Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 8

Creating an Acceptance Context for Treatment

SESSIONS 2 & 3

It’s like you’re surfing… The same wave that can be a source of pain, can be a beautiful flowing grace and source of power. It’s all a matter of how you respond to it.

—Trey Anastasio

Session 2: Evaluating the Workability and Costs of Past Control Efforts

Goals and Theme

This session seeks to induce creative hopelessness as a motivational enhancement component to normalize human suffering and to prepare the client for treatment. During this early phase of treatment, the therapist explores with clients the workability of the various strategies they have used to cope with anxiety and to reduce suffering. The purpose of creative hopelessness exercises is to let the client experience that, despite putting forth tremendous effort, their problems have remained. The therapist instills a sense of hopelessness, which is “creative” if clients are willing to do something different and let go of futile efforts to control unwanted thoughts and feelings. If clients start focusing on changing what they can change, their situation in life may improve. The key is to let go of the struggle with oneself instead of adding more strategies to reduce or control anxiety. Many clients have difficulty grasping what letting go means in practical terms and what letting-go behavior looks like. A practical aspect of letting go is to learn to observe anxiety-related experiences mindfully rather than by struggling with, or attempting to eliminate, such experiences. This theme is introduced with a metaphor and a mindfulness exercise.

SESSION OUTLINE

1.            _Centering Exercise (5 min.)

2.            _Review of Daily Practice (5 min.)

Review Daily ACT Ratings

3.            _Review of Patterns and Costs of Avoidance (25 min.)

o           Patterns and Workability of Avoidance

o           Costs of Avoidance

o           Develop Creative Hopelessness

4.            _Observing Rather Than Reacting to Anxiety (20 min.)

Acceptance of Thoughts and Feelings Exercise

5.            _Life Enhancement Exercises (Home)

o           Daily practice of Acceptance of Thoughts and Feelings exercise (at least 20 min.)

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

o           Complete worksheet: What Have I Given Up for Anxiety This Week?

o           Complete Daily ACT Ratings form

6.            _Session Materials and Handouts

o           Acceptance of Thoughts and Feelings exercise instructions (two sets)

o           Acceptance of Thoughts and Feelings practice form

o           Living in Full Experience (LIFE) form

o           Worksheet: What Have I Given Up for Anxiety This Week?

o           Daily ACT Ratings form

AGENDA

1. CENTERING EXERCISE (5 MIN.)

Begin the session with the centering exercise described at the end of Session 1.

2. REVIEW OF DAILY PRACTICE (5 MIN.)

First, review the LIFE form briefly, discussing the anxiety-related experiences clients had and any instances of clients engaging in behavior to manage unpleasant sensations and feelings. Also discuss costs associated with such management (i.e., whether that behavior got in the way of something clients value or care about) and client willingness to experience unwanted internal events. Finally, review Daily ACT Ratings and ask clients whether they have any questions regarding the last session and provide brief answers.

3. REVIEW OF PATTERNS AND COSTS OF AVOIDANCE (25 MIN.)

Therapists can begin this review by asking what clients typically do when they experience anxiety. The purpose is to identify patterns of experiential avoidance and/or experiential control efforts at the cognitive, emotional, and behavioral levels, and to identify the life-constraining costs of avoidance and control.

Patterns and Workability of Avoidance

The purpose of this discussion is to reveal ways in which clients feel “stuck.” Start by asking clients to describe things they have tried in the past to eliminate anxiety. Go through some specific examples of what clients have done. For instance, they may have tried to relax or distract themselves, breathe differently, take pills, reassure themselves, argue with their thoughts or worries, or talk to other people. Are there things that they have not tried? The goal here is to gather as much information as possible about major strategies (more, less, better) that the client has tried in the past and may be doing now.

The next step is to help clients evaluate how these methods to manage their anxiety have worked. Has avoidance worked? Has escape worked? Has distraction worked? The purpose of this discussion is to review the workability of past solution attempts. It is not about whether these efforts were right or wrong. It is about whether they have worked for the client. The authors of the first ACT treatment manual for anxiety (Hayes, Wilson, Afari, & McCurry, 1990) suggested to tell clients something like:

You have tried to do everything that can logically be done, tried all the obvious techniques. And none of them are working. If it is true that, in your experience, anxiety has not responded to your quite logical attempts to get rid of it, then something is wrong here. Could it be that your very efforts to solve the problem are actually part of the problem? What has always looked like a solution may not be a solution—it may actually be part of the problem.

Hayes and colleagues (1990) point out that clients may react by defending what they have done in the past because this exercise attacks their beliefs about the solutions to their problems, and by implication, their sense of self. It is important for therapists not to get caught up in the content of what clients say—no arguing, no attempts to convince the client of anything. Instead, return to the simple question about whether the strategies have worked for them. This, by the way, includes the act of defending what they have done about their anxiety with you in session. If the client makes a response implying that a particular strategy has worked, the therapist should gently point out that if this was the solution, why are they here?

In a dialogue of that nature, clients may feel blamed by the therapist for their predicament. As we indicated in chapter 6, it is imperative that a therapist not slip into a one-upmanship role with clients or attempt to logically convince them of a particular point of view (the therapist’s). We recommend that therapists explore attempted solutions to manage and control anxiety nonjudgmentally, with both eyes squarely on how they have worked in both the short and long term. Therapists should model compassion and show empathy by affirming all the hard work and effort clients have put into past control attempts, and should communicate understanding about clients’ reasons for engaging in such attempts. Remember that, in the short term, such strategies typically provide some partial or full relief of anxiety and fear. However, just as living a valued, rich, and meaningful life is a process made up of numerous small moments, the cumulative effect of such short-term anxiety management strategies is often long-term suffering.

Costs of Avoidance

The purpose of this discussion goes beyond evaluating the effectiveness of control and avoidance efforts to reduce and manage anxiety. The discussion must also identify the very personal costs of these efforts for clients in terms of restricting and limiting their lives. In this context, and again a bit later on in this section, you may draw upon experiences the client listed on the LIFE form. Crucial questions to ask clients are:

§    What have been the long-term costs of your avoidance patterns?

§    What have you given up as a consequence of managing your anxiety or worries?

§    What has happened to your life over time? Have you done more or less with your life?

§    Have your options increased or has your “life space” narrowed over time?

§    What would you do with your time if it were not spent trying to manage anxiety, fear, unsettling thoughts, memories, and the like?

Develop Creative Hopelessness

The discussion of past experiential avoidance and control efforts is likely to reveal that the old solutions have not worked. The discussion might also reveal that these efforts have come at considerable personal costs. Hopelessness is a state where clients feel and experience that past solutions have not worked, and will not work in the future, because they cannot work. Hopelessness is about experiencing that past anxiety management strategies have not worked, not giving up or giving in to despair. The therapist therefore should affirm a client’s fears about the hopelessness of current solutions while firmly resisting the temptation to console or motivate clients by reassuring them that “things will get better.”

Therapists may be reluctant to encourage hopelessness because it appears to contravene the generally held therapeutic tenet that therapists should provide clients with hope. Paradoxically, this is exactly what creative hopelessness does. It provides such hope, however, not by means of cheap reassurance but through honest feedback. Helping clients experience they have been caught in a self-defeating struggle is important and does not mean despair for the client; such hopelessness is creative because it allows for new things to emerge (cf. Hayes, Strosahl, & Wilson, 1999). What makes hopelessness creative is the emphasis on the hopelessness of past solutions and that these solutionsare hopeless, not the client. This emphasis implies that there is hope if the client chooses to adopt a different approach when anxiety shows up.

Here is a simple, true-to-life story to illustrate this perspective. Sally was out driving one afternoon and noticed that she was running low on gas. So, she stopped at the nearest convenience store, filled her car with gasoline, and headed inside to pay the cashier. Ahead of her was another man doing the same. He arrived at the door before Sally and pushed on it to get inside. Sally waited patiently behind. The man pushed and pushed on the door to get in, but the door would not open. Sally could hear the man huffing and puffing in frustration, and then watched him knock on the door, figuring that the door was locked from the inside. Sally looked past the man and noticed many people inside and a sign on the door. The sign read PULL. No amount of pushing against the door, even if unlocked from the inside, would open it. Sally then approached the man and kindly suggested that he might try something different: pulling, instead of pushing. Sure enough, the door opened and both walked inside to pay for their gasoline. Creative hopelessness is very much about helping the client to experience with kindness and compassion that pushing against anxiety does not work and a different response may be all that is needed.

The Child-in-a-Hole Metaphor

The purpose of this metaphor is to let clients experience the hopelessness of their struggle with anxiety and that it may be time to adopt a fundamentally different strategy when anxiety shows up. The basic idea here is to show that “more of the same” does not work. The purpose of this metaphor is to plant important seeds for subsequent interventions and break down old assumptions and unrealistic expectations about therapy. Specifically, it attempts to let clients experience that therapy cannot provide them with better control over their anxiety. The clients’ situation is unlikely to improve if the therapist tries to teach them the same types of control efforts they have used in the past without success. For instance, if clients have tried to reassure or distract themselves without success, then it would not be helpful for you, as a therapist, to use similar strategies again.

Imagine a happy child running through a wide-open field. We often think that this is how life is supposed to be: fresh and carefree. Try to imagine this scene vividly. Now, in a sad twist of fate, imagine the child running through the field and falling into a hole. It’s a hole named anxiety. It wasn’t the child’s fault—it just happened. The perfect life is now imperfect. The child struggles and struggles to climb out of the hole, but there is no escape. If climbing won’t work, there must be another way out. She thinks to herself, “Maybe digging is the way out.” So, the child squats down on her hands and knees and starts to dig. She digs and digs and digs … and keeps on digging. Yet after all this digging, where is the child? She looks around, and she is still in the hole. So she tries to dig much harder and faster, thinking, “Maybe it will work if I just work harder at it.” After a while, she stops and looks around again. And where does she find herself? She is even deeper in the hole. All this effort and hard work. And what is the result? The hole has only gotten deeper and wider, and she is more scared and frustrated.

Is this your experience? Clearly, the problem is not lack of effort. Just like the child who gave all she had to dig herself out, you’ve tried everything, too: you’ve used the distraction dig, the relaxation dig, the positive thinking dig, the seeing-a-therapist dig [insert other strategies the client has used]. Yet all this effort has not paid off. In fact, the effort is only creating a bigger problem. Perhaps the whole approach of digging is hopeless, and it doesn’t matter whether you use your hands, your mind, relaxation, or the help of other people. The bottom line is, you’re still digging, and that only gets you deeper into the hole.

Client: Perhaps you could show me or teach me a better way to get myself out of here?

Therapist: Actually, I don’t have a better way of digging, and even if I did, what does your experience tell you? Would that help you? After all, you’d only be digging better, and end up deeper in the hole.

Client: So are you telling me there is no way out of my anxiety hole, and I should just give up?

Therapist: Please do not believe what my mind or your mind tells you. Just look at your experience and examine what that tells you. I know your mind is telling you that you must find a better way of digging. Your mind has also told you to relax, to stay at home, to use positive thinking, and so on. Has it helped you when you listened to your mind and did those things?

Client: Sometimes those things have worked a bit, but ultimately they have been pretty useless. That is why I had really hoped you could help me. After all, you’re the expert.

Therapist: Actually, I think you’re the expert when it comes to your experience. Nobody knows that better than you. The crucial question for you is, Whom do you trust now? Your mind or your experience? Which of those two voices do you think will steer you closer to the life you want to be living?

Client: I’m not sure. I only know I’m pretty far away from where I want to be.

Therapist: I’d love to spend some time exploring with you where you want to be. So perhaps your job right now is not to figure out how to get out of the hole. After all, you have been doing this all along. You can’t do anything until you stop digging, and free your hands to use them for other activities. That is a very difficult and bold thing to do. Letting go of digging looks as though it will doom you to stay in the hole forever. Your best ally is your own pain, and your knowledge based on experience that no form of digging has worked. Have you suffered enough? Are you ready to give up digging and do something else? Can you allow yourself to simply be in the hole?

Blaming Versus Response-ability

Clients sometimes respond to the hole metaphor by asking whether you think they are to blame for their predicament. The hole metaphor makes it clear that it is not their fault that they are in this hole. As in the case of the girl wandering through the field, it doesn’t really matter how she fell into the hole—it just happened. This is one of the cards that life has dealt her. So the important thing is to accept that she is in the hole and that digging hasn’t worked. Blaming is useless because it serves no purpose and does not work. Will self-blame get the girl out of the hole? Lack of motivation is not the problem either. She has done everything she could and worked very hard. So who’s to blame is not the issue. Ask your clients, “Is blaming taking you closer to or further away from where you want to go”?

What is important to realize is that clients are responsible in the original sense of the word: response-able. It means clients are able to respond and can choose between different types of responses. The first thing for them to do is to let go of digging. Describe being response-able as a great gift because it means there are things that clients can do to improve their current life situation. They cannot choose the sensations that come up in their body or the thoughts that their minds serve up. Often they cannot choose what life may offer them. What clients can choose is what they do with their hands and feet to improve their lives.

Now is a good time to return to the LIFE form from last week. Ask the client to share life experiences where they found themselves in a hole with their anxiety and fear. What did they do about it? Did they use one or more ways of digging to manage it and how did that work for them? What were the costs? Did they end up blaming themselves or others as a consequence?

Feeding-the-Anxiety-Tiger Metaphor

Apart from showing that avoidance efforts have not worked, the feeding-the-anxiety-tiger metaphor is a powerful illustration of the ultimate cost of control efforts. Hayes and colleagues (1990) originally described this metaphor to show clients that they cannot control anxiety by trying to appease it (e.g., by giving in to what it seems to demand). It also shows how increasingly larger portions of the client’s resources and life space get eaten up by efforts to control and avoid anxiety.

It seems you have been dealing with your anxiety the way someone might who lives with a hungry baby tiger. Although the tiger is just a baby, he is scary enough, and you think he might bite you. So you go to the fridge to get some meat for him so he won’t eat you. And, sure enough, throwing him some meat shuts him up while he’s eating the meat, and he leaves you alone for a while. But he also grows just a little bigger. So the next time he’s hungry, he’s just a little bigger and more scary, and you go to the fridge to throw him more meat. Again, you feed him to keep him at bay. The problem is that the more you feed him, the bigger he gets, and the more frightened you feel. Now eventually that little tiger is a big tiger, and he scares you more than ever. So you keep on going back to the fridge to get more meat, feeding and feeding him, and hoping that one day he will leave you alone. Yet the tiger doesn’t leave—he just gets louder and more scary and hungry. And then one day you walk to the fridge, you open the door, and the fridge is empty. At this point, there is nothing left to feed to the tiger … Nothing? … Except you!

You’ve got anxiety monsters out there that look as though they could swallow you whole. When the emotional and bodily discomfort and disturbing thought monsters show up, you keep hoping that, if you feed them, they will go away. You keep hoping that if you trade in your life flexibility just a little bit more, eventually the anxiety monster will leave you alone. Does your experience tell you that this has ever really happened? Is there anything that indicates that it is going to happen?

To make this metaphor personally relevant for clients, ask them to consider examples of how they have fed the anxiety monsters in their own lives. If a client has difficulty coming up with examples (e.g., staying home alone to avoid having a panic attack), you can offer a few examples based on the client’s in-session comments or their responses to the LIFE form.

4. OBSERVING RATHER THAN REACTING TO ANXIETY (20 MIN.)

It is likely that clients will again ask what it is that they should do or do differently. At this stage, it is important to tell them not to change anything, and to just focus on observing how they are responding to their anxiety when it occurs, and to take note of how well that works. Go back to the notion that the skills for dealing with anxiety without more “digging” can only be acquired through direct experience—just like learning how to ride a bike. For this reason, the following mindfulness exercise is particularly useful because it helps clients just notice what is going on inside of them without getting involved with trying to change their experience.

Acceptance of Thoughts and Feelings Exercise

Mindfulness exercises that focus on breathing are a core part of traditional Buddhist teachings and practice (e.g., Chödrön, 2001). We have adapted the following exercise from more generic versions (Davis, Eshelman, & McKay, 2000; Kabat-Zinn, 1990; Segal et al., 2002) for the purposes of this anxiety treatment program. In this exercise, we focus on the breath because internal sensations such as thoughts, worries, bodily sensations, and feelings are constantly shifting and changing—just like our breathing. The goal is for clients to practice paying attention to a single focus, the breathing, and to allow other internal events, such as thoughts, feelings, and sensations, to come and go in their minds. Clients may also experience that no matter how bad an internal experience seems, it neither lasts forever nor can it do any physical harm. If they pay attention to it, they will see how it changes from moment to moment, how it comes and goes on its own, without any effort on our part.

Tell clients that mindfulness exercises are a way to learn that we cannot choose what comes into our minds and what we feel. We can only choose what we pay attention to and how we pay attention to internal events. The goal is for clients to notice any thoughts and images and their emotional responses to such thoughts and images, just as they are. Encourage clients to bring some compassion and kindness to their private experiences by not arguing or struggling with them and instead accepting them without judging them as good or bad. This is a concrete way of learning that anxiety is not the enemy. Simply noticing bodily sensations without trying to manage them is a difficult skill for individuals with anxiety disorders to learn, because it differs from the past control struggles they have engaged in when feeling anxious. So learning this new skill will require regular daily practice.

Right before starting the exercise, remind clients that the purpose of this practice is to learn to observe and make them better at feeling. Its aim is not to make them feel different, better, relaxed, or calm; this may happen or it may not. Instead, the goal of this practice is for the client to, as best they can, bring a compassionate, kind awareness to each breath, to any sensations they detect, and to any thoughts or worries that come into their mind. During the pauses in the exercise, feel free to remind clients to “gently focus on the breath” as often as seems natural, to help bring clients back to the exercise if and when their minds wander off. Some clients initially experience some difficulty understanding the instructions and following them. Remind them that they will become better at doing it with continued practice. The exercise itself should take about fifteen minutes to complete. We suggest that therapists read the instructions to clients in a slow and soft manner. The instructions for the exercise are also on the book CD.

1.            First, I would like to ask your permission to do another experiential exercise. Are you willing to do that? [Get clients’ permission and then move on.]

2.            Go ahead and get in a comfortable position in your chair. Sit upright with your feet flat on the floor, your arms and legs uncrossed, and your hands resting in your lap (palms up or down, whichever is more comfortable). Allow your eyes to close gently [pause 10 seconds].

3.            Take a few moments to get in touch with the movement of your breath and the sensations in your body [pause 10 seconds]. Bring your awareness to the physical sensations in your body, especially to the sensations of touch or pressure, where your body makes contact with the chair or floor [pause 10 seconds].

4.            Now, slowly bring your attention to the gentle rising and falling of your breath in your chest and belly. Like ocean waves coming in and out, your breath is always there. Notice its rhythm in your body [pause 10 seconds]. Notice each breath. Focus on each inhale … and exhale [pause 10 seconds]. Notice the changing patterns of sensations in your belly as you breathe in, and as you breathe out [pause 10 seconds]. Take a few moments to feel the physical sensations as you breathe in and as you breathe out [pause 10 seconds].

5.            There is no need to try to control your breathing in any way—simply let the breath breathe itself [pause 10 seconds]. As best you can, also bring this attitude of generous allowing and gentle acceptance to the rest of your experience. There is nothing to be fixed, no particular state to be achieved. As best as you can, simply allow your experience to be your experience, without needing it to be other than what it is [pause 15 seconds].

6.            Sooner or later, your mind will wander away from the breath to other concerns, thoughts, worries, images, bodily sensations, planning, or daydreams, or it may just drift along. This is what minds do much of the time. When you notice that your mind has wandered, gently congratulate yourself—you have come back and are once more aware of your experience! You may want to acknowledge briefly where your mind has been (Ah, there’s thinking or there’s feeling). Then, gently escort your attention back to the sensation of the breath coming in and going out [pause 10 seconds]. As best you can, bring a quality of kindness and compassion to your awareness, perhaps seeing the repeated wanderings of your mind as opportunities to bring patience and gentle curiosity to your experience [pause 15 seconds].

7.            When you become aware of bodily sensations and feelings, tension, or other intense sensations in a particular part of your body, just notice them, acknowledge their presence, and see if you can make space for them [pause 10 seconds]. Do not try to hold on to them or make them go away [pause 10 seconds]. See if you can open your heart and make some room for the discomfort, for the tension, for the anxiety, just allowing them be there [pause 10 seconds]. Is there enough space in you to welcome in all of your experience? [pause 15 seconds]

8.            Watch the sensations change from moment to moment. Sometimes they grow stronger [pause 10 seconds], sometimes they stay the same [pause 10 seconds], and sometimes they grow weaker—it does not matter [pause 10 seconds]. Breathe calmly in to and out from the sensations of discomfort, imagining the breath moving in to and out from that region of the body [pause 10 seconds]. Remember, your intention is not to make you feel betterbut to get better at feeling [pause 15 seconds].

9.            If you ever notice that you are unable to focus on your breathing because of intense physical sensations of discomfort in your body, let go of your focus on the breath and shift your focus to the place of discomfort. Gently direct your attention on and into the discomfort and stay with it, no matter how bad it seems [pause 10 seconds]. Take a look at it. What does it really feel like? [pause 10 seconds] Again, see if you can make room for the discomfort and allow it to be there [pause 10 seconds]. Are you willing to be with whatever you have? [pause 15 seconds].

10.        Along with physical sensations in your body, you may also notice thoughts about the sensations and thoughts about the thoughts [pause 10 seconds]. You may notice your mind coming up with evaluative labels such as “dangerous” or “getting worse.” If that happens, you can thank your mind for the label [pause] and return to the present experience as it is, not as your mind says it is, noticing thoughts as thoughts, physical sensations as physical sensations, feelings as feelings—nothing more, nothing less [pause 15 seconds].

11.        To help you experience the difference between yourself and your thoughts and feelings, you can name thoughts and feelings as you notice them. For instance, if you notice you are worrying, silently say to yourself, “Worry … there is worry,” just observing worry and not judging yourself for having these thoughts and feelings [pause 10 seconds]. If you find yourself judging, just notice that and call it “Judging ... there is judging” and observe that with a quality of kindness and compassion [pause 10 seconds]. You can do the same with other thoughts and feelings and just name them as planningreminiscinglonging, or whatever you experience. Label the thought or emotion and move on [pause 10 seconds]. Thoughts and feelings come and go in your mind and body. You are not what those thoughts and feelings say, no matter how persistent or intense they may be [pause 15 seconds].

12.        As this time for formal practice comes to an end, gradually widen your attention to take in the sounds around you … notice your surroundings [pause] and slowly open your eyes with the intention to bring this awareness to the present moment and into the upcoming moments of the day.

After completing the exercise, therapists should ask clients how they experienced the exercise and briefly discuss any comments, questions, or concerns. Therapists can weave into this discussion some basic points about mindfulness and acceptance. You will want to counteract any attempts by clients to misuse acceptance and this exercise as tools to control or reduce anxiety. Also remind clients that they will become better at being mindful observers with continued practice and that the stance entailed in this exercise is the basis for important exercises in subsequent treatment sessions. It is therefore critical that clients practice it regularly at least once a day at home and keep a daily record of their practice using the form at the end of this chapter and on the CD. The instructions for the exercises are also on the CD. Ask clients whether they are ready to commit to doing these exercises on their path of becoming a better observer and a full participant in life.

5. LIFE ENHANCEMENT EXERCISES (HOME)

§    Practice the Acceptance of Thoughts and Feelings exercise once a day for at least 20 minutes and complete the practice form after each practice. Give clients a copy of the instructions to take home.

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

§    Complete the worksheet: What Have I Given Up for Anxiety This Week?

§    Complete the Daily ACT Ratings form.

Explain to clients that the purpose of the new worksheet, What Have I Given Up for Anxiety This Week?, is to have them make contact with what they are giving up in the service of anxiety between sessions on a daily basis (the worksheet is at the end of this chapter and on the CD). This exercise is designed to let clients experience the costs associated with their efforts to manage and avoid anxiety. Such costs may include giving up opportunities to do things that matter to them and activities that clients could have done had they not been sidelined by control and avoidance strategies.

Session 3: Creative Hopelessness: Making Space for New Solutions

Goals and Theme

The first goal of this session is to establish control efforts as the problem, not the solution. The therapist further nurtures creative hopelessness by letting clients experience the unworkability of previous avoidance and control efforts and that nothing will change unless they change how they approach anxiety. A related message is that “You are not hopeless—only your past solution attempts are!” The first step in a new direction is to let go of past solution attempts. This letting go, in turn, makes room for new possibilities. Through in-session exercises, clients have the opportunity to experience that letting go of their struggle and doing things that go against the grain could be an option for them.

If anxiety reduction is not a stated goal of this program, then clients may rightly wonder, what is the ultimate goal? For this reason, we introduce the notion of value-driven behavior as an alternative to managing anxiety. Clients learn that moving in the direction of chosen values and living a full life is what this treatment is about and what makes the hard therapy work worthwhile.

SESSION OUTLINE

1.            _Repeat Acceptance of Thoughts and Feelings Exercise (15 min.)

2.            _Review of Daily Practice (5 min.)

o           Review Acceptance of Thoughts and Feelings exercise and Daily ACT Ratings

3.            _Control Is the Problem—Letting Go Is the Alternative (20 min.)

o           The Chinese Finger Trap Exercise

o           Tug-of-War with the Anxiety Monster Exercise

4.            _Value-Driven Behavior as an Alternative to Managing Anxiety (20 min.)

o           Review LIFE form and What Have I Given Up for Anxiety This Week? worksheet

o           Choosing Valued Directions

o           Values Make the Hard Work Worthwhile

o           What Matters Most in Your Life?

o           The Epitaph Exercise: What Do You Want Your Life to Stand For?

5.            _Experiential Life Enhancement Exercises (Home)

o           Daily practice of Acceptance of Thoughts and Feelings exercise (at least 20 min)

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

o           Complete worksheet: What Have I Given Up for Anxiety This Week?

o           Complete Daily ACT Ratings form

o           Complete one or two Write Your Own Epitaph exercise worksheets

6.            _Session Materials and Handouts

o           Acceptance of Thoughts and Feelings practice form

o           Living in Full Experience (LIFE) form

o           Worksheet: What Have I Given Up for Anxiety This Week?

o           Daily ACT Ratings form

o           Write Your Own Epitaph exercise worksheet (two copies)

o           Three Chinese finger traps: two for use in session and one to give to client to take home (available at party supply and novelty shops or through the Internet: www.supercoolstuff.com, then search for finger traps)

o           Bath towel for tug-of-war exercise

AGENDA

1. ACCEPTANCE OF THOUGHTS AND FEELINGS EXERCISE (15 MIN.)

Begin the session by repeating the Acceptance of Thoughts and Feelings exercise that was introduced and assigned for home practice in Session 2. Evaluate progress and difficulties during the in-session practice, and praise client efforts and willingness to do the exercise.

2. REVIEW OF DAILY PRACTICE (5 MIN.)

Review the client’s daily practice of the Acceptance of Thoughts and Feelings exercise, paying attention to any lack of compliance for reasons of lack of willingness, lack of commitment, or high fearfulness. Reiterate the rationale for home practice. Defer review of the LIFE form and What Have I Given Up for Anxiety This Week? form until the final part of the session that deals with value-guided behavior as an alternative to managing anxiety.

3. CONTROL IS THE PROBLEM—LETTING GO IS THE ALTERNATIVE (20 MIN.)

This treatment component addresses the problems associated with the use of experiential avoidance strategies. It continues to be important for clients to experience that past solution attempts involving experiential avoidance are not solutions but problems themselves. One of the goals of Session 2 was to show clients that past attempts to avoid experiencing anxiety have not worked for them. The goal of this session is to expand upon this theme. The metaphors and exercises in this session allow clients to make experiential contact with the unworkability of old anxiety avoidance and control solutions and how these strategies have resulted in considerable personal costs.

As in the previous session, it is important that therapists resist the temptation to rescue clients from their felt hopelessness by consoling and reassuring them that “things will get better.” The hopelessness that clients may experience at this stage is not the emotion of despair. Rather, it is the experience that past solutions are hopeless and will not work. As Hayes, Strosahl, and Wilson (1999) put it, the experience of hopelessness is bittersweet—both sad and hopeful, painful and empowering. It feels open, spent, sober, humble, and courageous. Such a state is likely to be beneficial and motivating (“creative”) because it allows clients to experience the unworkability of their self-defeating experiences straight on and unedited. This experience allows for new and fundamentally different ways of relating with anxiety to emerge.

At this stage, it is not necessary to be specific as to what this new approach might look like. The goal of these exercises is to let clients experience that (a) letting go of the struggle is an option; and (b) whatever they may do differently in the future must be fundamentally different from what they have done in the past. It may even be the complete opposite of what they have done before.

The Chinese Finger Trap Exercise

A Chinese finger trap is a tube of woven straw about five inches long and half an inch wide. First, you must slide both index fingers into the straw tube, one finger at each end. If you attempt to pull the fingers out, the tube catches and tightens, causing discomfort. The only way to regain some freedom and space to move is to push the fingers in first and then slide them out. The purpose of this exercise is to let clients experience how doing something seemingly counterintuitive (“leaning into one’s anxiety”) may be a better solution than persisting with the same old solutions that have not worked. The Chinese finger trap is a metaphor for moving toward suffering in order to lessen it and heal from it. We have adapted this exercise from the metaphor described by Hayes, Strosahl, and Wilson (1999), who present the metaphor to clients in verbal form. Based on the results of a study we conducted (Eifert & Heffner, 2003), we suggest allowing clients to act out the metaphor with an actual finger trap so that they may experience the effects of their actions. This experiential component is in line with the action-oriented nature of behavior therapy and could serve to enhance the credibility and effectiveness of the metaphor. Following the exercise, give clients an extra finger trap to take home.

The goal of this exercise is to let clients discover that attempting to reduce and control essentially uncontrollable sensations, while understandable and seemingly logical (like pulling out of the finger trap), only creates more problems: the harder you pull, the more the trap tightens, resulting in less room to move and even more discomfort. In contrast, doing something counterintuitive, such as pushing the fingers in rather than out and leaning into the discomfort, effectively ends the struggle. It gives the client more space to move and do other things. Doing the exercise together with the client is a good way to illustrate that we are all in this boat together and that clients are not alone in the way they attempt to deal with their struggles.

Give clients a finger trap and use one yourself. First, ask clients to slide in both index fingers, one finger at each end of the tube. After you fully insert your fingers, ask clients to try to get out of the finger trap. They are likely to do so by attempting to pull their fingers out. If they do that, ask them what they notice. They will experience and report some discomfort as the tube squeezes their fingers and reduces circulation. They might also voice some worry that they might be stuck inside the finger trap for the rest of the session. They may experience some confusion because pulling out of the tube seems the most obvious, natural way to escape. Yet it doesn’t work, and they are definitely stuck if they simply just go on pulling. Use the following dialogue as an example of how to individualize this exercise to specific client responses, suggestions, and comments as you and the client work through the exercise.

Therapist: Pulling out is a very natural and seemingly logical reaction to free yourself from the finger trap, but what happens when we do that? [Hold up your finger trap and encourage the client to try pulling out again.]

Client: It doesn’t work. I’m stuck.

Therapist: I notice that, too. Our fingers only get caught more tightly, creating more discomfort and less room to move.

Client: So how do we get out of here?

Therapist: Perhaps getting out is not the main issue. The good news is that there is an alternative that does work, insofar as it gives you some space and room to move. To get there, however, you have to approach this situation differently. What could that approach be?

Client: I am not quite sure. There has to be some kind of trick that will do it and get me out of here. Perhaps I need to pull in a different way.

Therapist: Okay, why don’t you go ahead and do that and see what happens.

Client: It doesn’t work either. I am still stuck.

Therapist: So am I. Let me give you a hint. We have to do something that goes against the grain and doesn’t seem to make sense at first. Instead of pulling out, we could push our fingers in. Let’s try that instead and see what happens. [Therapist models gently leaning into the tube.]

Client: Well, I can move now, but I still can’t get out of the trap. I’m still in it.

Therapist: So am I. We might not get out of the trap, but as you noticed, pushing the fingers in definitely gave you more space to move around. It seems like leaning into the tube gives us more wiggle room. What if we didn’t need to get out of the finger trap at all? What if we just created some more space for us to have what we have, to experience what there is to be experienced?

Client: That sounds weird and scary—and I don’t like it.

Therapist: I understand that you do not like and would want to get away from things that scare you like your [insert some of client’s worst fears]. But what happens when you keep on pulling away from what you have? The harder you pull away from your anxiety, the more the trap tightens, and the more stuck you are. Trying to get rid of your anxiety, trying to reduce it when it’s there, trying not to have it come back when it happens to be gone—what has all this pulling and controlling done to your life? Has it created more space for you to do what really matters to you, or has it taken over more and more of your life?

Client: Well, what I have done certainly hasn’t helped much or solved any problems. So tell me, what should I do instead?

Therapist: I am not quite sure, but when you look at these finger traps, pulling away doesn’t seem to work, does it? Yet doing something counterintuitive, pushing your fingers in rather than out, has given you space and new options to make moves. Perhaps doing something that goes against the grain is a way of getting yourself unstuck from where you are with your life right now. What could you do that would go against the grain?

The finger trap exercise is powerful. It is powerful precisely because it provides direct experience with our instinctive and often well-intentioned solutions to our problems and shows us how often these turn out not to be solutions at all. In fact, these so-called solutions may create even bigger problems than the ones they were designed to address. As Tim Dunn wrote in his book (no longer available) How to Escape the Chinese Finger Trap: A Manual for Changing:

In the end, all attempts to escape the fact that life contains suffering are doomed. A gloomy philosophy, you say? Not entirely bleak, I would respond. Because, THERE IS AN EXIT. Don’t try to escape it. Go towards it. Seek out what hurts and frightens you. It is mindlessly pulling away from pain and mindlessly seeking pleasure that causes people to greatly increase the troubles that life brings them. [cited by Hand-Boniakowski, 1997]

Dunn suggests that hope lies not in escape or avoidance. Instead, real hope comes about when we head toward suffering and embrace it with compassion and kindness. Only then will suffering have less of a stranglehold on our happiness. By embracing suffering, clients relax the weave of the trap that they have built for themselves, and can begin to escape from its hold on them and live their lives fully.

Tug-of-War with the Anxiety Monster Exercise

The notion of doing something counterintuitive and letting go of the struggle is likely to be quite alien to clients. In fact, they may be frightened by this notion. Also, clients often have trouble understanding what statements like “let go of your struggle” mean. We therefore recommend using an additional metaphor, tug-of-war metaphor. Similar to the finger trap exercise, this metaphor suggests letting go of a struggle by doing something opposite to what people typically do in a struggle. Interestingly, a woman with agoraphobia came up with this metaphorical story during ACT therapy and told it to Steven Hayes (Hayes et al., 1990).

After a brief verbal introduction of the tug-of-war metaphor, we recommend acting this metaphor out too. Give clients a bath towel and ask them to play tug-of-war with you in your newfound role as “the anxiety monster.” If they attempt to pull the anxiety monster over, the monster simply pulls back. Acting out this exercise lets clients physically experience how much energy and focus it takes to keep the anxiety monster in check. Also, we have found that almost all clients will grab the towel with both of their hands when you hand it to them. This is a very graphic illustration for clients because it shows how anxiety, and the efforts of fighting it, have left their hands tied up in the fight and no longer free to do other things in life. Incidentally, therapists need not worry about ending up in a fight with their clients. We have found that clients fully recognize and stay within the boundaries of the playfulness of the situation!

Therapist: It seems like your situation is like being in a tug-of-war with an anxiety monster. You hate the monster because it is so big and powerful. In between you and the monster is a pit, and so far as you can tell it is bottomless—an abyss. If you lose this tug-of-war, you will fall into the abyss and be destroyed. The anxiety monster will have won. You don’t want this to happen, so you fight back. You pull and pull, but the harder you pull, it seems the harder the monster pulls back—and all the time it seems you are pulled a bit closer to the edge of the pit. So how can this fight ever end?

Client: Either I win by pulling harder than the anxiety monster or the anxiety monster wins by wearing me out and I’m gone—kaput!

Therapist: Can you see how you are using both of your hands to keep the monster in check? Also look at your feet. They’re pretty much tied in one position. What else can you do with your hands and feet while you’re doing that?

Client: Just about nothing. I am stuck fighting.

Therapist: I notice your eyes are focused on the towel, too. What are you thinking?

Client: I’m wondering what your next move will be.

Therapist: So your mind, hands, and feet are all tied up in the struggle with anxiety?

Client: Yes, they pretty much are, and that is even more frightening than the anxiety itself. It seems I have nothing left to work with.

Therapist: You could indeed spend all your energy fighting anxiety monsters until the end. But there is a different way, which is perhaps hard to think of while you’re so busy fighting: You could simply drop the rope! The hardest thing to see is that your job here is not to win the tug-of-war. Your job is to drop the rope! Just imagine, what would happen if you refused to fight anymore and just dropped the rope? Are you willing to let go of the rope now and see what happens?

Client: [after letting go of the rope] The fight is over and my hands are free.

Therapist: Isn’t that great? And where am I—the anxiety monster?

Client: You’re still there. You probably fell on the floor when I dropped the rope on you.

Therapist: I am still here and the fight is over. And you’re right, I did fall down. But that won’t stop me from getting up and shouting at you, “Hey, pick up the rope. What’s wrong with you?” What do you do then? [therapist dangles the towel in front of the patient]

Client: I guess I have to listen, and I could pick up the rope—but I don’t have to pick it up, right?

Therapist: That is indeed a choice you have: You don’t have to pick up the rope! Just remember though, I am still here in the room with you, and I am still shouting at you. I am not dead and gone.

Client: I wish you were!

Therapist: I understand. So you can’t make me go away. What is it then that you can control?

Client: I cannot shut you up. The only thing I can do is not do what the monster tells me to do.

Therapist: That is your choice. You do not have to do what the monster tells you. You can’t make it shut up, as much as you’d like to silence it. Yet you also need not fight it or do whatever else it tells you to do. By the way, take a look at your hands and your legs now. Did you notice that they are free now? You are free to do all sorts of things that really matter to you now because you’re no longer caught up in the fight with the anxiety monster.

4. VALUE-DRIVEN BEHAVIOR AS AN ALTERNATIVE TO MANAGING ANXIETY (20 MIN.)

At this point, clients will inevitably ask, “So, what do I do next?” Consistent with what we have said about creative hopelessness, you may be tempted to respond with something like, “I don’t know what you should do,” or “There is really nothing that can be done.” Yet these responses are not genuine. You will likely have some ideas about what might be done to help a client get unstuck and move forward. The exercises in this and the previous session will have helped clients explore the unworkability of past change efforts and let them contact the experience of unworkability fully, without defense and avoidance, so as to create space to move in the direction of creative workability. So, when clients ask, “What am I to do?” you might respond by saying something like “There is no simple answer as to what exactly will work for you. What we don’t want to do is go down the same old road where you got stuck in the first place. Perhaps it is time that we explore what it is that you really want to do. What is it that you care about most?”

Choosing Valued Directions

Begin the discussion on choosing values by referring back to the feeding-the-anxiety-tiger metaphor. Trying to appease and manage anxiety (e.g., by giving in to the various avoidance and escape behaviors that it seems to demand) has led to a loss of increasingly larger portions of the client’s resources and psychological space. The anxiety thoughts and panicky feelings clients experience are like a monster growing inside. Each time clients give in to what panic, anxiety, fear, and worries ask them to do, they inadvertently feed the monster and make it grow bigger and bolder. Feeding the anxiety monster won’t make it calm and friendly in the long term. Ask clients, “Who is in control here? Who is choosing? Is it you or is it a monster called anxiety or panic?”

Feeding the anxiety monster has moved clients away from valued life directions and put living a valued life on hold. Tell clients that the remaining sessions are primarily devoted to reclaiming their lives. Whereas until now we have emphasized what clients cannot control (their internal experiences), we now focus on what clients can control with their hands and feet. A typical question ACT therapists might ask is, “In what valued direction are your feet currently taking you?” (Hayes & Wilson, 1994). Clients truly are in control and have the power to choose the direction they want their lives to take. At this point, the therapist could get up and walk around the room and point to their feet and legs to demonstrate that clients are in control of where their feet are taking them. They do not have to devote their time, energy, and lives to feeding the anxiety monster. Most importantly, they need not wait until they have “mastered” their anxiety, and have gotten rid of all the symptoms and problems associated with it, to move on with their lives.

Therapists can make this discussion more concrete by reviewing a few examples from the What Have I Given Up for Anxiety This Week? form clients completed at home and discussing the consequences and costs of anxiety management as related to living a full and valued life. You should also review last week’s LIFE form and focus on any instances of clients engaging in behavior to manage unwanted sensations and feelings. Again, point out costs associated with such management (i.e., whether that behavior got in the way of something clients value or care about).

Values Make the Hard Work Worthwhile

Clients often wonder why their therapist is talking about values in a treatment program for anxiety disorders. Tell clients that when they first entered therapy, their focus was on managing or getting rid of anxiety. This hasn’t worked in their lives. Instead, it has created more problems and solved very few of them. The purpose of the mindfulness exercises is to let them experience that they can observe aversive thoughts and feelings and approach situations that often got in the way of pursuing valued activities. The purpose of these exercises is to give clients skills that could be helpful as they start doing things that they really care about.

Tell clients that the last part of this session, and indeed the rest of the treatment, is about learning that they deserve to live a full life, and that you’ll be helping them find a path and commit to a plan that will lead them in that direction. As a therapist, you make a commitment to help your client explore and move toward their chosen values and goals in a systematic way so they can reclaim their lives. In the process, your clients may rediscover, or perhaps discover for the first time, what is most important to them. The following brief metaphor, adapted from Heffner and Eifert (2004), may help illustrate this process for your clients.

Think of life as a walk through a corridor with many doors. You [the client] have the power to choose which doors to open and enter. One of those doors is labeled “anxiety,” and you have chosen the anxiety door for so long that you may have lost sight of other options that are available to you. This session and the exercises at home will give you alternatives to explore. You can venture out and open up other doors. You can also choose to stay inside the anxiety room. What choice do you want to make? When you stay locked behind the anxiety door, what will that do to your life? Here is one of the most important questions for you: Do you want to be free of anxiety or panic, or do you want to have your life back? Now is the time to muster the courage to explore other doors in your life corridor. Think about your life. Besides anxiety, what other doors can you open?

In the past, clients have spent their energy trying to manage their anxiety almost as if anxiety management were their occupation. Now they can think about how they can use their energy in a different way, such as being a trusted friend, a student, an athlete, a loving sister, brother, partner, or parent, or by starting a more fulfilling career, rekindling a hobby, or doing whatever else their heart desires. Heffner and Eifert (2004) used the following brief metaphor to help illustrate this point:

Your life energy is a gift. You can think of it as being like a hammer. Just as you can use a hammer to build or to destroy, you can also focus energy on committing yourself to leading a full life, or waste your energy by trying to control the uncontrollable. Either way, anxiety will be with you.

What Matters Most in Your Life?

One way to get into a discussion of exploring values and living a full life is to ask clients what is really important to them. What really matters to them, and what do they care about? Some clients find it difficult to focus on what matters to them because their mind tells them anxiety control is what matters, precisely because anxiety appears to be the main barrier to doing what really matters to them. So, ask them whether they have ever wondered what their lives would be like if the anxiety monster did not rule them. For instance, what would be different if they didn’t have panic attacks, experienced less anxiety, or had fewer worries? What kind of things would they do or like to do if that were so? You may also ask the following: If you only had today to live, what would you do with the time you had left on this earth?

The Epitaph Exercise: What Do You Want Your Life to Stand For?

The purpose of this powerful exercise, adapted from Hayes, Strosahl, and Wilson (1999) and Heffner and Eifert (2004), is to help clients clarify their values and make contact with what they care about. Is it conquering their anxiety or living a valued, rich life? Therapists should give the client a copy of the epitaph worksheet, which is at the end of this chapter and on the book CD.

Imagine that one day this will be the headstone on your grave. Notice that the epitaph has not yet been written. What inscription would you like to see on it that will capture the essence of your life? What is it that you want to be remembered for? What would you like your life to stand for? What do you want to be about? Take this sheet with you and give yourself some time to think about this really important question. If you find an answer—or more than one—just write it down on the lines on “your” tombstone. This may seem like another strange and perhaps somewhat scary exercise. If you stick with it and complete it and feel a bit queasy, it will help you get in touch with what you want your life to stand for.

This is not really a hypothetical exercise. What you will be remembered for—what defines your life—is up to you. It depends on what you do now. It depends on the actions you take that are consistent with what you care about. This is how you can determine the wording of your own epitaph. Now, I make no promises that people will build a Lincoln-type memorial for you at the end of your life. Yet if you persistently move in your valued directions, chances are that people will write more on your tombstone than “Here lies [insert the client’s name]—she conquered panic disorder” or “Here lies [insert the client’s name]—he finally stopped worrying” [individualize to fit client’s main presenting problem].

What does it mean that people never mention those items on tombstones? Could it mean that the goal you have been working extremely hard to achieve is ultimately not going to matter much in the grand scheme of things? An important question to ask yourself now is, Are you doing things to be the type of person you want to be? If not, now is the time to live the life you want and do the things that are most important to you. Each minute you spend at home trying to not have panic [individualize and insert client’s worst fear] is a minute away from doing what really matters most to you.

Valued living is a lifelong process in which roadblocks and barriers arise. Each day you live is a day to move in a valued direction and take your painful thoughts and feelings with you. In a way, we write our own epitaph by the choices we make and actions we take each and every day. So once again, what do you want your epitaph to say when you’re no longer alive? It is one of the most important questions that we ask you in this program.

Before moving on, we wish to point out that there is another way this exercise can be done. You can give clients two copies of the epitaph worksheet. First, you ask clients to write their own epitaph as if they died today. The epitaph should focus on everything clients have done in the service of not having anxiety. For instance, a person with panic and agoraphobia might write the following:

I spent the last eight years homebound for fear of my panic. I have visited my doctor dozens of times to manage my anxiety. I have refilled countless prescriptions for medication. I have been unable to work for the past several years and have few friends outside of my immediate family. I have not gone to the beach all this time. I have not watched a sunset from a mountaintop since I was in high school. I haven’t felt the cool breeze of a warm summer evening on my face for a long time. My life has been about not having panic and I leave this earth having been enslaved by this goal and not having conquered it.

Then you ask clients to complete the second worksheet with what they want out of life and what they want their lives to stand for. Both tombstones can then be compared and discussed in the next session.

5. EXPERIENTIAL LIFE ENHANCEMENT EXERCISES (HOME)

§    Practice the Acceptance of Thoughts and Feelings exercise once a day for at least 20 minutes and complete the practice form after each practice

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

§    Complete the worksheet: What Have I Given Up for Anxiety This Week?

§    Complete the Daily ACT Ratings form

§    Complete one or two Write Your Own Epitaph exercise worksheets

acceptance of thoughts and feelings

what have i given up for anxiety this week?

write your own epitaph