Professional Documents
Culture Documents
In this book Wilson, an internationally respected therapist, provides an outstanding and innovative overview of new trends in behavior therapy and mindfulness
and shares his insights into the complexities of what happens when we try to use
our own mind to heal the minds of others. Beautifully written, clear and bristling
with wisdoms from a very experienced therapist, this gem of a book will be a
pleasure to read and a source for much reflection and learning.
Paul Gilbert, author of Overcoming Depression and
The Compassionate Mind
There is tremendous change occurring in our collective thinking regarding empirically supported interventions. Mindfulness for Two portends the direction of this
change, where the scientist, therapist and client are motivated and affected by
the same set of principles. Mindfulness in general and ACT in particular apply
to both the client and the therapist, and Wilson and DuFrene are insightful,
emotionally honest, and pragmatic. This is a refreshing and timely contribution
to therapy process.
Thomas J. Dishion, Ph.D., director of the Child and Family
Center and professor of psychology and school psychology at
the University of Oregon
This is an extraordinary book. Wilson speaks to the reader directly and honestly.
He uses not only state-of-the-art scientific research but also his own most intimate
personal experiences, his considerable clinical wisdom, and even great poetry to
explain some of the most technical concepts in modern behavior analysis. The
book avoids getting bogged down in detailed theoretical analysis of questionable
relevance to clinical work. Of equal importance, it avoids the kind of unprincipled,
superficial technology common to many clinical guidebooks. Wilson demonstrates
how the ancient concept of mindfulness, when understood within the context of
modern behavior analysis and the new behavior therapy known as acceptance
and commitment therapy, provides fresh insights into the psychotherapy process.
Mindfulness for Two is a must-read for both novice clinicians seeking an introductory treatment of modern behavior analytic psychotherapy and for seasoned
clinicians who wish to deepen their understanding and skills.
James D. Herbert, Ph.D., professor of psychology and associate
dean of the College of Arts and Sciences at Drexel University
Publishers Note
This publication is designed to provide accurate and authoritative information in regard to the
subject matter covered. It is sold with the understanding that the publisher is not engaged in
rendering psychological, financial, legal, or other professional services. If expert assistance or
counseling is needed, the services of a competent professional should be sought.
Distributed in Canada by Raincoast Books
Copyright 2008 by Kelly G. Wilson and Troy DuFrene
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
www.newharbinger.com
All Rights Reserved
Acquired by Catharine Sutker; Cover by Amy Shoup;
Text design by Tracy Marie Carlson; Edited by Jean Blomquist
Kindness is reprinted by permission of the author, Naomi
Contents
Chapter 7
Experiential Case Conceptualization . . . . . . . . . . . . . . . . . . . . . . . . . 149
with Emily Sandoz, MS
Chapter 8
Making Experiential Contact with Mindfulness. . . . . . . . . . . . . . . . 197
Epilogue
Slowing Down. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Appendix A
Using the Mindfulness for Two DVD-ROM. . . . . . . . . . . . . . . . . . . . 229
Appendix B
The Valued Living Questionnaire (Version 1) . . . . . . . . . . . . . . . . . . 231
Recommended Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
vi
Dear reader,
Welcome to New Harbinger Publications. New Harbinger is dedicated to
publishing books based on acceptance and commitment therapy (ACT)
and its application to specific areas. New Harbinger has a long-standing
reputation as a publisher of quality, well-researched books for general and
professional audiences.
The therapeutic relationship is the base of psychotherapy. Functional
analysis is the base of traditional behavior therapy and behavior analysis. Mindfulness, acceptance, and values are increasingly forming the
base of modern cognitive and behavioral methods. Mindfulness for Two
is the first book to bring these strands together in a way that empowers
and transforms them all. It is a groundbreaking volume that will leave
few readers unchanged. Whether new to ACT or experienced ACT
therapists, readers will find themselves drawn to a cusp and asked to
pause therenot because they are being abandoned, but because they
are being asked to experience what is possible when the question is as
important as the answer.
Mindfulness for Two carefully defines mindfulness from an ACT perspective and shows how it applies to the moment-to-moment interactions between therapist and client. It develops an approach to diagnosis
and case conceptualization thatrequires the clinician to slow down and
mindfully attend to what is present. The functional conceptualization
that this process yields is tightly linked to treatment and to what we are
learning in behavioral science. Each ACT process is used to help cast a
new light on the situation faced by clients and clinicians. The book challenges therapists to give up comfortable linearity and instead do their
work inside a flexible space where every ACT process is available and
potentially relevant to every therapy moment.
Kelly Wilson, Ph.D., is a leading developer, trainer, researcher, and
thinker in contextual behavioral science in general and ACT in particular. Mindfulness for Two speaks with Kellys voice, amplified by his cowriter Troy DuFrene. That voice, like Kelly himself, is passionate, caring,
and insightful. An author of the original ACT volume (Hayes, Strosahl,
& Wilson, 1999), Kelly has trained thousands, and his training experiences show in these pages. The book teaches. Details are given and
insights shared. The combination of head, hand, and heart that is ACT
exudes from every page.
As part of New Harbingers commitment to publishing books based
on sound, scientific, clinical research, we oversee all prospective books
for the Acceptance and Commitment Therapy Series. Serving as ACT series
editors, we comment on proposals and offer guidance as needed, and use
Are
to
viii
Acknowledgments
Writing this book has been part of an ongoing process for me. In 1985, I
began a journey out of an incredibly dark place. All along the way there
have been people who have nurtured mepeople who saw something in
me that I couldnt see in myself. I would like to acknowledge my teachers, especially Steve Hayes, Linda Hayes Parrot, Sam Leigland, Richard
Baldasty, Dexter Amend, Bill Follette, Victoria Follette, and Lois Parker.
These and many others brought me to this day. Sometimes I tell people
that my current job is to travel around the world falling in love with
peoplea pretty good gig if you can get it. Back in 1985, I could not have
imagined finding myself in the world I now inhabit.
I want to acknowledge New Harbinger. The NH folks have been
terrific and supportive. I especially want to thank Matt McKay. Matt,
with tears in his eyes, asked me for this book at the Association for
Contextual Behavioral Science Summer Institute in 2007. Matt said that
I didnt have to write a word, that I could just talk into a recorder and
send it off to New Harbinger. Of course, this book was not written that
way, but what Matt said seemed to free me up to write in my own voice.
Thanks also to Catharine Sutker for pursuing me for the past half dozen
years and for introducing me to Troy DuFrene. I feel that I have made a
friend for life in Troya true brother.
On the mindfulness front, I extend the warmest thanks to Jon KabatZinn for his kindness and support. Jons guidance in planning my sabbatical and the lovely week with him and Saki Santorelli at Mt. Madonna in
California were priceless. I would like to acknowledge John McNeil for
his kind assistance in helping me talk and think about the relationship
Prolegomenon
Finding My Way
to Mindfulness for Two
aware that youve driven a dozen miles without the slightest idea of what
you passed or what you had been doing while behind the wheel. When
this sort of thing happens, you snap to attention, but unless youve driven
off the road, there are no particularly serious consequences.
When you have a similar experience while engaged with a client,
though, the stakes are a lot higher. I recall with incredible clarity sessions in which I would suddenly find myself sitting in front of a client
who was pouring her heart out while I had no idea what she was talking
about. This is very embarrassing to admit, yet it is very true. Needless to
say, this problem with attention was a real deficit for me as a therapist, as
someone for whom careful listening is a core skill.
The truth for me, though, is that I have a busy mind. Ive always been
that way; as a young student, half of my attention was on my teachers in
school and the other was out the window, watching the clouds, thinking
about what would happen later and what had happened before. It isnt
surprising that I carried this tendency over into the therapy room. I was a
skillful enough conversationalist to keep clients from noticing my lapses
in attention, but I recognized that the lapses were occurring. And I felt
bad. Unlike the driving example, there were consequences. My clients
were only being half heardor, worse, not heard at all.
Ive had a long, unsuccessful history of privately promising myself to
mend various of my ways. Ive found that its typically more fruitful for
me to confess my misdeeds publicly and then set things right according
to what it is that I value. Thats what I began doing with clients. I would
say something like Im sorry, but Ive missed some of what you were
saying, and its important that I really hear you. So, if you would, lets
back up just a bit. Id like you to say again what you just said, and let me
listen. Let me listen until I hear the heart of what you are saying.
I recall a client I saw in therapy in the early 1990s as the first instance
in which I can clearly see seeds of my current practices. I was treating
a young woman, an artist. She was very bright and funny and odd and
troubled. Although she was otherwise quite articulate, she had very little
insight into her own emotional life. As I sat and listened to her, I would
occasionally see the smallest transient glimmer, a tiny hint of emotion
that would evaporate like a single raindrop on a hot summer sidewalk. I
would ask, What was that? She would reply she had no idea at all what
I was talking about.
She liked and respected me though and was willing, when I asked
her, to back up in the story and tell the part again that had stirred the bit
of emotion. It often took several attempts. She would come upon the bit
of difficult material. I would see that transient shift in her affect. Then
xiii
her pace of speech would quickly speed up, and wed be on to a new
topic. We often had to back up and slow our pace down many times in
the course of a session.
Eventually we learned to stop and linger at these cusps, these small
transitions. And in these margins we found a lovely richness. We found
much pain, which speeding along held at bay. But we also foundmixed
with those tearslaughter, love, and compassion. She learned to stop
on her own, outside sessions, and linger at those interstices. She drew on
this new experience to produce a series of paintings, which she displayed
in a show called Stopping. I still have a poster from the show. And I still
remember those moments we spent together, learning to stop.
Since that therapy experience, there have been grants, new academic
and research posts, many new students, and dozens of workshops, all of
which seem, in retrospect, to have led me inexorably from a complete
inability to listen well to the mission of teaching mindfulness for two, a
different sort of listening and speaking.
In writing about and conducting trainings using this material, Ive
found myself filled with questions. What if we took that focused yet
flexible, open, and accepting attention that we cultivate on the meditation cushion into our interactions with clients, trainees, and peers? How
would those conversations be transformed? How would they differ from
more ordinary conversations?
The adoption of a formal mindfulness practice isnt part of ACT,
although its in no way inconsistent with ACT. This book describes the
use of mindfulness processes in our interactions with clients; its much
less concerned with formal mindfulness practice. Since its not in my
field of expertise, Im happy to leave the teaching of practices such as
sitting meditation to those better qualified.
What I am expert in is behavior analysis and its application to psychological difficulties. The rise of mindfulness-oriented work in recent
years has spurred me to think more carefully about the role of mindfulness processes in ACT. Although the seeds of it were there from the
start, its only recently that I feel I have begun to grasp how integral
mindfulness processes are to other therapeutic processes in ACT.
In his lovely book On Becoming a Person, Carl Rogers says, What is
most personal, is most general (1995, 26). Ive bet my career that Carl
Rogers is right. This book is personal. Its personal for me, and I hope
youll allow it to be personal for you. I realize theres some risk in writing
predominantly to you, the reader, directly. You may find it intrusive that
I speak directly to you. If thats so, please forgive me. Many if not most
psychology texts are written to a remote third person; I realize youll be
xiv
used to this more formal but perhaps less engaged voice. But when we sit
down with our clients, their very presence in the room with us invites to
be more present with them, to be more aware of where we are in relation
to them. My hope is that, by addressing you directly, Ill be inviting you
to be more aware of where you are in relation to me, to the discussion in
this book, and to your clients.
Also, ACT doesnt draw any hard lines between clients and therapists, so it seems only right that I not draw any hard lines between
you and me. Many of us in the ACT-treatment-development community think that the same processes that create obstacles for clients create
obstacles for therapists. We share this sensibility with fellow travelers in
the mindfulness community. Further, we think that the best way that
therapists can learn about ACT principles is by examining them in our
own experiencea sort of self-as-laboratory perspective.
Consider this foreword, then, as a sort of informed consent. If youre
offended by me speaking directly to you, or if youre unwilling to sit with
hard things, both your own and your clients, this book isnt for you.
However, if youll accept my intrusion for a few pages, this book may
provide experiential learning in addition to the usual didactics that fill
our bookshelves.
Before we go any further, let me call your attention to the DVD-ROM
bound into the back of this volume. The disc contains QuickTime video
that demonstrates some of the things Ill be discussing as we go along. Ill
reference some of the content on the disc from time to time. For a more
detailed description of the contents of the disc and how to take advantage of it, flip back to Appendix A.
Im grateful to all those clients who suffered through my learning
curve and who helped me to find my way in that therapy room. I also owe
Judith Soulsby, who engineered the invitation to Bangor in 2006, a great
debt for putting me in a position that required me to think hard about
ACT and mindfulness. In the days since that workshop in Bangor, the
relation between the present-moment-focused ACT work I do in training
and mindfulness has thoroughly occupied my thinking. People who have
been to my workshops over the past couple years have been subjected to
my developmental process, much like the clients who came before them.
I owe all of them a debt and hope that there are things in this book that
partly repay their patience with me.
xv
Chapter 1
If it does, what might this mean for you? It might mean that half of
the people you know have had, or will have, a moment of such pain and
despair that death seems a kinder option than soldiering on. But will
they tell you? No. Not half or likely even one in a hundred will ever say
a word. Theyll come to work, to class, to therapy, to the dinner table.
Youll ask them how they are. And theyll tell you theyre fine.
Suicide seems safe as an obscure statistic. Its even pretty tolerable,
if worrisome, for most mental health professionals to talk about when it
strikes at work or at a local school. Yet completed suicide is rare. Even
when it strikes in our town or at work, it recedes from awareness before
long.
But really consider the implications of nearly half the population
giving serious thought to self-slaughter. Let yourself recognize whom this
is about. As you move through your day, pause for just a moment as you
greet each person and count silently again: one, two, one, two, one, two.
Let yourself hesitate and glance a moment and look into those eyes. Let
yourself wonder. Dont do anything about it. Just pause and wonder. At
the next staff meeting, cocktail party, or PTA social, let your eyes move
about the room. Let it sink in that nearly half of those youre seeing will
know this dark night of the soul. And, most likely, the next day theyll
come into work, and theyll be fine.
Even that is too abstract. How many brothers and sisters do you
have? Stop a moment and close your eyes. See their faces, and let yourself
quietly say their names as you do. And count again. One, two, one, two.
See if you can see, as you look into those eyes, hints of that suffering
just the other side of fine.
Worse stilldo you have children? One, two, one, two. See if you
noticeright in this momenthow much you want me to stop, to move
on to the next point. And, in that rejection, we find the altogether
human reaction to suffering. We want to hold it distant or not at all. In
that rejection, we also see the source of all that silence, we see why the
automatic answer to How are you? is Fine.
And how about you? Do you know that dark night? And how are
you? And who knows about that?
I was presenting this material recently, and a young man in the audience said somewhat angrily, Could you stop with the gruesome personal
examples?! I dont want to think about my own children being suicidal. It
would be easier to understand this if you didnt do that.
I did fall silent. I stood speechless for a moment in front of a hundred
people. And I did stop giving personal examples. But in that moment, in
the front of that room, I thought hard about Eliot: Go, go, go, said the
4
bird: human kind cannot bear very much reality. I suspect that the pervasiveness of human suffering isnt any easier to understand without the
personal examples, but I have no doubt its easier to tolerate. We so want
suffering to be an abstraction, to be about someone else, somewhere else,
or at least somewhen else. As an old Greek saying puts it, luck is when
the arrow hits the other guy.
I went silent that day, but in my hesitation, I became keenly aware of
the cost of that silence. I paid a price personally. So did all of the people
in the workshop. In a way, the countless people who go silent in the face
of suffering every day pay a price in that moment of concession. Why is
it that we, our brothers, sisters, friends, and, yes, even our own children,
will surely suffer and likely suffer alone? We all bear some responsibility
and possess some ability to respond. But we remain silent about our own
suffering. And, in sometimes subtle and sometimes not-so-subtle ways,
we conspire to silence suffering around us.
When talking with clients about suffering and especially suicidality,
Ive sometimes gone for a walk with them and counted: one, two, one,
two, one, two.
That one? And that one? And maybe that one.
I sometimes ask whom my clients have told. Most commonly they
answer, No one. Them too, I reply, nodding toward the ones we just
counted.
If they admit to having told someone, I ask, How did that go? The
most common response is near apoplexy on the part of the person in whom
they confided. This is often true even of mental health professionals.
Please be clear: Im not advising my clients to go out proclaiming their
suffering. This exercise of wondering how many of those we encounter
each day suffer in silence is an act of appreciation, not a prescription for
future action. Having to tell is as much a trap as having to remain silent.
The exercise is a chance for us to sit with suffering and appreciate the
size of the cloth.
What would it mean for us, as professionals, if we let ourselves see
that the supposed rarity of any given mental health diagnosis was a just
a trick of perception? The result of looking at the whole cloth of human
suffering as though it were a thousand separate threads? What would it
mean if we all learned to catch the thread of all sorrows? If we truly
apprehended the vast size of the cloth into which we, client and therapist
alike, are woven?
Im suggesting another path we can take. What if our willingness to
let this suffering come close allowed us to sit near our clients and to truly
hear the heart of their suffering? Really its not even so much letting it
5
come close as it is letting ourselves see how close it already is. Could it
be that in the same ways that we conspire to silence suffering, we could
begin to allow suffering to be present, for the good of our clients, ourselves, and those we love?
1985; Badia, Harsh, & Abbot, 1979). If pressing a lever changes a rats
environment from one in which shocks come at random times into an
environment in which they occur at regular intervals, the rats will press
to produce regular shocks. This is so even when the absolute number,
duration, and intensity of shocks are identical.
Humans are like that too. It isnt difficult to imagine why this might
be so. There are lots of ways for a species to survive. If youre a squid, you
spawn tens of thousands of babies. If five or ten thousand of your kids get
eaten, survival of your genes isnt especially threatened. But we humans
arent so prolific. We usually have our babies one at a time or, more rarely,
in twos or threes. If even one of your kids gets eatenwell, its likely to
be the low point of your day. So for us, as for all creatures with relatively
low reproductive rates, characteristics that lead to the survival of the
individual organism are at a premium.
Lets look at the relationship between ambiguity and survival in our
often hostile and dangerous world. Imagine you and I are two early hominids out on the savanna. We see, off on the horizon, a vague shape.
Is that a bear or a blueberry bush? I ask.
I think its a blueberry bush, you reply.
A little tentatively, I say, I dont know. It might be a bear.
No, I really think it is a blueberry bush.
Well, Im going back in the cave, just in case.
You shrug and dash off into the distance. Later, you come back to
the cave, belly distended, talking endlessly about how fabulous the blueberries were.
They were the biggest, juiciest blueberries youve ever seen! you
cry. I can hardly move Im so stuffed!
That night I go to bed a little unhappy and a little hungry. Imagine
that this scenario plays out several times. Each time, I express my concern
that it might be a bear and go back to the cave, and each time you
express your conviction that its a blueberry heaven, just like last time.
One afternoon you go sauntering off with your blueberry basket on your
arm, but you dont come back to the cave. When youre still not home
the next morning, I get up and go over to your part of the cave, gather up
your stone ax, that mammoth hide of yours Ive always secretly coveted,
and, most importantly, your mate.
If you go off to eat those blueberries enough times, eventually the
shape on the horizon turns out to be a bear, and that day youre the bears
lunch. For us, the central evolutionary imperative is that its better to
miss lunch than to be lunch. Were capable of missing lunch many, many
9
times, but we can only be lunch once (and after that, perhaps dinner and
breakfast, but thats largely up to the bear).
Were the children of the children of the children (and so forth) of
the ones who played it safe and went back to the cave. As we evolved
for millions of years in an unforgiving world, natural selection weeded
out the brazen and the brash. Our ancestors, the ones who survived and
passed on the genetic material of which we are all made, were selected
for their caution. They were the ones who assumed that whats bad is bad
and whats ambiguous is bad too.
I miss lunch
(and survive).
I am lunch!
I get lunch!
consider things with fairly high stakes: should I get married or divorced,
have children, change careers, or start a new business? Ponder one of
these or another that feels significant to you. Try doing this while intentionally not deciding one way or the other, and without evaluating or
drawing any conclusion. Rather than decide or conclude, let yourself
wonder what you will do.
If you notice yourself deciding or weighing the pluses and minuses,
gently let go of that process and come back to the question. Repeat the
question gently to yourself, listening with care to each word. If you find
yourself concluding, Well, Im not really going to do that or Sure,
thats a good idea, let yourself notice that you are drawing conclusions
about an unknown future. Your conclusion may indeed be the most
likely outcome, but sometimes very, very unlikely things happen. As
many times as you find yourself concluding or deciding, gently come
back to the question and linger. Let yourself wonder for a few minutes.
Notice also how quickly you are ready to move on to the next thing on
your to-do list.
This is jumping the gun a little, but theres another exercise in this
vein in chapter 6 called To Eat or Not to Eat. It serves another purpose
there, but if this idea of finding and just inhabiting the edge between
doing and not doing intrigues you, you can skip ahead and take a look.
Neither from nor towards; at the still point, there the dance
is,
But neither arrest nor movement. And do not call it fixity,
Where past and future are gathered. Neither movement
from nor towards,
Neither ascent nor decline. Except for the point, the still
point,
There would be no dance, and there is only the dance.
T. S. Eliot, Burnt Norton (1991, 175)
soft grass pressing into her back, looks up at the clear blue sky, smells the
sweet spring day, and feels the warmth of the sun on her face. Suddenly
she hears the roar of a lion. What happens to her awareness of the grass,
the scents in the air, the blue of the sky, the warmth of the sun? Gone. In
that instant, everything vanishes from her awareness except the lion and
the best way to make it safely to a nearby hole in the rocks that is just too
small to accommodate a lion. The lion and the hidey-hole are the only
things that matter in that particular moment.
The trouble for us humans is that things like self-doubt, anxiety
about failure, and concern about acceptancewhich feel every bit as
threatening to us as lions, tigers, or bearsare, in fact, very different in
kind from these threatening beasts. What happens if you linger with a
lion? You get eaten. But what happens, though, if you linger with depression, anxiety, or self-doubt? And what happens if you linger with a client
that presents these same things? You might be tempted to say, Id get
eaten metaphorically. Id be pulled in, and it would get worse. But I
think youd agree that there is significant difference, in kind, between
being eaten figuratively and eaten in fact. I think you can see where Im
heading.
What if problem solving twenty-four hours a day, seven days a week
werent the best way to live? What if problem solving twenty-four hours a
day, seven days a week werent even the best way to problem solve?
Fifteen.
Right again. And so, what do you do with a math problem? You
solve it. Or, maybe if its a hard math problem, you struggle for a while
first. And if its a really, really hard problem, maybe you struggle for a
while and then give up or you ask someone else to help you solve it. But
what do you do with a sunset?
The therapist pauses. You look at it?
Right, I reply. And if its a really gorgeous sunset, perhaps you
stop, rest a moment, notice the variation in color, the way it plays off the
clouds. You appreciate it. Do you ever try to solve a sunset?
No, the therapist replies.
Okay. So when you sit in the room with this client, whats it like to
be with her? Is she more like a problem to be solved or like a sunset to
be appreciated?
Yes, now I get your point.
Have you ever been a problem to be solved? I ask. Maybe in school?
Maybe at home with your parents? Or with your spouse or at work? Have
you ever been someones problem? What was that like? Whats it like to
be a problem to be solved?
Not fun, the therapist concedes.
And how about the way your client sees herself? Is she a sunset to be
appreciated or a problem to be solved?
All of this isnt to belittle attention to problems or to diminish in
any way the extraordinary problems our clients often bring to therapy.
Do our clients have problems? Sure. Are our clients problems? Sure. Are
they merely problems? No. Its simply the case that the problems get our
attention and tend to diminish our attention, awareness, and, perhaps
most importantly, appreciation of the whole human who is sitting in
front of us.
There is another side to this coin. Whats it like to be appreciated?
EXERCISE: Appreciation
I would ask you to think back in life to times when you were appreciated
by someone. Maybe it was a parent. Maybe you had a teacher who took
a special interest in you. Close your eyes a moment and see if you can
visualize that person or recall what it was like to sit with her. Linger,
for a moment, with what it meant to you to be noticed, seen, admired,
appreciated.
15
1990, so the survival prospects for AIDS were poor. Virtually everyone
in the group had watched a host of friends waste away and die. We had
AZT, but none of the newer, more effective antiretroviral drugs had been
developed.
In that very first session, I could see in her a longing for something.
I could see someone who, long ago, had imagined something better for
herselfsome ambiguous more. That more had not appeared, but the
spark of the longing survived. Humans are amazing.
I was moved to respond to that longing. I told her that if she wanted,
I could help her find a place in Reno where she could hunker down,
learn to take care of herself, and live out her time with some comfort.
The fight against AIDS was in its early days. People were terrified of
the disease. Even people who knew better would stiffen a bit when they
hugged someone with AIDS. The people in that group could feel it.
I told her that there was another thing she could do. In a war, the
first soldiers who step up out of the trenches are all killed in a hail of
bulletsevery single one. And in the next wave, more of the same.
Certain death follows for the soldiers in the wave after that. But perhaps
in the next, a soldier or two make a few steps forward, and after that, a
few more soldiers make it. And, if they keep coming and coming and
coming, eventually they make it across that field of fire.
I told her that day, with tears in my eyes, that I wished it were not
so, but that in the fight against AIDS we were seeing that very first line
of soldiers step up from the trenches. They would all fall. If she wanted,
she could do that. She could step from the trenches and give voice to the
plight of people suffering with her illness. There was a spark in her eyes,
and she picked that banner up.
Frontline soldiers, she said.
She lived for a few more years. She got clean and stayed clean. She
worked in substance-abuse treatment facilities and traveled around the
region talking to women in treatment at community events. She sometimes scared the hell out of people who took her around. Her language
was coarser than youd expect from a public speaker. But her message to
women was one of hope and love and compassion.
You can stop. Its okay. You dont have to live that way anymore.
And her message to the communities was a plea to care for the ill among
them.
When she died, there were maybe five hundred people at her memorial. We all benefited from the love shed brought to the world in those
18
five years. My clearest image of her toward the end of her life was from a
meeting we both attended. She was in wasting syndromethin, her hair
wispy, her skin gone transparent like a fine silk covering. I was there with
one of my daughters, who was an infant at the time. She asked to hold
the baby. I recall with such clarity the joy in her eyes as she looked down
into the eyes of my childone life ending, another beginning.
I felt then and feel blessed now to have known her. She didnt live
long, she didnt live without pain and struggle, but she lived well. She
wanted her life to be significant, to make a difference, and she chose to
not allow even death to be a barrier to that significance. She lives and
inspires still in the stories I and others whom she touched pass on. She
left behind a real and lasting legacy. If you ever have occasion to see that
great, sad AIDS quilt, she lives there too and reminds us all not to give
up on our fellows.
What is at the heart of this story? Sometimes, sometimes, very
unlikely things happen. How likely was that story? Not likely at all, yet it
happened. And whats possible from your most impossible clients?
WILSONS WAGER
Is it possible for something extraordinary, marvelous, to happen in the
lives of our most troubled clients? We dont know. But we get to bet with
our actions and with the posture we take with our clients. Blaise Pascal,
a mathematician and philosopher of the seventeenth century, proposed
a stake known as Pascals wager. This gambit examines the outcomes
of assuming and not assuming the existence of God using a two-by-two
contingency table. Ive always thought of this as the logicians approach
to faith. In philosophy, it is known as the argument from dominating
expectations. In a nutshell, Pascal proposed that, in the absence of a
way to verify the divine through reason, we still ought to live as if God
existed. If there is a God, and we live our lives as if there were so, we
gain infinite reward in heaven. If there isnt, were none the worse for our
pains. If we choose to live as if there is no God and were right, theres no
problem. But if were wrong, we suffer infinite loss. (Pascal didnt actually
describe the details of perdition, figuring that loss of infinite gain would
prove his point. But you can almost smell the sulfur.)
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PASCALS WAGER
God exists.
Infinite gain
No difference
Live as if God
doesnt exist.
No difference
WILSONS WAGER
Something
extraordinary could
happen.
Assume yes
Assume no
Something
extraordinary could
not happen.
You and your client get to You feel bad and your
experience richness.
client feels bad.
Your client gets
sold short.
Beginning with the upper right quadrant, imagine that, at the end of
days, you can tap some omniscient power and learn with certainty that
this client never had the chance to experience richness and beauty in his
20
life, yet in life you assumed something was possible and worked as if it
were so. Theres a cost that both you and your client paid. You peered out
into the future, longing for something marvelous that never came. You
and your client feel saddened by that loss. Thats a real cost.
Focus now on the lower right quadrant. This time the extraordinary
was impossible and you assumed so all along. Aha! I was right, you cry.
He really was a hopeless case! You get to feel good about being right. It
seems a small prize.
Now look to the bottom left quadrant, where you assumed your
client was hopeless but you were wrong. Against all odds, he could have
experienced something transformational and extraordinary. Instead, you
assumed the least and coached him to accept and pursue some minimal
existence. You sold him short.
And, finally, consider the upper left quadrant. You held out hope
that, against all odds, there was some spark of life, some unrealized possibility available to your client. You and he doggedly sought it out, wondered about its shape. You taught him to wonder, to dream, to feel for a
life that was significant for him. And, this time, you were right. That day,
you get to see things like I saw them with the client in my story and all
the others with variations on that story.
There are four outcomes in Wilsons wager, but only two ways to
bet. You either bet yes or you bet no. There are two mistakes possible in
Wilsons wager. One mistake is betting the client can have something
extraordinary and being wrong, and the cost is feeling bad. The other
mistake is betting the client cannot experience something extraordinary
and being wrong. The cost in that quadrant is selling the client short. So
you have to decide which kind of mistake youre willing to make.
You need to enter into Wilsons wager with open eyes. In contrast
to Pascals, my wager does have inevitable and painful consequences if
you bet yes and youre wrong. If you bet yes, with me, youll bury clients.
Theyll storm out the door and come to bad ends. Youll have to watch
them slip away, despite every ounce of your very best efforts. All of those
outcomes will bring you pain and self-doubt.
Yet the consequences of the other option, I think, are too horrific to
even contemplate, no matter what pain it might let us ignore. I assume
that its my job to bet yes on every single client who walks through my
door. No matter what. I assume that theres a way for my clients to live
their values under any and all circumstances. I assume that if Victor
Frankl could live his values and experience liberation in a death camp,
my clients, no matter what their history or circumstance, have that same
richness available to them.
21
SUMMING UP
So, pausing a moment, lets reflect on where weve come from. I claim,
along with many before me, that suffering is part of life. Im claiming that
its in the human condition to suffer and that were capable of suffering
under any and all conditions. I claim also that its in the human condition to resist suffering and that resisting psychological suffering has a
cost. Im claiming that the resistance is pathogenic and exacts a cost in
experienced vitality and fullness of life. Further, Im claiming that liberation is possible, that its possible for our clients (and for us) to experience
richness, beauty, and a sense of purpose under any and all conditions.
So what?
Well, if youre with me so far, it now falls to us to figure out how to
best act out our yes bet in the therapy room. Im arguing that this starts
with getting our clients and ourselves to fully show up in the therapy
room. In the next chapter, Ill start laying the foundation for an approach
to psychotherapy that I think makes this possiblean approach that
gives us the chance to really foster mindfulness for two. What follows in
chapter 2, as well as in chapters 3 and 4, is somewhat theoretical. Just so
you know, though, I will get to the practical stuff. Chapters 5 and 6 detail
practical ways to promote mindfulness in the therapy room, chapter 7
develops a new means of case conceptualization, and chapter 8 goes over
three major exercises that I think get to the very core of this work. But
first, in chapter 2, I want to go over some of the basic behavioral foundations of what Im proposing, and then, in chapters 3 and 4, I want to
situate mindfulness for two within the context of ACT.
Im grateful for your patience. I hope it will be well requited.
22
Chapter 2
A Clinicians Guide to
Stimulus Control
THINKING-FEELING BEHAVIORISM
All of us have a fraction of the world to which only we have direct access.
Others may see what we do with our hands and feet quite directly, yet
they dont have such direct access to our private events, that is, what
we think, feel, imagine, and desire. Any psychology that doesnt address
these matters is likely to be, and probably ought to be, rejected out of
hand. But this issue of whether private events are a proper subject of
study has been the frequent point of contention in the history of psychology. In the middle of the last century, empirical psychologyin its search
for a so-called objective psychologyran away from questions about this
world inside the skin.
In a symposium in 1945, the famous historian of experimental psychology Edwin Boring stated, Science does not consider private data.
Responding to Boring, B. F. Skinner quipped, Just where this leaves
my contribution to the symposium I do not like to reflect The irony
is that while Boring must confine himself to an account of my external behavior, I am still interested in what might be called Boring-fromwithin (Skinner, 1972, 384). Skinner never disavowed interest in private
events, but his was only one voice among many in behaviorism. And
many within the broader behavioral movement did call out for an analysis that dismissed our inner lifeor at least placed it outside the range
of science. Its very possible that a good deal of the contemporary rejection of behavior analysis has been in reaction to this rigidity, to positions that were held too stridently, to versions of behavioral psychology
that truly failed to take human cognition seriously. But, as even Hamlet
remarks, There is nothing either good or bad, but thinking makes it
so (Hamlet 2.2.250251). Commonsense observation alone suggests that
the human capacity for cognition exerts a considerable influence on our
behavior. Its not so far-fetched to imagine that, by neglecting to provide
a workable explanation of the role of private events within the framework of behaviorism, the mainstream of this tradition fell into disuse
during the ascendancy of cognitive psychology in the latter part of the
25
twentieth century. Regardless of the reason, the plain fact is that we now
find ourselves
Behavior
There are widely divergent views in psychology regarding what is
meant by behavior. My own first encounter with behavior was in developing and implementing behavior plans for individuals with developmental disabilities. I was taught in most of my introductory psychology
courses that behaviorism confined itself to publicly observable responses
walking, talking, speaking, and the like. My very first course on behavior
analysis was taught by Sam Leigland, an early mentor of mine who still
teaches at Gonzaga University. Sam is a tall fellow of Scandinavian descent
who can turn his entire body into a question mark. So, on the first day of
class, this tall Scandinavian question mark turned to us and asked, What
is the subject matter of behavior analysis? He didnt wait for an answer. He
supplied one emphatically: The subject matter of behavior analysis is any
and all of the activities of the integrated organism! Any and all!
At the time, I was carrying a copy of Mans Search for Meaning
around in my pocket as a sort of compass. I went to Sams office after
that class and asked him, What about this? Can behavior analysis help
28
Context
Just as behavior is anything that an organism can do, context is
anything that can happen to an organism. This includes both what is
currently happening and also what has happened to the organism all
the way back to the beginning of its existence. From this perspective,
context is anything outside of the behavior being analyzed that influences the development, expression, modification, or maintenance of that
behavior, including both current and historical context.
Context, or some aspect of context, is the independent variable in
our analysis. If we want to have an influence on our clients behavior,
we will need to understand that which influences behavior. We could
suppose that behavior just changes on its own or that change will come
spontaneously from the client, but if that is all there is to it, what is our
job as therapists?
29
The issue of influencing client behavior has been a sticking point for
behavior analysis. Perhaps it sounds manipulative. Sam had a response
to that too. He asked me what I wanted to do for people. I told him that
I wanted to help them to find meaning.
How? he asked. What will you do? In that simple question, Sam
was leading me back from clients behavior (meaning making) out into
their environment (their interaction with me and the world around
them). What will you do? is a practical question.
This is useful because we are an important part of our clients environment. Anything we do to influence our clients behavior is done
from outside that behavior. We change both the immediate context
of a behavior to give clients the opportunity to do something different
and, through a series of interactions, change the historical context of a
pattern of behavior. The context in which the behavior occurs is your
point of impact as a therapist. Context, then, is that which lies outside
behavior, and which exerts an organizing influence on the behavior
being analyzed.
but for now, lets stay focused on your clients behavior. Even when we do
look at your behavior, well want to start our analysis with one stream of
behavior at a time. Its simpler and more likely to be useful to do so.
technical
sense. On the response side, standing still is defined as a
response if I can demonstrate that standing still, as the response of interest, is capable of being organized by context, which is to say, capable of
being provoked by some kind of stimulus. For example, if I give you a
five-dollar bill when you stand still and take five dollars when you move
and thereby alter the probability that youll stand still, then standing
still meets our definition of behavior: its something the organism can
do. Also, standing still can be brought under contextual controlthat
is, its in dynamic interaction with a stimulating environment.
On the stimulus side, the most common error is to think of a stimulus as an object. We might, for example, see the five-dollar bill as the
stimulus that organizes behavior. In a limited sense, this is true, but a
more sophisticated way to think of this is that standing still changes the
world from one where you cant buy things to one in which, with your
crisp, new fiver, you can. It is that transition from not having the power
to buy things to having that power that organizes behavior, not the bill
per se. For example, if I gave you a billion dollars, the promise of an extra
five bucks would likely no longer organize your behavior, and you would
stand still or move as it pleased you. Or if I locked you in a cell where
money couldnt be spent or given away, five dollars (or even a billion)
wouldnt do much to organize your behavior. Why not? Because receiving the five-dollar bill in either of those two contexts wouldnt change
your world in any significant way.
In many applications, calling the five-dollar bill a reinforcer of
behavior is probably workable. (We should remember that, despite the
leaps and bounds of contemporary physics, Newtons classical mechanics
work just fine in most instances too.) However, we want a more sophisticated understanding of the dynamic interaction of responding and
stimulating.
Why does it matter? The distinction matters because sometimes
theres no object or immediate discrete event to which we can point.
Richard Herrnstein and Philip Hineline (1966) carried out a classic
experimental example that illustrates this point nicely. In their study, rats
were placed in an experimental chamber, and the floor of the chamber
was briefly electrified at random intervals. If the rats pressed a certain
lever within the chamber, the shocks would come at a slightly increased,
though still random, interval. What Herrnstein and Hineline found in
the experiment was that lever pressing was maintained in the rats. We
cannot understand the maintenance of the lever pressing by appealing
to the immediate effects of lever pressing. The most common immediate
effect of a lever press was that nothing would happen. In fact, as result
32
of the shocks coming at random intervals, the lever press was sometimes
followed immediately by a shock. Why did the rats press the lever? In
simple terms, the rats pressed the lever because doing so precipitated a
transition in context from one in which shocks are more frequent to one
in which they are less frequent.
These are just a few possibilities of patterns. Its likely that your client
will exhibit several patterns. Can you recognize them? Could you characterize them in terms of pitch, pace, tone, and content? This is the task
we have at hand: to make useful observations about the behavior that
our clients bring into the room.
33
environmentthe cat sneaking up, the delivery truck arriving, the can
opener whirringis quite obvious.
With humans, a transition is often not so obvious. You may sit and
listen to your client describe her week. At some point in the conversation,
you note a change in pace or tone. Suddenly she becomes very animated
or very anxious. Or perhaps youre asking about a clients visit to a friend
and see him become momentarily emotional. Why? Sometimes it may
be quite obvious what precipitated the transition, but sometimes it isnt
at all clear. As you delve more deeply into the ways context organizes
behavior, youll begin to see how you can look for particularly telling
transitions in behavior. Neither therapists nor clients are typically skilled
at detecting subtle shifts in context and the influence they exert over
behavior. However, such skill can be cultivated. Noticing such transitions in behavior can lead you to understanding what precipitated them
and to which interventions would be called for when you see them.
CONTEXT: ANTECEDENTS
AND CONSEQUENCES
Within the broad category of context, several distinctions can be made.
The simplest of these involves distinguishing whether the relevant stimulating context occurs before the behavior of interest (antecedent) or after
the behavior of interest (consequence).
Antecedent Stimulation
Some client behavior is under antecedent control. Antecedents are
stimuli that come before a response or pattern of responding that change
the likelihood that the response pattern will occur. For example, a
gunshot increases the likeliness that a startle response will follow. There
are other kinds of antecedents too. For example, if the phone rings, we
are likely to answer it. Both the gunshot and the ringing are antecedents, but as we shall see, there are important differences in the kinds of
behavior they precipitate. The gunshot has a sort of automatic effect on
behavior. Gunshotstartle. Gunshotstartle. We call this particular
kind of antecedent an eliciting stimulus. The ringing of the phone is different. If the phone rings, we will probably answer it but maybe not. If we
have a lot of other things to do, if a particularly good program is on the
35
Consequential Stimulation
Some client behavior is under consequential control. Consequences
are stimuli that follow a response and change the probability that the
response will occur again. Depending upon the effect on behavior, we
call these consequences reinforcers or punishers. Stimuli that follow a
response and increase the likelihood of a response are called reinforcers. For example, praise could be a reinforcer for a childs reading if it
increased the probability of reading. By contrast, stimuli that follow a
response that reduce the likelihood of a response are called punishers. A
painful burn could be a consequence that would reduce the likeliness of
touching a flame. These responses occur because the world changes in
some important way when they happen. When a man yells at home, his
wife and kids make no more demands on him. When a child cries, the
parents allow another hour of television. These examples illustrate ways
in which behaving (man yelling, child crying) changes the world, and
how that change or transition in context (no more demands, another
hour of television) influences the likelihood of that response happening
again.
Theres a link between consequences and antecedents. Sometimes
an antecedent, like the ringing of the phone, signals an available consequence. Discriminative stimuli and consequences go together. When the
phone rings and I answer it, there are consequences. My world changes
from one where I dont get to talk with you into one where I do get to
talk with you. This doesnt happen when I answer the phone when it isnt
ringing. It seems so unfair!
are documented cases of snake phobias where the individual has never
even seen an actual snake. Not only can humans become fearful of things
theyve never encountered, they can even become fearful of things that
dont exist: demons or monsters under the bed, for instance. If you think
about your difficult clients and the things that generate near-mechanical
reactions in them, the overwhelming majority of the events that precipitate these reactions are learned, not unlearned. They are conditioned
respondent behaviors. Some of these responses dont necessarily involve
very direct learning histories, but they are, nevertheless, learned and
therefore conditioned respondents.
Conditioned respondent behavior will be of particular interest to you
in your clinical work. It differs from unconditioned respondent behavior
in that it is much more malleable. If a person were to interact in a variety
of ways with a conditioned stimulus without the unconditioned stimulus,
the strong antecedent stimulus control would be reduced over time. For
example, if a tone were reliably followed by a shock, the tone would begin
to produce a stereotypical startle response. If the tone were presented
many times without the shock, the startle response would diminish. The
narrow patterning of behavior will be extinguished, leaving the stream
of behavior more sensitive to other aspects of context.
narrowness
of repertoire we find with aversive control. The greatest
breadth of behavioral repertoires tends to occur when behavior is under
the appetitive control of many sources of stimulation that the organism
will work to produceample food and security, an engaging environment, and so forth. Note, however, that abundance of reinforcement is
not defined independently of the behaving individual. Abundance is a
psychological factor, not one that can be defined by a physicist. A rich
social environment might seem to be a source of abundant reinforcement.
Even when people live among many others, though, they sometimes
experience themselves as being cut off, isolated, and alone.
cuts across categories. It may have many different forms, but the narrowness of the pattern is suggestive of behavior under strong antecedent
aversive control.
Take the example of a snake phobia. The defining features of a snake
phobia are arousal and avoidance in the presence of snakes. A typical
conceptualization of an exposure-based treatment is that as the phobic
individual begins to interact with snakes in a variety of different ways,
the probability of arousal and avoidance decreases.
This process can also be construed more broadly, considering the
range of responses that might be in the persons repertoire. People can
feed snakes, pet them, talk about them, study them, read about them,
watch them, and so on. With this in mind, snake phobia can be defined
not merely by the presence of arousal and avoidance but also by the narrowness and inflexibility of the range of behaviors in which the individual engages. Likewise, the effects of exposure would not merely involve a
decrease in arousal and avoidance but also an increase in the probability
of alternative responses.
With our clients, however, its not typically events that are intrinsically aversive, that create this narrowness and inflexibility. Rather, its
aspects of contextsuch as painful thoughts, feelings, memories, or
physical sensationsthat are experienced inside the skin. A client may,
for example, be interpersonally engaging and facile during sessions until
the memory of an abuse experience shows up. Suddenly that individual
begins to exhibit affective, verbal, physical, and attentional inflexibility,
just as if she had suffered an electric shock or other external aversive.
Some ACT interventions, such as values work, are about consequences. Specifically, they are about reinforcers. However, if the pattern
of behavior we see is under strong antecedent aversive control, talking
about values (that is, reinforcers) will have little effect. In fact, if the
person notices how his own behavior precipitates costs in some valued
domain, that too will be experienced as aversive, and narrow behavior
even more so.
If you can encourage this individual to sit quietly in the present
moment and to experience the difficult emotion with acceptance and
openness, then the strong antecedent stimulus control will lessen. As
it does, youll see the gradual emergence of flexibility in affect, speech
pattern, physical posture, and other aspects. Now, if you begin to gently
ask questions about valued living, those questions are much more likely
to be received in a more flexible and open way.
Being sensitive to the stimulus control being exerted can help to
direct your interventions so that they are responsive to the stream of
42
43
Chapter 3
to a gem cut into six facets. You could look into any of the six facets, but
what you would see in that facet would be the reflections of each of the
others.
In this chapter, well examine a stream of behavior by looking through
each of these facets or core processes. I dont make these distinctions
because these six are the fundamental atoms of behavior, but because
ACT holds that these are useful perspectives to take on behavior. The
basic distinctions we looked at in the previous chapter are like that too.
Theyre simply perspectives we can take on behavior, not the atoms of
behavior. We expect that there are many ways to view and understand
behavior that might be more useful for different purposes. Spiritual and
poetic understandings of behavior might, for example, be more useful
in some domains. The language used and the perspectives taken in this
chapter and in chapter 2 are intended to be useful for the development
of a science of behavior and for the orientation of practitioners. Beyond
those particular uses, I make no assertions about these distinctions.
ACCEPTANCE
Lets begin our examination of the six ACT processes from the hexa
flex with acceptance because acceptance is where the model began.
Acceptance processes involve taking an intentionally open, receptive,
nonjudgmental posture with respect to various aspects of experience. In
ACT, acceptance is typically spoken of in terms of experiential acceptance and its counterpart, experiential avoidance, which well look at
more closely below. The experiential reference in experiential avoidance is used to distinguish the nonacceptance of private events, such
as thoughts, from the nonacceptance of events in the external environment, such as an abusive relationship.
Experiential avoidance is not limited to cognitive avoidance. It also
includes other aspects of experience, such as bodily sensations, memories, thoughts, images, and behavioral predispositions. Behavioral predispositions are that cluster of thoughts, emotions, and urges that typically
precede some act. For example, drug addicts might experience a whole
array of thoughts, emotions, and bodily states and have a sense of inevitability that they will ultimately choose to take drugs. Similar experiences
can be found clinically in all of the impulse disorders, such as eating and
gambling, and in a lesser form in all of us as we gaze at the chocolate cake
and wonder whether we will have just one more slice. Of course, immediate relief from that discomfort is availablesimply take drugs, gamble, or
46
eat. When such acts are done in the service of managing these difficult
experiences, we call that experiential avoidance.
In practice, acceptance of both internal and external events may
serve an individuals values. For example, Frankl accepted internment
in a Nazi death camp in the service of caring for his patients. It is often
the case that acceptance or change of external events can be served
by acceptance of internal events. Some research data may help support
this conclusion. For example, one study found that increased mindfulness on the part of parents produces more effective child management
skills (Singh et al., 2006). In addition, some workplace stress studies
have shown that employees receiving an acceptance-oriented intervention went on to show substantial improvements in workplace innovation
(Bond & Bunce, 2000; Bond & Flaxman, 2006).
who wrote about their difficulties in school showed fewer health care
visits and better grades (Pennebaker & Beall, 1986).
Dont rush to answer these questions. Just hold them lightly for a
while and see what shows up for you. When youre ready, ease into the
exercise below. Consider first the things to you tend to avoid when youre
in session with your clients. Then think about what behavior repertoires
you engage in to keep these hard things away from you. Finally, consider
what the real consequences of this avoidance have been, both for you
and for your clients. I really encourage you to take your time with this. It
may be very hard for you, but if youre inventorying these things in the
service of something you valuenamely being an instrument of change
in the lives of your clientsI think youll be rewarded.
50
DEFUSION
Defusion means making contact with verbal products as what they are,
not as what they say they are. By extension, defusions opposite, fusion,
means taking these verbal products very literally, investing them with
authority and consequence. I know this definition sounds daunting and
technical, but we can look at it in a less technical way. Verbal product just
means that some event, either internal or external, has meaning as result
of verbal learning processes.
Sometimes verbal means actual words, like a thought you might
have (for example, I think Ill skip this section of the book). Things other
than words can also be verbal from this perspective. So, for example, if
you felt a palpitation in your chest, what you just experienced is a physical sensation. However, if a friend recently had a heart attack, the palpitation might be experienced as bad, frightening, or a precursor to a heart
attack, or as an occasion to go to the doctor, to increase your life insurance, to rethink eating that second donut, to start an exercise program,
to start taking your blood pressure medication again, and so forth. All
that from a little physical sensation! How did that sensation come to
mean all those things? Largely through verbal learning processes.
Words have an amazing capacity to make monsters present. We
confuse words with the things that the words point to. We do this sometimes when the thing pointed to doesnt even exist. There was a time
when many people wouldnt sail far out to sea for fear of falling from
the edge of the flat earth. Zen teachers sometimes say that the finger
pointing at the moon isnt the moon. We might need to go further still
the finger pointing at the moon isnt the moon, and, further, even the
moon isnt the moon.
ineffective if the value being pursued were being educated. In ACT, were
concerned much more with workability then veracity. What, though, is
to be done with such troubling thoughts?
Is Fusion Bad?
I know, Im starting to bore you. However, if you already know the
answer to the question Is fusion bad? Im beginning to make my point.
No. Fusion is not bad or good. Fusion simply is. In fact, theres extraordinary adaptive advantage to fusion. When one early hominid said to the
55
other, Dont go to the water hole, theres a lion there, if the other hominid
responded to the word lion as if he was responding to an actual lion, he
survived. Only one of these individuals actually saw the lion, but his words
made the lion present for his friend. In the end, they both lived.
Its relatively simple to generate examples of fusion that are benign
and sometimes even very helpful. For example, being deeply engaged
with the words of a novel to the point where you lose awareness of things
going on around you is good entertainment. If youre about to step into a
crosswalk and someone shouts, Watch out for that car! you might leap
from the street in response to the words in the same way that you might
respond to the actual car. Here fusion isnt only benign, its also adaptive.
There are many times, however, when fusion leads to behavior thats
directly contradictory to valued living. When the person with an alcohol
addiction drinks in response to the thought I cant stand these cravings,
when the someone with agoraphobia stays home in response to I cant
stand another panic attack, or when a depressed individual stays in bed in
response to I cant face this day, opportunities to live a vital and engaged
life are lost.
57
SELF-AS-CONTEXT
Questions of self in ACT are often focused on what might be called
fusion with self-as-content. Self-as-content involves strong identification of oneself with prominent contents of consciousness, such as mood,
thought, role, or bodily state. Self-as-context, by contrast, refers to the self
that has experienced every thought, emotion, role, and bodily state you
have experienced. This self is sometimes called the observer self or the
transcendent self.
Of course, there are many ways that we can understand self, including scientific views and spiritual views, among others. In order to understand self from an ACT perspective, one must understand a behavioral
view of self. This view doesnt preclude other views; its simply a way, not
the way, to understand self. From a behavioral perspective, self is not a
fixed entity (Hayes, 1984; Skinner, 1972). Self, or perhaps more properly
selfing, is a particular stream of behavior. As such it is shaped in an
ongoing and dynamic way by the context in which it exists.
Early in life, children make mistakes in distinguishing their own perspective and that of others. Over time, theyre asked many, many questions about their own perspective and that of others. What did you have
for breakfast? What did your brother have? Your sister wants ice cream.
What do you want? Where were you this morning? Whats your favorite
color? Through this series of questions, we learn to answer from a relatively consistent perspective. Like any behavioral pattern, however, its
not entirely fixed. Different contexts can change what we see, feel, and
think, and, importantly, even our sense of identity.
Self is conceived as an ongoing stream of behavior that one is born
in and as being dynamically shaped by that crucible of questions the
answers to which begin with I. A narrow focus on difficult content has
the potential to narrow the breadth of the experience of self. Consider,
for example, an individual with psychosis presenting to a mental health
professional. Almost certainly the three most consistent questions that
the counselor or therapist will ask him will be have you been taking your
medications, have you been having any side effects, and have you been
having any symptoms (for example, hearing voices, thoughts of persecution, and so forth)? If Im the individual with psychosis and my experience of myself is being shaped in a crucible of questions, what self is being
shaped here? Its worth asking ourselves if our focus on client difficulties
contributes to a narrowing of the experience of self. Are we helping to
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What stories do you tell yourself about who you are as you
sit in the therapy room?
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VALUES
Values are understood in many ways in different psychological, philosophical, and spiritual traditions. Values are, in an important sense,
central to ACT. They direct and dignify the difficult work we do. As
we move in the direction of our values, obstacles emerge. When these
are obstacles in the world, we have our life task before us. When the
obstacles are thoughts, emotions, and the like, we have a different sort
of life task. From an ACT perspective, the task is openness, acceptance,
and defusion in the service of movement in a valued direction.
aspects of this definition soon. Just hang tight.) Please, please note here
that Im not asserting that this definition exhausts what is meant by
values in any global sense. Rather this is a way of understanding values
as we use them in ACT.
we would want to live in. We could plan it and begin its construction. We
might make changes along the way. One day we might find ourselves living
in a house that was quite comfortable, one that fit our lives. It would be
odd to ask, Is this my true house? No. Its the house you built. Do you like
it? If not, what would you change? In the case of values, we ask, What is
the pattern I have made? How will I build it from here? There is an active
quality to such a line of questioning and one that is much less likely to lead
to incessant second-guessing about the truth of ones values.
your clinical work. What is it that you value in the work that you do? Or,
said another way, who would you like to be in the lives of your clients? At
workshops, I sometimes ask people to imagine that theyre at the therapist buffet. I then describe the dishes available to them: here we have
lousy therapist, then okay therapist, which is followed by pretty good
therapist, and in this last dish, we have amazing therapist. Which would
you like? Remember, this is a buffet. You can have any one you want.
Sometimes I ask people to say out loud what they want. Imagine what
this would be like for youto say out loud in a room full of therapists
what kind of therapist you want to be. Imagine I ask you to look around
the room, into the eyes of your peers, and then to say to them, I want
to be an amazing therapist. Imagine saying it loud enough to be heard
clearly and unambiguously. Imagine owning whatever comes up. What
do you feel? Can you feel a bit of constriction? A bit of reluctance? A bit
of hesitation? And let me ask the same thing of you right now: What if it
were possible for you to be an instrument of extraordinary change? What
if you could be an instrument of liberation in the lives of your clients? See
if you can feel the push and pull that arises when you consider claiming
that possibility.
As is often the case, poets express these kinds of tensions in ways
that behaviorists and psychologists might not:
Do I dare
Disturb the universe?
In a minute there is time
For decisions and revisions which a minute will reverse.
For I have known them all already, known them all
Have known the evenings, mornings, afternoons,
I have measured out my life with coffee spoons;
I know the voices dying with a dying fall
Beneath the music from a farther room.
So how should I presume?
T. S. Eliot, The Love Song of J. Alfred Prufrock (1991, 45)
Why do Eliots words ring so true over so many years and in so many
lives? And you, do you know something about measuring life out with
coffee spoons? Do you dare? Do you dare? If you can let yourself know
that hesitation, that small tremor, and meet it with equanimity, and
breathe it in and out like air, and welcome it with acceptance and kindness, you might know something of the push and pull your clients feel
around their values.
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This next exercise is a monster. Dont feel like you have to come up
with the right answers. Remember that values are ongoing patterns
of activity. I hope, though, that youll take the time to sit with these
questions.
COMMITTED ACTION
The last of our facets is committed action. Commitment in common
usage is often almost synonymous with a promise made with reference
to the future. While making such a promise might be part of a commitment, such a promise in no way exhausts what is meant by commitment
in ACT.
If we were always moving in a direction that was consistent with our
values, committed action would be synonymous with values. However,
committed action emphasizes the ongoing choosing and rechoosing of a
direction. Committed action, in flight, can be seen metaphorically in a
breathing meditation. In such practice, we choose our breath as a place
to bring attention to bear. Of course, what we find is that our attention
wanders. We begin to think of activities that we need to do later, or
perhaps different pains and discomforts capture our attention. When
we notice this, we may linger a moment. We meet our inattention with
equanimity, like meeting an old friend on the road. Hello, we say. We
let go of our inattention and gently return to our breath. I believe that
the heart of commitment lives in that gentle return.
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What
When
Can you gently return to them? What does that look like
for you?
room, with the client well met. Thats a place where possibilities are
born. We can give birth to that place in our moment-to-moment interactions with our clients.
Before we discuss the means by which we can learn to infuse our
conversations with mindfulness, well examine some technical aspects
of mindfulness in chapter 4. These aspects will be useful both in formal
mindfulness exercises, and, more central to this book, in the exercise of
a particular kind of conversation I call mindfulness for two.
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Chapter 4
Integrating Mindfulness
Work into ACT
Problems get hold of us from the moment we arise in the morning. What
will I eat? What time is it? When do I need to leave for work? What will
my first task be upon arriving there? What projects need finishing? What
meetings do I need to attend? Do I need to pick the kids up after work?
Are there piano lessons or soccer practice? Do I need to stop for groceries? What will I make for dinner? Problem solving is our most prevalent
mode of being. Its no coincidence that literature is filled with exhortations of carpe diem. We very often seem to be carried without much
awareness from one task to the next. And at what cost, this inattention?
Even figured against the events of our workaday livespicking up the
kids, doing the filing, raking the leavesmindlessness can be quite dear.
So what might the cost be of a lack of focused, present attention during
that rare hour each week we spend with a client? What details might
go unnoticed? What unproductive habits might be reinforced? What
opportunities might slip away?
In this chapter, well explore the ways in which mindfulness and
its lack can help and hinder the course of an ACT intervention. Well
examine technical aspects of mindfulness. Ill also provide some working
scripts you can use to facilitate and coach mindfulness. My hope,
though, is that these technical notes will help you develop the sensitivity and facility to construct your own exercises and mindful moments to
generally facilitate mindfulness for two.
our last session with this client. Our minds fast-forward to what we might
accomplish with this session, about a colleague we need to speak to,
about some administrative detail, and so forth. Similarly, our clients may
be trying to remember what they did during last session. They may be
worrying about whether they did their session homework or even trying
to remember what those assignments were. They may still be caught in
the hustle and bustle of breaking away from some activity to come and
meet with us. However you look at it, there is abundant opportunity for
inattention and distraction offered up to our clients and to us before the
start of each session. Mindfulness is a way to disrupt these patterns of
distraction and bring us rapidly into the here and now.
Right now, go to the bottom of this page and read the footnote.1
PLACEMENT OF MINDFULNESS IN
A SESSION
Since our sessions are essentially hour-long conversations, you can easily
see how much opportunity might be lost if half or more of the conversation in the room goes unnoticed. Integrating mindfulness into the session
is one of the best antidotes to this disconnected situation. But how and
where should you begin to introduce mindfulness into your work?
As I suggested above, dropping a small bit of mindfulness in at the
beginning of a session is a great idea. A brief mindfulness exercise prior
to experientially challenging exposure work is likely to facilitate greater
engagement with the distressing object or situation. Even two or three
minutes devoted to simply noticing the inflow and outflow of breath can
make an important difference. Tom Borkovecs work has been very suggestive in this regard. Tom has found that a bit of progressive muscle
relaxation prior to an exposure session causes the exposure to produce
better outcomes (Hazlett-Stevens & Borkovec, 2001).
This makes sense when you consider basic learning processes. We
learn better when were present than when were absent, distracted, or
preoccupied. Humans are great at being physically present but psychologically absent (several of my students have mentioned my capacity for
this). Exposure sessions are, like virtually all of the work we do in therapy,
opportunities to learn new behaviors. In particular, they are opportunities
to learn how to respond to distressing stimuli in new and, we hope, more
adaptive ways. The presence that the initial mindfulness work fosters
makes the goal of learning these new behaviors more easily attainable.
Another very good place for a mindful moment is when we find
ourselves or our clients working very hard. As a general rule, when
you find yourself in conflict, struggling, or exerting a lot of effort, a
mindful moment can help. Things capture our attention. Things we call
problems really capture our attention. Again, there are likely very good
evolutionary reasons for this: we remember very well from our days wandering the savanna that its better to miss lunch than to be lunch.
1
Without looking back, immediately write the words you just read
below. Then go to the footnote at the bottom of the last page in this chapter
(page 96).
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The problem with problems, though, is that they become merely problems. Its the mereliness of our problems and struggles that damns us.
Our problems often insist that they must be dealt with right this moment!
And this insistence can cause us to lose all sense of everything else that
surrounds us. Such a sense of struggle and effort while sitting in a chair is
a sure sign that your mind is trying to keep you from being eaten. When
either you or your client gets into this situation, look carefully around the
room. If you dont see any bears, its probably safe and useful to stop for
a mindful moment. Just let the silence fill in around you and encourage
your client to do the same. Sometimes the most surprising things will
show up in those moments.
I originally started doing this pretty naturally. I wasnt really thinking
in terms of mindfulness. I was just stuck and confused, and I somehow
learned to shut up, sit still, and cease any effort when I didnt know what
else to do. I learned to wait. I learned to practice acceptance. I learned
to let my thoughts run on ahead. I promised them that I would catch up
later (but really I was just shining them on). As I write this, I feel a tug
inside that wants me to write you a list of complicated-sounding instructions about how to do this. But the truth is that I got there by just sitting
still for a while and giving my mind permission to take a short holiday.
It sounds almost too easy, and it can be. But remember that, in the
context of a mindful moment, just sitting still can and should be done
quite intentionally and explicitly. Try it in your practiceeither in your
consultation group or with a client. When you notice yourself getting
busy, ask the client if you can take just a moment to settle. Let the room
grow still for a couple minutes. Get present to something, anything in
the current environmentsound, temperature, muscle tension, or your
breath. When you find your attention coming back to the problem youre
struggling with, notice that, and return gently to whatever it is that youre
focused on. Take a moment. Let the world fill in around you. And then,
having settled, come gently back to the task.
Im often asked about correct placement of these mindful moments.
Really, its difficult to go wrong. Human avoidance is so ubiquitous that
stopping humans at just about any given moment will mean stopping
them when theyre running. I sometimes joke at workshops that I have
a fail-safe detector that can tell me whether a person is in need of a
mindful moment. I then feel the persons wrist. If I can detect a pulse,
the answer is yes. If you really want to get a direct sense of the ubiquity
and automaticity of human problem solving, try what is suggested in the
previous paragraph. You can even try it all by yourself. Ill even make it
formal in an exercise.
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If you found yourself getting busy, welcome to the human race. Minds
hate unemployment. If theres nothing to do, theyre happy to generate
make-work projects. And they dont ask our permission when they do it.
Voice
Your voice is a powerful instrument in your sessions and can be used
to dramatically alter the quality of what you get done in them. You might
think of your voice as the pipe through which your education, clinical
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PACING
In short, go slow. How slow? My own guide is to pace mindfulness
exercises by actually following my own instruction. In the time it takes
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Notice
Speak
Then notice again, just a bit more mindfully
Then speak
Then notice
Speak again
Notice one more time
When I do this, I find that my pace works better for the clients than if
I think explicitly about how long to wait between instructions. I also find
that if my instructions come out of my experience, my pacing improves.
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few. The listener will hang on to the next word. I live in the South and
have heard some extraordinary African-American preachers. These
folks understand the potency of a well-placed pause. Listen to your
favorite music and notice how the pauses draw you forward into the
next phrase in the music. The rests in a piece of music are as important
as the notes. If you doubt this, I invite you to listen to one of those computerized greeting cards for half an hourthe ones that play Happy
Birthday or Jingle Bells in a piercing, computerized loop thats all
continuous music, with no rests or respites. If you do, I suspect youll
agree with me that the pauses between the notes add much-needed
interest to the sound.
How long should you pause? It depends. When Im guiding a mindfulness exercise, Im not in my head counting, Okay, elephant 1, elephant
2, elephant 3thats long enough. As for the general pacing of speech,
I measure the length of pauses by becoming a listener to my own words.
I hang a bit on my next word, listening for it for a moment. When I can
feel a bit of anticipation, I pause just a bit longer and then let the next
word drop. I hold these pauses as long as I can comfortably tolerateand
then I hold them just a little longer. I notice my urge to move ahead. I
will often comment on this urge: See if you can notice yourself trying
to move ahead in the exercise. Then I pause and notice myself longing
to push forward. Once again, the time I take to notice these impulses
to rush ahead will probably give my clients or trainees enough time to
do the same thing. Our natural inclination is most always to move more
quickly than is useful. As a general rule, slow down just a little more than
you think is enough.
A parallel concept to the pause in the spoken word is negative space
in the visual arts. Negative space is that space on the canvas or in the
sculpture that has nothing in it. Balancing positive and negative space
and playing with the two creates interest and draws attention. Novice
artists pay too much attention to positive space (the subject) and not
enough to negative space. Just as an example, in da Vincis painting The
Last Supper, the subjects are bunched together with the exception of
the space just to the right of Jesus. That small difference in spacing has
attracted enormous attention and speculation about the meaning of the
space. Whether or not you think there is any substance for the claimed
symbolism of the space, it is unquestionable that it has drawn extraordinary attention.
Consider the idea of negative space as you construct mindfulness
exercises and briefer mindful moments. A fairly organic way to introduce
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this into your mindfulness work is to take some time to appreciate negative space. Do mindfulness exercises with no one at all in the room.
Instruct your own attention to come to rest on something like your
breath. As you do so, introduce pauses into your speech and then linger a
moment over those pauses. Become interested in them. Attend to them.
Listen to them as if they had a secret they could tell you and then see
what happens. One thing thats likely to happen is that your mind wont
like the exercise. That is fine, and expected. Just persist and attend to
that negative space youre creating.
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The coolness at the back of the throat as air moves into the
lungs
The
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The list goes on. Deep and profound formal mindfulness practice
can center on awareness of the breath.
The same sort of winnowing of more prominent aspects of experience to more subtle ones can be done with tactile sensations. To guide
clients through this awareness exercise, begin by having them notice the
feel of their whole body as they sit in the chair. Then have them notice
the sensations of their feet touching the floor, the places where their body
touches the chair, and the places where their clothing touches their skin.
Have them further concentrate their attention by especially noticing the
marginsthe areas right at the very edge of where clothing touches and
does not touch. Guide them to notice the tiniest details of sensation that
tell them where their clothing touches and where it does not. Have them
trace the edge of these margins in their imagination as they notice the
sensory details along that transition between touching and not touching. These small details, which require a great deal of attention, assist in
bringing intentional, focused awareness to the present moment.
eye.
Notice the place where they touch and the edges of those places.
See if you can trace the outline of that slight pressure with your minds
See that shape of each place where your hand touchesjust breathe.
See if you can begin to notice the tiniest sensations in your handsthe
smallest tinglesfeel the blood moving.
Draw your attention now to your breath.
Take three very gentle, full, mindful breaths.
Notice each small detail, where you notice the inflow and outflow of each
breath.
Now gently, gently let yourself come back into the room.
When you are ready, open your eyes.
Depending on how seriously you take the injunction to make your
pauses good and long, this exercise might take you anywhere between
five and ten minutes. Done with care and intention, it can really transform the feeling of the room and make space where good work can be
accomplished.
INTRODUCING MORE
CHALLENGING MATERIAL
Thoughts, memories, and emotional reactions can be good material
for mindfulness exercises, but beginning with sensory details and then
moving to these more challenging domains is often a good strategy. To
put it in technical terms, with some exceptions, sensations, sounds, and
so forth are likely to carry fewer verbal-evaluative functions and therefore are less likely to generate fusion and avoidance. In other words, the
awareness of the sensation of a chair on the back of the legs or the coolness of the breath on the upper lip are far less likely to be distressing to
a client than, say, evoking the thought of a hectoring boss, a moment of
trauma, or another lonely night spent despondent on the couch.
There are exceptions, of course. Noticing heart rate might be very
loaded for a person with a history of panic, yet for someone with no
panic history, focusing on the heartbeat can be a nice, quiet meditation.
Likewise, a person with a severe sexual abuse history might struggle with
body awareness, but perhaps less so with becoming aware of the variations in temperature of the hands.
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MIXING CATEGORIES TO
DISRUPT CATEGORIES
Another way to disrupt the categorized world is to mix categories in ways
that violate the commonsense properties of the categoriesfor example,
give visual qualities to tactile events. Have your client close his eyes and
direct him to attend to his breath. After he settles a bit, ask him to
imagine that he can see his breath as you might on a very cold day. Ask
him to picture his swirling breath as it enters and leaves his body. Ask
him to let his breath take on colors, perhaps blues and greens on the cool
in-breath and oranges and reds on the warm out-breath.
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Many Gestalt-type imaginal exercises have this quality. These exercises often involve having a client visualize a difficult emotion, then give
color, shape, texture, temperature, and size to the emotion. In the next
chapter, where well discuss ways clients break contact with the present
moment and how to help them come back, well describe the ACT processes through which these sorts of exercises are thought to work and
offer detailed instructions on how to carry them out in the therapy room.
For the purposes of this chapter though, it will suffice to say that these
interventions disrupt the categorized world a bit and make contact with
the present moment more likely.
seek liberation from these constricting forces for the purpose of allowing
us and our clients to live richly vivid and purposeful lives. Ive situated
this personal psychology within a theoretical framework, and Ive either
introduced you to or reacquainted you with some of the basic behavior
principles that can animate and enliven your work with clients. Ive connected ACT to the tradition of behaviorism, and situated the practice
of mindfulness centrally within the ACT process model. And finally,
Ive explored the mindfulness practices and shorter mindful moments,
proposing a technology of mindfulness that can be useful to you in your
clinical work.
So whats next? In the chapters that follow, well take a look at the
specific kinds of opportunities youll encounter in the therapy room for
fostering greater contact with the present moment through mindfulness.
Well also take a look at a field guide that will help you recognize
the telltale signs of mindlessness or a lack of contact with the present
moment in both your clients and you. Well dive into the wild world of
transdiagnostic, hexaflex-oriented case conceptualization. And finally,
Ill share some annotated scripts of several exercises for fostering greater
presence.
In the meantime, though, put the book down (even if you didnt read
straight to here, no ones watching.) Stretch your legs. Take a few deep
breaths. Get some coffee or go for a walk outside.
Whats going on in the world? Maybe the sun is setting or rising.
Maybe your kids are outside playing. Maybe someone you love is watching
TV in the next room. Maybe, even now, your clients are out there somewhere, doing the best they can to live their lives in a way that matters.
Before you go on to the rest of the book, take a moment to sit inside
this question: what is the reading Im doing here in the service of? Dont
struggle for an answer. Just linger in the question. When youre ready,
please join me in chapter 5.2
2
Look at what you wrote. Did you write, Paris in the spring? Now go
back to the text and notice that the word the is repeated in the sentence. This
is an example of the part-attention we often pay to the stream of words that pass
by us every day.
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Chapter 5
COMING TO THERAPY
From an ACT perspective, fusion and avoidance drive a tremendous array
of psychological difficulties. We began this book by taking a hard look at
the ubiquity of human suffering and at the flip side of that suffering
the ubiquity of human problem solving. Our clients come to us because
theyre suffering. Theyre suffering, and theyre also doing something else,
something very sensible. Theyre doing everything in their power to end
that suffering. From an ACT perspective, its not the suffering per se that
takes away from life as much as it is our propensity to resist suffering.
What we ask clients to do in ACT is to let go of wholly sensible attempts
to solve the fundamental problem of human suffering.
And with all this done by a you that transcends the contents of consciousness
Worrying about the future. Worrying about the future is simply the
mirror image of rumination about the past. The worrier imagines scenes
and scenarios and all of the things that might go wrong. The promise
inherent in worry is that if we worry long enough and hard enough and
carefully enough, well be saved from these feared futures.
Worry and rumination to find reasons. Whenever something bad has
happened, theres a strong tendency to find fault or causea reason why.
The guilty must be exposed. Watch a movie, read a book, listen to a
story. Notice how unsatisfying it is when the story or book or movie ends,
and we have no idea who is at fault for the mishap around which the
story swirls. Another reason we strive so hard to find fault is that we live
in a culture that tells us that negative outcomes are often deserved. This
sensibility is so pervasive, there is even a generic name for it in social
psychology: the just world theory (Lerner, 1980). The just world theory is
derived from experimental findings in which people show a remarkable
tendency to believe that, when individuals experience bad outcomes,
they probably, somehow, had it coming to them. When we suffer some
negative outcome, we feel a strong urge to wonder what it is about us that
brought it on.
We like a coherent world, a world that makes sense. If we find ourselves in a bad way, theres a tremendous pull to come up with a reason.
Attributing the bad outcome to some personal flaw (specifically identified or not) at least gives some sense of resolution about why. We like to
know why. Think about how many times you or someone else has done
things after which you were left wondering why. Why did my relationship
go bad? Why am I so stingy? Why dont I ever get a break? Grinding over
such questions again and again can become a lifes work.
If we look at workaday events in the world, well find that searching
for reasons why is often quite useful. If your airline ticket is extremely
expensive and you do some investigation, you might find that traveling
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Storytelling
Our clients dont live in the world directly. None of us really do. We
live in a storied version of the worlda world modeled by the savanna
minds of our distant ancestors, shaped by countless generations of constant fear that we might either starve to death or be devoured by something with sharper claws and stronger jaws than we might ever hope to
possess. Its just a story.
Of course, storytelling isnt a bad thing in and of itself. Youve probably
guessed by now that I love a good story. But theres a version of storytelling
thats indicative of a failure of present-moment processes. I raise this here
because it will appear in session and directly interfere with just about any
intervention you might hope to provide. Storytelling can take a lot of different forms. The invariant and inflexible quality of this sort of storytelling
is the feature that youll want to learn to recognize and work with.
There are several versions of storytelling. Sometimes the stories will
be about negative instances in a clients history that are raised again
and again. These are in-session instances of rumination. Sometimes
the stories will be very proximal and wont involve repetition of longpast personal history. Instead the client may insist on a mind-numbing,
moment-by-moment recounting of every difficulty that occurred in the
past week. In this recounting, the client lists the problems in hope that if
the problems are delivered comprehensively and in enough detail, youll
be co-opted into joining him in the problem-solving task.
Unfortunately, this latter kind of storytelling can, at least initially,
be compelling to us as therapists. In the rehashing of this list of events,
we may be able to find something we can work on. But over time, this
pattern is wearying. There seems to be a never-ending supply of problems. Probably the best indicator of this kind of storytelling pattern is
when we, as therapists, find ourselves wrestling with incredible feelings of
boredom and frustration. (In chapter 6, Ill discuss some ways of dealing
with these, our own failures of present-moment processes.) As with rumination and worry, this pattern brings some relief to the client because he
at least feels as if hes working hard.
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Apologizing
A last indicator of the failure of present-moment processes commonly
seen in session is persistent apologizing. Its ironic that clients come to
therapy and apologize for having difficulties, yet we observe it all the
time. When clients persistently feel the need to apologizefor interrupting you, for being upset, for forgetting to do homeworkits likely that
theyre monitoring their relationship with you very carefully. Persistent
apologies may function to ward off anticipated rejection. To get a sense
of the narrowness of this pattern, try pointing it out. The most common
response will be to apologize for the apologies.
the other. One sure sign than clients are slipping away from the present
moment is the emergence of what I playfully call mind-y conversations. Mind-y conversations are those conversations our clients have with
others (including us) and with themselves that contain a lot of fusion
and avoidance. You can become skilled at recognizing mind-y conversations and how to intervene in them. In the next chapter, well look at
the ways these mind-y conversations can hook you and the work you can
do to open up this bit of inflexibility. For now, lets examine the kinds
of things you can watch for in your conversations with clients that can
indicate mindiness.
learned how to be with anyone. But how can I learn that if I cant keep
a partner? Maybe shell take me backgive me another chance. But
even if she does, I dont know what to do different. But if I dont try, it
will never work. But I dont know what to do.
So the conversation goes, ad infinitum. Sound familiar?
Joe:
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Joe:
I dont know.
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Therapist: Sure. Okay. Just close your eyes for a moment and let
Therapist: Okay, now. Slow down. And breathe. And lets just
Therapist: Okay. And breathe. Can I ask you to just stay with this
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Im needy. A lot of people dont really see it, but I live and
I just have to have the last word. It has cost me a lot over the
years, but I just cant seem to keep my mouth shut.
Im fragile.
Im bossy.
Im ugly.
Im boring.
Im mean.
Im impatient.
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What is it thats wrong with you? Pause and just spend a moment
inside that question. Whats wrong with you? Being weak means being
shunned. Being stupid means being shunned. Being inadequate, boring,
ugly, lazy, jealous, and so forth meanswhat? In the end, these all have
implications for our relationships, for the possibility of relationships, for
the future of our relationships. And all we need to do is look at our past
for that evidence.
What does it mean to our clientsto all of usto live our lives
under this kind of burden?
does it change when the topic gets hard? Listen for patterns in pace that
might be indicative of a response to threat. Sometimes this will take the
form of an almost staccato series of complaints.
Your clients may at times proceed at a pace thats almost tentative.
They may speak in partial sentences or with long hesitations. Another
common pattern in pacing is a somewhat rapid pace, as if the conversation is urgently attempting to get somewhere or away from something.
REPETITIONS IN CONTENT
As I mentioned in the section above on mind-y conversations, youll
often find content that will be repeated again and again in session. Watch
for the emergence and reemergence of these topics and patterns of speech.
Watch for the relative inflexibility of these patterns once they emerge.
REPETITIVE MOVEMENTS
Watch for things like nail-biting, hand-wringing, shifting in the chair,
fidgeting, foot tapping, clenching of jaws, and other small behavioral
stereotypies. Are there times when these are more pronounced, intense,
or driven?
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POSTURE
Often when people are in the throes of strong negative emotion, their
gaze will be downcast, shoulders hunched, and arms and legs crossed and
held close. There are a lot of social contingencies that cause people to
disguise and otherwise downplay the experience of negative emotion.
One way to accomplish this is to get small or to turn away slightly. Gaze
in particular is socially relevant. The social convention when weeping is
often for them to look away, to apologize, and, as quickly as possible, to
attempt to contain that display.
Emotional Tone
Note the emotional tone the client brings to the session. Most frequently the emotional tone will have an anxious or depressive quality.
But its also not uncommon to see an overly casual presentationsort of
an Im fine posture. The critical issue for you to pay attention to is not
the tone as such, but instead the pattern and the relative flexibility you
observe in that pattern.
Here you should be concerned both with transitions to and from relatively narrow patterns. When these patterns change, something in your
clients psychological world just changedremember, this is behavioral
patterning in a context.
The thing that makes human behavior far trickier to monitor than
that of nonhuman species is that the transitions in context among nonhumans are often signaled by apparent and significant changes in the
immediately observable world. Among humans, it can be more difficult
to see what changed. A simple word can call up a rich history. An image
can precipitate a persons worst and most private fears. Very, very often
the precipitants will not be at all obvious. However, if we can see the
transition in the patterning of response, we can know where to begin
looking closelyat the cusp of those transitionsfor the relevant shifts
in context.
Vuille, at the end of a long, hard workshop, told me of a French expression that captures this sense beautifully: la bonne fatigue.
Watch your client when she is anxious in anticipation of an exposure session. You can see vividly the narrowing, inflexibility, and context
insensitivity in behavioral patterning that emerges when the phobic
object is presented. You will be able to observe most if not all of the
indicators described above in a session such as this. Ask your client to
speak, and youll hear her choked voice and shallow breath, the stereotypy in her speech. Youll also see how difficult it is to engage her in conversation. Her exclusive sensitivity to the exposure will be pronounced.
Emotionally, youll see little flexibility. Her facial expression will be constrained and rigid. At the end of a good session, youll begin to see the
complement to that as more flexible patterns of behavior emerge.
In a certain sense, all acceptance and defusion work is kin to exposure. All three involve events that generate narrowness and inflexibility
in responding and insensitivity to shifts in context, except shifts directly
relevant to escape. As you bring your clients into the present moment
with fused and avoided content, as you slow them down and gently
coach their kind and careful attention, youll know that those events are
losing some of their ability to control behavior as the pattern of behavior
becomes more flexible. Youll see it and hear it right before your eyes.
Listen to the voice. Youll hear a softening and increase in the flexibility of tone. The voice will take on a more rolling and fluid quality.
Youll find that it becomes easier to set the pace of the interaction. Your
client will begin to respond to your prompts to stop, notice, and then to
move on. Her ability to appreciate values connected to vulnerabilities
will begin to emerge.
In terms of physical presence, youll begin to see her shoulders drop.
Her nervous movements will begin to damp down. Her breath will
become less strained, easier, more gentle. Her bodily movements will
become more fluid.
Emotionally, watch and youll see your clients capacity to move
among different felt states increase. The end of a really solid acceptance
and defusion session will leave your client able to move between tearful
sadness and easy laughter. Its odd: if you ask a person if he can stop
and notice how frightened or sad he had been at the beginning of the
session, hell be readily able to do so. Hell somehow be in better contact
with himself as frightened, distressed, or grieving, but at the same time,
hell be more hopeful, joyful, and vital. Again, what youll see is a sort of
rolling flexibility in emotional tone.
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Finally, perhaps the best place for us to look for these transitions is
in our own experience in the moment during sessions. Human behavior
is reciprocal, and when we feel our own behavior become narrow and
inflexible, its likely that the client is experiencing the same restrictions.
Even if its not the same aversive to which were responding, we dont
need to know whats generating that inflexibility in the client in order to
intervene appropriately. In the next chapter, well examine the ways that
we therapists lose contact with the preset moment and, of course, how
we can find the way back.
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Chapter 6
The things we look for as we sit with clients are all data. A certain narrowing and inflexibility in repertoire tell us that the client has entered scary
territory. The same principles that apply to clients apply to therapists.
Bob Kohlenberg, founder of functional analytic psychotherapy, made a
great contribution to my training by teaching me that everything that
happens inside your skin in the therapy room is data too (Kohlenberg &
Tsai, 1991). And my mentor, Steve Hayes, who was at the center of my
training as a scientist, taught me that data is always your friend.
same issues we looked at in chapter 5 but from the inside out. That is,
well explore how can you detect and understand disconnection from
the present moment when youre the one whos disconnected. Well look
at the most common manifestations of present-moment process failure
that youre likely to notice in yourselfwhat precipitates them, how to
identify them, and how to intervene. The process issues from the therapists side of the therapeutic interaction dont differ in kind from the
ones on the clients side. One of the radical things about ACT, and really
about behavior analysis, is that you dont need separate sets of principles
to understand client and therapist behavior. The same principles apply
to both. The best way to learn to make any discrimination is through
multiple exemplar training, which is a very technical way of saying that, if
you want to learn a basic principle, watch for it wherever it applies. Its a
mistake to use a principle to understand client behavior and then ignore
what it might be able to tell you about your own.
Its easy for us to assume that if clients are more present, theyre more
likely to profit from their exchanges with the world and the people in it.
If theyre to learn, change, and develop, we take for granted that theyll
be aided by an increased ability to focus attention on their activities. If
learning mindfulness is a priority, we practice these skills with them in
session.
If this is true for them, though, its equally true for us. By increasing
our own ability to focus on whats happening in the present moment,
we can sharpen our clinical skills. Our interaction with clients is a sort
of dance. We may lead, but we need to lead with flexibility, including
the flexibility to know when to give over the lead. We need to determine when its time to intervene and when well accomplish more by
sitting back and listening. Sometimes we need to speed things up; at
other times, slowing down is what the situation demands. In all of these
cases, studied and practiced attention to the present moment is one of
our greatest clinical resources.
Ive described the clients behavior as being in dynamic relation
with the environment. Client behavior is an evolving stream of activitya living, breathing thing. Our behavior is the same. For us, the
client is the central element in the environment of our sessions. To
fulfill our mission in the therapy roomto facilitate our clients change
and growthwe need to make close contact with them, moment by
moment. Like them, well profit the most from our exchange if were
fully present to it.
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were capable of that narrow and inflexible repertoire even when theres
nothing hungry nearby with sharp teeth and claws.
What generates that narrow and inflexible repertoire in therapists? I
would propose that its an alarmingly high prevalence of clientophobia
among therapists. If you work with easy clients, this probably isnt an
issue for you. If your clients come in, present a few problems, seek a bit of
counsel and open discussion, then go home and get their lives on track,
you can skip this chapter. Or, if youre one of those supremely confident
therapists and have a persistently positive view of your own work, this
chapter probably doesnt apply. But if youre like me and often have a
sense of working frighteningly above your capacity, or if your clients are
like my clients, you might want to stick around.
herself on the hands and feet with a small hammer. On one occasion, she
reported to me that she had carved a word into her own thigh. Later still,
she disclosed the childhood trauma.
Over the course of three years of treatment, we came a long way
from that initial, mild, college-student presenting problem. In session,
the work was so painful at times that she would literally howl like an
injured animal. The sound could be heard all over the clinic. And, like
an injured animal, she would frequently lash out. Once, a year or so into
treatment, she was clearly angry at me. I made what was, in retrospect,
a rather ham-handed interpretation suggesting that she was treating me
as she treated her father. She responded, Oh, no. Its worse with you. I
expected it from him.
Clients like this can teach us something valuable. When we sit with
clients who are in such pain that cutting themselves provides a sort of
relief, we dont have to wonder why theyre so frequently referred, overmedicated, and hospitalized. Sitting with someone in that much pain is
painful. These clients are often abandoned by family, friends, lovers, and,
too frequently, by therapists. Its very hard not to. Its hard to sit with
pain, and its hard to sit with slow or no progress.
And when we do leave these folks, we confirm their worst fears and
most certain self-evaluation: that they are fundamentally flawed and destined to die alone and unloved. Even when we dont leave them entirely,
we leave them in smaller ways right there in the room. The pain inherent
in such clients is often compounded by wonderful intelligence, creativity, humor, and passion. Seeing that capacity unrealized makes the work
doubly hard and our own failings doubly painful. Have you failed some
of these clients? Do you know something about that sigh of relief as you
hand them off to another professional?
If theres an afterlife, I suppose that there will be special dispensations for people willing to sit with someone in that kind of pain. Marsha
Linehan, founder of dialetical behavior therapy, has my undying respect
for her devotion to work with folks with this sort of pain. I sat with
the woman I described for three years, so maybe there is some small
dispensation for me.
Of course, all of these things may well be true, but if you found
yourself feeling defensive, notice that youre defending yourself again ink
marks on a piece of paper. Whats there to be argued with? Im not asking
or telling you whom you should or should not see. That wouldnt be my
place. But its worth noticing that even the mention of such clients can
sometimes move us to raise walls to protect ourselves.
spending some time with not knowing which. You should only try this
if youre one of the fortunate in the world who isnt one meal away from
starvation. If you want to see how minds work, heres your chance. Its a
little unfair to minds, so you have to be willing to tease your mind a bit.
But considering the way it has deviled you, turnabout seems fair play. So
far, Ive never heard of a mind dying from this, so you dont have to worry
about your minds tantrum.
And then just sit. Let yourself go quiet. Let yourself come to your
own breath. Settle into your own body, into what it feels like to sit in
your own skin. And watch the objections rise up. Notice your own body.
Notice how intolerant you are of problems (Im hungry) and a solution so
close (a meal before you).
In the end, either eat the meal or wrap it up for later and dont eat.
Let whether you eat or not be undetermined until youre finished with
the exercise. (And notice the huge sigh of relief your mind makes when
you finally choose.) Let me further encourage you to leave the length of
time spent at that cusp undetermined. Notice all of the reactions that
well up as you wonder how long youll wait or if you will eat at all. Notice
how much you want to resolve that before the exercise is over. Notice
how insistent your mind is in the face of the undetermined. Notice how
intolerant your mind is of the unknown, even when the unknown is as
trivial as whether or not you will eat a single meal.
If you actually do this exercise, and perhaps even if you dont, notice
yourself objecting to me. Perhaps youre writing a story in your head right
now about why you dont need to actually do this. Or better still, you tell
yourself, Oh yes, very good, I will do thatlater.
Minds dont like the places in between. This is what T. S. Eliot was
speaking of as the still point. Camus likewise knew this place as
waterless deserts where thought reaches its confines. At that last
crossroad where thought hesitates, many men have arrived and
even the humblest. They then abdicated that which was most
precious to them, their life. Others, princes of the mind, abdicated likewise, but they initiated the suicide of their thought
in its purest revolt. The real effort is to stay there, rather, in so
far as it is possible, and to examine closely the odd vegetation
of those distant regions. Tenacity and acumen are privileged
spectators in this inhuman show in which absurdity, hope, and
death carry on their dialogue (1955, 910).
You can use the little exercise above to take you to a place that
minds will assert does not existthat still point between doing and not
doing. As Camus suggests, your inclinations will be to jump. Youll want
to jump in (and eat). Or youll want to jump out, to retreat (and leave the
table). Or perhaps youll find your mind wandering to other mattersan
endless stream of befores and afters.
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See if you can reflect back on the exercise and notice the relationship between that exercise and your work with clients. Isnt it often our
intolerance of the unresolved that drives us to act or retreat? And dont
we see the same in our clients? Lurching ahead on a new effort to get it
together and by turns retreating again into the house, into the bottle,
into some respite from uncertainty? Moving in either direction can function as a means to avoid uncertainty.
And, looking a bit further still, see if this uncertainty isnt present in
every truly significant value in your life. Consider getting married. How
will that turn out? Consider a career change. How will that turn out?
Consider having children. How will that turn out? And, working with
clients, how do we bind our anxiety when that world gets uncertain? Do
we know in advance how that will go?
Uncertainty lies all about us. We cant eliminate it, but we can blind
ourselves to it. But what if its the case that theres no way to blind ourselves to uncertainty that doesnt also blind us to our values? We can
hide out in certainty, and sometimes we will settle for the illusion of
control. But, in doing so, the beasts dont go away. We just cant see them
anymore. The good news is that for most of us, since leaving the savanna,
the beasts are mostly the psychological variety. Ive never been eaten in
my office, though Ive often feared it.
Camus knew this still place between action and inaction, and he
knew also its remarkable bounty. What freedom would you possess if you
could sit in the face of ambiguity and uncertainty without having to act?
If you could allow yourself to settle in and become intimate with the
odd vegetation of those distant regions? Where terror lives, there is also
bounty. We dont like these places that we dont know, but its in precisely
these foreign places that possibility lives. If there were something possible
for you in those distant regions, would you travel there with me? And
would you travel there with your clients?
independent
of an entirely fused version of who they are and what the
world holds for them. In the last chapter we looked for signs of fusion and
avoidance in clients, and well now look for these signs in ourselves. Well
use the self-as-laboratory.
The first rule is look to your clients. If they look very, very stuck,
check yourself out. Youre likely to find a rich vein of avoidance and
fusion that can be mined. Youll not likely find this data with a smile on
your face. As I suggested, the data is always your friend, but often it does
not look the least bit friendly.
Now for a small pause for values and commitment in the face of
fusion and avoidance: Lets have a show of hands. Everyone reading, hold
up your hand if youd like to discover huge hidden hoards of fusion and
avoidance inside your own skin. Go ahead. Raise your hand. You know
you want to be rich in fusion and avoidance. No? Not so much? Why?
Well, because if we found a huge hoard of fusion and avoidance, that
would be bad. That would be a problem. And then we would have to find
a solution. And so we turn away.
And here we are, you and me and clinicians everywhere, all of us
together, having turned away a hundred times. Why are we here? Take
a moment and think about a client youve had whom you really, really
wanted to help, but whom you losta client who just never moved,
maybe one who left and you wonder about from time to time. Take a
moment and let your eyes close and let yourself see her face. Let yourself
see where she might be, right at this moment. I beg you, let your eyes
close and let yourself see your clients face. See if in that face you can see
the losses shes suffered and the seeds of losses to come. Can you, with
me, just take a moment to breathe that sadness in and out like air? Can
we, in honor of the fallen, let go of any resistance to seeing them and the
costs they paid?
I promise that Im doing so right now as I write this. I can see the
faces. The lost ones. The ones who sat across from me carrying some
small sliver of hope that I could help. And I can see their faces as they
slipped from my grasp. I can see them falling away. Can you? Will you?
Will you let those losses be your touchstone as you open yourself up to
hard material, to the unfriendly data that are nevertheless your friends?
Can we recommit to those folks right now, as if to say, I will not let your
loss be forgotten? I will keep you close as I do my work, to remind me of
why I would do such a hard thing as to look within, to remind me why I
would do such a hard thing as to sit gently in the face of ambiguity and
uncertainty.
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work? Do you find yourself drifting to thoughts of how your clients might
describe you to others?
Seriously entertain the idea for a moment that youre a failure as a
therapist and that even your best efforts will fade to mediocrity. Imagine,
just for a moment, that no matter how hard you study, try, work, youll
never be able to quite get in the room with your clients. Try this thought
on for a moment: Im a really weak therapist. Sometimes I can put on a
reasonable show, but deep down, Ill never be much of a therapist. What was
your reaction to those words? Of course, I didnt ask you to accept the
fact of failure, just the thought, and even that for just a moment. At least
some of our clients will precipitate a sense of failure in us, at least some
time. How busy do you get managing that sense when it emerges?
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BEING BIG
Theres an old saying that the best defense is a good offense. Looking
like youre in charge can sometimes ward off feelings of incompetence,
confusion, or frustration. There are many strategies that can help you
look and feel more in charge: sitting beneath a wall of framed diplomas,
referring to authoritative studies and texts a lot during sessions, letting
your conversation with clients stray to technical topics or analyses of
analysis where you can really let loose with the vocabulary. Somehow our
profession missed out on finding a reasonable excuse for wearing white
coats and stethoscopes. But we have our ways.
BEING SMALL
Although being big in one way or another is a common method of
managing the difficulties faced as a therapist, being small can be equally
protective. There are somewhat fewer strategies available, but you may
find that these fit better with your usual methods of managing anxiety.
You might look for moments when you avoid confrontation or when you
dont say things you think your client will find painful. Watch your voice
for a flat and gentle, nonthreatening therapeutic tone. Take note if you
always find yourself being kind and nurturing, never disagreeing, or never
showing anger.
BEING AN EXPERT
Doing a lot of psychoeducation, holding forth on the theory around
treatment, and explaining the mechanics of a treatment model can be
a great way to look and feel in charge. It puts you on ground that you
certainly know with more depth than the client. On a personal note, this
is my most likely mode of protection. Im prone to going positively professorial in sessions and in supervision. The trouble is that Im often correct
in terms of content (but Im just as often wrong in process), and Ive had
some practice at sounding like I know what Im talking about. And Ive
been doing this a while, so I can go on and on and on. Sigh.
BEING CLEVER
Getting to the heart of the matter and saying it out loud can help
(well, help with feelings of incompetence). A good penetrating analytical
mind can often make sense of whats driving behavior. The trouble is,
often enough, knowing plus a dollar leaves you short of enough money for
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a cup of coffee. Knowing that going outside wont hurt a client and that
doing so will ultimately lessen his feareven if you do a very good job
of communicating this factwont necessarily alter a clients motivation
to leave the house. Being clever can take the form of insightful analyses,
interpretations, and even treatment plans. But absent a connection with
your client, your cleverest assessment or keenest insight might not do
much to move her.
KEEPING IT LIGHT
Some clients protect themselves from hard material by coming to
session and taking about sports, politics, or other issues disconnected
from their own growth and development. Its very easy to join clients
in these conversations. The hour will fly by. A variation on this is the
client who brings in a steady stream of small problems. You can stay
busy putting bandages on small scrapes as the clients life bleeds away
from larger, more central injuries. This is a particularly palatable way of
staying small, since it has the form of doing good. And, by the way, the
same applies to clients. In moving from one small problem to the next,
they get to feel like they are doing good too.
CHASING UNDERSTANDING
Another common avoidance strategy is chasing understanding.
The domination of insight-oriented psychology has a long, long reach.
Psychoanalysis doesnt have the influence it once had in mental health
training, but its residue in the form of prizing insight and understanding remains. This is unlikely to change any time soon. Its deep in the
Western tradition and also in some interpretations of Eastern traditions.
The core idea is that understanding the nature of a thing will allow us
to act more effectively in response to it. I dont believe you can overestimate the pull of understanding. Of course, understanding has delivered
extraordinary gifts.
ACT, however, isnt an insight-driven model. Its not so much that
we dont love insights. We do. Theyre lovely. But we dont believe that
insight drives behavioral and emotional change. Rather, its the other
way around. Check for yourself. Look at insights youve had. See if it isnt
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the case that the insight followed some event or activity that changed
your view.
Some years back, I was at a meeting where the leader asked everyone
in the room to stand up if they were between eighteen and twenty-two
years of age. The group leader went on to say, This is what your parents
looked like when they made those decisions youve been mad about for
the last few decades.
What did I see before me? I saw kids. I saw bright young faces, full
of promise but largely unseasoned by the vicissitudes of decades. It was
somewhat disheartening to find myself, a middle-aged man, blaming kids
for, well, acting like kids. I made a decades-delayed phone call to my dad
after that meeting. Did I have an insight? You bet. But the insight followed the experience of taking a different view.
Insight is the exhaust, not the fuel. Experience is the fuel. Insight was
also not the best thing that came from that experience. The best thing
was a renewed relationship with my dad. The experience had several
outcomes: insight, changes in relationships, and changes in my own view
of myself as a son and as a father, among others. If I could only keep one,
it would be regaining my dad.
Chasing understanding is at such high strength that ACT has a variety
of interventions aimed directly at pursuit of understanding as the royal
road to well-being. Both clients and therapists are steeped in a culture that
teaches us the virtues of understanding and insight. The trouble is that
understanding is so unbelievably useful in so many domains of living.
Understanding aerodynamics has allowed human beings to fly.
Understanding math allows people to keep their checkbooks balanced.
Understanding allowed my fine doctors to treat the cancer that threatened my life in 1998. Understanding is essential in developing a coherent
and useful theoretical account of human behavior.
Its unquestionable that some human suffering arises from deficits
in information and understanding. If someone with diabetes doesnt
understand which foods are and are not high in sugar, she may have
trouble. If someone with an alcohol problem doesnt understand that a
drinkwhether beer, wine, or whiskeyis still a drink, that person may
have trouble. But very, very frequently, people already know as much as
they need to in order to act in a way thats consistent with their values.
How many folks with diabetes know what they should and shouldnt eat
but continue to eat in ways that lead to blindness, loss of limbs, and
death? How many people with drinking problems know that they need
to stop drinking yet drink themselves out of jobs, families, and friends
and straight into graves?
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PROVIDING CONSOLATION
One potential avoidance strategy is providing consolation to clients
who are suffering. Its quite natural to want to console someone in distress. But sometimes when clients are very troubled, we find ourselves
compelled to do so. Sometimes we cant tolerate how we feel when they
feel how they feel. In chapter 8, well use experiential exercises to explore
the strength of that compulsion.
Why would we care? Because sometimes consolation is just what the
client needs, but sometimes consolation can be insulting. When I was
being treated for cancer in 1998, I was very sick and very sad. I couldnt
look at my own children without wondering if they would have a father
next Christmas or just a story about a father. My sadness was quite apparent. I had wonderful medical care. Most of the nurses and doctors who
treated me provided a quiet presence as I sat sad in their offices. With a
few, however, it was very clear that the consolation was really more about
their feelings than mine. They couldnt sit with me, and I didnt want to
sit with them. Their words had the form of consolation, but there was
little consolation in them. Were all susceptible to this, but consider how
powerful it would be to be able to sit when sitting is called for and to
console when thats what is needed.
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Chapter 7
producing
evidence for the treatment of a diagnosis dont find treatment
utility in diagnoses, its suggestive of serious problems with the treatment
utility of the diagnostic system.
Present-Moment Processes
Present-moment processes appear quite dimensional in nature. We
could ask at different points in the day, and from day to day, the extent
to which this is true of ourselves. We would quite likely find that we
vary on this dimension within and among days. If we examine the ways
in which such a presentation can capture clinically relevant phenomena, classic signs of anxiety and depression will be apparent in worry
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Acceptance Processes
Likewise acceptance processes are wholly dimensional. We all, at
least at times, have aversions and avoid in ways that dont facilitate
valued living. We dont raise the price of our services because talking to
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our clients or our boss about our pay makes us feel uncomfortable. We
dont ask someone for a date because were anxious about rejection. We
can assess avoided content and avoidant repertoires by asking our clients
about important valued domains, what they see as major obstacles (possible avoided content), and how they manage those difficulties when they
emerge (possible avoidant repertoires).
Assess content thats unacceptable. Remember, even things that seem
pleasant may take on aversive qualities. Intimacy may be highly valued
and terrifying. Content may take any form. Although experiential avoidance refers to aspects of ones experience that are avoided, you should
also list external events that the client avoids in assessing avoidance.
Often external events are experienced as aversive in their own right.
For example, situations involving interpersonal conflict may be avoided.
Individuals doing so may find that these situations generate anxiety, fear,
and memories of conflict that are also avoided. Remember that experiential avoidance may take many forms. What is the client rationalizing,
tolerating, ignoring, or experiencing with resignation (which sometimes
looks a bit like acceptance but without the vitality)? Where you see these
you will find avoided content. Many of the items listed here will also
be important as potential areas for defusion work. List external events,
bodily states, emotions, thoughts, memories, urges, cravings, memories
that are avoided. Finally, list the personal qualities clients see themselves
as lacking (for example, courage or intelligence).
We need to assess means of avoidance that need not appear to be
avoidant. Avoidance is defined by the extent to which a response allows
the client to avoid, escape, or attenuate the aversive content listed previously. Ask a client how she copes (for example, gets busy, distracts, or
thinks positive thoughts). What clients do when such content emerges
will provide a starting place for our list of avoidant repertoires. Remember,
the form of avoidance doesnt have to look pleasant. Depending on
a clients history, getting angry might help him to avoid feeling sad.
Conversely, getting sad may help him to avoid feeling angry. Avoidance
doesnt even always have to look like avoidance, so things like putting
up with, resignation, tolerating, fighting, and rationalizing might all be
means of avoiding.
Avoidance might also be apparent in the ways that a client relates to
others. Some individuals have learned to use others responses to them to
manage their own private experiences. For example, a clients presentation may implicitly request some particular response on your part. Notice
your own reaction to the client. Do you feel pulled to offer attention,
permission, approval, pity, condemnation, abandonment, or some other
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social exchange? Your experience of being with that client is likely representative of what it is like for others to be with her.
Psychological difficulties like anxiety and depression, for example,
dont exist in a vacuum. As we enter a conversation with a client about
taking valued directions, he will present things like anxiety and depressed
mood as obstacles. Or he will present external obstacles. However, if we
inquire a bit further about external obstacles, we often find experiential
barriers. A thankless husband might be an external obstacle, but we can
go further and assess what experiential barriers there might be to either
really saying yes to staying in the relationship or to saying no, leaving,
and seeking another relationship. Examining experiential avoidance,
both avoided content and avoidance repertoires, within a conversation
about values reminds us of problems as situated in the context of those
values. This makes it less likely that well end up problem solving for
problem solvings sake. It keeps the work contextualized in values rather
than contextualized in the usual flight from problems.
Again, both treatment and ongoing assessment exist comfortably
side by side. Level of willingness to linger in the present moment with
difficult content tells us something about client avoidance (assessment)
and is also simultaneously a sample of treatment for avoidance. The only
particular distinction is that asking a person to linger a moment might
be a brief way to collect a behavioral observation, whereas asking permission, coaching, encouraging, and shaping willingness in a more drawnout way would constitute treatment.
Defusion Processes
When we assess defusion, were interested in life-organizing stories
and in how tightly these stories organize life. Were less interested in
the veracity of the stories, although veracity will be compelling for the
therapist. Were so used to playing the true/not-true game. If a story organizes life in very constrained ways, asking about the truth of the story
is akin to asking, when we see a rat conditioned to cringe when a tone
is sounded, whether the tone is true. Sometimes de-truthifying can
be a good intervention. The bathroom is down the hall to the left, not
the right might reorganize your bathroom-seeking behavior, but most of
our clinical problems are far less likely to succumb to a simple correcting
of information. I know this is repetitious from previous chapters, but the
slope is so slippery, I want to offer extra warnings.
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Were seeking to assess the level at which stories organize life in ways
that inhibit valued livingtypically through loss of contact with other
important aspect of the current life situation. What were interested in
examining is the breadth and integration of fusion. To understand what
is assessed, it can be useful to have a sense of the continuum of fusion.
The prototype case for infinite breadth and integration would be a
case of a very strong delusion. Just for reference, a delusion is the holding
of some belief in the face of strong contrary evidence. I once treated a
fellow who claimed to have been in Vietnam and to have gone behind
enemy lines to assassinate members of the North Vietnamese general
staff and politicians supportive of the North Vietnamese Army. A look
in his records revealed that he had been in the military for a very, very
short time in 1970. Hed had a psychotic episode in basic training and
had mustered out of the military with medical discharge. When asked
about this, he replied, Do you suppose they would put assassin in my
military records? When I mentioned that his mother corroborated the
story, he responded, Yes, the government got to her too.
Of course, such delusions can be wholly impenetrable. Any countervailing evidence is simply rolled into the delusion. In fact, sometimes
strong evidence to the contrary can have a strengthening effect. Suppose
we could extract every Vietnam-era document from the Pentagon and
Department of Defense and there was no evidence for this client as assassin. I suspect the client would say, See how deep the conspiracy runs?
Im just not very lovable. Most people dont see it, but if they
really get to know me, eventually they find out.
Im a big mouth. I always have to have the last word. You just
cant know how many relationships this has killed. Mostly I
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dont notice until its too late. Even when I do, sometimes I
just watch myself walk off the cliff.
ings and other places and I have something to say, but I just
sit there like an idiot and take it. I dont know whats wrong
with me.
Im guilty. Most people dont know the things Ive done, and
how much I dont deserve the things that I have. The people
who do know will never be able to look past them, no matter
what.
Self-as-Context Processes
There are several difficulties well see in assessing self processes. The
most common difficulty will be fusion with self-as-content. Fusion with
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160
Values Processes
There are a variety of difficulties well want to assess in the area of
values. Some clients will present with a very confused sense of what they
value. As we assess using the Valued Living Questionnaire domains,
such confusion will be apparent. Other clients will present with an assertion that they dont care about anything. Ironically, they sometimes
care deeply about not caring. It is ironic, of course, because valuing not
valuing is valuing. Some clients will come to us in a state where some or
all valued domains havent been exercised in a very long time. Among
these individuals, a sense of valued direction may be weak or absent.
Another variation of client difficulties in this area will be clients
who enter treatment with different versions of strongly held values. In
one version, the value is asserted as strong and consistently lived. This
client may confess to an array of difficulties but also assert that shes an
excellent parent. What we want to assess is not so much her goodness as
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a parent as the inflexibility with which the value is held. Note your own
experience as you listen to these assertions. Does it feel as if the person is
trying to justify or defend herself? Does it feel as if shes trying to convince
you? Does it appear that shes clinging to the value like a life preserver,
or holding it gently like something treasured? Another variation on this
theme is the client who has some strong, clear value and also has a strong
sense of not living consistently with the value. Look for the presence of
either struggle or resignation with respect to the value. Sometimes what
were seeing is a sort of defensive valuing. This isnt to say that there isnt
also a deeply felt value there to be lived. However, sometimes we cling to
a value out of fear. Holding values in fear, like any other behavior under
aversive control, is likely to be less flexible and less sensitive to subtle
shifts in context. Over time, most values require flexibility to be well
lived. Assessing sources of inflexibility for potential treatment will not
strip away the value, only the driven quality of its pursuit.
A final variation worth mentioning is the client who has a very
small set of valued domains where there is much thought or activity. For
example, the highly stressed, low-paid, single parent who has narrowed
his values down to work and parentingperhaps regretfully having let
many other areas go. Narrowing of valuing is not necessarily problematic; however, when its done under duress, its worth investigating.
Ask the client to describe domains of valued living as dynamic,
ongoing patterns. Generate short narratives in relevant valued domains.
Linger inside the questions about valued domains before allowing any
answers. Stay in the questions. Again, this is not mere information
gathering. Mindful appreciation is key.
Many of the difficulties described above will arise from values fusion
either directly or indirectly. The markers for values fusion are the same
as the markers for any other form of fusion. Look for a certain narrowing
of repertoire. Look for stereotypies in patterning and content of speech
as you discuss certain values. Probes when values are absent or confused
might include questions like I get that you just dont feel like theres
anything in any of these areas for you, but if a strong sense of value were
to somehow rise up in one of these domains, which would mean the most
to you? You might ask, Was there a time when you did have a strong
sense of valuing in this area? Can you tell me about that? Was there a
time in your life when you thought this would be a lifelong value? When
was that? When did that change? What happened? Do you have any
thoughts or memories about that as we speak of it here and now?
As we do the values assessment, we need to be mindful that it is
not mere information that we seek. We want appreciation more than
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Commitment Processes
Work in this area begins when you assess committed action and the
meaning of commitment for clients. In a world where the client could
make and keep commitments, what commitments would she make and
keep? What is a major commitment he would like to make and keep?
What small but meaningful commitment would she like to make and
keep? Very present-moment focused assessment will be helpful here.
The major problems in the area of commitment processes include
inaction, impulsivity, and avoidant persistence. As with values processes, fusion is a central driver of commitment problems. In fact, its
almost impossible to assess values problems without seeing indicators of
commitment problems. Commitment processes are quite tightly linked
to values processes. This is true to the extent that much of the fusion
we see in assessing values is actually commitment fusion. As soon as
we speak a value out loud, the action implications of the value rise up
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psychologically.
This arising will include both what has been done and
what must be done. A history of difficulty and failure within a valued
domain is very likely to generate fusion and, with it, avoidance. Assess
client stories about commitmentespecially failures, inevitabilities,
or any story that contains a strong sense of limitation or constraint.
Youll find these if you mindfully examine commitments across valued
domains.
Assessment in this area centers primarily around inflexible stories
about commitments, both those made and those missed. Within these
conversations, well find indicators of commitment fusionstereotypy,
inflexibility, and repetition, as well as other markers of fusion and avoidance. We ask clients about commitments theyd like to make and what
they see as obstacles. We ask about what they believe they can do. We
ask about what they wish they could commit to. The target in the area
of committed action is the capacity for defused, accepting committed action. As with values, we seek for our clients the ability to make
commitments that are chosen rather than driven.
where our view of the client and his behavior is so harnessed to the conceptualization that we lose close contact with the client. Understanding
this danger, some therapists resist any sort of conceptualization. Such
a solution puts therapy entirely into the realm of art. Its not a solution
thats conducive to scientific development.
I care about science and am alive today in a dozen ways as the direct
result of the application of science. Im sympathetic to the rejection of
case conceptualization and think I appreciate the downside. But if our
science of human freedom is to move forward, we need to learn to do a
gentle dance with conceptualization. In many respects, this is consistent
with ACT as a treatment model. We dont teach our clients that thoughts
are the enemy. We teach them to hold their thoughts lightly. Thoughts
about clients arent different in kind. Thus, as therapists, we seek ways
to think about our clients, to use those conceptualizations when theyre
useful, and to gently let them go when they arent.
your client remain closely connected to the ACT model. Work with client
struggles is always directed and dignified by valued living. Likewise, progress in ACT is ultimately to be found in increases in valued living.
This interview is in its earliest developmental stages. Because of this,
I recommend that you use it in conjunction with all usual and valuable
assessments that constitute good ethical treatment. The interview does
not, for example, contain a formal mental status examination, although
in my experience its quite simple to assess all aspects of mental status
within the interview. I currently recommend using the interview in conjunction with a good symptom checklist. The interview can be quite
compelling, and I dont want you to neglect screening questions for things
such as suicidality, homicidality, and substance abuse, for example. In
addition, many will use the DSM in treatment environments where syndromal classification is a requirement. I anticipate that many, if not all,
of the data needed for a DSM diagnosis will emerge within the interview
process. Any additional gathering of information should be guided by the
practitioners ethical responsibility to provide sound treatment.
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169
Possibility
Current
Overall
Importance Importance
Action
Satisfied
with Action
Concern
8. Spirituality
9. Community Life
10. Physical Self-Care
(diet, exercise, and sleep)
11. The Environment (caring for the planet)
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12. Aesthetics
(art, literature. music, beauty)
sensationsin your lips, your mouth, the gentle rise and fall of your own
breatheach time you drift, gently returning back to your own breath.
And if you find yourself irritated, wanting to move along, just notice
thatthat pushand imagine that you just gently release that and come
back to this very next breathand this breath.
You should ask the client to keep eyes closed and transition directly
into the following:
Im going to ask a series of questions about areas of life that some people
value. Some of these areas may be very important to you. Others may not.
Some areas you may think, no way! Others will seem just right. Its not necessary that you value all areas. I just want you to listen to the questions and
allow yourself to sit for a moment with each set of questions. Even if the area
isnt one thats important to you, just let yourself be curious about the question. Notice any thoughts, feelings, sensations, or memories that come up for
you and then gently release them. These are important areas of living, and we
dont always pause and give ourselves time to appreciate them. I dont want
you to necessarily answer these questions. Just imagine that these questions
flow over you like water. Just let the questions soak in. If you find yourself
drawing any conclusions, just gently let go of those conclusions and return to
the question.
And as you notice your reactions, let go of the urge to understand them,
to judge them, to grip onto them, or to push them away. When you notice your
reactions, just breathe that experience in, and on the next exhale, slowly set it
aside and see what shows up next.
Family
Lets look at the area of family generallyoutside of marriage and parenting. Ask yourself, if something were to happen in your life in the area of
family, what would that mean to you? What does it mean for you to be a son/
daughter, a brother/sister? What does family mean to you? Listen to these
words and just let yourself settle into each of them, noticing whatever shows
up. [Allow pauses between each word.] Brother, sister, grandmother, grandfather, granddaughter, grandson, cousin, aunt, uncle, niece, nephew, family.
Once again, just allow yourself to settle into those questions. Let yourself settle
into the meaning of these things for you and allow your awareness to stretch
out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
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Parenting
Ask yourself, if something were to happen in your life in the area of parenting, [if the client is not currently a parent, say, even if you arent a
parent now, let yourself stretch out in imagination,] what would that
mean to you? What does [or would] it mean for you to be a parent? Once
again, just allow yourself to settle into those questions, allowing your awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
Work
Next, lets look at the area of work. Ask yourself, if something were to
happen in your life in the area of work, what would that mean to you? Would
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it perhaps mean finding new life in the work you do? Or perhaps is there is
other work youve wanted but held back from moving toward? Whatever it
means, just allow yourself to settle into this question. If something new, something with life could emerge in work for you, what would that mean to you?
Once again, just allow yourself to settle into those questions. Once again, let
yourself settle into the meaning of these things for you and allow your awareness to stretch out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
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Spirituality
Next, lets look at the area of spirituality. Ask yourself, what is the place of
spirituality in your life? Take a moment and see yourself in your spiritual life.
If something new were to happen in your spiritual life, what would that mean
to you? Try this thought: Im a spiritual person. Listen to these words and just
let yourself try each on for a moment: spirituality, sacred, reverence, ritual,
religion, faith, holy. Whatever they mean to you, just allow yourself to settle
into the meaning of these things for you and allow your awareness to stretch
out into the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
Community Life
Next, lets look at the area of community. Community can mean many
thingsyour country, your town, your neighborhood, your church community, a club you belong to. And it can mean many activitiesvolunteer,
neighbor, club member. Ask yourself, what is the place of community in your
life? Who are you in the communities you inhabit? Who would you like to
be or become? Take a moment and see yourself in your community life. Ask,
if something new were to happen in your community life, what would that
mean to you? Whatever it means to you, just allow yourself to settle into the
meaning of these things for you and allow your awareness to stretch out into
the questions.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
Physical Self-Care
Next, lets look at the area of health and self-care. No matter your current
state of health, let yourself imagine developing and growing in this area. What
would it mean to truly care for yourself? Take a moment and try on this
thought: Im a person who takes care of myself. If something new were to
happen in the ways you care for yourself, what would that mean to you?
What would that look like? Listen to these words: healthy, fit, strong, well,
vigorous. Whatever they mean to you, just allow yourself to settle into the
meaning of these things for you and allow your awareness to stretch out into
the questions.
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And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
The Environment
Next, lets look at the area of the environment. Ask yourself, what role does
being a good steward of the environment and of the planet play in your life?
What would it be like for you to work for cleaner air and water, a reduction of
greenhouse gasses, and more conscientious use of our natural resources? See
yourself as a caretaker of the global community. If something could happen
in your life that would make it possible for you to care for the planet, what
would that be?
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
Aesthetics
Finally, lets look at the areas of art, music, and beauty. Maybe you dont
enjoy the arts as often or as deeply as you would like. If you could be a
part of creating beauty in the world, what could that mean for you? Maybe
you would attend more concerts or spend time learning or playing a musical
instrument. If you love literature, maybe you would spend time each week
with a great bookor start writing one yourself. Let your awareness flow
into these possibilities.
And gently breathe. Just settle and allow your attention to come gently to
rest on your own breath. [Pause briefly.]
Let your awareness touch gently each of these areasfamily, intimate
relations, parenting, friendship, work, education, recreation, spirituality, community, and self-care. And now Id like to call your attention gently back to
your own body here in this room right now. In just a minute, Im going to ask
you to open your eyes and take ten minutes to write about what shows up for
you as the most important thing or things in your life, and why this is important and meaningful to you. Write your deepest thoughts and feelings about
this area of living. What you write doesnt have to be grammatically correct.
Dont worry about spelling or even necessarily writing in complete sentences.
Please write for the entire ten minutes. If you cant think of what else you
might say, just write the last thing you wrote over and over until something
new comes up. When youre ready, open your eyes and begin writing.
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HFDEI WORKSHEETS
The HFDEI worksheets are a graphical view of the hexaflex model with
areas to make notes in each facet of the hexaflex. I currently use the
hexaflex for session observation (both live and recorded), for writing case
notes, and, finally, for use in this interview. (Below, and in PDF format
on the disc that comes with this book, Ive included one worksheet that
was used to code the first seven minutes of the video segment Emily
and Kate: Session 2. On the disc, look for the file titled Emily and Kate
2 HFDEI.pdf). Well use these worksheets in the hexaflex diagnostic
interview. Theres no difference in application between coding a segment
of a session, a whole session, or an intake interview, except that ratings of
whole sessions will be more global than you could reasonably make based
on a few minutes of a session.
The worksheet also contains a place to make numerical ratings for
each dimension of the hexaflex. In the examples later in the chapter, I
provide a description of observed behaviors in each dimension of the
hexaflex and a rating of client functioning in each dimension. The
ratings go from 1 to 5, where 1 is given for minimal functioning and 5 is
given for optimal functioning. Youll find both the longer narrative and
a brief version of the anchors for these rating scales. Look at the rating
scales, look at the video segment, look at the sample hexaflex worksheet,
and, finally, look at the case conceptualization below for the worksheet
example. Ive included additional coded hexaflex worksheets and case
conceptualizations on the DVD-ROM that accompanies the book; those
examples analyze each of the six experiential role play segments.
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CASE CONCEPTUALIZATION OF
WORKSHEET EXAMPLE
Look at the hexaflex worksheet and watch about the first seven minutes
of the video segment Emily and Kate: Session 2. Youll see on the worksheet that the therapist has handwritten some reminders that would contribute to ratings on the different facets of the hexaflex. The client in
the video, Kate, is a thirty-three-year-old woman who is the mother of a
small child. Shes a nontraditional college student and reports recurring
problems with depression and anxiety. In the current session, the primary
concern Kate has revolves around a recent experience in a biology class.
She had misspoken in answering a question and felt humiliated in front
of her classmates.
Im not advancing the following observations with certitude. Like
any case conceptualization, this is a work in progress. Some of the hexa
flex coding that follows, I think, amounts to reasonably sound conclusions. Some of it strays into hypothesis or hunches that I think are well
worth probing. Above all, the coding strategy Ive employed is focused
on developing good clinical questions. Good clinical questions make for
good clinical answers.
HEXAFLEX ANCHORS
gestures
facilitate connection with what the current contents express,
on the part of both the client and the listener. Even when the content
is focused on the past or on the future, the client is connected with
its moment-to-moment expression. Speech content is frequently specific and detailed. The client readily provides specifics and details when
prompted, and speech that is uniformly categorical is uncommon. The
client gently shifts attention between aspects of his experience, maintaining or quickly regaining his connection with his experience. The
client is able to identify when hes not connected to his experience in
the present moment, and to precipitate that connection independently.
The client reliably reconnects with his experience in the present moment
when directly prompted. Worry and rumination are rare.
A SCORE OF 3
The client exhibits inconsistent connection with her experience in
the present moment, perhaps having difficulty only when listening or
only when speaking. The pace, rhythm, intonation, volume, or content
of the clients speech may sometimes shift into stereotypy. Instructing
change from stereotypies is possible, but shifts back to sterotypies are
common. The clients posture, facial expression, eye contact, or gestures
sometimes prevent connection with the listener. The client sometimes
has difficulty staying connected in the present moment with expression of content, especially when content is focused on the past or the
future. Speech is frequently categorical and lacking in specific and
detailed content. The client responds to directions to provide specifics
and details, but her speech frequently shifts back to categorical mode.
The client sometimes perseverates on particular aspects of her experience and may sometimes shift attention abruptly, losing connection with
her experience. The client usually reconnects with her experience in the
present moment when directly prompted but rarely notices when shes
not connected. The client is unlikely to reconnect without prompting.
Worry and rumination are somewhat common.
A SCORE OF 1
The client exhibits almost no connection with his experience in
the present moment, either when listening or when speaking. The clients speech almost always takes on marked stereotypy with respect
to pace, rhythm, intonation, volume, or content. The clients posture,
facial expression, eye contact, and gestures almost always prevent connection with the listener. The client almost always has difficulty staying
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connected
with expression of content that is focused on the past or the
future. Speech is almost always categorical and lacking in specific and
detailed content. Response to directions to provide specifics and details
are short-lived, and his speech almost always shifts back to categorical
mode. The client almost always perseverates on particular aspects of his
experience, and shifts are almost always abrupt. The client rarely reconnects with his experience in the present moment when directly prompted,
and may actually become more disconnected. Worry and rumination are
common.
12345
Speech stereotyped and
insensitive to instruction
for pace and content
Physical presentation
adds to connection
Categorical speech
common, details difficult
to elicit
Categorical speech
5 uncommon, details
readily elicited
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A SCORE OF 3
The client describes and experiences himself in a variety of ways
but frequently becomes attached to particular diagnoses, symptoms,
thoughts, emotions, positive or negative self-evaluations, social roles,
personality traits, physical characteristics, or other conceptualizations,
especially when content is difficult. The client sometimes has difficulty
transitioning among content areas as the situation demands, even when
prompted, and may act ineffectively in certain situations as a result. The
client rarely contacts a sense of himself apart from self-conceptualizations.
The client sometimes allows conceptualizations of himself to limit activities. He can take different perspectives with difficulty when prompted
and rarely takes different perspectives spontaneously.
A SCORE OF 1
The client describes and experiences herself in very limited ways,
and repeatedly becomes attached to particular diagnoses, symptoms,
thoughts, emotions, positive or negative self-evaluations, social roles,
personality traits, physical characteristics, or other conceptualizations
with little or no awareness of self independent of that which is currently
occupying her awareness. The client rarely transitions among content
areas as the situation demands, even when prompted, and often acts
ineffectively as a result. The clients activities are severely limited by
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conceptualizations
of herself. She cant take different perspectives even
when prompted and doesnt take different perspectives spontaneously.
12345
Experience of self
constrained and in only
limited domains
Experience of self
5 flexible and broad
Transitions easily
among content areas
No experience of self
apart from content
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A SCORE OF 3
The clients experience of events is sometimes limited by particular thoughts, beliefs, emotions, and evaluations that dominate control
of her behavior. This domination isnt experienced as chosen. Stories
about how the world is (for example, about the future, the past, others,
or relationships) are sometimes held rigidly. Stories are sometimes rigidly
repeated, but the client moves to another topic or aspect of experience
when directed. She sometimes uses exclusive language such as must/
cant, should/shouldnt, always/never, or right/wrong, especially in the
face of difficulties. The client sometimes judges, justifies, or explains her
behavior. She shows occasional sensitivity to the workability of beliefs
but is frequently sensitive only to the true/false aspects of belief. The
client approaches new experiences with relatively rigid expectations and
rules for behavior, which sometimes persist even if they arent consistent
with the new experience.
A SCORE OF 1
The clients experience of events is almost always limited by particular thoughts, beliefs, emotions, and evaluations that dominate control of
his behavior. This domination isnt experienced as chosen. Stories about
how the world is (for example, about the future, the past, others, or relationships) are held rigidly and often repeated. The client doesnt move
to another topic or aspect of experience, even when directed. There is
much use of exclusive language such as must/cant, should/shouldnt,
always/never, or right/wrong, especially in the face of difficulties. The
client frequently judges, justifies, or explains his behavior. He shows little
or no sensitivity to the workability of beliefs and is sensitive only to the
true/false aspects of belief. The client approaches new experiences with
rigid expectations and rules for behavior, which persist even if they arent
consistent with the new experience.
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12345
Single aspect of
experience dominates
without choice
No single aspect of
5 experience dominates,
except by choice
Frequently judges,
justifies, or explains
Chooses assumptions
5 strategically, with a
focus on workability
A SCORE OF 3
The client sometimes embraces the full range of experience, but this
may occur only with direct instruction, for a limited amount of time, in
particular situations, or for less difficult experiences. The client sometimes
attempts to change the frequency or intensity of associated bodily states,
emotions, thoughts, perceptions, urges, cravings, or memories. The client
sometimes insists that an aspect of experience thats difficult must be
eliminated, or conversely that some desired state must be obtained. The
client experiences and describes difficult experiences, but sometimes in
a manner thats minimizing, rationalizing, or otherwise disconnected.
The client engages easily and openly at times, but at other times presents
implicit requests for attention, permission, approval, pity, condemnation,
abandonment, or some other social exchange. The client reports some
internal or external events that he isnt willing to experience. The client
may choose some difficult experiences, but this is sometimes in the form
of tolerance or resignation rather than acceptance. The client usually
opens up to his experience when directly prompted, but rarely notices
independently that hes engaged in avoidance.
A SCORE OF 1
The client rarely embraces the full range of experience and never
or rarely without direct instruction. The client often attempts to change
the frequency or intensity of associated bodily states, emotions, thoughts,
perceptions, urges, cravings, or memories. The client frequently insists
that an aspect of experience that are difficult must be eliminated, or
conversely that some desired state must be obtained. Difficult experiences are often described in a manner thats minimizing, rationalizing,
or otherwise disconnected. The client rarely engages easily and openly,
often presenting implicit requests for attention, permission, approval,
pity, condemnation, abandonment, or some other social exchange. The
client reports many internal or external events that shes not willing to
experience. The client rarely chooses difficult experiences, and when she
does, it almost always takes the form of fighting, tolerance, or resignation rather than acceptance. The client rarely opens up to her experience when directly prompted to do so and may actually become more
avoidant.
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12345
Attempts to change
experience common
Minimizes or
rationalizes difficult
events in session
Describes and
5 experiences difficult
events in session
5
5
Attempts to change
experience rare
Chooses difficult
5 experiences in service
of valued living
No change or more
avoidant with direction
A SCORE OF 3
The client chooses direction for her life, but this is sometimes limited
by what is perceived as possible or painful. She expresses a sense of
vitality and purpose in values but is less likely to do so when describing painful events. Values are sometimes held defensively and rigidly,
even when doing so has negative consequences in other domains of
living. The client notices and describes a somewhat limited number of
behaviors that could be chosen in service of a valued direction. The clients behavior varies in how consistent it is with pursuing this direction,
and is often inconsistent when outcomes are expected to be difficult or
unknown. The client sometimes describes her chosen values and degree
of valued living with limited openness, as evidenced by judging, justifying, explaining, or apologizing. The client sometimes experiences her
values as facilitative of experience and but also frequently as restrictive
or burdensome. When directly prompted, the client can sometimes let go
of limitations and make contact with values in an undefended wayher
stories loosen and she shows lessening signs of fusion and avoidance.
A SCORE OF 1
The client rarely chooses direction for his life in an active and flexible way. Most valuing is described as driven by circumstances and much
less by personal choice. He professes no sense or a weak sense of valued
direction; describes valued domains with rigidly held preordained conclusions about outcomes; or professes strong confusion about values. All
of these presentations are held rigidly even when directly probed. The
client expresses a sense of hopefulness and direction in values almost
exclusively when things are going well. This sense of direction is readily
lost when hes confronted with painful events. When values are held, they
are almost always held defensively and rigidly. Behavior shows insensitivity to costs in other domains of living. The client resists discussions of
values and does so only with excessive judging, justifying, explaining, or
apologizing. He almost always experiences values as restrictive, burdensome, impossible, or confusing, or with rigid enthusiasm.
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12345
Valued directions rarely
chosen, and limited by
possibility and pain
Valued directions chosen
with defensiveness
Valued directions held
at the expense of other
domains
Few behaviors described
as values consistent
Valued directions
5 chosen freely, regardless
of possibility or pain
Valued directions
5 chosen without
defensiveness
A variety of behaviors
5 described as values
consistent
Behavior consistent,
even when outcome
5
unknown or expected
to be painful
Discusses values and
valued living openly
Experiences values as
aversive and restrictive of
experience
Experiences values as
5 appetitive and facilitative of experience
that are experienced as consistent with her values. The client can see
and select from many potential goals, both small and large, that are consistent with her chosen life direction. The client notices when her behavior is inconsistent with valued directions independently and without
defense, and returns gently and with intention to commitments. The
client is responsive to direct instruction to notice inconsistency, and is
able to sit undefended in the face of inconsistency and return gently and
nondefensively to commitments when necessary.
A SCORE OF 3
The clients behavior in valued domains sometimes involves attempts
to relieve difficult thoughts and feelings through inaction, impulsivity, or
persistence despite ineffectiveness in pursuing values. Periods of inactivity are sometimes followed by activity that serves to undo and defend
the client from periods of inactivity. The client sometimes responds to
disappointing or frustrating outcomes by questioning his values or capacity to commit, and has some difficulty generating goals that are consistent with his values. The client can sometimes generate an array of
goals small to large, but at other times becomes attached to particular
forms of behavior as the only goal consistent with his values. The client
sometimes notices when behavior is inconsistent with valued directions
independently but may be somewhat defensive or, by contrast, ruminative about failures, making it difficult for him to return to commitments,
even with instruction.
A SCORE OF 1
The clients behavior in valued domains is almost always dominated
by attempts to relieve difficult thoughts and feelings through inaction,
impulsivity, or persistence despite ineffectiveness, or by lurching into
periods of activity. She may actively avoid making commitments or speak
about commitments in the language of must/cant, should/shouldnt, and
never/always. She has great difficulty generating goals that are consistent
with her values. The client is unable to generate a range of large and
small goals, and experiences the goals she does generate as the only goals
consistent with her values. The client is frequently insensitive to times
when her behavior is inconsistent with valued directions or she becomes
rigidly fixed on her failure to maintain commitment. Direct instruction
to notice the inconsistency and return to valued living is usually unsuccessful and may actually bring the client further away from valued living
by precipitating rumination and worry.
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12345
Behavior in valued
domains characterized by
1
avoidant inaction, impulsivity, or persistence
Difficulty generating
goals, and goals limited
and inflexible
Rarely notices
inconsistency of behavior
with values
Notices inconsistency
5 of behavior with values
Returns to valued
5 direction with
instruction
Little or no
5 rumination about
commitments
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Chapter 8
Simple information about what keeps you and your clients from the
present moment is of extremely limited use. Before jumping from a boat
and swimming to shore, you might know that you need to learn how to
swim. However, knowing is not swimming. Swimming comes from practice at swimming.
interactions, are central to the doing of therapy, this might be the most
important chapter of the book. It contains far less information than any
other chapter, but far more training experiences that provide a place to
put those principles into practice.
What follows is a series of three exercises. They begin with a very
simple one, Sweet Spot, in which the content is pleasant and your activities are pretty limited. The next exercise, Client Descending, involves
painful content but still a quite limited set of activities. Finally, Ill introduce the Experiential Role Play, where the content is difficult and the
interaction is decidedly more complex. Ill describe several variations on
the Experiential Role Play Exercise, including its use as a way to learn
and do case conceptualization in an experiential context. All of these
exercises require at least one other therapist. Ideally, youll have a total
of three or four therapists working together in order to get the most from
the Experiential Role Play.
Its fair to warn you that you wont like the restrictions I place on
your behavior during these various exercises. The exercises are a special
preparation that makes processes apparent that are typically invisible to
us. Just as in medicine, where tissue stains and dyes can sometimes bring
physical features into high relief, these exercises are designed to bring
psychological processes into sharp, bold resolution.
For example, in Sweet Spot and Client Descending, I impose turn
taking, and silence for the partner whos not speaking. Theres no
question-and-answer exchange allowed in these two exercises. Likewise,
I restrict other nonverbal social exchanges, such as nodding and smiling.
I also restrict problem solving in both of these exercises. Finally, Ill
impose hesitations and silent pauses into the exchanges. In the third
exercise, the Experiential Role Play, I allow questions and answers, but
I enforce adherence to the assigned role (either therapist or client) and
restrict stepping outside of the role during the exercise. I also impose
periods of silence.
I promise that youll find these impositions intrusive and uncomfortable. And I implore you to hold to them. If you dont for some reason, a
good deal of the exercises potential for instruction will simply vanish.
These role plays have been road tested on literally thousands of therapists and will do their work. Try the exercises as described. Hold to the
structure of the exercise. If you find over time that you wish to modify
them, feel free to do so, but give them a try as is before you do.
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notice yourself making a grocery list while doing sitting meditation. Your job is
to notice that and then gently come back to your breath.
Here youre just giving voice to this sweet moment, letting it pour from
you. Just like you took a glass of water and let that water pour out. Just like
that. If theres any effort involved, just notice your efforting, and just let yourself go silent and come back to giving expression to your sweet moment.
Your partners job is to appreciate. And for appreciators, the pitfall is trying
to understand. And another pitfall is trying to make sure that the expresser
understands that you understand. Appreciators will want to nodlike I get
it, Really, Right. Because think how uncomfortable the expressers would
feel if they didnt get that you got it. You know, here they are telling you about
this wonderful thing, and it just goes in one ear and out the other. How awful
would that be for them? So youll feel inclined to solve that problem by reassuring them that you understand.
I want you to notice how much you feel like you have to nod and smile.
Theres nothing wrong with scratching if you have an itch. But theres something that shows up in a meditation if you dont itch that scratchif you just
notice it, if you say yes to it. So Im going to ask you to just say yes to these
things that will show up for you.
You might say to yourself, I dont know if I really get this. And then youll
try to noodle it out. If you find yourself efforting and trying to understand,
just notice that. Notice the efforting and then gently bring yourself back to
the person whos sitting across from you. Just like watching a sunset. You
dont need to evaluate it. You dont need to understand. How many people
understand the physics of light refraction? Not so many. But are you able to
appreciate a sunset? Sure.
Im going to ask you to go silent. No talking in between here. We can talk
later. Just sit and be with the person across from you. After a while, Ill ask
the next person to go. When I do, you just switch jobs. Then Ill ask you to go
silent again. I dont want any conversations to intervene here. Ill ask you to
just sit with the person for a moment. Then Ill ask you to acknowledge your
partner and well come back together again.
Okay, so lets occupy the room.
Now during this session Im going to be coaching you. I can almost assure
you that another problem will occur. Youll think, Gee hes annoying. I was
really doing well here, but now hes bothering me. If you notice that, just notice
it and come back to your task. Im going to ask you to stop talking at certain
points, but you wont be done, and that will present itself as a problem. I want
you to just notice that and come back to your task. So if youre expressing and
I ask you to stop and let yourself grow silent for a moment, and you notice the
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thought But Im not done, then just notice that and let the expression continue
even though the words stop.
Allow yourself to sit comfortablymaybe with your feet on the ground.
You wont need any paper of pencil or anything like that. Just gently, gently let
your eyes close.
Id like you to begin by noticing the different sounds in the room. Imagine
that you have a sort of checklist. Begin with the most prominent sounds, and
just as you notice them, imagine that you check them off the list. See if you can
listen for smaller more subtle sounds. You might hear the sounds of vehicles
outside, the sound of a jackhammer. If you listen carefully, you might hear the
sounds of people around you. Breathe.
Begin to draw your attention to your own body. Slowly begin to notice
the place where your body makes contact with the floor, with the chair. And
breathe. Notice especially the little places where you can feel the transition in
that contact, the very edges of the place on your back thats touching the chair.
See if, in your minds eye, you can trace that very edge. See if you can begin
to notice the very small details in sensation that tell you this part is touching,
that is not. And breathe.
And now Id like to draw your attention to your own hands. Id like you
to start to notice the temperature of your hands. Maybe you can notice that
some places on your hands are a little warmer than other places. See if you
can notice the little details of sensation of those transitions from places that
are little warmer to places that are a little cooler on the skin of your own
hands. And breathe.
See if you can notice the sensation of your blood pulsing in your hands.
Notice just where in your hands you can feel that. Now Id like you to take
just a couple of nice slow breaths where you notice the details of the inflow
and outflow of your own breath. Let your lungs fill completely and empty
completely.
Now Id like you to imagine that in front of you there is a file cabinet.
Now imagine that you open the drawer and reach in and withdraw a picturea picture of you during that sweet moment. Let yourself draw that
picture up from the file cabinet and feel it in your hands. Let yourself look into
that face of yours in that picture and let yourself notice the details surrounding
you. Notice the look on your face. And now I want you to imagine as if your
awareness were some sort of liquid that could be poured into that you in that
picture. So imagine that now you are beginning to pour into the skin of that
you in that picture at that very moment. See if you can let yourself emerge in
that place at that particular moment. You can imagine opening your eyes in
that place and kind of let yourself see what you see there. Let yourself notice
the sensations that you feel on your own skin in that place. If youre outdoors,
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perhaps you feel a slight breeze. If youre with someone, you might feel the
warmth of his skin against you, the scent of her hair. Let it be as if you could
just breathe that moment in, as if each breath just filled you with the sweetness of that. Let it be as if every cell in your body can feel what it is to be in
that place.
Just take a moment to luxuriate in that presence. And now Im going to
ask you to gently, gently let your eyes open. I dont want anyone to speak yet.
Let yourself look into the eyes of that person who is sitting across from you
and let yourself notice that there is a person sitting right across from you who
has known sweetness. Just look into those eyes, and see if you can see not the
person present but the person who has known sweetness behind those eyes.
Now the person who is going to go first, I want you to just gently let that
sweetness fill you up slowly like some liquid, and when youre ready, I want
you to gently, gently begin to speak and give expression to that. Let the person
across from you hear, feel, and see that sweet moment. Stay with it. The
person who is appreciating, there is something there. Just notice the color and
nuance of it.
[Expression begins.]
Now Im going to ask you to gently grow silent, but see if you can just
let that sweetness continue to pour from you. Look in these eyes across from
you. Now were not going to switch yet. Im going ask the same person to start
speaking, but before you start, I want you to notice if there was any urgency
to explain yourself, any push, any effort. Ill ask you to gently notice that and
let go of that effort. And the same person again just gently come back to that
expression. Just let it come from you. Just let it flow.
[Expression resumes.]
Once again, gently, gently let yourself go silent. Look once more into the
eyes of the human being across from you who has known sweetness. Now Im
going to ask you to gently close your eyes for just a moment. The person who
was appreciating, Ill ask you to recall that sweet moment of your own. Just let
yourself see it. And let yourself be poured into that moment until you can feel
it in your very skin and your breath. And then, when youre ready, just gently,
gently open your eyes and look into the eyes of that human being across from
you. I want you to go gently as if you were walking through a forest. If you
walk very quietly, you might see things that you would miss if you hurried. So
in the gentlest way you can, just let that sweet moment be expressed.
[Expression begins.]
Now Im going to ask you to pause. Just let that sweetness fill you. Let it
pour from you with no words. Listeners, stay with your partners eyes. There
is a person there who has known sweetness right there. There she is. Then
Ill ask you to gently come back to the task. Just let it come. If you notice any
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effort at all, see if you can let go of that. And if youre appreciating and you
find yourself trying to understand, see if you can just let go of the trying and
just let the moment be poured forth into you as if you are a vessel. So gently
come back to it.
[Expression resumes.]
Ill ask you to just gently, gently let yourself grow silent. Just take a
moment and look into the eyes of that human across from you. Look at the
person behind those eyes who has known sweetness like you, who has known
life. Just look a moment into those eyes. Behold.
[Pause for a few moments.]
Now gently acknowledge your partner, and well start our debriefing.
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Let each breath invite you to notice your own body, your own person, sitting
right here, right now.
And if you find yourself getting ahead, just gently, gently come back to
the sound of my voice. Let your breath invite you back into this moment. And
then follow the next instruction that I ask of you. And breathe.
And Id like you to imagine now that, in front of you, theres a file cabinet.
Before you reach for it or open it, I would ask that you call to mind a client
who youve worried about, a client who maybe youve wondered whether you
could helpperhaps a client that you go home on weekends and you wonder,
is this one more weekend he spends in isolation? Will you even see him the
next week? Will he give up? Will he give up on you? On himself? And just let
yourself breathe then in and out for a moment.
And Id like you to let that file cabinet before you fill with photographs of
that client. And Id like you to imagine that you reach out so that your hand
just barely touches the handle of that file drawer. And let yourself feel your
fingertips, as if they were just barely touching the drawer. And breathe.
And let yourself know what is in that drawer. And gently, gently draw the
drawer open, and allow yourself to hear the sound of that drawer slide open.
And breathe. And imagine that you could reach in, toward the front of the
drawer, and place your fingertips on a photograph. Ill ask you to imagine that
you draw that photograph out of the file drawer. Listen to the sound of it as
you draw it out. And then allow it to come to rest in your lap. And let your
eyes begin to move across that image. And Ill ask you to let yourself see, to
let an image form there of your client as he is right now. It could be a picture
of him somewhere in his life or in your office. And let yourself see, in that
picture, the way that client holds his body. Is there tension in his body? Does
he look closed off? Or does he in some way look as if people might walk by him
and not even notice the sort of suffering that he has? But Ill ask that you let
yourself see that.
So let your eyes linger on that clients face and see if you can see in that
face, in those eyes, that person. And see that struggle that others may not see
but that you know about. And just take a moment and let yourself breathe
that struggle in and out. You can hear the echoes of it, maybe, from the sessions youve had. Hes begged you for answers. And see if you can see that
longing in that face. What is it that he hopes for in his life, if he were capable
of hoping? What does he long for? Can you let yourself see that?
And I want you to begin to notice how much you want to be able to reach
in there and help him, to reach in and make a difference for him. And let
yourself just breathe your own longing in and out like air. And Ill ask you, beg
you, to let it be so that no matter what you do, no matter how hard you try,
that helping him is beyond your grasp. Like someone falling down the stairs
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whos just out of reach. Where you reach out toward him to stop that tumble,
but you cant quite reach far enough. As if, when he begins to fall, you can
see that look in his eyes reaching out toward you and knowing that theres no
reach quite far enough.
Just linger at that cusp right there. Let yourself look into those eyes that
have that longing. Dont turn away. Just let yourself rest there for a moment and
breathe that longinghis longing and your longingin and out. And breathe.
And take one last look at that face, and allow that picture to be lifted
from your lap. And one last look. And let it drop gently, gently into the drawer.
And then I want you to just rest a moment and let what you just saw gather up
around you. Let yourself breathe in and out your own powerlessness. Maybe
your own insecurities about whether you could make a difference.
And then Ill ask you to reach in again, and Ill ask that you pull a photo
out that is ten years from this day. And if youre afraid this client is going to
die, I want you to let him still be alive. So, if hes someone who wants to die
now, let it be that that wanting to die just stretches out for ten more years, and
he carries that weight.
And draw that photograph of him out of the file drawer, and let yourself see
in that photo, as you carry it gently to your lap, what that face looks like after
ten more years of paying that cost. No one wants to look at him, but would you?
Let me invite you to just breathe him in and out. Let yourself see what ten more
years looks like written on that face. Linger on those eyes for a moment. Let your
awareness stretch out into his life and see all the costs that hes paid over those
ten years. Are his children lost to him? Partners? How many nights and days has
he spent alone? Let yourself see in those eyes that person who hoped something
could be different but maybe knew that it would go just like this.
Let yourself imagine it was as if you could reach out toward him, to stop
that tumble, but no matter how far you reached, no matter how hard you
tried, you couldnt prevent that tumble down. And breathe gently.
And if you notice yourself wanting to turn away, just gently turn back
and let yourself look into those eyes and see those costs written in his eyes.
And breathe.
And I would like you to just imagine now that you take one last look at
that image and let it slip gently. See if you can notice that you almost dont
want to let him go. But Ill ask that you do let him go and let him slip, slip back
into the file drawer. And let yourself feel the weight of those ten years of costs.
And breathe.
And now Im going to ask you to reach far, far back into the file cabinet.
And Im going to ask you to pull a photograph from the back of that cabinet
that shows that client on the very last day of his life, in his last hour. Let yourself draw that photo gently up, and bring it to your lap, and cradle it there. See
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if you can hold that photo as if it were on the most fragile sort of paper. And
let yourself look down into that face that has known a lifetime of costs. Let
yourself see that person as he takes that last hour to look back over his own
life at the things he had hoped for. There it is in his face. How many days has
he paid that price?
See if you can remember back to when you had hoped to reach in there,
how much you had wanted to make a difference for him. And let it be so that
no matter what you did, no matter what you said, that he slipped away and
found himself on that last day. How empty is that life? How painful? And how
it is written in those eyes?
And Ill ask that you honor him by being present in his last hour. Just let
that last hour saturate you, so that when he passes, someone will have known.
Someone will have known, someone will have cared to know. Would you be
his witness so that when he passes, someone knows? And breathe, breathe.
And as you breathe, just see if its possible for you to say yes to that suffering. To just allow it to be there and, for just a moment, to let go of the struggle
with that. To just let it saturate you.
And now Ill ask you to take that photo, and with the most gentleness
you can bring to it, take one last look at it, let yourself look one last time in
those eyes so that someone saw them, and let it slip gently, gently back into
the drawer. And place your hand on that drawer, and let yourself notice that
sound as the drawer goes gently closed and comes to a stop.
And Ill ask that you take a moment to just breathe in and out what you
saw. See if you can let go of any struggle with that for a moment.
Im going to ask you in a moment to open your eyes, and when I do, Im
going to ask that you listen to my coaching. And what I would like you to do
is this: dont explain the concern you have but let it be expressed as gentle as
water being poured from a jar. So if you find yourself trying to get it right or
make sure the other person understands, I want you to honor that person you
witnessed by just gently coming back to giving expression to that concern that
you carry and to that decline that you saw. Let yourself be the voice for that.
Im going to give you just a moment to linger and be saturated by what
you witnessed. And in a moment, Im going to let you open your eyes.
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been an instrument to her, to make a difference to her. See if you can let
yourself feel sorry for that. Then gently, gently let that clients photo slip back
into the file cabinet, and just linger for a moment with your hand on top of
those photos, breathingand gently let the drawer slide closed, listening to the
sounds as it slides closed.
Now imagine that youre in the therapy room, and that it is some time in
the next week, and that this client is sitting across from you, as she is right now.
If its a client you dont see anymore, let it be as though she has returned. Picture
her forming up in the chair across form you. Observe how she holds herself, how
she shapes her body as she sits in the chairand breathe. Let your eyes come to
rest on her face. Is she turned away from you, toward you? What is the look on
her face? Does she look sad, happy, angry, or bored? Just let yourself notice the
details of her face: the way the hair lies on her face, her eyes, her breathing. See
if you can look into that face and recall that person on the last day of her life,
and see if you can see those costs in that facethe price that will be paid. If you
looked into that face, you could see her own fear of the course her life will follow.
Notice your longing to make a difference, to reach out to her.
Take a moment of silence. Just be a witness to this client and her struggle. Just gently be a witness to that, as if you were watching a painting or a
sunset.
Now imagine that your awareness is like a liquid, and you can be poured
into the client. Your awareness is like water, and you begin to become aware
from the inside of what she feels like. Let that awareness gently fill her body and
beingto feel that the way she shapes her body shapes your awareness. Feel it
pull and twist at you so that the shape of that clients body, the way she holds
herself, starts to shape you. Let that awareness fill you and fill you, so that you
start to feel from within her skin what its like to sit in that room. Let it fill you
and fill you right to the top of your head. See what its like to be sitting across
from that therapist. What is it like to be sitting across from him? How do you
feel toward that therapist? Will he help you? Will he hear you? Can he possibly
know what its like for you? Let yourself breathe that therapy room in and out
with your clients breath. Let yourself breathe the air she breathes.
[Pause.]
Let the words drop away, let your eyes close for just a moment. See if you
can just feel the quality of the interaction so far. Notice the pitch and pace. If
youre the therapist, notice whats tugging and pulling at you. Are you trying
to get it right? See if you can get a feel for the way the client feels, for what
words shes usingalmost as if you can hear a faint song in the background.
If youre a witness, see if you can let yourself notice the client and the therapist,
the qualities of their interaction. Like a naturalist, stop, watch, and listen.
Therapists, if youre working hard, just let go of that. If youre the client, see
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if you can feel what its like to be that person. Be true to the client. Fight for
her experience in the therapy room. Breathe. When youre ready, let your eyes
reopen and rejoin the therapeutic interaction. Give yourself a chance to meet
that client; give the client a chance to be met.
And once again, let yourself pause. Let the words drop away and let your
gaze fall to the floor. Just let all of that experience sort of gather around you, as
if your awareness could come to light on one aspect of the experience and then
another. Without doing anything with it, notice anything you want to do something with. Let this go and just be a witness to that experience. Let all those
pushes and pulls be more of that air you can breathe in and out. And once
again, I want you to just gently come back to the interaction. Pause for just a
moment. When youre ready, let yourself come gently back to the interaction.
Debriefing: Client
Once more, let the words drop away. Take a moment or two in the next
section of the work. To the client, see if you can give expression to what its
like to sit inside the skin of the client. Dont be nice. What did you see, what
did you hear, what did you feel? Where were the places you felt joined or not
joined? Avoid analysis and stay very close to experience. What was the experience, how did it move, what were the contours as you moved through it? Stay
with the experience.
Pause for just a second and consider what the client might hope for in the
room.
Debriefing: Therapist
Stay close to experience. What was it like to sit in the room with the
client? What were the ebb and flow and contour of that experience? Again,
avoid analysis.
Debriefing: Witnesses
Now the people who witnessed the exchange, what was it like to watch
the client-therapist interaction? Again, no analysis. Stay with experience. How
did the interaction tug at you as a witness?
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Finishing Up
Let the words drop away. Take a moment, breathe, and let yourself be saturated by all of the different experiences in the interaction: the experiences of the
client, the therapist, and the witnesses. Pause and just appreciate the complexity,
the richness of those experiences. See if, for just a moment, your awareness can
just gently release those experiences. Let your awareness come to rest on your
own breath. Notice how your thoughts and experiences clamor for your attention. Return to your own breathing, to that same gentle inflow and outflow
of breath. See if you can notice that, through all of these interactions, there
remained that gentle inflow and outflow of breath, requiring nothing of you and
yet sustaining you. Kindly give your own breath a moment of appreciationa
simple thing that sustains you even when you dont have time for it.
Reinduction
Let your eyes gently close. Just let your attention come gently to rest on
your own inflow and outflow of breath. See if you can notice how steadfast
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your breath is, how reliable. And if you find yourself becoming distracted,
just see if you can notice those distractions, maybe give them a nodyou can
come back to them later. But for now, let your attention gently, gently come
back to your own breathing. See if you can begin to notice the tiny sensations
that can be found in the inflow and outflow of each breath.
It neednt be forceful, but when you find your mind wandering, gently
carry it back to your breath.
And now imagine once again that photograph of your client and hold it in
your lap. Let yourself recollect; let yourself see that face. And breathe. Just let
your eyes linger on that face for a moment, breathing in and out. And then let
that photo dissolve, dissolve, breathing. And let yourself begin to see that client
of yours as she is right now. See if the exercises youve done will let you see just
a little more deeply into the suffering of that person. Let yourself soften to that
suffering, let yourself be penetrated by it. Notice how she holds her body, how
she holds her life; feel that tension and that narrowness that constrains her.
Breathe. And once more, imagine that your awareness can become a liquid
that is poured into the skin of your client. With kindness, gently pour your
awareness into your client. Let yourself begin to feel that trap that your client
feels herself to be in. As your awareness fills your client up, let the way she
holds her body begin to shape yours. Let the trap that she finds herself in grab
hold of your awareness and squeeze it. Let yourself wonder, Will my therapist
see me? Can anyone understand me? Know me? Just let yourself breathe that
struggle in and out.
When youre ready, open your eyes as the eyes of your client. Be true to
her. Be her voice in this room. Respect her by being true to her. When youre
ready, rejoin the conversationthe same session, the next session. Go ahead
and rejoin that conversation.
[Pause.]
Let the words drop away. Let yourself go silent. You can continue to go
along this path, but stop for just a moment to rest. See if you can bring your
awareness to your own pace. Is there urgency to it? Are you hurrying? Just let
it well up around youand breathe. When youre ready, I want you to come
back to the interaction and see if you can really bring intention and awareness
to your pacing. See if you can find a pace where you are right there with your
client. Just take a moment, take a few breaths, and notice the gentle inflow of
breath. Witnesses, see if you can just practice bringing attention to one or the
other side of the interaction. Breathe. And when youre ready, just let it be as
if you stood back up on that same trail and then took your time moving back
in the way youve been going.
[Pause.]
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One more time let the words drop away, and let your eyes gently close.
Notice what its like to be that therapist, that client. If youre observing, have a
heart for both the client and the therapist.
Therapist, you have the flavor of your client now. Imagine that your
awareness could be poured into that body across from you. Imagine that your
awareness can be poured like water into the skin of the person across from
you. Let yourself take on the feel, the posture of that client.
[Participants reverse roles.]
Imagine yourself being poured across that transaction. When you open
your eyes, be yourself, the therapist, looking across at your client.
If you were the therapist, feel what its like to be the client. Was that
person hearing you at all? When you open your eyes, rejoin the workexcept
with the roles of therapist and client reversed.
[Pause.]
What is it like to sit in that aware place as a client and as a therapist?
Consider this question: If you werent in the room with that client, trying
to say the right thing, what would you like to say to her? Take a minute. Let
your attention come to rest on your own breath, and then gently, gently come
back to the interaction.
[Pause.]
One last time, let the words gently drop away. Youre not done. There
is no done. Let the whole experience gather around you. What was it like
client, therapist, witnesses? Draw your attention to your own breathing. There
it is, waiting for you. If you find your mind wandering, let it come to rest on
your own breath. Notice the way the mind wants to pull you this way and
that, to get on to the next thing. Notice then that your breath is there, waiting
for your return. Just take a moment to appreciate that sweet simple thing: your
own breath moving in and out of your body. This very breath.
And now open your eyes and take a few minutes here to stay close to the
experience. What kinds of things did you notice? Not analysis, but what was
the experience like? What was the transition like? If you were observing, what
did you see?
222
provides a very rich set of interactions. Linger over them. Your inclination is likely to be to absolutely launch into case conceptualization.
Notice that eagerness to move to the conceptual. Cause your little group
to pause until you can sit with the urgency. You can do this, but it will
require you to bring your careful attention to bear on the task in a way
that is very, very different from our usual shift into the conceptual.
In addition to the debriefing suggested in the previous exercises,
consider adding these small additional instructions:
1. Designate someone in your group to ring the bell, as it were,
to call the small group to a mindful moment during the
case conceptualization. Encourage anyone in the group to
request such a moment if they feel the process is racing away.
It will be good practice for the group to respect the process
for others and to notice their own drive to action.
2. Have everyone in your small group bring their hexaflex
worksheets into their lap and let their eyes travel across the
sheets. Remain silent and allow your eyes to travel across
the sheet without writing anything. If you begin to think of
things to write, gently let those go, and look around at your
little group and let yourself soak in the magnitude of the
human task we have all adopted.
3. Case conceptualization of the therapist: Work through a case
conceptualization of the therapist (as described in chapter
7). Be sure to walk all the way around the hexaflex. Take
some mindful moments in this process. Just stop. Please.
4. Case conceptualization of the client: Work through a case
conceptualization of the client (as described in chapter 7).
Be sure to walk all the way around the hexaflex. Take some
mindful moments in this process. Just stop. Please. We have
time enough.
223
Epilogue
Slowing Down
One of the central arguments of this book, and I think of ACT generally,
is that all of uswhether client or therapistexperience similar problems in living. These problems vary from each to each in degree but not
in kind. This egalitarianism of dysfunction, of course, extends to authors
too. So now its my turn to wander from the present moment and worry
about the unknowable future.
How will this book be received?
This book was born from science, but I didnt write it primarily for
scientists. There are a thousand places in the preceding pages where I
might have unpacked the empirical and theoretical justification for my
assertions. Had I done that, though, most clinicians would have stopped
reading before finishing the first chapter.
I believe there is relevant empirical evidence, theory, or both for the
work Ive described herein. I have spent a lot of time in other contexts
making the scientific argument for all Ive claimed in these pages, and
Ill continue to do so. But setting forth an exhaustive, scientific account
of the whys and wherefores of mindfulness for two wasnt the purpose of
this book. Instead, I wanted to offer you something in the way of a very
practical experience that could shape the conversations you have with
your clients.
Because I took for granted a number of theoretical and empirical
matters, I know Ill draw criticism for this book. Some scientists will
cluck their tongues. I can live with that. I never intended this to be an
endpoint of a scientific analysis. Rather my vision was for it to be part of
an iterative process that moves between the clinic and the lab, between
basic and applied theory, between the highly theoretical and the wholly
practical. My hope was to speak to clinicians, and, to a somewhat lesser
extent, to set an empirical agenda for scientists who can see both the
science from which this work comes and the human need it seeks to
fulfill.
We have time enough to sort these matters out, though it often
doesnt seem so. Our savanna minds didnt keep us alive by idling away
the hours. But you took time for this odd book. Perhaps you were looking
for a significant, hard-to-define something more in your own work. Its my
hope that taking this time will help you to make time for yourself and for
the people you serve.
What would it mean if we slowed just a bit? What would it mean to
stop long enough to recognize our own face in the mirror one morning?
What would it mean to look deeply into those eyes? What does that
person we see there need? Do we have time to recognize that person?
To listen? To hear our own hearts? What small gift could you make to
yourself this day? What kindness would you offer?
This book is a small gift Ive offered to myself. Its a place where Ive
let the years that have welled up around me spill out. Ive attempted to
give voice to the influences of hundreds of teachers, clients, students, and
friends of this work worldwide. This book is a place where Ive allowed
myself to speak in my own voice. I hope that all of you who have contributed will hear a bit of your voice echoed in mine. I hope that those of
you who are just now joining me will find things in these pages that serve
both you and the clients you serve. Well need to slow down in order to
really answer these questions. Kindness is a simple thing. And sometimes
a return to simple things can help us.
At times we feel the need to go back
to plain things. To stones, earth,
grass, wind. To things we have known
a long time, to what we knew
when what filled the hours was dirt
and a few sticks, a pile of leaves
or some thin, white bones
from a long-dead bird.
The huge rock near the creek
was not too hard to lie on then
226
Slowing Down
227
Appendix A
Bound into the back of this book, youll find a DVD-ROM with all sorts
of interesting things you can use to support your experience with the
book. Although the disc contains video, it isnt a DVD that you can play
in your DVD player and watch on your television set. In order to use the
disc, youll need a personal computer.
VIDEO
There are seven video segments on the disc. You can see the Sweet Spot
and Client Descending exercises, and you can practice case conceptualization on the six remaining experiential role plays. In particular, I offer
a case conceptualization of Emily and Kate: Session 2 in chapter 7.
The worksheets with my notes appear on the disc as Emily and Kate 2
HDFEI.pdf.
These segments were filmed in Denver, Colorado, in April 2008.
The individuals who appear in these videos as clients adopted invented
clinical personae for illustrative purposes, but I would resist calling what
you see in these segments acting. While the clients assumed some
details that would lend structure to the interviews, I think youll agree,
after you watch the videos, that something essentially human and undeniably real emerges. All of the participants, therapists and clients alike,
230
Appendix B
not at all
important
1 2 3 4 5 6 7 8 9 10
2. Marriage/couples/
intimate relations
1 2 3 4 5 6 7 8 9 10
3. Parenting
1 2 3 4 5 6 7 8 9 10
4. Friends/social life
1 2 3 4 5 6 7 8 9 10
5. Work
1 2 3 4 5 6 7 8 9 10
6. Education/training
1 2 3 4 5 6 7 8 9 10
7. Recreation/fun
1 2 3 4 5 6 7 8 9 10
8. Spirituality
1 2 3 4 5 6 7 8 9 10
9. Citizenship/community life
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
232
extremely
important
not at all
consistent
my value
completely
consistent with
my value
10
2. Marriage/couples/
intimate relations
10
3. Parenting
10
4. Friends/social life
10
5. Work
10
6. Education/training
10
7. Recreation/fun
10
8. Spirituality
10
9. Citizenship/community
life
10
10
233
Recommended Reading
What a dangerous section to include! This alone could take up the entire
page count. Id better keep it brief.
ON ACT
ACT literature for clinicians is growing fast. To date, much of it has
been published by New Harbinger, whose website is a good place to look
for other book and video titles: www.newharbinger.com. New Harbinger
also publishes a range of client-focused ACT books that can be used for
self-help or integrated into therapy, most notably Get Out of Your Mind
and Into Your Life, by Steve Hayes with Spencer Smith.
The major book that develops the theoretical foundations of ACT is
Acceptance and Commitment Therapy, by Steve Hayes, Kirk Strosahl, and
Kelly Wilson (Guilford Press, 1999). This title is currently under revision; the new edition will be available from Guilford in 2009. Arguably
the other foundational title for ACT is Relational Frame Theory: A PostSkinnerian Account of Human Language and Cognition, by Steve Hayes,
Dermott Barnes-Holmes, and Bryan Roche (Springer, 2001). While dense
and technical, these books offer unparalleled access to the theoretical
mechanics that make ACT what it is.
ON MINDFULNESS
There are quite simply too many books on the subject of mindfulness,
both within and without the great spiritual traditions, for me to mention.
To recommend some may seem to slight others through negligence, which
surely wouldnt be my intention. I have tremendous respect and affection for Jon Kabat-Zinn and believe that his books are required reading
for those interested in a clinical application of simple, conscious awareness to the present moment. In this area, however, I recommend that
you let your curiosity be your guide. I would also recommend the reader
look at the work of Mark Williams, Zindel Segal, and John Teasdale
on mindfulness-based cognitive therapy (MBCT). Though these books
all come at the work from a very different perspective, we are certainly
fellow travelers.
236
Recommended Reading
(Ballantine, 2003). Ernest Kurtz and Katherine Ketcham and their book
The Spirituality of Imperfection: Storytelling and the Search for Meaning
(Bantam, 1993) are a principal source of my persistent interest in sitting
inside significant questions. The book is nominally about spirituality in
Alcoholics Anonymous, but really the stories are marvelously universal.
I cannot overemphasize the importance of behavior analytic writing
and thinking on the development of this work. Do yourself a favor and
read what B. F. Skinner actually wrote rather than relying on secondhand reports by people who never really did their homework. I heartily
recommend Skinners essays in volumes such as Cumulative Record, first
published in 1959, or Contingencies of Reinforcement, published in 1969.
Neither is still in print, though used copies can be found online. If you
want to get a taste of the really odd edges of behavior analysis that captured my attention, please read some Willard Day. Sadly, Willard died
fairly young and talked more than he wrote. However, my first teacher of
behavior analysis, Sam Leigland, compiled a volume of Willards canonical papers in a volume called Radical Behaviorism, which can be purchased from New Harbinger under the Context Press imprint. With the
Skinner volumes and especially with Willards contribution, youll begin
to get a sense of the incredibly broad range of interests that can be found
within the behavior analysis tradition. Narrow indeed!
RECOMMENDED BROWSING
The Association for Contextual Behavioral Science (ACBS) is a central
point for all things ACT, and it serves as a hub for the functional contextual cognitive behavioral sciences. The website, www.contextualpsychology.org, features articles and information, a calendar of training events,
and the schedules of the ACT Summer Institutes and international conferences. Membership in ACBS is required to access much of the information on the site, but, in keeping with ACTs values orientation, ACBS
annual dues are values based. You set your annual dues according to how
much value you place on membership. As little as $1 will get you into this
exciting and supportive community.
237
References
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243
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