Psychology: Acceptance and Commitment Therapy

Three discussion posts and Reflection 

No Plagiarismfollow instruction

Acceptance and Commitment Therapy Seminar:

References

List

References

APA.org. (2012). What Are The Benefits of Mindfulness? Retrieved from https://www.apa.org/education/ce/mindfulness-benefits

Association for Contextual Behavioral Science (ACBS). (2019). State of ACT Evidence. Retrieved July 1, 2019, from https://contextualscience.org/state_of_the_act_evidence

Association for Contextual Behavioral Science (ACBS). (n.d.). About ACT. Retrieved from https://contextualscience.org/state_of_the_act_evidence

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7-18.

Eifert, G. H., Forsyth, J. P., Arch, J., Espejo, E., Keller, M., & Langer, D. (2009). Acceptance and Commitment Therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cognitive and Behavioral Practice, 16, 368-385.

Harris, R. (2009). ACT made simple. Oakland, CA: New Harbinger Publications.

Hayes, S. C., Pistorello, J., & Biglan, A. (2008). Acceptance and Commitment Therapy: model, data, and extension to the prevention of suicide. Brazilian Journal of Behavioral and Cognitive Therapy, X(1), 81-102.

Hayes, S. C. (2005). Get out of Your Mind & into Your Life. Oakland, CA: New Harbinger Publications.

Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30(7), 865–878. doi:10.1016/j.cpr.2010.03.001

Purser, R. (2015). The myth of the present moment. Mindfulness, 6(3), 680-686.

Society of Clinical Psychology. (SCP) (2016). Treatments Home. Retrieved June 30, 2019, from https://www.div12.org/psychological-treatments/

TEDx Talks. (2016, July). Mental Brakes to Avoid Mental Breaks | Steven Hayes | TEDxDavidsonAcademy [Video file]. Retrieved from https://www.youtube.com/watch?v=GnSHpBRLJrQ

TEDx Talks. (2016, February). Psychological flexibility: How love turns pain into purpose | Steven Hayes | TEDxUniversityof Nevada [Video file]. Retrieved from https://www.youtube.com/watch?v=o79_gmO5ppg&t=87s

Participation Assignment (Required for All Students): Module 1 – Introduction to Acceptance and Commitment Therapy & Doing What Matters

Prompt: Considering your experience of Module 1

Please address the following point in your response (please follow the directions “For full credit” bellow when completing this prompt):

· In your opinion, what were the two (2) most interesting or engaging things from Module 1?

· Why were those things especially interesting or engaging to you?

For this assignment, I want you to complete the prompt above and to post your response onto this discussion board. Click on “reply” below and type your response in at least 1 paragraph with at least 4 sentences in each paragraph.

In addition, please thoughtfully and kindly respond to at least one other classmate’s response to the prompt (more than just, “I agree.”).

For full credit

:

· Your response must be at least 1 paragraph long with at least 4 complete sentences. I highly recommend typing your response into a separate file first, then copying/pasting and submitting your response here.

· Your writing must reflect proper spelling, grammar, and punctuation.

·
All information that is obtained and discussed beyond the lecture and/or required or optional readings are appropriately cited and are only peer-reviewed scientific journal articles
.

PERSONAL VALUESPERSONAL VALUESPERSONAL VALUESPERSONAL VALUES

Card SortCard SortCard SortCard Sort

W.R. Miller, J. C’de Baca, D.B. Matthews, P.L.
Wilbourne

University of New Mexico, 2001

IMPORTANT TO MEIMPORTANT TO MEIMPORTANT TO MEIMPORTANT TO ME

VERY IMPORTANT TO MEVERY IMPORTANT TO MEVERY IMPORTANT TO MEVERY IMPORTANT TO ME

NOT IMPORTANT TO MENOT IMPORTANT TO MENOT IMPORTANT TO MENOT IMPORTANT TO ME

ACCEPTANCEACCEPTANCEACCEPTANCEACCEPTANCE

to be accepted as I am

1 9/01

ACCURACYACCURACYACCURACYACCURACY

to be accurate in my opinions and beliefs

2 9/01

ACHIEVEMENTACHIEVEMENTACHIEVEMENTACHIEVEMENT

to have important accomplishments

3 9/01

ADVENTUREADVENTUREADVENTUREADVENTURE

to have new and exciting experiences

4 9/01

ATTRACTIVENESSATTRACTIVENESSATTRACTIVENESSATTRACTIVENESS

to be physically attractive

5 9/01

AUTHORITYAUTHORITYAUTHORITYAUTHORITY

to be in charge of and responsible
for others
6 9/01

AUTONOMYAUTONOMYAUTONOMYAUTONOMY

to be self-determined and independent

7 9/01

BEAUTYBEAUTYBEAUTYBEAUTY

to appreciate beauty around me

8 9/01

CARINGCARINGCARINGCARING

to take care of others

9 9/01

CHALLENGECHALLENGECHALLENGECHALLENGE

to take on difficult tasks and problems

10 9/01

CHANGECHANGECHANGECHANGE

to have a life full of change and variety

11 9/01

COMFORTCOMFORTCOMFORTCOMFORT

to have a pleasant and comfortable life

12 9/01

COMMITMENTCOMMITMENTCOMMITMENTCOMMITMENT

to make enduring, meaningful
commitments
13 9/01

COMPASSIONCOMPASSIONCOMPASSIONCOMPASSION

to feel and act on concern for others

14 9/01

CONTCONTCONTCONTRIBUTIONRIBUTIONRIBUTIONRIBUTION

to make a lasting contribution
in the world
15 9/01

COOPERATIONCOOPERATIONCOOPERATIONCOOPERATION

to work collaboratively with others

16 9/01

COURTESYCOURTESYCOURTESYCOURTESY

to be considerate and polite
toward others
17 9/01

CREATIVITYCREATIVITYCREATIVITYCREATIVITY

to have new and original ideas

18 9/01

DEPENDABILITYDEPENDABILITYDEPENDABILITYDEPENDABILITY

to be reliable and trustworthy

19 9/01

DUTYDUTYDUTYDUTY

to carry out my duties and obligations

20 9/01

ECOLOGYECOLOGYECOLOGYECOLOGY

to live in harmony with the environment

21 9/01

EXCITEMENTEXCITEMENTEXCITEMENTEXCITEMENT

to have a life full of thrills and stimulation

22 9/01

FAITHFULNESSFAITHFULNESSFAITHFULNESSFAITHFULNESS

to be loyal and true in relationships

23 9/01

FAMEFAMEFAMEFAME

to be known and recognized

24 9/01

FAMILYFAMILYFAMILYFAMILY

to have a happy, loving family

25 9/01

FITNESSFITNESSFITNESSFITNESS

to be physically fit and strong

26 9/01

FLEXIBILITYFLEXIBILITYFLEXIBILITYFLEXIBILITY

to adjust to new circumstances easily

27 9/01

FORGIVFORGIVFORGIV

FORGIVENESS

ENESSENESSENESS

to be forgiving of others

28 9/01

FRIENDSHIPFRIENDSHIPFRIENDSHIPFRIENDSHIP

to have close, supportive friends

29 9/01

FUNFUNFUNFUN

to play and have fun
30 9/01

GENEROSITYGENEROSITYGENEROSITYGENEROSITY

to give what I have to others

31 9/01

GENUINENESSGENUINENESSGENUINENESSGENUINENESS

to act in a manner that is
true to who I am
32 9/01

GOD’S WILLGOD’S WILLGOD’S WILLGOD’S WILL

to seek and obey the will of God

33 9/01

GROWTGROWTGROWTGROWTHHHH

to keep changing and growing

34 9/01

HEALTHHEALTHHEALTHHEALTH

to be physically well and healthy

35 9/01

HELPFULNESSHELPFULNESSHELPFULNESSHELPFULNESS

to be helpful to others

36 9/01

HONESTYHONESTYHONESTYHONESTY

to be honest and truthful

37 9/01

HOPEHOPEHOPEHOPE

to maintain a positive and
optimistic outlook
38 9/01

HUMILITYHUMILITYHUMILITYHUMILITY

to be modest and unassuming

39 9/01

HUMORHUMORHUMORHUMOR

to see the humorous side of
myself and the world
40 9/01

INDEPENDENCEINDEPENDENCEINDEPENDENCEINDEPENDENCE

to be free from dependence on others

41 9/01

INDUSTRYINDUSTRYINDUSTRYINDUSTRY

to work hard and well at my life tasks

42 9/01

INNER PEACEINNER PEACEINNER PEACEINNER PEACE

to experience personal peace

43 9/01

INTIMACYINTIMACYINTIMACYINTIMACY

to share my innermost experiences
with others
44 9/01

JUSTICEJUSTICEJUSTICEJUSTICE

to promote fair and equal treatment for all

45 9/01

KNOWLEDGEKNOWLEDGEKNOWLEDGEKNOWLEDGE

to learn and contribute valuable
knowledge
46 9/01

LEISURELEISURELEISURELEISURE

to take time to relax and enjoy

47 9/01

LOVEDLOVEDLOVEDLOVED

to be loved by those close to me

48 9/01

LOVINGLOVINGLOVINGLOVING

to give love to others

49 9/01

MASTERYMASTERYMASTERYMASTERY

to be competent in my everyday activities

50 9/01

MINDFULNESSMINDFULNESSMINDFULNESSMINDFULNESS

to live conscious and mindful
of the present moment
51 9/01

MODERATIONMODERATIONMODERATIONMODERATION

to avoid excesses and find a
middle ground
52 9/01

MONOGAMYMONOGAMYMONOGAMYMONOGAMY

to have one close, loving relationship

53 9/01

NONNONNONNON—-CONFORMITYCONFORMITYCONFORMITYCONFORMITY

to question and challenge authority and norms

54 9/01

NURTURANCE

NURTURANCENURTURANCENURTURANCE

to take care of and nurture others

55 9/01

OPENNESSOPENNESSOPENNESSOPENNESS

to be open to new experiences,
ideas, and options
56 9/01

ORDERORDERORDERORDER

to have a life that is well-ordered
and organized
57 9/01

PASSIONPASSIONPASSIONPASSION

to have deep feelings about ideas,
activities, or people
58 9/01

PLEASUREPLEASUREPLEASUREPLEASURE

to feel good

59 9/01

POPULARITYPOPULARITYPOPULARITYPOPULARITY

to be well-liked by many people

60 9/01

POWERPOWERPOWERPOWER

to have control over others

61 9/01

PURPOSEPURPOSEPURPOSEPURPOSE

to have meaning and direction in my life

62 9/01

RATIONALITY

RATIONALITYRATIONALITYRATIONALITY

to be guided by reason and logic

63 9/01

REALISMREALISMREALISMREALISM

to see and act realistically
and practically
64 9/01

RESPONSIBILITYRESPONSIBILITYRESPONSIBILITYRESPONSIBILITY

to make and carry out
responsible decisions
65 9/01

RISKRISKRISKRISK

to take risks and chances

66 9/01

ROMANCEROMANCEROMANCEROMANCE

to have intense, exciting
love in my life
67 9/01

SAFETYSAFETYSAFETYSAFETY

to be safe and secure

69 9/01

SELFSELFSELFSELF—-ACCEPTANCEACCEPTANCEACCEPTANCEACCEPTANCE

to accept myself as I am

68 9/01

SELFSELFSELFSELF—-CONTROLCONTROLCONTROLCONTROL

to be disciplined in my own actions

70 9/01

SELFSELFSELFSELF—-ESTEEMESTEEMESTEEMESTEEM

to feel good about myself

71 9/01

SELFSELFSELFSELF—-KNOWLEDGEKNOWLEDGEKNOWLEDGEKNOWLEDGE

to have a deep and honest understanding
of myself
72 9/01

SERVICESERVICESERVICESERVICE

to be of service to others
73 9/01

SEXUALITYSEXUALITYSEXUALITYSEXUALITY

to have an active and satisfying sex life

74 9/01

SIMPLICITYSIMPLICITYSIMPLICITYSIMPLICITY

to live life simply, with minimal needs
75 9/01

SOLITUDESOLITUDESOLITUDESOLITUDE

to have time and space where I can
be apart from others
76 9/01

SPIRITUALITYSPIRITUALITYSPIRITUALITYSPIRITUALITY

to grow and mature spiritually
77 9/01

STABILITYSTABILITYSTABILITYSTABILITY

to have a life that stays fairly consistent

78 9/01

TOLERANCETOLERANCETOLERANCETOLERANCE

to accept and respect those who
differ from me
79 9/01

TRADITIONTRADITIONTRADITIONTRADITION

to follow respected patterns of the past

80 9/01

VIRTUEVIRTUEVIRTUEVIRTUE

to live a morally pure and excellent life

81 9/01

WEALTHWEALTHWEALTHWEALTH

to have plenty of money

82 9/01

WORLD PEACE

WORLD PEACEWORLD PEACEWORLD PEACE

to work to promote peace in the world

83 9/01

Other Value:Other Value:Other Value:Other Value:

Other Value:Other Value:Other Value:Other Value:

Other Value:Other Value:Other Value:Other Value:

This instrument is in the public domain and may be copied adapted and used without permission.

FORGIVENESS
NURTURANCE
RATIONALITY
• SELF-ACCEPTANCE

WORLD PEACE

Acceptance and Commitment Therapy-PSYC 498/598

Spring 2020 quarter

Kevin Criswell, Ph.D.

As Steve Hayes said in his TEDx talk in Nevada, “Life asks us questions…and one of the most important questions it asks us is, ‘What are you going to do about difficult thoughts and feelings?’”
1

A look at the past flyer from Summer 2020…

Ironically, even though ACT is not about making people feel “happy”, which is illustrated very well by ACT author and writer, Dr. Russ Harris in his The Happiness Trap, engaging in ACT-based work can help people feel better. It can say a lot about how individuals approach life: Which of the two words do they emphasize?
2

feeling better…

Choice
Feel better
Feel better
Seek pleasure
Avoid discomfort
Narrowing
“Bad” emotions are to be “fixed”
Emotional openness
Willingness/acceptance
Commit to personal values
All emotions can be experienced

Grading
Participation-brief, single-paragraph discussion posts for each of the three major sections of this seminar, due by 11:59pm on June 7th(each in their own modules in Canvas):
Module 1: Introduction to ACT & Doing What Matters
Module 2: Be Present
Module 3: Open Up
Reflection Discussion Assignment (Canvas), due by 11:59pm on June 7th
Graduate-level only (PSYC 598): Application Discussion Assignment (Canvas), due by 11:59pm on May 31st

Intended Audience & Purpose
Audience: Undergraduate (498) and graduate-level (598) students interested in learning about the evidence for, structure of, and application of Acceptance and Commitment Therapy (ACT).
Purpose
Describe the background and concepts involved in ACT.
Describe the evidence base for ACT.
Describe an ACT conceptual model.
Describe and experience how the six therapeutic processes can be applied to promote psychological flexibility.
Describe how ACT can be applied to a clinical case study.

Agenda
Part 1 (See lecture video within Module 1)
Introductions and “disclaimers”
What is “ACT”?
Evidence base for the effectiveness of ACT
Conceptual model of ACT (Hexaflex/Triflex)
Do What Matters
Part 2 (See lecture video within Module 2)
Be Present
Part 3 (See lecture video within Module 3)
Open Up
A clinical example of ACT applied to a client

Disclaimers
This seminar is not intended to provide sufficient clinical training for students to deliver ACT interventions in clinical settings and/or to individuals with the intention of treating a diagnosed mental disorder (this is consistent with the APA ethics code 2.01, in the area of “Competence”).
Students interested taking what they learned in this class and applying ACT to treat clients/patients should obtain supervised clinical training under ACT-trained clinicians.
https://contextualscience.org/civicrm/profile?_qf_Search_display=true&qfKey=efaaee08948b8245ef15b09c073b0586_5549
As of July 16, 2019: 100+ ACT therapists located in Washington state
I am a mandated reported of sexual harassment (Title IX), abuse of children/elders/vulnerable populations, and imminent danger to self and others.
Title IX: Confidential counseling and non-confidential resources at Bellevue and Cheney campuses are listed in the course syllabus.

7

Introductions
Who is your professor?
PhD in Clinical Psychology, Adult Health concentration (LLU 2016)
Clinical experience since 2011 across many settings.
ACT-related coursework in grad school.
Utilized and trained in ACT-based clinical treatment for 3+ years
Developed an ACT-based treatment protocol for couples adjusting to advanced cancer.

Introductions: What about you?
May follow along in your handout:
What do you already know about ACT or what do you think ACT is?
How would you define “mindfulness”? 
How would you describe the purpose of mindfulness?

What is “ACT”?
Let’s watch a TEDx talk by Steve Hayes, Ph.D.: https://www.youtube.com/watch?v=GnSHpBRLJrQ
Did you catch what he said about what ACT is?
What was the “little ditty” that he presented about his 30 years of research and what does it mean?
What were some of the ways that we can “put on the mental breaks”?
Other comments or questions about what you noticed in the video?

Evidence base for ACT (ACBS, 2019)
300+ RCTs as of May 2019 (e.g., anxiety, pain, depression, stress, substance abuse, weight loss, social anxiety, and more)
45 meta-analytic reviews of ACT-based interventions, as of Jan. 2019 (projected to hit 50 by the end of 2019)

Evidence base for ACT
APA, Div. 12 (Society of Clinical Psychology, 2016) Research supported psychological treatments (“pending re-evaluation”):
Chronic pain: strong research support
Depression: modest research support
Mixed anxiety: modest research support
OCD: modest research support
Psychosis: modest research support

“Strong” and “Modest” research Support? (SCP, 2016)
“Research support for a given treatment is labeled “strong” if criteria are met for what Chambless et al. (1998) termed “well-established” treatments. To meet this standard, well-designed studies conducted by independent investigators must converge to support a treatment’s efficacy. Research support is labeled “modest” if criteria are met for what Chambless et al. (1998) termed “probably efficacious treatments.” To meet this standard, one well-designed study or two or more adequately designed studies must support a treatment’s efficacy. In addition, it is possible for the “strong and “modest” thresholds to be met through a series of carefully controlled single-case studies. For a full description of the Chambless criteria readers are referred to Chambless et al. (1998). In addition, this site labels research support “controversial” if studies of a given treatment yield conflicting results or if a treatment is efficacious but claims about why the treatment works are at odds with the research evidence.”

Conceptual ACT-based Models of PsychoPathology and Wellbeing (Hayes, Pistorello, & Biglan, 2008)

Wellbeing “Hexaflex”
Pathology “Hexaflex”

Psychological flexibility? (Kashdan, 2010)
“…psychological flexibility…is a slippery construct to define. Psychological flexibility actually refers to a number of dynamic processes that unfold over time. This could be reflected by how a person: (1) adapts to fluctuating situational demands, (2) reconfigures mental resources, (3) shifts perspective, and (4) balances competing desires, needs, and life domains. Thus, rather than focusing on specific content (within a person), definitions of psychological flexibility have to incorporate repeated transactions between people and their environmental contexts” (p. 2).

The Vital Cycle vs. The Narrow Cycle (Hayes, 2005)

Creative Hopelessness (Harris, 2009)
Three questions about attempts to get rid of unwanted thoughts and feelings:
What have you tried?
How has it worked?
What was the cost?
The idea: If one continues doing what has been done, then they will continue getting what they have always got.
Consider (handout): What are some messages you have heard about how people should deal with uncomfortable or unwanted thoughts and feelings?

NOTE: This does NOT mean that all attempts at controlling or regulating emotions are unhelpful. It does mean that it may helpful to examine attempts to control thoughts or feelings if individuals are unsatisfied with their situation (emotionally, physically, spiritually, etc.).
17

A quick Aside: Metaphors
Why all the metaphors?
How my internship supervisor for trauma-related treatment explained it:
Novel concepts are put into understandable scenarios, and
The concepts are described as separate from an individual’s specific circumstances.
This is especially helpful when presenting new ways of thinking to those who may feel vulnerable, have difficulty trusting others, and/or are vigilant for signs of danger. They get to decide how the concepts apply to them.

Conceptual model of ACT: Simplified (Harris, 2009)

Warning: We are About to go through the Core Processes of ACT 
A popular opinion among ACT clinicians: “Practice what you preach”.
I am adopting this approach for teaching you about the core therapeutic processes.
What this means: I may ask you to participate in some ACT-based practices so you can experience what they are like for you, which is intended to enhance your learning experience.
What this does NOT mean: Again, this is not intended to treat any individual student’s diagnosed condition (e.g., OCD, chronic pain). Also, I am NOT requiring you to share details about your personal life (e.g., who are involved in your relationships), disabilities, or diagnosed conditions.

For those of you who find it too difficult or uncomfortable to apply the exercises to yourselves, I have a case study that you may use as a reference for most the exercises.
Case study option: You will be asked to fill out worksheets from the perspective of the case and provide some reasoning for why the individual in the case study would have responded that way.
20

Do What Matters

Do What Matters: Values
Consider (handout): How would you define the phrase “personal value”? Give some examples.
(ACBS, n.d.): “Values are chosen qualities of purposive action that can never be obtained as an object but can be instantiated moment by moment…In ACT, acceptance, defusion, being present, and so on are not ends in themselves; rather they clear the path for a more vital, values consistent life.”
My preference: I begin here (as opposed to focusing on opening up and being present) because values can be excellent reminders for why a client (or I) might go through the discomfort of learning new ways of relating to my thoughts and feelings.

metaphors for describing the function of values

Do What Matters: Values Identification
Values are not goals…but specific, measurable, attainable, relevant, and timely (SMART) goals can come from committing to the pursuit of a value.
Example: I value helping others learn (when I was 20-years-old).
Relevant goal: I want to make a career out of helping others learn.
More specific: I want to teach undergraduate-graduate level courses.
More timely, measurable, and attainable: I want to take part in at least one research assistantship and maintain good grades to increase the likelihood that I will be accepted into a PhD program, which will afford me opportunities to teach undergraduate-graduate students.

Do What Matters: Values Identification & Committed Action
Commonly used exercises include:
Values Card Sort (see on Canvas)-values only
Valued Living Questionnaire-values + committed action
The Life Compass-values + committed action
The Bull’s Eye-values + committed action
Committed Action Questionnaire (CAQ-8)-committed action only
And (many) more…

Do What Matters: The Bull’s Eye (Handout)
This exercise gets at values identification and committed action (i.e., how closely one is living consistently with one’s values).
Go to The Bull’s Eye handout, read the directions carefully and follow those directions.
Underneath each area of life (Work/Education, Relationships, Personal Growth/Health, Leisure), try answering the following two questions:
What sort of person do you want to be?
What personal strengths or qualities do you want to develop?
Reminder: If you would prefer not to apply these exercises to yourself, please let me know and I will provide you with a case study! Your job will be to fill it out from the perspective of the individual in the case study.

Do What matters: Reflection
Please take some notes on the following (this will help you with the reflection assignment on Canvas):
How easy or difficult was it for you to identify what sort of person you (or the individual in the case study) want to be in each of the major areas listed in The Bull’s Eye?
On a scale from (not at all) 1-10 (extremely) , how important is the area of Work/Education to you?
On a scale from 1-10, how important is the area of Leisure to you?
On a scale from 1-10, how important is the area of Relationships to you?
On a scale from 1-10, how important is the area of Personal Growth/Health to you?

Do What Matters: Final Words
Comparing levels of importance (e.g., 1-10 scale) with levels of acting consistently/inconsistently in valued area of life can provide important clues as to where much of the best work can be to move closer towards vital living.
A potential problem: But, everything is important (or too many extremely important values)!
Possible solution: Focusing on improvement in one area.
Possible solution: Recognizing that one has limited capacity, and perfectly living according to all values is impossible (e.g., values of being a present father and being a high-achieving researcher can conflict, at times).

Canvas Discussion Assignment(S)
Participation credit for Module 1: Brief Discussion post
Due by 11:59pm on June 7th
Carefully follow directions on the discussion assignment page!

“How can I feel better?” This is a question that all of us have probably
thought at least once in our lives. Another question that life throws at
us daily is “What are you going to do about difficult thoughts and
feelings?” Acceptance and Commitment Therapy (or “ACT” for short) is
a set of answers to those questions (TEDx Talks, 2016).
What you can expect from this seminar: We will go over the six core
therapeutic processes of ACT, sometimes called the “ACT hexaflex.” We
will go over the rationale for each process and participate in
experiential exercises to demonstrate each process. We will also discuss
how they can lead to “psychological flexibility.”
I look forward to seeing you there! –Dr. C
Dr. Kevin Criswell, Visiting Assistant Professor of Psychology
Email: kcriswell@ewu.edu | Reference: TEDx Talks. (2016, February). Psychological flexibility: How love turns pain into
purpose | Steven Hayes | TEDxUniversityofNevada [Video file]. Retrieved from https://www.youtube.com/watch?v=o79_gmO5ppgv

Acceptance and Commitment Therapy
PSYC 498.54/598.053 – Summer 2019 – July 26, 8am – 6pm

“HowcanIfeelbetter?”Thisisaquestionthatallofushaveprobably
thoughtatleastonceinourlives.Anotherquestionthatlifethrowsat
usdailyis“Whatareyougoingtodoaboutdifficultthoughtsand
feelings?”AcceptanceandCommitmentTherapy(or“ACT”forshort)is
asetofanswerstothosequestions(TEDxTalks,2016).
Whatyoucanexpectfromthisseminar:Wewillgooverthesixcore
therapeuticprocessesofACT,sometimescalledthe“ACThexaflex.”We
willgoovertherationaleforeachprocessandparticipatein
experientialexercisestodemonstrateeachprocess.Wewillalsodiscuss
howtheycanleadto“psychologicalflexibility.”
Ilookforwardtoseeingyouthere!–Dr.C
Dr. Kevin Criswell, Visiting Assistant Professor of Psychology
Email: kcriswell@ewu.edu| Reference:TEDx Talks. (2016, February). Psychological flexibility: How love turns pain into
purpose | Steven Hayes | TEDxUniversityofNevada[Video file]. Retrieved from https://www.youtube.com/watch?v=o79_gmO5ppgv
Acceptance and Commitment Therapy
PSYC 498.54/598.053 –Summer 2019 –July 26, 8am –6pm

Psychology 498

Module 1: Introduction to Acceptance and Commitment Therapy

and Doing What Matters

Practice Booklet

Acceptance and Commitment Therapy Seminar PSYC 498

Intended Audience & Purpose

·

Audience: students interested in learning about the evidence for, structure of, and application of Acceptance and Commitment Therapy (ACT).

· Purpose

· Describe the background and concepts involved in ACT.

· Describe the evidence base for ACT.

· Describe an ACT conceptual model.

· Describe and experience how the six therapeutic processes can be applied to promote psychological flexibility.

· Describe how ACT can be applied to a clinical case study.

· Please Note: The purpose of this seminar is to provide information about ACT, including its theory and how it may be applied. However, just taking one seminar will not provide the sufficient training necessary to know how to ethically and independently (i.e., without supervision on applying general principles to specific client/patient problems) deliver ACT-based interventions in clinical settings or to individuals with the intention of treating a diagnosed mental disorder. Students interested in using ACT to treat clients/patients should obtain supervised clinical training under ACT-trained clinicians.

· As of July 16, 2019: 100+ ACT therapists located in Washington state: https://contextualscience.org/civicrm/profile?gid=17&reset=1&force=1

· As of March 26, 2020: 2 ACT Trainers in Washington state: https://contextualscience.org/civicrm/profile?gid=20&reset=1&force=1

Introduction:

Questions to consider:

· What do you already know about ACT
or
what do you think ACT is?

· How would you define “mindfulness”?

· How would you describe the purpose of mindfulness?

· Conceptual ACT-based Models of Psychopathology and Wellbeing (Hayes, Pistorello, & Biglan, 2008)

·

· Wellbeing “Hexaflex”

·
·

· Pathology “Hexaflex”

·

Creative Hopelessness (Harris, 2009)

Three questions about attempts to get rid of unwanted thoughts and feelings:

1. What have you tried?

2. How has it worked?

3. What was the cost?

The simple idea: If one continues doing what has been done, then they will continue getting what they have always got.

Consider the following question: What are some messages you have heard about how people should deal with uncomfortable or unwanted thoughts and feelings?

Conceptual model of ACT: Simplified (Harris, 2009)

Do What Matters: Values & Committed Action (Harris, 2009)

Consider the following question: How would you define the phrase “personal value”?

Try Following the Directions in this Values exercise on this page, below:

Do What matters: Reflection

Consider taking some notes on the following (this may help you gather information you can use for the participation discussion post and/or the reflection assignment in Canvas):

· How easy or difficult was it for you to identify what sort of person you (or the individual in the case study) want to be in each of the major areas listed in The Bull’s Eye?

· On a scale from (not at all) 1-10 (extremely), how important is the area of Work/Education to you?

· On a scale from 1-10, how important is the area of Leisure to you?

· On a scale from 1-10, how important is the area of Relationships to you?

· On a scale from 1-10, how important is the area of Personal Growth/Health to you?

Optional Practice Materials: Values Identification & Committing to Valued Actions:

1. Values Card Sort

This is a very “classic” exercise to practice with clients who struggle with identifying which values they are committed to living consistently with. More specifically, this can be helpful with clients who…

1. Have become so detached from living in alignment with their values that they are numb and struggle with identifying what is important to them,

2. Believe that it is important to live according to (too) many values at once. Burning out or feeling overwhelmed by responsibility can be common in this clinical picture. Ironically, when fewer, specific values are selected and committed to, the other important values tend to follow in a more achievable, long-term fashion.

3. Struggle with choosing how to live. This person may recognize that there are several good options, yet also recognizes that everyone has limited time and capacity. Focusing on what matters most can be helpful.

Instructions:

(Note: This is the way I have found to work best with the most amount of clients. Just like mindfulness exercises, there are several ways that this exercise can be done.)

In general, the purpose of this card sort is to end up with 3-5 values that the individual considers “Very Important to Me.” If individuals have some idea about values that are very important to them, it may be more efficient to just select values that fit that category of importance. However, if it is unclear what personal values a person has, then it can be helpful to go through the entire list of values in the card sort and organize them into 3 piles: “Very Important to Me”, “Important to Me”, and “Not Important to Me.” Then, focus just on the “Very Important to Me” pile and try removing 1-3 cards at a time until 3-5 are selected.

Download the card sort (Miller, Baca, Matthews, & Wilbourne, 2001): file attached

2. Valued Living Questionnaire (VLQ)

Author: Kelly Wilson & Groom

The VLQ is an instrument that taps into 10 valued domains of living. These domains include: 1. Family, 2. Marriage/couples/intimate relations, 3. Parenting, 4. Friendship, 5. Work, 6. Education, 7. Recreation, 8. Spirituality, 9. Citizenship, and 10. Physical selfcare.

Scoring: Respondents are asked to rate the 10 areas of life on a scale of 1–10, indicating the level of importance and how consistently they have lived in accord with those values in the past week. For detailed information on scoring the VLQ see Wilson and Murrell (2004).

Reliability: The instrument has shown good test-retest reliability.

Validity: Currently being collected.

Reference: Wilson, K. G. & Groom, J. (2002). The Valued Living Questionnaire. Available from Kelly Wilson. Wilson, K. G. & Murrell, A. R. (2004). Values work in acceptance and commitment therapy: Setting a course for behavioral treatment. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive behavioral tradition (pp. 120-151). New York, NY: Guilford Press.

Valued Living Questionnaire

Below are areas of life that are valued by some people. We are concerned with your quality of life in each of these areas. One aspect of quality of life involves the importance one puts on different areas of living. Rate the importance of each area (by circling a number) on a scale of 1-10. 1 means that area is not at all important. 10 means that area is very important. Not everyone will value all of these areas or value all areas the same. Rate each area according to your own personal sense of importance.

Area not at all important extremely important

1. Family (other than marriage or parenting) 1 2 3 4 5 6 7 8 9 10

2. Marriage/couples/intimate relations 1 2 3 4 5 6 7 8 9 10

3. Parenting 1 2 3 4 5 6 7 8 9 10

4. Friends/social life 1 2 3 4 5 6 7 8 9 10

5. Work 1 2 3 4 5 6 7 8 9 10

6. Education/training 1 2 3 4 5 6 7 8 9 10

7. Recreation/fun 1 2 3 4 5 6 7 8 9 10

8. Spirituality 1 2 3 4 5 6 7 8 9 10

9. Citizenship/Community Life 1 2 3 4 5 6 7 8 9 10

10. Physical self-care (diet, exercise, sleep) 1 2 3 4 5 6 7 8 9 10

In this section, we would like you to give a rating of how consistent your actions have been with each of your values. We are not asking about your ideal in each area. We are also not asking what others think of you. Everyone does better in some areas than others. People also do better at sometimes than at others. We want to know how you think you have been doing during the past week. Rate each area (by circling a number) on a scale of 1-10. 1 means that your actions have been completely inconsistent with your value. 10 means that your actions have been completely consistent with your value.

During the past week

Area not at all consistent with my value completely consistent with my value

1. Family (other than marriage or parenting) 1 2 3 4 5 6 7 8 9 10
2. Marriage/couples/intimate relations 1 2 3 4 5 6 7 8 9 10
3. Parenting 1 2 3 4 5 6 7 8 9 10
4. Friends/social life 1 2 3 4 5 6 7 8 9 10
5. Work 1 2 3 4 5 6 7 8 9 10
6. Education/training 1 2 3 4 5 6 7 8 9 10
7. Recreation/fun 1 2 3 4 5 6 7 8 9 10
8. Spirituality 1 2 3 4 5 6 7 8 9 10
9. Citizenship/Community Life 1 2 3 4 5 6 7 8 9 10
10. Physical self-care (diet, exercise, sleep) 1 2 3 4 5 6 7 8 9 10

3. Committed Action Questionnaire (CAQ-8)

Participation Assignment (Required for All Students): Module 2 – Be Present

Prompt: Considering your experience of Module 2

Please address the following point in your response (please follow the directions “For full credit” bellow when completing this prompt):

· In your opinion, what were the two (2) most interesting or engaging things from Module 1?

· Why were those things especially interesting or engaging to you?

For this assignment, I want you to complete the prompt above and to post your response onto this discussion board. Click on “reply” below and type your response in at least 1 paragraph with at least 4 sentences in each paragraph.

In addition, please thoughtfully and kindly respond to at least one other classmate’s response to the prompt (more than just, “I agree.”).

For full credit

:

· Your response must be at least 1 paragraph long with at least 4 complete sentences. I highly recommend typing your response into a separate file first, then copying/pasting and submitting your response here.

· Your writing must reflect proper spelling, grammar, and punctuation.

·
All information that is obtained and discussed beyond the lecture and/or required or optional readings are appropriately cited and are only peer-reviewed scientific journal articles
.

Psychology 498

Module 2: Be Present

Practice Booklet

Acceptance and Commitment Therapy Seminar PSYC 498

Be Present: Mindfulness

Consider the following question: How would you define “mindfulness”? Also, what is the purpose of mindfulness?

Try a simple breathing meditation, which you can follow along with in the lecture video in Module 1.

After engaging in the breathing meditation

Reflection: Consider taking some notes on the following:

· What was your overall experience of this exercise?

· What is your best guess for how many times your mind pulled your attention to something different than your breath?

· What was the most difficult part of this exercise?

· What was the best part of this exercise?

Be Present: Self-as-Context

Try a “self-as-context meditation,” which you can follow along with in the lecture video in Module 1.

After engaging in the self-as-context meditation

· Reflection: Please take notes on the following:

· What did you notice the most during the meditation? Would you consider this thing “helpful” or “unhelpful” in terms of helping you pursue your personal values?

· What was the most helpful thing that your mind brought up as you went through the meditation? Why was it the most helpful thing?

Be Present: Reflection

Consider taking some notes on the following (this may help you gather information you can use for the participation discussion post and/or the reflection assignment in Canvas):

· How easy and/or difficult was it for you to engage in the exercises (e.g., the mindful breathing exercise) in this “Be Present” section of the seminar?

· On a scale from 1 (not at all important) to 10 (extremely important), how important do you think it is to “Be Present” in life? Why did you give that number?

· Can you come up with some examples of problems or issues that mindfulness exercises might
not
really help solve or make better?

Optional Practice Materials: Being Present:

1. UCLA Mindful Awareness Research Center Website (Free Recordings Available) link:

https://www.uclahealth.org/marc/mindful-meditations

2. UCLA-Semel-Breathing Meditation_Transcript

Breathing Meditation (5:31)

Find a relaxed, comfortable position

Seated on a chair or on the floor, on a cushion

Keep your back upright, but not too tight

Hands resting wherever they’re comfortable

Tongue on the roof of your mouth or wherever it’s comfortable.

And you can notice your body

From the inside

Noticing the shape of your body, the weight, touch

And let yourself relax

And become curious about your body

Seated here

The sensations of your body

The touch

The connection with the floor

The chair

Relax any areas of tightness or tension

Just breathe

Soften

And now begin to tune into your breath

In your body

Feeling the natural flow of breath

Don’t need to do anything to your breath

Not long not short just natural

And notice where you feel your breath in your body

It might be in your abdomen

It may be in your chest or throat

Or in your nostrils

See if you can feel the sensations of breath

One breath at a time

When one breath ends, the next breath begins

Now as you do this you might notice that your mind might start to wander

You might start thinking about other things

If this happens this is not a problem

It’s very natural

Just notice that your mind has wandered

You can say “thinking” or “wandering” in your head softly

And then gently redirect your attention right back to the breathing

So, we’ll stay with this for some time in silence

Just a short time

Noticing our breath

From time to time getting lost in thought and returning to our breath

See if you can be really kind to yourself in the process

And once again you can notice your body, your whole body, seated here

Let yourself relax even more deeply

And then offer yourself some appreciation

For doing this practice today

Whatever that means to you

Finding a sense of ease and wellbeing for yourself and this day

[bell rings]

3. UCLA-Semel-Body Scan Meditation_Transcript

Body Scan Meditation (2:44)

Begin by bringing your attention into your body

You can close your eyes if that’s comfortable to you

You can notice your body, seated, wherever you’re seated

Feeling the weight of your body, on the chair, on the floor

And take a few deep breaths

And as you take a deep breath

Bring in more oxygen and livening the body

And as you exhale

Have a sense of relaxing more deeply

You can notice your feet on the floor

Notice the sensation of your feet touching the floor

The weight and pressure, vibration, heat

You can notice your legs against the chair

Pressure, pulsing, heaviness, lightness

Notice your back against the chair

Bring your attention into your stomach area

If your stomach is tense or tight, let it soften

Take a breath

Notice your hands

Are your hands tense or tight?

See if you can allow them to soften

Notice your arms

Feel any sensation in your arms

Let your shoulders be soft

Notice your neck and throat

Let them be soft, relaxed

Soften your jaw

Let your face and facial muscles be soft

Then notice your whole-body present

Take one more breath

Be aware of your whole body, as best you can

Take a breath

And then when you’re ready

You can open your eyes

4. UCLA-Semel-LovingKindnessMeditation_Transcript

Loving Kindness Meditation (9:31)

To begin this practice

Let yourself be in a relaxed and comfortable position

We’re going to do the practice of cultivation positive emotion

In this case, loving kindness

Which is the desire for someone to be happy

Or yourself to be happy

It’s not dependent on something, it’s not conditional

It’s just a natural opening of the heart

To someone else or to yourself

So, you can check in to your body and notice how you’re feeling right now

Letting whatever is here, be here

Now let yourself bring to mind

Someone whom, the moment you think of them, you feel happy

See if you can bring to mind

It could be a relative, a close friend

Some with not too complicated a relationship

Just a general sense, that when you think of them you feel happy

Can pick a child

Or you can always choose a pet

A dog or a cat

A creature it’s fairly easy to feel love for

So, let them come to mind

Have them– have a sense of them being in front of you

You can feel them, sense them, see them

And as you imagine them

Notice how you’re feeling inside

Maybe you feel some warmth

Or there’s some heat to your face

A smile, sense of expansiveness

This is a loving kindness

This is a natural feeling that’s accessible to all of us at any moment

So now having this loved one in front of you

Begin to wish them well

May you be safe and protected from danger

May you be happy and peaceful

May you be healthy and strong

May you have ease and wellbeing

And as I say these words, you can use my words or your own words

And have a sense of letting this loving kindness come from you

And begin to touch this loved one

Reaching out

You might think in images

You might have a sense of color or light

You might just have a feeling

The words may continue to bring on more of this feeling

And I encourage you to say whatever feels meaningful to you

May you be free from stress and anxiety

May you be free from all fear

And so, as you’re sending out these words and these feelings of loving kindness

Also check into yourself and see how you’re feeling inside

And now imagine that this loved one turns around

And begins to send it back to you

So, see if you can receive the loving kindness

Take it in

And they’re wishing you well, may you be happy

Meaning you

May you be peaceful and at ease

May you be safe and protected from all danger

May you have joy, well-being

Letting yourself take it in

Now if you’re not feeling anything at this point

Or before in the meditation

It’s not a problem

This is a practice that plants seeds

And if you’re feeling something else other than lovingkindness

Just check into that

What is it I’m feeling

There may be something to learn here

Now if it’s possible and it’s not always easy to do this

But see if you can send loving kindness to yourself

You can imagine it coming down your body from your heart

You can just have a sense of it

May I be safe and protected from danger

May I be healthy and strong

May I be happy and peaceful

May I accept myself just as I am

And as you ask yourself the question “what do I need to be happy?”

See what arrises

And offer that to yourself

May I have meaningful work

A joyful life

Close friends and family

And now checking into yourself

And noticing what it is you feel as you do this

And now let yourself bring to mind one person

Or a group of people that you wish to send the loving kindness to

Imagine them in front of you

Sense them, feel them

May you be happy and peaceful

May you be free from all stress and anxiety and fear Worry

Grief

May you have joy and happiness

Wellbeing

And now let this loving kindness expand out

Spreading

Touching anyone that you want to touch right now

In all directions

People you know, people you don’t know

People you have difficulty with

People you love

Just imagine expanding and touching

And each person or animal

Whoever is touched by this loving kindness

Each person is changed

You can imagine that

So, may everyone everywhere be happy and peaceful and at ease

May we all experience great joy

[bell rings]

5. GGIA at University of California, Berkeley: Loving Kindness Meditation Recording and Script link:

https://ggia.berkeley.edu/practice/loving_kindness_meditation

Acceptance and Commitment Therapy-PSYC 498/598

Spring 2020 quarter

Kevin Criswell, Ph.D.

Just so you all are aware, students with the accommodation to do so may be audio recording this seminar.
As Steve Hayes said in his TEDx talk in Nevada, “Life asks us questions…and one of the most important questions it asks us is, ‘What are you going to do about difficult thoughts and feelings?’”
1

Be Present

Be Present: Mindfulness
Consider (handout): How would you define “mindfulness”? Also, what is the purpose of mindfulness?
APA (APA.org, 2012): “…a moment-to-moment awareness of one’s experience without judgment. In this sense, mindfulness is a state and not a trait. While it might be promoted by certain practices or activities, such as meditation, it is not equivalent to or synonymous with them.”
Jon Kabat Zin (in Purser, 2015): “The awareness that arises from paying attention, on purpose, in the present moment and non-judgmentally.”

Be Present: Mindfulness
Common myths:
Mindfulness = Meditation
Mindfulness is the goal/purpose of living
Mindfulness is…
Paying attention to something in a non-judgmental manner.
Moment-to-moment acceptance of whatever is experienced while paying attention to something on purpose.
Fostering a non-judgmental (and compassionate) “observer self”.
A means (mindfulness) to an end (values-based goals).

Be Present: Mindfulness
Some helpful metaphors:
“Monkey mind”
“Lion/scary animal outside the door”
“Dropping into Mindfulness” (Kabat Zin)
Approaching a freeway junction

“Dropping into Mindfulness” (Kabat Zin)
5

Be present: Mindfulness of the Breath
Let’s follow a basic breathing mindfulness meditation practice.
Reflection (handout):
What was your overall experience of this exercise?
What is your best guess for how many times your mind pulled your attention to something different than your breath?
What was the most difficult part of this exercise?
What was the best part of this exercise?

Be Present: Self-as-Context
Body Scan: Self-as-context to your own body
Loving Kindness Meditation: Self-as-context to the important people in your life
Let’s try the Loving Kindness Meditation

Be Present: Self-as-Context
Let’s practice the meditation…
Reflection (handout):
What did you notice the most during the meditation? Would you consider this thing “helpful” or “unhelpful” in terms of helping you pursue your personal values?
What was the most helpful thing that your mind brought up as you went through the meditation? Why was it the most helpful thing?

Be Present: Final Words
Practicing for “The Big Game” metaphor:
The best athletes devote a large amount of their time, energy, and effort into practicing before actually competing in an organized game.
In the same way, one cannot expect to practice something like mindfulness very well in high-stress/“performance” situations (e.g., emotionally regulating during a tense discussion) if that person has not practiced in low-stakes/lower stress situations (e.g., alone in a comfortable room).
The point: People can believe that mindfulness exercises do not work because they practice them only during difficult situations.
Other common metaphors: Practicing an Instrument & Building Muscle

Canvas Discussion Assignment(S)
Participation credit for Module 2: Brief Discussion post
Due by 11:59pm on June 7th
Carefully follow directions on the discussion assignment page!

Participation Assignment (Required for All Students): Module 2 – Open Up

Prompt: Considering your experience of Module 3

Please address the following point in your response (please follow the directions “For full credit” bellow when completing this prompt):

· In your opinion, what were the two (2) most interesting or engaging things from Module 1?

· Why were those things especially interesting or engaging to you?

For this assignment, I want you to complete the prompt above and to post your response onto this discussion board. Click on “reply” below and type your response in at least 1 paragraph with at least 4 sentences in each paragraph.

In addition, please thoughtfully and kindly respond to at least one other classmate’s response to the prompt (more than just, “I agree.”).

For full credit
:

· Your response must be at least 1 paragraph long with at least 4 complete sentences. I highly recommend typing your response into a separate file first, then copying/pasting and submitting your response here.

· Your writing must reflect proper spelling, grammar, and punctuation.

·
All information that is obtained and discussed beyond the lecture and/or required or optional readings are appropriately cited and are only peer-reviewed scientific journal articles
.

Acceptance and Commitment Therapy for Anxiety Disorders: Three Case
Studies Exemplifying a Unified Treatment Protocol

Georg H. Eifert, Chapman University
John P. Forsyth, SUNY–Albany

Joanna Arch, Emmanuel Espejo, Melody Keller, and David Langer, UCLA

Acceptance and Commitment Therapy (ACT) is an innovative acceptance-based behavior therapy that has been applied broadly and
successfully to treat a variety of clinical problems, including the anxiety disorders. Throughout treatment ACT balances acceptance and
mindfulness processes with commitment and behavior change processes. As applied to anxiety disorders, ACT seeks to undermine
excessive struggle with anxiety and experiential avoidance––attempts to down-regulate and control unwanted private events (thoughts,
images, bodily sensations). The goal is to foster more flexible and mindful ways of relating to anxiety so individuals can pursue life goals
important to them. This article describes in some detail a unified ACT protocol that can be adapted for use with persons presenting with
any of the major anxiety disorders. To exemplify this approach, we present pre- and posttreatment data from three individuals with
different anxiety disorders who underwent treatment over a 12-week period. The results showed positive pre- to posttreatment changes in
ACT-relevant process measures (e.g., reductions in experiential avoidance, increases in acceptance and mindfulness skills), increases in
quality of life, as well as significant reductions in traditional anxiety and distress measures. All three clients reported maintaining or
improving on their posttreatment level of functioning.

O VER the last 40 years, behavior therapy has led thedevelopment of empirically derived and time-
limited behavioral and cognitive-behavioral interventions
to assist those suffering from anxiety and fear-related
problems (Barlow, 2002; Beck, Emery, & Greenberg,
1985). This work continues in earnest, as researchers and
practitioners work to improve the potency, durability, and
effectiveness of such interventions. Gaining knowledge of
mechanisms and processes that mediate positive out-
comes continues to receive research attention as well.
Over the past decade, part of this effort has focused on
exploring mindfulness and acceptance-based approaches.
In its most basic form, mindfulness is about focusing our
attention on the present moment and making direct
contact with our present experiences, with acceptance
and without defense, and with as little judgment as
possible (Kabat-Zinn, 1994).

This work has led to innovative experimental and
applied applications for a wide range of psychopathology
(Hayes, Follette, & Linehan, 2004), including anxiety
(Hayes, 1987; Orsillo, Roemer, Block-Lerner, LeJeune, &
Herbert, 2005) and depression (Segal, Williams, &
Teasdale, 2002). Acceptance and Commitment Therapy

(ACT; Hayes, Strosahl, & Wilson, 1999) is part of this
newer line of exploration, and studies have shown that
ACT can be effective for the treatment of generalized
anxiety disorder (Roemer, Orsillo, & Salters-Pedneault,
2008), obsessive-compulsive disorder (Twohig, Hayes, &
Masuda, 2006), and posttraumatic stress disorder (Orsillo
& Batten, 2005). Our purpose here is to describe an
integrated application of ACT that can be adapted for
use with any of the major anxiety disorders (Eifert &
Forsyth, 2005), including outcome data from three
clients with different anxiety disorder diagnoses. In
doing so, we wish to point out that what follows is just
one of several ways (not the way) that ACT may be
applied to persons suffering from anxiety disorders.

ACT has two major goals: (a) fostering acceptance of
problematic unhelpful thoughts and feelings that cannot
and perhaps need not be controlled, and (b) commit-
ment and action toward living a life according to one’s
chosen values. This is why ACT is about acceptance and it
is about change at the same time. Applied to anxiety
disorders, clients learn to end the struggle with their
anxiety-related discomfort and take charge by engaging in
actions that move them closer to their chosen life goals
(“values”). Instead of teaching “more, different, better”
strategies to change or reduce unwanted thoughts and
feelings, ACT teaches clients skills to acknowledge and
observe unpleasant thoughts and feelings just as they are.

1077-7229/09/368–385$1.00/0
© 2009 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.

www.elsevier.com/locate/cabp

Available online at www.sciencedirect.com

Cognitive and Behavioral Practice 16 (2009) 368–385

This less avoidant and more flexible way of responding to
anxiety and other forms of emotional discomfort creates a
space for individuals to act in ways that move them in the
direction of chosen life goals even when unpleasant
thoughts, feelings, and bodily sensations are present.

An ACT approach to anxiety disorders is predicated on
the notion that anxiety disorders are characterized by
experiential and emotional avoidance, defined as a
tendency to engage in behaviors to alter the frequency,
duration, or form of unwanted private events (i.e.,
thoughts, feelings, physiological events, and memories)
and the situations that occasion them when such
avoidance leads to problems in functioning (Hayes
et al., 1999). The function of experiential avoidance is
to control or minimize the impact of aversive internal
experiences. Experiential avoidance can produce
immediate, short-term relief from negatively evaluated
anxiety-related thoughts and emotions, which negatively
reinforces such behavior. It becomes problematic when it
interferes with a person’s everyday functioning and life-
goal attainment. As described in more detail elsewhere
(Eifert & Forsyth, 2005; Forsyth, Eifert, & Barrios, 2006),
rigid and inflexible down-regulation of emotions and
patterns of emotional and experiential avoidance is
thought to function as a core psychological diathesis
underlying the development and maintenance of several
forms of psychopathology (Blackledge & Hayes, 2001;
Hayes, Wilson, Gifford, Follette, & Strosahl, 1996;
Kashdan, Barrios, Forsyth, & Steger, 2006), including all
anxiety disorders and depression (Barlow, Allen, &
Choate, 2004). For instance, Karekla, Forsyth, and Kelly
(2004) found that emotional avoidance was more
predictive of panic responses than other psychological
risk factors for panic such as anxiety sensitivity, even in
healthy individuals. This avoidance of discomfort is linked
with language processes (e.g., entanglement in one’s own
judgments and evaluations), rule-governed patterns of
action and inaction (e.g., “I might get anxious in that
unfamiliar situation, so I’d better not go”), and negative
self-evaluations (e.g., “I am worthless” or “I am incompe-
tent”). Such avoidance is problematic because it occurs in
the context of competing approach contingencies, that is,
actions that clients wish to engage in as part of a good
quality of life, and in that context the avoidance behavior
tends to dominate over approach behavior. This is why
experiential avoidance is one of the most important
treatment targets in ACT.

Apostureofexperientialacceptance,bycontrast,qinvolves
experiencing events fully and without defense . . . and
involves making contact with the automatic or direct
stimulus functions of events, without acting to reduce or
manipulate those functions, and without acting on the
basis solely of their derived verbal functionsq (Hayes, 1994,
p. 30). Acceptance, unlike experiential avoidance, reflects

an openness to all types of experience (both aversive and
pleasant) and a commitment to abandon the change
agenda where it does not work well and thereby has a
negative impact on functioning and only serves to
increase distress, namely, in the realm of private events
(Marx & Sloan, 2004). Several independent lines of
research (for an extensive review, see Hayes, Luoma,
Bond, Masuda, & Lillis, 2006) support the notion that
rigid and inflexible (i.e., context insensitive) attempts to
suppress and control unwanted private events are largely
ineffective, and can result in more (not less) unwanted
thoughts and emotions (Koster, Rassin, Crombez, &
Näring, 2003; Purdon, 1999), increase distress and restrict
effective life functioning (Marx & Sloan, 2004), and
reduce engagement in meaningful and valued life
activities with a concomitant poorer overall quality of
life (Dahl, Wilson, & Nilsson, 2004; Hayes et al., 2006).
Other related lines of work have shown that avoidant
coping strategies such as denial, mental disengagement,
and substance abuse predicted more frequent and intense
CO2-induced physical and cognitive panic symptoms than
acceptance-based coping strategies (Feldner, Zvolensky,
Eifert, & Spira, 2003; Spira, Zvolensky, Eifert, & Feldner,
2004). Similarly, Eifert and Heffner (2003) found that
when highly anxious females were exposed to CO2-
enriched air, participants in an acceptance context were
less avoidant behaviorally, reported less intense fear and
fewer catastrophic thoughts, and were less likely to drop
out of the study than participants in a control context.
These results were replicated in a procedurally similar
study with actual clients suffering from panic disorder
(Levitt et al., 2004). Lower experiential avoidance and
greater acceptance also enhance willingness to engage in
exposure exercises (Levitt et al., 2004) and may prevent
dropout (Karekla & Forsyth, 2004) in persons with panic
disorder. Collectively, this work suggests that experiential
avoidance is a potentially toxic process linked with forms
of distress and life impairment, and that strategies
promoting approach or acceptance of discomfort may
be worthwhile as healthier alternatives.

As in the mindfulness-based cognitive therapy program
for depression developed by Segal and colleagues (2002),
one of the core skills to be learned in ACT programs is
how to step out of entanglements with self-perpetuating
and self-defeating emotional, cognitive, and behavioral
avoidance routines. This is achieved by teaching clients
various skills aimed at undermining excessive and rigid
thought and emotion regulation (Masuda, Hayes, Sackett,
& Twohig, 2004). Based on the bulk of empirical data
showing the negative impact of experiential avoidance,
ACT does not attempt to help clients to control or
manage anxiety and instead teaches them how to let go of
their control struggle. Thus, ACT is different from what
many clients and therapists typically expect must be done

369ACT for Anxiety Disorders

to solve anxiety problems. It is therefore an essential first
step in treatment that therapists help clients experience
the costs of remaining trapped in the idea that effective
anxiety control is a prerequisite for leading a better life,
and how anxiety control strategies have negatively
impacted their life functioning and increased distress
when they failed to work as intended (see also Eifert &
Heffner, 2003; Levitt et al., 2004).

Treatment Overview

The ACT for Anxiety program is a unified treatment
protocol that guides therapists in the flexible application
of ACT principles and techniques for clients presenting
with any of the major anxiety disorders (Eifert & Forsyth,
2005). An expanded version of the protocol is also
available in the form of a self-help workbook (Forsyth &
Eifert, 2008). A formal evaluation and comparison of this
ACT protocol with a unified CBT protocol is under way
in the context of a clinical trial at UCLA that specifically
examines the relation between treatment outcome and
processes of change in the two treatment approaches.
Here, we will provide an overview of the original unified
ACT for Anxiety protocol, followed by outcome data
from three clients who have completed the ongoing
clinical trial.

The delivery of the treatment protocol itself is
organized around three interwoven phases. The goal of
Phase 1 (Sessions 1 through 3) is to create an acceptance
context for anxiety-related discomfort, and this work sets
the stage for the remaining treatment sessions. With the
help of metaphors and exercises, clients experience the
costs of past efforts to control and manage anxiety.
Rather than avoid their anxiety-related experiences,
clients begin to learn some basic skills to stay with
anxiety-related discomfort and look at it from a mindful
observer perspective.

In Phase 2 (Sessions 4 through 7), the focus shifts to
identifying clients’ most cherished life goals (values) and
teaching skills designed to build more flexible patterns of
behavior when anxiety and fear arise. During exposure
exercises, framed in the context of client values, clients
learn to practice mindfulness skills in the presence of
anxiety-related discomfort. Mindfulness is an important
skill to learn because it counteracts past experiential
avoidance strategies aimed at controlling or reducing
anxiety-related discomfort that tend to get in the way of
value-guided actions. In these sessions, therapists also
help clients make commitments to start engaging in
actions that are in accord with those values.

In Phase 3 (Sessions 8 through 12) the focus broadens
further to help clients engage in value-guided actions in
their natural environment and stay committed to moving
in those directions in the face of the inevitable anxiety-
related barriers. With the help of worksheets adopted

from behavioral activation programs (e.g., Addis &
Martell, 2004), therapist and client specify concrete and
achievable goals that are derived from one or two values
identified by clients in Phase 2. As clients engage in such
goal-directed activities, they invariably encounter anxiety-
related difficulties that used to serve as barriers and often
resulted in avoidance behavior. Therapists devote much
time to teach clients to move with such barriers by helping
them to apply mindful observation and other skills when
faced with anxiety-related discomfort. Increasing a client’s
willingness to stay on the course of committed action, and
“taking anxiety along for the ride” if it shows up, is an
important focus for the remainder of treatment.

An integral part of ACT is the use of metaphors and
related experiential exercises throughout treatment.
These exercises allow clients to make experiential contact
with thoughts, feelings, memories, and physical sensations
that have been feared and avoided because they were too
frightening to contact directly. Metaphors are verbal
stories that consist of analogies and pictures. As such they
cannot be taken literally and allow clients to make
experiential contact with an aspect of their experience
in a new way and from a different point of view (for a
more detailed RFT analysis of metaphors, see Stewart,
Barnes-Holmes, Hayes, & Lipkens, 2001). In so doing,
they help create distance between themselves and how
they are approaching their anxiety, while also opening the
door for new solutions to emerge (for detailed descrip-
tions of all metaphors and exercises used in our study, see
Eifert & Forsyth, 2005; Forsyth & Eifert, 2008).

Session-by-Session Treatment Program and Core
Process Targets

Although we outline the treatment program in the
form of session-by-session guidelines, the actual delivery
of ACT is more akin to a fluid dance around several core
processes rather than a linear progression. ACT is a
functional approach, not merely a therapy or collection of
treatment technologies. It builds on a model with several
interrelated treatment targets that are continually re-
visited throughout therapy. At a practical level, this means
that concepts, metaphors, and exercises introduced early
on, may be revisited again at any time they seem relevant.
Therapists are encouraged to sequence and apply
exercises and metaphors in a flexible and creative fashion.
This can be accomplished by individualizing and tweaking
techniques based on the specific circumstances and
responses of each client. This individualization should
be guided by an understanding of the core processes
targeted in ACT.

ACT may be applied to all anxiety disorders, in part,
because it targets a set of central processes that feed
anxiety-related problems, regardless of the specific form
or anxiety subtype: the struggle with unwanted emotions

370 Eifert et al.

and cognitions and low levels of engagement in meaning-
ful life activities (Hayes et al., 2006). The focus is on
changing the function (rather than form or specific
content) of unwanted thoughts and emotions so that they
no longer get in the way of effective action. In fact, a
considerable amount of treatment time is spent on
increasing client actions in everyday life that are
consistent with what clients value and wish their lives to
stand for. Where appropriate and necessary, the protocol
addresses anxiety subtype-specific considerations and
procedural variations are provided. The protocol also
provides therapists with practical guidelines to integrate
ACT principles and techniques with the most successful
and effective aspects of cognitive behavioral interventions
for anxiety disorders—in particular exposure and beha-
vioral activation as well as social skills training to remedy
deficits in some persons with social anxiety problems.

Treatment Orientation––Learning New Skills

The first session seeks to provide clients with an
understanding of the nature and purpose of anxiety and
what can make anxiety become problematic or a
significant life problem. Here, anxiety and fear are
described as adaptive emotions that may, however, turn
into life shattering problems when clients respond to
their anxious thoughts, feelings, and memories in rigid
and inflexible ways with the goal of not experiencing
them. Therapists introduce the notion that struggle and
control may actually interfere with the client’s everyday
functioning and life-goal attainment, and then explore
that notion briefly in terms of clients’ life experiences.
Therapy is framed as an opportunity to learn and
practice new and more flexible ways of responding
when experiencing anxiety. The goal is for clients to
learn skills and ways of no longer letting anxiety be an
obstacle to doing what they want to do so they can live a
rich and meaningful life. Therapists also use the first
session to emphasize the active, experiential, and partici-
patory nature of ACT, and focus on developing rapport
and dispelling common misconceptions about fear and
anxiety (e.g., anxiety is bad and a problem to be solved).

Examining the Effects of Anxiety Control
Efforts––Creative Hopelessness

The first step in a new direction is to identify and then
abandon strategies that have neither helped clients improve
their life goal attainment and quality of life nor actually
provided any lasting relief from anxiety distress. For this
reason, Sessions 2 and 3 focus on creating an acceptance
context for treatment as an alternative to anxiety control
and avoidance. This is accomplished by gently exploring
the usefulness (“workability”) and effects and costs of the
various strategies clients have used to cope with and manage

anxiety and by encouraging clients to make space for new
solutions. Specifically, clients examine (a) all the various
strategies they have employed to manage and control their
anxiety and how well those strategies worked, both in the
short and long-term, (b) how experiential avoidance and
efforts to control anxiety have constricted or limited the
patient’s life, and (c) what letting go of the struggle with
anxiety might look like. This is accomplished experientially
with the help of metaphor-based experiential exercises that
are acted out in session by the therapist and client together.
The purpose of these exercises is to (a) let clients
experience how all their various attempts to down-regulate
anxiety-related experiences (e.g., bodily sensations, images,
worries) have not worked and constricted their life, and (b)
that letting go of their struggle and doing things that go
against the grain is not only possible but may be more
viable. To illustrate, we provide two examples of metaphors
that are typically used at some point in Session 2 or 3.

The Chinese Finger Trap Exercise
A Chinese finger trap is a tube of woven straw about five
inches long and half an inch wide. Therapist and client
each take a finger trap and do the exercise together. First,
they slide both index fingers into the straw tube, one finger
at each end. If one attempts 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 discover through experience that
attempting to pull away from anxiety, 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 counter-
intuitive, such as pushing the fingers in rather than out and
leaning into the discomfort, effectively ends the struggle
and creates literally more space (“wiggle room”). Following
the exercise, clients take the finger trap home. We adapted
this exercise from the metaphor described by Hayes and
colleagues (1999), who present the metaphor to clients
only in verbal form. Based on the results of a study we
conducted (Eifert & Heffner, 2003), we suggest that both
therapist and client act out the metaphor with real finger
traps and together explore the experiential effects of
various strategies (i.e., pulling out vs. leaning in).

The Tug-of-War With the Anxiety Monster Exercise
Similar to the finger trap, this metaphorical exercise sets
up a struggle, while pointing to solutions that stand in
opposition to what people typically do in a struggle.
Interestingly, this metaphor was created by a woman with
agoraphobia in the context of her work with an ACT
therapist (Hayes, Wilson, Afari, & McCurry, 1990). While
therapists explore the clients’ efforts to defeat their

371ACT for Anxiety Disorders

anxieties and fears, they gently suggest that this struggle
sounds like a tug of war with an anxiety monster. The
client is asked if they are willing to see how this might play
out in the room. For the exercise, therapists play the role
of the anxiety monster. Both therapist and client take one
end of a rope (about 3 to 4 feet long) and start pulling. As
the tug of war unfolds, clients notice that efforts to pull
harder result in the monster pulling harder right back.
Acting out this exercise lets clients physically experience
how much energy and focus it takes to keep the anxiety
monster in check. Also, almost all clients will grab the
rope with both of their hands, and this dramatically shows
them how their efforts fighting anxiety have left their
hands and feet tied up in the fight and no longer free to
do other things in life. One key element of this exercise is
to let clients experience that they have a choice: continue
to fight or drop the rope. Once clients actually drop the
rope, they experience the difference this action makes
and what they gain from it: less strain and more room to
move. Clients also learn that the choice is not whether the
anxiety monster is there or not, but whether to pick up the
rope again and fight. Here clients experience in a very
concrete fashion what they cannot control (what the
anxiety monster does) and what they can control—what
they do with their hands and feet. To enhance the
exercise, therapists may bring important life areas into the
room, where the anxiety monster tends to show up and
gets in the way of what they want to do. 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 playful boundaries of the exercise.

Creative Hopelessness
These metaphors are used during this phase of treatment
to induce “creative hopelessness” (Hayes et al., 1999) by
letting clients experience that former solutions have not
worked (hopelessness) and that therapy presents an
opportunity to create new outcomes with a radically
different approach (accepting rather than struggling). To
get there, clients must let go of old strategies that have not
worked. 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
struggling with, or attempting to eliminate, such experi-
ences. This theme is introduced with a formal 12-minute
eyes-closed mindfulness exercise (“acceptance of
thoughts and feelings exercise”), which was adapted
from more generic versions (Davis, Eshelmann, & McKay,
2000; Segal et al., 2002) for the purposes of this anxiety
treatment program. The goal is for clients to practice
paying attention to a single focus, their breathing, and to
learn to watch and allow other internal events, such as
thoughts, feelings, and sensations, to come and go. If they

pay attention to their experience, they will see how it
changes from moment to moment, how it comes and goes
on its own, without any effort on their part. Clients are
asked to practice this exercises at least once a day at home.

Identifying Values and Goals

ACT is a constructive approach to behavior change with a
focus on enhancing quality of life. This is why perhaps the
most important goal of our program is to encourage clients
to engage in life-goal directed behavior as an alternative
agenda to managing anxiety. To this end, early on (typically
in Session 3 at the latest), clients complete several
experiential exercises to help them explore their core
values in their lives. Clients are encouraged to think about
what they want to do with their lives, not what they do not want to
have or feel. This re-orientation is achieved by helping clients
define what they want their lives to be about and stand for in
key life domains such as family, friends, romantic relation-
ships, leisure, spirituality, health, career, education, and
community (see also, Dahl & Lundgren, 2006). At a later
point, we use additional experiential exercises and beha-
vioral activation worksheets to define more specific goals
that lead them in the direction of those values.

As clients identify values, they often recognize that
anxiety management behavior has moved them away
from their life values. For example, a woman with a
daughter in elementary school told us that her most
important life goal was to be a good mother. Yet, she
recognized that her agoraphobic avoidance behavior has
kept her from attending her daughter’s school concerts.
In fact, she had not attended a single one. Rather than
continue to devote more time and energy to keeping
panic away, she made a choice to learn to observe and stay
with her discomfort so that she would eventually be able
to approach the previously avoided school auditorium
and watch her daughter perform.

Acceptance: Developing Willingness to Stay
With Discomfort

ACT aims to teach clients acceptance as an alternative
behavior to experiential avoidance. “Acceptance involves
the active and aware embrace of those private events
occasioned by one’s history without unnecessary attempts
to change their frequency or form, especially when doing
so would cause psychological harm” (Hayes et al., 2006,
p.7). The focus is on teaching clients acceptance and
mindfulness skills as ways of learning to observe unwanted
anxiety-related responses fully and for what they are (i.e.,
thoughts as thoughts, physical sensations as physical
sensations, images as images, feelings as feelings).

Session 4 and 5 introduce clients to acceptance and
mindfulness as a skillful way of approaching our various
life experiences. Clients learn to observe anxiety-related

372 Eifert et al.

thoughts and feelings without evaluation or judgment,
and without holding onto, getting rid of, suppressing, or
otherwise changing what they experience. We developed
the acceptance of anxiety exercise as a mindfulness tool to
teach clients how to assume an observer perspective in
relation to their anxiety-related feelings and thoughts.
This 15-minute closed eyes exercise, to be practiced once
or twice a day, builds upon the acceptance of thoughts and
feelings exercise. Clients again practice paying attention to
a single focus, their breathing, and to learn to watch and
allow specific anxiety-related thoughts and bodily sensa-
tions come and go without trying to change them. Clients
are encouraged to make full contact with the experience
of anxiety, notice all its facets, stay with it, watch it, and
“make room” for it. The goal is to increase willingness to
experience discomfort and undermine the tendency to
react to anxiety-related thoughts, images, and sensations
with strategies aimed at getting rid of such experiences.
The exercise also reinforces the notion of choices:
Although experiencing anxiety and fear is not a choice,
how clients respond to their discomfort is a choice. They
can choose to observe and acknowledge their anxiety for
what it is, or choose to react to it in a way that has limited
their options and their lives.

Additional metaphors and exercises in these sessions
are also designed to strengthen the skill of observing
rather than responding to anxiety with efforts to control
it. These exercises also provide clients with additional
practice distinguishing between experiences they have
(thoughts, emotions, and physical sensations) and the
person having them. Although these are somewhat
abstract notions, the development of an accepting
observer perspective helps clients experience at a gut
level that although their anxiety is part of them, they are
more than an anxiety-disordered individual.

Acceptance is closely related to willingness and
purposeful action. Linehan (1993) points out that
“willingness is accepting what is, together with responding
to what is, in an effective and appropriate way. It is doing
what works and just what is needed in the current
situation or moment” (p. 103). In a similar vein, Orsillo,
Roemer, Lerner, and Tull (2004) describe experiential
acceptance as a willingness to experience internal events
such as thoughts, feelings, memories, and physiological
reactions, in order to participate in activities that are
deemed important and meaningful. We view acceptance
as the willingness to stay with discomfort while also actively
and intentionally choosing to engage in life-goal directed
behavior (Eifert & Forsyth, 2005). Willingness is a skill to
be learned, not a concept or a feeling. It is not about
liking, wanting, putting up with, or tolerating, and not
about enduring anxiety with brute force of will. It means
being open to the whole experience of anxiety (Luoma,
Hayes, & Walser, 2007) and making a choice to

experience anxiety for what it is––a collection of
sensations, feelings, thoughts, and images. In this sense,
willingness is the opposite of control and avoidance and a
major treatment target in this program.

Cognitive Defusion

The concept of cognitive fusion may help to explain
why thoughts become so threatening to people that they
are prepared to engage in behavior that is clearly
detrimental to their well-being and quality of life.
Cognitive fusion refers to the tendency of human beings
to get caught up in the content of what they are thinking
with the end result that “literal evaluative strategies
dominate in the regulation of human behavior, even
when less literal and less judgmental strategies would be
more effective” (Hayes, 2004, p. 13). Cognitive fusion is a
process that involves fusing with or attaching to the literal
content of our private experiences. The event or stimulus
(e.g., “I”) and one’s thinking about it (“I am having a
heart attack”) become one and the same—they are so
fused as to be inseparable, which creates the impression
that verbal construal is not present at all (Hayes, 2004).
When fusion occurs, a thought is no longer just a thought,
and a word is no longer just a sound; rather, we respond to
words about some event as if we were responding to the
actual event the words describe. Thus, a fast beating heart
experienced during a panic attack is no longer just a fast
beating heart but a sign of an impending heart attack that
we must avoid at all costs by engaging in behavior aimed at
down-regulating the physical sensations experienced.

Learning the skill of cognitive defusion is central to
ACT. At a basic level, cognitive defusion is the process
whereby individuals learn to observe thoughts for what
they really are (just thoughts), not for what their minds
tells them they are (literal truths that must be acted
upon). As thoughts are taken less literally, clients are
freed to act on chosen values rather than reacting to
anxiety-related, thoughts, worries, and bodily sensations.
ACT utilizes a variety of cognitive defusion techniques
(e.g., metaphors, mindfulness exercises, paradoxical
statements, changing language conventions) to teach
clients to respond less literally to anxiety-related thoughts
and emotions, and create some distance to their thoughts
and feelings. Instead of responding to the literal content
of a thought, clients learn to respond to and experience
thoughts as just a thought that can simply be observed.
Defusion exercises are conducted throughout treatment
whenever clients appear to be trapped by and entangled
in their evaluative mind and when taking their thoughts
literally (“buying their thoughts”) interferes with values-
consistent behavior. The point of this work is to teach a
fine discrimination between thoughts that serve the client
well and those that do not. Clients also learn that a
thought can simply be observed and need not be

373ACT for Anxiety Disorders

corrected or struggled with, and most importantly, need
not be acted on.

For instance, when a client notices the thought “I am
having a heart attack” during a panic attack, defusion
techniques will help that client recognize and experience
the evaluative thought or image for what it is: a thought
that can simply be observed and need not be corrected or
struggled with, and most importantly, need not be acted
upon by dropping everything and driving to the next ER.
The goal of cognitive defusion is to help the client forge a
new relationship with their private experience (Orsillo &
Batten, 2002). Hence, defusion techniques do not target,
nor do they seek to correct, the content or validity of the
client’s evaluation of their physical sensations (whether
they are really having a heart attack), only the process of
evaluating itself. At the core, defusion techniques help
clients to notice the process of thinking. For this reason,
the mindful acceptance exercises described earlier are
also thought of as defusion strategies within ACT. They
help clients make contact with experience as it is, without
all the evaluative baggage, including verbal rules and
reasons, that are usually present when anxiety occurs.
Mindfulness exercises allow clients to notice the process
of thinking, evaluating, feeling, remembering, and other
forms of relational activity, and not simply the historical
products of such activities (Hayes, 2004).

Applying Acceptance, Willingness, and Defusion to Stay
With Anxiety (Exposure)

The goal of Sessions 6 and 7 is learning to stay with
anxiety. We describe this part of treatment to clients as
“getting ready to face anxiety with mindful acceptance
so you can get on with your life” (Forsyth & Eifert, 2008,
p. 187). During in-session exposure-like FEEL (i.e.,
Feeling Experiences Enriches Living) exercises, clients
employ mindful observation to let go of the struggle to
escape or control anxiety-related thoughts, worries, and
bodily sensations by acknowledging their presence and
even embracing and leaning into them. The actual
procedures used to practice are similar to those used in
CBT (e.g., hyperventilation, spinning, or worst-case
imagery in the case of chronic worrying). In fact, in the
UCLA RCTwe use the same exercises in both the ACTand
the CBT condition, albeit framed with very different
rationales and set within different contexts. In ACT, the
stated goal of these exercises is not to reduce or eliminate
anxiety but to provide clients with opportunities to
practice willingness in the presence of anxiety so they
can do what matters to them. The general purpose is to
prepare clients for the inevitable times when anxiety and
other forms of discomfort show up while engaging in real-
life chosen activities that move them in the direction of
their values. Thus, exposure exercises within ACT are
always done in the context of a client’s valued life goals.

Exposure practice is a logical extension of the mind-
fulness exercises begun earlier. Recall that these exercises
were designed to promote an observer perspective, whereby
thoughts, feelings, and physical sensations are noticed and
experienced as they are with a nonjudgmental and
compassionate posture. Using similar instructions as in the
acceptance of anxiety exercise, clients are encouraged to stay
with whatever they are experiencing to help them approach
anxiety-related distress from a nonjudgmental, compassio-
nate perspective.They are encouragedto choose to be open
to their experience and respond nondefensively. This
posture works to foster cognitive defusion so that evaluative
verbal-cognitive activity does not get in the way of life goal-
directed action. Consequently, the choice of the specific
interoceptive and imagery FEEL exercises for a particular
client is largely determined by whether the client’s reactions
brought on by the images or sensations have functioned in
the past as a barrier to life goal-directed action.

Exposure practice provides an important opportunity
for clients to develop willingness to experience anxiety
and to see that willingness is a choice. Nobody chooses
anxiety. It happens. The choice is whether one is willing to
experience anxiety when it arises and do what matters. So,
willingness is about control of choices and actions, not
feelings and thoughts, and as this work unfolds in and
outside of treatment, clients are encouraged to revisit this
central question: “Am I willing to move with my anxiety to
do what I really care about or am I going to run away from
anxiety and the life I truly want to live?” In this sense,
exposure exercises are willingness exercises, where clients
are encouraged to make the choice to experience anxiety
for what is. In this sense, exposure exercises are will-
ingness exercises, where clients are encouraged to make
the choice to experience anxiety for what is. Although
exposure exercises within ACT are not conducted for the
purpose of fostering extinction processes, such processes
are likely to operate regardless of the rationale clients
adopt for facing their anxiety rather than avoiding it. So
when anxiety reduction occurs as a consequence, we
consider it a bonus, not a targeted outcome.

Value-Guided Action (Naturalistic Exposure)––Moving
With Barriers

Sessions 7 to 12 are devoted to helping clients
implement meaningful activities that would move them
toward reaching selected goals related to their identified
values. Using worksheets derived from behavioral activa-
tion programs (Addis & Martell, 2004), therapists help
clients develop a specific plan of action for each week and
identify sequences of actions that need to be taken to
achieve goals. This work includes the following: helping
clients translate their identified values into goal-directed
actions, helping clients set realistic goals and criteria,
provide ongoing feedback, and monitoring progress. This

374 Eifert et al.

will almost invariably involve clients engaging in pre-
viously avoided activities or entering previously avoided
situations. Such activities look similar to naturalistic
exposure exercises, except that they are not conducted
in a context and with the stated purpose of extinguishing
anxiety. Clients choose and engage in activities with the
stated purpose of reaching important life goals.

In the process of engaging in life-goal directed
activities, clients inevitably encounter barriers. Most of
the time, they are related to anxiety-related concerns that
literally seem to hold clients back. An important recurrent
task for therapists during Sessions 7 though 12 is to help
clients handle barriers to committed action and focus on
making and keeping action commitments and on
recommitting to action after they have broken a commit-
ment. The focus is on teaching clients how to move with
potential barriers rather than try to overcome or push
through them. Therapists constantly encourage clients to
stay with difficult situations, unpleasant feelings, thoughts,
and other anxiety-related barriers to valued living by
practicing mindful acceptance and defusion skills. The
major goal here is to help clients develop more flexible
patterns of behavior when relating with the stimuli,
events, and situations that elicit fear or anxiety.

Therapists

continue to emphasize that the purpose of FEEL exercises
and value-related activities is to let clients experience that
they can do things that matter to them and be anxious at
the same time. The crucial point is for clients to learn that
anxiety does not have to go down first in order to do what
is important to them.

Method

Participants

Three individuals who were part of a larger rando-
mized clinical outcome trial comparing ACT and CBT
served as participants for this case study. We selected one
client from each of the three therapists who were seeing
clients (typically each saw two clients at a time) at the time
we decided to write up this case report. To illustrate the
flexible nature of the treatment program, we selected
three participants with heterogeneous anxiety disorders,
that is, each had a different principal anxiety disorder
diagnosis and also one other secondary diagnosis, which
was different in each case.

We selected one client from each of the three
therapists who were seeing clients (typically each therapist
saw two clients at a time) at the time we decided to write
up this case report. There were no particular selection
criteria other than that the three clients should be clearly
different. So we made sure they were not all of the same
gender, were from different age groups, and to illustrate
the flexible nature of the treatment program, each should
have a different principal anxiety disorder diagnosis with
one other secondary diagnosis, which was different in

each case. These individuals had presented for treatment
at the UCLA Behavioral Anxiety Disorders Research
Program in response to ads offering treatment. Clients
had not selected ACT as their preferred treatment but
had been randomly assigned to the ACT treatment
condition as part of the RCT. We changed the clients’
names to protect their anonymity.

All clients were assessed with the Anxiety Disorders
Interview Schedule for DSM-IV (ADIS-IV; Di Nardo,
Brown, & Barlow, 1994) and their principal and secondary
diagnoses are listed in Table 1. The ADIS-IV is a
semistructured interview that assesses for anxiety, mood,
and other psychiatric disorders. In addition to assigning
diagnoses, the interviewer makes a clinical severity rating
(CSR) for each diagnosis to capture the individual’s
current level of distress and impairment as a function of
the particular disorder. CSRs range from 0 (none) to 8
(very severe). All diagnostic interviewers had extensive
training in administering the ADIS-IV and none of them
acted as therapists. All diagnoses and CSR ratings were
reviewed by a doctoral-level clinical supervisor.

For the 6-month follow-up, therapists contacted their
clients by phone. Therapists talked with clients for about
20 minutes, following a standard protocol that included
obtaining ratings of the extent of struggle with anxiety,
willingness to experience discomfort, practice of mindful
acceptance, and progress in life-goal directed action. In
case clients had encountered any recurrent barriers to
committed action, therapists helped clients troubleshoot
solutions.

Therapists

The therapists were three advanced graduate students
enrolled in the doctoral program in clinical psychology at
UCLA (EE, JA, DL). All therapists had been trained in
ACT theory and methods by the first author and attended
a 2-day ACT experiential workshop conducted by Steven
Hayes. Treatment consisted of 12 weekly sessions, each
lasting 1 hour. All treatments followed the treatment
manual by Eifert and Forsyth (2005).

Anxiety Mood, and Distress Measures

The Anxiety Sensitivity Index (ASI; Peterson & Reiss,
1992) is a 16-item self-report questionnaire that assesses
an individual’s level of fear of anxiety-related symptoms
(e.g., rapid heart beat) based on the belief that such
sensations have negative consequences (e.g., embarrass-
ment). Respondents rate the degree to which they agree
or disagree with each item on a 5-point scale, anchored
from 0=very little to 4=very much. According to Peterson
and Reiss 1992), the ASI has a high degree of internal
consistency (alpha coefficients from .82 to .91) and stable
test-retest reliability over a 3-year period (r=.71).

375ACT for Anxiety Disorders

The Penn State Worry Questionnaire (PSWQ; Meyer,
Miller, Metzger, & Borkevec, 1990) is a 16-item measure
of trait worry with strong psychometric properties (Meyer
et al., 1990; Molina & Borkovec, 1994). Participants rate
the extent they agree with each statement on a 5-point
Likert scale. Scores can range from 16 to 80. The PSWQ
focuses on the generality, intensity/excessiveness, and
uncontrollability of clinical relevant worry (Molina &
Borkovec), and reliably distinguishes GAD from other
anxiety disorders (Brown, Antony, & Barlow, 1992). The
PSWQ demonstrates strong psychometric properties
(Molina & Borkovec), including good internal consistency
(α of .86 to .93 across clinical and college samples) and
test-retest reliability (r=.74 to .93 across 2- to 10-week
periods).

The Mood and Anxiety Symptom Questionnaire
(MASQ; Watson & Clark, 1991) is a 90-item self-report
questionnaire with five subscales: Anxious Arousal (17
items), Anhedonic Depression (22 items), General
Distress (i.e., General Mixed; 15 items), General Anxiety
(11 items), and General Depression (12 items). Thirteen
items do not belong to a subscale. Participants use a 5-
point Likert scale (1=not at all to 5=extremely) to rate the
extent to which they experienced each symptom “during
the past week, including today.” The MASQ anxiety and
depression subscales demonstrates good divergent (r=.02
to .09), convergent validity (r=.67 to .76) with other
anxiety and depression scales, and strong incremental
validity across student, adult, and patient samples
(Watson et al., 1995).

The Anxiety Control Questionnaire (ACQ; Rapee,
Craske, Brown, & Barlow, 1996) is a 30-item measure
designed to assess perceptions of control over potentially
threatening internal and external events and situations
associated with anxious responding (alphas from .80 to
.89; test-retest, r=.88; Rapee et al., 1996). Recent work

evaluating the psychometric properties of the original 30-
item ACQ in a clinical (N=1,550) and nonclinical
(N=360) sample suggests that the original 30-item ACQ
is best represented by a 15-item form equivalent (i.e.,
patient vs. nonpatient) unifactorial solution, and three
lower-order factors reflecting emotion control, threat
control, and stress control (Brown, White, Forsyth, &
Barlow, 2004). The present study relied on the 15-item
version of the ACQ, and the unifactorial solution
reflecting perceived control over anxiety-related emo-
tional events.

The Fear Questionnaire (Marks & Mathews, 1979) is a
15-item scale that assesses fear-related avoidance of a
variety of situations. The 9-point scale ranges from “no
avoidance” to “total avoidance,” and has shown adequate
reliability and validity in samples with a variety of anxiety
disorders (Cox et al., 1993; Marks & Mathews).

The Padua Inventory—Washing State University Revi-
sion (PI-WSUR; Burns, Keortge, Fromea, & Sternberger,
1996) is a self-report questionnaire containing 39 items of
the original Padua Inventory (Sanavio, 1988), which had
60 items. Using a 5-point scale, with responses ranging
from 1 (not at all) to 5 (very much), the questionnaire
assesses obsessions and compulsions related to harm to self
or others, contamination, washing, dressing/grooming,
and checking. Burns et al. (1996) found that the internal
consistency values of the PI-WSUR subscales ranged from
.77 to .88, the test-retest reliability values ranged from .61
to .84, and that the PI-WSUR was a more distinct measure
of OCD than the original PI.

ACT Process Measures

The Acceptance and Action Questionnaire (AAQ;
Bond & Bunce, 2003; Hayes et al., 2004) assesses two
aspects of psychological flexibility: experiential avoidance
and willingness to engage in action despite unwanted

Table 1
Pre and Post Data for Measures of Anxiety, Mood, and Distress for All Three Cases

Measure James Daniel Janet

Pre Post Pre Post Pre Post

ADIS Severity
–Principal 4 (panic) 0 5 (social) 3 6 (OCD) 3
–Secondary 3 (OCD) 0 4 (dysth) 0 5 (panic) 0

ACQ 28 49 31 59 50 41
ASI 27 7 43 7 34 12
PSWQ 54 45 53 30 48 34
MASQ 288 185 265 167 181 162
FQ –Total 40 17 36 12 39 24

–Social 12 3 21 8 11 7
Padua 9 7 35 7 106 57

Note. ADIS=Anxiety Disorders Interview Schedule-IV; ACQ=Anxiety Control Questionnaire (higher scores indicate higher perceived control
over responses to anxiety symptoms); ASI=Anxiety Sensitivity Index (lower scores indicate lower levels of anxiety sensitivity); PSWQ=Penn
State Worry Questionnaire (lower scores indicate lower levels of worry); MASQ=Mood and Anxiety Symptom Questionnaire (lower scores
indicate fewer depression and anxiety symptoms);FQ=Fear Questionnaire (lower scores indicate lower levels of fear).

376 Eifert et al.

thoughts or bodily sensations. The original AAQ consists
of 9 items loading on a single factor. In this study, we used
the revised 16-item version by Bond and Bunce (2003)
because Hayes et. al. (2004) pointed out that the longer
version may be more useful as a therapy process measure,
since the larger number of items may allow smaller
changes throughout therapy to be detected. The Willing-
ness Scale consists of seven items assessing willingness to
accept undesirable thoughts and feelings. The Action
Scale consists of nine items assessing whether individuals
act in ways that are congruent with values and goals.
Participants rate the extent to which they agree with each
statement on a 7-point Likert scale. The 16-item version is
scored in such a way that higher scores reflect greater
acceptance of experience and willingness in the presence
of discomfort. A study by Bond and Bunce (2003) using a
general population sample of 412 individuals examined
the psychometric properties of the 16-item version of the
AAQ. Internal consistence was good (α=.79) and a
confirmatory factor analysis of the construct validity of
the measure found that a two-factor (scale) solution was a
good fit to the data. Bond and Bunce also report that
higher acceptance scores predicted better mental health
and job performance over and above negative affectivity.

The 15-item Mindfulness Attention Awareness Scale
(MAAS; Brown & Ryan, 2003) assesses mindfulness across
cognitive, emotional, physical, interpersonal, and general
domains. Respondents indicate how frequently they have
experienced statements (e.g., provide an item example)
using a 6-point Likert scale (anchored from 1=almost
always to 6=almost never) with high scores reflecting more
mindfulness. Items are scored by summing all individual
responses. Brown and Ryan have demonstrated that (a)
the MAAS has good psychometric properties, (b) the scale
differentiates individuals who are mindful from those who
are not, (c) higher scores are associated with enhanced
self awareness, and (d) following a clinical intervention,
cancer patients showed increases in mindfulness over
time that were related to declines in mood disturbance
and stress. Within student and adult samples, psycho-
metric properties include good internal consistency
(α=.82 and .87, respectively), good test-retest reliability
(.81, assessed in student sample only), and strong
convergent and divergent validity (see Brown & Ryan,
2003). Brown and Ryan reported a mean score of 3.9
(SD=0.6) for a nonclinical sample compared to 4.3
(SD=0.6) for a group of Zen meditation practitioners.

The White Bear Suppression Inventory (WBSI; Wegner
& Zanakos, 1994) is a 15-item measure of the tendency to
suppress (i.e., not accept) and struggle with unwanted
thoughts and feelings. This measure has been used
extensively in laboratory and clinical settings to demon-
strate the negative effects of experiential avoidance (e.g.,
Koster et al., 2003). Clinical studies (e.g., Smari &

Holmsteinsson, 2001) involving people with various
anxiety disorders such as obsessive-compulsive disorder
and specific phobias have shown that the WBSI is sensitive
to measuring the effects of treatment. Items are scored by
summing all individual responses. Lower scores indicate
lower thought suppression. In a large, diverse student
sample for periods ranging from 3 weeks to 3 months, test-
retest reliability was reasonable (r=.69), internal reli-
ability was strong (α=.87 to .89), and the measure
demonstrated good convergent, divergent, and incre-
mental validity (Wegner & Zanakos, 1994). Depending on
sample characteristics, Wegner and Zanakos found that
average scores for nonclinical samples vary from 43 to 50.

The Believability of Anxious Feelings and Thoughts
(BAFT) is a 30-item self-report measure of defusion that
includes the content of all 16 ASI items and a set of
rationally derived items reflecting excessive thought and
emotion regulation getting in the way of effective action
(e.g., “When unpleasant thoughts occur, I must push them
out of my mind” or “I need to get a handle on my anxiety
and fear for me to have the life I want”). Rather than
assessing the presence, intensity, or degree of fear of
symptoms, the BAFT requires participants to indicate on a
scale from 1 (not at all believable) to 7 (completely believable)
how much they believe or “buy into” each statement.
Similar believability and defusion measures have been
idiographically developed and used successfully as process
measures in other ACT outcome studies (e.g., Bach &
Hayes, 2002), including mediating outcomes, and have
proven to be the most robust indicator of ACT outcome
(see Hayes et al., 2006). The BAFT total score is derived by
summing responses for all items. Initial psychometric
evaluation in a nonclinical university sample (N=400)
suggests that the BAFT is unifactorial, with strong internal
consistency (coefficient alpha=.95) and convergent validity
with other ACT process variables (e.g., experiential
avoidance, mindfulness, self-compassion, and quality of
life; see Herzberg, Sheppard, Forsyth, & Eifert, 2009).

The Quality of Life Inventory (QOLI; Frisch, 1994) is a
32-item self-report questionnaire developed to measure
life satisfaction in the areas of health, self-esteem, goals
and values, money, work, play, learning, creativity, helping,
love, friends, children, relatives, home, neighborhood,
and community. Participants are asked to rate the
importance of each area relative to their overall happiness
on a 3-point Likert scale (0=not important to 2=very
important) and how satisfied they are with each area on a
6-point Likert scale (-3=very dissatisfied to 3=very satisfied).
In addition to scores for each life area, the inventory also
yields an overall quality of life score. Data from over 1,000
individuals suggest that the QOLI has good stability (at 2-
week intervals), internal consistency (alpha coefficients
range from .77 to .89), as well as convergent, discriminant,
and treatment validity (Frisch et al., 2005).

377ACT for Anxiety Disorders

Case Descriptions and Results

The Case of James: A Man Suffering From
Panic Disorder

James, a single, 31-year-old Caucasian male, is an
aspiring actor and screenwriter. Just a few months before
starting treatment, around the time of his 31st birthday,
James experienced his first panic attack. Although he
reported experiencing very few panic attacks since his first
attack, he reported a number of changes in his life and
significant distress beginning around the time of the
attack. For example, he had given up drinking caffeine to
avoid bodily sensations that simulate panic. In addition,
he had given up drinking any alcohol because of concern
over doing anything that may harm his health. Also
beginning around the time of the attack, James began
experiencing difficulties sleeping. He reported laying
awake in bed late into the night distressed that his not
being able to sleep would disrupt the activities he had
planned for the next day. His concern over getting
enough sleep appeared to contribute to changes in his
activities during the day. For example, he began listening
to the radio less because of concern that a song may get
“caught in his head,” making it difficult for him to fall
asleep later at night. In addition, everyday decisions, such
as deciding what time he should exercise, became difficult
for him because they were evaluated in terms of its
potential impact on his sleep. Meanwhile, he struggled
with his decision not to drink alcohol because it was an
essential part of his Hollywood nightclub social life.

Although his principal diagnosis was panic disorder
(clinician ADIS rating=4) with subclinical symptoms of
OCD (clinician ADIS rating=3), it became clear during
the initial treatment sessions that it was his dissatisfaction
with the current state of his life that was most distressing
for James. He was frustrated with the lack of progress in
his career and was struggling with thoughts of not having
accomplished enough to this point in his life and fears of
being a “failure.” What was most upsetting for him about
his panic symptoms and his difficulty sleeping was that
they served as further obstacles to progress in his career.
He felt as if his life was closing in on him and was left
feeling increasingly out of control of his life.

Several metaphors, such as the Chinese Finger Trap,
presented early on in treatment, helped James connect
with his sense of being stuck within his current situation
and to his own experience of how his attempts to gain
control over undesirable internal experiences were
actually contributing to further distress and a narrowing
of his life space. While he related the metaphors to his
struggle with panic symptoms and his difficulty sleeping,
being able to relate the metaphors to his struggle with
feelings of failure and lack of accomplishment proved
more significant for James. His verbal attributions for the

lack of progress in his career, including “problems with the
industry” and “the incompetence of his manager and
agent,” while functioning to help him feel less like a
“failure” in the short-term, also served as barriers to taking
action and creating his own opportunities for career
progress. Following the second session, without any
prompting from the therapist, James resumed working
on a script that he had been putting off for several months.

Defusion, especially around the word “failure,” was a
major focus of James’ later sessions. James described a
long history of self-deprecating thoughts around being a
failure. Through a series of direct experiential exercises in
session, James gradually became less emotionally reactive
to the word “failure.” For example, when presented with
the word “failure” written on a flash card, James reported
wanting to rip up the card and throw it in the trash. The
therapist then asked James whether he was willing to put
the card in his lap, simply read it, let it be, and have the
card touch him as a thought. James agreed and was
surprised to notice that he could do this without getting
tangled up in what the card says. He was also willing to
take the card with him over the next week everywhere he
went. In addition, James and his therapist did an exercise
in which they rapidly repeated the word “failure” for
approximately 30 seconds (Masuda et al., 2004) while
observing what happens to the quality of the word when
doing so. James reported that after saying the word
repeatedly “failure” was reduced to merely a string of
almost unrecognizable sounds and he could see that it was
ultimately just a word. Exercises such as this helped James
to become a better observer of his own thinking and he
learned that he does not have to take his thoughts, even
historically difficult thoughts, so seriously and do what
they say. Decreases in the degree to which James believed
his anxiety-related thoughts are demonstrated by the drop
in his BAFT score from 122 at pretreatment to 51 at
posttreatment.

More importantly, James learned to use defusion skills
to help him persist in value-consistent behavior in the
presence of difficult thoughts. This change was also
reflected in the increase of his AAQ-Action score. For
example, during the course of treatment James com-
pleted his screenplay and put together a team of actors to
present his screenplay to an audience for the very first
time, despite experiencing occasional thoughts of failing
throughout the process. In addition, by the end of
treatment, James enrolled as a volunteer at a local
children’s hospital, something he had wanted to do for
years and has been putting off due to thoughts of “not
having enough time.” His increased participation in
valued activities was reflected in changes in his in QOLI
scores, which increased from a score in the 1st percentile
at pretreatment to a score in the 55th percentile at
posttreatment.

378 Eifert et al.

Meanwhile, his original concerns over panic symptoms
and difficulty sleeping faded increasingly into the back-
ground over the course of treatment. Toward the end of
treatment, James did note occasional trouble falling
asleep but that his episodes of sleeplessness were less
distressing than they used to be. During instances of
difficulty sleeping, James reported that he would watch his
mind “do the thing it does” until, sooner or later, he
would fall asleep. In addition, James reported less
interference in his daily activities as a result of panic
and sleep-related concerns. For example, without any
prompting from the therapist, James reintegrated
caffeine and alcohol into his daily life. Additionally,
James no longer reported distress over engaging in daily
activities that might influence his sleep. The lack of
interference and distress over panic and problems with
sleep are evidenced by increases in his AAQ-Acceptance
score (from 12 pretreatment to 36 posttreatment) and by
clinician severity ratings of 0 for both panic disorder and
OCD at the end of treatment. Increases in his ACQ score
and decreases in his ASI score also indicate that he
experienced more control over and was less concerned
about anxiety-related sensations.

At 6-month follow-up, James continued to report little
to no distress or impairment over panic or OCD-related
symptoms. Although he experienced a significant set-
back with respect to his career since completing the
treatment—he experienced an injury that put him out of
work for several months—James reported using the skills
he learned in therapy to help him accept the limitations
of his situation without becoming overly frustrated or
discouraged.

The Case of Daniel: A Man Suffering From
Social Phobia

Daniel, a 51-year-old Caucasian male, presented with
generalized social phobia and also received a secondary
diagnosis of dysthymia. The social situations he feared
most were public speaking, being assertive, speaking with
unfamiliar people, and attending social gatherings.
Daniel could not remember a time when his social phobia
had not been significantly distressing and impairing. In
recent years, his relationship with his anxiety symptoms
had also begun to disrupt his sleep and adversely affect his
physical well-being. He had maintained a mid-level job at
a government agency for over 15 years without a
promotion, although he believed he would qualify for
one if he applied. He reported that his coworkers
frequently took advantage of him because he would not
stand up for himself or express his opinions. He was
unable to approach his long-term girlfriend to discuss his
relationship concerns because he feared tension and
rejection. Understandably, he felt quite hopeless and
helpless. He approached his first session of ACT

motivated to change while simultaneously being highly
skeptical that change would be possible.

Initially, Daniel’s social anxiety manifested as reluc-
tance to express emotions that he feared would upset his
therapist. The creative hopelessness metaphors helped
Daniel recognize that his previous methods of dealing with
painful emotions (e.g., avoiding, struggling) left him
feeling hopeless and “trapped,” despite his best, life-long
attempts to avoid and fight these emotions. The mindful
acceptance exercises provided Daniel with the opportu-
nity to approach painful emotions in a different way. For
the first time in his life, he took a step back and looked at
his emotions and physical sensations with a more
compassionate stance, appreciating emotions and physical
sensations as momentary, ephemeral experiences. He
found the acceptance of thoughts and feelings and acceptance of
anxiety exercises so helpful that he practiced them more
than once a day (as requested by the protocol) and took
careful notes about his experiences.

Daniel reported that he experienced these exercises as
relaxing at times and anxiety-inducing at other times. It is
important for therapists to respond to any such client
comments, particularly if clients state they like the
mindfulness exercises because they find them relaxing.
The danger here is that clients link acceptance to positive
feeling outcomes and may be attempting to use mind-
fulness to achieve the goal of relaxation or anxiety relief,
which has little to do with mindful acceptance (Segal
et al., 2002). At that point, therapists should emphasize
that the goal of these exercises is not to bring about any
particular effect, such as relaxation, and that any effect is
fine as long as clients focus on watching thoughts and
feelings come and go. As Segal et al. indicate, the goal is
not to relax the mind or body but to learn to relax with
oneself. Daniel practiced challenging tasks, such as
declining inappropriate work requests from coworkers,
noticing the anxiety yet focusing on the task at hand. His
increased willingness to experience his emotions also
extended into other parts of his life once the treatment
started to focus on life goal-directed action. Instead of
delaying action until he eliminated his anxiety symptoms,
Daniel began to move towards his goals of improving
communication with his girlfriend and getting a promo-
tion at work with his anxiety symptoms present.

By the end of treatment, Daniel was more willing to
accept undesirable thoughts, as measured by the AAQ
and the WBSI, and to act in accordance with his values as
suggested by increases in his AAQ Action subscale score
(see Table 2). Daniel’s success at cognitive defusion was
clearly evident in a three-fold decrease from pre- to
posttreatment in the believability of thoughts and feelings
as measured by the BAFT. As he began to move forward in
his life, he also reported significant decreases in distress
related to anxiety and dysthymia. For instance, Daniel

379ACT for Anxiety Disorders

reported reductions in his anxiety sensitivity (ASI), worry
(PSWQ), mood-related distress (MASQ), and a dramatic
decrease in worry and obsessional thinking as measured
by the Padua. In addition, ratings of impairment (i.e.,
ADIS Severity) declined from 5 to 3 for social phobia and
from 4 to 0 for dysthymia. The magnitude of improve-
ments was impressive, yet changes occurred gradually
throughout treatment and seemed to occur subsequent to
Daniel’s increasing abilities with acceptance and defusion.

Daniel occasionally speculated whether he had per-
haps succeeded in eliminating his anxiety once and for
all. Whenever he brought this issue up, the therapist
reminded him that the objective was to move in a valued
direction regardless of his anxiety. If Daniel were to focus
on his decreased anxiety-related distress, the next time he
experienced anxiety he would be drawn back into the
metaphorical tug-of-war to “defeat” his anxiety again. At
the 6-month follow-up, Daniel reported that he was
consistently using the skills he developed in therapy. He
said he had not experienced much anxiety-related
discomfort and that experiencing such occasional dis-
comfort did not “get in the way of [his] life.”

The Case of Janet: A Woman Suffering From OCD and
Panic Disorder

Janet, a single, 52-year-old Caucasian female and
corporate accountant, presented with a lifelong history
and principal diagnosis of OCD and a secondary diagnosis
of panic disorder. Her obsessions involved severe fear of
contamination and having to urinate. Her compulsions
involved excessive washing behaviors and avoiding places
without an easy escape or readily accessible bathroom. For
several hours each day, Janet obsessed about her
contamination and urination fears, and engaged in
compulsive behaviors. She felt embarrassed and shameful

about these behaviors, which led her to limit meaningful
social contact and relationships. She also experienced
spontaneous panic attacks approximately once per week.
Following her first panic attack 5 years earlier, she had felt
worried and distressed about panic symptoms on a daily
basis.

Janet had for many years avoided intimate relation-
ships with men and close supportive friendships with
women, and had not completed her undergraduate
degree despite showing much academic promise. She
placed a high premium on her current job but had
remained with a “disrespectful boss” for several years. She
also felt unable to stand up for her needs or respond
effectively to her negative emotions at work, which
seemed to be linked with her decreased job satisfaction.
She feared being “an OCD” her entire life. Having
recently completed 20 years in therapy with little effect on
her anxiety symptoms, she was not confident ACT could
help her.

When Janet initially began to increase her experiential
willingness, she felt a strong increase in anxiety, sadness,
and anger as she allowed herself to feel fully what was
happening inside of her for the first time in her life. In
Session 3, she vigorously questioned the therapist
whether this treatment would ever help her or just be a
waste of her time. This is an important moment in any
treatment whenever this issue arises. The therapist
responded that we could not promise her anxiety
reduction but that she could learn new skills that would
most likely help her develop a new relation to her anxiety
if she persisted with practicing the acceptance, mind-
fulness, and other exercises. It is important for therapists
to address this common concern in a way that gets the
message across that ACT is about gaining new skills that
can be learned over time with sufficient practice. Indeed,

Table 2
Pre and Post Data for Process Measures of Acceptance, Mindfulness, and Defusion as Well as Participants’ Quality of Life

Measure James Daniel Janet
Pre Post Pre Post Pre Post

AAQ
–Acceptance 12 36 20 32 33 35
–Action 34 40 31 40 44 44

BAFT 122 51 174 53 92 87
MAAS 3.8 4.7 3.1 4.5 5.1 4.7
WBSI 66 53 45 36 65 38
QOLI

–Overall Score −1.2 2.8 0.7 2.9 2.6 3.3
–Percentile (%) 1 55 9 59 71 49
–Classification Very low Average Very low Average Average Average

Note. AAQ=Acceptance and Action Questionnaire (higher scores indicate higher levels of acceptance and valued action); BAFT=Believability
of Anxious Feelings and Thoughts (lower scores indicate lower believability of thoughts and feelings); MASS=Mindfulness Attention
Awareness Scale (higher scores indicate higher levels of daily mindfulness);WBSI=White Bear Suppression Inventory (lower scores indicate
lower levels of suppression and struggle with unwanted thoughts and feelings); QOLI=Quality of Life Inventory (larger QOLI scores indicate
greater reported quality of life).

380 Eifert et al.

once she honed her mindful observing skills through the
acceptance of thoughts and feelings exercise, she learned
through her experience that it was possible to simply
experience intrusive thoughts and uncomfortable emo-
tions, without having to do what they seem to be telling
her to do.

Janet showed substantial increases in self-acceptance
and increases in life-goal directed behavior during
therapy. For the first time, she discovered that she could
live according to her own needs and values rather than
spending time trying to reduce her anxiety and please
others. This discovery coincided with dramatic increases
in her willingness and acceptance of her OCD symptoms.
On a measure of thought suppression (the White Bear
Suppression Inventory), her score dropped from 65 at
pretreatment to 38 at posttreatment, indicating signifi-
cantly decreased suppression and increased willingness to
experience her obsessive thoughts. Whenever they
appeared, she literally began saying to herself, “Hello,
OCD thoughts and feelings! Hello, friends! How are you
today? You’re not my enemy. I can live with you.” She
began working with panic and anger-related experiences
in the same manner. Janet learned to recognize when she
avoided situations due to anxiety, and chose to respond to
anxiety differently. She attended more singles events,
resumed dating, socialized more with her women friends,
and communicated more honestly and compassionately
with her family, friends, and colleagues. Instead of
continuing to put herself down, she deliberately started
to engage in behaviors that were designed to be
“compassionate and kind to myself,” including taking
time to read, take baths, and watch movies. For the same
reason, she also began looking for a new job more to her
liking. With these changes, Janet also reported feeling
happier than she had felt in many years.

Janet’s pre- to posttreatment PSWQ, FQ, and ACQ
scores show lower levels of distress and more perceived
control over anxiety. Her OCD severity dropped from
moderately severe at pretreatment (clinician ADIS
rating=6) to subclinical levels at posttreatment (clinician
ADIS rating=3). Whereas her ADIS panic severity
pretreatment rating had been 6, her fear of anxiety-
related symptoms dropped so dramatically by posttreat-
ment (e.g., her ASI scores dropped from 34 to 12 pre to
post) that she no longer endorsed any panic disorder
distress in the posttreatment assessment (clinician ADIS
rating=0). Interestingly, she chose not to eliminate some
mild hand-washing compulsions via exposure, because
they no longer caused her distress or interfered with
valued activities. Although Janet reported more accep-
tance of urges informally, she did not report much change
on the formal measures of acceptance and defusion
except for a dramatic decrease of thought suppression
(her WBSI decreased from 65 to 38).

At 6-month follow-up, Janet’s OCD problems remained
at subclinical levels (clinician ADIS rating=3). She also
reported a significant change in her life. After remaining
in a job in which she endured poor treatment by her boss
for 4 years, she took a brief leave from work to clear her
mind, then quit her job and secured another. Although
several OCD problems remain, including mild hand
washing and urination compulsions, finding a new job
realized one of Janet’s major goals and reflected moving
toward her personal value of self-respect.

General Discussion

The three case studies illustrate several important
points about our ACT program for the treatment of
anxiety disorders. First, the ACT for Anxiety treatment
manual (Eifert & Forsyth, 2005) flexibly accommodated
different clinical presentations of anxiety disorders. In an
age of increasingly detailed distinctions among disorders
and equally detailed treatments, we take comfort in our
initial finding that a single treatment manual can be
flexibly applied to treat different forms of anxiety-related
suffering and presenting concerns.

Second, clients observed shifts in targeted processes of
change, including reductions in experiential avoidance
and defusion of anxiety-related thoughts and beliefs.
James, for example, realized that his fear of failure and
external attributions of his career difficulties (e.g.,
“problems with the industry,” “the incompetence of his
manager and agent”) contributed to inaction in the
pursuit of his writing and acting aspirations. Defusion of
his failure-related cognitions and his verbal explanations
for his lack of career success facilitated the completion of
value-oriented goals, including having his screenplay
performed before an audience for the first time. Daniel,
after a lifetime of struggling with his anxiety, no longer
defined himself by his symptoms; he saw his anxiety as a
part of his overall experience of life.

Third, although ACT does not target anxiety reduction
per se, all three clients experienced less distress at the end
of treatment, as evidenced by changes in virtually all
anxiety and mood distress-related measures. For example,
Table 2 shows significant reductions from pre- to
posttreatment in anxiety sensitivity (ASI), worry
(PSWQ), negative mood and anxiety (MASQ) as well as
general fearfulness and fear in social situations (Fear
Questionnaire). Moreover, the post-ADIS severity ratings
were much lower at the end of treatment than before
treatment. As in previous experimental studies (Eifert &
Heffner, 2003; Levitt et al., 2004), we observed a
paradoxical effect in regard to perceived control over
anxiety. As clients developed skills to let go of their
previous efforts to control unwanted cognitions and
emotions, two clients (James and Daniel) were surprised
to find that they actually felt more in control, as reflected

381ACT for Anxiety Disorders

in increased score on the Anxiety Control Questionnaire.
Janet, on the other hand, reported becoming more aware
of her inability to control the occurrence of obsessions
(reflected in increased score on the ACQ) but indicated
she accepted this inability and that she was not going to
fight it anymore.

Fourth, a focal point of ACT is living a life-goal-directed
life and addressing the barriers that are standing in the
way of such a life. Although we observed only modest
increases on the ACT Action scale for James and Daniel,
and none for Janet, all clients felt empowered by the
treatment’s focus on valued living and engaged in
behaviors in accord with their chosen life goals. The
resulting increases in the participant’s quality of life were
clearly reflected in the changes on the Quality of Life
Inventory. For instance, James completed and began
producing a screenplay and realized his dream of
volunteering at a local hospital, Janet began socializing
more broadly and found a new job, and Daniel
strengthened his romantic partnership and successfully
requested a promotion. In terms of barriers, there
continues to be a debate (e.g., Hayes, 2008; Hofmann &
Asmundson, 2008) whether cognitions are causal factors
for behaviors and feelings. Even if therapists are uncertain
as to where they stand in regard to this issue, they can
adopt the ACT strategy to change the function of
thoughts: clients can learn that cognitions (and emotions
for that matter) need not determine what they do even if
cognitions and emotions are intense and seem compel-
ling. This was one of the most important lessons for all our
clients to learn because all three clients felt that anxiety-
related thoughts and feelings were the main barriers in
their lives. As a result, therapists had to address those
barriers repeatedly throughout treatment. Following the
introduction of the mindful acceptance and other
defusion exercises, clients began to struggle less with
their thoughts and emotions. Janet’s increased kindness
and compassion in self-care illustrated this shift. Interest-
ingly, her shift occurred after she expressed skepticism
about the treatment’s ability to help her, which for her (as
would be the case for most clients) initially meant having
fewer obsessions and feelings of panic. Likewise, having
untangled his self-identity from his anxiety symptoms,
Daniel was able to make space for exploring who he
wanted to be and pursuing his values. His progress in
observing and accepting his thoughts and emotions freed
him to start moving, and his values guided his actions.
James learned that failure-related cognitions did not have
to be eliminated before he could engage in life goal-
directed behavior.

Apart from some new techniques and exercises, the
ACT for Anxiety program incorporates many established
behavior therapy interventions. They include behavioral
activation and exposure exercises—although they are

conducted in a different way and with a different
rationale than is typical. Behavioral skills training may
also be employed for individuals with social skills deficits.
As Hayes et al. (1999) indicated, “during the later
portions . . . ACT takes on the character of traditional
behavior therapy, and virtually any behavior change
technique is acceptable” (p. 258). On the other hand,
there is a crucial difference between ACT and traditional
CBT in how therapists approach difficult cognitive and
emotional content (e.g., “irrational thoughts”). Segal et
al. (2004) expressed this difference clearly in regard to
mindfulness-based cognitive therapy, and it applies
equally well to ACT: “Unlike CBT, there is little emphasis
in MBCT on changing the content of thoughts; rather, the
emphasis is on changing awareness of and relationship to
thoughts, feelings, and bodily sensations” (p. 54).

Arguing from an emotion regulation perspective,
Hofmann and Asmundson (2008) point out that CBT is
more focused on changing the evaluation of the
situational or internal emotion cues (antecedent-
focused emotion regulation), whereas ACT encourages
primarily emotion-focused problem-solving strategies—
changing a person’s response to emotions by encoura-
ging their acceptance rather than trying to change
them. ACT also recognizes, however, that there are
situations when it is not desirable to accept unpleasant
thoughts and feelings and focus on changing the
antecedent conditions. Examples might include
women who feel anxiety and terror because they are
trapped in an abuse relationship. In such cases,
treatment may very well focus on changing the
antecedent condition, that is, helping the women to
leave the relationship and the physical context of abuse.
Acceptance does not imply resigning oneself to a bad
situation, particularly if the situation is harmful and the
person can leave or change the situation. In such
instances, acting on what the person’s mind and
emotion are telling her (“get out”) is useful and serves
to enhance the person’s quality of life. Acceptance is
only the better option when acting on one’s thoughts
and feelings does not serve to enhance one’s quality of
life. Utility (or workability) is the ultimate criterion, and
this would seem apt with any strategy.

The unified transdiagnostic qone-shoe-fits-allq approach
presented herein has clear advantages in terms of greater
simplicity as well as more efficient training and dissemina-
tion. These advantages, however, are predicated on the
assumption that the same processes (e.g., experiential
avoidance, fusion) operate across all anxiety conditions.
Although there is considerable support for this assumption
(Hayes et al., 2006; Hayes, 2008), future studies will need
to examine what specific adjustments might need to be
made to the program when clients present with particu-
larly intense and overwhelming emotions as in PTSD.

382 Eifert et al.

Walser and Westrup (2007) have presented some useful
suggestions in this regard.

The purpose of this case study was to illustrate the
ACT for Anxiety treatment program, its implementation
in some detail, and point out some differences to
traditional CBT protocols. As with any case report such
as this, it is important to be appropriately cautious and
not make sweeping generalizations—the large clinical
trial from which we selected completed cases is still
ongoing. We must await the outcomes of that work
before making claims about the efficacy of this program
compared to an established CBT protocol. In the
context of the large RCT, we will particularly examine
the relation of treatment outcome to changes in
process variables. We will be able to address issues
such as client resistance and the impact of clients not
willing to let go of the struggle agenda, therapist
training and maintaining a consistent ACT or CBT
posture throughout treatment, and what variables may
trigger early termination and dropout.

We also noticed from supervision tapes that there
may be a relation between outcome and therapist
competence in terms of how successfully therapists
modeled the skills they wish to foster in their clients
(e.g., being mindful, open, genuine, and compassio-
nate). These are questions that cannot be addressed in
a case report and will need to be examined with
sufficiently large groups of clients. There is research
evidence that ACT outcomes are mediated by relevant
clinical processes such as acceptance, defusion, and
engagement in life-goal-directed behavior (for summa-
ries, see Hayes et al., 2006, 2008). In an updated
presentation on this topic, Hayes, Levin, Yadavaia, and
Vilardaga (2007) were able to show that pre-to-post
changes in ACT processes accounted for nearly 50% of
the pretreatment to follow-up changes in outcome
produced by ACT. The comparison conditions in the
set included CBT, pharmacotherapy, psychoeducation,
supportive treatment, and wait-list controls. Almost all of
the studies showed significant reductions in the direct
outcome path when adjusted for the mediator at least at
the pb.1 level (and the great majority at the pb.05
level). This work is now being subjected to further
careful scrutiny and criticism (Arch & Craske, 2008;
Hofmann & Asmundson, 2008), and we remain
optimistic that ACT and related acceptance-based
behavior therapies will continue to be guided by data
and help move the field forward in reaching our goal of
alleviating a wide range of human suffering.

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We are very grateful to Michelle G. Craske, Ph.D. for her full and
generous support of this project and for making the facilities of the
Behavioral Anxiety Disorders Program available for the conduct of this
study.

Address correspondence to Georg H. Eifert, Chapman University,
Department of Psychology, One University Drive, Orange, CA 92866;
e-mail: geifert@chapman.edu.

Received: November 12, 2008
Accepted: June 2, 2009
Available online 2 September 2009

385ACT for Anxiety Disorders

Psychology 498

Module 2: Open Up

Practice Booklet

Acceptance and Commitment Therapy Seminar PSYC 498

Open up: Titchener’s repetition

Try Titchener’s repetition, which you can follow along with in the lecture video in Module 1.

After completing Titchener’s repetition

Reflection: Consider taking some notes on the following:

· Were you able to imagine freshly baked cookies? How powerful would you say the image was to you?

· As you said “cookies” rapidly over 40 seconds, what happened to that image that you had of cookies? Did your feelings or thoughts about cookies change at all?

Open Up: Acceptance

Try a meditation for working with difficulties, which you can follow along with in the lecture video in Module 1.

Consider the following question: When focusing on psychological pain, what are the things we ought to accept vs. the things we do not need to accept?

After engaging in the Meditation for Working with Difficulties

Reflection: Please take some notes on the following:

· How willing did you feel as you considered difficulties during the exercise?

· How much do you think that willingness to have a difficulty (a difficult thought or a difficult emotion) is tied to living a vital, values-based life?

ACT question (ACBS, 2019)

1. (Self-as-context) Given a distinction between you and the stuff you are struggling with and trying to change…

2. (Acceptance) are you willing to have that stuff, fully and without defense…

3. (Defusion) as it is, and not as what it says it is,…

4. (Committed action) AND do what takes you in the direction…

5. (Values) of your chosen values…

6. (Contact with the present moment) at this time, in this situation?

If the answer is “yes,” that is what builds psychological flexibility.

Reflection: Open Up

Consider taking some notes on the following (this may help you gather information you can use for the participation discussion post and/or the reflection assignment in Canvas):

· How easy and/or difficult was it for you to engage in the exercises (e.g., the mindful breathing exercise) in this “Open Up” section of the seminar?

· On a scale from 1 (not at all important) to 10 (extremely important), how important do you think it is to “Open Up” to the unwanted parts of life (e.g., feeling stressed) that come along with living a value-driven life? Why did you give that number?

· Can you come up with some examples of when “opening up” to unwanted parts of a value-driven life might
not
really be helpful?

Acceptance and Commitment Therapy Anxiety Case Studies link: (link uploaded)

Optional Practice Materials: Opening Up:

1. Please note: this document builds on important content discussed in chapter 12 of 2nd edition of ACT Made Simple.

TITCHENER’S REPETITION: LEMONS, LEMONS, LEMONS

This exercise (Titchener, 1916) involves three steps:

1. Pick a simple noun, such as “lemon.” Say it out loud once or twice, and notice what shows up psychologically—what thoughts, images, smells, tastes, or memories come to mind.

2. Now repeat the word over and over out loud as fast as possible for thirty seconds. Please try this now with the word “lemon,” before reading on. You must do it out loud for it to be effective.

3.Now run through the exercise again with an evocative judgmental word—a word that you tend to use when you judge yourself harshly, for example, “bad,” “fat,” “idiot,” “selfish,” “loser,” “incompetent,”—or a two-word phrase such as “bad mother.”

Please try this now and notice what happens. (You need to do it aloud to get the benefit). Most people find the word or phrase becomes just a meaningless sound within about thirty seconds. At that point, we see it for what it truly is: an odd sound, a vibration, a movement of the mouth and tongue. (But when that very same word pops into our head and we fuse with it, it has a lot of impact on us.)

Note: If doing this exercise with a client, first pick a non-distressing word (e.g. lemon, chocolate, milk) and then repeat the exercise with a word that typically elicits a painful reaction in the client. For example, if the client often fuses with “I’m an idiot”, you could repeat the exercise with the word “idiot”. Single words usually work better than whole phrases.

2. Leaves on a Stream-Cognitive-Defusion-Exercise

Cognitive Defusion Exercise

Harris (2009) provides an excellent cognitive defusion exercise used in Acceptance & Commitment Therapy:

“Leaves on a Stream” Exercise

(1) Sit in a comfortable position and either close your eyes or rest them gently on a fixed spot in the room.
(2) Visualize yourself sitting beside a gently flowing stream with leaves floating along the surface of the water. Pause 10 seconds.
(3) For the next few minutes, take each thought that enters your mind and place it on a leaf… let it float by. Do this with each thought – pleasurable, painful, or neutral. Even if you have joyous or enthusiastic thoughts, place them on a leaf and let them float by.
(4) If your thoughts momentarily stop, continue to watch the stream. Sooner or later, your thoughts will start up again. Pause 20 seconds.
(5) Allow the stream to flow at its own pace. Don’t try to speed it up and rush your thoughts along. You’re not trying to rush the leaves along or “get rid” of your thoughts. You are allowing them to come and go at their own pace.
(6) If your mind says “This is dumb,” “I’m bored,” or “I’m not doing this right” place those thoughts on leaves, too, and let them pass. Pause 20 seconds.
(7) If a leaf gets stuck, allow it to hang around until it’s ready to float by. If the thought comes up again, watch it float by another time. Pause 20 seconds.
(8) If a difficult or painful feeling arises, simply acknowledge it. Say to yourself, “I notice myself having a feeling of boredom/impatience/frustration.” Place those thoughts on leaves and allow them float along.
(9) From time to time, your thoughts may hook you and distract you from being fully present in this exercise. This is normal. As soon as you realize that you have become sidetracked, gently bring your attention back to the visualization exercise.

3. UCLA-Semel-Meditation For Working With Difficulties_Transcript

Meditation for Working with Difficulties (6:55)

You can use this practice to work with difficult emotions or body sensations
Find a posture that’s comfortable to you
And then check inside your body and try to locate a part of your body that feels good to you right now
Pleasant, safe, at ease,
Or at the very least, neutral
You can check out your hands or feet or legs
But let your attention go to this pleasant part of your body
Hands or feet or wherever you’ve chosen
And let your attention rest there
Feel it
Sense it
Notice what those sensations are
Let your mind relax a bit
Feeling that part of the body
And now if there’s something difficult that’s happening for you
A difficult emotion, or a physical sensation that’s hard
Let your attention go to that
So, it may be an aching in your shoulder or back
Or a headache
Or it could be a sense of sadness
Or anxiety
Or anger
Where do you feel that sensation in your body
Where do you feel that emotion in your body
Notice it
Just notice it for one moment
Tap into it
Feel it
Make sure to breathe
And now return your attention back down to that area that feels at ease
Your hands or feet or legs
And just let yourself stay there for a moment
Feeling it sensing it
Relaxing. maintaining the mindfulness
Yet giving yourself a break from what could be potentially overwhelming to feel
And now once again return your attention to that part of the body that feels unpleasant
The body ache or pain
Or the emotion the sensations of the emotion in your body
The vibrations in your chest
Or the clenching in your belly
Or the tightness in your jaw
Just notice
And breathe
And let it be there
Let whatever is there, be there
And then bring your attention again back down to this pleasant or neutral part of the body
Hands, feet, so forth
Relaxing
Staying present and alert
Feeling the safety
The connection in that place
Now let yourself stay connected to this place
But see if you can cast what we might call a sidelong glance at the difficult area in your body
Is it possible to still feel connected to your body in the area that feels good
And yet know there’s something going on that feels unpleasant
And just let it be there
Keeping maybe 75% of your attention on the part that feels peaceful and at ease
Still breathing
Casting the side long glance at this difficult area
Noticing what happens to it, is it growing or shrinking
Is it changing, shifting into something else
Becoming aware of whatever it is it’s doing
Relaxing, breathing
And now see if you can bring some loving kindness
Just some kindness to yourself for whatever you’re feeling right now
Physical pain, emotional pain
Hold yourself with kindness
You’re not the only one
So, may we all be free from our pain and our suffering
May we all have happiness
[bell rings]
4. Struggling versus opening up worksheet-R. Harris
Struggling vs. Opening Up Worksheet
Fill in this worksheet once a day to help keep track of what happens when you struggle with your emotions and what happens when you open up and make room for them.

Struggling vs. Opening Up Worksheet

Day/Date/Time
Feelings/Sensations
What events triggered this?

How much did you
struggle with these
feelings?
0 = no struggle, 10
= maximum struggle.
What did you actually
do during the struggle?

Did you open up and make room for these feelings, allowing them to be there even though they were unpleasant? If so, how did you do that?

What was the long-term effect of the way you responded to your feelings? Did it enhance
life or worsens it?

5. HARD Barriers Worksheet – Russ Harris

What’s Holding You Back? Identify Your HARD Barriers.
The aim of this worksheet is to clarify your own internal barriers, holding you back from stepping out of your comfort zone, or trying new things, or facing your fears, or tackling your big challenges, etc. There are two ways to fill out this worksheet. One option is to do it for a specific domain of life – e.g. work, education, friends, partner, parenting, spirituality, hobbies, health etc. The other option is to do it as a broad overview of life in general.

H = HOOKED What reasons does your mind come up with for why you can’t, shouldn’t, or shouldn’t even have to take action? What bad things does it tell you will happen if you do take action? Please write them below.

The antidote: If you get hooked by these thoughts, then you probably won’t take action. So use your unhooking skills. You can’t stop your mind from saying these things, but you can unhook from them.

A = AVOIDING DISCOMFORT Personal growth and meaningful change means stepping out of your comfort zone. This inevitably brings up discomfort. And if you aren’t willing to make room for that discomfort, you won’t do the things that really matter to you. Please write below all the difficult thoughts, feelings, sensations, emotions, memories, and urges you are unwilling to have.

The antidote: Use your “expansion” skills; practice opening up and making room for your discomfort. Before you set out to do the challenging things that matter to you, think ahead: What sort of discomfort is likely, and are you willing to make room for it?

R = REMOTENESS FROM VALUES What values are you ignoring, neglecting, forgetting, leaving behind, or failing to act on when you opt out of doing these important things?

The antidote: Connect with your values. Why bother to do this challenging stuff if it’s not important? If it is important, then connect with what makes it meaningful. What values will you be living with every step you take?

D = DOUBTFUL GOALS On a scale of 0–10, how realistic do your goals seem to you? (10 = totally realistic, I’ll definitely do it, no matter what. 0 = completely unrealistic, I’ll never do it.) If your goals seem less than a 7, it’s doubtful you will follow through. Are your goals excessive? Are you trying to do too much? Trying to do it too quickly? Trying to do it perfectly? Are you trying to do things for which you lack the resources (such as time, money, energy, health, social support, or necessary skills)?

The antidote: Set more realistic goals. Make them smaller, simpler, easier, matched to your resources, until you can score at least a 7 in terms of how realistic they are.

Please write down your goals below and scale each one 0–10 in terms of how realistic they seem. If any score less than 7, you need to make them smaller, simpler, easier – or change them completely – until you can score 7:

Acceptance and Commitment Therapy-PSYC 498/598

Spring 2020 quarter

Kevin Criswell, Ph.D.

Just so you all are aware, students with the accommodation to do so may be audio recording this seminar.
As Steve Hayes said in his TEDx talk in Nevada, “Life asks us questions…and one of the most important questions it asks us is, ‘What are you going to do about difficult thoughts and feelings?’”
1

Open Up

Open Up: Defusion
“Defusion”? “Fusion”? What are you talking about?
Cognitive fusion: becoming “fused” with an idea that the mind brought up.
What “cognitive fusion” can look like:
Clipboard metaphor
“I am angry.”
“It would be great to see my good friend, but I am tired right now.”
And other ways we buy into the thoughts our mind brings up…

Open up: Defusion
What cognitive defusion can look like:
Feeding the tiger metaphor
Chessboard metaphor
Fix-it metaphor
“I am having the feeling of anger right now.” (see relationship to mindfulness here)
“It would be great to see my good friend, and I am tired right now.” (a glimpse into how DBT and ACT are similar in some emphases)
Titchener’s repetition
Leaves on a stream

Open up: Titchener’s repetition
Literally saying a word repeatedly for at least 40 seconds.
I want you to imagine cookies. Freshly-baked, your favorite variety (if you don’t like cookies, this will still work; just imagine them as best you can!).
Now say “cookies” rapidly as you can for 40 seconds straight…
GO!

Open up: Titchener’s repetition
Reflection (handout):
Were you able to imagine freshly baked cookies? How powerful would you say the image was to you?
As you said “cookies” rapidly over 40 seconds, what happened to that image that you had of cookies? Did you feelings or thoughts about cookies change at all?
Imagine using other words that have significant emotional or cognitive load:
Depression
Anxiety
PTSD
And more…

Open up: Leaves on a stream (meditation)
Another cognitive defusion exercise that is commonly combined with mindful awareness to detach from the natural function of our minds: to come up with thoughts constantly.
This has other versions that involve the same concept:
Clouds in the sky
Mind Train
Thoughts are placed on leaves and the individual is invited to observe the natural passing of thoughts, without the need to buy into or pause and seriously consider any of the thoughts as they float by.

Open up: Acceptance
Acceptance can be equated with the idea of willingness to experience discomfort in the service of living consistently with one’s values.
“…feel what is there to be felt even when it is hard.” (TEDx Talks, 2016, February)
In my opinion, this is the most difficult therapeutic process to facilitate.
The “sales pitch” for this is tough: “I want you to accept and/or be willing to experience discomforts that come along with living according to your values.”
I like front-loading the “why” one wants to change (i.e., values) and the “how” to make careful decisions about how one lives (i.e., building a strong “mindfulness muscle”).

Open Up: Acceptance
Consider (handout): When focusing on psychological pain, what are the things we ought to accept vs. the things we do not need to accept?
“Fix-it” metaphor
“Chinese Finger Trap” metaphor
“Quicksand” metaphor
A (possibly) helpful delineation: The “world within” vs. “the world without”

The point: The answer is going to be different for everyone, given different individual circumstances across different stages of life. This is why being client-centered here can be so critical.
9

Open Up: Acceptance
Meditation for Working with Difficulties
Reflection: Please take some notes on the following:
How willing did you feel as you considered difficulties during the exercise?
How much do you think that willingness to have a difficulty (a difficult thought or a difficult emotion) is tied to living a vital, values-based life?
Note: Just engaging in personal meditations is probably insufficient to truly build up willingness to experience necessary discomfort.
Self-monitoring methods can facilitate this process (e.g., “struggling vs. opening up worksheet”)

Open up: Acceptance
The interesting part: This process is not unique to ACT
“Vulnerability”
“Emotional Openness”
Given the empirical convergence, this typically suggests an important, transtheoretical process.
In other words: Willingness to experience discomfort along the way of a values-based life seems to be an important construct that impacts psychological wellbeing.

Putting it All Together
Let’s watch another TED Talk by Steve Hayes: https://www.youtube.com/watch?v=o79_gmO5ppg
How did he describe ACT in this talk?
How was this different compared to the talk I showed you towards the beginning of this seminar?

My take: This is an excellent example of an integrative framework of therapy, which is founded on the ACT approach to treatment.
12

Psychological Flexibility
(1) Given a distinction between you and the stuff you are struggling with and trying to change
(2) are you willing to have that stuff, fully and without defense
(3) as it is, and not as what it says it is,
(4) AND do what takes you in the direction
(5) of your chosen values
(6) at this time, in this situation?
If the answer is “yes,” that is what builds…
ACT question (ACBS, 2019):
Psychological flexibility

Clinical Example of Applying ACT
Treating anxiety-related issues with an ACT-based approach
Let’s read about the History involved in this case study together (See the Case Study in your handouts).

Clinical Example of Applying ACT
Partners/groups: How would you describe ACT to this client, assuming he has never tried an ACT-based treatment before?
Feel free to try to come up with your own metaphors or
Feel free to use some of the metaphors we already covered.
Note: Try connecting his issues that he struggles with to how ACT may be helpful to him.

Let’s broadly separate the course of treatment into 2 sections: Early and Later Sessions
Early sessions
From an ACT perspective, what are the most important things that James should work on during the first 2-3 sessions (think of the ACT Hexaflex or Triflex)?
Given the important things you identified above, can you think of some ACT exercises or practices that would help him improve during the first 2-3 sessions?

Course of ACT-based treatment: The Later Sessions
Later sessions
From an ACT perspective, what are some things you anticipate that James will need to continue working on for several sessions (think of the ACT Hexaflex or Triflex)?
Given the things you identified above, can you think of some ACT exercises or practices that would help him improve during the later sessions of ACT-based therapy?

What was the “textbook” course of treatment?
Let’s listen to the remainder of the case study of James (listen to my reading of the case, as written in the article by Eifert et al., 2009).
An important message: “Although we outline the treatment program in the form of session-by-session guidelines, the actual delivery of ACT is more akin to a fluid dance around several core processes rather than a linear progression…At a practical level, this means that concepts, metaphors, and exercises introduced early on, may be revisited again at any time they seem relevant. Therapists are encouraged to sequence and apply exercises and metaphors in a flexible and creative fashion” (Eifert et al., 2009, p. 370).

feeling better…

Choice
Feel better
Feel better
Seek pleasure
Avoid discomfort
Narrowing
“Bad” emotions are to be “fixed”
Emotional openness
Willingness/acceptance
Commit to personal values
All emotions can be experienced

Canvas Discussion Assignment(S)
Participation credit for Module 3: Brief Discussion post
Due by 11:59pm on June 7th
Carefully follow directions on the discussion assignment page!
Reflection Discussion Assignment (Everyone)
Due by June 7th by 11:59pm
Follow directions to get full credit!
Application Discussion Assignment (Graduate-level only-PSYC 598)
Due by June 7th by 11:59pm
Follow directions to get full credit!

Curious about ACT want to learn more?
Check the Canvas Course page.
ACBS website: https://contextualscience.org/about_act
Free Materials via “ACT Mindfully” (R. Harris): https://www.actmindfully.com.au/free-stuff/
The Happiness Trap (illustrated version available) and ACT Made Simple by Russ Harris
Get out of Your Mind and into Your Life by Steve Hayes

Thank you!
Questions? Email me at kcriswell@ewu.edu
Course Evaluation-pending

References
APA.org. (2012). What Are The Benefits of Mindfulness? Retrieved from https://www.apa.org/education/ce/mindfulness-benefits
Association for Contextual Behavioral Science (ACBS). (2019). State of ACT Evidence. Retrieved July 1, 2019, from https://contextualscience.org/state_of_the_act_evidence
Association for Contextual Behavioral Science (ACBS). (n.d.). About ACT. Retrieved from https://contextualscience.org/state_of_the_act_evidence
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66(1), 7-18.
Eifert, G. H., Forsyth, J. P., Arch, J., Espejo, E., Keller, M., & Langer, D. (2009). Acceptance and Commitment Therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cognitive and Behavioral Practice, 16, 368-385.
Harris, R. (2009). ACT made simple. Oakland, CA: New Harbinger Publications.
Hayes, S. C., Pistorello, J., & Biglan, A. (2008). Acceptance and Commitment Therapy: model, data, and extension to the prevention of suicide. Brazilian Journal of Behavioral and Cognitive Therapy, X(1), 81-102.
Hayes, S. C. (2005). Get out of Your Mind & into Your Life. Oakland, CA: New Harbinger Publications.
Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30(7), 865–878. doi:10.1016/j.cpr.2010.03.001
Purser, R. (2015). The myth of the present moment. Mindfulness, 6(3), 680-686.
Society of Clinical Psychology. (SCP) (2016). Treatments Home. Retrieved June 30, 2019, from https://www.div12.org/psychological-treatments/
TEDx Talks. (2016, July). Mental Brakes to Avoid Mental Breaks | Steven Hayes | TEDxDavidsonAcademy [Video file]. Retrieved from https://www.youtube.com/watch?v=GnSHpBRLJrQ
TEDx Talks. (2016, February). Psychological flexibility: How love turns pain into purpose | Steven Hayes | TEDxUniversityof Nevada [Video file]. Retrieved from https://www.youtube.com/watch?v=o79_gmO5ppg&t=87s

Self as
Context
Contact with the
Present Moment
Defusion
AcceptanceCommitted
Action
Values

Reflection Assignment (Required for All Students)

For this assignment, I want you to complete the prompt below and to post your response to this discussion board. Click on “reply” below and type your response in at least 4 paragraphs with at least 3 sentences in each paragraph.

For full credit

:

· Your response must be at least 4 paragraphs long with each paragraph having at least 3 complete sentences. I highly recommend typing your response into a separate file first, then copying/pasting and submitting your response here.

· Your writing must reflect proper spelling, grammar, and punctuation.

·
All information that is obtained and discussed beyond the lecture and/or required or optional readings are appropriately cited and are only peer-reviewed scientific journal articles
.

Prompt: Reflection on Your Experience during the ACT Seminar

Please address each of the following points (please follow the directions “For full credit” above when completing this prompt):

· If you were talking with a friend, how would you describe what ACT is? Try using what was discussed during the seminar.

· What was the most difficult part of the ACT seminar? This may include the exercises or discussions you found most challenging to engage in. In addition, why was it the most difficult part?

· What was the most engaging/interesting part of the ACT seminar? This may include the exercises or discussions you found the most interesting or fulfilling. In addition, why was it the most engaging/interesting part?

· In your opinion, what are at least three key take-away points from the ACT seminar?