Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 9

Acceptance and Valued Living as Alternatives to Managing Anxiety

SESSIONS 4 & 5

Trying to fix ourselves is not helpful because it implies struggle and self-denigration. Lasting change occurs only when we honor ourselves as the source of wisdom and compassion. It is only when we begin to relax with ourselves that acceptance becomes a transformative process. Self-compassion and courage are vital. Staying with pain without loving-kindness is just warfare.

—Pema Chödrön

Session 4: Mindfulness, Acceptance, and Choosing Valued Directions

Goals and Theme

This session has three goals. The first goal is to introduce clients to acceptance and mindfulness as a skillful way of approaching our various life experiences. Clients learn to observe anxiety-related thoughts and feelings without evaluation or judgment and without holding onto, getting rid of, suppressing, or otherwise changing what they experience. Clients learn to assume an observer perspective in relation to their anxiety-related feelings and thoughts via the Acceptance of Anxiety exercise. The exercise encourages willingness to make full contact with the experience of anxiety and provides clients with a tool for doing so. The larger goal is to undermine the tendency to react to anxious thoughts and sensations so as not to have them, including avoiding situations where anxiety may show up. The second goal is to help clients differentiate what they can control from what they cannot control in their lives. The third goal is to affirm valued living as an alternative agenda to managing anxiety. Based on the epitaph exercise and what clients want their lives to stand for, therapists help clients explore more specific values and identify goals by means of the Valued Directions worksheet to be completed by clients at home.

SESSION OUTLINE

1.            _Review of Daily Practice (5 min.)

Review Acceptance of Thoughts and Feelings exercise and Daily ACT Ratings

2.            _Learning to Accept Anxiety with Mindfulness (25 min.)

o           The Nature of Acceptance and Mindfulness

o           Acceptance of Anxiety Exercise

o           Acceptance Is Not a Clever Fix for Anxiety

3.            _Controlling Internal Versus External Events (10 min.)

o           The Polygraph Metaphor

4.            _Exploring Values (15 min.)

o           Making a Commitment

o           Valued Directions Worksheet

o           Values Versus Goals

5.            _Experiential Life Enhancement Exercises (Home)

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

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

o           Complete Daily ACT Ratings form

o           Complete Valued Directions worksheet

6.            _Session Materials and Handouts

o           Acceptance of Anxiety exercise instructions (two sets)

o           Acceptance of Anxiety practice form

o           Living in Full Experience (LIFE) form

o           Daily ACT Ratings form

o           Valued Directions worksheet

AGENDA

1. REVIEW OF DAILY PRACTICE (5 MIN.)

Review the client’s daily practice of the Acceptance of Thoughts and Feelings exercise and Daily ACT Ratings. Defer review of the LIFE form and Write Your Own Epitaph worksheet until you discuss values later in the session.

2. LEARNING TO ACCEPT ANXIETY WITH MINDFULNESS (25 MIN.)

Instead of the usual centering exercise, begin this session with a brief 5-minute introduction to clarify the nature of acceptance and mindfulness. This introduction should be followed by a 15-minute Acceptance of Anxiety exercise.

The Nature of Acceptance and Mindfulness 1

Please refer back to chapter 5 for a more detailed discussion on the nature of acceptance and mindfulness. Below is only a summary of the main points that therapists should convey to clients.

Acceptance means letting go of fighting the reality of having fear and anxiety. This means willingness to experience anxious thoughts, memories, sensations, and feelings as they are, without acting to avoid or escape from these experiences and the circumstances that may give rise to them, and without acting solely on the basis of what their mind may say about the meaning of these events (e.g., “I’m losing control,” “I must be dying or going crazy,” “I can’t do XYZ because I am too anxious”). Point out to clients the close relation between acceptance, willingness, and life goal–related behavior. Linehan (1993) defined willingness as accepting what is, together with responding to what is, in an effective and appropriate way. It is doing what works and just what is needed in the current situation or moment. Experiential acceptance is a willingness to experience anxiety-related thoughts, feelings, memories, and physiological reactions so that clients can participate in activities that they deem important and meaningful (Orsello et al., 2004).

These definitions make it very clear that acceptance and willingness are not feelings. They are a stance toward life and are very much about behavior and action. Stress that acceptance within the context of anxiety does not imply passive resignation (“giving up”), inactivity, or diminished personal responsibility. On the contrary, mindful acceptance creates space for clients to think and feel their thoughts and emotions rather than continuing to resort to automatic, habitual ways of responding. Let clients know that the mindfulness and acceptance exercises in this program are designed to help them broaden their behavioral repertoire and increase flexibility in responding (Wilson & Murrell, 2004)—they are literally meant to increase their response-ability.

When discussing these notions with clients, point out that acceptance does not mean approving or condoning their experience (past or present). It is simply about acknowledging and experiencing what is there. What makes mindfulness exercises so useful for clients is that they encourage observing without evaluation or judgment and without getting rid of, suppressing, or otherwise changing what they experience. Point out that such observation without judgment and with compassion is “acceptance behavior” or “skillful experiencing” of life in the present moment. This is actually an active response—just not in the way we usually think of being active (as in running, fighting, struggling, etc.). Mindfulness exercises teach clients to allow private events such as thoughts and emotions to come and go, simply sitting with and noticing them as they are in the present moment (Greco & Eifert, 2004).

The ultimate goal of mindfulness is happiness in terms of freedom from unnecessary suffering. Suffering occurs when we push psychological pain away and do things to escape from experiencing it. Recall how Marsha Linehan (1993) defines suffering as “pain plus nonacceptance.” Painful feelings of sadness and anxiety turn into suffering when we do not accept them and when we struggle to get rid of them. This leads us to become sad about being sad and fearful of having fear. Emphasize to clients that this is the type of suffering that mindfulness seeks to end and the type of freedom from suffering that mindful acceptance holds out for them. In this sense, the goal of mindfulness goes beyond acceptance of anxiety. Through mindfulness exercises, clients can gradually teach their mind to be less reactive, gain insight into how it works for and against them, and develop flexibility in responding to their mind. The goal is to develop a place of calm beneath the storm, to promote health and vitality, and to foster caring kindness toward themselves and others.

Acceptance of Anxiety Exercise

We adapted and tailored the Acceptance of Anxiety exercise to individuals with anxiety disorders from a more general set of acceptance exercises introduced by Segal and colleagues (2002) for use with depressed persons. At first, many clients are horrified by the notion that they should accept their anxiety, so explain to clients that accepting anxiety does not mean liking or wanting anxiety. It means dropping the rope and willingly making space for it when it is there—simply because it is there anyway. It means learning to see anxiety as it is (i.e., a jumble of uncomfortable feelings and physical sensations in the body) not as what their mind tells them it is (i.e., something dangerous, intolerable sensations that must be defeated, a sign that disaster is about to strike).

Tell clients that this exercise contains some elements from the Acceptance of Thoughts and Feelings exercise but focuses more explicitly on awareness of anxiety-related thoughts and bodily sensations and staying with such experiences until they no longer pull on the client’s attention. The exercise is about actively making space for anxiety-related thoughts, feelings, and other experiences by allowing or letting them be rather than rushing in to fix or change them (Segal et al., 2002). When clients let anxiety be—simply noticing and observing whatever is already present—they begin to create space for it, thereby opening up a fundamentally different way of being with their anxiety experience. This exercise is critical because it specifically teaches clients new skills that foster a new way of relating with anxiety-related aversive bodily sensations, thoughts, and feelings. Such experiences will likely show up in future sessions and in real-life situations as clients move forward on their path toward valued life goals. 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.            In our previous exercises, we have used the breath as the focus of attention. When the mind wandered off and started focusing on thoughts, worries, images, or feelings, you were asked to notice these thoughts and feelings and then gently redirect attention back to your breath. In this exercise, we actively and openly invite into our awareness bodily sensations and unwanted thoughts, worries, and images so that you may learn to approach them in an accepting and compassionate way. Just like in the finger trap and tug-of-war exercises, this exercise encourages you to lean into anxiety rather than fight it. Leaning into anxiety means creating a space for you to feel your emotions and think your thoughts, experiencing them as they are, rather than what your mind tells you they are. It also provides you with space to do things with your life that you may have put on hold for a long time. Are you willing to do an exercise to help you do that? [Wait for client’s 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 physical sensations in your body, especially the sensations of touch or pressure where your body makes contact with the chair or floor. Notice the gentle rising and falling of your breath in your chest and belly. There is no need 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 allowing and gentle acceptance to the rest of your experience. There is nothing to be fixed. Simply allow your experience to be your experience, without needing it to be other than what it is [pause 10 seconds].

4.            It is natural for your mind to wander away to thoughts, worries, images, bodily sensations, or feelings. Notice these thoughts and feelings, acknowledge their presence, and stay with them [pause 10 seconds]. There is no need to think of something else, make them go away, or resolve anything. As best you can, allow them to be … giving yourself space to have whatever you have … bringing a quality of kindness and compassion to your experience [pause 10 seconds].

5.            Allow yourself to be present to what you are afraid of. Notice any doubts, reservations, fears, and worries. Just notice them and acknowledge their presence, and do not work on them [pause 10 seconds]. Now see if for just a moment you can be present with your values and commitments. Ask yourself, Why am I here? Where do I want to go? What do I want to do? [pause 15 seconds]

6.            Now focus on a thought or situation that has been difficult for you. It could be a particular troubling thought, worry, image, or intense bodily sensations [pause 10 seconds]. Gently, directly, and firmly shift your attention on and into the discomfort, no matter how bad it seems [pause 10 seconds]. Notice any strong feelings that may arise in your body, allowing them to be as they are rather than what you think they are, simply holding them in awareness [pause 10 seconds]. Stay with your discomfort and breathe with it [pause 10 seconds]. See if you can gently open up to it and make space for it, accepting and allowing it to be [pause], while bringing compassionate and focused attention to the sensations of discomfort [pause 15 seconds].

7.            If you notice yourself tensing up and resisting what you have, pushing away from the experience, acknowledge that and see if you can make some space for whatever you’re experiencing [pause 10 seconds]. Must this feeling or thought be your enemy? [pause 10 seconds] Or can you have it, notice it, own it, and let it be? [pause 10 seconds] Can you make room for the discomfort, for the tension, for the anxiety? [pause 10 seconds] What does it really feel like—moment to moment—to have them? [pause 10 seconds] Is this something you must struggle with or can you invite the discomfort in, saying to yourself with willingness, “Let me have it; let me feel what there is to be felt because it is my experience right now”? [pause 15 seconds]

8.            If the sensations or discomfort grow stronger, acknowledge their presence, stay with them [pause 10 seconds], breathing with them, accepting them [pause 10 seconds]. Is this discomfort something you must not have, you cannot have? [pause 10 seconds] Even if your mind tells you that you cannot, can you open up a space for it in your heart? [pause 10 seconds] Is there room inside you to feel that with compassion and kindness toward yourself and your experience? [pause 15 seconds]

9.            Apart from physical sensations in the body, you may also notice thoughts coming along with the sensations, and thoughts about the thoughts. When you notice any such thoughts, also invite them in . . . softening and opening to them as you become aware of them [pause 10 seconds]. You may also notice your mind coming up with evaluative labels such as “dangerous” or “getting worse.” If that happens, you can simply thank your mind for the label [pause 10 seconds] 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].

10.        Stay with your discomfort for as long as it pulls on your attention [pause 10 seconds]. If and when you sense that the anxiety and other discomfort are no longer pulling for your attention, let them go [pause 15 seconds].

11.        Then, when you are ready, gradually widen your attention to take in the sounds around you in this room [pause 10 seconds]. Take a moment to make the intention to bring this sense of gentle allowing and self-acceptance into the present moment [pause 5 seconds], and when you are ready, slowly open your eyes.

Acceptance Is Not a Clever Fix for Anxiety

After completing the exercise, ask clients how they experienced the exercise and discuss any comments, questions, or concerns. Therapists can also weave into this discussion some more points about the nature and purpose of mindful acceptance.

As we outlined early on, clients may use mindfulness as yet another control strategy to get relief from anxiety. Briefly point out that it is essential that clients not use mindfulness and other exercises in this program as clever ways to combat or fix their anxiety. This may work in the short run, but it is a step back to the old, unworkable control agenda. Hence, therapists should pay careful attention when clients talk about their experiences with mindfulness exercises. Examine whether clients are using such exercises to control or manage anxiety. For instance, it is fine when clients report that they find themselves better able to allow anxiety-related thoughts and feelings to be rather than fighting them or pushing them away. Here clients are making progress toward being more accepting of their experience.

On the other hand, when clients report positive changes (e.g., symptom relief) as a result of having used the mindfulness exercises, they link acceptance to positive feeling outcomes. In such instances, clients may be attempting to use mindfulness as part of the “doing/driven” mode to achieve the goal of relaxation or anxiety relief, which has little to do with mindful acceptance (cf. Segal et al., 2002). Remind clients that “acceptance is so important because its opposite is too risky. An unwillingness to accept negative feelings, physical sensations, or thoughts [because they are aversive] is the first link in the mental chain that can rapidly lead to the reinstatement of old, automatic, habitual, relapse-related patterns of mind” (Segal et al., 2002, p. 223).

Also emphasize that mindfulness and acceptance ultimately occur in the service of committed action. Hence, acceptance is a more skillful way for them to relate to anxiety by acknowledging its presence, allowing it to be and making space for it as it is, so that they can move forward with their lives. Acceptance empowers them to do what they really want to do and experience whatever they may experience along the way. It will also be important to reiterate this purpose when providing the rationale for exposure exercises in subsequent sessions.

3. CONTROLLING INTERNAL VERSUS EXTERNAL EVENTS (10 MIN.)

The purpose of this section is to discuss with clients the contingencies that govern controllability. Ask clients whether they have heard of the serenity creed: Accept with serenity what you cannot change, have the courage to change what you can, and develop the wisdom to know the difference. Although many clients will have heard of it and agree with it, they simply do not know what they can change and what they cannot change in their life. Living the creed is difficult. We suggest the following text as a possibility for discussion.

The metaphors and exercises in this section are designed to help you to recognize what you can and cannot control, and to distinguish one from the other. Being able to make this distinction will help you better understand why anxiety became a problem for you, and it will point you in the direction of what to do and not to do. By now you already know that distracting yourself or telling yourself [use examples from client’s experience or LIFE form] has not really worked to control your anxiety and worries. Yet there is a good reason why you keep on doing this type of thing. The reason is that taking control does work well in certain situations. For example, if you had this chair in your room and you no longer liked it, you could get rid of it by getting up, taking it, and throwing it into the garbage [therapist stands up, goes to a chair in the room, and hints at throwing it away]. Once it is gone, it’s much like the saying “Out of sight, out of mind.” [Ask clients to come up with similar examples on their own, and discuss them briefly.]

These and other examples involve situations where you really are in control. The important question is, what makes these situations controllable? They all involve objects or situations in the outside world—the world outside the skin. Getting rid of things you don’t like in the outside world often is possible and has worked well for you.

Now what about controlling your thoughts and feelings? Can you also get rid of them or change them? By distracting yourself or using positive affirmations, you may feel better at first. But does it last? Do the worries, concerns, memories, and fears come back after a while? Do you recognize this pattern? Unlike old chairs that stay away after you toss them away, your thoughts and feelings keep coming back. The problem here is that what works well in the external world just does not work well in our internal world of thoughts and feelings. Here we are not in charge—our bodies and minds seem to march to their own tune. Yet, we often deal with our thoughts and feelings in the same way we deal with clothes we don’t like or the chair we wish to throw away. If we don’t like what we think and feel, we want to throw out those thoughts and feelings. And it just doesn’t work.

The Polygraph Metaphor

At this point, remind clients of the finger trap and tug-of-war exercises. The purpose of these exercises was to demonstrate that control efforts do not work and that clients have the option of ending their struggle by letting go and doing something counterintuitive; that is, something different from what they have done in the past. The polygraph metaphor (Hayes, Strosahl, & Wilson, 1999) is therefore particularly suited for clients with anxiety disorders because it illustrates the paradoxical effects of attempting to control and reduce anxiety-related responses and how such efforts can backfire. Such control efforts typically are ineffective, and often make matters worse. In a sense, the polygraph metaphor illustrates the vicious cycle of anxious apprehension, bodily sensations, catastrophic evaluations of such sensations, and panic (Barlow, 2002).

Imagine you are hooked up to the best and most sensitive polygraph machine that’s ever been built. Because this polygraph is incredibly effective in detecting anxiety, there is no way you can be aroused or anxious without the machine detecting it. Now here is your task: All you have to do is stay relaxed—just stay calm. If you get the least bit anxious, however, I will know it. I know you really want to stay relaxed. So I want to give you a special incentive to succeed. I will hold this revolver to your head [point your finger to your own temple and gesture about it going off]. If you just stay relaxed, I won’t shoot. In fact, I will even give you $100,000! But if you get nervous—and remember, this perfect polygraph will notice that immediately—I’m going to have to kill you. So, just relax!

Therapist: What do you think would happen in this situation?

Client: I don’t think I could do it, but what about you? Could you do it or help me do it?

Therapist: I don’t think I could do it either. The tiniest bit of anxiety would be terrifying. We’d be going “Oh, my God! I’m getting anxious! Here it comes!” We’re dead.

Client: I thought I was the one with the problem. Why can’t you do it?

Therapist: Because none of us can stay calm with a gun pointed at our head. If I were in that situation, I’d get shot, too. So it’s not that you are somehow broken and need to be fixed by me. We’re in this together.

Client: Are you saying there is nothing we can do or control?

Therapist: I’m not saying that at all. What if I had told you, “Get rid of that painting on the wall or I’ll shoot you,” instead of telling you to relax? You probably would have taken down the picture and given it away, and everything would be fine. That is how the world outside the skin works. We can change and control things by doing stuff with our hands and feet. But if I simply told you, “Relax, or I’ll shoot you,” what would happen?

Client: I guess I’d get quite nervous and would get shot if there really was a gun.

Therapist: The harder you’d try, the more nervous you’d get because you would be able to tell it wasn’t working. So why does it not work? What’s the difference between getting rid of a picture on your wall and staying relaxed?

Client: Well, I can get rid of the picture by literally throwing it away with my hands, but I can’t get inside my brain and change what’s going on there. That’s why I have tried talking to myself—you know, trying to calm myself down.

Therapist: How has that worked in your experience?

Client: Sometimes a bit, but not for long and certainly not as much as I would like it to.

Therapist: It is interesting that you mention your brain, because it is actually the command center of the perfect polygraph, and you’re already hooked up to it. Your nervous system is better than any polygraph and will detect any anxiety you have. Now, in your situation, you’ve got something pointed at you that is even more threatening than any gun: the workability of your life. So what do you get when you notice anxiety and hold that powerful workability gun to your head and say, “Relax”?

Client: I’m getting shot! This is what my life feels like, and it’s definitely not what I want.

Therapist: Perhaps we should be looking more closely at what it is that you do want. I mean what really matters to you deep down—and what it is that you can get.

Apart from illustrating the paradoxical effects of attempting to control and reduce anxiety-related responses, the polygraph metaphor helps clients experience the difference in how control works for most things in the external world versus how control works against us when applied to aspects of the private world. Conscious, deliberate, purposeful control works great in the manipulable world, where the following rule applies: “If you don’t like it, figure out a way to get rid of it, and then get rid of it.” This type of control, however, does not work with emotions, feelings, memories, worries, and bodily sensations. In fact, when control is applied to unpleasant thoughts and emotions, it tends to give us more of the very experiences we do not want to have. In such cases, deliberate control is not a solution; it becomes part of the problem or even the problem. Again, remind clients, “You can run but you can’t hide. You simply cannot avoid yourself and what is happening inside of you. These experiences define what is uniquely human about you. To act against them is to act against your very being.”

Any references to values in these discussions plant an important seed for future sessions and are a good transition to the next treatment section. Recall that valued living often gets pushed out of the way as anxious clients struggle to manage fear, panic, worries, and so on. Continued practice and work with the LIFE form serves to identify and emphasize these personal costs. In the last part of this session, we begin exploring values—something clients do have control over.

4. EXPLORING VALUES (15 MIN.)

Making a Commitment

This is an important emotional and potentially very motivating moment in therapy. First, review last week’s LIFE form and focus on any instances where engaging in behavior to manage anxiety-related feelings and thoughts was associated with short- or long-term costs. Then move on to the epitaph exercise and discuss the client’s experience with this exercise. If clients have identified one or more core values, the therapist can ask clients whether they are willing to take a stand and commit to these values.

Therapist: I want you to connect with this statement on your epitaph and what you really intend to have in your life. Are you willing to stand up, look me in the eye, and tell me what is most deeply true about you, what you’d want your life to be about if you weren’t living a life in the anxiety box?

Client: I am not sure whether I will get out of the box, but I do know what I want in life.

Therapist: Okay, then please stand up, look at me, and tell me: what do you want to be about?

Client: I want to be a loving partner, independent, and a great architect.

Therapist: [keeping eye contact with the client] Then I want what we do together to be about that! [pause] You can have that.

The discussion of what clients want their lives to stand for and their subsequent commitment to these values is a good basis for a more specific discussion of values and goals. Some clients initially are confused as to what therapists mean by “values.” A simple way to describe values is to refer to them as parts of life that are important to most people. We categorize values into domains or areas: family, friends, romantic relationships, leisure, education, career, citizenship, health, and spirituality. Although we list domains separately, most domains overlap. For example, the value of education can lead to a career, and your career can lead to meeting new friends.

The epitaph exercise and other value-related exercises often make people sad when they realize how much of their lives they put on hold in the service of managing or avoiding anxiety. This is a good opportunity to reassess the client’s agenda. Until now, this agenda typically has been, “I will only be able to move on with my life after my anxiety symptoms are lessened or controlled.” Therapists can encourage clients to use these life directions as both a guide and a justification for the hard work of treatment. Whenever therapists notice, or clients report, attempts at symptom alleviation, therapists should ask clients whether these attempts move them toward or away from life goals. Again, the issue is not whether control or acceptance behavior is the “better” strategy—the question is what behavior works and helps clients move toward their chosen life directions.

Valued Directions Worksheet

Therapists should briefly explain how to complete the Valued Directions worksheet provided at the end of this chapter and on the book CD. It is a somewhat lengthy form that incorporates the ten life domains examined in the Valued Living Questionnaire (Wilson & Groom, 2002) and parts of the value worksheets presented in our ACT anorexia workbook (Heffner & Eifert, 2004) and in the book by Hayes, Strosahl, and Wilson (1999). It is essential that clients complete this worksheet at home and bring it back to the next session because the identified directions will be used to construct a Life Compass and identify barriers to moving in those directions. This exercise also will become the focus of exposure exercises in subsequent treatment sessions. So ask clients whether they are 100 percent willing to make a commitment to complete this worksheet for the next session.

Values Versus Goals

One of the most common problems we encounter when we ask clients about their values is that they confuse values with goals. For instance, a client may say, “I want to be less anxious” or “I want to be more at peace with myself.” Both statements sound like values, when they are really goals. One could regard being less anxious and more at peace as emotional goals. Essentially, being more calm or at peace is an outcome, a result that may (or may not) happen after we start moving toward our values. Values are a direction. They must be lived out (Hayes, Strosahl, & Wilson, 1999). They are what you do.

Goals are destinations. Goals are actions that people can tick off and complete—you’ve done it or not (e.g., losing ten pounds, taking a vacation, getting a degree, mowing the lawn). Once we reach a goal, the work is done, and we are finished. For example, getting married is a goal. Once that ring is on your finger, your goal is achieved. Values are lifelong journeys. One can answer the question “Am I done yet?” for goals, but not for values. They have no end point. Instead, they direct us throughout life. For example, the value of being a loving, devoted partner is not complete the moment you say “I do.” Being a loving, devoted partner is something you must constantly keep on working toward, and there is always room for improvement. Also, reaching a particular goal (getting married) is just one of many steps in a valued direction (being a loving partner).

Although values and goals are not the same, they are related. Also, different values can underlie the same goal. For instance, most college students pursue the same goal: They want to graduate from college. They have reached this destination or goal when they have the degree certificate in hand. Different values may underlie the goal of a college education. Some people want to earn a degree because they value learning and education. Others value being financially secure, and earning a degree is a step toward a higher income. Others value friendship, and college is a way to meet new people and make friends. You can then ask clients to examine their own behavior and identify the values that underlie their goals. Ask them to think of one or two goals they have set for themselves. To determine the value that underlies the goal, they can ask themselves, “Why am I doing this?” “What am I trying to accomplish in my life with this goal?” “Where am I heading with this?”

5. EXPERIENTIAL LIFE ENHANCEMENT EXERCISES (HOME)

§    Practice of the Acceptance of Anxiety exercise for at least 20 minutes daily, 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 Daily ACT Ratings form

§    Complete the Valued Directions worksheet

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Session 5: Moving Toward a Valued Life with an Accepting, Observing Self

Goals and Theme

The major goal of Session 5 is to prepare clients for subsequent in-session and between-session exposure exercises and to link those exercises to the client’s values and goals. Previous exercises have already laid the necessary groundwork. At this point, clients should have developed some rudimentary skills for observing anxiety in a mindful, accepting way. Several exercises in this session are designed to facilitate further development of an accepting observer perspective (self-as-context). In so doing, clients will gain additional practice distinguishing between experiences they have (thoughts, emotions, and physical sensations) and the person having them. Clients also learn that they have a choice. They can choose to observe and accept their anxiety for what it is, or choose to react to it in a way that has limited their options and their lives.

Using the Valued Directions worksheet as a guide, begin by helping your client complete the Life Compass by focusing attention on specific values, goals, and barriers to achieving those goals. Clients and therapists should then compare the importance of identified values with how much time clients have recently devoted to these values. A discussion of the discrepancy between importance and consistency ratings will identify some common barriers to movement in valued directions. This exercise serves an important motivational function for exposure exercises in subsequent treatment sessions, and provides the context for such exercises.

SESSION OUTLINE

1.            _Centering Exercise (5 min.)

2.            _Review of Daily Practice (5 min.)

o           Review daily practice of Acceptance of Anxiety exercise and Daily ACT Ratings

3.            _Self as Context Versus Content (20 min.)

o           Playing Volleyball with Anxiety Thoughts and Feelings

o           The Chessboard Metaphor and Exercise

o           Anxiety News Radio Metaphor

4.            _Life Compass—The Ultimate Reason for Exposure (25 min.)

o           Review LIFE form

o           Review Valued Directions worksheet

o           Complete Life Compass

5.            _Experiential Life Enhancement Exercises (Home)

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

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

o           Complete Daily ACT Ratings form

o           Rewrite Life Compass based on in-session discussion

6.            _Session Materials and Handouts

o           Acceptance of Anxiety practice form

o           Living in Full Experience (LIFE) form

o           Daily ACT Ratings form

o           Life Compass form (2 copies)

o           Chessboard with two teams of players

o           Printout of Anxiety News Radio metaphor text (if possible, also paste text on the front and back of an index card for client to take home)

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, briefly review Daily ACT Ratings and the client’s daily practice of the Acceptance of Anxiety exercise, paying attention to any lack of compliance for reasons having to do with unwillingness, lack of commitment, or high fearfulness. Defer reviewing the Values Assessment worksheet and LIFE form until you introduce the Life Compass later in the session.

3. SELF AS CONTEXT VERSUS CONTENT (20 MIN.)

The idea of a self that is context as opposed to a self that is defined by its content (what is in it or what it is made of) is quite abstract and difficult to grasp, even for professionals. Self as context is a stance toward oneself and the world. Here the self is not the experience but simply provides the context for experience. Clients often have a hard time grasping this concept and the notion of an observer self. The observer self simply observes experience without taking sides (e.g., “good” or “bad”). The metaphors and exercises in this session are designed to help clients experience that they are not the content of their experience. They are the context for their experiences. The metaphors also bring out the behavioral implications of being an observer: Clients can make choices that are different from those they made in the past.

Start the discussion by pointing out that most people (not just clients) find it difficult to grasp the idea that we are not our experience; that is, we are not our thoughts, our worries, our bodily sensations, our feelings, our histories. These experiences are a part of us. They come and go. We do not own them. We cannot hold on to them if we like them. We cannot make them go away if we dislike them. Also, one thought does not define us more than another thought. The content, and perhaps social desirability, of our experiences may change over time. Yet, a “good” thought (“I am confident”) is not more like us than a “bad” thought (“I’d like to hit this man”). Either thought is no better or worse than any other thought. Much like a house provides the context (e.g., rooms with walls, floors, and ceilings) for people to live in along with all their furniture and other belongings, the self (with the brain and the rest of the body) provides the context for our experiences to occur (Hayes, Strosahl, & Wilson, 1999). The house basically remains the same regardless of who lives in it, what furniture is in it, and whether its walls are painted white or red. And as far as we know, the house probably doesn’t care much about who lives in it, what people do in it, what they think or feel, or what furniture its inhabitants may put in it. The house just provides the space or context for all of that living to occur.

Playing Volleyball with Anxiety Thoughts and Feelings

We first used this metaphor in the context of an ACT treatment program for anorexia (Heffner & Eifert, 2004). Below is an adaptation for use with clients with anxiety disorders.

Throughout a volleyball match, both teams strive to keep the ball in action, back and forth from one side of the court to the other and never letting the ball hit the ground. Each time the ball is about to sail across the net to one side of the court, a player in the front row jumps up to block it with her bare hands. Behind the blocker are five other players strategically positioned to keep the ball in motion. If the ball is not blocked, a player in the back row dives to the ground with her arms stretched out to pop the ball into the air, as another teammate is set up to deliver a mighty spike to send the ball back to the other side. All the while, each player stands alert and ready, trying to read the opponents in anticipation of their next move.

The strategy of volleyball is a way of describing how you are responding to anxiety-related thoughts and feelings. Imagine that a volleyball match is going on inside your mind. Instead of volleying a ball back and forth, the teams inside your head are volleying thoughts about you. Much like competitive volleyball, which is not exactly the fun leisure activity you play on a nice day at the beach, your anxiety-related thoughts seem intense and forceful. And just when you thought they might be taking a rest, they are right back in your face, challenging you and yelling at you to take them on.

On one side of the court is Team A (Anxiety). Team A serves up the following thought: If you go to the mall tomorrow, you’re going to have a horrific panic attack. This could be the big one you’ve always been afraid of!

Team S (Struggle) is ready for action, diving to the ground to prevent that thought from touching down: Wait a minute. I have gone before and I can do it again.

At this point, Team A keeps the ball in motion: That’s what you think now, but when you get there, I am going to be so big that you’ll just run and leave as quickly as you can. I’m going to yell right into your face and tell you to get out of that place. You might not even get out in time and just end up lying on the floor with people staring at you.

Across the net, the thought goes, with Team S ready for the return: I am going to ask my friend to come with me. She can help me if things get out of control.

Before that thought crosses the net, Team A blocks it with: But she can’t really help you. When I attack you, you have no chance of beating me—no matter who is with you. I am in control here, in case you hadn’t noticed it.

Then, Team S powers back with: Well, at least I can try to beat you.

And so the game goes on and on. As soon as Team Anxiety serves up an unsettling thought, Team Struggle responds to that thought by somehow arguing with it. Have you noticed how this volleyball competition of thoughts and feelings seems to go on in your head?

Ask clients to think of examples of mental volleyball they have been playing with anxiety-related thoughts and feelings. For clients with GAD or OCD, you can use the activity of worrying or struggling with intrusive thoughts as perfect examples of mental volleyball.

After discussing a few examples of how your client plays mental volleyball, you can present an additional metaphor that suggests the possibility of responding differently by taking a different perspective. Fighting with anxiety has become a firmly ingrained habit for most clients. So the idea of deliberately observing rather than mindlessly participating in a struggle with anxiety is likely to be quite foreign to them. The following chessboard metaphor illustrates that clients do have an option that is different from struggling. The chessboard metaphor was first described by Hayes, Strosahl, and Wilson (1999) and can be applied in a flexible way to address fighting with internal events such as thoughts, feelings, memories, and physical sensations. Instead of choosing to be a member of Team A or Team S in the volleyball game, clients can choose to be the chessboard instead of being a player on either the black team or the white team. In fact, they are the board already—it’s just that they have never before taken this perspective.

The Chessboard Metaphor and Exercise

Rather than presenting this metaphor verbally, we prefer to use an actual chess board with two teams of players on it. Using a real board with players should help increase the experiential salience of the metaphor and make it more concrete. Also, even if people don’t know anything about the rules of chess, they will get the general idea of the game if you demonstrate how players knock each other off the board and try to outsmart each other through various maneuvers.

Look at this chessboard. It’s covered with different-colored pieces—black pieces and white pieces. They work together in teams: The white pieces fight against the black pieces and vice versa. You can think of your thoughts and feelings and beliefs as these pieces; they also hang out together in teams. For example, “bad” thoughts, memories, and feelings like anxiety hang out on one side (the “dark team”), whereas the “good” pieces (e.g., thoughts expressing self-confidence, feelings of being in control, etc.) hang out on the other side of the board. They all move toward members of the other team in an effort to defeat the other side—to take over the opposing team’s space on the board, and ultimately the whole board. So, when the dark knight of the anxiety team attacks, you get up on the back of the white queen, ride into battle, and knock the dark knight out by doing or thinking something to defeat the dark knight. [Therapist can literally knock a few players off the board.]

Therapist: Is this the end of this war? Is the anxiety team gone and defeated?

Client: No, one of the other guys will step forward and try to knock me down.

Therapist: It seems like there are a lot of anxiety players left on this board, just patiently waiting for their chance to attack you.

Client: It sure feels like that. But if I fight back using smart tactics and maneuvers, can’t I eventually take them all out? I mean, eventually all the anxiety thoughts and feelings should be dead and gone.

Therapist: I can see your point. Looking back at your experience, has this ever happened in your struggle with anxiety?

Client: I wish it had. I guess I wouldn’t be here then. Perhaps I’m just not smart enough.

Therapist: Or perhaps this is not at all about being smart? Something in this game is different from an actual chess game. If we were playing a real chess game, I would be in charge of one team and you would be in charge of the other. I would never know your strategy and next move and you would never know mine, because we are two different players. If you were to use a clever strategy and make the right moves in that situation, you could actually beat me for good. When it comes to the chess game against your anxiety, however, a tricky problem arises that ensures that you can never win that game. The two opposing teams are really one team, and there is only one player in this game: you. The thoughts on both sides of the board are your thoughts and feelings. They both belong to you. You support them with your board. No matter which side wins, one part of you will always be a loser. You can never win a competition where your own thoughts compete against each other. If you side with one particular team, huge portions of yourself are your own enemy. It’s like waging a war against yourself. This is a game you just cannot win.

Client: And the game is very tiring, too.

Therapist: This war game surely sucks up a lot of life juices. You are fighting to win the war against anxiety, trying to knock off enough of those pieces so that you eventually dominate them. Except in this game, you can’t ever seem to win the battle. Although you can knock down the black pieces temporarily, you can’t ever knock them off the board for good. They keep coming back to life no matter what you did to strike them down beforehand. So the battle goes on, every day, for years. You feel hopeless and sense that you can’t win, and yet you can’t stop fighting. And as long as you’re on the back of that white horse or queen, fighting is the only choice you have.

[This is a good time to introduce a new perspective—one that clients probably have not contemplated before.]

Therapist: Let’s step back and think about what is really going on here. What if I told you that those chess pieces aren’t you anyway? Can you see who else you would be? [Respond to all client answers; ultimate answer is, “You are the board.”] Within this game, what would happen to all the pieces if there were no board?

Client: They’d just go away. We couldn’t play. Without the board, there is no game.

Therapist: Yes, it seems like the role of the board is to let it all happen. If you’re the pieces, however, the outcome of the game is very important; you’ve got to beat that anxiety as if your life depends on it. But if you’re the board, it doesn’t matter if the war stops or not. The game may go on, and it doesn’t make any difference to the board. As the board, you can see all the pieces, you can hold them and have them played out on you, and you can simply watch all the action. And the board doesn’t care which team seems to be winning or losing. Same thing with the volleyball game: Instead of siding with Team A or S, you could be the volleyball court and simply look at the action.

Client: Is that why we’ve been doing these mindfulness exercises?

Therapist: Well, they are a way of getting in touch with the part of you that is the volleyball court and the chessboard. You can simply watch what is going on, and you don’t need to respond to anything. For instance, the volleyball court is merely there and watches and holds all of the players, the net, and the ball. The court does not care who wins or loses. The court does not worry about the outcome and will continue to be there after the game is over, as different players come and go. Occasionally, the players pounce and dive on the court, and it is possible that the court will suffer some scuff marks and poundings.

Client: It seems like I have quite a few of those.

Therapist: And it is okay to feel that pain. The fact that you, the court, sometimes experiences pain is just a reminder that being an observer is easier said than done. As you observe your thoughts and feelings, you notice that some of them are painful and scary. You may not like what you think or feel, and you may wish you felt differently. However, your thoughts and feelings—all of them—are a part of you. They are not you, but they are all a part of you. If you choose to be the court and the board, you are an impartial observer who watches the games take place; you need not be a player with a stake in the outcome of each game.

Anxiety News Radio Metaphor 2

The chessboard and volleyball metaphors serve to illustrate the notion that we need not fight and struggle with our experience—we can choose to observe and accept instead. Perhaps an even simpler way of summarizing this ACT principle is that we can choose what we pay attention to. This choice is humorously illustrated in the Anxiety News Radio metaphor. The text of this metaphor is also on the book CD. Though most metaphors used throughout this book should not be read verbatim, we suggest that you print both parts of this metaphor on the front and back of an index card and read it verbatim to the client in the voice of a radio news anchor. At the end of the session, clients can then take the index card home or put it in their pocket, purse, or briefcase and refer to it later as they see fit.

ANXIETY NEWS RADIO (WANR): “This is Anxiety News Radio, WANR, broadcasting inside your head twenty-four hours a day, seven days a week. Wherever you are, the signal will reach you. When you wake in the early hours, we’ll be there to make you aware of all the unhappy aspects of your life, even before you get out of bed. Let us take over and control your life. Anxiety News Radio is compelling listening, and guess why! It’s the news station you’ve grown up with, and now it comes to you automatically, 24/7. Pay attention! Anxiety News Radio knows what’s best for you and we want you to buy our products. We advertise only what is most disturbing and distressing to you personally. So don’t forget that, and remember, if you should forget us and ACT without seeking permission, then we’ll broadcast all the louder. Remember, what you think and feel inside your skin can be really awful, so you should stay tuned to this station to know what to think and how to control it.”

JUST SO RADIO (WJSR): “Wake up! Anxiety News Radio is just a station—you can tune in, or you can tune out! One thing is guaranteed though, whatever the time of day, you’ll hear the same old stuff on WANR. If that’s been really helpful to you, then go ahead, tune in and stay tuned. That would make sense. If not, then tune in more often to Just So Radio. We bring you the news of actual experience, in the moment—all live, all the time. Actuality is our business! We give it to you straight—as it is, not as your mind says it is. In contact with the world outside and inside the skin, you can experience what it is to be human, and it’s entirely free! We can guarantee that experiencing what’s inside the skin—exactly as it is—will never damage you, but it just might bring you joy. Just So Radio brings you information about how things are, not how you fear they might be. Just So Radio invites you to step forward and touch the world, just as it is, and to touch your life, just as it is. We get louder the more you listen to us. So, stay tuned. Give us a fair trial, and if not convinced by your own experience (please don’t take our word for it) then WANR—Anxiety News Radio—is still there on the dial.”

Our colleague, Peter Thorne, who provided the Anxiety News Radio metaphor, also shared an interesting comment with us from one of his clients with an anxiety disorder. She told him that she’d gotten tired of listening to Anxiety News Radio long before she came into therapy. However, it had never occurred to her that she didn’t have to stay glued 24/7, slavishly believing all the broadcasts inside her mind. The idea that she could tune into more helpful sources of information out there in her world of actual real-life experience was a helpful new direction for her.

4. LIFE COMPASS—THE ULTIMATE REASON FOR EXPOSURE (25 MIN.)

Return to the discussion on values by first reviewing last week’s LIFE form and focusing on any instances of clients engaging in behavior to manage anxiety-related feelings and thoughts and how such behavior may have interfered with what clients really care about or wanted to do.

Next, take out a Life Compass form and tell clients you will be using the information from their Valued Directions worksheet to complete the Life Compass (Dahl et al., 2002). Explain that the person in the middle of the compass is the client, surrounded by ten life domains. This is a good opportunity to help clients clarify or simplify any value statements. Sometimes clients find it easier to refer to these value statements as intentions—that is, how they would like to live their life in that area. Ask clients to copy the intention statements from the worksheet into the life compass for areas they rated as at least moderately important. What is most important to them in that area? Then ask clients to copy their importance rating from the worksheet to the “i” box connected to each value. The next step is to examine how much their current behavior is in accord with these importance ratings.

We have gone all around your life compass and looked at how important each dimension is for you, and you have written your intentions in each area that matters to you at least moderately. Now please think about your activities in the past week. We can call your activities your “feet.” In this past week, how consistent were your feet with these intentions, the ones you just wrote down? How consistent have your actions been with your intentions? In other words, how actively have you been working toward those intentions? I am not asking about your ideal in each area or what others think of you. I just want to know how you think you have been doing during the past week. So for each intention, rate how often have you done something to move you forward in this area during the last week. Use the same activity rating scale as on the Valued Directions Worksheet (0 = no action, 1 = once or twice, 2 = three or four times, 3 = more than four times). Write your ratings in the “c” box next to the “i” box connected to each value. These ratings will give you an idea of how consistent your behavior has been with your values.

[The next step is to compare how well intentions and behavior have matched. Are clients doing things that are important to them? It is quite likely that there will be discrepancies between importance and consistency ratings. This means that clients have identified their values but are not moving in a direction that supports those values.]

Therapist: What do you see when you look at your life compass?

Client: It doesn’t look good. It looks like I am living a life far different from the one I wanted. But I guess that’s what happens to everyone. What you want is one thing and how things turn out is something else.

Therapist: Which of those values has changed?

Client: None of them, it’s just that some are probably unrealistic and others are just too darn hard.

Therapist: Tell me why they are unrealistic or too hard. What is stopping you from reaching those goals and moving closer to your intentions? Is it okay if I write your reasons under the heading of “stories” or “barriers”?

Go to each area where you see high importance ratings and low activity/ consistency ratings, and ask clients to explain the discrepancy. Ask clients to think about what stands in the way of pursuing the valued direction they have identified. Although clients are likely to report a number of barriers that stand in their way, many of them will be directly related to anxiety. Summarize them in succinct one-line statements and write them into the Valued Directions worksheet. The barriers can also be written in brief telegram-style fashion on the Life Compass next to the corresponding arrow. It is helpful to separate the stories into internal and external barriers. Typical examples of internal barriers are thoughts, feelings, and worries. Common examples of external barriers are lack of money, time, space, and availability. At this point, therapists need not discuss how to deal with barriers. This will be a major focus of subsequent sessions.

In our experience, making concrete the major discrepancies between highly valued intentions and low consistency ratings is a powerful emotional experience for clients. It shows clients in their own handwriting what they want to do with their lives and how much they have given up in the service of managing their anxiety and worries. Again, the issue is not whether controlling anxiety or accepting anxiety is the better strategy—the question is what type of behavior works in terms of moving clients closer to their chosen life goals.

We have found that by working on and rewriting intentions and barriers, the Life Compass tends to look rather messy by the end of the session. For this reason, we give clients a clean form to take home and ask them to copy the statements and rating numbers from the form used in session onto the clean form at home. Doing so alone at home will once again let clients experience what they care about and what they have been missing out on.

5. EXPERIENTIAL LIFE ENHANCEMENT EXERCISES (HOME)

§    Practice the Acceptance of Anxiety exercise for at least 20 minutes daily, and complete the practice form after each practice

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

§    Complete the Daily ACT Ratings

§    Rewrite the Life Compass based on in-session discussion

life compass