Contacts, Resources, and Readings The websites for ACT and for Relational Frame Theory are both now subsumed under the Association for Contextual Behavioral Science site: www.contextualpsychology.com. Upcoming workshops are always posted there. I highly recommend joining ACBS. It costs as little as $1 (dues are “values based” meaning you pay what you think the work is worth and what you can afford) and the resources there are incredible (you cannot download them unless you are a member). If you have any interest in ACT or RFT it would frankly be goofy not to join.
There is an email list serve for ACT and one for RFT. The website above has links to these and other special purpose ACT list serves. People talk about various issues, ask questions of each other, and so on. It is a world-wide conversation. There are 1500 participants on the ACT list and 450 on the RFT list.
Workshops: Regularly at AABT, ABA, and elsewhere. There are ACT trainers all around the world. A list of trainers is posted on the ACT website, along with the values statement ensuring that this whole process is not money focused or centrally controlled.
Next big ACT meeting: The ACT, RFT Summer institute, Chicago, May 2008. Details are on www.contextualpsychology.comThe Values of the ACT / RFT Community
What we are seeking is the development of a coherent and progressive contextual behavioral science that is more adequate to the challenges of the human condition. We are developing a community of scholars, researchers, educators, and practitioners who will work in a collegial, open, self-critical, non-discriminatory, and mutually supportive way that is effective in producing valued outcomes for others that emphasizes open and low cost methods of connecting with this work so as to keep the focus there. We are seeking the development of useful basic principles, workable applied theories linked to these principles, effective applied technologies based on these theories, and successful means of training and disseminating these developments, guided by the best available scientific evidence; and we embrace a view of science that values a dynamic, ongoing interaction between its basic and applied elements, and between practical application and empirical knowledge. If that is what you want too, welcome aboard.
How to Learn ACT in 5 Steps
1. Join ACBS and ideally the list serves; 2. Starting reading the key books (a couple of general ones from the list below initially); 3. Come to a workshop or a whole ACT convention; 4. Get the ACT DVDs; 5. Form a Peer Consultation Group (www.contextualpsychology.org/act_peer_supervision_groups)
General ACT Books Luoma, J., Hayes, S. C. & Walser, R. (2007). Learning ACT. Oakland, CA: New Harbinger. [A step by step learning companion for the 1999 book. Very practical and helpful. Great book.]
Hayes, S. C., Strosahl, K. & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York: Guilford Press. [This is still the main ACT book but it should no longer stand alone. A revision will be out in 2009.]
Harris, R. (2008). The happiness trap. New York: Shambala. [accessible ACT book for the public]
Hayes, S. C. & Smith, S. (2005). Get out of your mind and into your life. Oakland, CA: New Harbinger. [A general purpose ACT workbook. RCTs show that it works as an aid to ACT or on its own, but it will also keep new ACT therapists well oriented]
Hayes, S. C. & Strosahl, K. D. (2005). A Practical Guide to Acceptance and Commitment Therapy. New York: Springer-Verlag. [Shows how to do ACT with a variety of populations]
Helpful ACT Books and Tapes
Trauma: Professional book
Walser, R., & Westrup, D. (2007). Acceptance & Commitment Therapy for the Treatment of Post-Traumatic Stress Disorder & Trauma-Related Problems: A Practitioner's Guide to Using Mindfulness & Acceptance Strategies. Oakland, CA: New Harbinger. [A very practical and accessible approach to using ACT to treat post-traumatic stress disorder (PTSD) and acute trauma-related symptoms.]
Trauma: Client book
Follette, C., & Pistorello, J. (2007). Finding Life Beyond Trauma: Using Acceptance and Commitment Therapy to Heal from Post-Traumatic Stress and Trauma-Related Problems. Oakland, CA: New Harbinger. [Applies the principles of ACT to help readers cope with the after effects of traumatic experience. Straightforward, practical, and useful]
Depression: Professional book
Zettle, R. (2007). ACT for Depression: A Clinician's Guide to Using Acceptance & Commitment Therapy in Treating Depression. Oakland, CA: New Harbinger. [An solid book from one of the founders of ACT on one of the most pervasive problems human beings face.]
Anxiety: Professional book
Eifert, G. & Forsyth, J. (2005). Acceptance and Commitment Therapy for anxiety disorders. Oakland: New Harbinger. [Good book with a protocol that shows how to mix ACT processes into a brief therapy for anxiety disorders].
Worry: Client book
Lejeune, C. (2007). The Worry Trap: How to Free Yourself from Worry & Anxiety using Acceptance and Commitment Therapy. Oakland, CA: New Harbinger. [A guide to the application of ACT to worry and generalized anxiety.]
Chronic pain: Professional books
Dahl, J., Wilson, K. G., Luciano, C., & Hayes, S. C. (2005). Acceptance and Commitment Therapy for Chronic Pain. Reno, NV: Context Press. [Describes an ACT approach to chronic pain. Very accessible and readable. One of the better clinical expositions on how to do ACT values work.]
McCracken, L. M. (2005). Contextual Cognitive-Behavioral Therapy for chronic pain. Seattle, WA: International Association for the Study of Pain. [[Describes an interdisciplinary ACT-based approach to chronic pain
Chronic pain: Client book
Dahl, J. C., & Lundgren, T. L. (2006). Living Beyond Your Pain: Using Acceptance and Commitment Therapy to Ease Chronic Pain. Oakland, CA: New Harbinger. [Uses ACT principles to help those suffering from pain transcend the experience by reconnecting with other, more valued aspects of their lives.]
Anger: Client book
Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new Acceptance and Commitment Therapy guide to problem anger. Oakland, CA: New Harbinger. [The first book to adapt ACT principles to dealing with anger. It teaches readers how to change their relationship to anger by accepting rather than resisting angry feelings and learning to make values-based responses to provocation. Has been tested successfully in a small randomized trial.]
Caregivers: Client book
McCurry, S. M. (2006). When a family member has dementia: Steps to becoming a resilient caregiver. Westport, CT: Praeger Publishers. [Although not directly on ACT or mindfulness, this book for caregivers does include a significant emphasis on acceptance, as might make sense given that the author is on of the early ACT therapists from UNR.]
Eating disorders: Client book
Heffner, M., & Eifert, G. H. (2004). The anorexia workbook: How to accept yourself, heal suffering, and reclaim your life. Oakland, CA: New Harbinger. [An eating disorders patient workbook on ACT.]
Diabetes management: Client book
Gregg, J., Callaghan, G., & Hayes, S. C. (2007). The diabetes lifestyle book: Facing your fears and making changes for a long and healthy life. Oakland, CA: New Harbinger. [You cannot tell from the title but this is a book applying ACT to diabetes management.]
Organizational issues: Professional book
Hayes, S. C., Bond, F. W., Barnes-Holmes, D., & Austin, J. (2007). Acceptance and Mindfulness at Work: Applying Acceptance and Commitment Therapy and Relational Frame Theory to Organizational Behavioral Management. Binghamton, NY: Haworth Press. [This was a special issue of the Journal of Organizational Behavior Management that was bound into book form. Don't buy it expecting a smooth presentation of the applicability of ACT and RFT to organizational issues -- it is a collection of journal articles gather into a book. But it is still worthwhile if I/O is your area and you are wondering how ACT and RFT might apply.]
Human performance: Professional book
Gardner, F.L., & Moore, Z.E. (2007). The psychology of enhancing human performance: The Mindfulness-Acceptance-Commitment (MAC) approach. New York: Springe.
[This book provides theory and empirical background, and a structured step-by-step, protocol for the assessment, conceptualization, and enhancement of human performance with a variety of high-performing clientele including executives, athletes, artists, and emergency/military personnel].
General ACT book for Clients
Hayes, S. C., & Smith, S. (2005). Get out of your mind and into your life. Oakland, CA: New Harbinger.
So far the only general purpose ACT book for the public. This book can supercharge ACT clinical work when used as homework -- very easy to use as an aid to almost any course of ACT treatment. Cheap and easy for clients to get, since it is in most bookstores. Also designed to be useful on its own and can virtually be a treatment manual for beginning ACT clinicians. Send Mom a copy and she will understand what the heck you are talking about. Or send her the Time Magazine or O Magazine on it. Has been tested successfully in large randomized trials, both alone or within ACT treatment protocols.
Twohig, M., & Hayes, S. C. (2008). ACT verbatim: Depression and Anxiety. Oakland, CA: New Harbinger; Reno, NV: Context Press. [Good example of ACT in actual practice]
Tapes and DVDs Hayes, S. C. (Ed.). (2007). ACT in Action DVD series. Oakland, CA: New Harbinger. [A set of six DVDs on the following topics: Facing the struggle; Control and acceptance; Cognitive defusion; Mindfulness, self, and contact with the present moment; Values and action; and Psychological flexibility. The tapes include several ACT therapists from around the world in addition to Steve, including Ann Bailey-Ciarrochi, JoAnne Dahl, Rainer Sonntag, Kirk Strosahl, Robyn Walser, Rikard Wicksell, and Kelly Wilson. As the marketing folks say: you've read the books, now see the movies.
Hayes, S. C. (2008; due out later this year). Acceptance and Commitment Therapy. Washington, DC: American Psychological Association [Therapy skills DVD using real client].
A 90 minute ACT tape from the 2000 World Congress is available from AABT (www.aabt.org). It costs $50 for members and $95 for non-members. It shows Steve Hayes working with a client (role-played by a graduate student – Steve did not, however, meet the “client” or know their “problem” before the role playing started so it appears relatively realistic). Recommended, however the mike was not properly attached for the “client” and she is a bit hard to hear.
AABT also markets a taped interview with Steve Hayes about the development of ACT and RFT as part of their “Archives” series. Cost is the same as above.
Hayes, S. C., Follette, V. M., & Linehan, M. (2004). Mindfulness and acceptance: Expanding the cognitive behavioral tradition. New York: Guilford Press. [Shows how ACT is part of a change in the behavioral and cognitive therapies more generally]
Greco, L. & Hayes, S. C. (2008) (Eds.). Acceptance and mindfulness treatments for children and adolescents: A practitioner’s guide. Oakland, CA: New Harbinger. [Similar to the above but for children and adolescents.]
Chantry, D. (2007). Talking ACT: Notes and conversations on Acceptance and Commitment Therapy. Reno, NV: Context Press. [This is an edited version of the ACT listserv from July 2002 through August 2005 compiled by a therapist, for therapists. Functions as a quick reference on a wide range of ACT topics (acceptance, anxiety, behavior analysis, choice, clinical resources, contextualism, etc)]
Hayes, S. C., Jacobson, N. S., Follette, V. M. & Dougher, M. J. (Eds.). (1994). Acceptance and change: Content and context in psychotherapy. Reno, NV: Context Press. [Some of the fellow travelers. This was the book length summary of the 3rd wave that was coming. Still relevant]
Basic Theory Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001) (Eds.), Relational Frame Theory: A Post-Skinnerian account of human language and cognition. New York: Springer-Verlag. [Not for the faint of heart, but if you want a treatment that is grounded on a solid foundation of basic work, you’ve got it. This book is the foundation.]
Hayes, S. C. (Ed.). (1989). Rule governed behavior: Cognition, contingencies, and instructional control. New York: Plenum. (2007) Reprinted by Context Press.
There are several additional RFT relevant books (see contextpress.com) and a practical book on applying RFT that is coming in 2008 from New Harbinger.
Philosophical Foundation Hayes, S. C., Hayes, L. J., Reese, H. W., & Sarbin, T. R. (Eds.). (1993). Varieties of scientific contextualism. Reno, NV: Context Press. [If you get interested in the philosophical foundation of ACT, this will help]
There are several additional books on contextualism (see contextpress.com) and a new book on functional contextualism that is coming within the next year or so.
A Sample of Theoretical and Review Articles Relevant to ACT
(New empirical studies are listed later)
Longmore, R. J., & Worrell, M. (2007). Do we need to challenge thoughts in cognitive behavioral therapy? Clinical Psychology Review, 27, 173-187.
A comprehensive review of the evidence in three keys areas that question the idea that trying to change the form of thoughts is helpful. It finds little evidence that specific cognitive interventions significantly increase the effectiveness of CBT or that cognitive change is causal in the symptomatic improvements achieved in CBT. It does not find enough evidence to conclude that there is an early rapid response to CBT (before cognitive methods). Overall, the review supports the view of the basic ACT criticism of traditional CBT.
Hayes, S. C., Luoma, J., Bond, F., Masuda, A., and Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44, 1-25.
[A meta-analysis of ACT processes and outcomes. Reviews all AAQ and ACT clinical studies]
Hayes, S. C., Masuda, A., Bissett, R., Luoma, J. & Guerrero, L. F. (2004). DBT, FAP, and ACT: How empirically oriented are the new behavior therapy technologies? Behavior Therapy, 35, 35-54. [Tutorial review of the empirical evidence on ACT, DBT, and FAP]
Hayes, S. C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the third wave of behavioral and cognitive therapies. Behavior Therapy, 35, 639-665. [Makes the case that ACT is part of a larger shift in the field.]
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Emotional avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152-1168. [This reviews the data relevant to an ACT approach to psychopathology, as of the mid-90’s. Still relevant]
Salters-Pedneault, K., Tull, M. T., & Roemer, L. (2004). The role of avoidance of emotional material in the anxiety disorders. Applied and Preventive Psychology, 11, 95-114. [A more recent review of much of the experiential avoidance literature]
ACT and RFT assessment devices are rapidly increasing. This area is moving too fast to put a lot in here. You have to see the websites. There are measures for scoring tapes, for values, defusion, and for psychological flexibility in specific areas (e.g., smoking, diabetes, epilepsy, etc).
What follows is the AAQ I, which is particularly good for population based studies of an aspect of experiential avoidance but can also be used clinically. The validation study for the 9-item version of the AAQ is Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M., A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W., Forsyth J. P., Karekla, M., & McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a working model. The Psychological Record, 54, 553-578. It is posted on the ACT website. Mean in clinical populations: about 38-40. The higher above that, the more experientially avoidant. Mean in non-clinical populations: about 30-31. This may not the best process of change measure for ACT (more specific ones generally work better) – good as a kind of trait measure for large correlational studies of a key aspect of experiential avoidance. Its scores are set up so that up is bad. Alpha is sometimes marginal or even unacceptable due to item complexity. The AAI II solves that. There are two 16-item versions of the AAQ I: one is described in the study above on page 561. The other is described in Bond, F. W. & Bunce, D. (2003). The role of acceptance and job control in mental health, job satisfaction, and work performance. Journal of Applied Psychology, 88, 1057-1067. It has separate factors for Willingness and Action, so its scores are set up so that higher scores are good. (I know this is confusing. This will all be cleaned up in the new AAQ-II, which is done and being written up. Frank Bond is taking the lead on it. There are also two scales for children being developed by Laurie Greco. Ruth Baer’s mindfulness scale seems to work also as an ACT process measure.
The Acceptance and Action Questionnaire –
All Validated Versions of the AAQ I Below you will find a list of statements. Please rate the truth of each statement as it applies to you. Use the following scale to make your choice.
never very seldom seldom sometimes frequently almost always always
true true true true true true true
_______ 1. I am able to take action on a problem even if I am uncertain what is the right thing to do. [Use in AAQ-9, reverse score. Use in single-factor AAQ-16, reverse score. Score in Action factor in two factor AAQ-16 and do not reverse score]
_______ 2. When I feel depressed or anxious, I am unable to take care of my responsibilities. [Use in AAQ-9. Use in single-factor AAQ-16. Score in Action factor in two factor AAQ-16 and reverse score]
_______ 3. I try to suppress thoughts and feelings that I don’t like by just not thinking about them. [Use in single factor AAQ-16. Score in Willingness factor in two factor AAQ-16 and reverse score]
_______ 4. It’s OK to feel depressed or anxious. [Use in single factor AAQ-16 and reverse score. Score in Willingness factor on two factor AAQ-16 and do not reverse score]
_______ 5. I rarely worry about getting my anxieties, worries, and feelings under control. [Use in AAQ-9, reverse score. Use in single-factor AAQ-16, reverse score. Score in Willingness factor in two factor AAQ-16 and do not reverse score]
_______ 6. In order for me to do something important, I have to have all my doubts worked out. [Use in single-factor AAQ-16. Score in Action factor in two factor AAQ-16 and reverse score]
_______ 7. I’m not afraid of my feelings. [Use in AAQ-9, reverse score. Use in single-factor AAQ-16, reverse score. Score in Willingness factor in two factor AAQ-16]
_______ 8. I try hard to avoid feeling depressed or anxious. [Use in single-factor AAQ-16 and do not reverse score. Score in Willingness factor in two factor AAQ-16 and reverse score]
_______ 9. Anxiety is bad. [Use in AAQ-9. Use in single-factor AAQ-16. Score in Willingness factor in the two factor AAQ-16 and reverse score]
_______ 10. Despite doubts, I feel as though I can set a course in my life and then stick to it. [Use in single-factor AAQ-16, reverse score. Score in Action factor in two-factor AAQ-16 and do not reverse score]
_______ 11. If I could magically remove all the painful experiences I’ve had in my life, I would do so. [Use in AAQ-9. Use in single-factor AAQ-16. Score in Willingness factor in the two factor AAQ-16 and reverse score]
_______ 12. I am in control of my life. [Use in single-factor AAQ-16, reverse score. Score in Action factor in two-factor AAQ-16 and do not reverse score]
_______ 13. If I get bored of a task, I can still complete it. [Use in two-factor AAQ-16. Score in Action factor]
_______ 14. Worries can get in the way of my success. [Reverse score. Use in two-factor AAQ-16. Score in Action factor]
_______ 15. I should act according to my feelings at the time. [Reverse score. Use in two-factor AAQ-16. Score in Action factor]
_______ 16. If I promised to do something, I’ll do it, even if I later don’t feel like it. [Use in two-factor AAQ-16. Score in Action factor]
_______ 17. I often catch myself daydreaming about things I’ve done and what I would do differently next time. [Use in AAQ-9]
_______ 18. When I evaluate something negatively, I usually recognize that this is just a reaction, not an objective fact. [Use in AAQ-9 – reverse score]
_______ 19. When I compare myself to other people, it seems that most of them are handling their lives better than I do. [Use in AAQ-9 and in the single factor AAQ-16]
_______ 20. It is unnecessary for me to learn to control my feelings in order to handle my life well [Use in the single factor AAQ-16, reverse score]
_______ 21. A person who is really “together” should not struggle with things the way I do [Use in the single factor AAQ-16. Do not reverse score … actually this is one folks who do not understand ACT are surprised by. Thinking you should never struggle is itself a kind of struggle. Neat that it loads that way]
_______ 22. There are not many activities that I stop doing when I am feeling depressed or anxious [Use in the single factor AAQ-16, reverse score]
Notes: This 22 item version can be used to score all four validated versions of the AAQ in existence. The multiple versions are confusing in several areas.
Direction: People have used the AAQ in various contexts and it has sometimes been scored so that high scores equal high experiential avoidance or so that high scores equal high acceptance/willingness. In a non-clinical context (e.g., Bond’s two factor solution was used in an I/O context) the high scores equal high acceptance/willingness works. In a clinical context the high scores equal high experiential avoidance works. That’s why items are reversed or not depending on the version.
Versions: This overall version can be used to generate the scores all for validation versions: the single factor, 9-item solution; the single factor, 16 item solution (described on page 561 in the Hayes et al validation study); Bond and Bunce’s 16-item dual factor solution; or Bond and Bunce’s 16 item single factor solution. Whew.
They are all very, very highly correlated, but they do have some slightly different operating characteristics.
The validation study for the 9-item and the 16-tem single factor version is:
Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M., A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W., Forsyth J. P., Karekla, M., & McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a working model. The Psychological Record, 54, 553-578.
The validation study for the 16-item dual factor version with 3 rewritten items (and a single factor version based on those same items) is in the Journal of Applied Psychology. The reference is:
Bond, F. W. & Bunce, D. (2003). The role of acceptance and job control in mental health, job satisfaction, and work performance. Journal of Applied Psychology, 88, 1057-1067.
If you want to use it for the Hayes et al single factor, 16 item solution go to the Psychological Record validation article and that will tell you which 16 to use … in order not to be too confusing the “16 item” references above are referring only to the Bond and Bunce versions.
If you want to use it for Bond and Bunce’s single factor solution, you can just sum the two subscales (he actually did that in one part of the Bond and Bunce study). Frank found that the two factors had a latent factor and he encourages using the single factor scale for that reason (he’s published a few things using it that way). When you use the Bond and Bunce versions score those so that up is bad.
Confused? That’s why we are creating an AAQ-II. Frank Bond is heading up that effort internationally (email@example.com) and we have a version BUT it is not published yet so it is a bit risky to use it. Which version to use: large population studies work with any of these. For process of change studies, probably either of the 16 item versions would work better than the 9 item just because it gives you more room to move. If you use this 22 item version, though, you can reconstruct all four methods of scoring, so just using this and deciding later seems fine.
There is no need to ask permission to use this instrument. Do ask permission if you want to translate it because we would not want multiple versions in any given language, and to avoid that we need to keep track. We will approve any careful and needed translation efforts.
Here is the AAQ II. It’s alpha is generally much better than any of the AAQ I version because the items are simpler
AAQ-II Below you will find a list of statements. Please rate how true each statement is for you by circling a number next to it. Use the scale below to make your choice.
very seldom true
almost always true
Its OK if I remember something unpleasant.
My painful experiences and memories make it difficult for me to live a life that I would value.
I’m afraid of my feelings.
I worry about not being able to control my worries and feelings.
My painful memories prevent me from having a fulfilling life.
I am in control of my life.
Emotions cause problems in my life.
It seems like most people are handling their lives better than I am.
Worries get in the way of my success.
My thoughts and feelings do not get in the way of how I want to live my life.
higher scores indicate greater psychological flexibility. Here are the preliminary data on the AAQ II
6 data sets: N ranged from 206-854
Reliability: .81 - .87
Variance accounted for by the one factor: 40 - 46
Scree plot also indicates one factor
With the exception of 1 item across 2 studies, all loaded on the factor at > .40.
The one exception loaded at .38 in one study and .26 in another
Total DASS score: -.601**
Depression Anxiety Stress Scales:
BDI II: -.75**
General Health Questionnaire: -.31**
Correlates at least to a ‘medium’ extent with the SCL-90 subscales.
Marlowe-Crown: r = .17 (p = .14)
White Bear Suppression Inventory:
BUT we have not yet used the scale in mediational studies (etc) so there is a certain amount of hoping and praying if you use it that way.
Which version to use: large population studies work with any of these. For process of change studies, use a more specific version if available and if not use the 22 item AAQ I version, and try the different methods of scoring or use the AAQ II.
There is no need to ask permission to use this instrument as long as you tell us about interesting things you find (firstname.lastname@example.org). When using, remove the title of the instrument and use “AAQ” instead. Do ask permission if you want to translate it because we would not want multiple versions in any given language, and to avoid that we need to keep track. We will approve any careful translation efforts.
An ACT Case Formulation Framework I. Context for case formulation
The goal of ACT is to help clients consistently choose to act effectively (concrete behaviors in alignment with their values) in the presence of difficult or interfering private events.
II. Assessment and Treatment Decision Tree
Beginning with the target problem, as specified by the client or significant others, refine these complaints and concerns into functional response classes that are sensitive to an ACT formulation and to the client’s contextual circumstances, and link treatment components to that analysis
A. Consider general behavioral themes and patterns, client history, current life context, and in session behavior that might bear on the functional interpretation of specific targets in ACT terms. These may include:
1. General level of experiential avoidance (core unacceptable emotions, thoughts, memories, etc.; what are the consequences of having such experiences that the client is unwilling to risk)
2. Level of overt behavioral avoidance displayed (what parts of life has the client dropped out of)
3. Level of internally based emotional control strategies (i.e., negative distraction, negative self instruction, excessive self monitoring, dissociation, etc)
4. Level of external emotional control strategies (drinking, drug taking, smoking, self-mutilation, etc.)
5. Loss of life direction (general lack of values; areas of life the patient “checked out” of such as marriage, family, self care, spiritual)
6. Fusion with evaluating thoughts and conceptual categories (domination of “right and wrong” even when that is harmful; high levels of reason-giving; unusual importance of “understanding,” etc.)
B. Consider the possible functions of these targets and their treatment implications.
1. Is this target linked to specific application of the tendencies listed under “A” above
2. If so, what are the specific content domains and dimensions of avoided private events, feared consequences of experiencing avoided private events, fused thoughts, reasons and explanations, and feared consequences of defusing from literally held thoughts or rules
3. If so, in what other behavioral domains are these same functions seen?
4. Are there other, more direct, functions that are also involved (e.g., social support, financial consequences)
5. Given the functions that are identified, what are the relative potential contributions of:
a. generating creative hopelessness (client still resistant to unworkable nature of change agenda)
b. understanding that excessive attempts at control are the problem (client does not understand experientially the paradoxical effects of control)
c. experiential contact with the non-toxic nature of private events through acceptance and exposure (client is unable to separate self from reactions, memories, unpleasant thoughts)
d. developing willingness (client is afraid to change behavior because of beliefs about the consequences of facing feared events)
e. engaging in committed action based in values (client has no substantial life plan and needs help to rediscover a value based way of living)
C. Consider the factors that may be perpetuating the use of unworkable change strategies and their treatment implications
1. Client’s history of rule following and being right
(if this is an issue, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Level of conviction in the ultimate workability of such strategies
(if this is an issue, consider the need to undermine the improperly targeted change agenda, i.e., creative hopelessness)
3. Belief that change is not possible
(if this is an issue, consider defusion strategies; revisit cost of not trying; arrange behavioral experiments)
4. Fear of the consequence of change
(if this is an issue, consider acceptance, exposure, defusion)
5. Short term effect of ultimately unworkable change strategies is positive
(if this is an issue, consider values work)
D. Consider general client strengths and weaknesses, and current client context
1. Social, financial, and vocational resources available to mobilize in treatment
2. Life skills (if this is an issue, consider those that may need to be addressed through first order change efforts such as relaxation, social skills, time management, personal problem solving)
E. Consider motivation to change and factors that might negatively impact it
1. The “cost” of target behaviors in terms of daily functioning (if this is low or not properly contacted, consider paradox, exposure, evocative exercises before work that assume significant personal motivation)
2. Experience in the unworkability of improperly focused change efforts (if this is low, move directly to diary assessment of the workability of struggle, to experiments designed to test that, or if this does not work, to referral)
3. Clarity and importance of valued ends that are not being achieved due to functional target behavior, and their place in the client’s larger set of values (if this is low, as it often is, consider values clarification. If it is necessary to the process of treatment itself, consider putting values clarification earlier in the treatment).
4. Strength and importance of therapeutic relationship (if not positive, attempt to develop, e.g., through use of self disclosure; if positive, consider integrating ACT change steps with direct support and feedback in session)
F. Consider positive behavior change factors
1. Level of insight and recognition (if insight is facilitative, move through or over early stages to more experiential stages; if it is not facilitative, consider confronting reason giving through defusion strategies; pit being right versus cost to vitality; consider need for self-as-context and mindfulness work to reduce attachment to a conceptualized self)
2. Past experience in solving similar problems (if they are positive and safe from an ACT perspective, consider moving directly to change efforts that are overtly modeled after previous successes)
3. Previous exposure to mindfulness/spirituality concepts (if they are positive and safe from an ACT perspective, consider linking these experiences to change efforts; if they are weak or unsafe – such as confusing spirituality with dogma – consider building self-as-context and mindfulness skills)
III. Building interventions into life change and transformation strategy
A. Set specific goals in accord with general values
B. Take actions and contact barriers
C. Dissolve barriers through acceptance and defusion
D. Repeat and generalize in various domains
THE QUICK AND DIRTY ACT ANALYSIS OF
Psychological problems are due to a lack of behavioral flexibility and effectiveness
Narrowing of repertoires comes from history and habit, but particularly from cognitive fusion and its various effects, combined with resultant aversive control processes.
Prime among these effects is the avoidance and manipulation of private events.
“Conscious control” is a matter of verbally regulated behavior. It belongs primarily in the area of overt, purposive behavior, not automatic and elicited functions.
All verbal persons have the "self" needed as an ally for defusion and acceptance, but some have run from that too.
Clients are not broken, and in the areas of acceptance and defusion they have the basic psychological resources they need if to acquire the needed skills.
The value of any action is its workability measured against the client's true values (those he/she would have if it were a choice).
Values specify the forms of effectiveness needed and thus the nature of the problem. Clinical work thus demands values clarification.
To take a new direction, we must let go of an old one. If a problem is chronic, the client's solutions are probably part of them.
When you see strange loops, inappropriate verbal rules are involved.
The bottom line issue is living well, and FEELING well, not feeling WELL.
Assume that dramatic, powerful change is possible and possible quickly
Whatever a client is experiencing is not the enemy. It is the fight against experiencing experiences that is harmful and traumatic.
You can't rescue clients from the difficulty and challenge of growth.
Compassionately accept no reasons -- the issue is workability not reasonableness.
If the client is trapped, frustrated, confused, afraid, angry or anxious be glad -- this is exactly what needs to be worked on and it is here now. Turn the barrier into the opportunity.
If you yourself feel trapped, frustrated, confused, afraid, angry or anxious be glad: you are now in the same boat as the client and your work will be humanized by that.
In the area of acceptance, defusion, self, and values it is more important as a therapist to do as you say than to say what to do
Don't argue. Don’t persuade. The issue is the client's life and the client’s experience, not your opinions and beliefs. Belief is not your friend. Your mind is not your friend. It is not your enemy either. Same goes for your clients.
You are in the same boat. Never protect yourself by moving one up on a client.
The issue is always function, not form or frequency. When in doubt ask yourself or the client "what is this in the service of."
ACT THERAPEUTIC STEPS
Be passionately interested in what the client truly wants
Compassionately confront unworkable agendas, always respecting the client’s experience as the ultimate arbiter
Support the client in feeling and thinking what they directly feel and think already -- as it is not as what it says it is -- and to find a place from which that is possible.
Help the client move in a valued direction, with all of their history and automatic reactions.
Help the client detect traps, fusions, and strange loops, and to accept, defuse, and move in a valued direction that builds larger and larger patterns of effective behavior
Repeat, expand the scope of the work, and repeat again, until the clients generalizes
Don’t believe a word you are saying ... or me either