Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 5

Balancing Acceptance and Change

Radical acceptance is the only way out of hell—it means letting go of fighting reality. Acceptance is the way to turn suffering that cannot be tolerated into pain that can be tolerated.

—Marsha Linehan

One of the most important themes of this chapter (and this entire book) is acceptance and helping clients learn to accept themselves with all their flaws, weaknesses, strengths, and talents—the whole package. Acceptance is willingness to participate in life in an active and open manner. Yet when clients hear the word “acceptance,” they often think acceptance means giving in or even giving up and losing. Giving in or giving up is what we call passive acceptance or resignation. This is not what this chapter or ACT is about. We certainly don’t want our clients to give up. We are not asking them to grin and bear their anxiety and do nothing.

This chapter is about active acceptance and balancing acceptance with meaningful life change. In fact, acceptance is what allows change and what really makes change possible. Acceptance breaks apart the fundamental struggle and control agenda that many anxious clients are consumed with. It removes the need to engage in a constant struggle with thoughts, emotions, and life circumstances first, so as to live with meaning and purpose later. Acceptance provides clients with the space and psychological flexibility to make life changes now that are consistent with what they truly care about. When clients begin to accept themselves the way they are right now, they begin a new life with new possibilities that did not exist before. Anxiety and fear are no longer obstacles to living. They are part of living and a natural consequence of a life lived well. The key to transforming anxiety-related suffering into meaningful life changes is to accept first that suffering and pain do exist, but they are not the same. Acceptance is the way to turn suffering that seemingly cannot be tolerated into pain that can be tolerated—or put differently, radical acceptance turns suffering into ordinary pain (Linehan, 1993).

Acceptance as an Alternative Agenda for Being with Anxiety

Acceptance involves a counterintuitive approach toward constructive living in which clients are encouraged to give up their struggle to change what cannot be changed for the sake of promoting change in domains of their life where change is possible (Heffner, Eifert, Parker, Hernandez, & Sperry, 2003; Heffner, Sperry, Eifert, & Detweiler, 2002). The basic idea is to let go of ineffective and unworkable change agendas to open the door for genuine, fundamental change to occur. When clients experience that they need not run from or struggle against their anxious thoughts and feelings, they become free to live. In fact, freedom is an emergent property of this process. It comes from being liberated from the grip of nonacceptance and the losing battle against oneself and one’s own life experiences. You cannot fight against yourself and win.

Technical and Nontechnical Definitions of Acceptance

In a nontechnical sense, acceptance involves taking a nonevaluative posture toward living with oneself and the world, characterized by compassion, kindness, openness, present-centeredness, and willingness. More technically, acceptance “involves experiencing events fully and without defense … and making contact with the automatic or direct stimulus functions of events, without acting to reduce or manipulate those functions, and without acting on the basis solely of their derived verbal functions” (Hayes, 1994, p. 30). When applied to anxiety disorders, acceptance means letting go of the fight with fear and anxiety. Such an acceptance posture would translate into willingness to experience anxious thoughts, memories, sensations, and feelings as they are, without acting to avoid or escape from these experiences and the circumstances that may give rise to them, and without acting solely on the basis of what the mind may say about the meaning of these events (e.g., “I’m losing control,” “I must be dying or going crazy,” “I can’t do such-and-such because I might feel anxious”).

Acceptance is closely related to willingness and purposeful action because “willingness is accepting what is, together with responding to what is, in an effective and appropriate way. It is doing what works and just what is needed in the current situation or moment” (Linehan, 1993, p. 103). This relation between acceptance, willingness, and life goal–related behavior is also evident in the definition provided by Orsillo, Roemer, Lerner, and Tull (2004), who describe experiential acceptance as a willingness to experience internal events such as thoughts, feelings, memories, and physiological reactions, in order to participate in activities that are deemed important and meaningful. Please note that acceptance and willingness are not feelings. They are a stance toward life and are very much about behavior and action.

In the context of treatment, acceptance is highly experiential. At its core, acceptance is about approaching and making contact with thoughts, emotions, and life experiences fully and without defense. It is doing with feeling, not doing because of feeling. This means that acceptance must be experienced directly. The procedures and exercises outlined in later chapters (e.g., creative hopelessness, defusion, mindfulness, and exposure-like exercises) are designed to facilitate the development of acceptance as an experiential process.

Whether acceptance can simply be instructed is unclear at this time. Our sense is that acceptance is unlikely to develop via instructions alone and that it needs to be experienced. In fact, in one form or another, clients have already heard someone else tell them that they should stop doing what they have been doing and just accept their fear and anxiety. Many have told themselves the very same thing, without much success. The problem here is neither lack of motivation nor lack of desire or willpower. The problem is that changing our experience with the world requires that we allow ourselves to experience the world directly, unedited—as it is. Unless the change and control agenda is first challenged and undermined, clients will likely use acceptance as another new, snazzy tool to feel less anxiety, worry, fear, and other forms of psychological pain (Hayes & Pankey, 2003). The transformative power of acceptance comes about via directly experiencing life as it is: nothing more, nothing less.

We should add here that acceptance is an active, vibrant process that does not come easily or naturally for most of us. We tend to color our world with our own preconceived notions of what is or what should be. This is especially true for anxious clients, who seem tangled up in a web of doubt, what-ifs, and patterns of experiential avoidance and escape focused on events that exist mostly in the mind. Clients can, however, learn to be open to “what is” without contaminating this experience with their evaluations, justifications, and reasons for “what is” and “what ought to be.” Acceptance is ultimately about choice: choosing to make contact with how one has lived up to this point, some of which might be painful, and then choosing to make the commitment to act differently and consistently with what one values. An acceptance posture on one day will not necessarily carry over to the next day. It is an ongoing process and a choice that needs to be made every day—again and again.

Acceptance is not about liking our experience (past or present), nor is it about approving of what happened or did not happen to us. It is also not about being right. It is about being proactive, not reactive, and acknowledging and experiencing what is, as it is. It is also about acknowledging, not condoning, what happened to us in the past. This move is courageous, empowering, open, honest, and compassionate. This move is also liberating. When we ask clients who have made the choice to accept, “How does acceptance feel to you?” they often say things like, “A burden has lifted” or “I feel free and ready to move on.”

Acceptance Is Not Giving Up

There is an importance difference between the active form of acceptance we have been describing and a passive form of acceptance. To distinguish passive from active acceptance, let us go back to the serenity creed: Accept with serenity what you cannot change, have the courage to change what you can, and develop the wisdom to know the difference.

In this book, we define passive acceptance as failing to muster the courage to change what can be changed. Passive acceptance or resignation is akin to just giving up and failing to take action in areas of life that can be controlled. For instance, if your client is a student who decides not to go to class because she fears what others might think of her when she makes a class presentation, she lets her feelings (which she cannot control) guide her actions (which she can control). This type of passive acceptance and resignation is narrowing and limiting. It is not what we want clients with anxiety problems to do.

In contrast, active acceptance means letting go of the struggle with what cannot be controlled. As we mentioned in previous chapters, these are the thoughts and feelings anxious clients have about themselves, many of which they understandably do not like and would rather not have. Active acceptance means mindfully acknowledging thoughts and feelings without taking them as facts, approving or disapproving of them, or doing anything about them. By embracing an acceptance posture, clients are positioned to regain energy and time that might otherwise be wasted on attempting to change what cannot and need not be changed. Active acceptance liberates clients to take action toward what truly can be controlled and what really matters as part of living.

Hank Robb (personal communication, 2004) recently offered a spin on the serenity creed—the “Formula for Serenity in Action”—that nicely illustrates the nature of acceptance as an active process within an ACT approach. He has kindly allowed us to share it here:

Let me seek acceptance of life as I find it, even though I may not approve of what I find, wisdom to see what would be good to change, willingness to act as well as willingness to follow through, and gratitude for the opportunity to live my life as best I can.

The reason why we refer to this type of acceptance as active acceptance is that clients must be willing to experience thoughts, situations, and emotions that they have strived to avoid. This move is about choice and shows that active acceptance is a challenging and courageous activity.

Initially, clients will find it difficult to be willing to have anxiety-related thoughts, images, or sensations deliberately and to do what is important to them anyway regardless. Yet, this is precisely what needs to be done to get on the path of living. In fact, active acceptance actually creates space and allows people to move their hands, feet, and mouth in directions that are important. Acceptance is easier than nonacceptance precisely because the avoidance, struggle, and control ropes that would normally tie up and bind a client with their anxiety are let go. There is no need to struggle, no need to fight. The battle and tug-of-war with one’s thoughts and feelings need not be fought. In fact, with acceptance there is no fight left to fight. Acceptance ends the tug-of-war by letting go of the control ropes—a core metaphor we use in treatment (see chapter 8). Mindfulness exercises that encourage present-centeredness and nonevaluative experiential knowing of reality as it is can help facilitate the development of active acceptance. We describe mindfulness approaches briefly below and include such exercises in later treatment chapters.

Origins of Acceptance-Based Strategies

Acceptance-based ideas are not new within psychology, and yet it is only recently that they have made their way into cognitive behavioral therapies (Hayes et al., 1994; Hayes, Follette, et al., 2004). For instance, variations of therapist- and client-focused acceptance are at the core of humanistic (Rogers, 1961) and existential psychotherapies (Greenberg, 1994; Perls, 1973). Even Freud (1920) considered repression and avoidance of unwanted thoughts and emotions to be toxic psychological processes (Hayes & Pankey, 2003). We could go on and on with other examples of acceptance playing a key role in psychological theory and practice, including several religious traditions that predate psychology as a discipline. Such examples simply illustrate that most therapists believe that some form of acceptance is necessary for meaningful therapeutic change.

What is new about acceptance within mainstream psychology is its manualization, systematic conceptualization, operationalization, and inclusion in established, empirically supported psychotherapies (e.g., Acceptance and Commitment Therapy: Hayes, Strosahl, & Wilson, 1999; Hayes & Strosahl, 2004; Dialectical Behavior Therapy; Linehan, 1993, 1994; Integrative Behavioral Couples Therapy: Jacobson et al., 2000). Acceptance is viewed not as a therapeutic goal itself but rather as a means of empowering the achievement of valued life goals (Hayes & Pankey, 2003). It is a process, not merely an outcome, and shares an affinity with Eastern traditions emphasizing acceptance and mindfulness.

Eastern Philosophy and World Views

Mindfulness is fundamentally an acceptance-oriented psychological process derived largely from 2,500 years of Buddhist philosophy and meditation practice (Kabat-Zinn, 2005; Robins, 2002). Its origin can be traced back to as early as the first millennium B.C., to the foothills of the Himalayas, when Shakyamuni Buddha, the Buddha of this era and founder of Buddhism, attained enlightenment. Buddhism is intensely empirical and more closely aligned with experiencing life fully and openly than with any particular religious beliefs. Its focus is on the fluid aspects of reality as it unfolds, and it includes a microscopic examination of the very process of perception and experience. To reveal reality as it really is, its intention is to strip away that screen of evaluative distortions of reality that normally color how we see the world. This process undermines responding to evaluations rather than experiences, while promoting openness, flexibility, and contact with experience. Thus, it allows for contingencies to shape and guide behavior. This is precisely what ACT aims to do as part of the process of getting the client to move in life directions that are freely chosen and valued.

There are several strands of Buddhism, and two main forms of meditation stem from them: Vipassana (insight) and Samatha (concentration or tranquillity). Vipassana, the oldest form of Buddhist meditative practice, involves a clear awareness of exactly what is happening as it happens. Samatha is a state in which the mind is brought to rest, focused only on one item and not allowed to wander. Most systems of meditation emphasize the Samatha component, sometimes referred to as a concentrative approach. Here the meditator focuses the mind upon a single object, such as prayer, a certain type of box, a chant, a candle flame, a religious image, or some other thing, and excludes all other thoughts and perceptions from consciousness. The goal is a state of calm and peace. If achieved, however, such effects are temporary and only last as long as the meditator is meditating. Most systems of meditation focus on the achievement of peace and tranquillity as goals on the path to enlightenment. Not so with Vipassana meditation. Vipassana meditation is most closely aligned with mindfulness meditation. Mindfulness is about the act of purposefully paying attention to experiences as they are, and not how we say they are because of our conditioning histories. As such, mindfulness is to be used deliberately in daily life with eyes wide open, not simply during meditation sessions (Kabat-Zinn, 2005). It is this feature of practicing mindfulness in all life situations that makes mindfulness so relevant and useful for ACT.

Mindfulness as Process and Practice

Life is lived in the present, and living is ultimately about the fluid unfolding of a series of present moments. Yet, it is notoriously difficult for humans to remain psychologically present in the here and now. We frequently live in the past or the future, and we cloud our present experiences with evaluations of them, while failing to recognize that the evaluations are not the experiences. They are evaluations of the experience; the experience will be regardless of our evaluations of it. Yet our minds constantly fuse our experiences and our evaluations of those experiences, creating a language trap that is responsible for much human suffering. For instance, when the neighbor’s dog starts barking loudly and uncontrollably before dawn, what do we do? We probably say something like, “Damn it … there goes that dog again,” “I really can’t sleep with this noise,” “I’m not going to be alert today,” “Why can’t they shut him up,” “Why don’t they keep him inside,” and so on. We may even think about calling the neighbors to request that they do something about their dog, and may consider calling the police. In the process, we fail to notice the experience of the dog barking—sounds that have a unique quality and beauty in their own right. It never occurs to us that we can simply experience the dog’s barking as it is.

Several researchers (Bishop et al., 2004) have suggested an operational definition of mindfulness that contains two components. The first component involves the self-regulation of attention so that it is maintained on current experience, that is, observing and attending to the changing field of thought, feelings, and sensations from moment to moment. The second component involves adopting an orientation of curiosity, openness, and acceptance to one’s experiences in the present moment. In this manner, a stance of acceptance is taken toward each moment of one’s experiences. This involves a conscious decision to abandon one’s agenda to have a different experience and an active process of allowing current thoughts, feelings, and sensations, no matter whether we like or dislike them.

In its most basic form, mindfulness is about making direct contact with our present experiences, with acceptance and without judgment (Kabat-Zinn, 1990; 2005). If you can imagine taking a neutral, scientist-like perspective while also observing your internal and external experiences from a nurturing, loving, compassionate perspective and with intention, then you can imagine what a mindfulness posture is like. Such observation without judgment and with compassion is actually an active response—just not in the way we usually think of being active (as in running, fighting, struggling, etc.). This stance is an antidote to the stimulus control exerted by literal language (Hayes & Shenk, 2004) and thereby facilitates acceptance and full contact with life experiences, both inside and outside the skin. At the core, mindfulness is very much about running into reality, not away from it!

This process of mindfulness is quite different from what most of us usually do. We usually do not take the time to see what is really there in front of us. Instead, life is viewed through a screen of thoughts and concepts. We all have a tendency to mistake those mental objects for reality, to focus on outcomes and not the process, and to get so caught up in dealing with an endless stream of evaluative thoughts that reality flows by unnoticed. Clients with anxiety-related problems spend an enormous amount of time engrossed in this activity, caught up in an endless pursuit of calm and peace and an ongoing flight from pain and unpleasantness. They expend lots of energy trying to make themselves feel better by burying fears, doubts, worry, and pain. Meanwhile, the world of real experience flows by untouched and untasted. Recall that an essential aspect of mindfulness is observing without evaluation or judgment and without holding onto, getting rid of, suppressing, or otherwise changing what we experience. The paradox is that real peace and joy come when we stop chasing them.

Though a deep sense of peace, calm, and relaxation may be a natural consequence of a mindfulness posture, this is not the goal of mindfulness from an ACT perspective. The transformative and therapeutic power of mindfulness practice derives directly from openness to all experience as it is. The goal of mindfulness is full awareness of experience—to become liberated from the blinders of our learning histories, evaluations, preconceptions, self-talk, and the like, and to wake up to life as it really is, not as our mind says it is. In this sense, mindfulness meditation has been described as the “Great Teacher.” This teacher is one of several forms of acceptance behavior, and like any new behavior, it must be practiced regularly before it can be applied freely as part of daily living. Meditation practice creates a context in which experiential avoidance directly interferes with the process of meditation itself (Hayes & Shenk, 2004).

Incidentally, meditation practice is only one way to develop mindfulness skills. Other behavioral techniques foster mindfulness by teaching clients to distinguish experiences from evaluations of their experience; we introduce some of these cognitive defusion techniques (including mindful exposure) in the treatment chapters. The goal of all these practical exercises is to apply a mindful, accepting posture to all our experiences. Mindfulness that is only applied to meditation practice but not to daily living and anxiety-related situations is sterile and of limited value.

Mindfulness Is a Cognitive Defusion, Not an Anxiety Control Strategy

It is essential that our clients do not use mindfulness or any exercises as a control strategy to manage their anxiety. Our experience tells us, however, that clients are likely to do so. You can recognize it when clients come in saying, “Mindfulness doesn’t work for me” but also when they enthusiastically say, “Mindfulness really works for me.” In both cases, they may be trying to combat anxiety with mindfulness.

To address such behavior, therapists need to have a clear understanding of the function that mindfulness and other exercises serve in ACT. Instead of an evaluative avoidance stance, these exercises are designed to foster a nonevaluative approach toward the world of experience. For instance, mindful breathing is not designed to be a relaxation strategy to control or manage anxiety. It is a defusion strategy that aims to help the client make contact with experience as it is, without all the other evaluative baggage, including verbal rules and reasons, that usually come along with it. As with acceptance, mindfulness allows clients to notice the process of thinking, evaluating, feeling, remembering, and other forms of relational activity, and not simply the products of such activities (Hayes, 2002). Relaxation, peace, and a sense of calm may occur as by-products of mindfulness. Similarly, mindfulness might result in the experience of distressing thoughts, memories, and feelings. In both cases, the real aim of mindfulness is to help clients experience their experiences fully, including their evaluations, thoughts, and memories as they are, in a context where experiential avoidance is unnecessary and counterproductive.

In ACT, we consider mindfulness exercises a useful tool to help people experience their anxiety without trying to fix it. We do not consider mindfulness to be therapeutic in itself. We do not encourage it as a way of life to feel better. Mindfulness is not an escape hatch, emergency exit, or ejection seat (like the ones used by fighter pilots) to break away from aversive experiences. Instead, it is a way to become better at feeling on the path to living better. The prize here is a life, and as many casino signs read, “You need to be present to win.” Mindfulness is designed to help clients wake up to their own experiences as fully functioning human beings. The danger here is that clients may start using mindfulness and other exercises to get relief from anxiety as a new way of avoiding, escaping, or fixing what they experience. This may work in the short run and reinforce old control patterns. As a consequence, clients may do more of the same in the future. At the same time, it would prevent a lasting change and be a step back to the old, unworkable control agenda.

Linking Acceptance Techniques to Behavior Theory

Cognitive behavioral therapies are intensely empirical, experiential, practical, time limited, and present focused. Their popularity and effectiveness stem largely from these characteristics. Acceptance-based behavior therapies retain the core elements that have made behavior therapy so popular and add to them in several ways, chief among them being how psychopathology is conceptualized. We have already outlined many of the core elements that comprise an ACT approach to anxiety-related suffering. A few additional characteristics are worth mentioning here, particularly as it has become increasingly clear to us that ACT is quite different from mainstream cognitive behavioral therapies for anxiety disorders. For therapists to practice ACT, they really need to get their own head and heart around what acceptance is about.

We have said that ACT is an approach, not a set of techniques targeting symptoms. Its characteristics—focusing on experiential openness and values, and developing the human capacity to live on purpose and with meaning—follow directly from the view that a good deal of human suffering stems from actions that cut persons off from such uniquely human characteristics. One initial goal of therapy is to create a new context where such human qualities can thrive. Doing so requires therapists to rethink the symptom-focused change agenda that has come to characterize many mainstream cognitive behavioral therapies for the anxiety disorders.

The Language Trap

Recall that anxiety does not become disordered because of what people feel, or because anxiety and fear are too intense, or because such emotions often occur in situations that do not demand such a response. Rather, it is the language-based capacity for humans to evaluate, and respond relationally to their own evaluations, thoughts, and feelings with more evaluations, while acting not to have them, that sets up a trap for anxiety to become an anxiety disorder. Such tendencies do not come from nowhere. They are socialized and learned by about the age of two and are fundamentally built into human language and cognition:

Humans have a hard time accepting the present moment with openness and curiosity … since the present moment may contain events that are … evaluated as undesirable. A primary benefit of language in an evolutionary sense is its contribution to problem solving, and typically the primary goal of problem solving is to produce desirable rather than undesirable events. Avoiding psychological pain is thus built into the normal function of language itself, even if that process causes harm. (Hayes & Shenk, 2004, p. 252)

As a therapist, you can think of the basic process that sets up this trap as a tendency to respond to one’s own responses, or more technically behavior-behavior relations. These relations, in turn, are at any moment situated in and within a context. The context controls the nature of a relational response and the kinds of evaluative relational activity that might occur, including what clients ultimately do with their hands and feet as a consequence. As Hayes (2002) put it, “mindfulness and acceptance catch this bird in flight, and like an audience that learns how a magic trick is accomplished, they can profoundly change the effects of the language illusion” (p. 104). Consider, for instance, the case of Jerry.

Jerry suffered from panic attacks while driving. During such attacks, he would routinely focus on his evaluations of the physical sensations he experienced, saying to himself things like, “My God, I must be having a heart attack … I must be dying.” Typically, Jerry would immediately pull over during such attacks, and eventually ride out the attack until he felt well enough (another evaluation) to drive home. Ultimately, Jerry sought out consultation from a cardiologist and underwent a routine exercise EKG. While undergoing this test, Jerry experienced a range of physical sensations, many of which were quite similar to those that normally would accompany his panic attacks while driving. However, in the “safe” context of the doctor’s office, Jerry neither thought “I must be having a heart attack,” nor did he stop the exercise or escape. This case illustrates a key point about how context controls our evaluative relational activities and overt behavior, and it can help you, as a therapist, conceptualize client problems and how to work with anxious clients from an ACT perspective.

THE FUSION-OF-EVALUATIVE-THINKING-WITH-REALITY TRAP

First, the events felt during anxiety and other emotional responses are characterized by physical sensations that are well within the range of normal human experience. The responses “I am having a heart attack” and “I must be dying” are purely derived forms of evaluative activity. Note that the form or content of evaluative activity is not problematic in itself. To illustrate, go ahead and say to yourself “I am crazy,” “I am worthless,” “I can’t breathe,” “I might be dying,” or “My heart is racing.” These statements likely had little effect on you, showing that an evaluative thought or statement is just that: an evaluation, a series of words. Yet, evaluations have a tendency to become fused with our experience and can entail other relations. For example, “I must not stand up and speak because I will make a fool of myself in front of this crowd” is no longer just an evaluative thought. The thought takes on the function and is experienced as a representation of the actual event (e.g., social rejection) that then needs to be avoided. Also, the thought “I am a social failure” is likely related to other evaluations, such as “I am not happy,” “I am sick,” “People will think badly of me,” or “I can’t do X, Y, or Z.” Many of us, in fact, are guided more by our evaluations of the world then by events in the world as they are. This is not to say that the fusion of evaluative thought with actual experience is necessarily and always a bad thing. The point is to help clients recognize the difference between what the mind says and how the world is, and to respond flexibly as the circumstances require while moving in the direction of valued goals.

THE AVOIDANCE TRAP

Our second point has to do with the typical outcome of this fusion process and its treatment implications. The outcome for anxious clients is almost universally to engage in obvious and sometimes more subtle forms of experiential avoidance. Clients with anxiety disorders typically find themselves ensnarled in evaluative fusion activity (thoughts = feelings = reasons = justifications = action and inaction), and then do what appears to be the most sensible thing to do: avoid or run from the circumstances that contribute to the anxious thoughts, unpleasant memories, and associated feelings. What they are really doing, however, is responding to the evaluation—not the real contingencies of the situation—and they often do so in an inflexible and rigid manner. As a therapist, you could think of this as the product of a generalized insensitivity to contextual factors that would normally promote a more flexible and less evaluation-driven repertoire of responding. These actions, as we described earlier, function as the nails on the coffin door for human beings who want to have a life worth living.

Implications for Treatment

The acceptance and mindfulness posture of ACT can be thought of as a way to “defuse” or loosen and disentangle the fusion of events or experiences with the evaluations of such experiences. This is important because evaluative forms of cognitive activity that set up relations amongst feelings, thoughts, and experiences, and action tendencies (e.g., anxiety suppression, control, and avoidance) are typically unworkable as solutions. There are several obvious and not-so-obvious treatment implications that follow from an ACT approach. These implications are simply different, rather than better or worse, than those typical of mainstream cognitive behavioral therapies.

Reframing the Clinical Context

As a therapist and human being, take a moment to think about what you are ultimately trying to accomplish when working with other human beings who come to see you because they are suffering. You may have come up with several responses. Perhaps you focused on intermediate goals, achieving insight, and, more likely, symptom alleviation. You probably use a wide variety of techniques to get there. Ultimately, however, most therapists want to see their clients living better, not simply feeling better.

There are countless examples, some quite extraordinary, of human beings who experience emotional and psychological pain, hardship, and just about every possible disadvantage and, in spite of having every reason to feel bad and give up, they nonetheless choose to live life to its fullest. There are also many examples of individuals with many advantages and reasons to feel good who still suffer miserably. As a therapist, you have likely seen clients who represent both ends of this spectrum. Feeling good is a sensible and reasonable starting point if one starts from the posture that feeling better is a prerequisite for living better. This is also the same posture that many clients operate from and expect from therapy. Most mainstream cognitive behavioral therapies for anxiety disorders similarly focus on helping clients feel better in order to live better. Implicit in this move is the notion that one needs to manage the symptoms first so as to live a life later. The stakes are high if client and therapist buy into this change agenda. What if that anxiety management program does not work? They better get on top of the “anxiety problem” or else … there will be no life!

With ACT, the relation is reversed and the clinical context reframed to focus on the real prize—a life lived well, not living to feel well. Feeling better may happen as a by-product of living a full, rich, and meaningful life—or it may not happen. The clinical focus is first and foremost on helping clients get on the path of living consistently with their values and goals. This focus actually takes a lot of pressure off the shoulders of clients and therapists alike.

More Flexible Treatment Goals and Targets

The emphasis on living well redirects clinical attention away from symptom-focused eliminative techniques so often used in cognitive behavioral therapies for anxiety disorders. In fact, clients are often surprised to hear us say that an ACT approach to anxiety disorders is not simply about anxiety. The focus is much broader than that. ACT is about enriching a human life and undermining destructive forms of human activity that get in the way of living. For instance, learning to be fully present in the moment will likely enhance a client’s quality of life, whether anxiety shows up or not. It also serves to broaden the range of events that might regulate behavior, while undermining narrow forms of verbally regulated behavior that get in the way of effective actions (Hayes & Shenk, 2004).

Similarly, loosening the experiential avoidance and change agenda is likely to help clients when confronted with various forms of human suffering, by enriching their experiences with the world and relationships with others in that world. Choosing to accept what cannot be changed and choosing to live a valued life with meaning and purpose are likewise broadband repertoire-expanding actions that are not specific to anxiety. In fact, anxiety-related problems could be thought of as one of several consequences of unwillingness, avoidance, and inaction. ACT intervention strategies, as we outline in later treatment chapters, are ultimately about fostering the development of whole, fully functioning human beings. Who ever said that behavior therapy cannot be “humanistic”? Acceptance-based behavior therapy is deeply experiential and humanistic. Therapists, therefore, need to think in terms of fostering psychological flexibility, growth, and meaningful life change when working with anxious clients from an ACT perspective. A variety of strategies may be used to accomplish such goals. This is why ACT, and behavior therapy more generally, is not limited to a specific set of techniques.

Recontextualizing Exposure

In vivo and imaginal exposure exercises are at the core of virtually all cognitive behavioral therapies for anxiety disorders, and for good reason. Exposure is designed to counteract the powerful action tendency to avoid or escape from anxiety and fear-provoking events. This is accomplished by arranging structured approach activities, usually in the form of a fear hierarchy. Corrective emotional learning comes about as clients make full contact with anxiety-provoking events, usually in increasing order of difficulty. Within standard cognitive behavioral therapies, repeated exposure takes advantage of extinction processes, and thus results in attenuation of anxiety and fear to previously avoided cues and situations. In fact, exposure is ultimately an eliminative technique and is conducted with the explicit goal of reducing anxiety. Implicit in this move is the assumption that anxiety needs to be reduced so that the client can feel and function better. Otherwise, exposure as traditionally practiced within cognitive behavioral therapy would not make much sense.

Within ACT, exposure is recontextualized in several ways. It is no longer an eliminative technique to be applied within a framework of mastering and controlling anxiety. To do so would be inconsistent with an ACT therapeutic stance, for it sends a message to the client that the anxiety is the problem and thus must be reduced or managed before a client can feel better. Rather, exposure within ACT is best thought of as one of several experiential exercises, with the goal being to feel better (i.e., become better at feeling), not to feel better (i.e., feel less anxiety). This mastery of experience framework for ACT exposure exercises is again about creating a fully functioning human being. The goal is not to help clients manage or get rid of anxiety and fear, but rather to help them develop willingness to experience thoughts and feelings for what they are. Thus, exposure exercises within ACT are framed in the service of fostering greater psychological flexibility, experiential willingness, and openness. They are about growth and are always done in the service of client values and goals. This is an important point, and it’s why we refer to them in later treatment chapters as Feeling Experiences Enriches Living (FEEL) exercises. As you will see, FEEL exercises are included along with several other Experiential Life Enhancement Exercises in the treatment chapters.

As a therapist, you should always frame exposure in such a way that it is linked with a client’s values and goals. The goal of exposure is to help move a client toward living consistently with their valued life goals. When in doubt, ask yourself, “What is this exposure exercise in the service of?” If a client’s values and goals do not show up in the answer, then the purpose of the exercise will need to be clarified. Along the way, continue to be mindful that anxiety reduction is not a necessary prerequisite for meaningful behavior change. In fact, an acceptance-based approach allows for the possibility that anxiety levels may remain unchanged, so long as the client is showing greater willingness and is taking steps to use their hands and feet to live consistently with what matters to them. Again, it is likely that clients will experience some anxiety reduction or at least learn new ways of relating with their anxiety. Yet, even without anxiety reduction, therapy can still be a success, as long as the client is living a more meaningful and richer life. This posture is quite different from mainstream cognitive behavioral therapies, where anxiety reduction is seen as the main goal of exposure exercises.

Mindfulness, acceptance, and defusion are not just a different way of treating … problems of depression or anxiety. They imply a redefinition of the problem, the solution, and how both should be measured. The problem is not the presence of particular thoughts, emotions, sensations, or urges: It is the constriction of a human life. The solution is not removal of difficult private events: It is living a valued life. (Hayes & Wilson, 2003, p. 165)

Implications for Assessment

We see assessment closely tied with case conceptualization and treatment as well as monitoring of outcome. Within ACT, the assessment and treatment relation is ongoing and recursive. It starts from the moment a client walks through the door and continues throughout treatment, and, when feasible, for some period of time after treatment. This is simply good clinical practice. Thus, we adopt this approach throughout the treatment chapters that follow.

We should add that ACT presents an enormous opportunity for therapists to make a difference, not only in their clients’ lives but also within the clinical professional community. Although the empirical base of ACT is growing rapidly, it is still in its infancy (Hayes, Masuda, et al., 2004). Thus, therapists who collect assessment and outcome data using ACT with their clients, and who make an effort to disseminate their data via case conferences, workshops, and traditional publication outlets, truly stand to make an impact on the development of ACT in the years to come. This is no exaggeration. You, as an ACT therapist, can make a contribution to researchers and clinicians using, and attempting to further develop, acceptance-based treatments. What follows in this section is meant to help orient you to some broader assessment considerations. The issues we address are not meant to be inclusive. Rather, we provide an overview of some available assessment measures and their suitability in the context of an ACT approach to treatment.

Current Measures and Their Suitability Within ACT

There are numerous empirically supported assessment devices you may use with persons suffering from anxiety disorders. Most are designed to evaluate emotions, thoughts, and overt actions consistent with the tripartite model of fear and anxiety. As a therapist, you will likely not have the time or resources to include more expensive assessment technologies such as physiological monitoring. Thus, we limit this brief overview to the chief modalities for gathering information about your clients, beginning with the clinical interview.

Though the clinical interview is typically unstructured, there are good structured interviews available for anxiety-related problems. For instance, both the Anxiety Disorders Interview Schedule for DSM-IV(ADIS-IV; Brown, DiNardo, & Barlow, 1994) and the Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV; First, Spitzer, Gibbon, & Williams, 1996) are suitable if the goal is to conduct a thorough diagnostic assessment. Yet, we encourage you not to limit your assessment to diagnosis alone. This recommendation is based on several considerations.

First, psychiatric diagnoses are limited to symptoms and syndromes, whereas ACT is about behavior and processes that contribute to human suffering. Recall that symptoms are less important from an ACT perspective than getting the client unstuck from the pattern of avoiding and controlling those symptoms. Second, psychiatric diagnoses are widely known to have limited treatment utility. Simply because we build our treatments around diagnostic labels is not a good reason to use diagnosis as a guide for treatment. Many of the issues addressed from within an ACT approach are not disorder specific; ACT instead means to address variables and processes that underlie human suffering more generally. Third, and consistent with the aims of an ACT approach, diagnoses—however necessary for insurance purposes—create the false impression that disorders are more dissimilar than they truly are. This book in particular is about addressing the core processes that underlie disordered experiences of anxiety and fear. Though the particular issues will vary from client to client, the nature of the treatment is quite similar across each of the anxiety disorders. Remember, ACT is an approach, not simply a technology. It is about helping clients live fully and richly, rather than about alleviating disorders. Thus, psychiatric diagnoses have only limited utility from an ACT perspective.

You may also consider using one or more empirically supported paper-and-pencil self-report measures to assess common and more specific characteristics of anxiety-related suffering. The universe of options here is large, and we simply cannot describe each of the available measures. A good starting point is the Practitioner’s Guide to Empirically Based Measures of Anxiety (Antony, Orsillo, & Roemer, 2001). This volume contains information on almost all of the measures that have demonstrated usefulness in assessing core features of anxiety and related disorders. Many of these measures are also quite useful in that they provide information about various forms of experiential avoidance. In fact, virtually all of the available self-report measures for anxiety, in one form or another, assess the psychological consequences of experiential avoidance.

Take, for example, the Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1992; Reiss, Peterson, Gursky, & McNally, 1986), a sixteen-item questionnaire designed to assess fear of anxiety-related physical symptoms. Not surprisingly, fear of anxiety-related symptoms is characteristic of most persons with anxiety disorders and particularly persons suffering from panic disorder. From an ACT perspective, however, anxiety sensitivity is simply a manifestation of a toxic and more basic underlying process, namely experiential avoidance. Persons who are unwilling to have physical sensations and who consider them bad and something to be avoided tend to respond to their own responses, and the circumstances that occasion them, with apprehension and fear. In fact, in the context of experiential avoidance, fear of fear (i.e., elevated anxiety sensitivity) makes sense as a natural outcome. Now consider anxiety sensitivity in the context of willingness or acceptance. Here, anxiety sensitivity makes little sense, for now we are left with the experience of physical sensations as they are, willingness to have them for what they are, and consequently no need to do anything about them. They are just feelings, sensations, and related thoughts. As a consequence, we would expect to see a reduction in ASI scores following ACT treatment. Responses to many other anxiety-related measures can be conceptualized similarly and should show pre-post treatment changes as a result of a decrease in experiential avoidance. Thus, we encourage you to include them routinely in your work with clients.

Numerous other more traditional forms of assessment may prove useful in the context of an ACT approach, and these are only limited by the creativity and skill of the therapist. For example, direct observation of a client’s behavior in session and outside of session can be enormously useful. In particular, many of the exercises outlined in later chapters are introduced and practiced in session. How clients respond to you as another human being can provide valuable information about how they may respond to other human beings in their daily lives. Similarly, be attuned to how your clients respond to the treatment exercises (both verbally and nonverbally). Watch for subtle and more obvious clues to patterns of rigidity, experiential avoidance, and struggle. Address such issues with compassion as they unfold, and be mindful of how you respond to your client and how your client is responding to you in the present moment. Such present-centeredness can help you develop a clear formulation of your client’s difficulties, while also helping you more appropriately tailor treatment to your clients’ unique circumstances.

ACT-Specific Process and Outcome Assessment

Assessment technology suitable for ACT is developing at a rapid clip. Some assessments exist in published format and others were developed or adapted specifically for the purpose of this treatment program. For instance, in the treatment sections of this book, we provide several measures that may be used to assess ACT-relevant clinical processes and outcomes. You will also find electronic versions of all these measures and worksheets on the CD that accompanies this book. This, we hope, will make it easy for you to incorporate these measures into your clinical practice. Although these measures can be used to document pre-post treatment effects, they are equally useful as ongoing measures to monitor changes in experiential avoidance and willingness, as well as difficulties clients may be experiencing between sessions.

EXPERIENTIAL MONITORING FORMS

Living in Full Experience (LIFE)

Right from the beginning, we ask clients to monitor contexts where anxiety and fear show up, associated experiences (thoughts, physical sensations, and overt behaviors), their willingness to have those experiences, and how they respond to them in ways that get in the way of their values and goals. At the end of chapter 7 (and on the book CD) we provide a worksheet—Living in Full Experience (LIFE)—that can be used to track some of the above domains. The acronym LIFE is not accidental. It’s a deliberate effort to frame this exercise in terms of what really counts: living.

Daily ACT Ratings

Throughout treatment, we also ask clients to complete the Daily ACT Ratings at the end of every day. You’ll find this rating form at the end of chapter 7 and on the book CD. Clients make simple ratings on a scale from 0 (not at all) to 10 (extreme amount) for each of the following domains: (a) how upset and distressed over anxiety they were that day, (b) how much effort they put into making anxious feelings or thoughts go away that day, (c) to what degree they would consider that day to be part of a vital, workable way of living, and (d) how much they engaged in behaviors that are in accord with their values and life goals.

Assessing the Major Components and Processes of ACT

Let us now outline the main component processes of ACT and what therapists might want to assess specifically within each area.

Assessing Creative Hopelessness

The goal here is to assess your clients’ efforts to manage and solve their anxiety-related difficulties and how well such efforts have worked for them. The assessment is not about the feeling of hopelessness, but rather the workability of former solutions. Such assessment is important and needs to be thorough. The focus here should be on what clients have done in the past to manage anxiety and how well such strategies have worked. You do not want to spend time in therapy doing more of what has not worked for your client. Additionally, it is useful to begin to relate such strategies with broader issues that pertain to client values and how they wish to live their life. For instance, you may ask how each of these solutions has gotten in the way of your client’s ability to live a full, rich, and value-consistent life. What was given up in the service of not having anxious thoughts and feelings? Perhaps the most crucial question to ask with insistence and compassion is, “What have been the short-term versus long-term costs of these strategies; have they moved you closer to or further away from your values?” Such questions begin to plant the seeds for the values work to come.

Assessing Control and Avoidance Versus Acceptance and Willingness

The goal here is to identify avoidance and control efforts that the client has been using. Most of these, as we have discussed, can be described as experiential avoidance strategies, and many will center on unwanted thoughts and feelings, as well as the situations that occasion them. Such strategies function to distance human beings from contact with the world of experience as it is, and when rigidly and inflexibly applied to private events, they manifest as struggle, control, and avoidance, or value-inconsistent actions. Experiential avoidance may seem like a trait, but it’s best thought of as a predisposition to relate with oneself and the world in particular ways. It is something that people do, not something they have.

This predisposition can be assessed globally using the Acceptance and Action Questionnaire (AAQ; Hayes, Strosahl, et al., 2004; a copy is in appendix A and on the book CD). The original AAQ consists of nine items loading on a single factor. A revised version by Bond and Bunce (2003) consists of sixteen items and includes two subscales: The Willingness Scale consists of seven items assessing willingness to accept undesirable thoughts and feelings (items 3R, 4, 5, 7, 8R, 9R, 11R—item numbers followed by R are reverse scored). The Action Scale consists of nine items assessing whether individuals act in a way that is congruent with their values and goals (items 1, 2R, 6R, 10, 12, 13, 14R, 15R, 16). The original nine-item AAQ comprises items 1, 2R, 5, 7, 9R, 11R, 17R, 18, 19R. We include all nineteen items in appendix A so you can decide which version you’d prefer to score. Higher scores reflect more willingness/acceptance and action. Research thus far indicates that the AAQ has good psychometric properties (Bond & Bunce, 2003; Hayes, Strosahl, et al., 2004) and that it correlates with several other measures of negative affectivity and anxiety-related pathology (Forsyth, Parker, & Finlay, 2003; Hayes & Strosahl, 2004). Although the AAQ seems to work well as a measure of acceptance and willingness, it is still a relatively new measure. An expanded version (AAQ 2) is currently under investigation.

Another useful process and outcome measure is the White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994; a copy is in appendix B and on the book CD). The WBSI measures people’s tendency to suppress (i.e., not accept) and struggle with unwanted thoughts and feelings. This measure has been used extensively in laboratory and clinical settings to demonstrate the negative effects of experiential avoidance (e.g., Koster, Rassin, Crombez, & Nöring, 2003). Clinical studies involving people with various anxiety disorders such as obsessive-compulsive disorder (Smari, 2001) and specific phobias have shown that the WBSI is sensitive to measuring the effects of treatment. Items are scored by summing all individual responses (see Wegner & Zanakos, 1994, for more information on norms and interpretation).

The fifteen-item Mindfulness Attention Awareness Scale (MAAS; Brown & Ryan, 2003; a copy is in appendix C and on the book CD) assesses mindfulness across cognitive, emotional, physical, interpersonal, and general domains. Using a six-point Likert scale, individuals indicate how frequently they have the experience described in each statement, with high scores reflecting more mindfulness. Items are scored by summing all individual responses. A number of studies conducted by Brown and Ryan (2003) show that (a) the MAAS has good psychometric properties, (b) the scale differentiates people who practice mindfulness from those who don’t, (c) higher scores are associated with enhanced self-awareness, and (d) following a clinical intervention, cancer patients showed increases in mindfulness over time that were related to declines in mood disturbance and stress.

Assessing Willingness as an Alternative to Control

Once patterns of control and avoidance of anxiety are identified and assessed, you will be positioned to address the more experiential aspects of an ACT approach to anxiety, which entails nurturing experiential willingness. Willingness is very much about fostering approach behaviors as an alternative to control and avoidance. Like hopelessness, willingness is not a feeling. It is not about wanting, putting up with, or tolerating. Willingness is both a stance toward life and an activity. It is about doing, and doing in the direction of what the client values and truly cares about. Willingness is the opposite of avoidance and means to show up and be open to experiencing life as it is. That is, one must be willing to experience what is and accept what cannot be changed in order to be positioned to change what can be changed; this is truly what ACT is all about.

Assessment of willingness is part of the process on the road to acceptance and value-guided action. In a sense, all three questionnaires described in the previous section provide assessments of willingness. These measures also are useful for assessing pre-post treatment effects and changes. In addition, the Daily ACT Ratings provide ongoing assessments of willingness. As a therapist, you can also assess your client’s descriptions of an event, what they were thinking and feeling, and what they were willing to do. In the process, you will be helping your clients distinguish between clean and dirty discomfort. The former of these comes about simply as a consequence of living a life (e.g., the inevitable and sad loss of one’s parents), whereas the latter involves suffering that is created by efforts to control or avoid the emotional and psychological pain that are normal consequences of living. Such assessments tend to be somewhat idiosyncratic and will most often occur in the context of metaphors, mindfulness, and other experiential exposure-like exercises.

Assessing Defusion

This facet of ACT builds upon what we have outlined previously in regard to the dark side of language. Much human suffering is related to cognitive fusion, a process that involves fusing with or attaching to the literal content of our private experiences. When fusion occurs, a thought is no longer just a thought, and a word is no longer just a sound; rather, we respond to words about some event as if we were responding to the actual event the words describe. Cognitive defusion means uncoupling or disentangling words and thoughts from the actual events that such words and thoughts refer to. The aim of defusion is to loosen a client’s tendency to treat verbal evaluative processes of language as being equivalent with the actual experience that language refers to. The goal is to help clients create distance between what is and what their mind says that is. Simple descriptions of events, using “and” instead of “but,” are part of this process and can be assessed directly. For instance, a client might say, “I want to go camping but I’m afraid of snakes” when a more accurate statement would be “I want to go camping and I am afraid of snakes.”

Similarly, cognitive defusion seeks to undermine the fusion of evaluations with the actual experience. For instance, before treatment, the experience of a rapidly beating heart and dizziness is fused with the statement “I could be dying” or “I’m having a heart attack.” These two thoughts are verbal evaluations of experiencing a rapidly beating heart, dizziness, and other physical sensations. If defusion is successful, a client would come to demonstrate a shift in evaluative statements about their experiences. Thus, they might say something like, “I feel my heart racing and dizziness and I’m having the thought that I may be dying of a heart attack.” Likewise, a statement such as “I’m scared to get on a plane” would be defused to something like “I am having the feeling of being scared about getting on a plane.” This component of therapy is not about simply replacing one thought with another thought or statement. Rather, it is about helping the client to approach their thinking and feeling as an observer and to describe how they think and feel from a self-as-context (observer) versus self-as-content perspective. In this sense, defusion techniques are also mindfulness techniques. Both function to help clients to become aware of what they are experiencing (e.g., thinking evaluative thoughts) while noticing the experiencing without judging it as good or bad.

At times, cognitive behavioral therapists mistake defusion in ACT as a form of cognitive restructuring. At the surface, they do indeed look similar because both seek to undermine and disentangle client evaluations of an experience from the actual experience. Defusion in ACT, however, is more radical than cognitive restructuring techniques. For instance, defusion is not aimed at correcting the erroneous assumption or prediction of persons with panic disorder that they will die during the next panic attack. Defusion is not about changing the content of the evaluation. Instead, defusion aims at having the client recognize and experience the evaluative thought for what it is: a thought, nothing more and nothing less. Its rightness or wrongness (its content) does not matter. What matters is that it is a thought that we can simply observe. The thought need not be evaluated, corrected, or struggled with. It comes and goes on its own accord. We simply have it and get on with doing what is important to us.

Fusion is a subtle and remarkably pervasive and insidious process. In fact, it is so overlearned and occurs with such high frequency that this habit is not easy to break and change. There have been a number of efforts to develop and utilize measures of defusion. In fact, some of the best process measures are in the defusion area. Most of these tend to be somewhat idiosyncratic (see Bach & Hayes, 2002), or standardized within a domain. An example of the latter is the Stigmatizing Attitudes Believability Scale (SAB; Nevada Practice Improvement Collaborative)—a measure of the believability of stigmatizing thoughts of substance abuse treatment providers toward their clients. The SAB, in turn, has been adapted to assess avoidance and defusion in persons undergoing a smoking cessation program (Gifford et al., 2004). The Automatic Thoughts Questionnaire-B (ATQ; Hollon & Kendall, 1980), augmented by item believability ratings, also may be used to assess defusion, as could the Thought-Action Fusion Scale (TAF; Shafran, Thordarson, & Rachman, 1996).

You will see that we have included measures to help you assess fusion and defusion in your clients. You may also wish to create other measures of defusion on your own as you go. This is relatively straightforward to do by simply adding “believability” ratings to lists of difficult thoughts in the specific domain being addressed. For instance, the thought “I need to get a handle on my anxiety and fear for me to have the life I want” could be rated in terms of how much the client believes this statement using a ten-point Likert-type scale anchored from 1 = not at all believable to 10 = completely believable. As defusion takes hold, your client ought to hold their thoughts and evaluative statements more lightly and be less inclined to believe in them and act because of them.

Assessing Values and Committed Action

This is ultimately the real prize and the guiding framework for an ACT approach to anxiety disorders. Thus, we have made values assessment a core feature of all treatment chapters. The aim of values assessment is to help clients identify valued life goals, then move in the direction of those values, and to commit to doing just that even in the face of anxious thoughts and feelings. Such assessments are relatively structured and straightforward. As a therapist, you help clients to clarify their own values over the course of treatment and then move in a direction toward meeting small goals that are part of valued living. We include several measures in the treatment chapters and on the enclosed CD to help you in this regard.

You will see that we do not limit values to circumstances related to anxiety. Values are much broader than that, and include domains that most of us typically associate with a good quality of life (e.g., family/relationships, work, social activities, play, education, spirituality, being a good citizen, and health and well-being, to name a few). The therapeutic task here is to clarify the direction of client values, while assessing client statements about valued ends and barriers to the achievement of valued directions (Wilson & Murrell, 2004). Most barriers for anxious clients involve anxiety-related thoughts and feelings, as well as strategies used to manage and control them. In chapter 11 we describe a number of mindfulness and other defusion techniques that therapists can use to help clients move with, rather than struggle with, these internal barriers. These techniques serve to illustrate that past solutions have not worked, that a direction in life depends on choices that are made, and that a life is made up of what people ultimately spend their time doing.

In our value work, we ask clients what they want their life to stand for—what really matters to them—and then we ask in what direction they are taking their feet. Where are they going? As Dahl (in press) points out, this distinction between valuing as a feeling and valuing as an activity is an important one because most clients do not separate these two aspects of valuing and simply assume that valuing is how they feel about a particular dimension or area in their lives. For instance, if they say that they value their career and working, then they should be doing just that: working. If they do not work, or do not put forth their best effort at work, then they do not value their career, regardless of how they feel about a career.

Values are not static or finite things; they are not goals that we can accomplish and be done with or destinations that we can reach. Values are a direction and must be lived out (Hayes, Strosahl, & Wilson, 1999). For instance, being a loving person or a good parent is an ongoing action, not something that we can finish while we are alive. Clarification of client values is similarly a process that helps generate a list of relevant goals that are important to the client. The goals, however, are not the values. Again, consider the value of being a good parent. One cannot complete this and tick it off in the same way one can complete and tick off a concrete goal. Goals are nonetheless important in this process, because it is the cumulative effect of such goals that, in the end, represents value-guided actions. Only a few of these goals can realistically become the focus of therapy. In fact, a client may not reach most of their goals by the end of treatment—and that is okay, because the client’s journey does not end when therapy ends. Valued living takes a lifetime. As this process continues to unfold, and as long as clients stay on track in the direction of their value-guided goals rather than doing what their anxiety tells them to do, therapy has not failed. The same is true of making and keeping commitments. Here the issue is about making a choice to move one’s hands and feet in the direction of valued goals, and to do so willingly and without defense. The reason for making the choice is that it makes sense to do so. The previous avoidance agenda will not get them to where they want to go. Remember the experiential avoidance loop in chapter 3. As commitment is about doing, it is typically assessed by whether the client did what they had set out to do.

As indicated, we provide several measures and worksheets in the treatment chapters (7 to 11) and have reproduced them for you on the enclosed CD. The Valued Directions worksheet is designed to help you and your client clarify relevant values and goals. For an individual with an anxiety disorder, moving in the direction of values involves a combination of anxiety exposure-type activities and behavioral activation. We have therefore designed three forms to assess client activities related to values: FEEL record forms, Weekly Valued Life Goal Activities, and the Goal Achievement Record. These forms specifically assess a client’s progress in moving toward their goals, experiences during goal-related activities, and obstacles they encounter along the way.

Valued Directions Worksheet. Based on several value assessment forms published in Hayes, Strosahl, & Wilson (1999), we have designed a condensed and simplified Valued Directions Worksheet. You can find it at the end of chapter 9 and on the CD. This assessment tool is particularly useful for identifying what areas of life are important to a client and how satisfied they are with the quality and depth of their experience in those areas. In addition, clients are asked to come up with intention statements of how they would like to live their lives in areas of importance to them and identify what may stand in the way of pursuing their valued directions. Importantly, our questionnaire adds a quantitative goal-related activity measure by asking clients to indicate how often they have done something to move them forward in areas of importance to them during the last week. This measure in particular could be a very useful pre-post outcome measure because we would expect to see a noticeable increase in valued activities as treatment progresses.

FEEL Record Forms. Following activities that may have elicited fear or anxiety, we ask clients to complete FEEL forms. The acronym stands for Feeling Experiences Enriches Living. Using FEEL record forms (see chapter 10), clients record the intensity of the sensations they experienced, their 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.

Weekly Valued Life Goal Activities. We also ask clients to use a Weekly Valued Life Goal Activities form (chapter 11) to record their goal-related activities for each day of the week based on their commitments made in session. Clients record whether they engaged in the activities they committed to, how much time they spent on each activity, 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 end of each activity. Again, all ratings are made using the same 0 (low) to 10 (high) scale.

Goal Achievement Record. For each goal clients have set, you can keep track of their progress and achievement using the Goal Achievement Record (chapter 11). On this form, clients record the date they have set their goal and committed to it. They also record the activities necessary to achieve the goal, the date they committed to doing an activity, and the actual date on which they completed the activity.

Summary of Key Concepts

Human beings have a notoriously difficult time living in the present, and most human suffering is a direct consequence of this very problem. This chapter introduced acceptance and mindfulness as means to foster contact with present experiences as they are. This stance runs counter to the control and avoidance agenda that clients typically engage in to manage their anxiety-related thoughts and feelings. Acceptance is very much about choice—running into life, not away from it. It is about living life without defense, about choosing not to spend time in a needless and unproductive struggle with unpleasant thoughts and feelings, so as to live fully.

Acceptance opens the door to experience. It loosens the grip of verbal-evaluative self-talk that shuts clients off from contact with direct experience, and thus frees them to do things with their hands and feet that truly matter to them even if that means that their anxiety, worry, unpleasant thoughts, and histories come along for the ride. Young children are masters at being open to such experiential knowing—the first taste of ice cream, the first sunset, playing, and even direct pain—and only later do these experiences become tainted with evaluative processes. Such processes, and particularly cognitive fusion and experiential avoidance, diminish contact with the world and underlie various forms of human suffering. Anxiety-related problems are consequences of this process, which is why acceptance and mindfulness strategies open the door to living better without first having to feel better.