Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 10

Creating Flexible Patterns of Behavior Through Value-Guided Exposure

SESSION 6

It is only by practicing through a continual succession of agreeable and disagreeable situations that we acquire true strengths. To accept that pain is inherent and to live our lives from this understanding is to create the causes and conditions for happiness.

—Suzuki Roshi

Goals and Theme

The major goal of Session 6 is to create broader and more flexible patterns of behavior by means of exposure, mindful observation, and defusion. Recall that the main problem with anxiety disorders is not that clients experience extreme or intense levels of anxiety. The problem is that clients approach anxiety management much like they would a full-time job. This managerial position is demanding and requires that clients put their lives on full or partial hold to get the job done right. In the process, living is not getting done. If there were such a thing as a company called Life, many anxious clients would end up being fired for spending too much time with anxiety management decisions. This sharp narrowing of behavioral response patterns focused on dealing with anxiety is the source of a great deal of suffering and a major barrier to living (Wilson & Murrell, 2004).

During in-session exposure-like FEEL exercises, clients learn to let go of the struggle to escape or control anxiety-related thoughts, worries, and bodily sensations by acknowledging their presence and even embracing and leaning into them. The general goal of these exercises is not to reduce or eliminate anxiety. Instead, the goal is to provide clients with more flexible patterns of behavior when experiencing anxiety. By increasing their psychological and experiential flexibility, clients gain space to move in valued directions and freedom to become general contractors of life. In the process, clients may experience fear reduction as a by-product of running toward reality instead of away from it. This is so, in part, because extinction (i.e., anxiety attenuation) processes operate when one is willing to be exposed to reality as it is, regardless of the reasons used to justify exposure.

SESSION OUTLINE

1.            _Centering Exercise (5 min.)

2.            _Review of Daily Practice (5 min.)

3.            _Emotional Willingness (5–10 min.)

o           Trying Versus Doing: The Pen Exercise

o           Willingness Thermostat Metaphor

4.            _Dealing with Intense Feelings and Thoughts (15 min.)

o           The Bus Driver Exercise

5.            _Exposure Within ACT: FEEL Exercises (25 min.)

o           How Does Traditional Exposure Work?

o           The Context and Purpose of Exposure in ACT

o           Rationale for FEEL Exercises: To Facilitate Valued Living

o           Determining Appropriate FEEL Exercises

o           Types of Interoceptive FEEL Exercises

o           Implementation of FEEL Exercises

o           Dealing with Urges to Escape During Panic Attacks and in OCD

6.            _FEEL Exercise Practice (Home)

o           Daily practice of Acceptance of Anxiety exercise for at least 20 minutes

o           Practice of at least one interoceptive and/or imagery exercise chosen by client for at least 30 minutes per day

o           Continue monitoring anxiety and fear-related experiences using the LIFE form

o           Complete Daily ACT Ratings form

7.            _Session Materials and Handouts

o           Acceptance of Anxiety practice form

o           Living in Full Experience (LIFE) form

o           Daily ACT Ratings form

o           FEEL Sensation Record forms (as needed; one for each day of practice)

o           FEEL Imagery Record forms (as needed; one for each day of practice)

o           Weekly Valued Life Goal Activities form

o           4 index cards for the bus driver exercise

AGENDA

1._CENTERING EXERCISE (5 MIN.)

Begin the session with the centering exercise described in Session 1.

2._REVIEW OF DAILY PRACTICE (5 MIN.)

Review the client’s daily practice of the Acceptance of Anxiety exercise and discuss any problems they may have encountered with the exercise. Next, review the Daily ACT Ratings form followed by the LIFE form, focusing on any instances of clients engaging in behavior to manage thoughts, sensations, and feelings. Help the client see the connection between such actions and short- and long-term costs in terms of how they want to live their lives. For instance, did behavior in the service of managing anxiety get in the way of something that clients value or care about as mentioned in their Life Compass?

3._EMOTIONAL WILLINGNESS (5–10 MIN.)

Now is a good time for a brief discussion of emotional willingness, because it is directly related to internal barriers (“too much anxiety” or “can’t stand it”) that clients will have mentioned. Discussion of willingness also is important because it represents an essential aspect of the upcoming exposure-like exercises.

Recall that willingness is a concept that can easily be misunderstood. Many clients think that willingness is something they do not feel when it comes to anxiety. That is, they tend to see willingness as a feeling that does not make a whole lot of sense given that they clearly do not like the way they feel about anxiety. When you, as a therapist, use the term “willingness,” clients might think that you are asking them to change how they feel about anxiety. This is not the case. According to Webster’s dictionary, willingness is “readiness of the mind to do.” For an individual with an anxiety disorder, anxiety is already present anyway. Willingness means simply choosing to experience that anxiety. In this sense, willingness is the opposite of control. It means making a choice to experience what there is to be experienced, and then experiencing it without trying to change the experience. In this way, willingness is similar to mindfulness. It means being open and accepting of your experience, whatever it may be.

Recall our discussion in chapter 5 where we pointed out the close relation between acceptance, willingness, and purposeful action. With your clients, you will want to emphasize that acceptance and willingness are not feelings. Instead, they are a stance toward life and about behavior and action. That is, willingness is about doing, not trying to do. We have found that the pen exercise helps clients experience that distinction in a practical and simple way.

Trying Versus Doing: The Pen Exercise

“I will try” is one of the most common answers clients give when an ACT therapist asks them whether they are willing to do an exercise or commit to a certain activity. At this point in therapy, you have probably heard this sort of response from your client already. At other times, clients return to a session saying something like, “I have tried to go to work and face my fear of failure. I have tried really hard, but I just couldn’t do it. My anxiety was just too high. So I stayed at home.” Similarly, right before doing something that could provoke anxiety, a client might say, “I can try to do it—honestly, I will definitely try—but I don’t know whether I can go through with it.” Rather than explaining the difference between trying and doing, we recommend doing the pen exercise (Hayes et al., 1990). This brief exercise is a powerful demonstration that willingness is an all-or-nothing action: It is something you do, not something you try to do.

Therapist: What I would like you to do is to try to pick up this pen. Try as hard as you can. Go ahead and try it. [Therapist puts a pen on a table or desk in front of the client and then waits. Just when the client is about to touch the pen, the therapist interrupts.] Wait—you’re actually picking up the pen. I only wanted you to try to pick it up.

Client: [probably a bit confused] Well, I can’t do that. Either I pick it up or I don’t.

Therapist: So what exactly happens when you only try to pick it up?

Client: My hand is hovering over the pen, but I am not actually picking it up.

Therapist: So trying is really “not doing,” and that is why I never want you to try anything. You must first make a choice about whether you are willing to have what there is to be had. And if you are willing, if you are completely willing rather than just a bit willing, then go ahead and just do it. If you’re not willing, I will respect you making that choice. Simply tell me, “I won’t do it.” There is no gray area here. It’s either yes or no.

Spend a bit of time talking about the issue of trying, and that there really is no such thing as trying, there is only doing or not doing. Your clients may equate trying with failures of doing. For instance, they pick up the pen and it slips from their fingers and drops to the floor. They say, “You see, I tried … but it didn’t work.” Note, however, that nothing would prevent the client from bending over and repeating the act of picking up the pen if that is what they are willing to do. Some activities in life simply require persistence and doing something over and over again. Failure is an evaluation that the mind may dish out, but that need not get in the way of willingly doing what is important, even if that doing takes time. If you deem it useful, you can repeat the pen exercise to drive home the important point that we cannot try to do—we can only do or not do.

Willingness Thermostat Metaphor

Hayes et al. (1990) originally developed the willingness thermostat metaphor for clients with anxiety disorders and later expanded it for use with persons suffering from other disorders (Hayes, Strosahl, & Wilson, 1999). We have shortened and simplified this metaphor for the purpose of this program. One of the implications of this metaphor is that it can lead into a useful discussion on the issue of response-ability versus being a victim of anxiety.

Look at these two thermostats. They are like the ones you use to control the temperature in your house. One thermostat is called “anxiety” and the other is called “willingness.” Both thermostats can go from 0 to 10. [Therapist draws two vertical lines on a piece of paper and labels them accordingly.] When you came to this clinic, you were probably thinking, “My anxiety is too high—it’s way up here [therapist points to the top of the anxiety thermostat]. I want it to be down here instead.” In contrast, your willingness thermostat was set the exact opposite way because you really didn’t want to experience any anxiety. So you set it all the way down here [therapist points to the bottom of the willingness thermostat]. Now, for the past few weeks we’ve been playing with changing the setting on the willingness thermostat to see what happens when you set it higher, as in the mindfulness exercises. I understand that you’re more concerned about the anxiety thermostat. So I’d like to share a little secret with you. The willingness thermostat is really the more important of the two, because it is the one that is going to make a difference in your life. When you experience a lot of anxiety and you’re trying hard to bring it down, you set your willingness thermostat down here at 0. Yet, when you’re not willing to have and feel this anxiety, then your anxiety is something to be anxious about, and it locks into place: When you’re not willing to have it, you’ve got it.

This may even make you feel like you’re a victim of anxiety, that you are helpless, because if you were in control of it, you would have already brought it down to 0. It’s not that you didn’t work hard enough or weren’t clever enough; it simply doesn’t work. Now, what if you stopped trying to set the anxiety thermostat, because you know from experience you cannot control that, and instead turned your attention to willingness? In contrast to the anxiety thermostat, you actually do control where you are on the willingness thermostat. This is a place where you are response-able. It is your choice whether you keep it down here or whether you turn the willingness thermostat up all the way. I’m not sure what would happen with your anxiety if you did that. I only know one thing: You really can set the level on that willingness thermostat exactly where you want it to be. And if you make a choice to set that willingness thermostat high, things might start to happen in your life. For instance, you could start doing what you want to do and [insert a client valued direction here].

At the end of this metaphor, it is important to emphasize that this is not talk about ignoring anxiety. Clients probably do not know how anxiety will work in the absence of attempts to control it. They may have a prediction. Yet, based on experience, they simply may not know because they may never have approached anxiety with willingness to have it. Clients may ask how exactly they can set their willingness thermostat high. Tell them it is neither a feeling nor a thought. It is a choice they can make that needs to be followed up with committed action. The crucial question is, “Are you willing to go out with your hands and feet and take your anxiety with you? Remember, willingness is simply a choice and a commitment to have what you already have. Like in the pen exercise, you either do it or you don’t.”

4. DEALING WITH INTENSE FEELINGS AND THOUGHTS (15 MIN.)

Although clients may be willing to have their anxiety-related thoughts and feelings, avoidance and escape are old habits that have been learned and reinforced in many situations typically over long periods of time. As a result, these old habits are powerful and difficult to break. The exposure-like exercises to be introduced in this and subsequent sessions are meant to elicit feared feelings, images, and thoughts that previously prompted clients to engage in escape and avoidance behavior. Before we start with these exercises is therefore an opportune time to introduce the bus driver metaphor as guidance on what to do, and what not to do, when intense and highly aversive thoughts and feelings seemingly threaten to take over the clients and “make” them do things, such as leaving the room.

The Bus Driver Exercise

The bus driver metaphor was originally described by Hayes, Strosahl, and Wilson (1999). This metaphor is useful because it can teach clients what to do with thoughts and feelings that seem to bully them around. It also illustrates the costs of allowing thoughts and feelings to be bullies. The client is pictured as the driver of a bus called “My Life.” Along the road, the client picks up a number of unruly bully passengers (anxiety-related thoughts and feelings) that yell at the client to change course and go where they want to go instead of where the client wants to go. Joanne Dahl (in press) has converted the metaphor into a powerful experiential exercise that we have adopted for the purposes of this treatment program. The basic idea is that clients can drive and act in a valued direction no matter what the anxious passengers throw at them and tell them to do. It encourages clients to let values, not their anxious thoughts and feelings, guide them through life.

bus driver exercise

Therapist: Imagine yourself as the driver of a bus called “My Life.” Along your route, you pick up some unruly passengers, which are unwanted anxiety-related thoughts that your mind serves up for you. These passengers intimidate you as you drive along your chosen route. Perhaps you can think of a recent experience where you experienced anxiety. What are some of those statements that seem to be very intense and steer you off course? Is it okay if I write them down on these index cards?

[Therapist takes out four index cards and writes down four passenger statements, such as, “This anxiety (or panic) is too much to handle,” “This is really dangerous and is going to take me down,” “Everyone is going to think I’m stupid,” and “I can’t stand all these germs on me.” After writing each statement on a separate index card, the therapist puts the index cards on the floor in a semicircle resembling a clock, putting one card at 12 o’clock, the next at 2 o’clock, the third at 4 o’clock, and the last card at 6 o’clock (see illustration below). Then therapist and client both get up and face one another. The therapist reads the statement on the card at 12 o’clock and asks the client to respond to it by disputing it or coming up with some other statement or strategy to silence the passenger. Then the therapist asks the client to move to the next passenger statement. While facing the therapist at the second card, the client attempts to cope with that statement. This move will require the client to “change course” and move sideways toward the 2 o’clock position. Following the same procedure and moves, the client will stay facing the therapist but will eventually end up turned the opposite direction from where they were going at the start. The procedure is illustrated above.]

Therapist: What has happened? Where are you headed?

Client: Not where I was going! I can’t even see the road ahead anymore.

Therapist: Isn’t that a high price to pay for attempting to silence the passengers? Every time you responded to, and got tangled up with, your thoughts and feelings, you ended up no longer moving in the direction you wanted to go and got further off course.

Client: I feel I just had to respond. These thoughts seem to be so forceful and have such power over me.

Therapist: Well, there is another way of responding. You don’t have to struggle with those thoughts and let those passengers steer you in a direction that is not yours but theirs.

Client: How do I do that?

Therapist: I will read the same passenger statements to you one more time. However, this time, why don’t you just listen to the statements—they’re just thoughts anyway. You won’t be able to avoid hearing them, because I will be very loud. You can choose to focus on going forward and not doing what the thought says. You can choose to continue to drive the bus in your direction rather than where the thoughts are trying to get you to go. Remember that this is your life bus and you are the driver. Your hands, not the words of the passengers, steer that bus. Words and thoughts alone cannot take you off course, no matter what they say. They will probably be right in your face and even get louder when you don’t do as they say. You can make a choice to be willing to have the thoughts and stay on the valued route no matter what the passengers say to you. You can simply let them yell while you stay committed. Are you willing to do that?

Client: Okay. It will be hard and I won’t try [laughing]—I’ll do it.

[After the client commits, therapist moves the client to the starting position and repeats the exercise. This time the therapist moves around from card to card reading the passenger statements as before, while the client stays put facing forward, not disputing or otherwise responding to the statements. Afterward, therapist and client should briefly discuss the experience, focusing on the different outcome this time around.]

Therapist: There may be times both here in session and at home when you carry passengers on your bus that try to convince you that you don’t feel like doing this anymore or that it’s all too much and too difficult. Even if you start to think about giving up on a valued direction, continue moving. You have already experienced in the mindfulness exercises that thoughts and feelings come and go, but the progress you make toward your goals will be for real and won’t just go away. This is what really matters. Ultimately, you are in control of the direction of your life bus—you control it with your hands and feet. Although you can’t control what kind of anxiety-related passenger feelings, thoughts, or worries will ride along with you, you do control the steering wheel of your life bus with your hands and the accelerator with your feet. You will go where you let your hands and feet take you. That is what you truly can control.

5. EXPOSURE WITHIN ACT: FEEL (FEELING EXPERIENCES ENRICHES LIVING) EXERCISES (25 MIN.)

How Does Traditional Exposure Work?

We pointed out in chapter 3 that exposure therapy is founded on two interrelated learning processes. The first of these is based on extensive laboratory research showing that stimuli can acquire fear-evoking functions via Pavlovian or respondent learning processes. The controlled and systematic presentation of such fear-evoking cues without the anticipated aversive consequences can attenuate the capacity of such stimuli to evoke fearful responding. This reduction in fearful responding over repeated nonreinforced exposure trials is based on the principle of extinction. Accordingly, the exposure-like exercises in this and subsequent sessions will likely result in some extinction of conditioned emotional responses to bodily sensations (most relevant to panic disorder and specific phobias) and to thoughts or images (most relevant to PTSD, social phobia, OCD, and GAD). If clients show only minimal responses to any of the internal fear cues—thoughts, sensations, images—therapists would normally move on to exposure to external cues.

ACT therapists use these principles and techniques too, but as you will see, exposure exercises are framed quite differently within ACT compared to traditional CBT. Exposure within ACT targets conditioned emotional responses that may occur in situations and contexts that have particular meaning and personal value for clients. Initial behavioral testing, described below, should enable therapists to make an informed choice about what type of exposure-like exercises are most appropriate (e.g., internal bodily sensations or images).

The second learning process is not as well understood. It refers to factors that account for clients’ tendency to respond fearfully to conditioned processes associated with otherwise normal bodily cues, and specifically what type of exposure can change this tendency. This issue is critical when considering that there is nothing inherently abnormal about conditioned fearful responses. As we discussed in chapters 3 and 4, the responses themselves are quite adaptive and become problematic only when clients (a) respond to them in narrow, inflexible ways in an effort to reduce their frequency, intensity, duration, and (b) when such behaviors interfere with and restrict a client’s capacity to live a full and valued life. In other words, both (a) and (b) are the problems, and barriers to living. This view is where an ACT approach departs from traditional exposure-based therapies.

The Context and Purpose of Exposure in ACT

Exposure within ACT is always done in the service of a client’s valued life goals. We think of exposure as a logical extension of the mindfulness exercises begun earlier. Recall that these exercises were designed to promote an observer perspective, whereby thoughts, feelings, and physical sensations are noticed and experienced as they are, with a nonjudgmental and compassionate posture. This posture works to undermine cognitive fusion, which lets evaluative forms of verbal-cognitive activity get in the way of action. Mindfulness also makes experiential avoidance and escape nonsensical, because such actions run counter to what is needed to be accepting of experience in all its forms.

What we are doing in this section is encouraging clients to set the willingness thermostat quite a bit higher by using experiential life enhancement exercises designed to help clients make full contact with thoughts, feelings, and sensations that normally accompany anxiety. We are also going to help clients make contact with the disruptive consequences of experiential avoidance in their lives. We call these FEEL (Feeling Experiences Enriches Living) exercises to avoid the somewhat perjorative connotations of the term “exposure.” We encourage clients to use the mindfulness skills they have been practicing at home to embrace reality as it is. In fact, with FEEL exercises, the targeted processes are the same as in those exercises. The main change is that the therapeutic focus and context are now much broader.

The context for FEEL exercises must be framed in the service of client values and goals. This alone is quite different from traditional exposure therapies, wherein the goal typically is to master anxiety and test the accuracy of catastrophic predictions. This, we believe, is one reason why many anxious persons look upon traditional exposure with dread. Symptom reduction for its own sake seems quite limiting, particularly when considering the amount of pain clients must experience in the hope of feeling better. Recall that living better does not necessarily follow feeling better. Within ACT, therefore, FEEL exercises are presented and conducted with an eye on the real prize—living fully, richly, and meaningfully. They foster growth and movement in valued directions by encouraging clients to be with, and not act upon, the urge to avoid and escape anxiety, while doing what is important to them.

We have included a fair number of exposure-like exercises in the sections that follow. The mindfulness and other exercises conducted in previous sessions, along with the rationale provided below, should provide the motivation, willingness, and commitment to feel anxiety-related experiences as they are, and for what they are, rather than letting these experiences deter clients from their path toward living the life they have chosen.

Rationale for FEEL Exercises: To Facilitate Valued Living

Providing clients with a thorough rationale for the FEEL exercises presents an opportunity for the therapist and client to develop a collaborative effort, set expectations, and prepare the client for exercises that are probably difficult to do initially. The basic goal is to provide clients with an easy-to-understand explanation of the procedure, the rationale underlying it, and the anticipated costs and benefits. Therapists should refer to the earlier experiential exercises and metaphors when explaining the rationale.

Emphasize to clients that the ultimate purpose of these in-session exercises is to help them deal with the anxiety-related barriers listed on the Valued Directions and Life Compass worksheets in real-life situations. Using examples from these worksheets, review with clients how subtle and overt forms of avoidance and escape behavior have served to maintain their difficulties and how efforts to run away from or avoid anxiety have not worked and have ended up constricting and debilitating their lives. Describe FEEL exercises as focused opportunities for clients to practice running into, rather than away from, their anxiety. It’s about making space for all those unwanted experiences that clients have avoided for so long.

You can guarantee clients that as long as they respond the way they have been responding (i.e., attempts to avoid or escape from their own psychological and emotional experiences), they will continue to have the problems they are having. At some level, most clients suffering from anxiety know this already. So the purpose is to learn to do something different from what they have been doing, a process that should be well underway by this point in therapy. Instead of struggling with what their mind and body are doing during fear and anxiety, they can drop the rope and face these experiences. This is a new way of responding to their own responses in order to get back onto their chosen path and do all the things they care about and want to do.

For this process to come about, clients must be willing to experience their fear, worries, and anxiety, because change and new learning occur through experience and doing, not by talking or thinking about doing. Sensations that will be induced during FEEL exercises (e.g., bodily sensations during interoceptive FEEL exercises) are precisely those that the client wishes not to experience. As with traditional exposure, there is some truth to the trite phrase “no pain, no gain.” Yet, exposure is more than this. In our view, exposure transforms suffering about pain (i.e., nonacceptance plus pain), into the very real human experience of pain and pain alone. Therapists can revisit the example we outlined earlier about the process of learning how to ride a bike. FEEL exercises, like riding a bicycle for the first time, are difficult. This is to be expected, particularly given that clients are unfamiliar with how to ride feelings on the path to living. The good news is that these exercises will get easier over time and with practice. They are designed to help clients to move in valued directions. Ask clients, “Are you willing to have what you have in the service of moving closer to your stated intentions (values)?”

Therapists can describe FEEL exercises as experiential strategies that are designed to assist clients in mastering their ability to experience a full range of emotional responses, fully and without defense, for what they are and not for what their mind tells them they are (i.e., something dangerous and harmful). Remind clients of the tug-of-war exercise showing that when one side pulls, the other side simply pulls back harder. Likewise, when anxiety and fear are met with resistance, there is only one natural outcome: more resistance and suffering. Wars rarely emerge in the context of acceptance, joy, compassion, and genuineness toward the self and others.

The same is true with anxiety. Defending themselves from their own experiences tends to foster more negative experiences and prolongs the struggle. This context breeds suffering. Tell clients they cannot be at peace with themselves if they remain in a fight with their own experience. FEEL exercises are designed to assist them in approaching their anxiety and fear from a nonjudgmental, loving, and compassionate perspective—to be the chessboard instead of one of the struggling teams. Dropping the rope liberates them from the losing battle with their own thoughts, memories, physical sensations, and histories. Just like in the finger trap exercise, clients can choose to lean into their experiences and treat themselves with the same compassion, openness, love, and caring that they would extend to other human beings. Over time, the result is that they learn to respond to their responses differently and without defense. This nonavoidance posture, in turn, frees them to live differently. Therapists can accelerate this process initially by repeating exposure exercises in a controlled, systematic fashion with minimal variability.

Determining Appropriate FEEL Exercises

Before starting the first exercise, it is useful to reiterate to clients that the processes and principles that have contributed to their anxiety are quite normal and adaptive. Perhaps you can remind clients of an example from their lives where fear or anxiety was originally adaptive. Somewhere along the path of life, your clients began treating anxiety as if it were the enemy, and began to make strong efforts to reduce, eliminate, and avoid experiencing any fear-related sensations, images, and thoughts. This is when the situation gets tricky—remember President Franklin Roosevelt’s famous statement, “The only thing we have to fear is fear itself”? Fear takes its toll on the lives of anxious persons when they do not want to experience it and start running away from it. When that happens, their lives become constrained and limited because clients will act to avoid any activity or experience where the probability of experiencing unwanted sensations, images, and thoughts is high.

For someone with panic disorder, such experiences include, but are not limited to, anger, surprise, excitement, stress, medications, drinking caffeinated beverages, exercise, driving, and interpersonal situations where anxiety and other unpleasant feelings are likely. Attempts to avoid changes in physical state or activities that induce shifts in bodily state prevent corrective learning that the physical sensations are not harmful, need not be avoided, and can be tolerated. This sets up a trap for anxiety to become disordered. Let clients know that the goal of these exercises is to help them get out of that trap. Explaining this sequence as part of the rationale for conducting FEEL exercises is appropriate for most persons suffering from anxiety problems, and particularly for clients who suffer from panic disorder, PTSD, specific phobias, and social phobia.

Similar principles and processes apply to images and thoughts. Examples of such images for each anxiety disorder are as follows:

§    Panic disorder—suffocating and writhing on the floor

§    Social phobia—being jeered at or criticized by a group of people

§    PTSD—being abused or reliving the trauma

§    GAD—being found out as a sham or incompetent

§    OCD—doing something violent, obscene, or blasphemous

In previous sessions, the goal has been to mindfully observe unwanted thoughts and feelings when they arise naturally. Now, the goal is to deliberately bring about the physical sensations and images that normally would elicit distress so as to place such sensations in a context where the tendency to avoid or escape from them is unworkable and unnecessary. That is, one cannot be mindful of anxiety while avoiding anxiety. The goal is to increase client response-ability by helping them to accept their anxiety-related experience for what it is.

Types of Interoceptive FEEL Exercises

In this section, we describe a number of commonly used interoceptive exposure activities. In ACT, the choice of interoceptive and imagery FEEL exercises should be largely determined by whether the client’s reactions to the images or sensations brought on by these exercises have functioned as a barrier on the path to some valued life domain.

The next step is to establish relevant bodily cues and images for each client. Here the universe of possible FEEL exercises is limited only by a therapist’s creativity and available resources. The following is a partial list of commonly used in-session exposure exercises, including information about their implementation and typical effects. All can be completed in session and practiced outside of session.

Therapists should be mindful that contextual effects may modulate reactivity to interoceptive cues. Context may even move the tendency toward experiential avoidance up or down. Thus, some individuals will show a generalized tendency to respond to bodily sensations with fear in all contexts. That is, no matter where they are, these individuals are anxious about physical sensations and act to avoid them. In other clients the tendency to avoid experiencing bodily sensations becomes acute only in some contexts and not in others (e.g., only when clients are alone or in unfamiliar places, or only when they have no good explanation for the physical symptoms).

Spinning

This FEEL exercise can take several forms, and is designed to defuse fearful reactions evoked by sensations of dizziness and vertigo. Such exercises may include spinning in an office chair, spinning while standing, or having a client place their head between their knees, then suddenly move to an upright sitting position.

Hyperventilating

This procedure involves voluntary paced overbreathing and is capable of inducing panic attacks, including dissociative symptoms, in susceptible individuals. This occurs, in part, because oxygen is inhaled at a rate greater than metabolic demand, leaving too much oxygen and too little carbon dioxide in the blood. After first demonstrating a few full exhalations and inhalations through the mouth at a pace of about one breath for every 2 seconds, the therapist asks the client to join in and continue with this procedure for up to 3 minutes.

Breathing Through a Small Straw

Several inexpensive small- and large-bore straws can be used for this FEEL exercise. The nose should be occluded while the client breathes through a straw for 30 seconds or more. This exercise evokes breathlessness and sensations of smothering, and can be combined with other FEEL exercises, for example, breathing through a straw while climbing stairs.

Breath Holding

Breath holding involves asking the client to hold their breath for a period of time. The duration of breath holding can be increased in a graduated fashion over repetitions of FEEL exercises. This procedure typically evokes broadband cardiorespiratory sensations, and specifically the feeling of suffocation or air hunger.

Climbing Steps or Step-Ups

These exercises and their variants (e.g., fast walking, jogging in place) evoke cardiorespiratory sensations and more widespread sensations of autonomic arousal associated with physical exertion. Modifications to this procedure can range from climbing up and down one or two steps to climbing several flights of stairs. As appropriate, the pace of climbing or step-ups can be graduated within different levels (e.g., two steps, five steps, ten steps, and for varied durations within each level).

Staring at Self in the Mirror

This exercise involves simply looking at oneself for 2 minutes. The procedure typically elicits feelings of derealization and is particularly suitable for clients who report such feelings as part of their anxiety experience.

Other Interoceptive FEEL Exercises

Other exercises can be designed to suit particular client fears. For example, if your client is frightened by visual symptoms, you could ask them to stare at a light for 30 seconds and then look at a blank wall to see the afterimage. Alternatively, you may have them stare at a disorienting visual stimulus. For persons afraid of throat sensations or choking, suggest they press down on the back of their tongue with a tongue depressor or toothbrush. Alternatively, spend 1 minute just focusing on swallowing. Other means to produce interoceptive FEEL experiences include wearing nose plugs (used for swimming) to generate the sense of suffocation; strong smells (e.g., Worcestershire sauce) to induce nausea; tight collars, ties, or scarves to induce a sense of tightness around the throat; looking at venetian blinds with the sun shining in from behind the blinds to induce visual symptoms; and somersaults to induce a sense of being off balance or falling.

Implementation of FEEL Exercises

The general format and procedure for FEEL exercises is summarized below. It is important to let clients know what they should do during these exercises. Remind them to apply the same behaviors of acceptance and mindfulness during FEEL exercises as they have in previous exercises in session and at home. Their general task is to practice mindful observation in the presence of feared bodily sensations, thoughts, or imagery. This posture creates a dialectic between approach and avoidance tendencies, while undermining various forms of cognitive fusion. The basic idea is to observe, accept, and make space for anxiety-related experiences rather than suppress or struggle with them.

General Format and Procedure of FEEL Exercises

1.            Provide the rationale for the exercise and ask clients to apply a mindfulness posture during exercise.

2.            Conduct FEEL exercises, continuing for 30 to 60 seconds beyond the point at which the sensations are first noticed, and 5 minutes beyond the point at which the imagery is vivid.

3.            Obtain FEEL Record ratings.

4.            Ask clients to return to mindfulness practice for approximately 1 to 2 minutes, and provide occasional prompts for clients to observe and make space for what they are experiencing.

5.            Ask what clients did during the FEEL exercise and briefly discuss their experience; also provide feedback and, if necessary, make suggestions for mindful acceptance.

6.            If clients report or show high levels of unwillingness, struggle, or avoidance, therapists should conduct a more closely guided FEEL exercise (see section below). Therapists can also use these exercises to defuse any evaluative thoughts clients report (“This is not working,” “I can’t stand this anxiety anymore”). Ask clients to approach the exercise from an observer perspective the next time (“I am having the thought that this is not working,” “I am having the thought that I can’t stand this anxiety anymore”).

7.            Repeat FEEL exercises in this session and, if necessary, in subsequent sessions until client willingness levels are 7 or higher and struggle and avoidance levels are 3 or lower.

8.            Include at least one full repetition of a particular FEEL exercise in subsequent sessions.

Implementation of Interoceptive FEEL Exercises

Prior to having the client engage in an exercise, you should explain and model it from the same posture that you want clients to adopt: mindful, nonjudgmental, and open. After you model the FEEL exercise, you should then carefully observe the client doing it to ensure it is completed correctly. During the exercises, therapists need to be particularly watchful for subtle and overt forms of escape or avoidance (e.g., distraction, taking fewer and more shallow breaths during hyperventilation), because such avoidance indicates low levels of acceptance of the client’s experience, which can retard the process of thought-emotion-action defusion. Therapists should introduce and practice exercises in a graduated fashion. Before each exercise, ask clients’ permission to proceed and whether they are willing to go ahead with the exercise. If they report being willing, ask clients to approach these exercises very much like they have practiced experiencing bodily sensations, thoughts, and images in the mindfulness and acceptance exercises at home.

Ask clients to focus on the experience without trying to change what they experience. When they notice bodily sensations or unwanted thoughts or images, encourage them to acknowledge their presence, stay with them, and see whether they can make some room to have them instead of attempting to make them go away. Ask clients to simply allow them to be and to give themselves space to have whatever they have while bringing a quality of kindness and compassion to the experience. You can use similar language as in the Acceptance of Anxiety exercise.

Then the therapist induces bodily sensations, continuing for 30 seconds to 1 minute beyond the point at which the sensations are first noticed. Following the induction, use the FEEL Sensation Record and ask clients to rate the intensity of the sensations, level of anxiety, how willing they were to experience what they experienced, how much they struggled with their experience, and how much they tried to avoid it. All ratings are made on a 0 to 10 scale with 10 being the maximum rating. After obtaining the ratings, the therapist redirects the client to return to mindfulness practice for approximately 1 to 2 minutes, occasionally prompting them to observe and make space for what they are experiencing. Then, the therapist asks clients what they did during the FEEL exercise and briefly discusses the client’s experience, providing feedback and, if necessary, making suggestions for mindful acceptance using similar language as in the Acceptance of Anxiety exercise. For instance, therapists can encourage clients to notice any thoughts and feelings, acknowledge their presence, and stay with them rather than attempt to push them away. Ask clients to see if the bodily sensations need to be their enemy or whether they can open up to them and make space for them, accepting and allowing them to be, always noticing them for what they are (just normal bodily sensations) rather than what their mind tells them they are.

If clients report only low to moderate sensation intensity (less than 4), reassess the appropriateness of the exercise, the way a client might be doing it, and/or subtle forms of avoidance behavior. For instance, a client may only hyperventilate very mildly. If a FEEL exercise fails to elicit any anxiety, then ask clients if they would be distressed by the exercise if it was done alone or without the presence of the therapist. If so, it can still be practiced as an experiential home exercise.

feel sensation record

Implementation of Guided FEEL Exercise

If clients report or show high levels of unwillingness, struggle, or avoidance, therapists should conduct a guided FEEL exercise. During a guided FEEL exercise, the therapist again elicits the bodily sensations and guides the client’s attention to two to three bodily sensations, one at a time. Therapists ask clients to acknowledge the presence of this discomfort, stay with it, breathe with it, accept the discomfort, and open up to it. Just like in the Chinese finger trap exercise, this is the perfect time to lean into anxiety and invite it in rather than struggling with it. If the clients report evaluative thoughts and labels (“dangerous,” “getting worse,” “out of control”), ask clients to thank their mind for such labels and continue to observe what they experience with gentle curiosity, openness, and compassion. In addition, therapists can help clients reframe such statements by means of defusion techniques. For instance, a client statement such as “I’m losing control” can be defused and recontexualized as “I’m having the thought/feeling that I’m losing control.” Similarly, a statement such as “I’m too weak for this” might become “I’m having the thought that I’m too weak for this,” whereas the thought “I want to do this but it is so hard” becomes “I want to get better and it is too hard.” A sample dialogue below illustrates the guided FEEL procedure.

Therapist: [after spinning the client around in a chair] What sensations are you experiencing?

Client: I feel dizzy and my heart is racing. I’ve been trying to calm myself down.

Therapist: [asks for all five FEEL ratings]

Client: Sensations are 7, anxiety is 8, willingness is 4, struggle is 7, and avoidance is 6.

Therapist: Okay, I want you to close your eyes for a moment. See if you can allow this dizziness to be what it is, a feeling in your head, nothing more and nothing less. Is this something you need to push away from, or can you acknowledge its presence and make room for it? [pause 5 seconds] Can you make space for it? [pause 5 seconds] What does this dizziness really feel like? Where does it start and where does it end? [pause 5 seconds] Must this particular feeling be your enemy? [pause 5 seconds] Is this dizziness and the anxiety something you must not have, something you cannot have? [pause 5 seconds] Even if your mind tells you that you can’t have it, are you willing to open up a space for it in your heart? [pause 5 seconds] Is this something you absolutely need to struggle with, or is there room inside you to feel all that and stay with it? [pause 5 seconds]

Client: I don’t like it, and no matter what I do, I am having it anyway.

Therapist: I understand you don’t like it. And can you be willing to have it? As you said, you are having it anyway. Can you not like it and be willing and have it? Is that possible? [pause 5 seconds] So are you willing to do this again? [If client is willing, repeat exercise, obtain ratings, and focus attention on another core sensation such as the racing heart.]

The therapist can use the same procedure with all major bodily sensations and with evaluative thoughts. To maximize the process of corrective emotional learning and teaching the client new ways of responding to their own responses, clients should practice each exercise for several minutes and repeat it two or three times during the therapy session. A client should make willingness ratings of 7 or higher and struggle and avoidance ratings of 3 or lower within the same exercise before moving on to the next exercise.

FEEL exercises may require several in-session practices before any clinically meaningful increases in willingness and reductions in struggle and avoidance are observed. This is fine and to be expected. After clients complete exercises successfully in session, ask them whether they are willing to complete the exercises at home during the following week and keep track of their daily practice using the FEEL Sensations Record form.

The Mirror Exercise

Many of the FEEL exercises are not simply about evoking and being with unwanted bodily sensations. They are also about developing acceptance for the self when being anxious and in the eyes of others. Thus, we suggest that for people with social phobia, and others who are concerned about experiencing anxiety in public, interoceptive FEEL exercises be done, to the extent possible, in front of a mirror. The purpose of having the mirror always present is to help the client develop acceptance and compassion for how they appear in front of themselves and others when being anxious. Many clients tend to feel self-conscious when anxious. Using a mirror provides opportunities for clients to practice acceptance and defusion about how they appear when anxious. The goal here is to help clients develop compassion for themselves and how they look when they are anxious or afraid. In the process, they may become more comfortable with the way they appear in the public eye, and also less anxious about how they appear to others—a welcome by-product, although not an explicit target. Ask clients if they are willing to practice interoceptive FEEL exercises at home in front of a full-length mirror. If so, they are to follow the steps outlined below.

1.            _Practice interoceptive FEEL exercises in front of a full-length mirror.

2.            _After completing an exercise in front of the mirror, clients should make their ratings using the FEEL Sensation Record.

3.            _After making their ratings, they are to take a good hard look at themselves in the mirror. Here clients should observe and describe their bodies from head to toe. What do they see? How do they look?

4.            _Ask clients to come up with descriptions, not judgments, about how they look in the mirror. When experiencing judgmental thoughts, such as those listed below, clients should simply notice the thoughts and feelings that arise as they are. Just listen to them, be with them, notice them from a compassionate observer perspective.

Judgments: “I look terrible, blotchy, all red in the face. People will notice how anxious I am.”, “The way I look is embarrassing.”

Descriptions:“I can see that my face is flushed.”, “I notice that I am sweaty and out of breath.”, “I experience some shakiness in my hands and legs.”

5.            _Ask clients to allow themselves to experience those thoughts and feelings as they are. Can they develop room for being with their anxious self in the mirror? Can they bring compassion and acceptance to this experience? It is important that clients stay committed to the exercise. Ask them to watch themselves in the mirror after each interoceptive FEEL exercise for at least 1 to 2 minutes. It is important for clients to stay the course, meaning that we do not want them to give in to their discomfort by terminating the exercise prematurely.

Imagery FEEL Exercises 3

For clients with recurrent fear-producing images (particularly relevant to clients with PTSD, OCD, or GAD), generate a list of fear-provoking images based on their “worst-case scenario.” Ask clients to generate a few sentences to describe each image, particularly in terms of their responses, the stimuli associated with it, and their meaning. Here are some examples: “My children drowned in the bathtub, and it was my fault; I feel sick to my stomach and my heart is pounding”; “I am living on the streets, without food or help, because I am incompetent, weak, and unable to think”; “I am in a psychiatric ward because I am crazy; my hands are shaking, I am disoriented, and nobody can understand me”; “I am being attacked and I’m frozen in fear; I can’t lift my hands to protect myself, I am helpless”; “If my husband’s health gets worse, he might die and we will lose our home.”

Generate a series of images and ask clients to rate their willingness to have that image. Next, establish a graded hierarchy of images based on your clients’ willingness ratings. Gradation is particularly important for PTSD, where images of past traumas are very provocative. Throughout the imagery scene construction and later during FEEL imagery exercises, there may be occasions of numbing, dissociation, or a full flashback in cases of severe PTSD. If you suspect this is going to happen, talk with the client in advance about ways of dealing with such experiences, such as methods of reality checking, touch, and approaching the experience from an observer rather than a participant or player perspective. Note that such experiences are consequences of the fusion of verbal evaluations with reality. They are within the range of human experience. If they happen in session, then they are likely a part of the client’s experience outside of session. When the client responds to the flashback in ways so as not to have it or to make it go away, these responses are likely barriers to living. In such cases, you may focus attention on the psychological and experiential consequences of the imagery for the client, rather than on the imagery itself. The task is to develop a mindful and accepting posture toward those consequences. After all, the problem is the client’s reactions to the consequences of FEEL exercises, not the consequences themselves.

In the case of generalized anxiety disorder, the catastrophic images that usually underlie excessive worry may not be immediately apparent to clients. Such images can be identified by asking the client to find the “picture” of the worst-case scenario at the end of the worry chain. For example, if the client worries excessively about their children’s safety on the public transport from school to home, an underlying catastrophic image may be of the children lying on the road in an automobile accident. The meaning of the catastrophic image typically pertains to the client’s sense of self-competency. In the example just given, the image is not restricted to the children’s injury. It extends also to the meaning that the client was a bad parent for letting that happen to the children. The latter image in this chain likely cuts to the core of a client’s sense of self and value. The client is then asked to imagine this scene using the same general procedure described on the next page.

Clients with obsessive-compulsive disorder mostly find their images to be abhorrent and unacceptable, and their sense of shame and guilt may lead to resistance in verbalizing the content of the images. Similarly, fears that putting the content of the images into words might make them “come true” may also contribute to resistance. This type of internal barrier (resistance) is just another form of experiential avoidance. In therapy it means that the client is not showing up with willingness. Therapists need to address such barriers whenever they come up. For instance, a therapist might say,

You seem to not want to tell me what you are thinking right now, and I understand that you think the thought may come true. I’d like you to think for a moment about how this “not telling” is working for you, right here, right now. We are both here together in this room to help you live life more fully, richly, and deeply. Is not speaking out your thoughts getting in the way of your commitment to treatment and improving your life? Is it getting you closer to or further away from your valued directions? Is it taking your life bus north or south? What does your experience tell you? Where do you want to go? Can you be willing to set your willingness thermostat high?

In addition, therapists can do more defusion work by asking clients to hold the thoughts or images gently in awareness and recognize and label the images as images rather than as facts or actual occurrences. Such mindful, compassionate, and kind observation is a new way of dealing with unwanted cognitive material and is different from past attempts to get rid of them or resolve them somehow. Referring back to the bus driver exercise, therapists can help clients identify these thoughts as bullies that will not steer them off course as long as clients choose to stay in the driver’s seat of their life bus and continue on their chosen path. In the case of this exercise, it means continuing with the exercise, observing the experience, and noticing bully thoughts and feelings for what they are (just thoughts and feelings). In the next chapter, we provide additional suggestions to help clients relate to unwanted cognitive and emotional material both in session and in situations of everyday life.

Before each exercise, ask the client’s permission to proceed and whether they are willing to go ahead with the exercise (“Have you set your willingness thermostat high?”). The general format for FEEL imagery exercises is similar to the interoceptive exercises. Imagery exercises, however, tend to be longer and should be continued 5 minutes beyond the point at which the imagery is vivid. If the imagery is insufficiently vivid, consider incorporating newspaper stories about tragedies, illnesses, or accidents to elicit imagery. Also, movies or photographs of places or people can be helpful. After obtaining ratings using the FEEL Imagery Record below, ask what clients are experiencing. Encourage them to notice any thoughts and feelings, acknowledge their presence, and stay with them rather than attempting to get rid of or push them away. Ask them to see if the thoughts, feelings, and worries need to be seen as enemies or whether they can open up to them and make space for them, accepting and allowing them to be, always noticing them for what they are (just thoughts and feelings) rather than what their mind tells them they are.

Again, if clients report or show high levels of unwillingness, struggle, or avoidance, then therapists should conduct guided FEEL exercises. These exercises help clients to create space for their discomfort, encourage them to accept rather than struggle, and defuse any evaluative thoughts clients report, as described in the interoceptive exercise section.

feel imagery record

Some clients may continue to report low willingness and high levels of struggle and avoidance over either the physical symptom induction or imagery induction. In those cases, continue with repeated FEEL exercises in this and subsequent sessions until client willingness levels are 7 or higher and struggle and avoidance levels are 3 or lower before moving on to the next exercise. Also be sure to frame these exercises in the context of barriers to valued living. Remember that these exercises are all about movement north. They are not about being with anxiety and fear for the sake of being with anxiety and fear. Values help contextualize the FEEL exercises and give them meaning and real purpose.

Dealing with Urges to Escape During Panic Attacks and in OCD

Virtually all cognitive behavioral programs for anxiety disorders emphasize that it is important to prevent escape behavior in the presence of high anxiety, such as during panic attacks. For instance, cognitive behavioral programs for OCD emphasize how essential it is for clients not to undo the exposure imagery exercises by carrying out rituals or other forms of neutralizing. These compulsions are functionally forms of experiential avoidance and precisely what these exercises are designed to undermine. The typical strategy used within standard CBT is first to find out what a client normally does in response to their intrusive images (e.g., compulsions, neutralizing behaviors, checking on the safety of others, seeking reassurances), and second to instruct the client not to carry out those reactions during or after the imagery exposure. The reason is that such actions undermine any corrective learning that may come about via imagery exposure and serve to reinforce old, problematic patterns of behavior.

Preventing Escape Behavior

From an ACT approach, it is also desirable to prevent escape behavior in clients with OCD or during panic attacks. However, simply instructing the client not to engage in the ritual or other escape behavior is not congruent with an ACT approach. The reason is that the compulsion is already in a tight functional relation with various obsessions and related negative consequences. Suppressing or avoiding the elements may, therefore, bring about the other undesired elements that are part of a network of relations. Ask clients to recall what happens when they try not to think of pink elephants. They actually get more thoughts of pink elephants. The most important aspect of FEEL exercises in clients presenting with OCD is this: to let them experience intrusive recurrent thoughts, along with the urge to act on them, for what they are—thoughts and feelings. Efforts to suppress or neutralize thoughts and urges should be examined for their workability and defused. Ask the client to recall what happens when they do engage in rituals in terms of both their obsessive thoughts and their urges (anxiety goes down for a while, but tension and urge always come back). So compulsions do not work because the obsessive thoughts always come back and, more importantly, because these actions get in the way of living a valued life.

Then, move on to helping clients relate to urges from a mindful, accepting stance. Rather than instructing clients not to engage in a compulsive ritual, therapists can explore such urges and employ defusion methods during FEEL imagery. This strategy is also relevant for clients with other anxiety disorders, particularly when they report a strong urge to escape from a situation (e.g., while experiencing a panic attack). If clients report urges to wash their hands (OCD) or leave a situation where they experience anxiety, Hayes and colleagues (1990) recommend taking clients into these thoughts and helping them defuse from their thoughts. This is also a good opportunity to reintroduce the Anxiety News Radio metaphor from Session 5 (see chapter 9). Therapists can ask clients to read the text in the voice of a news anchor to help them defuse the thought-action relation while not buying into the content of their thoughts. If the person is actually about to run away or wash their hands, do not physically prevent it. Instead, therapists may be able to delay such escape by saying something like this:

That’s fine. You could do that. Now, I’d like you to stay for just a couple of minutes. And right here and now, we have the opportunity to work on this—the thoughts and feelings associated with wanting to run out of the room [or wash your hands]. If you choose to go, you can go, although right now you have the opportunity, rather than the problem, of experiencing what it’s like to have these thoughts and feelings in the context of being willing to have them. What is it like to have them when you set the willingness thermostat on high?

Putting Thoughts and Urges on Cards Exercise

Hayes, Strosahl, and Wilson (1999) devised another simple defusion exercise that helps clients make contact with the effort involved in fighting off urges and unwanted thoughts as opposed to observing them with mindful acceptance. In this exercise, the therapist writes the client’s urge, worry, or other unwanted thought on an index card. Then the therapist puts the card in the palm of their hand and asks the client to push against the card. As clients push, the therapist can adjust the strength of their pushing to let clients experience that when they push harder to make the urge or thought go away, the urge or thought pushes back harder too. After taking down the card, the therapist asks the client to simply sit there and do nothing. Then the therapist puts the card in the client’s lap and asks them to look at the card and the text on it, and notice the difference in effort between pushing the urge away compared to simply letting it be and looking at it.

These strategies may be enough for clients to stay and not engage in escape behavior. The goal is to hold them as long as possible without making it look like the therapist is doing the holding, and to help the client engage in the experience fully and without defense. Therapists should obtain FEEL ratings and continue engaging the client in this exercise and dialogue until willingness ratings are high and struggle and avoidance ratings come down. The main purpose of this dialogue is to remind clients of the skills they have learned and assist them in whatever way is appropriate to apply these skills in this difficult situation.

6. FEEL EXERCISE PRACTICE (HOME)

§    Practice the Acceptance of Anxiety exercises for at least 20 minutes daily and complete the practice sheet after each practice.

§    Practice of at least one interoceptive and/or imagery exercise chosen by the client for 30 minutes per day. The sensations and/or imagery induced by the exercise should be barriers to valued activities in the client’s life.

§    Continue monitoring anxiety and fear-related experiences using the LIFE form.

§    Complete the Daily ACT Ratings form.

Take a moment to explain to clients that their practice of FEEL exercises outside of therapy is an integral component of the treatment and ultimately more important than in-session work. Emphasize that the real purpose of these in-session exercises is to help clients move with and eventually let go of their anxiety-related barriers in real-life situations. The exercises are about making space for all of the unwanted experiences that clients have avoided for so long. This space will then allow them not to be steered off course by the anxiety bullies on their bus and to get on with the task of creating their life and living it. The purpose is to learn to do something different from what they have been doing. Instead of struggling with their mind and body during fear and anxiety, they can face these experiences for what they are and as they are, while staying on their chosen path and doing all the things they care about and want to do.

A similar process is at work with FEEL practice outside of therapy. Initially, such exercises may simply include practice with the FEEL exercises covered in session (e.g., practicing breath holding at home). Doing FEEL exercises in a structured format at regular, clustered intervals (i.e., several times a day) and in a comfortable environment (e.g., at home) will help clients learn the skill of experiencing anxiety for what it is. Ask clients to follow the same general procedure that was used in session. Remind them that their task is to practice mindful observation in the presence of feared bodily sensations, thoughts, or imagery during FEEL exercises. In the coming weeks, they are to use the same skills in session that they have been practicing at home during mindfulness exercises. The basic idea is to observe, accept, and make space for anxiety-related experiences rather than suppressing or struggling with them.

Returning to the simple metaphor of learning to ride a bicycle for the first time can be helpful to convey to clients the importance of practice. Nobody learns to ride a bike the first time they try, and often the process can be painful. To make learning a bit easier, we add training wheels. Home practice is analogous to using training wheels when learning to ride a bike. The goal is to learn the basic skills first before applying them in other situations and settings that are more challenging and more important to them. With repeated practice, clients can expect to get to the point of being able to remove the training wheels and ride without them. At that point, there may be a few more bumps and bruises along the way. Recall that even seasoned bicyclists fall once in a while, but they spend more time on the bike riding than they do falling on the ground.

Ask clients whether they are willing to practice FEEL exercises at home regardless of whether they feel anxious or distressed about exercises or other matters. If clients indicate they are willing to do so, ask them whether they are willing to keep a daily record of their practice and activities using the Valued Life Goal Activities form provided at the end of this chapter and on the book CD. If they agree, give them a copy of the form and ask them to write down their commitment to practice on the form for every day they intend to practice. The client takes this form home and records whether they engaged in the activity and how much time they spent on each activity. They also rate how much anxiety they experienced, how willing they were to have what they experienced, and how much they struggled with their experience at the beginning and at the end of each activity using the same 0 (low) to 10 (high) scale as on the FEEL forms. During the week, they can record whether and for how long they practiced every day. Give clients seven copies of the FEEL record form (one copy for each day of the week). This form provides more detailed information about their experiences during those exercises.

Both forms are designed to help clients keep track of their daily practice. It is essential that therapists convey to clients the importance of keeping commitments and daily practice of the FEEL exercises as part of that commitment. Therapists should routinely collect and review practice records at the beginning of each session. Practice reviews, along with verbal statements acknowledging the client’s work, serve to reinforce client commitment to treatment and effort to make meaningful life changes. Therapists who do not review or discuss home practice activities send their clients the message that such work between sessions is not important—so clients may wonder, why bother doing them?

Lastly, and perhaps most importantly, we must stress the importance of maintaining a value-focused context for FEEL exercises. These and many of the exercises to come are designed to help clients use their hands and feet to move in the direction of valued life pursuits rather than to spend their time trying to get rid of anxious thoughts and feelings. If therapists do not relate such exercises to client values and goals (short- and long-term), then the FEEL exercises will look, feel, and sound like exposure in disguise. Clients, in turn, may rightly ask, “Why should I go through more pain and suffering? I have enough of this in my life already.” Thus, we suggest that therapists clearly link FEEL exercises to client values and goals and encourage the client to do the same with home practice. Keeping the focus on values serves to dignify the treatment. For instance, a client may notice how her responses to dizziness and shortness of breath get in the way of leaving her house and doing what she cares about. During FEEL exercises, this client may focus from a compassionate perspective on the thoughts and sensations brought on by voluntary hyperventilation, while keeping a mindful eye on what she would like to do with her hands and feet when such sensations arise again. The real prize here is moving openly, willingly, and with feeling and purpose in the direction of what matters most in a client’s life. This is precisely what the FEEL exercises and this treatment program are about.

weekly valued life goal activities