This exercise is a fun way to help clients understand acceptance.

1st part: The clinician gives a sheet of paper and a pen to the client and says "I'm going to ask you to write a sentence if you're okay". Then the clinician puts an obstacle (a piece of carton board, for ex) in front of client's eyes and says "Wait a minute, is this annoying you if I put this in front of your eyes? Would you prefer if I'd take it off? Well I'm sorry but I'm going to let it there though. However, as you said you prefer to see while you're writing, I allow you to do everything you want to try to see what you're writing. You can move your head, you can get up... Just do everything you can to see what you're writing. Is that okay? So let's go!"

Usually, after 20 to 30 seconds the client has still not written anything readable because s/he has been too occupied with trying to avoid the obstacle so we stop the first part of the exercise. The clinician then says "How was it? Was it difficult? Have you been able to write the sentence? Can we read it?" Obviously not.

2nd part: The clinician says "Well, I'm going to propose you another approach to help you write this sentence finally. I'm sorry but I'm going to let the carton in front of your eyes again. But this time, I propose you not to try to bypass the obstacle but to concentrate your efforts on writing. Maybe it won't be easy but just do your best to write the best you can so as we will be able to read the sentence."

Generally, the client very quickly writes a sentence that we are able to read and we can debrief then. A possibility is to ask the client to write some action linked to his/her value and to write on the carton the thing s/he tries to avoid (a painful thought for ex). Also: sometimes clients or participants in workshops get the thing during the first part of the exercise (i.e. s/he stops trying to avoid the obstacle and starts writing the sentence).

This is good too because it means they understand the approach by themselves. But it can be also interesting to encourage them to do as much as possible to see while writing so as to make them observe the difference between the two approaches.

This worksheet provides an Acceptance based alternative to ERP, graded exposure and behavioural experiments. You can download any of our ACT, CFT or CBT resources by visiting http://www.thinkcbt.com and following the free downloads tab. We also welcome new ACT or RFT resources from other therapists. Our ACT, CFT and CBT resources are free to download and share with clinicians and members of the public.

Attached is an ACT take on the traditional CBT thought record.  I have used this with clients and also in training workshops to illustrate one of the differences between ACT and CBT; acceptance, present moment awareness, and values vs. the 'struggle' of evidence for and against, and changing thinking.

Disclaimer: This is a worksheet which is designed to be used by a therapist for therapy purposes only. The therapist using the worksheet takes full responsbility for its use and any impact of it on the client/therapy process.

Purpose of the worksheet: The aim is that the therapist works through the four steps with the client sequentially, you can break these up and divide it over a few sessions. It is most useful for people who are struggling with everyday activities, or activities of daily living (ADLs). This may be because of mood issues or physical discomfort. 

Originally submitted by Josh Hillie:

Attached is an exercise that I transcribed from Dr. Sonja Batten's interview from “ACT in Context podcast #4” time mark 48:20 – 1:04. Overall I have found the podcast to be a great resource and very informative. Thank you to all who are doing this good work!

Important pieces for clinician to be mindful of:
1) It is important to have some kind of therapeutic bond/trust first where the client is willing to have therapist do something a bit odd/unconventional.

2) It is not about creating this grand AHA! moment, but more about the process of getting the client to understand the different ways of responding to their struggles.

3) This exercise does not have to make complete sense to the person at that very moment it was conducted. The clinician can revisit the exercise, and/or parts of it, and tie it in to later in that session, our revisit it in later sessions.

4) Therapist and client can create their own shorthand and sometimes when people can relate to things physically it can make it a little more understandable.

5) Appropriately choose your target for this type of exercise. For someone who has a significant very real trauma history you do not want to work with them to defuse or minimize their experience in anyway. Rather you might choose a medium level target, so maybe not focusing on your client’s thoughts and feelings about the traumatic event itself, but instead come up with examples about how in other ways these struggles are coming up in their lives.
Ex. An Interpersonal violence survivor where intimacy is really difficult: rather than doing this exercise with the actual thoughts, feelings, memories of the specific event itself… but instead some of the thoughts and feelings that show up when they are with their significant other or with other people who get physically close to them and it makes them physically uncomfortable. Focusing on targeting something in the here and now vs. targeting something that is related to the past trauma itself.
 

Acceptance Physical metaphor via Dr. Sonja Batten: ACT in Context podcast

Materials: small index cards & marker

First: Identify what person is struggling with.

Second: Once issue is identified then ask:
When dealing with ___ what’s the first thing that shows up? Client responds.

Third: When your [insert person’s response] what thought goes through your head?

Fourth: And what shows up next?

Fifth: Continue asking questions until you have 6 – 10 separate index cards with client responses pertinent to the specific struggle that they have identified.
(i.e. Thoughts?, Feelings?, Bodily Sensations?, Images that come to mind?, Memories that show up?, Urges?)

Example Script:
Client identifies struggle with Panic.
When dealing with Panic what’s’ the first thing that shows up?...My chest gets tight.
Clinician: write on index card “chest gets tight”
So when your chest starts getting tight what thought goes through your head?...I can’t take this.
Clinician: Write on a separate index card “I can’t take this”
And what Happens next? I have trouble breathing
Clinician: Writes on a separate card “Trouble breathing”
Sixth: Ask permission.
Clinician: “Would you be willing to do something a little bit odd/different/wacky with me?”
If client agrees “Yes”

Seventh: Set up 2 chairs across from each other (a couple feet apart)
Suggest if they would be open to practicing different ways to responding to these thoughts, sensations, images etc. when they show up.

Eighth: Sit in respective opposite chairs:
Clinician: “I am going to gently toss these cards one at a time over to you and what I want you to do is bat them away or move your body or do whatever you have to do to not be in touch with these cards in anyway. Clinician goes through each card one by one reads it and gently toss it over to the person…take a pause...then read next card…pause…repeat until all cards are read.
Process activity: Take time to process with the person what that experience was like.
Clinician: “How was the experience for you?”
Client: “I was a little nervous at first but I was able to batt them away and it was ok I was able to do something about it”
Clinician: “So as we were doing that do you think you would have been able to do something that was important to you at the same time?” (Adapt that to something that is important to the person that these problems have been getting in the way of)
Ex. Clinician: “Do you think while you were batting those things away could you have____ ? “ ex. done that work presentation?... read that book to your kids?,… had that important conversation with a loved one?
Client: “No, I was too focused on making sure that those cards didn’t touch me.”

Ninth: Gather the cards up with the person and tell them we are going to do this in a different way.
Clinician: “This time I want you to cover your eyes with your hands and try to distract yourself however you can. You are not going actively fight with these things but I want you to not to look at them, not to try to notice what’s going on, and just try to distract yourself as much as you can.”
Clinician goes through each card one by one reads it and gently toss it over to the person…take a pause...then read next card…pause…repeat until all cards are read.
Process activity: Take time to process with person what that experience was like.
Clinician: “What was that experience like for you?
Client: “It was sort of upsetting, I wasn’t doing anything, but after a while I was able to check out and distract myself thinking about what happened yesterday” (or whatever they were distracting themselves with during the activity)
Clinician: “And when you were in that stance would you have been able to ____?” Ex. do that work presentation?... read that book to your kids?,… have that important conversation with a loved one?
Client: “well no because I was focused on just checking out at that moment”

Note: Distraction or numbing emotions, or finding different ways to check out in the present moment, if that is your characteristic, most common, and routine way of dealing with stress or difficult situations, then that is likely to be a problem.

Experiential avoidance: It’s not that avoidance is bad per say, it’s just that when doing so creates more problems, or it can be harmful (i.e. doing drugs). Pervasive way vs. way that someone mindfully chooses to use distraction.

Tenth: Third step in this exercise gather up cards again with the client.
Clinician: “Ask you to remain in the chair with feet flat on the floor and put your arms on your lap with palms facing up in an open welcoming gesture. Would you be willing to try this a third time?"
If yes…
Clinician: "Now I am going to call out each card one at a time and gently toss these cards over to you and I want you to notice what I am saying, be present here in the moment, and keeping you open welcoming gesture can you let the cards come over and do what they are going to do?”
Clinician: goes through each card one by one reads it and gently tosses it over to the person…take a pause...then read next card…pause…repeat until all cards are read. This time the cards might fall on the persons lap, bounce off them, miss them and land at their side. Client’s job is just to be there and be present and in contact with each one of those experiences for however long it’s there.

Process activity: Take time to process with person what that experience was like.
Clinician: “So if you were in this open stance could you at the same time that these cards were coming over to you have been able to____?” Ex. do that work presentation?... read that book to your kids?,… have that important conversation with a loved one?
Client: “Yeah, at least in this stance I could get closer to it. I feel I did a little better than the other times at least.”

Purpose of activity: It is not trying to get the person to have any one particular experience but rather it’s a physical metaphor to help distinguish between the different ways that we can respond when these certain thoughts, memories, feelings, sensations come up.
a) We can try to fight them and take these active measures to control these thoughts, feelings, sensations etc. when they show up.
b) We can try to ignore, dissociate, distract, or numb and not be in touch with what’s going on.
c) Or can you be open and willing to experience whatever is there for however long it wants to stick around for. Without Holding onto it or pushing it away.

I wrote this exercise based on the "Thoughts as Butterflies" metaphor found in various ACT materials such as the "Learning ACT" book.  I have used it in my ACT group and have recieved positive feedback.  Feel free to comment and critique!

Spanish version submitted by Paulina Salles.

This is a note from Steve Hayes about the book

I wanted to say a little about what we are learning about the impact of Get Out of Your Mind and Into Your Life

We have used or are using the book as part of our protocols in four scientific studies. The book is very flexible -- you can fit it to almost any issue, so these studies are in several different areas.

One study that is now done is Jason Lillis’s dissertation on weight maintenance. It’s a really neat study, and I predict it will get some publicity when it comes out in a journal.

In that study everyone in the ACT condition got a 6 hour workshop on ACT (not really focused on weight – but focused on doing what you value and learning to sit with difficult thoughts and feelings that get in the way). And everyone in the ACT condition also got the book.

When we then asked at the follow up if people used the book we divided up the groups into those who used it very little and those who used it regularly and carefully. We compared that last group (the readers and regular users) to people in the ACT condition who got the workshop but did not use the book much.

(In truth, in other analyses we also compared the frequent readers to the control group, and the effects there were huge, but that comparison includes the workshop in one group and not the other so it is really not as relevant to the question of whether the book itself was helpful).

At a three month follow up, those who read and used the book carefully in the ACT condition:

• Had a higher quality of life
• Were less judgmental toward themselves
• Felt less judged by others
• Were more accepting of difficult thoughts and feelings about weight issues
• Were more successful in living their values
• Had more intrinsic and less avoidant or socially compliant values

All of these folks got an ACT workshop, and the workshop itself had a really big impact – so this was over and above that. Overall (not dividing the group by whether they read Get Out of Your Mind carefully) people in the ACT condition lost more weight over 3 months, lowered their diastolic blood pressure, had better overall mental health, were more distress tolerant, and so on through a long list of good effects. But on top of that the book seemed to make an impact.

Tami Lazzarone has recently completed a randomized trial of the book with 236 teachers and staff in K - 12. At post those who read the book had small to medium improvements in general mental health, anxiety, depression, and burnout. At a 3 month follow up all of these effects were larger -- mostly medium to large. At the process level changes were found in mindfulness, acceptance, and psychological flexibility and these post changes mediated follow up outcomes.

Takashi Muto has done much the same thing with a Japanese translation of the book -- applying it to college students from Japan who are adjusting to life in the US. It is still underway but at post the effects are very good.

Anyway, let me just say this: there are a lot of books out there that say they will help you. It is one thing to say that. It is another to put a book on the line and see, objectively, how it works in controlled studies. So far the results coming in are very supportive.

BUT
How do we get everyone who buys it to read it carefully and to do the exercises? It seems to take that to make a real difference.

But probably a third of the folks who buy it will get bogged down and some will just abandon the book.

That really distresses me, since I know some of those people are suffering and could be helped if they gave the book a chance.

The bogging down may be due to my science geek writing style (I’m learning, but it is hard for me not to talk like a geek after 30 years in the University, even with a professional writer like Spencer Smith helping me). But the other part is this: this is a tricky area!

The human mind does not like being dethroned, and it is hard to use words to rein in the word machine. That is especially true in a non-interactive medium like a book.

But I do think there are steps that can help.

I suggest this if you buy this book:

1. Join the list serve ACT for the Public. This is the link: https://groups.io/g/actforthepublic. It’s free. Post to it when and if you get stuck. Don’t abandon the book before you get help with it. Please.
2. It is hard to really do the book carefully right off from the beginning. It takes a while to see what it is really up to.

I suggest that you skim the whole thing in a day or two, skipping the exercises and not stopping if you get confused.

Then let it sit for a day or so.

Then if you sense that there may be something of value for you in the book, open it up at page one and read it carefully, doing the exercises as you go. That process will take at least a month. If an exercise or sections bogs you down, put a post-it note there and move on … you can come back later. And you can post an email about the issue on the list serve.

I hope this helps and good luck!

Steve Hayes

The attached worksheet, developed by Brandon Scott, has been used as a daily exercise to trigger and harness creative hopelessness for individuals with chronic pain. It has been used to help clients grow into living their life even if the pain exists.

I use this a lot with clients who tend to keep derailing the session. It’s incredibly powerful, and it trains defusion, acceptance, contact with the present moment, and committed action all in one simple intervention. (I wanted to put it into ACT Made Simple, but there was no space –so here it is in print for the first time).

To use this strategy, first, you need to agree that you and the client are a team - working together for a specific goal. (Obviously if the client’s goal is to get rid of their anxiety, you can’t agree to that – you just declare your helplessness; admit you don’t know how to do it in any manner that enriches life; and offer them the alternative: to ‘learn how to handle anxiety more effectively so it has less influence and impact over you’.)
So in this case you and the client might agree the goal is to have ‘more successful social interactions’, or to ‘learn how to handle anxiety more effectively so it has less influence and impact over you’, or to ‘increase social life’ etc.
Okay, that’s step one: agree on a goal, and agree you’re a team.

Step two: you say, ‘Now here’s my prediction. I could be wrong, but i predict that throughout this session, every time we start to really knuckle on down to achieving this goal, your mind is going to try and derail us; to pull us off track. And what I’d like for us to do, if you’re willing, is to identify all the different tactics your mind uses to do this; so we can spot them when they show up, and make sure we don’t get derailed by them. Is that okay?’

Step three: Therapist pulls out a large sheet of paper and a pen.
T: ‘So I’m going to write down here every tactic your mind uses. I’ll start off writing for the first few tactics, and then I’ll pass the paper over to you, and you can take over, okay?’
C: Okay
T: So what’s your mind saying now about this?
C: It won’t work.
T: Okay. Let me jot that down. ‘It won’t work’. (As the therapist says it aloud, he also writes down: ‘It won’t work’). What else?
C: This is bullshit.
T: Okay. ‘This is bullshit.’ (As the therapist says it aloud, he also writes down: ‘This is bullshit.’) What else?
C: I don’t see how this will help me.
T: Okay. ‘I don’t see how this will help me.’ (As the therapist says it aloud, he also writes down: ‘I don’t see how this will help me.’) What else?

After writing down five or six ‘derailing tactics’ - such as, ‘this is weird’, ‘but nothing has ever worked in the past’, ‘I won’t be able to do it’, - the therapist hands the paper and pen to the client.

T: So what I’d like you to do, if you’re willing, is each time your mind comes up with one of these tactics to pull us off track, just put a tick by it, so we can see how many times it shows up. Okay? And if your mind comes up with a new tactic I’ll get you to write it down, add it to the list, okay?
C: Well I can do that, but I don’t see how it’s going to help.
T: Okay, now you’ve already got that one on the list, right there: ‘I don’t see how this will help me’ – so can you place a tick by it?
(Client ticks the statement on the list)
T: See how quickly that one showed up? I bet it’s gonna come back at least another 3 or 4 times this session. Any others showing up?
C: Yeah, this is bullshit.
T: And that’s there too, isn’t it? So put a tick next to that one.
(Client ticks the statement on the list)
T: Any others showing up?
C: Yes. (smiling a little – ticks two of the other statements on the list)

As the session continues, every time the client tries to move away from the goal, the therapist calls it out as a derailing tactic and asks the client to write it down. Most clients have a repertoire of about five to fifteen tactics, and the others they come up with are just variants on these basics. At some point, the therapist is likely to need to have the following conversation:

T: Okay, so now let’s get back to that goal we agreed on.
C: There’s no point. It won’t work.
T: Is that one on the list?
C: Yes. (ticks it) But it’s true! It really won’t work!
T: Well, here’s the thing – I can’t guarantee you that it will work. In fact if you ever visit any professional who guarantees you that their treatment will work, I suggest you don’t go back to them, because they’re either bullshitting you or they’re deluded. Go to the world’s greatest surgeon for an operation and she will not guarantee you a successful outcome; she will ask you to sign a consent form in which you acknowledge all the things that could possibly go wrong. So I could show you lots and lots and lots of research on ACT to prove how effective it is with depression, anxiety, addiction, schizophrenia, you name it ... but that wouldn’t guarantee it will work for you. So here’s what I DO guarantee: I guarantee I will do my very best to help you, using the skills and knowledge that I have. I also guarantee, that if we stop the session because your mind says it won’t work, then I will be of no help to you whatsoever. So here we are – your mind is saying this won’t work – shall we let it say that and carry on, or shall we stop the session?
C: Carry on.
T: Great. So can you write down the words ‘But it really is true’ just there on your sheet, in front of ‘This won’t work’ – and put another tick by that thought, and let’s get back to the goal.


The beautiful thing about the ‘off-track, on-track’ strategy is that you are training defusion, acceptance, contact with the present moment, and committed action without even mentioning that this is what you are doing, and with minimal psycho-education – you’re just right into it. Plus, it helps the therapist defuse and stay on track.

The life line exercise is an experiential metaphor to help the therapeutic dyad discuss and establish the basic ACT principles.  It comes from The Art & Science of Valuing in Psychotherapy: Helping Clients Discover, Explore, and Committed to Valued Action Using Acceptance and Commitment Therapy (Dahl, Plumb, Steward, & Lundgren, 2009).  This brief summary was put together as a way of teaching ACT for workshops in Sierra Leone.

Loving-kindness meditation is like a warm embrace for the mind, one that fits hand-in-glove with ACT. It’s not about pushing away the tough stuff or painting everything with a sunny sheen. Instead, it’s about opening your heart to kindness and caring—first to yourself, then to others—making it easier to handle life’s ups and downs with a grounded sense of compassion. It’s a heartfelt companion to ACT’s journey towards embracing life as it is, with all its thorns and blooms.

Lovingkindness Meditation Script PDF (and instructions)

.  

I put this together to help clients with defusion and self-as-context exercises; using small sticky notes or writing directly on it, clients can label their observations/emotions/predictions/evaluations. By writing these and putting them on the paper, it can serve as a direct example of letting go of our mental content.

Let me know what you think and if any additions/revisions might be helpful. I work with clients who experience psychosis, mood fluctuations, and anxiety so that was what I had in mind when I put this together.

It is a basic insight in ACT that irrespective what body sensations, feelings or thoughts which occupy us, we can accept that and focus on our values and chose our ACTions and behaviour accordingly.

The problem with insomnia is that sleep is not a behaviour, nothing we can “behave” but a state of consciousness. Of course we can use exercises as muscular relaxation, mindfulness focusing on the body, as body scan or breathing which can relax us an increase the tendency to fall asleep. But  it is clearly stated e.g. that in body scan  we shall not fall asleep but  be awake.  Focus on body and breath will not led all the way to sleep,  because in sleep we don’t experience, at least not normally, neither the body nor the breathing.

But I think there is a mindfulness exercise, which can bring us even closer to sleep.

When we close our eyes we see, so to speak, behind our eyelids lighted and shaded areas.

If we focus on these phenomena exactly as we do in the raisin exercise, that is focus on the seeing of lighted and shaded areas in all minute details and not evaluating or thinking about what we see, it is my experience that sometimes this can lead to more picture like phenomena. And sometimes more dreamlike sequences which can lead into dream sleep and so in to the cycles of sleep.

I have tested this exercise with a few clients, one with pain often preventing sleep, and it worked sometimes.

It is my hope that others in the ACT community will find this simple exercise worth testing and even develop it further.

Jan Pilotti

M.D. Child and Adolescent psychiatrist

B.Sc. Mathematics, Theoretical physics

Örebro Sweden

dr.pilotti@telia.com

PS See also the clear and valuable article  Lundh, L.G. (2005). The role of acceptance and mindfulness in the treatment of insomnia. Journal of Cognitive Psychotherapy, 19, 29-39.      http://contextualscience.org/Lundh_2005

I think the excercise above can be used in the broader setting which the article clearly present.

This is a reworked version of the old acronym that I put to gether for working with Clients. Feel free to use, hope it helps your work and your Client.

Cheers,

Nik

Attached is the Tin-Can Monster exercise, which I recorded using the script from Get Out of Your Mind and Into Your Life. This is a really powerful willingness/acceptance exercise.

I recorded separate tracks for each experiential domain (bodily sensations, emotions, behavioral predispositions, thoughts, memories). This enables clients to repeat tracks to cycle through as many experiences in a domain as they'd like before going on to the next domain.

To go through the whole exercise just once takes a fairly long time (45 min) but people can do this acceptance work in smaller chunks over time. To download the tracks, you must first LOGIN to the site (and be a current paid member) & then when you click on the link & the dialog box appears, click "SAVE" not "play."

Please watch the video below (https://www.youtube.com/watch?v=U4vbz8BPS0M&feature=youtu.be) that explains the virtual values card sort and then have a play around with the PowerPoint file attached that contains the cards. 

Please feel free to adapt, evolve and share the virtual values cards so that they are helpful to your context and so that other people may benefit from them too.

Please contact me at: drrichardcoates@gmail.com if you have any queries. I'd also love to hear how you get on with using them.

The virtual values card sort was a result of values-based behaviour of 'creativity, connection and learning.'

I hope they can be helpful and accessible to everyone, everywhere.

Warm wishes

Richard

Dr. Richard Coates

Clinical Neuropsychologist

UK

This is an exercise adapted from Russ Harris's ACT Made Simple (Chapter 9, Drop The Struggle) as an exploration of the areas that we cannot control and developing the ability to control what we can. I ask the client to carefully circle only those phrases  that describe what we can potentially control. Once they circle at least nine different phrases we discuss and process their choices. This becomes a teaching tool for exploring the concept of dropping the struggle. I usually will discuss the wisdom of the Serenity Prayer and how our work together will involve identifying and relinquishing control of what we cannot control so that we can develope (psychological flexibility) skills for what we potentially can. Whether or not the client circles incorrect responses, it tends to open the door for exploration and discussion.