process here, the organization of the sections below don’t
exactly parallel this process. The process itself is straightforward to understand, so we’ve chosen to
focus on some of the most important aspects of this work.
Identifying Effective Values-­Based Goals and Linking
Them to an Action Plan
Typically, therapist and client work together to identify one or two high-­priority areas as the initial
focus for committed action. It’s usually helpful to focus on areas of living in which the client feels a loss
of engagement, choice, or vitality and in which this constriction appears to result in ongoing suffering
(Wilson & Murrell, 2004). Therefore, the therapist would ideally suggest areas of high importance to
the client. The goals selected should include actions that are likely to occasion private experiences that
the client tends to fear and avoid, as this will maximize the client’s opportunity to build psychological
flexibility. After identifying an initial focus, therapist and client work together to develop specific plans,
including the place and time for engaging in the chosen actions. Workable goals can be characterized
by the six key qualities:
•
They are clearly linked to the person’s values.
•
They are specific and measurable.
•
They are practical and are things the person is able to accomplish.
Building Patterns of Committed Action •
They are active, not framed as “dead person’s goals.”
•
They are committed to in a public way.
•
They are linked to the evidence and a functional analysis of the person’s behavior.
243
LINKED TO VALUES
Any goals or actions clients commit to need to be on target, meaning linked to the client’s values.
Then, as clients move toward their goals, they need to attend to how well their actions align with their
valued directions. Typically, when people move in a valued direction, natural feedback occurs in the
form of a sense of vitality, freedom, and flexibility. Clients can begin to develop a sense of this vitality
and use it as a guide, helping them know whether they’re traveling in their chosen direction or off
course. It’s also important that goals reflect the qualities of the values clients intend to reflect in their
actions. For example, “Calling my brother this week” might be specific and measurable (the next topic),
but what the client says while on the phone and how he listens will be a big part of whether he’s being
a loving brother. In this instance, the client might seek to listen attentively or to vulnerably share something in order to bring valued qualities to his action, rather than simply complying with the form of the
action.
SPECIFIC AND MEASURABLE
A common error is to set vague goals, making it difficult to assess whether they’ve been accomplished. Here are some examples of vague goals: “Engaging more with friends,” “Calling my brother
more,” and “Being more accepting of my daughter.” Although the activities specified may be values
consistent, it would be difficult to determine whether the client had accomplished these goals. It’s more
effective to have specific, measurable goals, such as “Call my friend Jake on Saturday at 2 p.m. and ask
him to go to a movie of his choice,” “Go to coffee with Rebecca on Sunday at 10 a.m. at the cafe,” “Call
my brother two times this week, once on Tuesday before dinner and once on Friday right when I get
home from work,” and “Get my daughter a greeting card while at the grocery store on Sunday and, by
the end of the day, write in it how much I love her.” Goals should be clarified by specifying when,
where, and even how the actions will be done. Therapists often need to initially work with clients to
help them come up with specific, measurable goals until clients are able to do this on their own.
PRACTICAL AND WITHIN THE CLIENT’S CAPABILITIES
Goals also need to be practical and things that the client can actually accomplish. Taking steps
with intention and consistency is generally more doable than heroic leaps, especially if those leaps
occur only sporadically, though big leaps are sometimes necessary. It can be helpful to start with goals
that are actually easier than what the client is capable of to facilitate building a pattern of consistency
between commitment and action.
When clients lack the skills to accomplish particular goals, therapists can support them in developing the needed skills as an intermediate goal, as this too is a values-­consistent step. A quick way to
assess whether a client first needs to learn additional skills is to ask, “How confident are you that you
244 Learning ACT, 2d edition
can accomplish this goal on a scale of 0 to 100 percent?” Answers to this question can serve as an
important assessment tool, indicating both client commitment and the difficulty of the goal. If a client
reports a low number, therapist and client can work together to revise the goal. Here’s one way to
broach this topic: “The size of the goal here isn’t important. What’s important is that you’re taking
steps in the direction of what matters, that you’re moving forward in a way that counts. How fast isn’t
important. So let’s find an action you can commit to that you’ll be able to do before the next session.”
ACTIVE, NOT FRAMED AS DEAD PERSON’S GOALS
Avoid “dead person’s goals” (Lindsley, 1968): objectives that a dead person could do better. For
example, a dead person would almost always do better than a client if the goal is something like
“Withdraw less from my mom,” “Be less lazy,” or “Argue less with my husband.” Put another way, dead
person’s goals are like giving someone directions by only telling the person which streets not to go down
(Heffner & Eifert, 2004). Dead person’s goals specify what someone is trying to avoid. In ACT, the
focus is on building the ability to approach a chosen goal. Generally, dead person’s goals can be reformulated fairly easily. Using the previous examples, reformulated statements might be “Spending time
connecting with my mom,” “Being productive at work,” and “Being supportive toward my husband.”
However, these examples are still somewhat vague, so to make them more useful, they can be further
reformulated to be more specific and measurable: “Having dinner with my mom this week and telling
her how much I miss her,” “Spending at least two hours every day working on computer code,” and
“Helping my husband during this stressful week by mowing the lawn.”
COMMITTED TO PUBLICLY
Research has shown that when people make public commitments, they’re more likely to follow
through and accomplish their goals (Hayes et al., 1985). So ideally, clients would commit to specific
goals in the presence of the therapist, and together they would record the goals in a way that allows
them to be checked later. For example, a goal can be written on a card, diary sheet, or goals document.
This also provides a physical reminder to prompt clients to remember their commitment. Without a
physical reminder, clients often don’t remember exactly what they intended to do. It’s helpful to provide
forms on which clients can track their goals and achievements over time; documenting their progress in
this way can provide effective reinforcement. (For an example, see Eifert & Forsyth, 2005, pp. 218, 244).
BUILT ON FUNCTIONAL ANALYSIS
Finally, goals are best linked to the evidence base and to a functional analysis of client behavior.
This requires that the therapist have knowledge of and skill with evidence-­based methods of behavior
change, guided by a functional analysis linked to basic principles of behavior. ACT expands on basic
behavioral principles such as operant and respondent conditioning by adding additional principles
based on RFT. The literature on functional analysis and behavioral methods for specific problems is so
vast that it’s is impossible to cover here, even in a cursory way. For those interested, The ABCs of
Human Behavior (Ramnerö & Törneke, 2008) provides an accessible introduction to functional analysis and the use of behavioral principles in clinical work. In addition, when working on establishing
client goals it can be useful to incorporate evidence-­based interventions that are rooted in behavioral
Building Patterns of Committed Action 245
principles, such as exposure therapy, various forms of skills training, contingency management, stimulus control strategies, and behavioral activation. Other evidence-­based interventions not based on
behavioral principles might also be used if they’re consistent with the flexibility processes.
INTEGRATING ALL SIX QUALITIES INTO GOALS AND ACTION PLANS
The six qualities of goals described above are relevant to every ACT case. Suppose a client values
being intimate and supportive in friendships. For a client with those values who doesn’t have close
friendships, a long-­term goal might be developing such a relationship with two people. Various intermediate actions and steps would be necessary to achieve this longer-­term goal. For example, the client
could join a sports league. Smaller substeps toward that intermediate goal might include finding information about leagues that are available, choosing one, and then enrolling. In addition, it may be necessary to focus on small, precise skills to enable the client to achieve even intermediary goals. Continuing
with the preceding example, this self-­isolating client may need to practice how to make such a phone
call or how to interact with fellow players in a way that could lead to friendship.
It’s important to keep in mind that committed action is not simply about achieving goals; more
accurately, it’s about the process of living a meaningful life. Goals serve as signposts that let clients
know they’re headed in the right direction and staying on track. Another therapeutic purpose of goals
and larger action plans is to help clients engage in a process of values-­based living while simultaneously
developing greater psychological flexibility. The focus is not on attaining goals per se, but on working
toward them in a certain way: staying grounded in the present, using defusion skills, being willing, and
noticing the workability of each step.
WORKING WITH UNWILLINGNESS TO ESTABLISH GOALS
A common problem is that clients are unwilling to generate goals because they feel nothing new is
possible for them. This is less likely to occur if clients have already done some work on defusion, acceptance, and values. So if you encounter unwillingness to set goals, defusion and acceptance techniques
will probably be helpful. In the following dialogue, the therapist uses defusion as a way to overcome
verbal barriers to commitment by focusing on the functional utility of the client’s thinking.
Client:
Why should I write down goals? I never follow through on them anyway. It just seems like
a waste of time.
Therapist:
If you were to listen to the advice of that thought—­that you never follow through on your
goals—­would that lead you toward or away from this value of making a difference with
your life?
Client:
Hmm. Away.
Therapist:
And if you were considering this value and it were to give you advice, what would it say
with respect to setting goals?
Client:
It would say, “Go ahead and set the goals, then go for it!”
246 Learning ACT, 2d edition
Therapist:
So, if you could choose between those two directions, which would you choose?
Client:
I’d choose to set goals.
Therapist:
I guess I am left with this question: Will you? Here with me now?
Client:
(Sighs.) Okay.
Therapist:
I can hear the hesitance, but let’s see what happens. Let’s start with the first step: setting
goals. If you were living your life in the service of this value, what’s one thing you would be
doing that would be about that?
Another common problem is that clients are able to identify a broad goal linked to a value but need
help in setting more concrete intermediary goals. In such cases, the therapist can provide guidance on
how to divide larger goals into more manageable steps. The following dialogue illustrates one way of
doing this.
Client:
Yeah, I know I want a job that’s more rewarding, that requires more from me than the one
I have now, but I don’t know what to do to get there.
Therapist:
Okay, so let’s break this down a bit. You don’t need to leap all the way to the goal of having
a new job in one step. Can you think of one action that, if you completed it, would put you
one step closer to that new job? Maybe something you’ve been thinking about doing but
are afraid of doing?
Keeping Commitments in the Presence of Emotional Barriers
ACT assumes that a common barrier obstructing clients from taking action with respect to their
values is a desire to first eliminate unpleasant and difficult private experiences. After all, working on
goals and building patterns of committed action usually brings people into contact with previously
avoided thoughts and feelings. So when clients do engage in committed action, they are also engaging
in exposure to feared and avoided stimuli. This is beneficial in many ways—­among them that it gives
clients opportunities to practice other ACT skills and develop greater psychological flexibility.
When working with clients on committed action, the focus is on helping them learn to lean in
toward their experience, including negatively evaluated experiences such as anxiety, sadness, depression, boredom, negative thoughts, or unpleasant memories, along with positively evaluated experiences,
such as happiness, fun, relaxation, or excitement, as clients may also avoid the latter. Through the
process of choosing goals and taking action on them despite difficult internal experiences, clients build
new patterns of perseverance in the face of difficulty and get the chance to build breadth and flexibility
of responding by interacting more richly or intimately with avoided experiences. As they pursue valued
directions, life provides the material for practicing acceptance and defusion. So in a very real sense,
ACT is an exposure-­based method. But there are several key differences in how ACT approaches this
work, discussed in the following section.
Building Patterns of Committed Action 247
EMPHASIZING RESPONSE FLEXIBILITY
Because defusion and acceptance enable exposure to the process of thinking and feeling, not just
the products of thinking and feeling, ACT allows for engaging in a type of exposure that would otherwise be impossible. For example, a client who thinks I’m bad doesn’t need to expose himself to being
bad, but rather to the process of thinking I’m bad.
A key distinction between exposure in ACT versus in traditional approaches is that in ACT exposure is always linked to values. For example, a between-­session commitment for a client with a germ
phobia could be to go to a restaurant with a friend and work on being present and engaged with her
friend and to share freely about herself. A form of deliberate exposure could be included as part of this
goal, such as by limiting hand washing to once before the meal and once again before leaving the restaurant. This exposure wouldn’t be about the goal of reducing anxiety per se, but about the goal of
increasing behavioral flexibility linked to the client’s value of being present and engaged with her friend
and sharing freely about herself. This value necessarily involves not spending excessive time engaging
in compulsive rituals aimed at eliminating thoughts about contamination; thus, the exposure is in the
service of the client’s values.
Finally, the model of exposure that is embraced in ACT is not as much about response elimination
and emotion reduction as it is about response flexibility and breadth of repertoire. Thus, exposure
would never be presented to an ACT client as a method of reducing arousal or distress; rather, it offers
clients situations in which they can practice willingness, committed action, and psychological flexibility. Because ACT is based on a response-­flexibility model of exposure, ACT therapists deliberately
create variable responses during exposure. The goal is to watch for subtle forms of avoidance and
undermine both avoidance and fusion. The following dialogue offers an example of conducting an in
vivo exposure in session. However, a similar dialogue could also be used for out-­of-­session exposure
work. The client is a man with social anxiety who’s planning to attend an upcoming family reunion
with his wife.
Therapist:
This reunion has been weighing on you. I know that even thinking about it has been
causing you some distress.
Client:
My wife will throw a fit if I don’t go, but I really don’t want to. Her relatives ask me questions. I have to be in a good mood. I just don’t want to go.
Therapist:
Yeah, it makes sense to want to stay away from things bring anxiety.
Client:
Even just talking about it now makes me feel hot.
Therapist:
I’m wondering if you might be willing to lean into that experience—­let yourself feel this
heat and notice its qualities.
Client:
It makes me want to run. I want to get cooled off.
Therapist:
Is your mind telling you anything right now?
Client:
Yes, it’s saying that this is too much, like the heat is going to kill me.
248 Learning ACT, 2d edition
Therapist:
Let’s see if it’s possible to notice what your mind is doing in this moment of heat, and then
whether you can simply let yourself feel it. (Brings in defusion by helping the client notice his
thoughts.) Notice how you experience the heat.
Client:
I feel it in my face and hands, like I’m red and burning up.
Therapist:
Okay, see if you can move to your hands first. Turn your attention to sensations of heat in
your hands. (Slows down, adding pauses.) Notice the sensation… See if you can stay with
the experience there… Gently observe it without making any effort to make it come or
go… Are you with me?
Client:
Yes, I can feel it. My hands want to move.
Therapist:
Go ahead and let them move, but do it with awareness, following the movement and heat.
Client:
(Moves his hands slowly.) Okay, I can feel it.
Therapist:
Great, just stay with the experience of your hands moving and feeling the heat.
Client:
(Takes a deep breath and sighs.) Okay.
Therapist:
Now take a look at me… Okay, good. Now, can you remember why we are doing this
right now?
Client:
Um… Because this is what happens when I’m in social situations?
Therapist:
Right. We’re practicing opening up to this experience now so that you can be there at that
reunion for your wife. Doing this difficult exercise now is in the service of your relationship
with your wife. (Reconnects the client to his values as the context for willingness.)
Client:
Right.
Therapist:
So while you keep in mind why you’re doing this, can you also notice any urges?
Client:
Yeah, I want to run out of here.
Therapist:
Excellent. See if you can just observe that urge. See if your attention can hover over it,
observing it, like a helicopter hovering over a spot on the ground… Just watching it, whatever it’s doing. (The therapist continues this exposure for another minute.)
Therapist:
Now I’m going to invite you to gently shift your attention to your face. Do you still feel the
heat there?
Client:
Yes, but not as much as I did at first.
Therapist:
Okay, go ahead and let yourself turn your focus to your face, becoming aware of what you
feel there. Where do you feel the heat?
Client:
In my cheeks and neck.
Building Patterns of Committed Action 249
Therapist:
Let’s start with your cheeks. Are you able to feel the heat there?
Client:
Yes.
Therapist:
Okay, just like you did with your hands, let yourself gently focus on and be present to the
heat in your cheeks.
Client:
It’s uncomfortable. I feel like people can see my anxiety.
Therapist:
Okay, let’s welcome this discomfort, this thought “I feel like people can see my anxiety,”
not just for its own sake, but for what it’s important to you to do. (Connecting with the
­client’s values again.) See if you can open up and just let the feeling of heat be there. You’re
carrying it now in the service of going to your wife’s family reunion.
This dialogue shows how ACT exposure seeks to create response flexibility in the context of
values-­based action, acceptance, defusion, and mindfulness. It includes elements of interoceptive exposure (i.e., exposure to feared bodily sensations), which is entirely consistent with ACT. The goal of this
approach is not to reduce the anxiety or symptoms the client is feeling, but to practice defusion from
anxiety-­related thoughts, develop awareness of experience as a conscious observer, and promote acceptance of urges and other unpleasant experiences. These are all nested inside the larger context of building psychological flexibility in the service of the client’s values.
PREPARING CLIENTS FOR BARRIERS
As with any good exposure procedure, it can be useful to prepare clients for experiential barriers
they may encounter as they engage in committed actions. Without awareness of potential barriers, clients
who choose to engage in committed actions probably won’t willingly accept these barriers. Helping
clients consider likely barriers enhances their sense of choice, as demonstrated in the following dialogue with a socially anxious male college student.
Therapist:
One thing I can pretty much guarantee is that as soon as you head in this direction you
value, some uncomfortable thoughts and feelings will start to show up. For example, as
soon as you start to make moves to develop friendships with people, those passengers on
your bus who say, “It’s not worth it; people are disappointing and will hurt you,” are almost
certainly going to show up. The question life is asking you in these moments is “Will you
have those feelings, thoughts, images, and sensations—­will you say yes to those passengers
when they show up?” Remember, this isn’t about whether you want them there; it’s about
whether you’re willing to have them there. It’s a bit as if you just got out of bed feeling really
depressed, and your friend Craig, whom you haven’t seen in several years, knocks on your
door and asks if he can come in. Now, you might not want him there, but could you be
willing to let him in? Similarly, with this goal of asking the guy you met in your English
class to play racquetball, would you be willing to do that, knowing it means you’ll need to
make room for those passengers who say, “It’s not worth it,” “He’s going to disappoint you
anyway,” and “You’re eventually going to be hurt”? The question I have is this: Are you 100
percent willing to have these passengers show up and to ask this guy to play racquetball?
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Client:
Yeah, but I’ve done this before, and people don’t want to be friends with me. Why should
I be willing when it’s not likely to work out?
Therapist:
What’s not likely to work out?
Client:
He’s probably not going to say yes.
Therapist:
Well, there’s no guarantee of a particular outcome. What I’m asking you is if you’re going
take a stand in your life for what’s important to you. You told me before that you want more
friends in your life. The outcome will be what it will. And if you don’t ask, you definitely
know how that will turn out: very little possibility of making a new friend. Asking creates
the possibility, doesn’t it? From there, it will either work out or it won’t. What I’m asking is
this: What are you going to stand for? If you ask this person to do something, is it about
working toward making friends?
Client:
Yeah, I guess so… Yeah, it is.
Therapist:
Then, not knowing whether it will work out, and knowing that it’s possible you may feel
rejected—­and that you will certainly feel anxious and worried—­are you 100 percent
willing to feel and think all these things and take steps in the direction of making more
friends by asking this guy to play racquetball?
Client:
Yeah, I’m going to do it, and I’m willing to feel whatever I need to feel.
As you can see, the therapist helped the client be aware of his barriers to committed action. Such
barriers can generally be divided into two categories: internal barriers, such as difficult emotions, traumatic memories, fear of failure, or a desire to be right, and external barriers, such as lack of financial
resources, lack of connections, an unsupportive spouse, or lack of effective skills. We use “external
barriers” to refer to any situation in which a change of overt behavior is needed to address the problem.
Internal barriers generally call for acceptance, mindfulness, and defusion, whereas external barriers
usually call for setting goals that will facilitate moving in valued directions.
Overcoming external barriers often requires hard work and some sort of practice. Change strategies such as skills training, psychoeducation, problem solving, behavioral homework, and exposure are
appropriate here as long as they’re targeted at an overt behavioral level. For example, a client may value
intimacy in social relationships but lack the social skills to engage effectively with others. In this case,
a subgoal could be to engage in social skills training in order to develop these skills prior to engaging
in broader goals.
At times, it can be hard to differentiate between internal and external barriers. For example, the
client statement “I don’t know” may function as an internal barrier that keeps the client from moving
ahead, such as when “not knowing” is seen as justifying not engaging in a difficult social situation.
However, the statement “I don’t know” could indicate a problem in regard to actual knowledge. In this
case, the problem might be solved by taking preliminary steps such as gathering more information
about the subject at hand. If in doubt as to the function, you may be able to clarify the nature of the
problem by asking the client to gather information. Then you can see whether acquiring information
moves the process along. Another indicator provided by this strategy is whether the client pursues
Building Patterns of Committed Action 251
additional knowledge in a way that’s vital and represents growth. If so, the barrier is probably external
rather than internal.
Occasionally, a barrier to committed action arises when a goal isn’t connected to the client’s values
but is instead a result of avoidance, trying to be right, trying to make others happy, or social pressure
(e.g., from parents or the therapist). When committed action isn’t linked to values, clients have little
motivation to engage in the hard work of therapy and the process of contacting feared states. If you
think this may have happened, your job is to return to the process of defining valued directions, searching for values that are vital, present oriented, and freely chosen by the client.
Highlighting the Qualities of Committed Action
Committed action is about the qualities of chosen actions, not the speed with which they are
accomplished. What matters most is maintaining growth and forward movement, not the amount or
rate of movement. Drawing attention to this can help clients learn to discriminate the sense of expansion generated by committed action from the sense of constriction or loss of choice and possibility
generated by avoidance or fusion. For example, an ACT therapist might help a client savor or linger
with the experience of the moment when engaging in a values-­based behavior. This serves two functions. First, it increases the chance that any potentially positive reinforcing consequences will actually
function as such, and second, noticing the qualities that are intrinsic to values-­based actions can help
clients become more clear about what’s important to them, helping them further clarify their values.
ACT uses various metaphors about journeying, sports, or growth to help clients recognize the
qualities of vitality and growth in their behavior. If clients can discriminate these qualities, they can
use them as guides for effective action. The following dialogue demonstrates a metaphor that can be
used for this purpose.
Client:
I feel as if I’ve been playing it safe for so long, as if I’m always scared.
Therapist:
I’d like to share a metaphor and see if you feel it fits the experience you’re talking about
here. The metaphor is of a basketball game. There are two basic groups of people at a basketball game: the people in the stands and the people on the court. People in the stands
have certain sorts of conversations. They sit there and talk, analyzing the game, trying to
figure out what’s happening, cheering sometimes, eating, whatever. They do lots of talking.
But, ultimately, how much impact does this have on how the game turns out? Very little,
right? Let’s contrast that with the people on the court. The kinds of conversations the
people on the court have are all about advancing the game. They aren’t doing a lot of
judging and predicting how it’s going to turn out. In order to play well, they’re working on
being present, staying fully invested, and moving the game along. The kinds of conversations they have affect the game strongly and make a big difference. And ultimately, they
are the ones taking the risks. How the game turns out matters most to them. Where do
you find yourself in your own life: Are you sitting in the stands, watching and evaluating?
Or are you on the court, working and having conversations that will advance the game?
Client:
In the stands.
Therapist:
Where do you want to be?
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Client:
Of course I want to be on the court.
Therapist:
If you were going to be on the court this week, what would that look like? What’s one
thing you could do that would let you know you were on the court?
The above metaphor might be used if the therapist wants to highlight the qualities of engagement
and vitality that are part of values-­based action. In contrast, the metaphor below might be used to help
clients discriminate between a sense of expansion versus constriction in the choices they’re making. It
also clearly links committed action to willingness.
(Draws the image at right.) The dominant metaphor of the good life in our society is that life
is always supposed to be going up, getting
better over time, until the moment you die,
preferably in your sleep or some such. I want
to suggest that you’ve been following this
metaphor without knowing it for a long time,
always trying to get better, achieve the next
goal, have better self-­
esteem, reduce your
anxiety, rack up the next accomplishment,
whatever.
Client:
Okay, that seems about right.
Therapist:
In therapy here, we’ve been working on a bit
of a different metaphor for what it means to
live a good life. This metaphor is more like an
expanding circle. It isn’t about things getting
better in life, but about how much space you
have to live your life in, how much room you
have to move around; it’s about having
freedom. (Draws the image at right.) The way
this metaphor works is that you’re always
either expanding or contracting in your life,
growing or retreating. And on the outer edge
of this circle, there’s always some experience.
Part of the time it’s something difficult. Let’s
say that for you it takes the form of fearing
you’ll panic or go crazy. So, here’s the thought
“I’ll go crazy,” and here’s the feeling “anxiety.”
Now imagine that in a particular moment in
your life, your bubble happens to bump up
against these. The question life is asking you
at that moment is this: Are you willing to
have this—­are you going to say yes to this
experience and have it inside you, as part of
Anxiety
Growth edge
Therapist:
I’ll go
crazy
Panic
Life Space
TENSION
Building Patterns of Committed Action 253
you? Or will you say no, which means your bubble will shrink a little and limit your life
space? If you say no enough times, your bubble could get so small that you don’t have much
room to live in at all. Now, in this metaphor, some things are always on the outside, always
asking yes or no, and life is waiting for you to answer. The question we are working on here
is, are you going to say yes or no to life?
ACT therapists also help clients discriminate between these qualities in their behavior during sessions. In session, the therapist might notice a shift from client behavior that reflects avoidance, fusion,
or reason giving to behavior that embodies committed action (e.g., making a choice to do something
life affirming or exploring a possibility) or that involves opening up to fear or judgmental thoughts. In
such moments, the role of the therapist is to help clients notice the differences between their experience of these forms of behavior so they can better discriminate between them in the future. For
example, a therapist could let a client talk for a minute or so about why she’s stuck in a current pattern
of behavior, and then say, “You’ve spent the last couple of minutes talking about all the reasons you’re
stuck. As you did this, did you feel freer and more open, as if your life were expanding, or did you feel
more stuck, as if the life were draining out of the room? Slow down for a second and check out your
experience at this moment before you answer the question.”
Building Patterns of Values-­Based Action Over Time
To help clients build patterns of committed, values-­based action over time, it’s best to start small
and encourage clients to act more consistently as their willingness increases. It’s kind of like learning
to drive a car with a manual transmission. When you’re first learning, every little action is awkward and
requires attention: how hard to push down the clutch, which gear to shift into, how to coordinate the
release of the clutch while pressing down on the gas, and so on. However, with practice and time, these
small patterns of behavior become almost automatic and you only need to attend to the larger pattern.
Similarly, supporting clients in engaging in small patterns of committed action is important because
when practiced regularly, small behaviors can eventually become automatic and part of larger
patterns.
One key element of focusing on larger patterns over time is to help clients see how their present
behavior influences where their life is heading. The goal is to verbally tie current actions to larger patterns they’re creating and to bring active, intentional valuing into as many moments of their life as
possible. For example, part of what leads to drug addiction is that short-­term consequences are a stronger determinant of behavior than the long-­term consequences. Therefore, an ACT therapist working
with addiction endeavors to bring long-­term consequences into the moment by helping clients see the
larger pattern of behavior linked to drug use and how this behavior relates to their life goals and values.
Linking behavior in the moment to larger patterns brings the influence of the latter to bear on current
behavior, weakening the influence of short-­term consequences.
Consider a situation in which a client with a weight problem is beginning a new program of diet
and exercise. Part of the program involves eliminating sugary snacks between meals. After two days,
the client has a candy bar between meals. Building larger patterns of committed action requires that
this moment be integrated into a healthy pattern. The client may be tempted to quit based on the
thought I can’t keep my commitments, which can fuel an ineffective pattern of making a commitment,
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keeping it for two days, breaking it, fusing with the thought I can’t do it, and abandoning it. A more
effective pattern would be to make a commitment, keep it for two days, break it, notice the thought I
can’t do it, and then renew the commitment and keep it for at least three days. If the client is mindful
of the process and chooses the second option, and if he then breaks the second commitment, say after
a week, the cycle can continue—­a much more workable approach than abandoning the commitment.
Such slips or relapses are a fairly common difficulty in committed action, so we’ll take a more in-­depth
look at this issue in the following section.
Handling Slips and Relapses
Fusion, avoidance, dominance of the conceptualized future or past, and attachment to the conceptualized self are all heavily supported by our culture at large and therefore tend to be highly practiced
by clients, resulting in an ongoing recurrence of these processes. In addition, research has shown that
old patterns of behavior, both verbal and nonverbal, are likely to reappear when new patterns of behavior are put under stress or challenged (Wilson & Hayes, 1996). For these reasons, and others, clients
are likely to relapse into old patterns of behaving. The job of the ACT therapist is to help clients learn
how to integrate relapses into the larger patterns of effective action that they’re trying to build into
their lives.
One way to approach setbacks is to teach clients to expect them as a part of being human. Relapse
often occurs in the form of a return to an old control agenda in the face of negative self-­evaluations,
unpleasant emotions, or painful memories. The role of the ACT therapist is to support the client’s
deepest wishes and dreams, especially during times when the client is out of contact with them. The
therapist aligns with the client’s desires, even when the client’s mind isn’t being supportive, and encourages the client to return to engaging in values-­based action while working with thoughts, feelings, and
other difficult private events with acceptance, mindfulness, and compassion.
Another approach is to use metaphors related to journeys to emphasize that life is not a perfectly
straight road toward continuous improvement, but rather a meandering path—­one that can take a
person in a certain direction despite its many twists and turns (see the Path Up the Mountain metaphor in Hayes et al., 2012, p. 332). Detours can be seen either as times the client got off the road or as
turns in the path that were chosen by the client. In this metaphor, the client may sometimes even be
facing in a direction opposite that intended but still be on the path. This metaphor can help clients give
themselves a break when they make mistakes or don’t follow through on committed actions.
When clients return to old behaviors (e.g., depressive behavior, anxious avoidance, judgmental and
distant interpersonal behavior, addiction), they may find themselves dispirited and confused about
what they want in the moment. Such clients have fused with current evaluations, have gotten caught
up in worries about the future, are ruminating about past mistakes or regrets, or are living out a story
about how their life “should” or “must” be. Clients who have slipped back into old behavioral patterns
may think that their values have changed simply because their actions in the moment aren’t taking
them in valued directions. While values may change with time, they don’t go away simply because a
person fails to live by them consistently. Here’s one way you might address this with a client.
Therapist:
Given everything that’s happened, it’s not surprising that you feel hopeless and helpless.
You feel that you’re unsure about what you want and unsure about what to do. Given this,
Building Patterns of Committed Action 255
I have one question for you: Have your values changed? What I mean is, a few weeks ago
you told me that what’s really important to you is having a good relationship with your
wife—­one that’s more connected and intimate. Has that value changed? Is she still important to you, or has going back to drinking resulted in your not valuing that anymore? And
if she is still important to you, what stands between you and getting back on track right
here and now?
The therapist may also want to use a metaphor about what to do when starting to skid while
driving. If we find ourselves in a skid and headed toward a telephone pole, the natural thing to do is to
turn and look at the object as it comes toward us. But the thing we need to do instead is to keep our
eyes focused in the direction we want to head and turn the wheel in that direction. Then the therapist
can ask the client, “What would keeping your eyes on the road look like for you in this situation? And
how would you know you were looking at the telephone pole?”
Finally, therapists help clients prepare for and steer clear of setbacks by identifying high-­risk situations and developing ACT-­consistent plans for dealing with these situations. It’s a good idea to record
these plans on paper so the client has a reminder when those situations arise. These plans generally
involve applying particular ACT techniques or strategies that the client has learned during therapy.
The purpose of therapy is the empowerment of a human life. And that can ultimately be tested
only in the world of behavior. Behavior is the bottom line.
Experiential Exercise:
Committed Action
Please write your responses to the following questions. Give yourself time to be thoughtful and seriously
consider your answers.
What would be a bold, values-­based move for you to make in your life? Think big, be creative, and
consider taking a risk. Choose something you currently aren’t doing.
What are the barriers to making that move?
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Imagine what your life would look like if you were to make that move, and describe it here:
Name one thing you could do today that would be in the direction of making this bold move.
See if you can take this one action while intentionally making space for whatever shows up during the
action. Once you’ve done so, describe your reactions here.
Core Competency Practice
This section is intended to provide practice in helping clients engage in committed action, with a focus
on demonstrating ACT’s core competencies for this process. These exercises take a wider variety of
forms than in previous chapters; instructions on how to complete each exercise are provided.
Core Competency Exercises
Competency 37: The therapist helps the client identify values-­based life goals
and build an action plan linked to them.
Building Patterns of Committed Action 257
Key to implementing this competency is recognizing the qualities of effective goals. In the following
three exercises, we invite you to consider the client’s goal in terms of the six key qualities of effective
behavioral goals within the ACT model (specific and measurable, practical, active, publicly committed
to, aligned with client values, and linked to the evidence and a functional analysis). You might want to
review the section “Identifying Effective Values-­Based Goals” prior to completing this exercise. Then,
for each goal, describe all the problems you can see in it in terms of the six properties. You may find as
many as six.
Exercise 37.1
A client with an anxiety disorder wants to begin to face anxiety-­provoking situations by worrying about
them less.
Exercise 37.2
A socially withdrawn client has the goal of calling thirty women each week to ask them out on dates.
Exercise 37.3
A father states that he’s going to make a commitment to be less critical of his daughter over the next
week.
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Competency 38: The therapist encourages the client to make and keep
commitments in the presence of perceived barriers (e.g., fear of failure, traumatic
memories, sadness, being right) and to expect additional barriers as a consequence of
engaging in committed action.
Exercise 38.1
The client is a thirty-­four-­year-­old woman with a lifelong history of panic disorder. The therapist has
already worked on the other core flexibility processes with her and has developed a plan during the last
session to go with the client to the mall for five minutes to practice willingness to be present with
anxiety. The therapist and client have just arrived at the mall when the following dialogue occurs.
Therapist:
So, are you ready to go in? The only commitment is that you will stay physically present for
five minutes. Anything else is gravy.
Client:
I don’t want to go.
Therapist:
Okay. So notice that thought. What else are you feeling?
Client:
My heart is pounding really fast. Can I go home? I really want to leave.
Write here (or in a notebook) what your response would be, demonstrating competency 38:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Building Patterns of Committed Action 259
Exercise 38.2
This dialogue continues with the same client.
Therapist:
What are you feeling now?
Client:
Sick.
Therapist:
Where exactly?
Client:
In my stomach… There’s a kind of tightness. (Closes her eyes.) Jeez. I’m losing it completely.
I can’t even think. I’m losing my mind!
Write here (or in a notebook) what your response would be, demonstrating competency 38:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 38.3
This dialogue continues with the same client.
Therapist:
What are you afraid will happen?
Client:
I’ll just fall down. I can’t go on. I’m going to make a complete fool of myself.
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Write here (or in a notebook) what your response would be, demonstrating competency 38:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Competency 39: The therapist helps the client appreciate the qualities of
committed action (e.g., vitality, sense of growth) and to take small steps while
maintaining contact with those qualities.
Exercise 39.1
A fifty-­six-­year-­old client reports that his PTSD is causing him to experience a lot of anger and preventing him from interacting with his children. He fears that his children have come to hate him and
reports that they don’t understand what he’s dealing with when he flies into a rage. He’s identified his
values in relation to his children and the therapist is now working on helping him identify behavioral
goals that are in line with his values.
Client:
I’m not going to let my anger push me around anymore. I’m going to make a phone call to
my youngest daughter and tell her how I feel about her and that I’m not going to yell at her
anymore.
The client has said this several times before in session and hasn’t followed through. As his therapist,
you think this is because it’s too big of a step, given his current level of willingness, and you want to
help him break the goal down into smaller steps in an ACT-­consistent way.
Building Patterns of Committed Action 261
Write here (or in a notebook) what your response would be, demonstrating competency 39:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Exercise 39.2
What are two smaller, concrete actions the client could take that would lead him in the direction of his
values regarding his daughter and also prepare him for the eventual conversation with his daughter?
Action 1: Action 2: Competency 40: The therapist keeps the client focused on larger and larger
patterns of action to help the client act on goals with consistency over time.
Exercise 40
The client is a forty-­seven-­year-­old single man who, in the previous session, contacted a value of wanting
to be understood by and have a deep and rich relationship with a woman. His three previous significant
relationships were marginal and unsatisfying, with women he felt little connection with or attraction
to, but he stayed with them because he didn’t want to be alone. About a month ago, he found himself
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alone after once again fading out of a relationship, in this case with a woman he’d been seeing for four
years. His pattern of excessively focusing on issues about money, work, and financial security draws him
away from relationships. In the previous session, he made a commitment to write a personal, open,
heartfelt personal ad in preparation for participating in a professional dating service. When he arrives
at the next session, the following exchange occurs.
Therapist:
So, how did it go with the ad?
Client:
(Speaks quickly.) I wasn’t able to do it. Things blew up at work. All I’ve been doing is
working to keep from being overwhelmed.
Therapist:
Let me slow you down for a moment. How do you feel as you tell me this?
Client:
I…um…okay…I mean, I would have done it if I had time, but I didn’t.
Therapist:
That thought—­that you don’t have time—­is that a familiar one? An old one?
Client:
Yeah, that happens all the time.
Therapist:
And when you follow that thought—­that you don’t have time—­where does it lead you?
Client:
Away from what I value. But I really didn’t have time.
Therapist:
(Speaks jokingly.) Ooh, there it is again! That passenger on your bus is back! And where
does that lead you?
Client:
Away… But I don’t know what else to do.
Write here (or in a notebook) what your response would be, demonstrating competency 40:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Building Patterns of Committed Action 263
Competency 41: The therapist nonjudgmentally integrates client slips or relapses
into the process of keeping commitments and building larger patterns of effective action.
Exercise 41
A thirty-­four-­year-­old single man who’s been abusing alcohol since the age of fifteen is in his seventeenth session. He’s had several periods of sobriety lasting a few years, but none in the past decade,
since his wife divorced him. For the last five years, he’s had no friends and has been living with his
parents. His only income is from disability payments related to a diagnosis of schizophrenia he received
at the age of twenty-­three. He reports that his family members are jerks and that they take advantage
of him frequently, for example, by borrowing money and not paying him back. He isn’t on any medication and doesn’t currently show any symptoms of psychosis. Over the past few months he’s started
volunteering at the local humane society and has developed a friendship with a fellow volunteer named
James. The two of them have gone to baseball games together three times. He’s been able to successfully make room for his social anxiety and intense fears of humiliation for the past four weeks without
drinking.
Client:
I…uh…uh…I didn’t do well this week.
Therapist:
Didn’t do well?
Client:
Yeah, James… He turned out to be a jerk.
Therapist:
A jerk? (Pauses.) What happened?
Client:
Well, I was supposed to go to the baseball game with him on Saturday, and he never
showed. So I went home and got hammered. It always turns out like this. I should just stay
home… I’m an idiot.
Therapist:
And then what happened?
Client:
Well, I kept drinking and didn’t stop until this morning because I was supposed to come
in here.
Therapist:
And how were you able to do that?
Client:
I just did. It’s important for me to keep these appointments.
Therapist:
So, where do you go from here with your value of having friends?
Client:
I’m done. I give up. It always turns out like this.
Therapist:
Yeah, it’s hard to meet people you connect with. It’s going to be painful. Lots of them will
reject you. But if you keep trying, you’re more likely to find some who won’t. It seems as if
your mind is saying James is one of those who’s rejecting you.
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Client:
Yeah, well, he ditched me. I’m tired of trying. I should just go back home and stay there.
It’s just not that important. It’s not worth it.
Write here (or in a notebook) what your response would be, demonstrating competency 41:
In your response, how are you conceptualizing the client’s behavior and what are you hoping to
accomplish?
Core Competency Model Responses
Competency 37
Exercise 37.1: This goal has strong problems in the area of specificity and measurability. It isn’t an
active goal, and the link to the client’s values is unclear. The stated goal doesn’t reflect an empirically
supported approach, and the link to the functional needs of the client is unclear.
Exercise 37.2: The goal is specific, measurable, and active but impractical. It’s hard to imagine finding
that many women to call and making calls at that rate, and even harder to imagine going on the
number of dates that could be called for if the client is successful. Smaller steps are needed. It’s also not
clear how the goal links to the client’s values.
Exercise 37.3: This isn’t an active goal: a dead person could be even less critical than the client. This
kind of goal is also unlikely to feel vital or be on target in terms of the client’s values. A more active,
vital, values-­consistent goal might be scheduling a father-­daughter dinner at which the client makes a
point of telling his daughter how much he loves her and what he appreciates about her. Finally, this goal
is neither specific nor measurable. A week later, it could be hard to tell whether he’s accomplished his
goal.
Building Patterns of Committed Action 265
Competency 38
Model Response 38.1a
Therapist:
And you can leave. But before you choose to do that, would you be willing to watch your
mind scream, “I want to leave”? Just listen to it. How familiar is this place? How old is this?
Client:
Very old. Very familiar.
Therapist:
Good. Let’s take advantage of this moment. Here we get a chance to take an up-­close-­and-­
personal look at something that’s been troublesome for you. What shows up in your body
as you hear the words “I want to leave”?
Explanation: Never try to stop a client from leaving, especially not physically. It has to be the client’s
choice. At the same time, therapists should try to guide clients toward whatever they’ve been avoiding.
Every minute that a client stays and goes into the experience a little more deeply is a minute of progress.
Small steps are a great opportunity and are in no way a failure.
Model Response 38.1b
Therapist:
We came here to find something. We came to find exactly what’s coming up right now so
we can learn ways to do something truly different with it. It’s not bad that fear is here now.
So let’s just reconnect with why we’re here. Are we here to not be anxious?
Client:
No. But I wish I could be.
Therapist:
Right. And attachment to that is the core of the whole system. How much suffering is
enough? Have you had enough?
Client:
More than enough.
Therapist:
Cool. Let’s take a turn right here, right now, in a new direction. Are you willing?
Explanation: The barriers appear as problems, but they aren’t; they’re opportunities. Taking the client
into them is something new and gives the client an opportunity for growth.
Model Response 38.2a
Therapist:
“Help, I’ve fallen and I can’t get up!” So, would you be willing to lose your mind for a few
minutes? Just a few. I’ll be here to rescue you if need be. How would you go about losing
your mind?
Explanation: Humor is a powerful ally if well timed. In this response, the therapist uses some humor
but then returns to the client’s avoidance right away.
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Model Response 38.2b
Therapist:
So just open your eyes. Look around for a moment. If you’re going to lose your mind, let’s
at least see where you are when you lose it. Where are you?
Client:
At the mall.
Therapist:
Right. And as you notice that, notice who is aware of that. Who’s at the mall?
Client:
I am.
Therapist:
Right. And notice that you are not the mall. Now go back into those thoughts and feelings
deliberately. Notice a tightness. And deliberately think, “I’m losing it completely. I can’t
even think. I’m losing my mind.” And, once again, notice who is aware of that.
Client:
Okay. I’m here. I’m just having thoughts and feelings.
Therapist:
And they are not your enemy.
Explanation: In this response, the therapist uses acceptance, defusion, a transcendent sense of self,
and contact with the present moment to situate the frightening feelings and thoughts in a different
context, one in which they operate differently and need not undermine the client’s commitment.
Model Response 38.3a
Therapist:
Would you be willing to lie down on the ground with me here? Maybe we could both make
total fools of ourselves. How could we do that?
Explanation: This is an advanced move, but if the therapist is willing to do it and it’s well timed—­and
if the therapist can manage the client’s waves of emotion—­going exactly where the client doesn’t want
to go can be a powerful move. The client’s urges to move away from difficult experiences can be like a
reverse compass: whatever the mind says to move away from is exactly where it’s necessary to go—­with
willingness. This can help the therapist identify where exposure practice is needed.
Model Response 38.3b
Therapist:
Super. There goes Mr. Mind again. Elegant. And before we spend more time making fools
of ourselves, what else is there to do here at the mall?
Client:
Other than have a lot of anxiety?
Therapist:
(Chuckles.) Right. And other than watching Mr. Mind scare us.
Client:
I could do some shopping.
Therapist:
Super. So, let me ask you a question, but don’t answer this right away. Would you be willing
to have the thought “I’ll just fall down. I can’t go on. I’m going to make a complete fool of
Building Patterns of Committed Action 267
myself” and go buy things, if that meant you were now free to shop? Don’t answer. Just sit
with the question. And would it be okay if we went and bought something while you considered the answer?
Explanation: This is a move in which acceptance and defusion lead quickly to yet another commitment—­a small one, but one that’s probably linked to the client’s values. By asking the client to sit with
the question, the therapist facilitates defusion because this guides the client to observe her thinking
while simultaneously engaging in action that appears, from a fused standpoint, to depend on the answer
to that very question (buying something).
Competency 39
Model Response 39.1a
Therapist:
I know you’re frustrated right now and want to jump to make big changes. But we’re not
here to win a race. What’s more important is making small, consistent steps in that direction, rather than huge heroic leaps. Those tend to be a lot harder to accomplish. What I’d
suggest is that we develop some intermediate goals that may seem a bit easier and that
would take you in the direction of eventually making a call like that to your daughter. Do
you have any ideas for some steps? If not, I could suggest a couple.
Explanation: Without blaming or shaming the client or questioning the importance of the client’s
value or larger goal, the therapist simply suggests backing off on the size of the commitment while
keeping it connected to the client’s values. The size of the step is not important; rather, the focus is on
getting the pattern started.
Model Response 39.1b
Therapist:
I can hear the urgency in your voice indicating how badly you want to change how you’ve
been with your daughter. You really want to leap into this with guns blazing! I think maybe
we can use that energy to our advantage, but we also need to keep the long-­term picture
in mind. My sense is that if you really want to make some changes here, it’s going to take
time. Yes?
Client:
Yeah.
Therapist:
It seems we can be pretty sure that your daughter isn’t going to respond the way you’d like
right away, and that the relationship is only going to change if you’re consistent in acting
on your value over a good bit of time. To do this, it’s probably going to be important to keep
your eye on how you want to be with your daughter and let go of how you think she should
respond, at least for now. In coming up with a longer-­term strategy, we’ll need to consider
a number of goals you might want to have in addition to phoning her and making this
commitment to her. Some of these goals may seem easier than phoning her. That seems
like a pretty big step right now. I wonder, would you be willing to brainstorm about other
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actions you could take that would lead you in the direction of having a better relationship
with your daughter?
Explanation: The client seems to be a bit constricted in his selection of possible actions and goals to
take him further in his valued direction. Opening him up to multiple possible goals could increase his
flexibility and give him more of a sense of choice in the matter. Additionally, the therapist orients the
client toward the process of living his value while simultaneously letting go of the outcome.
Model Response 39.2
Action 1: Ask the client to make a list of five feelings he has with respect to his daughter. Ask him to
practice stating these out loud to his wife before making the call to his daughter, for example, “I love
you,” “I feel happy to be around you,” “I feel sad when I get angry and push you away,” and so on. Ask
the client to do this practice while being mindful of other thoughts and feelings that come up and
making room for them.
Action 2: Ask the client to write one paragraph about how he thinks his anger toward his daughter has
affected both of them. Ask him to try to let go of any defense and self-­judgments that show up. Have
him to bring what he’s written to session the following week so you can review it together.
Explanation: These actions, or subgoals, have the qualities of effective goals set forth in this chapter.
They’re likely to be helpful in the sense that they give the client a chance to practice approaching
avoided thoughts and feelings in a context that hopefully won’t surpass his current level of
willingness.
Competency 40
Model Response 40a
Therapist:
Well, this is a bit tricky because, in some ways, you do know what to do. We’ve been spending time talking about it. The thought “Time is a problem; I’m too busy” appears to keep
getting in the way. So, would it be fair to say that knowledge about what to do isn’t standing in your way?
Client:
Yeah, that would be fair.
Therapist:
So, here we are, reaching an important point in your therapy, asking what sorts of patterns
you’re going to build into your life by your actions. What I’m wondering about is what
pattern you’re going to build here, with this commitment, in this very moment. Over the
last week, you’ve strengthened an old pattern slightly: make a commitment, have thoughts,
break the commitment. Right now you have a choice. What kind of pattern do you want
to build?
Client:
I want to remake the commitment.
Building Patterns of Committed Action 269
Therapist:
Okay. I want us to spend some time getting back in contact with what this is about for you.
Are you willing to do that?
Client:
Yes.
Therapist:
What are you working for here?
Client:
I want to learn how to have love in my life.
Therapist:
Okay. But what kind of pattern gets in the way of that?
Client:
I start focusing on all the things I have to do and gradually my relationships fade away.
Therapist:
Similar in some ways to this week, yes?
Client:
(Speaks softly.) Yeah. I don’t want to continue that. I know where it leads.
Therapist:
So what are you going to do this week?
Client:
I’m going to write that ad.
Therapist:
And if something comes up?
Client:
I’m going to feel however I feel about it, and then write the ad.
Therapist:
I’ve got your back.
Explanation: The therapist sees that if the client doesn’t recommit to this values-­based goal, he’ll build
a pattern of “make a commitment, give up on the commitment.” This is a dangerous pattern when
people are trying to create a life in which they can keep their commitments in the face of difficulties.
The therapist points out this pattern to the client and suggests that he choose to establish a new
pattern that includes recommitting after breaking a commitment. After all, values are a choice and a
direction, so they inherently entail recommitting to values-­based action time and time again. Building
a pattern of recommitting after a slip is necessary for everyone; we all get off track sometimes.
Model Response 40b
Therapist:
The patterns we’re trying to build are big, but they’re built from tiny moments, like this
one, right now. And old patterns are hard to change. But if we can take them moment by
moment, we have a chance. So what are you pulled to do right now?
Client:
(Pauses.) Explain myself.
Therapist:
Good. That’s not new. Right?
Client:
(Pauses.) Right.
Therapist:
So that’s not it. What else are you pulled to do? Right now. Take your time. Try to look for
more subtle things, as well.
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Client:
Give up. Get angry. Go to work. (Pauses.) Cry.
Therapist:
Perfect. The first three came easily, so they can’t be it either. I’m not sure about that last
one. What’s inside that?
Client:
I want to have love in my life. I just don’t think anyone really will love me. They’ll all reject
me. It will hurt too badly.
Therapist:
It may hurt. And this doesn’t? Which would you rather have: the pain of love and loss, or
the pain of closing yourself off from what you most deeply desire? Slow down before you
answer. You’re building a pattern right now—­right now in this very moment.
Explanation: Acknowledging patterns, taking responsibility for them, and constructing new ones may
sound like a dry and intellectual process. However, it’s anything but. It’s an active, often emotional
process that occurs moment by moment in the present and requires and is enhanced by every aspect of
the ACT model.
Competency 41
Model Response 41a
Therapist:
Yeah, this feeling of it being really disappointing is a familiar one. These thoughts are
familiar too, right? “It’s not worth it.” “It’s not that important.” It seems as if these thoughts
are trying to protect you from something, right? It’s almost as if they’re saying, “Hey,
buddy, we’ll keep you safe. Just hang out with us. Those guys are all jerks anyway.” But
let’s check your experience. When you do what these thoughts tell you to do, where does
that lead you?
Client:
I don’t know… To being alone.
Therapist:
Yeah. This thought, “It’s not worth it.” This is an old thought, yes?
Client:
Very old.
Therapist:
And that’s great because it gives us a chance to break an old pattern, to do something new,
really new.
Explanation: The therapist doesn’t take the statement “It’s not worth it” as a literal example of what
the client would choose, given a variety of options. Rather, she first helps the client gain a little distance
from this thought by objectifying it, and then she moves back to the original commitment.
Model Response 41b
Therapist:
Let me ask one thing: as a result of your slip, which of your chosen values has changed?
Client:
I don’t understand the question.
Building Patterns of Committed Action 271
Therapist:
Which of your values has changed? Which one is fundamentally different today than it
was two weeks ago?
Client:
None of them has changed.
Therapist:
But notice that your mind is telling you that you have to stop caring about what you care
about, that you can’t move in the direction of what you care about. All very old stuff, yes?
So, let me ask a second question: What would you need to have or what would you need
to let go of in order to turn in the direction of what you value?
Client:
I’d have to have the pain of being let down.
Explanation: The logical, problem-­solving mind can’t help but be oriented toward avoidance. But it
carries a cost: the client has to pretend he doesn’t care about what he does actually care about. A slip
means he can’t be sober. A rejection means he can’t have relationships. The therapist is quickly cutting
through this thicket with questions that focus on the heart of the matter, as is called for by this
competency.
For More Information
For more information about committed action, including exercises and metaphors, see
Hayes et al., 2012, chapter 12. You’ll also find a wide range of exercises and metaphors
related to committed action in Stoddard & Afari, 2014.
For exercises and worksheets related to committed action that you can use for yourself
or clients, see Hayes, 2005, chapter 13.
For more about functional analysis and behavioral principles as applied to clinical work,
see Ramnerö & Törneke, 2008.
CHAPTER 8
Conceptualizing Cases
Using ACT
There is nothing so practical as a good theory.
—­Kurt Lewin
Learning to conceptualize cases from an ACT perspective is fundamental to the skillful and consistent
use of the approach. Developing a coherent picture of how a given client’s behavior is functioning in
context will guide you not only in what to do in therapy across time but also in moment-­to-­moment,
in-­session interventions. Case conceptualization can range from a formal procedure that includes
assessment, history taking, understanding the presenting problem, human diversity considerations, and
treatment planning to brief and rapid conceptualization to guide an intervention in a fifteen-­minute
encounter in a primary care setting. Regardless of the context, ACT therapists must be able to develop
an initial working conceptualization of clients and also engage in ongoing work to keep the conceptualization updated. The key to conceptualizing cases from an ACT perspective lies in understanding the
function, or purpose, of clients’ behavior.
Looking Through a Functional Lens in ACT
Case Conceptualization
In this chapter, our orientation toward case conceptualization is guided by what might be called a
middle-­level theory, in which we use language that is only moderately technical compared with a more
rigorous analytical account of client behavior. We focus on understanding client behavior in terms of
the processes described in chapter 1 that either detract from psychological flexibility (experiential
avoidance, fusion, and so on) or promote it (acceptance, defusion, and so on). Case conceptualization
can also be conducted using a more technical approach that relies on the principles of operant and
classical conditioning, RFT, or other principles from behavior analysis. There are other resources that
Conceptualizing Cases Using ACT 273
can guide you in learning more about functional analysis, basic behavioral principles, and RFT if you
are inclined to understand the theory at that level (e.g., Ramnerö & Törneke, 2008; Törneke, 2010;
Villatte et al., 2015).
ACT favors the use of general principles of behavior over the DSM-­guided model of diagnosis and
treatment and, as such, is a transdiagnostic approach. Case conceptualization from this perspective
refers to applying these general principles to client behavior and then using the understanding gleaned
to guide the selection of treatment interventions and evaluation of their outcomes. By “behavior,” we
mean everything a person does, including thinking, feeling, and sensing, in addition to overt action.
All behavior is observed through the lens of ACT’s six core processes, with a central goal of increasing
psychological flexibility in the service of the client’s values.
From the ACT perspective, when psychological flexibility is present, life experiences (i.e., what
behavior theorists call contingencies) tend to lead to effective behavior and a life filled with meaning,
vitality, and well-­being (see Kashdan & Rottenberg, 2010). Said more plainly, psychological flexibility
allows people to learn from what life has to teach. Therefore, it’s important to explore behaviors linked
to psychological flexibility as part of the conceptualization process. For instance, the ACT clinician
will want to assess clients’ ability to adapt to various situational demands or modify their behavior
when their well-­being is becoming compromised, as well as assessing their capacity to shift perspective
or balance multiple desires and needs across a variety of life domains. To that end, conceptualization
involves examining the learning history and current life context of clients and thinking through which
ACT methods can be used to target the functional processes that may support or reduce the i­ ndividual’s
psychological flexibility. In essence, an ACT approach to case conceptualization seeks to answer the
following question: What unique factors in a particular client’s life have given rise to her particular
problems and led to her specific version of psychological inflexibility and life constriction? In other
words, how is the client’s behavior functioning to keep her stuck in suffering and disengaged from living
in accordance with her values?
With functional analysis, interventions can be selected based on the purpose of the client’s behavior, rather than its form. Less technically stated, understanding the function of behavior means understanding where the behavior comes from (e.g., learning history) and what that behavior is for (e.g.,
purposes such as escape or avoidance), rather than what it looks like (e.g., specific symptoms). This
approach allows for the possibility that different interventions will be effective for sets of client problems that look similar but are functionally distinct. Functional analysis has traditionally referred to the
direct manipulation of antecedents and consequences of behavior to observe their function on behavior. In ACT, the term “functional analysis” is typically used more loosely to refer to attempts to understand the function of behavior, particularly in relation to the presence or absence of flexibility processes.
For example, a growing body of evidence (Hayes et al., 2006) suggests that most anxiety disorders are
maintained, at least in part, by the same functional process: experiential avoidance. In PTSD, clients
are attempting to avoid thoughts and feelings related to a trauma; in panic disorder, clients are attempting to avoid the experience of panic (i.e., the thoughts, feelings, and sensations that arise during a
panic attack); and in OCD, clients are attempting to avoid obsessive thoughts. (Although PTSD is no
longer considered to be an anxiety disorder, it is defined—in part—by experiences of anxiety and fear.)
Although the form of what is avoided and how it is avoided can vary a great deal from client to client,
the common functional process is experiential avoidance—­escape from internal events. In these examples, behaviors that appear different share the same function.
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Yet it is also true, as just noted, that clients can perform behaviors that appear the same but are
functionally different. For example, one client might throw a barbecue for friends to show off and avoid
feelings of inferiority, while another client might throw a barbecue because he’s following a rule learned
from his father about holiday barbeques and would feel guilty if he didn’t host the gathering. Both sets
of behavior are similar in form, and both even appear to be under aversive control, with avoidance or
escape from a negative experience maintaining the behavior. However, a third purpose for hosting a
barbecue might be to express appreciation for friends and act on values related to connection and community. This is a quite different function, even though the form of the behavior is similar. In this case,
the behavior appears to be under appetitive control and is maintained by positive contact with valued
ends.
In sum, in the ACT approach to case conceptualization, the therapist’s job is to look beyond the
particular form of a client’s behavior, whether it be an action, a thought, or a feeling, and to make intelligent guesses, which are then tested in therapy, about the function of that behavior, given the client’s
unique life history and context. The therapist works to understand the history that gave rise to the
behavior, why it occurs in particular contexts, and what continues to maintain it. This functional
analysis is then used to guide the selection of interventions, rather than to provide clients with insight
into the meaning of their behaviors.
Functional Thinking as an Ongoing Process
As mentioned, in ACT, case conceptualization isn’t solely undertaken early in therapy as a formal
process, such as we’ll outline shortly; it also occurs on an ongoing basis throughout therapy. As noted
in the core competency practice in chapter 4, when attempting to understand the functions of client
behaviors in an ongoing way, it’s useful to conceptualize client behavior at four levels:
Overt content: Perhaps most obviously, what a client says can be taken at face value, or literally.
For example, if a client says he’s anxious, you can deal with this as a literal report of anxiety.
As a sample of the client’s social behavior: Client in-­session behaviors can be seen as samples of
their social behavior. Because all therapy interactions are also social interactions, whatever clients
do in session may reflect more general patterns of interaction with their social world. (We’ll discuss
this further in chapter 9.) For example, a client who’s complaining about anxiety may be showing
you how he regulates the behavior of others by talking about being anxious.
In terms of the therapeutic relationship: Whatever a client says might also be relevant to the
therapy relationship itself. At this level, the focus is on the quality of the therapeutic alliance and
includes attention to the client’s feedback about how the therapist is affecting him. Attention to
this level requires that the therapist be open to the feedback and aware of ways in which the therapist’s own history and behavior might be contributing to difficulties in the relationship. An example
of this level would be if a client makes complaints that subtly communicate therapy isn’t helping,
that he wants you to back off, or that he wants you to take the role of an authority in the moment.
As a functional process: Client behavior can be analyzed in terms of functional themes. For
example, a complaint of anxiety may be a way to avoid discussing another topic.
Conceptualizing Cases Using ACT 275
Ongoing case conceptualization asks clinicians to actively practice the skill of tracking multiple
levels of client communication, listening for all four levels at once. For example, suppose a client who’s
usually excessively quiet and compliant says, “Gee, it’s cold in here.” You could consider this in terms
of overt content (a report of the temperature of the room); as a sample of social behavior (perhaps this
is a step forward for the client in terms of learning to ask for things); as a move in the therapeutic relationship (perhaps the client is asking, “Are you noticing my needs?” or stating, “I’m feeling more equal
to you”); and in terms of a functional process (changing the topic to avoid something or using the
temperature as a metaphor for emotion or sexuality). Depending upon the broader case conceptualization, the therapist might emphasize responding to the behavior at different levels. For example, if a
client has so many interpersonal difficulties that he’s unable to form a productive therapeutic relationship, the therapist may pay more attention to the social behavior and therapeutic relationship levels to
develop the client’s psychological flexibility and a strong working alliance. In this event, the case conceptualization might focus heavily on behavior that’s evoked in response to the therapist and that
relates to the social and functional aspects of the case conceptualization.
Looking through a functional lens means repeatedly asking yourself during session, including in
the initial intake and assessment, “What is the client’s current behavior in the service of?” or “What is
the purpose of this behavior?” In addition, if you’re seeing the client’s behavior through a functional
lens, you should be able to quickly describe the purpose of what you are doing from an ACT perspective
and state how this matches your conceptualization of the client. A useful practice for beginning ACT
therapists is to pause in session and reflect on these questions:
“Why am I doing what I’m doing right now?”
“What process am I targeting?”
“What is it about what the client is doing that tells me this is a good intervention to be conducting
at this time?”
A good case conceptualization will guide you to clear and fluid answers to these sorts of questions.
If you aren’t able to answer such questions rapidly, you probably need to consider more deeply how your
choice of interventions relates to your conceptualization of the client’s problems.
Why Case Conceptualization?
Case conceptualization is useful in at least three clear ways. First, it can help you learn ACT theory in
a deeper and more nuanced way. Having a thorough understanding of the theory underlying ACT is
essential for using it fluidly and flexibly. Practicing ACT case conceptualization can help you see
clients’ behavior through a functional lens and aid in developing your theoretical understanding, which
in turn will allow you to select, modify, and present techniques to fit the needs of individual clients.
Second, solid case conceptualization leads to more focused, consistent, and thorough interventions. This is particularly important for complex, difficult, or multiproblem clients, who often push
therapists to the limits of their abilities and frustrate a more linear implementation of ACT. Furthermore,
without a good case conceptualization linked to a practical theory, therapists tend to be erratic and
unfocused in choosing interventions. Interventions selected in this way can sometimes work, but if they
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fail the therapist hasn’t learned much to inform a decision about what to try next. Practiced and
ongoing case conceptualization provides ideas about what to do when a technique fails, falls flat, or
misses. If you can assess which functional processes are most important for a particular client, you can
be creative, persistent, and flexible in working with various individual processes, interwoven processes,
and exercises and techniques that support those processes.
Finally, case conceptualization will guide your understanding of and approach to cases across time.
Identifying important patterns of behavior to target will help you keep a better focus on those patterns
from session to session and allow you to notice which variables affect their occurrence and when those
patterns of behavior change. You’ll know where to start, which processes to target in any given session,
and how to sequence interventions over the course of therapy.
As crucial as this process is, we must point out that the case conceptualization process described
in this chapter would be just one part of a more general assessment. It’s also necessary to consider
mental status, physical health, family functioning, developmental history, and the like. Indeed, you may
encounter clients for whom the flexibility processes aren’t central. For example, a child with problems
stemming primarily from a deficit in reading skills that doesn’t involve experiential avoidance or cognitive fusion would be more appropriately treated with an intervention that directly addresses those
deficits.
Using Self-­Report Measures to Assess
Psychological Flexibility
Administering self-­report measures on a regular basis can help you track clients’ progress across time
and better understand clients’ perspective on what is changing. Symptom-­focused measures, such as
standard instruments assessing the degree of anxiety people are feeling or how much distress they’re
experiencing in relation to a trauma, can be informative in terms of understanding the degree of
clients’ difficulties and can also tell you something about their functioning. However, we also encourage you to consider using assessments that illuminate client functioning in terms of the flexibility
processes. If you see improvements in psychological flexibility and mindfulness over time, then you’ll
probably see subsequent improvements in other realms, such as symptom reduction or improved quality
of life and functioning (Gloster, Klotsche, Chaker, Hummel, & Hoyer, 2011; Spinhoven, Drost, de
Rooij, van Hemert, & Penninx, 2014). If, on the other hand, these measures show no improvements,
it’s probably time to revise your case conceptualization, revisit treatment goals (including whether you
and the client have the same goals), and adjust the intervention.
In the remainder of this section, we’ll provide descriptions of a few key self-­report instruments. For
a larger list of ACT-­related assessments, visit http://www.contextualscience.org/act-specific_measures.
For a global assessment of psychological flexibility, the Acceptance and Action Questionnaire-­II
(AAQ-­II; Bond et al., 2011), is a measure that assesses the degree to which an individual fuses with
thoughts, avoids feelings, and is unable to act in the presence of difficult private events. Higher scores
indicate greater experiential acceptance and psychological flexibility. Importantly, this measure has
been found to mediate outcomes for a number of client problems and disorders. The AAQ has been
adapted to a number of populations and translated into many languages. The Five Facet Mindfulness
Questionnaire (FFMQ; Baer, Smith, & Allen, 2004; Baer, Smith, Hopkins, Krietemeyer, & Toney,
Conceptualizing Cases Using ACT 277
2006) assesses present-­moment awareness, the ability to defuse, and observing without judgment. At
the ACBS website, you’ll also find information on measures of values-­based action (some of which were
discussed in chapter 6), fusion and defusion, and mindfulness.
If you employ self-­report measures of psychological flexibility in your practice, we encourage you
to follow general guidelines for using them effectively to monitor progress (e.g., Persons, 2008). We
won’t cover those guidelines here, other than to briefly say that they call for comparing scores to
norms, charting scores to monitor change across time, discussing the results with clients, not assuming scores are correct but checking them against clients’ experience, reviewing individual items to see
if they might lead to additional information, and utilizing all of this information to guide case
conceptualization.
Conceptualizing Cases in Terms of Flexibility
and Inflexibility Processes
The remainder of this chapter sets forth an ACT-­consistent method of case conceptualization in detail
and provides a case conceptualization worksheet to structure the process. We’ll guide you through this
process of analyzing client behavior with a focus on the flexibility processes and explain how to use this
analysis to tailor interventions employing the methods outlined in chapters 2 through 7. We also
provide guidance on incorporating other, non-­ACT interventions that could be helpful. The overarching goal in case conceptualization is to help clients move from behavior (including thoughts, feelings,
sensations, etc.) that’s relatively rigid, insensitive to context, and disengaged from values to behavior
that’s more open, aware, and engaged—­ACT’s three pillars of flexibility.
Overview of the ACT Case
Conceptualization Process
What follows is a concrete, nine-­step process you can use to conduct an ACT case conceptualization.
While you probably wouldn’t use such an intensive process with all of your clients, we encourage you to
work through the full process with at least a couple of clients. We’ve received feedback from many
readers and trainees indicating that completing this case conceptualization process can deepen and
expand clinicians’ understanding of ACT theory and increase the flexibility and fluidity of interventions. You might also consider using the full process when you feel that treatment isn’t progressing for
a particular client. Here are the steps, which we’ll explain in detail in the sections that follow. The
ACT Case Conceptualization Form we provide later in the chapter is organized around these steps.
1. Identify the presenting problem as understood by the client.
2. Detect rigidity related to private experiences (inflexibility: being closed).
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3. Detect insensitivity to the present moment and limited perspective taking (inflexibility: being
mindless).
4. Detect disengagement (inflexibility: disconnection).
5. Consider factors that may limit motivation to change.
6. Consider the client’s cultural, social, and physical environments and their influence on the
client’s ability to change (see chapter 11 for an in-­depth discussion).
7. Identify client strengths that can contribute to psychological flexibility.
8. Describe a comprehensive treatment plan.
9. Reevaluate the conceptualization throughout treatment, and revise functional analyses,
targets, and interventions as appropriate.
1. Identify the Presenting Problem as Understood by the Client
A key focus of ACT early in therapy is drawing out the client’s conceptualization of the problem
that brings her to therapy and considering how psychological inflexibility is involved in that problem.
A variety of questions can facilitate this exploration:
•
“How do you see your problem at the present time?”
•
“How long have you been struggling with this issue?”
•
“What do you think you need to do to make things better?”
•
“What are your goals for therapy, and for your life?”
•
“What have you done to try to deal with or solve this problem?”
It often helps to get descriptions of presenting complaints in fairly concrete terms. Open-­ended
questions generally elicit more information than closed questions, for example, “If I could hear what
you were saying to yourself during an anxiety attack, what would I hear?” or “What do you notice happening in your body when you’re anxious? What are the physical sensations?”
In ACT, the general assumption is that many of the things clients have been doing to solve the
problem are often part of the problem. As outlined in chapter 2, the therapist’s job involves drawing out
the verbal system that has kept the client stuck in the presenting problem (e.g., needing more confidence or better self-­esteem; needing to feel better or stop having negative thoughts, and so on). Although
this process informs assessment, it’s also an intervention wherein therapist and client collaboratively
gain more insight into the functions of the client’s behavior. To facilitate this, it’s important to take an
open, nonjudgmental stance, and to avoid either buying into or challenging the initial formulation
presented by the client. From a case conceptualization perspective, the goal is to understand the client’s
formulation of the problem and then reformulate that understanding in ACT-­consistent terms.
Conceptualizing Cases Using ACT 279
As the preceding list of suggested questions indicates, one aspect of identifying the client’s presenting problem is getting a sense of the client’s initial goals for therapy. As you consider these goals in this
first step of the process, remember that clients’ cultural backgrounds can affect their goals for therapy
(see Step 6). At this early stage, just be aware of this consideration, particularly if a client’s background
doesn’t match your own.
Clients usually describe a range of goals for therapy, some of which can be considered outcome
goals and some of which can be considered process goals. In an ACT formulation, outcome goals refer
to desired end states linked to the client’s values, such as having a better relationship with a partner,
being more engaged at work, being a supportive and loving parent, living with integrity, developing
close and fun friendships, or growing spiritually. Process goals seem to serve outcome goals in the sense
that clients think attaining their process goals will make it possible to achieve their outcome goals.
Clients often put forward process goals such as reducing anxiety (e.g., “I need to be less anxious so I can
meet new people”); being less self-­critical (e.g., “In order for me to be close to people, I need to stop
comparing myself to them”); having less pain (e.g., “I can’t do the things I used to do because it’s too
painful”); and feeling less depressed (e.g., “I can’t reengage in life until I get past this depression”).
Some clients initially appear to lack goals, as reflected by statements like “I don’t know what’s
wrong with me. I’m useless and can’t do anything right.” However, further exploration often reveals
that they’re attached to process goals: “If I didn’t have this depression, then maybe I’d feel better. But
that’s not possible.” What appears to be a lack of goals is actually unclear values coupled with fusion
with stories about the hopelessness of achieving process goals, leading to a lack of outcome goals. In the
ACT view, that kind of linkage between process goals and outcome goals is often a key part of what’s
keeping clients stuck, and this linkage therefore must be targeted during therapy.
An ACT reformulation usually focuses on helping clients live better and feel better (i.e., get better
at feeling) while reducing the emphasis on feeling good. At a deeper level, any reformulation must be
consistent with the client’s most cherished life goals and values (the outcome goals) and be detailed
enough to create a treatment contract focused on initial goals and methods of treatment. Clients typically identify negative feelings, thoughts, memories, or sensations as the problem. In ACT, these
“­problems” are fundamentally reformulated in the case conceptualization. The target becomes the client’s relationship to these experiences (e.g., not wanting them, being overly attached to them, or having
rigid rules about them), rather than the experiences themselves. For example, a client may come into
therapy complaining, “I don’t care about anything anymore. My relationships are terrible, and my job
sucks. It’s hopeless.” This complaint might be reformulated as “The client undermines close relationships and work commitments in an effort to avoid feelings of rejection and failure.” In other words,
pushing people away and underperforming at work function to avoid rejection and failure. As another
example, a client may come to therapy with the presenting complaint “I want help feeling better about
myself. I need to have higher self-­esteem.” An ACT reformulation here might be “The client is fusing
with negative evaluations of self, and as a part of that process, declines opportunities to expand social
engagement.” In other words, being fused with negative thoughts about the self functions to keep the
person from developing meaningful relationships.
Finally, you’ll want to score and review any self-­report assessment measures given to clients, considering their current level of psychological flexibility, mindfulness, and defusion as you begin to collate
information about their situation. You might consider using such measures as part of the exploratory
process with clients.
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2. Detect Rigidity Related to Private Experiences
Clients often identify difficult private experiences as part of their presenting problem. It isn’t
unusual for clients to be experiencing a combination of avoidance and fusion that has gotten them
stuck in psychological or behavioral rigidity. (This is the first pillar of inflexibility: being closed.) Clients
are often avoidant of thoughts, feelings, memories, sensations, and situations or fused with thoughts in
ways that lead to limitations or excesses in behavior. Such avoidance and fusion may be obvious in
many cases, but sometimes you may have to do a bit more exploration. This is also the time to start
looking through a functional lens to see how these behaviors are operating in the client’s life. For
example, you might ask, “What do you do when you feel anxious?” as a means of exploring the client’s
forms of escape behavior. Or you could ask, “Can you give me some examples of what happens to you
before, during, and after an anxiety attack?” to better understand the antecedents and consequences of
the behavior. Usually, both therapist and client need to develop their ability to track the particular patterns of behavior that are leading to rigidity in the client’s life.
Recording avoidance behaviors and fused thoughts formally as part of your case conceptualization
can help you begin the work of planning treatment and selecting ACT interventions. At this early
point, the purpose of recording the content of avoided or fused content is not to change or modify that
content, but to make it available for use later in treatment as a target for experiential learning focused
on increased acceptance and defusion. Nonetheless, at this point you may be able to identify acceptance and defusion interventions that could be effective for the client.
AVOIDANCE
Avoidance of experience, which shows up as efforts to decrease, eliminate, or otherwise control
emotions, thoughts, or sensations, is one of the more prominent forms of psychological rigidity. A great
deal of suffering is found in the denial of pain. In addition, experiential avoidance often creates a self-­
amplifying loop, leading to additional suffering. Clients may report intense anxiety related to the experience of anxiety or even imagining anxiety. Experiential avoidance takes many forms, including overt
behavior, internal verbal behavior, or a combination of the two, and is a key component of case conceptualization. At times, you may see patterns of avoidance behavior directly in session, and at other
times you may have to rely on client reports. Here are the three primary types of avoidance to look for,
with examples of each:
•
Internal avoidance behaviors: distraction, excessive worry, dissociation, attempting to think
differently, daydreaming
•
Overt emotional control behaviors: drinking, using drugs, self-­injury, thrill seeking, gambling, overeating, avoiding physical situations or physical reminders
•
In-­session avoidance behaviors: changing the topic, being argumentative or aggressive, dominating the conversation, dropping out of therapy, coming to sessions late, always having an
acute crisis that demands attention, arguing against feedback, focusing exclusively on the
positive
Conceptualizing Cases Using ACT 281
In assessing these experiences for your case conceptualization, it’s important to look beyond content
and notice patterns of behavior, for example, when a question goes unanswered. Avoidance also shows
up in body language. Pay attention to the client’s gestures and body language, including such things as
looking away when asked about difficult topics, smiling during moments of sadness, sitting with shoulders slumped, fidgeting, and so on. By extension, changes in such body language can be an indicator of
change during treatment, such as when a client no longer smiles when feeling sad.
In some cases, avoidance behaviors may not occur at the beginning of therapy, but you might be
able to predict them based on behaviors that are functionally the same, allowing you to address them
before they happen. For example, imagine you discover that a client has the tendency to flee relationships when he begins to feel threatened by intimacy. In order to decrease his risk of dropping out, you
might have a conversation at the start of therapy in which you predict the appeal of dropping out,
casting it as experiential avoidance and talking about what the client could do instead of leaving
therapy should this arise.
Finally, assess the pervasiveness of experiential avoidance in the client’s life. Is it a major controlling variable for behavior across most domains of the client’s life or only a few? Or is the client’s life
consumed by experiential avoidance to the extent that almost everything the client does is tied to it?
FUSION
Fusion works together with experiential avoidance to create psychological rigidity. We humans
don’t just avoid uncomfortable thoughts, emotions, sensations, and memories; we constantly talk to
ourselves about this process. We create stories about why we’re having these experiences (reason giving)
and explain, justify, and link our actions to these reasons. Sometimes we develop plans and goals that
focus on experiential avoidance. We can get so caught up in this conceptualized world that we miss our
experience of life in the here and now and all of the opportunities it affords.
A more rigid form of cognitive fusion can be seen in clients who come to therapy with a strong
belief that unworkable control strategies will eventually work or who continue to engage in unworkable
strategies despite being aware that they aren’t working. If you see this, it’s important to address it early
in therapy through creative hopelessness interventions targeted at undermining strong beliefs about the
ultimate workability of these strategies.
Another highly fused pattern occurs when clients are attached to excessively logical or rigid thinking patterns. For some clients, this can take the form of a strong attachment to being right, even at
significant personal cost. For others, it may manifest as a great deal of reason giving for their behaviors
or having an excessive focus on understanding or insight. Some clients tend toward overconfidence in
their evaluations of themselves, others, or situations. They may then hold rigid expectations of themselves and others despite the unworkability of these expectations. The primary interventions for this
pattern of behavior include undermining reason giving through defusion strategies, reducing attachment to the conceptualized self, and helping clients examine the costs in terms of their vitality and life
direction.
Another type of fusion with thoughts that may show up early in therapy and inform case conceptualization is clients’ evaluations of themselves, their experiences, or their situations. Typically, these
kinds of thoughts include self-­judgments such as “I’m worthless” or “I’m incompetent,” which are often
stated as part of the presenting problem. That said, fusion with some forms of evaluation can be tricky
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to detect, as it’s presented not as a thought but as an implicit characteristic of whatever is being described
(e.g., “I have social anxiety”).
If a client tends to focus strongly on the behavior of others or chronically engages in avoidance, it
can be hard to find key targets for defusion. For example, a client who doesn’t call a friend to ask him
to get together may do this to avoid thinking he’s a loser and having the feelings that could arise if his
friend were to say no; however, he may explain that he simply was unable to make the call. In this
example, fusion with the self-­concept of “loser” is probably an important target to identify in the case
conceptualization, but it may not be disclosed unless the therapist inquires about it. So if a client avoids
particular situations or people, try to uncover the feelings, thoughts, or other experiences associated
with it that may be difficult for the client. This can illuminate “hidden” fusion.
Fusion can occur with other kinds of thoughts, beyond judgments and evaluations. A client might
be fused with rules, rigidly following them to the point of suffering. For example, a client who strictly
follows a learned family rule that anger is not allowed may find it difficult to stand up for herself when
necessary. Or a client following the rule “I must be happy” may find himself unable to conform with
the rule after repeatedly encountering disappointment. Ultimately, the key to detecting fusion in clients
involves noticing when their thinking leads to rigid and inflexible patterns of behavior that generate
suffering and interfere with values-­based living, and for whom there is little or no awareness of the
distinction between the person and the mind. Lastly, be aware that clients can become fused with positively evaluated thoughts in ways that are problematic, even though such thoughts typically aren’t
presented as a problem. For instance, a client who’s fused with the thought “I’m better than others” may
find himself struggling in the social world.
KEY CONSIDERATIONS IN ASSESSING AND WORKING WITH
AVOIDANCE AND DEFUSION
Here are some questions to consider as you assess for avoidance and fusion and choose interventions to target these processes:
Of the various private experiences identified in the case conceptualization, which are most central
and important to target? Which private experiences lead to the most rigid and problematic patterns of avoidance? Which patterns of avoidance tend to be the most problematic in terms of creating suffering or interfering with flexible, values-­based behavior?
Are there particular evaluations of self or others that structure how this client responds to herself,
or rules that this client tends to follow in a rigid or inflexible manner? If so, what exercises, metaphors, or techniques would be best for working with this particular client’s behavior?
If you identified avoided situations, do you know what thoughts the client fuses with in those situations and what emotions or other private experiences she tends to avoid? If not, how can you
investigate this further?
Are there any in-­session forms of avoidance or fusion that you need to attend to because they may
threaten the therapeutic relationship itself? If so, what can you do to address these possibilities?
Conceptualizing Cases Using ACT 283
Does the client display gestures, body language, or vocal qualities (e.g., tone of voice, pace) that
might point to hidden avoidance or fusion? If so, what are they, and have you explored the client’s
present-­moment experience when these behaviors occur?
How are you affected by this client’s avoidance or fusion? Are there any moments that are particularly difficult for you with this client? What might this tell you about the client? What might this
tell you about what you need to do or techniques you might need to use to maintain your psychological flexibility with this client? Is there anyone you might want to consult with about the reaction you’re having?
3. Detect Insensitivity to the Present Moment and Limited
Perspective Taking
The third step of this case conceptualization process focuses on tracking patterns of insensitivity
to events occurring in the present moment that might influence the client’s behavior, difficulty with
shifting perspective, or an inability to take perspectives other than self-­as-­content. (This is the second
pillar of inflexibility: mindlessness.) Clients who are focused on what happened in the past, who are
persistently worried about the future, or who have little self-­awareness or perspective on the self may
repeatedly suffer due to reliving past pains and worrying about imagined futures or from consequences
of this behavior. In addition, clients who have a reduced capacity to observe themselves, others, and
situations from different points of view run the risk of clinging so tightly to a single point of view (e.g.,
“I’m a failure”) or identity (e.g., “I’m a soldier”) that flexibility is compromised, potentially leading to
consequences that intensify suffering. In short, being out of touch with the present moment or being
attached to conceptualized selves can lead to limitations or excesses in behavior.
LACK OF CONTACT WITH THE PRESENT MOMENT
There are three primary types of behavior patterns related to lack of contact with the present
moment to be considered when conceptualizing a case.
First, clients may poorly track their ongoing, moment-­to-­moment experience. They may generally
be unaware of what they’re thinking, feeling, or sensing in the moment, or if they are somewhat aware
of these experiences, they may lack the ability to put words to them. This can take a variety of forms,
from an alexithymic client who says he doesn’t have feelings to a client who responds to all questions
about what she’s feeling by saying, “I’m stressed.” Such clients may provide socially acceptable but
hollow answers that are unrelated to their current experience or what’s happening in therapy. One sign
of this would be if you believe you’ve observed an emotional reaction in a client but, upon inquiry, the
client is unable to describe feeling anything. Clients exhibiting such patterns of behavior tend to stay
at a conceptual level in therapy and rarely use emotional terms, particularly in response to their current
experience. You can address this issue by naming emotions when possible or by catching clients’ emotions in flight and helping clients slow down enough to contact these experiences. You can also invite
clients to notice sensations or experiences in the body (e.g., heaviness in the chest). In addition, you
284 Learning ACT, 2d edition
might consider using mindfulness techniques and experiential exercises to promote in-­the-­moment
experiencing of emotions.
Second, lack of contact with the present moment can show up as a narrowness of focus, with inattention to the broad range of events in the environment. For example, such clients may not notice that
you have a new pair of glasses or that your office has changed, or they may frequently ask you to repeat
yourself. Exercises targeted at contact with the present moment, including simply observing and describing current experiences in a relatively safe context, will help such clients learn how to track their
ongoing, moment-­to-­moment experience and allow them to open up to other relevant contingencies
that could shape their behavior. This might include focusing on bodily sensations and experiences in
the here and now, as well as Gestalt-­type exercises that allow clients to take a closer look at their experience by describing bodily sensations, emotions, and thoughts. You can also recommend exercises
designed to increase regular contact with the present moment (e.g., daily mindfulness practice). It’s
often effective to help clients become more mindful during situations in which they’re trying something
new or experiencing a difficulty; this might entail approaches such as diaries or worksheets for tracking
private experiences and difficulties in the moment or in-­session experiments in which difficult private
events are brought into the room and clients notice how they react.
Finally, clients who are excessively caught up in the conceptualized past or future tend to engage
in patterns of pervasive worry, anticipatory fear, resentment, or regret, all of which function to block
constructive behavior. This will generally be exhibited in reports of events that occur outside of therapy,
but it can be seen in session when clients repeatedly engage in lifeless storytelling or cycles of ruminative thinking. For such clients, extensive work may be necessary to help them practice contact with the
present moment, in and out of session. You may need to frequently interrupt them (after a discussion
about why this is important) and bring them back to what’s happening in the moment. To that end, you
might engage such clients in brief mindfulness exercises that help them be more aware of their present-­
moment experience at the start of each session and during sessions as needed. Consider identifying
feared, evocative content at the end of the “worry chain” or identifying uncomfortable past memories
linked to regret, and then conduct imaginal or in vivo exposure or willingness exercises using these
scenes or related stimuli, in combination with a focus on values and perspective taking. It will also be
important to help these clients develop a sense of self-­as-­context, as described in the next section, so
they can observe their thoughts about the past or future without buying into them or rejecting them.
ATTACHMENT TO THE CONCEPTUALIZED SELF
People can live so tightly within their self-­concepts that they lose contact with the experiencing
self. Clients may get trapped in notions of who they are and, in trying to live up to their own or others’
ideas of themselves, pay great personal costs. This particular kind of insensitivity is often linked to
fusion, as clients get drawn into defending the conceptualized self as if it were their physical self. This
can lead to behavioral rigidity and trap them in patterns of living that are limiting and unworkable.
In conceptualizing cases, consider how strongly attached clients are to particular roles. For instance,
if you’re working with a war veteran who’s complaining about how others don’t follow rules, you might
consider whether the client is overly attached to the identity “soldier.” Is he a soldier at work, at home,
and in play? Is he a soldier in his relationship with his wife and children? Is he a soldier in all aspects of
his life? If the answer is yes, then he’s probably found himself in unworkable situations with respect to
rule following. If clients are unable to observe that they are more than a single or small subset of roles
Conceptualizing Cases Using ACT 285
or identities, it will be helpful to work on flexible perspective taking and contacting the perspective of
self-­as-­context—­in other words, the self as experiencer of these roles. If this isn’t addressed, it may
continue to interfere with clients’ flexibility in bringing their personal values to life.
Attachment to the conceptualized self can also be observed in clients who are strongly identified
with a particular view or story about themselves or others. For example, a client can be very attached
to a description such as “I’m cheerful…peppy. I bounce back.” Although this self-­assessment is seemingly positive, it can be a problem if the client distorts or interprets events to make them consistent
with this conceptualization, rather than acknowledging and addressing situations in which she didn’t
act cheerful or bounce back. Alternatively, clients can be wedded to a self-­concept such as “I’m broken,
defective, and weak” and defend this conceptualization and the story that supports it, despite its superficially negative form. Another manifestation of attachment to conceptualized self shows up when
clients are unable to consider alternative perspectives on their problems or the possibility that others
may have views that differ from their own.
A considerable amount of experiential work on self-­as-­context and perspective taking, blended
with defusion, may be necessary to address all of these types of attachment to the conceptualized self.
In particular, the therapist needs to work on differentiating primary, directly observed qualities of
events (descriptions) from secondary, verbally derived qualities of events (evaluations). The client can
be asked to take on different perspectives, acting out different roles or self-­concepts, or be invited to
contact a felt sense of self that is larger than experiencing. Other aspects of this work include helping
such clients develop more compassionate ways of responding to themselves by connecting with the
experiences of others and seeing themselves as part of something larger than themselves. All of these
approaches are aimed at freeing clients from limiting roles and self-­concepts, which will make choice
and behavioral flexibility more available.
A final consideration pertains to clients with chronic and pervasive problems as well as those with
an extensive history of trauma. Such clients often come to therapy with a strong belief that they can’t
change or that a better life isn’t possible for them, combined with a strong attachment to a life story
that supports this belief. This can be combined with an identity that is defined in simplistic or black-­
and-­white terms (e.g., “I’m weak,” “I’m evil,” or “I’m broken”). It can also appear as a victim stance that
manifests in frequently blaming others for the client’s actions. For these clients, it’s particularly important to engage in defusion and self-­as-­context work targeted at undermining attachment to limiting life
stories. Without directly challenging such life stories, you can help clients examine the cost of following
the story (e.g., in terms of living a full and meaningful life) and determine whether they want to continue this pattern. Consider autobiographical rewrite exercises (see Strosahl et al., 2004). Also conduct
behavioral experiments to see whether even small changes could occur. Later in therapy, you may want
to consider working more directly with forgiveness and victimization (Walser & Westrup, 2007).
KEY CONSIDERATIONS IN ASSESSING AND WORKING WITH LACK
OF PRESENT-­MOMENT AWARENESS AND SELF-­AS-­CONTENT
Here are some questions to consider as you assess for lack of present-­moment awareness and attachment to the conceptualized self and choose interventions to target these processes:
In what life situations or contexts does this client most lose contact with the present or get caught
up in self-­as-­content, both in and out of session? How can you target those contexts?
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Are there particular moments in therapy when the client seems to lose contact with the present
moment (or when you can anticipate that happening), for example, by ruminating about the past,
worrying about the future, or being insensitive to your presence? What can you do to more regularly notice those moments and respond to them?
Does the client have particular stories about the self or others that tend to lead to the most restricted
patterns of living? When do these tend to show up? What strategies can you use to address attachment to these stories?
When do you tend to leave the present moment with this client? For example, when do you begin
to zone out, get caught up in content, passively listen, or otherwise lose an experiential learning or
present-­moment focus? What might this tell you about what you need to do or techniques you
might need to use to maintain your psychological flexibility with this client? How can you remind
yourself to do those things?
4. Detect Disengagement
ACT is fundamentally about helping clients create full, meaningful, vital lives. In therapy, this
work is accomplished by helping clients clarify their values and supporting them in making and keeping
behavioral commitments tied to those values. Thus, in a complete case conceptualization, the therapist
should consider a broad range of life domains (e.g., family, health, relationships, spirituality, and work)
to get an overview of the client’s functioning, learn about what’s meaningful to the client, and identify
behaviors that would instantiate the client’s values. The completeness of this part of the conceptualization will vary depending on the context of the intervention and the extent to which values are a focus
of treatment. For example, if values only become a major focus later in treatment, your case conceptualization in this regard might not be fully fleshed out initially. Nevertheless, even in very brief treatment
it’s important to give some consideration to areas in which behavior is excessively narrowed or in which
valued living is highly constricted.
When people respond with avoidance and fusion, are overly identified with the conceptualized self,
or are out of contact with the present moment, their behavior tends to become excessively rigid and
narrow, resulting in a lack of flexibility in engaging in values-­based living. (This is the third pillar of
inflexibility: disconnection.) Behavior that isn’t working may persist, and conversely, in areas where
persistence is needed, behavior may change impulsively. It’s common for clients to be so thoroughly
adjusted to these patterns that they no longer notice them. Clients’ time and energy may be primarily
oriented toward relief from psychological pain, resulting in a loss of contact with their values and
values-­based action.
UNCLEAR VALUES
There are a number of different strategies you can use to discover and delineate values. However,
it may take time to explore values and committed action sufficiently to get a clear understanding of a
client’s disengagement in these areas. At an extreme, clients may have completely abandoned some or
all of their valued life domains. Alternatively, their engagement may be excessively narrowed, inflexible, or inconsistent. This may result in limited effectiveness, expression, or vitality. These actions exist
Conceptualizing Cases Using ACT 287
on a continuum, so be on the lookout for subtle forms of these processes. For example, two quite different dynamics could be maintained by avoidance of vulnerability: one client may cut off any sort of
interaction with potential romantic partners, whereas another has a partner but engages in the relationship in a superficial or limited way.
Clients who struggle with these processes may be unable to describe what they want, be unclear
about what holds meaning for them, or engage values in a way that’s heavily socially determined or
influenced by the presence of the therapist or other major figures in their lives. When clients’ behavior
is dominated by pliance, or following social rules because of a history of being reinforced for rule following, they often present as motivated and seek to be “good” clients. Their behavior tends to be oriented toward “shoulds” and looking for the “right” answer to the therapist’s questions. What they want
in life may be drastically influenced by the person to whom they are currently responding. In conducting values clarification with such clients, closely track your own behavior and do your best to remove
cues that could seem to suggest what the right thing to do is or what the best values are. It may be
necessary to help such clients gradually build their ability to contact and describe their needs and
desires.
Some clients’ behavior may be so dominated by escape and avoidance that they’re unable to articulate goals and values that are heartfelt or meaningful. Alternatively, clients may describe tightly held
but unexamined goals (e.g., being popular or making money) as if they were values. To the extent that
clients’ behavior is tied up in experiential avoidance, they will have a hard time saying what they really
want in life because doing so produces a sense of vulnerability. You may need to devote additional work
and attention to helping such clients clarify and develop values that are solid and strongly held. Here,
it’s important to contrast their current life direction with their values-­based directions, to help them
engage in committed actions that reflect their values, and to assist them in examining the costs of
engaging in behaviors that are rewarding only in the short term. The key is to bring the extended
verbal consequences related to values into the present moment so those consequences can more actively
influence clients’ behavior in situations where avoidance is likely, allowing longer-­term desired qualities
to exert greater control over their behavior. Creative hopelessness exercises can be helpful here.
Other helpful interventions include focusing on the most important areas of clients’ lives, particularly domains in which they experience a lack of engagement, choice, or vitality. It may be useful to
initially target one or two domains in which a client’s behavior is most narrow and inflexible and
wherein this constriction appears to result in ongoing suffering. You’re more likely to have leverage for
facilitating behavior change in these domains.
LACK OF COMMITTED ACTION
In part because of experiential avoidance, clients can develop ever-­larger patterns of action that are
detached from their long-­term goals and values. Behavior is narrowed to getting by or surviving the
moment, rather than broadened toward building a life that would be more rewarding, meaningful, or
workable in the long run. In such cases, clients are typically less sensitive to learning opportunities and
the possibility of putting their values into action in the here and now. Their disengagement can take
many forms, including low quality of life and impulsive or self-­defeating behaviors. For these clients,
your case conceptualization should include a description of how their behavior is constricted in the life
domains you explore. Finally, it can be helpful to ask, “If a miracle were to occur and you could do what
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you wanted, what would that be?” Clients’ answers provide a good starting point for beginning to
understand which behaviors to target for committed action goals.
As you assess whether clients are disengaged from healthy action (stated this way to include impulsive behavior), you may learn that a client’s life is relatively free of the acute experience of pain, but also
fairly narrow and unsatisfying. This pattern is often seen in clients who feel stuck in unsatisfying jobs
or relationships due to fear of the unknown or of the consequences of change, and in clients who have
chronic physical pain. Clients with this pattern will benefit from learning about the qualities of committed action, such as holding goals lightly, and from focusing on the process of living rather than on
the outcome of particular actions. Working with clients to clarify the distinction between choices
(freely made or selected simply because they can be) and decisions (made after the pros and cons have
been weighed) can free them to make new or different choices, rather than continuing to live out old
stories. When clients are engaged in novel actions, you can provide support by helping them develop a
mindful, nonjudgmental, compassionate, and accepting stance toward themselves in those situations.
Finally, paying attention to whether clients engage in impulsive or self-­defeating behavior is important. Avoidance behaviors result in powerful short-­term reinforcement, which can overshadow behavior that’s ultimately more workable but potentially more painful in the short run. This dynamic can
show up as chronic self-­control problems, such as impulsivity, substance use, aggression, or risky or
self-­injurious behavior. Clients may have problems delaying gratification or have an extremely low tolerance of difficult emotional experiences. Impulsive clients tend to have limited practice in engaging in
planned, step-­by-­step patterns of action, and this can show up in many ways—­procrastination, underperformance, poor health behaviors, and difficulty completing homework in therapy, to name a few.
When such clients begin to engage in committed action, start small and reinforce them for being
willing to commit and for following through, no matter how small those initial actions may seem.
Additionally, when such clients are disengaged from values-­based behaviors, or are engaged in impulsive behaviors or inflexible behaviors in session, turning the focus to contact with the present moment,
acceptance, and defusion can help them develop greater flexibility to persist in or change their behavior as required by the situation.
KEY CONSIDERATIONS IN ASSESSING AND WORKING WITH
UNCLEAR VALUES AND LACK OF COMMITTED ACTION
Here are some questions to consider as you assess for unclear values and lack of committed action
and choose interventions to target these processes:
When you talk to the client about valued areas of living, how much do the four qualities of effective
values conversations show up (i.e., present-­moment orientation, vitality, choice, and willing vulnerability)? What does this say about what you need to do with this client during values conversations?
Which exercises or metaphors might be most useful? What’s getting in the way of fostering these
qualities? What qualities do you need to bring to these conversations as a therapist?
How much should you focus on values early in treatment? Would it be better to focus on other
processes first? What can inform this choice?
Conceptualizing Cases Using ACT 289
Which domains of valued living should be targeted first? How can you work collaboratively with
the client to identify which should be the initial focus? How can the two of you begin translating
more of the client’s values into practical action steps?
What sort of changes in this client’s life would be most meaningful or inspiring to you as a therapist? Does this align with the client’s goals? If not, what does this say about the client or about your
relationship? What might you need to do or understand in order to address this discrepancy?
5. Consider Factors That May Limit Motivation to Change
As you assess the preceding inflexibility processes, also consider the client’s motivation to change.
For example, experiential contact with the costs of avoidance is essential before doing acceptance or
exposure work that requires significant motivation. For clients who aren’t in contact with the costs of
experiential avoidance, and especially if their values are unclear, it can be helpful to begin with a
heavier than usual focus on values and then to examine the discrepancy between clients’ current
behavior and their personally meaningful life directions and goals. It also can be helpful to link work
that requires significant motivation to valued goals and relationships. For example, you could ask, “If
allowing yourself to feel anxious could make it possible for you to be the kind of teacher you really want
to be, would you be willing to feel anxious?”
Another kind of motivational problem occurs when clients are strongly attached to fears about the
consequences of confronting challenging events. This may call for focusing on defusion and self-­
as-­context prior to any work that involves facing feared situations. Be sure to titrate exposure or willingness exercises to a level at which the client is willing to experience them fully and without defense.
Small steps with 100 percent willingness are much better than white-­knuckling it through larger steps.
Research has shown that the therapeutic relationship can be a powerful motivator for change. In
the ACT model, relationships are built using flexibility processes (something we’ll discuss at length in
chapter 9). In assessing the quality of the therapeutic relationship, look for signs that the client is
present, caring, and engaged, as well as signs that the client feels coerced or misunderstood. If you
detect any problems, check on the integrity of the therapeutic contract. Are you and the client working
toward agreed-­upon goals, or is there a mismatch between your goals and the client’s? Consider your
level of commitment to the client. Are you lacking investment, or do you feel distracted when working
with this client? Also consider whether the client is triggering emotions or thoughts that are difficult
for you. For example, are you engaging in avoidance and undermining the relationship yourself? If your
own reactions are a cause for concern, generate an action plan that addresses those reactions (e.g.,
consultation).
6. Consider the Client’s Environments and Their Influence on
the Client’s Ability to Change
Clients do not live in a vacuum. You need to know whether any of the ACT-­relevant processes that
apply to the individual are being played out at the cultural level (discussed in chapter 11), social level,
290 Learning ACT, 2d edition
or even the physical level. Clients may be reinforced for engaging in behaviors that promote the status
quo in many realms: financial, social, cultural, familial, and institutional. For example, a client may be
motivated to remain disengaged in order to keep receiving disability payments; a client’s spouse may
find change on the client’s part difficult and therefore be unsupportive; or an addicted client may not
have any friends who are sober. Considering how cultural, social, and physical environments bear on
an individual’s case may influence decisions around committed action. If possible, consider direct
interventions that could change the environment either by engaging people who can support the client
in new behaviors or by directly reducing behaviors that impede growth (e.g., engaging in couples
therapy if the client’s spouse is unsupportive or fearful, referring to support or therapy groups, or including important people from the client’s social network in therapy).
7. Identify Client Strengths That Can Contribute to
Psychological Flexibility
Be sure to explore whether clients have engaged with past difficulties in ACT-­consistent ways.
Sometimes these previous experiences can be used to catalyze rapid change in therapy. Past experiences of acceptance, mindfulness, and committed action can serve as models for how the client might
behave in the current situation. Drawing parallels between the current struggle and a struggle the
client previously overcame can facilitate transferring useful action tendencies and perspectives from
the past event to the new one. If a client has had positive experiences with mindfulness, 12-­step programs, spirituality and religion, or other approaches that appear to conform with the ACT perspective,
you can explicitly link current experiences to these. For example, if a client practiced letting go of a
struggle with uncontrollable thoughts, memories, or feelings in the past and had positive results, or if a
client has evidenced a healthy sense of humor or irony regarding a past difficulty, you can bring these
experiences to bear on the current situation in a helpful way.
Likewise, sometimes effective behavior in one life domain can serve as a template for effective
behavior in a domain in which the client’s current behavior isn’t as effective. For example, a client may
have facility with acceptance or mindfulness, or with setting step-­by-­step goals and following through
in one domain (e.g., work) but not in another (e.g., relationships). The domain in which this skill is
strong can serve as a template for action in the other domain. Or a client may have a prior experience
of setting out in one direction and then switching course to another, more rewarding direction. Such
experiences can be used as models for acceptance, flexibility, and persistence in moving in a valued
direction.
8. Describe a Comprehensive Treatment Plan
After completing steps 1 through 7, you should have the information you need to develop an ACT-­
consistent treatment plan. Although most treatment plans address all six flexibility processes in some
fashion, the level of emphasis on each process should be tailored to the case conceptualization. As you
complete this section, we recommend reviewing steps 1 through 7 of the case conceptualization, particularly the treatment implications.
Conceptualizing Cases Using ACT 291
Finally, as part of your treatment plan, you may want to incorporate the following types of resources:
•
Find and adapt a specific, relevant treatment manual that has been shown to be effective with
this type of client (see http://www.contextualscience.org/treatment_protocols or various ACT
books).
•
Obtain flexibility process and outcome measures, determine which are relevant, and score,
record, and interpret as appropriate (see http://www.contextualscience.org/act-specific
_measures).
•
Identify resources available to the client to support treatment: financial, vocational (e.g., training or education), or social (e.g., family therapy, couples therapy, spiritual guides or ministers,
mentors or advisors, support groups).
•
Consider other compatible techniques and treatments that may be relevant but aren