Contributed by: Francis De Groot Part II: The clinical methods of ACT Chapters 3 to 9 present the ACT concepts and strategies. ACT = Acceptance and Commitment Therapy = Accept, Choose and Take action Goal: to move in the direction of chosen values, and accept the automatic effects of life's difficulties. Barriers: experiential avoidance & cognitive fusion Source of these barriers: verbal Act stages focus on shift from content of experience to context of experience Why?: to enable clients to pursue valued goals in life. During treatment metaphors, paradoxes, and experiential exercises are frequently used to undermine the traps of literal language and pliance. Metaphors:

• are not specific & proscriptive (less pliance)
• are more like pictures (more experiential)
• are easily remembered

Therapeutic paradox:

• not the classic therapeutic paradox to eliminate certain sympoms: e.g. "don't obey me". They rely on pliance
• = inherent paradox: functional contradictions between literal and functional properties of a verbal event: e.g. "try to be spontaneous"

Experiential exercises: To help contact potentially troublesome thoughts, feelings, memories, ...

• experience in a different context
• allows experience to be observed & studied experientially
• superior to discussing

Summary: More:

• pursuing of valued goals
• direct experience
• acceptance of negative experiences (thoughts, feelings, memories, bodily sensations, ...)

Less:

• literal language
• pliance

Use of: less "literalizing" verbal modalities: metaphors, paradoxes, experiential exercises Focus on: WHAT DOES YOUR EXPERIENCE TELL YOU? This also goes for therapists? Let's go for some tracking, not for pliance!

Contributed by Kate Partridge Creative Hopelessness: Challenging the Normal Change Agenda [Comments in square brackets are from me. I know this summary is almost as long as the section itself, but doing it has really helped me understand it. Kate] Theoretical Focus Resistance to Change: Clients enter therapy because they have already struggled for a long time with "the problem", in many different ways (contemplation, planning, discussion, praying, reading, tapes, etc.) In spite of so much effort having been exerted, no solution to the problem has arisen. In this sense, the client is resistant to change. There are [at least] two reasons for this: 1) The client has not found the right way to fix the problem. 2) There is a fundamental flaw in the model for change, which is based on culturally sanctioned, language-based rules for solving problems. Culturally Sanctioned [Unconscious] Problem-Solving Rules:

• Psychological problems = the presence of unpleasant inner experiences (feelings, thoughts, sensations, etc.). The presence of these unpleasant experiences signal that "something is wrong and must be changed".
• "Healthy living" = the absence of these negative experiences.
• These experiences need to be eliminated by the correction of inner deficits (e.g., lack of confidence), through the understanding or modification of their causes (e.g., overcritical parents).

The underlying metaconcept is: "The problem is one of bad content; change the content and the problem will go away." ACT Assumption [Message of Hope and Liberation]: The Change Agenda Is Not Workable: The culturally sanctioned problem solving rules are like water to fish - they are taken so much for granted that to challenge them seems nonsensical. The ACT therapist works to undermine the sense of normality surrounding these rules, by showing that efforts based on these rules can actually be the source of problems, not their solution. The therapist asks: • "Which will you believe, your 'mind' or your actual experience of the unworkability of these rules?" [Not expressed in these words, naturally.] The therapist takes apart for the client the underlying logical assumption: 1) Identify the problem: "bad" thoughts and feelings. 2) Eliminate the problem: " " " " 3) Life will then improve. By drawing out multiple examples from the client's own history, the client can become experientially connected to what is often a long series of unsuccessful attempts to use this strategy. This can be quite painful. The therapist aims to organize most of the client's solutions into a general class of events that can be described as: "Control of private experience = Successful living." The client is (gently) encouraged to confront the reality of their multiple experiences of the unworkability of this assumption. This leaves the client often not knowing what to do next, in a state of "creative hopelessness". The state is "creative" because entirely new strategies can be developed with being overwhelmed by the old and previously unconscious rule system. Clinical Focus In this phase of ACT, the therapist focuses on the following issues:

• Client has tried everything, but the problem remains.
• The problem is not one of motivation, nor of specific tactics. The client is not to blame for being stuck.
• There is a paradox here: Working hard to solve the problem makes the problem seem worse. The solution is part of the problem. [I need some concrete examples here of how the solution makes things worse - KAP]
• The logic of the problem-solving system is flawed. A more valid and reliable source of problem-solving is the client's own direct experience and their feedback from life.

TABLE 4.1: ACT Goals, Strategies, and Interventions Regarding Creative Hopelessness. [There is no point in summarizing this useful table. It is on Page 91]. Informed Consent ACT interventions can be intense, and the client must be prepared for this by being provided with:

• general descriptions of operating principles [How general?]
• frank discussion of areas of ambiguity [What does this mean?]
• alternative forms of therapy that could be followed instead of ACT

Treatment involves the client in having to face previously avoided experiences. When this occurs, the client can start to question his/her commitment to treatment. Therefore, the client should be committed to meeting for a certain number of sessions, to expect ups and downs, and to hang in until a progress review occurs at a specified session. In this way, the client is guided away from impulsively dropping out of treatment.

Drawing out the system-developing the idea with the client that the process of trying to solve the problem-verbalized as actions taken by the mind or as "language", creates a logical trap that if directly described presents its own paradox of being linear, literal and analytical-the very process we are attempting to discredit. A less direct approach: What do you want? Outcome goals: Love others, have children, be content...Process goals: A technique (I think) that leads to outcomes. Example-Outcome goal: living well, Process goal: changing bad feelings. Linking these two by a technique such as drinking is an unworkable system. I'm confused about this. "Process" seems dynamic while "Outcome" seems static. Aren't "drinking" and "changing bad feelings" both processes? In other words, isn't "changing bad feelings" a strategy while drinking is a tactic (subset)? Anyway then-What has the client tried? This is where you identify with the client and follow along with his historic plan of solving his problems, clarifying with examples the process of attempts, and agreeing on their relative success of lack thereof(there should be lack thereof or the person wouldn't be here, right?). How has it worked? Using the "mind" metaphor to reify the process of producing inflexible and unworkable verbal rules that persist as technique in spite of experiential feedback that they aren't working. Also pointing out the false solution of "trying harder" when confronted with this reality. This (1) focuses on verbal understanding and (2) helps client look at mental reactions rather than through them. The essence of this section is creating the dichotomy of what your mind tells you versus what experience is telling you.

Confronting the System: Creative Hopelessness (this is a little long, but wanted to make sure I covered everthing adequately)

• Begins by noting that engendering creative hopelessness is the first ACT intervention (following thorough assessment of the client's 'presenting problem', change agenda, and strategies that have been tried to resolve it.
• Also notes (or warns) that doing this inevitably involves the use of human language, which is part of the trap the client is in anyway - the conundrum of attempting to side- step the trap of language, but needing to use language to deliver interventions. The therapist is thus just as susceptible as the client to the trap of literal language, and must be careful about too strongly believing or becoming fixed on the logic of words.
• This highlights the equality of therapist and client, with the therapist's only advantage that of having an outside perspective (the client would also have this advantage were the therapist's problems the topic of discussion).
• The therapist confronts the system by working outside it, using language only to meet certain ends, not to change beliefs or model more "rational" beliefs and thoughts. If those ends are not met, then the words are not true, no matter how logical. So this takes us from the typical reliance on logic to relying on workability - this become our metric. The question for both clients and therapists is "does that work for you?".

Workability and Creative Hopelessness

• In the beginning of this section, the authors provide a caveat that it is written with severely affected clients in mind (although the tools are still useful in less severe circumstances).
• The work starts with confrontation, although of a different sort than typically thought. The confrontation is between the client's change agenda and the client's experience of the workability of that system. The message of the therapist and client being in the same boat as far as confronting this system (i.e. the therapist is not some expert who has all the answers) can be powerfully conveyed by the therapist sitting next to the client, with the system imagined as out in front, being confronted by both people together.
• The therapist is armed at this point with information related to strategies the client has tried in the past that haven't worked.
• Unworkability is gently suggested - the therapist highlights how hard the client has been thinking and working at the change agenda, and that consulting a therapist is another attempt to find a solution. Another powerful intervention here is to highlight that usually when we work this hard, things get accomplished, but that this situation seems different. All this effort has not resolved the issue.(this is a subtle way to highlight the role of the client's experience)
• This moves into a discussion of the notion that perhaps looking for solutions is part of the problem. That the client is stuck, and it's not because they are not clever enough to figure it out or are not trying. Perhaps it is because it can't work. The authors suggest that a way to make this more tangible to the client is to suggest that the client doesn't actually believe there is a solution - that anything offered by the therapist would likely just be refuted by the client based on the client' s experience that it would not work. So here, the idea that experience and mind tell the client different things, and that experience is more accurate is brought to the discussion.
• The authors break from the therapeutic dialogue here to discuss the importance of framing creative hopelessness as a positive thing. Being careful not to suggest that the client is hopeless or to engender hopeless feelings. But rather to introduce this idea as a starting point for giving up unworkable strategies and opening up for new possibilities to emerge.
• Several metaphors are provided, including the Man in the Hole metaphor, p. 101, to side-step the trap of language. This metaphor is flexible and can be used to address many issues a client might raise, such as:
  • giving up
  • belief in the need to delve into the past
  • responsibility
  • blame
  • continuing to look for solutions - this one actually seems really important and I think best highlights the goals of this part of therapy. The therapist really seems to stay away from promising solutions, but takes on a role of saying "I don't know". The goal at this point is batter down the tendency toward sense-making and to stay with the importance of the client giving up unworkable strategies, even without any promise of what will come next. This is a leap of faith and should be noted as such, since clients (like the rest of us) are definitely not used to not trying to make sense of things when there are problems in our lives.
  • illustrating the opportunity suffering presents for us to learn to disentangle ourselves from our own minds.
  The goal of this dialogue and the highlighting of what experience tells us, then, is to break apart the control-private-events-to-control-life-quality believe system. It is also to make contact with the client's knowledge of how the world works (rather than systems of logical language and rules that govern behavior). The authors highlight the importance of being mindful of this goal through this discussion.

Chinese Handcuffs Metaphor illustrates that sometimes the counterintuitive solution is the one that works. Brief; can be used to reinforce the message of the more extended Man in the Hole metaphor or to introduce the therapy as part of an informed consent procedure. Understanding: Belief versus Experiential Wisdom Expressions of belief or disbelief on the part of the client are irrelevant and probably signify that the old control agenda is trying to claim any new territory opened up by metaphorical talk. The dimension of belief and disbelief is toward the nonexperiencing, derived stimulus functions end of the experiencing-nonexperiencing continuum. This includes the therapist's beliefs as well as the client's. Persuasion is not an ACT move; consulting one's experience is. Confusing No Hope with Creative Hopelessness 2 possible errors: confusing creative hopelessness with hopelessness as a negative feeling state or with hopelessness as a belief. Creative hopelessness is an action or a behavioral posture that results from experiencing the uselessness of deliberate control over unwanted thoughts and feelings, because this control cannot deliver the promised rewards. The over expansive track that maintains the control agenda is undermined. This prepares the way for a fundamentally new approach. However, talking about hopelessness is a sign of persuasion efforts on the part of the therapist. Hopelessness the feeling is often used as a move to coerce someone (God, a spouse, the therapist, oneself) to rescue the client from despair. Hopelessness the belief tends to be over expansive, in the sense that the person sees him or her self or life or situation as hopeless, rather than the more circumscribed control agenda. Barriers to Giving Up the Unworkable System It can be hard for clients to give up unworkable control strategies because previously avoided material quickly shows up in consciousness and there's no clear alternative. Metaphors that can be useful here include: Feedback Screech Metaphor, which illustrates how control moves amplify the inherent discomfort in living and make "tiptoeing around the stage" seem like a good solution; and Sports and Activities Metaphors, in which practice makes better, you have to "step up to the plate" or "get in the water," and overthinking interferes with the process. Letting Go of the Struggle as an Alternative Tug of War with a Monster Metaphor illustrates that letting go of the struggle with unwanted private experiences can be a more workable strategy than trying to win the struggle. Clients may want to know how to "let go of the rope" and describing the process would be a bit like describing how to swim or hit a baseball or drive a car: better learned by experience.

The chapter on creative hopelessness ends with a few therapeutic do's and dont's. I took the freedom to add some do's and don'ts from the list and one of my own 1. Am I hurting or helping the client seems to be a question that's often asked in workshops. Kelly Wilson suggests on this list (April 15th) that this is about the therapists' own experiential avoidance when sitting with the patients' pain. Empirical findings show that you don't have to be afraid that your patients will quit therapy, get deeply depressed or even kill themselves when they discover the futility of their struggle. In other words the message is essentially a hopeful one, and patients may feel relieved. CR may be the first step towards an increase of degrees of freedom of the patients' respondent behavior. 2. I suggest that as a therapist you have to face your own creative hopelessness in order to be able to sit with the patient when he or she is testing his rule sytem against experience. 3. Don't expect anything to change (yet), because any change can be linked to the intentional change agenda, and so become just another avoidance strategy. This is paradoxical. As I try to grasp it right now, experiential avoidance seems to be an escape reaction triggered (or conditioned) by a certain class of stimuli (Sd, like for instance the possibility of being criticized), and thus it's under antecedent control (see also Kelly Wilson's note on this). Each time I face this type of situation I feel stressed or aroused (CER), want to escape or avoid by procrastination, let's say (CAR). This is reinforced by nicely elaborated verbal rules (COV)(and each time I think I'm right is a reinforcement, a +S+). Moreover, i feel relieved in the short run because the criticism is avoided (-S-). If I try to change this chain of behavior without loosening the conditioned response, I may just get entangled in a more complex conditioned avoidance response. In terms of 'Mary had a little .... ' I will get even more 'lamb' connections on the dots. I guess the idea is that behavior change will result spontaneously when the link between the situation and your avoidance reactions will be weakened, for instance by an increase of awareness of the unworkability. And isn't hope just the same as finding more and new opportunities to achieve your goals? Just like the two Swedish colleagues I 'd like to try to describe these processes in behavior analytic terms, but feel very insecure about it. It seems to me very helpful in the process of understanding ACT, and also in grasping the patient's struggle. So who wants to join or help in this enterprise? 4. Give homework to help people become aware of how they struggle, and what situations trigger it. Just do self monitoring, and not behavior change (see above) 5. The book (and the discussion on the list as well) seems to suggest that there should be a fixed order in therapy with CH as the starting point. I'd like to cite Kelly Wilson (April 15th) on this: " No you absolutely don't need to do CH like it says in the book. If it needs to be done, you will end up doing it. why? Well as you pursue values, it will appear as an obstacle--then you will do defusion of hopelessness, and the emergence of what we like to call creative hopelessness." 6. A very important do was formulated yesterday by Joanne Steinwachs. I'll just cite her contribution, can't do it better, as she's also including a beautiful metaphor. "I find it useful to begin the questioning with 'beginner's mind'. Perhaps what they tried did work out, in some way for them. Of course, if they're stuck in a framework of unworkable rules, then in the larger picture, it doesn't work, but sometimes talking to people about what they do and how it works in their idiosyncratic rule system illuminates the rule system both for them and for me. If I start with the agenda of discovering unworkability, then I can miss a lot of the nuances of trappedness, both for them and for me, and I feel like I move into a place of expert rather than co-explorer. I also feel that using "discovering unworkability" as my guide, respect and curiosity are harder to maintain as my base feelings towards the client. I can't do this if I've got the agenda of discovering unworkability. I have to hold the idea that the system DOES work for the client as a possibility. Usually, in my experience, clients have worked hard and creatively, their shtick does work in some way and it's often an elegant and creative adaptation to some crazy rule. I talk to people about the pre-Copernican world, and how astronomers were trying to describe the path of the planets, starting from the wrong assumption that the earth was the center of the universe. They came up with elegant and complex theories that sometimes could predict the position of the planet. Men spent their entire lives on these theories. To let them go took enormous courage and great pain. That conversation comes after I and the client understand the complex rules that govern their "planetary movement" and we've paid tribute to the fact that the rules can in some ways predict and control their experiences." Perhaps techniques as interviewing for solutions (De Shazer) can be useful here. Progress to the next phase can be seen when clients express doubts about their system of coping and avoidance. Personal work for the clinician is building on the work on page 80. Somehow this questioning is a bit too abstract for me-as-a-client. Me-as-a-client needs a bit more encouragement and support as to what is a problem, how can I analyze it in ACT terms, what level of detail is required to gain awareness or insight. I like to be as concrete and detailed as possible, and I try to find out what exactly is is what a client did (does), thought (thinks) and felt (feels) when using his or her strategies. Underneath abstract descriptions of an apparent intelligent strategy can hide a completely invalid schema (can I use such a term here?).

Control Is the Problem In ACT, attempts at controlling private events are thought of as part of the system that have brought the client into therapy. Four factors are identified that most clients bring into therapy (and, that have been wrestled with at various times in this forum):

1. "Deliberate control works well for me in the external world."
2. "I was taught it should work with personal experiences (e.g., 'Don't be afraid...')."
3. "It seems to work for other people around me (e.g., 'Daddy never seemed scared...')."
4. "It even appears to work with certain experiences I've struggled with (e.g., relaxation works for a while to reduce my anxiety symptoms)." It is emphasized that the examination of control strategies is based entirely on the clients experience, with workability as the unit of analysis, and that the therapist needs to be extremely careful not to dictate or demand that the client evaluate their control strategies as unworkable. Therapist techniques that are mentioned include using metaphors and experiential exercises to help the client develop increasing sensitivity to directly experienced contingencies. Also, the authors mention that asking questions rather than stating conclusions can be helpful in reducing pliance on the part of the client.

Giving the struggle a name - control is the problem Continuing to explore unworkable strategies (i.e., "digging" in the man in the hole metaphor) without interpretation. The goal here is to explore the form and function (immediate goals) of client's behaviors and hold these up against the change agenda. At this point in time there is no need to do any more than just touch and clarify these behaviors and their functions. Eventually the goal is to lump these responses into a single class "emotional control" The rule of private events The key lesson here is that purposeful control works in the successful manipulation of external events but that the same strategies do not work in controlling private events as these are governed by historical and automatic factors. The rule "if bad events are removed, then bad outcomes can be avoided" is not effective with regards to private events. On pages 120-122 is a good transcript showing a therapist bringing out the paradox of control:

• If I'm not willing to have it (e.g., anxiety), I have it
• If I don't get so uptight about being anxious, I will be less anxious
• If I am willing to have it in order to get rid of it, I am not willing to have it and I will have it again

Polygraph metaphor (page 123) is a core intervention in this stage of therapy - particularly useful for anxiety or mood disordered clients. In short the metaphor describes being hooked up to the most sensitive and accurate lie detector ever built. The task is simple, STAY RELAXED. An extra incentive is given, "stay relaxed or I’ll shoot you". Not surprisingly, any hint of anxiety would escalate ("Oh my god, I’m getting anxious.") and BAM!, it’s all over. There are three elements that can be drawn from this metaphor:

1. contrast between controllable behaviors (i.e., paint the wall or I will shoot you) versus behavior that is not regulated successfully by verbal rules (relax or I'll shoot you)
2. People carry their own polygraph with them all the time (their nervous system) and their own gun (self-esteem, self-worth). They are constantly monitoring for symptoms (e.g., anxiety) and firing the gun at themselves
3. How seemingly successful attempts to make situation work, don't work in the long term. For example, taking valium may help you relax initially but what about when it wears off?

Chocolate cake exercise (124) - particularly effective with clients struggling with obsessive thoughts or ruminations In short, don't think about delicious warm chocolate cake with icing and cream! (yum) Two things here:

1. either it is particularly difficult not to think about it (me included in this group)
2. or attempts to not think about it (e.g., "I thought about something else") actually require you to think about chocolate cake (you have to know what you are not thinking about)

Similar idea can be applied to physical reactions (e.g., salivation) "The key lesson here is for the client to make direct contact with the ineffectiveness of conscious purposeful control in these domains" (my own personal comments: I really like these ideas, and regularly use similar concepts no matter what therapeutic style I am incorporating. I think a lot of these ideas have filtered into the CBT framework, whereby automatic thoughts are treated more as uncontrollable private events and B (behavior change) is emphasized. The only trouble I have with some of this stuff is picking those clients that respond well to discussing these kinds of issues. This is totally my personal opinion, but I think many therapies suffer from some kind of intellectual bias, that is, techniques developed by well-educated, trained minds. I have trouble breaking down psych concepts to layman concepts. This is not a big issue at this stage, because the use of metaphors breaks down that barrier, but when it comes later to exploring the traps of language, I think this is so.

How Emotional Control Is Learned At this point in therapy, the client is coming to the realization that "control doesn't work". In the recovery business this is the same as "taking" the first step (12 step approach) where the client comes to the realization that they are "powerless." This can be a frightening step. As the book points out, the "thought that repeatedly applying a seemingly unworkable strategy proves there is something wrong with the client 'deep down inside.'" and this can be quite troubling. Again, in recovery we would say, that this is like "doing the same thing and expecting a different result." It is like the guy that thought he had figured out how to fly with a wing like contraption attached to his arms. He got up on his roof and ran straight off the end and flapped his arms like crazy. But, as you would expect, he landed with a thud and broke several bones in his body. After healing he thought, well I don't think I jumped high enough, or flapped my arms fast enough. That's what I have to do, jump higher and flap faster. I don't think I need to tell you what happened. Getting back to my assignment, at this point it would be easy for the client to blame them self for the predicament that they have gotten themselves into, however, as the book points out, all of the conditioning that got them here is actually very random. The trick now is how do we "come to believe"(step 2) this. The book suggests, "Experiential exercises are particularly useful for demonstrating how easy it is to condition a irrelevant and nonfunctional private response." The "'What Are The Numbers?" exercise is a good intervention at this point. In this exercise the book demonstrates the arbitrariness of reactions, thus hopefully helping the client see that ""I'm bad" is no more meaningful than "one, two, three."" The therapist would than help the client move into examining the apparent success of a control agenda. Which brings us to, Examine The Apparent Success Of Control At this point it is suggested that we help the client explore the "cost of using this change agenda in the wrong places." The therapist is helping the client "establish discrimination." Which always makes me think of the serenity prayer, God grant me the serenity to accept the thing I can not change (or control), the courage (or willingness) to change (or control) the things I can, and the wisdom to know the difference ("establish discrimination"). I see this step as helping the client become more aware of when this control (change) agenda works and when it doesn't. The book gives a good dialogue of walking a client through this process. But as the client begins to get a sense of the unworkability of this control agenda, they can feel naked and vulnerable to the world, and desperately looking for someway to cover up. At this point all we want to do is help the client recognize what thoughts and feelings are showing up. This is not an easy task. The therapist needs to continually undermine the clients need to avoid the distressing thoughts and feelings and to help the client become more "willing" to experience these things in the here and now. All of this leads the client to "the alternative to control: willingness" which is next weeks homework. However, it brings me back to the serenity prayer, and how I see willingness (or courage), "to change the things that I can."

The Alternative to Control and the Two Scales Metaphor The objective here is to point to an alternative to the control agenda. Use willingness instead of acceptance-because it is often confused with resignation or tolerance/defeat. Two Scales Metaphor

• designed to look at concept of control and its relationship to distress
• Should be linked to clients' experience of their own futile effort to control distress, can link it to more mundane or less meaningful examples for the client (for example, trying to sleep during a bout of insomnia. The harder you try to fall asleep the less sleep you get. In supervision, we often use the Chinese finger trap example-the harder you try to get out of it, the less out of it you are- you get stuck.)
• Want to undermine the client's confidence in the control strategy and depathologize the struggle over control
• Not crazy, just using the wrong strategy

Metaphor Two scales--anxiety (or whatever fits for the client here) and willingness. Willingness has been low, anxiety has been high. Client came in with the goal of getting anxiety to be low. But what if there's this other scale that we haven't been using, haven't even seen, called willingness. Make a promise about what will happen if willingness is set high-anxiety will be low except when it is high and then it will be high. If you move willingness up, then anxiety is free to move around. Seems like the goal here is not describing acceptance or distinguishing acceptance/resignation, but merely providing an alternative to their endless, futile struggle Can distinguish between mind/experience here. Mind tells you that if you demand anxiety to go down, then it will. However, experience says that this doesn't work "Suppose life is giving you this choice: You can choose to try to control what you feel and lose control over your life, or let go of control over discomfort and get control over your life" (p.135) Willingness is one thing that only you have control over. I can influence you feeling anxiety for example, but I cannot control how willing you are to have that anxiety. Comment: This was a perfect reading for me this week! I recently used ACT in my abnormal psychology class in the service of changing the stigma of the mentally ill and making a difference in my students' lives. I provided an alternative to their control agenda, but I spent a lot of time distinguishing between acceptance and resignation. I had one student in particular who would not "accept" the thing he hated most about himself (which was what I used in exposure and defusion exercises) because he refused to "just get over it and move on". I like using willingness instead of acceptance because it frames the whole concept in a different way. There's no question about what willingness is, acceptance can have different connotations. Another thing: When first reading this section, I thought "how can you describe willingness", "willingness to what...?" I think that my class would have benefited from my using the willingness to experience as opposed to acceptance. This seems much clearer to me.

The Cost of Unwillingness CLEAN DISCOMFORT: discomfort that comes and goes as a result of just living your life (= primary discomfort?) ------------- cannot be controlled DIRTY DISCOMFORT: emotional discomfort & disturbing thoughts created by efforts to control feelings = discomfort over discomfort (= secondary discomfort?) ------------- disappears when willingness is high and control is low ---------------> clean discomfort stays when dirty discomfort disappears Box full of stuff metaphor: p. 136. Shows the additive nature of history; nothing is subtracted! You can only add to life. You can fill it up with things you want to avoid until you can't move anymore. Various reactions are put into the box = deliteralizing: treated as objects, dispassionate observation of reactions. WATCH OUT! Client's worldview can be put upside down! Clients can insist on using old strategies. This has to be supported. DON'T START LECTURING DON'T START INTELLECTUALIZING (& do all the talking; it's no question of trying to convince) DON'T START EXPLAINING & DISCUSSING CONTROL STRATEGIES (this keeps you within the existing language paradigm) DON'T FEEL PRESSURED TO MOVE INTO SUBSEQUENT STAGES with multiproblem clients (they need more time) DO ENCOURAGE CLIENTS TO NOTICE THE COMING AND GOING OF DISTRESS (when they cling to control strategies) DO STAY ON THE EXPERIENTIAL TRACK DO STAY WITH THE CLIENT's EXPERIENCE OF THE WORKABILITY OF CONTROL STRATEGIES Clients may be ready for the next stage when:

• willingness is appearing spontaneously in situations that used to elicit control
• clients report spontaneous examples of feeling feelings differently

Chapter 5 finishes with:

1. personal work for the clinician
2. a clinical vignette
3. appendices containing daily experiences diary, identifying programming exercise, feeling good exercise, rules of the game exercise and clean versus dirty discomfort diary. I'll deal with each of these in turn:

Personal work for the clinician Having identified a problem in your own life, explore the strategies that you have used or are currently using to solve this problem a) consider each strategy and designate it as either an acceptance or control strategy b) examine the distribution of control and acceptance strategies. Is there a trend? c) For each control strategy, identify what it was that you hoped (hope) to control, avoid, manipulate, change or eliminate Clinical Vignette The clinical vignette describes a 45yo male with severe anxiety attacks at work and more recently at home. There is stress at work (high stress job), a recent move and relationship difficulties. The client uses deep breathing, distraction, hypervigilance to physical symptoms, avoidance of work and tranquilizers to cope with the anxiety. The question(s) for clinicians are: a) how would you conceptualize the client's major coping strategies and assumed goals? b) How would you discuss these solutions with the client? c) What would your goal(s) be in doing so The answers are as follows: a) strategies are primarily to reduce or control anxiety and appear not to work (long term) b) is anxiety serving another function? Are there areas in your life that you legitimately have reason to be anxious about c) Goal is to separate clean versus dirty anxiety (legitimate stressors versus the struggle, fusion) Appendices Daily experiences diary Client records uncomfortable moments, including feelings, thoughts and bodily sensations as well as efforts to handle these things Client and therapist can explore the use of acceptance versus control strategies. Therapist can reinforce strategies that reflect acceptance. Willingness diary Client provides a global rating for each day (e.g., emotion rating from 1-10). Client records the amount of effort put in to getting this to go away (rating 1-10) Client records how workable the day was (rating 1-10) Client and therapist explore the relationships between the struggle to controland the workability of the day. Identifying programming exercise Clients are encouraged to explore how a significant childhood event (or events) shaped or programmed who they are now to demonstrate how dysfunctional coping strategies are passed on. This is to demonstrate the arbitrary nature of learning events. Feeling good exercise Clients fill out a questionnaire tapping into a number of specific language rules that act as self-instructions (e.g., "the way to be healthy is to learn better and better ways to control and eliminate negative emotions") Rules of the game exercise Clients are asked to generate their favorite life sayings (e.g., no pain, no gain). Client and therapist can then explore sayings with reference to acceptance versus control strategies or on the basis of a number of other dimensions (e.g., black/white thinking, severity of consequence, good versus bad) Clean versus Dirty discomfort diary Client is encouraged to explore particular "high risk" situations in terms of clean discomfort (what immediately showed up in the way of thoughts, feelings etc) versus dirty discomfort (what emerged as a result of the struggle with these initial feelings)

Building Acceptance by Defusing Language

Here are some nuts and bolts followed by questions and critiques:

1. The distinction between process and content: language is a learned set of derived stimulus relations, while languaging is the action of deriving those relations.

2. Humans (therapists, clients, etc.) often don't make this distinction and often relate on (and become connected to) the content level. Taking these contents at "face value" (i.e., literally, tangibly) in turn, leads to powerful and predictable behavior patterns (that are often destructive) on the part of the client.

3. One of the main paradoxes in ACT is that language cannot be weakened by more language; however the essence of deliteralization is to take advantage of loopholes in the way language functions (by teaching the client to see that thoughts and feelings are just that-thoughts and feelings).

4. Page 152 contains a table (6.1) of ACT goals, strategies, and interventions to use regarding deliteralization.

5. One of the ways to begin addressing the paradox and function of language is to demonstrate to the client the limits of language in deciphering human experience (and to elicit their own examples). For example, there are two metaphors (found on page 153) that communicate how describing something is different from experiencing it. One metaphor is "finding a place to sit," which essentially describes how talking about a chair (its features, uses) does not help when one wants to actually sit down. In other words, one cannot "sit" in a description of a chair. One can only sit IN an actual chair. A corollary of this metaphor is that one can describe the experience of swimming (how the water feels moving through it, its temperature, etc.). However, one cannot learn to swim in or by a description.

6. There is an assumption in ACT that "your mind is not your friend." Extrapolating from pre-human experience, one can see that the (human) mind was not developed to make humans or "prehumans" feel good. It was developed to keep humans from danger and was mostly comprised of negative content. Explain to clients the paradox "your mind is not your friend AND you cannot live without it."

7. Another assumption is that language is arbitrary and that once it is learned, it becomes relatively independent of immediate environmental support. This reminds me of my nanny's (successful) efforts to train my 20 month-old son to say "bling-bling" when he sees jewelry-now without her having to label it.

8. There is a provocative quote related to the usefulness of nonverbal (experiential?) knowledge at the end of this section on page 154: "If we suddenly had all nonverbal knowledge removed from our repertoires-we would fall to the floor quite helpless."

Comments/questions:

9. It has been my experience that, while clients appear "fused" to a lot of different ideas/contents, a great share of them come to my office without having specific terms/language to describe their experience. In fact they come ONLY with experience, which they have a difficult time describing in words. For example, an extremely anxious patient I had (with Posttraumatic Stress Disorder) wouldn't ever label himself as "anxious," rather he just knows he feels bad.

10. I don't know if behavior patterns follow from the premise that one does not make a distinction between the process of thinking and actual thought, and becomes fused with actual thought content, thereby leading directly to ingrained behavior patterns. I suppose one could explain this as troublesome behavior patterns becoming automatic due to conditioning (i.e., not being aware of the interaction pattern itself); however, I'm not sure if this is because one is fused to a verbal event.

11. Have any of these hypotheses been evaluated using individuals with various types of brain injuries (resulting in apraxia, aphasia, acquired deficits in language versus acquired deficits in motor ability, etc.)?

Deliteralizing Language Several exercises are described to help people improve their skill of looking at the process of language instead of looking from language.

• Thoughts are used to structure our perception of the world. We don't even notice that we look at the world from our thoughts, because we believe them in literal way. To look at the process of language involves focusing attention on language as language, cryptic as this may sound. A bit of defusion from literal 'understanding' can be achieved by watching the direct stimulus functions of language like sound, the feeling of your muscles, the sight, etc.
• An elegant way to watch your attention switch from the symbolic function of a word to some of its direct stimulus functions is by repeating a word over and over again for one or two minutes. This is the classic milk, milk, milk exercise (Titchener, 1916). Present it as an experiment or experiential exercise and help the client notice how the literal meaning of the word disappears and one can see the word as an instant of the language process.
• I like the notion of skill learning here. Deliteralization is a skill you can practice, it's not another rule to follow. One can play with direct stimulus properties and thereby loosen the 'grand illusion of language' by realizing that the symbolized thing is not there at all. The only thing that's there is sound, movement, breathing and so on. And this is not a fact, but a skill, something you do.

Another skill that helps to defuse from nasty or frightening thoughts is practiced in the passengers on the bus exercise. In this exercise the relation between a person and his or her thoughts (or avoided inner experiences) is reframed. These are the elements of the metaphor:

1. You, the driver of the bus. You want to go places and do your job.
2. The passengers are your thoughts and all kinds of inner states. Some are nice, some ugly, scary, nasty.
3. The scary ones threat you and want to come up front where you'll see them.
4. You take this very serious and stop the bus (you don't go anywhere anymore) and try to make a deal with them: they'll keep quiet in the back of the bus, only when you do exactly what they tell you.
5. This means your route plan is greatly impaired and you're always on the watch inside the bus.
6. What happens is that you let these passengers control the whereabouts of the bus. You, the driver, are not in control at all.
7. Even though these passengers look scary, nasty, threatening etc. they can't take control (unless you let them). They can't make you do something against your will.

Summary: We are in Chapter 6, Building Acceptance by Defusing Language. Page 158 begins the section titled "Don't Buy Thoughts". The subject is the deliterization of language. The explanations, exercises and metaphors are designed to enable the client to become aware of and "assume" self as perspective and to focus that perspective on thoughts and feelings themselves as they are experienced. Comment: The ease or difficulty of this and degree of success may vary greatly from person to person, but those who find it most difficult may also reap the greatest benefits. The shift to looking at literal meaning from looking through literal meaning is subtle. "Having a thought" may be distinguished from "buying a thought" or "buying in". A common example is the shift from "I am a bad person" to "I am having the thought that I am a bad person". The idea is to expose the process of thinking often hidden behind the content of thinking. Mindfulness exercises include Zen-like meditation, Soldiers in the Parade Exercise, Leaves in the Stream Exercise, Contents on the Card Exercise, and Taking Your Mind for a Walk Exercise. The client/therapist dialogue (pgs. 159-161) illustrates a therapy situation using the Soldiers in the Parade. Note how you have to get the client to try this and then give you feedback as to what they are experiencing. The client is specifically reminded that thoughts like "This isn't working" or "I can't do this" should be placed on the soldiers' placards (along with "This therapist must be one of those nutty Gestalt guys I've heard about."). The therapist sort of anthropomorphizes the mind and speaks of it trying to "hook" the client on literal meaning. He also points out how the parade stops when the client "buys" or is "hooked" by a thought. I additionally had the thought in this section that while "Contents on Cards" and "Taking Your Mind for A Walk" may seem gamey or contrived, these might be necessary and effective with certain clients who experience very emotional fusions such as cluster B type folks(or the more politically correct "multi problem client"). Undermining Reasons as Causes A troublesome class of thoughts, reasons tend to disguise themselves as deterministic statements with a cause-effect function which they really may not have. Reasons often actually function as language community justifications. Personal history is often cited as a reason things can't change. This has always been a real pain for psychodynamic therapists (I speak from personal experience). Statements focusing on functional utility rather than literal truth are suggested as helpers, such as, "And what is this story in the service of"(Ouch! They may get angry!), "If God told you that your explanation is 100% correct, how would this help you?", etc. Another dialogue (pgs. 164-166) illustrates how reasons may be deliteralized to the clients' advantage without loosing their true function. An additional "tips" section is Disrupting Troublesome Language Practices (pgs. 166-168). A discussion of the etymology of the word "but", for example, reveals how it can be a psychologically limiting verbal behavior that may be changed to "and". "I want to go, but I am angry" could be "I want to go and I am angry" leading to behavior which may not be controlled by the language conceptualization of it. The "And/Be Out Convention" inset describes how this might be communicated to a client. I had the thought that this requires some careful listening to insert this timely intervention when it can be most useful to the client. I will only comment that this is an extremely important section, drawn from RFT research and Zen and Gestalt traditions which are nuclear to ACT. It strikes me as needing a great deal of experience and/or training to be handy with it. I suspect that psychodynamically trained therapists, such as myself, have a harder time with it because we have to unlearn and learn at the same time.

Evaluation versus Description Evaluations masquerade as descriptions of things and events because language makes little distinction between them. Descriptions may be thought of as primary properties of things and events while evaluations are secondary properties, reactions to things and events. The authors point out that most clients bring negative self-referential evaluative self-talk directed toward themselves ("I'm a despicable human being") to therapy that would be difficult to accept if it described the essence of a person. The Bad Cup Metaphor illustrates this principle by pointing out the difference between essential properties of a cup (such as that it is made of metal or ceramic or whatever) and our evaluations of the cup (good cup/bad cup). As an aside, my husband, who is not a therapist, really related to the question of "If all the humans on earth died tomorrow, would this still be a good (or just, or moral, etc.) ____?" as a way of identifying evaluations. A second strategy for highlighting the kind of thought or speech someone is engaged in is to have them label each thought or sentence as a description, an evaluation, a feeling, a thought, a physical sensation, a memory, etc (Cubby Holing). Although this is awkward, it can be very effective at promoting defusion with private events. Willingness: The Goal of Deliteralization The goal of deliteralization is to decrease the role of evaluation and strengthen the client's ability to take a non-judgmental, observer perspective so that they can begin to observe their own disturbing private events with less struggle and more willingness. Two exercises that give the client live experience with willingness are the Physicalizing Exercise and the Tin Can Monster Exercise. The Physicalizing Exercise has the client treat their unwanted content (depression, anxiety, addiction, etc) as an object, by describing its physical attributes (size, weight, color, density, etc). Then the client sets it aside and describes reactions to the "object" they described; they repeat the exercise with the reaction. They then go back and look at the first "object"; often it is less intense in some attributes (smaller, lighter, etc). The Tin Can Monster Exercise helps the client get in touch with their "observer you," then uses that perspective to explore several domains (physical sensations, thoughts, feelings, memories) associated with the problem area. The focus is on staying with the uncomfortable, unwanted content while letting go of the struggle to make it go away.

Therapeutic do's and don'ts The goal of deliteralization is a hefty one. Chapter Six offers a dazzling array of ACT metaphors and exercises: confronting nasty passengers on the bus, endlessly saying milk, milk, milk, soldiers wandering around in a parade amongst the recesses of the mind, taking your mind for a walk, reasons as causes, avoid use of those 'buts," and practicing awareness of your experience, to name just a few. Deliteralization is an essential step in the ACT process, and yet its filled with perilous pitfalls for our heroic ACT therapist. First, there is the challenging task of entering the client's language system The therapist seeks to realize that it is a language system, while at the same time avoid the many opportunities presented to "fuse" with the system. This challenge occurs because we are using language to point out the dangers of language in an effort to convince a person to avoid being taken in by the power of their own words. Encouraging willingness and deliteralization by using words alone may result in an overuse of logic. Hence, words are always connected to metaphor (and hopefully experience) as a way of avoiding this pitfall. On the other hand, the use of metaphors presents another challenge in that the therapist may get totally caught up in the process of painting pictures. Telling stories and doing exercises keeps everyone awake, but the goal of willingness and deliteralization may get lost in the mix. Focusing on one metaphor per session at most (and any given metaphor may be useful for more than one session) is the best remedy. Most important, metaphors are adapted to fit a client's particular form of fusion. Context always is combined with content in the client's experience for the proper and judicious use of metaphor. Next -- How to determine when its time to get out of Dodge City and move on to the next stage of ACT? First, we know there's progress when a person does not automatically respond to every troublesome thought (or emotion) with the same overwhelming and automatic connection. They cease to automatically fuse with their language system and instead are able to "wake up" and be aware of non-workable reactions, sometimes in the very midst of the process. Second, from this evolving stance of observer to their reactions, a person demonstrates an increased capacity for a willingness to experience content that would have previously brought automatic fusion. In other words, they do not always and automatically respond with well worn methods of control and avoidance. ACT would argue that this occurs when a person ceases to fuse and there is a "weakening of social/verbal context of control." The client is able to have more difficult experiences and demonstrates a willingness to set aside moves of experiential avoidance. From this point, the clinician is then advised to observe thyself in an exercise which eventually encourages one to "release" attachment to cherished notions of self, whether they be the best of things or the worst of things that you think about who you are. How difficult is it to release our attachment to these statements about self as "literal" realities of who we are? Perhaps this will develop an empathy for the challenges faced by our clients. Then we are presented with a clinical vignette about a 31 year old man with panic attacks whose life has become constricted because he avoids situations that produce feelings of anxiety and panic. How to conceptualize this situation? What strategies are we to use here? An ACT perspective would suggest that the client is confusing content with context by treating any appearance of a dreaded symptom of anxiety and panic as a harbinger of absolute danger ahead. An effective strategy would seek to use deliteralization exercises (e.g. Milk, Milk or Tin Can Monster) that encourage the person to step back and avoid the automatic literal response (disaster is here), and instead see these experiences as experiences -- nothing more and nothing less. Can the client allow these symptoms to occur without fusing? Then these symptoms can take their "natural course" without the rollercoaster wrought by cognitive fusion. Finally, the chapter concludes with two exercises for client homework The first seeks to analyze the extent to which reason giving pervades experiences outside the session. This will hopefully make the client more aware of how they use reason giving and to see reasons as merely content to be considered as useful only when they meet the criteria of workability. The second exercise is an awareness exercise which encourages a mindfulness and acceptance of present moment experience that helps one practice being in the role of observer. A useful and life long task indeed.

This is all open to feedback, of course, as I am never sure I have this stuff quite right. But then again, it's only a bunch of thoughts, so don't believe me anyway. Somehow this self stuff reminded me of a recent interview with Clint Eastwood (paraphrased from memory) --

• Int: So, we've talked a lot about what your critics think of you and your work, what your wife and ex-wives and children think. I have to ask, what do you think about Clint Eastwood?
• CE: I tend not to think about him very much.

ACT (181): In order to face one's monsters head-on, it is necessary to find a place where this is possible. I believe there is a Zen story (don't recall where I heard or read this) of a man who is alone in his house trying to eliminate all of his demon's. One after one, he faces them down, and they all disappear as he sees them for what they are -- except one. This is the largest demon of all, and as hard as the master-to-be tries, he cannot eliminate this demon. He cannot avoid the monster, he cannot talk the demon into going away, he cannot make a deal with the chimera. Finally, after he thinks he has attempted everything he could possibly do, he jumps right into the mouth of the demon, and it disappears. ACT- Three Senses of Self Conceptualized Self -- The me who I think I am Clients come into therapy, counseling, etc with varying goals regarding this self -- to defend the self, to fix the self, to find the self, to avoid the self ACT View for Success Regarding the CS -- to have the client voluntarily experience conceptual self suicide expurgate the boundaries of the self and (my thought) broaden the psychological world of the client to make room for all history and experience - to bring the clients to where they began and to see it again for the first time (I can't remember where I stole that one, either). Self as concept might make a statement like "I am a person who ....." and this statement is taken literally with many predicates, even predicates which do not work. Examples "I am a person who breathes" compared to "I am a person who is sad, happy, " This universality can cause mucho problems. (Here's a reach) If I am a person who is sad, I may not notice the times when I am happy- they don't fit my self concept. On the other hand, if I am a person who is happy, what does it mean on an afternoon - when it is cold and wet and rainy in Minnesota, and it is June, and dammit, isn't supposed to warm and sunny now - when I am sad? With this concept we, and the community around us becomes very invested in my maintaining my "image" of being a certain kind of person; or

1. When I am x and I and my community do much better when I am x, I am pretty invested in remaining x, because if I act as Y there are consequences
2. Our history has taught us to see and maintain patterns.
3. We have equivalency statements that may not be equivalent "I am 5'10" (maybe 9") becomes the same as "I am alcoholic."
4. If I try to act outside of "who I think I am," it seems almost life (or self?) threatening. Note: I wonder about this with the "guys" I work with. Many are domestic violence offenders, and even though their physicality is usually not threatened, many lash out when their sense of "self" is threatened, the "manly man syndrome." OR "Eliminate conceptualization = eliminate me."

The self can be "maintained more easily simply by distorting or reinterpreting events if they are inconsistent with our conceptualized self." I am concurrently (as my bathroom bibliotherapy) reading a book - The Tao of Zen - there is a quote there that I somehow want to fit into this chapter. You decide - " For all Chinese philosophy is essentially the study of how [people] can best be helped to live together in harmony and good order ... [There is] nothing more dangerous than that theories and doctrines which belong to the world of language should be mistaken for truths concerning the world of fact." Our conditioned responses to and with language create the prison which many people go into therapy to theoretically escape, and get there and work hard to build stronger walls. Page 183 - "To escape a prison it is first necessary to see the prison itself." Most therapy to date has been designed to paint the walls of the prison with different thoughts and/or emotions, whereas ACT's design is for the client to see the prison from both the inside and the outside. Ongoing Self Awareness While the conceptualized self is a verbal trap, it is still necessary to have an idea of who you are and how you are when you are there. Without getting attached to the content, there still has to be a verbal self knowledge of life to engage with it. In this sense, it seems it is more like a surfer riding the waves, than a swimmer battling the water, or maybe, better yet, than a non-swimmer flailing in the waves. The surfer knows the water (language, words, content) is there, but does not get caught up in the depth, the swirls and eddies that come along moment to moment. A thought is just a thought, a feeling is just a feeling. The client is encouraged to engage some of these things descriptively, rather than evaluatively - to look at a thought, rather than through it. The Observer Self The "I" is a place, a locus, a perspective. It came about and is used to differentiate my experience from the experience of others? "I" am looking at my computer screen. "You" are not. The "I" sets up the context for description. ( I think I have this right, or at least am making sense of it.) Spirit/Matter distinction which has emerged in all cultures. Spirit - a private event that cannot be experiences as a thing or object. Sense of self-as-perspective has same properties as spirit. This is important because we/I/You as context is the one place any of us can stand that is enduring. Even though we are constantly changing, we always have that sense of "being there," of seeing all that is in our life from behind these eyes. This important in the change process because there is something grounding about there being one part of us that will go through all of "this" unscathed, at least for the time we are aware of. With all of the threatening things that happen in therapy, life, etc, there is that sense of I that will remain. ( I think) In ACT, it is important that the I/you-as- context will always be there, at night, in the clouds, through sleet and hail and thunder, wherever I am, whatever happens, there I go. Page 187 - "The trick lies in teaching the client how to be aware of content, to be aware of the awareness of content, and yet not be so preoccupied with content or attached to it as a matter of personal identity ... without objectifying these events or mistaking them for" the real me. Be careful not to pay too much "attention to that little man behind the curtain."

We're looking at the first part of the 'Clinical Focus' section of chapter 7 'Discovering Self, Defusing self'.

As will have been outlined earlier, this is an important part of ACT. The section begins with a brief outline of the core perspectives that are introduced here. Table 7.1 (p.188) provides the ACT goals, strategies and interventions regarding self.

Initially, it is helpful to 'Undermine Attachment to a Conceptualized Self'. Clients may vary in readiness to work on this area. The timeless struggle between content and context is presenting itself here. ACT promotes the idea that the problem may lie in attachment to beliefs, rather than in the beliefs themselves. This may be seen as a reversal of some views in which self-conceptualization and performance are linked. The 'Mental Polarity Exercise' can be used here to demonstrate the effects of attachment to evaluative thoughts. The description of the exercise also describes the etymology of the word 'perfect'. This is also a powerful and important point, that, in my view is worthy of detailed attention.

Next we have a section on 'Building Awareness of the Observing Self', that aims to help the client notice the process of consciousness and sense of perspective. A 'central ACT intervention', the Chessboard Metaphor, is then described in detail, and a helpful brief therapist/client transcript provided. The Chessboard metaphor can be physically acted out in therapy. Issues such as willingness can be demonstrated through observing how little effort it takes for the board to hold the pieces. An important phrase - " The point is that thoughts, feelings, sensations, memories etc are pieces on the board, they are not you" (p.192).

A couple of notes from a beginner: As p.189 notes, 'therapists and clients are in this language stew together'. It is therefore as important for therapists to work on attachment to their own conceptualized self(-ves), as for the client (a theme of the book). I especially like the brief paragraph on perfect (p.190). In this sense, who is not 'thoroughly made'? This perspective may also carry over to the judgments and evaluations we make of others.

The Chessboard Metaphor is very useful - although I have had one or two clients wanting to sweep all of the pieces from the board (wipe the slate clean). John Billing gave us alternative metaphor on 16.06.04 (or 06.16.04, depending on which side of the pond you're on)

Experiential Exercise with the Observer Self Observer Self exercise: This is a "key" lengthy exercise that brings the person to the place where they are observing the changes that have occurred in their life from a perspective that seemingly does not change. Phase1: The exercise begins with general focusing and by noticing bodily sensations. From there it moves onto observing sensations of a recent memory; then to observing a further away memory, then lastly it moves to observing sensations of a distant memory. The main focus is on being aware of the self that was present at those past moments is the same self that is presently noticing; the observer self is a sort of common denominator; it's the soul prospective. It is also practice in "seeing seeing" where seeing is defined as what we feel, think, and sense. Phase2: Is similar to what occurred in Phase1, just the content has changed. The client is guided through observing the roles they play and the emotions and thoughts that they have; roles, thoughts, and emotions change, come and go but there is a you that is having them and has stayed the same while they have changed. The perspective of Observer Self is one where a person can more easily observe themselves engaging in the behaviors of thinking and sensing. Paraphrasing Skinner, "a person who is aware of his own behavior is in a better position to [influence] his behavior." Pick an identity: This is an exercise where a few semi-random statements about a self are picked from a box, randomly, and then the client uses these statements to take on that personality, with the help of some guidance. This equates to the client's real life experience of picking a few statements about themselves and becoming that person. This is an experience in flexibility where being flexible has not been utilized (much). Faking it: is a good example of how our minds' can give us the opposite experience of what we actually experience. "I feel like a fake because I am having a good time but I am not a person who has a good time; I'm depressed! Therefore I must be having a good time just to make other's feel like I am having a good time (which of-course I couldn't be). Since I am a fraud this really sucks." The benefits of being able to observe these thoughts as thoughts and not truths should be obvious. Buying these thoughts will lead to one experience where the experience itself yields or is a much different experience.

Here is my attempt at the next couple of section called "Therapeutic Do's and Don'ts", "Progress To The Next Phase", "Personal Work For The Clinician: Is Your Self Getting In The Way?", and "Clinical Vignette". In the fist section "Therapeutic Do's and Don'ts", the authors caution clinicians about a couple of things. First "Reinforcing the Problem", in this section we a cautioned about joining in with the client's language, which will show "itself in the development of an excessive amount of logical, rational talk about why the client can't trust his or her thoughts, the lack of self-confidence, and so on." I usually see this rearing it ugly head when I realize that I am talking way to much, and at times trying to convince the client of something. At these moments the authors suggest we return the focus to "experiential exercises and metaphorical talk." We should also "Reaffirm for clients that there is no secret formula that delivers happiness in any consistent way." Because, inevitably we want to take our new found tools for living and turn them into shovels and start digging new holes. Next "Spirituality As An Experience, Not A Religion", warns of the dangers of seeing ACT as a religion. This is a pitfall that we have seen since the beginning of AA, where they warned of being swept up in a religious zeal. These new ways of living daily can bring with it a new found spiritual awakening, and as the book says "that is gravy." As therapist, we need to "emphasize the concept of workability for the client, not a belief system." Next "The Multiproblem Client And Self-Obliteration", in this section the authors deal briefly with the topic of more seriously dysfunctional individuals. I see this section as boiling down to two sentences from the section. One, "The destructive effects of trauma lie less in the event per se than in the escape and avoidance maneuvers used to compensate for the event.", and Two, "ACT strongly promotes the use of experiential and metaphorical exercises that undermine the need for avoidance with such clients." And isn't that the lesson to learn? This reminds me of a poem I once wrote; "Lost and Found I lost what I was looking for Because I was looking for what I hadn't found. I hope I find what I'm Looking for Before I've lost what I find that I found." Next "Progress To The Next Phase", how do we know when it is time to move on to the next stage? When clients start to speak of "looking at, rather than being caught up in, private experiences." The authors also state "Another critical sign at this stage is the ability to laugh at oneself in earnest." In my own life it shows when I spontaneously think of how I "dig my holes" and can laugh to myself as I say "Mark, step awayyyyyy from the shovel." Next "Personal Work For The Clinician: Is Your Self Getting In The Way?", this is where you break out your pad and pen, and get a chance to play along at home. In this section we are suppose to look at the "monsters" we have been avoiding in our own lives. This is not for the squeamish, but it can be truly freeing. I will share one of my "Monsters", but I suggest you use your own. "Remember to save your work." (My "Monster" is the internal circus that happens every time I am called Doctor.) 1. What emotion does this problem present that is most difficult for you to deal with? (When this happens, fear rushes through me, and I think someone is going to expect me to be something.) 2. What thought(s) does this problem present that is most difficult for you to deal with? (That I am unworthy, and inadequate) 3. What memory or personal history does this problem present that is difficult? (I have many memories of being told in High School that I wasn't college material, and that the best I could hope for was maybe getting in the military.) 4. Is there anything in these private experiences that, considered on their own terms, you cannot have and still live a vital life? If you can't have them or a part of them, just notice you are not having that part. (I don't think this issue for me rises to this level, however, there are times that it gets in the way of me making my opinion known.) 5. Are you willing to get into contact with these emotions, thoughts, memories right now? If so, practice having them in a new context. For example, if there is a horrible thought, say the thought out loud 50 times as fast as you can. If it's painful feeling, hold the feeling in your mind and mentally describe its shape, color, texture, temperature, or smell. Try to see it as a feeling and see yourself feeling it. If it's a painful memory, consider holding it in mind and separating out the physical sensations first, then put them "out there," then move on to the emotions and put them out there, then the images and put them out there. (I have found that when separating out the sensations, emotions, and images that I can move in to the present without the negative effects of these past experiences.) 6. As you consider each of these content areas, notice also that a conscious person is considering them. Review items 1 to 5, but this time see whether you can also be aware of the person "behind the eyes" who is aware of what you are aware of. (Wow, that was a trip. You may need to be in a quiet place to try this, but it seemed as if I was invading my own body.) Finally "Clinical Vignette", here you are asked to "conceptualize the client's dilemma from an ACT viewpoint." This is a good exercise that folks can check out in the book starting on page 202.

What are values? 1. Values represent "verbally constructed global desired life consequences", different from goals in that they specify a more general direction and hence can not ultimately be satisfied, completed or achieved. For example the goal of completing this summary serves a larger goal of learning about ACT, that is consistent with my life value of continuing to learn as much as I can about psychology and its disciplines. Values typically elicit a number of goals, that is, values are "a verbal glue that holds sets of goals together". 2. Values are an action, not a feeling. Values are followed through behaviour, not through it necessarily "feeling right". 3. Values are a more stable form of "verbal rules" re-aligning a client in the present to a valued direction. Thoughts and feelings can be contradictory and inconsistent. 4. The main goal of ACT is help clients develop a "behavioural trajectory" that is vital and valued. 5. All of the techniques in ACT feed this main goal. Techniques such as defusion and acceptance are only useful in so far that they provide a means for a client to achieve a valued end. Are values innate or learned? 6. All clients have the capacity to define their life direction (i.e. develop values) 7. Verbal fusion and experiential avoidance are common barriers to following these values 8. Developing values is linked more to removing barriers (e.g., verbal fusion) rather than needing to teach valuing skills. 9. A lack of values in a client may reflect a chaotic, unpredictable environment, where the development of values/goals has met with frequently painful or disappointing consequences. 10. The social/verbal community requires that we have explanations or justification for our actions. Citing values may not appease this community, hence they are not always socially reinforced. Why have them? 11. People's behaviour is shaped by consequences, both experienced and verbally constructed. While learning histories provide a means of shaping behaviour over the short term, language provides the means by which behaviour can be shaped over longer periods (i.e., knowing that I will receive my degree at the end of 4 years keeps me studying, even though short term consequences can be somewhat aversive). 12. Values are part of this language process, specifying long term consequences for current behaviour. They can coordinate current actions over long time frames and since they are global, they require a person to do this on a day-to-day basis, different from specific goals in that they are not achievable per se. Stance of the ACT therapist with regards to values: 13. ACT therapists are asking clients a number of questions with regards to values: 1) What are your values (this will be explored with other people's summaries) 2) Can you act in a way that is consistent with your values, even when your thoughts or feelings tell you otherwise?" 3) What stands in the way of you acting in accordance with your values? 4) In pursuing a valued life direction, are you willing to have what emerges, what you encounter along the way? 5) Is there a difference between feeling a belief and acting on a belief? How will others know? (The "argyle socks exercise" is a useful way of addressing some of these questions)

This is a section I find very compelling and challenging. It has parts I can put into words but don't understand. It has other parts I understand, but can't put into words (Should the "buts" be "ands"?). At least it seems that way to me. I can put into words the difference between judgments and choices but can't seem to differentiate in practical examples. I have, for example, a vague feeling for where I want to go with the organization I manage. This feels like a value. I want everyone to be relatively happy and do a good job. That seems like a goal. What's my value here? I begin with "Choice" on page 212. Choice is distinguished from judgment-almost as a residual category (defined by what it isn't) of behavioral processes with certain characteristics that are used to select among alternatives. A selection among alternatives based on reasons is a judgment. Reasons are verbal formulations of cause and effect which answer the question "why?". The formulations serve as a justification of sorts which may make reference to societal or personal outcomes or use quasi scientific historically based deterministic assertions. For example, "I eat fruits and vegetables because they clean out my system". A choice is a selection among alternatives that may be made with reasons but not for reasons. The live demonstrative exercise is to offer your fists and say, "Choose!". The client points to one. When ask "Why?", he may or may not formulate a reason; but most persons will realize that the reason is formulated after the act of choosing and therefore not functioning causally in the selection process. In a judgment, the weighing of pros and cons actually influences the outcome of the selection process. For example, "I was going to hire Mr. Smith because of his job skills. I decided not to hire him when I considered his poor health." Is it a judgment because my awareness of Mr. Smith's health problems precede my selection of Mr. Jones? Would it have been a choice if I met them both, wanted to hire Mr. Jones but didn't do so until I found out about Mr. Smith's health? Then there's this business on 213 and 214 about asking why a reason is true as a way undermining the causal relationship between the reason and the selection(in the mind of the client, that is). Or asking why a food is chosen and then when they say it tastes good you say you asked the person to choose and not their taste buds. Maybe this is over my head. The authors acknowledge that there is no "free choice" in a scientific sense. Is this then a question of creating the subjective illusion of "free choice" by impeachment of reason(or reason giving)? This seems to be the point of the paragraph at the end of this section. I can't quite grasp this. Help me Francis or Patty or Hank or someone. Valuing is always occurring as a behavior. The dialogue between Therapist and Client on page 215 is to show how choices are always being made and purposes fulfilled. The point here does not seem to be to elucidate how these selections among alternatives are choices rather than judgments even though the word "choice" is used. Perhaps this follows in some logical way from the previous section. Still the implication is that clients are not conscious of the selection among alternatives process being "choice making" and this dialogue will make them so. What do you want your life to stand for? The dialogue is with an independently wealthy client presumably because such an unfortunate is stripped of the illusion that working for a living guides life, I guess. Anyway, they do the exercise about attending the client's funeral and what he wishes everyone would say. The therapist comments that he doesn't expect them to say "...he was no fluke." I think this is to make the point that avoiding negatives is out as a value in the sense that we're after here(File it. Along with judgments and stuff determined by reasons). They're mainly trying to distinguish values, whatever they are, from the clients current real life actions. This section ends with Albert Schweitzer as an example of someone known by what he stood for rather than specific accomplishments and it recommends the values assessment homework assignment (pages 224-225). We'll get to that shortly. I wish I could've gone to Dr. Wilson's ABA workshop on this; but I chose Prof. Barnes-Holmes' RFT workshop (or was it a judgment? Does it matter how I think I arrived at the selection among alternatives?). Choice and Commitment. If actions are based on reasons and reasons change, then "true commitments" are better done as choices than as judgments. The heart of the ACT life strategy seems to be to develop a life direction in the behavioral sense relatively independent of thoughts and impulses of the moment. The marriage commitment is given as an example of a commitment that is undermined 50% of the time by divorce. The authors see the "cause" of divorce as the persons involved not knowing how to make commitments and marrying on the basis of judgments, decisions, and reasons-therefore not having made a commitment at all by our definition (right?). Is this logic circular? Does it follow that divorce can have no other cause? Maybe so-for our purposes. Anyway, the experience (private event?) of falling in and out of love is rather unpredictable compared to the "choice" quality of commitment. This frames things in a way that life can be lived differently for some than those who "believe" in love feelings as a guideline for action taking. They conclude that commitments are choices free of reasons and changeable verbal cover and suggest the Chessboard Metaphor and Gardening Metaphor as ways to illustrate conceptually.

These pages concern how to differentiate goals from values, methods to clarify values, ways to elicit actions related to values and how to evaluate barriers to valued action.

Outcome is the Process through which Process Becomes the Outcome

This section relates how needing to attain goals creates motivation and direction for action, but does not provide vitality in life. Attaining goals does not equal happiness or life satisfaction, as one is forced to live in a constant state of deprivation (interestingly, it is pointed out that the etymology of the word "want" is "missing").

The Gardening Metaphor describes how to stick it out with an initial choice (i.e., value) to see what happens (without believing that the "grass is greener on the other side," no pun intended). Another "goal" in this phase of therapy is to help clients see that the process of living equals the outcome of interest. The Skiing Metaphor describes this well. Your stated "goal" may be to get down to the lodge and you are planning to ski there. If someone whisks you off in a helicopter to bring you to the lodge, that would make you mad. It is the process of getting to the lodge (i.e., skiing) that is what is to be enjoyed.

Finally, process cannot be measured from moment to moment like goals. If one continually monitors progress toward specific goals, they may miss the " big picture" (i.e., what they have accomplished to date). Here the Path up the Mountain Metaphor comes into play. It highlights what is wrong with monitoring only "snapshots" of life. If you are hiking up a mountain, you may notice twists and turns, circling around (perhaps even going down the path in parts) ultimately to get up the mountain. You may think at any given time: "I'm doing well" (for instance on an up-path) or conversely: "I'm doing poorly" (on a down-path). Yet, an observer with binoculars across the way (looking down at the hikers) may notice steady, continuous progress toward the overall goal.

Values Clarification: Setting the Compass Heading

In this section, values work is further elaborated. The authors point out that doing values work can be an intimate experience between therapist and client, as oftentimes values are not something the client has ever articulate before to someone else. One of the "values" of "values work" is in the fact that values may help point out to clients what IS working in their lives (i.e., they may be leading valued lives in certain areas they hadn't even recognized). There are some values worksheets on page 224. There are three forms, including a values narrative form, values assessment rating form, and goals, actions, barriers form you can use with clients. The goal is to review the worksheets together and build on them. Values work may be a helpful assessment tool as well. In doing the values work, therapists can uncover possible "ulterior motives" for certain values. The authors give three examples:

1. when values statements are controlled by the presence of the therapist, the consequence can be therapist approval or lack of disapproval.
2. when values statements are controlled the presence of the culture more generally, the consequence can be the absence of cultural sanctions, broad social approval, or prestige.
3. when values statements are controlled by stated or assumed values of the client's parents, the consequence can be parental approval

This is not to say that these factors don't affect EVERYONE'S values, but the extent to which the client takes ownership of their values is important to assess. When a client is wedded to the consequences mentioned above, the therapist can ask the client what would happen if the stated consequences were not there (i.e., "What if your parents did not know you received a Ph.D.?"). Another point the authors make is that it is not uncommon for values to change in valence over the course of therapy. Sometimes (oftentimes) clients may leave certain (or many) domains completely empty. In this situation it can be helpful for the therapist to ask the client what values he/she held earlier in life.

Assessing Goals and Actions

After values work is underway, the focus is on developing goals and specifying the actions that can be taken to achieve those goals. A goal is define as a specific achievement, accomplished in the service of a particular value. Clients do homework in acting according to values either as a one-time deal or from a commitment to repeated and regular acts in the service of a given value. The therapist and client monitor for a close connection between action, goal, and value and try to "accumulate small positives." The authors assert that little steps consistently taken are more useful than heroic steps taken inconsistently. What to do about barriers? The authors mention that engaging in valued action almost always provokes a psychological reaction (often in the form of barriers). At these times, clients may get stuck because they avoid taking values actions as a means of avoiding painful emotional barriers. The therapist then helps the client examine:

1. the type of barrier
2. ask if the barrier is something they can make room for and still act
3. find out what aspect of the barrier may actually help reducing your willingness to have it without defense
4. assess whether barriers are a form of emotional control or avoidance

Question

Although I am a big proponent of values work (or I wouldn't be doing this therapy), I am still struck by the similarity of values homework to "monitoring progress toward a goal," not noticing the process itself. In other words, the question "How well did you move toward this goal this week by these actions" seems like the very "snapshot" that is proposed as problematic in the initial part of this section. Any reactions?

Willingness to have barriers and barriers to willingness: willingness is a value-based action, a choice: see the "Bubble in the road" metaphor p. 230. Therapeutic do's and don'ts:

• coercive use of choice: conflicts are possible between the therapist's and the client's values. Take care not to use "choice" as a way to blame the client.
• confusing values and goals: "I want to be happy" is not a value. It's no direction. It's something you can have or not have, like an object. Values cannot be achieved and maintained. Helping question: "What would you be able to do if that was accomplished?" Values are no means to an end.

Willingness and commitment: putting ACT into action ACT is not only about defusing and defining life values. Essentially ACT is all about living, action. This chapter focuses on the commitment part of ACT: "getting the client engage in valued actions while making room for their intended or unintended consequences". Theoretical focus Willingness & behavioral commitment = actively engaging in actions that may invite the presence of negative evaluated thoughts, emotions, and bodily states. This induces a confrontation with the unworkable aspects of old rule systems. Verbal and nonverbal aspects are important here. Verbal: formulating valued ends & intermediate goals Nonverbal: through action, actual movement, behavior can actual contingencies be met. Nonverbal behavior is necessary to find out what actually works. The difference with systematic exposure and behavior change lies in the focus on overt situations + on private events. The emergence of the old rule systems is helpful in the defusion process. Goal of this phase = to elicit behavior & to support the client's commitment to sustaining such change. Comments: - ultimately ACT is no talk therapy, it's behavior therapy. No behavior therapy without action. The proof of the pudding is in the eating. -old rule systems can be very though. Is it possible to change them in old people, with problem histories of tens of years?

Willingness and Commitment chapter Clinical Focus 1. The goal of clinical work in this section is to elicit behavior change and support the client's commitment to sustaining this change. 2. Therapeutic topics center around willingness and committed action. 3. There is a chart with goals, strategies, and interventions related to willingness and commitment on page 239. My comments: 4. The authors note that committed action is "funded by valuing." I find that description very helpful! Experiential Qualities of Applied Willingness 5. The experiential piece of willingness relates to increasing the client's ability to detect internal struggles and abandon them-even in the midst of the most difficult moments. 6. The authors differentiate willingness from wanting in that often clients feel that they have to want something to do it. They also often feel that if they withhold willingness to have X, X will go away (yet they experience just the opposite). 7. Joe the Bum metaphor (page 24) is used to illustrate willingness. * This metaphor underscores two characteristics of the fantasy of unwillingness: 1) If only invited and wanted guests came to the party, life would be grand. 2) Withholding willingness to welcome the unwanted guest will somehow promote peace of mind. My comments: 8. I am struck by how often we expect life to be rosy and don't want anything to happen to upset the applecart, when that's just a frightening way to live! Willingness Has an All-or-nothing Quality 9. There is an old Zen saying: "You cannot jump a canyon in two steps." The authors provide an experiential exercise on page 241 related to the simile: "willingness is like jumping." They discuss how the quality of jumping is the same whether one chooses to jump off of a book on the floor, off of a chair onto the floor, and off of a building to the ground. It is merely the context that changes and limits willingness. When you try to change the quality of willingness (for example, by trying to reach your toe to the ground from the book or chair), you destroy it altogether. My comments: 10. Maybe someday I'll be gutsy enough to jump off a chair in my office in the service of illustrating this point to a client-I'll have to commit to that J Reconnecting with Values, Goals, and Actions 11. At this stage, the therapist reviews the client's contemplated actions in each life domain. 12. While some domains may not be filled in, it is important to develop at least one high priority target and to keep the focus on willingness, not barriers. 13. A couple of therapist statements to illustrate the above are: "What stands in the way of you setting your willingness on high right now?" (the therapist noting the barriers the client cites) and "Has being unwilling worked to protect you over the long haul from those reactions?" Committed Action as a Process 14. It is not unusual for clients to avoid making a commitment because of the fear of failure to keep it. 15. There is a therapist-client dialogue on pages 243-244 demonstrating the difference between process and outcome (and how to help the client see this difference). My comments: 16. I think it's crucial in any behavior change undertaken by humans to realize (intellectually and experientially) that it is a process, and one will inevitably "fall off the wagon." I attribute this to "stress inoculation" or the Zen meditative notion of guiding one's wandering mind back to task.

The section titled "Committed Action Invites Obstacles" begins with the idea that once we have a value-guided game plan, it is time to act. The Eye Contact Exercise is a live demonstration of action and a way to begin to behaviorally confront a common avoidance behavior. This exercise may elicit the reactions described. My experience has been also that many of the client's friends, relatives and acquaintances may perceive a change in the client as eye contact improves. Sometimes it gives them "the creeps". An action oriented, surprisingly powerful intervention. The FEAR and ACT algorithms are introduced as help aids in identifying barriers to willingness(Fusion with thoughts, Evaluation of experiences, Avoidance of experiences, and Reason giving for behavior) and maintaining focus on the game plan(Accept your reactions and be present, Choose a valued direction, and Take action). These can be printed on cards and carried. Live confrontational exercises in the therapy hour are suggested and the "Looking for Mr. Discomfort Exercise" is described on page 247. There's the business of renegotiating the clients relationship with "Mr. Discomfort" and possible use of earlier references to the Passengers on the Bus Metaphor. "Culprits" or likely suspects in failure to complete committed action sited in the book are actions not connected to client's valued ends(direction?) with possible influence by wishes of others, being hooked on literality bolstered by destructive reason giving, or taking a step that is too large or with insufficient preparation. There is also the tip in exposure exercises of identifying component experiences(bodily sensations, memories, emotions, thoughts) and being willing to have them rather than what it says it is or may become. There is also the technical tip of reminding awareness of external environment while encountering negative private experiences. This is helpful when the client "can't stand it" and resorts to devaluing the valued end(direction?). The authors' use of "valued end" in this section bothers me as it seems to raise the specter of goals rather than the previously emphasized compass direction. The Swamp Metaphor on page 248 helps illustrate the idea of walking "through pain the service of taking a valued direction". The Expanding Balloon Metaphor considers the edge of the balloon as a growth zone where the question is asked: "Are you big enough to have this?" You may respond to each issue with a yes or no. Yes, you get bigger. No, you get smaller. No matter how big you get, there's always more "big" to get. It does not get easier (very important) as each issue may seem relatively as difficult. It may become habitual, however, which begins to provide a source of strength and confidence in the process. Figure 9.1 illustrates how avoided issues cause one to distort life around the issue until it is faced. The Take Your Keys with You Metaphor additionally helps deal with the relationship between avoidance and action. The keys represent difficult emotions, thoughts, reactions, sensations, etc. The client may pick up and carry the keys without them preventing the action and the keys may open doors(an illusion to insight?) The metaphor is given on page 250 and its use creates a tangible for the client to use in his outside therapy life. I'm surprised at how few comments there are on the summaries. These metaphors can restructure a persons' cognitive experience of life and facilitate behavior change. Is it a form of insight? Is that an important question? Is anyone else bothered by the "valued end" versus "valued direction" thing? Is it important? Why or why not? The idea that willingness never gets easier and can't be done piecemeal strikes me as important. I take an exercise class that seems to have this characteristic. It involves recurrent unpleasant private experiences, but doesn't seem to harm or traumatize me. The instructor reminds us, "If this was easy, everyone would be in here doing this." Is this an example of acceptance in service of health as a valued direction? I can tell you, it never gets easier. Do the FEAR and ACT algorithms que rule directed behavior? Could they have a down side?

Primary barriers to committed action:

When a client resists committed action, often the client is struggling with how the action will alter his (or her) personal history; how the client has created in his own mind his place in his world. The client may also be grappling with the impact this history has had on his conceptualized self. The client has constructed a self perception of who he is. If he has been subjected to an abusive or otherwise harmful environment, his self perception embraces how he has been victimized by others.

Not surprisingly, the client is threatened with the possibility of positive change. This threat challenges both the client's self perception and the hope that an abuser may someday validate the client's self perception and make amends. For example, a client was physically abused as a child. He now perceives himself as a victim of physical abuse; the perception is intertwined with his identity. If he makes positive change, he may no longer appear as a victim to himself or his abuser. He loses his self perceived identity (as a victim).

Clients with history of painful events (especially in childhood) may have learned that life can be unpredictable and punitive. By limiting their exposure to painful thoughts, they mistakenly believe they can curb their sense of trauma. The opposite is often true. Psychological pain hurts but does not damage; whereas psychological trauma is pain without the willingness to experience the pain. This unwilling causes damage; the effect of the pain persist.

An exercise to teach the difference between psychological pain and trauma:

1. Ask the client to describe past painful and traumatic events in detail. 

      - distinguish between the original pain and, 

      - the client's reaction to the events.

2.  Inventory the area of responses (i.e. physical reactions, emotional reactions, memories, thoughts, etc.)

3.  Note the sense of trauma

4.  As the client becomes aware of the reaction, ask the client to let go of the struggle with the reaction.

The client's willingness will shift the context of the events; this change will often reduce the client's tension related to the event. As a consequence, the client will be begin to distinguish between trauma and pain. The pain will remain; the trauma will disappear; positive change may occur. A client's reluctance and resistance can be expected. If so, the clinician should:

1. point out to the client the burdened caused by resisting the avoided content
2. have the client notice physical, emotional and cognitive responses that attach to the unwillingness
3. prompt the client to let go of the struggle with unwillingness and be willing to be unwilling
4. if the client is able to do this, ask the client to notice the difference between struggle and letting go
5. encourage the client to continue the process of letting go and bringing up avoided material.

Things to remember:

• The therapist must identify the functional connection between failing to be "right" about being a victim and remaining a victim who demands redress.
• If the client believes he must remain "broken" in order to prove someone else wrong, the client is stuck, not broken.
• Intervention is delicate.
• The events in question are not being disputed.
• What is being disputed is the necessity of living in a self defeating life in the service of waiting for the recognition and redress that seldom, if ever, comes.

Guilt and Self-loathing (not in Las Vegas, not Hunter Thompson) Guilt = "I'm bad" is a stance that weakens the client's valuing ability. It is connected to past, dead behavior, and, when functionally connected to such a chimera, prevents the client from living in the present, in real time, and moving ahead with life.. In the example shown, the client implies that guilt/shame regarding past behavior is making a visit with a brother an extraordinarily stressful event. The client holds on to contradictory concepts, "I want to be close to my brother, so I cannot tell him the truth." The client is feeling numerous emotions, and seems to get that he is trying to bargain with them, and get them to the back of the bus. When he sees the cognitive dissonance (?), he appears to be able to also see the disconnect, which scares him. Therapist asks what is between him and honesty with his brother -- answer: fear, He can bring that to the front of the bus as well and is still able to drive. Forgiveness Clients often think fear is a change in stance where once they 'knew' someone was wrong, bad, untrustworthy, and to forgive is to say they are no longer these things, they are right, good, etc. The client has, in essence, changed their mind. It can also appear to be emotional avoidance -- excusing, denying, forgetting old angers. It is actually a gift to oneself, to give the self that which came before. It gives the for-giver the ability to regain the grace under which they can neutralize the injustices -within themselves. To paraphrase "the injustices of others can only be made permanent by the victim, not the perpetrator," or pain is unavoidable, but suffering is optional. Example used is the Gestalt "empty chair" exercise. It may be best to allow the client work on the pivotal, profoundly personal issue of forgiveness outside of the session, where the necessary privacy and time for self-reflection is available. Behavior When the client is nearing the end of the willingness and commitment phase, ACT begins to resemble other Behavior Therapy, while maintaining an ACT flavor. Skill building, couples work, role-playing et al, are used from an ACT perspective. Termination Termination comes when the client has reached a point where valued behavior change has been actualized for him or her. Therapy is not designed to be permanent -- Woody Allen "I have been in Analysis for twenty years. I think I will give it another ten and if that doesn't work, I will call it quits." It is to help the client get unstuck. When a client shows openness to change, a rating scale may be used to gauge further commitment to same. Termination may be tapered off, shorter for the functional client, and longer for the multiple problem client. This phase is used to bolster key ACT principles (Oh how quickly we forget) and for relapse prevention. This, thinking of diClemente's stages of change, is the maintenance and transition stage. During this period, if the need to reenter therapy arises, the therapist will be aware of it during these phasing out visits.

THERAPEUTIC DO'S AND DON'TS Even in Relapse, Values are Permanent When client is experiencing a relapse, the first thing therapist and client must know is if there's a change in client's values. Most of the times, there's not a change in values but on client's confidence to achieve them. When client experiences a relapse, there's probably inner conflictive talk about different rules and memories. If the therapist confirms that the client's values are the same, he can use a metaphor to say that even though obstacles may show up in the way, the way to arrive to the committed goal is the same. omments: What if the client's approach to his value allows him to foresee a "danger" (such as the non accomplishment of other values). On the other hand, the client might answer that if one is tired to drive to San Francisco it is not recommendable to do it, or that if he knows the road is blocked because of an accident, he should wait till another day or month. My comment might be silly but since my short therapeutic experience, clients are very good at refuting and turning over all kind of metaphors adjusting them to their immediate needs. The Client Owns Committed Action In this section, the authors emphasize the importance that the client follows his own values and not the ones that might be a non intentional influence of the therapist. Noncompliance is not Failure When client's behavior doesn't change, therapists use to think it's a failure, and when this happen, therapist pushes the client to act according to his own values (the ones of the client). That strategy doesn't lead to a good outcome, and client's behavior gets resistant or definitely avoidant. The best way to cope with that situation is to accept the client's struggle and non-action from the point of view of the client. Comments: It's interesting to me that in this situation the main problem is not the client's resistance, but the therapist resistance to accept the client's behavior. PERSONAL WORK FOR THE CLINICIAN: COMMITTED ACTION In this exercise, the therapist takes one value and establishes goals, actions and obstacles according to it. Then, the therapist thinks about which private events would show up once committed action begins and if he is decided to make room for them. Comments: it's very interesting to me the difference between ACT approach and CBT. In my clinical experience as a CBT I remember that after the assessment and before treatment, we had to write down together the client's goals, but most of the times, even though classifying them in different areas and making a hierarchy, there was a lack of certain "structure", not only in the result but also in the process of "outcoming" goals, so the goal sessions used to be quite unsatisfactory. CLINICAL VIGNETTE In this section, the authors expose an example of how a client can mislead committed action as a process, and as an outcome. The client relates "drinking again" to not to be a "loving and emotionally available husband", so he experiences negative private events. But he should consider "drinking again" as an obstacle which is part of the whole process, and not the outcome. The other point of the example to stand out is that the client misleads blame and responsibility. But considering "drinking again" as part of a process and not as an outcome, he would understand that he is able to choose again from now on. Three metaphors are provided. APPENDIX: CLIENT HOMEWORK Accepting Yourself on Faith Exercise The therapist differentiates between conclusion and assumption, and defines assumption (something we use to do other work). Then, after checking that the client validates himself making a conclusion, impels the client to choose the assumption that he is acceptable and valid. That's called Faith Exercise. When the client chooses to be acceptable, some contents such as self-doubt depend on the previous assumption and so they loose their meaning. Comments: I understand that assumptions are so frequent and necessary as breathing, and also, that approaching the problem of self acceptance might be easier and quicker that way. But I think that self validity can be approached from a filogenetical point of view. What we are is the outcome of millions of years of environmental and social selection. That has a great value per se, and is not an assumption. If we have being selected is that we are good. But on the other hand I understand that sometimes that's something difficult and maybe long to explain. What do you all think about it?

The Effective ACT Therapeutic Relationship The chapter begins with the statement that the therapist stance towards the client and therapy is an important variable, and as a result therapy becomes an intense experience for both, client and therapist. Then, the problem of language traps is introduced as a process in which the therapist may fall down itself. The beginning of the chapter also announces the possibilities and limitations of all therapeutic relationships, their lights and shadows. Comments: the last passage of this page makes me think that in a therapeutic relationship, due to the fact that there's a short history of contingencies between client and therapist, words in that context have a great amount of relations, and so, the range of meanings is wide. For example, when talking to an old and close friend, some words, sentences or non verbal behaviors have an unique meaning. Usually it happens the opposite in therapy. Positive leverage points in ACT As a main feature of ACT stance it is presented its sensitivity: its open, accepting and coherent stance towards client. But the paradox of using rule governed behavior to direct and influence the therapist behavior is presented in a quick and clearly way. Comments: I ask myself which are the historical antecedents and conditions that lead to a sensitive therapist. Understanding the word "sensitivity" as a track to therapists is important, but I think that every kind of human relationship called therapy, shares (regarding other psychological models) the fact that therapy is an art, and art is a practice. And in that sense I think that the beginnings of all kind of therapy are mechanical, not only because of the model but mainly because of the lack of experience. ACT in a functional sense Then, the authors present an example of a therapist being caught up by the literal meaning of an internal event and the possible consequences of it. The point referred is not how to "resolve the problem" but how to accept the fact of experiencing this kind of thoughts. The therapist itself must become a living flesh example of individual being stuck by a rule ("Good therapists would know what to do in that case") that accepts its own inner events and commits to therapy goals. Comments: I like the fact that the possible interventions of therapist are not a memorizeable standardized list of sentences, just contingencied, spontaneous responses. Otherwise, I like the impel to consider therapy as a struggle DURING therapy and not a previously manufactured "solution". Observer Perspective Another of the positive leverages of ACT is an observer perspective that takes an extremely care in not rationalizing and justifying through verbal behavior our private events. The ACT model emphasizes the importance of the acquisition of this skill by the therapist, arguing that the way the therapist behaves during therapy regarding internal events is important to influence the way the client will behave itself. Comments: following the argument I agree that personal growing and maturity of the therapist is a fundamental variable in therapy Wisdom is Gained by Approach, Not Avoidance And as an end to my summary, the authors explain the difference between achieving goals and values and the stance of coping them despite of "secondary effects" hung on them. They say that therapist should show this stance during therapy, and furthermore, that they should have experienced such a coping stance. An effective ACT therapist is the outcome of that condition. Comments: I appreciate the difference between merely achieving goals and to live while achieving goals. I always thought that a goal oriented stance was not enough.

Contradiction and uncertainty: the willingness to entertain contradictory themes of uncertainties without feeling compelled to use verbal behavior or verbal reasoning to resolve them. Two things come to mind: The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function. One should, for example, be able to see that things are hopeless and yet be determined to make them otherwise. - F. Scott Fitzgerald And "Alice laughed: "There's no use trying," she said; "one can't believe impossible things." "I daresay you haven't had much practice," said the Queen. "When I was younger, I always did it for half an hour a day. Why, sometimes I've believed as many as six impossible things before breakfast." The phrase "field of play" seems apt to me. When I am in ACT mode with a client, it does feel like play, even if we're working on heavy painful stuff. Field of possibility is another way I think of it. No guarantees, no warranties-just living. My clients and I have a bus metaphor when we talk about the impermanence of life. Years ago, when I was making another appointment with a client, he told me he planned to be there, but as John Lennon said, "Life is what happens when you're busy making plans," and that either of us could be hit by a bus. He was right and I try to remember it. It seems to me that this awareness leads right into values work. If you have no guarantee that you will survive the day, how does that affect what you're doing right now? Tolerate paradox, ambiguity, confusion and irony. I suppose you'd have to be a fan of Monty Python, then, hey? I still find the rescuing bit hard not to buy. Getting older helps. I'm beginning to realize on a gut level that I have no idea what happens next. Some days that's really hard. One woman and I were discussing the whole uncertainty thing and I got rescue-y. I suggested to her that it was like being a trapeze artist, and you just let go of one trapeze, fly through the air for a while and grab then next. She replied, "Right. Except for a few things: you've never seen a trapeze before, you're blind, all of your enemies are watching, your hair's on fire and you're naked." Point taken. Identification with the client: "We are not cut from different cloth, but from the same cloth." This, to me, is perhaps the most precious thing about doing ACT. Being trained in the psychodynamic camp, I always felt like a fraud. I knew that I wasn't necessarily stronger or more psychologically healthy, but the work seemed to need me to put on my therapist suit and pretend that I was. So the client would be wearing their client suit and I'd be wearing my therapist suit and we'd sit in the room and pretend not to notice when the suits slipped. Not as much fun as you might imagine. Normal reassurance vs. soft reassurance. How I make this distinction is this-normal reassurance has the flavor of the tense pat on the back and the underlying desire for them to stop talking. "It will be all right," is usually for me. I can feel the tenseness in my face when I'm being normally reassuring, and I can find myself wandering, thinking about grocery shopping and whatnot. When I'm doing soft reassurance, I'm often more uncomfortable, tending to see how close their suffering is to mine and I'm riveted. I can't hold anything else, just the awareness of how hard it is sometimes to be human. Often, I get teary, especially when I get in touch with the amazing courage it takes for some of my clients to just get out of bed in the morning. Self-disclosure: An essential aspect of developing a human relationship. Where I still struggle is with the workability of the self- disclosure. If I'm having a terrible day, I think the client can tell, but they're paying me to be present for them, although some of them would love to caretake me in the session, if only to avoid their stuff. It's messy, this edge, and I like precision. But I think the messiness is where the life is. Perhaps. Therapeutic Use of Spirituality. "A view of the world that recognizes a transcendent quality to human experience, acknowledges the universal aspects of the human condition, and respects the client's values and choices. " Stepping back from a personal struggle and examining it openly and non-defensively. Easier said than done. This is where the observer exercise comes in, for me. I've had the experience of transcendence with this exercise, and clients had described the same. When they can dip into that open hearted space and observe themselves from there, their faces and bodies soften. It's really wonderful to watch. This observer position is the most fluid position I can take in the session as well. That being said, it takes repeated effort and intention to come to this place. But when someone--myself or client--has had the experience of this observer self, they know that it's possible. There's a “there there” for them, if you will. Until the experience happens, there's no there for them to go to. At least as I see it. Radical respect: "There is no right of wrong way to live one's life. There are only consequences that follow from specific human behaviors." Another quote I've stolen from a client. "So the way I look at it, there's six billion and counting humans on the planet. There's probably not one right way to be a human being, so my job is to find the way I want to be a human being and choose things that get me there." In my experience, this defining of valued direction tends to evolve over time. Not many of the people I work with can immediately describe what matters to them. We tend to do successive approximation, and look for a non-verbal response, sort of an aha experience. Values work is the part of ACT I struggle with the most. Clinical use of humor and irreverence: "The therapist's irreverence comes from an appreciation of the craziness and verbal entanglements that surround human living." It seems to me that this can backfire if I'm not in radical respect. Radical respect seems to infuse all of the work with a client from the ACT perspective. RR for their values, RR for their history, RR for their choices. RR for how they show up in the room. Is RR the same as acceptance? It's great when the client begins using humor and irreverence with their stuff. Another steal: Client's doing a lot of reason giving, catches themselves and says, "Anyway, that's my story and I'm sticking with it." Then laughs. Very cool stuff.

Negative leverage points in ACT ACT is not an intellectual exercise Overemphasizing verbal content and trying to convince clients is the antithesis of an effective ACT relationship. Better: - be "compassionately confrontational" - no more than 20% of the session involving explaining ACT principles - use metaphors and exercises Modeling a lack of acceptance This is especially difficult with more disturbed clients (suicidality, self-mutilation, bizarre behaviors,...) Ways of nonacceptance: - selective reinforcement of socially desirable thoughts & behavior, while ignoring or disputing negatively evaluated experiences - using the language of choice in a socially coercive way: "It's your choice, and you're not making it!" - "Where did you learn that way of thinking?" Heavy emphasis on history & reason giving Solution: acknowledge it & let go of it. Excessive focus on emotional processing Misconception: clients should "get in touch with their feelings". This is true only insofar as avoidance blocks them taking a committed direction in life. No emotional rediscovery for it's own sake. This is the most seductive error. Solution: come back to active exercises linked to values and behavior change. Countertransference There will be issues that are as salient for the therapist as for the client. Resulting in: topic avoidance, advice giving, excessive reliance on personal experience. Solution: self-acceptance for the therapist • The therapeutic relationship: strong, open accepting, mutual, respectful, loving. It's not an end purpose per se. • ACT in context - Don't "believe" a word in this book - Important (different from many other clinical traditions): link with experimental research - "Are we using language or is language using us?" - It's our job to try to establish & support cultural practices inside & outside psychotherapy that ameliorate these destructive processes in a socially broader way (e.g. acceptance & cognitive defusion). Psychotherapy sometimes undermines valuable existing traditions (spiritual & non-rigid, non-punitive religious traditions). THE END Comments:

• some useful rules are given (esp. for beginners): no more than 20% explanation, back to exercise, ...
• excessive focus on emotional processing: I was exactly doing this the very moment I read this piece. Back to values and behavior!
• remaining questions: what about clients not seeking help, but needing it (involuntary treatment); how to integrate RFT with other problems (not having to do with avoidance): impulsivity, aggression, ...