We can try to control the uncontrollable by looking for security and predictability, always hoping to be comfortable and safe. But the truth is that we can never avoid uncertainty and fear. So the central question is not how we avoid uncertainty and fear but how we relate to discomfort. How do we practice with difficulty, with our emotions, with the unpredictable encounters of an ordinary day? When we doubt that we’re up to it, we can ask ourselves this question: “Do I prefer to grow up and relate to life directly, or do I choose to live and die in fear?”
Goals and Theme
The major purpose of Sessions 7 through 12 is to continue to create broader and more flexible patterns of relating with the stimuli, events, and situations that elicit fear or anxiety in clients. This goal will be achieved by continuing to conduct in-session and between-session FEEL exercises, as well as value-related activities in the real world. It is fine if anxiety goes down as a result of these activities, but that is not our main concern. The crucial point is for clients to learn that anxiety does not have to go down first in order to do what is important to them. Continue to emphasize that the purpose of FEEL exercises and value-related activities is to let clients experience that they can do things that matter to them and be anxious at the same time.
The general goal is to put valuing into action and to learn to be in and with the situations, feelings, thoughts, and other barriers to valued living through continued exposure, mindful observation, and defusion. The therapist’s task is to help clients implement meaningful activities that will move them toward reaching selected goals by helping clients develop a specific plan of action for each week and identifying sequences of actions that need to be taken to achieve goals (preferably involving previously avoided situations or events). Therapists can give feedback and help clients set realistic goals and criteria, monitor progress, and brainstorm solutions for overcoming barriers. Such assistance is to be framed in the context of what clients want out of a life lived well.
1. _Centering Exercise
2. _Review of Daily Practice
3. _Repeated FEEL Exercises
o In-Session Exercises
o Consolidating Progress Through Home Exercises
4. _Naturalistic Value-Guided Behavioral Activation
o Behavioral Activation Treatment: The Core of Value-Guided Action
o Selecting Activities Based on Life Compass
o Creating an Activity Hierarchy and Commitment for Action
o Monitoring Progress and Giving Feedback
5. _Dealing with Barriers and Avoidance
o The Basic ACT Value Question: Are You Heading North or South?
o Defusion and Mindfulness Techniques
o Recognizing Mind and Language Traps
o Eliminating Safety Signals and Behaviors
o Problems with Values
o Traveling with Your Fears
6. _Dealing with Setbacks Through Mindful Acceptance and Compassion
7. _Experiential Life Enhancement Exercises (Home)
o Practice Acceptance of Anxiety exercise once a day for at least 20 minutes and complete practice sheet after each practice
o Daily practice of FEEL exercises (interoceptive and/or imagery exercises) and/or Valued Life Goal Activities
o Keep track of FEEL practice and value-related activities by completing the Weekly Valued Life Goal Activities record form each week and the Goal Achievement Record
o Continue monitoring anxiety and fear-related experiences using the LIFE form
o Complete Daily ACT Ratings form
8. _Preparing Clients for End of Treatment (Session 12)
o Provide Treatment Summary
o Prepare for Relapse and Setbacks
o Identify High-Risk Situations
9. _Session Materials and Handouts
o Acceptance of Anxiety practice form (1 form for each week)
o Living in Full Experience (LIFE) form (1 form for each week)
o Daily ACT Ratings form (1 form for each week)
o Weekly Valued Life Goal Activities form (1 form for each week)
o Goal Achievement Record form
o FEEL Sensation Record forms (as needed)
o FEEL Imagery Record forms (as needed)
AGENDA FOR SESSIONS 7–12
1. CENTERING EXERCISE
Begin all sessions with the centering exercise described in Session 1.
2. REVIEW OF DAILY PRACTICE
Review the client’s daily practice of the Acceptance of Anxiety exercise and briefly discuss their experiences with it. After reviewing the Daily ACT Ratings, briefly discuss the LIFE form and any instance of clients engaging in behavior to manage thoughts, sensations, and feelings. Again, help the client see the connection between such actions and short- and long-term costs, particularly in the context 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 a client values or cares about, as described in the client’s Life Compass? Next, review practice of FEEL exercises and other goal-related activities. Praise clients for their practice and progress and discuss any difficulties they may have had. Any obstacles and barriers should be dealt with as outlined in this chapter.
3. REPEATED FEEL EXERCISES
Due to time constraints, only a few FEEL exercises were probably conducted in Session 6. In Sessions 7 and 8, therapists should set aside 25 to 30 minutes to conduct several more of the interoceptive or imagery exercises outlined in chapter 10. As indicated, the choice of exercises needs to be individualized and ought to produce sensations and/or images that are related to barriers that have gotten in the way of valued activities in the client’s life. For guidance here, look to responses that came up as barriers when discussing the Life Compass and home exercises. It is critical that FEEL exercises continue to be framed in the service of client values and goals. These exercises are nothing more than focused opportunities to practice running into, rather than away from, anxiety in order to foster personal growth and movement in valued directions. Therapists should emphasize that the ultimate purpose of in-session exercises is to help clients move with rather than around anxiety-related barriers that come up when engaging in out-of-session goal-related life activities that matter to the client. The general format and procedure for conducting these exercises is the same as described in Session 6 (chapter 10).
Consolidating Progress Through Home Exercises
Once clients begin to show clinically meaningful and stable increases in willingness and reductions in struggle and avoidance during the FEEL exercises conducted in session and at home, therapists can move to the next step, which involves clients engaging in the same acceptance posture while going about their usual daily activities and when they experience anxiety. The purpose here is to remove the training wheels and to start allowing clients to practice experiencing the totality of their feared experiences while performing routine activities. For instance, practice with interoceptive FEEL exercises should continue several times during the day and should occur in those situations where the anxious thoughts, feelings, or sensations are particularly disruptive— that is, when they are normally allowed to get in the way of the client doing what they care about doing (e.g., school, work, driving, walking, attending a meeting). For example, interoceptive FEEL exercises such as applying pressure to the throat or standing up suddenly can be performed at a desk while at work (Zuercher-White, 1997). To derive the maximum benefit, clients should perform FEEL exercises in as many different contexts and situations as possible. This will serve to broaden the client’s range of functioning while counteracting the disruptive and life-limiting tendency to engage in avoidance of anxiety. Recall that the clinical goal here is to foster greater psychological, experiential, and behavioral flexibility.
Before the end of the session, obtain a commitment from the client to perform at home the FEEL exercises practiced during session and ask them whether they are willing to engage in any other goal-related activities. If clients indicate they are willing to engage in exercises and activities, ask them whether they are willing to keep a daily record of their practice and activities using the Valued Life Goal Activities form they’re already familiar with. Again, ask clients to write down commitments to activities for each day of the week on the form.
Also explain to clients that there are several ways to maintain and consolidate the progress they have made so far. First, hesitation to engage in a valued activity because of fear is a clear signal for clients that they should go ahead and do it, particularly when they have committed themselves to the activity already. These are opportunities for practicing leaning into and creating space for anxiety analogous to pushing into, rather than pulling out of, the Chinese finger trap. At those turning points, clients need to ask themselves whether they can make space for their discomfort and be willing to go ahead and do what they committed to doing. For instance, hesitation about driving for fear of having a panic attack is a signal to make space for and accept that discomfort and deliberately drive anyway. Similarly, starting to avoid hot places or certain foods for fear of a panic attack is a signal to make space for and accept that discomfort and deliberately enter hot places and eat those foods. If clients are not willing to have these thoughts and act effectively in their lives, keeping value-driven commitments will be impossible (Wilson & Murrell, 2004). Obstacles that emerge, such as “This is too painful” or “I just can’t do it” ought to be addressed with experiential exposure and defusion exercises as discussed later in this chapter.
4. NATURALISTIC VALUE-GUIDED BEHAVIORAL ACTIVATION
Traditional CBT typically follows in-session exposure exercises with naturalistic exposure exercises in a wide range of situations and under diverse circumstances. The aim of naturalistic exposure exercises is to promote generalization of extinction (Taylor, 2000). These exercises may involve clients performing common daily activities (e.g., drinking coffee, having sex, watching scary TV programs) or entering situations that produce feared somatic sensations in increasingly more dreaded and less “safe” situations (Otto & Deckersbach, 1998). For example, the client may begin by performing a particular exercise at home, first with their spouse present and then without a safe person present, then in a shopping mall with a safe person present, and ultimately in the mall alone.
Other common examples of naturalistic interoceptive exposure include going to an amusement park and going on scary rides, or engaging in a workout program such as running, cycling, or aerobics. Though naturalistic interoceptive exposure and situational exposure have common elements, they differ in that the goal of naturalistic interoceptive exposure is to induce symptoms of autonomic arousal, whereas the goal of situational exposure is to expose the client to the feared situations themselves, without regard for the somatic sensations they produce (Taylor, 2000). Nonetheless, both interoceptive and situational exposure are designed to promote anxiety reduction through extinction processes.
The purpose of naturalistic activities in ACT is to promote valued living. The Life Compass and Valued Directions worksheets serve as the basis for activity selection because many of the tasks we ask clients to do are highly aversive, particularly early in the process. In terms of treatment compliance, evidence suggests that we ought to make the client’s choice to engage in painful therapeutic work as salient as possible (Wilson & Murrell, 2004). Apart from helping clients get moving on the road toward establishing meaning in their lives, it also gives them a sense of control. Lab studies show that people and animals clearly prefer controllable painful events and tend to show less fear under such circumstances compared to uncontrollable pain-inducing events (e.g., Lejuez, Eifert, Zvolensky, & Richards, 2000; Zvolensky, Lejuez, & Eifert, 1998).
Behavioral Activation Treatment: The Core of Value-Guided Action
The greatest challenge for therapists is to keep clients on track as they move to re-create the life they have given up on in the service of managing anxiety. The problems that therapists encounter here are twofold: one has to do with helping clients engage and stay committed to a program of life goal–related activities, and the other has to do with barriers that clients encounter along the way. Both issues concern motivation and keeping commitments. Unfortunately, neither existing CBT manuals nor the ACT literature provide much guidance here. This section, therefore, is designed to provide therapists with some guidelines for keeping clients on track on their path to reclaiming their lives. We have adapted these guidelines from behavioral activation programs that have been used successfully in the treatment of clients with depression (Hopko, Lejuez, Ruggiero, & Eifert, 2003) and with concurrent anxiety and depression (Hopko, Hopko, & Lejuez, 2004).
Behavioral activation treatment (BAT) is based on two major premises (Lejuez, Hopko, & Hopko, 2001, 2002). The first is consistent with ideas presented throughout this book, namely, that it is difficult to control or directly change negative emotional states and that the best strategy to improve negative affect is to directly target what is controllable. The second premise involves a behavioral principle called the “matching law” (McDowell, 1982). Applied to anxiety, this principle states that the relative value of anxiety-related behavior, compared to life goal–related behavior, is proportional to the relative value of reinforcement obtained for anxiety-related behavior compared with life goal–related behavior. One critical therapeutic implication of this principle is that we can reduce the relative value of anxiety-related avoidance behavior by increasing client contact with positive consequences resulting from engaging in more life goal–related behavior (e.g., driving to visit friends; going to a job interview to get a job). This is why we have stressed values from the beginning. Values matter. Activities that get in the way of valued living result in suffering. Behavioral activation should help promote increases in the frequency of life goal–related behavior, while decreasing anxiety-related avoidance and escape behavior. Acceptance, mindfulness, and defusion exercises can help accelerate this process by weakening forms of evaluative struggle focused on anxious thoughts and feelings, thereby promoting willingness and full contact with experiences that matter to the client.
BAT involves a number of steps that we outline in the next sections. These steps are (a) selecting activities based on chosen life goals, (b) creating an activity hierarchy and commitment to action as well as setting criteria for action, and (c) monitoring progress and giving feedback. BAT as used within ACT is, at the core, about fostering commitment to engage in value-guided action.
Selecting Activities Based on Life Compass
The first part of this process is for you and your client to revisit the importance of various valued life domains and goals consistent with those domains. The next step is to identify actual activities that move clients in the direction of living according to their values. Although activity selection in BAT is guided by life goals, the ultimate choice of an activity is determined largely by how pleasant the activity, or the outcome of the activity, is for the client. Making pleasantness the criterion for activity selection could perpetuate the seek-pleasure-and-avoid-pain approach to life that underlies a good deal of human suffering (see chapter 4). In ACT, we suggest using importance of the value as the criterion for activity selection, particularly when the client’s anxiety is linked to a low frequency of activity in an area. Thus, both values and high avoidance of value-related activities provide us with the targets for exposure. They also guide the choice of what activities to pursue in behavioral activation.
To start, refer back to the Life Compass and Valued Directions worksheets. Ask the client to identify one or two value areas and some activities that are part of those areas that could serve as goals they want to work toward. The activities should be those that the client has put on hold or avoided in the past because of their anxiety problem. The next step is to identify clusters of actual activities related to living in the direction of the valued domain (Lejuez et al., 2001, 2002). For monitoring purposes, it is best to select activities that are both observable and measurable. For example, one value area may be education. Education, in turn, may include a long-term goal of attending college. This goal, in turn, includes smaller specific actions such as making a phone inquiry about programs, driving to campus to make more specific inquiries or speak to an admission officer, enrolling in classes, and buying textbooks. Another example of a broad valued direction may include developing closer relationships with a family member. This direction, in turn, may include several activities such as spending more time with a family member in places that a client has previously avoided (e.g., going to a movie or theater show, dining out, traveling out of town, or riding a bike). Recall, however, that value-guided action is not simply about the achievement of goals. It is an ongoing process with several intermediary steps (i.e., small goals or tasks). The steps are the goals that move clients in a direction that is part of a much larger process. Recall also that valued living takes commitment and has no clear end point. Goals, on the other hand, are steps in the direction of values that can be ticked off as one moves in that direction.
Creating an Activity Hierarchy and Commitment for Action
First, discuss with clients the perceived difficulty of value-guided activities as you and your client create an activity hierarchy. This hierarchy will help clients break down complex goals into smaller and more manageable tasks and give them a concrete plan of action and a clear sense of what lies ahead of them. For each activity, the therapist and client collaboratively determine clear criteria for doing the activities in terms of when and where to do them as well as how to do them and for how long. Next, when asking clients whether they commit to engage in one or more activities for the next week, make sure they have a clear understanding of what commitment means and what it does not mean.
Therapist: Doing this activity at home is probably not going to be easy for you. In fact, I am pretty sure that the passengers on the bus will be yelling at you with full force, “Don’t do this,” “You’ll never make it,” “You will just make a fool of yourself,” or “You’re going to get hurt.” Anticipating all that, are you willing to commit to this activity 100 percent and go through with it? Remember, willingness is not something you can try or have a bit of.
Client: It seems tough. I’m not sure whether it will work.
Therapist: I am not asking you to commit to a particular result or outcome. What I am asking is whether you are willing to commit to doing something that will work for you and to taking all those passengers with you on your life bus. Will you do that and mean it?
Client: Yes, I do mean it, but what if I can’t keep it?
Therapist: The commitment is to do it and mean it. The commitment is not that you will never break it. In fact, I predict you will break it at some point. Your commitment is that if and when you do break a commitment, then you will recommit, mean it, and get back on track and do whatever you can to keep your commitment as best as you can.
Client: Okay, I will do it. I don’t know how well it will go but ¼ I mean and I will do it.
After the client has committed to doing particular exercises and/or activities for the upcoming week, ask the client to enter them on the Weekly Valued Life Goal Activities form provided at the end of the previous chapter (see also the book CD). FEEL exercises and other goal-related activities are also entered on the Goal Achievement Record. This form provides more of a summary of exercises and activities. At the top of the form, clients state the name of the goal and record the date on which they set the goal and committed to it. Then they record the activities (mini-goals) necessary to achieve the larger goal and record the session date they committed to doing an activity. Later at home clients can record the date when they completed the activity. For instance, if the client’s goal is to attend a school concert, guided by her value of having a supportive relationship with her son, during the first week of conducting FEEL exercises at home, an activity entry could be “Do FEEL exercises on 6 out of 7 days to prepare me for driving to Paul’s school concert.” Apart from linking activities and values, this form also becomes an important record of achievement for the client on their path to valued living
Monitoring Progress and Giving Feedback
At the start of each session, the Weekly Valued Life Goal Activities form needs to be examined and discussed. Praise clients for their practice and progress and discuss any difficulties they may have had. Any obstacles and barriers should be dealt with as outlined in section 5 of this chapter. Based on the client’s entries from the previous week, clients can then record on the Goal Achievement Record the next set of activities. If it is possible to convert records of activities into some type of visual graph, therapists should do so because such graphs are an easy-to-understand and compelling record of progress. The treatment manuals provided by Lejuez and colleagues (2001, 2002) provide more detailed suggestions on how to chart progress and also contain a number of additional record forms (e.g., daily activity logs, activity hierarchy sheets) that therapists might find useful during this part of treatment. The Goal Achievement Record should be kept and reviewed by clients periodically. Doing so provides clients with valuable feedback on how they are progressing and is a great method of self-reinforcement.
5. DEALING WITH BARRIERS AND AVOIDANCE
During both in-session and home exercises, clients will invariably experience barriers that have the potential of keeping them stuck where they are. A common example is a client telling the therapist that, despite committing to an out-of-session activity, they simply could not do it because they were too anxious. Therapists need to examine what got in the way of task completion and deal with obstacles to valued action using some of the strategies described earlier and in the next section. It is really important that we do not approach such barriers with a stance of wanting to overcome them. Overcoming and coping imply struggle. As Hayes, Strosahl, and Wilson (1999) point out, “commitment involves getting in contact with these barriers and moving ahead, not by getting over [or] around them, but rather by embracing and moving through or with them” (p. 271).
Some barriers are external, such as lack of money, time, opportunity, physical space, geographical constraints, or even weather. Therapists can often help clients work through some of these barriers by brainstorming alternatives and making appropriate suggestions that clients may not have thought of. Yet by far the most frequent and difficult barriers that clients with anxiety disorders face are those nagging internal barriers in the form of anxiety-related thoughts, feelings, worries, and bodily sensations.
Regardless of their specific content, all these thoughts and reasons send the same old loud message as broadcast 24/7 on Anxiety News Radio: Do not do what you have decided and committed to do (although it might change your life for the better)—instead, do what you’ve always done and what is safe (although it hasn’t worked for you and will keep you stuck). Commit to struggling to manage your thoughts and feelings! Below we suggest a number of specific defusion, mindfulness, and value-related techniques therapists can use to deal with these internal barriers. In addition, there is one question that therapists can almost always ask clients when these barriers come up. This question refers back to the workability of past solutions and the direction clients want their lives to take.
The Basic ACT Value Question: Are You Heading North or South?
Whenever clients come up with internal barriers, take out a copy of the Life Compass and ask them this crucial question: “Is your response to this thought, feeling, worry, or bodily sensation moving you closer to or further away from where you want to go with your life?”
Below are some variations of this critical question that make specific reference to the life compass “heading north” analogy:
§ If that thought (emotion, bodily state, memory) could give advice, would the advice point you north?
§ In what valued direction have your feet taken you when you listened to this advice?
§ What does your experience tell you about this solution? And what do you trust more, your mind and your feelings or your experience?
§ If your intention is true north, does a particular action (e.g., an avoidance or escape-type behavior) head true north?
§ What advice would the value [insert a pertinent client value here] give you right now?
§ What would you advise someone else or your child to do?
It is important not to get involved in a discussion of the content or correctness of a concern or reason clients come up with. Instead, therapists should acknowledge the presence of these concerns (“Thank your mind for this”) and consistently go back to variants of the above questions to model for clients what they need to ask themselves in the face of adversity. All of these questions and their answers may also bring creative hopelessness back into the room by again highlighting the unworkability of past solutions and the current opportunity to do something radically different.
Defusion and Mindfulness Techniques
Apart from referring back to variants of the basic ACT question, therapists can use a number of defusion techniques to help clients deal with their numerous mind and language traps. These techniques are designed to disentangle client evaluations of their experience from their actual experience and help them observe their experience with compassion.
Recognizing Mind and Language Traps
There are a number of language conventions that tend to keep people stuck. “Yes-butting” and “buying their thoughts” are two pervasive problems that can trap clients into corners, keep them stuck where they are, and seemingly prevent them from moving forward. Clients often mention both of them as reasons for not changing what they have been doing and to justify avoidance and escape behavior. For this reason, making some simple and subtle changes in verbal behavior can make a big difference. Such changes can help clients get unstuck by buying less into their thoughts so that they may move on with actions that are consistent with the life they want to live.
Getting Off Your But(s)
You may remember from early sections that one of the most common barriers clients get caught up in is the “yes-but” trap. Almost invariably, clients will say something like “I like to go out, but I am afraid of having a panic attack.” What a client is saying here is that going out cannot occur along with being afraid. By saying “but” after the first part of the sentence, we undo what we said in that part, that is, we make it go away. This is actually what the word “but” literally means. “But” derives from the words “be out” and undoes or discounts everything that precedes it (Hayes, Strosahl, & Wilson, 1999). So when a client says, “I like to go out, but I am afraid of having a panic attack,” they will not go out. They stay home because that “but” takes the “like to go out” away. It seemingly makes going impossible. Unfortunately, clients are likely to use the word “but” many times every day as a reason for not acting. This unnecessarily restricts their lives and reduces their options.
Ask clients to imagine what would happen if they simply replaced the word “but” with “and.” “I would like to go out, and I am afraid of having a panic attack.” This little change can have a dramatic impact on what might happen next. If clients put it that way, they could actually go out and be anxious and worried all at the same time. It would allow them to go out. It would also be a more correct and honest statement. A client may indeed feel afraid about having a panic attack in the context of going out. Ask clients to imagine what would happen if they started to say “and” instead of “but” every time a “but” keeps them on their butts. Imagine how much more space they would have in their lives. How many more opportunities would they gain to do things? How much space would open up for them? Getting off their but(t)s could be one of the most empowering things they have ever done.
As with other exercises, it is important for therapists to model the use of “and” instead of “but” throughout treatment. These language habits are firmly ingrained in our verbal repertoire and will only change gradually. So repeated modeling by the therapist and exposure to using “and” is essential.
Don’t Buy into Your Thoughts
Most of the previously introduced exercises aim to teach clients that they are not their thoughts, and they need not buy into what their mind tells them. Although it often seems to clients that thoughts are factual entities, they are, in fact, still just thoughts, even when those thoughts appear highly believable. Most of us have heard a variant of this truism during our childhood years in the form of “Sticks and stones may break my bones, but words will never hurt me.” Still, thoughts, evaluations, memories, and the like can hurt when we take them literally, in the sense of treating them as if they were the same as sticks and stones in the real world. Clients will likely buy into their thoughts from time to time. It means that clients buy into verbal representations of their experience and the world to such an extent that the content of thinking hides the process of thinking (Hayes & Wilson, 2003).
A simple technique to help clients not to buy into their thoughts is to ask them to preface evaluative statements with I am having the thought that ¼ For example, when clients say, “I will have a panic attack if I go out,” ask them to say out loud, “I am having the thought that I will have a panic attack if I go out.” Likewise, if a client says, “If I don’t learn to control my anxiety and worries, things are going to go downhill for me,” ask them to say out loud, “I am having the evaluation that if I don’t learn to control my anxiety and worries, things are going to go downhill for me.” Tell clients that you realize this sounds awkward. Yet, if they start describing their thoughts in this cumbersome way, it will help them see a thought for what it is (just a thought). Even the most scary and intense thought is still just a thought. This technique helps clients create an important distance between themselves and their evaluations of themselves and their experience.
Anxiety and Panic Are Also Just Words
Recall that anxiety, fear, and panic are generally unpleasant emotional events and well within the range of normal human experience. It is how clients with anxiety disorders evaluate those emotional experiences that gets them into trouble. Such evaluations are heavily tangled up with language. This is how panic, fear, and anxiety can turn into “bad” events—not simply events—that need to be dealt with like other real-world experiences that can truly cause injury or pain (e.g., the sticks and stones). Ultimately, however, these evaluations are just words that, because of unique learning experiences, become fused with a variety of negative consequences and meaning. This sort of fusion tends to get clients with anxiety problems into trouble because it diminishes contact with the world as it is (not as we say it is) and is responded to needlessly when time and effort could be put to better use for events that are truly important and controllable. To undermine and weaken fusion, while illustrating that panic and anxiety are nothing more than words, Hayes, Strosahl, and Wilson (1999) suggest a very simple exercise called “milk, milk, milk.” We illustrate an adaptation of this exercise for panic and anxiety below.
Therapist: Can we do another simple exercise? Are you willing to do this?
Client: Sure, I’ll give it a shot.
Therapist: Okay. I’d like you to think of the word “milk.” Go ahead. Now, tell me what comes to mind.
Client: Well, I picture a drink that is white, cool, satisfying, even creamy.
Therapist: Good. That’s right. Anything else?
Client: Hmm. I also see it going well with peanut butter and jelly sandwiches, chocolate chip cookies, cereal … but not with, say, orange juice.
Therapist: Okay. So there is a lot more to milk than just the word. Thinking the word seems to bring about a variety of experiences for you, some of which have little to do with milk itself.
Client: Actually, that happens a lot. I start thinking of something and then something else pops us.
Therapist: Well, let’s do a little exercise about that. I’d like you to say aloud “milk [pause 1 second], milk [pause 1 second], milk [pause 1 second]” and I will do it with you. Ready? [Now, both therapist and client say “milk, milk, milk, milk,” pausing about 1 second between each word for twenty to thirty repetitions. Then, the therapist speeds up the repetitions faster and faster for another twenty or so repetitions until it is somewhat difficult for the therapist and client to say the word properly. Now ask the client to say “milk” again to see if anything has changed regarding the experience. Ask the client, “What happened to your experience of milk?”]
Client: The other thoughts and sensations I had before when first thinking about milk are gone. I’d have to work a bit to get them back.
Therapist: What has happened here? The word “milk” once brought about lots of other related experiences for you. You could almost taste it. Now, it is just a word. It has sort of lost its punch. Are you willing to repeat this exercise with a thought or emotion that is bothersome to you? [After the client agrees and has come up with a word related to a barrier—for instance, panic, anxiety, worry, health, an obsession, or an aspect of pain or emotional trauma—repeat the exercise as before, substituting that word for the word “milk.”]
The milk exercise is a simple way to illustrate how evaluative forms of activity can become diminished as we disrupt the natural tendency to hold onto the evaluations, meaning, and other relations that may be fused with language and problematic content, including emotions, thoughts, imagery, and the like. This exercise strips away those normal functions associated with language, leaving only a word as it is, not as we say it is.
Watching Thoughts Drift By
When clients have a lot of difficulty taking an observer perspective in regard to their anxiety-related thoughts and worries, therapists can introduce two other mindfulness and defusion exercises that can help clients see their thoughts as thoughts, which they can observe without having to change or struggle with their content. The exercise is about watching thoughts on leaves drifting downstream (Davis et al., 2000; Hayes, Strosahl, et al., 1999). If clients find themselves becoming distracted by thoughts and feelings, the basic task is to simply notice and acknowledge the presence of their thoughts and feelings with compassion and gentle curiosity and without trying to force them to go away. Below is a sample script.
1. _First, I would like to ask your permission to do another mindfulness exercise. Are you willing to go ahead with that? [Get clients’ permission and then move on.]
2. _Just get in a comfortable position in your chair. Sit upright with your feet flat on the floor, your arms and legs uncrossed, and your hands resting in your lap, palms up or down, whichever is more comfortable. Allow your eyes to close gently [pause 10 seconds].
3. _Take a few moments to get in touch with the physical sensations in your body, especially the sensations of touch or pressure where your body makes contact with the chair or floor [pause 10 seconds].
4. _It is okay for your mind to wander away to thoughts, worries, images, bodily sensations, or feelings. Notice these thoughts and feelings and acknowledge their presence. Just observe passively the flow of your thoughts, one after another, without trying to figure out their meaning or their relationship to one another. As best you can, bring an attitude of allowing and gentle acceptance to your experience. There is nothing to be fixed. Simply allow your experience to be your experience, without needing it to be other than what it is [pause 15 seconds].
5. _Now, please imagine sitting next to a stream [pause 10 seconds]. As you gaze at the stream, you notice a number of leaves on the surface of the water. Keep looking at the leaves and watch them slowly drift downstream from left to right [pause 15 seconds].
6. _Now, when thoughts come along into your mind, put each one on a leaf, and observe as each leaf comes closer to you. Then watch it slowly moving away from you, eventually drifting out of sight. Return to gazing at the stream, waiting for the next leaf to float by with a new thought [pause 10 seconds]. If one comes along, again, watch it come closer to you and then let it drift out of sight. Think whatever thoughts you think and allow them to flow freely on each leaf, one by one. Imagine your thoughts floating by like leaves down a stream [pause 15 seconds].
7. _You can also allow yourself to take the perspective of the stream, just like in the chessboard exercise. Being the stream, you hold each of the leaves and notice the thought that each leaf carries as it sails by. You need not interfere with them—just let them flow and do what they do [pause 15 seconds].
8. _Then, when you are ready, let go of those thoughts and gradually widen your attention to take in the sounds around you in this room [pause 10 seconds]. Take a moment to make the intention to bring this sense of gentle allowing and self-acceptance into the present moment … and when you are ready, slowly open your eyes.
Eliminating Safety Signals and Behaviors
Safety signals and behaviors are important obstacles that keep clients off track, away from their goals, because they get in the way of processes that underlie corrective emotional learning (e.g., the extinction process, defusion). The function of safety behaviors such as seeking and giving reassurance, repeated checking, or being with a significant other is to ward off feared events.
Common safety signals include specific people or objects that have come to acquire the property of making clients feel safe from anxiety, physical injury, or embarrassment. Other examples include the presence of other people, water, money (to call for help), carrying a cell phone, empty or full medication bottles, a weapon, scanning for exit signs, looking for familiar landmarks when traveling, going out to run errands when the likelihood of finding many people is low (e.g., early morning or very late at night), or driving during the day and not at night.
These behaviors are problematic because they are part of, and perpetuate, the old unworkable control agenda. They are, in a sense, part of the system that clients have used in varied, and often quite subtle forms, to keep their anxious thoughts and feelings at bay. For this reason, it is essential that therapists watch out for safety signals and behaviors during any of the in-session or home exercises. Specific examples of safety behavior and signals in the various anxiety disorders include:
§ Social phobia: averting eye gaze; not saying anything controversial or confrontational; being submissive; not appearing in any way out of the norm; never holding small objects for fear of shaking; using aids that prevent shaking, sweating, or blushing, such as wearing light clothing or braces; speaking quietly; diverting attention to others in the group; filling conversation gaps; overpreparing for what to say; using extra makeup; being accompanied by someone else who can carry a conversation.
§ Panic disorder: getting through situations as quickly as possible; keeping the mind preoccupied throughout activities; reassurance seeking; driving in the far right lane only; driving very fast or very slow; driving only with a significant other present; preparing in advance to know exits, hospitals, or landmarks; staying near exits; carrying a cell phone, emergency phone numbers, paper bags to hyperventilate, or food (hypoglycemia); relying on other people, medications, or distractions.
§ GAD: obtaining as much information as possible before decision making; seeking reassurance; diverting decisions to others; avoiding demands and challenges; being overly early; preparing for every potentially negative event or outcome.
§ OCD: seeking reassurance from others; checking on safety of others; being overly clean; having wet wipes readily available.
§ PTSD: hypervigilance or checking situations and people; carrying self-protective weapons; being with particular people or preferring to be alone.
Identifying Safety Behaviors and Signals
The first step is for clients and the therapist to work together to identify both subtle and obvious safety signals and behaviors. The therapist may observe clients during in-session exercises and activities and then ask clients whether they did anything in order to prevent catastrophic outcomes or make the situation less frightening. The therapist and client should compile a list of safety signals and behaviors and continually assess those domains, particularly as clients engage in exercises and activities in naturalistic contexts. It is not uncommon to find that clients utilize different safety signals and behaviors in different situations, or even several different safety signals and behaviors across similar situations (Taylor, 2000).
Review with clients examples of their own particular safety signals, and discuss concrete ways of going through FEEL exercises and goal-related activities without them. Also review the client’s safety behaviors as they pertain to the FEEL exercises and chosen goal-related activities, and discuss ways of performing the task differently and without engaging in safety behavior.
Increasing Psychological Flexibility and Developing Repertoire-Expanding Solutions
From an ACT perspective, safety behaviors are really forms of experiential avoidance. They are used, sometimes consciously and sometimes automatically outside a person’s awareness, to minimize or avoid the dreaded events associated with anxiety-related problems. As with other struggle and anxiety control strategies, safety-guided behavior tends to get in the way of living a full, rich, and meaningful life. For this reason, it is important for clients to experience that their safety signals and behaviors are ineffective as a solution for their problems. It is essential that therapists let clients experience the functional role safety signals and behaviors play in maintaining their problem, including how they have actually constricted their ability to live a full and valued life.
Conducting FEEL exercises and goal-related activities effectively means that clients face fear-provoking situations while weaning themselves off safety signals. It means facing the situations in a direct and open manner, without crutches. Many of the behaviors that have helped clients get through anxiety-provoking situations have ultimately not been helpful because they ended up trapping them and narrowing their options. By this point in therapy, many of these issues will be out on the table already. Yet clients will occasionally be reluctant to simply give up their tendency to use safety signals and behaviors and move the willingness thermostat up to its highest setting.
For this reason, it is important to let clients experience how such behaviors continuously get in the way of them living fully, richly, and without defense. This can be accomplished by doing mini in-session behavioral experiments that involve the client first engaging in an exposure FEEL exercise in the presence of a safety signal or while also engaging in a safety behavior, and then repeating the experiential exposure exercise without the safety signals or behaviors (Taylor, 2000). When safety signals and behaviors show up, therapists can ask the client “How well has this worked for you?” and “What does your experience tell you about doing XYZ? Are such actions taking you closer to or further away from where you want to be with your life?”
Therapists cannot promise what will happen to clients’ anxiety as they engage in repeated exposure exercises. What therapists can promise clients is that those exercises will add flexibility and new choices in a way that clients will not have experienced for a long time. This is the most important aspect of exposure—or what we call FEEL exercises—from an ACT perspective. Recall that the problem for a socially anxious person is not that they get anxious or avoidant when asked to join a group meeting. The problem is that their repertoire has narrowed to avoidance only and it seems there is no other option available to them (Wilson & Murrell, 2004). The most important benefit of FEEL exercises is to broaden the client’s repertoire and make it more flexible with respect to the avoided events. When combined with mindfulness and experiential openness, exposure creates a context where clients make full contact with many life events as they are, and without acting to change the experience because of what they think the experience is or means. While avoidance remains an option, FEEL makes other options available, such as joining the meeting without saying a word and feeling anxious. This client may subsequently attend the meeting again and say one or two sentences and feel anxious. The week after that, the client may attend the meeting and pose a question and say one or two sentences and feel anxious. The anxiety level may not have changed much, but the client has added two more response options that were not there before. Eventually anxiety levels may also go down due to extinction processes. This would simply be a welcome by-product of the more important behavioral repertoire expansion.
Problems with Values 4
A number of different obstacles may arise that are related to values and the achievement of goals. Let us briefly deal with some of the more common issues clients come up with.
I Don’t Have Any Values!
Some clients will say that they don’t value anything. The reality, however, is that they do, in fact, have values. The problem is that they may feel too hopeless and afraid to express their values, or they may not have had the space to be in full contact with their values. Sometimes, caring hurts, especially if the value a client cares about has been a source of suffering. For instance, a client once told us, “I don’t value being part of a loving family because I don’t even know what a loving family is all about. Every time I try to reach out to a family member, they just push me away. My family is so dysfunctional that there is no point in me even thinking about family values.” On the one hand, the client said that she does not value family. On the other hand, she mentioned that she reaches out to her family (and cares!). To help her out of this apparent dilemma, we asked her to reframe the way she identified her values. Instead of asking herself, “Can I achieve this?” we recommended she ask herself, “Do I care about this?”
Remember that values are different from goals, and they are not about achieving outcomes. The client was thinking in terms of goals and achievements. Values, in her view, were focused on outcomes: “If I care for my family, then they ought to reciprocate by showing caring for me.” It was difficult for her to see that she could value and live her life as a caring individual even when others might not do the same toward her. She was correct that there was no point in setting the impossible goal of having the most loving family in town. However, she could certainly keep her value of caring about her family, and behave in ways that support that value, even knowing that her family’s dysfunction might not yield the loving outcome she desired.
Second-Guessing Values and Goals
Some people complete the Valued Directions worksheet and easily identify what they care about. Their gut reaction is often, “Yes, I value parenting, friendship, communing with nature, and education.” Then they begin to doubt and question their values. Do I have enough money? Do I have enough time? Am I too stupid to do this? What would my friends think if I chose this? With these worries, clients can literally second-guess themselves into behavioral paralysis, wondering if they truly hold their chosen values. We recommend using some of the defusion techniques described earlier to deal with these worries. Also remind clients that acceptance is about not judging their thoughts as “good” or “bad.” Actually, there is no such thing as a good value or a bad value. Values are what they are and should be judged relative to their workability for clients in their social context. Values are not decisions—they are choices that need not be justified or defended. Encourage clients to go with their gut reaction and choose without judging. To explain the concept of choosing, we use an example described by Eugene Herrigel in his book Zen in the Art of Archery (1953). He described how animals and infants reach for objects without hesitation. On the other hand, adults tend to evaluate their choices, often hesitating before reaching for an object: “Do I really want to reach for that object?” All of us have much to learn from babies and animals in this regard. We and our clients can choose to act thoughtfully and without hesitation. Ask clients, “Will you step into this and stay committed to your valued direction and keep moving in that direction, no matter what your mind says?”
Is It Really the Client’s Value?
At times, clients seem less than enthusiastic about their stated values. If that is the case, then examine whether the stated values and goals are really theirs and not the result of social pressure or wanting to please others. When people complete the Valued Directions worksheet, they sometimes choose values that sound socially appropriate or values that their loved ones expect of them. Be sure that the stated values are really their values, not values that society, friends, or family have imposed on them. Encourage clients to ask themselves: Why am I doing this? Am I doing this for me or for someone else? Remind them that the pursuit of values is about discovering or rediscovering their own life. It is time to put themselves first! If they are familiar with air travel, they know the standard safety instruction: “When the oxygen masks come down, put your mask on first before attending to others” (Heffner & Eifert, 2004).
We are not advocating that clients live their lives in a hedonistic, self-serving fashion with blinders that block how their chosen values affect people (including themselves). For instance, if a client values travel and seeing the world and is a parent with a spouse and children to care for, it would likely not be a good thing for this client to simply decide that from now on he is going to travel here and there whenever he can and for as long as he feels like it, without also considering the consequences of these actions on the family. In this situation, the client may feel a real tension between family values and other values, and these must be balanced. The same is true of most value-based decisions. Values do not occur in a vacuum. Values are not a one-at-a-time activity. They are situated in a stream of ongoing activity and multiple, competing value-based decisions that must be weighed. Clients can still be encouraged to put themselves first in the sense of living as a compassionate human being, which really is the crux of the matter. Values guided by good intention usually will not go wrong when the feet, hands, and mouth follow.
Valued Living Ain’t Easy
Obviously, if valued living were easy, then we would all be living valued lives. Valued living is about ongoing commitment. It is a test of our integrity. Commitment means getting up after being knocked down. To face barriers as they come and as they are on the journey through life is true commitment. When clients report difficulty staying on course, remind them that they are the driver of their life bus. They really are in control of their destination. Their hands and feet, not the words of the unruly and loud passengers, steer that bus. Ultimately thoughts are just words and words are just sounds. The passengers’ taunts are far less important compared with moving in a valued direction.
Also, your clients may bring up the issue of risk. It is undoubtedly risky to make changes. Things can and sometimes do go wrong. Yet, it is often the case that the biggest risk in life is not taking a risk at all. There are few outcomes in life that are certain. The future is, by definition, not knowable. Most choices involve risk for this very reason. Choosing to play it super safe is a surefire way to guarantee that nothing will change. Clients can count on that. And if nothing changes, they will definitely go where they were headed. Is that the place where their values are? Is that where they truly want to go?
Traveling with Your Fears
Clients need to travel with their anxieties, fears, and pain just as they do with their joys, hopes, dreams, and loves. This obviously is an enormous challenge for most anxious clients. When barriers come up, ask clients, “Are you 100 percent willing to go to the places that scare you so much that you do not live a valued life?” In the book Hope for the Flowers (1973), Trina Paulus writes, “How exactly does one become a butterfly? You must want to want so badly to fly that you are willing to give up being a caterpillar.” Ask clients whether they are ready to change and want to fly so badly that they are willing to do things they may have avoided doing for years.
There is a Buddhist saying “If you don’t decide where you are going, you will end up where you are headed.” Values can prevent clients from heading toward a gloomy destination called “chronic and exhausting anxiety management.” This is where clients have spent a good deal of their time already. After completing the values exercises and LIFE forms for some weeks, many clients have probably begun to recognize the cost of managing their anxiety and may wonder if they will ever become the person they want to be. They may realize that every minute they spend managing their anxiety is a minute that they are not devoting to their values and life goals. It is natural to feel impatient about the change process. Remind clients that valued living is a process comprised of a series of small commitments over time. It is recognized by actions, and often only upon reflection, when all of these small moments are considered in hindsight. Then, and usually only then, do we say, “Now there is a life lived well.”
Therapists can occasionally remind clients that practicing FEEL exercises and life-goal activities with mindfulness is not about getting it right or attaining some ideal state. It is about helping them to stay present with themselves and continue on their path. For instance, when clients notice their response to anxiety-related thoughts getting in the way of what they wish to do, you may suggest coming back to the present moment using the “touch and let go” instruction. We touch thoughts by acknowledging them as thinking; we touch feelings by noticing them as feelings; we touch evaluations by noticing them as evaluations. We touch them lightly like we would touch a bubble with a feather so that we can let them go and continue with what we set out to do. In ACT, relaxation is not about relaxing muscles in your body. It is about relaxing our struggle and relaxing with ourselves. When clients notice intense feelings, the practice is to drop whatever story they are telling themselves and lean into the anxiety or fear and make space for it—just like in the finger trap exercise. This is what Chödrön (2001) calls “opening the fearful heart to the restlessness of our own energy” (p. 29). It is through this process that we learn to stay with and accept the experience of our emotional distress.
6. DEALING WITH SETBACKS THROUGH MINDFUL ACCEPTANCE AND COMPASSION
No matter how often you remind clients to stay open to whatever arises, from time to time they are still going to use the techniques they have learned in this program as a way to suppress or escape from their emotions, thoughts, and painful memories. Reiterate some of the notions described in chapter 10 about how acceptance should not be abused as a clever way to fix anxiety. Remind clients that change is gradual and only occurs when they remember, day by day, and every month of every year, to move toward their emotional discomfort with compassion for themselves and without condemning their experience. There is no point in beating up on themselves for not being perfect at acceptance and keeping commitments. Trying to fix themselves is neither necessary nor helpful because it implies struggle and self-denigration. Although self-improvement can have temporary results, lasting change occurs only when we honor ourselves by approaching our imperfections with kindness, compassion, and patience. It is only when we begin to relax with ourselves, instead of relaxing our body, that acceptance becomes a transformative process (Chödrön, 2001). It is change if we stop running from ourselves, our imperfections, and our setbacks. Accepting ourselves is changing ourselves.
Tell clients that they cannot expect always to catch themselves spinning off into their old habitual patterns of evaluating and avoiding. When clients notice they are engaging in self-evaluative or catastrophic thinking, it is important they recognize such thinking without harshness and without putting themselves down for having such thoughts. As Chödrön (2001) puts it, staying with pain without loving-kindness for oneself is just warfare! That is why self-compassion and courage are vital. Ask clients to simply acknowledge thinking as thinking and return to the out breath during a mindfulness exercise, or at any other time, and continue with what they were doing. The label “thinking” becomes a code word for seeing “just what is.” This activity is a move forward and an index of progress. “In essence, the practice is always the same: instead of falling prey to a chain reaction of self-hatred, we gradually learn to catch the emotional reaction and drop the story lines” (Chödrön, 2001, p. 33).
Chödrön (2001) also has an intriguing way of describing emotions as a combination of self-existing energy and thoughts, and she explains how we can use this energy in constructive ways. Emotions typically proliferate through our internal dialogue, that is, our evaluative thoughts. She reminds us that although we can label thoughts as “thinking” when we notice them, there is something that remains below the thoughts. There is a vital pulsating energy to our emotional experience, and there is nothing wrong, nothing harmful about that underlying energy. Just as we have repeatedly indicated in this book, there is nothing disordered about anxiety per se. The practice is to stay with it, experience it, leave it as it is, and when possible put it to good use. So when emotional distress arises uninvited, ask clients to let the story line, their thoughts, go and connect directly with the energy. What remains is a felt experience, not a verbal commentary on what is happening. Ask clients to feel the energy in their bodies. If they can stay with it, neither acting it out nor suppressing it, it can wake them up and provide them with energy to do things that move them forward toward their goals. This is somewhat similar to the amazingly large number of stage actors who never lose their “stage fright” and who typically use all the anticipatory anxiety and adrenaline as a source of energy for their subsequent acting. They do so because they will not sacrifice the acting they care about by quitting their career. So night after night they willingly go out on stage, do what they love to do, and take their anxiety with them.
7. EXPERIENTIAL LIFE ENHANCEMENT EXERCISES (HOME)
§ Practice the Acceptance of Anxiety exercise for at least 20 minutes daily and complete the practice sheet after each practice
§ Practice FEEL exercises (interoceptive and/or imagery exercises) and/or Valued Life Goal Activities daily
§ Keep track of FEEL practice and value-related activities by completing the Valued Life Goal Activities form each week and the Goal Achievement Record
§ Continue monitoring anxiety and fear-related experiences using the LIFE form
§ Complete the Daily ACT Ratings form
8. PREPARING CLIENTS FOR END OF TREATMENT (SESSION 12)
Toward the end of treatment, it is essential to discuss relapse prevention and a plan for ongoing self-directed therapy using the strategies learned thus far. Monthly follow-up calls can be used to assess client progress and to minimize therapeutic setbacks, or what we think of as reverting to the old avoid and control agenda.
Provide Treatment Summary
In Session 12, therapists can help clients summarize the principles of this treatment program, what they have learned, and how it was learned. It is also important to revisit some of the most significant and frequent barriers that have come up and point out to clients that they will almost certainly continue to come up from time to time. Emphasize that clients have learned a great deal. They have made many changes. How clients are now approaching anxiety-related thoughts and feelings is different from their early tendency to run from them. Now, they are back in contact with their values and moving day by day on a path toward a valued life. A good way to illustrate a client’s progress is to pull out some of the earlier LIFE forms and the Goal Achievement Record and ask them to compare where they were and where they are now. Do they see a difference? Have they allowed themselves to experience a difference?
There are numerous ways clients can maintain their process and learning. Here are two of them that you can discuss with your clients: One way is to continue to practice mindfulness and acceptance exercises.Encourage clients not to limit such exercises to anxiety-related situations. Mindfulness and acceptance are much bigger than anxiety. The second strategy involves continuing to set short-term goals for each week in the post-treatment period. Clients can make commitments to themselves to make progress in an area that is important to them and then monitor their progress in the same way they have done during treatment.
Prepare for Relapse and Setbacks
Therapists need to discuss the likelihood of experiencing a relapse. In an ACT program, relapse is a setback in a person’s attempt to continue on their chosen path. Such setbacks are periodic failures to live up to or keep valued commitments. It is a return back to the old unworkable avoid and control agenda that landed clients in therapy in the first place. Informing clients to expect setbacks teaches them that recommitting to valued action after a setback is the key to getting back on track. These lapses or setbacks may be experienced as flare-ups of anxious symptoms that clients respond to with struggle, unwillingness and control efforts, or the reinstatement of safety signals or avoidance. How clients handle such setbacks is very important. Clients may quickly evaluate themselves as complete failures and use this evaluation to justify stopping all efforts at moving closer to their goals. In such cases, what is really happening is that clients are experiencing what it is like to be fully human. Our values do not ordinarily change because we fail to act consistently with them. Encourage clients to deal with self-deprecating thoughts with self-compassion and mindful acceptance, treating them as just another example of unruly passengers on their life bus. Their choice is to continue steering the bus in the direction that they truly want rather than where those passengers might tell them to go.
Identify High-Risk Situations
Relapse prevention is also about thinking ahead, during periods of success, to how clients might handle more difficult times. High-risk situations are events, thoughts, behaviors, and emotional reactions that increase the potential for lapsing into the old avoid and control agenda. Potential situations also include negative emotional states, interpersonal conflict, and social pressure, and life stress more generally. Continued practice of mindful acceptance can defuse such events from serving as relapse triggers, but they cannot and are not meant to prevent the actual experience of such events. The events can and will happen as clients expand their lives. What we want to do here is to ready clients to not give in to such events and to welcome them, always with an eye on living fully and moving in the direction of what they care about.
Therapists can assist clients with generating a list of high-risk situations and strategies to approach them. A good starting point is to revisit any previous setbacks a client has experienced during therapy and how they dealt with them. The aim of this exercise is to increase a client’s awareness of the factors that contribute to setbacks and to prepare them for dealing with setbacks using what they learned so far.
A client may not recognize a relapse has taken place until they experience a full flare-up of anxiety or panic and find themselves in the middle of attempting to control or manage it. At that time, the client should engage in the mindful observing practices that they learned during FEEL exercises. In fact, typically such flare-ups are just another FEEL exercise waiting to be experienced. Therapists can emphasize that the client now has the skills to move through those events or situations. Ultimately, every situation is part of the totality of human experience and is time-limited. Therapy has given clients new strategies for living with such events and others that may come. The client’s perception of their ability to handle situations is crucial to continued improvement beyond therapy. Remind clients of their prior accomplishments by referring back to the Goal Achievement Record. Reviewing the Goal Achievement Record is a useful strategy during good times to stay on track, and it is useful and important during setbacks to maintain perspective.