Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 6

Core Treatment Components and Therapist Skills

We are coming to understand health not as the absence of disease, but rather as the process by which individuals maintain their sense that life is comprehensible, manageable, and meaningful, and their ability to function in the face of changes in themselves and their relationships with their environment.

—Aaron Antonovsky

In previous chapters, our intention was to lay the groundwork for this chapter and the remaining treatment chapters. This background is critical as you begin your journey of practicing ACT with persons suffering from anxiety disorders. Arguably, some of the earlier material is difficult, even counterintuitive, and requires that you—the therapist—make a commitment to rethinking some of the tried-and-true assumptions about psychopathology and psychotherapy. One of these, as the quote above emphasizes, has to do with what constitutes psychological wellness or, more broadly, a life lived well.

Hayes, Strosahl, and Wilson (1999) have stressed the importance of struggling with the conceptual and theoretical material that underlies good ACT therapy. We agree. In fact, if what we said in previous chapters came across as intuitively obvious to you, then we would suggest that you go back and reread it, grapple with its conceptual and applied implications, and attempt to relate it to your own experience and that of the clients with whom you have contact. There is no need to get it right away, so long as you commit to the process of understanding. To facilitate this process, our intention here is to provide a brief overview of the core components of an ACT approach to the treatment of persons suffering from anxiety and other emotional problems. In so doing, we also address therapist skills and competencies that underlie good ACT practice, described in detail by Strosahl, Hayes, Wilson, and Gifford (2004). The competencies we outline are, in some sense, aspirational, meaning that they describe a process of behaving in an ACT-consistent fashion. The competencies, therefore, are actions that therapists ought to do and work at doing better, not something they have or attain in an absolute sense. This is similar to the process of becoming a good writer. Most good writers are never satisfied with their writing. Instead, they are humbled by it, trying to do better the next time. The same is true of the process of living life well or becoming a good therapist. Both are processes that take a lifetime.

Overview

Abraham Maslow defined psychotherapy as the search for value. ACT similarly picks up on this theme. Within ACT, actions that get in the way of valued living are conceptualized as obstacles or barriers, and represent the problems that warrant clinical attention. Many such obstacles, as we have said, have to do with clients acting in ways to avoid unwanted private experiences. Such actions, in turn, can readily consume one’s life. Fr. Alfred D’Souza came to a similar realization, and we share the following comment from him to illustrate that ACT is about fostering the development and growth of fully functioning human beings:

For a long time it had seemed to me that life was about to begin—real life. But there was always some obstacle in the way. Something to be got through first, some unfinished business, time still to be served, a debt to be paid. Then life would begin. At last it dawned on me that these obstacles were my life.

Within ACT, we certainly do not want our clients to continue to do what has not worked for them, or to act in ways that are unworkable. ACT is about helping clients recognize that their personal histories, thoughts, feelings, and memories are not obstacles to living fully and richly. Instead, they are, in a real sense, part of a life lived well. The real obstacles to living a valued existence tend to be actions directed at not having aspects of our psychological experience. These actions, in turn, get in the way of living and result in needless suffering. An ACT approach to the treatment of anxiety disorders is very much about loosening the grip of such actions on our clients, thus creating space for clients to do what matters most to them. When the fight with anxious thoughts and feelings need not be fought, anxiety and fear are no longer obstacles to living. Ultimately, we hope that our clients’ lives will come to be defined by doing more of what they consider worthwhile and what is meaningful to them and be less about trying to control, avoid, or escape from their fears and anxieties.

Focus of ACT for Anxiety Treatment

We noted early on that many obstacles to living are products of human language. We evaluate. We judge. We reflect. We plan. Such actions can be directed at ourselves, the actions of others, and the world in which we live. So much of human experience is laden with verbal-symbolic processes that it is difficult to imagine a nonverbal event in human beings. For instance, humans can quite literally beat themselves up in the present because of what they have done in the past or because of past events that may have occurred outside of their control (e.g., trauma, poor schooling, bad parenting). With the help of language, they struggle with emotional and psychological experiences that they do not wish to have (e.g., anxiety, fear, distressing thoughts, memories) and create doom and gloom about a future that has not yet happened. Acting solely on the basis of such verbally derived constructions, and not actual experiences, unedited and as they are, is both a natural human tendency and a potential trap. This natural tendency, when taken to the extreme, creates many problems in living.

Indeed, anxious clients spend a good amount of time engrossed in numerous battles to not have their unpleasant psychological and emotional experiences. This is both a trap and a fight that cannot be won. This trap, in turn, is what we have referred to as the dark side of language, and specifically the fusion of evaluative language with experience (i.e., the events that language refers to). You can think of this as a generalized tendency to react to one’s own evaluations. This tendency, in turn, is often coupled with obvious (or subtle) forms of escape and avoidance so as to not have the negatively evaluated experience. Such actions, when rigidly and inflexibly applied, often get in the way of living and doing what matters most to clients suffering from anxiety disorders. An ACT-based treatment technology seeks to undermine the tendency for anxious clients to respond to their evaluations of the world and their private experiences in that world in a literal and inflexible way.

It is simply notoriously difficult to devote substantial portions of time and effort each day to avoiding and minimizing anxious feelings and thoughts, while also living life fully. Nonetheless, many clients with anxiety problems see such actions as sensible and logical solutions to their problems and expect something similar from psychotherapy (e.g., alleviation of symptoms = restoration of health = being able to live happily ever after). From an ACT perspective, the attempted solutions, however reasonable and sensible, are problems themselves and function to perpetuate anxiety-related suffering and human suffering more generally. For this reason, an ACT approach to the treatment of anxiety-related problems aims at fostering psychological flexibility, experiential acceptance, and ultimately movement in the direction of client values and goals.

ACT Is an Approach to Living Better

At the core, ACT is about helping suffering human beings live better, which means more fully, deeply, and meaningfully. It is about helping our clients use their hands, feet, mouths, and minds in the service of goals and values that they care about. It is about helping our clients make contact with what they truly care about and doing what is important to them. The treatment is not about getting rid of anxious thoughts and feelings, nor is it about teaching clients new or more elegant ways to control their anxiety. Such strategies are common elements of many cognitive behavioral therapies for anxiety problems and only make sense from the perspective that (a) anxiety is a problem, (b) anxiety is a cause of human suffering and other life problems, and (c) to live a life, one must control or reduce anxiety. An acceptance and mindfulness approach to anxiety treatment operates from a different stance:

§    Anxiety is what it is, in many instances a perfectly adaptive response and in other instances a nuisance—either way, it is part of being a fully functioning human being.

§    Anxiety is part of living rather than a cause of not living.

§    To live a valued life, one must be willing to take the totality of human experience along for the ride.

Adopting this posture means that one need not struggle to manage anxiety first in order to live with meaning and purpose second. Rather, one can live with anxiety and have a life that is both rich and meaningful. The focus of an ACT approach to anxiety, therefore, is all about fostering the development of fully functioning human beings, with an eye on helping anxious clients live consistently with chosen values. Living life to its fullest, even in the face of difficulty and hardship, is what most persons ultimately associate with a life lived well. To do this, however, requires that clients give up old, unworkable strategies, and instead use their hands and feet in the service of living better, not simply feeling better. The procedures we describe in part 3 are designed to help foster such movement, and are truly about helping our clients spend their precious time each and every day doing what is important to them.

ACT Is Not a New Bag of Tricks

Magicians are renowned for their ability to reach into a bag of tricks and pull out a new illusion. The effectiveness of the illusion, however, depends not on the trick. Rather, it depends on the skill of the magician in the appropriate delivery of the trick to achieve the intended illusion. A magic trick in the hands of someone lacking skills in the art of illusion will likely not produce the intended effect. The same is true of the application of psychosocial treatment technologies, such as the approach we are describing here for those suffering from anxiety and other emotional disorders.

You will recall that ACT is an approach to the alleviation of human suffering and the promotion of human growth and value, one with a sound philosophical, conceptual, and empirical base. ACT also has a relevant treatment technology. Only recently has this technology appeared in the form of treatment manuals and guides (e.g., Hayes, Strosahl, & Wilson, 1999; Hayes & Strosahl, 2004). In chapters 7 through 11, we describe this technology in detail to facilitate your work with anxious clients.

One danger in specifying any treatment in manualized form is that one can lose sight of the approach and rationale for the treatment, and instead get bogged down in the application of the technology and treat the manual like one would a cookbook. We strongly urge you not to fall into this trap for two reasons. First, a technology-focused approach tends to reduce therapists and psychotherapy to the mere application of treatment techniques. Accordingly, therapists are nothing more than technicians. Increasingly, however, we are learning that effective psychotherapy depends on effective therapists, not simply the application of intervention technologies. In our view, you will be much more effective using the treatment technology we describe herein if you also keep your eyes firmly set on the processes you wish to target and the underlying rationale for doing so. Second, a technology-focused approach lends itself to excessive rule following. Rules are not necessarily bad, even in a psychotherapy context. Yet, we know from countless studies that rule-governed behavior tends to result in insensitivity to present contingencies, especially those that may contradict the rule. In a therapy context this means that, by focusing solely on applying the treatment technology just so, therapists may become inflexible and insensitive to the unique needs of clients and the clinical moments that arise during therapy.

The effectiveness of any treatment technology depends to a great extent on the effectiveness of its delivery. This, in turn, requires a thorough understanding of the strategic rationale for use of the technology (i.e., what do you intend to accomplish by using a particular intervention component?), as well as skill in its appropriate delivery. Throughout the treatment sections, you will find descriptions of the techniques and procedures, but also a good bit of information about the conceptual rationale for using them. Take time to understand the rationale for the intervention components we describe, and work to tailor the intervention to the unique concerns and needs of your clients. This individualized approach is good practice anyway, and ought to help you work effectively and meaningfully with your anxious clients using an ACT approach. Remember, ACT is not a bag of tricks!

Core Treatment Components and Therapist Strategies

As indicated in chapter 1, one of the best ways to describe the core treatment components of ACT is to break the ACT acronym up into its three functional components: AcceptChoose Directions, and Take Action. In the following sections we provide you with an overview of how the major goals and components of ACT can be captured by this acronym. Apart from competency in understanding the core processes, therapists must also have sufficient technical knowledge in selecting and implementing interventions such as experiential exercises, metaphors, paradoxical strategies, behavioral tasks, and home-based practice. After describing each of the core components, we therefore also describe some competencies and skills that therapists should develop to deliver ACT effectively. There are several therapist postures and skills that are part of typical ACT intervention strategies. These therapist actions also are related to the three major treatment components. Because such postures are transparent, we simply list them under the three core ACT themes in table format. We provide more detailed instructions and examples to guide you in the delivery of specific techniques in the treatment chapters (7 through 11) that follow.

Accept What You Have and Cannot Change

Recall that acceptance is an active process. It is not about passive resignation, nor is it about giving up. Rather, acceptance is about acknowledging and connecting with who we are (the whole package) while recognizing aspects of our lives that can and should be changed and those that need not or cannot be changed. Acceptance is important within ACT because it provides a context for living in and within the world that runs counter to the struggle and control agenda that anxious clients are all too familiar with. It makes space for doing something different than what has been done in the past. To live with purpose and meaning, clients need not first alter unwanted private experiences. Giving up the struggle to do so paves the way for fundamental life change and renewed focus on what can be changed. When clients accept where they are, resisting aspects of their psychological experience becomes unnecessary. Acceptance is an ongoing process that is nurtured and developed within ACT via the following strategies.

DEVELOPING CREATIVE HOPELESSNESS

Creative hopelessness is a process that comes early on within ACT. The aim is for the therapist and client to explore the client’s former solutions to their problems, with an eye on how well they have worked (both in the short and long term) and whether they are workable at all. Remember, this is not about feeling hopeless. Rather, creative hopelessness is about helping clients make contact with the unworkability of former strategies and solutions to their anxiety-related problems. This process is creative and empowering because it makes space for clients to do something else that may be more workable, while also creating room for clients to act in a manner consistent with what they care about.

The more general objective of this phase is to undermine and weaken the dominance of what may sound like reasonable and socially acceptable solutions to problems (e.g., “Once I feel less anxious, then I will be able to have a more intimate relationship with my partner”), while clarifying how those former solutions are, in fact, problems themselves. In the process, the therapist addresses what the client wants, what the client has tried, and how well those efforts have worked. Therapists need to be mindful of strategies that denote subtle and obvious signs of unwillingness, struggle, and control of anxious thoughts and feelings. Therapists need to alert clients to the consequences of such actions in terms of the client’s quality of life, values, and goals.

The following is a brief example of an excerpt from a therapist and client exchange during this stage of therapy. The focus is on understanding what this particular client has done to manage her social anxiety.

Therapist: You’ve been suffering from anxiety in social situations for some time. Can you tell me what you have tried to do to get over it?

Client: Well, I’ve tried so many things … I’m not really sure where to begin.

Therapist: How about during a typical week… Tell me some of things you tried last week.

Client: Normally, I just steer clear of people as much as I can. For instance, last week I went grocery shopping at 2 a.m. I also screened all of my phone calls so that I wouldn’t get caught off guard not knowing what to say. I’m pretty messed up.

Therapist: How has this worked for you?

Client: Not well. It’s hard to get things done when you constantly have to dodge and weave around other people. I feel like such a freak [tearfully]. It is affecting my schoolwork, my job, my whole life. God, I’m twenty-five and haven’t had a close relationship with someone other than my family.

Therapist: So, a good part of your day is spent steering through a maze of people so as to avoid…?

Client: Being embarrassed, saying something stupid, and then getting all nervous and panicky. I just want to feel better.

Therapist: So, if I hear you right, you’ve tried several reasonable strategies to cope with your anxiety. Now, what does your experience tell you about how well these strategies are working for you? Are they helping you live the life you want to have?

Client: Well, sometimes they work, but then the anxiety comes right back again. If I could only get a handle on my anxiety, then I think I would be able to be more normal.

Therapist: Is this what you want out of therapy? A way to control your anxiety, a way to be more normal and like other people?

Client: Yes. I want to be like most other people … you know, normal.

Therapist: So, if I hear you correctly, you have tried a number of strategies to get a handle on your anxiety, and most of them have not really worked. It also sounds like your mind tells you all sorts of things … like you are being watched, you might do something embarrassing, that you are a freak, that your life is messed up, that most people aren’t like you, and so on. These thoughts or concerns keep coming back to haunt you despite your best efforts to overcome them. And, you are here with me right now still feeling miserable. I’d like you to consider the possibility that the sensible strategies you have tried up this point may never work the way you want them to work. Your mind is telling you they will, but what does your experience tell you about everything you have tried up to this point to get a handle on your anxiety and your life? Is it working? Is this the way you want to live your life?

Client: No, that’s why I am here. I feel really stuck.

Creative hopelessness is an ongoing process that is designed to undermine the dominance of evaluative language and its relation with actions that on the surface seem reasonable, but ultimately keep the client stuck and miserable. If done appropriately, creative hopelessness should leave clients with a sense that what they have been doing will not work and cannot work, while also fostering a willingness to abandon the old change agenda and do something new. That new direction as well as the willingness to do something new are the creative parts of hopelessness. The tendency for clients to justify their own behavior in cognitive and emotional terms is also explored early on, as well as throughout treatment. The same is true of efforts to control, suppress, or eliminate unwanted anxious thoughts and feelings. The believability of reasons as causes for action and inaction are addressed via strategic use of therapeutic metaphors and paradoxical statements.

UNDERMINING REASON GIVING AND LITERAL THINKING

Recall that many anxious clients tend to justify their own behavior in cognitive and emotional terms. “I cannot fly in planes because I might panic” and “I cannot go out with friends because I might be embarrassed” are but two examples of reasons that implicate undesirable private events as causes of inaction. Such reasonable-sounding reasons usually implicate unwanted thoughts, feelings, physical sensations, and memories as causes and are supported by family, friends, teachers, employers, and the larger social community. Not surprisingly, many anxious clients come to believe their reasons and feel compelled to act accordingly. Consequently, it makes perfect sense for anxious clients to try to control or eliminate the unwanted causes that are connected with inaction or action. Thus, to be able to fly in a plane, one must first get a handle on the panic. This is the more general system that an ACT approach seeks to undermine.

Defusion strategies that weaken the literal meaning of language and its connection with the self and behavioral actions include use of metaphor, stories, and paradoxical statements (e.g., the only way to change is to first accept what is). Metaphors are nothing more than stories. Because they cannot be taken literally, they allow clients to make experiential contact with an aspect of their experience that may be frightening for them to contact directly. In so doing, they help create distance between the client and how they are approaching their anxiety, while also opening the door for new solutions to emerge. Studies have shown that figurative metaphorical language is emotionally more meaningful, and hence more likely to impact a person’s overt behavior, than straightforward rational-logical talk (Hayes & Wilson, 1994; Samoilov & Goldfried, 2000). Similarly, in a study with preschool children comparing metaphorical with literal relaxation instructions, we found that the children unequivocally preferred metaphors over literal instructions (Heffner, Greco, & Eifert, 2003). This may also be one of the reasons why, for centuries and across different cultures, authors have used fairy tales to teach values (“the moral of the story”) to children and adults instead of simply telling their audience what to do or refrain from doing.

The therapeutic goal of defusion strategies is not to confuse clients. Rather, the intent is to weaken the fusion of language, experience, and behavioral actions, particularly when it involves thoughts and feelings that cannot and need not be changed in order to live a life with meaning and purpose. In a sense, the goal is to weaken the dominance of what the mind says “is” or “ought” to be, and instead allow the client to experience directly and fully what is, for what it is, while doing what matters to them. Clients are not their disorders. Anxiety is not bad. One can live richly and meaningfully with a full range of psychological and emotional content.

EXPERIENCING ANXIETY WITH ACCEPTANCE

Experiencing anxiety from a kind, open, and accepting posture is probably the last thing that any anxious person would come to expect from a psychosocial intervention. Yet, this posture is precisely the stance that an ACT approach to the treatment of anxiety problems seeks to establish. Acceptance, you will recall, is antithetical to the struggle and control agenda that anxious clients know all too well by the time they enter therapy. At the core, acceptance represents a deliberate and courageous stance on the part of a client to approach aspects of their psychological experience (the good, the bad, and the ugly) as they are, fully and without defense. The goal is not to create priestly clients, but to create fully functioning human beings who are intimately in contact with the world of their experience. Acceptance is about experiencing what is, for what it is, while not acting on the experience to change it—particularly when the experience cannot and need not be changed. Somewhat paradoxically, this stance allows clients to be where they are and who they are, and thus defuses the tendency to do something about their thoughts and feelings.

Please note that developing and nurturing acceptance is an ongoing learning process that requires a good deal of experiential practice and commitment. Mindfulness techniques, including experiential exposure-like exercises, are included throughout the treatment sections as a means to help clients learn to be with anxious thoughts and feelings in an accepting and willing manner and to foster an acceptance posture more generally. As we have stressed, acceptance of anxiety is itself not a therapeutic goal, but a process that frees clients to work toward living consistently in the direction of valued goals.

Table 1 lists a number of therapist strategies and behaviors that can foster the development of greater acceptance and willingness (We have adapted this table from a more comprehensive list provided by Strosahl et al., 2004). These skills are related to inducing creative hopelessness and undermining experiential control, fostering defusion of language from experience, and developing an observer self that is focused on making contact with the present moment in a nonjudgmental fashion.

Table 1. Therapist (T) Strategies for Developing Acceptance and Willingness

Undermining Experiential Control

§    T helps client detect emotional control strategies and examine direct experience instead.

§    T helps client make direct contact with paradoxical effect of emotional control strategies.

§    T detects client emotional control attempts in session and teaches clients also to detect them.

§    T uses concept of “workability” to help clients evaluate costs of experiential avoidance and control efforts.

§    T communicates that client is not broken, but is using unworkable strategies.

§    T actively encourages client to experiment with giving up the struggle for emotional control and suggests willingness as an alternative.

§    T helps client investigate relation between levels of willingness and sense of suffering.

§    T helps client make experiential contact with cost of being unwilling to reach valued life goals.

§    T uses exercises and metaphors to help client contact willingness—the action—in the presence of difficult material.

§    T identifies client’s emotional, cognitive, behavioral, or physical barriers to willingness.

§    T structures graded steps or exercises for client to practice willingness.

§    T models willingness in the therapeutic relationship.

§    Undermining Cognitive Fusion

§    T helps client defuse experience from evaluations and directs attention to the present moment.

§    T actively contrasts what the client’s mind says will work with what the client’s experience says is (not) working.

§    T uses language tools (e.g., get off “buts”), metaphors, and experiential exercises to create a separation between the client’s actual and conceptualized experience.

§    T uses various exercises, metaphors, and behavioral tasks to reveal the “hidden” properties of language that can serve as traps and blind alleys for the client.

§    T suggests that “attachment” to literal meaning and evaluations of experiences makes willingness difficult to sustain.

§    T helps client elucidate the client’s own “story” and helps client make contact with the arbitrary nature of causal relationships within the story.

§    T helps client make contact with the evaluative and reason-giving properties of the client’s story (e.g., no thing matters).

§    T detects “mindiness” and fusion (e.g., intellectualizing, evaluating, judging, reason-giving) in session and teaches the client to detect such mind games as well.

§    Developing Observer Self: Getting in Contact with the Present Moment

§    T teaches client to just notice events with simple awareness and without evaluating content.

§    T helps client separate self-evaluations from the self that evaluates (e.g., “thank your mind for that thought,” calling a thought a thought, labeling thoughts or sensations).

§    T employs metaphors and mindfulness exercises to help client make contact with self-as-context (“observer self”).

§    T helps client experiment with “having” and observing these experiences, using willingness as a stance.

§    T detects client drifting into past and future, and models coming back to present moment.

Choose Valued Life Directions

The verbal-evaluative traps we have been describing all along, coupled with experiential avoidance and escape, tend to mask clients’ ability to choose and follow a life direction that is important to them. An ACT approach is very much about removing these and other blinders to reveal what clients are capable of doing already—namely, defining a life direction (Wilson & Murrell, 2004; Dahl et al., 2004). In fact, when you strip away client concerns about the past, anxieties about undesirable emotional or cognitive content, distress about unwanted bodily states, and the like, what you are left with is a human being with a life that is not working. The overarching aim of ACT is to redirect attention and effort away from futile and costly goals (e.g., diminishing unpleasant thoughts or feelings) toward actions that define, in a real sense, what clients wish their lives to stand for. Everything that we describe within our treatment approach is, at its core, about helping clients clarify how they wish to live their lives, and helping them to do just that. Actions that get in the way of value-driven choices are, therefore, viewed as barriers to living and targets of our therapeutic efforts. These hooks or traps are assessed and brought out on the table throughout treatment, as they can readily get clients sidetracked and stuck back in the same old struggle and control agenda that ultimately brought them into therapy to begin with.

Table 2 lists some therapist strategies and behaviors related to helping clients choose and define their valued directions and their life goals related to such values (see also Strosahl et al., 2004). More details on specific techniques are provided in chapters 9 and 10.

Table 2. Therapist (T) Strategies for Choosing and Defining Valued Directions

§    T helps client clarify valued life directions by means of values worksheet and other exercises (e.g., Valued Directions and Values Compass worksheets).

§    T helps clients commit to what they want their lives to stand for and make therapy about that.

§    T teaches client to distinguish between values and goals.

§    T puts own therapy-relevant values in the room and models their importance.

§    T respects client values and, if unable to support them, finds referral or other alternatives.

Take Action

Choosing a valued direction is the first step on the road toward living well. It is an important and necessary step, but choosing is not enough. Ultimately, values are defined by what people do, not simply by what they say they want their lives to stand for. For instance, if a person values being a loving spouse, then we would expect that person to take actions that are consistent with loving behaviors toward their spouse. Saying “I love you” now and then is one such action, but it is not enough. We must show that we love others by what we do with our hands and feet. So many human actions can be plugged into this basic format. Values are defined, in a very real sense, by what we spend our time doing. Coming to terms with this truism can be a painful pill to swallow.

Alcoholics, for instance, exert an enormous amount of time and effort (and money) each day to obtain and ingest alcohol. In a sense, one could say that an alcoholic values drinking and the high that comes along with it. Their lives are consumed by it, and not surprisingly the life of the alcoholic typically suffers as a consequence. The struggle, control, and avoidance trap that many anxious clients find themselves in is similar in many respects to the life of the alcoholic. The lives of anxious persons tend to revolve around their anxieties, fears, and related physical sensations and thoughts, and particularly around not having them. Judging by what most anxious clients do, one could say that they enter therapy with a life defined by the value of not having anxiety. Here, it is important to note that anxious clients should not be faulted for acting in this manner. The problem is that the more important facets of their lives typically suffer as a consequence. No anxious client would wish their tombstone epitaph to read, “Jane spent twenty years of her life in the service of not having panic attacks, and died without winning the fight.” The approach we describe is designed to help clients get their hearts and minds firmly fixed on what matters to them. This is why we first help clients clarify their values and how they want to live their lives. The second, more important objective is to help them start putting those words into action.

Recall that most value-guided action is not an all-or-none affair (i.e., you achieve it or you don’t). Rather, valued living is about making a commitment to take small actions that are consistent with what one cares about. It does not matter whether values focus on being a good parent or a loving spouse, eating well, helping others who are less fortunate, taking care of the environment, or being a good neighbor or citizen. What is important is that clients take actions that move them in the direction of what they value, while recognizing that valued living is a process that has no clear end point. Living consistently with values, therefore, often requires small actions each and every day. For clients with anxiety disorders, this almost invariably means engaging in behavior that they previously avoided because it was associated with anxiety. These actions, over time, add up to what most people would consider a life lived well. Our experience from working with clients tells us that, over time, anxiety will not be as much of an issue for clients anymore, either because it weakens in frequency or intensity as a result of “naturalistic,” value-driven exposure exercises, and/or because it becomes less important to clients relative to the pursuit of goals.

Note that the commitment to engage in small actions on the road to valued living is itself a value. It implies caring and respect for oneself and the courage to live as one would wish to live. To facilitate such movement, behavioral activation is a key component in later sections of the treatment, and we encourage you to implement this approach with coaching, compassionate encouragement, and as much humor as possible. Remember that values are neither good nor bad. They are defined by actions. These actions will be idiosyncratic for each client you see in therapy.

Table 3 lists several therapist strategies and behaviors related to helping clients build patterns of committed action toward valued life goals and for maintaining such action in the face of setbacks and adversity (see also Strosahl et al., 2004).

Table 3. Therapist (T) Strategies for Building Patterns of Committed Action

§    T helps client build an action plan based upon identified life values.

§    T encourages client to take small steps and to look at the quality of committed action.

§    T encourages client to move with barriers and to make and keep commitments.

§    T uses exercises and nontraditional uses of language to reveal hidden sources of interference to committed actions.

§    T integrates slips or relapses into the ongoing process of recommitting to future effective action.

Core Competencies in the Basic ACT Therapeutic Stance

In the previous section, we identified a number of specific competencies and skills that therapists should develop to deliver ACT effectively. The following section describes basic therapist competencies and behaviors that characterize an ACT-consistent therapeutic stance (see also Strosahl et al., 2004). Like many treatment traditions, ACT emphasizes the importance of therapist warmth and genuineness, but it also emphasizes the importance of compassion. This stance is an especially important factor for good ACT practice. It emerges quite naturally from the core understanding of human suffering from an ACT perspective. When we see our clients trapped by language and patterns of experiential avoidance, we also see ourselves and the traps that generate our own pain. An “I and thou” perspective is the natural precipitant of this recognition. The basic psychological stance of the ACT therapist involves being able to make contact with the “space” from which ACT naturally flows, as well as modeling psychological flexibility that we seek to help our clients to (re)gain.

What follows here is a summary of core competencies of an ACT therapeutic stance as outlined by Steven Hayes, Kirk Strosahl, and Kelly Wilson in consultation with a group of therapist trainers of ACT that we are a part of (a detailed account of these competencies can be found in Strosahl et al., 2004). Though still in development, the following features capture much of the essence of an ACT therapeutic posture and what it means to do ACT therapy. These competencies and postures relate to the core therapeutic processes, the effective delivery of ACT itself, and all stages and aspects of the therapy. Therapists should make an effort to return to this section often, as it is quite easy to fall back on a non-ACT-style therapeutic posture. We encourage you to spend some time with the material that follows here. Think about it and apply it. Play with it.

§    Being Compassionate—The therapist realizes that he or she is in the same soup as the client and speaks to the client from an equal, vulnerable, genuine, and sharing point of view. Consequently, the therapist takes a compassionate and humanizing stance toward the client’s suffering and avoids criticism, judgment, or taking a one-up position.

This is by far the most important point, and we cannot overemphasize its significance. It is easy to use the procedures outlined in this book from a dominating, controlling, one-up position rather than from a compassionate, caring, equal-level position. For instance, therapists can easily slip into using metaphors in an examlike fashion by testing whether the client “got it.” This is not helpful, and clients sense that they are being put on the spot and in a one-down position. If you sense a lot of resistance from a client, then you are probably violating this most basic rule. ACT is not about convincing clients that your analysis is the correct one. It is not about replacing one set of beliefs (“Anxiety must be controlled”) with another set (“Controlling anxiety doesn’t work and only makes things worse”). It is about making contact with suffering—one human being to another—so as to help facilitate fundamental change.

§    Applying Techniques in a Creative, Flexible Manner—The therapist tailors interventions to fit the client’s language and immediate life experience and avoids the use of “canned” ACT interventions. The therapist sequences and applies specific ACT interventions in response to client needs and experiences, and is ready to change course to fit those needs at any moment. For instance, new metaphors, experiential exercises, and behavioral tasks are allowed to emerge from the client’s own experience and context.

This point is about flexibility and tailoring the intervention to fit the unique needs of your clients—a point we have stressed several times already. Metaphors, for example, are nothing more than stories that can help in not taking the mind literally. They should not be delivered in a canned fashion. Instead, embellish them, tweak them, and modify them as appropriate, depending on the client’s responses to them. In fact, clients typically comment on metaphors by expanding or otherwise modifying them. This is a good sign that clients are actively engaged in therapy. Your task as a therapist is to run with such comments and modifications and spin them along the path your client points out to you. Do not fall into the trap of somehow correcting client changes and getting them to revert back to your version or the one you read in this book. Changes made by clients are probably reflective of their experience and, as such, are more valuable and powerful therapeutically than anything you could ever make up yourself.

§    Modeling Acceptance and Willingness—The therapist models acceptance of experience and willingness to hold contradictory or difficult ideas, feelings, memories, and the like without needing to resolve them.

Many therapeutic traditions see resolution of internal conflict as a goal. Not so with ACT. It is quite natural for human beings to experience multiple contradictory or difficult ideas. Our natural tendency is quite often to seek some sort of resolution. This is unnecessary from an ACT stance. Recall that we are trying to foster experiential openness and willingness in our clients. As such, therapists should model what they are asking of their clients in session. This means that you let clients experience contradictory or difficult ideas for what they are, while resisting the temptation to resolve apparent conflicts for the client. These facets of human experience are quite normal. Difficult ideas need not be interpreted, fixed, or resolved. Help clients experience them for what they are.

§    Focusing on Client Experience—The therapist always brings the issue back to what the client’s experience is showing, and does not substitute his or her opinions for that genuine experience.

Opinions are simply another form of verbal evaluative behavior that can get in the way of experiential knowing. This is particularly important in the context of creative hopelessness, where one goal is to facilitate the client making contact with the unworkability of the change agenda. We want clients to contact fully the experience of their experience, unedited, as it is. We are aiming to foster psychological flexibility and less rule-governed behavior, while promoting more experiential, direct contingency-shaped behavior. Clients already have more than enough opinions about their experiences and what needs to be done about them. We do not need to add to that with more opinions.

§    No Arguing, Persuading, or Convincing—The therapist does not argue with, lecture, coerce, or attempt to convince the client of anything. If you find yourself attempting to change a client’s mind, please stop, because you are not doing ACT.

Remember that ACT is not about who is right or wrong and not about convincing the client that your analysis is somehow superior to the client’s. It is not about replacing one rule (“Anxiety must be controlled”) with another one (“I can be anxious and do what I want to do”). ACT is much more radical, and it aims at a more fundamental change. ACT questions the dominance of language and rules, particularly when they do not work for an individual. ACT is not about what you think as a therapist. It is about workability—what works for the client and what does not. It is about not buying into anyone’s mindiness, including that of the therapist. This is why ACT therapists say seemingly odd things like, “Don’t believe what I tell you” or “Don’t listen to my mind.” Instead, we want clients to pay attention to their own experiences, because all of the solutions are right there. So when you find yourself lecturing, or even arguing with your clients trying to convince them of anything, you are on the wrong track. Do not try to “sell” ACT—there is no need for that. Instead, return to the client’s experience with past solutions and let them experience how well those solutions worked. Also, ask whether a particular solution that clients are considering now is likely to bring them closer to their life goals or farther away from them.

§    No Explanations or “Cognitive Insight”—The therapist does not generally explain the “meaning” of paradoxes or metaphors to develop insight.

Remember that one goal of using paradox and metaphor is to loosen rigid and inflexible verbal regulation of client behavior. Explanations are simply more verbal behavior that can undermine the process of loosening verbal regulation. What we would like to see is a client relating to their experiences differently via paradox and metaphor. No detailed explanation of the metaphors is required for this to happen. It is sufficient for the therapist and client to discuss the client’s reactions to the metaphor and its message for them. After clients see a point, it is also common to help them state it verbally. Insight, or a sense of distance and perspective, may come as clients discover that their quality of life is starting to improve when they don’t always do what their mind tells them to do. However, such insight is not a requirement for meaningful change to come about.

§    Therapist Self-Disclosure—The therapist is willing to self-disclose about personal issues when it illustrates a therapeutic point.

This point should be obvious to most seasoned therapists. Judicious use of self-disclosure helps to convey to the client that you, as a therapist, are human and hence suffer and at times struggle. This, by the way, may include disclosure about your experiences in session that occur as a function of what the client may say or do. For instance, you may experience certain thoughts or emotions as a function of what a client says or does in therapy. Depending on the context, it may be appropriate to acknowledge that experience as it is (e.g., “I am experiencing sadness in response to what you just said…”). Such disclosure can help foster a close therapeutic working relationship, while modeling the appropriateness of being honest and open about oneself and one’s own experiences and personal history.

§    Focus on Clinically Relevant Behavior—ACT-relevant processes are recognized in the moment and, where appropriate, are directly targeted in the context of the therapeutic relationship.

It goes without saying that clients seek therapy because of problems they are having in the world outside of therapy. They do not normally seek therapy because of problems that occur in therapy. Nonetheless, it is easy for therapists to focus on problems clients are having outside of therapy, while failing to see clinically relevant behaviors and processes as they show up during therapy. Some client actions in session are clinically relevant and, when they occur, therapists should recognize and support them. The same is true of clinically relevant processes that you wish to influence. This approach is characteristic of Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991), and it is common for ACT therapists to use FAP methods to target clinically relevant behaviors that occur in session. Fusion, evaluation, avoidance, escape, and reason giving are a few general processes that will likely show up in session as you work with anxious clients. There is no better way to shape and influence such clinically relevant behavior and processes than doing so directly, gently, and in the moment when they occur during therapy (for a more detailed description of techniques, see Kohlenberg & Tsai, 1991).

Overview of the Treatment Program

Before outlining the treatment program in the chapters that follow, let us provide you with an overview of the goals and main components of the program on a session-by-session basis.

The ACT treatment program for anxiety disorders we outline in this book consists of twelve sessions lasting approximately one hour each. By placing the treatment in this twelve-session format, with suggested time limits for the various sections, we do not wish to imply that you must implement the program that way. Both number of sessions and the suggested time limits for sections are meant to be a guide. With some clients you might be able to move a bit faster, whereas with others you may need more sessions and more time to accomplish what you and your client need to do. There is nothing wrong with taking longer, and we caution you not to rush through the treatment. Humans are organisms with a history. The processes that are being worked on here have long histories of development that cannot be undone quickly or superficially. Also, short of a lobotomy, humans do not get rid of previously established automatic functions so much as they add new ones (Wilson & Roberts, 2002). It takes time for this new learning to occur and consolidate.

Session 1 seeks to provide clients with a general understanding of the nature and purpose of anxiety and what can make anxiety become disordered. The session also introduces clients to the active, experiential, and participatory nature of this treatment and its emphasis on living a rich and meaningful life rather than focusing on anxiety reduction.

Sessions 2 and 3 review and evaluate the strategies clients have used in the past to cope with anxiety. The goal is to undermine the client’s anxiety control agenda and create an ACT-specific treatment motivation (creative hopelessness) by letting clients experience (a) the unworkability and futility of past avoidance and control efforts and (b) that nothing will change unless clients are willing to do something differently about and with their anxiety, and hence how they are living their lives. Session 3 introduces the notion of value-driven behavior as an alternative to managing anxiety.

Sessions 4 and 5 focus on acceptance and mindfulness as ways of learning to observe unwanted anxiety-related responses fully for what they are. The goal is to provide clients with more response options when experiencing anxiety—that is, to broaden the client’s current narrow set of responses (e.g., escape, avoidance, suppression) so as to make responding more flexible. Clients also learn to differentiate what they can control from what they cannot control in their lives. Sessions 4 and 5 continue to develop and affirm valued living as an alternative to the anxiety management and control agenda. This alternative agenda functions to help clients focus on what really matters in their lives by choosing valued directions and by identifying specific goals as well as potential barriers. In sum, Sessions 1 through 5 are designed to create a more flexible acceptance-oriented context that sets the stage for the remaining treatment sessions, where clients learn to be and move with anxiety from a mindful observer perspective while engaging in value-driven action in their natural environment.

Sessions 6 and 7 introduce in-session experiential exposure exercises, defusion, value-guided action, and making commitments to move in valued life directions. In-session exposure exercises are designed to let clients practice mindful observation, acceptance, and cognitive defusion in the presence of anxiety-related responses. They are to be done initially in a safe environment with the guidance of the therapist. Cognitive defusion techniques do not target the content or validity of clients’ negative evaluations (of themselves, their reactions, thoughts, histories, etc.), only the process of evaluating itself. That is, these techniques teach clients to respond to their experience as it is rather than to the evaluation of their experience. The goal of these in-session exercises is to foster a new stance when anxiety-related responses show up while engaging in real-life client-chosen activities that move them in the direction of their values. Anxiety reduction is not a stated goal. It is, however, likely to occur as a by-product of in-session and between-session exercises.

The remaining portions of treatment (Session 8 and beyond) focus on movement forward and doing. Behavioral activation is used here to assist clients in doing what matters most to them, with particular focus on making and keeping value-guided commitments, as well as moving with barriers to valued action. Although our treatment program differs in several important respects from the mindfulness-based cognitive therapy program for depression developed by Segal and colleagues (2002), one of the core skills to be learned in the ACT program is very similar to theirs: how to step out of and stay out of self-perpetuating and self-defeating emotional, cognitive, and behavioral avoidance routines:

Letting go means relinquishing involvement in these routines, freeing oneself of the aversion driving the [routines]—it is the continued attempts to escape or avoid unhappiness, or to achieve happiness, that keep the negative cycles turning. The aim of the program is freedom, not happiness, relaxation, and so on, although these may well be welcome by-products. (Segel et al., 2002, p. 91)

Summary: ACT as a Core Process Approach

There is a clear link between ACT components and core clinical processes and targets for treatment. For this reason, we reemphasize that ACT is not another or more sophisticated bag of tricks that contains lots of nifty techniques such as cute metaphors and playing with Chinese finger traps. It is fundamentally different because its choice of treatment targets is based on identified dysfunctional processes that underlie anxiety disorders and psychological suffering more generally. Rather than narrowly focusing on symptom reduction and control, ACT instead focuses on life-expanding targets: weakening experiential avoidance and client efforts to reduce or control their anxiety, loosening the dominance of verbal and evaluative forms of behavior, promoting psychological and experiential flexibility, and fostering actions that move clients in the direction of their values. This is what ACT therapists mean when they say in an uncannily simple fashion, “ACT treatment is not about anxiety symptoms—it’s about life and what the client wants it to stand for.”